Proper clinical research exposure in medical school is a somewhat modern invention. Prior to changes implemented by Harvard Medical School in the 19th century, medicine was more application-focused, but gradually medical schools began to expose students to basic and clinical research. By the 20th century it was the norm that doctors would have a foundation in research and physician-scientists were their teachers.

More recently, things have begun to revert to a more 18th century culture. Medical schools without a well-oiled political machine know they are not going to get funding for a lot of basic research so they are staying focused on the applied part of medicine. Government is now the biggest customer for most hospitals, and government does not need physician-scientists, it needs general practitioners and it needs them at a reasonable cost.

Focus on government-driven applied medicine has become so evident that in the last generation even existing doctors are not sure modern medical students should become doctors. 66 percent of doctors recommend that smart people become Nurse Practitioners instead, it will save them a lot of student loans and they will end up doing the same job.  And even government funding for medical training has become political. Well-connected states like New York get 20 percent of the entire country's medical training funding while 29 states that have an actual shortage of physicians get less than 1 percent. It isn't that Democrats are suddenly penalizing Republican states that did not want the Affordable Care Act, the political skew was obvious before that. 

Want a doctor who is up on the latest research? You'd better live in the northeast because it leads in Medicare-sponsored medical residents per 100,000 people. Credit: George Washington University

We're on the verge of creating have- and have-not medical schools - the lower groomed in a 'teach to the protocol' environment while the upper tier will get exposure to cutting-edge clinical research. The middle class is not just being wiped out economically, the medical middle ground is going away also. 

There are arguments that this is not a bad thing. There is a difference between the background of a scientist in academia and an engineer in the real world because society needs a lot more engineers - and scientists accept that if they stay in academia, competition for government funding will be fierce while engineers are going to get a job relatively easily, so those cultures appeal to different people. Doctors who want to help in urban medical centers don't need access to clinical research, they are helping just by being there at all.

Writing in Science Translational Medicine, a group contends that it is a funding problem, and it is true that President Obama has let NIH funding slide compared to President Bush, but that is a superficial comparison. The telling metric is that New York gets billions from the government for medical schools while Mississippi gets .01 of that. More funding would not solve the problem because if there is more funding, New York is going to get more funding because they will argue they have the best schools - due to having more funding. 

If you know your Dr. Seuss, some Sneetches are going to have stars and some are not. If you just want to have a doctor for a check-up, he may not have a star you'll be fine. 

Credit: Dr. Seuss Enterprises

"Research at our nation's medical schools has led to discoveries that have changed the face of American medicine," Arthur Feldman, MD, PhD, Executive Dean of Temple University School of Medicine and Chief Academic Officer for the Temple University Health System, said in their statement, which absolutely no one argued otherwise. "Unfortunately, many of the nation's newer medical schools do not prioritize research or are unable to compete for scarce research funding. The result is an increased proportion of U.S. medical school graduates matriculating from programs where the faculty members pursue little to no clinical or translational research."

America leads the world in science output and if less medical research is being done in academia, it is because less is being done by corporations - and that is due to government regulations and costs. Doctors who care will still learn, it's not like they don't understand the scientific method and won't read journals if their instructors were not at a wealthy university in the northeast. Doctors are individuals and some are better regardless of the name on their school.

And it may be that many physicians prefer empiric instruction, the same way accountants may not get much value out of a condensed matter physics class. Since they are the ones paying the increasingly higher fees, mandating that they take on more loans to match the desire of doctors in a commentary - who just happen to be working at wealthy teaching schools attached to expensive universities - when they want to go to a community hospital seems elitist. The authors argue just the opposite, that it is because of their elite status they can see the problem.

We can dream of a world where every hospital has an array of "House, M.D." types who are synthesizing new scientific data to care for each individual patient but the modern reality is that if young doctors don't follow the protocol they were taught to follow, they are going to endure the cultural buzzsaws of hospital committees, lawyers, insurance companies and now the state and federal governments all demanding to know why they did not obey the checklist.

Clinical research will not help solve the defensive medicine problem.

Citation: A. M. Feldman, M. S. Runge, J. G. N. Garcia, A. H. Rubenstein, American medical education at a crossroads. Sci. Transl. Med. 7, 285fs17 (2015). DOI: 10.1126/scitranslmed.aaa2039