Primary Care, Medical School Debt, and US Health Needs: Analysis from the Graham Center

.

Bob Phillips MD, Executive Director of the Robert Graham Center, the American Academy of Family Physicians’ (AAFP) DC-based policy center, gave one of the plenary speeches at the recent annual meeting of the Society of Teachers of Family Medicine (STFM). His talk, available at the Family Medicine Digital Resource Library (www.fmdrl.org) presented a great deal of data regarding the current, and anticipated future, state of the US primary care workforce. There are currently 222,308 primary care doctors (FPs, GPs, general internist, general pediatricians and geriatricians), or one for every 1358 people, and an additional 86,000+ NPs and PAs in primary care, for a total of about 308,000, or about 1 primary care provider for every 1000. This is not a bad ratio, looking at the nation as a whole, but geographic distribution is another matter, with the ratio of primary care providers (PCPs) to person ranging from 500:1 to 5,000:1 in various primary care service areas (PCSAs); the nearly 5000 PCSAs with a shortage have a deficit of over 54,000 PCPs, which is equal to the “surplus” in the 1,600 or so PCSAs who have higher ratios. And, of course, those underserved PCSAs comprise the vast majority of the US geographic area (see figure).

Phillips and colleagues estimate that we will need an additional 50,000-60,000 primary care physicians by 2025. The largest cause of the growth is, of course, the projected growth in the US population, but it is augmented by the aging of that population (older people require more health care services) and, significantly, the increase in the number of insured-and-thus-likely-to-access-health-care created by the new coverage provisions in the Affordable Care Act (ACA). This portion of the increase is smaller, but unlike the gradual growth resulting from the other two causes, will “hit” all at once in 2014, and our primary care workforce is in no way prepared to meet it. This lesson was emphasized by the experience that Massachusetts had when it introduced near-universal coverage; in addition to adding more people to the “insured pool”, the group that is added has pent-up health care needs. Moreover, the currently uninsured are largely clustered in areas with the lowest current PCP:population ratios, so that what will happen when they gain insurance is that they will end up seeking primary care in the emergency room. While the Graham Center estimates a need for an additional 8,500-10,000 primary care doctors, given what Dr. Phillips calls our “voodoo” workforce policy -- which not only does not incent students to enter primary care or locate in rural and underserved areas, but in fact does quite the opposite -- the actual increase in the number of providers would need to be many times higher. Much recent work has demonstrated the decrease in student interest in primary care, and in particular the phenomenal decrease in the percent of internal medicine graduates entering primary care (as opposed to entering subspecialties or hospitalist practice), as documented by Garibaldi[1] and Hauer[2] among others (see A Quality Health System Needs More Primary Care Physicians, Dec 11, 2008). More recent data collected by the American College of Physicians (ACP – the internists’ group) from residents taking required examinations in 2009 indicate that only 21% of these residents are planning careers in general internal medicine (65% subspecialties, 10% hospitalist) and the actual results tend to show that these plans tend to skew even more to the latter two groups when decisions are actually made.

I have pointed to money, specifically the anticipated income related to student debt, as a major determinant of specialty choice, and Dr. Phillips makes this quite graphic by comparing the ratio of primary care and family physician incomes to more highly paid specialties over time. Using Diagnostic Radiology and Orthopedic Surgery as comparators, primary care incomes, which were about 60% in 1979, dropped to barely 35% in 2003, a trend that has not decreased since. Other graphs show that the % of graduate training (residency) positions filled by US medical graduates tracks linearly with specialty income, and that the growth in new residency positions has been almost entirely in those high-income specialties with drops in primary care positions. (This is not only because of student interest; it is also because many of these new positions are funded by hospitals. The same specialists – radiologists, cardiologists, orthopedists, anesthesiologists – that make big incomes for themselves also make big profits for the hospitals, so that hospitals are more interested in increasing their capacity to do these functions by having more trainees, residents and fellows, in these specialties.)

