Would eliminating medical school debt produce more primary care doctors?

There’s little question that medical school debt is rising rapidly, affecting the career choice of medical students.

It’s one of the main reasons why the disparity between the number of specialists and primary care doctors is widening. There have been a variety of proposed solutions — most recent of which are medical schools completely subsidizing their tuition. I think that’s a good step forward, but so far, has only been limited to a few schools nationwide.

The WSJ Health Blog recently discussed a more innovative solution, where tuition would be dispensed of entirely. Instead, doctors will contribute a fixed percentage of their income to medical education:

[The proposal suggests] that med schools cut out tuition and fees during medical education, then collect a fixed percentage of income for 10 years after a physician has finished training. Because specialties vary in their training time, a neurosurgeon might not start paying until 13 years after entering med school, while for a family practitioner payment could start as soon as seven years after beginning school …

… Public med school attendees would pay 5% of their gross income per year for a decade, and those who went to private schools would pay 10%. Docs would be paying out of their post-tax income unless tax policy changed.

Using a fixed percentage would help doctors choose a specialty or an employer without worrying as much about how it would affect their ability to repay educational debt, says Weinstein. “Those students who are financially successful in lucrative specialties will return more financial support to their medical school, whereas those in primary care specialties, public health professions or charity work will pay less,” the authors write.

There would be adjustments for doctors working part-time, or those who take extended breaks for clinical care.

Interesting idea, but it’s unlikely to be adopted anytime soon, making this an interesting thought experiment.

Without the burden of medical school debt, would medical students be more inclined to become primary care doctors? Some might. But the salary disparity is so huge, doctors who become specialists will still financially come out ahead.

Until that changes, like one commenter from the WSJ wrote, “it’s like re-arranging deck chairs on the Titanic.”

Indeed.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • http://bakirita.blogs.com/xico EKB

    How about the possibility of post-internship service for a year or two in rural or otherwise underserved communities as a requirement of new doctors and in return for elimination of tuition? Such service could be compensated with cost of living allowances and perhaps payments for debts for education acquired before medical school.

  • http://drpullen.com Edward

    Nice idea, but there must be an incredible number of legal nuances that will make it unlikely to happen. I still think simply changing the RBRVU scale to make payment for E&M services similar to procedural codes in terms of time spent doing them would be easier to pass, and equally effective. A minor increase in E&M fees, coupled with a major reduction in procedural fees could be cost neutral and make the decision on what specialty to choose based on talent and aptitude, not money.

  • r watkins

    In response to the title of the post, “No.”

    Med students can do simple arithmetic and quickly figure out that cutting med school debt is a drop in the bucket compared to lower earnings over a career. The only solution is to increase payment for E&M codes, as Edward states.

    Everyone knows that this is what needs to be done, but no one is willing to do it (in large part due to lobbying by the AMA to preserve the status quo).

  • Dr. Jerry

    I graduated without debt. I made my career decision free of financial and social debts. I did not come from a medical family. Yet, I did not choose primary care. It was not as interesting to me as the other choices that were available. When you pick what you want to do for 35 years, during the third year of medical school, paying off school tuition is not what all of us think about. Some of us might use that as an excuse, but realistically, for many of us, primary care just wasn’t what drove us through more than 20 years of schooling. I tell parents who want their children to go into medicine, when I graduated 26th grade, the end of my fellowship, I looked back and realized that high school was not even the halfway point of school. You have to LOVE school and studying to finish 26th grade and it continues every year, re-certification is now an annual affair required by my board.

    Some people would be surprised to learn that not all physicians are driven by a desire to amass a huge fortune. To be an excellent primary care physician is difficult. Primary care is hard and for me, it simply wasn’t as interesting as the other choices available to me.

  • Vox Rusticus

    It isn’t the disparity between the specialist income and the generalist income, nor is it the fact that medical school debt is greater now than ever. The reason is that hard working generalists just don’t get paid all that well for their time.

