Free tuition in medical school is only one step toward producing the doctors America needs

The NYU School of Medicine shook the world of medical education recently by announcing that tuition would be free. The NY Times article about it says that ‘Rising tuition and six-figure loans have been pushing new doctors into higher-paying fields and contributing to a shortage of researchers and primary care physicians.’ Certainly, it is easy to understand that a $55,000 per year tuition bill is going to be way beyond the ability of most medical students and their families to pay, and that a total indebtedness that is often over $250,000 may well affect the specialty choice of medical school graduates. While physicians in any specialty make far more than the average American, compound interest makes the payments a lot more than $25,000 a year for 10 years; often more, indeed, than that average American income (think about the payments on a $250,000 home loan, which usually has a lower interest rate). This may tip the balance between choosing betwee, say, family medicine or anesthesiology, when the latter choice can be expected to result in an additional $7 million in lifetime income.

The other, presumably obvious, impact of free tuition could be the ability of the school’s admissions committee to take more students from lower income families than they currently do. Note “lower income” is not necessarily the same as “low income”, as 80% of medical students now come from the top 20% of income. And, yet, they still have a lot of trouble paying for school, tuition plus the Times’ estimated $29,000 a year in living expenses (in NYC). It is not necessarily true that ability to pay is a significant criterion in the admissions decisions of medical schools, but rather that there are confounders. A big one is that being from a high-income family is associated with having the higher grades and test scores that are so valued by medical school admissions committees (probably especially those, like NYU, that are very interested in producing MD/PhDs and other laboratory researchers). Free tuition, however, might mean that those students from lower-income families who do gain admission will be under less financial pressure to take paying jobs while in school (a really bad idea when trying to succeed in medical school). In addition, those students who have started their own families or whose families of origin have counted on them helping to support them, would have one big less thing to worry about.

We definitely need more family physicians and other primary care doctors than we are producing now (and NYU has produced one of, if not the, lowest number family physicians of all US medical schools). We also need far more students from lower-income and underrepresented minority and rural backgrounds. The reason is not just for ethical or moral, or making up for past practices. It is directly about providing quality healthcare to all the American people, because physicians are most likely to practice in settings like those in which they grew up and feel most comfortable. Thus, students from upper-middle and upper income, primarily white (and Asian) suburbs are most likely to practice in those settings – which are precisely those least in need of more doctors. Students from rural or low-income or minority communities are much more likely to practice in such communities, and these are the places most in need of more doctors. Of course, the correlation is far from 100%, but the trend is overwhelming. Thus, to the extent that free tuition can increase either of these goals, it would be a great thing.

So what is the problem? Well, it is far from certain that free tuition will lead to these desirable outcomes. This point is made by family physician (and NYU medical school graduate) Kenny Lin, MD, in his Common Sense Family Doctor blog. Although Dr. Lin’s 2001 class had only four graduates entering family medicine, it was a larger number than any class since. He points to the fact that NYU has never had a Department of Family Medicine (one of the few such schools, almost all of which are “elite” private and on the East Coast). He also notes that in terms of producing other primary care doctors (general internists and general pediatricians), NYU has also done very poorly.

More important, Dr. Lin cites a study published in the JAMA Network by Grischkan, George, Chaiyachati, et al., that demonstrates that students entering family medicine (one of the lowest paying medical specialties) have a higher average debt load than those entering fields such as radiology, dermatology, and ophthalmology. He writes

These findings suggest, paradoxically, that physicians with the highest debt burden are preferentially choosing a specialty with among the lowest income expectations - why on earth would that be? What it says, actually, is that students from less well-off backgrounds are more likely to be attracted to primary care in the first place.

This is a very important point. Dr. Lin, focused on the critical issue of producing more family physicians and primary care doctors, believes that eliminating tuition and thus taking students from more diverse backgrounds “will likely have a small, but measurable, positive effect on primary care.” He urges that NYU and other schools increase their “pipeline” programs to help students from less advantaged background gain the skills that they need to be both admitted to and successful in medical school. I agree, but I would go beyond that.

