NYU's free tuition move called precedent setting, will open doors for primary care, rural health

When NYU announced their School of Medicine would slash tuition down to $0 for current, incoming and future students, they certainly stunned their audience and lots of others, too. According to the Association of American Medical Colleges, the burden of debt right now for medical students in close to $200,000.  Ratcheting that number down to the cost of housing, food and other living expenses is a stark contrast.

"It's amazing and it's so refreshing because one of the things that we focus on is physician well being and professional satisfaction. Especially for early career physicians, one of the biggest stressors they have is paying their medical school debt so this is really good news," said Clifton Knight, American Academy of Family Physicians' Senior Vice-President for Education. Knight was a family physician in Indiana for nearly 25 years.

But beyond alleviating stress on the back end, the free tuition coups can influence trends in who becomes a doctor, what they practice and even where. And change is needed.

It's no secret now that the country is facing a significant physician shortage upwards of 120,000 by 2030, and one of the specialties most in jeopardy is primary care. Notoriously one of the lowest paid specialties next to Geriatrics, primary care's comparatively lower compensation, coupled with the high debt accrued in the course of medical education, have proven prohibitive for those budding physician considering the specialty. 

Eradicating the threat of decades of student loans might go a long way to free medical students from the tyranny of debt and allow them to decide their specialty based on desire. 

AAMC's chief healthcare officer and former physician Janis Orlowski said compensation isn't the only thing deterring students from primary care, citing trends in how family medicine is practiced, the high volume of patients doctors tend to try and fit in each day and other issues. But she agrees the compensation plays into it. 

"Money isn't the only factor but it's one of the factors," she said.

Knight and Orlowski both said the diversity, or lack thereof, of medical school student bodies could see a shift thanks to the massive tuition break. Because it is possible, if not probable, that when those from disadvantaged backgrounds consider pursuing the field of medicine, despite the promise of future high compensation, the idea of shouldering hundreds of thousands in student loans is too ominous a specter to ignore. Especially when you and your family have already experienced income challenges and the hardship they bring. 

Moreover, Knight said when you look at who is most likely to go into primary care, medical school students from disadvantaged socioeconomic backgrounds are more likely to go into primary care. Enter the double whammy of lower compensation than other specialties.

Sadly, the lack of primary care physicians only hurts communities since the presence of primary care physicians in a community is known to increase quality outcomes and decrease the overall cost of care. And diversity and inclusivity in the physician workforce can serve to inspire those considering practicing medicine.

"For potential medical students from underrepresented populations who don't see themselves in the role models around them, it's hard for them to see themselves going into medicine because they don't see people who look like them or are from the same background. Then they see the costs of med school and that adds on," he said.

Lack of inclusivity also hurts patients, because when they don't see doctors of the same race or culture, that can be intimidating especially when there are language and cultural barriers. Overall, it's just disheartening to not see yourself in your peers or in a workforce you aspire to be a part of, a vicious cycle in which Knight hopes the free tuition concept will make a major dent.

Orlowski thinks free tuition might also boost the willingness of medical graduates to consider practicing in rural communities, positions that often pay less than in bustling urban areas with high-brow hospitals and health systems.

And while she doesn't believe that free tuition will help cure the physician shortage, she said it will boost enrollment in medical students. Since the early 2000s, when AAMC first spoke of a potential physician shortage, there's been an increase in medical students of almost 28 percent and the number of medical schools nationwide has gone from 123 to 154. Class sizes are bigger too.

With free tuition, people who felt they didn't have the means to go to medical school may now feel they can take a shot. So the tuition waiver could mean a further boost in medical students.

A major barrier that both Knight and Orlowski cite in addressing the physician shortage is federal funding for residency positions. The number of these positions has been frozen since 1997 and both groups are pushing to increase the number of residency positions available to help with the growing shortage.

The AAFP has a target of increasing medical school graduates choosing family medicine to 25 percent of all graduates. Right now there are not enough residency position to reach that target, so Knight said it's a top priority to increase the number of graduate medical education positions in family medicine.

"AAFP believes the system funding medical education residency training isn't transparent as far as where funding is going and there is no target on the investment the federal government makes in producing a certain number of family physicians," Knight said. "More than $15 billion a year goes into graduate medical education funding with no coordinated strategy to makes sure that investment goes towards training the right specialty mix."

The government, namely CMS, needs to shift some of the current funding from fellowship training to residency training, he said. State and local opportunities exist to fund additional residency programs and it's important for states to look at the needs of their communities from a healthcare standpoint and work toward funding expansion of family medicine residency programs through public or private funding, they said.

Still, the idea that the most notorious barrier for higher education, especially medical education, has been almost completely removed by one very well-known institution is almost too hard to believe, and too good to be true, with the power to open doors for so many.

"This is a great bright spot to bring attention to these issues. It's also really critical that medical schools admit people who are more likely to go into primary care and admissions committees pay strict attention to the diversity of the students that they bring in," Knight said.

"I think this is precedent setting and I think there will be others that will try to follow...every medical school does and should continue to work very hard to make medical school as affordable as possible," Orlowski said.

Twitter: @BethJSanborn
Email the writer: beth.sanborn@himssmedia.com