Three Problems, One Solution: A New Way to Pay for Medical Education
A middle aged man named called Joe decided in mid life that he would become a doctor. A former boxing instructor, Joe felt compelled to learn medicine to help his fellow man. Already in his 30s, he worked hard to develop the prerequisite education to enter medical school, which he did in the late 1990s.
I met Joe in my first year of medical school. He was a very bright guy and had a great sense of humor. He was a bit different than most of us, and not just in age. I remember him asking me once “why would we use anti-hypertensives to treat hypertension. I mean, if a person’s blood pressure is that high, maybe that’s what their body needs it to be at!”. I remember thinking it was a strange way to think, given that allopathic medicine pretty much presumes that letting the body do whatever it will may not actually be the best course for long term health.
Joe did reasonably well through the first two years of medical school. In his third year he had moderate success, and sometimes struggled with having a different outlook on what medicine should be that the attending physicians that were instructing him. Over time, this became a bigger problem, and Joe eventually made the decision that being an allopathic physician wasn’t what he wanted to do for the rest of his life.
I remember asking Joe when he announced his decisions to his colleagues, “Joe… but you must be over a hundred thousand dollars in debt from your school so far! How will you ever pay it off if you don’t become a doctor???”. He just smiled and said “I’m going to go teach boxing again. I won’t be able to pay it, but hey there is no debtor’s jail. I’ll just never be able to buy a house or a car, that’s all.” He actually seemed OK with it and was quite happy to be leaving school to pursue another path.
This always seemed unfair to me. Joe entered medical school in good faith with the belief that he could contribute as a physician. But like all of us, he really had no idea what it was to be a doctor when he made that decision. I’ve always thought that you don’t really understand that until well into your residency, far past any opportunity to ever go back. That just doesn’t seem right. A young student buries him or herself in to deep educational debt in order to become a physician, yet a subset of those students, not realizing what they were getting to, feel that they would rather not be doctors. Joe was truly courageous to leave, partially because his world view was divergent enough to not care that his credit would be totally destroyed by not paying his student debt. But most people don’t do that. They just continue through residency, usually being miserable, and go on to have a career that they hate. They have to do it, because they have so much debt that there is no other reasonable course that could ever allow them to pay it off. Sadly, these people rarely are good doctors, which is bad for the people they will take care of.
So this is problem. Students who realize that medicine isn’t for them should be able to leave medical school without that decision destroying their life financially
A medical student named Cassandra once came to me for advice on her speciality choice. After discussing various options, it seemed like the thing that really fit her best was to be a pediatrician. We talked it over, and she was very reluctant to choose pediatrics because it is more or less the lowest paid speciality in medicine, and she had tremendous educational debt, both from medical school and her undergraduate education. She came from a family of modest means, and while getting some scholarships she was still graduating with several hundred thousand dollars in debt. She eventually chose to go into radiology and did a subsequent fellowship, and eventually landed a high paying job. She was very bright and talented, and no doubt does great work with what she does. But I always thought that she would have made a great pediatrician, and am saddened that she chose not to do that not because she wanted to be a radiologist, but because she felt like she needed the resulting higher salary to pay her educational debt. I think some kids lost out on this one.
It is a strange thing that different specialties of medicine are paid so differently, but it is true. Because of the ways doctors are paid, physicians who perform procedures will always be paid far better than physicians who primarily do intellectual work. It would be wrong to say that an internal medicine physician is less important to a patient than an orthopedic surgeon, but the way doctors are paid would certainly imply this is the case, to the order of three or four times more important. Heck, even subspecialty trained gynecologic surgeons like me are valued at 60% of what other subspecialty surgeons are paid. Are we worth less to patients? Is any doctor worth less? I would say no, but because they are paid as if they are, medical students will always be drawn away from the primary care fields in search of more money in the specialties.
So this is also a problem. People should be able to choose the speciality that suits them best, without feeling pressured by their debts.
Cases 3 and 4
A medical student names James got into medical school on his second attempt, and struggled through his first two years. He was studious, he worked hard, but he just didn’t seem to have the aptitude to do well with the material. By the third year of medical school he was barely squeaking by. He failed his boards twice before finally passing them. In residency he struggled to master the material of his craft, and made a number of mistakes that injured patients. He became discouraged, but put one foot in front of another and eventually graduated. He failed his speciality boards the first time, but passed the second time and went on to be a licensed but ultimately very mediocre physician.
James wasn’t a bad guy, nor was he not intelligent. But for some reason he didn’t have what it took to do well as a physician. But he scraped through and is now a not particularly good doctor in practice.
Another medical student named Hendrick had problems with professionalism. He did decently on an academic level, but acted very immaturely throughout his school process. He was written up many times, and hardly a single written evaluation was given that didn’t mention that he acted unprofessionally, and some even said that there were concerns that he should graduate medical school. He was put on probation several times, but he also eventually graduated. Though I have no specific followup, most likely Hendrick by now has been sanctioned by the state board and probably has had his license pulled for some kind of issue.
