Recently, I listened to a Sound Medicine broadcast where the discussion was a plan for making primary care more attractive to medical students by eliminating medical school tuition. There was a similar article in the New York Times appearing on May 29th where Drs. Bach and Kocher lay out a plan for making primary care more attractive. They proposed a plan to make medical school tuition, which averages $38,000 per year, 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 (borrowing instead), $50,000 on average. It was mentioned that 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 an intriguing idea and perhaps worth the discussion. But I am sure that someone in a specialty area poised to be burdened the most under such a plan may have significant reservations. Neurosurgeons, for instance, have perhaps the longest training of any specialty. The majority of neurosurgical residencies are 7 years and with a couple of years of fellowship training the burden for future neurosurgeons could be upward of $450,000 under the current proposal at $50,000 a year.
I would imagine that you could highlight several other specialty examples in a similar light, but you could also argue that their earnings potential will outweigh the burden. In the above 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. It can be said and speculated that while the average income for a primary care physician is more homogenous, 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.
By making medical school tuition-free, is it going to enough of an incentive to consider primary care? I am not so sure. In my opinion, with the specialty areas (especially the most lucrative specialties), I’m not sure the incentive will be enough. Consider the numbers, based on some of the reported median specialty and primary care incomes ($325,000 for specialty areas and $190,000 for primary care respectively), it may not be totally realistic if you have a 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 loan guarantee by the government used by the pediatric neurosurgeon and they are 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
This example shows that there is still incentive for medical students and residents to choose a high paying specialty area. So, I have serious doubts making medical school free will significantly bolster the future of primary care, but it is an intriguing idea.