Bioethics.net

Craig Klugman, Ph.D.

In a National Public Radio story on February 15, economist Dean Baker shared his idea that physicians should be looked at like any other commodity if we want to bring the cost of health care delivery down. He says that if you want to reduce the cost of shirts, you look to import shirts from other countries that have lower manufacturing costs. Likewise, he said that the U.S. should look at doctors, like shirts. If it’s cheaper to import doctors and educate them elsewhere than it is to educate them ourselves, then we should do so.

The difference, as NPR points out, is that shirts rarely kill.

For foreign medical graduates (FMGs), the path to becoming a licensed physician in the United States is a long, difficult, and expensive one. With few exceptions (Canada), FMGs have to pass several exams and complete a U.S. residency before they can practice here, even if they have been licensed and practicing physicians in other countries. The reason is that it is hard to know the quality of medical education in other countries since curricula, degrees and even length of training time differ widely. Still, 22% of practicing U.S. physicians went to medical schools in other countries.

Depending on the source, there are currently 625,000 to 954,000 physicians practicing in the U.S. Of those, 209,000 to 352,000 are in primary care. No matter the numbers, the conclusion is the same: only one-third of doctors are in primary care. Yet, 51.3% of all patient visits are to primary care providers. For comparison, in Canada over 51% of all physicians practice in primary care.

Historically, U.S. medical schools alone cannot fill all of the residency spaces that exist each year. U.S. medical schools enroll 18,000 students annually. Of those, 16,000 will enter the residency match for one of the 24,000 residency slots available. The remaining slots are filled from the 15,000 applicants from Canada and other countries with 13% going to non-U.S. citizen FMGs.

But times are a changing. Although the U.S. has often had a problem with shortage of physicians, the situation has become more acute. With 35 million people gaining health insurance in 2014, we will need more doctors than ever. Projections hold that by 2015, there will be a shortage of nearly 63,000 doctors and in fifteen years that number will rise to a deficit of 150,000. Over the last few years many new medical schools have opened (Florida International, Florida Atlantic, Central Michigan, Oakland University, Virginia Tech, LIJ), more new ones are planned (University of Texas Austin), and many existing programs are expanding their class size. Still, these expansions will not fill the need. And with the average medical student graduating with $145,000 in debt, these efforts will not be cheap. In fact, medical students tend not to choose primary medicine specialties because the lower pay decreases their options in paying off their loans and affording to live life with a house, marriage, children, vacation, and retirement.

Medical school in the U.S. can cost anywhere from $52,000 ($13,000 annually) for 4 years (East Carolina’s Brody School of Medicine) to $220,000 ($55,000 annually) for 4 years (Tufts in Boston). Medical education in other countries does cost the student less. For example, in Eastern Europe the price is $14,000 per year, China is $7,700, the UK $32,000 and India $15,000 (at a private school).

From a purely economic standpoint, the numbers suggest setting up a supply chain of importing physicians from other countries. We do it now to a limited extent. So, we would simply have to outsource more medical education. Since much of U.S. medical education is paid out of state and federal coffers the savings would not just be health dollars but would free up money for other uses. And med students would save money since not only the cost of school could be less but in many countries, but the cost of living is less as well.

Baker says that to encourage FMGs and even our own students pursuing medical education offshore, we just have to make the process for them to practice in the U.S. simpler. He suggests having students in other countries that want to work here to simply take the same tests that U.S. students and residents take. If you pass, then you are welcome to come work here. Some foreign med schools could also choose to use a more U.S.-style curriculum and even apply for accreditation through the Liaison Committee on Medical Education (LCME).

The problem is that medicine is not a commodity (no matter what the economists think) and physicians are not shirts. By accepting FMGs, the U.S. has established a brain drain on other countries and we are using the resources of these other nations to subsidize our medical care. Consider that the families, villages, and governments of these other countries paid for the student’s education before medical school. For state supported medical schools, these countries, like the U.S., heavily subsidize the cost of medical education. The cost for FMGs coming to the U.S. is that there are fewer physicians available in these countries, and they are the people who paid to create a physician workforce.

Likewise, closing U.S. medical schools and sending U.S. students to train in other countries (outsourcing medical education) would be taking advantage of these other nations and would be taking up spaces that they need for their own citizens to train to serve their own landsmen.

The solution will have to be multifaceted. Innovative programs to reduce the cost of medical education in the U.S. are one option. Many schools are developing six or seven year BS-to-MD programs. Other programs offer loan repayment for working a certain number of years in a physician shortage area. If physicians are not choosing or are unable to choose primary care specialties, then perhaps the answer is in training more nurse practitioners and physician assistants and giving them a larger scope of practice so that they can write prescriptions and order tests and function as primary care providers in all states. These disciplines have shorter and less expensive training and cost less when delivering care. Other countries have also adopted promotora or community health agent models that are trained to take care of every day health needs and to know when a specialist is needed.

Baker is correct in thinking outside of the box in finding solutions to our physician shortage. He is incorrect in thinking that the solution is simply looking for a less expensive manufacturer, even when the product is made to U.S. standards. The cost to those foreign nations is too high and we should not be looking to be a burden to other countries in order to solve our problems.