Medical Education and Health System in the United States

Medical education in the United States includes educational activities involved in the education and training of physicians in the country, with the overall process going from entry-level training efforts through to the continuing education of qualified specialists.

A typical outline of the medical education pathway is presented below. Medicine is a diverse profession with many options available. For example, some physicians work in pharmaceutical research, occupational medicine (within a company), public health medicine (working for the general health of a population in an area), or even join the armed forces in America. Others are primary care physicians in private practice and still others are employed by large health systems.

Issues in higher education in the U.S. have particular resonance in this context, with multiple analysts expressing concern about a physician shortage in the nation. Others say maldistribution is a bigger challenge, and medical deserts have been a topic of concern.

In the U.S., a medical school is an institution with the purpose of educating medical students in the field of medicine. Most medical schools require students to have already completed an undergraduate degree, although CUNY School of Medicine in New York is one of the few in the U.S. that integrates pre-med with medical school.

Once enrolled in a medical school, the usually four years of progressive study (sometimes three years or five years^[) is often divided into two components: pre-clinical (consisting of didactic courses in the basic sciences) and clinical (clerkships consisting of rotations through different wards of a teaching hospital).

Historically, these two parts were roughly equal, but the pre-clerkship phase has been getting shorter in recent years with the clinical phase becoming longer. Many schools have also created meaningful clinical roles for students, starting as early as the first year. This provides clinical context for the foundational concepts and is important in professional identity formation.

Inter-professional education (IPE) is becoming an increasingly important part of medical school. IPE entails students from health care disciplines studying together to enhance teamwork and teaming skills and improve patient care results. This method is especially pertinent as health care services are transitioning to a team oriented approach.

The degree granted at the conclusion of medical school is Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.) depending on the institution. Both degrees allow the holder to practice medicine after completing an accredited residency program.

Most U.S. medical students fund medical school themselves through a combination of personal and family resources and loans. A total of 73% of medical school graduates have education debt, with $200,000 being the average amount of debt.

This cost contributes to the lack of economic diversity among U.S. medical students with nearly a quarter of all medical students coming from families with incomes in the top 5% of the country. Half of all U.S. medical students come from families with incomes in the top quintile.

The various options to defray the costs of medical school include scholarships and service commitments (military or public service). Some medical schools also no longer charge tuition.

During the last year of medical school, students apply for residencies, also referred to as graduate medical education (GME), in their chosen field of specialization. These vary in competitiveness depending upon the desirability of the specialty, the prestige of the program, and the number of applicants relative to the number of available positions. All but a few positions are granted via a national computer match algorithm. This algorithm prioritizes the preferences of the applicant and pairs them with programs that also prefer them.

Residents are both trainees and employees of the health system hosting the GME program, and the amount of graduate medical education required for licensure as a physician who can practice independently varies by state.^[ A minimum of one year of graduate medical education is required in some states with many states requiring two years or more. International medical graduates may be subject to additional requirements.

In July 2015, the Accreditation Council for Graduate Medical Education, the American Osteopathic Association, and the American Association of Colleges of Osteopathic Medicine signed a memorandum of understanding to work toward a single accreditation system for residencies that would train MD and DO physicians. This process concluded in June 2020, and MD and DO students participate in a single match. The single match increased the match rates for graduates of osteopathic medical schools.

The Accreditation Council for Graduate Medical Education has established Common Program Requirements and a shared competency framework^[31] for all accredited residencies, although each specialty defines its own learning objectives and required experiences. Programs range from 3 years after medical school for internal medicine and pediatrics, to 5 years for general surgery, to 7 years for neurosurgery.^[32]

A fellowship is a formal, full-time training program that focuses on a particular area within the specialty, with requirements beyond the related residency. Many highly specialized fields require formal training beyond residency. Examples of these include cardiology, endocrinology, oncology after internal medicine; cardiothoracic anesthesiology after anesthesiology; cardiothoracic surgery, pediatric surgery, surgical oncology after general surgery; reproductive endocrinology/infertility, maternal-fetal medicine, gynecologic oncology after obstetrics/gynecology. There are many others for each field of study. In some specialties such as pathology and radiology, a majority of graduating residents go on to further their training.

