Medical school in the United States
Encyclopedia
Medical school in the United States is a four year graduate institution with the purpose of educating physicians in the field of medicine
Medicine
Medicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....

. It provides a major part of the medical education in the United States
Medical education in the United States
Medical education in the United States includes educational activities involved in the education and training of medical doctors in the United States, from entry-level training through to continuing education of qualified specialists....

.

History

In 1910 the Flexner Report
Flexner Report
The Flexner Report is a book-length study of medical education in the United States and Canada, written by the professional educator Abraham Flexner and published in 1910 under the aegis of the Carnegie Foundation...

 reported on the state of medical education in the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...

 and Canada
Canada
Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...

. It was written by Abraham Flexner
Abraham Flexner
Abraham Flexner was an American educator. His Flexner Report, published in 1910, reformed medical education in the United States...

 and published in 1910 under the aegis of the The Carnegie Foundation for the Advancement of Teaching
The Carnegie Foundation for the Advancement of Teaching
Founded by Andrew Carnegie in 1905 and chartered in 1906 by an act of the United States Congress, the Carnegie Foundation for the Advancement of Teaching is an independent policy and research center, whose primary activities of research and writing have resulted in published reports on every level...

. It set standards and reformed the American medical education.

Admissions

Admission into medical school typically requires a four-year bachelor's degree
Bachelor's degree
A bachelor's degree is usually an academic degree awarded for an undergraduate course or major that generally lasts for three or four years, but can range anywhere from two to six years depending on the region of the world...

 or at least 90 credit hours from an accredited college or university (although for reasons of academic tradition, most medical schools do not officially require the baccalaureate). Many applicants obtain further education before medical school in the form of Master's degrees, or other non science related degrees. Admissions criteria may include overall performance in the undergraduate years and performance in a group of courses specifically required by U.S. medical schools (pre-health sciences
Pre-health sciences
Pre-health sciences refers to the undergraduate courses to prepare American college students for admission in medical, dentistry, pharmacy, optometry, veterinary, and physical therapy schools, and for training as a physician assistant...

), the score on the Medical College Admission Test
Medical College Admission Test
The Medical College Admission Test is a computer-based standardized examination for prospective medical students in the United States and Canada. It is designed to assess problem solving, critical thinking, written analysis, and writing skills in addition to knowledge of scientific concepts and...

 (MCAT), application essays, letters of recommendation (most schools require either one letter from the undergraduate institution's premedical advising committee or a combination of letters from at least one science faculty and one non-science faculty), and interviews.

Beyond objective admissions criteria, many programs look for candidates who have had unique experiences in community service, volunteer-work, international studies, research
Research
Research can be defined as the scientific search for knowledge, or as any systematic investigation, to establish novel facts, solve new or existing problems, prove new ideas, or develop new theories, usually using a scientific method...

, or other advanced degrees. The application essay is the primary opportunity for the candidate to describe his/her reasons for entering a medical career. The essay requirements are usually open-ended to allow creativity and flexibility for the candidate to draw upon his/her personal experiences/challenges to make him/her stand out amongst other applicants. If granted, an interview serves as an additional way to express these subjective strengths that a candidate may possess.

Since 2005, the Association of Medical Colleges has recommended that all medical schools conduct background checks on applicants in order to prevent individuals with convictions for serious crimes from being matriculated.

Most commonly, the bachelor degree is in one of the biological sciences, but not always; in 2005, nearly 40% of medical school matriculates had received bachelor's degrees in fields other than biology or specialized health sciences. All medical school applicants must, however, complete year-length undergraduate courses with labs in biology, general chemistry, organic chemistry, and physics; some medical schools have additional requirements such as biochemistry, calculus, genetics, psychology and English. Many of these courses have prerequisites, so there are other "hidden" course requirements (basic science courses) that are often taken first.

A student with a bachelor's degree who has not taken the pre-medical
Pre-medical
Pre-medical is a term used to describe a track an undergraduate student in the United States pursues prior to becoming a medical student...

 coursework may complete a postbaccalaureate (postbacc) program. Such programs allow rapid fulfillment of prerequisite course work as well as grade point average improvement. Some postbacc programs are specifically linked to individual medical schools to allow matriculation without a gap year, while most require 1–2 years to complete.

Several universities across the U.S. admit college students to their medical schools during college; students attend a single six-year to eight-year integrated program consisting of two to four years of an undergraduate curriculum and four years of medical school curriculum, culminating in both a bachelor's and M.D. degree or a bachelor's and D.O. degree. Some of these programs admit high school students to college and medical school.

While not necessary for admission, several private organizations have capitalized on this complex and involved process by offering services ranging from single-component preparation (MCAT, essay, etc.) to entire application review/consultation.

