The Baltimore Sun has an article about the effects of medical malpractice tort. A couple things jumped out at me with this part of the story:
In the Hopkins case, Enso Martinez and his wife, Rebecca Fielding, also claimed their son became oxygen-deprived in his mother’s womb and that medical staff should have performed a Caesarean section sooner than they did. The birth had started at home, overseen by a midwife whose license was later suspended, but the mother was rushed to Hopkins because of complications. The judge in that case excluded evidence about the midwife’s license, saying it would prejudice the jury.
The first bit is about midwifery, which I am broadly supportive of if that is what a woman chooses to do in that regard. And I would support laws that would help women make that choice. That said, one of the things that midwives are very critical of obstetricians about is c-sections. And here we had a midwife who screwed up (or appeared to) and a doctor who lost a massive lawsuit for failing to provide a c-section. When we look at the high c-section rate in this country, the fact that doctors rarely get sued over unnecessary c-sections and do get sued for failing to perform them needs to be thrown into the soup. I don’t even think it’s necessarily even a direct thing where doctors are choosing c-sections in borderline cases for fear of lawsuits, but it contributes to a culture of intervention. I’m not sure it’s something that tort reform would be able to fix, as it’s more about frames-of-mind than anything. It’s one of the things that has me concerned about expanding access with current mentalities in place. That’s not to say that we shouldn’t, but it is one of the things I see on the horizon that disturbs me.
The Wall Street Journal has an article about the expanded access and the lack of providers to provision them:
When demand exceeds supply in a normal market, the price rises until it reaches a market-clearing level. But in this country, as in other developed nations, Americans do not primarily pay for care with their own money. They pay with time.
How long does it take you on the phone to make an appointment to see a doctor? How many days do you have to wait before she can see you? How long does it take to get to the doctor’s office? Once there, how long do you have to wait before being seen? These are all non-price barriers to care, and there is substantial evidence that they are more important in deterring care than the fee the doctor charges, even for low-income patients.
For example, the average wait to see a new family doctor in this country is just under three weeks, according to a 2009 survey by medical consultancy Merritt Hawkins. But in Boston, Mass.—which enacted a law under Gov. Mitt Romney that established near-universal coverage—the wait is about two months.
When people cannot find a primary-care physician who will see them in a reasonable length of time, all too often they go to hospital emergency rooms. Yet a 2007 study of California in the Annals of Emergency Medicine showed that up to 20% of the patients who entered an emergency room left without ever seeing a doctor, because they got tired of waiting. Be prepared for that situation to get worse.
This is something that is going to need to be tackled. We can blame Obamacare for failing to do so, but it at least made moves in the right direction and Republicans have not really been offering their own solutions. At the same time, more doctors and more access will lead to increased costs. Worthwhile costs, perhaps, but it’s something that is going to need to be accounted for.
The Atlantic’s Ben Gallagher has a plan:
Despite such significant investments in physician education, the government asks very little in return. Doctors are free to choose what type of medicine to practice, where to set up shop, how many hours to work per week, or whether to practice medicine at all. It should come as no surprise, then, that physicians’ choices so often diverge from what legislators have in mind. In a country with a scarcity of primary care doctors and with many regions suffering shortages of health care providers, this situation is untenable.
Politicians and voters should insist on a fix to this system. An initial approach might be to raise awareness of government spending on medical education among current students. The topic was never broached when I was applying to medical school in 2010, and has not been discussed by my school’s administration since I was admitted. If more students knew that their government was making an expensive investment in them, they might strive to become the kinds of doctors their country needs.
But medical students are only human, and we’re more likely to follow financial inducements than civic callings. State and federal lawmakers should begin considering policies that would force more doctors to go into primary care, work in underserved communities, and work full-time.
My wife will be moving to a “part time” schedule that will almost certainly leave her working more than forty hours a week. A lot of the shift away from “full time” work to “part time” work has to do with the fact that full time and part time take on different meanings in that profession than in others. Physicians work long hours and generally do not retire young (though they do semi-retire, sometimes). Burn out is a serious problem. Further, the problem with “underserved” areas is precisely the commitment it requires.
However, I am in favor of nudging more doctors into primary care. Nudging them into underserved areas is also a worthwhile project. But this should be divorced entirely from the notion that doctors are broadly not carrying their load.