Medical schools should train the doctors America needs. This means fewer subspecialists, and more primary care doctors. This means a smaller percentage of doctors practicing in the suburbs of big cities, and a larger percentage practicing in rural areas and underserved inner-city communities. This is not going to happen if we keep taking the same students we currently do, no matter how nice they are, no matter how high their grades are, and no matter how much they are like (or often are) the children of the faculty of the medical school. If you don’t think this is important, a recent paper from the National Bureau of Economic Research by Alsan, Garrick, and Graziani titled “Does Diversity Matter for Health? Experimental Evidence from Oakland” (reported in the Times article “The Secret to Keeping Black Men Healthy? Maybe Black Doctors”) demonstrates that it does: a significantly higher percentage of black men received important tests, took medicines, and made lifestyle changes when advised to by a black doctor rather than a white or Asian one. Importantly, this comes from more than a knee-jerk reaction to the race of the physician; it has a lot to do with how they were treated. While the ‘white and Asian doctors often wrote comments like “weight loss,” “tb test” and “anxiety” — cryptic notations that referred to medical recommendations…black doctors often left more personal notes, like “needs food, shelter, clothing, job’. This goes beyond race, and suggests that both our overall medical curriculum focuses too much on the disease and not the person, and further that minority physicians may be more likely to realize that it is a person who needs to be treated, and identify the social determinants of health.

Indeed, Elisabeth Rosenthal, the editor of Kaiser Health News, argues in an Op-Ed in the Times that medical school should be free only for those who make a firm commitment to entering specialties and practicing in areas that have real need:

…if a student chooses to become an ear, nose and throat surgeon in suburban New York or a private cardiologist in Miami, fine. He or she can pay back what has been borrowed. But if that doctor chooses to deliver babies in rural Oklahoma or practice pediatrics on the South Side of Chicago, then he or she should get to keep every penny of salary.

I agree, and believe that to make this likely, medical schools, both private “elite” schools like NYU, and certainly state-supported schools, need to take a much higher percentage of students from the lower half of the family income scale, from rural areas and from groups that have been historically underrepresented in medicine. And not just a few more, not just a pilot program with 2% or 5% or 10% of the class. These programs must be far more extensive. The entire class should be composed either these groups of students or of students who, while perhaps from wealthier, whiter, more suburban backgrounds, have demonstrated an extended commitment to service to others. Extended, like the Peace Corps, or Teach for America, or VISTA, or working abroad for years in service programs, not a car wash fundraiser one Saturday.

Some, and sadly this may include many in the administration of medical schools, particularly “elite” ones, will say this can result in the exclusion of the “best” applicants. It may, in fact, lead to the exclusion of some of those with the highest grades, and may even require additional work on the part of the faculty to help students with less rigorous academic preparation. Or, perhaps, elimination of much of the nonsense memorize-detail coursework of the pre-clinical curriculum. But while “best” can mean many things, if the definition is not “most likely to make a positive difference in the health of all the American people” it needs to change, and soon.

Free tuition, at NYU, or other private schools, or state-sponsored schools, may be a terrific idea, and one that should be widely imitated. But it is only one part of an overall strategy, including changes in the selection of applicants, the curriculum of the schools, and the reimbursement of primary care, to significantly change the kinds of doctors that are produced so that they meet our nation’s needs.

Are resident doctors unhappy? Why?

In a New York Times “Upshot” piece on December 7, 2017, Dhruv Khullar notes that “Being a doctor is hard. It’s harder for women”. I do not doubt it, especially the second part. Dr. Khullar goes through a host of reasons for why it is harder for women, most of them related to sexism (including internalized sexism) such as having children, having the bulk of the responsibility for maintaining a household, being seen as less smart or competent by supervisors and colleagues, and on and on. The idea that “being a doctor is hard” is also one I can agree with. However, Dr. Khullar’s piece focuses mainly on residents, medical school graduates who are in specialty training. He opens it with a parody of Tolstoy’s Anna Karenina: “Happy medical residents are all alike. Every unhappy resident would take a long time to count.”

