Roughly Speaking: What happened to the State Center project?

The gap in medical education

Since its inception more than a century ago, modern medical education has undergone a series of quiet revolutions, stretching and scaling to accommodate advances in biomedical science. Yet this comprehensive expansion in one critical area masks a relative neglect of another. Despite their staggering scope — spanning genetics to geriatrics, and everything in between — medical curricula today largely omit training on health policy.

Medical schools: A Jan. 3 Op-Ed about medical school training stated that the Stanford School of Medicine does not offer a required course on health policy. Stanford’s core curriculum incorporates a multi-disciplinary Practice of Medicine course, which includes a substantial health policy block for all students.

The result? Even as today's medical students graduate with a deep scientific fluency, they leave all but illiterate when it comes to the healthcare system.

Consider, for example, the findings of a 2009 study in the journal Academic Medicine analyzing survey data from the Assn. of American Medical Colleges. Polling nearly 60,000 graduating medical students, the analysis found that less than half of the respondents felt they had an adequate grasp of health economics, managed care or healthcare systems. Compare this result to the corresponding statistic for clinical care, which clocked in at well over 80%.

Moreover, in a 2011 New England Journal of Medicine survey of medical deans, almost 60% of respondents reported their institution's curriculum as containing "too little" health policy training.

I can bear witness to this disparity firsthand. The curriculum of Stanford Medical School, where I am a deferred first-year student, does not incorporate a single required course on health policy or the healthcare system across four years and 249 credits of training.

And this oversight comes with consequences. To illustrate, recent research in JAMA Internal Medicine found that fewer than half of medical students nationwide understand even the basic components of the Affordable Care Act. On a systemic level, this illiteracy directly impedes our ability to institute meaningful health policy reforms that tackle such thorny issues as quality-based physician payments, comparative effectiveness guidelines or end-of-life care. Without willing and capable physician leaders to guide, implement and sustain such major shifts for the decades to come, reform efforts almost certainly will founder.

Consequently, efforts to rein in healthcare costs and improve patient outcomes must begin by modernizing medical curricula to incorporate health policy training. For example, a national mandate that fundamental knowledge of health systems be a prerequisite for medical licensing would encourage medical schools to incorporate course work on basic principles of health policy and economics. This teaching, moreover, should be nonpartisan and nonideological, focusing instead on the nuts and bolts of health systems — akin to what law or business school students learn about policymaking and institutional governance.

This training need not be comprehensive or all-encompassing. Just as pre-clinical instruction in the medical sciences provides a basic foundation that is built upon in later clinical training, health policy education in medical curricula can offer a baseline understanding that is reinforced in subsequent years. Even ensuring just a rudimentary level of health policy literacy could go a long way.

Furthermore, the advent of so-called massive open online courses, or MOOCs, means that financial concerns — the costs of expanding medical curricula to encompass healthcare policy — may be unwarranted. Online health policy courses, such as the one taught by physician/policymaker Ezekiel Emanuel at the University of Pennsylvania, could serve as a functional stand-in when a university lacks a department or set of instructors dedicated to health policy.

Whatever the medium, it is imperative that we install health policy as an integral part of the national medical curricula, lest we continue to churn out a generation of students who are ill-equipped to make sense of the challenges and changes to come. Amid the dynamism of our 21st century healthcare system, policy fluency is at least as important as a mastery of biomedical concepts.

Rahul Rekhi, a student at Stanford University School of Medicine, is currently studying as a Marshall Scholar at Oxford University. He served as special assistant to the Maryland secretary of health in 2013.


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