The training programs for these fields are known as fellowships and their participants are fellows, to denote that they already have completed a residency and are board eligible or board certified in their basic specialty. Fellowships range in length from one to three years and are granted by application to the individual program or sub-specialty organizing board. Fellowships often contain a research component.

Physicians must pass exams in their specialty in order to become board certified. Some specialty boards also require logs of early practice experiences. Each of the 24 medical specialties has different requirements for practitioners to undertake continuing medical education activities.

Continuing medical education (CME) refers to educational activities designed for practicing physicians. Many states require physicians to earn a certain amount of CME credit in order to maintain their licenses. Physicians can receive CME credit from a variety of activities, including attending live events, publishing peer-reviewed articles, and completing online courses. The Accreditation Council for Continuing Medical Education (ACCME) determines what activities are eligible for CME.

There is a growing emphasis on diversity, equity and inclusion (DEI) in education. Tackling health inequities and providing care are vital aspects of medical instruction. Medical institutions are placing importance on DEI efforts, including attracting and supporting minority students integrating competence training and advocating for diversity, among faculty and leaders. These initiatives strive to establish a health care workforce that mirrors the patient communities it serves.

There is a growing emphasis on diversity, equity and inclusion (DEI) in education. Tackling health inequities and providing care are vital aspects of medical instruction. Medical institutions are placing importance on DEI efforts, including attracting and supporting students from historically minoritized communities, integrating competence training, and advocating for diversity among faculty and leaders. These initiatives strive to establish a health care workforce that mirrors the patient communities it serves.

In June 2023, the Supreme Court of the United States struck down the use of affirmative action in college admissions, including medical school.

In recognition of the exponential growth in medical knowledge, an increasing number of medical schools are incorporating the Master Adaptive Learner Model. This metacognitive approach to learning or “learning to learn” is based on self-regulation that fosters the development and use of adaptive expertise in practice. This concept emphasizes the importance of lifelong learning, self-regulation, and adaptability, enabling health professionals to provide high-quality care in an ever-changing environment.

In recognition of the increasing complexity of the health system, health systems science is becoming a more common part of medical education. Health systems science (HSS) is a foundational platform and framework for the study and understanding of how care is delivered, how health professionals work together to deliver that care, and how the health system can improve patient care and health care delivery.

Some medical schools integrate health systems science throughout all four years. Health systems science has also been integrated into graduate medical education and continuing professional development.

Health in the United States

The World Health Organization defines health as “a state of complete physical, mental and social well-being”. Average life expectancy at birth was 78.7 in 2017. Heart diseases are responsible for the greatest number of deaths in the United States.

All 50 states in the U.S. require immunization for children in order to enroll in public school, but various exemptions are available by state (such as for religious reasons). Immunizations are often compulsory for military enlistment in the United States.

It is estimated that one in five adults in the US lives with a mental health disorder, with 50% receiving treatment for their condition. Sexually transmitted infections impact the health of approximately 19 million yearly. The two most commonly reported infections include chlamydia and gonorrhea.

In the context of ensuring the continuation of medical services, concerns of a current and future shortage of medical doctors due to the supply and demand for physicians in the United States have come from multiple entities including professional bodies such as the American Medical Association (AMA), with the subject being analyzed as well by the American news media in publications such as Forbes, The Nation, and Newsweek. In the 2010s, a study released by the Association of American Medical Colleges (AAMC) titled The Complexities of Physician Supply and Demand: Projections From 2019 to 2034 specifically projected a shortage of between 37,800 and 124,000 individuals within the following two decades, approximately.

Sexually transmitted infections (STIs) remain a major public health challenge in the United States. CDC estimates that there are approximately 19 million new STIs yearly. The country experienced a reduction in reported STIs early in the COVID-19 pandemic, likely due to reduction in care devoted to them, but rates have rebounded in ensuing years. The two most commonly reported infections with 1.5 million total cases (2009) are chlamydia and gonorrhea. Adolescent girls (15–19 years of age) and young women (20–24 years of age) are especially affected by these two diseases.

