Free medical school may not help the future of primary care

In an op-ed appearing in the New York Times on May 29th, Drs. Bach and Kocher lay out a plan for making primary care more attractive to medical students. They propose the following: “Under our plan, medical school tuition, which averages $38,000 per year, would be waived. Doctors choosing training in primary care, whether they plan to go on later to specialize or not, would continue to receive the stipends they receive today. But those who want to get specialty training would have to forgo much or all of their stipends, $50,000 on average. Because there are nearly as many doctors enrolled in specialty training in the United States (about 66,000) as there are students in United States medical schools (about 67,000), the forgone stipends would cover all the tuition costs.”

It’s novel and I think worth discussion.

But sitting in a specialty poised to be burdened the most under such a plan I have some reservations. Neurosurgeons have perhaps the longest training of any specialty. The majority of neurosurgical residencies are 7 years and with fellowship training the burden for future neurosurgeons could be upward of $450,000 under the current proposal at $50,000 a year.

There are a number of other specialties as well, where the average income falls well short of the median cited in the op-ed. In a specific example, neurosurgeons who go on to do 1-2 years of fellowship in pediatric neurosurgery take a significant pay cut as compared to those neurosurgeons who go into practice straight out of residency and treat adults. Or consider the infectious disease specialty where the average income is hardly more than that of a primary care physician but require extra fellowship years. The point is that while the average income for a primary care physician is has a shorter distribution and is more homogemous, there is great variability in income for specialists. The proposal is likely to drive medical students and graduating residents, now forgoing primary care, out of certain specialties including infectious disease, physical medicine and rehabilitation and many pediatric surgical specialties to name a few.

My second contention is that, for the most lucrative specialties, I’m not sure the incentive will be enough. Let us consider the numbers given in the op-ed concerning the median specialty and primary care incomes. They cite $325,000 and $190,000 respectively. It may not be totally realistic but will serve my point if we have a pediatric neurosurgeon earning the former and a primary care physician earning the latter.

Let’s say the pediatric neurosurgeon takes 8 years of training and owes $400,000 at the end. The primary care physician does 3 years of training and owes nothing. Assuming some level of government guarantee of the loans used by the pediatric neurosurgeon and he or she is paying them off over 15 years at a 6.8% rate.

Over a 20 year period (from the time the primary care physician enters practice after completing his or her free training to the time the pediatric neurosurgeon is finished paying his or her loans) the gross numbers stack up like this:

Primary care physician 20-year earnings
20 years x 190,000 = 3,800,000

Pediatric neurosurgeon 15-year earnings
Remember the specialist will be in training for five years while the primary care physician is out earning.

15 years x 325,000 = 4,875,000 – 640,000 loan payments = 4,235,000

On the sum there is still incentive for medical students and residents to choose a high paying specialty.

Finally, I’ve discussed this before, but self reported surveys continue to show that medical student’s decisions concerning primary care are only partly related to future earning potential and other factors are more important. This plan doesn’t address the appearance problems that primary care suffers and the expectations of health care in this country which, in addition to the comparatively low earning potential, make primary care unattractive to American medical students.

I am a strong proponent of strengthening primary care. The reality is we need to normalize primary care and specialist reimbursement and dramatically reduce the number of specialist training positions in order to force a more tertiary health care system more in line with the rest of the western world.