This is where I take issue, at least a little, with his perspective. Mainly this is because I do not remember being unhappy as a resident several decades ago. Tired, often, but not unhappy. I liked the work I did, as a family medicine resident at Cook County Hospital in the late 1970s, both caring for patients in the hospital on a variety of specialty services and in our hospital and community-based outpatient practices. I liked my colleagues, in family medicine and in other departments, and liked working with them. I learned a lot from them. I don’t recall most of my colleagues being unhappy either, and checked with a few with whom I am still in touch, and they also do not recall being unhappy. One, indeed, said he wasn’t even that tired, as he slept through most noon conferences!

There were not only fewer women residents and medical students, but they were (in my  experience) less likely to be married and have children. A small minority of students in my medical school class were married, but now it is common. I married (another resident) and we had our first child during residency, but when I was a program director, the majority of my residents were married by the time they started (I remember a year when five women started the program with different last names than they had interviewed with).

Yet several studies do tend to support Dr. Khullar’s assertions about residents in general being unhappy, as well as feeling overworked, and I think my experience as a family medicine program director and that of one of my colleagues (and former wife) as an internal medicine program director, support the idea that more recent residents seem unhappier, at least compared to us, then, at that hospital. There could be many reasons for this, including the possibility that memory is inaccurate, and distance dulls the pain, but I don’t think that this is the main one.

Another reason could, theoretically, be that the work was less or easier back then. Indeed, at Cook County Hospital in the late 1970s most residents had every-fourth-night call, a direct result of having a residents’ union in the hospital that negotiated working conditions. Dr. Khullar asserts that “The structure of medical training has changed little since the 1960s, when almost all residents were men with few household duties.” I think that he is wrong about this. Residents who trained in the late ‘60s and early ‘70s, before me and the union, often had every other night call (yes, work all day and all night and the next day, then go home and crash and come back to work). There is a reason that these doctors in training are called “residents” and “interns”; Cook County had a residents’ residence, where many actually lived and all had “call rooms” where we could get, maybe, a couple of hours rest. Although call was every 4^th night, there were no other “hours rules”; Cook County had 16 medical services, with 4 taking call every 4^th night and taking every 4^th admission, and the two interns on each service thus taking every 8^th, but this could easily be 10 or more patients per intern per night. And one didn’t get to go home the next day at a certain time even though other services were on call. One specific example was CT scans; Cook County Hospital didn’t have one then, but the private hospital across the street, Rush, did. We could take our patients there, but only at night, when they were finished with their routine scans, and the patients had to be accompanied by the Cook County intern caring for them. Often at midnight, the night after they had been admitted. Residents also did most of the work; attending physicians were not in the hospital at night, and in the day had time only to round on new admissions and those who were very sick. Even having every 4^th night call was a big change from every other or 3^rd night, but I do not think we had less work than most residents have today.

My point is not to try to disparage the tiredness or unhappiness of more recent residents by citing the “bad old days” when things were worse and we had to walk to school in the snow uphill both ways (although the weather was worse in Chicago then, thanks to global warming, and it was possible in winter to arrive and leave in the dark, and thanks to the system of tunnels under Cook County never see the sun). It is simply to note that workload is not the sole, or main, determinant of whether residents are happy or not. And here I can just speak from my limited experience. Many of us who were residents at Cook County Hospital were there for a reason. From the several Chicago medical schools and those further afield, we came because we were committed to providing the best possible care for people who were poor, underserved, and often ignored. We knew, and daily had reinforced, that our best efforts could not make up for the impact of poverty and discrimination; that despite the fact that the hospital did not charge patients, even for outpatient medications (although they had to wait hours for their prescriptions to be filled) the obstacles to their health were enormous. But we, most of us, cared, and tried to do our best. Our residency was not just a step on the path to a career as a successful physician, but an opportunity to work with and try to help people who had real need. We had a mission, not necessarily in the religious sense (although many who came as residents to Cook County were inspired and motivated by their religious convictions).

