Why Aren’t More Students Applying To Medical School?

Did you know that there are only two applicants for every place in U.S. medical schools?

In Canada, surprisingly, close to four students apply for each opening. The training in the two countries is very similar; indeed, the Association of American Medical Colleges (AAMC) accredits medical schools in both countries.  And, in the U.S., at the high-end, physicians  can hope to earn far more than Canadian doctors.

Why then do so few Americans apply to medical school?

The answer is that we have priced a medical education well beyond the reach of most middle-class students.  In 2004, tuition and fees at a public medical school averaged $16,153. Students who attended a private school paid $32,588 according to a 2005 study published in The New England Journal of Medicine. 

The author, Dr. Gail Morrison, Vice Dean for Education at University of Pennsylvania School of Medicine, tacks on $20,000 to $25,000 a year for living expenses, books and equipment to calculate that the total cost of four years of medical education comes to a heady $140,000 for public schools and $225,000 for private schools.  I’d add that, in many American cities, students would be hard-pressed to cover rent, food, clothing, utilities and transportation for $20,000 a year—let alone books and equipment.

This helps explain why 60 percent of all medical students come from the wealthiest one-fifth of all U.S. families. Another 20 percent come from families lucky enough to be on the fourth step of a five step ladder.

In Canada, by contrast, a medical education is much more affordable. In
Quebec province, for example, students paid a piddling $2,943 in
tuition last year—though admittedly, this deal was available only to
Quebecers. But elsewhere in Canada, tuition averaged just $12,728—about
25 percent less than Americans were paying to attend a public medical
school back in 2004, and about 60 percent less than they laid out to
attend a private school.

As a result Canadian students are much more open to becoming primary
care physicians, even though they know that internists earn lower
salaries than specialists. Granted,  in Canada the government
determines the ratio of residencies for primary care versus specialties, but students are willing to fill the spots. Canada is now
close to its goal of having 50 percent of its physicians practicing primary care.

In the U.S., where the Association of Medical Colleges strongly
supports free choice of specialty for students, only about one-third of
medical school graduates become primary care physicians. This is
understandable: the average U.S. student leaves med school with
$130,000 in debt. Moreover, unlike law or business students who enter
the workforce immediately after graduation and can begin to pay off
their debt, the average medical school graduate spends an additional
three to six years in postgraduate training programs while interest
continues to pile up. Meanwhile, he is painfully aware of salary
differentials: recent numbers show the average family doctor earning
$146,000 while the typical invasive cardiologist brings home $400,000.
And at the beginning of his career, a family doctor can expect to earn
much less—perhaps $100,000, before taxes.

Little wonder then, that the share of medical students pursuing careers
in primary care has plummeted from 49 percent in 1997 to 37 percent in
2003; over the same span, the number gravitating toward careers in
radiology, orthopedics, ophthalmology, and dermatology has sky-rocketed.

Yet we don’t need more dermatologists. But we do need more primary care
physicians. Decades of research done at Dartmouth University show that
when Americans see more family doctors and fewer specialists, outcomes
are better, in large part because patients receive more preventive care
and ongoing management of chronic diseases before they become serious.
(I have previously written about this issue for Dartmouth.)

But it’s not just that the high cost of med school is leaving us with
too many specialists and too few generalists. Spiraling tuition also
explains why middle-class and working-class Americans are not
well-represented in the profession. Keep in mind that only 20 percent
of physicians come from the lowest three steps on that five-step
ladder—which includes the third step where median-income families live.

According to the NEJM,
a recent national survey of under-represented students reveals that the
cost of attending medical school was the number-one reason they did not
apply. Meanwhile an Institute of Medicine report found that while
Hispanics constitute 12 percent of the population, they account for
only 3.5 percent of all physicians, and though 1 in 8 Americans is
black, fewer than 1 in 20 physicians is black. As Morrison observes:
“Continuing this trend has far-reaching consequences for the national
health care workforce, which needs diverse physicians in order to
address the needs of an increasingly heterogeneous patient population.”

