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Letters to the Editor

From the April ACP Internist, copyright 2012 by the American College of Physicians

Sounding off on scribes

Thank you for the article about using scribes (“Scribes: A write way and a wrong way,” ACP Internist, February 2012) in an era when we are being encouraged to use electronic medical records (EMRs). While the convenience of electronic storage and retrieval of medical tests is undeniable, I am concerned about the likelihood of having to pay attention to the laptop to the detriment of the patient. The foundation of medical care starts with the patient-doctor interaction. That something so fundamental could be disrupted by EMRs may be one of the reasons for their slow adoption by medical practices. High costs for EMR system acquisition and maintenance and substantial loss of practice productivity certainly contribute as well.

Cory Krueger, MD, FACP
Cottonwood, Ariz.

Regarding the recent article on scribes, we've come to a point where the “tail is wagging the dog.” The EMR has already seriously degraded the quality of physician-patient communication, turning a narrative into a checklist. An effective therapeutic relationship involves transference/countertransference, employing body language and other nonverbal forms of communication. With a scribe, the intimacy and confidentiality that lead to disclosure of important emotional material can't possibly occur. We old-timers understand the importance of the emotional dynamic to the therapeutic equation. Are we soon to expect scribes in the office of psychiatrist colleagues?

Richard Lipton, MD, FACP
New Hyde Park, N.Y.

Paying for medical school up front

Over the past half-century, as medical school became more accessible, banks stepped in to provide student loans to these new students. But average medical school debts now top $160,000, and actual repayment sums have snowballed to about twice that, according to data from the Association of American Medical Colleges (AAMC). Paying for medical school up front could ensure access while saving money.

According to studies in the March 6, 2010 Lancet and the Sept. 7, 2011 Journal of the American Medical Association, there are about 10 times as many total active physicians in the U.S. as there are total enrolled medical students. Therefore, any pay cut to physicians could cut tuition by 10 times for students. Based on AAMC data (available online) the weighted average cost of a year of medical school (public and private) is $38,000. To cover this for all medical students, each physician could take a $3,800 annual pay cut. Since the cuts would be replacing education costs, doctors would actually end up making more money.

AAMC estimates indicate that the average physician spends about 15 years repaying loans, at a cost of about $21,000 per year. Even with a $3,800 annual pay cut, physicians would see a net gain of $17,200 per year for the first 15 years of their careers. The cuts would only start to become a net loss if a physician worked for more than 67 years. And the savings would come at a pivotal time, when most physicians are living off meager resident incomes, beginning families, buying homes, and trying to start saving for retirement.

Society would also benefit. Graduating debt-free would enable more students to specialize in family medicine, pediatrics, geriatrics, and obstetrics and gynecology rather than higher-paying specialties. Taxpayers too would benefit, since they would no longer have to subsidize federal loans. The only ones who stand to lose are the banks, which according to AAMC data currently make over a billion dollars in interest per graduating class of physicians.

To implement this plan, a coalition of public and private insurers could agree to cut physician reimbursements and put that money in a pool to fund medical school tuition. Creating such a coalition would be difficult, but the federal government, which already controls most health care spending, could act alone. In this case, we would need to keep physicians-in-training from accepting a free education but later refusing government-insured patients. One solution would be creating a buy-in program similar to the military's: Students could go to medical school for free or at a discounted rate in exchange for a promise to serve Medicare and Medicaid patients after training.

As medical education debts have ballooned and interest rates have shot up, loans have become the very barriers they were once meant to break down. Our current trajectory leaves medical students and doctors increasingly constrained and the country with a shortage of primary care doctors, with taxpayers footing much of the bill. Paying for medical education up front benefits all of these parties with a potential downside only for the banks.

Farzon A. Nahvi, ACP Student Member
New York City

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