And, as a result of this shared mission we were each others’ greatest support, personally as well as medically. Medically, the 4 services with 4 residents, 8 interns, a chief resident, and medical students, shared an “admitting ward”, as so we were all together, to consult, to review x-rays, and help with procedures. But personally, we could reinforce each others’ beliefs, and provide support, succor, and even inspiration. I think that was the biggest part, for me at least.

Certainly, my experience at Cook County may not have been typical for residents of the era (indeed, that is part of why I chose it). Certainly, there were unhappy residents then, and uncommitted residents then, and women residents who were burdened with the care of the household and children. And, as certainly, there are now and have been ever since, happy and committed and inspirational residents. I guess “if you’ve seen one, you’ve seen one”. But I am pretty sure that a commitment to something greater than yourself and your self-interest helps a lot, as does training in a place where many of your colleagues feel the same way. And maybe that’s a lot of what we need as doctors, not just residents.

And as people.

Are primary care practices prepared for complex patients? Is this even the right question?

The goal for our national policy should be that every person have the best health status that they can. One component of this, although certainly not all of it, is access to high-quality appropriate health care services. This means that people can receive the care that they need, when they need it, and do not receive unnecessary or harmful care. Access includes both financial and physical (geographic) access, and also access to high-quality care (see, for example, "Et qui vendit pellucidum", a recent blog post by my friend Dr. Allen Perkins).

One part of having access is that there need to be sufficient numbers of providers, appropriately trained and distributed to meet those health needs. It also means that those providers should have no reason or incentive to preferentially provide certain types of care rather than others, or care to certain people rather than others. Unfortunately, the profit motive skews this in the US; we have redundancy of profitable services like “cancer centers” and “heart centers” in major metropolitan areas, with hospitals competing for the same pool of patients, while in other areas even primary care is unavailable. We have excess capacity in some areas (every hospital, for example, needs an MRI or patients might go somewhere else, even if the number of MRI scans the population needs doesn’t justify it; providers prefer to take care of less-complex patients – a single joint replacement in an otherwise-healthy 45 year old with an athletic injury is more profitable than, and thus preferable to, doing a joint replacement in an 80 year old with multiple medical problems).

A recent survey of primary care providers in 10 countries by the by Robin Osborn and colleagues from the Commonwealth Fund, “Primary Care Physicians In Ten Countries Report Challenges Caring For Patients With Complex Health Needs”[1], published in the December 2015 issue of Health Affairs (only the abstract is available free on line) sought to determine whether primary care physicians (there are, at least in the US, other providers like NPs and PAs who are not physicians) feel competent to provide various types of care. The 10 countries were all wealthy and highly developed (Australia, Canada, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States). All but the US have some form of universal health care, although the way that it is organized (e.g., single-payer government health insurance in Canada, a national health service in the UK, multiple non-profit insurers in several others) varies from country to country. In most countries, “primary care” meant family physicians or GPs, but in others (including the US), it also included general internists and general pediatricians.

The researchers found both similarities and differences by country in the percent of primary care practices that had confidence in their ability to adequately address population health needs, especially those that are increasing because of the aging of the population. For example, the confidence of these practices in managing patients with multiple chronic conditions was generally high (from 70% in Canada to 88% in Germany and the Netherlands; the US was at 76%). Fewer practices were confident in other areas, and there was greater variance. For example, 92% of practices in the Netherlands and 81% in the UK had high confidence in providing palliative care, while Sweden (25%), the US (41%), and Canada (42%) were much lower. Similar variations existed for other services (see table); for example, confidence in dealing with patients with substance use related issues were much lower (from 16% in the US to 41% in the UK).

