Just years away from becoming full-fledged health care providers, students at Dartmouth Medical School said they find the U.S. health care system deeply dysfunctional and in need of widespread change.
"The system is broken," Adam Kassam DMS '12 said. "I don't think you'd find anyone in the medical community that would disagree with that."
Many DMS students expressed frustration with the misconception that higher costs lead to better medical outcomes, and pointed to the need for more primary-care physicians. The Dartmouth Atlas of Health Care has shown that communities with vastly different levels of spending on health care generally enjoy similar health care quality.
Crandall Peeler '03 DMS '10 said he spent one of his away rotations, in which students spend time working at a medical facility off campus, in rural Bethel, Alaska, several hundred miles west of Anchorage. The region is a "roadless wilderness" where airplanes are needed to transport people in the surrounding communities to a single hospital, he said.
The mostly Native Alaskan population must call the hospital to determine whether they are ill enough to be airlifted to the medical center because there are no primary care physicians in outlying areas, he said.
Peeler described how one patient, a woman in her 20s with advanced AIDS, died en route to the hospital.
"It's crazy to me that someone with HIV would be living so far away from doctors and a hospital because their care is so complex," he said. "People in their 20s with HIV should not be dying in the U.S."
Kassam pointed to the disparity between the number of students going into primary care and those entering specialized fields. When students graduate from medical school with tens of thousands of dollars of debt, he said, many do not want to go into the less lucrative field of primary care.
Alexandra Coria DMS '12 explained that primary care doctors receive lower reimbursements from Medicare and insurance companies than do doctors in specialized fields that require more procedures.
"It adds a perverse incentive to the system," Coria said. "We need to switch the incentive so that more people get better care."
Coria said she wishes that those who oppose health care reform could spend one day in an inner-city emergency room to see what happens to the uninsured.
Dana Lin '06 DMS '12 said she believes there will be an increased emphasis on prevention and evidence-based medicine in order to reduce costs over the next few years. Even with prevention, however, an effective infrastructure must be in place to treat those who become ill, she said.
"A lot of the things that revolve around health care aren't involved in choice," Lin said. "When you realize the diseases that your family or friends have gotten through no fault of their own, you wouldn't want to deny them health care."
Ryan Jaber DMS '11 said in an e-mail that, in his clinical work, he often sees patients who have delayed routine procedures because they are uninsured. As a result, their illness was in a more advanced and less treatable phase once they sought care, he said.
Doctors "don't know how to think in an economic way," which can make hospital administration inefficient, Coria said.
Brian Guercio DMS '10 said in an e-mail that he worked at a hospital where an administrator proudly explained that the landscaping budget had remained untouched as other departments cut costs. Guercio said this doctor told him that patients would lose confidence in the quality of care at the facility if they saw that the hospital could not take care of its flowers.
Medical students repeatedly said that they wish people would stop focusing on the misinformation presented in the ongoing health care debate about so-called death panels, which would allegedly decide which patients would receive treatment and which would not.
"The patient always has autonomy over how their life ends," Lin said.
Many medical students are not well informed about the health care debate because the DMS curriculum is packed with classes that focus primarily on science and medicine, Coria said.
"The attempts to infuse the curriculum with more health care policy have not been very effective," she said. "We're sort of entering new territory. It's important that medical students know how much their voices matter in this debate."
While students interviewed by The Dartmouth did not overwhelmingly support one of the policy proposals currently being debated, they agreed that change is needed to improve the current system.
"Everyone needs to rally behind the idea that we can fix it and provide health care to everybody," Kassam said. "It's a fundamental necessity."