Throughout the country, colleges and universities are expanding their traditional programs to meet the needs of "non-traditional" students. It is time for accredited medical schools to do the same. They should establish distance learning curricula that would allow experienced community-bound health professionals, such as physician assistants (PAs) and nurse practitioners (NPs), to take medical school courses from home or at work. By doing so, they could build upon the talents of these "non-traditional" but seasoned clinical veterans to increase the number of practicing doctors in rural and medically underserved areas as rapidly and cheaply as possible.

There will always be a need for traditional four-year on-campus medical schools but these programs bypass a wealth of highly qualified health professionals who have the potential to better serve their communities. There have been situations in the past where medical schools have accepted advanced standing students based on prior knowledge and experience and have awarded these students medical degrees whenever they believed they were ready to take the medical practice qualifying examinations. About 35 years ago, before the age of space exploration, the market for Ph.D. graduates collapsed while the market for MD graduates remained robust.. A medical school in Florida decided that the first two years of the Ph.D. program covered the science requirements for medical practice and accepted Ph.D. students into the third year class of medical school. As physician-in-chief of Duke Hospital, I appointed several of these "fast-tracked MDs" to the resident staff. They performed as well and in some instances better than the students who had spent four rather than two years in medical school.

What should be the admission requirements for these community-bound, non­traditional students? I would suggest that the first pool of applicants be drawn from the ranks of physician assistants and nurse practitioners who are already working in collaboration with physicians in certain targeted communities of great medical need. These individuals should be at least 27 years old, have master degrees and have graduated from accredited educational programs that included one year of the sciences necessary for medical practice and one year of rotating clinical clerkships necessary to work in primary care specialties and settings. Most PA and NP schools meet these requirements. Finally, the candidates should have completed at least three years of practice under the supervision or in collaboration with a MD or group of MDs who are willing to write support letters and to serve as mentors for them once they are accepted into the distance learning program. Prior to acceptance, students would commit to being educated as generalist physicians and to staying and working in their home communities or similar settings after graduation and residency training - the bulk to be completed in their home communities.

Having the student, once accepted, remain in their practice will strengthen the practice bond as the student learns more and becomes a more significant contributing partner. Remaining in a rural or underserved community where their families have put down roots will increase the likelihood that they will remain in the community as physicians once their education is completed. As physicians, these individuals will be more likely to employ PAs and NPs in their own practices and to use the team approach for delivery of cost effective health care services.

What about the curriculum - how should it be organized, presented and evaluated? I would start the online, at distance learning program with 20 students who would spend one or two weeks on the medical school campus during the summer prior to beginning the online courses in the fall. The dean assigned to these students would have the help of the traditional medical school faculty. They would develop a set of written and oral examinations, clinical skill problems and other evaluative methods to determine what additional courses or units of learning each of these 20 students needed to be able to pass the qualifying examinations for medical practice. The curriculum would be individualized, drawn from existing material, and delivered over the Internet to the students with both on campus and community-based mentors to assist in the development of necessary additional skills. If done appropriately, I believe these students when ready could take both the basic sciences and clinical qualifying examinations in the same week. The performance of these nontraditional students on these examinations could be compared with the traditional four-year medical students' performance. If the pass rates are the same or higher for the nontraditional students then the program can be declared a success. Past experience shows that older students, knowing they are in school and anxious to make up for lost time, perform better than younger students do. Because of their prior commitment, we will be assured from day one that more of these nontraditional students will practice in rural or medically underserved communities than traditional students.

As founder of the Duke University Physician Assistant Program and PA movement, I am well aware of the benefits of having a physician assistant share in my practice. As a practicing physician, I enjoyed the freedom given to me by my very capable assistant. If you need proof of the difference that the MD/PA alliance made in my professional and personal life - just ask my wife. To this day PAs are mostly recruited, educated and employed by physicians. They and their professional organizations are committed to strengthening the bonds that already exist between us. The majority of PAs are highly satisfied with their personal careers and don't want to be physicians. But those who are ready and willing to continue their education should be given the opportunity to do so. Especially those who are willing to continue working in primary care and in rural or other medically under served communities. We the medical profession owe them that much and should through the use of modern technology and willingness to give credit for prior knowledge and skills not waste seven years of precious time to meet the need of so many of our citizens for appropriate health care services.

Which medical school will be the first to take the lead? Which has the courage to explore alternative pathways to becoming a physician? Some school will step forward because it makes good sense to do so. I would enjoy hearing from any of you who are interested in my proposal.

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