Why Aren't More Students Applying to Medical School?

Did you know that there are only two applicants for every place in U.S. medical schools?

In Canada, surprisingly, close to four students apply for each opening. The training in the two countries is very similar; indeed, the Association of American Medical Colleges (AAMC) accredits medical schools in both countries. And, in the U.S., at the high-end, physicians can hope to earn far more than Canadian doctors.

Why then do so few Americans apply to medical school?

The answer is that we have priced a medical education well beyond the reach of most middle-class students. In 2004, tuition and fees at a public medical school averaged $16,153. Students who attended a private school paid $32,588 according to a 2005 study published in The New England Journal of Medicine.

The author, Dr. Gail Morrison, Vice Dean for Education at University of Pennsylvania School of Medicine, tacks on $20,000 to $25,000 a year for living expenses, books and equipment to calculate that the total cost of four years of medical education comes to a heady $140,000 for public schools and $225,000 for private schools. I'd add that, in many American cities, students would be hard-pressed to cover rent, food, clothing, utilities and transportation for $20,000 a year -- let alone books and equipment.

This helps explain why 60 percent of all medical students come from the wealthiest one-fifth of all U.S. families. Another 20 percent come from families lucky enough to be on the fourth step of a five step ladder.

In Canada, by contrast, a medical education is much more affordable. In Quebec province, for example, students paid a piddling $2,943 in tuition last year -- though admittedly, this deal was available only to Quebecers. But elsewhere in Canada, tuition averaged just $12,728 -- about 25 percent less than Americans were paying to attend a public medical school back in 2004, and about 60 percent less than they laid out to attend a private school.

As a result Canadian students are much more open to becoming primary care physicians, even though they know that internists earn lower salaries than specialists. Granted, in Canada the government determines the ratio of residencies for primary care versus specialties, but students are willing to fill the spots. Canada is now close to its goal of having 50 percent of its physicians practicing primary care.

In the U.S., where the Association of Medical Colleges strongly supports free choice of specialty for students, only about one-third of medical school graduates become primary care physicians. This is understandable: the average U.S. student leaves med school with $130,000 in debt. Moreover, unlike law or business students who enter the workforce immediately after graduation and can begin to pay off their debt, the average medical school graduate spends an additional three to six years in postgraduate training programs while interest continues to pile up. Meanwhile, he is painfully aware of salary differentials: recent numbers show the average family doctor earning $146,000 while the typical invasive cardiologist brings home $400,000. And at the beginning of his career, a family doctor can expect to earn much less -- perhaps $100,000, before taxes.

Little wonder then, that the share of medical students pursuing careers in primary care has plummeted from 49 percent in 1997 to 37 percent in 2003; over the same span, the number gravitating toward careers in radiology, orthopedics, ophthalmology, and dermatology has sky-rocketed.

Yet we don't need more dermatologists. But we do need more primary care physicians. Decades of research done at Dartmouth University show that when Americans see more family doctors and fewer specialists, outcomes are better, in large part because patients receive more preventive care and ongoing management of chronic diseases before they become serious. (I have previously written about this issue for Dartmouth.)