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by James Gaulte, MD

Should medical student applicants be chosen less for their demonstrated ability to master large amounts of knowledge and solve problems and more for their social consciousness and desire to push forward with social justice?

That appears to be the suggestion of a panel of experts from the AMA in a project called the Initiative to Transform Medicine (ITM) who believe an altruism deficiency underlies the migration to certain more lucrative medical specializations at the expense of forsaking primary care causing a shortage of primary care doctors.

Duke Cheston gives a good summary and exposition of reasons more convincing than a sudden attack of selfishness, greed and hypertrophied self interest as to why fewer medical students choose primary care. Yes, it does depend to a significant degree on income, but there is more to it.

The suggestion made by the panel that social awareness or social consciousness should be weighed more heavily than ability to master a formidable load of knowledge and problem solving ability in selecting students for primary care residency training reflects a lack of awareness of what is required in primary care and a demeaning characterization of primary care medicine. Often more problem solving skill is demonstrated in sorting out a patients diagnoses from a myriad of often non-specific complaints that is evident in the specialists subsequent handling of the case which arrive in his office with the label already properly applied. Internists were once thought of as being at the top of the problem solving food chain but now those limit their practice to outpatients seem to be considered merely as members of the category of primary care provider.

I believe the shift of medical students from primary care to specialties is due less to some alleged “altruism gap” than to the combination of three other gaps; 1) an income differential gap, 2) a lifestyle differential gap, and 3) a practice hassle

How did the income gap come about? This is a story often told in the medical blogs of the Resource Based Relative Value Scale and the now infamous RUC and the role that once obscure group played in protecting the income of procedure oriented physicians versus those who do not do procedures.

In addition to the altruism deficiency the panel “determined” another weakness of physicians as they are trained today:

Physicians are generally not prepared to be advocates for patients on issues related to social justice (for example, elimination of health care disparities, access to care) and to be citizen leaders inside and outside of the medical profession. This also includes engaging in advocacy on public health issues.

Apparently in the view of this group of self designated experts, one of the many requirements of physician training is to prepare them to work for social justice, which must involve redistribution of wealth. Perhaps lessons in community organizing could be added to the curriculum. I suppose libertarians need not apply. Neither should anyone who thinks Thomas Jefferson had it right when he said,

To take from one because it is thought that his own industry and that of his father’s has acquired too much, in order to spare to others, who, or whose fathers have not exercised equal industry and skill, is to violate arbitrarily the first principle of association — the guarantee to every one of a free exercise of his industry and the fruits acquired by it.

The general philosophical basis of the ITM is the same as that underlying to the creation of The New Medical Professionalism, which seriously weakens the fiduciary duty of the physician and inserts a nebulous duty to society to the physician ‘s obligations.

James Gaulte is an internal medicine physician who blogs at retired doc’s thoughts.

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