Arak Journal

Putting a Price on Life

By Alex Arellano

I have lived all around the world in my lifetime, but the
one place I called home for most of my childhood was the hospital. From
catching the Swine Flu in Singapore, to getting water parasites in Vietnam,
none of my constant visits to the ER could prepare me for the bug that would
afflict me for the rest of my life: the dream of being a doctor. There was
something reassuring in hoping that one day I would have the opportunity to
help others as those before me have done, through all their accidents and ailments.
That dream would be enough to push me out of my hospital bed and send myself
flying towards achieving greater heights in academics and extracurriculars.
Before coming to college, I felt like nothing was going to stop me from pursuing
that dream. That is until I was introduced to the world of student loans.

Facing the possibility of up to half a million dollars
in student loans with interest after medical school, I?ve found myself lost,
questioning if saving lives is still worth the cost. Unfortunately for the
medical field, these thoughts are not that uncommon among medical school
prospects. As the cost of schooling continues to rise in the United States,
many students from middle and lower-class families have turned their backs on
the dream. Ultimately, the financial factors associated with going to medical
school far outweigh the benefits for many students, leading to a shortage in
doctors, despite the sharp growth in demand for physicians in the coming years.

To understand how the financial burden of medical
schools is affecting attendance rates today, one needs to understand how medical
school debt has changed over time. Dr. Ryan Greysen of Yale University School of
Medicine notes in his article A History of Medical School Debt? that schooling
since 1963 has been growing increasingly loan dependent as attendance costs
rose, with 86% of medical students graduating with debt as of 1984 (840-841). This
growth in loan dependency was a direct result of increasing medical school
costs, as family and personal contributions would no longer be sufficient to cover
most of tuition. To emphasize this growing loan dependency, Greysen highlights
how the number of students graduating with debt between 1984 and 2010 remained
?relatively the same?, but total indebtedness spiked alarmingly to [an
average] of $158,000?, with payback periods of 25-30 years? (840). Not only
would this make the issue of loans a problem for the recipient, but a problem for
the loaner as well. With more and more loans left unpaid for longer periods,
?fewer lenders [are] willing to stay in the student loan business? (841). For
the loan services that remain in the student loan business, less competition means
that they are able to inflate their interest rates, driving the amount students
will be paying even higher.

Medical school indebtedness shows no signs of slowing
down. Current projections estimate that by 2033 graduates will be graduating
with a debt of nearly three-quarters of a million dollars? (AAMC-OSR Student
Affairs Committee and OSR Administrative Board 1) before interest. Despite
this, some argue that increasing salaries are more than enough to counteract
the rising costs. Between 1995 and 2012, salary increases for doctors ranged
anywhere between 50% for some specialties and 10% for primary care physicians (Rosenthal
2). This wide range in salary growths is not proportionate to the growth seen
by loan amounts and will leave many physicians still paying off their loans
throughout their career. If debt levels continue to rise at their current rate,
regardless of increasing salaries, then more students will be left questioning
if medical school is still worth the investment in the long term.

The growing uncertainty in future medical school
attendance rates will only serve to cause the medical field to suffer. Like the
cost of medical school, the demand for doctors in the coming years shows no
signs of decreasing. Current projections estimate that by 2030 the United
States will be faced with a shortage of between 42,600 and 121,300 doctors
(?Physician Supply and Demand Through 2030?). Of course, there are several
reasons why the US is facing this shortage. The major driving force of this
growth in demand is an aging population. In the next twenty years, the
population of individuals 65 and older in the United States is expected to rise
by more than 50 percent (?Physician Supply and Demand Through 2030?). This
spike is incurred by the baby boomer generation now preparing to retire. While
older individuals typically have higher medical costs, the baby boomers
retiring will also take with them approximately one quarter of the United
States? public health workforce (Leider et al., 5). While rising cost of
medical school is not the greatest factor influencing this growing demand for
doctors, it is the main factor that can be fixed to address the shortage.

The shortage of doctors can also be attributed to a
lack of socioeconomic diversity among medical school students. In her editorial
for Academic Psychiatry The Rising Cost of Medical Education and Its Significance
for (Not Only) Psychiatry?, Marcia Verduin and her co-authors argue that the
rising cost of medical school has made it difficult for lower-income families
to afford to send students to medical school (305). Verduin?s study found that
in 2005, only 10 percent? of graduating medical students had come from
families in the lower two quintiles of household income?, while a quarter of
medical students came from the lower two quintiles? in 1971? (306). This drop
in enrollment from lower-income families is directly correlated to the rise in
cost covered in Greysen?s article. As the costs rose, the allure of a high
income was no longer enough to convince many to make the investment in medical
school education. This idea affected lower-income families the most, as many
would be willing to risk what little they have in one of the most difficult and
competitive career fields.

