Shomaker, T. Samuel MD, JD
Dr. Shomaker is Jean and Thomas McMullin Dean of Medicine and vice president for clinical affairs, Texas A&M Health Science Center College of Medicine, Bryan, Texas.
Correspondence should be addressed to Dr. Shomaker, Texas A&M Health Science Center College of Medicine, 3050 Health Professions Education Bldg, 8447 Highway 47, Bryan, TX 77807; telephone: (979) 436-0205; fax: (979) 436-0092; e-mail: firstname.lastname@example.org.
Following World War II, Europe was in ruins and communism threatened to take over much of the continent. In response, the United States implemented the Marshall Plan in 1948, providing $13 billion to rebuild the economy and infrastructure of Western Europe. When it ended in 1952, the plan was credited with preventing disease and starvation, averting economic chaos, and laying the foundation for a free, democratic Western Europe.1
Today the medical profession faces unprecedented challenges. Although most patients still trust their individual doctors, the standing of the profession as a source of moral authority has suffered significantly.2 The notion of the family doctor as a trusted source of advice has eroded in the face of the expanding use of technology, increasing subspecialization, and the pressures of commercialization. Conflicts of interest in relationships with pharmaceutical and device companies, physician ownership of for-profit medical facilities, and the growing number of doctors who close their practices to uninsured or publicly insured patients have contributed to a growing public perception that medicine is more about money than about healing. Health care reform, in which physicians seem unwilling to make sacrifices of income or prerogative, has only accentuated this trend. The medical profession needs a Marshall Plan to rebuild its service ethic and public image.
The four major goals of the Medical Marshall Plan are
* to restore public trust in medicine through a significant commitment to service by the profession and medical schools,
* to reinforce the altruistic impulse in our students, communicating the importance of giving back in exchange for the privilege of serving as a trusted healer,
* to remove the financial pressure of medical school, ensuring that the profession remains open to people from all economic, ethnic, and social backgrounds, and
* to address major workforce issues facing the health care system, including the shortage of primary care doctors, the maldistribution of physicians in urban core and rural areas, and the inadequate access of underinsured patients to primary and specialty care.
Under the Medical Marshall Plan, the federal government would fund the first two years of medical school for all students. Tuition payments would be set at the national average of public and private school tuitions; students desiring to go to schools with tuition more expensive than the average would pay the difference. All students would get a loan for the third- and fourth-year tuition based on a similar methodology.
In return for the first two years of tuition forgiveness, all graduating students would complete a rotating (transitional) internship followed by one year of compulsory service as a general practitioner (GP). Service could be performed in a variety of settings benefiting the local, regional, or national community, including Health Professional Shortage Areas, which are found in urban core and rural areas characterized by chronic shortages of care providers; Federally Qualified Health Centers; the Veteran's Administration; the Indian Health Service; the U.S. military; a local, regional, or national public health agency; or as a research fellow at the National Institutes of Health. A national match of sites and GPs, based on the National Resident Matching Program, would be used to place graduates. GPs would provide primary care in ambulatory settings, serving patient populations that frequently lack adequate access to primary and preventive health care. They would be supervised by board-certified attending physicians, either directly or remotely by telemedicine. GPs would receive a small stipend and living expenses during their service.
Following the year of compulsory service, GPs would have three options. First, they could stay on in their practice site, earning an additional year of tuition forgiveness for each additional year of service and receiving preferential treatment in subsequent residency program applications.
Second, they could return to primary care residency training, an election that would trigger forgiveness of the remainder of their medical school indebtedness. Third, they could enter a specialty residency, in which case the debt from the third and fourth years of medical school would become theirs to repay. However, on graduation, should they agree to work for a public service provider, their debt would be forgiven at the rate of one year of forgiveness per year of service.
The Medical Marshall Plan would be expensive and require major modifications of the current practice and educational environment. However, it holds promise as a way to address some of the nation's health system issues that are likely to become more pressing as health care reform expands access for millions of new beneficiaries. It would also go a long way toward rebuilding medicine as a trusted, service-oriented profession.
2Imber JB. Trusting Doctors: The Decline of Moral Authority in American Medicine. Princeton, NJ: Princeton University Press; 2008.