Tuesday, May 31, 2011

The Unintended Consequences of Free Medical School

Don't it always seem to go,
That you don't know what you've got 'til it's gone.
They paved paradise,
And put up a parking lot."

- from "Big Yellow Taxi" by Joni Mitchell
An opinion/policy piece appeared two days ago in the New York Times entitled "Why Medical School Should Be Free." Hey, why not? If it's free it's for me!

After all, such a system the rage in many other socialized medical systems.

But rather than focus a critical eye on why medical school has become so exorbitantly expensive, the authors choose to offer a proposal to make it free. By doing so, the authors suggest there is no need for introspection about the antiquated and costly system of medical school education that exists today. There's no need to reconsider the academic tenure system and it's burden to state budgets. There's no need to consider that many university programs are already crumbling under large debt loads and struggling to meet the training and case-load demands of their students, farming them out to private institutions to assure they meet their requisite number of cases.

Heck no. Better to perpetuate the current system and make it free! Students would no longer object to schools that could finally crank their tuition higher! (Trust me, *wink wink,* taxpayers won't know the difference!)

And don't worry about the broad-based specialist shortages that exist today. Heck no. It's all about primary care. Have a hernia and need a surgeon? Or a bypass? Ooops. Not seeing much in this piece to correct our current shortcomings. What's another $50,000+ per year of education for for those employed specialists-to-be making $37,000 per year as residents?

Mere chump change.

For those military and National Health Service Corps recruiters out there, you'd better start thinking of another incentive program to recruit doctors since offering free medical education in return for a few years of service to your country no longer looks like such a good deal.

Beyond these things, we should also ask: has there been a benefit to patients when medical school's compete to attract the best and brightest doctors?


Look, it'd be nice if no one had to pay for medical school. (It would be nice if I didn't have to pay for college education either for that matter.) But let's not forget the real issue here: doctors are losing all autonomy and ability to advocate for their patients' needs above those of their employers, be they public or private. Since someone will now be paying a doctor's tuition, someone else will decide a doctors' work and level of expertise. Someone else will decide their hours and of course, someone else will decide their pay. As a result, will this new medical school curriculum model shun individual ingenuity in favor of health care budgetary imperatives? When a doctor has little monetary skin in the game, how will such a system assure an adequate work ethic from doctors going forward? A suppose time clocks would work.

Bottom line: there never has been and will never be a free lunch for anyone without some very big strings attached.


Kevin Pho, MD gives his reasoned take on the same New York Times article from the primary care perspective.


Keith said...

From my perspective here in Chicago, I fail to see what shortages of physicians we truley have. I find that the only access problems that exist are for those who lack adequate insurance or have none at all. Certainly there are areas of the country where access may be an issue, but it does not seem to exist in the major metropolitan areas of this country where physicians choose to live and practice.

Paying for medical school and not for specialty training will not likely do much to change the primary care/specialty equation, since by my math, it still would prove much more lucrative to do specialt training, albeit with some hit to the specialists net take, but not enough over the course of years to make a significant dent in the disparities.

I still maintain that specialty training is not the main differntiating factor in income disparity anyways. It is whether one does things to patients (procedures and tests) vs diagnosing and treating. Otherwise, we would have endocrinologists, rheumatologists, and infectious disease specialists making as much as radiologists and dermatologists, but this is clearly not the case! The answer to the problem is to calculate payment on the basis of time spent working with some differnetial increase in the pay for those with extra levels of training, but the differential should not be so high, as it is at present, to discourage medical students to enter fields with less residency training time.

Given the recent studies that have been released regarding the overuse of stents, and placement of ICDs, it might not be such a bad idea to have some relative shortage in these areas. These studies alone give one pause to wonder that if we are performing these procedures for inappropriate reasons, how does this square with the notion that we are undersupplied with cardiologists that perform these procedures? Do cardiologists really have time to do these types of interventions if there are not enough of them to go around? It seems more likely that there is a misalignment of supply in many fields with competitve areas of relative oversupply of cardiology services that result in the inappropriate application of criteria in order to stay busy. The Dartmouth data show that areas of high specialty density actually have worse health outcomes proving once again too much of a good thing can be bad for you.

Katie D'Aiuto said...

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Tim said...

Let's begin by realizing that Drs. Bach and Kocher, who wrote the article advocating free medical school, do not ACTUALLY see and treat patients. They are policy wonks- population doctors, not diagnosing and treating disease. They never diagnosed a patient with coronary atherosclerosis and had to decide whether a stent was needed or not. All they can do is read studies done by others about the necessity of care and pontificate. They don't even identify thmselves as MDs as authors under the title. They are identified as "doctors" at the end of the article by the NYT. Does that mean PhD, MPH, and/or MD? I'd place a bet that, like Obama, their heart's desire would be a single payer health care system, run by the government. Any takers?
Then, the government's committee on medical education distribution could decide how to allocate training positions. Cass Sunstein's nudging becomes a shove! Remember how the government used to pick out athletes to groom for Olympic competition whether they were interested or not? No! Wait! That was the now defunct USSR! Policy wonks like Bach and Kocher want to be able to produce more primary care doctors, whether students want to do primary care or not!
If all medical schools in the US doubled their output, we could not make up the impending shortages which are only worsened by dumping 32 million more patients in the mix under Obamacare (by making them buy health insurance whether they want it or not- nudge). The Bach/Kocher Plan would result in other shortages. What good is it if a Primary Care physicain diagnoses a glioblastoma if there are no neurosurgeons to treat it? What's the benefit of their diagnosing a 1 mm thick melanoma if there's no surgeon who can perform a sentinel node excision?
Of course, policy pundits want to reduce the amount of medical care performed, because they know that that is the only way to reduce expenditures. They also want physicans to offer their services free whether you got your education free or not. If you don't believe that, just look at reimbursement trends!
I could barely afford to go to medical school. I trained for 8 years after medical school graduation. If ihad had to spend that 8 years without the subsistence income I got, I would have been forced not nudged or persuaded to go into primary care! Under the Bach/Kocher Plan, only the congenitally rich will be able to afford to be a specialist!
I agree with Wes- there are no free lunches. A few "out-of-the-box" government minds are no match for millions of individual minds in making these types of decisions. To believe therwise is to be a socialist!