Lane: 21st Century Uncle Sam: ‘I want you’ (for primary care)

We’ve all seen the old recruiting posters in high school history class: Uncle Sam stares outwards, his eyes blazing with determination and his finger pointed straight at you. In all capital letters, “I WANT YOU FOR U.S. ARMY” is printed. Back then, the military was looking for young men to turn into soldiers. Now, we are — or more accurately, we should be — looking for more college students we can turn into primary care physicians. Across the US, we simply don’t have enough, and it’s hurting us.

Haven’t heard of this primary care shortage? You can see it for yourself on this interactive map from the Rural Health Information Hub, which is based on data from the federal Health and Human Services Department. Every single state has counties in shortage, and none even come close to having more counties with enough primary care doctors than ones without. Many states entirely lack counties that aren’t at least partially experiencing a shortage, including New Hampshire. In New England, only Chittenden County in Vermont has enough primary care doctors. It’s ridiculous! How is our health system supposed to function if we don’t have the doctors we need to do the basic diagnoses and preventative care that forms the bedrock of keeping people healthy in the long-term?

Primary care doctors are essential. Why should be obvious if you believe the old saying that “an ounce of prevention is worth a pound of cure.” Primary care doctors help people stay healthy by encouraging better eating and exercise habits, helping people quit smoking and other dangerous habits, managing chronic illness, and detecting potentially fatal diseases early when they are more easily and inexpensively treatable. Simply being generally available for anything that hurts, aches, stings, or just feels off, but also doesn’t quite feel ER-level urgent, is crucial too. They are key members of their communities, especially in rural and low-income urban areas. Community doctors are community anchors. But, even if you don’t see the fairly obvious conclusion here, the data backs it up too. In a cohort study done in Rhode Island from 2007 to 2016, researchers found that when primary care is put in the driver’s seat, not only do emergency room visits and hospital admissions in general decline, but preventable ER visits in particular go down and the highest-risk patients see the biggest benefits.

What can we do about this problem? A big, but addressable, part comes from the fact that primary care physicians only make about half of what most specialists make. A quick exercise with the Bureau of Labor Statistics’ website will show the disparity: when compared to family medicine doctors and general internal medicine doctors — two of the three types of primary care doctors — cardiologists make on average about 50% more, anaesthesiologists make almost 40% more, and both radiologists and dermatologists make over 25% more. That’s saying nothing about pediatricians, the third type of primary care doctor, who make only about 80% of what the other two types make. Given that medical school is so expensive, why should students go into primary care? If you have hefty student loans, you will likely want the highest income you can get. Tuition at Dartmouth’s Geisel School of Medicine, for example, is almost $70,000 a year, and even though they do give need-based aid, it can include loans, which are hardly financial aid. Financially speaking, going into primary care is really hard! Given that we need more primary care doctors, we need to address this disincentive.

Because physician fees are controlled by a board that is overwhelmingly composed of the high-earning specialists — the American Medical Association’s Relative Value Scale Update Committee — the better way to solve the issue is for states or the federal government to help medical school graduates pay off their student debt if they go into primary care. Extra aid can be given to those who choose to work in areas considered to be in shortage by HHS. Governments could also make tuition at public medical schools free via additional funding, which would have the added benefit of pressuring private medical schools to rein in their ridiculous fees. Both of these ideas, while costly upfront, would likely trickle back to taxpayers via fewer visits to expensive emergency rooms and hospitals.

In addition to the financial side of the equation, the quantity of medical students also needs to be increased. It’s incredibly difficult to get into medical school, and for no good reason. Geisel’s acceptance rate is a tad over 4%. Nationally, medical schools average at about 6%. Surely, not all of the roughly 94% of applicants that a given medical school turns away are unqualified? Pre-med students put themselves through hell out of fear of these harsh cutoffs, and all the while, we have a shortage of doctors. We are torturing college students who hope to enter a noble profession just so we can also torture the American population at large on the other end.

The point here is that medical schools need to admit more students. It sounds simple, but the reality is that no school will do so out of fear of jeopardizing their rankings, which are often based on their acceptance rate. More admitted students means a higher acceptance rate, which means a lower ranking. Terrifying, I know. Like any collective action problem, the only way to get more medical students without jeopardizing those precious rankings is the simultaneous admission of more students. Government action is again the best solution here. Grants can be given to any school who in turn uses that money to add the necessary facilities and faculty to admit more students, with a clawback mechanism for schools that don’t actually end up admitting more students. State schools, already answering to state legislatures, would be a good first target for these grants, and combined with a surge in applicants driven by free tuition, their rankings could surge. Private medical schools would have to respond, kicking and screaming as they may.

I’m well aware that none of these policy solutions are easy asks. But, nothing that is worth it is an easy ask when it comes to big problems. If we want to stave off the decline of preventative medicine, we will have to swallow uncomfortable pills like these.