And lastly, apparently some medical schools are looking to speed up the process:
Administrators at N.Y.U. say they can make the change without compromising quality, by eliminating redundancies in their science curriculum, getting students into clinical training more quickly and adding some extra class time in the summer.
Not only, they say, will those doctors be able to hang out their shingles to practice earlier, but they will save a quarter of the cost of medical school — $49,560 a year in tuition and fees at N.Y.U., and even more when room, board, books, supplies and other expenses are added in.
“We’re confident that our three-year students are going to get the same depth and core knowledge, that we’re not going to turn it into a trade school,” said Dr. Steven Abramson, vice dean for education, faculty and academic affairs at N.Y.U. School of Medicine.
At this point, the effort involves a small number of students at three medical schools: about 16 incoming students at N.Y.U., or about 10 percent of next year’s entering class; 9 at Texas Tech Health Science Center School of Medicine; and even fewer, for now, at Mercer University School of Medicine’s campus in Savannah, Ga. A similar trial at Louisiana State University has been delayed because of budget constraints.
But Dr. Steven Berk, the dean at Texas Tech, said that 10 or 15 other schools across the country had expressed interest in what his university was doing, and the deans of all three schools say that if the approach works, they will extend the option to larger numbers of students.
For those wondering, this won’t create more doctors because medical schools themselves are not the bottleneck. Allowing doctors to graduate with less debt is a good thing for doctors, of course. There are arguments to be made that this might help combat the need of doctors to rat-race when they get out in order to pay down their student loans. But it may have no effect at all. There are a lot of factors at play.
Most doctors I know like money. I mean, who doesn’t? That’s why they call it “money.”
What’s confusing is why the market doesn’t correct for shortages in critical service areas. Not enough ER doctors? Then it seems doctors should demand more money for that kind of work, and insurers and hospitals and Medicare — and thus ultimately patients and taxpayers — through those intermediaries ought to pay it.
That seems simple, but the insurers and hospitals and government agencies are obviously thick filters so the available pool of people to do the work doesn’t seem to match the market.
Well, Jimmy Fallon has found some people who don’t want more money. And a lot of doctors (like others) forgo more money in favor of a sense of mission or life satisfaction or whatever, but generally, yeah, docs respond to the same incentives as everyone else. (Worth noting is that some of the other incentives also can push people away from family medicine.)
It is strange to me that the market mechanisms that are supposed to be driving things… aren’t. How areas where the greatest shortages exist can’t use their leverage and areas where there is less of a shortage continue to make a mint. It goes to show that The System is bigger than the market just as it is bigger than the government.
I don’t know about healthcare, but I’ve seen some pretty funny complaining in other fields about how “Unemployment can’t be high, we can’t get workers” and note that their salaries/hourly rates are insulting.
They can’t get workers because they won’t pay for them, and apparently the part of supply and demand where they increase wages to attract more workers is lost on them. Instead they complain that, say, they can’t find coders willing to work for 80% of the going rate.
It varies from case to case. Some employers are indeed lowballing. Often, though, it’s a case of regional misallocation (the fields of North Dakota and West Texas are paying quite nicely). A couple years ago when I went back home, they were practically handing jobs out at the airport. A friend was complaining about the inability to find IT people, but he told me the job and how much it was paying and I have to say it was pretty solid. So it’s not just lowballing. Honestly, I think a far bigger issue than lowballing is an unwillingness to train combined with a demand for perfect skills/experience alignment.
Oh god, that’s true. I’m a software engineer — and when scanning the job postings (or when I get the occasional headhunter call, and trust me if you’re lucky enough to be in a field with headhunters you should NOT extrapolate your experiences and leverage when it comes to employment with, well, anyone else’s. We’re the exception, not the rule)…
Well, it’s really obvious they’re looking for the guy who just left. EXACTLY that guy. With an eclectic collection of skills he’d either grown in the process of doing the job for a decade, or had brought to the job and used to make something….
And I read “10 years experience C++, 8 years Java, 6 years [insert random tool here], 6 years [another random tool], 15+ years [obsolete tool], 5 years [tool like four people total have ever used]” and find out that, indeed, they really want applicants who meet exactly that (never mind that C++ and Java are close cousins, that the random tools are practically identical) AND they want to pay you less than the guy who just left.
It’s really not hard to tell the HR person “You probably should have just given that guy a big raise and kept him”.
They never want to train, ever. But worse than that, they don’t understand their own requirements.
