Would making medical school free improve physician culture?

Peter Bach and Robert Kocher have an op-ed in the Times arguing that medical school should be free. As they put things:

Huge medical school debts — doctors now graduate owing more than $155,000 on average, and 86 percent have some debt — are why so many doctors shun primary care in favor of highly paid specialties, where there are incentives to give expensive treatments and order expensive tests, an important driver of rising health care costs….

Bach and Kocher’s preferred way to cover these costs would gladden the hearts of many within the primary care and public health communities:

We estimate that we can make medical school free for roughly $2.5 billion per year — about one-thousandth of what we spend on health care in the United States each year. What’s more, we can offset most if not all of the cost of medical school without the government’s help by charging doctors for specialty training.

Like Don Taylor, I find their financial analysis rather uncompelling. Differences in compensation across medical specialties are far larger than differences in debt. Medical debt itself, though an issue, is no higher than is assumed by many professionals who receive advanced training. My handy mortgage calculator indicates that monthly payments on a $155,000 30-year, 5 percent loan are only about $832. Primary care is in difficult straits for many economic and organizational reasons that go well beyond the burden of loans.

At the level of psychology and behavioral economics, though, I wonder if such a policy might have greater impact than one’s narrow calculation might otherwise predict. Six-figure debt provides a large overhang of anxiety at a critical moment in people’s careers. It creates a salient reason to pursue a higher income.

These common burdens also reinforce questionable professional attitudes and norms. I often speak with doctors about the need to make difficult changes in medical practice to improve patient care. When these changes are too unpalatable, or when doctors’ status or income comes into question, the words “we have our loans” are spoken with striking regularity. It is as if a Greek chorus has been summoned. This becomes a powerful call for insularity and for drawing sharp, often unconstructive boundaries between insiders and outsiders to the medical profession.

If relieving physicians of practical burdens would loosen these boundaries and the accompanying sense of grievance, $2.5 billion would be well worth it.

Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect, tnr.com, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

19 thoughts on “Would making medical school free improve physician culture?”

  1. I’m more convinced by Harold’s numbers than his social analysis. Fancy law schools have the money to try to buy a social conscience for their students, and offer them all kinds of debt forgiveness if they do some kind of public interest work. The students generally don’t take advantage of this. Or, to pick another example, most Ph.D. science programs pay stipends to their students–enough for a single person to live off of. But everybody kvetches about a lack of scientific talent in the US.

  2. We have a social problem: too many specialists, not enough primary care docs. Why? Because specialists are paid much more than primary care docs. Solution: Let’s give tax dollars to all docs!
    Just what we need – social program consisting of giving no-strings attached money to doctors, who clearly don’t make enough money now and need to be subsidized by the government.
    How courageous of the NY Times to print an article advocating free gifts to doctors.

  3. Instead of subsidizing school, how ’bout just mandating that licensing boards abolish transcripts and college credits, and go to exams and OJT (residency). I would not object to surgical treatment from a veterinarian who apprenticed out of elementary school, if s/he had a reputation for competence.

  4. Why am I not surprised that Malcolm wants the full barber-surgeon treatment?
    I mean, licensing as rent-seeking is a problem, and I’m hardly going to claim that licensing in Medicine is perfect. But Malcolm’s idea that what we really need is barefoot doctors is so … Maocolm.

  5. Bloix repeats a trope that should be dismantled.

    The concept of “primary care doctor shortages” is a myth that has been repeated in the literature for over a quarter century. Given the advance of PAs into of the field of preliminary diagnostics, the notion that there are “too many specialists” is no longer a valid critique of the health care system. The simple statistical truth is that we have about the right number of specialists that we need–probably more, but it is not yet a delivery-system problem. A swelling of the ranks of primary care physicians produces a regime of MDs who are but one small step ahead of the PAs currently being trained and two steps behind the regime of specialist MDs who are prepared to enter into protocols of treatment immediately relevant to the conditions of disease and diagnosis of patients.

    I am a tenured full professor at a first rate university with a first rate medical school. I write letters for pre-med students every academic year. Students who get into American Medical Schools right now in the USA are the best of the best. The very basic, undeniable fact that these students come out of medical school with crippling debt as a primary problem for their career and value decision-making models should be a major concern for policy makers who are making sober decisions about health care policy.

    Either we subsidize their intellectually exclusive, wildly expensive, and ridiculously difficult educations for a relatively small sum at the front end or we will will continue to pay for the career risks and dicey economic entrepreneurship at the back end of their careers.

  6. Ebenezer Scrooge says: “Or, to pick another example, most PhD. science programs pay stipends to their students–enough for a single person to live off of. But everybody kvetches about a lack of scientific talent in the US.”

    First, not everybody. The people kvetching are (a) the people who want cheap grad students, post docs and cheap PhD.’s, and (b) the talking heads who repeat such garbage.

    Look at starting pay for PhD.’s, look at job openings, and it’s another story. In many fields, post docs are now the norm, and usually multiple post docs. In others, almost all those who get jobs in academia only get adjunct jobs. Universities and colleges can pick from a large number of qualified applicants for whatever scraps of bread they wish
    to throw.

    There is no evidence at all of a shortage, and vast evidence of a glut. [I don’t count employers b*tching because they can’t get people to work for ‘three hots and a cot’ to be evidence of anything except human nature]

  7. Lars Macomb-
    You’re right – I repeated the trope that formed the basis for Bach and Kocher’s op-ed. I dont’ doubt that it’s false, which undercuts even further the basis for their argument.

