Primary Care: Collapsing the Pipeline

With a 35,000 primary care physician shortage coming up in 2025, eventually the healthcare policy agenda is going to shift back to the medical education pipeline. In my previous piece on the Iranian healthcare system, I predicted that community health workers were a political dead-end because of the labor market lockout that the AMA has on the healthcare industry. I still predict that’s going to be true, which means that the conversation is instead going to focus on training physicians more efficiently. Fortunately, there’s already work being done on this front.

NYU SoM’s annual report highlights (NYU Three Year Pathway) the three-year medical program that the school launched in 2013. Back then the primary goal of the compressed schedule was to lower the overall cost of medical education and differentiate NYU SoM from the rest of the competition in the medical school marketplace, but the efficiency gains due to reduction in training must not be ignored.

The first batch of students in the compressed program are now graduating, with 15 out of 16 in the inaugural class successfully completing the degree. In addition, testing of the students shows the three year students demonstrating better knowledge and clinical skills than four year students at the end of their respective programs. This finding has enormous potential ramifications and requires additional research. Was the first three year class special, with top performing students self-selecting into the more ambitious program? I’d like to see a comparison of the three year program graduates against other program applicants who were rejected from the three year program due to space limitations and enrolled into the four year program instead. In addition, the three year students may be performing better because they’ve simply had one year less to forget everything that they crammed in MS1; it would be interesting to compare the clinical skills and knowledge of the three year graduates against their four year conterfactuals after they’ve been practicing medicine for a decade to determine which method is really better at integrating the knowledge for long term use. In the meantime, however, the three year program appears to be winning.

accelerated-three-year-md-pathway

What’s important about the accelerated program is that it’s still not fully optimized. The majority of the program time savings is done through cutting down on the time dedicated to electives and residency interview. This is possible because the three year applicants are admitted with a guaranteed residency slot. However, the  students in the three year program retain the option of switching back into the four year program,m which means that the core curriculum is still over-training physician to be able to go to any residency. The core curriculum can therefore be collapsed even further to focus only topics and rotations relevant to primary care. I would be shocked if such a degree can’t be reduced to a two year program. Could we produce a family physician in one year? Probably not. But a two year program would be a 100% efficiency gain.

Not to mention that being able to filter out primary care physicians out of the same pipeline that needs to train academic researchers and neurosurgeons would allow institutions to price the degree more appropriately, therefore further reducing the cost barrier of entry. The specialization could also allow institutions to relax their requirements for acceptance. Could we then get away with accepting people with high school degrees into this specialized primary care program, therefore collapsing the current 8 year primary care physician pipeline into a 2 year one? I don’t see why not. There’s no reason to require a Bachelor’s degree; practicing clinicians don’t use what they learn for their premed coursework and MCAT. Students in Europe start medical school straight out of high school and our kids aren’t any dumber.

The efficiency gains are enormous, but we’ll need to do the work to achieve them.

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