One evening recently, I met with a group of medical students as part of their “ethics journal club.” The issue we discussed that evening was whether, given the extent to which the state subsidizes their medical education, it was appropriate for it to tell them what specialty they had to choose and what patients they had to take care of.
We focused on the fact that every expert says that the United States is way below the ideal numbers of primary-care docs — family physicians, general internists and general pediatricians. The students readily admitted that their peers often selected specialties by logging onto a Web site that showed the relative incomes of physicians in different fields. As you may guess, the primary-care specialties generally rank at the very bottom of the income list — although almost all U.S. doctors do well financially by virtually every objective measure.
But doing well is apparently not enough for many medical students. Why do merely well if you have the chance to do really well? Especially after going into debt in medical school, often to the tune of $100,000 to $140,000, and spending innumerable sleepless nights as a resident in training?
The club ended without coming to a clear conclusion. The next day, I became aware of a paper that had been published in the latest issue of Annals of Family Medicine, by Dr. Barbara Starfield of Johns Hopkins and George Fryer of New York University. Starfield is, perhaps, the greatest U.S. expert on primary care; she quite literally wrote the book about it.
The article caught my attention as it spoke to the “ethical implications” of the “primary-care-physician work force.” Our journal club had talked the night before about ethics and the choice of specialty, but you seldom see “work force” and “ethics” in the same journal title.
Starfield and Fryer said that the United States lacks primary-care physicians that it needs and cannot coax enough American medical-school graduates to fill those slots. So we recruit foreign-born and trained physicians.
Starfield and Fryer showed that the United States tends to recruit specialist physicians from the countries that have the greatest indigenous health resources. We tend to recruit primary-care docs from the countries with the worst health needs and least resources.
That is — we rob the countries that most desperately need their primary-care physicians to stay home and take care of their own people so we can get enough such physicians to meet the needs here that our own medical students don’t feel like filling.
Starfield and Fryer think this raises some ethical issues. I agree. I intend to ask the student journal club next time we meet, too.
Dr. Howard Brody, a family physician, is director of the Institute for Medical Humanities at the University of Texas Medical Branch. The views expressed are his own and do not represent the official opinion of the University of Texas Medical Branch.
