Would free medical school be enough to save primary care?

Would free medical school be enough to save primary care?Medical school should be free.

That’s an argument made by physicians Peter B. Bach and Robert Kocher in the New York Times.

This isn’t a new concept.  I’ve discussed whether medical school should be free for students who choose primary care.  And, for some in the country, it’s already happening.  Like at Case Western Reserve University, for instance.  The Cleveland Clinic subsidizes tuition there, although their intent is to drive more students to choose academic careers, not necessarily primary care.

In Drs. Bach and Kocher’s piece, they propose to make medical school free for everyone.  But doctors training to be specialists won’t be paid during residency:

Doctors choosing training in primary care, whether they plan to go on later to specialize or not, would continue to receive the stipends they receive today. But those who want to get specialty training would have to forgo much or all of their stipends, $50,000 on average.  Because there are nearly as many doctors enrolled in specialty training in the United States (about 66,000) as there are students in United States medical schools (about 67,000), the forgone stipends would cover all the tuition costs.

Most specialists train, on average, between four and seven years, that means sacrificing up to $350,000 upfront.  But since the salary disparity between primary and specialty care is so great (at a median annual salary of $325,000, specialists make 70% more than primary care doctors), it’s argued that this can be made up for rather quickly.

A few weeks ago, I criticized the Times for running an unbalanced op-ed on hospital bullying — today I applaud them for publishing this one.  Rescuing primary care requires bold ideas.  Not the piecemeal ones introduced in the Affordable Care Act, such as better funding community care clinics, or the National Health Service Corps, neither of which are enough to influence  medical students to look away from lucrative specialist careers.  As much as some would like to deny it, the cost of education influences the career choice of medical students.

To be sure, there are some problems with the proposal.  It doesn’t solve the lifestyle and bureaucratic disadvantages that burden primary care.  Specialists will say, with justification, that there are physician shortages outside of primary care — like general surgery.

And it doesn’t address the root problem of the primary care-specialist pay disparity, which is the result of specialist-dominated RUC:

Our plan would not directly address the chronic wage gap between primary care providers and specialists. But efforts to equalize incomes have been stymied for decades by specialists, who have kept payment rates for procedures higher than those for primary care services.

But what this op-ed does do is frame the primary care shortage in stark terms, and injects urgency into the media narrative.  The public needs to understand that it’s such a problem that it requires ideas this radical, and this out of the box, to even begin fixing it.

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

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  • paul

    can you go to med school for free and then open a boutique primary care practice that doesn’t accept insurance?

  • http://twitter.com/#!/SiMBa37 SiMBa37

    Kevin, I agree with everything you said, and the Times piece is a bold idea…and we need bold ideas. Tuition costs are anything but trivial. I’m a US citizan, but did my medical school in the Caribbean and I have >$250K of debt looming now that I’m completing my subspecialty training. My subspecialty is not very lucrative, but its better than a primary care MD.

    But I think there are other reasons for lack of primary care specialization as well. I’ve tweeted this recent, but its worth restating. The current state of Internal Medicine residency training in this country is teaching residents/students how to be a hospitalist as the focus is 95% inpt 5%, outpt. There are reasons why med students positively rate their IM rotations, but still don’t want to practice it. The don’t see that real world IM in 90% outpt, 10% inpt.

    There needs to be a tectonic shift in IM residency training away from inpt medicine and towards outpt. It has been noted that there will be a shortage of 63K MDs by 2015 http://bit.ly/jrHF4Y .

    Salary gaps have a HUGE impact on medstudent decision away from primary care. As noted in the Times article, the average post medschool grad debt is around $140K http://bit.ly/1Z0EJZ .

    IMHO, med student and resident satisfaction with general IM and primary care would increase if shown the value of being a good primary care MD rather than a good hospitalist.

