For various reasons our nation’s public health programs have been decimated. This comes at a time when the number of unemployed and health uninsured are at a record high number. Additionally, we are seeing individuals live longer and experience more chronic debilitating illnesses and conditions that stretch the resources of an already under manned and under funded health system.  Emphasizing prevention and healthy living should be a lifetime necessity for each individual and for each community. For this reason I propose the creation of a National Health Service Corp that meets the manpower needs of America and at the same time exposes future doctors and nurses to the varied and diverse health problems that the average citizen faces as they age.

The National Health Service Corp would be part of a National Service Corp developed in the United States.  All graduating high school seniors or 18 year olds would be asked to devote one or two years to providing service before they move on to college or the real work world.  During those two years, enrollees would be trained in civics and government, healthy lifestyle and living, nutrition and first aid while they are providing necessary manpower for rebuilding America.   Enrollees could be used to assist in infrastructure modernization and rebuilding, staffing day care centers so young parents could work, staffing senior day care centers to provide respite care for the increasing number of seniors with cognitive dysfunction and chronic disease and health care facilities such as skilled and assisted living facilities.  The service would be open to healthy seniors and adults as well.  Members of the Service Corp would receive benefits towards higher education and towards the expense of their future health care.  Healthy senior volunteers could receive preferential tax incentives and breaks in exchange for their services.

The National Health Service Corp would be composed of graduate level physicians, nurses and health care trainees who have completed professional school and a newly proposed “general internship “in their profession.  Medical residency and training programs would be extended by two years. The first year would include the old fashioned “rotating internship” during which doctors in training rotate through all the medical specialties including general surgery, emergency medicine, family or general medicine, pediatrics, obstetrics and gynecology.   The purpose of the general training is to acquaint the young trainees with the unique problems that their colleagues are faced with on a daily basis while treating disease and performing procedures.

In today’ s medical education system, doctors in training receive, at best, a few weeks of training in each of the different areas of medicine during their third year of medical school. They can complete medical school and go directly into specialty training programs directly without receiving the additional necessary training and understanding of the problems each discipline faces in day-to-day decision making.  I believe the lack of familiarity of what other disciplines must consider with regard to decision making care is what contributes, to a large degree, to the poor handoffs and communications between clinicians regarding patient issues and the over dependence on expensive testing and technology rather than the use of clinical judgment.

The enrollees in the National Health Service Corps would be supervised by their residency programs’ faculties as part of  a Federal funding change which discriminates in favor of training programs in primary care and other areas of need and, discriminates in funding and grant approval to programs stressing subspecialty procedure oriented training. Bluntly speaking, programs promoting primary care and specialty programs deemed in short manpower supplies would be funded while those promoting procedure oriented specialties regardless of local and national manpower needs would be penalized with little or  no funding. A doctor in training would be unable to train in a specialty until they have completed their “general training” including serving in the National Health Service Corp.  Those chosen for specialty training would be competitively selected based on the needs of that individual specialty.

The members of the National Health Service Corps would rotate through newly vitalized community Public Health Clinics,  Adult and Children’s’ Day Care Centers, Skilled Nursing Facilities, Assisted Living Facilities, Public Schools and communities underserved by physicians and nurses. Physician and nurse participants of the program would be compensated with salary and benefits appropriate for their post graduate year of training level.  After a year of participation they would return to their post graduate training programs and complete their specialty training.

The manpower generated by the National Health Service Corps would be used to provide public school nurses on a daily basis. It could be used to teach basic health as well as cooking and nutrition courses from the elementary school through high school level.  Public health clinics would be reopened to provide care and services to the general public.  The cost of these visits could be established on a sliding scale level based on an individual’s income and resources. Doctors and nurses would staff day care centers and skilled nursing facilities. This would allow seniors to be treated for most illnesses at the SNF and eliminate the extraordinarily expensive daily ritual of calling 911 and transferring the elderly to an acute care hospital ER because the understaffed and over regulated facilities cannot provide basic services on-site or are fearful of doing so.

In exchange for serving in the volunteer health service and then entering an area of medicine where a true need for manpower exists, the Federal Government would pay for the doctors’ and nurses’ educational expenses if they stay in the needed area of medical care for a 15-year period.

I believe the cost of educational expenses will be more than offset by being able to reduce preventable illness and keep individuals out of expensive inpatient hospital care settings.  Laws would need to be passed to provide sovereign immunity against medical malpractice and frivolous medical liability claims for the doctors, nurses and technicians providing care as part of the National Health Service Corp. This would reduce liability for day care centers and senior facilities as well as public health medical facilities and emergency departments.

The creation of a National Health Service Corp should be part of the overall health care reform program developed by the United States as it moves forward in the 21^st century. There is no need to reinvent the wheel and create large impersonal organizations like “Accountable Care Organizations” run by insurance companies and hospital systems.

Instead, we need a return to a broader trained generalist providing service at every community level while having the availability of fewer but better utilized specialists to provide guidance and advice when asked. The specialists may become the leaders of the care team for unique and severe medical conditions (I.e., Acute Crohns Disease or Acute Renal Failure) but in most cases will provide guidance, advice and recommendations to the leaders of the care team.  Any guidelines established for patient care will clearly outline the circumstances specialists will be consulted for and when they will have day-to-day involvement in the care of the patient.

Steven Reznick is an internal medicine physician and can be reached at Boca Raton Concierge Doctor.

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