Of course low-income students could take out loans just the way more
affluent students do. But if you are coming from a median-income
household (with a joint income of roughly $50,000), it is easy to see
how the idea of being $130,000 in debt could seem terrifying. After
all, what if you married, your wife became pregnant, and you had to
move out of your tiny one-bedroom apartment just as you were beginning
your career? What if you and two fellow graduates opened a small
practice—and discovered, after a year, that the three of you just
couldn’t make the overhead? More fledgling practices go under than one
might imagine. What if you gave birth to twins and realized that you
needed to take a nine-month sabbatical from your medical career? How
would you continue paying off your debt?

Students coming from families on the top step of the ladder have a
financial safety net. They know that, in an emergency, it is likely
that parents or grandparents will come forward with interest-free loans
or a gift. Students from poorer families realize that they will be out
there, alone, with tens of thousands of dollars in loans.

Finally—and perhaps most importantly—the sky-high cost of a medical
education creates a shallow applicant pool, making it harder for
medical schools to find the very best doctors. Schools, after all, are
looking for those rare individuals who are not only fiercely
intelligent, but compassionate and committed to medicine as a service
profession. What a patient needs is both competence and kindness.

Yet, if medical schools are accepting one out of every two applicants,
just how discriminating can they be? How often must they wind up taking
students who are bright, hard-working and ambitious enough to nail the
required GPA—but lack the imagination to understand that there is more
to being a doctor? A larger applicant pool—a pool that was both broader
and deeper—would be more likely to yield students who possess the range
of talents needed to become  an exceptional physician.

When Morrison tries to find a solution to these problems, she runs into
a brick wall.  She suggests that the federal government needs to do
more by expanding and protecting the National Health Service Corps Loan
Repayment Program, for example, and broadening the tax-exempt status of
medical scholarships. “But,” she acknowledges, “these initiatives may
not be top priorities for a government dealing with war in Iraq, a
growing national debt, and threats of terrorism.”

“Perhaps, then,” she concludes, “our best hope lies in individual
medical schools finding creative ways to reduce the need for loans and
to adjust financial policies so as to reduce tuition.”

But the truth is that in order to train students, medical schools need
to make enormous capital investments in the priciest, newest medical
technologies. As a result, the cost of educating a student can easily
outstrip the tuition the school receives. And while academic medical
centers have other sources of government funding, many also provide
more care for uninsured and Medicaid patients than the average
hospital. They’re in no position to slash tuition.

Ideally, the federal government would find the funds to offer far more
generous scholarships to students willing to become primary care
physicians and practice in the areas where they are most needed for
four or five years after graduating. Many might well put down roots.

As an alternative, Princeton economist Uwe Reinhardt has proposed an intriguing solution. In a “Health Affairs” article titled “Dreaming The American Dream: Once More Around On Physician Workforce Policy
Reinhardt suggests that the government might create a “human capital
market in which medical students could borrow the funds needed to pay
for their own medical education”—and pay off the debt gradually, the
way one pays off a mortgage.  “A graduate’s indebtedness of, say,
$200,000 upon entry into medical practice could  be fully amortized
over twenty-five years, at an interest rate of 8 percent, with annual
payments of about $18,700,” Reinhardt explains.  "If the payments were
made tax-deductible, as they should be, the net burden on the physician
might be no higher than half that amount. As Main Street enterprise
goes, this is not an enormous debt-service burden.” [my emphasis]

“If all physicians were forced to debt-finance the full cost of their
medical education,” he continues,  "then a public physician workforce
policy might take the form simply of judiciously targeting tax-financed
loan forgiveness to achieve certain desired social ends, be it a
desired ethnic or gender mix in the physician supply, a desired
specialty or spatial distribution of physicians, or a desired delivery
of health services, such as care provided below the physician’s
opportunity costs (including uncompensated care.) In principle, one
could even use the mechanism to modulate the overall size of the
physician workforce."