The authors also surveyed whether practices had a number of characteristics that many experts think are important for being able to effectively and efficiently manage complex patients. These included use of electronic health records (European countries were ahead, but the US and Canada, late adopters, are catching up), team based care, after hours care not requiring visiting the ER (the US is very low), access of patients to their medical records (the US is very high as this is one of the criteria for “meaningful use” payments from the federal government), communication between different hospitals, specialists, and ERs with the primary providers (all over the board including in the US), and many other areas.

Of course, these surveys reflect the experiences of physicians in different countries, and are thus subjective rather than compared to some iconic “gold standard”. People do not know what they do not know, or haven’t experienced, or cannot even imagine; their experiences are context-dependent, and so cannot be directly compared. For example, the survey asked whether physicians thought that (their) “system works well; only minor changes needed”.  Only 16% of US doctors answered positively, with the high being in Norway, 67%. However, in the UK the number was also very low – 22%. How can we interpret that? In all of these countries, save the US, including the UK, everyone is covered. 78% of UK physicians may not believe that their “system works well; only minor changes needed”, but what would they think if the alternative was a non-system like the US where there are large numbers of uninsured people? Would they think that a better system? Probably not, but can’t tell from this data.

Finally, and perhaps most important, the survey does not look at whether there are a sufficient number and appropriate distribution of primary care providers to meet a country’s needs even when the practices are well-organized. It is my impression that the answer to this question is closer to “enough” in most of these other countries; I am certain it is not in the US. In our country, the financial rewards for subspecialization and the “lifestyle” (and sometimes financial) rewards for urban location are major determinants in our distribution of providers across specialties and geography. There are far too few primary care providers as a percentage of all physicians, and while family physicians are far more equitably distributed than other specialists, there are still big geographic disparities. Among the many “solutions” that have been suggested, I believe that only one will work: eliminate, or at least dramatically decrease, the income differential between primary care and subspecialties. This is not as far-fetched as it seems; as I have discussed before, high income for some specialists and procedures are not market-drive but are set by policy; Medicare sets these rates.

As far as geographic disparity is concerned, this is an issue that most effects primary care and a few other specialties (psychiatry, general surgery) since most subspecialists practice only in urban areas where there are sufficient populations to use their services. This also can be addressed by money: pay providers differentially more for more rural practice. We also need to provide financial resources to support these practices not only for income, but for wrap-around care. Support must be provided to these practices so that they can afford the capacity to care for the complex problems addressed in the survey.

A general practitioner from Denmark (not one of the 10 countries surveyed) told me about how his anesthesiologist son-in-law really liked his work. I chuckled about how much he must make. He told me no, actually in Denmark GPs make more. This is a good illustration of how our assumptions are context bound.

It is also the way we need to go in the US.

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[1] Osborn R, Moulds D, Schneider EC, et al., “Primary Care Physicians In Ten Countries Report Challenges Caring For Patients With Complex Health Needs”, Health Affairs 34, no.12 (2015):2104-2112, doi: 10.1377/hlthaff.2015.1018

Medicare Advantage plans, CMS, and providing high-quality care to -- and care for -- all people

Medicare Advantage plans, also known as Medicare HMOs, or officially as Medicare Part C, are an alternative to traditional Medicare. By enrolling in such a plan, at additional out-of-pocket cost, the Medicare recipient gets additional benefits that are characteristic of HMOs. This may include smaller (or no) copayments or deductibles, coverage for things not covered by traditional Medicare like dental care, eyeglasses, and hearing aids, and other “advantages”. There are disadvantages, also, of course, just as in other HMOs. Beyond cost, the main one is that there is a limited panel of providers – doctors and hospitals – that the person can use. This is particularly an issue for retired people who travel a lot, or may spend the winter in a warmer climate, since these HMOs’ panels are usually in a limited geographic area.

