Other countries don't put their new doctors in debt. Why should the U.S.?**
I first publicly declared I wanted to become a doctor in sixth grade. I clearly remember in ninth grade, during a test, when my English teacher commented over my shoulder, “Oh my, you’ve already started to write like a doctor!”
It truly takes a village to make a doctor, and it is not for the undevoted or those who want to pursue this career for lesser selfish goals. It’s a calling! It takes a lot of passion, grit and perseverance under pressure to not give up and stay the course. I would have quit the medical profession twice, had it not been for my family and friends who encouraged me.
I was fortunate to start my medical education right out of high school and obtained a license to practice medicine in about six years through the University of Bombay, India, without any debt, completely paid for by the government medical school, paying less than $10 per semester as fees. I then had to work in an underserved area for one year or pay back a large amount to the government for my “free” medical education.
After I completed an additional three years of MD in General Medicine from the University of Bombay, life happened; I got married and moved to the US. I am not complaining that I had to repeat my MD in Philadelphia, after giving the USMLE exams. But most non-US international medical graduates (IMGs) start residency in the U.S. about six years after high school, much younger and without any debt because their medical education in countries such as the UK, Germany and India is funded by the government and comes with little or no tuition. In contrast, U.S. medical graduates have to study for eleven years before getting a license and typically have $200,000 in debt when they enter residency.
U.S. medical students typically have $200,000 or more of debt when they enter residency.
A bachelor’s degree or better is required under a structure outlined over 100 years ago in the Flexner report — even though the degree may not even be related to medicine — before students can embark on the six to seven years of medical school and then additional years for specialization. The journey of becoming a physician in the U.S. is not for the faint-hearted. No one becomes a doctor just for the high paying job — it’s not a get rich quick scheme! Who is so foolish enough to study until they’re thirty and be drowned in thousands of dollars in debt that takes decades to pay off — not to mention the sacrifices along the way — and has high burnout rates due to overwork and high risk of death by suicide?
Even though I moved to the U.S. as an IMG about 25 years ago, I was recently shocked to hear the amount of debt my colleagues were still in. My colleague Candice, after eight years of being a practicing physician, has not yet paid off her student loans, has no wealth that a doctor is expected to have, and ended up paying double —due to high interest rates — compared to those who paid the whole amount upfront.
Medicine has not only become a profession for the rich, the high costs of medical education have contributed to health inequity, fewer medical students going into primary care, fewer specialists in underrepresented minority communities, and rising health care costs for all. It has also caused increased mental health issues amongst medical students and physicians, which leads to increased burnout rates.
The average price of medical education increased by 750% from the 1960s to 2018, and is rising every year. This is unsustainable, says David A. Asch, MD, an internist and Senior Vice Dean for Strategic Initiatives at the Perelman School of Medicine. Dr. Asch advocates for reducing the actual cost of medical school, not just the tuition, by reducing the cost of elements such as faculty time, course materials, classrooms, and administrative time.
“The way we produce doctors is expensive, and we all benefit if we can do it at a lower cost, as that is part of the reason what doctors do is so expensive,” Asch says. “It is part of the reason a more diverse population doesn’t enter medicine.”
How does the high cost of medical education affect everyday Americans? Medical students are avoiding primary care fields due to the disproportionately rise in income of specialist physicians compared to primary care physicians. The lack of primary care physicians, who provide preventive services and health education to their patients, leads patients to more expensive care settings like urgent care or the emergency room. In addition to forcing students into specialties, the cost of medical school also contributes to a lack of diversity among physicians; that creates a shortage of doctors in underserved areas that can lead to increased morbidity and mortality and higher costs for patients. (Ask me about the many patients airlifted to my tertiary hospital for medical management of conditions that could have been provided in their own community if they had interventional cardiologists or radiologists). Health inequities account for roughly $320 billion in annual U.S. health care spending and is going to increase in the future, according to a recent analysis from Deloitte.
Increased spending does not mean better health care. In fact, Americans experience worse health outcomes than their peers around the world, with life expectancy falling and worsening infant and maternal mortality rates.
In spite of a record number of applicants to medical school, an increasing number of medical schools, and a recent but insignificant rise in the number of residency programs, the U.S. is expected to face a shortage of primary care physicians ranging from 21,000 to 55,000 by the year 2033, according to the AMA. However, many U.S. medical residents do not want to go into the low paying primary care jobs which do not allow enough time, after an exhausting week, to do extra work to pay off debt. We have the longest, most expensive medical education system in the developed world, and among the lowest number of physicians per capita, especially in primary care and underrepresented minorities.
What causes the high cost of medical education? Some of the reasons mentioned in various opinion articles are medical schools are charging more for tuition simply because they can and there is an increased demand among students who are willing to pay the price (because their parents can or they are willing to take on the mammoth debt). Other factors cited include decreased federal funding for residency programs and high interest rate loans by banks.
“One of the reasons that health care is 20% of our GDP is that nobody knows their cost structure and yet everybody thinks they’re losing money somehow,” Amitabh Chandra, the director of health policy research at Harvard’s Kennedy School of Government, told Scientific American. “The key irresponsibility at the heart of medicine: the inability and unwillingness to learn one’s underlying cost.”
Federal loans cannot be discharged, even if the physician is bankrupt, and the debt balloons over the years due to high interest. This possibility of the debt following them even after their death, taking over assets and possibly leaving loved ones homeless in order for the federal government to recoup its investment — with interest — has contributed to burnout by increasing anxiety and depression amongst physicians. Even the Public Service Loan Forgiveness Program encourages the accumulation of interest and ballooning of loans over time, takes decades to pay off, and has a high degree of rejected applications.
The only way to increase the number of doctors working in the U.S. is to increase the number of doctors trained in the U.S. I’m not alone in voicing my opinion on how we’re wasting four years and increasing debt in the form of so-called “pre-med” degrees in subjects sometimes totally unrelated to the field of medicine. The idea of shortening medical school by one year is becoming popular, but students will benefit more by shortening pre-med years to two years of intensive, fast-track medical education. Shifting medical school curriculum into students’ undergraduate educations will help decrease debt and increase the number of physicians sooner.
The only way to increase the number of doctors working in the U.S. is to increase the number of doctors trained in the U.S.
IMGs are also invaluable as a way to reduce physician shortages in the U.S.; they are the cream of the crop from other countries who have to pass the USMLE exams and complete a three-year residency to practice medicine in the U.S. However, I believe all IMGs should be mandated to work in underserved areas for a certain number of years, irrespective of the type of visa they hold, So should nurse practitioners and physician assistants, who are given a license to work much sooner, and who make up 50% of the primary care workforce. I have worked in an underserved area for four years myself and it is not difficult at all. And what about the thousands of unmatched medical students every year? Missouri is the first state to allow them to work in underserved areas until they get into a residency.
Schools like NYU Grossman School of Medicine started the trend of free medical education, after building a $650 million endowment, but not many schools have followed suit. America needs more physicians, but we continue with a system that leads to debt and burnout. Legislation that would promote medical training by making loan interest tax deductible, reduce the burden on residents or reward physicians for spending their first years in underserved areas would be helpful but would also require a sizable investment by state and federal government. Perhaps it's also time to revisit the Flexner report, which has a lot of pros but has been criticized for introducing policies that encourage systemic racism and sexism.
It is a tall order and will take daring moves to change the status quo. I am hopeful that our physicians and legislators will take a stand in what I believe is a moral obligation to make medicine more accessible as a career so that Americans will have the quality health care they need.
