The United States conducts the best medical research in the world and has the best doctors. Our medical schools consistently produce revolutionary research, and doctors like Alfred Blalock and Clarence Walton Lillehei have invented and reinvented fields of medicine everyday.
Yet, upon reading Atul Gawande’s column in The New Yorker this past week, I couldn’t help but be reminded that we must do better. According to the World Health Organization, the United States is ranked below Costa Rica and Chile at 31st in life expectancy, one of the lowest ratings among developed countries. Exacerbating the U.S.’s substandard level of life expectancy is the exorbitant cost of a healthcare system among developed countries that still leaves citizens uninsured.
In “The Heroism of Incremental Care,” Gawande, public health researcher and accomplished surgeon, critiques our healthcare system differently than the usual gripes of excessive cost and inefficiency. Through sharing stories of primary care doctors whose “steady, intimate care” often helps people more than the “intensive, one-off procedures” of specialists, Gawande argues that we have de-prioritized the ability to provide consistent, effective primary care in favor of the glamour of specialization. As a result, Gawande believes that we have devalued prevention and undermined the effectiveness of incremental, human relationships in healthcare. The economic forces show that pretty easily.
The five highest-paid specialties in American medicine are orthopedics, cardiology, dermatology, gastroenterology and radiology, all interventionist trades, while the lowest-paid specialties are pediatrics, endocrinology, family medicine, HIV/infectious disease, allergy/immunology, internal medicine and psychiatry, all incremental by nature. There is no questioning that doctors remain some of the highest-paid professionals, regardless of specialty. However, in a stressed environment where medical students are saddled with an average of over $100,000 in debt, the rational decision is often to opt for the interventionist specialty, with greater value both financially and often publicly. Thus, even amidst studies showing that states with higher ratios of primary-care physicians have lower rates of general mortality, infant mortality and mortality from specific conditions such as heart disease and stroke, the economics make it difficult to change this alarming trend. In the face of a public health crisis where we don’t have enough primary care supply to adequately care for our patients, we must look to reform some aspect of the health care system. In this situation, I think that aspect must be reforming medical and premedical education.
Unlike India, China and most of Europe, the U.S., along with Australia and Canada, is one of the few countries that requires a bachelor’s degree as a prerequisite towards attaining a medical degree. Requiring so much education undoubtedly contributes to the exceptional care that our doctors provide. However, between the years of undergraduate education, medical school and residency, the percentage of primary care doctors practicing under the age of 35 is decreasing. Reforming medical training should achieve three goals: accessibility, quality and redistribution. Fortunately, all three goals can be achieved through similar policies and reforms.
The impact of primary care on chronic disease management is the subject of much research. Peer-reviewed studies done in U.S. have consistently that interactions with primary care physicians significantly reduce rates of high cholesterol and diabetes. Additionally, while the research is still evolving, it appears that areas that report an increase in local primary care doctors correlate with a greater public utilization of preventative health care. The first step to increasing the primary-care physician pool is to increase accessibility to the medical field. The exclusiveness of the profession has ensured high quality of services and high compensation for doctors, yet has also contributed to the rising price of healthcare. By making medical school cheaper and more accessible to women, minorities and nontraditional paths, the number of doctors – and more importantly, good doctors – will increase. Suggested solutions to this path include providing subsidized preparation for the MCAT, condensing the medical education from four years to three and the proliferation of medical schools like Mt. Sinai School of Medicine in New York and St. George’s University in Grenada, both of which accept non-premedical students or students who have had prior careers.
In terms of maintaining and enhancing quality of medical students, New York City’s Mt. Sinai School of Medicine FlexMed program provides a great example. Since 1987, humanities majors have entered Mt. Sinai having neither undergone traditional premed science preparation nor having taken the MCAT but still join traditional premed students. These “HuMed” students attend an eight-week summer program at Mount Sinai after their junior year in college that exposes them to clinically relevant organic chemistry, physics and clinical rotations, and they work in summers to hone relevant premedical material. And while admitted students must have a 3.5 GPA to be accepted and HuMed students have reported taking more time off during their medical school journey, the results have been remarkable. There have been no differences in the proportion who failed courses, were required to repeat a year of medical school or withdrew or were dismissed from medical school. No significant differences were found in their choices of specialties, and almost 45 percent of HuMeds have been ranked in the top 25 percent of the past six graduating classes. Lastly, and perhaps most importantly, a higher proportion of HuMed graduates are affiliated with a medical school and hold an academic position than the traditionally prepared graduates.
The current premedical and medical curriculum is still largely based on the Flexner report of 1910 and the adaptations and evolutions in the 1930s. And while Flexner’s report may have improved health outcomes in the 1930s, we have failed our health system by allowing premedical curricula to stagnate despite advances in science, clinical practice and technology.
In addition to updating curriculum, we must work to redistribute medical students away from interventionist specialties and towards incrementalist specialties. This goal is the toughest, as it requires either changing attitudes towards internal medicine and/or changing incentives. In 2008, among 954,224 total doctors of medicine, 784,199 were actively practicing and 305,264 were practicing in primary care specialties (32 percent of the total and 39 percent of actively practicing physicians). The proportion of specialists was over 60 percent of all patient care physicians. However, some options do present themselves. St. George’s University, for instance, has a partnership with the New York City Health and Hospitals Corporations, where students pay no medical school tuition in exchange for spending four years in a city hospital serving the poor. Scholarship programs like this could be used to bolster primary care physician numbers in targeted areas and could help mitigate the flight of doctors away from rural areas. Additionally, many top medical school programs – including Stanford – offer dual degree programs for students looking to pursue interdisciplinary work in policy, business, law or academia. Strengthening and refining these programs would only increase the ubiquity of a medical education and put allow for a greater creativity in medical study. Lastly, market changes and healthcare reform is difficult, but it is conceivable that we can create a health system that rewards primary care more than its current state.
Not changing the status quo, as Gawande argues, isn’t a bloodless policy choice, but instead a medical emergency, leaving “millions of people to suffer and die from conditions that, increasingly, can be predicted and managed.” Reforming premedical and medical training can be an actionable and manageable step towards increasing the quality and quantity of primary care. We can keep medical training tough and preparatory without weeding people out. We can keep training doctors rigorously, but we can also train and judge their candidacy fairly. The best doctors are out there. They are the ones that care about the long-term outcome of patients, and are trained and patient enough to develop a human connection while providing the highest quality treatment. We just have to do more to find them.
Contact Kyle D’Souza at kvdsouza ‘at’ stanford.edu.