Posted on May 4, 2009

Medical student debt and specialty selection


Where Did All the Doctors Go?

The New York Times
May 3, 2009

To the Editor:

Re “Shortage of Doctors Proves Obstacle to Obama Goals” (front page, April 27), about a lack of primary care providers :

As those of us responsible for delivering health care know, the battle between specialists and primary care doctors has been going on for years, and one side has been winning.

The marketplace has rewarded specialists financially, and like any other special interests, they are amply financed for this conflict. Still, I don’t fault them. They have studied and worked hard, and are responding to market incentives, like good red-blooded Americans.

What we really need is a European-style single-payer system, with primary care doctors who emerge from their training with European-style debt loads: zero.

Georganne Chapin
Tarrytown, N.Y.

The writer is president and chief executive of the Hudson Health Plan, a not-for-profit managed care organization.


Subject: Graduate Medical Education: Trends in Training and Student Debt

GAO (Government Accountability Office)
May 4, 2009

In summary, we found that medical students prefer surgical and procedural specialties, and physician subspecialization is increasing. Relative to the number of available residency positions, more medical students have preferred surgical and procedural specialties over primary care specialties since 1999, according to national data.

Some factors may also lead students to pursue certain specialties while avoiding others. For example, the desire for a controllable lifestyle — a predictable schedule and fewer on-call hours — and high salary may lead students to pursue procedural specialties such as anesthesiology, and avoid other specialties such as primary care.

Medical school tuition and fees have increased significantly since 1998. Medical students can borrow up to $40,500 per year through the federal Stafford loan program with additional funding available through other federal loan programs; these loan programs can cover the full cost of medical school. The median amount of educational debt for indebted medical students graduating in 2008 was $155,000 — a 53 percent increase since 1998, controlling for inflation. Once out of medical school, residents earn stipends — on average about $3,729 a month for a 1st year resident. With $155,000 in debt, a resident’s monthly loan payment could reach over $1,700 (about 48 percent of pretax income). However, residents have repayment options that can reduce their monthly debt payment until they complete postgraduate training.


By Don McCanne, MD

This statement from a highly respected executive of a not-for-profit managed care organization, and this new GAO report, both further confirm what we already knew. Medical students are graduating with excessive debt, and this is likely contributing to the decline in the numbers choosing the primary care specialties.

Without increasing total health care spending, a few policies could be adopted which would realign incentives to improve our primary care infrastructure, while relieving students of the necessity of accumulating debt. That would be much easier to accomplish through a single payer monopsony than through a dysfunctional, fragmented, multi-payer, health care financing system.