Does Free Tuition Fix the Primary Care Shortage?

This transcript has been edited for clarity. 

Would free medical school encourage more students to pursue primary care? Overpriced medical training in this country definitely contributes to burnout and the physician shortage, and all that debt may influence what type of specialty somebody goes into. 

The question remains: If we change that one variable and make medical school free, is that enough to convince students to pursue primary care? 

Assumptions Behind Free Tuition Initiatives

Now, this question is based on an assumption that there already is a large group of medical students who want to go into primary care, and the reason they're not or the reason they're reluctant to is because of tuition. If you take that stress away, you fix the problem. 

This was at least part of the assumption made when NYU announced free tuition for all medical students back in 2018. One goal was to encourage more students to go into primary care. The other was to broaden the application pool to include more diverse students from different socioeconomic and racial backgrounds. We'll get back to that.

Quick numbers. In NYU's 2022 match, the first tuition-free class, about 25% of students matched into a primary care specialty— internal medicine or pediatrics — and there were zero matches into a family medicine residency. I can't find the data, but anecdotally that 25% is a slight increase from prior years.

Primary Care Match Rates Post–Tuition Waiver

There's some fine print to consider. Some of the residents who matched into internal medicine or pediatric programs may subspecialize and not work in outpatient medicine at all. Also, a majority of students matched in major urban areas such as New York, Boston, or Los Angeles. We know that historically, people tend to work where they train, so that's not looking too great for recruitment to rural communities or underserved areas. 

There is some hope. In 2024, slightly more students from NYU matched into primary care specialties, including to family medicine. This is amidst a new record in family med residency matches nationwide. Rightfully, in the beginning, NYU was applauded for this tuition-free decision, but there was some criticism about who should be prioritized for financial assistance. Consider a future surgeon from a wealthy family vs a first-generation student committed to rural primary care. 

NYU said, "No, equality for all." Even acclaimed physician and bioethicist, Dr Ezekiel Emanuel weighed in and suggested "forgiving medical school debt for students who commit to a career in primary care in an underserved area. Two years of service for each year of free tuition." At least this would allow resources to be focused only on building a primary care pool. 

Also, after the tuition-free announcement, applications to NYU increased by almost 50%, and from underrepresented groups, 100%. Not that surprising. The average MCAT score and GPA also increased, but the acceptance rate stayed at around 2%. 

How much difference will this tuition-free program really make in the future? Time will tell, but I do think that NYU set an important precedent here. Medical schools should be critically looking at where tuition money goes and what financial incentives could be used to attract a more diverse student body, with more hopefully going into primary care. 

Let's take a look at NYU's Grossman Long Island campus. They have an accelerated 3-year program, tuition-free, primary care focused, and 67% of their graduates went into primary care.

In California, Kaiser Permanente School of Medicine, which is also tuition-free and focused, had 38% of their graduates go to primary care. 

What are these programs doing differently? Well, they're tuition-free, they have focused tracks, and they have enough accredited sites so that students can get a realistic and broad look of what it's actually like to practice primary care. 

Attracting Med Students to Primary Care

This leads to a broader question: How do we create an environment beyond tuition that encourages more students to go into internal medicine, pediatrics, or family medicine? 

Right now, across those three specialties, the average salary is $250,000, which is lower than in other subspecialties. There's a high amount of administrative workload, loss of autonomy, and plenty of burnout. You want to get more students to go into primary care? We need to fix primary care. 

That involves many factors. Get ready for this. I actually had to make a list based on what I've read in articles and heard from my colleagues. 

If we want to attract more students to primary care, we need to talk about:

• Improving reimbursement;
• Better mental health support;
• Highlighting the importance primary care plays in public health;
• Expanding care teams;
• Creating more medical students and training sites in rural and underserved areas;
• Expanding the use of telehealth services;
• Creating early exposure programs for high school and college students; and
• Paying attention to how local policies and statistics, such as crime, housing, and abortion bans, may push people away from practicing in certain areas or states.

Clearly, this is a large number of considerations that goes far beyond the altruistic tuition-free gifts. 

Look, it's no surprise we have a physician shortage that affects multiple specialties, but it is alarming that by 2034, there's going to be an estimated shortage of 50,000 primary care doctors. 

Stay Tuned

What do you all think? Is free tuition enough to actually move the needle in the long term, or should NYU have made a more focused gift? Comment below. 

I know what you're all wondering why I didn't talk about tuition waivers in terms of diversifying the student body. That's because that deserves its own video. Stay tuned for part 2. 

Alok S. Patel, MD, is a pediatric hospitalist, television producer, media contributor, and digital health enthusiast. He splits his time between New York City and San Francisco, as he is on faculty at Columbia University/Morgan Stanley Children's Hospital and UCSF Benioff Children's Hospital. He hosts  The Hospitalist Retort video blog on Medscape.