Why medical training in the U.S. needs to be reformed
Current education practices should be reconfigured, not because medicine is too hard, but because the pipeline no longer matches practice.
A cardiologist rules out coronary syndrome in a patient with chest pain and says it may be anxiety. “Follow up with primary care.”
A GI physician discovers severe hypertension during pre-procedure evaluation for a routine colonoscopy. “You should see cardiology or your primary care doctor.”
A psychiatrist identifies new-onset atrial fibrillation on a psych unit. The patient is transferred to a medical floor for stabilization.
Each of these handoffs is clinically reasonable. But together, they reveal something deeper; the U.S. training pipeline is increasingly misaligned with the way care is delivered today — narrow scopes, heavy handoffs and primary care left holding the bag.
Medical training today involves a long and expensive pipeline that’s daunting for those pursuing medical practice. Residency involves essential training but represents a heavy burden. There’s misalignment because clinicians train broadly, then typically have a narrow focus in their practices. With looming shortages in clinicians, there’s no better time to consider reforms to the system.
Medical training today
In the U.S., it can take 10 or more years after high school to produce a practicing physician, and longer for many subspecialists. The pathway is rigorous for good reasons, but the time and financial burden are not side effects — they shape who enters medicine, what specialties they choose and where they practice.
Depending on what you count (tuition and fees vs. total cost of attendance), published estimates put the cost of medical school alone well into the hundreds of thousands of dollars. For example, Kaplan’s summary of AAMC cost-of-attendance data shows four-year totals that vary widely by school type and geography. Other compilations estimate totals around $228,959 for the class of 2025, with higher projections in later years — often including undergraduate costs. The exact number matters less than the direction – debt pressure is real and growing.
Residency is where physicians become doctors in the practical sense. It is also a period defined by long work weeks and intense responsibility. The ACGME’s common requirements cap clinical and educational work hours at 80 hours per week averaged over four weeks, but anyone who has trained knows how easily intensity can exceed what the rule can capture.
At the same time, residents are paid a fixed stipend. The Medscape 2024 Resident Salary & Debt Report is commonly summarized as an average around $70,000 per year, varying by region and training year. That may sound reasonable until you price in the hours, the debt load and the opportunity cost of delaying full earnings for years.
Questioning standard practice
Here’s the uncomfortable question many clinicians quietly ask – why do we put some specialties through extremely long pipelines if the day-to-day practice environment increasingly pushes physicians into narrow lanes and redirects common problems elsewhere?
This isn’t a moral critique of specialists. It’s the logic of modern medicine – billing, risk, time constraints, complexity and institutional incentives that reward focus over breadth. But when you combine very long training pathways with debt burdens and narrow practice incentives, you get what patients experience as fragmentation – more handoffs, more “not my lane” and more work falling back to primary care.
The debate often collapses into a false choice: keep training exactly as it is or “dumb down” medicine. That’s not the real choice. The real choice is whether pathways are redesigned to reach competence more efficiently, using outcomes, competency-based progression and targeted training models that already exist.
Accelerated medical pathways are real. NYU Grossman’s three-year MD directed pathway is one example of a structured approach designed to shorten time-to-practice while maintaining performance expectations. And combined baccalaureate–MD programs compiled by the AAMC show that streamlined entry points are already part of the landscape in many states and program lengths.
How to achieve reform
A serious reform agenda could include:
Even if you disagree with specific proposals, the pressure is not theoretical. The AAMC’s physician workforce projections estimate the United States could face a shortage of as many as 86,000 physicians by 2036. The response can’t be simply asking more people to endure a longer, costlier, more debt-laden pathway, especially if the system then places them into roles where much of their training is underutilized.
Reforming U.S. medical education should not be framed as “making it easier.” It should be framed as making it smarter — more aligned to modern care, less financially punishing and better matched to the workforce the country needs.
If training can be shortened where it makes sense, the cost and debt burden can be reduced while preserving what matters most — clinical competence and patient safety.
Krishna Vedala, MD, MPH, MBA, FACHDM, Dipl. ABOM, CSPPM, CSPR, CSBI, FACP, is an internal medicine physician at Norman Regional’s Primary Care Moore clinic and specializes in weight management.