AAFP Members, Congressman Look for Ways to Ease Medical School Debt

Fifteen AAFP members from the Washington, D.C., Baltimore and Richmond, Va., areas had an opportunity recently to make their views on medical school debt known to a representative from Congress. They pointed out that the level of medical school debt often discourages students from pursuing careers in primary care medicine, making it imperative for state and federal officials to find ways of alleviating that debt to address the nation's growing shortage of primary care physicians.

The conversation between Rep. Jim McDermott, M.D., D-Wash., and the AAFP members took place at the AAFP's headquarters in Washington on Feb. 6 during a meeting to discuss workforce issues.

"We have put this 'jerry-rigged' system together to finance medical schools and residencies," said McDermott, a licensed psychiatrist and a longtime supporter of primary care. "It is a very complicated financial arrangement that works, but it does not work for students."

McDermott described medical school debt as the worst part of medicine, saying that students at the University of Washington's medical school come out with about $175,000 in debt, which induces students to choose more lucrative subspecialties rather than primary care.

"If you are 25 years old and you are $175,000 in debt, you make different choices than I made," said McDermott, the senior Democrat on the Health Subcommittee of the House Ways and Means Committee, who entered medical school in 1957.

AAFP President Jeff Cain, M.D., of Denver, who moderated the discussion, told McDermott that subspecialists, on average, make about $2.8 million more than primary care physicians during the course of their careers. "The truth is, medical students come to medical school talking about careers in primary care and come out as (sub)specialists," said Cain. "As a result, primary care physicians make up only 32 percent of the physician workforce when they should make (up) 40 to 50 percent of the workforce for the high-quality, low-cost health care system that our country deserves," Cain said.

McDermott is the sponsor of legislation that would establish a state-based scholarship program for primary care medical students who would agree to practice in medically underserved areas for five years after residency. The legislation, known as the Restoring the Doctors of Our Country Through Scholarships Act, also would prioritize scholarships for students enrolled in six-year accelerated family medicine programs, as well as programs that include clinical training in underserved communities.

"I am basically trying to make it possible for medical students to go into primary care and not have to worry about the money," McDermott said in an interview with AAFP News Now.

The AAFP members who met with McDermott included academic family medicine leaders, medical students, residents and practicing physicians. In their discussions with the congressman, the members explained how medical school debt -- or the lack of it -- influenced their career decisions.

Kisha Davis, M.D., a family physician in North Potomac, Md., and president-elect of the Maryland AFP, said she was "lucky enough to have a full scholarship to medical school," which changed the trajectory of her career. "I was able to work at a community health center part time because I was not saddled with debt," Davis said.

She also was able to take a year off from practice to work as a White House fellow. "Not being saddled with debt has totally changed the options that are open to me as I move through my career," Davis said. "I can be the doctor that I wrote about in my medical school essays."

Laura Hehn, a fourth-year family medicine student at Georgetown University, is able to attend medical school because of a health professions scholarship. To fulfill the terms of the scholarship, Hehn has agreed to spend four years in the military on active duty and another four years in the reserves.

"When I did the math, it was eight years of my life in the military serving a great population or possibly the next 30 years of my life paying off my loans," Hehn said.

Adam Fletcher, a fourth-year medical student at Virginia Commonwealth University (VCU) in Richmond, said he is the first member of his family to attend college. "It is a great privilege, but it has come at a great expense," he said. The yearly tuition at VCU's medical school is $30,000, and Fletcher now owes about $200,000 in undergraduate and medical school loans, which are compounding at a yearly rate of 6.8 percent.

James Welsh, M.D., chair of the Department of Family Medicine at Georgetown University in Washington, said he was able to attend medical school through the National Health Service Corps Scholarship program. Without that program, Welsh said he "probably would be doing colonoscopies as we speak."

AAFP members told the congressman that one of the ways to increase the number of family physicians is to identify potential FPs before they enter medical school.

"There is a need to recruit people before they get to medical school -- to preselect those candidates who are likely to go into primary care and then support them along the way," said Matt Burke, M.D., a member of the Department of Family Medicine at Franklin Square Hospital in Baltimore.

Joey Nichols, M.D., a second-year resident at Medstar Franklin Square Medical Center in Baltimore, talked about two programs in Texas that identify and seek to get high-school students interested in careers in primary care medicine. "My point is there are things you can do reaching way back to identify students, (to) get them excited about careers in health and medicine," he said.

Mark Stephens, M.D., an associate professor at the Uniformed Services University of the Health Sciences in Bethesda, Md., also decried the "hidden curriculum of medical school" that creates a "toxic environment" in which medical students are discouraged from choosing careers in primary care.

"If I had a dollar for every person who told me I am too smart to be a family physician, I wouldn't have to worry about my loans," said Stephens, prompting nods of agreement from other AAFP members at the meeting.

Stephens said "these young people endure a bludgeoning" about their decisions to go into family medicine. "It takes a lot of guts to stand up and say you are going to be a family physician. I applaud these young folks (here today) for doing it."

If enacted, McDermott's bill would create more family physicians, thus helping to overcome some of the entrenched attitudes in medical school that discourage careers in family medicine, the congressman said. "If you have 100 students who are going in (to primary care) you have a lot of people to talk to who think it is a cool idea."