Three years ago, at my class’s white coat ceremony during the first week of medical school, the photographer told us to smile and yell “Tuition-free!” rather than “Cheese!” We were horrified: The notion of tuition-free medical school — admittedly something that had been circulating in the pre-orientation rumor mill — seemed imaginative at best, delusional at worst, and thoroughly inconsiderate on day four of probably the most debt-accumulating pursuit in our adult lives. The following week, the photographer issued an apology.
At yesterday’s white coat ceremony for its class of 2022, New York University School of Medicine announced it will cover tuition for all medical students, regardless of their financial situation. The announcement (which I certainly wouldn’t have minded coming three years earlier) isn’t just great news for NYU medical students. It could also help shape the landscape of health care in the United States in four key ways.
Alleviate the looming physician shortage. Tuition alone for four years of medical school has increased up to fourfold in the past three decades. It now averages $125,000 for public schools and $212,000 for private ones. The American Association of Medical Colleges (AAMC) estimates that more than eight in 10 graduating students bear a debt burden in excess of $100,000, with a median debt of $192,000. That’s a major deterrent for qualified premedical students considering a medical degree. Tuition and its debt burden may be a factor contributing to the projected shortage of up to 120,000 physicians in the United States by 2030.
To be sure, applications to medical schools exceed the available seats — the admission rate was just over 41 percent in the most recent application cycle. Yet the invisibility of “lost applications” may underrepresent interest in the medical profession that could drive the acceleration of development and credentialing of new medical training programs.
Improve the diversity of the physician workforce. Debt incurred by paying for medical school tuition fundamentally influences the demographic profile of medical school classes. In the most recent application cycle, only 18 percent of matriculating medical students were African-American, Hispanic, American Indian, or native Alaskans, even though they make up nearly 33 percent of the U.S. population. Tuition is a key contributor here — 77 percent and 57 percent of African-American and Hispanic medical students respectively report educational debt in excess of $150,000, and African-American students are 2.7 times more likely than others to accumulate that much debt. Potential medical students from underrepresented minorities cite cost as the top barrier to application.
This application and enrollment gap is relevant to the health disparities that exist in the U.S. The life expectancy of blacks is 3.4 years shorter than whites, and every seven minutes an additional black individual dies prematurely relative to whites. Given that graduating medical students from underrepresented minority groups are 2.5 times more likely than white students to work with underserved populations, the increase in diversity that tuition-free medical school might engender has profound implications for reducing health disparities in this country.
Increase primary care physicians. Debt accumulated during medical school influences decision-making about what specialty to choose. In the U.S., only 3 in 10 students choose to practice in the primary care specialties of internal medicine, family medicine, and pediatrics, which generally have lower salaries than specialties like cardiology or anesthesiology. That is partly propelled by the fact that nearly half of third- and fourth-year students say that their choice in medical specialty is influenced by projected income — or by debt burden.
Income is a particularly sensitive issue for those pursuing primary care. They incur expenses in excess of earnings for up to five years after residency (until the age of 33, on average). Yet by 2030, as the prevalence of chronic disease continues to skyrocket and the population of Americans over age 65 years increases by 50 percent, the primary care physician shortage may end up larger than that of every other specialty combined.
Eliminating medical school tuition, and thus medical school debt, could help nudge more students to choose much-needed careers in primary care.
Ease burnout. Educational debt can affect practicing physicians on highly personal level: the 48 percent of students graduating with greater than $200,000 in debt are 1.7 times more likely to experience symptoms of burnout. To the extent that burnout precipitates depression and early retirement —as well as increased medical error rates and poorer patient care — debt incurred during medical training is yoked to patients and providers alike.
The decision by NYU to provide free tuition to all of its students may cause ripples well beyond a four-block stretch along the East River. By liberating both prospective and present medical students from the shackles of educational debt, a medical school can alter the topography of American health care by helping increase diversity in the provider population, improve access to care by minority patients, resolve the deficit of primary care physicians, and empower the battle against burnout. These benefits would be vastly compounded if other schools follow suit.
And that would be something to smile about.
Eli Cahan is a fourth-year medical student at New York University School of Medicine.
First, let me say, good on NYU for finally making this feasible it will be a huge benefit to the students who attend! That said, this article is very detached from reality in thinking that even a fraction of the societal benefits they claim will occur.
Physician Shortage: Absolutely not an ounce of that will be impacted. In order to be able to offer no tuition NYU has actually, over the years, cut down the size of their incoming class. Additionally for every one person who made the tough choice that becoming a doctor was not financially possible, there are 100 people in line behind them who would happily fill that spot. This is all disregarding the largest bottleneck perpetuating the shortage which is the number of residencies, which will again not be impacted by this.
Diversity: I am incredibly skeptical about this point. Primarily there are hundreds of road blocks and hurdles to jump to even have a shot at medical school that disadvantaged people are systemically at the back of the pack for. Paying for undergraduate, getting an average 522 MCAT and 3.9 GPA (the average stats for NYU SOM, which will only increase after this) is no small feat for anyone, let alone for people who have been dealt a bad hand in society. Consider the thousands of dollars needed to take the MCAT, the prep courses for it, pay for the applications and secondaries, and travel to interviews. More to that point, there are a number of options available that provide free education – namely the military. I don’t see how a class of ~90 people will really have a significant measurable increase in diversity. This is forgetting that you’ll still leave NYU with at least 100k in debt not including an undergraduate debt. All that to say, this is but one barrier along the way and it is at the end of the road.
Primary Care Physicians: This is very optimistic. I suggest that you take a look at NYU’s latest match list and see where their graduates ended up. Some highlights for those short on time, they have more students match to derm (7) programs than family medicine (2). Yes this could change, but I am not holding my breath. A good number of large academic centers look down upon primary care and that is instilled in their students. Columbia for example wanted to do away with their primary care residencies, at one point.
Burnout: This is likely the most salient point. Working 80+ hour difficult weeks and not being overly worried about paying loans, car payments, food bills, rent/mortgages is likely to reduce this burden quite a bit.
In short, aside from easing burnout, this article was a whole bunch of grasping at straws and trying to make this sound like the biggest gift to society since sliced bread. It will be great for their students, but I am willing to wager society wont see much of that benefit.
As a Brit living in Italy, I always marveled at the thought that in this country (where the idea of university was originally born) the best universities are public, and almost free. Students pay a couple of thousand euros per year, depending on which faculty they choose, the rest is subsidized by the State. Also, the most prestigious teaching positions are in public universities, while the few private ones are the butt of many jokes, the reason being that with a few exceptions they are crap.
The concept of education as a business is wrong and counterproductive: every taxpayer cent spent on education is an investment in the future of a country. Granted, misappropriations are common, but that’s a small price to pay in exchange for a generally kept educated population.
There is already a school where every student graduates debt free but with an obligation to serve their country. USU, the Uniformed Services University in Bethesda, MD. There are a significant number who go into primary care but diversity didn’t move until we made an effort to increase the diversity. Financial barriers are real but the lack of diversity in medicine is much more complex than paying for tuition.
I think it is wishful thinking that eliminating medical school tuition, and thus medical school debt, will help nudge more students to choose much-needed careers in primary care.