It’s well known that there is a shortage of primary care physicians which is only going to get worse over time.

To address this problem, Dr. Peter Bach, the director of the Center for Health Policy and Outcomes at Memorial Sloan-Kettering and Dr. Robert Kocher, a guest scholar at the Brookings Institution, propose making medical school free. They argue that medical students would be more likely to choose primary care over specialties if the debt burden of medical school was eliminated. To pay for this, residents in specialty training would, “forgo much or all of their stipends, $50,000 on average.” Residents in training for primary care would continue to receive their stipends as usual.

Though this sounds like an interesting proposal, in reality it wouldn’t work. First off, this is unfair to specialists in training. I’ve gotten into numerous heated discussions about how unfair it is that specialists are compensated much more generously than primary care physicians. That doesn’t mean that I think we need to stiff residents and fellows who go into specialty training; they deserve to be paid for the work they do. Our problem isn’t that any given person becomes a specialist; it’s that too many people become specialists instead of primary care physicians. A better solution would be to decrease the number of spots for specialty training.

Second, the disparity of pay between specialties and primary care wouldn’t change so the economic incentive to go into a specialty would be intact. If the debt of student loans seems manageable by entering a specialty, wouldn’t any debt incurred while training to be a specialist be just as manageable, if not more so? Between moonlighting, family support, and physician loans supporting oneself during specialty training for the promise of a bigger payday is an ever better bet than accruing medical school debt hoping that you can pay it off. In fact, this seems to tilt the scales towards selecting those from higher socioeconomic backgrounds for specialty training since they would have the greatest potential for family economic assistance during specialty training.

Lastly, the authors acknowledge that specialists have been successful over the years in preventing any decrease in the disparity of pay between primary care and specialists. What makes them think that specialists would all of sudden be okay with allowing their trainees to be underpaid or unpaid for their training?

So what do I think we should do? Well, to address student debt we currently have national and state programs that pay off debt for those who enter primary care in underserved areas. We should extend this program to include all physicians who are actively practicing primary care. Loan repayment of $15,000 a year would make the average physician’s $155,000 of debt disappear in 15 years (assuming a 5% interest rate). Such an investment in primary care would certainly be worth the expense. Furthermore, since this is money is unrelated to compensation, it would be outside the political theater that surrounds any change to Medicare. (Medicare sets the compensation for medical services which in turn determines the compensation of all physicians). Decreasing the wage disparity between primary care and specialists is too large a topic to cover here. Suffice it to say, if we’re serious about boosting the number of primary care doctors, we’ll need to address this issue head on.

I applaud Drs. Bach and Kocher for attempting to address the worsening shortage of primary care physicians. But, to really deal with the problem we need to attack the root cause of the primary care shortage, the burden of student debt combined with the large pay disparity between primary care and specialists.

Nilesh Kalyanaraman is a physician who blogs at Progress Notes.

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