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The Non-Inferiority Complex in Medicine

“You know, the globus pallidus.”  My coaxing words ripened in the air between us.  Josh admitted it sounded familiar, but couldn’t quite remember the time or the place.  This concerned me, because my friend was a highly accomplished emergency physician, yet he wrinkled his nose at “globus pallidus” like it was a piece of decomposing fruit. “It’s in the brain,” I said helpfully.

He smiled, “That’s probably why it sounds familiar.”

A few hours before, my neuroanatomy group had held in our hands several axial sections of brain, that great throne of our being.  Every structure seemed essential, every discovery a Christening of my soul.  And among them, the globus pallidus, an important-looking triangle of grey matter wedged between the putamen and internal capsule.  I swore I would remember it.  I would remember it forever.  But here was Josh, sitting across from me with his casual disregard.  “It’s not that important.  You might have to remember it if you go into neuro.”

This was the most recent in a series of conversations I had with various physicians about my medical school subject of the week.  The pulmonologist couldn’t really remember the branches of the facial nerves.  The cardiologist didn’t know Sonic Hedgehog was an embryological ventralizing factor.  The urologist only vaguely recalled vitamin B12 having something to do with nucleotide synthesis.  It seemed there were huge swathes of data that would apparently be lost sometime between medical school and the day when I finally became full-fledged physician.  Why was I learning this soon-to-be-forgotten material?  Was there really no way to differentiate between the essentials and what seemed to be pork barrel curriculum?

Medical education strives for excellence.  It learns from its mistakes, engaging in a perpetual cycle of reinvention and improvement to give us advances like systems-based education, early clinical hours, and improved training in patient communication.  It wants to make each successive generation of doctors better than the last, pushing us to new heights of medical expertise.  Quite simply, medical education has a superiority complex.  And yet, the current medical school rubric is a relic of the late nineteenth century, requiring a college degree, four years of medical education, an intern year, and residency, meaning that every new, shiny improvement is still packaged into the same, old box.  It means that, while medical research and technology are advancing at near asymptotic speed, educators scramble to fit everything into the four years of medical school like a hastily-packed suitcase.  The real question, however, is not how to continue improving medical school education, it is whether we need to.  In his book “Outliers,” Malcolm Gladwell posits that superiority does not equal achievement; one must merely be good enough to seek out success.  Maybe medical schools don’t need to invest the time, money, and effort to educate better doctors when they can just educate doctors who are “good enough.”  Maybe what medical education really needs is a non‑inferiority complex.

The concept of non-inferiority is well-known in the clinical trial realm.  A non-inferior treatment is one that is “not unacceptably worse” than the current standard of care or an appropriate comparator.  It is an odd collection of words, often pejoratively disregarded much as you would dismiss a movie that “wasn’t terrible” or a meal that “could have been better.”  After all, why would we want to treat patients with something that, while not being unacceptably worse, is still worse?  But this question misses the point of non-inferiority.  The idea is that a non-inferior treatment confers some other appreciable benefit that makes it not only an acceptable option, but a more attractive one.  A non-inferior drug, for example, might offer a better safety profile, a simplified treatment regimen, or a lower cost.  A non-inferior movie might offer exciting action scenes; a non‑inferior meal may be blessed with a good selection of beer.

Non-inferiority has three components: the customer; a core value that must be maintained at an acceptable standard; and an accessory value, which, when combined with the core value, increases the overall attractiveness of the product.  We, the medical students, are the obvious consumers of medical education, with a certain level of expertise in scientific knowledge and clinical skill being our core value.  The accessory value is more plastic, but many, if not most, students would accept a non-inferior education if it were one of two things — cheaper or shorter.

Medical school is an undeniably hefty investment.  Tuition alone exceeds $53,000 per annum and, all told, those four years leave student credit reports with an average scar of $169,901, while an unlucky minority rack up debts in excess of $250,000.  It is a time of low, if any, income, without any of the benefits that one would receive had he or she decided to join the workforce, such as bonuses and retirement.  While options like the armed forces Health Professional Scholarship Program and the National Health Service Corp scholarship program provide full-ride opportunities, the necessary years of service and stringent requirements do not align with the career goals of many students.  And still, tuition rises faster than inflation, year-over-year adding weight to the already immense burden incurred by us medical students, this temporarily penniless population.  Popular sentiment suggests we stop complaining because we will be part of that rarified medical class, and our loans will eventually be paid.  This argument is meant to be consoling, but it really just drives us towards higher paying specialties, and makes our loans everyone’s problem.

Despite the ever worsening shortage of primary care physicians in the United States, medical students are not adequately incentivized to pursue primary care as a career.  Whether we have chosen medicine for personal fulfillment or to serve the greater good, upon graduation, the more immediate concern is often the amount of money we owe.  Indeed, who among us would not argue that we deserve to be paid x dollars because we invested y into our education?  Should we really walk around with $169,901 dollars of crushing debt and not feel at least a little entitled to proper compensation?  It’s simple arithmetic.  The obvious solution is to remove cost as a factor, even if that means taking a pay cut as a newly-minted MD or DO and a graceful entry into the middle class.  Perhaps students could work as dedicated employees of their alma mater’s practice program for enough years to pay back the cost of their education, similar to how private companies subsidize employee education in return for a block of dedicated service years.  Loan-free students would be empowered to pursue more fulfilling personal goals, rather than pushing themselves towards lucrative specialties out of fear.  And, in fact, this is the exact experience of student doctors in other parts of the world.