    I don’t doubt that the solution to the primary care shortage is not more primary care physicians, but more PA’s and nurse practitioners – a solution, by the way, that the medical profession has opposed for a very long time. I also agree with you that higher education costs too much money. And I also agree that the need to pay student debt – not only for physicians – unduly affects career choices.

    Where I disagree with you is that the solution is a new government-funded social program to channel hundreds of thousands of dollars to some of the highest income earners in our society. Newly graduating physicians earn between $200,000 and $400,000 per year.

    I also find it astonishing, in an era when we read that teachers and other government workers are paid too much and have to be “flexible” (I.e. laid off), that the Times gives its valuable editorial space to advocate for a massive subsidy program to some of the wealthiest people in our society. No, actually – I don’t find it astonishing – I find it depressingly predictable that the Times cares a great deal about the problems of the rich as individuals.

    As long as there is no overall shortage of physicians, then the problem of the cost of physician education is not a social problem, and it’s way down the list of problems that are deserving of a new, multi-billion dollar government program.

  8. Harold: Nice post. I also am dubious of the argument. There are loan payoff programs for primary care that often go begging. Partly it’s the huge disparities in pay as you note, but partly it is also the lifestyle people want when they choose to “hit the ROAD” as the med students say — Radiology, Opthamology, Anesthesiology and Dermatology — offer more controllable and fewer hours and less stress. Those things matter a lot perhaps especially to women, who are getting to be th majority of medical students.

  9. Given the condition that specialty care has a guaranteed higher income, almost every doctor is going to want go into it, even if we give them free money. The root of the problem is whatever is causing that condition to be true. Concentrate on fixing that before giving bags of money to the intellectual elite.

    The economics of medicine are messed up enough as it is.

  10. Barry,
    You’re absolutely correct. But the glut is that of foreign Ph.Ds. US nationals have long seen through this scam, and voted with their feet. There are fewer of them every year.

  11. Discussions of this proposal that rely on assertions about the current population of doctors are a priori not very useful. The big-money nature of getting a medical education has created a culture that is largely antithetical to serving patients well. The timescales we’re talking about for reform, however, mean that roughly half of today’s doctors will be retired by the time even the current set of changes is fully established.

    But it’s been a truism for 30 years at least that most medical school entrants are going there to make serious money rather than to “help people” or whatever a semi-altruistic, merely careerist motive might be. (At my university, pre-med courses were uniquely notorious for books removed from the library, pages razored out of books before returning.) And if pre-med doesn’t weed out all the wimps, the prospect of residency, with lives on the line for endless 100-hour weeks, will get the rest of them. Someone who simply wants to treat sick people and make a decent living isn’t going to want anything to do with that process, especially when the outcome of a misstep at any point in the process (even allowing for the chancy possibility of tuition-repayment plans) is crippling lifelong debt in a country that does not treat its bottom 50% well.

    So free medical education is probably a necessary but not sufficient step to reforming medical culture in the US. Sure, it won’t do everything, but by reducing the stress of the immediate requirement to make lots of money (and thus the requirement to pay doctors lots of money) it could make a lot of other systemic reforms possible.

  12. (Warren): “Malcolm’s idea that what we really need is barefoot doctors is so … Maocolm.
    That was not my recommendation. Just suppose we took final exams from the full 8 year sequence of pre-Med and Medical School courses and allowed students to test out. Set the fee per course at the marginal cost per exam of grading exams. Anyone who passes gets full credit. School is a means, not an end in itself. Clearly, policy makers could reduce the cost of school by reducing the amount of seat time required to get your Physiology BS and MD. School is a means to the various ends of school employees, and it serves their interests to sustain the false equation “education” = “school”. I have said before, if the US tax- subsidized K-PhD school system is not an employment program for public-sector workers, a source of padded construction and supply contracts for politically-connected insiders, and a venue for State-worshipful indoctrination, why cannot any student take, at any age and at any time of year, an exit exam (the GED will do for the K-12 part) and apply the taxpayers’ school subsidy toward tuition in later coursework or toward a wage subsidy for OJT?
    The cost of school includes the opportunity cost to students of the time they spend in school and the opportunity cost to society of the innovation in educational techniques that a competitive market in education services would generate.

  13. I’m amazed that anyone could use the word “only” to describe the obligation to pay nearly $30 per day, seven days per week, in after-tax income for the next 30 years.

  14. If you have to choose between subsidising medical students and expansion, I’d take expansion any day.

    It does does look as if the problem is a shortage of GPs rather than specialists, so a targeted programme of debt forgiveness for primary care physicians (and nurses!) could be worthwhile. In Britain the NHS just pays GPs well.

  15. Given that the American doctors have the tightest, best funded union that has ever existed, the possibility of any change is total nonsense unless the doctors themselves push change.

    That is not going to happen.

  16. Given that the American doctors have the tightest, best funded union that has ever existed, the possibility of any change is total nonsense unless the doctors themselves push change.
    Add the consideration that unionized college faculty (NEA, AFT) are well-paid, articulate, and have abundant free time, and the taxpayers’ chances in this contest indeed look hopeless. Still, budget problems in most US States and at the Federal level will compel change. Do you expect to see the college professors who contributors to this site advocate against their immediate financial self-interest?
    That is not going to happen

  17. (James): “It does does look as if the problem is a shortage of GPs rather than specialists, so a targeted programme of debt forgiveness for primary care physicians (and nurses!) could be worthwhile.
    Anything but reduce the tax-generated revenue stream which flows into the bank accounts of government employees. We can’t allow that.

  18. Physician debt load due to loans is shocking when you look at the raw figure, but if you look at the ratio between total loan debt and annual (or lifetime) income, you see that there are many occupations that have the same ratio, or even a worse one.

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