Older “closed panel” HMOs usually had only doctors and other providers employed by the HMO itself. There are fewer of these than there once were; some of them, like Kaiser, are well-known. Other HMOs are “open panel”, where any doctor can be “approved” to be part of their provider group, but many doctors may choose not to be for reasons such as lower reimbursement or onerous regulation. Thus, it is at least theoretically possible that a Medicare Advantage enrollee could receive lower quality care from the doctors and hospitals that were part of the HMO’s network than from another doctor or hospital that might not be, but would be available to traditional Medicare patients. In addition, some Medicare Advantage plans are open to “dual-eligibles”, people with both Medicare and Medicaid, with Medicaid paying the additional premium. That such programs might provide worse care than others isnot an unreasonable concern based upon other services targeted Medicaid patients (e.g., nursing homes) and other programs targeted specifically to low income people.

Thus, Medicare has developed a rating system for Medicare Advantage plans, which assigns from 1 to 5 stars based, presumably, on carefully considered and assessed quality measures. If you want a good plan, it would behoove you to choose one with a “5 star” rating. Provided, of course, one is available in your area, and provided you can afford the out-of-pocket costs, or, if you have Medicaid, it is one that Medicaid will pay for. Unsurprisingly, many plans that have enrolled Medicaid or other lower-income patients have had lower ratings, based on the outcomes of those patients. The plans argue that this is because these low-income patients are higher-risk, have more co-existing medical, mental health, and social conditions outside of the plan’s control. Others, including the Center for Medicare and Medicaid Services (CMS), which administers Medicare, have argued that considering these characteristics might “give a pass” to plans that provide lower-quality care to poor people. A similar rating system exists for hospitals, and similar arguments have been made. As I discussed in a blog from November 10, 2013, “Does quality of care vary by insurance status? Even Medicare? Is that OK?”, there are legitimate arguments to be made on both sides.

Now, however, according to a report in “Modern Healthcare” on October 21, 2015, CMS interim administrator Andy Slavitt and his deputy administrator who runs the Center for Medicare, Sean Cavanaugh, are considering adjusting its quality ratings for Medicare Advantage plans based upon the pre-existing risk of the patients enrolled. This is important to the plans, since Medicare can drop them if they have several years of lower-than-3-star ratings. And they don’t want to be dropped, because these plans are moneymakers, in no small part because CMS treats them, financially, better than traditional Medicare plans (a result of purposeful federal policy to try experiments to “privatize” Medicare). While new criteria have not been officially announced, and would not take effect until 2017, “The comments from Slavitt and Cavanaugh were somewhat surprising because the CMS has previously downplayed the effects of socio-economic status on the ratings. The agency described the effect as ‘small in most cases and not consistently negative’ in a summary of findings from an analysis the CMS commissioned by the RAND Corp.”

It is not only surprising, but when one considers why the (possible) change of heart is happening, it is difficult to not consider the financial and political clout of the insurance industry that sponsors these programs, and the political support that such “private” Medicare-replacement programs have.  It is worth noting that CMS has not indicated that it will consider revising the ratings for hospitals, despite the fact that hospitals that care a higher proportion of poor and socially disadvantaged people face the same issues. The financial penalty for hospitals is very direct, as Medicare is not paying for readmissions which occur within 30 days. If this seems, on its face, reasonable, consider that sometimes even when the care provided in the hospital is of high quality, people go back to their homes (or long-term care facilities) where it may not be. This is sometimes a result of lack of money, lack of social support, and other stressors, but the result is that they are more likely to be readmitted. Again, CMS has argued that it would not want to encourage hospitals providing lower-quality care for poor people (which certainly would be a bad thing). But if CMS penalizes hospitals for readmissions that are outside their control, it simply encourages hospitals to not care for low-income people, or, if they are sole providers in their community, possibly even close their doors, and that would be a very bad thing. Studies that have been done indeed show that readmissions are higher when hospitals care for lower income and Medicaid patients, and that this is not the result of poorer quality care provided when those people are inpatients. (See “Aiming for Fewer Hospital U-turns: The Medicare Hospital Readmission Reduction Program” from the Kaiser Family Foundation and “Socioeconomic status and readmissions: evidence from an urban teaching hospital” in Health Affairs.)

