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Sunday, May 27, 2012

Legal versus Medical Education and some blatant 'crowdsourcing'

In many posts on the state of legal education and the legal profession (on this blog and others) I've seen repeated references to medical education. While I imagine that there exist certain "apples and oranges" aspects to this comparison, it is intriguing. However, I am going to state something that I think might apply to a lot of people - that is, while I have a vague notion of what occurs in medical education (from TV and movies), I feel that I don't really know enough about it to make proper comparisons to legal education (something on which I have experience from both sides of the podium).

Therefore, my purpose here is to blatently 'crowdsource' this information. I have a few questions (ok, a lot of questions) posted below for folks who have experiences with medical education (preferably first-hand, but second-hand is ok too). In the best case scenario we might get some JD/MDs to weigh in on this matter.

If there is any interest, I'd be happy to share my comparative experiences as a new lawyer vs. political science PhD grad (and perhaps fellow guest prawfs blogger Bob Howard can chime in on this)  - although there may not be a great market for that discussion  ;-)


1) How difficult is it to get into medical school? (gpa, % test scores, etc.)

2) How much does it cost to go to medical school? (per yer tuition for private/public; how many years do you pay full tuition, etc.)

3) Um, what happens in class? 1st year, 2nd year, 3rd year, etc.? How are you tested/graded? Is it very competitive (e.g. backbiting) or is it 'everyone's a winner'?

4) What are faculty teaching loads? How are they evaluated for rank/tenure (research; teaching evaluations) ? Are rank and tenure the same as in law and/or other fields (e.g. assistant, associate, full)? How are faculty recruited? What is faculty worklife like? Do they make significantly less than non-faculty doctors?

5) How important are grades for medical students in getting jobs? Is there a significant split (as there seems to be in law) between the salaries for the top 15% of the class (or top 15 law school) and the rest? What else matters?

6) How much do doctors make after they begin private practice? Five years out? Ten years out? Is there a large gap between pay for rural vs. urban areas?  (Related to question #3 please discuss salaries during the residency years - this question is about after all of that)

7) How mobile are medical degrees/licenses? How difficult is it to start a practice in another state?

8) How hard is it to get a job as a doctor as a new graduate?


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Medicine and law emerged in the early decades of the twentieth century as tough, extremely organized professions with high status, escalating rewards, and rising autonomy. Professional claims of mysterious knowledge, collegial solidarity, and impartiality were established by members of the profession and the general public. Professional schools in both disciplines copied university connections and achieved principal positions in the preparation of new professionals. Patterns of medical and legal education recognized during this influential period.

Since then, the institution and activities of doctors and lawyers have altered markedly under the influence of improved specialization, increasing bureaucratization, and extended competition. Each profession is haunted by fears that fragmentation, commercialism, and excessive competition will undermine traditional professional values such as autonomy.

Despite these comparisons, educators in the two professions have proceeded in isolation from one another. There has been little understanding or deliberation by those in one profession of developments in the other. Little effort has been made to evaluate the two fields of professional education and to ask whether each could gain knowledge from the experience of the other. It begins with a summary of determined the differences in medical and legal education, examines and attempts to clarify some common failings, and concludes with some timid comments on what medical education might study from legal education.

Posted by: James Martin | Aug 16, 2012 9:08:17 AM


The obvious authority for this is Barbara Starfield, who devoted most of her career to the point. Seiyu Shi's work on this is also good, as is Stephen Kunitz.

That's not to overstate the point: even an utopian model of health care services pales in comparison to the effects of income and education on health and its distribution, but the extent of the contribution is up to 2.5 times bigger for a robust primary-care driven model than for a specialty/sick care model.

Feel free to email me if you'd care to discuss this more; I'm in the book (i.e., Google).

Posted by: Daniel S. Goldberg | May 30, 2012 2:41:06 PM

Further to the point above that med school costs more because it is four years, med students also don't have the same lucrative bourgeoisie law firm summer positions that are available to some law students, and which definitely make a nice dent in the student loans.

