“Free Tuition” Isn’t a Primary Care Pipeline

This week, there were two types of discussions on my social media feeds: non-medical friends fascinated by New York University’s announcement of free tuition for all its medical students, and medical friends frustrated that their own schools weren’t so generous (gee, thanks, Vanderbilt!)

To be clear, it’s an impressive and laudable feat to cover tuition—at present, around $55,000 per year—for about 450 students in perpetuity. By the Association of American Medical Colleges’ numbers, 75% of the Class of 2017 graduated with education debt; on average, over $190,000 per student, between eight years of undergraduate and medical studies. NYU raised $600 million in donations to ensure that its graduates don’t have such financial considerations hanging over their early-career decisions.

NYU’s stated rationale here is twofold: to reduce the cost barriers that would prevent some students from pursuing careers in medicine, and to encourage students to choose less-lucrative specialties like primary care. “I don’t want people moving away from what they’re passionate about because of their fear of the money,” said Rafael Rivera, NYU’s Associate Dean for Admissions and Financial Aid.

I think those are pressing problems for medical education, and I applaud NYU for putting forth a bold, ambitious solution. I just don’t think it’s the best fix for either issue.

Free tuition is a definite game-changer for students from less-affluent backgrounds that otherwise might not have been able to afford medical education. As a society, we need these people to become doctors. They’re more likely to return to the communities and populations they’re from to practice. Moreover, seeing as there’s a wealth of literature on the implicit biases that shape our care of women, minorities, and socioeconomically disadvantaged patients, medicine could certainly benefit from the added diversity of represented backgrounds and viewpoints among its ranks.

That being said, NYU students will still have to take on $27-29,000 per year in costs of living and other expenses, which may continue to deter some of those cost-prohibited prospective physicians.

It’s also not clear how this improves access over less costly initiatives, like Columbia’s $250 million plan to eliminate medical student loans. From my own medical school experiences, many of my classmates (though certainly not all) came from well-off backgrounds. I’d estimate at least 30% were themselves children of doctors, myself included. Can’t a university like NYU find a better use for the extra $350 million its plan will take over Columbia’s than to give aid to some students like me who, ultimately, would likely be able to become doctors and attain well-off lifestyles without it? Its education or social work students, for whom a six-figure income at their ten-year reunion is less assured, probably have some ideas.

Free tuition is a start to medical education’s access problem. A real solution, though, needs to consider the myriad ways low-income students are shut out from medicine—like limited early exposure, fewer test-prep resources, and less resume-building opportunities, to name a few—and act broadly to make a substantial impact.

If free tuition is a suboptimal solution for improving access, it’s even worse for solving the shortage of primary care physicians.

A $220,000 four-year tuition relief makes primary care specialties more feasible for altruistic students who are deterred from lower-paying fields by the prospect of loan repayments. It doesn’t, by any measure, make such careers more financially attractive in the U.S.’ current payment structure, in which doctors are paid for doing things, and paid even more for invasive or interventional things than for time spent talking to people or thinking through complex diagnoses.

According to Doximity, the average Manhattan general pediatrician makes $181,000; for family physicians and internists, it’s $205,000 and $207,000, respectively. When an NYU medical student chooses primary care, they choose to forgo the salary of an orthopedic surgeon ($458,000), radiologist ($384,000), or cardiologist ($391,000) out of an intellectual interest or sense of social duty in preventive care or population health management. Against a lifetime of thirty to forty years’ worth of accumulated earnings, the cost of a medical degree—even considering the interest on loans a student might otherwise take—is a drop in the bucket.

Don’t get me wrong: primary care is muchmuch more important than the salary comparison suggests. It’s just not any better a financial decision with a free medical education than without it.

To add an even more cynical perspective, as NYU’s application pool undoubtedly draws even more competitive, talented applicants, it wouldn’t be surprising to see its match list tip even more toward selective specialties like derm., IR, ortho., or ENT.

So, if medical schools really want to cultivate primary care doctors, they can introduce tracks for primary care-specific training and exposure, like the ones at Duke and Johns Hopkins. They can offer accelerated training programs for primary care, as Mercer and Texas Tech do. If they go the scholarship route, like NYU, they can borrow from UC Riverside‘s playbook: it covers tuition, but only if the students stay and practice in underserved Inland Southern California.

What NYU and its donors have done is an incredible gift for its future graduates, one which will surely have an impact on its students’ bank accounts—not to mention, its upcoming years’ U.S. News rankings. It’s every bit as generous and impressive as it seems. It’s not, though, the moonshot strategy for improving access to medical education or promoting careers in primary care that some, like The Atlantic, NPR, or Fox News, suggest.

P.S.: If you’re from NYU Med and reading this, I’m totally not related to any other Utrankars you might see an application from in the next few years.

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Why professional societies are worth it

As someone who’s all too familiar with the ‘student loan life,’ there are few things I’d recommend as essential buys besides UWorld, ramen noodles, and Keurig cups. One that’s often overlooked by medical students, though, is membership in the professional society for your future specialty.

Cue the collective groan. I know, and I get it: why pay an annual subscription fee to join a club, add a line on your CV, and pay your respects to “the guild?” At first, I felt similarly skeptical. As a digital native, I was confident that I didn’t need my professional society. I had a blog. I had a Twitter account and LinkedIn profile. I could advocate for myself, and network for myself.