This creates a problem. The Graham Center data support much other research that has been cited in this blog by Starfield and others indicating that a health system that is based on primary care, with 40-50% PCPs, creates the greatest benefit in health and lowers cost. We have currently about 32% PCPs. With an interest in primary care among medical students now at about 22%, the problem is going to grow, not shrink. And, as I have often written, if we are interested in increasing primary care specialty choice, we are largely taking the wrong students into medical schools (e.g., Primary care specialty choice: student characteristics, July 12, 2010). Given that these characteristics are in large part negatively associated with family income, the changes in funding for medical schools are also troubling. Phillips cites an interview with the founding dean of the University of Missouri-Kansas City (UMKC) medical school, E. Grey Dimond MD, in the Kansas City Star (April 25, 2011). Dr. Dimond is asked how UMKC, as the “public” medical school with the least state funding of any in the US, survives, and he answers that they have increased tuition to become the highest tuition school in the country. This, of course, does not bode well for low-income students, urban or rural, becoming physicians: “Farm kids in Missouri from little towns that need doctors can’t pay what we have to have.” And, for those low (and middle, and even upper-middle) income students who graduate with debts often exceeding $250,000, those income differences among specialties loom very large – and this does not bode well for primary care.

Phillips provides evidence that Medicare costs and avoidable hospitalizations and hospital readmissions drop dramatically when there are higher primary care ratios (ratios of 1 FP+NP+PA:1500-2000 people, or 1:1000 if all PCPs considered[3]). He cites a large number of studies demonstrating essentially the same thing.

Is there a bright side? Are there solutions? Well, the contributions of primary care are now being widely acknowledged, and there are lots of calls for increasing primary care physicians. The ACA bill provides some increased funding for primary care (about a 10% increase under Medicare) and major funding increases for the National Health Service Corps (NHSC), which pays for medical education by (some) scholarships or (mostly) loan repayment for physicians who enter primary care (and sometimes general surgery) and practice in an underserved area for a period of years. Unfortunately, these are not sufficient; a 10% increase sounds like a lot, but if it brings the primary care doctor’s income from 33% to 37% of that of a specialist (and this would be if the whole practice were Medicare), it is not going to do the trick. The loan repayment from NHSC is good, but it rarely covers the whole bill.

What would work? Medicare, taking the lead among all payers, needs to increase primary care physicians’ income dramatically. The Council on Graduate Medical Education (COGME) estimates in its very impressive 20^th Report, Advancing Primary Care, that a family physician must be able to anticipate earning 70% of what a subspecialist makes if the goal of having a 40% primary care workforce in 20 years is to happen., the level at which income expectations tend to wash out of the decision on specialty choice. The federal and state governments should learn from successful models and repay all of the loans of medical school graduates who enter primary care over 8-10 years (enough time to ensure they are actually practicing primary care) and do it twice as fast for those who practice in an underserved setting.

This is what it will take to bend the curve of specialty choice, and, as a result, to bend the cost curve of providing health care.

---

[1] Garibaldi, RA, Popkave C, Bylsma W, “Career plans for trainees in internal medicine residency programs”, Acad Med 2005 May;80(5):507-12

[2] Hauer KE, Durning SJ, Kernan WN et al., “Factors associated with medical students’ career choices regarding internal medicine”. JAMA 2008;300(10):1154-64

[3] The benefit on cost of hospitalization, avoidable hospitalizations, and readmissions is more difficult to assess for general internists than for family physicians; this would be unsurprising given that their training in almost all in the hospital rather than in the ambulatory setting.

US Medicine and Medical Education: The Good Part

.
I have often, and I think with good justification, been highly critical of the US health (non-) system, particularly in two areas: the fact that we do not have universal financial access to health care (a completely intolerable situation, which cannot be justified or defended morally, although it often is – always by those who have coverage!), and the fact that we have a great deficiency of primary care physicians. I thought it might be time to address two areas in which I think US medical education and practice is superior to that in Europe and much off the rest of the world.

