The 3-Year Curriculum: Disruptive Innovation and the Change Imperative From Texas Cowboy Boots on the Ground

Betsy Goebel Jones, EdD

Betsy Goebel Jones, EdD

For the past 5 years, I have been intimately involved with the Family Medicine Accelerated Track, or FMAT, at Texas Tech University Health Sciences Center School of Medicine (TTUSOM), so I’m always interested when an item lands in my Twitter feed or inbox about 3-year medical school curricula. As a result, it’s been hard to ignore the irony of not one but two Perspective articles in the September 19 New England Journal of Medicine (by Abramson et al.) and (Goldfarb and Morrison) and at least one prominent blog post (by Pauline Chen), all prompted by NYU’s launch of a 3-year pathway to the MD—and just as I was preparing for the AAMC meeting in Philadelphia that had as its theme “The Change Imperative.”

At TTUSOM, we’re not simply talking about the imperative for change in medical education, we’re implementing it through our FMAT program. In fact, TTUSOM Dean Steven Berk, MD, and I had the privilege of delivering one of the keynote presentations at the 2013 STFM Conference on Medical Student Education in which we described the FMAT program as we see it: a “disruptive innovation” in medical education. As a business model, a disruptive innovation—like Twitter, the iPad, or even the retail clinic—is that new thing that creates a new market or network, disrupting or fundamentally changing the old. Such innovations are often greeted with skepticism and grumbling about inferior quality, but the innovations that truly have the imperative for lasting change eventually create new networks.

By way of background, TTUSOM’s FMAT program was approved by the LCME in February 2010 and recruited its first class in 2011—eight students who graduated from TTUSOM in 2013 and who are currently flourishing as first-year family medicine residents in TTUSOM programs in Lubbock and Amarillo. Three additional classes are currently in training and we are recruiting the next. FMAT students complete the same curriculum as do their peers in the traditional curriculum with the following exceptions: an 8-week systems-based intensive experience after the MS1 year, a longitudinal and enhanced family medicine clerkship in the MS2 year, an 8-week capstone course in the MS3 year concentrating on inpatient experiences, and no fourth year. Of the 24 students in our first three classes who began FMAT training, two transitioned back to the 4-year curriculum due to academic challenges. No students have left the program because they had a change of heart about family medicine (which they may do at any time and return to the 4-year curriculum), although we know we will face that loss eventually.

What should be most apparent, especially to readers of this blog, is the “FM” that begins the program’s acronym: FMAT is specifically targeted at reducing shortages in the primary care physician workforce—which can be guaranteed only through increases in family medicine. Like NYU’s 3-year program, ours provides a seamless transition between medical school and residency training, but unlike NYU’s program, FMAT was developed by and is focused on family medicine. The program is also eligible for the NRMP’s family medicine accelerated track exception to the new “All-In” residency rules. Abramson et al point to the need to reduce student debt. We contend that debt reduction is especially important to students interested in primary care; thus, FMAT reduces debt from tuition and fees by 50%, both by eliminating one year of training and from scholarship support provided by TTUSOM.

So, a few final observations about accelerated training from our Texas cowboy boots on the ground:

  • We argue that the most logical deployment of 3-year curricula is to bend the curve toward primary care—the very thing that makes the innovation disruptive. That disruptive curve is possible by reducing student debt, developing mentoring relationships between students and family medicine faculty and residents, and—if we’re honest—eliminating a year of training that can often be corrosive to primary care.
  • And speaking of the MS4 year, both Chen and Golfarb and Morrison look back fondly at the fourth year of medicine school as valuable for pursuing electives and interviewing at potential residency sites. However, for students who have chosen a specialty (family medicine) and a residency program (one affiliated with TTUSOM) where they have already received extensive mentoring from program faculty, the fourth year is less important and may even dilute their intensive third-year clinical experiences.
  • Also of critical importance in the FMAT acronym is the “A” for accelerated—a measure of time. Fast-paced programs offer few opportunities for remediation; the decision to enter the program requires the maturity of an early decision but also a goal of entering the workforce earlier; and the ability to succeed requires motivation and excellent time-management skills. So an accelerated program is not for every student,or for every student interested in family medicine. Some students need all 4 years to develop competencies and determine career goals, and some—as we’ve all seen—need even more. On the other hand, because the challenging nature of an accelerated program requires high-achieving students who can manage multiple demands, the result is a new level of prestige that is clearly recognized within the confines of a medical school’s ecosystem.