Ireland has a well-regarded system of medical education, with a half-dozen medical schools offering a variety of programs ranging from four to six years.  The popular Atlantic Bridge program even affords prospective North American students the opportunity to study medicine in Ireland, and its graduates consistently match into top tier residencies.  And for citizens of the European Union, an Irish medical education is tuition free, with this revenue instead coming from non-European Union attendees, of which there are plenty.  Obviously, European doctors graduating from these schools are not paid as well as their US counterparts, but they also experience the freedom afforded by zero debt.  In fact, Ireland has so many general practitioners that 97 percent of patients can be seen without an appointment or within 24 hours.  If Massachusetts is any indication of where we are heading with the Affordable Care Act, patients may be waiting nearly six weeks for a family practitioner appointment.

For many years, United States medical schools have focused on enhancing education, thus driving up costs and necessitating increased tuition to maintain profitability.  But typically, businesses strive to decrease costs, for example, by improving manufacturing processes or choosing alternative raw materials.  This is why we can finally buy a flat screen TV for under a thousand dollars and why personal care companies employ entire divisions to reformulate a line of shampoo.  There is always a faster, cheaper way to do things, while still producing, at the very least, a non-inferior product.  How is it then, that with over 100 years of experience in manufacturing doctors, we haven’t figured out how to make the same product for less money?  Schools continue to push increasingly comprehensive and expensive curricula, when they should be focusing on eliminating unnecessary classes, lectures, and factoids.  Are better doctors made by sheer inertia, and the assumption that providing sufficient educational mass will propel us into our medical careers?  I would argue they are not, and schools should instead focus on stripping education down to the essentials and choosing the right investment tools — those students who are good enough to find success on their own.

The other, albeit intimately related, path for enabling a non-inferior education is decreasing the overall length of medical school.  Institutions such as New York University have already stepped down this road with an optional three-year track that is “identical to the core curriculum of the four-year pathway.”  One less year of education means one less year of tuition, one less year of interest accrual, and, yes, one less year of education.  A 2012 paper by Ezekiel Emmanuel and Victor Fuchs, however, estimated that medical school could be reduced by as much as 30 percent with little to no decrease in ultimate physician skill or quality of patient care.  They note that “the ideal physician has been the triple threat: an incisive diagnostician and empathetic clinician, a productive researcher, and a scintillating teacher,” resulting in an ever more expansive training regimen.  Meanwhile, there is no evidence that students enrolled in reduced training programs do any worse on standardized tests than their four-year counterparts.  Essentially, Emmanuel and Fuchs suggest that healthcare has become a team effort, as opposed to an individual endeavor.  Much like the transition of major league pitcher from complete game warriors to a complement of highly specialized starters, relievers, and closers, doctors no longer need to do everything or do it alone.  So why are we still being trained that way?  It is not cramming our heads with facts that makes us better clinicians, it is being incisive about which facts to choose.

Very often, doctors are seen as a font of all medical knowledge, able to pluck esoteric medical facts from their encyclopedic brains.  They are seen as kings, rather than jacks of all trades.  It is why people ask their urologist about how much fat they should eat or discuss a recent divorce with their pulmonologist.  Obviously, cutting education means that we may not learn the ins and outs of cutting edge stem cell technology or have the ability to identify every bit of the human body with a microscope and an H&E stain.  We will not have all the answers, but we were never going to have them all anyway.  How many psychiatrists know the ins and outs of how to perform a TURP procedure?  How many ER physicians actually remember what the globus pallidus is?  With a shorter education, we might not be the best at everything, but at least we would be not unacceptably worse.

Of course, decreasing tuition and shortening medical school may be a boon for medical students, but for schools, it might mean sacrifice.  It might mean simplifying the pre-clinical curriculum to focus on the USMLE requirements and eliminating non-value-added classes.  It might mean cutting faculty, an obvious problem in the convoluted political hierarchy of higher education.  It might mean relying more on self-study and distance-learning rather than in-person instruction and printed handouts, a strategy already being embraced by many institutions.  It might mean holding onto old facilities, rather than investing in renovation or new construction.  And it might take a bit of humility for a school to say, “We’ll give you the tools to be a not unacceptably worse physician.”  Because with a non-inferior education, greatness would be left up to us.

Daniel Coleman Daniel Coleman (5 Posts)

Medical Student Editor

Georgetown University School of Medicine

Daniel graduated from Tufts University in 2004. His subsequent pursuits included everything from cell cycle research to manufacturing shampoo. Medically, his interests lie in emergency and wilderness medicine, infectious disease, and health care sustainability. Daniel is medical student at the Georgetown University School of Medicine, Class of 2017.