“In effect,the policy would be a slight variant of the current ROTC
program for the military or the National Health Service Corps for
physicians. These two programs prepay the cost of the student’s human
capital and then hope to collect on it through mandated subsequent
service. The program proposed here would force the student to
accumulate financial indebtedness first and forgive that debt only in
step with actual service delivery.”

Reinhardt admits that this would be “a radical departure from
conventional physician workforce policy in the United States and in
other countries.” Though he notes that, “unlike the United States, most
other countries do not treat health care as basically a private
consumer good and medical practice as just another form of free
enterprise. Instead, they tend to treat physicians as quasi civil
servants with explicit social obligations.”

Would such a program fly in the U.S.? It’s hard to imagine requiring
all medical students to take out loans to finance their education.
(Though the truth is that today, only 20 percent pay cash for
tuition—the other 80 percent go into debt.) Moreover, the idea of
amortizing medical school loans, like a mortgage, over 25 years, and
making them tax-deductible is appealing. It means that young doctors
who are trying to start a career and a family won’t be as strapped as
they are today. And if the government “judiciously” targeted
loan-forgiveness programs to achieve desired social ends, we could hope
to have both primary care doctors and specialists more evenly
distributed around the country, in the places where they are needed
most. This, in turn, could make universal health care more affordable.

Reinhardt’s proposal is just one scheme for financing the cost of
medical education.  But it’s provocative, and should encourage us to
begin thinking about how to open the doors of our medical community to
a larger group of applicants coming from a much broader spectrum of
society.

16 thoughts on “Why Aren’t More Students Applying To Medical School?

  1. Maggie,
    I would encourage you to adjust your numbers a bit. If you figure with living expenses public schools in the $140K range and private schools in the $225K I am not sure how you got the average on the low end of that. I would also add that a pre-med four year education is required for medical school, this also costs money and most people do not pay it off between school, thus increasing the medical student’s debt above that figured in your piece. Finally, I would add that I am personally from the lower middle class, (prior to med school I had jobs such as retreading tires, cutting trees and fixing ski lifts), and this is how comming from no money effects debt. Most (if not all) of my school colleagues where from some money, they didn’t have to borrow extra to pay for many of those little things (travel home for christmas), gifts, recreation etc. If I wanted those things in my life (most necessary for my psych) I had to borrow more, my colleagues got it from mom and dad.

  2. Maggie,
    You frequently make the point that becoming a doctor is about more than money and that people who only care about how much money they can make should not go into medicine. I’m sure there are plenty of people who consciously choose a medical career with full knowledge that they could make considerably more in law or business. Opportunity costs are not irrelevant, however, even if medical school tuition were fully paid by taxpayers. After all, to become a PCP requires four years of undergraduate education plus four years of medical school plus at least two years of internship and residency. At the same time, one could become a pharmacist in six years total (four years of undergraduate school plus two years of pharmacy school) and go to work for one of the large retail drug chains or PBM’s for about $40 per hour ($80K per year) plus health and retirement benefits plus regular hours and, for those who want it, the opportunity to work part time.
    As for the alternative of getting an MBA (two years) to pursue a business career or a law degree (three years of law school), I wonder what the comparable entry level salaries are in Canada for management track MBA’s and lawyers joining the large corporate law firms as compared to U.S. salaries.
    I would have no problem if PCP’s made $200K on average after, say, five years of practice and if the typical specialist made $500K. I would be especially comfortable with this level of compensation if we had a system where all doctors and hospitals used interoperable electronic medical records, medical disputes were settled in a fair, objective and consistent manner (using health courts or arbitration but not lay juries) and we had a sensible approach to end of life.
    I saw an estimate on the Healthcare For All blog last week that suggested that fully 70% of the excess medical costs in the U.S. vs the OECD average relate to care delivered in hospitals – both inpatient and outpatient. This is where end of life care is delivered. This is where the absence of interoperable electronic records lead to lots of duplicate testing and adverse drug interactions. This is where doctors often encounter patient they don’t know (especially in ER’s) and are most inclined to practice defensive medicine to minimize the chance of a lawsuit if there is an adverse outcome. So, it’s not doctors’ salaries that are the problem. It’s excess, unnecessary, and often unwanted utilization. Let’s focus our cost reduction efforts there and on comparative effectiveness research and streamlining and simplifying insurance offerings.