  • Jay

    what about those that truly have a passion for a specific specialty? Now they will enormous debt and on top of that will not be able to earn a penny until they are 30+? what if they have families? I think this idea is a bit far fetched

  • http://www.robinsonfamilymedicine.com Stacey Robinson MD

    I chose Family Medicine because I loved the relationship with patients, the continuity, the variety of patients and problems, and the challenge of being on the front line of medicine. I never thought about the money. Because I was in the Air Force, I did not have much debt so you could argue that the paucity of debt is why money didn’t play a role in my decision. My husband on the other hand had over $150,000 in debt and chose Anesthesiology. His decision was based on lifestyle and ability to spend time with his family, not on money. I would argue that almost all physicians choose their specialty based on interest in their chosen specialty and desired lifestyle, not money and debt. I don’t think that free medical school and stipends would impact these choices significantly. This proposed plan would be a drastic change in our medical education system and to assume this will solve the primary care shortage seems like a stretch to me.

  • pcp

    “Would free medical school be enough to save primary care?”

    No.

  • PAULMD

    “…and I said nothing. Then they came after me….”

  • Lil A

    This is an interesting point. It might help those who want to go to medical school that don’t have the money away to do so, yet have the aptitude to do so. Is this going to solve this shortage? I wouldn’t know. I can see the pros and cons to this but i still think it is worth a shot.

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

    In my line of work, this is called a workaround. You know there’s a defect, but instead of fixing it, you just apply a band aid and do things a bit differently to avoid manifestation of the defect.
    I say, fix the problem at its source. If primary care is paid inappropriately, fix it. Surely, setting up a system of free tuition and coordinating hundreds of schools, programs and stakeholders is not less difficult than having Medicare double the E&M reimbursement codes with one stroke of a pen (more or less).
    At this point though, I doubt that even such increase would work as well as we need it to work. The system’s view of where primary care fits in, and what primary care is, would probably need to be altered as well, and not in the direction we seem to be currently moving .

    • buzzkillersmith

      Right. Workarounds are unnecessarily complicated and potentially loaded with unintended consequences. Better to kill the termites under the house than to build a new room next to infested one.

    • Leo Holm MD

      Much of what I am seeing to fix the pay disparity is to pay specialists less.

  • ninguem

    There’s a school in Florida that’s tuition-free.

    Tuition is ZERO.

    The idea was supposed to answer the very question posed here. It’s a brand-new school, it will be a year or two before they graduate a class. We’ll see how this turns out. I suspect the effect will be modest. It makes primary care less unattractive, but does not really make it attractive. Medical school can’t change the reality on the ground for the practicing physician.

    • Joe

      I thought that deal at UCF was just for the inaugural class, and was meant to gain publicity and attract a high caliber of students despite the issues with being in the first class at a new school that is working to get fully accredited, will undoubtedly have tweeks to make, etc. Every school wants to have that 30+ MCAT average. Well played if they can spin it as attempting to boost primary care.

      • pj

        Ning…. If u mean UCF,, it is only inaugural as Joe said.

  • Angela Caffaratti, MD

    The greatest problem for primary care is the cost of doing business and increased administrative hassles and difficulty getting paid that all drive up the cost of doing business. This is a viscious cycle and it needs to be addressed from many aspects. Quite frankly, this country likes it’s medical industrial complex more than it likes good and affordable care, especially because other people pay for it.

  • solo fp

    Medical school is not the problem. You can pay back low interest loans quickly if you forgo a new car and large house the first few years of practice. I paid mine off early, while my friends bought expensive homes and cars and wonder why they are deep in debt..
    That said, the problem with primary care is the increasing burden on administration. In the last 10 years, copays have gone from $10 to $35, and insurance checks on each visit are less the copay. Deductible have increase. I have to prior auth chronic meds if they are brand name and am not supposed to refill a PPI for greater than 90 days without filling out forms. I have to fill out forms that still give a denial on the med and then require a letter and a doctor to doctor call. I have staff to help in prior auths of CTs/MRIs/Stress echos, so that the specialists get paid while I learn new CPT codes and keep the patient from having to pay more than a copay for no personal gain. For 2011, after my staff has wasted time with a high school grad and then a nurse, the prior company requests a doctor to doctor prior auth. I then for free talk to the doc. My staff is paid to do this, and the prior auth doc is paid. I do this for free. I also provide free phone and fax refills on meds and paperwork for disability/FMLA. Often this requires a doctor to doctor call to the disability center for unpaid time for the final approval of short term disability.
    I spend an average of 2 hours a day or more on insurance and Medicare administration that does not improve the care of the patient but saves the patient and the insurance company thousands.
    Each year new studies are added to the prior auth lists, and don’t get me started on the leftover HMOs that require online referral numbers to see a patient’s regular eye doctor for glaucoma or a cardiologist for the due stress test that will also require prior authorization. The insurance companies rake in millions and cut costs with mail order companies and third party prior auth companies who all get paid to provide lower costs to the patient while increasing my costs to practice. Most insurance companies are posting record profits and have CEOs with 7 and 8 digit salaries. Unfortunately, the docs from the 80s allowed the insurance companies to takeover. No good solution is on the horizon. To do primary care, you have to enjoy seeing the patients, regardless of costs.

