Primary Care Physicians, an Endangered Species?: How Rising Medical School Debt Is Threatening Our Health Care System
Zhu, Jane, Metzler, Ian, Kennedy School Review
Susan Tomkins will graduate from Harvard Medical School in May 2012 with $196,000 in loans. As a first-year student she had hoped to carry her father's worn black medical bag into the rural Oregon community where she was born. But faced with the burden of high debt--totaling nearly $500,000 over twenty to thirty years when interest is included--Susan reluctantly eliminated every primary care specialty from her career plans. She recently chose to pursue dermatology, a specialty that commands nearly double the salary of family care physicians. "I didn't expect to have to worry about the economics of it all," she explains. "But the harsh reality is that I have to choose between relieving my family from an enormous debt and pursuing a greater good in my small hometown. As is, I'll be paying my debts until my forties or fifties."
A composite of three real-life medical students, "Susan" illustrates the kinds of choices that all too many aspiring doctors face today. As education costs grow larger than most people's personal resources, more students are going into debt to finance their degrees; in fact, more than 85 percent of medical students now graduate with outstanding loans. Average student indebtedness is $157,990, with nearly 80 percent of graduates owing at least $100,000. Just two decades ago, indebtedness averaged $27,000 (American Medical Association n.d.). Physicians' incomes have increased much more slowly during the same period--and even more slowly than consumer prices--making it more difficult for doctors to repay their educational loans today than ever before.
This trend is costly not only for new generations of doctors but also for American society. For one thing, it will deprive us of a critical presence in our medical ranks: doctors from low-income and ethnic minority backgrounds. One of our most pressing health care challenges is the need for a more diverse physician workforce to serve an increasingly racially and socioeconomically diverse population. By 2050, more than half of the U.S. population will be racial and ethnic minorities (Association of American Medical Colleges n.d.), and as the recent Occupy protests have reminded us, the income gap continues to widen. It is no wonder that the Association of American Medical Colleges and many other physician organizations have called for increased diversity in medicine as a way to improve access to health care for the underserved.
But it is unlikely that these communities will be fully served without reforming who we educate to become doctors. The evidence is clear: minority physicians are more likely than White doctors to practice in low-income and minority communities. When it comes to underserved communities, a diverse workforce builds better patient-doctor relationships, increases patient satisfaction, and encourages more culturally competent care (Association of American Medical Colleges n.d.). But despite there being two applicants for every medical school spot, cost remains the strongest deterrent for minority and low-income students considering a medical degree, and these groups remain severely underrepresented in medicine (Jolly 2005). Only one in ten graduating MDs is Black, Hispanic, or Native American; just 3 percent of medical students are from households in the bottom 20 percent of U.S. income earners. Meanwhile, more than half of all medical students come from families in the top 20 percent (Greysen et al. 2011). If the current rate of debt continues, there may come a time when only the elite can finance a medical education. Millions of Americans will suffer as a result.
The specter of debt also profoundly influences postgraduate career choices and discourages future doctors from entering primary care. Primary care has always been the foundation of our health care system, allowing doctors to establish long-term relationships with patients and to ensure coordination of care. But nearly one in five Americans today does not have access to primary care due to a shortage of nearly 30,000 primary care physicians (Cullen et al. …