Since then, as I’ve furthered my interest in anesthesiology and advanced my involvement in the specialty, I’ve come to see the value that a $10 American Society of Anesthesiologists (ASA) student membership provides. Here, I’ve outlined a few of the high-yield benefits of the ASA Medical Student Component—and, I should add, even if you’re not a gas-passer in the making, these same benefits likely extend to the society for whichever specialty’s caught your heart.

Know what’s happening in the field, and where it’s headed. Through the ASA, I receive a complimentary print subscription to Anesthesiology, its peer-reviewed journal; the ASA Monitor, its monthly magazine; and ASAP, the weekly email newsletter. As an outsider looking in, these publications provide an introduction the ‘hot topics’ in anesthesia research and practice and an overview of educational content that’s likely to be useful on your anesthesia rotation (and not to mention, future training). Not all of it applies to learners, so feel free to gloss over the articles on practice management or billing code jargonology, but you’ll pick up enough to show attendings that you’ve done your homework, and to show interviewers that you know what you’re getting into.

Learn, do, and network at the Annual Meeting—for freeThe ASA and other specialty societies know that their students are their future, and they invest in our growth (and theirs!) by waiving students’ registration fees for the ANESTHESIOLOGY Annual Meeting. This conference is a ‘must-do’ for the future anesthesiologist, without question. It’s an opportunity to learn what’s new in anesthesia through presentations and panel discussions, practice procedures in hands-on skills workshops, and network with residency programs (and future employers!) And again, it’s all for free—which, right behind “go home” and “do you want to do this procedure?” are a medical student’s favorite words.

Support the people who are fighting for your future. In medical school, it’s sometimes easy to be complacent about advocacy, policy, and the landscape of physician practice; after all, life after residency seems so far away that we’re rarely looking beyond the next shelf exam. Even if you’re not looking ahead to the future, your professional society is. That’s why, in the last year, the ASA has been looking out for anesthesiologists and their patients and advocating for physician-led anesthesia care—and for evidence of that, look no further than the Safe VA Care initiative. And these are challenges facing every specialty: family medicine, internal medicine, pediatrics, psychiatry, radiology, you name it. Even if you view your membership as solely an investment in the safety of patients and the relevance of your future profession, it’s well worth it. And of course, if you want to go the extra mile, there are advocacy opportunities and leadership positions available.

When you think about what it costs to become a physician today—medical school tuition, supplies for clinical rotations, test prep resources, residency application and interview travel fees, and much more—a $10 annual membership to the American Society of Anesthesiologists (or your specialty’s professional society), with all it affords, is easily the right decision. If it does present a financial challenge for you, don’t worry; your medical school’s student affairs office, your school’s anesthesiology department, or your state’s anesthesiology society can likely lend a hand. Whatever the case, don’t overlook the chance to tap into this valuable resource and the education, professional development, and advocacy advantages that come with it.

Bottom line: prospective members, join the ASA, or your professional society, ASAp (#badpuns, I’ll admit). For current members: what additional benefits or perks have you gotten from your involvement in your professional societies? Leave a comment to weigh in!

Disclaimer: I am a medical student member of the American Society of Anesthesiologists and a member of the ASA Medical Student Component Governing Council. This blog post is not on behalf of the ASA, nor has it been authorized or supported by the ASA (or any other organization) in any capacity; it represents my views, and my own advice for my fellow future anesthesiologists, alone. [In short, I speak for myself, because I’m fairly certain nobody wants me to speak for them anyway!]

The eStudent: Nothing About Me, Without Me?

I recently had the wonderful privilege of being accepted to present at a conference on medical education. I’m excited; this is a first for me!

It also came with a less-than-wonderful ‘first’: the privilege of paying a hefty conference registration fee.

Now, I can appreciate that organizing a conference is an expensive endeavor. Venues cost. Staffers cost. Esteemed keynote speakers cost. I get that.

What I don’t get is how a conference on medical education can accurately reflect interests and engage stakeholders in medical education by pricing out the main recipients of medical education: students.

Sure enough, looking over this conference’s speakers list, students are scarce. Plenty of deans, administrators, clinician-educators, and research scholars, though. It’s a conference about learners, but without learners.

To be fair, this isn’t a new phenomenon. Last year, I was elated to see the AAMC webcast its Medical Education conference. With great interest, I watched. I learned. I chimed in via Twitter when the dialogue called for (more often, presumed) a student’s perception or perspective.

And then I rolled my eyes when the post-conference survey, to the question, “Which of the following describes your role?” failed to include the option, “Student.” That moment spoke volumes, and it said everything about the student’s role in educational innovation and curricular design.

This is the essence of the problem. As students, there has to be a bigger role for us in medical education than taking post-intervention comprehension assessments or filling out satisfaction surveys. There has to be, to draw upon clinical analogies, a shared decision making model that invites students’ values, goals, and habits throughout the design process. Medical education without student engagement makes about as much sense as patient care without patient involvement.

To give credit where it’s due, I’m lucky to attend an institution where the student voice is present from the inception of an educational design process. But my experiences on the national scale imply these are outliers, not norms, and that’s a fundamental flaw.

ePatients, as advocates for access to their clinical records and active involvement in their own care, have in recent years coined the moving message, “Nothing about me, without me.”

That’s the attitude we need in medical education. That’s what we have to aspire to, and advocate for. To be eStudents: learners who don’t just participate in and function within an educational ecosystem, but actively shape it.