    • buzzkillersmith

      That’s one reasonable level of analysis. Another level of analysis is that your payments are too low. Double your payment per patient and these administrative costs are outweighed by increased revenue.
      I submit that if revenue per unit of work in family medicine does not increase substantially, then all attempts to save it will be futile.
      Profit=revenue-costs. I always try to remember, when thinking about these issues, that medical students can do simple arithmetic.

      • pcp

        “I submit that if revenue per unit of work in family medicine does not increase substantially, then all attempts to save it will be futile.”

        Wait a minute.

        The AAFP tells us that, if we “transform” our practices into PCMHs and increase the work per unit of revenue, all our problems will be solved.

        Don’t tell me they’re wrong.

      • Lil A

        Luckily people are able to do basic arithmetic in college, but will that be the case in 20 years? I had a class in my freshmen year of college that consisted of basic algebra! No kidding, and this was at a state school! I felt like an idiot because I was put into it and because it was incredibly easy. It was almost an insult to my intelligence looking back on it. I didn’t care though, I would do anything that required less work, including being a part of classes that made me look like an idiot.

        I know that this is a little off-topic, but that is what I thought of when you sad, “I always try to remember, when thinking about these issues, that medical students can do simple arithmetic.” This is a sad reality that I don’t think a lot of us are aware of or pay attention to.

        • Lil A

          And when I say basic algebra, I’m meaning middle school pre-algebra. We did things such as probability and reducing fractions and the like, something that I learned and perfected in middle school. And to think that I was in Pre-Calculus in high school!

  • Lil A

    That would be an option. However, there is still the need for physicians in underserved areas. While nurses are educated somewhat about the human body, they don’t know as much as doctors do and shouldn’t be expected to do the job of a doctor. When that happens, we start treading in pretty dangerous water. After all, in some cases the knowledge of a doctor can be necessary.

    I think that we need a system where people are seen first by a nurse, and if the problem can’t be handled by the nurse, then it should be passed onto the physician. This would eliminate those people coming in to see the doctor for a splinter or simple first-aid. You don’t need to see a doctor in those instances. However, this would require that you train nurses more, therefore a school would not be able to spit out a new nurse after two years.

    I still think that there would still be a shortage of physicians and that this needs to be dealt with through private corporations. Award those seeking to go to medical school more scholarships, or even give similar benefits to doctors in training that they give to nurses (if you work for x employer for y number of years in this area, we will help you pay off some of your student loans). That way the organizations that want to give can and those that don’t want to don’t have to. I don’t think it wise to throw the cost of training new doctors onto the taxpayers. We are only going deeper into debt when we need to come out of it.

    • Lil A

      Yeah, I have had my fair share of visits to the doctor where I have left saying, “What a waste of time, I could have found out more about what I have on WebMD,” and in some instances, I have. There have been other instances I have felt that a doctor was needed. For example, I was diagnosed with appendicitis this January. In this instance, I am glad that there was a doctor around, as I was diagnosed with it and quickly shuttled to surgery. Time is of the essence in this case, and it is important that a correct diagnosis be made.