Posted by: anon | May 29, 2012 8:26:54 AM

From my experience in medical school (a bit dated, i.e., late 90s -- early 2000s).

1) Getting in is hard. Not only do you need pre-med curriculum, but there are also interviews. So a high GPA/MCAT in and of themselves are not enough. There are also "fads." At some point, med schools sought "more mature" people, i.e., ones who did more than just college. They also looked at "diversity." Not in the racial/ethnic/gender sense (though that too), but in the "what's your major" sense. My class had ballerinas, opera singers, religion majors, a lawyer, and other "non-traditional" candidates in addition to the usual bio/chem/science majors.

2) Tuition at private med schools is on par with tuition in private law schools. Except it takes 4, rather than 3 years. It is not unusual for someone to graduate with 200-250K in debt.

3) That varies. Some schools take a traditional approach with lectures during the first 2 years and courses being somewhat free-standing (Biochemistry, Pharmacology, Anatomy, Pathology, etc.) Other schools take a more "problem-based/case-based" approach. They present a case to students and then discuss the anatomical, biochemical, pathological and other issues that appear in that case. In terms of grading, most schools go with P/F, but some (notably Hopkins) retain grades. Ultimately, your chances of securing a good residency most likely rest not on your grades, but on your Board scores.

In 3rd and 4th years, you are on the wards shadowing doctors and learning by doing. The amount of "doing" you get to do depends both on your preceptor and the hospital (even within the same medical school). My medical school had 4 associated hospitals. You got most hands-on experience in the poorest hospitals (like County) and least hands-on experience in the richest academic centers. Conversely, the amount of didactic lectures was highest in academic centers and lowest in places like county hospitals.

4) That I don't know for a fact. In my med school, the 1st and 2nd year faculty were similar to undergrad faculty who taught, say, organic chemistry. Teaching was a small part of their lives that centered mostly around research. I imagine they were paid based on their research and not their teaching. With respect to 3rd and 4th year, most teaching was done by doctors who already worked in these hospitals. Teaching medical students and residents was kind of part of the deal of being a doctor in a teaching hospital. As it happens, usually doctors are paid less in academic centers than in private hospitals (despite having teaching responsibilities).

5) Grades, to the extent they exist may be important. But given that most schools have done away with grades, what's important is the Boards (USMLE) score. Th is what determines whether you will get into a competitive residency. There are really no differences in salary between residents (irrespective of specialty). Of course, differences appear once residency is over. So dermatologists generally make more than pediatricians (and it is much harder to get the former residency). But the differences don't appear for 3-5 years.

6)Very much depends on the specialty and whether you are in private practice or academic practice. There is a big rural to urban gap, but sometimes in an unexpected direction. For example, some rural areas that are short on radiologists, often offer nearly twice as much as what NYC would pay with double vacation. The same may not be true with internists or pediatricians. Also, what is a "hot" specialty varies. For instance, about 20 years ago, no one wanted to go into radiology. Then, starting 15 years ago, it became impossible to get into. Now, it again slid from the top choice. Salaries in specialties vary according to the "hottness" of the specialty.
7) Licenses are essentially transferable. The USMLE (boards) are uniform throughout the country. So once you pass, you are done. You have to do the paperwork (which may be onerous) but that is pretty much it. Indeed, there are some doctors (specifically radiologists) who have licenses in all or nearly all states, because they do tele-medicine, and therefore need to be licensed in every state where work is coming from.
There may be some small quirks that differ between states which may make licensure difficult for some candidates (e.g., some states may restrict the amount of attempts to pass the USMLE or the number of years between beginning and completing the USMLE series (there are 4 exams)), but generally that affects very few candidates.
8) I have never seen an unemployed doctor. At least not one with a degree from a US medical school.

