Tuesday, December 23, 2008

Debt Free

Medical student debt is the first thing we need to rectify as we try to address the primary care issue. One quarter of students are graduating with loan obligations totalling over $200,000. Consider that most med school grads are in their late twenties/early thirties and often have families to support. The pressure is on to make some money fast. Why pursue a career in a field that pays pennies?

The article notes that $2.5 billion in federal loans are available to medical students every year. What if, as part of the Obama health care revolution, we invested that $2.5 bill in our future doctors? Or even half that. What's a billion buckaroos when we've already doled out hundreds of times more than that to cover up corporate malfeasance?

What if medical school was free in the country, given that you signed a contract stipulating an agreement to pursue primary care (family practice or internal medicine) as your specialty? Wouldn't that be enticing? If you changed your mind and just had to be an interventional cardiologist, then you would have to pay back the costs of your schooling. Like if you decide to drop out of ROTC before fulfilling your obligations, you owe the government the costs already accrued.

Medical school debt is no doubt the driving force behind the primary care shortage. Merely increasing the remuneration by a certain percentage points on office visit billing codes is like putting duct tape over a smashed windshield. Plus it looks unsightly. It isn't enough. It's not going to significantly alter the distribution of grads who opt out of primary care.

It's time this country bailed out something besides Armani-attired executives who fly into Washington DC on chartered jets. Whether or not Chrysler totters along for another twenty years isn't going to affect American prominence in the world nearly to the extent that a crumbling health care system will. It's time we invested in something a little more worthy of a liberal democracy....


OHN said...

From your lips, to somebody's ears.

When I heard about the Christmas bonuses that were given to the recently bailed out banking system, I wanted to puke.

HudsonMD said...

THat's just a waste of money!
Jonathan Glauser

Anonymous said...

amen. my father (internal medicine physician) can't pay for my med school. This eats at him given that his father, an immigrant/ low level government bureaucrat, was able to cover his med school 40 years ago. Not really how generational advancement is supposed to work.

with 160k debt, I probably couldn't do primary care if I wanted to.

Anonymous said...

I think reducing medical school debt (or eliminating it) is very important. However, that won't be nearly enough by itself. Choosing to specialize can easily result in lifetime earnings $10 million higher than choosing primary care. A cardiologist, dermatologist, radiologist, etc. will be able to pay back his/her loans with the extra income earned in the first year of practice, and then it's all gravy from there on out. Med students realize that and won't be swayed by simply reducing the debt load, unfortunately.

Anonymous said...

You only need 250K if you're goin to some fanzy schmanzy private school, I got by with only borrowin 15K and that was to buy a motorcycle and some other toys. The military still can't give their scholarships away, and heck, whats wrong with a State School? Even with Uncle Sam payin for my books I sold every one I could to the next class of suckers comin through...I mean whens the last time you looked at a Biochemistry Book??

Anonymous said...

which medical specialty gets paid pennies?

I suppose they all do but an awful lot of them.

webhill said...

You know what's nuts... I'm a veterinarian, and my colleagues and I have been discussing lately the problem of new student debt... a new grad can have $250K in debt, easy. Heck, when I was in vet school in the late 1990s, tuition was about $25K/year. It's only risen since then. Veterinarians just do NOT make that kind of dough! You get out of school and live as a total pauper at this point. it's horrendous.

Bianca Castafiore? said...

It's hard to have much sympathy, frankly, but when the moaning over earnings quiets, the necessity and importance of medical professionals wins out over the desire to say, "Look, you make informed choices, just like everyone else..." I have as much post-graduate education as some medical specialists, but there is something about French literature and criticism... it just doesn't drive the economy the way it used to.

If the premise that "[m]edical school debt is no doubt the driving force behind the primary care shortage" is correct, I join OHN in hoping that a person of importance reads your proposals. I like them and they appeal to my political spirit. I am afraid, though, that you overestimate the sense of "calling" among med students. The rustling of the green is a greater call. You have built in some recognition of that with the good old ROTC "gotcha"!

Anonymous said...