      A lot of times too people visit the doctor for a refill on their prescription. This could be handled by a nurse too, talking in conjunction with the physician. There is no need for a patient to waste a copay on this when it would be best done over the phone. In fact, I have found it relatively easy to do this, as I often forget to mention that I need a refill at the appointment.

  • Charles Phillips

    If Medical school is free in the future then the current med students and recent grads should have their debt relieved. Now!

  • http://briarcroft.wordpress.com Emily Gibson

    The doctor I want taking care of my family and myself is not someone who chose primary care because the debt load would be lighter. It is an individual who chose primary care because of a commitment to being the front line for their patients through their journey of assessment, diagnosis, treatment and referral if necessary. That means being open to innovative and less expensive ways of making that care as accessible as possible, whether it is through coordinating a team of physician-extenders or making extensive use of online and electronic communication.

    A primary care doc must have a unique blend of qualities that “free” simply can’t buy: relational, compassion, advocacy, team leader and commitment beyond the usual medical work day.

    I work in a setting where more than half of the patient visits are performed under clinical protocols by registered nurses, or independently by nurse practitioners/physician assistants. Physicians are seeing patients four per hour as well as serving as clinical back up and oversight for the RNs and ARNPs/PAs. As the clinical team leader, I’m responsible for everything that happens to our patients, no matter who sees them. It requires a trusting and collaborative clinical team as no physician can see sixty+ patients a day in the clinic by themselves and another sixty+ needing advice/refills but not needing to come to clinic. When that is the number of patients who must be seen, the primary care doc must be someone who can coordinate the care process and accept responsibility for all that happens.

    Free medical school won’t create that doctor.

    • Lil A

      “A primary care doc must have a unique blend of qualities that “free” simply can’t buy: relational, compassion, advocacy, team leader and commitment beyond the usual medical work day.”

      I agree with that so much. Maybe I’m going the wrong way about things. Maybe I should be aiming at medical school in the future, as I believe I actually possess these qualities. I can’t talk for those who have been in medical school, but I get the sense that these qualities have been discouraged among medical students.

      And I agree that free medical school won’t create that in the doc. Some are born with that kind of gift, others learn it, and still others are born with it and experience only refines it. However, free medical school might bring in those that have these qualities that are at less of advantage due to family finances or problems. For example, I cannot take out a private student loan, even with a cosigner with excellent credit because my mom maxed out a credit card in my name on a bankruptcy attorney. I tried to do so, and was turned down one right after the other. I even had one that contemplated for a time, just to turn me down later (that is the worse, wait and think that you have it and then be told that you don’t). Anyways, if I wanted to go to medical school, I would have to wait 7 years for the stuff to fall off my credit to be able to go (I’m going to do that anyway-work as an RN and take some of the prerequisites for medical school on the side until my loans are paid and I have a stable living situation), find sponsors to help (probably another thing I will do), or not go at all. Help with paying for medical school would allow for people like me to reach what they dreamed.

      Now I can see how unrealistic it may sound, but I propose that private corporations come together to make this possible, in a scholarship fund of sorts instead of putting this onto the college or the taxpayers. It needs to remain in the private sector, as America is maxed out on its credit card already, and it wouldn’t be wise to increase the limit on the loan. I would probably say, based on the need of the student and what federal aid that they can get, award them partial to full-ride scholarships from this co-op of supporting companies. After all, I believe that if someone wants to do something, then nothing should stop them from attaining their dreams.

  • Charles Phillips

    Well said Emily. Amen to that!

  • asdf

    Please tell me why everyone that wants to go in to primary care is a ‘saint’ and doing it for the relations while anybody doing a sub-specialty is doing it for the money?

  • Lil A

    Apart from all of this, just wanted to post a point for those people who think that a public option may be best.