Posted by: DrGrishka | May 29, 2012 1:16:00 AM

A few observations concerning the above information (thanks, btw) and comparisons to legal education and practice:

1) It appears to be a good bit harder to get into medical school - no doubt this is in part due to the expansion of law schools relative to med schools. It also appears to be very expensive - if this is 4 years of tuition? - but not massively more expensive.
2) It appears to be much more work than law school. Frankly, (& I'll pay for this) if one wants to just graduate from most law schools (as opposed to graduating at a certain rank) then it simply isn't that hard (relative to other professional endeavors) - hold on, dont throw things yet - keep in mind that I am saying this about *law school* and not the other responsibilities (e.g. home responsibilities or part time work) that one might have - that's a different matter. From what Jeff Lipshaw suggests, it seems that medical school would make part time work much more difficult to handle than it is in law school.
3)Law school and medical school faculty comparisons are somewhat difficult - different animals in many ways. Perhaps there is a better comparison group.
4)Medical salary outcomes vary considerably but start at the low end toward the high end of law salaries at entry level. Of course there are reasons for this ... Also, grades appear to matter, but not as much ... job opportunities are better

So, with this in mind - and I'm certainly amenable to correction on any of these summary points - what can we say about using medical school as a template for assessing law school education reform?

One final point/question - I know that law school attrition is pretty low relative to graduate school - I'm wondering how it compares with medical school and what role attrition has in assessing professional programs. My personal opinion is that in graduate programs - where it's more prevalent - it serves to sort people out (sometimes good and sometimes bad, to be fair) and that this addresses market oversupply (to a degree).

Posted by: Jeff Yates | May 28, 2012 4:07:59 PM

oops should have been "health outcomes" at the end.

Posted by: TomH | May 28, 2012 3:16:22 PM

I guess I need to take a look at your stuff. I'd be very interested in evidence that different health care delivery systems have differential effects on health. I'm not aware of any such evidence, but perhaps you can point me to it.

Best I can tell, most of the superiority of other countries population level health statistics to the US have to do with non-health care related characteristics of those other countries. And a few areas of US superiority (e.g. survival in the 9th decade of life) likely do connect to the US health care system.

For me, the minor effect of health care on health suggests that in so far as we're interested in health, we ought to spend on public health and behavior change rather than on health care. But, of course, health care is something people tend to want. And the rationale for spending on it has little to do with health care outcomes.

Interesting, the notion of health inequities. Deep waters, there.

Posted by: TomH | May 28, 2012 3:13:56 PM


My work in public health ethics actually centers on the social determinants of health and structural determinants, inequities, etc.. Thus, the idea that the delivery of health care services is actually only a minor determinant of health and its distribution is a point of departure for my work.

That said, the evidence also suggests that some models of health care services exert greater effects on health outcomes than others, in no small part because they eschew the sick care model that dominates American health. So, if we are going to pay any attention to health care at all, we ought to go for those models that exert larger effects on health and that promise to compress rather than expand health inequities (NOT health care inequities -- those are different for the same reason health is different to health care).

The evidence is very good that such a model is a primary-care driven model, IMO. That's really all I was referring to here.

The idea that we should focus on health rather than health care is literally the central aspect of my scholarship and research in public health ethics, so thanks for bringing it up here.

Posted by: Daniel S. Goldberg | May 28, 2012 2:57:25 PM

Howard, thanks. The issue of theory and practice in professional training continues to fascinate me, and I now recall it was your med school friend's anecdote about being on a plane in an medical emergency that caused me to talk about the subject with my son. I did write about it. Here is the URL: http://lawprofessors.typepad.com/legalwhiteboard/2012/03/lessons-from-med-school.html. I'm not here to defend medical education's many flaws, but only to say it's a far more intense experience than law school.

I posted again at The Legal Whiteboard a couple days ago about Donald Schön's great work, "The Reflective Practitioner." http://lawprofessors.typepad.com/legalwhiteboard/2012/05/mild-epiphanies-while-re-reading-the-reflective-practitioner.html. To pile on Daniel Goldberg's comments, I think there's something to be said about Schön's distinction between scholarly problem-solving and professional problem setting, particularly as it relates to general practice of any kind (including law or medicine) versus specialization. One of our friends here in Cambridge is an internist at MGH, and has made the argument to my son and to me that family practitioners and internists require particular gifts of intellect and intuition precisely because they are obliged to set the problem in first instance. Said differently, in super-specialization, the gap between the Technical Rationality (Schön's coinage) of researchers and the art of the practitioner is not so wide.

