Wednesday, August 6, 2014

Half Docs

Much ink has been spilled about the lack of training of new medical residents. Severe work hour restrictions imposed by the ACGME to prevent abuse of residents and supposedly improve patient safety have caused the competence of these new doctors to plummet. Now there are plans afoot to take even more training out of our future physicians.

For years the cost of medical education has been cited as a root cause of doctors fleeing to the ROAD specialties. With student debt running well over $200,000 upon medical school graduation, it is natural that smart kids will flock to the highest paying specialties, abandoning the lower paying but desperately needed primary care fields. Now there are plans to alleviate this debt by cutting back medical school education from the traditional four years to only three. This would instantly reduce student debt by at least $50,000. But is it a good idea?

A three year medical education may not be such a bad idea if it cuts out a lot of fluff inherent in the current curricula. How many doctors can still trace a carbon molecule running through the Kreb's cycle in organic chemistry class? And how relevant is that really for patient care? Two University of Pennsylvania medical school administrators lament that students would miss out on subjects like medical ethics, patient safety, and health policy. But is taking a year to acquire that non clinical knowledge worth the price of a new Mercedes, not counting compounded interest? Should harried students be studying those topics while there are literally thousands of other facts that need to absorbed before they can become competent physicians?

Instead of eliminating one of the first two years of med school that is more likely to contain these superfluous subjects, many of the schools contemplating a three year program plan to cancel the fourth year. Frankly that is when medicine finally gets interesting for students. Medical students are like stem cells. They enter school with no clear direction. But over time, they eventually start differentiating themselves into different lines of work. Some realize that they are best at being pediatricians. Others have revelations that pediatrics would be the last thing they want to do for the rest of their lives and perhaps settle on radiology. The fourth year of medical school is when much of this decision making takes place. Without that last year of experimentation with different subjects, there could be a lot more unhappy doctors in the future who realized too late that they chose the wrong line of work or think wistfully about what else they could have become.

NYU is experimenting with a three year program for select students in its medical school. The catch is that the students have to decide from the very beginning which medical field they want to enter at the end. NYU will then guarantee that student a residency spot of his or her choosing after graduation. This is being done in the hopes that by phasing out one year of medical school, the student would save $50,000 and hopefully enter a primary care field. But guess what. The two students interviewed in the New York Times article chose orthopedic surgery and gastroenterology, two of the highest paying fields in medicine. Surprise! They are not stupid. Guarantee a medical student a job of his choice and he will decide on the highest and most competitive job available. Any hopes of using the savings from one less year of school to encourage students to take up primary care has to be weighed against a still substantial student debt in the six figures.

One idea that I think should be given more serious consideration is a reduction in medical school tuition. Everybody is wringing their hands over the high student debt load leading to a lack of student interest in pursuing primary care. But why should the student be the one responsible for our primary physician crisis? Chopping school tuition would take care of both problems quickly. Can that be done? Consider that most medical schools are part of public university systems. Therefore the tuition costs are directly set by the state governments. They can raise or lower tuition at will. Decreasing school costs will need to be compensated by the taxpayers to maintain the same standard of care in teaching. But since the product of medical school education is beneficial to all, there shouldn't be any difficulty in justifying this additional government expense. This will give new doctors less of an incentive to flock to the specialty fields and keep their focus on treating their patients instead of their wallets. The private medical schools could either match the new rates with help from their large endowment funds and alumni drives or hold their tuition while hoping they can still attract the best and brightest with their names alone.

While the idea of cutting medical school to three years from four is being done under the best of intentions, the emphasis should still be on exposing our future physicians to as many patients as possible, not have them continue to slumber in classes while the real patient care electives get shunted aside. We are already concerned about how little time our residents have to understand and treat their patients due to work restrictions. Isn't it folly to also treat medical students the same way? Or will this new generation of doctors always be known for having half the education of their older colleagues?

No comments:

Post a Comment