Sarah Kliff says that maybe medical school debt isn’t the problem behind the absence of primary care docs. She cites a couple of reasons:

  1. A program for medical student loan reimbursement had absolutely no applications.
  2. Those with the largest student loans tend to actually go into primary care, rather than avoid it.

It might be overstated as a reason, but there are other factors going into what she’s taking about that should be addressed. Clancy took a pass on Arapaho’s student loan reimbursement program. It had nothing to do with being unworried about student loan debts. Rather, it was based on (a) the bureaucratic difficulty of signing up and (b) committing to the job for six years. She signed a three year contract, and there will be a financial penalty when she leaves early, so San Mateo’s more generous program might have been something we’d have signed on with when we didn’t sign on with Arapaho’s. But specific programs that offer reimbursement often do so precisely because they are among the most uncomfortable jobs. the jobs that someone is least likely to want to commit to. And the repayment is often backloaded. And you’re making payments in the meantime anyway and interest is accumulating. And the jobs will often pay less than you could make elsewhere, with the student loan reimbursement failing to account for the difference.

As far as the second thing goes, well, there it’s more complicated as well. My wife graduated in the top third of her class and didn’t have to go into primary care. But a lot of doctors who end up going into primary care do so with little choice. I suspect that these people are also those with the most amount of student debt. They couldn’t get into a state flagship (as my wife did) and end up going to an expensive (non-elite) private college. I don’t know this to be the case, but I think it’s a factor.

To me, the really pernicious effect that student loan debt actually doesn’t have all that much to do with the dearth of doctors willing to go into primary care, however. Rather, it has more to do with the medical culture itself. The desire to make as much money as early as possible in order to get out from under. This makes high-paying jobs that, on the face of it, are questionable. There were jobs that paid significantly more than the job Clancy took. She took a pass, but the ability to pay off student loans in a year is tempting nonetheless. And while you might tell yourself that it’s temporary, I think that once you’re making that sort of money, it’s hard to go back. It sets the pace for contributing to The McAllen Problem.

So what’s the solution? I’m not sure. Relieving student loan debt for doctors who want to go into primary care may help, but since such programs are often so back-loaded, I’m not sure how much of an effect they would really have. Since they’re not something you can really count on, I think a lot of docs would end up taking the enterprising course anyway.

Not that I wouldn’t mind someone stepping in and taking care of that for us.

Category: School

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8 Responses to Med School Student Loans

  1. Ω says:

    Debt is only one source of the pressure that younger physicians feel to make money. There is also the concern that they have lost many years of potential savings. They have to pay off debt and establish a nest egg for retirement. The ones who marry and establish families after training have those expenses to worry about as well. Many new-to-practice doctors also want an improved standard of living to make up for all of the scrimping and saving that characterized the medical school and residency years. It’s hard to be able to afford that on top of the loans, child-related costs and retirement savings.

  2. superdestroyer says:

    The physicians who attended elite private universities always seem the ones most motivated by money. They all had friend and acquaintances who were making a killing on Wall Street and those physicians resented that the guy who could not survive organic chemistry was making more money than they were.

  3. Ω says:

    “The physicians who attended elite private universities always seem the ones most motivated by money.”

    If they were undergrads at one of those institutions, perhaps, but graduates of the medical schools at elite private universities are more likely to enter academia, at least for the early part of their post-training career. Ultimately, it’s futile to obsess over the Wall Streeters’ wealth. They make so much more money than even the high-powered subspecialty surgeons that it is impossible to compete.

  4. trumwill says:

    That’s a really good point, Omega. One that I didn’t fully appreciated until we were in our thirties with little savings.

  5. SFG says:

    Here’s a solution: cut Medicare reimbursements for specialty procedures. People follow the money, after all. And it would get rid of abominations like unnecessary spine surgery.

  6. trumwill says:

    The concern with doing that is an increased output in procedures. If you cut the profit margin from $200 to $100, an enterprising doctor can find something else to do that’s also worth $100.

    (You might be wondering why they don’t do that already, the answer being that it requires investment in new machines and such. It’s not worth it if you’re already making $200, but loss-aversion is a stronger motivator than profit-seeking.)

  7. Ω says:

    “unnecessary spine surgery”

    Not all spine surgery is unnecessary, and people who can actually benefit from it may be left to suffer unnecessarily (and unproductively) if guidelines are politicized to reduce the number of procedures. One of my relatives was back at work and pain free within a few days after surgery for a herniated disc. Had he listened to his doctor and the published guidelines, he would have suffered needlessly for months and been in and out of work during that period.

    Also, Medicare reimbursements to physicians are often a joke. General surgeons can do very poorly per case because the payment for required followup visits is bundled into the payment for the procedure, which itself isn’t very high. If you don’t want anyone competent to bother with medicine, keep taking that line. There is a threshold below which some of us would throw up our hands and expatriate out of spite even if we would have to drive taxis.

  8. Ω says:

    I’m not a surgeon, btw. Just using that as an example.

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