Sunday, August 19, 2018

Will tuition-free NYU produce more primary care physicians?

When I graduated from NYU School of Medicine in 2001, I was one of four in my class to enter a residency program in family medicine. That turned out to be the largest number of family physicians that an NYU class would yield in the 21st century. In several subsequent years there were none at all, and the Class of 2018 produced only two. In one sense, this meager output is unsurprising - NYU, like Harvard, has never had a Department of Family Medicine - but my class also produced only a handful of primary care internists (internal medicine residency-trained physicians who did not subspecialize) and general pediatricians. NYU did not always undervalue primary care. When I attended the annual alumni brunch in Washington, DC, I met many generalist NYU graduates from the 1980s and earlier who asked me when going into primary care specialties started becoming so unfashionable, and who is going to "take care of the folks" when they all start retiring.

Last Thursday, when my best friend from medical school (now an emergency medicine physician in San Francisco) texted me about NYU's stunning announcement that its current and future medical students will no longer pay any tuition, my first reaction was: why didn't they come up with this idea 20 years ago? But when I got over that, I carefully pored over the press release, which implied that the goals of this generous policy are to increase the socioeconomic and racial diversity of their classes, and to encourage more students to choose primary care:

Overwhelming student debt is fundamentally reshaping the medical profession in ways that are adversely affecting healthcare. Saddled with staggering student loans, many medical school graduates choose higher-paying specialties, drawing talent away from less lucrative fields like primary care, pediatrics, and obstetrics and gynecology. Moreover, the financial barriers discourage many promising high school and college students from considering a career in medicine altogether due to fears about the costs associated with medical school.

I am fortunate that student loan debt did not play a role in the type of physician I became. I took out a modest amount of loans during medical school - less than one-third of the average $190,000 debt of 2016 medical school graduates - and knew that I would be able to pay them off regardless of the specialty I chose. In the wake of NYU's announcement, a spirited debate occurred on Twitter about whether the tuition-free school will actually attract more medical students to primary care, or simply vault it past its rivals in the U.S. News rankings and subsidize the education of radiologists, ophthalmologists, anesthesiologists, and dermatologists (the so-called R.O.A.D. specialties, with some of the highest incomes and best lifestyles).

It is hard to imagine that a school with no family medicine department or required clerkship, and few visible outpatient primary care role models, is suddenly going to start churning out family doctors by the dozens. But NYU's decision to go tuition-free may put pressure on other medical schools with similar fundraising prowess and stronger primary care infrastructures to follow its lead. Then the question becomes: will reducing financial obstacles to medical school attract more applicants who are likely to become family physicians?

A recent observational study of the distribution of medical education debt by specialty found that family physicians were the least likely of all the medical specialties to have no student loans at graduation, with 16% and 20% of 2010 and 2016 graduates, respectively, reporting no debt. (Since internists and pediatricians don't decide to subspecialize until well into their residency programs, the researchers could not assess the debts of those who might ultimately choose primary care.) In contrast, in 2016, 40% of future ophthalmologists and 36% of future dermatologists reported no debt. These findings suggest, paradoxically, that physicians with the highest debt burden are preferentially choosing a specialty with among the lowest income expectations - why on earth would that be? What it says, actually, is that students from less well-off backgrounds are more likely to be attracted to primary care in the first place.

Although making medical school tuition-free for all is an inefficient strategy for producing more family physicians, I predict that increasing the diversity of medical school applicants (and accepted students) will likely have a small, but measurable, positive effect on primary care. To magnify that effect, health care institutions must also invest resources into pipeline programs for underrepresented high school and undergraduate students such as the Comprehensive Medical Mentoring Program and ARCHES, academic family medicine departments (looking at you, Harvard and NYU), and community-based residency training programs such as Teaching Health Centers.

I'm proud to be an NYU School of Medicine graduate, and I'm happy for current and future students who now have one less obstacle to fulfilling their dreams. Perhaps they, too, can aspire to be family physicians someday.