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
“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