Accelerated Medical Degree may Boost Primary Care Supply
About six years ago I wrote about the merits of a 3-year medical degree. This involves medical students essentially skipping the rotation that occurs in their fourth year of medical school and beginning residency training. At the time, there were only three universities in the United States and Canada that offered a program that allowed doctors to begin residency after only three years of medical school. Now there are about a dozen according to Robert Grossman and Steven Abramson, writing in the Wall Street Journal. Nearly one-third of medical schools have (or are) considering ways to speed up medical training programs. Is probably a good idea.
The programs I reviewed six years ago were basically students agreeing to go into primacy care in return for a year less schooling and the associated debts that go along with paying tuition and being out of the workforce one extra year. There’s another potential benefit (depending on your point of view). Students who agreed to this program had to declare the desire to go into primary care early on. I’ve been told by people who attended medical school that many students come in with the goal of working in primary care. But the pressure to abandon primary care for a more highly paid specialty begins soon — and students’ own professors are the ones who introduce the idea. Often it’s a financial decision because of a student debt and the number of years out of the workforce medical school entails. Maybe more people would go to medical school — and go into primary care — if they didn’t have to spend as long in school and take on as much debt.
Devon,
Considering the time, money and hassle factors in being Primary Care these days, a young person is much better off becoming a NP or PA if they really want to practice medicine and help patients. Any more, Primary Care docs are just data entry personnel.
I am a fan of nurse practitioners and PAs. All the research suggests they do a good job in primary care and (according to the research) are better listeners!
There are other options as well. Every year about 20% of medical students fail to match to a residency program. Increasing the number of residencies may boost physician supply. There are also foreign medical graduates who have spent years working in other countries who would like to come to the United States. The barriers to working here are onerous. Basically you have to start over with the exception of medical school (assuming you forgot nothing and can pass your exams without spending a year or two studying). Also, they have to complete a residency. If the training and practice in their home country was similar, there should be an abbreviated path to practice. The (low) cost of training and licensing a foreign medical graduate who has spent years caring for patients should be a bargain for both doctor and American society.
First, I have nothing against NPs and PAs. But we have to decide what role each type of provider is going to play in health care. Primary Care docs usually go into it because they like the give and take with the patients and getting to know patients. These relationships have been hijacked by the onerous requirements by the gov’t and insurance and resulted in the 15″ mini-appointment as opposed to a real conversation.
If you really want to entice MDs to do PC, you have to not only make it less time consuming and expensive, you have to enable the docs to basically go back to the Marcus Welby approach to medicine. I think if you were able to do that, docs would be happier and more willing to do PC.
Short of that, the numbers will continue to dwindle.
If physicists had been subjected to such nonsensical rules in 1942, we Amerikans would all be dead or radioactive. Thank Darwin there is no certification or licensing needed to make nuclear weapons! Medicine in Amerika is still in the stone age.
Remember, now, that post-graduate education for physicians is funded mainly by Medicare. My impression from a cursory reading of the medical “literature” is that Medicare contributes $18 Billion annually with a distribution formula heavily skewed toward the institutions with high research budgets. Also, I am not aware of any requirements for the use of these funds preferentially for Primary Physicians. With the increase in the number of medical students in the last 3-4 years, many students next May will not MATCH for a residency program in the USA.
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So, we now expect a medical student to accept a personal debt of more than $100,000 with no guarantee that she or he will be able to earn enough money to reasonably pay it back. Hmmmm! Only in America.
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Professor Elinor Ostrom has a definition for an INSTITUTION. She says that it may be defined “… as the rules that humans use to organize all forms of repetitive and structured interactions including within families, neighborhoods, markets, firms, sports leagues, churches, private associations, and governments at all scales. Individuals interacting within rule-structured situations face choices regarding the actions and strategies they may take, leading to consequences for themselves and for others. The opportunities and constraints individuals face in any particular situation, the information they obtain, or are excluded from, and how they reason about the situation are all affected by the rules or absence of rules that structure the situation. If the individuals who are crafting and modifying the rules do not understand how a particular combination of rules affects the actions and outcomes in a particular ecological or cultural environment, rules changes may produce unexpected and, at times, DISASTROUS RESULTS.” (EMPHASIS MINE)
Another option that some countries use is allowing pharmacists to dispense selected drugs without a prescription. The list of drugs they are allowed to dispense generally falls within a category known as behind the counter drugs.
This idea has not gained much traction in the United States. Some of the stakeholders (including the trade association for the OTC industry, among others) worries that a behind-the-counter class would become the “safe” place for a risk-averse FDA to place any prescription drug that would otherwise be approved for over the counter sales. I tend to agree that is a very significant risk. There would have to be some sort of provision that behind the counter is a temporary class on the way to OTC. Otherwise, it would be a step backward. Self-care is the best option where it is appropriate.
http://well.blogs.nytimes.com/2012/12/20/where-have-all-the-primary-care-doctors-gone/?_r=0
Maybe the solution to the primary care provider shortage is doctors telling their patients…
Primary care really isn’t something that insurance should pay for. The fact that my insurer has to track my primary care office visits means they are more costly than they would otherwise be. I can see a need for a surgeon to have negotiated rates with insurers. My primary care doctor should be competing for my patronage on price, quality and other amenities — not because he happens to be in my network.
“Primary care really isn’t something that insurance should pay for.”
Devon I think your idea is correct, but your statement is wrong since that decision should be left to the individual. As soon as the patient learns the economics of his decision by losing money he will change his tune.
Who is paying the bill for physicians to be educated in the US? I noticed in this string that Medicare contributes. Do other Federal agencies contribute?
There are some state and federal grants for medical training. For instance, students agreeing to practice in underserved areas for a number of years may get some of their tuition waived. But for the most part students themselves pay their own tuition. State and federal government supports universities with some funds.
Medicare pays for most residency programs. To a much smaller degree state Medicaid programs also pay for some residency programs.
There are a number of new medical schools that have opened in the past few years. The bottleneck is residency programs. It makes sense to create and subsidize primary care residency programs as a means to expand physician supply. Several thousand medical students a year don’t match to a residency and about one-quarter of residency slots are filled by foreign medical graduates. Merely creating more residency slots could potentially increase the number of physicians able to treat patients each year.