The first is our medical education system. In specific, I am very happy that our medical schools are graduate schools, entered by students after achieving a bachelor’s degree. This is unlike the situation in most countries, such as Britain, where the medical degree is indeed a bachelor’s degree, MBBS, bachelor of medicine/bachelor of surgery. Medicine as a graduate school is the norm only in the US and in Canada; in virtually every other country, students enter medical school out of high school at 18, and graduate 6 years later. While this still can produce excellent physicians, it is in my opinion less desirable. First of all, they do not have the advantage of the broader education that comes with a bachelor’s degree. Secondly, they are very young. In the US, a student entering medical school right from undergraduate studies would usually be 22, but because many take off for a few years (or have another career first) the actual mean entry age in most US medical schools is about 24 (with the median a little lower). This means a more mature student body, with life experiences – at least the experiences of 4 years of college, if not in another profession, in business, in the Peace Corps, etc. This makes a difference. It also means that US medical students are more likely (and, throughout this piece, when I say “more likely”, that is what I mean – greater probability, not 100%) to really want to be doctors, rather than being there because, at 18, their doctor parents told them that they were going to medical school.

I believe that this greater maturity and life experience lead to greater independent community involvement, creation and management of free clinics, etc. As an example, at the University of Kansas Medical School, the Jaydoc student-run Free Clinic is not only completely student-run, it was student developed, maintained and expanded. There are physicians who supervise at each clinic session, but that is their entire role; the students make the schedules, recruit the volunteers, organize the operation, follow up the results, raise the money (including writing grants and doing benefits). When the clinic was created, a call went out from a student, and over 80 students attended the first meeting. They identified what had to be done: find a venue, decide on frequency, raise money, organize scheduling, on and on. Hands went up from volunteers: “I was an accountant!” “I was a community organizer!” “I was a grant writer!” “I was a teacher!” Even those who had not a previous job or career had their college experiences behind them: “I organized the fund raisers for my sorority!” “I volunteered in the free clinic in the community where my college was located!” I don’t think this happens – could happen – in a school whose students all entered at 18.

Moreover, US medical schools use a variety of criteria for choosing the students to admit. They look for such volunteer work, demographic diversity, achievements in a variety of arenas. While many students are “pre-med”, majoring in biology and chemistry, as we have seen in Medicine, science, and humanities: what is their role in medical education?, August 26, 2010, many are history, English, or art majors. (“What is the course for pre-med?”, a Brazilian medical student, in his 4th year at 21 and still confused about the 4 years US students do before medical school, asked me.) In most countries a cognitive examination is the sole criterion for entry into medical school, and social values are not even considered. Thus, say, in São Paulo (which I know a little) to say that the top 200 scores go to the most prestigious medical school, 201-400 to #2, 401-600 to #3, etc., would not be far off! I have been critical of US medical admissions because they are so skewed to upper-middle-class suburbanites (80% of our medical students come from the top 20% of income), but this skew is even more pronounced in other countries where the cognitive exam is the only criterion, and the greatest likelihood predictor of doing well on these exams is going to the “best” (and most expensive) private preparatory schools. The top 2 medical schools in São Paulo are both public and free – something the socialist government is proud of – but the catch is that it would be virtually impossible for a public school student to get a high enough score on the exam to get into one of them. To get into the free, public medical school requires attending the most elite private prep schools!

The second area in which I think American medical practice – here I am talking about the practice of family medicine – is better is that, to a large degree, our family doctors take care of their patients in the hospital. In Hospitalists, December 4, 2008, I bemoaned the fact that this was changing and that primary care doctors are more and more often choosing to (or being required by their employers to) delegate the care of their hospitalized patients to others. I will not reprise all the reasons why I think this is largely a negative trend, since they are detailed in that piece; what is relevant here is that in most other countries primary care physicians (who are, in most other countries, all family doctors or general practitioners), never cared for their own hospitalized patients, turning them over to internists or pediatricians. In this sense, the trend in the US to hospitalists is emulating practice in Europe and elsewhere; unfortunately, in my opinion, it is emulating one of the more less-desirable aspects of that practice.