    Paying off medical school debt is really no different than paying off any other large practice expense. Subsidizing office rent or staff salaries would work just as well. If the perception is that doctors dislike primary care because of poor pay, the obvious answer is that to get more of them, then the work they do has to be paid better. The big problem right now is that there is much more unpaid work demanded of these doctors than was the case in the past and the paid work is under relentless pressure–lower payments and more difficult and expensive documentation and collection procedures.

    The problem of primary care under-supply isn’t going to be fixed by piecemeal picking up the cost of medical school while doing nothing else. That really isn’t going to work. You have to make practice pay better, be more pleasant and less burdensome,

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    Once again, I am compelled to link the post on my NHSC (loan-repayment-for-service) experience:

    http://drjshousecalls.blogspot.com/2010/02/national-health-services-corps.html

    It was NOT a matter of the Federal government not being able to enforce its own agreements and contracts . . . it was a matter of the Federal government not being the least bit interested in protecting its investment in a primary care physician by enforcing those agreements. Everyone dived under their desks – and to date have stayed there. It’s inexcusable, and I’m not going to sit by while other physicians suggest or advocate such deals as a solution to this problem. Because it’s not.

    “Creating” primary care physicians is NOT NEARLY as hard as KEEPING them. But it will be soon, if attitudes do not change.

  • EA

    Agree w/ Dr. Jerry. Nobody ever mentions the fact that for some people, primary care just doesn’t float their boat. Even if I had graduated w/ no debt, I still wouldn’t have gone into primary care, b/c it wasn’t what interested me. This is no disrespect to the great PCPs out there. It just wasn’t the right choice for me, money and debt aside.

  • SmartDoc

    Sorry, but once the Bad Guys own you, you become a enslaved government without the benefits.

  • Chris Bennett

    How about decreasing the standards for those who want to enter primary care. By accepting lower MCAT scores, decreasing the years in medical school, and the costs, students who are interested in primary care from the onset of medicall school but who do not see a valuable pay off in respect to their time and financial commetment may opt for a more lenient family care track that begins in undergrad.

    • Jman

      Many have advocated that same response to the problem. Why decrease the standards ? Primary care is one of the hardest and most diverse fields of medicine despite what many people seem to believe. What the general public thinks is that the primary care physician is just a vehicle to get a referral to a specialist and fill out paperwork, that’s not the case.

      Medical school is a long and arduous process for a reason. In both DO & MD schools you have to take three different licensing exams before you are a licensed physician. Would you want a doctor who didn’t know what they are doing ? If there are people who are interested in medicine but don’t want the financial or time commitment, there is always the option of a mid level provider like a PA or NP.

      It is expensive, but for those who are really interested in medicine, the loans are a necessary evil. Don’t get me wrong, I would love to have less debt right now, but that’s something I accepted and so (in somewhat of a preliminary manner) do all those people who apply to medical school.

    • Vox Rusticus

      One does not follow the other. Medicine, done right, is often very challenging and difficult. One has to be able to think well and quickly and to pay close attention. Which of those abilities (or others) would you like to do without in your physician to save a buck? In my medical school, lots of top students still chose primary care. Family medicine is not easier just because it is easier right now for a medical school graduate with lower qualifications to gain a FP training slot than it is for a slot in orthopedics.

      I know enough of the variability in quality of the graduates in my own medical school–which was/is a well regarded one–to know I wouldn’t want the standards lowered the least little bit.

    • twicker

      First, as has been expressed many times here before, I seriously doubt that most doctors are looking for a large payoff.

      Some, yes.* Most, no. If they wanted money, they’d go into finance — fewer years, and no having to deal with sick people or reimbursement issues.

      Further, reducing the requirements for a family or internal medicine doctor would do more damage to the profession than you would believe. People would lose trust in their physicians — even ones who were trained under the old regimen. *No one* would want to go see their “hack” family or internal med doctor; everyone would want an immediate referral to a “real” doctor, to a specialist — so you’d actually make the problem worse.

