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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