How do we improve medical student to family medicine resident recruitment?
I have seen class after class come into our medical schools bright and eager to practice the excitement of the specialty of family medicine only to come out four years later entering limited practice specialty residencies.
Individuals in internal medicine training delay their decision to avoid general medicine only by a few years since 80 percent of their pipeline in residency ends up in a sub-specialty.
Why does this happen?
In early August, I ate lunch at the AAFP Resident and Student Conference with two delightful students - one from a southeastern state university medical school and one from a metropolitan mid Atlantic city. - The one from the southeast is considering family medicine, pediatrics and psychiatry as career choices. She had taken a year off between her second and third year to get away from the stress of worrying about the debt - yes the debt - not the curriculum - not the call - the debt. She was at that point $80,000 in debt and wanted to figure out if it was worth going on. Fortunately, for the thousands she will touch and help in the future, she decided it was worth it and she came back.
The other student was more up-front. She goes to a private medical school and her borrowings yearly average $75,000 a year. Her debt for her medical education will equal a house purchase. She is enthusiastic and excited and sees the investment as worth it.
To quote James Carville, "it's the economy, stupid."
Students coming out of medical school see years of debt repayment (the southeastern student figures she will be paying off her educational notes for the rest of her life.) vs. life in a "doughnut specialty" with high procedural payments able to give them a comfortable life and pay off a mountain of debt at the same time.
We used to worry about the academic bigotry and specialty racism endemic in the non-family medicine faculty in our academic centers. I'm not seeing that as much recently. It may still be a factor but the quality of our graduates turned out in difficult times and the excellence of our faculties hopefully have put that to rest. Sure, there are some screamers around but they are recognized for what they are - insecure within their own persona as physicians and people. To again quote James Carville, "it's the economy, stupid!"
We must reform how family physicians are paid for their services. Pay family physicians 2/3 of what an orthopedist, a dermatologist or a radiologist makes and you won't have enough slots out there to train eager smart young medical students who are passionate to be family physicians. There are typically two types of services provided - episodic illness (usually structural problems) and ongoing continuous, comprehensive, coordinating, compassionate, caring for life and wellness for life care (apply these to any other specialty and they will come up wanting).
Unfortunately, we in the US have been boxed into the single type of payment - episodic payment for illness-based care for our services. Take out my appendix and follow me for 6 weeks and get paid a global fee. Deliver me from my mother, protect me by immunization, suture my lacerations, counsel me about sexuality, manage my diabetes, control my hypertension, diagnose my chest pain, counsel me when I find drugs in my kids room, advise me about the risks and benefits of prescription drugs, care for me during my surgeries, find my cancer and hold my hand as I die (The Value of Family Medicine) and get paid a pittance for each episode - having to fight a system that does not recognize the value of comprehensive life long care.
That care needs to be paid as a comprehensive service. Paul Ellwood and the Jackson Hole Group were right with the HMO concept. Call it now the RUC proposal for the Medical Home. Call it concierge medicine. Comprehensive payment on an ongoing basis for comprehensive ongoing care is long overdue. The AAFP needs to have a seat at the table leading up to the changes in the American medical system. If not for us, then for those two young students and their patients. I promised it to them.
Individuals in internal medicine training delay their decision to avoid general medicine only by a few years since 80 percent of their pipeline in residency ends up in a sub-specialty.
Why does this happen?
In early August, I ate lunch at the AAFP Resident and Student Conference with two delightful students - one from a southeastern state university medical school and one from a metropolitan mid Atlantic city. - The one from the southeast is considering family medicine, pediatrics and psychiatry as career choices. She had taken a year off between her second and third year to get away from the stress of worrying about the debt - yes the debt - not the curriculum - not the call - the debt. She was at that point $80,000 in debt and wanted to figure out if it was worth going on. Fortunately, for the thousands she will touch and help in the future, she decided it was worth it and she came back.
The other student was more up-front. She goes to a private medical school and her borrowings yearly average $75,000 a year. Her debt for her medical education will equal a house purchase. She is enthusiastic and excited and sees the investment as worth it.
To quote James Carville, "it's the economy, stupid."
Students coming out of medical school see years of debt repayment (the southeastern student figures she will be paying off her educational notes for the rest of her life.) vs. life in a "doughnut specialty" with high procedural payments able to give them a comfortable life and pay off a mountain of debt at the same time.
We used to worry about the academic bigotry and specialty racism endemic in the non-family medicine faculty in our academic centers. I'm not seeing that as much recently. It may still be a factor but the quality of our graduates turned out in difficult times and the excellence of our faculties hopefully have put that to rest. Sure, there are some screamers around but they are recognized for what they are - insecure within their own persona as physicians and people. To again quote James Carville, "it's the economy, stupid!"
We must reform how family physicians are paid for their services. Pay family physicians 2/3 of what an orthopedist, a dermatologist or a radiologist makes and you won't have enough slots out there to train eager smart young medical students who are passionate to be family physicians. There are typically two types of services provided - episodic illness (usually structural problems) and ongoing continuous, comprehensive, coordinating, compassionate, caring for life and wellness for life care (apply these to any other specialty and they will come up wanting).
Unfortunately, we in the US have been boxed into the single type of payment - episodic payment for illness-based care for our services. Take out my appendix and follow me for 6 weeks and get paid a global fee. Deliver me from my mother, protect me by immunization, suture my lacerations, counsel me about sexuality, manage my diabetes, control my hypertension, diagnose my chest pain, counsel me when I find drugs in my kids room, advise me about the risks and benefits of prescription drugs, care for me during my surgeries, find my cancer and hold my hand as I die (The Value of Family Medicine) and get paid a pittance for each episode - having to fight a system that does not recognize the value of comprehensive life long care.
That care needs to be paid as a comprehensive service. Paul Ellwood and the Jackson Hole Group were right with the HMO concept. Call it now the RUC proposal for the Medical Home. Call it concierge medicine. Comprehensive payment on an ongoing basis for comprehensive ongoing care is long overdue. The AAFP needs to have a seat at the table leading up to the changes in the American medical system. If not for us, then for those two young students and their patients. I promised it to them.
posted by George W. Shannon, MD at
6:03 AM
2 Comments:
I am a board-certified internist. Family practice doctors, internists and pediatricians do need to be paid for their services. However, looking to the government or third-party payers to do this is futile. The answer lies in direct financial relationships between doctors and patients, what is called concierge medicine. I opened one of the first concierge practices in the country 8 years ago. I would never go back to a third-party payer system again.
Steven D. Knope, MD
Author, "Concierge Medicine, A New System to Get the Best Healthcare"
www.conciergemedicinemd.com
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