A slightly longer version of this piece was originally published on Bill of Health, the blog of Petrie-Flom Center at Harvard Law School.

Recently, Derek Thompson pointed out in the Atlantic that the U.S. has adopted myriad policies that limit the supply of doctors despite the fact that there aren’t enough. And the maldistribution of physicians — with far too few pursuing primary care or working in rural areas — is arguably an even bigger problem.

The American Medical Association (AMA) bears substantial responsibility for the policies that led to physician shortages. Twenty years ago, the AMA lobbied for reducing the number of medical schools, capping federal funding for residencies, and cutting a quarter of all residency positions. Promoting these policies was a mistake, but an understandable one: the AMA believed an influential report that warned of an impending physician surplus. To its credit, in recent years, the AMA has largely reversed course. For instance, in 2019, the AMA urged Congress to remove the very caps on Medicare-funded residency slots it helped create.

But the AMA has held out in one important respect. It continues to lobby intensely against allowing other clinicians to perform tasks traditionally performed by physicians, commonly called “scope of practice” laws. Indeed, in 2020 and 2021, the AMA touted more advocacy efforts related to scope of practice that it did for any other issue — including COVID-19.

The AMA’s stated justification for its aggressive scope of practice lobbying is, roughly, that allowing patients to be cared for by providers with less than a decade of training compromises patient safety and increases health care costs. But while it may be reasonable for the AMA to lobby against some legislation expanding the scope of non-physicians, the AMA is currently playing whack-a-mole with these laws, fighting them as they come up, indiscriminately. This general approach isn’t well supported by data — the removal of scope-of-practice restrictions has not been linked to worse care — and undermines the AMA’s credibility.

The AMA’s own scope of practice website hardly bolsters its case. Under a heading that states “scope expansion does not equal expanding access to care,” the AMA claims only that “nonphysician providers (such as [nurse practitioners]) are more likely to practice in the same geographic locations as physicians” and “despite the rising number of [nurse practitioners] across the country, health care shortages still persist.” But unsurprisingly, both physicians and nurse practitioners (NPs) are more likely to be found in geographic locations with more people, although NPs do represent a larger share of the primary care workforce in rural areas.

The AMA’s scope of practice lobbying is particularly frustrating because the Association could improve both the supply and allocation of physicians in a more evidence-based way: by reforming U.S. medical education. In other countries, physicians receive fewer years of training but provide comparable care. Instead of insisting that NPs and other clinicians get more training, the AMA should be working to make U.S. medical education more efficient by pushing for the creation of more three-year medical degrees, more combined undergraduate and medical school programs, and shorter pathways into highly needed specialties. The AMA could also make careers in primary care and rural areas more accessible by lobbying for more loan forgiveness programs, scholarships, and training opportunities for medical students interested in these paths.
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Now is a pivotal time for the AMA to reconsider its aggressive scope of practice lobbying. Temporary regulations allowing NPs and other clinicians to do more during the COVID-19 pandemic could be evaluated and, if safe and cost-effective, expanded. At a time when the health care workforce is facing an unprecedented crisis, the AMA should fully atone for the workforce shortages it helped create.

This piece was originally published on Bill of Health, the blog of Petrie-Flom Center at Harvard Law School.

Today, the average medical student graduates with more than $215,000 of debt from medical school alone. The root cause of this problem — rising medical school tuitions — can and must be addressed.

In real dollars, a medical degree costs 750 percent more today than it did seventy years ago, and more than twice as much as it did in 1992. These rising costs are closely linked to rising debt, which has more than quadrupled since 1978 after accounting for inflation.

​Physicians with more debt are more likely to experience to burnout, substance use disorders, and worse mental health. And, as the cost of medical education has risen, the share of medical students hailing from low-income backgrounds has fallen precipitously, compounding inequities in medical education.

These changes are bad for patients, who benefit from having doctors who hail from diverse backgrounds and who aren’t burned out. But the high cost of medical education is bad for patients in other ways too, as physicians who graduate with more debt are more likely to pursue lucrative specialties, rather than lower-paying but badly needed ones, such as primary care. Doctors with more debt are also less likely to practice in underserved areas.