  3. Dr. Matt & Barry–
    First, Dr. Matt– I’m not quite sure where you find a problem with the math: 16 plus 20= 36 X 4 = 144 . ..
    I absolutely agree that poorer med students do have to borrow more, just to live. While many affluent med students are very independent, and trying to make their own way, they will of course, receive Christmas gifts, birthday gifts, etc. And if their parents know that a daugher or son is having a hard time making ends meet, and one of the parents’ cars is ready to be traded in, they may well just give it to the. med-student.
    This is the sort of thing that makes all of the difference in terms of feeling (and being) financially secure.
    Barry– I, too, would have no problem with primary care docs averaging $200,000 after, say 4 years. We need to pay them more.
    As for alternative careers in Canada, the one thing I can say is that since so many Canadians are far to the left of us, a career in business may not be as appealing for some young people.
    Meanwhile, Canadians are quite proud of their health care system–proud of the solidarity it represents. Canadians have always been our poor cousins, but this is one thing that many (not all) Canadians feel they have done better than us.
    So this may be another reason why Canadians are more eager to become doctors.
    In terms of whether most of the waste in our health care system occurs in hospitals, I’m not sure.
    But I do know that end-of-life care is not the biggest expense. The biggest chunk of our healthcare dollars is spent treating patients suffering from just 5 chronic diseaes: diabetes, congestive heart failure, astham, coronary heart disease and depression.
    How much of that money is spent while patients are in the hospital (because we didn’t do a good eough job managing the disease, I don’t know.) But I do know that we spend so much on these diseases because people live with them for a very long time–so you’re talking about years and years of bills. And by and large, there is no cure.

  4. Dr. Matt & Barry–
    First, Dr. Matt– I’m not quite sure where you find a problem with the math: 16 plus 20= 36 X 4 = 144 . ..
    I absolutely agree that poorer med students do have to borrow more, just to live. While many affluent med students are very independent, and trying to make their own way, they will of course, receive Christmas gifts, birthday gifts, etc. And if their parents know that a daugher or son is having a hard time making ends meet, and one of the parents’ cars is ready to be traded in, they may well just give it to the. med-student.
    This is the sort of thing that makes all of the difference in terms of feeling (and being) financially secure.
    Barry– I, too, would have no problem with primary care docs averaging $200,000 after, say 4 years. We need to pay them more.
    As for alternative careers in Canada, the one thing I can say is that since so many Canadians are far to the left of us, a career in business may not be as appealing for some young people.
    Meanwhile, Canadians are quite proud of their health care system–proud of the solidarity it represents. Canadians have always been our poor cousins, but this is one thing that many (not all) Canadians feel they have done better than us.
    So this may be another reason why Canadians are more eager to become doctors.
    In terms of whether most of the waste in our health care system occurs in hospitals, I’m not sure.
    But I do know that end-of-life care is not the biggest expense. The biggest chunk of our healthcare dollars is spent treating patients suffering from just 5 chronic diseaes: diabetes, congestive heart failure, astham, coronary heart disease and depression.
    How much of that money is spent while patients are in the hospital (because we didn’t do a good eough job managing the disease, I don’t know.) But I do know that we spend so much on these diseases because people live with them for a very long time–so you’re talking about years and years of bills. And by and large, there is no cure.