It is important for CMS to ensure that the care provided to all Medicare recipients (indeed all people) by a hospital is not discriminatory or inequitable and that all patients have access to the care they need at the highest possible quality level. But unadjusted readmission rates are a very crude measure of quality, and it is unreasonable for CMS to expect that hospitals will be able to compensate for the impacts of poverty and lack of access to preventive care and early diagnosis and treatment. It is not unreasonable, however, for us, the American people, to expect that our government develop and help pay for programs that ensure that people’s basic needs for shelter, food, clothing, warmth and other social determinants of health, as well as post-hospital care (access to primary care, home health, and high-quality long-term care).

A single-payer health system is insufficient to address all of these needs. But it is a good start for some of them.

Who will care for the underserved? The role of off-shore medical schools

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I have written in several previous posts (most recently Universal Coverage and Primary Care: The US needs both, May 27, 2010) about the challenges facing American medicine, particularly regarding specialty choice (=not primary care, not rural, not underserved) of US allopathic graduates, and the problems this has already created in providing health care to the American people, which is only likely to worsen as this trend continues. I have noted that, in the production of physicians as in any other process, the outcome results from variables in inputs (who is admitted in this case), the process itself (in education, the curriculum, both formal and informal), and output variables (in the case of physicians, what the practice environment is: reimbursement, work load, quality of life, respect and regard within the profession and community). I have argued that, while output variables may be the most important in terms of specialty choice and practice location, it is the one over which medical educators have the least control. While the curriculum, the process through which we educate medical students, is critical (see Are we training physicians to be empathic? Apparently not., Sept 12, 2009), it is likely that the characteristics of the students selected is most important in determining practice location, particularly for rural areas, but also for urban underserved settings (Medical Student Selection, Dec 14, 2008). Selecting students who grew up in the suburbs of major cities (what Robert Bowman, MD, who has done much research in this area, calls “major medical centers”) in homes with high socioeconomic status and excellent high school and college educations (which is what is mainly done) will result in students with excellent test performance and is likely to produce skilled physicians, but not ones likely to practice in rural or underserved areas.

Students from rural areas, from underserved communities, from low socioeconomic status backgrounds, and from underrepresented minority groups are much more likely to serve these populations, as are students who are older at the time of matriculation. But their lower grades and MCATs, may make them less likely to be accepted, and to have difficulty with the pre-clinical medical curriculum. Students, even from privileged backgrounds, whose prior life history includes significant service are also more likely to work in urban underserved settings; less so (although more than their colleagues without these characteristics) in rural areas. But what about schools of other types or medical schools not in the US?

In a conversation with US Senator Sam Brownback on a visit to his office last year, members of the Kansas Academy of Family Physicians (KAFP) noted the challenges in getting KUMC graduates to work in rural areas. In an off-the-cuff response (I don’t mean to suggest that this was thought-out or his real position; I use the statement as a basis for comment) he suggested that we then just start a medical school at Kansas State University that would train rural primary care doctors. This type of response to a system that is not having the impact that policy makers wish for is common – create a new school, or focus on another different type of school (e.g., osteopathic), or another profession (nurse practitioners, physician’s assistants). But, of course, if they take the same sorts of students and offer them the same range of career opportunities, why would one expect different outcomes? Osteopathic graduates, while still entering family medicine and primary care at higher rates than allopathic, are increasingly becoming specialists. NPs, and especially PAs, are increasingly joining specialty physician practices and remaining in urban areas with high income potential rather than high need. Why would they not? Would you, or your children?

