H.L. Mencken once wrote, “… there is always a well-known solution to every human problem — neat, plausible, and wrong.” Now, more than a hundred years later, and it’s still obvious that Mencken knew what the heck he was talking about.
For example, in the 10+ years I’ve spent helping build residency programs, I’ve heard my share of overly simplified theories about what is behind the perpetual shortage of physicians. The one that people are most likely to cough up is, “Residents don’t go into low-paying specialties because they have too much student debt.” It’s neat, plausible and entirely wrong. It’s wrong because it bluntly strips away any notion that this highly personal decision is anything other than the outcome of an economic equation.
To be sure, medical school is extraordinarily expensive ($250,000+ debt is common). So it’s not hard to believe that when it comes time to pick a specialty, medical students (a group that generally includes more than a fair share of high achieving, scientifically minded people) would prefer, say, neurosurgery over family medicine. In reality, most in this group of scientifically minded people will tell you — with their mouths as well as their feet — that they didn’t get into medicine for the money, they do it to help people. For evidence, look no further than the fact that most physicians in a hospital are, actually, not neurosurgeons.
Unfortunately, this simple fact — which is evident to anyone that simply looks at the actual makeup of their hospital — doesn't stop leadership from using the “debt drives all decisions” argument to influence or rationalize choices they make for their own physician workforce. Nearly every residency program leader I’ve talked to has asked me if/when they could start up a neurosurgery, orthopedic surgery or cardiology program. You know what all these specialties have in common? They employ the highest paid physicians, and they’re the most lucrative for the host institution.
Conversely, my discussions with hospital leadership about family medicine, pediatrics and psychiatry programs often contains words like “necessary,” “community focused” and “loss leader.” You can’t blame hospital leadership for thinking this way; after all, they really do have to consider every decision through an economic lens. But it is hard not to feel like sometimes they’re trading their community’s chance at better care for a steady stream of dollars flowing in to just a few lucrative specialties.
This is why I think Dr. Ruth L. Gottesman’s recent donation — a remarkable gift that will ensure that no student at Albert Einstein College of Medicine will have to pay tuition again — was both extraordinarily generous and extraordinarily wise. A significant number of physicians will, by necessity, give debt undue sway when it comes time to choose a practice. Her donation will remove that burden for these fortunate Einstein students.
One can hope that the impact of Dr. Gottesman’s donation might be enough to create the first major cracks in the foundation of the “debt drives all decisions” argument. The medical students at Einstein will eventually leave school and join their new residency programs debt free. Will this group of students select their specialties differently from other medical school cohorts that do have major debt? My guess is, no. Debt is a major factor in this decision, but it’s not the only one. Prestige, location, relationships and expectations all play a role, but those factors are not as easy to quantify as dollars and cents. Some of these students will go on to be neurosurgeons, and some will go on to be pediatricians — with or without student loans. I can almost guarantee it.
So, my thoughts on what to do next are a little different. I think we should ask this group of scientists if they want to be part of their own science experiment. One could track the next five graduating classes from Einstein as they pick their specialties, attend their residency programs and undertake post residency employment over the next 15 years. Then we would see how they compare to both their peer cohorts as well as with one another. Maybe we’ll see a huge shift towards pediatrics and psychiatry, both of which are desperately needed in many communities. Maybe we’ll see a rise in niche specialties like clinical informatics and preventive medicine. Or maybe we’ll see no change at all. I don’t know (despite working at Krystal Ball, I can’t see that far into the future). But I do know two things for sure: Dr. Gottesman’s generosity should make the world a better place, and Mr. Mencken remains surprisingly relevant in that world.
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