The high cost of medical education: Who should be trained to become doctors?

Medical school is expensive. College, for that matter, is expensive, but medical school is more expensive. According to a consultant website, based on data from the Association of American Medical Colleges,

On average, medical school tuition, fees, and health insurance during the 2019-2020 academic year ranges from $37,556 (public, in-state) to $62,194 (public, out-of-state). Average private school figures come in just below public schools for in-state and out-of-state students, at $60,665 and $62,111, respectively.

That is a lot of money. Per year. Multiply by 4 years. Add books, living expenses (you know, food, rent, like that), and miscellaneous other costs, and it is not surprising that the average medical student graduates a quarter-million dollars in debt.

Of course, if your family is very wealthy, it is not a problem. But given that the mean household income in 2019 was about $63,000, just about a year’s tuition in many of these schools, it would be a stretch for those families to pay such expenses. Indeed, at the 75^th%ile ($113,000) it would be more than half of gross income, and I doubt that even those at the 90^th%ile ($184,000) would find it easy to support a medical student. As medical schools (hopefully) strive for increasing diversity, by income of family of origin, race and ethnicity, and geography (rural vs. urban), this cost becomes a bigger and bigger issue, much more than when only children of the elite (including physicians) attended medical school.

Of course, these students are going to be doctors, on average the highest-paid profession in America. According to most sources, including this one based on a survey on the doctor site “Medscape”, even the lowest-income medical specialties would be easily in the top 10% of income, and several way into the 1% ($475K). (Indeed, the income for those highest-paid specialties seems to be lower than those I have known, who not uncommonly make over $1M.) But even using those numbers, there is a several-fold difference in being in, say, Pediatrics ($212K) or Family Medicine ($219K), and Orthopedics or Plastic Surgery ($500K). It is certainly understandable that, at such high debt loads, the greater income of a high-paid specialty seems more attractive, and may further decrease student choice of primary care (lower paid) specialties. (At a difference of almost $300K a year, a plastic surgeon could expect, over a 30 year career, to earn almost $9M more than a pediatrician! That is real money!)

In addition to their own cost of living, often having to help support, rather than be supported by, a family, is another reality for those who are in medical school and later in residency training. This is a major focus of an important NY Times article on the topic published November 26, 2019, “I have a PhD in not having money”, about the challenges that low-income medical students have, and by extension the challenges for medical schools that really might wish to have a diverse class. The challenge is not only for minority students, who on average come from families with significantly less wealth and income, but across-the-board for students from families with incomes that are not in the higher ranges. It includes most students from rural areas.

In fact, there is an enormously close correlation between students from areas and population groups which are most needed in medicine and those most poorly represented in medical school. In some ways this is a tautology; since doctors are likely to practice in communities like those in which they grew up, poor, minority, and rural communities which are dramatically underrepresented in medical school are the least served. Also, the higher income earned by subspecialists (and, let us not forget, the explicit and implicit encouragement by faculty for students to enter these fields) means that they can practice only in “major medical centers”, places with populations big enough to support a need for that specialty and with hospitals that can provide them a place to practice. Thus, fewer medical students train to be family doctors, who can practice in and are much needed in rural areas, exacerbating the existing reticence of students brought up in cities and suburbs to relocate there.

The Times article is good, but it focuses almost entirely on the issue of paying for medical school. Clearly this is incredibly important. The students featured in it say things like “You have to decide, do you use your loans for a study aid or for a rainy-day fund in case someone at home gets sick?...I haven’t had dental insurance in two years. When tuna is on sale for 80 cents a can, I go buy 30 at CVS,” and “There’s this idea that because we’ll all be doctors one day, the loans don’t matter and it’ll all even out. But that doesn’t account for day-to-day expenses now, like if my mom texts me asking for help.” This begins to get at the larger issues, that it is not only the question of how to pay for medical school, but a variety of related things that characterize students from lower-income backgrounds.

Students from poor families tend to live in poor neighborhoods. Because of the US’ regressive system of financing public education, which depends a great deal on local funds, the quality of the education is likely to not be as good. I refer not to the skill or dedication of the teachers, but the resources to provide additional instruction, instructional support, and special classes such as Advanced Placement. Similar conditions apply in rural areas. Where the student from an upper-middle-class suburb may have many advanced placement classes, especially in sciences, by the time they graduate from high school, and have learned disciplined study habits and been given lots of role models, students from less-well-off school districts are much less likely to have. In a rural area, there may be one science teacher who is shared by more than one district. This gives the more privileged students a leg up before they even start college. Before they start high school. Before they start school altogether.

Then, disadvantaged students have to compete on academic criteria with those from wealthier backgrounds on Medical College Admissions Tests (MCATs), a type of test for which those others have been prepping for years. Medical school faculty on admissions committees often can’t – or don’t care to -- distinguish between the ability to perform well academically and the potential for becoming a good doctor if given the right support. A child of a well-to-do family who has had not only excellent schools but tutors and other support when needed, and who looks like the children of the MD and PhD faculty, might be “hitting on all cylinders” to do as well as they are, while the child of a farm worker or motel cleaner in a rural area may have unlimited untapped potential.

And, yet, it is still more. Producing more doctors from the top income levels means that the communities like those they come from, which already have enough or more than enough physicians, will become more overserved; that the specialties that exist in abundance in those locations will have more members. And lower income communities, rural communities, minority communities, communities that need primary care doctors, will remain underserved. And the health of the US population will be further jeopardized.

Some schools, like Mount Sinai in New York, have eliminated tuition. That is a good thing for the students who are admitted, especially for those who are from low-income families, but it does not explicitly choose students from low-income families. That is a major flaw; it mostly serves to further advantage the most-highly-advantaged students who comprise the bulk of the class. To care for the American people, medical schools need to admit and train physicians who “look like America”, for real, not a few token students in a class mostly comprised of scions of the top 25% or even 10%. This means that the first pass for admission should be demographic – students who come from low-income, from rural, from minority communities, students who don’t look like most current students, students who don’t look like the children of medical school faculty and their neighbors. If there are to be some slots reserved for those who are from privileged backgrounds and overserved communities, they should be for those who are most likely to practice in areas and specialties unlike those in which they were raised, those who have a demonstrated history (not an essay expressing intent) of real service. Were they in the Peace Corps, or AmeriCorps, or Teach for America, or something that actually required extended work and sacrifice?

Those students who are admitted will need maximal financial help, scholarships as much as loans, and even more educational support, so that they can reach their full potential and be able to become the doctors who can help their communities if they choose to return (not all will but they are much more likely to than others). That is what medical school funds should be spent for.

And we need it to start soon. It will be 30 years before currently accepted medical students replace the existing doctors, and we shouldn’t have half-measures.