Thankfully, my current job was “You know C/C++? Excellent. You have experience with GUI’s? Great, we use [x] but it’s pretty well documented, if a bit kludgy compared to more modern stuff, but we’ve got tons of legacy code. You should pick it up fast if you’ve even used a WYSIWTG editor. Woah, you have some educational background in data mining and doing higher order math in computers? Sold. Admittedly most of our math is FORTRAN, which you don’t code and you’re not expected to learn, but we’ve been looking at offloading some stuff to C++ and it’d be nice to have someone who has even a hint of theory to help out”.
They wanted someone with a relevant background, not perfect credentials.
To me, the really irritating part about people not wanting to “train” software engineers is that we’re essentially self-training. It’s not like you’re hiring a line cook and turning him into a machinist. We learn programming languages and computing tools for a living.
I wouldn’t take a pure Java programmer for any sort of C++ job. too much potential for shooting their leg off, and your project with it.
Memory management is a bitch.
A contracter for Google: “So it turns out that I was helping code Chromium. Who knew?” (he was on the memory architecture)
I dunno. C++ is an awful language. I like Java coders who’ve written C language but I’ve never found a C++ coder who could debug the messes he’d created. It’s horrid at low level. It’s also horrid at high-level.
“If we train people, other companies will just steal them! That’s why we have a policy where we steal people from other companies.”
Blaise,
You see one here. My code don’t leak, and it doesn’t break (often. and that’s caught in development). This month’s fun is ramdisks and stupidly-easy multithreading.
You seen x264’s code? Nobody writes true C anymore, not since the early 1990’s, since OO came out.
I’ve written C (and read other people’s, which counts for more), I’ve dabbled in assembly extensions.
There is only one way to debug C++ effectively, get a copy of Comeau and have it generate C code. Then examine the C code.
Blaise,
Oh, stuff and nonsense! I use memset just as much in my C++ code as anywhere else…
Besides, if you’re using structs, there’s practically no difference between C and C++ anyhow.
Oh please. Nobody writes C any more? Guess you never wrote anything for an embedded system in kernel space. If you write C++ for Google, you confine yourself to single inheritance, like Java.
C++ has so many drawbacks for writing OO applications, I view it as a strategic hazard. I use the Google guidelines if I have to support C++ anywhere.
Eh, I don’t do much multi-inheritance. What I do seem to get is tasked with fixing a C-programmer’s idea of what C++ code should be, which is “badly”.
Inheritance used willy-nilly (and wrongly), encapsulation violations — good lord, I have one piece of code where the designer passes a pointer to the main class down to objects it creates!
*facepalm*. It is, shocker, buggy. 🙂
I’ve been writing C for an awfully long time now. I was at Bell Labs when C++ (then C with classes) was the new hot thing. I don’t buy the argument that C coders don’t understand objects and encapsulation: they did and they do. Stroustrup didn’t understand how to write a compiler for his own language. More exactly, Stroustrup didn’t understand compilers, period.
C++ is a mess. It’s not a good OO language by anyone’s definition. I write it, I know how to take off my C hat and put on my C++ hat, but it’s a sloppy, slippery language best left to MSVC weenies who need to write Microsoft applications to their crummy spec.
Nobody writes C any more? Guess you never wrote anything for an embedded system in kernel space.
Or applications running naked on the underlying hardware. Next week’s project is the annual reprogramming of The World’s Most Sophisticated Whole-House Fan Controller™. Yeah, it could be written in C++, but the parts involving interrupt handlers are a pain — you end up having to work around the C++ name-mangling in order to defeat encapsulation, and there are opportunities for extraneous instructions to creep in. At least the contemporary code optimizers for C generate tighter assembler than I can most of the time.
@Michael: Heh. C++ has been promising us good things for so long and failing to deliver, perhaps we ought to start labelling it as ++C .
There is only one way to debug C++ effectively, get a copy of Comeau and have it generate C code. Then examine the C code.
I was going to object, but if the problem is overuse of operator overloading, copy constructors, etc, you’re right that you’ll see the actual method calls.
+100 to Frog and Jay. (Which gives me an idea…)
@BlaiseP: Clearly, you and I are both “of an age”. I was the stuckee who got to port C with Classes to a different UNIX variant (and more importantly, a C compiler independent of anything Bell Labs had done) for a software research group at Bellcore. The task got done, after some interesting e-mail exchanges with Stroustrup.
