“So doctor,” she said as I pulled my stethoscope out to listen to her heart, “where did you go to medical school?”
Terrific piece by Pauline Chen describing the stark disconnect between our national health care workforce needs and what our medical schools produce.
Our nation desperately needs a larger and more effective primary care workforce. This need is driven by the decades of research linking high performing health systems to good primary care. People who have more access to good primary care (easy access, good relationship, comprehensive services, care coordination) are less apt to end up the hospital or emergency department - an outcome we can all agree is in our personal as well as collective best interest.
Even better, people who receive good primary care are more apt to have preventive care needs met and those with chronic conditions are more likely to have those conditions under better control. Adding to the benefits: people with good primary care are less likely to miss days from school or work and their total costs of care are lower.
Populations served by high concentrations of intensivists/proceduralists/specialists have increased cost with no demonstrable (and sometimes worse) overall outcome improvement.*
U.S. medical schools are pumping out ever increasing proportions of intensivist/proceduralist/specialist that our country does not need while the pipeline of primary care dries up.
One root cause of this problem is the way the NIH funds medical schools. Inside the industry, medical school rank is a pissing contest to see who gets the biggest NIH check. The bulk of NIH funding goes to highly specialized research while very little supports the core issue plaguing our nation today: ineffective, over stretched, over burdened primary care unable to meet the needs of America. (And I suspect almost nothing is spend to study how to better support solo and small practices that still make up the majority of practices in the U.S.)
Our national culture equates dollars with value. The low dollar flow to primary care research implies low value and predicts the culture of medical school faculty who systematically belittle primary care as a career choice and berate those who admit an interest in primary care.** An expressed interest in primary care can turn the back-to-back specialty rotations of third and fourth year of medical school into a prolonged hazing incident.
Nothing short of a major funding shift will change this culture. The occasional rotation with a PCP, the extra lecture or two from a community primary care physician, the extra residency slots for primary care are all nice but all fail to address the root cause: money.
It is time to stop this misadventure in funding that supports systematic bias against our urgent needs as a nation. Washington must send a clear signal that the status quo is unacceptable with a major shift in funding to support research in effective primary care. This federal signal would force medical schools to stop considering primary care orphan step-child of medicine and consider its rightful place as the foundation of a high performing health system.
* Starfield, B: Threads and Yarns: Weaving the Tapestry of Co-morbidity Ann Fam Med 2006;4:101-103
See also the Dartmouth Atlas
** Hauer KE, Durning SJ, Kernan WN; et al. Factors associated with medical students' career choices regarding internal medicine. JAMA. 2008;300(10):1154-1164.