Med Schools Choosing Bedside Manner Over Healing Skills?

To all the pre-med undergraduates out there, put down the organic chemistry text book and MCAT prep flashcards. You may be wasting your time.

To combat the shortage of primary care doctors, medical schools are changing their admissions criteria. A recent initiative within the medical community will see to it that grades and test scores count for less in medical schools’ acceptance policies while personal qualities such as “social accountability” count for more.

In his book Med School Rx: Getting In, Getting Through, and Getting On with Doctoring, Walter Hartwig discusses the new direction medical school admissions have taken as a result of this “Initiative to Transform Medical Education,” prepared by experts commissioned by the American Medical Association.

The initiative issued 10 recommendations. The first instructs admissions officers at medical schools to “Apportion more weight in admissions decisions to characteristic of applicants that predict success in the interpersonal domains of medicine.”

“The basic intent of the recommendation,” Hartwig explains, “is to improve our ability to find future primary care physicians in the applicant pool, and history suggests that they are not among the high MCAT [the Medical College Admission Test] achievers.”

Until now, the AMA claims, medical-school admission processes selected mostly for applicants’ “abilities to acquire knowledge and to problem-solve.” But the authors of the initiative believe that those talents “may lead physicians to perceive patients simply as sources of data and ‘problems to be solved,’ instead of as individuals in need.”

Furthermore, during their training, today’s physicians “lose altruism and the caring aspects of medicine.” They do not become “advocates for patients related to issues related to social justice (for example, elimination of health care disparities, access to care) [or] citizen leaders inside and outside of the medical profession.”

But some evidence suggests that the AMA is going after the wrong target. Government policy, not lack of “altruism,” appears to be behind the shortage of primary care physicians.

Only a small fraction of graduating medical students go into primary care today. One probable reason is that it pays a lot less than specialty practice — slightly more than half the amount, on average ($161,816 in 2004 compared with $297,000 for specialists).

Price manipulation by a government-sanctioned system is a factor in the pay differential. In a 2007 Annals of Internal Medicine article, “The Primary Care-Specialty Income Gap: Why It Matters,” Thomas Bodenheimer, Robert A. Berenson, and Paul Rudolf list several reasons why primary physicians earn less. One factor is technology, which enables specialists to increase the number of their procedures. Primary care doctors find it hard to increase the number of patients without diminishing patient satisfaction.

A more fundamental reason is the way that treatment prices are assessed. At the heart of the medical pricing system is a small panel of central planners called the Relative Value Scale Update Committee, a panel of 26 voting members, the vast majority of whom represent specialty societies. RUC is part of the Resource-Based Relative Value Scale system, the model used by Medicare, Medicaid, and nearly all HMOs to determine compensation for physician services.

In a policy enshrined in U. S. law in 1989, the RUC assigns a value for each new procedure and considers price revisions for existing services. Doctors’ representatives on this committee basically vote themselves raises.

Specialists are favored over generalists because under the Balanced Budget Act of 1997, the total amount of money paid by Medicare is like a pie. If one group receives a larger slice due to increased fees or greater volume, everyone else gets a smaller slice.

Because primary care physicians make up about half of all doctors, higher fees for them would decrease fees for most RUC voting members severely. But specialists’ fees are only a small slice of the compensation pie, so increasing those fees doesn’t hurt the earning power of the other members as much.

Another factor is that private insurers have embraced the government-sanctioned RBRVS system. And, due to the negotiating power of organized specialty groups like the American College of Radiology, insurers are forced to pay higher fees to specialists.

Technology, government policy, and organized interests have combined to make specialty medicine attractive financially to graduating medical students.

Duke Cheston is a reporter and writer for the John W. Pope Center for Higher Education Policy in Raleigh (popecenter.org).