I think it’s your turn to go chase the whippersnappers off of the lawn :^)
The impression I’m left with from this thread is that you software guys have a lot of time on your hands. Cuz it seems like the most prolific commentators are all IT. Maybe getting paid to look like you’re working?
Rod,
Yes, we are the ones paid to stay up till 4am on a regular basis. And carry a pager, and mind the shop while everyone else sleeps. A bit of rec time at work is good for clearing the head.
Blaise,
Oh, if you’re just going off on a rant about multiple inheritance? I dig. I dig.
Never worked on embedded systems.
Do you like C better as an OO language than C++? 😉
morat20,
yeah, inheritance -can- be a good idea. it -can- simplify what you’re doing.
Michael,
I dig the name mangling issue with C++. Tis a bitch. I know someone who got /more features/ added to C++ (apparently Stroustrup had left one or two out).
It’s more like we’ve got 5 (or 8, or 13, or 17) windows open and we can jump back between our document, our other document, our batch script, our email, and our browser.
I, personally, tend to be mentally writing and editing comments while, physically, I’m cleaning up install instructions… and I’m usually able to do that without writing a paragraph for our installers about the difference between matters of morality and matters of taste.
The impression I’m left with from this thread is that you software guys have a lot of time on your hands. Cuz it seems like the most prolific commentators are all IT. Maybe getting paid to look like you’re working?
At least for me, I’m mostly retired, am trying to write a couple of books, and these days only write code for little projects that interest me. So no one except my wife can complain that I’m commenting at the League instead of doing something more important :^)
The desire to hire the guy who just left makes me laugh… because it’s so true. My brief experience in middle management taught me that getting people raises in order to keep them and the skills they have accumulated is nigh-impossible. But train someone new? Too expensive!
The COO at a former employer of mine actually took the position that it was morally wrong for an employee to ask for a raise. Because they agreed to work for a certain amount. And now, suddenly, they want more? To do the same job they agreed to do for less? It was less difficult under his successors. Particularly when we were fortunate enough to be able to hold on to our team for a protracted period of time. We were able to point to the enormous increases in productivity that was occurring. Their response was torn between “See? We can get this paying XML programmers $9.50 an hour. We are awesome!” and recognizing that departures tended to come in waves and we were due for one. It turned out to be a moot point because the company hit an iceberg and sank. (They’re still around, but as a shell of their former selves.)
But even leaving side compensation, just some accommodation could help them retain talent. At the aforementioned company, the previous wave of departures had been due to a crack-down on Internet usage*. At a later employer, the company lost half of its tribal knowledge and our team lost its best employee because she couldn’t get to work by 8am. Despite the fact that this was not only not a job that required someone to work from 8-5, but that it was actually useful to have someone staying a couple hours late every day. Oddly enough, the Japanese management was willing to accommodate this – though they didn’t like it – but once the team was turned over to an American, she was fired. The previous (iceberg) employer had a similar issue, wherein it was helpful to have someone staying late but they would rather disallow it and pay someone overtime than let them come in at 10:00.
* – They couldn’t even say “If they want to surf the Internet at work, we don’t want them working here” because two of the departures constituted 33% of the previous six months worth of Employees of the Month and both cited the Internet policy.)
Want to avoid this predicament? Keep the coders away from everyone else. Have middle management communicate though a designated White Shirt Person. I’ve had to kinda Get Tough about this issue: some people’s management style is to take the temperature of a project by sticking their finger stuck up the coder’s fundament. I don’t have the luxury/mandate of doing that to their people and don’t allow it to be done to mine.
In this case, it wasn’t even so much that they saw people surfing the Internet. It was that they implemented a tracker without telling anybody and then counted “hits.” Then yelled at everybody for surfing on company time. Then told people they would get a maximum of “50 hits” a day.
I turned out to be one of the worst offenders because I was listening to Rhapsody while I worked. You might think that the bandwidth for streaming audio was the problem, and reasonably it might have been. But I’d specifically asked about that and they said they preferred that to having “probably illegal” MP3’s on their computers. The problem is that Rhapsody generates a new “hit” every song and every time a new image appears in the ad section, making it appear that I was surfing a new website every three seconds for eight hours a day.
Good times.
If people realised how programmers work, it might be different. I try to explain it this way: it’s like deep sea welders. They spend a lot of time getting down there, they can only spend a limited amount of time at depth, then they have to spend time getting back up. You can interrupt them, haul them up from depth immediately. They’ll die of the bends if you do and you won’t get much work out of them for the rest of the day. A motivated coder will do maybe two hours of work a day, max. The rest of the time, he’s thinking. Measure twice, cut once, etc.