  5. Maggie,
    good post. One thing you need to know about the NHSC (national health service corps).
    Originally, it was intended to be for doctors only.
    However, over the years, the dentists, nurses, nurse practitioners, physician assistants, pharmacists, and LCSWs lobbied to be included in the program, arguing that they were “just as valuable” as doctors to rural areas.
    But of course, thats a load of crap. A rural doctor is worth far more than a rural dentist, rural nurse, etc.
    The NHSC budget has remained very flat over the years, and with the influx of all the other people trying to get their hands in the pie, the funding for doctors has decreased over the years. Now its incredibly competitive for a doctor to get an NHSC grant.
    NHSC should be refunded to give preference to doctors first and foremost. Any funds that arent used by doctors should then be available to the rest of the groups.

  6. Madam:
    A couple of points:
    1. Number of applicants/admits, from
    http://www.aamc.org/newsroom/pressrel/2007/071016.htm
    From AAMC’s USA figures: 2.376 applicants per admit (42,300 / 17,800 = 2.376)
    2. As with most things health care, this is a highly complex matter, filled with confounding v’bles that make simple comparisons worthless.
    At bottom: the lack of socio-economic status diversity in med schools, including Rural America, are a concern. To wit:
    http://www.unmc.edu/Community/ruralmeded/birth_origins_articles.htm
    3. There is no such thing as a “free lunch.” Someone pays; someone always pays.
    4. My own take:
    http://healthcaremoney-newsblog.blogspot.com/2007/10/md-money.html#links

  7. Maggie,
    I admit about 600 patients per year and have tracked my top 10 DRGs for some time. My sample is representative of what you will find in most acute care hospitals. Taking into account some variation, eg, more sickle cell in urban AA populations for example, the usual suspects pop up continuously.
    I want to clarify what you call “chronic diseases” vs “hospital/EOL care.” They are indistinguishable. Almost universally, you will find:
    1) Chest Pain
    2) CHF
    3) Asthma
    4) Diabetes, uncontrolled
    5) GI Bleed
    etc., amongst all these folks.
    The wards reads like a chronic disease list of woe, and is universally comprised of above, again, HTN, DM, etc., plus lung disease, geriatric related problems (UTI/PNA), and slew of others you know well. It all gets back to disjointed care, lack of routine health maintenance (patient or system driven), and everything else we all blog about.
    My point is, EOL and acute care is all tied together–it is the diabetic complications and related immunosuppression that put grandma in the ICU with MRSA to begin with.
    Brad

  8. Maggie,
    A point that I would have liked to see you consider is that unlike many career paths out there, medicine is rarely the sort of thing one spontaneously chooses after graduation from college in the US.
    While there are excellent post-baccalaureate programs for those who want to take the premed science requirements after graduation, the total number of students these programs supply is far less than that total number of applicants. Applying to medical school requires an early commitment — often times as early as high school, as good grades there will lead to admission to the good colleges that make medical school admissions easier. Most students must decide on medicine in their freshman or sophomore year to complete the requirements, research, and volunteer hours needed to convince admissions committees that they are good candidates. The MCAT, that final stumbling block, is an exam that requires at least a good month of preparation, usually more.
    Isn’t it possible, then, that the low rate of applicants in the US is also a result of massive self-selection that occurs in the years before application? A few friends of mine have wished out loud they had thought of being pre-med in college. They find too many roadblocks in the way of completing their requirements to try for it now.
    Even removing debt considerations will not improve the lack of primary care doctors in the US until they receive pay and respect at the same levels as specialists. It is becoming financially insupportable to provide Medicare/Medicaid services, still see patients adequately, and keep a practice afloat. One way or another, market forces will correct.
    As for turning my medical school tuition into a mortgage I have to pay off — I worked extremely hard the years before I applied to save so that I could pay half now, half later through loans. Any system that forces us into that repayment is inherently flawed. Either procedural-based payment will end, or the general physician will be edged out in favor of the mid-level provider. I don’t see why we need to step in, except in the case of slashing Medicare payments.
    Matt’s point of excessive use of end of life care seems a decent step in that direction.

