Free med school tuition won’t solve the shortage of primary care physicians

Last month, nearly 40,000 medical students were accepted into residency programs on “Match Day.” Surrounded by family and friends, these soon-to-be-physicians opened envelopes revealing where they would begin their careers. This moment marked the culmination of a residency match process that requires medical students to make a series of choices and rankings about which medical specialty to practice and at which health system, along with the various lifestyle factors inherent in such a decision.

Each year, match data provide important signals into the desirability and workforce health of various medical specialties. For example, dermatology, anesthesiology, general surgery, and plastic surgery maintained their usual high fill rates, while more than 250 pediatrics positions and more than 600 family medicine positions went unfilled.

These results come as no surprise and are in line with a longstanding shortage of new physicians entering primary care specialties. To address these workforce gaps, medical schools are trying a new approach: tuition-free medical education.

In February, Albert Einstein College of Medicine was the latest program to become tuition free, thanks to a $1 billion gift from Dr. Ruth Gottesman, whose generosity and modesty in asking nothing — not even naming rights — in return for her donation should be applauded. This gift followed similar programs at NYU Grossman School of Medicine and Kaiser Permanente Bernard J. Tyson School of Medicine, among others.

There is no doubt that not having to pay tuition for medical school saves students from a crushing debt burden. This is no small feat. It may also help draw more applicants from underrepresented groups, although the jury is out on this outcome.

But a larger goal of freeing medical students from the burden of student debt is to enable them to pursue a wider range of specialties or geographies, minimizing the need to steer towards the highest-paying options in the biggest cities to pay off student loans. According to Einstein’s website, the primary goal of the new program is to allow graduates “to choose their specialty based on passion and aptitude rather than financial obligation.” One motivator for Gottesman’s gift was her recognition of the challenge for students to choose primary care while saddled with educational debt. As one profile of her states, “the hope … is that [the gift] provides the opportunity to stay in a place like the Bronx and give care where it is needed.” Similarly, NYU’s dean of admissions suggested in a 2018 interview that the school’s new tuition-free policy would create more primary care physicians to help address the national shortage.

Unfortunately, on training primary care physicians or sending graduates to underserved areas, tuition-free medical school gets an F.

NYU’s 2024 residency match list shows that free tuition barely made a dent toward these goals. Last month, the third class to graduate with all four years of tuition-free medical school matched into residency. Only 14% of NYU’s graduating class chose primary care specialties, far below the proportion of U.S. physicians working in primary care (30%). This includes just 2 out of 107 graduating NYU students entering family medicine, despite 9% of medical school seniors nationally choosing this specialty. And NYU sent a lower percentage of its students into pediatrics (6.5%) than peer institutions without tuition-free policies, such as Johns Hopkins (7.4%) and the University of Pennsylvania (8.8%). Furthermore, nearly three-quarters of NYU’s graduating students matched into programs in just three states — New York (59), Massachusetts (9), and California (8) — nearly all of them in big-name academic health centers in major cities.

Taken together, NYU’s latest Match Day results are not meaningfully different from any other top-tier medical school without a tuition-free policy: The vast majority of students steer toward the usual-suspect specialties and health systems.

Medical school debt is just one factor in students’ decisions about choosing a specialty or the location of their residency. And it may be more tangential than many think. Myriad other incentives induce medical trainees to avoid primary care and underserved areas, and these incentives are deeply and historically entrenched in the structure and culture of the U.S. health system. Efforts to change these incentives indirectly — such as tuition-free policies — will be overwhelmed by the current choice environment facing medical trainees.

What really needs attention is the pay differential between primary care and specialty physicians. The average annual compensation for primary care physicians ranges from $250,000 to $275,000. Cardiologists, by comparison, average $507,000 and orthopedic surgeons average $573,000. Over a 30-year career, that pay difference is worth $7.5 million. Students don’t have to be money grubbing to allow such financial considerations to influence their decision-making.

There’s also the prestige factor to consider. Since the emergence of National Institutes of Health grants and fellowships after World War II, specialists have been the high-status faculty within academic medicine. Over time, this prestige has been reinforced by their higher reimbursement weights in the fee schedule used by Medicare and other payers.

Medical schools need to be more intentional about linking their training cohort to meet the nation’s workforce gaps and care needs. An estimated 83 million people in the U.S. live in areas without sufficient access to primary care. Studies show that a strong foundation of primary care yields better outcomes and equity, serving as the bedrock for addressing social drivers of health and managing complex patient care. Yet a record number of pediatrics residencies went vacant this year, and a record number of family medicine residencies went vacant last year.

If medical schools truly want to help improve primary care in the U.S., they need to create a better choice environment for medical students. Four investments can reshape incentives so more students go into primary care and underserved areas.

First, instead of free tuition with no conditions, medical schools should implement strings-attached loan forgiveness programs. All students would be given low-interest loans to cover all medical school costs. These loans are then forgiven for students who enter primary care, pediatrics, or psychiatry, or who work in underserved urban or rural communities. For each year of education financed, they must provide two years of this service. Students who choose orthopedics, dermatology, or other highly paid specialties must repay the loans with accruing interest, sustaining the overall funds. Loan forgiveness directly incentivizes students to make career choices that benefit underserved patients.

Second, more carefully target tuition-free policies. Very few medical schools can raise $1 billion, but many could raise $50 million or $100 million. By reserving the earnings of those relatively modest endowments only for students pursuing a handful of underserved specialties, other medical schools have an opportunity to affect the physician workforce crisis more directly than Einstein College of Medicine will. For example, NYU’s Grossman Long Island School of Medicine is also tuition free, but it specializes in primary care medicine, with a focus on training students committed to careers in internal medicine, family medicine, pediatrics, OB-GYN, and general surgery. Two weeks ago, 67% of its graduating class decided to enter primary care residencies, and many have chosen to stay local, a sharp contrast with the residency results of NYU’s main campus.

Third, publicly support policy efforts that increase pay for non-procedure based clinical activities, one of the few mechanisms to decrease the enormous pay disparity between primary and specialty care. For example, new Medicare billing codes have been proposed to better reimburse physicians for complex patient office visits, but they face consistent resistance from specialist lobbying groups.

Fourth, expose students to primary care earlier and put more emphasis on team-based care in medical school. By changing the culture around primary care — such as emphasizing primary care’s central role in complex care management — more students will properly associate it with impact and engagement.

By covering every student’s tuition with no conditions, Einstein College of Medicine is hoping more of its students make public-spirited career choices. But come Match Day, its students will face the same pressures as other medical school graduates, steering them away from areas of medicine that can do the most good. More intentional and structural solutions are needed to alter the choice environment in medical education and better link graduating physicians with growing patient care gaps.

Ezekiel J. Emanuel is an oncologist, vice provost for global initiatives, and co-director of the Healthcare Transformation Institute at the University of Pennsylvania. Matthew Guido is a project manager in the Healthcare Transformation Institute.