What lawyers and Mexican medical schools can teach us about primary care

David Lenihan: ©David Lenihan

There’s good news about the of primary care physicians in the U.S. and diminished access to primary care medicine by patients across the country: It’s finally being addressed.

The not-so-good news is that a proposed Congressional fix, while well-intentioned, does not guarantee the delivery of improvements nationwide – particularly among many of the states where it’s urgently needed.

For example, 11 states have chosen not to expand the Affordable Care Act’s Medicaid coverage for their residents. Ironically, most of these states are at the lower end of the national ranking of primary care providers per 100,000 people.
The takeaway of this comparison is that even if a $26 billion bipartisan bill aimed at expanding PCP shortages by Sens. Bernie Sanders (I-Vt.) and Roger Marshall (R-Kan.) passed, the number of primary care doctors and patients with access to primary care would likely not budge in many medically underserved areas of the U.S.

Two solutions that could be launched across the U.S., regardless of whether or not the states in which they’re implemented have expanded Medicare coverage for their citizens, can be borrowed from two unlikely sources: the legal industry and Mexican medical schools.

1. Make pro bono hours providing primary care in community health centers mandatory for all doctors, regardless of their specialties.

American lawyers don’t need to donate their services to worthy causes, but it is recommended. According to the American Bar Association Model Rule of Professional Conduct 6.1, “Every lawyer has a professional responsibility to provide legal services to those unable to pay. A lawyer should aspire to render at least (50) hours of pro bono publico legal services per year.”

Along with benefiting the recipients of their services, lawyers also secure advantages from their pro bono work: their legal aptitude widens, they attain crucial practice that could be applicable in their professional roles, and they grow their awareness and experience beyond their at-work responsibilities.

This same approach could extend to doctors at hospitals across the country: as part of their tenure, they’d need to dedicate a certain number of hours per year working as, or alongside, primary care physicians at local community clinics, aka Federally Qualified Health Centers (FQHC). These clinics can be affiliated with the hospitals within their locales.

The individuals who need first-level preventative and diagnostic care the most would benefit from this arrangement by having better access to PCPs.

New doctors who’d be pro bono-ing their expertise and schooling would also gain by interacting with patients from diverse backgrounds, ramping up their capabilities in a wide range of care scenarios beyond their chosen areas of specialty, and knowing that they contributed to preventing their patients’ health problems before they began or became urgent.

In addition, experienced doctors/specialists would ameliorate their talents and outlooks by doing pro bono work as PCPs. Rather than caring for patients experiencing dire health conditions (their usual patients), they’d be working with - and guiding - people for whom their expert preventative care recommendations could bring significant lifelong improvements.

Obviously, before enacting a pro bono PCP program, considerations such as determining the number of hours that residents would be expected to donate, avoiding conflicts with residents’ hospital duties and work schedules, figuring out the parameters of the service that’s expected, and supervising the clinical care that’s being provided would need to be determined. But those barriers can be equitably and sensibly defined. Once established, a viable route to making primary care more accessible to patients in need – and a creative way to enhance the abilities of new doctors - would be achievable.

2. Create an optional year of social service at medical schools in medically underserved areas of the United States.

In Mexico, doctors and health care graduates must complete pasantia, which is one year of social service following their four years of medical school. Established in 1936, the pasantia program is staffed by pasantes (social service physicians), who bring supervised medical care to the most marginalized populations nationwide.

The Lancet Commission for Health Professions Education recognized the transformative education experience that pasantia offers new doctors. The Commission also acknowledged how it delivered the potential for [pasantes] to enhance their career journeys by “helping them to develop leadership attributes and enlighten them as agents of change”.

Other findings included how the “program fundamentally changed the way the pasantes considered their future; all experienced an increased commitment to work with the poor and underserved. In addition, [the pasantes] reported greater clinical leadership skills and a more nuanced understanding of the Mexican health care system.”

The pasantia idea should be imported into the U.S., specifically at medical schools in or near our country's most medically underserved areas.

American pasantes would provide primary care medical services in hospitals or rural clinics in the MUAs. The program could fall under the auspices of CMS, which oversees the FQHC program, and FQHC physicians would supervise these new doctors. CMS’ direct graduate medical education (DGME) payments would provide the pasantes’ compensation - which would be similar to that of a first-year resident.

The benefits of a U.S. version of pasantia would be forward-thinking and multi-faceted:

• Low-income patients would have access to consistent care to prevent painful and expensive ailments.
• Medicare/Medicaid would save money due to indigent or low-income patients reducing their health risks thanks to attentive primary care. These patients would otherwise be unable to afford the management of such untreated (and costly) health challenges.
• New doctors would derive the same upsides as described in the above pro bono option in addition to a long-term, career-enhancing perk: socio-economic competency.

According to the Stanford Medicine 25 blog, when physicians possess such competency, “they are better equipped to engage patients and develop trusting relationships, which can streamline healthcare delivery, optimize the patient experience and improve safety.”

Profound economic bonuses are also possible for medical students who study in states that pursue pasantia-esque initiatives. They could include improved med school acceptance possibilities, reduced tuition, and favorable loan repayment terms if the students commit at the onset to staying in-state after graduation and practicing as PCPs in the state’s MUAs. Such a program is already being offered in Ohio with the Ohio Physician Loan Repayment Program.

Keep in mind that the above proposals to upgrade the availability of American primary care medicine to patients who need it are not quick fixes: they will take time to envision, organize, and launch. However, they aren’t hypothetical or theoretical notions. They have proven themselves intelligent solutions in different industries (legal) and countries (Mexico). With persistent and creative vision, both have great potential to deliver effective, enduring, and affordable results for patients, medical students/new doctors, and the U.S. health care system.

Dr. David Lenihan is the past president of Ponce Health Sciences University, a medical school with campuses in Ponce, Puerto Rico, and St. Louis, Missouri.