I did some further research after Aline’s comment, and found more alarming information on the projected shortage of primary care physicians (sources: http://www.newsweek.com/2010/02/25/the-doctor-won-t-see-you-now.html, http://www.accessnorthga.com/detail.php?n=238189).

 “Last year, the Association of American Medical Colleges predicted a shortage of 45,000 primary care physicians nationwide by 2020. Experts say better pay and better hours are drawing medical students away from primary care to other specialties.” 

“If every American went to one of these [primary care] doctors regularly, health-care costs might come down as much as 5.6 percent a year, saving $67 billion, according to one estimate.”

“In the nation as a whole, there are currently 631 people for each primary care physician. But in Whitfield County the ratio of residents to primary care physicians is 1,078 to one, and in Murray County it's a whopping 5,791 to one, according to the 2011 County Health Rankings, published by the University of Wisconsin Population Health Institute and funded by the Robert Wood Johnson Foundation.”

“The annual number of American medical students who go into primary care has dropped by more than half since 1997.”

“The reason behind America's doctor gap is a matter of money. The average income in primary care is somewhere in the mid-$100,000s, which sounds like a lot but is less than half what specialists such as radiologists and dermatologists make. Given that doctors may graduate with as much as $200,000 in med-school debt, it's easy to see why primary care started hemorrhaging recruits more than a decade ago and why radiology and other well-paid, high-tech specialties took off in popularity.”

“The field has since entered a vicious cycle. As fewer people have entered primary care, the doctors who are left have been forced by tight schedules to shortchange some patients, forgoing the long, meandering chats that used to be a big part of checkups in favor of 15-minute, checklist-style appointments. The close relationships that general practitioners once had with patients drew many idealistic students into the field. Now recruiters face an extra-tough sell: they have to convince bright young would-be docs to pursue a career that won't pay very well and won't be as emotionally fulfilling as it once was.”

“…nurses and PAs are subject to the same economic forces that drive medical students. Almost half of current nurse practitioners and physician assistants work in specialty practices, where the money is. Then there's the fact that the country already has a nursing shortage. How are nurses going to replace doctors if there aren't enough nurses to begin with?”

“There's one more group of people, foreign medical graduates, who could theoretically fill in for the missing primary-care providers. The trouble is, they're already doing that. More than a quarter of primary-care doctors currently practicing in the United States have gotten their diplomas abroad. Increasing their numbers would be problematic for both the left (which might object to poaching doctors from developing countries that need them) and the right (which would surely object to recruiting non-Americans to do a job that reliably pulls in six figures, especially when unemployment is high).”

“And then, what exactly constitutes a task that should be reimbursed? For a high-tech specialist, this is often clear-cut: each scan or chemical test counts. But what about all the things primary-care doctors do that don't involve technology? ‘You don't get paid to talk to people and tell them to stop smoking. Nobody values my time to do that,’ says Joe Gravel, a family physician and chief medical officer at the Greater Lawrence Family Health Center in Massachusetts. ‘They'll pay for the lung transplants, but they won't pay to prevent 50 people from needing them.’"

“’Many doctors don't want to work 70 or 80 hours a week anymore. They want to be able to come home to their family at a set time,' said Dr. Stephen Rohn, chief quality officer at Hamilton Medical Center. `It's becoming more and more difficult to recruit to small communities where the call burden is an issue. More and more physicians want to work in a large group and work set hours.’'' 

These factors will exacerbate the shortage:

1.     An increase in the number of people enrolled in healthcare plans.

2.     An aging population.

3.     The current baby boomers who retire from their positions as physicians.

It seems like this shortage is a result of factors beyond people simply preferring to be specialists to primary care physicians. One such factor must be the cost of medical school, and consequent debt new physicians are left in, which drives them into higher-paying specialist positions.

Side note: One of the people I shadowed left me with a slightly unsettling answer when I asked if there had to be a cap on the useful  number of specialists that could exist (he said that in Canada, for example, there were hardly any specialists, and there, people had to drive significant distances, and sometimes, wait for months, before seeing specialists): “As long as there are specialists, people will be referred to them”. I’m not sure if there is data to back up this claim, but it is certainly disturbing.

So, if physicians become specialists, instead of primary care doctors, because of the cost of medical school, and their large amount of debt, the question becomes: why is medical school so expensive?

The first article I read after I did that search was one called, “The Medical Cartel: Why are MD Salaries So High?” (http://wallstreetpit.com/5769-the-medical-cartel-why-are-md-salaries-so-high). With the chart below, it points out that U.S. physicians are paid way more than physicians in other countries.  

The author then goes on to suggest that one of the reasons doctors can charge so much is that the American Medical Association (AMA) is restricting the number of medical schools, and consequently, the number of medical students, and physicians.

 “In 1963, there were only 135 law schools in the U.S. (data here), and now there are 200, which is almost a 50% increase over the last 45 years in the number of U.S. law schools. Unfortunately, we’ve witnessed exactly the opposite trend in the number of medical schools. There are 130 medical schools in the U.S. (data here), which is 22% fewer than the number of medical schools 100 years ago (166 medical schools, source), even though the U.S. population has increased by 300%. Consider also that the number of medical students in the U.S. has remained constant at 67,000 for at least the period between 1994 and 2005, according to this report, and perhaps much longer.”

 He suggests that turning away fewer applicants to medical school would mean more doctors, and lower healthcare costs, and compares the AMA to a medical cartel.

 “One reason we might have a “health care crisis” due to rising medical costs, and the world’s highest physician salaries is that we turn away 57.3% of the applicants to medical schools. What we have is a form of a “medical cartel,: which significantly restricts the supply of physicians, and thereby gives its members monopoly power to charge above-market prices for their services.”

