Free medical school may not help the future of primary care

In an op-ed appearing in the New York Times on May 29th, Drs. Bach and Kocher lay out a plan for making primary care more attractive to medical students. They propose the following: “Under our plan, medical school tuition, which averages $38,000 per year, would be waived. 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.”

It’s novel and I think worth discussion.

But sitting in a specialty poised to be burdened the most under such a plan I have some reservations. Neurosurgeons have perhaps the longest training of any specialty. The majority of neurosurgical residencies are 7 years and with fellowship training the burden for future neurosurgeons could be upward of $450,000 under the current proposal at $50,000 a year.

There are a number of other specialties as well, where the average income falls well short of the median cited in the op-ed. In a specific example, neurosurgeons who go on to do 1-2 years of fellowship in pediatric neurosurgery take a significant pay cut as compared to those neurosurgeons who go into practice straight out of residency and treat adults. Or consider the infectious disease specialty where the average income is hardly more than that of a primary care physician but require extra fellowship years. The point is that while the average income for a primary care physician is has a shorter distribution and is more homogemous, there is great variability in income for specialists. The proposal is likely to drive medical students and graduating residents, now forgoing primary care, out of certain specialties including infectious disease, physical medicine and rehabilitation and many pediatric surgical specialties to name a few.

My second contention is that, for the most lucrative specialties, I’m not sure the incentive will be enough. Let us consider the numbers given in the op-ed concerning the median specialty and primary care incomes. They cite $325,000 and $190,000 respectively. It may not be totally realistic but will serve my point if we have a pediatric neurosurgeon earning the former and a primary care physician earning the latter.

Let’s say the pediatric neurosurgeon takes 8 years of training and owes $400,000 at the end. The primary care physician does 3 years of training and owes nothing. Assuming some level of government guarantee of the loans used by the pediatric neurosurgeon and he or she is paying them off over 15 years at a 6.8% rate.

Over a 20 year period (from the time the primary care physician enters practice after completing his or her free training to the time the pediatric neurosurgeon is finished paying his or her loans) the gross numbers stack up like this:

Primary care physician 20-year earnings
20 years x 190,000 = 3,800,000

Pediatric neurosurgeon 15-year earnings
Remember the specialist will be in training for five years while the primary care physician is out earning.

15 years x 325,000 = 4,875,000 – 640,000 loan payments = 4,235,000

On the sum there is still incentive for medical students and residents to choose a high paying specialty.

Finally, I’ve discussed this before, but self reported surveys continue to show that medical student’s decisions concerning primary care are only partly related to future earning potential and other factors are more important. This plan doesn’t address the appearance problems that primary care suffers and the expectations of health care in this country which, in addition to the comparatively low earning potential, make primary care unattractive to American medical students.

I am a strong proponent of strengthening primary care. The reality is we need to normalize primary care and specialist reimbursement and dramatically reduce the number of specialist training positions in order to force a more tertiary health care system more in line with the rest of the western world.

I have serious doubts making medical school free will significantly bolster the future of primary care.

Colin Son is a neurosurgical intern who blogs at Residency Notes.

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  • Robert Bowman

    Primary care problems will be addressed with interventions specific to primary care. Too many designs are deflected to generic increases in graduates, promises not kept by students or institutions, or entire new types of workforce that are now two-thirds not primary care. SMART designs are specific to primary care and result specifically in permanent primary care trained in primary care and most experienced in primary care. Also support teams must also be trained and retained in primary care – these require more spending specific to primary care along with less spending upon non-primary care. Design changes are required. In the 1965 – 1980 almost any intervention worked, because policy designs favored primary care at least as much as non-primary care. Both doubled 1965 – 1980 by design. Since that time non-primary care has doubled each 15 years while primary care remains stagnant – by design. Primary care cannot remain a side effect. SMART design is required.

  • Med School Odyssey

    This idea of thinking that forgiving tuition will attract people to medicine is a red herring.  Medical schools reject 30,000 applicants a year – graduate school tuition prices do not prevent people from entering medical school.  There are scores of people that wish to practice medicine – indeed, many that want to be primary care doctors – that are prevented from becoming physicians because the US refuses to allow expansion in the size or number of medical schools.

    The US currently trains something like 17,000 doctors a year.  Regardless of the percentage of those that decide to do primary care, the physician shortage will continue to persist because we simply do not produce enough physicians.  As long as we refuse to address this underlying supply problem, all of these attempts to produce more PCPs are nothing more than moving the deck chairs around on the Titanic.

  • Bob Builder

    I had a full tuition private scholarship to medical school.  I loved being free of a massive debt burden, which seriously allowed me to consider primary care as well as all other medical specialties.  What did I choose?  Not primary care.  Only it didn’t have anything to do with money, it just wasn’t for me.  My opinion is this….if you really want to force more people into primary care you need to do one thing; instead of admitting the best of the best to medical school, admit some who aren’t.  They won’t perform as well in medical school, or on Step 1 or Step 2, and when it comes time to pick a specialty, primary care will be their only option.  Asking the best students in our nation to willfully choose primary care over more interesting, higher-paying specialties is a little crazy.  Free tuition doesn’t change any of that.  

    The other way I see of making primary care more appealing would be to MAKE it more interesting- take back some procedures from the sub-specialties, increase the scope of what conditions they can manage, pay them a little bit more, and find ways to make the residents happier.  This last point was HUGE for me; the level of depression among the IM residents infected me as a 3rd year student, and I instantly ruled it out.  On the flip side, I seriously considered Family Medicine because we have a great family department- the residents are happy, enthusiastic, friendly, they do little things like free lunches, and they teach procedures aggressively.  What turned me off was when we were forced to rotate through external family medicine departments around the state; what I saw there was the same thing I saw in internal medicine, and I wanted no part of it.  

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