Welcome

In case you haven’t noticed, I am pretty verbose. My incredible high school English teacher Mr. Boone often said that it is easy to write a lot. It is much harder to write a little, while maintaining quality.

In that spirit, and clearly not without a preface, I aim to jump right in with a shorter version of the newsletter. I’ll likely poll in the future (you can always reply with feedback too!) to see how we like a longer Thursday, shorter Sunday schedule.

Doctors WITH Borders (aka Restrictions)

Continuing on some of the public health themes from Thursday I have long wondered how our medical education system works. I am known to say the phrase “why is nobody talking about it” in reference to quite a few topics and this is one. If the conversation is happening elsewhere, please do let me know!

There are strikes in the US health system, but also in public systems from Canada to the UK. While pay disputes exist, a lot of strikes simply involve workload and hazardous conditions, partially fueled by understaffing.

We may need an internal reshuffling across specialties (primary care, geriatric, etc.) as our population ages, but that will still require the same number, if not even more, doctors and workers in healthcare than we have today.

While efforts have been made by some medical schools to increase enrollment, there is still a projected physician shortage in coming years and, as anyone trying to make an appointment today probably feels, likely already one right now. Despite such projections and experiences, the number of residency slots has hardly budged as it is largely (up for debate) outside the control of medical schools. In fact, Congress has capped the number of slots at 1996 levels.

So, while there has been a nearly 50% increase in medical students in the US in the last two decades, there has been a miniscule increase in residency openings. Still, due to specialization and other factors, residency slots across a few dozen specialties go unfilled while more popular ones are “oversubscribed.” Preceptors are also being overwhelmed as they take on more students with the same amount of oversight and administrative support.

One-off grants can be valuable in bolstering healthcare access in specific locations, but federal and state policies have also been potentially driving certain specialties away with nearly half of US counties not having adequate Ob-Gyn care available.

While the federal government certainly needs to look at caps, and they have a place in directing funding and workload, the funding is primarily through Medicare and, ironically, referred to as “Medicare patients’ share of medical education,” implying there are others to foot the bill. Medicaid and Veterans Affairs also make contributions to medical education, but what about those on private health insurance? How do they contribute?

Educational institutions are increasingly covering some costs of residency programs, but the practice is not standardized. Efforts are being made directly by states, but importantly via Medicaid funding. Private insurance “implicitly” covers costs through the patient care being conducted. I do not have the ability to untangle the disjointed nature of our system of education and healthcare in the US, but I will simply say it seems that we could approach the issue more holistically, rather than (essentially) solely through Medicare and assuming the general costs of care factor in teaching costs on the private (often for-profit) side.

While I said no one is talking about this, there have been some attempting to tackle it. One of the most comprehensive papers discussing the matter is here. 2021 and 2023 also saw some adjustments to add ~1,000 more spots, but again there is no consistency or long-term plan.

The US isn’t alone in its issues nor future ones with Europe also referring to its situation as a crisis. However, they are aiming for solutions with much more robust and unified health and education systems compared to the scattering of institutions and systems in the US.

I have brushed over recent announcements in threats to federal funding of universities and healthcare and other issues like the private equity takeover of hospital systems and our increasingly for-profit ambulance and EMS system in some places, costs of our system, social factors affecting our health, nurses and other healthcare workers who often take on the same workload as doctors and face their own shortages, and racial disparities in health outcomes and treatment. Thankfully some of that is getting “traditional” attention and I hope I have just illuminated another facet of what we face.

Another thing I do want to mention is telehealth which has freed up some time for doctors, but I know for many it also means even longer schedules and less breaks. Importantly, it has also greatly increased access to healthcare for those living in rural areas and the elderly everywhere, reducing the need to travel to all appointments. However, its existence has been tenuous and certain approvals have only been allowed through the end of this year! Not only should telehealth coverage be permanently extended, but we also need reform so telehealth can be utilized across state lines, allowing for consistency with a doctor, especially in a country that is on the move. Even with a recent stagnation in moves, a significant percent of the population still does so not to mention college students and those traveling for work.

The Tangent

Two different $1 billion gifts in recent years have made Albert Einstein College of Medicine and Johns Hopkins Med School essentially tuition free with others also using the tactic to alleviate the financial burden of medical school and diversify their base of students.

Relatedly, Canisius lowered its “sticker price” for undergraduate education a few years ago, noting that scholarships lowered the true cost paid for most students, but that many people who could have attended did not even apply because of the advertised tuition. In effect, Canisius was not set to lose much money by lowering tuition, but rather attract more students and advertise a price closer to the net costs most ultimately pay.

Universal free college programs have occasionally been derided as giving the rich a free ride - shouldn’t those that can afford to pay for college do so? While I agree, research has shown that administering an income-based program may actually cost more in paperwork and time, deterring those eligible from even applying. A similar argument applies to universal healthcare. Further, a proper progressive taxation system would ensure the rich pay for any and all government services and subsidize poorer people receiving the same rather than the other way around. My favorite description of the conundrum is that implementation would be “administratively nightmarish.”

My work with the incredible folks at the Climate Solutions Accelerator has also highlighted that even for those that qualify for any given program, providing proof of income is difficult and can be embarrassing or risky. When pursuing energy efficiency rebates, a tenant may not want to share their income directly with a landlord in the process, afraid they may raise rents. The organization is working with the state on a program where if the majority of people in a given zip code or census tract qualify for a program by income, demographic, or otherwise, the whole area can pursue that program. This simplifies the process greatly, only requiring address verification, helping the individuals access what they are entitled to and reducing the administrative burden on the state and involved nonprofits and businesses.

A Massachusetts electrification pilot on Cape Cod is a related, but slightly different example I encourage you to read further about as well.

Like healthcare, there are many other industries with job shortages, particularly electricians in the shift toward an all-electric, decarbonized economy. Yet we often hear about the job market and the decline of certain industries. The concept of the Just Transition aims to address that, but it is also not so simple to send someone working in coal into a clean energy role.

Zooming back out, while the gifts above and the concepts of free or more accessible college are great and may be necessary, it is difficult to watch them when realizing that that free initial education will lead to an underfunded residency system. What if $500M went to reduced tuition and another $500M went to opening even a few more needed residency spots and at specific locations? As always, it is not that simple, but it also doesn’t seem to be an option anyone considered as the government is assumed to be the one covering residency funding, not nonprofits or donors.

How Do We Sustain With Age From Here?

There is a specialty, geographic, and funding mismatch in our medical education and larger healthcare system, mirroring mismatches in other industries and aspects of the sustainability transition. In addition to increasing the number of residency slots and paying rural healthcare workers in a way that allows them to establish a successful life there, pursuing such a long post-graduate education should not just have limited costs, but actual pay so medical students can eat and live and those who otherwise could not pursue such a career can do so. The current funding of such an aspiration is shaky and inconsistent to say the least.

There are some “workarounds” at the local and institutional level. The only explicit way I have seen where you can go around the “caps” on residents is through programs sponsored by other countries to get their students residencies. They are matched through the same national matching program and standards, but “new” spots open up at any institution they are matched to because of the separate foreign government funding. Seems like there is money and the ability to open more spots…

Peace,

Kyle