When Patricio Lau came to the U.S. from Nicaragua eight years ago as a teenager, it didn't take him long to notice one of his new home's more glaring paradoxes. Despite the country's vast wealth and medical resources, the working-class Miami neighborhood where his family settled had scant access to family physicians and most people saw a doctor only when a costly emergency hit. To Lau, it didn't seem much different from the situation back in his impoverished Nicaraguan hometown of Chinandega. "Miami has a lot of problems, but the biggest is that too many people don't get primary medical care," says Lau, now 23. "There's a bit of a mind-set that being a doctor here means taking care of pretty people on pretty beaches."
Lau would like to contribute to changing that. So while he was accepted to nine U.S. medical schools last year after graduating from Miami's Florida International University, he decided to stay at FIU and join the first class of its new Herbert Wertheim College of Medicine largely because the school focuses on training primary-care physicians who hook up with the kind of communities Lau hails from. In fact, under the innovative FIU curriculum that started in August, those neighborhoods are laboratories for students like Lau, who, starting in their second year, will go into disadvantaged pockets like Miami Gardens and Opa-locka on a weekly basis.
Wertheim College is an idea that couldn't have come at a better time not just for low-income communities in South Florida and elsewhere, but also for the broader cause of health-care reform. The U.S.'s chronic shortage of primary-care doctors has become "catastrophic," says Dr. Joseph Stubbs, president of the Philadelphia-based American College of Physicians, one of the nation's largest medical organizations. "If things continue as they are," says Stubbs, "by 2025, the U.S. will be 45,000 primary-care physicians short." That dearth of first-level preventive care will push even more U.S. patients to costlier secondary care like specialists and emergency rooms, which threatens to nullify any appreciable cost savings that Congress might pull out of its hat this fall. "If we fill the primary-care void," Stubbs estimates, "we could keep annual health-care cost increases to around 4% or less. If not, we'll stay at about 7% a year or more."
There are 100,000 primary-care physicians in the U.S. today, but they account for only a third of all doctors; the other two-thirds are specialists. The ratio, say most experts, should be at least 50-50, as it is in countries like Canada. But the number of U.S. medical students opting for primary-care careers has plummeted 52% over the past decade, according to the American Academy of Family Physicians. Fewer than 10% of the 2008 graduating class of medical students opted for a career in primary care, and only 42% of residency positions for family medicine are being filled today, leaving a deficit of some 1,500 a year.
"We have a health-care system today that is geared toward the management of acute episodes instead of the appropriate preventive measures you see in other countries," says Dr. John Rock, dean of Wertheim College. "Because of the lack of family doctors, we're not dealing with obesity; we're dealing with the expensive diabetes hospitalizations that result from the obesity."
Wertheim College is not the first U.S. medical school to train community-based primary-care physicians. (Florida State University's medical school, for example, lets its third-year students do clinical work in rural areas of the state's Panhandle.) But it's considered the first to make that mission its raison d'être. Under its NeighborhoodHELP (Health Education Learning Program) scheme, which will forge permanent relationships with underserved zones of Miami, students are assigned a household along with counterparts from fields like nursing, social work and public health. Rock developed the idea with FIU's Dr. Pedro Greer whose pioneering efforts to deliver medical care in poor areas won him the Presidential Medal of Freedom this year after his work in New Orleans during Hurricane Katrina drove home the need for "embedding health care more deeply in communities." Says Miami Gardens Mayor Shirley Gibson: "I am very hopeful that this will change not only the dynamics of accessibility, but nurture physicians who understand how these communities' socioeconomic cultures affect patient behavior."
But despite the obvious urgency, little will change unless more can be done to lure young docs back to primary care and that means prime financial incentives. The average medical-school graduate carries a six-figure loan debt, so you don't have to be a brain surgeon to figure out why so many people are opting to be radiologists scoring $500,000 a year instead of general practitioners pocketing $150,000. Over the summer, President Obama announced the Public Service Student Loan Forgiveness Program, which erases big chunks of debt for medical students who do 10 years of primary-care work at clinics in communities like those the FIU students are serving. And Congress has health-care-reform companion bills pending that would boost the number of primary-care doctors by some 15,000 by subsidizing their training. Experts also insist that ways have to be found to make family-physician salaries and Medicare reimbursements more competitive.
Those enticements are especially critical given that health-care reform could bring an additional 46 million Americans into the ranks of the insured meaning 46 million more people who will need primary care. Without enough family doctors to serve them, "they'll be like people who've been given a new car but can't start the ignition," says Stubbs.
The car key may well be more medical schools like FIU's, which has 43 students in its first class (chosen from more than 3,000 applicants) and hopes to train almost 300 per year. One of them, Pete Leahy, 23, a University of Notre Dame graduate, had planned to become a pediatric oncologist. But after taking a year off to work at a health clinic for the poor in Puerto Rico, he's leaning toward primary care. "After that experience," says Leahy, "I think I'd rather be the doctor who impacts a patient's health behavior before it ends up impacting the health-care system." It might not be as glamorous or lucrative as doing breast implants on Ocean Drive, but in cities like Miami, it could end up saving a lot more lives and a lot more money.