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Why Aren’t More Students Applying To Medical School?

Did you know that there are only two applicants for every place in U.S. medical schools?

In Canada, surprisingly, close to four students apply for each opening. The training in the two countries is very similar; indeed, the Association of American Medical Colleges (AAMC) accredits medical schools in both countries.  And, in the U.S., at the high-end, physicians  can hope to earn far more than Canadian doctors.

Why then do so few Americans apply to medical school?

The answer is that we have priced a medical education well beyond the reach of most middle-class students.  In 2004, tuition and fees at a public medical school averaged $16,153. Students who attended a private school paid $32,588 according to a 2005 study published in The New England Journal of Medicine.

The author, Dr. Gail Morrison, Vice Dean for Education at University of Pennsylvania School of Medicine, tacks on $20,000 to $25,000 a year for living expenses, books and equipment to calculate that the total cost of four years of medical education comes to a heady $140,000 for public schools and $225,000 for private schools.  I’d add that, in many American cities, students would be hard-pressed to cover rent, food, clothing, utilities and transportation for $20,000 a year—let alone books and equipment.

This helps explain why 60 percent of all medical students come from the wealthiest one-fifth of all U.S. families. Another 20 percent come from families lucky enough to be on the fourth step of a five step ladder.

In Canada, by contrast, a medical education is much more affordable. In Quebec province, for example, students paid a piddling $2,943 in tuition last year—though admittedly, this deal was available only to Quebecers. But elsewhere in Canada, tuition averaged just $12,728—about 25 percent less than Americans were paying to attend a public medical school back in 2004, and about 60 percent less than they laid out to attend a private school.

As a result Canadian students are much more open to becoming primary care physicians, even though they know that internists earn lower salaries than specialists. Granted,  in Canada the government determines the ratio of residencies for primary care versus specialties, but students are willing to fill the spots. Canada is now close to its goal of having 50 percent of its physicians practicing primary care.

In the U.S., where the Association of Medical Colleges strongly supports free choice of specialty for students, only about one-third of medical school graduates become primary care physicians. This is understandable: the average U.S. student leaves med school with $130,000 in debt. Moreover, unlike law or business students who enter the workforce immediately after graduation and can begin to pay off their debt, the average medical school graduate spends an additional three to six years in postgraduate training programs while interest continues to pile up. Meanwhile, he is painfully aware of salary differentials: recent numbers show the average family doctor earning $146,000 while the typical invasive cardiologist brings home $400,000. And at the beginning of his career, a family doctor can expect to earn much less—perhaps $100,000, before taxes.

Little wonder then, that the share of medical students pursuing careers in primary care has plummeted from 49 percent in 1997 to 37 percent in 2003; over the same span, the number gravitating toward careers in radiology, orthopedics, ophthalmology, and dermatology has sky-rocketed.

Yet we don’t need more dermatologists. But we do need more primary care physicians. Decades of research done at Dartmouth University show that when Americans see more family doctors and fewer specialists, outcomes are better, in large part because patients receive more preventive care and ongoing management of chronic diseases before they become serious. (I have previously written about this issue for Dartmouth.)

But it’s not just that the high cost of med school is leaving us with too many specialists and too few generalists. Spiraling tuition also explains why middle-class and working-class Americans are not well-represented in the profession. Keep in mind that only 20 percent of physicians come from the lowest three steps on that five-step ladder—which includes the third step where median-income families live.

According to the NEJM, a recent national survey of under-represented students reveals that the cost of attending medical school was the number-one reason they did not apply. Meanwhile an Institute of Medicine report found that while Hispanics constitute 12 percent of the population, they account for only 3.5 percent of all physicians, and though 1 in 8 Americans is black, fewer than 1 in 20 physicians is black. As Morrison observes: “Continuing this trend has far-reaching consequences for the national health care workforce, which needs diverse physicians in order to address the needs of an increasingly heterogeneous patient population.”

