Drs. Bach and Kocher make the argument that large medical school debt is pushing students into more lucrative fields to pay back their loans as quickly as possible. Their solution is to make medical school free, but then charge people for specialty training. They believe that this would incentivize students away from sub-specialization. As a medical student who will accumulate around $200,000 of debt to be educated (and who is married to a medical student with similar school loans), I clearly understand the financial constraints that this places. However, debt is only a portion of the entire story for why students are not choosing primary care fields. By putting all our focus on the debt issue, it will distract us from finding the real reasons why students are not going into primary care.
Medical students are not exposed to the wonderful sides of primary care medicine. In a general medical practice, the problems are often complex and the solutions are challenging, so it takes months or even years to attack the issues effectively. Students come in and out of primary care services on a month-by-month basis, so seeing any long term solutions to improving and promoting overall health is nearly impossible. Also, primary care physicians across the country are seeking innovative ways to improve patient care. This work is exciting, intellectually demanding, and extremely difficult to implement. We do not get exposed to this aspect of care because often times these projects take years to develop. Another issue is that in the academic setting, primary care is highly disrespected. This should not be that surprising considering academic centers are filled with super sub-specialists who do not fully appreciate how difficult it is to care for the whole patient, rather than a small part. Lastly, primary care, at its core, is about relationships. By being placed temporarily on a service, any relationships formed are superficial and casual.
Focusing solely on debt is a flawed solution. There are many programs for loan-forgiveness if students go into primary care fields. The debt argument looks dramatic on paper, but the real issues for why students are not going into the field are much deeper. Those are the areas on which we need to focus our attention; provide students with the chance for continuity of care, involve them in clinical innovations, and show them firsthand that the field is respectable and worth pursuing.
BWC
Response to Op-Ed: http://www.nytimes.com/2011/05/29/opinion/29bach.html?_r=2
Nice post Branden.
ReplyDeleteI think there is another issue as well. And while it doesn't deal with money in terms of student debt, it does deal with money in terms of primary care-specialist pay differential. This article describes my point well.
http://thehealthcareblog.com/blog/2010/06/14/how-can-we-encourage-medical-students-to-choose-primary-care/
My view, and I can't find the more rigorous study that was presented at a conference a few years back that backs this up, is that medical students don't want to go into primary care because they get paid far less per year than specialists. This is related to many of the things you mentioned (respect, exposure, etc) and I feel a more balanced pay structure would improve many of these issues.
While I hate to admit it, money matters. Medical students have a fairly arbitrary choice to make in their third year that goes something like this: "What residency should I apply to?" They are far more likely to choose medicine or surgery simply because a 150K physician is not what they want to be.