Chlamydia remains the most commonly reported infection in the United States. There were more than 1.2 million cases of chlamydia (1,244,180) reported to CDC in 2009, the largest number of cases ever reported to CDC for any condition. The rate reached 1.6 million cases in 2020, which was actually a decrease from 2016.

There were 301,174 reported cases of gonorrhea in 2009 (10 percent less than in 2008), making gonorrhea the second most commonly reported infection in the U.S. In 2009, the gonorrhea rate for women was slightly higher than for men. By 2020, there were more than twice as many cases reported, about 678,000, a 45% increase from 2016.

In 2009, there were 13,997 reported cases of primary and secondary syphilis — the most infectious stages of the disease — the highest number of cases since 1995 and an increase over 2007 (11,466 cases). The number of cases was ten times the 2009 figure by 2020, about 134,000, more than a 50% increase from 2016. According to a report from the Centers for Disease Control and Prevention on April 11, 2023, syphilis is now at a rate not seen since the 1950s, increasing by about 30 percent between 2020 and 2021, a big jump from syphilis rates recorded in the early 2000s, where only about 30,000 cases were recorded each year.

• Foodborne illness outbreaks in the United States

The Advisory Committee on Immunization Practices makes scientific recommendations which are generally followed by the federal government, state governments, and private health insurance companies.

All 50 states in the U.S. mandate immunizations for children in order to enroll in public school, but various exemptions are available depending on the state. All states have exemptions for people who have medical contraindications to vaccines, and all states except for California, Maine, Mississippi, New York, and West Virginia allow religious exemptions, while sixteen states allow parents to cite personal, conscientious, philosophical, or other objections. An increasing number of parents are using religious and philosophical exemptions; researchers have cited this increased use of exemptions as contributing to loss of herd immunity within these communities, and hence an increasing number of disease outbreaks.

The American Academy of Pediatrics (AAP) advises physicians to respect the refusal of parents to vaccinate their child after adequate discussion, unless the child is put at significant risk of harm (e.g., during an epidemic, or after a deep and contaminated puncture wound). Under such circumstances, the AAP states that parental refusal of immunization constitutes a form of medical neglect and should be reported to state child protective services agencies.

Immunizations are often compulsory for military enlistment in the U.S.

All vaccines recommended by the U.S. government for its citizens are required for green card applicants.^[25] This requirement stirred controversy when it was applied to the HPV vaccine in July 2008 because of the cost of the vaccine, and because the other thirteen required vaccines prevent diseases which are spread by a respiratory route and are considered highly contagious, while HPV is only spread through sexual contact.^[26] In November 2009, this requirement was canceled.^[27]

The United States has a long history of school vaccination requirements. The first school vaccination requirement was enacted in the 1850s in Massachusetts to prevent the spread of smallpox. The school vaccination requirement was put in place after the compulsory school attendance law caused a rapid increase in the number of children in public schools, increasing the risk of smallpox outbreaks.

The early movement towards school vaccination laws began at the local level including counties, cities, and boards of education. By 1827, Boston had become the first city to mandate that all children entering public schools show proof of vaccination.

In addition, in 1855 the Commonwealth of Massachusetts had established its own statewide vaccination requirements for all students entering school; this influenced other states to implement similar statewide vaccination laws in schools as seen in New York in 1862, Connecticut in 1872, Pennsylvania in 1895, and later the Midwest, South and Western US. By 1963, 20 states had school vaccination laws.

These school vaccination resulted in political debates throughout the United States, as those opposed to vaccination sought to overturn local policies and state laws. An example of this political controversy occurred in 1893 in Chicago, where less than 10 percent of the children were vaccinated despite the twelve-year-old state law. Resistance was seen at the local level of the school district as some local school boards and superintendents opposed the state vaccination laws, leading the state board health inspectors to examine vaccination policies in schools.

Resistance proceeded during the mid-1900s and in 1977 a nationwide Childhood Immunization Initiative was developed with the goal of increasing vaccination rates among children to 90% by 1979. During the two-year period of observation, the initiative reviewed the immunization records of more than 28 million children and vaccinated children who had not received the recommended vaccines.