In 2006, the average GPA and MCAT for osteopathic matriculants was 3.46 and 24.6 respectively, and 3.64 and 30.4 for MD matriculants. In 2010, 42,742 people applied to medical schools in the United States through the American Medical College Application Service. 18,665 of them matriculated into a medical school for a success rate of 44%.

Curriculum

Once admitted to medical school, it generally takes four years to complete a Doctor of Medicine
Doctor of Medicine
Doctor of Medicine is a doctoral degree for physicians. The degree is granted by medical schools...

 (M.D.
Doctor of Medicine
Doctor of Medicine is a doctoral degree for physicians. The degree is granted by medical schools...

), or Doctor of Osteopathic Medicine (D.O.) degree program. However, at least one school, Texas Tech University
Texas Tech University
Texas Tech University, often referred to as Texas Tech or TTU, is a public research university in Lubbock, Texas, United States. Established on February 10, 1923, and originally known as Texas Technological College, it is the leading institution of the Texas Tech University System and has the...

, is now offering a three year accelerated program for those students going into primary care
Primary care
Primary care is the term for the health services by providers who act as the principal point of consultation for patients within a health care system...

. The course of study is divided into two roughly equal components: pre-clinical and clinical.

Preclinical study comprises the first one to two years and consists of classroom and laboratory instruction in core subjects such as anatomy
Anatomy
Anatomy is a branch of biology and medicine that is the consideration of the structure of living things. It is a general term that includes human anatomy, animal anatomy , and plant anatomy...

, biochemistry
Biochemistry
Biochemistry, sometimes called biological chemistry, is the study of chemical processes in living organisms, including, but not limited to, living matter. Biochemistry governs all living organisms and living processes...

, physiology
Physiology
Physiology is the science of the function of living systems. This includes how organisms, organ systems, organs, cells, and bio-molecules carry out the chemical or physical functions that exist in a living system. The highest honor awarded in physiology is the Nobel Prize in Physiology or...

, pharmacology
Pharmacology
Pharmacology is the branch of medicine and biology concerned with the study of drug action. More specifically, it is the study of the interactions that occur between a living organism and chemicals that affect normal or abnormal biochemical function...

, histology
Histology
Histology is the study of the microscopic anatomy of cells and tissues of plants and animals. It is performed by examining cells and tissues commonly by sectioning and staining; followed by examination under a light microscope or electron microscope...

, embryology
Embryology
Embryology is a science which is about the development of an embryo from the fertilization of the ovum to the fetus stage...

, microbiology
Microbiology
Microbiology is the study of microorganisms, which are defined as any microscopic organism that comprises either a single cell , cell clusters or no cell at all . This includes eukaryotes, such as fungi and protists, and prokaryotes...

, pathology
Pathology
Pathology is the precise study and diagnosis of disease. The word pathology is from Ancient Greek , pathos, "feeling, suffering"; and , -logia, "the study of". Pathologization, to pathologize, refers to the process of defining a condition or behavior as pathological, e.g. pathological gambling....

, pathophysiology
Pathophysiology
Pathophysiology is the study of the changes of normal mechanical, physical, and biochemical functions, either caused by a disease, or resulting from an abnormal syndrome...

, and neurosciences. Once students successfully complete preclinical training, they generally take step one of the medical licensing boards, the USMLE
USMLE Step 1
The USMLE Step 1 is the first part of the United States Medical Licensing Examination. It assesses whether medical school students or graduates can apply important concepts of the sciences fundamental to the practice of medicine. US medical students typically take Step 1 at the end of the second...

, or the COMLEX.

The clinical component usually occupies the final two to three years of medical school and takes place almost exclusively on the wards of a teaching hospital
Teaching hospital
A teaching hospital is a hospital that provides clinical education and training to future and current doctors, nurses, and other health professionals, in addition to delivering medical care to patients...

 or, occasionally, with community-based physicians. The students observe and take part in the care of patients under the supervision of resident
Residency (medicine)
Residency is a stage of graduate medical training. A resident physician or resident is a person who has received a medical degree , Podiatric degree , Dental Degree and who practices...

 and attending physicians. Rotations (also known as clerkships) are required in internal medicine
Internal medicine
Internal medicine is the medical specialty dealing with the prevention, diagnosis, and treatment of adult diseases. Physicians specializing in internal medicine are called internists. They are especially skilled in the management of patients who have undifferentiated or multi-system disease processes...

, surgery
Surgery
Surgery is an ancient medical specialty that uses operative manual and instrumental techniques on a patient to investigate and/or treat a pathological condition such as disease or injury, or to help improve bodily function or appearance.An act of performing surgery may be called a surgical...