      To go from bad to worse, any high performers who wanted to become family or internal med doctors would now be stuck in the “backwater” of medicine — and would be discounted, no matter what their actual intelligence. For them, the pressures to become (what would now be seen as) a “real” doctor — i.e., a specialist — would be even more intense. Pretty soon, the primary care ranks would only consist of the dimmest + a few really committed souls. It would be like becoming a public school teacher: almost everyone would say, “Don’t do it!,” no matter how resolved you are to help people in this way.

      So: you lose patients, lose reimbursements, lose status, and everyone thinks you’re a “loser” because you “weren’t good enough to be a real doctor.” No, this idea is a complete non-starter.

      Allowing for some tuition reimbursement would be a great start (IMHO), as well as increasing reimbursements, especially for the unpaid activities. There needs to be a good, comfortable wage paid, with fewer administrivia stresses. You’ll still have a hard time attracting primary care physicians to the boonies (the boonies still don’t have large movie theaters and major cultural districts), but you’ll at least be more likely to find a few who’re willing to go.

      * As I mentioned, there are some people who go into medicine for the money. I’m reminded of a med student I knew who wanted to go into radiology for the money and hours; I tried to explain to him that his was one of the easiest jobs to offshore, to no avail. AFAIK, he’s now doing his residency in radiology, still blissfully unaware that somewhere in Lahore or Cancun, there’s a fully-qualified radiologist — quite possibly US-trained — who’s happy to take his job for 1/2 the cost, given that the costs of living in those places are far, far less than 1/2 of what it is in, say, New York or Washington — or even Raleigh, NC.

  • http://notwithstandingblog.wordpress.com The Notwithstanding Blog

    What about emulating success stories like Qliance and moving to low-cost, accessible retainer practices for primary care? No need to beg CMS for E&M boosts every few years, and no need to ponder the philosophical intricacies of a 99201 vs. 99202 (etc) for every patient visit.

    As for the SAFE proposal mentioned in the original post, it’s an interesting one, but the most interesting aspect of it in my view concerns the incentives it would provide medical schools to control cost. I’ve discussed the proposal in some detail in a recent post, for those interested in the nitty-gritty.

    • twicker

      Very interesting blog post, Dr. Notwithstanding.

      One thing that seems to be missing here and in other discussions is what incentives med schools would then have to selectively recruit for, and/or push their students into, lucrative specialties. If the school gets 5% (or 10%) of all of its graduate’s earnings, up to … well, up to whatever they make, then the school has a really, really strong incentive to crank out neurosurgeons, dermatologists, CT surgeons, plastic surgeons, etc. It might be a wash for the students, but the just-under-top schools would suddenly become a hotbed for all the big-money specialties (the very top schools — the Harvards of the world — would keep on keeping on, given their endowments, endemic senses of mission, and lack of need to prove anything to anyone because they’re already awesome; the schools one level down would be under the pressure to try to catch up).

      I do think we need to give some tuition reimbursement for primary care doctors who stay in the field; I think cost of schooling *will* influence even prospective students (especially if their loan statements show, “Owed if you continue into primary care: $Loan-Reimbursement. Owed otherwise: $Loan”). After that, we do need to make sure reimbursements rise for primary care — including possibly making available extra funding for having a “home doctor” who coordinates things and, thus, can receive reimbursement for the odd phone call, the occasional e-mail, etc. — all those myriad things that doctors currently don’t get reimbursed for.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    If it’s not entirely the money, and I never thought it really was, how about the prestige and perception?
    I agree that standards shouldn’t be lowered. I don’t think there’s a shortage of qualified candidates.
    Instead, as many wrote, the E&M reimbursements should be drastically increased, but that won’t be enough either.
    The system has to change and restore primary care to what it used to be, and maybe empower PCPs even more then ever before. It is probably the only way to contain health care costs and to turn family medicine into a prestigious, intellectual challenge floating more and more boats.

    • r watkins

      Wherever money goes, prestige follows. I don’t think that many students enter med school with an overwhelming desire to become dermatologists, but that’s the residency position everyone wants.

  • http://fertilityfile.com IVF-MD

    What about eliminating the monopoly on medical education and opening it up to those who want to take a stab at doing it less expensively and more efficiently – streamlined, practical, and innovative? That could greatly reduce the cost. The graduates would still have to pass the same testing as graduates from current schools. Just a thought.