Indeed, the trend over the last several decades to increase the proportion of medical students with a broad liberal education is being challenged by a counter-trend, which sees education not as important in itself, but as “job training”-- whether this is in trade school, technical college, professional school, or university. In Medical Student Selection, December 14, 2008, I present my concerns that we will narrow the cohort of medical students rather than broaden it.

Thus, as I take this opportunity to laud some of the aspects of US medical education and practice, I also caution us to continue the positive aspects of our system and guard against adopting the negative aspects of the health system in other countries, as we continue to stand rigidly against adopting their proven effective strategies of providing access to health care for all.
.

Medicine, science, and humanities: what is their role in medical education?

.
How much of the practice of medicine is “science”? How much science, as in “how many science courses” should be required of students applying to medical school? How much science must be taught to students once they are in medical school? To what degree does this require the memorization of mountains of facts as opposed to learning to and practicing the scientific approach to thinking and problem solving and analyzing data? What about other material that might help in being an effective physician…the social sciences of psychology, anthropology, sociology, or the broader content of a “liberal” education such as literature, history, philosophy, foreign languages? Is there a place for these in medicine? Is there a need for these in medicine? If there is, what is the best way to ensure that students acquire the knowledge, both temporally (prerequisites or in medical school) and pedagogically?

These questions are important to medical educators, and to students planning to apply to medical school, as well as “pre-med” advisors in colleges. Most medical school faculty are physicians or “basic scientists” (physiologist, biochemists, anatomists, pharmacologists, neuroscientist and those straddling the disciplines or creating new ones). There are usually a few social scientists, especially epidemiologists and psychologists, based in departments of preventive medicine, community medicine, and public health, and psychiatry. There are also likely to be a small number of people with degrees in education (largely in the office of medical education), and in humanities (frequently involved in teaching ethics, the branch of humanities most commonly taught in medical school). In general, the basic science faculty believe that the material they teach is crucial to the creation of competent physicians, while clinicians range from agreement (perhaps less passionate) to a belief that they don’t use or remember much of the biological sciences that they had to learn, and the main thing students need to do is to get through it, pass “Part I” (of the US Medical Licensing Examination, USMLE, which emphasizes basic science and is usually taken after the first two years of medical school), and get on to the “important stuff”, their clinical education and training.

Occasionally, the faculty even engage in in-depth discussion and analysis of how the material is taught; whether intensive study of sciences in the first two years of medical school tested by recall of facts on examinations is the best way to learn – and retain so that it can be used years later in clinical work – the content. Many, if not most, schools, have gone to some form of “integrated” curriculum in the first two years, most often based on organ systems, teaching the aspects of each of the basic sciences relevant to that system, mixed in with clinical perspectives, epidemiology, ethics, and social determinants of health. Most have decreased the number of hours of lecture and increased small-group learning, including Problem-Based Learning (PBL) in which groups of students review a patient case, with a facilitator, with the goal of learning how to approach thinking about a patient and their problems and how to work with not only their disease but with them, in all of complexities of life that they face. Some schools, such as the new Paul L. Foster Texas Tech medical school at El Paso, spent over a year with educators, clinicians, and basic scientists poring over every piece of the curriculum and how it would be delivered and reinforced, before admitting their first class.