  9. K, Brad, CAChien, and Joe Blow–
    Again, thank you for your comments. As usual, the people posting here are making extremely thoughtful contributions to the thread, and I appreciate it-
    K– I agree that it’s hard to apply to medical school unless you make up your mind to become pre-med by sopohmore year. But it’s equally hard in Canada–the requirements are as stiff, and it’s very hard to go back and fill them after you have graduated.
    And even if you are pre-med with very good grades, it’s difficult to make the cut. (I have a friend in Ottawa whose son did take the required courses and applied two years in a row without getting in.)
    So the need to make the decision early in your college career doesn’t explain why roughly twice as many Canadians apply for every space in their schools.
    Moreover the fact that, in the U.S., 60% of those who enter school come from famlies in the top quintile economically does suggest that cost is a major barrier here. (A wider spectrum of society applies to med school in Canada as well as in other countries where a medical education is largely subsidized.)
    I like Reinhardt’s “mortgage” idea (with the payments tax deductible) because it makes paying off the loan doable–even for someone who doesn’t have a financial safety net. And, as with a mortgage, inflation would make the payments smaller and smaller (as a percentage of income) over time.
    But I definitely agree with you that I don’t see how we could “force” everyone into this system of financing their med school education.
    On the other hand, I think we could make a “mortgage” option attractive enough (particularly by forgiving all or part of the loan if the student chooses to go where he/she is most needed after graduation) that many students might choose it.
    And Congress might actually pass the legislation because, after the inital outlay, the program would begin to pay for itself as students paid back loans (or served in parts of the country where people are not getting enough preventive care and management of chronic diseases, thus reducing the nation’s total health care bill.)
    Finally, you write: “It is becoming financially insupportable to provide Medicare/Medicaid services, still see patients adequately, and keep a practice afloat. One way or another, market forces will correct.”
    I agree that it is becoming almost impossible to make it as a primary care physician in many places. And I’m afraid that market forces are already correcting. Some primary care practices are going under. Many primary care docs are simply refusing to take Medicaid patients, and, at least in NYC, many are beginnig to refuse Medicare patients.
    Thus, Medicare patients are joining Medicaid and the uninsured in the bottom tier of a two-tier health care system that, in the end, will be very costly for all of us. People who don’t get timely care and chronic-disease management become very expensive patients later on.
    The solution, I think, is three-fold: Medicaid reimbursements must be raised to meet Medicare reimbursements, and both Medicare and Medicaid reimbursements must be raised for primary care, family docs, etc. Meanwhile, Medicare has to re-examine its coverage. Right now it’s covering too many unnecessary, often unproven and over-priced procedures. This means that some specialists will find their reimbursements cut–largely because they’ll be doing fewer of these procedures.
    The Medicare Payment ADvisory Comission is already heading in this direction, and I suspect that, over the next 2 or 3 years, Congress will follow their recommendations largely because it won’t have any choice.
    The only alternative,under current Medicare law, is to slash physicians payments by 10%, across the board. And that won’t happen. Politically, it’s a non-starter, and everyone realizes that an across-the- board cut is a crude tool.
    Finally, to survive, I think primary care docs (and other docs) are going to have to join large multi-specialty group practices or work as hospitalists. The days of the solo-practioner are coming to an end.
    Given the cost of real estate, wages for staff, and the informtation technology that all doctors are eventually going to need, solo-practice just isn’t practical.
    In rural areas, doctors may organize themselves into virtual networks clustered around the hospital where they refer patients. They may not share space, but they’ll use one back office to manage the business : (everyhthing from billing, buying IT, and training staff on IT to hiring a cleaning service, answering service etc., and they’ll share EMRS.)
    In the long run, this will lead to better-co-ordinated, higher quality care. Right now, too many “Lone Rangers” are practicing medicine without anyone knowing what they are doing. Some are excellent; some are less than mediocre.
    If a group of doctors are all working with the same electronic medical record, they will quickly realize if someone is consistently deviating from best practice guidelines. . .
    Brad–you write: “The wards reads like a chronic disease list of woe . .. It all gets back to disjointed care, lack of routine health maintenance (patient or system driven), . . . My point is, EOL [end-of life] and acute care is all tied together–it is the diabetic complications and related immunosuppression that put grandma in the ICU with MRSA to begin with.”
    I completely agree–and this is where we need to focus reforms that will raise quality and reduce costs. It seems counter-intuitive, but when you look at reforming our system, lower costs and higher quality almost always go hand in hand.
    Chien–
    The numbers you cite are for one year only. There tends to be a boom and bust cycle in med school admissions–depending on how much funding med schools are getting from Medicare.
    In any case, whether it’s 2.3 applicants per place or 2 applicants, you and I are in agreement that we need a more diverse (and so by definition, larger) pool of applicants.
    Joe Blow– I agree that funding for NHSC needs to be restored. But I can’t agree that dentists, nurses, nurse practioners shouldn’t be included in the program. As you know, an infection from an abscessed tooth can kill a person. And nurses and nurse practioners are essential for preventive care. That said, I don’t see why the funding to include them has to come out of the funding needed for doctors.