    • Vox Rusticus

      Those programs already exist at many places in the USA. Most combine undergraduate coursework with medical school in a six-year track, somewhat similar in length to European schools. Could we use more of those? Maybe, although the admissions selectiveness of those condensed programs tends to be high, at least as selective as conventional medical school applications.

      Again, there is no way to force any student into any particular specialty, nor should there be.

      Making primary care a better job is what will work: the practice has to pay better and enjoy better working conditions.

  • http://leonardof.med.br/ Leonardo Fontenelle

    What about making primary care more lucrative?

    • http://fertilityfile.com IVF-MD

      There lies the question. In a natural setting free of any artificial coercive constraints, if you produce something that is truly desired and is in great demand, then it will be naturally demonstrate itself to become more lucrative. I have asked for counterexamples to this theory time and time again and have yet to find a valid example which refutes it. I welcome a chance to be proven wrong.

      So if the assertion that some people are throwing out there is that “Being a primary care physician is not worthwhile”, then one has to explore the reasons for this.
      Either:
      1) That statement is false and it IS worthwhile
      2) the services provided are not really that valued by the people who are in a position to want it or not
      3) some outside hindrance is interfering with the natural market forces

      I have my theory of how much each of these contributes to the explanation. What’s yours?

      • twicker

        About your question: re the example you desire:
        Something can be truly desired, in great demand — and be in abundant supply, so that the value placed on a single unit of the stuff (say, a glass of tap water) remains really, really low. Now, the price might rise as scarcity sets in, but it will take some time for it to rise.

        Further, a form of labor might be truly desired and in great demand (say, K-12 teaching, or pre-school teaching), and even be in somewhat shrinking supply but, because of social norms, the price offered remains low, while any shortfall in supply would be made up through overutilization of existing supply. This also works for “tragedy of the commons” type items that are desired, in great demand, and, because of abundance and ability to harvest without regard to long-term consequences, end up being overharvested (think tuna, or cod, or any of a number of other fish species — or land game species that are able to roam).

        Now, these may, indeed, become more lucrative over time, but they have the force of social norms that are pushing the price down to a substantially less-lucrative level than simple rational theory/Homo economicus-school economics would suggest, just because actual Homo sapiens sapiens are far more stubborn than that.

        As for your three suppositions about what might contribute to whether a primary care physician is “worthwhile:”
        A quick digression: there’s much in this life that is worthwhile that is not lucrative. Many people believe that raising children is worthwhile; it is generally not lucrative (usually quite the reverse). Thus, money does not determine whether or not an action is worthwhile. Now, on to your three theses …
        Re: #1) I’d say the statement is, overall, false, and that it is worthwhile, even if not lucrative — much as teaching is worthwhile, while definitely not lucrative. It’s not for everyone, but some do, indeed, have a calling to the field. That sense of calling may actually hinder greater reimbursement, since physicians may be uncomfortable asking for more money from their patients — at least up until the money issue becomes so large that they question their sense of calling, at which point it may no longer seem to be worthwhile (one reason we need to do something about reimbursement sooner rather than later).
        Re: #2) I would say that the services are, at least in some cases, not (correctly) valued by the people who are in a position to want them (i.e., patients). People seem to value specialists over generalists, even though they would likely be better off overall if they saw the generalist more and had someone who was monitoring their whole health picture. So — this definitely plays into it.
        3) Absolutely, some hindrance is interfering — mainly, people’s overvaluation of specialist care and undervaluation of generalist care, along with the uninsured who skip past primary care and go straight to the emergency room. PCPs don’t see everyone they medically should, because patients either skip on the high end or on the low end. You’ll remember HMOs attempting to do something to balance for this; that backfired due to the horror stories that came out (ignoring the greatly-increased costs that also occurred). So, you have higher reimbursements for specialists (insurance companies want them in their system) and lower for generalists (not nearly as popular with insurers).

