Important Proposals for Education-Service Exchange Programs

In this issue of the journal you will find ten essays responding to my 2010 Question of the Year, What are the most effective ways to make medical school tuition and fees free to students in exchange for public service?1 The many essays that were submitted generated considerable discussion among editorial board members and the journal's professional editorial staff as we deliberated about which ones to publish. The choices were not easy. But I believe you will agree that the ten that were chosen offer an impressive array of ideas that could lead to new and expanded initiatives to make medical school tuition and fees free to students in exchange for public service. Some essays describe functioning programs; others offer fresh, innovative ideas. For example, Waechter et al. at the Uniformed Services University of the Health Sciences describe the longstanding military-related and Public Health Service options in the United States, including the Health Professions Scholarship Program. Likewise, Shoucri and Hanson discuss the Medical Officer Training Program of the Canadian Forces as an option for Canadian medical students to participate in a return-of-service program. Alternatively, Shomaker proposes a new idea built on a historic one—the Medical Marshall Plan—that combines federal funding of medical school tuition with service in federal health professions shortage areas or other settings. Wagoner and Suriano present a new idea to reduce both the time and cost of a medical school education while providing incentives for individuals to pursue a career in primary care. Medical students weighed in with their own innovative ideas. Vohra and Sylla propose reducing a physician's educational debt through a novel point system that takes into account factors such as the physician's specialty choice and attributes of his or her practice locale (e.g., the degree of medical need and how much time the physician spends in the area). And Izenberg suggests the inventive notion of a “service residency” that would make a few years of service part and parcel of the training requirement of residency programs. Existing programs described in the essays draw from both public and private funding. For instance, Humphrey et al. describe the Repayment for Education to Alumni in Community Health program, a joint effort of the Pritzker School of Medicine and the University of Chicago Medical Center—a privately funded program focused on improving health in the neighborhoods around the University of Chicago. In contrast, Chumley et al. describe the Kansas Medical Student Loan program, a publicly funded initiative of the State of Kansas aimed at producing more primary care doctors who will practice in Kansas. Additionally, you will find that the programs and ideas discussed in the essays cover multiple venues. Bittrich et al., as a case in point, invoke the use of Veterans Administration outpatient clinics along with public health departments in their proposal. Finally, one essay is from an enterprising medical student, Sidney Morgan, who engaged in a partnership with his rural hometown community. The community is paying his medical school tuition in exchange for his promise to return to his hometown to practice. As I have stated previously, the purpose of the Question of the Year “is to foster deeper, more comprehensive thinking about issues important to medical schools and teaching hospitals, to open new avenues of exploration, and to engage readers with the journal in a new way.”2 While the authors of these ten essays achieve these goals by describing efforts to subsidize medical school tuition and fees in exchange for service, there is an implicit theme woven through every essay: education-service exchange programs have the potential to improve care in underserved areas, for active-duty military personnel, for veterans, in the immediate vicinity of a teaching hospital, in public health clinics, and even in a student's own rural hometown. I extend my appreciation to each member of the journal's editorial board and professional editorial staff for helping me judge the submitted responses and for their enlightened perspectives and thoughtful comments. • We are nearing the end of the centennial celebration of Flexner's 1910 report, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Thus, in this issue of the journal, you will find more on Flexner. To complement the articles in the February 2010 issue of Academic Medicine, which was devoted in its entirety to analysis and discussion of the Flexner Report, this issue has articles, commentaries, and letters to the editor on related topics, including Pritchett's introduction to the Flexner Report, Flexner's contributions after his report, and Flexner's influence on Dutch medical education. Steven L. Kanter, MD

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