In 1922 the constitutionality of childhood vaccination was examined in the Supreme Court case Zucht v. King. The court decided that a school could deny admission to children who failed to provide a certification of vaccination for the protection of the public health. In 1987, a measles epidemic occurred in Maricopa County, Arizona, and another court case, Maricopa County Health Department vs.

Harmon, examined the arguments of an individual’s right to education over the state’s need to protect against the spread of disease. The court decided that it is prudent to take action to combat the spread of disease by denying un-vaccinated children a place in school until the risk for the spread of measles has passed.

Schools in the United States require an updated immunization record for all incoming and returning students. While all states require an immunization record, this does not mean that all students must get vaccinated. Opt-out criteria are determined at a state level. In the United States, opt-outs take one of three forms: medical, in which a vaccine is contraindicated due to a component ingredient allergy or existing medical condition; religious; and personal philosophical opposition.

As of 2019, 46 states allow religious exemptions, with some states requiring proof of religious membership. Only Mississippi, West Virginia, California and New York do not permit religious exemptions. 18 states allow personal or philosophical opposition to vaccination.

Over the last decade vaccination rates have been declining in the United States. Although the rate is fairly limited on a larger scale, vaccine-preventable disease outbreaks are occurring in pockets across the U.S. “In 2012, exemption rates ranged from a low of approximately 0.45 percent in New Mexico, to a high of 6.5 percent in Oregon.

The outbreaks have significant correlations with unvaccinated children, and state policy exemption processes. California, which is currently in the process of changing its state exemption policies, dealt with a 2015 measles outbreak stemming from the popular Disneyland park. Significantly, most of the afflicted were unvaccinated, which eventually spread to over 17 separate states across the U.S.

In 1790, people over the age of 65 were less than 2% of the American population. In 2017, they were about 14%.

Climate change continues to affect every country in the world and the United States is no exception. In the U.S. the average temperature has increased between 1.3°F – 1.9°F since record keeping began in 1895, with most of the increase having occurred since about 1970. Additionally, hurricanes and winter storms have increased in both intensity and frequency and the length of the frost-free season has been increasing nationally since the 1980s, affecting ecosystems and agriculture.

Climate change and climate variability has many potential effects on the health of Americans. It can exacerbate existing health threats or create new public health challenges through a variety of pathways. Although all Americans will face some health effect from climate change, certain individuals are more vulnerable than others due to levels of exposure, sensitivity, and ability to adapt (See Table).

Determinants of Vulnerability of Human Health to Climate Change

Determinant	Definition	Example
Exposure	The degree to which an individual is susceptible to contact with a stressor induced by climate change.	A family in a low-income NYC neighborhood may not be able to afford air conditioning and therefore be more likely to die of heat stroke.
Sensitivity	The degree to which the individual could be harmed by the exposure.	A child with asthma is more susceptible to negative health effects from poor air quality than his classmates.
Ability to Adapt	The degree to which the individual can adjust and respond to a harmful situation caused by the exposure.	Someone with a physical disability may have a tougher time evacuating during a storm warning.

The Center for Disease Control (CDC) has identified nine national health topics relating to climate change.^[38]

1. Air pollution

Ground-level ozone (a key component of smog) is associated with multiple health problems. Examples include diminished lung function, increased hospital admissions and emergency room visits for asthma, and increases in premature deaths. Health-related costs of the current effects of ozone air pollution exceeding national standards have been estimated at $6.5 billion (in 2008 U.S. dollars) nationwide, based on a U.S. assessment of health impacts from ozone levels during 2000–2002.

2. Allergens and pollen

Climate change will potentially lead to shifts in precipitation patterns, more frost-free days, warmer seasonal air temperatures, and more carbon dioxide (CO2) in the atmosphere. These occurrences will lead to both higher pollen concentrations and longer pollen seasons, causing more people to suffer more health effects from pollen and other allergens. In a recent study looking at pollen metrics from 60 metric stations in North America between 1990 and 2018 scientists found that pollen seasons were starting up to 20 days earlier and lasting for up to eight days longer.