Of course low-income students could take out loans just the way more affluent students do. But if you are coming from a median-income household (with a joint income of roughly $50,000), it is easy to see how the idea of being $130,000 in debt could seem terrifying. After all, what if you married, your wife became pregnant, and you had to move out of your tiny one-bedroom apartment just as you were beginning your career? What if you and two fellow graduates opened a small practice—and discovered, after a year, that the three of you just couldn’t make the overhead? More fledgling practices go under than one might imagine. What if you gave birth to twins and realized that you needed to take a nine-month sabbatical from your medical career? How would you continue paying off your debt?

Students coming from families on the top step of the ladder have a financial safety net. They know that, in an emergency, it is likely that parents or grandparents will come forward with interest-free loans or a gift. Students from poorer families realize that they will be out there, alone, with tens of thousands of dollars in loans.

Finally—and perhaps most importantly—the sky-high cost of a medical education creates a shallow applicant pool, making it harder for medical schools to find the very best doctors. Schools, after all, are looking for those rare individuals who are not only fiercely intelligent, but compassionate and committed to medicine as a service profession. What a patient needs is both competence and kindness.

Yet, if medical schools are accepting one out of every two applicants, just how discriminating can they be? How often must they wind up taking students who are bright, hard-working and ambitious enough to nail the required GPA—but lack the imagination to understand that there is more to being a doctor? A larger applicant pool—a pool that was both broader and deeper—would be more likely to yield students who possess the range of talents needed to become  an exceptional physician.

When Morrison tries to find a solution to these problems, she runs into a brick wall.  She suggests that the federal government needs to do more by expanding and protecting the National Health Service Corps Loan Repayment Program, for example, and broadening the tax-exempt status of medical scholarships. “But,” she acknowledges, “these initiatives may not be top priorities for a government dealing with war in Iraq, a growing national debt, and threats of terrorism.”

“Perhaps, then,” she concludes, “our best hope lies in individual medical schools finding creative ways to reduce the need for loans and to adjust financial policies so as to reduce tuition.”

But the truth is that in order to train students, medical schools need to make enormous capital investments in the priciest, newest medical technologies. As a result, the cost of educating a student can easily outstrip the tuition the school receives. And while academic medical centers have other sources of government funding, many also provide more care for uninsured and Medicaid patients than the average hospital. They’re in no position to slash tuition.

Ideally, the federal government would find the funds to offer far more generous scholarships to students willing to become primary care physicians and practice in the areas where they are most needed for four or five years after graduating. Many might well put down roots.

As an alternative, Princeton economist Uwe Reinhardt has proposed an intriguing solution. In a “Health Affairs” article titled “Dreaming The American Dream: Once More Around On Physician Workforce Policy” Reinhardt suggests that the government might create a “human capital market in which medical students could borrow the funds needed to pay for their own medical education”—and pay off the debt gradually, the way one pays off a mortgage.  “A graduate’s indebtedness of, say, $200,000 upon entry into medical practice could  be fully amortized over twenty-five years, at an interest rate of 8 percent, with annual payments of about $18,700,” Reinhardt explains.  “If the payments were made tax-deductible, as they should be, the net burden on the physician might be no higher than half that amount. As Main Street enterprise goes, this is not an enormous debt-service burden.” [my emphasis]

“If all physicians were forced to debt-finance the full cost of their medical education,” he continues,  “then a public physician workforce policy might take the form simply of judiciously targeting tax-financed loan forgiveness to achieve certain desired social ends, be it a desired ethnic or gender mix in the physician supply, a desired specialty or spatial distribution of physicians, or a desired delivery of health services, such as care provided below the physician’s opportunity costs (including uncompensated care.) In principle, one could even use the mechanism to modulate the overall size of the physician workforce.”

“In effect,the policy would be a slight variant of the current ROTC program for the military or the National Health Service Corps for physicians. These two programs prepay the cost of the student’s human capital and then hope to collect on it through mandated subsequent service. The program proposed here would force the student to accumulate financial indebtedness first and forgive that debt only in step with actual service delivery.”

