Director, Robert Graham Center for Policy Studies in Family Medicine and Primary Care

By Alex McEllistrem-Evenson

The Robert Graham Center, located in Washington DC, is a research center sponsored by the American Academy of Family Physicians that is dedicated to bringing a family practice and primary care perspective to health policy deliberations. In March 2009, the Robert Graham Center published a report with the support of the Josiah Macy Jr., Foundation titled “What Influences Medical Student & Resident Choices?,” the culmination of one of the most comprehensive analyses of medical student debt load to date. Dr. Phillips, also a practicing family physician, was the lead researcher on the project.

Can you provide an overview of your method of studying student debt?

I was at an AMSA meeting on student debt several years ago with Dr. Fitzhugh Mullan and we were talking about how thin the evidence was relating to the effects of debt. I said if I were going to study this I would probably work retrospectively and get all the data on current practicing physicians: look back at their training experiences, at their debt loads out of medical school, about the options that they took or didn’t take for National Health Service Corps regarding loan repayment programs, and try to get a real handle on how debt does or does not play a role. He thought that was a great idea and the AAMC folks were in the room and were feeling generous and said “you should come talk to us, we have some of that data.” So the AAMC was instrumental in giving us the graduate questionnaire data. We got physician specialty and location data and we matched it up to their experiences in medical school and some of their background, including debt on graduation and debt on entry into medical school.

It really was, I think, the most thorough analysis of how those experiences and those characteristics either do or don’t help explain where physicians wind up in practice. The project didn’t ask “what are your intentions, what are you doing in your choice of residency right out of medical school,” it’s “where are you practicing and in what specialty?” which is why I think it’s so powerful in telling us what the debt thresholds that matter are and pointing to this polarity of who’s getting into medical school, who’s graduating with debt, and how it affects their choices.

Please provide a brief assessment of the impact that student debt load has on the number of primary care professionals entering the health workforce.

I think that debt, particularly the speed at which it has risen over the last ten or fifteen years, has created a barrier for production of primary care clinicians that we don’t even recognize. It’s keeping people from even considering going to health profession schools, because the thought of taking on that kind of debt is out of reach for people even in the middle class. So we see in medical school that the number of people coming from affluent families has risen considerably. I think that’s not just an indication of better opportunities and education and meeting the hurdles for getting into med school, but I think it actually represents the fall-off in people from middle and lower class in thinking about taking on the level of debt that most of these students do.

We recognize that a lot of the folks coming into medical school who are able to graduate with no debt – that’s a growing proportion of these students – come from families and neighborhoods where the earning potential of the primary care physician is not consistent with the lifestyle that they’re used to. So I think that compounds the debt issue.

On the other side, we see a number of students taking National Health Service Corps scholarships or loan repayments and going into primary care at much higher levels. So there obviously is a group of these students who are willing to trade debt for service. I think it really is polar—it’s become more polar in medical school and health profession schools.

There are a number of programs designed to mitigate debt load in various ways. Are there any you would choose to highlight which you feel are particularly effective or underrated? Is there anything new or innovative in this regard?

I think we’ve shown that the National Health Service Corps is a pretty potent program for helping students to trade debt for service. Sure, a lot of those folks come in with altruistic ideals, but we know based on our work that they really are filling some of the high need areas and they’re staying for six to ten years beyond their obligation. It’s an extremely important program and an important opportunity for people to reduce their debt and meet some real need. The ARRA [stimulus] funding which expands the National Health Service Corps is quite important. We’ve actually looked back at the Reagan years when they cut the Corps and looked forward and shown that we probably have about 5,000 fewer physicians in underserved areas than we would had the Corps not been cut during that period of time. So we think that this expansion is going to be a big deal for shortage areas and a big opportunity for people to choose primary care because they can offload some of their debt.

In our Macy paper we talked about a study that’s been done in New York with law schools, I don’t know whether it would carry over to medical schools directly or not, but it showed that scholarships are critically important for helping people make service career decisions. I know that the NHSC scholarships have been reduced based largely on evidence that people are graduating unhappy about some of their forced choices, and I think there are ways to deal with that too. North Carolina has a really innovative scholarship program in which people can take scholarships with a choice to go into primary care. They can choose differently at the end, they just have to repay the loan with some interest. They’ve gotten a lot higher yield of primary care professionals as a result; they’ve also created a self-sustaining scholarship program because now it is completely sustained by people changing their minds and paying back with interest.

I think we should really support more of the scholarship programs and look for ways to make them self-sustaining. The reason I think that’s so important is it allows people to come into medical school who might not otherwise because they’re not taking on the debt. The law school study shows that some people are just so averse to taking on debt, even though they know that they can get it repaid, that it keeps them from going to school.

What is the role of private foundations in all of this? Should foundations be working more closely with government to alleviate these primary care and debt load problems?

I don’t have a lot of experience working with private foundations. I do know that there are some which probably make the greatest impact locally and which really work on helping students go to school who say they’re coming back home. I think there are a lot of small family foundations that might be of great help to small and underserved communities, working with people they know in those communities with whom they can create a relationship and a contract to come back. I think that might be a little harder on a larger scale, although it’s an interesting question — if a foundation could create a self-sustaining scholarship program like the one North Carolina has, I think that could be a great opportunity.