Here's an example. When my youngest son (not the med student) was two, his pediatrician spotted something in his ear during a regular checkup that didn't look quite right. It turned out to be a cyst called a cholesteatoma in the middle ear that if untreated could be life threatening. The actual surgery is microscopic laser surgery, and we ended up having it done by a surgeon whose entire practice this kind of surgery. No recent medical school graduate is going to do the latter (pace Dru Stevenson), but providing the combination of science and practice in spotting the issue in general pediatrics is EXACTLY the kind of thing I think med schools do far better than law school, particularly when we think about the huge percentage of the profession that ISN'T Big Law or specialized.

But... and this was one of the points in my first Legal Whiteboard post ... my son's first two years at the University of Michigan Medical School were not only the usual science. They were also an immediate introduction to practical patient care in a variety of settings (I was his guinea pig in one of the examination rooms when he practiced doing a physical exam). At Harvard Medical School (I know this from a friend), in addition to the basic sciences, the entering students also take something called "Doctor-Patient 101." And to correct Howard only slightly, I think all four years are far more intense than anything law students do - that's why there are no evening medical school programs. If we were to replicate the med school experience in law school, in the first year, doctrinal classes would run from 8 am to noon most days, and the afternoons would be filled not only with legal writing, but "Lawyer-Client 101," shadowing of more experienced students in clinics, training in counseling, etc., leaving the evenings just barely free to read the casebooks for the next morning's doctrinal classes.

It doesn't sound fun, and I don't think fun is how my son would describe med school. But I would listen to, and take seriously, his opinion on a lot of general medical issues. More, I suspect, than on legal issues if he had just graduated from law school.

Posted by: Jeff Lipshaw | May 28, 2012 1:46:56 PM

A point I would add is that med schools (actually, academic med centers) seem very different institutions to me to law schools. As a clinician-educator faculty member I have my finger in multiple pies, corresponding to the multiple functions served by the institution--clinical care in hospital and in clinic, grant-driven scholarship, education in the classroom, education on the wards, hospital administration (in the form of committee work), my own non-grant supported writing, and probably some other things....

The effort put in by med school faculties at teaching medical students is only a small part of what med school faculty members do. And such effort is generally either remunerated poorly or not remunerated at all (except for a favored few who run courses or clerkships). Salary support comes from taking care of patients and from grants. Tuition and/or state money directed at education doesn't reach most of the clinical faculty. That seems to me an important determinant of what med schools are like.

I agree with Daniel that some specialists seem overpaid; I would take issue with any suggestion that the form of a health care system, whether primary care or specialty oriented, has much to do with health outcomes. Far from their being indisputable or overwhelming evidence that primary care driven systems lead to good health outcomes, what the evidence actually shows is that health outcomes have little to do with health care delivery systems and much to do with societal economics, behaviors (levels of violence, risk taking, dietary, etc) and culture.

Posted by: TomH | May 28, 2012 1:29:00 PM

Jeff Lipshaw (who has a son in med school) has written quite well on the law school/med school comparison, most recently at the blog The Legal Whiteboard. Not sure if he specifically addressed these questions, but he touches on a lot of this. FWIW, he argues that the 3d and 4th years are far more intense than anything law students do.

Posted by: Howard Wasserman | May 28, 2012 11:34:04 AM

My sense is that Professor Grimmelmann's answers are generally spot on.

For purposes of embellishment:

(Caveat: I currently work at a medical school that is unusual for a variety of reasons, so that colors my answers. But I was raised in an academic medical family, did my doctorate in an academic medical center, and did a postdoc in a medical school in the largest medical campus in the world, so I'm hopefully not clueless).

