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INTRODUCTION

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America's medical education system is generally viewed as the best in the world. Despite the decline in physician salaries over the past 10 years1 and a corresponding increase in the bureaucratic oversight of health-care delivery, many of the brightest students in the world compete for the opportunity to enroll in one of America's 129 medical schools, with an average of two to three applicants for each of the 15,000 to 16,000 available seats.2 After investing four years to earn their medical degrees, these newly minted physicians move on to three to five additional years of residency training, where 24,000 positions await them.3 Those seeking careers as specialists then undergo one to five additional years of training in a fellowship.

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The graduates of this remarkable system of medical education comprise a group of highly trained, highly motivated individuals eager to deliver the best care possible. Counting college, tomorrow's doctors will have spent 10 to 18 of the most productive years of their lives just training for their careers. Will those careers be what they've hoped for? Many finish this training with well over $100,000 in debt.4 Will their income give them an appropriate return for this investment?

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Our medical schools have inspiring missions, seeking to train "people committed to leadership in alleviating human suffering caused by disease."5 But it is an expensive vision—and not just for students. In 2007 the Centers for Medicare and Medicaid Services alone spent $8 billion on Graduate Medical Education.6 Is society getting an appropriate return on this investment?

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We fear that society at large, and tomorrow's doctors in particular, will be disappointed. The basic architecture of our medical schools' curriculum was designed nearly 100 years ago. The content of the building blocks within this architecture has changed substantially, of course, but the fundamental design of the experience is a century old. The result of our medical schools being stuck in this rut is that it takes much longer to educate tomorrow's doctors than other curricular architectures would require. And despite the time and cost invested, some of our best medical providers find that new doctors still are not ready to work, needing as much as two additional years of on-the-job training before they can practice profitably within their systems.7

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Our medical schools face two crises. The first relates to what the model of disruption terms the sustaining trajectory of performance improvement—helping the existing system perform better, according to the measures of goodness broadly accepted among the existing schools. The need to improve the existing system is vast and urgent. New models of teaching, such as those that employ medical simulators, are needed to ensure that our schools continue to train the best possible physicians. The second crisis is disruption—competitors that are or will be disrupting our medical schools from four directions: foreign medical schools; alternative medical training such as ...

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