The American medical education system was in a state of crisis in 1910 when Abraham Flexner published his treatise, Report on Medical Education in the United States and Canada (Carnegie Foundation Bulletin Number Four).1 A century later, we face another crisis in medical education—not in terms of its scientific foundation or quality standards as in Flexner’s exposé, but in its financial basis.
According to a report from the Association of American Medical Colleges (AAMC), the median 4-year cost of attending a U.S. medical school ranges from $187,000 (public school) to $264,000 (private school).2 Moreover, the median cost of medical school has grown at almost twice the rate of inflation, and the median debt medical students have at graduation is staggering.
Squeezed Tighter Each Year
It is estimated that 86% of medical students have substantial educational debt; the average debt is $205,674 for osteopathic medicine students and $162,000 for allopathic students.3, 4, 5 According to the AAMC, depending on the repayment structure, a medical school graduate with $162,000 of debt would have monthly payments ranging from $1,500 to $2,100 after residency training.2
In addition, the Obama administration and some members of Congress want to cut the funding of resident training in more than 1,000 of the nation’s teaching hospitals. (Each year the federal government contributes about $9.5 billion in Medicare funds, and approximately $2 billion in Medicaid dollars, and the states add about $3.78 billion through Medicaid funds.6) So the costs and debt have been going up, while the training and compensation have been going down. The new graduates are being squeezed tighter each year.
The economic reality of medical school debt certainly affects decisions about choosing between primary care and one of the traditionally more lucrative subspecialties. A primary care position pays about $150,000 per year, whereas a surgical subspecialist may earn $400,000 or more. Thus, the cost of education and the incurred debt are public health issues.
The American Academy of Family Physicians predicts that the United States will require an additional 40,000 family physicians by 2020. It is little wonder that the aging population will be faced with a shortage of primary care doctors. In addition, if the medical home concept and accountable care organizations are to work in the future, the gap between the growing need and the expected primary care physician shortage must be closed.
Resolving the Debt
There are a number of methods of loan forgiveness: States help repay or forgive loans if doctors serve in rural areas, the NIH helps repay loans when doctors enter into research programs, and the National Health Service Corps also has loan repayment plans. There is even a proposal to charge subspecialty residents (by not giving them a residency salary) for their education, yet continue the annual stipend for primary care residents,7 and there are numerous medical schools in the United States and England that offer a 3-year medical school without any apparent reduction in the quality of the education.8
Only through creative, fresh approaches will the public health issue of medical school debt be resolved. Doctors are privileged in many ways, accounting for 18 of the 20 highest paid professions in the United States. But disincentives to enter primary care including relatively less income compared to their specialty colleagues and greater difficulty paying off debt, results in a reduction in exactly the physicians who we need to care for Americans now and into the future.