(3) The structure of medical school curricula has not changed much in 80 years (since Flexner). The first two years are basic science; the last two are clinical years. The assessments in the first two years are mostly focused on synthesis of an enormous amount of material, though they can be tested by hands-on practical exams (i.e., gross anatomy) and traditional multiple-choice/short-answer exams (pharmacology). Assessments in the last two years are heavily weighted towards the evaluations of preceptors, senior residents, and attending faculty.

(4) Teaching is generally impoverished in a medical school. Medical schools have enormous budgets compared to law schools; faculty salaries are a much smaller fraction of this budget than at law schools. The priorities at most medical schools are the generation of revenue and the production of research, which are coextensive since the acquisition of grants is one of the two ways to actually generate revenue (the other being the provision of clinical services). Although most medical schools say much about how they value teaching, there is widespread belief that this is not so, and that a gifted teacher who does not generate revenue by the practice of medicine or the acquisition of grants will not last long. Roy Poses, over at the fine Health Care Renewal Blog, has documented these beliefs.

Much medical school teaching is team-based, which means it does not make sense to talk about 2-2 or 3-3. But the actual contact hours for teachers outside of the core basic science curriculum can be quite light. Rank and tenure are generally equivalent, although it is quite a bit harder to obtain tenure at the average medical school than at the average law school. In addition, tenure does not mean nearly as much at a medical school because job security is much more reliant on the generation of revenue via grants and clinical practice than it is on the institution of tenure.

Tenured professors can be and are made quite unwelcome if they do not acquire the money needed to fund their salaries and that of their staffs, labs, etc.
Faculty are recruited in similar ways to other kinds of faculty, although medical schools tend to be much less reluctant to hire from within than law schools. Most faculty physicians make less through their academic salary than non-academic physicians, but since many faculty are practicing physicians, their salary is not limited to what the actually school or university pays them (they will typically sign contracts with the university practice group that pays their clinical salary).

6) This is one of the most salient controversies in medical education. The evidence is overwhelming to the point of being indisputable that a specialty-driven model of health care services is far inferior in terms of health outcomes and their distribution to a primary-care driven model (I am biased because the mission of my medical school is to produce primary care physicians, and we are by far the best in the country at this. Yes, I am proud of this). Yet we pay people much, much more to deliver specialty care like dermatology and radiology and pay people much, much less to become primary care physicians. There is a serious workforce problem in rural areas. The evidence suggests we are both over and underserved in terms of the physician workforce. We have too many physicians of certain kinds in certain areas, and not nearly enough of certain kinds in other areas.

Hope this helps.

Posted by: Daniel S. Goldberg | May 28, 2012 5:38:56 AM

(1) Medical admissions are more competitive than law school admissions. The overall acceptance rate is about 10%, and is well under 5% for the most selective schools. Median GPAs are typically between 3.5 and 3.8.

(2) Private tuition and fees are typically on the order of $50,000 a year, as are public non-resident tuition and fees. In-state students at public medical schools may pay half of that.

(3) First and second years are all-day five-day-a-week lectures, taught by a large and rotating cast of faculty. Exams are generally multiple-choice or objective (very) short answer (e.g. "name this body part."). The emphasis is strongly on memorization of large quantities of material. Depending on the school, the lectures may be intercut with simulations, small-group discussions, and shadowing affiliated doctors--but these aren't the dominant part of the curriculum. Third and fourth years are spent rotating through a wide variety of medical specialties, shadowing actual doctors, answering questions they put to you, and doing whatever smaller tasks make you most useful. (E.g., in surgery, "Hold this and don't move for the next two hours.") Grading in third and fourth years is based on some tests, but more on evaluations by the doctors with whom one works.

(4) Faculty are split between practicing doctors, laboratory researchers, and a (much) smaller contingent of lecturers. There are typically many more of them than at a law school, with much lighter individual classroom teaching loads. (E.g., it is not uncommon for a doctor's entire classroom teaching responsibilities for a year to be a week's worth of lectures.) Grading is trivial, due to the objectively graded exams. These faculty should generally be thought of as doctors and bench scientists first, and as teachers second: they just happen to have "faculty" positions that require some teaching, and they're hired for their other work. Promotion within the faculty ranks is based on research. Residents and affiliated physicians may do some TA-like precpting work.