 Finally, the author compares the AMA to OPEC, and refers to Friedman’s book, Capitalism and Freedom.

 “In his classic book Capitalism and Freedom, Milton Friedman describes the American Medical Association (AMA) as the “strongest trade union in the United States” and documents the ways in which the AMA vigorously restricts competition. The Council on Medical Education and Hospitals of the AMA approves both medical schools and hospitals. By restricting the number of approved medical schools and the number of applicants to those schools, the AMA limits the supply of physicians. In the same way that OPEC was able to quadruple the price of oil in the 1970s by restricting output, the AMA has increased their fees by restricting the supply of physicians.”

 In summary,

 “If we had 130 law schools (instead of 200) and 200 medical schools in the U.S. (instead of 130), it would probably go a long way to solving our “health care crisis.” More MDs at much lower salaries along with fewer lawyers and lawsuits would be a good thing, wouldn’t it? Can’t breaking up the medical cartel, training more physicians, and lowering MD salaries be part of the discussion for health care reform?”

Though interesting, this article did not answer the original question, which was, “Why is medical school so expensive?”. By expensive, I mean… “The average medical school debt today, according to the Association of American Medical Colleges, is $156,456.” And, “Ninety percent of medical school students incur some type of student loans to finance their education” (http://fmignet.aafp.org/online/fmig/index/premed/career/expense.html).

Apparently, “Tuition is just one source of increasing debt burdens. Other causes include:

•  Interest accrued on loans over time significantly adds to the total cost of student debt.
•  Students are now entering medical school with more education debt from undergraduate education.
•  Increasing numbers of “non-traditional” students who have children to support” (http://doctorsgates.blogspot.com/2010/09/increased-medical-student-debt.html).

One author says, “The thing is, American healthcare is expensive. But so is medical education. As we embark on this century, what are the odds that physicians with $240,000 loans for medical school will be able to offer inexpensive care? What are the odds they will enter low-paying specialties? They might be interested in charity care at first, but when the first loan payments come due all the good intentions in the world won’t change the fact that lenders want their money back. Likewise, it won’t change the hard reality that it will be extremely hard for these young physicians to pay for their student loans, buy a house, have a practice (pay malpractice) and raise a family; at least without making a large amount of money in their practices. And then there’s this striking (but seldom mentioned) fact: student loans are non-bankruptable. Student loans are friends for life, or until payed off. Whichever comes first (http://www.kevinmd.com/blog/2011/03/medical-education-affordable.html).”

Still, why is medical tuition so much higher than that of other programs? I’m not sure about this, but after doing some more research, it appears to me that the yearly tuition for medical school is generally not a huge amount more costly than other, especially private, graduate programs. However, unlike other programs, medical schooling is a very long undertaking. Instead of being done in four or five years, medical students must spend (after four years of undergraduate education) four years in medical school, and then three to eight years in residency, for a total of eleven to sixteen years of study. Residency is usually paid for, as with an educational stipend, so the cost of the would-be tuition is covered. However, medical students, after their first eight years of college (undergraduate and medical school), can’t really start earning money yet, like their peers in other graduate programs. Thus, their debts wait for them, gathering interest, and they continue training for another three to eight years. The combination of a slightly higher tuition to begin with, and the longer period of education, must account for the increased debt amongst medical students.

The length of medical education in other countries is sometimes shorter than it is here. In some Asian countries, like China and India, students decide to go to medical school directly after high school, so the program becomes an undergraduate program.

If you are interested in a few reasons why colleges can’t cut back and lower tuition, you can read this article: http://www.nytimes.com/2009/09/05/your-money/paying-for-college/05money.html.

It seems like it is in everyone’s interest to lower the debt of medical school students. As we found out a few years ago, larger debts and loans are not a good thing for the economy, people worried about their loans are less likely to spend money, which will also hurt our economy, and maybe, the cost of healthcare will decrease if graduates aren’t worried about paying back their debts.

The most expensive part of healthcare is the cost of labor, which is why the government is trying to encourage more efficient use of that labor through the implementation of electronic health record systems, but maybe we should explore decreasing the amount doctors are paid, by wondering how they first came to be paid this much, and if it was out of necessity (if it was out of necessity…why does that necessity exist?).

Some of the main reasons for increasing college tuitions are: reductions in government subsidies, a higher rate of inflation than the rest of the economy (due to an increase in the prices of scholarly journals, pressure to upgrade facilities and technology, and increased insurance costs since 9/11, college costs are doubling every 12-18 years, compared to everything else in the economy doubling in cost every 32 years), increased demand, scholarships (“As college costs rise, more students need scholarships. As larger scholarships are given, it continues to raise the price of higher education for the remaining students. This leaves more students needing scholarships to meet the skyrocketing costs, and so on.”), and decreased availability of classes, which means students sometimes have to stay another year to complete their requirements (http://www.nytimes.com/2009/09/05/your-money/paying-for-college/05money.html, http://collegesavings.about.com/od/understandingcollegecosts/a/risingcosts.htm).

In closing, let’s take a look at inflation. “For the school year 2010-11, in-state tuition and fees at public four-year colleges and universities rose to $7,605, up 7.9% from a year ago, the College Board reported Thursday. At private four-year institutions, the average cost rose 4.5% to $27,293” (http://money.cnn.com/2010/10/28/pf/college/college_tuition/index.htm). So, the average inflation in college tuition last year was 6.2%. Funnily enough, the average inflation in healthcare is 8% each year, and 2% is due to technology. Are college tuition and the price of healthcare rising at approximately the same rate for a reason? Or is this simply a coincidence of numbers?