Response to 2010 Question of the Year
Currently, the National Health Service Corps (NHSC) and an array of military Health Professions Scholarships provide no-cost medical education in exchange for a period of service. While such programs fill key needs and spare future doctors a substantial economic burden, they come with major costs as well. The NHSC, an excellent program dedicated to drawing young physicians into primary care for the underserved, has drawbacks. To get the full cost of education covered upfront, medical students must commit to primary care even before beginning rotations, a risky move, as many students will testify. Military scholarships bring dedicated physicians into the armed forces but demand lengthy service periods and raise the specter of future involvement in conflicts both ongoing and unforeseen. This prospect is no doubt a deal-breaker for many future physicians.
In light of these concerns, I propose an alternative vision, called a “service residency.” A service residency would be a postgraduate medical training program incorporating an additional three- to four-year service component as part of the training requirement. The goal is to allow medical students to incorporate a substantial and coherent period of dedicated service into their residencies in exchange for no-cost medical education. Given the demographics served by a number of major teaching hospitals, many residencies are already partly service opportunities as much as they are educational ones; a service residency, however, would make dedicated medical service to those patients most in need a core part of the educational process and a point of emphasis for trainees.
The service residency program would be funded by grants from the federal government, which already pays for the bulk of graduate medical education in the United States. In exchange for a commitment to the program prior to matriculation, medical students would receive funding to cover the costs of their medical education and living expenses. These students would engage in a separate residency match. To ensure a service residency placement, the program would limit the number of medical students entering this match to not exceed the number of available slots (extra slots could be made available to other residency applicants, in exchange for debt forgiveness). The federal government would benefit from such a program because more physicians would be available to provide care for the underserved. Residents would, during their service years, essentially be on salary from Medicare to provide low-cost care in high-need areas.
Service residencies could be implemented for practically all specialties at a variety of training centers. Each residency would consist of several years of standard training followed by a service placement. The number of postgraduate years required before beginning the service period would likely vary by specialty, from perhaps two years for internal medicine to four or more for other specialties such as surgery. The resident would, during the service period, work full-time in a high-need area, either near the training center itself or at a more distant location, for example, in a rural setting or even overseas for a time. The sites where service residents might work include federally qualified community health centers, county hospitals, prisons, etc. Because the service period would presumably involve a higher degree of independence, completion of the United States Medical Licensing Examination Step 3 and program approval would be required before commencing those years of work. Through their relationships with academic health centers, young physicians involved in the program would have access to the resources of their institutions through regular consultation with mentors, continuing education programming, and research opportunities. After completion of the service component of the program, residents could continue with any final capstone training years. Program directors would have the option to allow fellowship training to occur before the service period, bringing more skills, where needed, to the community.
A major benefit of the service residency program is that it would allow medical students the flexibility to choose from a variety of specialties, instead of solely providing a primary care option. The availability of service residency slots in certain fields would encourage more students to enter those areas for which need is acute, such as family medicine and psychiatry; however, the program would also provide routes for service-oriented training in surgery, dermatology, cardiology, and any number of other specialties. Some may question the idea of loan forgiveness for those physicians opting to specialize. We should consider, however, that students entering more lucrative specialties still have the opportunity to choose where and how they practice and that underserved populations also need specialist care. Relieving medical students, regardless of the specialty they choose, of the burden of debt while encouraging them to engage with underserved patients early on in their careers will not only improve the quality of life of physicians and reduce their stress levels but also will foster a lifelong commitment to service across all specialties and enhance care for underserved populations.