3. Diseases carried by vectors

Within the United States the impact of climate change from domestically acquiring diseases is uncertain due to vector-control efforts and lifestyle factors, such as time spent indoors, that reduce human-insect contact. However, the impact on the geographical distribution and incidence of vector-borne diseases in other countries where these diseases are already found can still impact Americans, especially due to travel and trade.

4. Food and waterborne diarrhea

Diarrheal diseases are more common when temperatures are higher, although location and pathogen can also affect the pattern. Extremely high and low precipitation has also been linked to an increased frequency in the occurrence of diarrheal diseases. Additionally, sporadic increases in stream flow rates, often followed by rapid snowmelt and changes in water treatment, have also been linked outbreaks. Risks of waterborne illness and beach closures resulting from changes in the magnitude of recent precipitation (within the previous 24 hours) and in lake temperature, are expected to increase in the Great Lakes region because of climate change. In the United States, those who are exposed to inadequately or untreated groundwater are most likely to be affected. Additionally, children and the elderly are most vulnerable to serious outcomes.

5. Food security

Food production, quality, distribution, and prices can all be affected by climate change. Not only are crops affected by changes in rainfall and extreme weather, but livestock and fish are also being impacted. The related health effects will vary. Due to rising prices, poor persons will turn to “nutrient-poor but calorie-rich foods and/or they endure hunger, with consequences ranging from micronutrient malnutrition to obesity.” Additionally, nutritional quality will be impacted because “elevated atmospheric CO2 is associated with decreased plant nitrogen concentration, and therefore decreased protein, in many crops, such as barley, sorghum, and soy. The nutrient content of crops is also projected to decline if soil nitrogen levels are suboptimal, with reduced levels of nutrients such as calcium, iron, zinc, vitamins, and sugars. This effect can be alleviated if sufficient nitrogen is supplied.”

6. Mental health and stress related disorders

Extreme weather and high temperatures can affect mental health in a variety of ways for both individuals with, and without preexisting mental health conditions. Additionally, the symptoms can be short-term or long lasting.^[44] For example, studies done after Hurricane Katrina hit the United States Gulf Coast showed that children affected by the hurricane have found high rates of depression, anxiety, behavioral problems and post- traumatic stress disorder (PTSD).

7. Precipitation extremes

The United States has seen an increase in the frequency of heavy precipitation events, and the upward trend is supposed to continue throughout the different regions of the country. These events such as floods and droughts present immediate risks to the health of Americans during the occurrence but can also affect health in the period following the catastrophe. For example, flooding can cause water damage to buildings leading to mold or need for demolition. These events can necessitate the forceful relocation of an entire family which may be distancing them from schools, primary doctors and other resources that they may have gotten used to.

8. Temperature extremes

Increasing concentrations of greenhouse gases lead to an increase of both average and extreme temperatures. This is expected to lead to an increase in deaths and illness from heat and a potential decrease in deaths from cold. Days that are hotter than the average seasonal temperature in the summer or colder than the average seasonal temperature in the winter cause increased levels of illness and death by compromising the body’s ability to regulate its temperature or by inducing direct or indirect health complications.

Loss of internal temperature control can result in a cascade of illnesses, including heat cramps, heat exhaustion, heatstroke, and hyperthermia in the presence of extreme heat, and hypothermia and frostbite in the presence of extreme cold. Temperature extremes can also worsen chronic conditions such as cardiovascular disease, respiratory disease, cerebrovascular disease, and diabetes-related conditions. Prolonged exposure to high temperatures is associated with increased hospital admissions for cardiovascular, kidney, and respiratory disorders.

9. Wildfires

In 2021 we have seen an increase in the news and social media coverage about wildfires spreading throughout California as shown in the image at the end of the section. No doubt, one of the many effects of climate change, these wildfires have many harmful (short and long term) effects on the health of Americans. Not only do many people lose their homes, livelihoods and even lives in these fires, but smoke exposure has many negative effects on physical health as well. It increases respiratory and cardiovascular hospitalizations; emergency department visits; medication dispensations for asthma, bronchitis, chest pain, chronic obstructive pulmonary disease, and respiratory infections; and medical visits for lung illnesses.