    The UN has declared that the right to healthcare is a basic human right. With the public option, there will be people that are denied care based on age or other health factors, possibly dying as a result. One such plan (as I discussed in my online class) is the so-called “complete lives system,” where most of the medical resources are applied to the youth. While it is understandable that we should keep the youth healthy, it is the elderly that need the most care, as we don’t get healthier as we age. Putting the most resources into the youth would deprive the elderly of this care, thereby denying them of basic human rights. On top of it, the Conservative solutions (socialized medicine, single-payer) are closed-systems whereby innovation is stunted by perverse incentives and government bureaucracy and inefficiency, A healthcare-for-all system also violates the 15th amendment by enslaving those who produce to the collective. If we are wanting to remain ethical, then the current proposals obviously need to be reassessed, as they violate both basic human rights and constituional rights.

  • Lil A

    Yeah, but the one thing that we can all agree on is that the constitution must be upheld and that we should avoid egregious violation of the Constitution.

    I am not saying that we should maintain status quo, as I know the status quo is not going to get us anywhere. What we need to do is streamline healthcare so that it is safe yet efficient and costs less for the the consumer an the physician. Throwing everyone on a one-size-fits all sort of plan and expecting the taxpayer to shoulder the burden will not work. America, with its debt now passing its GDP, cannot bear this kind of drastic reform. We need to work on reducing our national debt, not building it up. This means that we need to reassess programs that we are going into debt for. We need to streamline a lot of them, scrap some, and radically change others. I take this from my own model. If I’m working and in debt, I will reassess my budget in order to pay off the debt that I have. If that means not going out to eat three times a week, not having an expensive car, and living in an apartment rather than a house for a time, that is what I will do. I don’t think that the federal government is any different. Rather than pushing for an easy healthcare reform that violates basic human rights and constitutional freedoms, we should be pushing government to reassess their budget and cut out things that are not necessary to the people and encourage privatization of other programs. We need less government bureaucracy in the lives of the American people, not more.

    • Lil A

      First of all, not everyone has access to healthcare in these countries. There is still rationing of healthcare.

      Second of all, Taiwan’s, Japan’s and the UK’s governments cannot cover the costs of this plan and are resorting to borrow from the banks to be able to provide for these plans. This is completely unsustainable as the banks will eventually stop lending to these government agencies. When they do, the healthcare system will cease to exist. They have no capitalist fallback, like the current health insurances in America have.

      Second of all, your argument is a strawman fallacy. I wasn’t arguing for the status quo, as this is the first sentence in the second paragraph of my post:

      “I am not saying that we should maintain status quo, as I know the status quo is not going to get us anywhere.”

      I’m obviously not arguing to maintain the status quo. What I was saying is that government needs to reassess its current spending before taking on new debt.

      Your argument was also the either-or fallacy, because you presented only your option and the status quo. There are other options out there than these two options, and my point is to get people to think about other ways of reforming healthcare that does not involve government take-over.

      • Lil A

        And one other point that I wanted to bring up. Canada, in the landmark case of Chauolli v. Quebec, ruled that the single-payer plan was a violation of basic human rights, and lifted the ban on private insurance. Not only that, but:

        “In August 2005, delegates to the Canadian Medical Association adopted a motion supporting access to private-sector health services and private medical insurance in circumstances where patients cannot obtain timely access to care through the single-payer system.”

        Here is the full article, published in the Canadian Medical Journal:

        http://www.cmaj.ca/cgi/content/full/173/6/585

        I want to end by asking a few questions. 1) If this system was so great, why is Canada going away from it and towards the private sector? 2) Isn’t it illogical for us to think that a single-payer system will work here when it hasn’t been effective in other countries?

      • http://Www.twitter.com/alicearobertson Alice

        I think the legality of Obamacare is the mandating…which does tie in with the Canadian system you so admire…but is much more problematic than you give it credit for.  It said for every American doctor that goes there 19 Canadians come here.  There is a doctor shortage there.  American doctors just think they want to duplicate it because so many like easier payments…..which we know are spiraling downwards.  But you are right…there is no medical money tree to endlessly pick from (doctors sorta picked it clean in the past…not that Medicare and Medicaid fraud isn’t happening at astronomical rates today)…there are forms of rationing in every single answer.  It is a given…the crux we shall choose to help us decide just how much we are willing to pay and sacrifice…and hope and pray we can maintain some rights to even have a choice.

