Sunday, August 26, 2018

Free tuition in medical school is only one step toward producing the doctors America needs

The NYU School of Medicine shook the world of medical education recently by announcing that tuition would be free. The NY Times article about it says that ‘Rising tuition and six-figure loans have been pushing new doctors into higher-paying fields and contributing to a shortage of researchers and primary care physicians.’ Certainly, it is easy to understand that a $55,000 per year tuition bill is going to be way beyond the ability of most medical students and their families to pay, and that a total indebtedness that is often over $250,000 may well affect the specialty choice of medical school graduates. While physicians in any specialty make far more than the average American, compound interest makes the payments a lot more than $25,000 a year for 10 years; often more, indeed, than that average American income (think about the payments on a $250,000 home loan, which usually has a lower interest rate). This may tip the balance between choosing betwee, say, family medicine or anesthesiology, when the latter choice can be expected to result in an additional $7 million in lifetime income.

The other, presumably obvious, impact of free tuition could be the ability of the school’s admissions committee to take more students from lower income families than they currently do. Note “lower income” is not necessarily the same as “low income”, as 80% of medical students now come from the top 20% of income. And, yet, they still have a lot of trouble paying for school, tuition plus the Times’ estimated $29,000 a year in living expenses (in NYC). It is not necessarily true that ability to pay is a significant criterion in the admissions decisions of medical schools, but rather that there are confounders. A big one is that being from a high-income family is associated with having the higher grades and test scores that are so valued by medical school admissions committees (probably especially those, like NYU, that are very interested in producing MD/PhDs and other laboratory researchers). Free tuition, however, might mean that those students from lower-income families who do gain admission will be under less financial pressure to take paying jobs while in school (a really bad idea when trying to succeed in medical school). In addition, those students who have started their own families or whose families of origin have counted on them helping to support them, would have one big less thing to worry about.

We definitely need more family physicians and other primary care doctors than we are producing now (and NYU has produced one of, if not the, lowest number family physicians of all US medical schools). We also need far more students from lower-income and underrepresented minority and rural backgrounds. The reason is not just for ethical or moral, or making up for past practices. It is directly about providing quality healthcare to all the American people, because physicians are most likely to practice in settings like those in which they grew up and feel most comfortable. Thus, students from upper-middle and upper income, primarily white (and Asian) suburbs are most likely to practice in those settings – which are precisely those least in need of more doctors. Students from rural or low-income or minority communities are much more likely to practice in such communities, and these are the places most in need of more doctors. Of course, the correlation is far from 100%, but the trend is overwhelming. Thus, to the extent that free tuition can increase either of these goals, it would be a great thing.

So what is the problem? Well, it is far from certain that free tuition will lead to these desirable outcomes. This point is made by family physician (and NYU medical school graduate) Kenny Lin, MD, in his Common Sense Family Doctor blog. Although Dr. Lin’s 2001 class had only four graduates entering family medicine, it was a larger number than any class since. He points to the fact that NYU has never had a Department of Family Medicine (one of the few such schools, almost all of which are “elite” private and on the East Coast). He also notes that in terms of producing other primary care doctors (general internists and general pediatricians), NYU has also done very poorly.

More important, Dr. Lin cites a study published in the JAMA Network by Grischkan, George, Chaiyachati, et al., that demonstrates that students entering family medicine (one of the lowest paying medical specialties) have a higher average debt load than those entering fields such as radiology, dermatology, and ophthalmology. He writes
These findings suggest, paradoxically, that physicians with the highest debt burden are preferentially choosing a specialty with among the lowest income expectations - why on earth would that be? What it says, actually, is that students from less well-off backgrounds are more likely to be attracted to primary care in the first place.

This is a very important point. Dr. Lin, focused on the critical issue of producing more family physicians and primary care doctors, believes that eliminating tuition and thus taking students from more diverse backgrounds “will likely have a small, but measurable, positive effect on primary care.” He urges that NYU and other schools increase their “pipeline” programs to help students from less advantaged background gain the skills that they need to be both admitted to and successful in medical school. I agree, but I would go beyond that.