For the medical students who chose to take on the
burden, the debt they incurred has directly lead to a shortage in primary care.
The medical field can be divided in to two general categories:primary care and
specialty care. Primary care consists of physicians who have general knowledge
of most fields. Specialty care consists of the fields of medicine that focus
specifically on one aspect of medicine like cardiology or oncology. Primary
care counts as one field, and if a case goes beyond the training of a primary
care physician, that physician will refer a patient to a specialist. By examining
the Association of American Medical Colleges? (AAMC) projected ranges for both primary
care and overall physician shortages, it can be calculated that shortfalls in
primary care physicians will account for between 34% and 40% of overall
projected shortages based on the highest and lowest estimated shortage values (?Physician
Supply and Demand Through 2030?). The shortages of primary care providers can
be attributed to the salary growth previously established (Rosenthal).
Rosenthal highlights that with the salary growth disparity, there is also a
shortage with graduating students entering primary care. Each year, only about
25 percent of graduating doctors choose to enter the primary care field
(Rosenthal 3).  Making less money than
those in specialty fields, primary care physicians find it increasingly
difficult to pay off their debt, with many pediatricians and general doctors?
struggling to survive? (Rosenthal 3). Since primary care physicians are the
first line of health care in the United States, a shortage in primary care will
result in several repercussions throughout the medical field for more than just
doctors.

The financial burden tacked onto doctors not only
affects physicians but will have great implications on patients as well. As
previously established, primary care physicians are facing the greatest
shortage in the wake of rising debt, deterring many new doctors from the field.
How is doctor specialization bad for the patient? Wouldn?t more doctors in the
specialty fields reduce costs because of competition? Unfortunately, this is
not the case. Melinda Abrams et al. argue in their editorial Realizing Health
Reform?s Potential?, primary care reduces medical costs by focusing on
preventative medicine, decreasing the use of tests and procedures that are more
expensive (2). Rosenthal touches on this idea as well by referencing one
individual?s experiences (1). This patient had the least dangerous form of skin
cancer but raked in a total care bill of $25,000 because s/he had to see three
different specialists, who each ran their own series of expensive tests (Rosenthal
1). While a primary care physician may not be qualified to run such tests or
even treat it, a primary care physician would have been able to refer the
patient to a single specialist.

Now that the issues of costs regarding
doctor-preparation programs that face the medical field have been brought into
the spotlight, the question of how to fix them arises. The federal government
currently has several programs in place like the Public Service Loan
Forgiveness program and the Primary Care Loan Program to reduce loans for
doctors after graduation, yet these programs alone will not fix the shortages.
Capping public medical college costs will help reattract students from lower
income groups in the long run. However, doctors won?t be able to solve the
shortage issue alone anymore. Considering undergraduate studies, graduate work,
and residencies, it takes doctors a long time to complete their training. With
a demand spike for doctors looming over the coming years, the medical field
does not have enough time to wait on new doctors to finish their studies. The
medical field will also need to look to alternative healthcare providers like physician
assistants and nurse practitioners to address the immediate issue the medical
field faces.

Taking a closer look at what?s being done about the
issue, we can see that the federal government already has several programs,
grants, and scholarships in place to help medical students pay for schooling.
Like undergraduate students, medical students have access to federally granted
loans like the Primary Care Loan Program. For this program, medical students
are guaranteed low loan rates in exchange for completing their residency in
primary care and working in that field for at least 10 years (Marcu et al.,
967). By providing students with a low-interest loan in exchange for working in
the primary care field, the government is making efforts to address the
shortages primary care will be facing. Of course, loans are still a cost future
physicians will have to worry about, which is why the government is attempting
to shorten how long doctors are in debt with the Public Service Loan
Forgiveness Program, which allows physicians to have the remaining value of
their loan forgiven? after 120 loan payments, leaving physicians debt free
from that point forward (967).

 That may take
some of the loan worries off students? shoulders, but is it possible for
students to entirely avoid loans and remain debt-free after graduation? The
federal government answered this question with service-based scholarship
programs. Organizations like the National Health Service Corps sponsor medical
students and provide them with a monthly stipend while in medical school, in
exchange for practicing medicine in regions like rural communities where doctor
shortages are greater, for each year they were sponsored (967). The Health
Professions Scholarship Program (HPSP) and Uniformed Services University (USU)
are both program sponsored by the military to tackle medical shortages in the
military. The HPSP is a scholarship program that covers the tuition of medical
school for students, in exchange for the same number of service years that they
were sponsored for by the scholarship in the sponsoring military branch (967).
The USU is a military medical college that provides students with free medical
education in exchange for a minimum of seven years active military service
(967). While these programs are in place, why is the doctor shortage still a
cause of great concern? The simple answer is that the funding for these
programs is limited at this time. To re-attract lower-income students to the
medical field, funding must be increased for these programs to open more slots.
Efforts to address costs are not only a national issue, but are now being
addressed as a state-level issue on a state-by-state basis.

