Response to 2010 Question of the Year
The passage of the Patient Protection and Affordable Care Act raised the prospect of 37 million newly insured Americans able to seek the services of primary care physicians, a change that will require a significant increase in the number of primary care physicians practicing in the U.S. In January 2010, the Josiah Macy Foundation convened a conference to address primary care needs. In Conclusion II, Recommendation 2 of their proceedings, the following point emerged as a solution to this shortage of primary care physicians: “Implementing and expanding scholarship and loan repayment programs in partnership with health systems, governmental agencies and communities for those pursuing primary care.”1
Like a number of other medical schools, such as the University of California Merced and Tulane,2 that have developed “fast track” programs, we propose a new approach that reduces the total time and cost of medical school, called, “The Primary Care Med-ED Plan.” Participating medical schools would develop educational programs that allow students to complete the requirements for an MD degree in three and a half years. Once accepted to medical school, students interested in the Med-Ed Plan would choose a length of involvement, ranging from two years to a maximum of three and a half years. In addition, the U.S. Department of Education would sponsor and administer the loan portion of this new program, called the Med-ED Loan Program. Loans awarded to students under the plan would go directly to the medical school for tuition and fees, and any award for living expenses would be distributed to the student through the financial aid office. Any remaining financial aid needs could be met by the federal Stafford Loan program.
On graduation in January of the fourth year, entry into a rotating internship through the medical school's hospital consortium would be required, thus circumventing current National Resident Matching Program issues. At this time, students would select an emphasis that reflects the primary care specialty they would like to practice after Year One of the internship. At the completion of this two-year internship program, physicians would begin their service in an approved, federally qualified local clinic. New physicians would be salaried and receive year-for-year Med-ED loan forgiveness for each year of service up to three and a half years.
The Accreditation Council for Graduate Medical Education and the primary care specialties will need to increase the flexibility of their board certification requirements without altering the quality of both the internship year and the more focused second clinical year. The clinics and nearby medical centers with approved residency programs will be encouraged to develop supervised experiences that could be accessed by these graduates. While a physician is repaying his or her Med-ED loans, a select number of these supervised experiences could be put toward completing a residency in the primary care specialty that was chosen by the participant, thus leading to the graduate's ability to seek board certification while still serving the community. For those physicians who completed the Med-ED program, the remaining length of time of their residencies would be reduced. Should they wish to stay in the system and obtain board certification, that option would exist as well.
Similar scholarship or loan programs with a service component are frequently seen by students as seriously reducing freedom of choice and lengthening the time until students are able to practice as they desire. Thus, constructing a program, like the Med-ED Plan, that counterbalances some of the prevailing attitudes, is necessary. The opportunity to reduce total indebtedness, as tuition and fees amount to at least 60% of the total cost of medical school for instate students and significantly more for out-of-state students, while meeting many, if not all, residency requirements, should be particularly attractive to prospective students. We also anticipate that primary care specialty boards will accept most (or all) of the internship year toward their residency requirements. Primary care clinics will be encouraged to provide appropriate supervised experiences so that additional residency requirements can be met at that time as well. In addition, as the number and location of primary care clinics will have to be expanded to meet the nation's health care needs, students can expect to have considerable latitude in selecting a personally desirable clinic for payback service and will not have the stress of competing in the normal resident match. Finally, students can look forward to engaging in activities that remain consistent with future career goals. Together, these features represent an education–service exchange program that will appeal to many students.