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Will free medical school lead to more primary care physicians?

Ken Budd , Special to AAMCNews
December 3, 2019

As schools move to reduce or eliminate student debt, some hope that more students will choose primary care specialties. Here’s why that might not happen.

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Confetti fell on beaming medical students at a Cornell University event in September. The occasion: Weill Cornell Medicine Medical College announced that it would eliminate debt for all medical students who qualify for financial aid, thanks to a new $160 million scholarship program.

“From now on, no more student debt,” dean Augustine M.K. Choi, MD, declared to cheers.

With its grateful students and proud donors, Cornell became the latest institution to reduce or eliminate medical school debt. In April 2019, Washington University School of Medicine in St. Louis committed $100 million to scholarships that will allow up to half of its future medical students to attend free of tuition (other students will receive partial tuition support). Columbia University Vagelos College of Physicians and Surgeons launched a program in July 2018 to replace loans with scholarships for students who qualify for financial aid (about 20% of medical students will receive full-tuition scholarships). At University of California, Los Angeles, David Geffen School of Medicine, the David Geffen Memorial Scholarships cover the annual cost of education for up to 20% of students. And in the most ambitious, most highly publicized move, the New York University School of Medicine announced in August 2018 that it would offer full-tuition scholarships to every medical student, regardless of merit or need.

Much of the NYU coverage — which included stories from NBC, CNN, NPR, and many more — focused on an enticing idea: that eliminating debt would spur more students to pursue careers in primary care. The median debt level for students who take out loans is $200,000 and, the thinking goes, that debt level forces them to choose higher-paying specialties. But there’s a problem with that theory. A 2014 study in the Annals of Family Medicine found that while “high educational debt deters graduates of public medical schools from choosing primary care, [it] does not appear to influence private school graduates in the same way.” And most of the institutions offering debt- or tuition-free programs are, yes, elite private institutions.

The other issue? The AAMC’s data show that debt has little influence on specialty choice.

“That is consistent year after year,” says Julie Fresne, AAMC senior director of student financial and career advising services. “When you ask graduating students what most influences their choices, specialty content and personality fit are always at the top, and debt is always at the bottom.”

“We got a lot of press for the hope that this will impact primary care, and that's great, but it’s not our primary mission here. Our primary mission is to allow the very best physician workforce to come out of this. It allows students to pursue career choices based on their passion, based on their fit for the field, based on whether they would be a great surgeon, a great internist, a great psychiatrist.”

 Rafael Rivera, MD, New York University School of Medicine

Even officials at NYU say that the tuition-free decision was primarily about letting students pursue their passions.

“We got a lot of press for the hope that this will impact primary care, and that's great, but it’s not our primary mission here,” says Rafael Rivera, MD, NYU’s associate dean for admissions and financial aid. “Our primary mission is to allow the very best physician workforce to come out of this. It allows students to pursue career choices based on their passion, based on their fit for the field, based on whether they would be a great surgeon, a great internist, a great psychiatrist — you name it.”

So will eliminating debt really lead to more primary care physicians? Will it inspire more low-income students to enter the field? Or is that just wishful thinking?

The problem of perception

By 2032, the United States could experience a shortage of 21,100 to 55,200 primary care physicians, part of an overall projected shortage of 46,900 to 121,900 physicians, according to data published in April 2019 by the AAMC. In rural areas, the problem is already acute: Rural Americans are almost five times as likely to live in a county with a shortage of primary care physicians compared to urban and suburban residents, a 2018 UnitedHealth Group report found (44 million Americans — 13% of U.S. residents — live in areas with a primary care shortage).

It’s not due to lack of opportunities. In 2019, the National Resident Matching Program offered a record number of primary care positions, yet the percentage filled by students graduating from U.S. MD-granting medical schools was a new low. Of 8,116 internal medical positions that were offered — also a record high — just 41.5% were filled by U.S. students; a majority of spots went to foreign-trained physicians and U.S.-trained osteopathic physicians.

“When you ask graduating students what most influences their choices, specialty content and personality fit are always at the top, and debt is always at the bottom.”

Julie Fresne,  Association of American Medical Colleges

“It is clear that more and more U.S. physicians are entering practice as sub- or sub-subspecialists,” noted an article in the February 2019 issue of The American Journal of Medicine. “At present, more than twice as many U.S. medical school graduates (MDs and DOs) are choosing to be sub- or sub-subspecialists as those choosing family medicine.”

One issue in attracting more U.S. medical students to primary care? Perception.

“If you say you’re interested in primary care, the first thing people are probably going to say is, ‘You’re too smart for that’ or ‘Why do you want to waste your career?’” says Robert M. Centor, MD, the former regional dean of Huntsville Regional Medical Campus of the University of Alabama School of Medicine. “If you’re exposing students to people who look down their nose at primary care and then expect that they're going to go into it just because they don’t owe money, you’re sort of fooling yourself.”

To help counter that perception, third-year students at UAB’s regional campus in Huntsville spend one month with primary care physicians. UAB also provides scholarships to pay for students’ fourth year if they enter family medicine.

That approach holds promise: In a 2013 study published in Academic Medicine, researchers surveyed 1,500 students at 20 medical schools about the role of medical school culture in primary care career choice. Not surprisingly, they found that schools that offered positive experiences in primary care clerkships increased the likelihood that those students would choose primary care. That same study, though, found that only 8% of specialty choice was affected by medical school factors.

The biggest benefits

So how will debt-free programs at U.S. medical schools affect the workforce? It’s too soon to say, notes Fresne, but big beneficiaries will include the institutions themselves. In addition to generating publicity, the programs will almost certainly increase student applications. It’s a high-profile advantage in a competitive academic marketplace. But it could also attract a more diverse pool of students.

“Part of NYU’s purpose was to attract a broader range of applicants, particularly those from historically underrepresented backgrounds,” says Fresne. “That was one of the hopes: That by offering free tuition to everyone, it would encourage students who might otherwise be dissuaded by the cost.” That’s already happening at NYU, which has seen not only an increase in applications, but in applications from minority and low-income students, says Fresne.

“A potential upside would be to increase students who were otherwise put off by the cost to apply to medical school,” she says. “That’s the real upside, and that’s a real benefit if it happens.”

“I’m speaking very globally, but I think that students who have experienced disadvantage tend to have more empathy for disadvantaged populations. I think they tend to identify with primary care more and identify with the altruistic impetus for choosing medicine.”

Julie Phillips, MD, Michigan State University College of Human Medicine

If more low-income students enter medical school, that could indeed result in more students studying primary care. Students from lower-income families have more debt but are also more likely to enter primary care specialties, according to a 2014 Annals of Family Medicine study led by Julie Phillips, MD, an associate professor of family medicine at Michigan State University College of Human Medicine.

“I’m speaking very globally, but I think that students who have experienced disadvantage tend to have more empathy for disadvantaged populations,” says Phillips. “I think they tend to identify with primary care more and identify with the altruistic impetus for choosing medicine.”

 Another benefit? Eliminating debt may reduce anxiety and burnout, Phillips says.

“I think they are doing a wonderful thing for their students,” Phillips says of NYU. “But I don't know if that is enough to make a big difference in the physician workforce.”

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