Medical School in Three Years? Educators Test a New Model

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Deborah Powell, MD, has never been a big believer that four years of medical school is the magic number. After years of discussing the issue with peers and colleagues, she decided to test her hypothesis.

The result is the Education in Pediatrics Across the Continuum (EPAC) Project, a competency-based medical education model now being piloted in the United States at four medical schools. EPAC’s core philosophy is the idea that students who advance through medical school on the basis of their mastery of certain competencies are just as prepared for residency as those who complete four years of education. The program began in 2009 and welcomed its first students in 2013.

The AAMC has been involved in EPAC since its inception and is sponsoring the pilot project with a grant from the Josiah Macy Jr. Foundation. To date, six students taking part in the EPAC pilot have begun residency.

“It’s been a messy process, but we’ve already built so much and learned so much,” said Powell, professor of laboratory medicine and pathology and dean emerita of the University of Minnesota Medical School. “We’ve learned that some students can make decisions about specialty choices a lot earlier than we think, and that opens the door for us to create different pathways for medical students, instead of assuming that one size fits all.”

Powell, who first conceived of EPAC and is a member of its steering committee, said nearly any specialty could have piloted the effort, but those in the pediatrics community were willing and able and had a history of educational innovation. Carol Carraccio, MD, MA, vice president of competency-based assessment programs at the American Board of Pediatrics and a member of EPAC’s steering committee, said pediatrics was a good fit because it was one of the first medical disciplines to develop competency-based educational milestones.

“One of the advantages of competency-based education, in general, is that instead of being predicated on expert opinions, it’s predicated on the needs of the populations we serve,” said Carraccio.

Each of the four schools participating in the pilot—University of Minnesota Medical School (UMN), University of Colorado School of Medicine (CU), University of Utah School of Medicine, and the University of California, San Francisco, School of Medicine—is implementing EPAC differently. For example, not all the schools select EPAC students at the same point in their educations. CU selects EPAC students at the end of their first year, while UMN selects in the second year. But there are some common threads: all EPAC students know early on that they want to practice pediatrics; all advance on the basis of a set of competencies and entrustable professional activities, or a set of skills students should master; and all have longitudinal clinical experiences. In addition, if students demonstrate competence and fulfill requirements for a medical degree, they are guaranteed a residency slot with their schools’ affiliated teaching institutions.

 A paradigm shift 

At Utah, the first group of EPAC students began residency in January. They transitioned about six months earlier than is typical, reported James Bale Jr., MD, EPAC site director in Utah and a professor of pediatrics and neurology. In his view, the students were “superbly” prepared for residency.

“It’s been a messy process, but we’ve already built so much and learned so much. We’ve learned that some students can make decisions about specialty choices a lot earlier than we think, and that opens the door for us to create different pathways for medical students, instead of assuming that one size fits all.”

Deborah Powell, MD
University of Minnesota Medical School

For instance, the typical Utah medical student does not participate in a long-term clinical experience. However, EPAC students do, which gives faculty the opportunity to observe them over time, identify areas of need, and provide feedback and additional experiences to fill in any gaps, Bale said. EPAC students also develop long-term mentor–mentee relationships that often follow them into residency, he added.

“I think this is going to be a game changer when it comes to medical education,” Bale said. 
UMN medical students learn about EPAC during their first and second years. After students apply, up to four are chosen in the middle of the second year, said John Andrews, MD, the school’s EPAC site director and associate dean for Graduate Medical Education. UMN recently selected its third EPAC cohort. Its first cohort transitioned into residency just a few months ago during what would have traditionally been their fourth year of school.

While most UMN medical students participate in a series of block-model clerkships, EPAC students participate in a longitudinal integrated clerkship (LIC) based in pediatrics. In other words, Andrews said, they are exposed to a variety of specialties, but with a pediatric twist. For instance, their LIC includes child psychiatry or pediatric surgery. 

Each year, CU selects four EPAC students, who begin their specialized curriculum in the second year, said Jennifer Soep, MD, CU’s EPAC site director and director of the school’s pediatric clerkship program. While all CU medical students have early clinical experiences, the EPAC experience is much more in-depth. In particular, Soep said, EPAC students are paired with a preceptor in their second year and work with that same person through residency. That means they develop a long-term mentoring relationship and follow newborns they first meet in the hospital nursery well into their toddler years.

“They can develop relationships with faculty and patients that no other students can,” Soep said.

Powell described the EPAC Project as a “fact-finding” mission. In particular, she said EPAC is changing traditional beliefs about medical education and opening the door to wider innovation. “I think we’ve done some things that have really changed the paradigm of medical education,” she said, “and that’s what’s so exciting to me.”