In both of these cases, the students should have been kicked out of medical school. But they weren’t because while it is incredibly difficult to get into medical school, it is almost impossible to get kicked out. You can get in by the skin of your teeth, and pretty much no matter how bad you do thereafter the school is going to create remediation programs to try to get you through. And you can act as un-doctorly as you like, and while you may get written up and your colleagues can hate you, unless you commit a crime it is unlikely that you will get kicked out.
This is a problem, in both cases. In the admissions process, medical schools try very hard to identify who is going to have trouble in school, but sometimes they make a mistake. But once that person puts on their first white coat, is almost impossible to get them out. After all, how can you tell someone to rack up $150,000 in debt in their first two years of medical school and then tell them they can’t continue? If they can’t, how are they ever going to pay it off? The answer is that they can’t. And this play into decisions to terminate students mightily. School have a fiduciary duty to help a student succeed once they accept them, even if they don’t seem to have the right stuff to do so. And as such, a medical student is almost never terminated from the program.
I have seen 13 medical school classes over my career, 17 if you include the four I saw while I was in school. Without exception, there were 3-4 people in each class that should have been fired from medical school for just not having what it took to be a good doctor, for one reason or another. It wasn’t in dispute by anyone, sometimes not even by the students themselves. But except for one exception, none of these students were kicked out. I have had the opportunity to be in committee meetings where termination of a student was considered, and in every meeting the crux of the discussion was that we had a fiduciary duty if at all possible to complete the student’s training so they would be able to pay off their debts.
And this is also a problem. We should be able to fire medical students who aren’t going to be good doctors, and they should be able to go on to other productive careers without their non-success in medical school destroying them financially.
I have a lot of ideas about what is wrong in medicine, and I have always wanted to write about them. I’m starting to do that here. But one thing I will never do is tell my readers about what is wrong in medicine without proposing a solution. And in this case, I think I have a good one.
Medical school is paid for all wrong. We pay for it up front, before we ever find out what medicine even is. Students are buried with debt before we can really assess if they will be good doctors. They are buried with debt before they can pick their speciality. And they are buried with debt before a few of them demonstrate that actually they would be better off doing something else with their life.
So let’s just pay for it differently. I propose that medical school is free. You pay nothing at all.
Now before you say this is a Bernie Sanders dream, let me clarify. Doctors will pay for the cost of medical education, but they will pay for it with a tax on their income. Right now I pay about 600 dollars a month to pay off my medical education over 30 years. I suspect for most students today its more like 1200 dollars. Based on this, I suspect that a 2 to 3 percent tax on gross income of physicians, redirected to pay for the education of all medical students, would work well. Obviously, this tax would be progressive. The neurosurgeon who makes 700k a year would pay far more tax than the pediatrician who makes 150k a year. And that would be just fine. And it would fix so many problems.
The student that enters medical school and realizes it isn’t for them can just leave. They don’t have any debt, and the world doesn’t have to suffer a burned out mediocre physician that was trapped in a career they realized they didn’t want far too late.
The student who just isn’t cutting it can be cut loose from the school, allowed to pursue something that they are more fit for. The faculty of the school doesn’t have a fiduciary duty to keep them around, so they don’t. The world is saved from a mediocre physician who was pushed through the system because he or she had so much debt.
And a student can choose any field they want, knowing that their medical education is paid for either way. They will still make more money choosing a more lucrative specialty, but by making that choice they will also bear a larger share of the nation’s cost of medical education. The big earners may not like that, but its entirely just and fixes a lot of problems.
Such a system could be implemented fairly easily. It could be phased in over four years. Upon initiation, all medical school is free. The first class to get a free year would have to pay a 1/4 share of tax, the next class 1/2 share, the next 3/4 share, and the next and all remaining classes would pay the full share. The only cost to get it started would be enough money to fund medical school for one year across the country, which while in the many millions wouldn’t be an absurd amount of money. Well perhaps it would take more than one year of funding since the first few classes would still be in residency not paying much back into the system, but in the end it still wouldn’t take that much money to get it started.
Obviously for a such a system, there would be some criticism from conservatives. Let me address some of that here.
Why should I pay for students who dropped out of school?
Because you had an opportunity to drop out as well. You just didn’t.
Why should I pay for a student who got kicked out?
Because if you had been kicked out you would be paid for, and the entire medical community benefits from raising the standards for physicians, not to mention the patients.
Why should I have to pay more because I make more money?
Because by doing so, we allow students to choose the specialty that suits them best without undue financial stress, which in turn leads to better patient care, not to mention happier physicians. And you will pay the same percentage of your income as everyone else – you just pay more because you make more.
I’m still a resident, do I have to pay?
Yes! You are a physician that makes money. But since you don’t make much, you won’t pay much. But you still have to pay.
Isn’t this socialism?
No it’s not. It’s delaying paying for your education until you are making money to do so, and doing in a way that is proportional to how successful you are. Its still doctors paying for their own educations.
Couldn’t we do this with lawyers too?
Of course we could.
What about engineers?
What about computer programmers?
Wait… so if we could do this for every career, couldn’t we just tax everybody that took advantage of higher education proportionally to their income and make higher education free, fixing all kinds of problems in society, including allowing people to pursue the career that suits them best without concern to the cost of the educational process for that career?
Who’s asking that? Bernie Sanders?????