Medical Homelessness  

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With millions of people newly insured thanks to the Affordable Care Act, a lot of people will be seeking medical care for the first time in a while.  While many of these will be people with problems needing specialty care due to problems that have gone untreated, many others will be in search of primary and preventive care (most of which is not subject to cost sharing).  For several years there has been talk of a shortage of primary care physicians – seems that will only become more acute.

There has also been a lot of talk about increasing the supply of physicians selecting primary care specialties.  The pendulum swings back and forth.  But, as nicely summarized by Pauline Chen,  there has been no major, sustained trend toward more physicians going in to primary care, despite a variety of initiatives such as medical school expansions, dedicated primary care training tracks, loan repayment programs.  With many subspecialists enjoying shorter hours and much higher salaries – the recent release of data on Medicare payments to physicians was particularly eye-opening – simply creating more of the same doctors and asking them to pretty please go into primary care is simply not going to work.  We need to, as Steve Jobs said, “Think Different.”

1.  Expand the role of non-physician providers.  New York recently became the latest state to expand the ability of nurse practitioners to provide care independently by removing the requirement for a written practice agreement with a physician.  Nurse practitioners are already beginning to fill important holes in primary care in a number of underserved communities – including two inner-city clinics resulting from a partnership between Children’s Hospital of Wisconsin and Marquette University School of Nursing.  This model is very likely to be an important part of meeting the national primary care gap.  We need to commit to increasing the number of NPs, and to removing the unnecessary barriers to their ability to practice to the full extent of their training.

2.  Make primary care providers more productive.  Fields like education and medicine, being relatively reliant on the human element, typically have much smaller increases in productivity than industries like manufacturing that are amenable to automation.  That appears to be changing, with numerous actual or promised innovations such as remote sensors and other forms of telemedicine, better care management, and newer therapies that require, frankly, less skill.  By simply embracing innovations that promote efficiency – not to mention a shift in focus from medical care to maintaining wellness –  we should be able to get by with relatively fewer providers.

3.  Rethink how we train physicians.  The current model of medical education – four years of college, then four years of medical school with two full years of basic sciences, followed by a minimum of three years of residency – is neither long-standing nor the international norm.  In most European countries, university and medical training are combined over a period of six years, and tuition is often free or far lower than in the US.  In the 1970s and 80s, a number of medical schools in the US experimented with alternative pathways, including 6 year combined undergraduate and medical degrees, or 3 year medical school.

The 3 year alternative is attracting new attention.  One important motivator is to allow students to graduate with lower debt, thus decreasing the barrier to entry into lower-paying primary care fields.  At the Medical College of Wisconsin, a Community Based Medical Education Program is being implemented, with satellite campuses in rural parts of the state and a 3-year curriculum.  The idea is that by attracting students with an interest in primary care in a rural setting, allowing them to decrease their tuition burden by 20-25%, and providing residency training programs in those communities, it is much more likely that they will choose to practice primary care in those areas.

I certainly hope this works.  But I think we need to use the opportunity to re-examine what is required for medical education.  In designing the community-based program, there has been a lot of thought to how to provide the basic science education (e.g., remote learning, offering some classes on local campuses, etc.).   I think the real question is how much basic science do you need, especially for a clinical (as opposed to research) career.  The opportunity to do less microanatomy and biochemistry, with earlier clinical exposure, may be even more appealing to those with an interest in primary care.

This borders on heresy in the world of medical education.  Without thousands of hours of basic science instruction, doctors will simply be “technicians,” no different than nurse practitioners!  Hmmm…..

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