A reader of “Why you should become a nurse or physicians assistant instead of a doctor: the underrated perils of medical school,” asks, though not quite in this way, what a better doctor education system would look like. It’s surprising that it’s taken so long and so many readers for someone to ask, but before I answer, let me say that, while the question is important, I don’t expect to see improvement. That’s because current, credentialed doctors are highly invested in the system and want to keep barriers to entry high—which in turn helps keep salaries up. In addition, there are still many people trying to enter med school, so the supply of prospective applicants props the system up. Meanwhile, people who notice high wages in medicine but who also notice how crazy the med school system is can turn to PA or NP school as reasonable alternatives. With so little pressure on the system and so many stakeholders invested, why change?

That being said, the question is intellectually interesting if useless in practice, so let’s list some possibilities:

1. Roll med school into undergrad. Do two years of gen eds, then start med school. Even assuming med school needs to be four years (it probably doesn’t), that would slice two years of high-cost education off the total bill.

2. Allow med students, or for that matter anyone, to “challenge the test.” If you learn anatomy on your own and with Youtube, take the test and then you don’t have take three to six (expensive) weeks of mind-numbing lecture courses. Telling students, “You can spent $4,000 on courses or learn it yourself and then take a $150 test” will likely have… unusual outcomes, compared to what professors claim students need.

3. Align curriculums with what doctors actually do. Biochem is a great subject that few specialties actually use. Require those specialties to know biochem. Don’t mandate biochem for family docs, ER, etc.

4. Allow competition among residencies—that is, allow residents to switch on, say, a month-by-month basis, like a real job market.

There are probably others, but these are some of the lowest-hanging fruit. We’re also not likely to see many of these changes for the reason mentioned above—lots of people have a financial stake in the status quo—but also because so much of school is about signaling, not learning. The system works sub-optimally, but it also works “well enough.” Since the present system is good enough and the current medical cartel likes things as they are, it’s up to uncredentialed outsiders like me to observe possible changes that’ll never be implemented by insiders.

I wrote “Why you should become a nurse or physicians assistant instead of a doctor: the underrated perils of medical school” five years ago and in that time we’ve seen zero changes at the macro level. Some individuals have likely not screwed up their lives via med school, and some of them have left comments or sent me emails saying as much, and that’s great. But it’s not been sufficient to generate systems change.