        You know the Brits think they have the best system in the world, Canadians defend their system, Americans their own…..but stats show both countries have longer wait times than we do.

        Personally, I prefer our system…which is so highly regulated.  I believe the care is better.  I think they can expand the VA system everyone wants to cover those without insurance.  I have a child battling cancer and I do not want longer wait times.  It can be the difference between life and death when drugs are not available, machines are older (as they are in the UK and Canada…my daughter’s cancer was caused by radiation…older machinery from lack of funding doesn’t make me want to do cartwheels).

        Both Canada and UK residents have found solice in the free market and private insurance.  Realizing one could argue the current gist does not take that away.  I will answer that if it is presented.

  • Lil A

    Yes, that was a law that Canada did pass. However, doctors, after that minimum two years are up, are going into the private sector. And in the UK, if the wait times are too long, they can go to the private sector abroad for their healthcare. If you look at it this way, a lot of people are coming from other countries to partake in our healthcare. If it were so bad here currently, why are people from many foreign countries coming here for medical care when they could be treated there? I’m sure that there are many highly trained doctors out in their country.

    As for our politicians not getting the fact that it is about the survival of the fittest, I think they get it more than they let on. However, this Social Darwinism has been a primary instinct of people since the dawn of time, and there will be no way to totally eradicate it from humankind, no matter what. This is one of our primeval instincts, and we seek to fulfill it every day. Have you ever felt jealous of someone who had more or became angry when people cut in front of you in line? This is Social Darwinism at its heart. You were there first, you were faster than they were, so you should get to eat first. Even the poor practice it. I would encourage you to stand outside a food bank or homeless shelter when people are coming to get food or shelter. As food gets scarce or people are being turned away, people get angry. Social Darwinism. Interviews for jobs require someone who can sell themselves better than those other candidates and have more skills. Social Darwinism, it’s everywhere, and I don’t think we can get rid of it.

    About your other statements, I don’t think that there is any perfect plan, no matter what solution we put into place. There will be people falling through the cracks in all the plans. It is more about the sustainability and innovation that one solution brings to another. My brother and I have been talking about this, and he proposes that the FDA have a fast track plan for drugs and medical devices of 2-5 years of testing. On top of it, he says that we need to allow for newer, better technology to come in to reduce the cost of older technology. He also says that there needs to not be so many restrictions on insurance companies, such as pre-existing condition and having to have something pre-approved. If a doctor rules that it’s medically necessary, it should be approved. In de-regulating insurance companies like this (and keeping government out of this, as the more government gets involved, the higher the cost of healthcare), the cost of insurance will go down. With all of these things my brother and I proposed in place (including what I mentioned in previous posts), the cost of insurance and health care would go down, thereby allowing more and more people to have healthcare. Rationing of healthcare would be reduced, but again, there will always be those that fall through the cracks.

    As for not having a “greed-based” system, I don’t know if this is at all possible. Greed is one of those things (along with Social Darwinism) that people naturally have. When things are scarce, people naturally want to stockpile. Playing to scarcity is actually a very effective persuasive tool that is used to fool people every day. If you feel that you could run out of something, such as food or water, your natural inclination is to save whatever you can during times of abundance. People have been doing this since the beginning of civilization, as Egypt had done this as a protection against famine in biblical times. We can’t get rid of our natural instincts, but we can try our best to do something other than our instincts, but it takes a lot of conscious effort to do so. Without that conscious effort, we fall back on our instincts, sometimes doing things that may be against what we believe in order to survive.

    Overall, what we, as people, are looking for is a perfect solution to a problem in a world where perfect does not exist. We seek after this perfection, only to fall short and end up in worse financial straights than we were before. We end up no farther, but in deeper debt. What I am saying is to revise the way our country spends its money in order to get out of, and remain out of, unreasonably high debt.

  • Dave

    Slave labor for specialists isn’t the solution. It’s a best a workaround, at worst heinously immoral. Pay PCPs more or specialists less, post-residency, but the current $50k stipend only works out to around $12/hour. That’s right, your resident doctors get paid less than social workers.

    I would go get my MBA and go into biotech so quickly if this came to pass.