Puh-lease, doc, let's you and me stick to cutting and doctoring, and enough with all the bright ideas about how to ease the primary care shortage.
We got unto this mess by allowing the government to get it's nose into the profession's tent by first just letting it help our patients pay for their care. Now government regulations and rules are so ingrained into our every move and thought that we can not get through a patient interaction without interfacing with a government/JointCommie decree.
Now you think that the solution to the primary care shortage that has been caused by government interference is more government tinkering with the system?
I don't think so. The only way that your plan might work is if it worked exactly as you propose- loan forgiveness with NO additional strings attached. You know it ain't gonna go down that way. Some bureaucrat will get the bright idea that once we have enough peds, we have to figure a way to get them where they are really needed. Then going to Fort Stinkin' Desert or East Armpit to serve out an obligation will be the trick to solve all our problems. Then, someone else will notice that Persons of Gender (aka women) or Persons of Longevity (old folks) are waiting a few days longer for an appointment, and then we'll have a requirement that doctor's offices are opened with Ladies' Rooms only, or entrances that are passable only by wheelchair-Americans. You know it's inevitable.

How about some old fashioned American free-market capitalism? You would be hard pressed to find an instance where it did not work to solve a shortage of a good or service if really tried. Let's lose the price controls. Let's start running our clinics and hospitals according to proven medical principles, not the need to justify the holy 9921X, or get from observation status to "Full Admit." Let's make insurance a matter between patient and the insurance company, and make it illegal for the insurance company to have any contact whatsoever with a physician or her office.
Medicare started in the 1960s as a promise to help old folks pay for their health care. It now controls every aspect of what you and I do every day, and it's so ingrained in our every activity that we don't even notice it. The streets of America were not littered with the corpses of people who died from lack of medical care before government healthcare came into being- we as a profession made sure of that.
The answer to the primary care shortage, which was caused by government meddling in the health care system, is NOT more government meddling.

Merry Christmas!

Jeffrey Parks MD FACS said...

JB- First, merry xmas to you too.

Now is not an ideal time to be a hard core proponent of completely deregulated markets. Something tells me that the stench of AIG/Lehman Brothers has left a foul lingering taste in the motuh of the population with regards to "free enterprise".

Besides, I'm not proposing universal health care or socialism. I just think we need more primary care docs and the only way to entice younger students into pursuing that career is to make it financially viable. It's no different than a podunk city somewhere in the midwest offering tax breaks to keep the Big Factory in town.

Free med school is not "government meddling". It's the government using supply/demand, free market principles to its advantage.

Dr. Matthew Mintz said...

While I don't agree that complete deregulation is the answer, and your excellent idea of debt forgiveness for students choosing primary care is not the same as government meddling, JB's main point is correct.
"Medical school debt is no doubt the driving force behind the primary care shortage" is not really correct. Students exposed to (usually academic) primary care physicians, don't like what they see. Not enough control, too much paperwork, decreased time with patients, insurance hassles, etc. The lower salary in the face of student debt is really the icing on the cake.
I agree that loan forgiveness is one step in the right direction, but the only real way to reinvigorate primary care is to change the way it is reimbursed. Pay me (respectibly) for the time I spend counselling a patient, for the time I spend talking to a patient on the phone, for the time I spend answering lengthy emails, for time I spend with complex medical decision, etc. Similarly, decrease all barriers and hassles for getting my patients the treatment they need (prior auths) or paying me (billing and coding).
Virtually all physicians who practice concierge medicine practiced medicine the old way for years and did not go into primary care for the money. Many switched to concierge practices because they got fed up practicing primary care under its current conditions. Unfortunately, many people can not afford concierge medicine.
If the system does not change soon, you will have two kinds of primary care: for those that pay out of pocket and for those that pay using insurance. The care delivered will be drastically different. This has already happened to psychiatry, and it is beginning to happen in primary care.

Jeffrey Parks MD FACS said...

Dr Mintz-
What if you made the same salary but could see half as many patients? Is it the bottom line number that you enter on your April tax forms that bothers you or the sense that your efforts aren't compensated commensurate with the amount of work you do?