        So – there’s my set of theories. Back to you, IVF-MD … :)

        • http://fertilityfile.com IVF-MD

          Twicker,

          I thoroughly enjoy discussing matters with you and others on this site. It makes me rethink and retest my views and that’s always a good thing.

          I would address your water analogy as such. Currently a glass (or bottle, let’s say) of tap water is not in demand so that if you were to try and sell it for $50, nobody would buy it. Of course, if there were a drought and it was the only source of clean water, then YES it could command that price. But again, that only confirms my assertion that price reflects how much something is valued, even if that value changes from day to day and situation to situation.

          As for teaching, the reality is that unless you have some amazing teaching skills that can turn a 5 year old into a piano virtuoso in 4 months, it would be unlikely that anybody would pay a lot for your services. So even though you say that teaching is a form of labor that is truly desired, the fact is that if the prices got too high, many people would end up deciding to quit their jobs and home-school their kids, in order to save money and get better results.

          As for the cod example, if cod were in short supply, I surmise that you’d see a slight bump in prices, but not a great deal. More likely than not, people would buy trout and salmon instead rather than pay really high prices for cod.

          So the premise that (barring any coercive artificial taxes or subsidies), the market succeeds in establishing a price on things that is reflective of the balance of desirability and scarcity still holds true.

          So back to the three possible explanations of why primary care is or is not lucrative, I agree with you that being worthwhile is not the same thing as being lucrative. Life happiness does not hinge solely on salary, not by any stretch. That’s a whole different argument all together.

          So what if we asked a totally different question. Are primary care doctors paid what they are worth? My answer is that because of artificial subsidies (ie someone ELSE is paying for your primary care), it distorts the value that people wish to pay for such services. It’s a lot more complicated than that. There is the factor that with a specialist, there is the perception that one can better define the desired outcome. How much would you pay for a painful gall bladder to be cut out of your body? How much would you pay for your blood pressure to drop by 10 systolic? Or as in my field, how much would you pay to stop being childless and end up with a newborn baby girl?

          So one of the reasons that primary care doctors get paid less, is that the demand (IN THE MINDS OF THE PATIENTS) is less. People get up the initiative to seek medical care because they want to relieve pain, either the pain of unrelenting migraines, the pain of burning upon urination, the pain of being unable to perform at peak physical strength or the pain of being childless. With the exception of sophisticated patients bearing great foresight, most don’t think in terms of seeking help because their HDL cholesterol is too low or that their Hb A1C is too high.

          Another major reason is the third party involvement. You speak of how much insurance companies want to reimburse specialists and how much insurance companies want to reimburse PCP’s. See, then it becomes less of a matter of how valued something is and more of a matter of how politically positioned a particular school of doctors is. Do they have good political representation on the committees that set the rates? That’s a horribly unfair way for something to be valued, but it is what it is in our broken system today.

          As always, thanks again for the civil discussion.

          • twicker

            I’ll address the teaching example quickly (with the cod, the whole tragedy-of-the-commons issue is really too broad for this thread):
            For teaching, home-schooling is certainly a possibility — for those who are willing and able to stay home. Single parents, not so much, and plenty of people actually pay a great deal over and above taxes to have their students schooled, even if they don’t turn into 5-year-old piano virtuosos (full disclosure: I, myself, am a private school brat, and am not a piano virtuoso). Plenty more would pay more if they felt it would bring direct results — and some school systems do pay their teachers rather well (see the recent NY Times article for the starting salary for some of the TfA teachers — more full disclosure, I was one of them, too). People don’t expect piano virtuosos; people are willing to pay more, if they think the money will go into teachers’ pockets and they come with accountability standards (we could discuss the problems with tenure, and with its enforcement, but that’s waaay off topic).

            So: the market is, frankly, willing to pay a good bit more — if asked, and even more if the expectations are there that the money will be well-used and, thus, well-spent. Which brings us back to the PCP pay issue: we can’t devalue the appearance of PCPs and expect that we’ll have the market providing anything but a race to the bottom. Instead, we need better integration of patients with their PCPs so that they see a greater quality benefit, and more pay for PCPs to retain the ones we have and keep new ones flowing in, along with accountability for PCP results.