At TTUSOM, we look forward to continuing to tell the FMAT story. Our first graduates took their in-training exam last week, so in a few weeks we’ll review those results. Until then, we can report that the addition of an accelerated family medicine training model within an established medical school creates an opening for educational innovation and new methodologies that are the very example of an Imperative for Change in medical education and for delivery of health care.

Are you considering an accelerated training model at your medical school? What are your reasons for or against this model? Let me know here or reach me on Twitter @betsygjones.

4 responses to “The 3-Year Curriculum: Disruptive Innovation and the Change Imperative From Texas Cowboy Boots on the Ground

  1. I’m wondering if there is any data concerning how these students compare in USMLE performance to students in a traditional system? My guess is that their performance is equivalent, similar to that of students in longitudinal community curricula. Perhaps a further threat to the assumptions of the ivory tower concerning medical educatIion?

  2. Colleen T. Fogarty MD MSc

    Great model!
    Many Canadian applicants to our residency comment on their desire to do a 3 year post-graduate training in US rather than 2 year post-graduate in Canada. Perhaps the 3+3 model is better than either the 4+2 (CA) or 4+3 (US) for excellent FM training.

  3. geoffrey goldsmith

    Hi all.
    At graduating from UCLA, I decided to do something different for medical school. Go to Canada’s newest 3 year medical school. I graduated from the three year curricula at McMaster University Faculty of Medicine (in Hamilton, Ontario, Canada). It was three years of intense, all night studying for the first 18 months of then diving into the clinical clerkships. Eat, sleep, study- it is a blur now 40 years after graduation in the 1970s. I preferred interacting with people and patient contact, thrived on case study learning over lectures and tests. Medical school was a joy for me. We had neither tests or lectures and media based problem based learning involved watching lots of audio-visual materials and examining simulated patients ( one of whom, she simulated a patient in coma, became my girlfriend- she really did have a good personality when she was awake).

    I did terrible on my part 1 of the US board exam. And I awful on my Canadian licensing exam (the LMCC test,)-I think something like part 3 of the US Boards. I didn’t think I could function in the US licensing exam world and that I was distend to practice forever cold, in the Canadian tundra. But I enrolled in a FP residency in the states and I guess I was accepted because back then because few people were interested in enrolling in a FP residency. I finally passed a test, the one that allowed me to get a medical license in any state.

    I am saying this all because passing I test is essential to get a license but not worth much else. I understand I was only one of 2 people in my entire medical school class that either had a low pass or failed at their initial try on the US license test. The other person went on to become an eminent psychiatrist in San Francisco. I served as a chair of a FM dept for 20 years, won all times of awards for teaching, was the PI on several research grant and even a clinical care award. McMaster followed the graduates of our three year classes for at least ten years. I dutifully reported how I was doing in practice, research, teaching and leadership. Others did the same. It would be instructive for anyone following this blog to read through the outcomes of McMaster graduates. I think you will find that we did quite well.

    I think one advance a 3 yr. program might make is to prepare trainees for required tests, and to make the training about 3 yrs and 3 months. I sure needed a rest when I finished medical school and 3 months to volunteer, observe health care in another country or hang out on a beach, all on my own dime, would have been rejuvenating. Geoffrey

  4. My name is David Keith, DO. I was the first Family Medicine grad of the same type of Program at LECOM(Erie) in 2010, the first in the county in some time. I was started 2 years before the TX program. LECOM was the 2nd cheapest private Medical school in the nation at the time, so my med school loan burden was not excessive as some of my friends.

    I just graduated from a competitive FM residency and am in practice delivering babies, Working an ER and doing full practive FM. I fond the 3 year program awesome! I was able to do exactly what I wanted right away. I was in small preceptorships starting the 3rd month, so when I started rotations I was ahead of the pack. I did struggle with the COMLEX 2 because I took it almost a year earlier than the other test takers, but on my retake I was above average 2 months later with some extra time. I didn’t need electives, because I knew exactly what I was doing. I used my last 2 rotations to do in and outpt medicine at my residency site and so day 1 I was already in the groove. I passed both the MD and DO FM boards before graduation and had good yearly in training exams.

    I believe it is a perfect way to prepare FMs for the need for today. Other students went IM, so they were able to help the need as well.

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