I have often written about who does, or should, get into medical school, particularly in the context of predicting specialty choice for primary care (e.g., Medical Student Selection, December 14, 2008; Are we training physicians to be empathic? Apparently not., September 12 2009). A recent article in Academic Medicine, “Challenging Traditional Premedical Requirements as Predictors of Success in Medical School: The Mount Sinai School of Medicine Humanities and Medicine Program”[1] by David Muller and Nathan Kase, looked at the performance of students who were taken in a special program that did not have science requirements with that of “traditionally prepared” students. Their conclusion is that “Students without the traditional premedical preparation performed at a level equivalent to their premedical classmates.” Of course, there were some differences; they performed a little worse (statistically significantly, but still well) on the USMLE Part I. They performed better on their psychiatry clinical clerkship, and not significantly better or worse on their other clerkships. The success of the students in this program (“HuMed”) was great enough that more students who were not science (or “pre-med”) majors were accepted by Mt. Sinai outside the program; nationally, 18% of students matriculating in medical school in 2009 were humanities and social science majors while at Mt. Sinai it was 25% without HuMed students and 43% counting them. There are a lot of caveats: the HuMed program offered (voluntary) pre-matriculation introductions to organic and biochemistry, and the HuMed students were all very high performers in their areas of college study. Perhaps it means that if you are a very smart – and skilled, for being a successful student is a skill – student you can make it in medical school even without lots of premedical science, but if you are not, the science helps.

This article does not answer this question, but it did receive significant national coverage. The New York Times article by Anemona Hartocollis on July 29, 2010, “Getting into med school without hard science”, generated many blog comments and letters. One, by a Mills College professor of chemistry and physics, David Keeports, notes that “Many people have great personalities, but medicine is a science. A person who has avoided fundamental scientific and mathematical knowledge and the scientific approach to problem solving isn’t the person I want to see when I have a medical problem.” Well, he is a physical science professor, and maybe not representative of the entire population, most of whom really value the ability of a doctor to successfully communicate with him. More important, however, is his comment, that “I see no place in medical school for anyone who hasn’t demonstrated an ability to easily learn, assimilate and analyze technical information.” I agree with that completely; I have frequently written about the need to understand the scientific approach and thought process. I believe that the most important of these is epidemiology (listed above as a social science). It is critical that physicians are able to understand and interpret the data coming from scientific studies, and be able to explain it effectively to their patients. This is, however, different from being required to memorize huge numbers of facts that you will forget soon after the exam, and not miss later.

Because the amount of scientific information continues to increase, and because much of it renders what we used to “know” incorrect, medical school faculties should be able to identify what pieces of factual information a student really needs to know to become a doctor and to be able to think scientifically, identify how to effectively teach it and measure learning, and tie that to the skills that a practicing physician will need. The concept of “competency based education”, rather than an education devoted to learning and regurgitating content, has been around for a long time. One of the best publications on competency-based medical education was published by the World Health Organization (WHO) in 1978, and examine such education from an international perspective. Competency-Based Curriculum Development in Medical Education. An Introduction. Public Health Papers No. 68., by WC McGaghie, GE Miller, AW Sajid and TV Telder provides guidelines for effective teaching and learning in medicine that are as valuable, and as needed, today as they were more than 30 years ago when it was written. They argue against teaching a course (say, in the first year of medical school) and expecting that the material learned will be remembered and usable in future years. They note that only a small portion of what is learned in a course is remembered only a few years later if it is not used. I would add that the material that is remembered is less likely to be that which the student will need in the future than that which was so counter-intuitive that it took many hours of rote memorization. They argue for a curriculum that teaches relevant material, and effective ways of thinking, in the context in which it will be used, and teaching and measuring competency rather than memory.

Too much of medical education is driven by inertia and vested interest, e.g., these are the kind of students we’ve always taken, this is the material we’ve always taught, this is the way we’ve always taught it, this is the way we’ve always measured it, and (surprise!) the kind of students we’ve always taken are those who do best on the tests that we give which measure retention of what we’ve taught the way we taught it. Rather, we should start from the other end: what kinds of doctors do we want and need, what set of skills and knowledge do we want them to have? Then we need to figure out what characteristics of incoming students (personality, knowledge, and life experience) are most likely to make them become those kind of doctors (input variables), and what content and educational methods will me most effective in helping them to learn the skills they will need (process variables). This makes a lot of sense, but it can challenge existing models of who teaches, how they are reimbursed, and who gets in to school.

