What needs to be done to make sure we have enough providers, particularly at
the primary-care level, to serve all Americans?
BRATER: It’s a [multifaceted] issue. I heard the comment that we need to build on what’s working. As far as I can tell, nothing is working. The entire system is broken. The deficit of primary care is just one small element of that, but it’s symptomatic of many of the issues that are involved here.
So why aren’t kids going into primary care? One reason is that today’s generation of students, when you survey them and ask them what determines their choice of specialty, they list debt. Debt’s on the list, but the No. 1 thing they list is lifestyle. So the perceived lifestyle of a primary care practice in a small community is such that that scares a lot of kids away. I don’t have a ready answer to that.
Are there things that we can do to try to make it less onerous to be practicing primary care? [Can we] change the perceptions of the kids that are being attracted into medicine in the first place? Maybe we’re not admitting the right people to medical school. I think we have to ask ourselves all of those questions.
If you go into primary care, you end up on average coming out of medical school with $150,000 of debt. And practicing primary care is not remunerated sufficient for anybody to rationally look at that debt and what they might make and say, “This is a wise decision.” It doesn’t make any financial sense to do it.
So we have to address the screwed-up economics of how we reimburse for care and the things that primary care physicians do. Everybody says it’s extremely important. Well, why aren’t we rewarding them for it? So we need to just start from scratch and blow the whole thing up and begin from zero.
EVANS: To Craig’s point, I have encouraged—and so has the school—the Indiana delegation to help young physicians on the other end of their experience. That is, in forgiving or discharging their debt if they go in to certain fields. We do it in other parts of society. We just went through Cash for Clunkers. Why wouldn’t we have a similar program to encourage physicians to go into certain areas? The bills being kicked around are mute on the issue of medical education. So it looks to me that even if we have health care reform, major parts of the system are going to remain, to quote Dr. Brater’s technical term, “screwed up.” And we just need to brace ourselves for that.
OBEIME: I am a family physician, and today I look back and I have no regrets that that’s what I did. I say this to remind everybody that there are doctors out there who will practice medicine and be very happy with what they’re doing even if we’re not paid for it. That does not mean, though, that we should not be respected and that we should not be compensated.
I know the system is broken, but we have the ability to look at what has been done everywhere else in the world. I talked to a friend of mine a couple of days ago who is a general practitioner in Europe. We went to medical school together. He did OB-GYN when he went to London. Then two years ago, he called me very excited that he finally got a position to practice as a general practitioner. I said, “Why would you do that?” And then he explained to me that family practitioners were more respected, they got paid more, they had a better lifestyle, and a lot of people’s goal was to work their way to get to that position.
It wasn’t about how much money they get paid. It was the fact that they practiced as a team. In this country we have physician assistants, we have nurse practitioners, we have dietitians, we have social workers, and we have lifestyle modification specialists. If we all allowed the situation where we would work together as a team to take care of patients, we would not need a doctor to see each patient all the time. It would drive down the cost, and it would make the patients happier.
Patients who come to my office, I don’t think they’re happy because they see me. They’re happy because they see my social worker, Brooke, who helps them figure out how to get their food, how to get transportation, how to get medications when they cannot afford it.
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