I think one of the problems with foundations and increasingly even the federal government is that they’re really interested in short term gains. When you talk to legislators they want programs that are going to put more primary care doctors in their communities tomorrow. And when you start talking about scholarships or programs that operate farther back in the pipeline, they lose interest. So I just think we need to engage them and convince them that this long-term investment will have much bigger payout than looking for quick fixes.

Is that a reason why AHECs always seem to be struggling for funds, because they work so far ahead in the pipeline that it’s harder to produce immediate demonstrable results?

Absolutely. AHECs and Title VII funding both really struggle because it’s so hard to point to their effects; it’s so far down the pipeline. We were able to show for Title VII at least that there really is an effect that’s measureable – rather, that there’s an associated effect that’s measurable. We’ve made that case several times, but you’re dead-on. The folks evaluating them, the folks in Congress, want to know that a given project is having an impact right away, and things like AHECs and Title VII can’t have an effect like that.

Your study found that being born in a rural county—not necessarily growing up in a rural area—increased the odds that a student would practice medicine in a rural area by 2.4 times and nearly doubled the odds that a student would choose to practice family medicine. I was surprised to see how much of a factor that was.

I was too and I was talking to folks from the AAMC about that yesterday. It would be much better if we could include where their high school was because that’s a much better measure of rural background. But even that something as distant as being born in a rural area had such predictive value is pretty amazing. I grew up in a rural area and I think it means that people can think of living in those areas and know what it means to live there and say “you know, that’s a viable place for me to raise my family.” People who were born or raised in the suburbs may not consider these places to be an option. They’ve never been exposed to it.

And I think those folks who choose to practice in rural areas know too that while primary care physicians earn less, their cost of living is going to be lower in the rural areas. I think that they recognize that their dollar will go farther there in some cases. The other thing we saw is that students who had rural rotations in medical school were more likely to go into primary care. I think that exposure is important, whether it’s that growing-up exposure or your training exposure, and I think that Howard Rabinowitz has shown that to a great degree in Pennsylvania. They just have such high success with students going into rural areas of practice because of their rural track in medical school.

A lot of people are wondering about health reform and how that might have an effect on primary care workforce issues and debt load in particular.

I’ve been largely disappointed with the health reform discussions about workforce. They’ve been unwilling to do anything really substantial with Title VII or any kind of funds to really affect school choices about who they accept into medical school – accepting more rural students, for instance. They’re unwilling to invest more in the things that affect curriculum and in exposing students to primary care and underserved or rural health care careers. They’ve been unwilling to touch the ten to eleven billion dollars of Graduate Medical Education money that funds residency training and move it from hospitals into outpatient areas. They’ve done some important small suggestions, moving training into community health centers for example, but the money behind that is just so small compared to what’s pouring into hospitals for training now. So they’ve made some important small steps but not the kind of big steps they’re going to need to make if they suddenly open up access to health care for everyone. That pipeline is just not prepared to put primary care into play like they’ll need.

It seems like primary care is valued differently around the world, more highly, than it is here.

That’s absolutely true. Primary care docs may not be paid any more than they’re paid here, but they’re not paid that much less than their non-primary care colleagues. That relative difference in payment and earnings is less. In our report we showed that making the choice to go into primary care is making the choice to give up about 3.5 million dollars over your career, if you were to go into any of the average paying non primary care specialties. That’s a hard choice. It not only affects physician choices, but it affects the business model of hospitals and clinic systems, that they’re going to be much more focused on and value more highly the work of subspecialists and that gets communicated to students.

In other countries where the health system is focused on equity, on giving everyone access to good health care which improves population health and drives down costs, this is predicated on a good primary care foundation. The UK made that choice in the 1940s and France made it in the 1960s and Spain made it twenty years ago in the 1980s. You can look at what’s happened since they made those choices, comparing them to themselves and certainly comparing them to the U.S., and see that they all improved in their outcomes, they improved in the rate of growth in their health care costs. There is considerable evidence that we are going to need to improve our primary care foundation if we really hope to give everyone access to care and also hold down costs.

Ultimately is this going to require a shift in culture surrounding primary care attitudes or is this something that can be mitigated with increased funding?

Well, pushing more money at it is not necessarily the option. That’s one option. The other is to lower the amount of money that flows into non-primary care specialties, or some combination of the two. I think if we try to do this by modifying culture, it’s not worth doing. You’ve got to change the economic equation and the satisfaction equation and that will change culture. But saying we’re going to work on culture has never worked for anything. You’ve got to let culture change with your other strategies.

Thanks for talking with us today. Before we conclude, is there anything else you would like to highlight for our readers?

I would point you to the Council on Graduate Medical Education and the COGME letter that came out in May. I am really concerned because we’ve got really good evidence that the primary care pipeline is almost reduced to half of what it was a decade ago. We have a workforce that’s 35% primary care and a pipeline that’s producing about 19-20% primary care at this point and the projections are that it will go down to 17% in the next five years. You just can’t sustain a primary care workforce when you’ve cut the pipeline in half. It’s a problem that not many people are paying attention to. It’s certainly not being addressed in this round of health reform. Most of that can be explained exclusively by growth in subspecialty training options. Almost nothing else explains that.

Please note that the views expressed in this article are the opinions of the interviewee and do not reflect the official policies, positions, or opinions of the Health Workforce Information Center or its funder.