May 3rd, 2019
The Atlantic, in partnership with STAT, recently hosted its third annual conference on health care in Boston. Pulse: The Atlantic Summit on Health Care featured experts on a wide range of topics, from Medicare for All, to discrimination and sexism in medicine, to social determinants of health. There was also plenty of discussion on “fixes” for these tough problems in health care.
Changes to medical training were a hot topic at Pulse this year, for good reason — the way we train clinicians directly affects how they will practice medicine. Here are a few of the top solutions that were proposed to “fix” medical training:
One solution that a few presenters mentioned was targeting the high cost of medical school that often acts as a barrier to entry and source of anxiety for students.
“We have created a kind of horror show for medical education,” said Ezekiel Emanuel, Chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania. The high cost of medical school (the average medical student debt is now $190,000) creates “perverse incentives” to go into high-paying specialties after training, when the real need for doctors is in primary care and care in underserved.
To ameliorate this problem, Emanuel suggests forgiving medical school debt for doctors who go into primary care in an underserved area — 2 years of service for each year of free tuition. “The total cost of medical education is peanuts when you consider $3.5 trillion health care economy,” said Emanuel.
For Robert Grossman, Dean and CEO of NYU Langone Health, the decision to make medical school free was a moral imperative. “There were kids living hand to mouth, operating at the margin. We didn’t want to obligate the students family and the students for operational costs at the institution,” said Grossman.
It took 12 years of fundraising to be able to secure this endowment, but Grossman believes it is possible for other schools to follow in the footsteps of NYU (as Kaiser Permanente’s medical school has done). “Medical schools ought to ask themselves what they’re doing with the tuition money,” said Grossman.
While Grossman cites substantial increases in the number of racial minority and low-income applicants, the effect of free tuition on diversity of future graduating classes remains to be seen. As some have pointed out, NYU’s free tuition is not purely philanthropic, but also serves to increase its competitiveness (and thereby its national ranking).
Medical training has begun to include more information on the social factors that determine health, such as education, income, and racism. However, as experts at Pulse pointed out, these topics are still for the most part on the margins of medical education.
The structure of medical education signals to students what is important in medicine. Much of the first two years of medical school are based around biochemistry, molecular biology, and physiology, but barely touch on doctor-patient communication, social determinants of health, or racial health disparities. “There’s this idea that it’s not hard science,” said Damon Tweedy, Associate Professor, Duke Medical School and Author of Black Man in a White Coat.
By treating topics that are essential to patients’ health and wellbeing as marginal, students learn that they aren’t “really important” to the practice of medicine. “Students will say, ‘It’s nice to know about social determinants, but we’re not getting tested on that,'” said Tweedy.
We need to restructure medical education to center the skills and information that students will use the most in their practice, including learning about the social factors that determine health, communicating with patients, and critical thinking skills.
We know that representation in medicine matters for people of color and medical training can be either a pipeline or a barrier to this representation. How can we improve diversity in the medical student population?
If we are expecting medical schools to solve the problem, we’re looking too far downstream. “The solution to this is a systems problem and we need the educational system to be involved,” said Patrice Harris, President-elect of the American Medical Association. That includes not only medical schools but elementary education and early childhood education. “It has to start with the 0-3 population…in how we care for our children, and how we make sure that they have the appropriate educational opportunities,” said Harris.
Being able to show young children of color that they can be doctors is extremely important as well. “The first time I actually saw an African American male physician I was in college, and it was a big part of my decision to go into medicine,” said Tweedy.