The high cost of medical education also is bad for the public. A substantial portion of medical school loans are financed by the government, and nearly 40 percent of medical students plan to pursue programs like Public Service Loan Forgiveness (PSLF). When students succeed at having their loans forgiven, taxpayers wind up footing a portion of the bill, and the higher these loans are, the larger the bill is. The public benefits from programs like PSLF to the extent that such programs incentivize physicians to pursue more socially valuable careers. But these programs don’t address the underlying cause of rising debt: rising medical school tuitions.

Despite the detrimental effects of the rising cost of medical education, little has been done to address the issue. There are several reasons for this. First, most physicians make a lot of money. Policymakers may correspondingly view medical students’ debt — which most students can repay — as a relatively minor problem, particularly when compared to other students’ debt.

The American Association of Medical Colleges (AAMC) employed similar logic last year when it advised prospective medical students to not “let debt stop your dreams,” writing: “Despite the expense, medical school remains an outstanding investment. The average salary for physicians is around $313,000, up from roughly $210,000 in 2011.” Although this guidance may make medical students feel better, the AAMC’s guidance should hardly reassure the public, as to some extent, doctors’ salaries contribute to high health care costs.

Another challenge to reducing the cost of medical education is the lack of transparency about how much it costs to educate medical students. Policymakers tend to defer to medical experts about issues related to medicine, meaning medical schools and medical organizations are largely responsible for regulating medical training.

Unsurprisingly, medical schools — the institutions that set tuitions and benefit from tuition increases — have taken relatively few steps to justify or contain rising costs. Perhaps more surprisingly, the organization responsible for accrediting medical schools, the Liaison Committee on Medical Education (LCME), requires medical schools to provide students with “with effective financial aid and debt management counseling,” but does not require medical schools to limit tuition increases or to demonstrate that tuitions reflect the cost of training students.

This is worrisome, as some scholars have noted that the price students pay may not reflect the cost of educating them. After all, medical schools have tremendous power to set prices, as most prospective students will borrow as much money as they need to in order to attend: college students spend years preparing to apply to medical school, most applicants are rejected, and many earn admission to only one school. And although some medical school faculty claim that medical schools lose money on medical students, experts dispute this, with one dean suggesting that it costs far less to educate students than students presently pay, and the tuition students pay instead “supports unproductive faculty.”

Medical schools should take several steps to reduce students’ debt burdens. First, schools could reduce tuitions by reducing training costs. Schools could do so by relying more on external curricular resources, rather than generating all resources internally. More than a third of medical students already “almost never” attend lectures, instead favoring resources that are orders of magnitude cheaper than medical school tuitions. The fact that students opt to use these resources — often instead of attending classes they paid tens of thousands of dollars for — suggests students find these resources to be effective teaching tools. Schools should thus replace more expensive and inefficient internal resources with outside ones.

Schools could also reduce the cost of a medical degree by decreasing the time it takes to earn one. More schools could give students the option of pursuing a three-year medical degree, as many medical students do very little during their fourth year. A second possibility would be to shift more of the medical school curriculum into students’ undergraduate educations. For instance, instead of requiring pre-medical students to take two semesters of physics, medical schools could instead require students to take one semester of physics and one semester of physiology, as some schools have done.

Finally, medical schools could simply reduce the amount they charge students, as the medical schools affiliated with NYU, Cornell, and Columbia have done. Because tuition represents only a tiny fraction of medical schools’ revenues — as one dean put it, a mere “rounding error” — reducing the cost of attendance would only marginally affect schools’ bottom lines. Rather than eliminating tuition across the board, medical schools should focus on reducing the tuitions of students who commit to doing lower paying but valuable specialties or working in underserved areas.
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Unfortunately, most medical schools have demonstrated little willingness to take these steps. It is therefore likely that outside actors, like the LCME and the government, will need to intervene to improve financial transparency, ensure tuitions match the cost of training, and contain rising debt.

This piece was originally published on Bill of Health, the blog of Petrie-Flom Center at Harvard Law School.

In my junior year of college, my pre-medical advisor instructed me to take time off after graduating and before applying to medical school. I was caught off guard.