The last person I want on my team is a Hard Worker. Those people are the bane of my existence, cranking out code and not testing it, no spec, no comments, no code review, no unit test, no adherence to standards. Awfully “productive”, though.
I’m trying to see how adding lots more people into the “system” and imposing top level cost reduction is going to do anything but fubar the “market”, such that it is, less. The primary cause for all of the problems in “healthcare” is that the receiver of care does not pay for the care, and therefore, is insensitive to price.
Damon, the idea is that if you flood the market with doctors, you can draw government payment rates down because you will be able to find doctors willing to do the work for less. And with enough suppliers that are desperate rather than overflowing for business, they will find ways to cut overhead.
By itself, I don’t see it having an effect. But I do have some difficulty seeing rates being drawn down while maintaining the shortage of physicians that we have. Though I am, of course, not anxious to see physician fees drawn down, I do think that has to be a factor in controlling costs. My hope is that we can do it by focusing on how much is done rather than how much is spent each time it is done, but I don’t know if that’s enough. (Just as I don’t know that cutting insurance bloat by going to single-payer is in itself enough.)
The fundamental issue here is whether healthcare “customers” can ever really be sensitive to price they way people are to other goods and services.
I can tell you from experience that a couple years ago when my little girl was run over by a car and they had to call an air ambulance to take her to the nearest regional medical center, the last thing I was thinking about was whether there was some cheaper alternative.
And I can tell you from experience that when my wife was diagnosed with ovarian cancer last year the last damn thing I was worried about was how much the treatment would cost.
I’ve come to the opinion that the best way to control medical costs isn’t too different from the way we currently operate. I mean, who has more leverage on prices? The consumer in one of the situations I just described, or an insurance company with hundreds of thousands of subscribers?
the customer, if he’s poor and can’t afford any treatment at all. Then he just dies, with or without insurance.
The insurance company otherwise, except in the cases of children, where they are notoriously free with their spending.
Well, I’m already on the record over at BT with regard to home-based midwifery. I don’t support it, but having already dived into that fight with as much gusto as I have, I’m going to pass on resuming it. To your point in the OP, failing to account for the negligence and incompetence of the midwife in the baby’s poor outcome is a miscarriage of justice.
The medical school I attended was chartered largely to provide primary care physicians for the state where it is located. There was no financial incentive to go into those fields, just a lot of focus on those fields in our curriculum. IIRC, a large percentage did end up going into family practice and internal medicine, though how many of those latter ended up further subspecializing I couldn’t say.
I find NYU’s efforts fascinating. I have an old academic affiliation with that medical school, and can tell you that the medical students I knew back in the day could not have (in general) evinced less interest in primary care (certainly pediatrics) than they did. I’d be interested in finding out how those efforts pan out.
Maybe Burt can explain what the legal rationale behind excluding the midwife from the equation was. The only thing I can think of is that since the mother and baby could have arrived in that state without a midwife then it shouldn’t be considered a factor. However, it seems to me that (a) by going with midwife care the mother assumed certain risks that should be considered at least mitigating for the physician and (b) that this tragedy did not occur in a vacuum should itself be considered significant.
I swear I wasn’t trying to bait you! I thought about linking to your piece, but I thought I would spare you the wave of commentary with a fresh link.
I wouldn’t expect NYU grads to go into family medicine… I’ll leave it at that. Texas Tech, LSU, and so on… that’s where such things could come in more helpful. But next up (as far as medical posts go), I will be posting a couple links suggesting that primary care physicians aren’t necessary anymore. I thought about tacking that onto this one, but it was already running too long.
I swear I wasn’t trying to bait you! I thought about linking to your piece, but I thought I would spare you the wave of commentary with a fresh link.
Heh. I kind of like that comment thread. First, it validated my feeling that, of all the subs, BT gets by far the most vociferous commenters (with the exception of when Rush is discussed). And it came right before Leaguefest, so I got a lot of “wow, that was epic” discussion out of it. I’ve walked away from engaging it, however, so any new comments wouldn’t get any reply anyhow.
And yes, my medical school was a state school.
I think for a lot of “bread and butter” medical care, NPs and PAs do every bit as well as an MD. For more complex care, I still feel strongly that the additional training of a medical degree is necessary.