One example of the medical crisis being addressed on
the state level can be seen in Texas. As the second largest state in the US in terms
of both both square mileage and population density, Texas faces a doctor crisis
higher than the national average. As of 2016, Texas was ranked 43rd
in the United States for physician-patient ratio (Dickey 1). This was worrying
to Texas lawmakers, as Texas? population was far outgrowing its physician
population growth. To address this issue, lawmakers passed a bill which capped
in-state public medical college tuition at roughly $6,550 a year (Satyanarayana
1). At those tuition rates, in-state medical students from Texas will be
graduating with potentially less than $100,000 in student debt. This has helped
Texas attract even more medical students from lower-income families.

For many Texas medical school students, the idea of
having copious amounts of debt is now one less worry they will have to think
about. Of course, with even more medical school graduates with an average debt
significantly lower than the national average, how could you guarantee the
retention of those doctors? The simple answer was to increase funding for Texas
residencies. Texas had passed a budget for the 2018-2019 year that included $97
million just for supporting its residency programs and increasing the number of
spots available in them (Satyanarayana 2). Through its efforts, Texas has
managed to increase its graduate retention rate to 65 percent (Satyanarayana 2).
What Texas has done is what needs to be done nationwide. Federal efforts need
to be refocused towards capping public medical school tuition rates to a cost
that will make schooling more affordable to those from lower-income families.
With an influx of medical school graduates, lawmakers will need to increase funding
towards residency programs, allowing more spots for the increased number of
students. This effort will help combat the national shortage of doctors in the
long run.

While reducing costs will attract doctors for the
foreseeable future, the amount of time it takes for medical education for
doctors is still great. Including undergraduate studies and residency, it may
take doctors approximately 11-16 years to complete their studies (?Deciding on
a Career in Medicine?). The United States does not have the time to wait for
new doctors with the looming patient crisis. Doctors are expected to meet
certain expectations in background and knowledge, so shortening medical school
and residency lengths would only be detrimental to the quality of healthcare in
the United States. So how can the US address the immediate issue of doctor
shortages? The answer: by increasing the role of nurse practitioners and physician
assistants in the healthcare field. Nurse practitioners and physician assistants
are advanced-practice healthcare providers who can perform many of the duties
and responsibilities of a physician (?Nurse Practitioner vs. Physician
Assistant: Which Career is Right for You). Physician assistants are only
allowed to practice under the direct supervision of a physician, while some
states allow nurse practitioners to operate autonomously without supervision
(?Nurse Practitioner vs. Physician Assistant: Which Career is Right for You).
This difference in freedom is a result of the time it takes to become a
Physician Assistant or nurse practitioner. Becoming a physician assistant only
takes 6 years, including undergraduate studies, while becoming a nurse
practitioner takes 8 years, due to the requirement for prior nursing experience
(?Nurse Practitioner vs. Physician Assistant: Which Career is Right for You).
Regardless, both career paths still take less time than it does to become a physician.
While nurse practitioners can?t perform all the duties a physician may be able
to, utilizing nurse practitioners in primary care will help alleviate some of
the immediate shortages the field currently faces. Physician assistants, while
requiring the supervision of a physician to operate, can perform procedures
that nurse practitioners cannot. With a physician working in primarily a
supervisory role, several physician assistants can work for one physician,
which will help alleviate the shortages seen in specialty care.

For me, America was supposed to be the land of
opportunity, and I believed that if I work hard enough, I can achieve my dreams.
Unfortunately, dreams come with a price tag, and the reality of affording a
dream education for a dream job only hit me as I grew closer to achieving my
dream. The idea of this dream turning into a financial nightmare also afflicts
other students. The few who choose to take on the debt find themselves
influenced by their debt to enter fields with higher incomes, taking away
qualified physicians from the fields that need them the most, like primary
care. This makes rising medical education costs not only a problem for
physicians, but for patients as well, sending patient costs skyrocketing.
Ultimately, America has found itself on the brink of a crisis that will affect
more than just doctors. While efforts have been made to address the rising
costs, America?s lawmakers need to take on a more aggressive approach to
increase federal funding for healthcare education programs. To address the
issue immediately, members of healthcare teams like nurse practitioners and
physician assistants will need to play a larger role in patient healthcare. Until
America realizes how the cost of having fewer doctors will affect the country,
hopeful physicians will be left asking how can I afford this instead of
asking how can I help you