Medical schools should train the doctors America needs. This means fewer subspecialists, and more primary care doctors. This means a smaller percentage of doctors practicing in the suburbs of big cities, and a larger percentage practicing in rural areas and underserved inner-city communities. This is not going to happen if we keep taking the same students we currently do, no matter how nice they are, no matter how high their grades are, and no matter how much they are like (or often are) the children of the faculty of the medical school. If you don’t think this is important, a recent paper from the National Bureau of Economic Research by Alsan, Garrick, and Graziani titled “Does Diversity Matter for Health? Experimental Evidence from Oakland” (reported in the Times article “The Secret to Keeping Black Men Healthy? Maybe Black Doctors”) demonstrates that it does: a significantly higher percentage of black men received important tests, took medicines, and made lifestyle changes when advised to by a black doctor rather than a white or Asian one. Importantly, this comes from more than a knee-jerk reaction to the race of the physician; it has a lot to do with how they were treated. While the ‘white and Asian doctors often wrote comments like “weight loss,” “tb test” and “anxiety” — cryptic notations that referred to medical recommendations…black doctors often left more personal notes, like “needs food, shelter, clothing, job’. This goes beyond race, and suggests that both our overall medical curriculum focuses too much on the disease and not the person, and further that minority physicians may be more likely to realize that it is a person who needs to be treated, and identify the social determinants of health.

Indeed, Elisabeth Rosenthal, the editor of Kaiser Health News, argues in an Op-Ed in the Times that medical school should be free only for those who make a firm commitment to entering specialties and practicing in areas that have real need:
…if a student chooses to become an ear, nose and throat surgeon in suburban New York or a private cardiologist in Miami, fine. He or she can pay back what has been borrowed. But if that doctor chooses to deliver babies in rural Oklahoma or practice pediatrics on the South Side of Chicago, then he or she should get to keep every penny of salary.

I agree, and believe that to make this likely, medical schools, both private “elite” schools like NYU, and certainly state-supported schools, need to take a much higher percentage of students from the lower half of the family income scale, from rural areas and from groups that have been historically underrepresented in medicine. And not just a few more, not just a pilot program with 2% or 5% or 10% of the class. These programs must be far more extensive. The entire class should be composed either these groups of students or of students who, while perhaps from wealthier, whiter, more suburban backgrounds, have demonstrated an extended commitment to service to others. Extended, like the Peace Corps, or Teach for America, or VISTA, or working abroad for years in service programs, not a car wash fundraiser one Saturday.

Some, and sadly this may include many in the administration of medical schools, particularly “elite” ones, will say this can result in the exclusion of the “best” applicants. It may, in fact, lead to the exclusion of some of those with the highest grades, and may even require additional work on the part of the faculty to help students with less rigorous academic preparation. Or, perhaps, elimination of much of the nonsense memorize-detail coursework of the pre-clinical curriculum. But while “best” can mean many things, if the definition is not “most likely to make a positive difference in the health of all the American people” it needs to change, and soon.

Free tuition, at NYU, or other private schools, or state-sponsored schools, may be a terrific idea, and one that should be widely imitated. But it is only one part of an overall strategy, including changes in the selection of applicants, the curriculum of the schools, and the reimbursement of primary care, to significantly change the kinds of doctors that are produced so that they meet our nation’s needs.


Kollisch said...

When Dr. Rafael Rivera, a radiologist, the NYU administrator who spoke for NYU, was interviewed on National Public Radio, he was asked if NYU expected more students to choose FAMILY MEDICINE careers. He answered that students would now be more able and likely to choose such less-well-paid specialties as PEDIATRICS and RESEARCH. He dodged the question.

johnjose said...

You touch on some of the issues that are necessary to really make US medical schools socially responsible - and even state institutions are unwilling to state that as a significant part of their social mission and be held accountable for it. Put students from socioeconomically disadvantaged families in medical school for free and don't require that schools have an obligation to train the proper workforce for the country and those students will go the same direction that all the other students are going. Make hospitals and departments who train subspecialty fellows pay for those fellows rather than take it from Medicare and we will see a mysterious decrease in subspecialists. Free tuition in exchange for two years of social service, pay for residents through the first three years but not after PG 3, pay all physicians with a salary and there might be a shift in the right direction.

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