This blog is about medical education in the US and around the world. My interest is in education research and the process of medical education.

The lawyers have asked that I add a disclaimer that makes it clear that these are my personal opinions and do not represent any position of any University that I am affiliated with including the American University of the Caribbean, the University of Kansas, the KU School of Medicine, Florida International University, or the FIU School of Medicine. Nor does any of this represent any position of the Northeast Georgia Medical Center or Northeast Georgia Health System.

Wednesday, January 11, 2012

Impact of medical school tuition

In my blog, How much should medical school cost?, I wrote about an innovative proposal by Peter Bach and Robert Kocher to make medical school free. Dr. Bach is the director of the Center for Health Policy and Outcomes at Sloan-Kettering Cancer Center. Dr. Kocher is a special assistant to President Obama on health care and economic policy. Their proposal has gotten a lot of press. It seems that many people have an opinion about the cost of medical education. Dr Joshua Freeman wrote in his blog, Medicine and Social Justice Would free medical schools increase primary care?.  Dr Kenny Lin, in his blog the Common Sense Family Doctor wrote Strengthening the primary care pipeline.  Dr Pauline Chen wrote in the New Times Health blog about The Hidden Cost of Medical Student Debt

I was thinking about another aspect of the cost of medical school.  It is something that I have not heard people talking about. Most of the negative aspects that have been talked about are related to the negatives to the student and the impact on their future career choices. There is also some (important) talk about the societal negative of less students choosing primary care and family medicine.

But what about students who never graduate from medical school?  Medical schools try very hard to keep students in school because of the big investment in that individual student. If you get into medical school in the US, your chances of graduating are extremely high. Something like 96 percent.1  But what happens if you don't graduate? At most schools, the student would be on the hook for the cost of their education.  Wow!  Saddling a medical school graduate with $150,000 in debt is bad, but we say--they are going to be doctors, they can afford it. But if a student leaves school or is dismissed from medical school for academic reasons, they are still going to have that debt of $150,000.

It is a big deal. When the faculty are talking about the academic performance of a medical student, they should not have to worry about the financial ramifications of their decision. But, honestly, how can they not consider the implications. They are essentially condemning someone to financial ruin by saddling them with a debt that rivals that of a new home. And state schools are relatively cheap. If they are at a private medical school or one of the osteopathic schools, their debt may be as much as $300,000. 

The faculty on a dismissal committee are given an unenviable task. They are acutely aware of their responsibility to the public and society. They do not want to graduate a student who is not qualified to be a physician. By the time a student gets to this point they have been on the dean's office radar for a long time. These students have generally failed several courses or national standardized examinations, they have been through a lot of remediation, and there has been an enormous effort to salvage their medical career. The faculty have invested a lot of time and effort into the student. The faculty really care about the students. The school has invested a lot of money in them. A position in the medical school class can never be regained, so if a student is dismissed that spot is gone forever. The faculty feel that they have failed when a student is dismissed. The financial ramifications just make it worse.

So, I would like medical schools to consider a no-fault system.  If a student is dismissed from medical school, their tuition and fees are refunded to them. Let's take the financial part completely out of the discussion.  This will be better for the students and for the faculty. An potential effect of this policy, would be to encourage schools to take a chance on more at-risk students.  Some of these students might be from disadvantaged backgrounds, some might be underrepresented minorities, and some might be from rural areas. These students are less likely to apply to medical school and even when they apply, less likely to graduate.1 Disadvantaged students may choose to not even try medical school because of the financial consequences of failure. A no-fault system would eliminate those consequences.

What do you think?

1) Garrison G, Mikesell C, Matthew D. Medical School Graduation and Attrition Rates []. Analysis in Brief AAMC.  2007. Vol 7 Number 2.


  1. There are also other financial factors that involve borrowing such a large amount of money for college and/or medical school. Many non-medical people enter the work force at around age 21-22 yrs of age. They begin saving for retirement through 401K accounts or other investment vehicles. Medical students and residents defer work for 6-8 years or more. They lose the importance of early savings and the power of the compound interest curve early in life. The added burden of a loan repayment schedule further impacts saving for retirement. It is a little known fact that many physicians do not have adequate funding for retirment other than social security benefits. There is also a question about the tax implication of a write off on a school debt. Medical School loans are excluded from bankruptcy forgiveness, much like taxes.

    1. Thanks for the comment!
      The debt burden is real. It weighs on student's minds. It also influences their choice of specialty.

  2. Another interesting issue is that by making medical school free, there is the real possibility of more students "trying it out", and then failing out. This happens in open-admission colleges (even, indeed, at KU with its almost-open-admissions policy). So what? The student is not out so much money, but the student services support will be much more strained and less effective. And it is the more academically marginal (and often rural, low-income and minority) students that are more likely to face this outcome.

    1. Trying it out would be good if it was no-fault
      Some would make it and others wouldn't
      We have that system now for at-risk students but it is not no-fault

  3. Thanks for the comment!
    So the plus would be that those academically "marginal" students (at least by number criteria) would be more likely to try it out. Some of those would be successful. Clearly some would not but it would allow us to see them in person rather than excluding them solely on MCAT or GPA.

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  7. Great information you shared here and By the time a student gets to this point they have been on the dean's office radar for a long time. These students have generally failed several courses or national standardized examinations, they have been through a lot of remediation, and there has been an enormous effort to salvage their medical career so i think some ideas are better.
    Thanks for sharing...


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