Shortening U.S. medical education can significantly improve U.S. population health. As patients and stakeholders of U.S. health care, we are at crisis levels. There are not enough primary care doctors for the U.S. population — a basic human need for health and safety — which creates inequities. Peer-reviewed medical literature and mainstream media both document the highest burnout rates are in primary care and ER doctors, especially since the pandemic, particularly in female physicians, who are half the U.S. physician workforce.
The Commonwealth Fund showed in 2021 that the U.S. has the lowest percentage of primary care doctors (20 percet) compared to all the other developed nations, who have 50 percent of their doctors practicing primary care. Last year in The Atlantic, an article showed the U.S. to have both the highest medical student debt and patient debt of any country.
Data from WHO show that we have the lowest birth survival rate of any developed country, especially for Black mothers, and are worse than Cuba for many health care metrics such as maternal health.
Our mutual interests should be to have primary care access, decrease health care costs, and improve U.S. public health outcomes. U.S. minorities, particularly Blacks, are severely impacted by the shortage of primary care doctors. Both urban and rural regions have need for more primary care. Many U.S. minorities seek primary health care in more costly settings such as ERs; others experience delays in health care, which results in higher costs and inferior outcomes. When patients must receive care in ERs, it is more costly to patients, insurers, and the health care system.
Jonas and Kovner’s book Healthcare Delivery in the United States shows minorities’ health care outcomes improve when treated by doctors of similar ethnicity. However, there is a shortage of minority doctors due to the educational costs in the U.S., which are a barrier for many, especially students of color. By reducing medical student debt, more students will want to become primary care doctors and practice in areas of need.
Historically, college debt has outpaced inflation. Compounding the medical student debt is the fact we have the longest medical training time of any country, which typically takes ten years in the U.S. (four years of undergraduate college, with a typical two “gap years” students take to gain admission, followed by four years of medical school), compared to six years in most countries. Note: Regardless of the country where a medical student is educated, there are an additional three-plus years of residency training before they can practice medicine. We update our children’s education every five to ten years but fail to do this with U.S. medical education. In 2012, Health care economists Emmanuel and Fuchs predicted U.S. medical education, which is currently based on a 113-year-old model, can be shortened by 30 percentand improve our overall health care.
U.S. medical schools are accredited by the American Association of Medical Colleges (AAMC). By eliminating some elective rotations, U.S. medical education can accommodate a shortened program. Many of the fourth-year rotations are not required to practice primary care or could be picked up as electives during residency training. Medical school applications remain at an all-time high, yielding no loss of tuition income to medical schools. There is a continuous supply of medical students. Currently, there are 21 three-year medical and another 31 seven-year combined (direct admission “accelerated”) undergraduate programs out of 183 total U.S. allopathic medical (MD) and osteopathic medical (DO) schools. They have not experienced any financial losses as applications are at an all-time high. The trend favors shortening U.S. medical schools, which 28 percent of U.S. schools already have done.
By increasing shortened medical schools for those who wish to specialize in primary care to either a three-year medical school or direct admission from undergraduate studies “accelerated” seven-year program, (eliminating the typical two+ “gap” years delay to enter medical school after U.S. college), should incentivize future doctors. Medical students will enter the workforce sooner and start paying federal income tax after just seven years as opposed to the typical ten years mentioned earlier. (This should be beneficial for female doctors who wish to bear children and often have to delay pregnancy due to training time.) The accelerated programs correspond exactly to the economists Emmanuel and Fuchs’s prediction that education time can be reduced by 30 percent. The income taxes at an average current salary of $248K per year for a primary care doctor yields over three years $260K in federal taxes, which is higher than and erases the average medical student debt!
Therefore, by reducing the education time to seven years to entice medical students to pursue primary care, medical school student loans could be effectively wiped out by using the tax collected providing debt relief. This change allows primary care access to increase, health care costs to decrease, and U.S. population health to realize its potential. The result will be to bend the arc of health care access and equity towards justice for all our citizens.
Amol Saxena is a podiatrist.