Here's an email from a former medical student who heard my EconTalk with Russ Roberts. Reprinted anonymously with his permission.
Good afternoon Drs. Caplan and Roberts,
My name is [redacted] and I recently listened to your conversation
on Econtalk regarding education. I wanted to pick your brains regarding the
structure and finance of medical education in the US.
I recently left medical school after one semester. I spent
years and thousands of dollars on tuition, preparing and taking the MCAT,
applying to medical school, going on interviews, etc. Ultimately I came to the
decision that my heart wasn't 100% in medicine and I was unwilling to pay the
I've actually applied to anesthesiologist assistant (AA)
programs, which are just two years in length. AAs legally must work under the
supervision of a physician anesthesiologist and they essentially function like
physician assistants, but are specific to anesthesia.
This got me thinking about the practice of medicine and the
scope of practice issues that have come up in the last few decades across state
legislatures. I am not an economist by any means, though I definitely wish I
took more econ courses in college. I even though about grad school in public
policy but that's a conversation for another time.
I'm not sure if any of your research has addressed the topic
of medical education or not. I've heard the American Medical Association
referred to as a cartel in another podcast, Freakonomics.* I think the episode
was discussing the role of nurse practitioners which has made some primary care
Specific to anesthesia has been the ongoing battle between
certified registered nurse anesthetists (CRNAs) and anesthesiologist
assistants, who have actually been around for over 40 years. According to legal
precedents, anesthesia is considered both a nursing specialty as well as a medical
speciality. The CRNA lobby is phenomenally politically savvy and they have
blocked legislation for AAs to work in various states. Currently, AAs are only
allowed to practice in 18 states. Of course the irony is not lost upon me since
the very same arguments CRNAs use against AAs are the same ones physicians have
used against other mid-levels.
Having worked in healthcare prior to med school, I was able
to see the enormous financial decisions that go into patient care. There are
clearly external forces influencing behavioral decision making, from C-suite
executives to physicians-in-training.
As an intellectual exercise, I've often pondered about the
state of medical education in the US. Nowhere else in the world are medical
students required to attend college for four years before matriculating into
medical school. The so-called Hopkins model has been championed by the Flexner
Report of 1910 and we apparently still think it's the only appropriate
pedagogical model to train the next generation of physicians.
Perhaps it was one of the major reasons why I left med
school. The constant testing and ineffective teaching strategies left
much to be desired, particularly for long-term retention. Even the licensing
schedule that has developed through the years has become cumbersome: Step 1,
Step 2 (which has two parts), and Step 3. This does not include the exams you
take in your actual specialty once you finish residency. Each exam can cost
thousands of dollars, not including preparation materials that help you pass
The argument for all of this testing is always in the name
of "patient safety" and to "protect the public." I think it
also serves to exclude others who would otherwise try to practice medicine.
I question the sustainability of this system. Billions of
dollars pour in from Medicare to fund graduate medical education and yet we're
still projected to have a physician shortage. To be fair, I have also read
research indicating it's not so much a shortage of physicians as it is a maldistribution
of physicians. I think physicians are trying to have their cake and eat it too:
restricting other providers' scope of practice while simultaneously refusing to
practice medicine in underserved areas.
I see the issue of medical education as both a public policy
concern as well as a curricular one. Yes, the curriculum is rigid and doesn't
reflect the advances made in technology and learning sciences. It's also
incredibly expensive. Some med schools charge out-of-state tuition upwards of
$60,000 for ONE year. Where the money goes, I have no idea. I think if you cut
out the mandatory baccalaureate degree, people would be able to save time and
money. Most other countries allow students to begin medical studies right after
My sister is a high school sophomore and I'm trying to steer
her in the right direction so she doesn't make the same mistakes I did. My
parents are immigrants from Vietnam and neither of them have a college
education. We were always told to go to college and the hard work will pay off
in the future. That piece of paper will mean something. And then 2008 hit and
things changed. I see the proliferation of meaningless master's degrees and a
certification test for X, Y, Z field. I don't think this rampant obsession with
credentialism actually brings forth any value though.
what are your thoughts on the state of American healthcare? Do you think more
healthcare providers makes economic sense or does it endanger patient safety?