My opinion (from the perspective of a general surgeon, so hack away at any legitimacy I have): Merely increasing pay isn't going to improve the cost of the delivery of care. Your still going to be overworked. You're still going to need to outsource a lot of the patients to specialists. It's still going to be stressful, whether you make 150 grand or 210. Instead, what if we made it financially feasible to maintain your current income while seeing half the number of patients you do now? You could spend a half hour with each patient and have time marked aside for semi-urgent patients from home. Would that be a satisfactory compromise? Maybe you wouldn't send all your chronic abdominal pain patients to a gastroenterologist. Maybe that diabetic wouldn't need an endocrinologist because you'd be able to take the time to manage him yourself....

I realize I'm basically a random general surgeon in ohio who is probably acting a little too credulous. But there are basic tenets to reform, as I see it:

1. More primary care docs
2. Primary care docs will be able to see fewer patients at same compensation
3. Medical school loan forgiveness for those who pursue primary care
4. The influx of residents into specialties will be diminished by implementation of the above...

Ok. Feel free to unload.

Toni Brayer, MD said...

Buckeye: I think you are on to something. jb thinks the free market will fix things...I suppose he wants to get rid of Medicare and let folks pay the doctor the old fashioned way. That worked when office visits were $30 and you just died if you had leukemia. Sorry, there is no way to turn back the clock...ever.

Free med school for primary care is a grand idea. There are so many people who would love to be a physician and would love be able to look in the mirror and realize they have made a contribution in life.

This is "out of the box" thinking and will be a lot more successful than paying a few pennies more for "medical home" and expecting primary care to do even more with less.

Buckeye, you are a thinking surgeon!

MedZag said...


I'm attending an in-state medical school (the ONLY in-state school, so it's not like I had many choices, mind you). I am only taking out loans to cover tuition and academic costs and relying on savings to live frugally. I will still graduate with $160,000 in debt.

kareylou said...

I would just like to submit that I too am $120,000 in debt. I am a graduate of breast cancer treatment. I do have health insurance, even as a vegetarian, fit, yoga-practicing, non-smoking teetotaller. I guess I didn't read the policy closely enough.
My medical expenses are currently 45% of my gross income, and I will never buy health insurance on the open market again. Many of us advanced breast cancer patients spend more time dealing with insurance companies than we do on our treatment, or spending precious time with our loved ones.
I would trade places with any of you in a New York minute.
Not to make you feel bad, just to tap you on the shoulder.

MSN Student said...

This is a complicated problem, and I don't have the answer, but I am living proof of your claim that high education costs are affecting the shortage. I was interested in medical school but opted for nursing instead because of the costs. I have a genius I.Q. and am very disciplined, so I was not intimidated by the schooling, only the length of time & amount of debt incurred before I was finished. With nursing, a person could get a two year degree and start working while earning advanced degrees. Also, if you find you want to change professions, you only have a comparatively small debt to pay back. A doctor that wants to change professions is absolutely trapped by his/her debt. A med student that drops out doesn't have a practical undergrad degree.

If the costs were more affordable, and doctors less scarce, there would be enough competition to drive some of those doctors into the lower paying positions where they are so desperately needed.

Anonymous said...

One serious issue is that med school tuition increases are outpacing the rate of inflation.

I'm a med student and I can tell you that I support costs like the anatomy lab while I oppose costs like free lunches for many student groups who host "electives" or "conferences".

I've also seen it at the local (County) hospital where the Department of Medicine are faculty of my university. I've seen many old greybeards elbowing to get the free burritos at Grand Rounds. I can understand wanting to give residents a once a week lunch, but many of the people eating are paid really nice salaries (MDs, Nurse Practitioners, Pharmacists, Clinic nurses, Administrative Assistants, etc). Not to mention that they all also bully over the bag lunches at M & M conferences.

The lack of budgeting I believe is due to the easy availability of loans. Once you are in, you can't really negotiate and just have to take more money out. Tuition this year at my school is up thousands, I just want them to budget!

Marlynn said...

Federal loans for medical students require 2.5billion dollars,that was a huge money but it was very much useful to medical students.
Debt Free