Increase Numbers of Primary Care Physicians in the U.S.

The AMA - Thinking Inside The Box

With a jolt of excitement yesterday, I clicked on an internet link that read, %u201CAMA Responds to Medical Students' Search for School Debt Relief%u201D. I found the link while reading through one of the ongoing discussions about health care in the widely-read Student Doctor Network on-line discussion forums (www.studentdoctor.net).

The conversation revolves around the fact that medical students are increasingly rejecting primary care in pursuit of higher-paying specialist training after school, largely because of their debt (on average today, $180,000). To my great dismay, my elder medical colleagues, recently attending their annual meeting in Chicago, failed to address the real problem, which is the pay-structure in American medicine, and instead tried to come up with ways to make med school cheaper. They provided some of the most out-moded and vacuous attempts at solving the problem I could have imagined. Their proposals are so devoid of reason and intelligence, I wondered if a more Machiavellian strategy drove their collective thinking.

Here are some of their %u201Cideas%u201D:

* Identify and promote work-study opportunities for students %u2013 This idea is, frankly, just stupid. The demands of medical school regularly destroy families and personal health. The hours are often grueling and by the 3rd year are frequently irregular. Besides, the money would be a pittance against a 40k/year bill anyway.

* Match parental savings contributions to medical education costs with financial investment funds - This doesn't lower the cost at all, it just fleeces the parents. It%u2019s as if the AMA thought that by draining the retirements of both the students and their parents, everyone would suddenly think med school is cheaper.

* Offer paid rotating internships for certain fourth-year students %u2013 Like the work-study idea, this is nominal money. The idea looks like window dressing to extend a rather short list of ideas in the first place.

* Provide Medicare funding for undergraduate medical education %u2013 Our social security system, including Medicare, is nearly bankrupt. They%u2019re currently trying to cut payouts to PRACTICING doctors by 10% now, and another 5% this January. The AMA thinks they can lean on this system to pay med students?

* Make medical education tuition costs and/or loans deductible %u2013 This idea MIGHT be helpful if confined to those who choose primary care.

* Consider using a competency-based curriculum that could shorten the length of undergraduate education and medical school %u2013 This is the only idea they came up with that makes some sense. There's a LOT of inefficiency in all the hours required for medical training, especially the 4-year degree requirement prior to school. Everywhere else in the world runs a 6-year program which includes undergrad. In the rest of the world, if you want to be a doc, be a doc. Don't study naked statues in Rome first.

* Use endowment funds to lessen the impact of educational costs on medical students - The Harvard endowment is in the tens of BILLIONS of dollars and they still regularly pump their undergrad and graduate students for tuition. They lean hard on their alumni for donations also. Money comes in to these private institutions. It rarely goes out.

Primary care medicine is generally good work, and many would-be doctors every year choose the specialty on the merits of the job alone. Students are often drawn to the field for altruistic reasons, but few are happy in a system that not only demands their altruism, but preys upon these sentiments for even further gain. Thus, if an American medical graduate wants to get out of debt, have a retirement and send the kids to school, they%u2019re wiser to choose specialty medicine.

The AMA is trying to say that med school needs to be cheaper so people are less burdened by debt when they make their specialty choice. While containing costs and possibly shortening the training time will help, the REAL problem is pay differential between specialist and generalist. The answer to that problem is simple, too: Pay specialists less, pay generalists more. Currently, our system financially rewards procedures and specialist care while paying relative ignorance to primary and preventive care. The American medical system is the most expensive in the world, but ranks around 18th place globally when all important health markers such as maternal mortality, infant mortality, obesity, diabetes and life expectancy are averaged together. The countries that beat us %u2013 Cuba trounces us at a fraction of the cost, for example %u2013 do so largely because they invest intelligently in primary care medicine.

It could be that the AMA is craven and strategic; their true goal being to prop up this specialist-heavy medical system that is overly reliant on high-tech, high-cost procedures. They may believe that primary care doctors should be replaced by lesser-trained physician%u2019s assistants, %u201Cdoctor%u201D nurses, and nurse practitioners, all of whom have a lower threshold to refer to specialists. But specialist care is expensive, and the money is drying up. When the money%u2019s gone, the specialists will be out of work too. So, if they aren%u2019t being underhanded, then this particular effort at solving the problem is merely inept. Either way, they%u2019re shooting themselves in their collective feet%u2026a top-heavy medical system cannot sustain itself.

It is time for Americans to accept the fact that most of the developed world has better medical systems and healthier people than we do, at significantly less cost. We can catch up to them by simply investing in preventative and primary care medicine. But if even the AMA can%u2019t (or won%u2019t) address this issue, who will?

If you agree that this uneven playing field is detrimental to healthcare in the U.S. and driving medical students away from choosing primary care specialties, please sign our petition.  If enough voices are heard, perhaps the AMA will press for real change and support primary care as strongly as they have specialty medicine, not just meaningless lip-service.

Thank you for your time.