  10. MATH NEEDS WORK
    ” .. In any case, whether it’s 2.3 applicants per place or 2 applicants, you and I are in agreement that we need a more diverse (and so by definition, larger) pool of applicants ..”
    1. Yes — sometimes to U.S. applicant pool is much higher, bringing into question the example about Canada. The applicant pool is often a function of overall economic conditions.
    2. Increasing enrollment (and, under the current paradigm, costs) does n-o-t guarantee more diversity.
    That is: what is most of the growth is in metro areas? And not any directed Rural America?
    What if the growth merely draws more upper-middle-class students (of all races), which is the case now? How does that increase SES diversity?
    As noted previously — v’bles can be confounding.

  11. C.A. Chien-
    You wrote “sometimes the applicant pool is much larger . . ”
    I’m wondering where you got that information . . The fact is that the record high reatio of applicants per place was 2.8 in the mid 1970s was tuition was much much lower and many more scholarships were available (tied to a student’s willingness to work in underserved areas.)
    Since then the number of applicants has dropped.
    By 1987, The New York Times was reporting that “traditionally the ratio has been 2 to 1” and
    fewer students are applying each year to the University of Connecticut School of Medicine in Farmington and at the Yale School of Medicine in New Haven, Connecticut’s two medical schools.
    School officials attribute this phenomenon to the high cost of medical school, the large debts students incur before
    graduating . . .
    Declining applications at UConn and Yale reflect a national trend that began about a decade ago. Applications to the nation’s 127 medical schools totaled 27,923 this year; 31,323 last year, and 32,893 in 1985, according to the Association of American Medical Colleges in Washington. This year, 15,725 places were available at medical schools nationwide,, , ,
    So as you can see, by 1987, a two to one ratio was the norm–and has continued to be the norm with some fluctuation.
    But it was only in the 1970s –when school was more affordable that it went as high as 2.8.
    And it’s quite clear that lower tuition would mean not only a larger pool, but more diversity. Look at the poll of under-represented students saying that the main reason they didn’t apply was the cost.
    Older Medical school administrators also say that when they were in school, med students came from many different classes.