I can take a bit of credit for that BT thread exploding, I’m mischievously proud to say.
Well, if I’m allowed to take perverse pride in having the craziest trolls around these parts (and I hasten to clarify that I’m not lumping a lot of the people who took exception to my views on midwifery into the “troll” camp), then you can be mischievously proud of luring angry, angry people to my comment thread.
Some of my wife’s PCP colleagues went to private school (including some well-regarded ones). None went to private school in the northeast, however. A couple of public school northeasterners, though.
I like MLP’s in the abstract, though my only experience seeing one was not encouraging. I do think that it’s going to be the future, though.
Some of my wife’s PCP colleagues went to private school
Yet a lot of people think public schools are the ones with big drug problems.
My experience with NPs and PAs (and I will have to admit to a generally better impression of the former) has been largely positive. With a couple of exceptions, they’ve all been wonderful, competent and caring medical providers.
And I’ve worked with a lot of stupid MDs in my time.
I think for a lot of “bread and butter” medical care, NPs and PAs do every bit as well as an MD.
Two data points:
1. Our family “doctor” is a Nurse Practitioner and we’re quite satisfied with her. But my wife (see comment above to Damon) also has quite a few specialists that she sees.
2. When I was stationed onboard the USS Monongahela, our sole medical staff was a nurse practioner (and maybe an enlisted corpsman, now that I think of it). This was for a crew of maybe a couple hundred. That’s very independent duty since you’re out on the water, but we also had the option of evacuating someone to the carrier in our battle group if we really had to and those things are like floating cities (maybe 5000 crewmen).
So I’m firmly in the camp that your primary family physician doesn’t necessarily need to be an M.D. to be effective.
My best guesses about excluding the midwife are:
a) Already settled with her.
b) Client has irrational emotional affinity for her.
“Maybe Burt can explain what the legal rationale behind excluding the midwife from the equation was. ”
Did she have professional liability insurance? Because my first guess is that it would be connected to the answer of that question.
I am a fan of home-based midwifery, but the laws in a lot of states (maybe all) and maybe some provinces (thankfully, not Ontario) are so fished up that they result in homebirths being exclusively the domain of under-trained midwives. Seriously, WTF? I don’t understand how that even makes sense (except to try to exercise a lot of control and, possibly, kill homebirth).
That being said, if a state-regulated, poorly trained (and, apparently incompetent) homebirth midwife screwed up to such a degree that it should have been obvious to the doctor that a c-section was necessary, doesn’t that count as malpractice*? Similarly, if it had been a paramedic who really screwed up in the ambulance on the way to the hospital, wouldn’t we still expect the doctor to identify and fix the mistake?
Of course, none of that would preclude the midwife from also being sued (if the law so permitted).
*I’m not arguing for or against the current state of malpractice torts.
Maybe that’s the rationale. That still doesn’t justify keeping the midwife story away from the jury, though. But for the midwife and the risks the mother assuned, the doctor wouldn’t have been in the situation to have to make the call to begin with. Od course, I am biased not only by having an obstetrics performing wife but also having a chip on my shoulder because of the ways the system penalyzes her for her non-interventionist philosophy.
Do the risks people assume go into malpractice cases? If you get a head injury in a car accident, and the doctor amputates your leg, does it matter that you were driving 100 mph*?
*100 mph, that’s fast, right? Please just adopt the metric system already.**
**I’m kidding. I often hate the metric system.
That’s a good question. I’d assume that the answer is “sometimes.” I’d think it would be more likely to apply to cases where the two are directly related. Which I consider them to be here, though maybe that’s disputable.
“…it contributes to a culture of intervention.”
This is perfectly stated, Will.
The Canadian provincial governments have a variety of schemes whereby if you work for the government for a certain number of years, your student loans are forgiven. It seems like it should be easy for the US to do the same with med school loans – work in an underserved community for 3-5 years, and your student debt is cancelled. It might lead to those communities being stuck with unexperienced doctors just out of med school, but it’s better than them not having anyone. Probably harder to use financial incentives to get doctors at a later stage in their career to change their behaviour, as they’d have to move, and that’s not something financial incentives can necessarily outweigh.
We have various programs here for debt forgiveness. I have mixed feelings about them, but there are a lot of strings attached (committing to any job for six years is tough) and ultimately even if you counted it as straight salary, it doesn’t compensate for the income differential.