Maybe models such as those of Mt. Sinai and Paul L. Foster schools of medicine will help lead the way. But we all need all medical schools to move into the modern era, of identifying societal needs, what their graduates need to look like to meet those needs, and measuring the degree to which these outcomes are achieved.

[1] Muller D, Kase N, “Challenging Traditional Premedical Requirements as Predictors of Success in Medical School: The Mount Sinai School of Medicine Humanities and Medicine Program”, Acad Med Aug 2010;85(8):1378-83.
.

Who will care for the underserved? The role of off-shore medical schools

.
I have written in several previous posts (most recently Universal Coverage and Primary Care: The US needs both, May 27, 2010) about the challenges facing American medicine, particularly regarding specialty choice (=not primary care, not rural, not underserved) of US allopathic graduates, and the problems this has already created in providing health care to the American people, which is only likely to worsen as this trend continues. I have noted that, in the production of physicians as in any other process, the outcome results from variables in inputs (who is admitted in this case), the process itself (in education, the curriculum, both formal and informal), and output variables (in the case of physicians, what the practice environment is: reimbursement, work load, quality of life, respect and regard within the profession and community). I have argued that, while output variables may be the most important in terms of specialty choice and practice location, it is the one over which medical educators have the least control. While the curriculum, the process through which we educate medical students, is critical (see Are we training physicians to be empathic? Apparently not., Sept 12, 2009), it is likely that the characteristics of the students selected is most important in determining practice location, particularly for rural areas, but also for urban underserved settings (Medical Student Selection, Dec 14, 2008). Selecting students who grew up in the suburbs of major cities (what Robert Bowman, MD, who has done much research in this area, calls “major medical centers”) in homes with high socioeconomic status and excellent high school and college educations (which is what is mainly done) will result in students with excellent test performance and is likely to produce skilled physicians, but not ones likely to practice in rural or underserved areas.

Students from rural areas, from underserved communities, from low socioeconomic status backgrounds, and from underrepresented minority groups are much more likely to serve these populations, as are students who are older at the time of matriculation. But their lower grades and MCATs, may make them less likely to be accepted, and to have difficulty with the pre-clinical medical curriculum. Students, even from privileged backgrounds, whose prior life history includes significant service are also more likely to work in urban underserved settings; less so (although more than their colleagues without these characteristics) in rural areas. But what about schools of other types or medical schools not in the US?

In a conversation with US Senator Sam Brownback on a visit to his office last year, members of the Kansas Academy of Family Physicians (KAFP) noted the challenges in getting KUMC graduates to work in rural areas. In an off-the-cuff response (I don’t mean to suggest that this was thought-out or his real position; I use the statement as a basis for comment) he suggested that we then just start a medical school at Kansas State University that would train rural primary care doctors. This type of response to a system that is not having the impact that policy makers wish for is common – create a new school, or focus on another different type of school (e.g., osteopathic), or another profession (nurse practitioners, physician’s assistants). But, of course, if they take the same sorts of students and offer them the same range of career opportunities, why would one expect different outcomes? Osteopathic graduates, while still entering family medicine and primary care at higher rates than allopathic, are increasingly becoming specialists. NPs, and especially PAs, are increasingly joining specialty physician practices and remaining in urban areas with high income potential rather than high need. Why would they not? Would you, or your children?