Reinhardt admits that this would be “a radical departure from conventional physician workforce policy in the United States and in other countries.” Though he notes that, “unlike the United States, most other countries do not treat health care as basically a private consumer good and medical practice as just another form of free enterprise. Instead, they tend to treat physicians as quasi civil servants with explicit social obligations.”

Would such a program fly in the U.S.? It’s hard to imagine requiring all medical students to take out loans to finance their education. (Though the truth is that today, only 20 percent pay cash for tuition—the other 80 percent go into debt.) Moreover, the idea of amortizing medical school loans, like a mortgage, over 25 years, and making them tax-deductible is appealing. It means that young doctors who are trying to start a career and a family won’t be as strapped as they are today. And if the government “judiciously” targeted loan-forgiveness programs to achieve desired social ends, we could hope to have both primary care doctors and specialists more evenly distributed around the country, in the places where they are needed most. This, in turn, could make universal health care more affordable.

Reinhardt’s proposal is just one scheme for financing the cost of medical education.  But it’s provocative, and should encourage us to begin thinking about how to open the doors of our medical community to a larger group of applicants coming from a much broader spectrum of society.

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of  “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

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MarkDanShelleymaggie maharMaggie Mahar Recent comment authors
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Mark
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Mark

Quit simply, this is wrong.
I’m in the middle of applying the medical school. I’m quite sure that my competition is much greater than having to beat out only one other guy for a seat in my first medical school class.
The acceptance rate is often well under 10%.
There seems to be a growing voice in politics to suggest that American voters shouldn’t take care of doctors, care should be free. But not to worry, there are still plenty of young students hoping to take care of you!

Dan
Guest
Dan

So, You Want To Be A Doctor…… Lately in the media, others have said and appear to express concern about the apparent shortage of primary care doctors in particular. Typically, the main reason believed and speculated by others for this decline of this health care profession specialty that historically has been the apex of our health care system is lack of pay of this specialty when compared with other specialties chosen by potential physicians while in training, as the annual salary of a PCP is around 130 thousand a year on average, others have concluded may be the national average… Read more »

Shelley
Guest

Here several reasons why American med school apps are down: How to Fix the United States Health Care System We Must Do It Ourselves “Problems cannot be solved at the same level of awareness that created them.” –Albert Einstein Identify the Components: Ones That Work and Ones That Don’t The first step to solving any seemingly daunting problems is to break it down into component parts, identify what works about the existing status; and what doesn’t. It’s crucial to learn from the past. As a physician and owner of a solo practice (small business) I’ve experienced the health care system… Read more »

maggie mahar
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maggie mahar

Docanon– First, thanks for commenting and providing so many sources on why students do or don’t go into primary care. I’ll look at them. The one thing I would say is that things have changed since the mid to late 1990s when HMOs were peaking. (See my reply to Diane in my long comment above.) Secondly,you are entirely right when you say that “those students from wealthy backgrounds taking on government-subsidized loans are basically making a good investment for their families, with the attached guarantee of never truly experiencing economic hardship. My debt is considated at a ridiculously low rate.”… Read more »

Maggie Mahar
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Maggie Mahar

Peter–I agree with you about cultural drive. (Though there are always those few loner kids who just want to get away from everything their parents and community represent. And they do it with virtually no parental support or community support– though if they’re lucky, they find support in college. On nature vs. the city: this is a very subjective topic. But I do find that nature becomes more and more meaningful the older you become. (And I’m not that old!) But when I was very young I was just too impatient to take it in. I greatly preferred art to… Read more »

docanon
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docanon

Hi Maggie- I think there might have been a typo in your response. Not sure I said everything you quoted. But here are some refs on the debt vs. specialty choice issue. Kahn et al. Is medical student choice of a primary care residency influenced by debt? MedGenMed 2006. Rosenblatt RA et al. The impact of U.S. medical students’ debt on their choice of primary care careers: an analysis of data from the 2002 medical school graduation questionnaire. Acad Med. 2005 Sep;80(9):815-9. Kiker, B. F. Relative income expectations, expected malpractice premium costs, and other determinants of physician specialty choice. J… Read more »

