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Will students with a free medical education choose primary care?

As referenced in the October issue of the GME e-Letter, the first class of students at the new University of Central Florida College of Medicine will receive full scholarships for all four years of their medical education (American Medical News, Sept. 7).

Many point to student debt as a factor in medical school graduates eschewing primary care for higher-paying fields. What effect (if any) will a free medical education have on these students' choices of specialty/subspecialty? We received the following feedback from a reader of the e-Letter.

"As a lay person involved in medical education and a frequent consumer of health care services at this stage of my life, I would argue that a 'free ride' for obtaining medical education at the undergraduate level will have no effect on the graduate's choice of specialty area. The notion that underlying educational debt influences specialty choice has been articulated for some time now. And the public buys this argument, unaware that the cost of undergraduate medical education is largely tied to living expenses while pursuing that education and not solely to the cost of tuition. That fact alone influences specialty choice to a considerable degree, given that some medical students attempt to 'live' the status of a physician before fully becoming an independent practitioner.

"Lifestyle choices are made while in medical school and not during residency because young adults today are constantly bombarded with the acquisition of status and images of the 'good life' and what it entails during their adolescent and teen years. While every personal statement made in the medical school application no doubt includes some reference to the desire to serve others, the intent becomes somewhat distorted during the actual process of 'becoming.'

"Older medical students, I feel, are less influenced by the media and are more intent most likely due to family circumstances. They know what they must do and have little time for indulgence. These are the ones, I most often see, who initially intend to opt for primary care specialties. With a family in tow, they (at least the ones which whom I am most familiar) want to get into practice as soon as they can, and residency in one of the primary care specialties allows them to do so. Some medical students will stay 'true in intent' from the beginning to end, but I also see a disappointing number speak in conversation about choosing a specialty based on how long they will have to work and how much they can expect to make. For this reason, I deliberately choose older physicians in solo practice and, when I’m referred to a subspecialist, I make an assessment during the initial contact as to whether the individual is interested in me as a patient or a 'billing opportunity.'

"Indeed, it will be interesting to see what the outcome will be for the charter class at UCF. My feeling is that there will have to be a strong articulation and persuasion by the school's administration and faculty that more physicians are needed in primary care. It could be that the later reflections 'forced' on this group by subsequent classes, which will not have the benefit of a free medical education, will cause this cohort to feel the need to 'pay back' by opting for primary care specialties or at least service in an underserved area for a period of time—it is stated, after all, that to whom much is given, much is expected. The current call for health care reform may also play a factor in the choices these future physicians will make relative to medical specialty. In the long run, however, the public wants physicians, regardless of specialty, to treat us as partners in our medical care and to regard us as fellow humans in the quest for good health. This is particularly true as American society grows more and more culturally and linguistically diverse."