, pediatrics
Pediatrics
Pediatrics or paediatrics is the branch of medicine that deals with the medical care of infants, children, and adolescents. A medical practitioner who specializes in this area is known as a pediatrician or paediatrician...

, family medicine
Family medicine
Family medicine is a medical specialty devoted to comprehensive health care for people of all ages. It is a division of primary care that provides continuing and comprehensive health care for the individual and family across all ages, sexes, diseases, and parts of the body...

, obstetrics
Obstetrics
Obstetrics is the medical specialty dealing with the care of all women's reproductive tracts and their children during pregnancy , childbirth and the postnatal period...

/gynecology, neurology
Neurology
Neurology is a medical specialty dealing with disorders of the nervous system. Specifically, it deals with the diagnosis and treatment of all categories of disease involving the central, peripheral, and autonomic nervous systems, including their coverings, blood vessels, and all effector tissue,...

, and psychiatry
Psychiatry
Psychiatry is the medical specialty devoted to the study and treatment of mental disorders. These mental disorders include various affective, behavioural, cognitive and perceptual abnormalities...

. Beyond these, a variable number of specialty electives are required. Additionally, students are generally required to take a sub-internship
Sub-internship (medicine)
A "sub"-internship , or acting internship is a clinical rotation of a fourth-year medical student in the United States medical education system usually at a different hospital than the student's medical school affiliations...

 rotation where they will perform duties at the intern level. During the fourth year, most medical students take Step 2 of the medical licensing boards (USMLE Clinical Knowledge
USMLE Step 2-CK
The USMLE-Step 2-CK is the multiple-choice portion of the second part of the United States Medical Licensure Examination. It assesses clinical knowledge through a traditional, multiple-choice examination. In contrast to the USMLE Step 1, the focus is much more on clinical application of medical...

 & Clinical Skills [for M.D.], or COMLEX Cognitive Evaluation & Performance Evaluation [for D.O.]).

Many medical schools also offer joint degree programs in which some medical students may simultaneously enroll in master's or doctoral-level programs in related fields such as a Masters in Business Administration, Masters in Healthcare Administration, Masters in Public Health
Master of Public Health
The Master of Public Health and the Doctor of Public Health are multi-disciplinary professional degrees awarded for studies in areas related to public health....

, JD
Juris Doctor
Juris Doctor is a professional doctorate and first professional graduate degree in law.The degree was first awarded by Harvard University in the United States in the late 19th century and was created as a modern version of the old European doctor of law degree Juris Doctor (see etymology and...

, Master of Arts in Law and Diplomacy, and Masters in Health Communication. Some schools such as the Wayne State University School of Medicine and the Medical College of South Carolina both offer an integrated radiology curriculum during their respective MD Programs led by investigators of the Advanced Diagnostic Ultrasound in Microgravity
Advanced Diagnostic Ultrasound in Microgravity
The Advanced Diagnostic Ultrasound in Microgravity Project is a US Government funded study investigating strategies for applying diagnostic telemedicine to space. The Principal Investigator is Scott Dulchavsky, Chairman of Surgery at the Henry Ford Health System...

 study.

Upon completion of medical school, the student gains the title of doctor and the degree of M.D. or D.O., but cannot practice independently until completing at least an internship and also Step 3 of the USMLE
USMLE Step 3
Step 3 is the final exam in the USMLE series of examinations. It is part of the licensing requirements for M.D.s, D.O.s, and FMGs to practice medicine in the United States.It is considered as the final step in the series of medical licensure examinations...

 (for M.D.) or COMLEX (for D.O.). Doctors of medicine and doctors of osteopathic medicine have an equal scope of practice in the United States, with some osteopath doctors supplementing their practice with principles of osteopathic medicine.

Grading

Medical schools use a variety of different grading methods. Even within one school, the grading of the basic sciences and clinical clerkships may vary. Most medical schools use the pass/fail schema, rather than letter grades; however the range of grading intervals varies. The following are examples of grades used with different intervals:
  • 2 Intervals = Pass/Fail
  • 3 Intervals = Honors/Pass/Fail
  • 4 Intervals = Honors/High Pass/Pass/Fail (or ABCF)
  • 5 Intervals = Honors/High Pass/Pass/Low Pass/Fail (or ABCDF)


In addition, a Medical School Performance Evaluation, also called Dean's letter, more specifically describes the performance of a student during medical school.

Accreditation

All medical schools within the United States must be accredited by one of two organizations. The Liaison Committee on Medical Education
Liaison Committee on Medical Education
The Liaison Committee on Medical Education is an accrediting body for educational programs at schools of medicine in the United States and Canada. The LCME accredits only the schools that grant a doctor of medicine degree; osteopathic medical schools are accredited by the Commission on...