Because there are far more residency training positions than there are US graduates, many of these positions are filled with international medical graduates. A special group of these are “US IMGs”, Americans who, unable to be admitted to US medical schools, attend those outside the country. In the Caribbean, there are many schools, for-profit, set up for precisely this purpose. I recently had the opportunity to give the “White Coat Ceremony” talk to the class entering the largest of these: Ross University School of Medicine (http://www.rossu.edu) on the island of Dominica. Ross, in existence for over 30 years and now owned by DeVry, the largest for-profit educational company in the US, has a “business model” that enrolls 3 classes per year paying tuition much the same as a private US private school or an out-of-state student at a US public medical school. After the first two years, students do clinical clerkships in 70 hospitals in the US that are affiliated with the school – and paid by them. The student body is ethnically very diverse, with over half the members of the class I spoke to born outside the US (although 95% are US citizens or permanent residents; the rest mostly Canadian), but not including a large percentage of students from traditional underrepresented minority groups, and certainly not many from poor families. Ross graduate disproportionately enter primary care specialties, but this is almost certainly because primary care is less competitive than many subspecialties, and the fact that they didn’t train at US schools puts them at a competitive disadvantage in the selection process. Nonetheless, there are several positive things to be said about the Ross experience. First, Ross has a single mission – medical education. The considerable funds it generates are not required to support a large research or clinical enterprise, but can be directed to that mission. Second, it takes students who, because of their grades, wouldn’t – didn’t – get into US medical schools, and gives them a chance to succeed. If there is a high failure rate as a result, there are also unquestionably outstanding doctors produced who would not have otherwise existed. They are able, because of their business model, to take a “chance” on these students – and if they work hard, they can be successful.

While there a very many Caribbean medical schools, of different ages, quality, and size, operated more-or-less on the Ross model, a quite different model exists on another island – Cuba. Whatever its failures, one of the great successes in Cuba since the revolution of 1959 has been the expansion of medical care to the entire citizenry of the nation, and exportation of trained physicians, both Cuban nationals (they are even on Ross’ home island of Dominica) and those from other countries educated in Cuba. The Latin American Medical School (Escuela Latino-Americana de Medicina – ELAM), which educates students from other Latin American countries, began to take students from the US a number of years ago. Unlike those attending Ross and other costly schools, US students at ELAM are virtually all from low socioeconomic backgrounds and mainly from underrepresented minority groups. Tuition is free and living expenses are paid, but there are prices for the students to pay. Admission requires a bachelor’s degree, but students are still required to spend the entire 6 years of medical school that is the usual for countries outside the US and Canada, or 7 if they need to learn Spanish first. They live in minimal dormitories, have very limited access to the internet (1-2 hours per week), and work very hard. They receive a medical education that particularly emphasizes public health, community medicine, and prevention. They promise to complete their training and enter practice in service to the communities from which they come, but it is a promise – obviously the Cubans have no way to enforce this. They receive no training in the US prior to graduation unless they are able to arrange summer observerships on their own, and are not particularly prepared for the “National Board” exams, the USMLE, that are required for US licensure and admission to US residencies. MEDICC (Medical Education in Cooperation with Cuba) , a US group that exists to support US students at ELAM and its graduates, tries to find them mentors who will help orient them to the health system in their own country, the US, teach them about applying to US residencies, and offer guidance in the study for USMLE. The first US graduates of ELAM have entered a few US residencies this year; I have met one, who is phenomenal. Other US medical educators are working with ELAM graduates and offering both advice and opportunities for volunteer training.

The US students at ELAM are the “right students”. They come from underserved backgrounds, are committed to their communities, and are willing to work very hard (perhaps ten years between bachelor’s degree and entering a residency). The question, of course, is not “how can they go to that Communist country?” but rather why are we allowing Cuba to pick up the role that our own medical education system fails to fulfill. Indeed, it would be particularly for those who oppose Cuba and socialism to develop such programs in our own country.

Senator Brownback, if we are going to start a new school in Kansas, let’s model much of it on ELAM. Let’s make it free, and recruit students from underserved communities and underrepresented minority groups, and low socioeconomic backgrounds, and teach them public health and prevention and primary care, and send them out to serve their communities of origin. In the meantime, let us at least have a “sliding scale” loan repayment program where the percent of your loan your repay is tied to your post-residency income, as well as your practice location and specialty choice.
.