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In August 2018, New York University (NYU) announced it will offer full-tuition scholarships to all current and future students in its MD degree program, regardless of need or merit.1,2 The primary goals of this approach by NYU are the reduction of a continually increasing student debt, an increase in the number of students who choose primary care specialties, and an increase in socioeconomic diversity of the student body.1 The general consensus is that ever-increasing medical school debt is one of multiple variables that influence the specialty choice of many medical students and also creates a potential barrier for many students from marginalized and disadvantaged populations who might pursue a career in medicine.
According to information from the Association of American Medical Colleges (AAMC), in 2017, the median educational debt for graduates from both public and private medical school was $192 000.3 As a result, the health care workforce does not reflect the increasingly diverse population it serves. The question is whether free tuition will increase the number of students entering primary care specialties while simultaneously increasing workforce diversity. As pointed out in the NYU announcement, the cost of professional school is only one factor that is a challenge in increasing diversity.1
In taking this step to provide free tuition, NYU joins other medical schools that have attempted to reduce student financial burden through approaches that include no-loan financial aid packages (Columbia University Vagelos College of Physicians and Surgeons), fully paid tuition and fees targeting physician-scientists (Cleveland Clinic Lerner College of Medicine of Case Western Reserve University), and merit-based full scholarships (UCLA David Geffen School of Medicine).4 With the exception of the Cleveland Clinic Lerner School of Medicine at Case Western Reserve University (started in 2008), many programs are new and have been in place for only a few years. There is a lack of published outcome data directly correlating free medical school tuition with increased enrollment of underrepresented minority students or an increase in the number of students pursuing a primary care specialty. In addition to the small number of schools offering free or reduced tuition, the types of tuition reductions are varied and, for the most part, institution specific. This ranges from merit-based scholarships, full tuition scholarships, and loan-free tuition packages to free tuition targeting a select group of students.
The 2018 Medical School Graduation Questionnaire showed that the percentage of medical school graduates who said their educational debt affected their choice of medical specialty has steadily decreased, and now, more than half (55.3%) of respondents (16 223) state that it has “no influence” on their specialty choice, with only 21.3% stating that debt has either a “strong” (6.3%) or “moderate” (15.0%) influence.5 According to AAMC data, during the past 5 years, the strongest influence on specialty choice reported in the 2018 Graduation Questionnaire was “Fit with personality, interests, and skills.” In addition, the content of specialty and the influence of role modeling were cited as strong influences.5
Most students, including minority, disadvantaged, and marginalized students, enter medical school pursuing a lifelong dream of practicing medicine with little sense of projected incomes or what specialty or subspecialty they would like to pursue. As shown by AAMC data, most students do not make specialty choices solely on the basis of the high cost of medical school or the overall potential revenue based on specialty.5 Most specialty choices are likely based on social, educational, and health care experiences; experiences in medical school; and the prospect of a 30-plus-year career in an area of medicine that provides a level of personal comfort, support, and fulfillment.
During a 36-year period (1980 to 2016), the overall number of applicants to US medical schools increased by 47% from 36 083 to 53 042, and the number of students admitted to US medical schools increased by 27% from 16 587 to 21 030.6 In contrast, the numbers of black or African American and Hispanic or Latino applicants increased by only 1.2% (7.0% to 8.2% and 5.0% to 6.2%, respectively), while the numbers of Alaska Native and American Indian applicants declined by 29 (from 0.4% to 0.2% of all applicants). During this same period, the total number of African American matriculants increased from 999 (6.0%) to 1497 (7.1%), whereas the number of Hispanic matriculants increased from 807 (4.9%) to 1335 (6.3%), which are increases of only 498 (14/year) and 528 (15/year), respectively.6 Despite an increase in the total number of available medical school positions between 1980 and 2016, representation of black or African American, Hispanic or Latino, and American Indian or Hawaiian Native individuals increased by only 2.4% (11.3% to 13.7%),6 remaining far below the current proportion (33.0%) of minorities in the US population.7 The relatively low numbers of both applicants and matriculants is likely a reflection of the lack of student support and engagement at the preadmissions (kindergarten to college) level and, in some cases, an admissions process that continues to focus on standardized test scores.
If medical school admissions processes continue to be weighted toward metrics and the number of minority, disadvantaged, and marginalized applicants remains stagnant, attempts to diversify the health care workforce will fall far short, despite reduced or free tuition.
As a result of free tuition, the number of minority students accepted and matriculating at NYU may increase. NYU should be able to attract, enroll, and support minority and disadvantaged students who have high GPAs and MCAT scores and are considered highly competitive. The NYU program may increase diversity at NYU, but taken in context with the stagnant national applicant pool, the increased enrollment at NYU may result in a “zero sum effect” on the national health care workforce as it relates to diversity and, by extrapolation, have no significant effect on our efforts to reduce health disparities and improve population health. This approach will reduce student debt but it must be coupled with funds that support activities, programs, and policies focused on increasing the applicant pool through pipeline programs focusing on science, technology, engineering, and mathematics (STEM); mentoring; role modeling and shadowing; and targeting minority, underserved, and marginalized populations. If not, free tuition may result in the “shuffling” of students, with more top performers attending a select number of medical schools with no significant increase in national enrollment numbers.
In the current system of postgraduate training, most medical students do not simply decide between pediatrics and neurosurgery. In some respects, medical students behave as stem cells. At some point, they are all undifferentiated and multipotent. Given the right environment and stimuli, students are able to differentiate and pursue careers in any specialty. Setting aside metrics, there are vast differences in the skill sets that are unique to each specialty. The absence of debt or the potential for a higher salary should not persuade any student to pursue a specialty in which they are not comfortable and happy, or that does not foster solid interpersonal relationships that are so important in developing a successful career. In short, the student should consider what specialty is the “best fit.”
The admissions process continues to be key to efforts to diversify the health care workforce. Medical school leaders must continue to support a holistic admissions process that includes both socioeconomic status and race/ethnicity as well as other noncognitive attributes of applicants from minority groups and those with lower socioeconomic status. Maintaining or altering the admission process to one that is holistic in nature, not entirely metrics driven, and designed to achieve the institutional mission should be the goal of medical schools.8 Changes in the institutional admissions process may be the quickest way to select and graduate a cohort of physicians that will help fill the shortages in primary care specialties, improve patient access, close the health disparities gap, and ultimately improve population health.
Corresponding Author: Billy Thomas, MD, MPH, Center for Diversity Affairs, Department of Pediatrics, University of Arkansas for Medical Sciences, 4301 W Markham, Little Rock, AR 72204 (email@example.com).
Published Online: December 7, 2018. doi:10.1001/jama.2018.19457
Conflict of Interest Disclosures: None reported.
Thomas B. Free Medical School TuitionWill It Accomplish Its Goals?. JAMA. Published online December 07, 2018. doi:10.1001/jama.2018.19457
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