Med students: We'll accept lower pay to get true health reform

December 13, 2009|By Megan Buresh and Ben Keleman

We, as first-year medical students, have followed the national discourse on health care reform, anticipating more accessible and affordable care. Current legislation promises to reduce the number of uninsured. However, patchwork reforms will not be enough to fix our broken system.

As future physicians from a wide variety of educational, political and geographic backgrounds, we and our six co-authors feel a duty to provide healing to our patients regardless of their circumstances. We believe that quality health care is an individual right. Although we have not yet had much clinical experience, we have listened closely to the words and experiences of our teachers and clinical mentors. We have heard them describe a system of fragmented care that rewards a myopic view of patient health. Thus, we advocate a health care system that values holistic patient care, improves patient outcomes and rewards evidence-based medicine.

The disjunction between our medical values and the fee-for-service billing system demands reform of the payment structure. Current incentives reward specialty care while marginalizing sensible primary care, mental health services and preventive medicine. Clinical mentors have taught us that doctors are not reimbursed by the fee-for-service system for "cognitive functions" such as coordinating care for chronic conditions. Yet, the patient benefits of such disease management strategies are clear. We have seen firsthand doctors whose patients thrive under a salaried payment system that encourages holistic care. Consequently, we plan to work in salaried or capitated (per-patient rather than per-procedure payment) systems that spare us the conflict of choosing between monetary self-interest and quality patient care.

Given the complexity of the clinical decisions we will face, we want to be evaluated on existing evidence-based standards. We envision a system in which providers report treatments and outcomes and receive quantitative feedback on provided care. We want to be held accountable for our failures as well as our successes, our small oversights as well as our obvious mistakes. Recent studies in intensive-care medicine have consistently improved patient outcomes by creating precise procedural guidelines and ensuring physician adherence. Such standards prevent small missteps, easily overlooked by the individual clinician, that greatly impact the lives of our patients. We want to know the level of care we provide, and we want to know when we fall short of the care our patients deserve.

We realize the idealism of our goals. We do not expect to donate our services or to work for fees that fail to compensate us for the extensive training we now pursue. We also realize we are asking for nothing less than an overhaul of the health care system. Nonetheless, all of us, whether bound for specialty practice, academic medicine or primary care, are committed to health care reform that places patients first.

We will embrace financial compromise to ensure universal, quality care for our nation. As a country, we can build a health care system that works to prevent as well as heal, and that incorporates practices to improve health at the lowest cost to society and the patient. Though we have concerns for the future, we are confident our generation of physicians, lawmakers and voters can meet these challenges head-on.

Megan Buresh and Ben Keleman, along with co-authors Neil Bhutiani, Eben Clattenburg, Meghana Desale, Jason Liebowitz, Kerry Schnell and Christina Velasquez, are first-year medical students at the Johns Hopkins University School of Medicine.

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