  12. C.A. Chien-
    You wrote “sometimes the applicant pool is much larger . . ”
    I’m wondering where you got that information . . The fact is that the record high reatio of applicants per place was 2.8 in the mid 1970s was tuition was much much lower and many more scholarships were available (tied to a student’s willingness to work in underserved areas.)
    Since then the number of applicants has dropped.
    By 1987, The New York Times was reporting that “traditionally the ratio has been 2 to 1” and
    fewer students are applying each year to the University of Connecticut School of Medicine in Farmington and at the Yale School of Medicine in New Haven, Connecticut’s two medical schools.
    School officials attribute this phenomenon to the high cost of medical school, the large debts students incur before
    graduating . . .
    Declining applications at UConn and Yale reflect a national trend that began about a decade ago. Applications to the nation’s 127 medical schools totaled 27,923 this year; 31,323 last year, and 32,893 in 1985, according to the Association of American Medical Colleges in Washington. This year, 15,725 places were available at medical schools nationwide,, , ,
    So as you can see, by 1987, a two to one ratio was the norm–and has continued to be the norm with some fluctuation.
    But it was only in the 1970s –when school was more affordable that it went as high as 2.8.
    And it’s quite clear that lower tuition would mean not only a larger pool, but more diversity. Look at the poll of under-represented students saying that the main reason they didn’t apply was the cost.
    Older Medical school administrators also say that when they were in school, med students came from many different classes.

  13. With rising malpractice premiuma and decreasing reimbursement by both CMS and MCO’s, how would any young physician be able to repay Student Loans? These factors alone would dissuade all but the most altruistic from pursuing a career in medicine.

  14. DUE TO GOVT?
    Did it ever dawn on anyone that the number of MD school applicants is inversely correlated to the amount of government rules?
    That one of the worst places to be, is to invest your money in a profession that is regulated by government bureaucrats?

  15. MATH, AGAIN
    ” .. You wrote “sometimes the applicant pool is much larger. . ”
    Madam: Inconvenient facts —
    Thanks in part to LBJ, there was a big boom in MD schools 20 years ago, creating over-capacity in medical schools until recently. In fact, the number of MD-student positions has been fixed at about 20,000 for two decades. Why else would off-shore medical schools start up?
    The applicant/admit ratio is one of division. The denominator is fixed (20,000).
    Applicants have some wiggle-room; but per my previous notation on GPA and MCAT, what good does it do for someone with 3.0 and 50% MCAT to apply, if they know they will be rejected? Kind of silly to apply if standards are set so high, wouldn’t it?
    This matter is more complex than a simple comparison between the U.S. and Canada. Which, everyone knows, are not comparable for only about 100,000,000,000,000+ reasons.

  16. Art Fouger, Russ and Chien-
    First, Art Fouger and Russ: As you point out, medical school is no longer a sure road to wealth as it was, at least for some specialties for a couple of decades. (Prior to the early 1960s, most doctors were GPs and while they made a good living most were not extremely wealthy. It was only with the advent of the specialities and Medicare as well as private insuers paying fee for services that doctors’ incomes began to climb.
    Beginning in the 1980s, Medicare began to pare back reimbursements. Then in the 1990s managed care began to cut into doctors’ earnings. Meanwhile the cost of med school spiraled and while low-interest loans continued to be available, scholarships became rare.
    Finally, the possibility of further government regulation in the form of national health reform does mean that a doctor entering the profession today really can’t know what shape his career will take.
    On the other hand, if, as you suggest, this draws more altruists into the profession, presumably that would be all to the good. But I’d like to see the financial obstacles removed. Students shouldn’t be graduating with crushing levels of debt.
    A.C. Chien– I find your post hard to follow. You write “Thanks in part to LBJ, there was a big boom in MD schools 20 years ago, creating over-capacity in medical schools until recently.”
    First, LBJ wasn’t president 20 years ago (1987). And what were seen as the excesses of his Medicare legislation had been addressed long before–particulary under Reagan (1980).
    Secondly I don’t know what you mean by “over capacity” in medical schools. “Excess capacity” is probably what you’re referring to–but what does “excess capacity in medical schools” mean? Too many places for the number of students applying? Too many medical schools?