At 21, it had already occurred to me that completing four years of medical school, at least three years of residency, several more years of fellowship, and a PhD, would impact my ability to start a family. I was wary of letting my training expand even further, but this worry felt so vague and distant that I feared expressing it would signal a lack of commitment to my career.

I now see that this worry was well-founded: the length of medical training unnecessarily compromises trainees’ ability to balance their careers with starting families.

In the United States, medical training has progressively lengthened. At the beginning of the 20th century, medical schools increased their standards for admission, requiring students to take premedical courses prior to matriculating, either as undergraduates or during post-baccalaureate years. Around the same time, the length of medical school increased from two to four years. In recent decades, the percentage of physicians who pursue training after residency has increased in many fields. And, like me, a growing proportion of trainees are taking time off between college and medical school, pursuing dual degrees, or taking non-degree research years, further prolonging training.

The expansion of medical training is understandable. We know far more about medicine than we did a hundred years ago, and there is correspondingly more to teach. The increased structure and regulation of medical training have made medical training safer for patients and ensured a standard of competency for physicians. Getting into medical school and residency have also become more competitive, meaning many trainees feel they must spend additional time bolstering their resumes.

However, medical training is now longer than it needs to be. Many medical students do very little during their fourth year of medical school. Residency programs also require trainees to serve for a set number of years, rather than until they have mastered the skills their fields require, inflating training times. And many medical schools and residency programs require trainees to spend time conducting research, whether or not they are interested in academic careers. While many trainees appreciate these opportunities, they should not be compulsory.

There are many arguments for shortening medical training. In other parts of the world, trainees complete six-year medical degrees, compared to the eight years required of most trainees in the U.S. (four years of college and four years of medical school). The length of medical training increases physician debt and healthcare costs. In addition, it decreases the supply of fully trained physicians, a serious problem in a country facing physician shortages. Since burnout is prevalent among trainees, shortening training could also mitigate burnout. And critically, the length of medical training makes it challenging for physicians to start families.

Because medical trainees work long hours, have physically demanding jobs, and are burdened by substantial debt, they are sometimes advised or pressured to wait until they complete their training before having children. But high rates of infertility and pregnancy complications among female physicians who defer childbearing suggest this is a treacherous path.

Starting a family during training hardly feels like a safer option. In my first year of medical school, I attended a panel of surgical subspecialty residents. I asked whether their residencies would be compatible with starting a family. The four men looked at each other before passing the microphone to the sole woman resident, who told us she could not imagine having a child during residency, as she didn’t even have time to do laundry, so instead ordered new socks each week.

In my second year of medical school, a physician spoke to us about having a child during residency. I asked how she and her husband afforded full-time child care on resident salaries. She confided that they had maxed out their credit cards and added this debt to their medical school debt to pay for daycare. There have been encouraging anecdotes, too, but these have often involved healthy parents relocating, significant financial resources, or partners with less intense careers.

Admittedly, shortening medical training would not be a magic bullet. Physicians who have completed their training and have children still face myriad challenges, and these challenges disproportionately affect women. Maternal discrimination is common, and compared to men, women physicians with children spend more than eight hours per week on parenting and domestic work and correspondingly spend seven fewer hours on their paid work. Nearly 40 percent of women physicians leave full-time practice within six years of completing residency, with most citing family as the reason why.

However, shortening medical training would enable more trainees to defer childbearing until the completion of their training. This would help in several ways. For instance, while most trainees are required to work certain rotations (e.g., night shifts), attending physicians often have more flexibility in choosing when and how much they work. In addition, attending physicians earn much more money than trainees, expanding the child care options they can afford.

In recent years, many changes have been made to support trainees with children, from expanding access to lactation rooms, to increasing parental leave, to creating more child care facilities at hospitals. But long training times remain a persistent and reduceable barrier. To address this, medical schools could only require students to take highly relevant coursework, reducing the number of applicants who would need to complete additional coursework after college. Medical schools could also increase the number of three-year medical degree pathways and make research requirements optional. Residency and fellowship programs could create more opportunities for integrated residency and fellowship training and could similarly make research time optional.
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It will be challenging to create efficient paths that provide excellent training without creating impossibly grueling schedules. But this is a challenge that must be confronted: physicians should be able to balance starting a family with pursuing their careers, and streamlining medical training will facilitate this.