Institute free medical school tuition to increase the number of primary care physicians and decrease the costs of health care; and do it now as it takes time to qualify, apply, and train new doctors. This is the message of the May 29, 2011 New York Times article in the Sunday Opinion section written by two reputable physicians, Drs. P. Bach and R. Kocher, both with laudable credentials in health care reform and politics. Their simplistic solution and hypothesis, however noble, is confusing.
The premise of the article is that more physicians graduating from medical school need to enter primary care practices instead of specialization. Drs. Bach and Kocher propose accomplishing this goal by eliminating the financial burden of medical school tuition. The authors state that young doctors specialize because specialists make more money than primary care physicians and these young doctors need to make more money in order to repay the loans they accumulated during medical school. Therefore, they hypothesize, if medical school was free, the number of medical school graduates entering primary care would increase.
Free medical school tuition would certainly decrease the financial burden, but I believe that it is unlikely to be sufficient to steer medical students to enter primary care practices. The authors of this referenced article further propose that the primary care resident would continue to receive a stipend while the trainees going into other specialty residencies would forgo their stipends. Even if medical school tuition were free, living without a stipend after four years of graduate school seems too severe of a burden and would probably result in young doctors forced to moonlight, which could jeopardize their specialty training.
It is untenable to argue that providing a stipend for only primary care training would result in an increase of primary care practitioners. Young doctors choose specialties for various reasons; while income potential may be one, it is not the sole driving force. Pediatrics and psychiatry, for instance, are specialties that are not among the highest paying specialties. However, both require physicians to be dedicated to their specialty despite having loans to pay off following their medical training.
Subsequent to training, a career as a primary care physician is hard. Some primary care physicians choose to work in hospitals and are referred to as hospitalists, but the majority work in out-patient settings. While hospitalists have set hours and benefits from working in a hospital, private practice primary care physicians must be available 24/7, 365 days a year.
To achieve the quality of life expectations of recent trainees, young doctors will often work in a group practice and/or part-time. Patients receiving care at a group practice need to feel comfortable with all the physicians in the group, not just one. These group practices also often employ physician extenders, e.g., Physician Assistants and Nurse Practitioners. Patients typically see physicians and physician's extenders interchangeably, which makes access to health care easier. Reimbursement at Medicare fee levels will not be sufficient to support the rent and malpractice costs and quality of life expectations of these young physicians. An unfortunate outcome of free medical school tuition, however, might be the decrease in value and stature of the primary care physician. While future physicians would probably have job security, they may not have the same prestige or income-earning potential as in the past.
Should prestige and compensation of physicians become diluted, free medical school may be the only way to have college graduates even consider selecting medical school. One could argue that all postgraduate education, e.g. law school, engineering, MBA, etc., should be free. Why make only medical school tuition free? If all graduate schools were free, then the playing field for college graduates would be more equitable.
Since many primary care physicians are needed, free medical school tuition and a paid residency may be worth considering, but I believe that other options and incentives will also need to be created. Otherwise, many of our brightest youngsters will pursue careers in finance, business and technology instead of going into medicine. Furthermore, it is conceivable that those excellent, potential pre-med students may forgo graduate school and become (for example) an automobile mechanic instead of a physician. As an automobile mechanic, their income will start at a younger age, their hourly compensation may be greater, and a successful outcome of their diagnostic and technical efforts may be more appreciated than if they become surgeons.
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