(5) Grades in medical school are important only in not flunking out and in applying for residencies. The other important factor in residency applications is recommendations from doctors one worked with during third and fourth year. After that, the brand name of one's residency program, recommendations, and personal contacts are the most important factors in finding a job. Thus, grades (especially first- and second-year grades) matter, but in an indirect way that can be compensated for later.

(6) The principal exception to this point is that salaries diverge strikingly based on medical specialty. ROAD specialties (Radiology, Opthalmology, Anesthesiology, and Dermatology) are reported to have the highest salaries, and family practice the lowest. The AAMC reports a range from perhaps $150,000 for lower-paying specialties to $350,000 and up for the higher-paying ones. There's geographic variation, too, and seniority, and type of practice, so it gets complicated quickly. Thus, medical school grades can have a significant effect on your job and salary by affecting what specialty you get a residency in.

(7) The licensing practice is absurdly annoying, but it's less of a big deal than retaking the bar exam. Each state has its own licensing board, there are controlled-substance rules, etc. -- it adds up to a lot of paperwork and delay to be licensed in a new state. But the crucial exams and certifications are national.

(8) Because of the residency requirement, no medical school graduate can go out and just start working as a doctor. But there are well more than enough residency slots to go around (provided one is willing to compromise on geography or specialty). Leaving residency, the norm is that everyone who still wants to work as a doctor will find a job. Put another way, our regulatory system has too few residency slots given the demand for doctors, and too few medical school slots given the number of residency slots.

Also, pace Jimbino, medical schools generally require 32 course hours of STEM work in college -- 8 in biology, 8 in physics, and 16 in chemistry -- plus the MCAT, a majority of which tests science. Given the competitive nature of medical school admissions, a year of math and a year of biochemistry are strongly encouraged.

Now, it's time for the gentle scolding. All of your questions are amenable to Googling. All of them. I have enough secondhand experience with medical school that it wasn't hard for me to give (partial) answers. But really, shouldn't crowdsourcing be saved for questions to which crowds can give better answers?

Posted by: James Grimmelmann | May 27, 2012 11:18:58 PM

I know a couple of things Med and Law Schools have in common: they do not require of entering students much competency in STEM and, in the 3-4 years they pretend to teach the student, they do nothing to remedy the situation. Surprisingly, the English Language skills of the students do not seem to be that much better.

The obfuscating prose of lawyers is legendary, but try reading anything a doc or nurse writes, whether in the NYT or in a professional journal, and you will see numerous instances of "at risk for [some disease]" where "at risk of [some disease]" would be the proper form. These are folks who are missing some serious processing between ear and tongue.

It is disastrous for this country that so many of POTUS, COTUS and SCOTUS are drawn from the miserable pool of law-school grads, most of whom have taken undergrad degrees in mickey-mouse majors like History, Philosophy, English and International Affairs. That accounts for the fact that only Breyer of 9 on SCOTUS, only some 8 of 535 in COTUS, and nobody since Carter as POTUS has shown any sophistication when it comes to STEM.

Posted by: Jimbino | May 27, 2012 7:37:48 PM

There is a ton of information available on the Association of American Medical Colleges website:

Posted by: Jeff Lipshaw | May 27, 2012 7:00:28 PM

I think that Qs 3,4, and 6 (primary questions) would probably be the most helpful - sorry for extended Qs ... once I get going ...

Posted by: Jeff Yates | May 27, 2012 6:34:11 PM

Goodness, I set out to write an answer, but these would take me like 45 minutes or so to complete. Respondent burden is way too high!

I'd like to help, but can you trim it down to 4-5 questions (and no compound questions, please!) you'd most like to get some answers to?

(I am an attorney and a faculty member in a medical school).

Posted by: Daniel S. Goldberg | May 27, 2012 6:05:21 PM

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