 (LCME), jointly administered by the Association of American Medical Colleges
Association of American Medical Colleges
The Association of American Medical Colleges is a non-profit organization based in Washington, DC and established in 1876. It administers the Medical College Admission Test...

 and the American Medical Association
American Medical Association
The American Medical Association , founded in 1847 and incorporated in 1897, is the largest association of medical doctors and medical students in the United States.-Scope and operations:...

, accredits MD schools, while the Commission on Osteopathic College Accreditation of the American Osteopathic Association
American Osteopathic Association
The American Osteopathic Association is the representative member organization for the over 78,000 osteopathic medical physicians in the United States...

 accredits osteopathic (D.O.) schools. There are presently 134 M.D. programs and 26 osteopathic programs in the U.S.

Accreditation is required for a school's students to receive federal loans. Additionally, schools must be accredited to receive federal funding for medical education. The M.D. and D.O. are the only medical degrees offered in the United States which are listed in the WHO/IMED list of medical schools.

Indebtedness of US Medical Graduates

Unlike many other countries, US medical students finance their education with personal debt. In 1992, the average debt of a medical doctor after residency, for those graduating with debt, was $25,000. For the Class of 2009, the average debt of a medical student is $157,990, with 25.1% of students having debt in excess of $200,000 (prior to residency). For the past decade, tuition prices have increased 5-6% each year- it is not clear what has caused these increases.

Medical schools do not have accounting transparency, so it is difficult to pin-point the root cause of tuition increases. Medical education is still based on the 2 + 2 model posited by the 100 year old Flexner report
Flexner Report
The Flexner Report is a book-length study of medical education in the United States and Canada, written by the professional educator Abraham Flexner and published in 1910 under the aegis of the Carnegie Foundation...

. Some have suggested that the medical education role of medical schools has been subordinated to the patient care and research missions of the academic health center.

A current economic theory suggests that increasing borrowing limits have been the cause of the increased tuition. As medical students are allowed to borrow more, medical schools raise tuition prices to maximally increase revenue. Studies show that schools raise prices 97 cents for each one dollar increase in borrowing capacity.

There is no consensus on whether the level of debt carried by medical students has a strong effect on their choice of medical specialty. Dr. Herbert Pardes and others have suggested that medical school debt has been a direct cause of the US primary care shortage. Some research suggests that for a sub-set of debt sensitive medical students, this is certainly the case. For most students, debt is but one consideration in choosing a residency. Whatever the cause may be, the 2008 Family Medicine Residency match filled only 44% of available slots with US graduates, down from the 1984 level of 98%.

Academic Health Centers

Medical schools reside inside complex multi-purpose institutions known as academic health centers. Academic health centers aim to educate medical students and residents, provide top quality patient care, and perform cutting-edge research. Since medical students are educated inside academic health centers, it is impossible to separate the finances from other operations inside the center. Funding for medical students--and higher graduate medical education--comes from several sources above and beyond personal debt financing.

- DGME (Direct Graduate Medical Education- 2.2 billion in 2002) financing payments under the auspices of Medicare/Medicaid. This funding was altered by the Consolidated Omnibus Budget Reconciliation Act of 1986. Each hospital receives payment based on how many Full Time Equivalent Residents are being trained.

- IME
IME
-IME:* Institute of Management Education,* IME, Hayatabad Peshawar, PhD and MS Faculty-Organizations:* Institution of Mechanical Engineers, British engineering society...

 (Indirect Medical Education - 6.2 billion in 2002) adjustment. This payment compensates teaching hospitals for their higher Medicare inpatient hospital operating costs due to a number of factors.

- Managed care and insurance organizations reimburse at a higher rate for teaching hospitals, explicitly acknowledging the higher costs of the academic health center.

- The vast majority of revenues come from third-party payers reimbursing for patient care, usually through the Faculty Service Plan.

- Incentive programs such as the MSTP (Medical Scientist Training Program
Medical Scientist Training Program
Medical Scientist Training Programs are combined M.D. and Ph.D. graduate degree programs offered by a small number of United States medical schools with financial support from the National Institute of General Medical Sciences , in recognition of the increasing need for scientists to bridge the...

), NHSC (National Health Service Corps
National Health Service Corps
The National Health Service Corps is part of the United States Department of Health and Human Services, division of Health Resources and Services Administration, Bureau of Clinician Recruitment and Service....

), Armed Services Health Profession Scholarship and now the Income Based Repayment Plan.

-Many academic health centers in the U.S. are tied to undergraduate university systems while others solely focus on graduate medicine, training, research, and education.

External links

Medical school associations
Application services
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