Because there are far more residency training positions than there are US graduates, many of these positions are filled with international medical graduates. A special group of these are “US IMGs”, Americans who, unable to be admitted to US medical schools, attend those outside the country. In the Caribbean, there are many schools, for-profit, set up for precisely this purpose. I recently had the opportunity to give the “White Coat Ceremony” talk to the class entering the largest of these: Ross University School of Medicine (http://www.rossu.edu) on the island of Dominica. Ross, in existence for over 30 years and now owned by DeVry, the largest for-profit educational company in the US, has a “business model” that enrolls 3 classes per year paying tuition much the same as a private US private school or an out-of-state student at a US public medical school. After the first two years, students do clinical clerkships in 70 hospitals in the US that are affiliated with the school – and paid by them. The student body is ethnically very diverse, with over half the members of the class I spoke to born outside the US (although 95% are US citizens or permanent residents; the rest mostly Canadian), but not including a large percentage of students from traditional underrepresented minority groups, and certainly not many from poor families. Ross graduate disproportionately enter primary care specialties, but this is almost certainly because primary care is less competitive than many subspecialties, and the fact that they didn’t train at US schools puts them at a competitive disadvantage in the selection process. Nonetheless, there are several positive things to be said about the Ross experience. First, Ross has a single mission – medical education. The considerable funds it generates are not required to support a large research or clinical enterprise, but can be directed to that mission. Second, it takes students who, because of their grades, wouldn’t – didn’t – get into US medical schools, and gives them a chance to succeed. If there is a high failure rate as a result, there are also unquestionably outstanding doctors produced who would not have otherwise existed. They are able, because of their business model, to take a “chance” on these students – and if they work hard, they can be successful.

While there a very many Caribbean medical schools, of different ages, quality, and size, operated more-or-less on the Ross model, a quite different model exists on another island – Cuba. Whatever its failures, one of the great successes in Cuba since the revolution of 1959 has been the expansion of medical care to the entire citizenry of the nation, and exportation of trained physicians, both Cuban nationals (they are even on Ross’ home island of Dominica) and those from other countries educated in Cuba. The Latin American Medical School (Escuela Latino-Americana de Medicina – ELAM), which educates students from other Latin American countries, began to take students from the US a number of years ago. Unlike those attending Ross and other costly schools, US students at ELAM are virtually all from low socioeconomic backgrounds and mainly from underrepresented minority groups. Tuition is free and living expenses are paid, but there are prices for the students to pay. Admission requires a bachelor’s degree, but students are still required to spend the entire 6 years of medical school that is the usual for countries outside the US and Canada, or 7 if they need to learn Spanish first. They live in minimal dormitories, have very limited access to the internet (1-2 hours per week), and work very hard. They receive a medical education that particularly emphasizes public health, community medicine, and prevention. They promise to complete their training and enter practice in service to the communities from which they come, but it is a promise – obviously the Cubans have no way to enforce this. They receive no training in the US prior to graduation unless they are able to arrange summer observerships on their own, and are not particularly prepared for the “National Board” exams, the USMLE, that are required for US licensure and admission to US residencies. MEDICC (Medical Education in Cooperation with Cuba) , a US group that exists to support US students at ELAM and its graduates, tries to find them mentors who will help orient them to the health system in their own country, the US, teach them about applying to US residencies, and offer guidance in the study for USMLE. The first US graduates of ELAM have entered a few US residencies this year; I have met one, who is phenomenal. Other US medical educators are working with ELAM graduates and offering both advice and opportunities for volunteer training.

The US students at ELAM are the “right students”. They come from underserved backgrounds, are committed to their communities, and are willing to work very hard (perhaps ten years between bachelor’s degree and entering a residency). The question, of course, is not “how can they go to that Communist country?” but rather why are we allowing Cuba to pick up the role that our own medical education system fails to fulfill. Indeed, it would be particularly for those who oppose Cuba and socialism to develop such programs in our own country.

Senator Brownback, if we are going to start a new school in Kansas, let’s model much of it on ELAM. Let’s make it free, and recruit students from underserved communities and underrepresented minority groups, and low socioeconomic backgrounds, and teach them public health and prevention and primary care, and send them out to serve their communities of origin. In the meantime, let us at least have a “sliding scale” loan repayment program where the percent of your loan your repay is tied to your post-residency income, as well as your practice location and specialty choice.
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