Peter
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Peter

Maggie, by “cultural drive” I meant that usually kids do what their parents do, they tend to elevate to the intellectual and economic level of their parents – usually the father. Kids that want/can to go outside their community/cultural norm need a lot of support and encouragement from their parents and peers and from the community they need to go to to be successful. This support is not always there. Black kids wanting to succeed outside their community are labeled, “too white”; from direct experience with Alaska Natives living on reserves any kid that wanted to leave the reservation to… Read more »

Maggie Mahar
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Maggie Mahar

Docanon, Diane, Phyician Stafffing,Eric, Barry and Sonoma. anoni and Peter — Thank you all for your comments. Docan: With regard to why fewer students go into primary care, you write: “The current linkage between medical school debt and specialty choice is questionable. Studies on what factors influence the decision to enter primary care don’t bear out the conventional wisdom.” You also write: “Trying to get the elite class to work in rural America for rural America pay is not going to be possible or cost effective. If you think there is a lot of disease in rural America now, wait… Read more »

Peter
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Peter

I’m not sure if Canada has it right when it comes to getting docs and getting docs to practice in rural areas, Canada does have a lot of rural acreage. I do know that a medical education in Canada is cheaper and some self serving docs (3%) do come south for the big bucks while slamming Canada’s “socialzed” medicine – after they’ve gotten their cut rate Canadian education of course. But there seems to be shortages of docs anyway. One of the biggest problems is getting the doc’s wife to relocate to a rural area. There are also considerations of… Read more »

anoni
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anoni

perhaps medical school(and tuition) should be left to those who feel they need it to pass the boards…
why should paying enormous amounts of money to medical institutions be a requirement to take the board?
why should the exam itself (and a nominal registration fee) not be the judge of who qualifies to sell services in the market?
a central committee is not the market, I think alot of the inefficiency is because of this bottleneck.

sonoma
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sonoma

This is just another “Canadian socialized medical system good…US private enterprise system bad” argument. Maggie is nothing if not reliable on this point. Couple notes: 1) How many of those Canadian docs head south at some point? 2) If you want to guarantee fewer (and lower quality) US medical school applicants, go with the civil servant model. 3) The cost of a medical education is a bargain at even $300,000. Bargain. 4) As to the primary care “problem,” most physicians are overqualified. NP’s and PA’s can perform most of these functions just beautifully. 5) A well-qualified student accepted at multiple… Read more »

Barry Carol
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Barry Carol

At a conference a couple of months back, David Brailer and Jonathan Gruber were the luncheon speakers on successive days. One of them (can’t remember which) made the point that medical school tuition increased much faster than business school tuition in recent years. One of the reasons for the slower growth in business school tuition was significant push back from the corporations that hired most of the graduates. They told the business school administrators in no uncertain terms that rapid tuition increases would force the employers to raise salaries higher and faster than they deemed desirable so the graduates would… Read more »

diane
Guest

I wonder if the decrease in income related to involvement of HMOs could be another factor………

eric Novack
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eric Novack

Maggie-
1. just for comparison, what percent of American born PHD graduates (all disciplines) come from each income area?
2. was the point of the piece to examine the high costs of medical education or a concern for ‘lack of socioeconomic diversity’ in medical students across the USA?
3. most students already defer loans during residency and many refinance to create a single loan with terms as you mention above? And if they are federally guaranteed, those consolidation rates (my own included) are generally below ‘commercial’ loan rates.

Alex
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Alex

It’s worth mentioning that physicians are human beings too (superhuman if you ask them)and want a lot of the same things other folks do which is a big reason why they locate where they do and why it is hard to get them to certain areas. Living in cities with culture, art, great restaurants, good schools, and Mercedes dealers and the like is nice. I have 7 friends in medical school right now and they are all going for dermatology, ortho, or anesthesia. Dermatology has exploded because it has got to be the best 9-to-5 job in America. Ortho and… Read more »