Works Cited

Work Cited

AAMC-OSR Student Affairs Committee and OSR Administrative Board. “The High Price of a Dream Job.” American Association of Medical Colleges. 2010. pp. 1-12. https://www.aamc.org/download/276596/data/thehighpriceofadreamjob.pdf

Abrams, Melinda et al. “Realizing Health Reform’s Potential.” The Commonwealth Fund. June 2011. pp. 1-28. http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2011/jan/1466_abrams_how_aca_will_strengthen_primary_care_reform_brief_v3.pdf

“Deciding on a Career in Medicine.” Association of American Medical Colleges. https://students-residents.aamc.org/choosing-medical-career/article/deciding-career-medicine/

Dickey, Nancy. “Retaining Medical School Graduates in Texas” Texas Medical Association. February 2016. https://www.texmed.org/Template.aspx?id=35118

Greysen, Ryan et al. “A History of Medical Student Debt: Observations and Implications for the Future of Medical Education .” Association of American Medical Colleges. July 2011. pp. 840Grer-845. https://journals.lww.com/academicmedicine/fulltext/2011/07000/A_History_of_Medical_Student_Debt__Observations.16.aspx#pdf-link

Leider, Jonathon et al. “Reconciling Supply and Demand for State and Local Public Health Staff in an Era of Retiring Baby Boomers” American Journal of Preventative Medicine. March 2018. pp. 334-340. https://www.ajpmonline.org/article/S0749-3797(17)30649-9/ppt

Marcu, Mircea et al. “Borrow or Serve? An Economic Analysis of Options for Financing Medical Education.” Academic Medicine. July 2017. pp. 966-975. https://journals.lww.com/academicmedicine/Fulltext/2017/07000/Borrow_or_Serve__An_Economic_Analysis_of_Options.40.aspx

“Nurse Practitioner vs. Physician Assistant: Which Career is Right for You?” MastersinNursing.com. https://www.mastersinnursing.com/guide/nurse-practitioner-vs-physician-assistant-which-career-is-right-for-you/

“Physician Supply and Demand Through 2030: Key Findings” Association of American Medical Colleges. April 2018. https://aamc-black.global.ssl.fastly.net/production/media/filer_public/b2/09/b2096c37-00aa-43e0-bfac-63cf532a7997/aamc-physician-supply-demand-key-findings-2018.pdf

Rosenthal, Elisabeth. “Patients’ Costs Skyrocket; Specialists’ Incomes Soar.” The New York Times. 18 January 2014. www.nytimes.com/2014/01/19/health/patients-costs-skyrocket-specialists-incomes-soar.html?_r=0.

Satyanarayana, Megha. “Med School on the Cheap: Why becoming a Doctor in Texas is a Bargain.” Statnews. 30 October 2017. https://www.statnews.com/2017/10/30/texas-medical-school-bargain/

Verduin, Martha et al. “The Rising Cost of Medical Education and its Significance on (Not Only) Psychiatry.” Academic Psychiatry. June 2014. pp. 305-308. https://link.springer.com/content/pdf/10.1007%2Fs40596-014-0118-7.pdf

Paper Prompt

E110

Spring 2019

Dr. Taylor

Research-Based Writing

Goal:  To write a research-based paper that makes and develops a claim about a topic of interest to you.  The writing must NOT merely convey information.

General Goals to Consider:

• Ask and answer a new question
• Offer alternatives to existing ideas or evidence
• Provide a new perspective or better evidence on something already known

Question Prompts That May Help You Frame Your Thinking:

• What does x mean
• What can be said with truth about the relationship between x and y? 
• What should be done about x? 
• Which is better, x or y? 
• How can we best achieve x or y?  Why should we stop doing x or y

Some Suggested Approaches:

• A problem that needs to be solved in your intended major
• A question or uncertainty in your intended major
• Propose alternatives to existing ideas OR weigh the validity of existing ideas
• Provide a new perspective or fresh evidence on an existing problem
• Examine the validity of arguments around a controversy in your field
• Analyze the prospects of a particular career path in your intended major

Sources:  Incorporate at least ten, eight of which you must cite at least two times

Length:  8-10 pages, plus Works Cited Page

Process Pieces:  To stay on track with the process of writing the paper, the following guidelines should help:

• 4/30:  Have at least 10+ sources; Go or NO Go Decision on topic
• 5/9:  Outline
• 5/14:  Draft for peer review
• 5/16:  Final Draft
• 5/23:  Revisions

Due Date:  No later than 5/16 at midnight.  Deductions of 10% per day late.

Value:  30 points (outline = 5 pts.; final draft = 25 pts.)