            Gotta run; (maybe) more later.

          • twicker

            IVF-MD — I’m going to take this as a series of responses, just because you’ve given me a fair bit to chew on (for which I’m grateful).

            First, about the water:
            I’d argue (and I suspect that you may agree) that the reason it isn’t expensive isn’t because of a lack of demand but because of the presence of an abundant supply. For example, I suspect that, this year alone, the amount of water I use will have more mass and volume than my car. I will drink more water by volume than any other liquid (with the possible exceptions of coffee and diet soda, and those are mostly … water). I will consume more water than any single foodstuff, more water (by mass and volume) than all the clothes I wear. I will use, through ingestion, showers, etc., enough water, in fact, to fill my home, my car, my office, and still have water left over. However, I won’t spend very much at all on it — because I live in an area with abundant freshwater supply.

            So — I desire it (especially when I’m playing sports), I demand it (a lot of it), but I pay dit squat for it, because there’s plenty of it. Now, I should actually probably be paying more for it, because growth and more-persistent droughts have led us to have less of it around here and we’re not taking into account the long-term negative externalities, but that’s a different ball of wax.

  • Med Student

    I am a 4th year medical student and have chosen Family Practice as my specialty for residency. I am fortunate in that I knew what I wanted to do as I entered medical school and was able to apply for and receive the NHSC Scholarship. I chose FP/ primary care for several reasons and even though I never considered student loan debt a road block it is always apparent to every medical student. I think that medical students are unaware of their options when it comes to loan repayment. The NHSC, military, state run programs as well as hospital signing bonuses after residency all offer ways to assist with student loan debt. Not to mention the various ways to repay student loans: differment, forbearance, income based, etc… My mother is a family physician and neither her or her colleagues have ever complained that they are poor or don’t have enough money to live their lifestyle and pay back their loans. I think if we educate students of the possibilities that are in front of them and stop talking about the road blocks that some people dwell on and everyone has to face, we can show them that primary care is a valid option and student loans should not be a barrier to practicing medicine.

  • http://bakirita.blogs.com/xico EKB

    Med student makes an important comment. It is really time to stop valuing the meaning and success of one’s life in terms of earnings. Of course one should earn enough to be comfortable and a bit more, and of course there will be variety in amounts, but the notion that specialties are worth more than family practice or internal medicine is false. The latter are, in terms of social good, far more valuable, and I suspect much more interesting. I was a psychiatric social worker (licensed clinical). Our tribe which included also psychologists received less money and had far less prestige than the psychiatrists on our staff, but I think those of us who provided direct care on a long term basis felt we had the better jobs. We really got to know our patients/clients (even consumers in PC language at one point),learned tremendous amounts about who they were and how their various disorders and illnesses were interwoven in their identities, could understand their resistances and work with them to help them improve their lives. I would think (though perhaps any MD would shrink from the comparison to social workers) that primary care physicians, if given the chance to really practice family and internal medicine rather than serving as switchboards to specialists, would find similar benefits. Also, patients, rather than being shunted to specialists for treatment of this or that part even when a competent primary can address their problems, could be seen as whole people. Their overall care would benefit: an MD with a meaningful relationship with his patients can deal with issues such as treatment resistance, patients’ habits, influences of their environments and lives, etc.

    In the US at this point it does seem as if medicine is, as a friend of mine says, machine medicine.

    PS I think to the resources Med Student suggests, the federal government should expand its programs in underserved areas as means of repaying med school debt and encourage their use. Certainly such service is as important as military ser ice.

  • http://www.ohiosurgery.blogspot.com buckeye surgeon

    How is this “solution” any different than taking out student loans, deferring payment until you are an attending, then paying a grand or so a month??? I don’t get it. Please explain.

  • primary care advocate

    The province of British Columbia in Canada is offering up to $100,000 in incentives, including $40,000 debt reduction, to young family doctors who want to set up a primary care practice in area of need in BC. It has had a very good response so far, but some positions are still available. A three-year commitment is required.
    Check out http://www.gpscbc.ca/family-practice-incentive/family-physicians-bc

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