Commitment to Care for the Community

Once again health care reform is a national priority, and President Obama has made a commitment that his administration will work to ensure health care for all US citizens. It is assumed that this includes the 47 million individuals who are currently uninsured and the other millions who have inadequate insurance because they lack the financial means to purchase adequate health care.

The United States has assiduously opted not to join other developed nations by enacting a national health service, a national health insurance, or any single-payer health system, and there is little likelihood that this will occur now. Why is this the case? The United States is a nation built on commitment, certainly to freedom and to capitalism. But what has happened to the entreaty “Give me your tired, your poor, your huddled masses yearning to breathe free . . . ,” inscribed on a bronze plaque currently located inside the Statue of Liberty exhibit?¹ Perhaps US citizens have become too tired and there are too many poor, huddled masses yearning, so the sense of community has dramatically changed.

Certainly, especially in current times of great economic stress, few if any want to provide for those who can provide for themselves but will not. Commitment to community means all doing whatever they can to provide for themselves and family and then providing whatever they can to help those who, for legitimate reasons, simply do not have enough. Perhaps it is unrealistic to believe that there are enough resources in the United States to ensure that no citizen should go hungry or without shelter or health care. But knowing how the United States has prospered despite great stresses such as wars and financial depressions, it seems logical to hope that the nation can once again prosper and share that prosperity with all deserving Americans.

One aspect of health care can serve as an example of how commitment to community could work. There has been a maldistribution of US physicians by specialty and geography for many decades. The solution for maldistribution by specialty rests primarily on eliminating the lack of primary care physicians² and perhaps the lack of general surgeons.³ In 2008, only 16.9% of medical students chose the primary care specialties of general internal medicine (5.1%), family medicine (6.1%), and general pediatrics (5.7%), and only 6% chose general surgery.⁴

In addition, 87.6% of medical students graduate with loans, and 79.3% graduate with loans of more than $50 000. The mean educational debt for indebted medical school graduates is $139 517.⁴ With that degree of indebtedness, and considering the current salaries of generalist physicians, the likelihood is low that more medical school graduates will choose primary care. One peculiarity is that this is not true for general pediatricians. In this issue of JAMA, Freed and Stockman⁵ report that, over the past 3 decades, there has been a steady increase in the ratio of generalist pediatricians from 32 per 100 000 children aged 0 to 17 years to 78 per 100 000 in 2005. However, although the number of generalist pediatricians does not appear to be a problem, their geographic maldistribution remains.

The current lack of primary care physicians, at least for adults, especially in underserved areas, is not a new phenomenon, and several solutions to alleviate this problem have been proposed. One attempted solution to the primary care problem was to increase the number of medical schools in the United States. A total of 41 new medical schools were opened in the United States between 1970, when there were 85 schools, and 1990, when there were 126 schools. The majority (27) of these new schools were opened in the 1970s (Henry M. Sondheimer, MD, Association of American Medical Colleges; oral communication). Graduating more physicians from more medical schools clearly did not solve the issue of specialty or geographic maldistribution.

Another proposed solution centered primarily on the relatively low reimbursements to primary care physicians when compared with subspecialists.^{2 ,6} In this issue of JAMA, Baron⁷ proposes that a more substantial problem affecting primary care is the lack of capacity for generalist physicians to perform well despite their intentions. This problem is a function of both the mental models of primary care (ie, taking responsibility for advocating for and supporting patients) and the available funding to support that care. This problem is exemplified by Wu,⁸ also in this issue of JAMA, who writes about his experience with one patient in A Piece of My Mind.

Solving the geographic maldistribution problem is even more complex than the specialty problem. Most, if not all, physicians are educated and trained in institutions with full medical services. Even if a newly trained physician would like to provide care in an underserved area, having a lack of partners, which leads to being on call much more than desired; having few or no specialists to whom patients can be referred; and lacking a full-care hospital where patients can be admitted mitigate the likelihood of settling and practicing in those areas.

One partial solution to the specialty and geographic maldistribution problem that has been scarcely tapped is the US National Health Service Corps. In this issue of JAMA, Saxton and Johns⁹ propose expanding the National Health Service Corps (NHSC). They describe how an expansion of the NHSC, with the mission of improving the health of the nation's underserved, could provide for the direct delivery of health care, for the development and building of better models of care, and for providing experiences for young physicians who desire a career in primary care.

With the variety of proposed solutions to the problem of so many Americans not having access to care, in this case primary care, the common theme is commitment to care for the community. This includes commitment by physicians and other clinicians to provide the kind of care they know is best for patients, commitment by all payers—private or public—to provide the resources needed for this care, and commitment by patients to pay for what they can and not to misuse the system that provides care for them. Some individuals might believe this effort to be a pipe dream, but without the commitments by all those involved, there will never be a health system in the United States to care for all who truly need it. Perhaps one good outcome from this time of economic stress for virtually everyone is that charity (I invite everyone to look up the various definitions and meanings ascribed to this beautiful word) will prevail and commitment to care for the community will result, finally, in the beginning of ensuring health care for all.