Many in academic medicine have worried for decades that medical school is too expensive for medical students.1–3 Some maintain that high tuition and fees can lead to enormous debt, affect career choice,4 increase stress,5 and diminish the socioeconomic diversity of entering classes.2
But if a student had the option to pay for medical school, not with money but, instead, by contributing service to a community, region, or nation, that would go a long way toward allaying some of these vexing concerns, and tangible, timely benefits would accrue to medical students, medical schools, and society.
So, it is in this spirit that I invite responses to my 2010 Question of the Year: What are the most effective ways to make medical school tuition and fees free to students in exchange for public service?
Benefits of an Education-Service Exchange
An education-service exchange program would offer at least ten important benefits:
* Such a program would allow students to avoid or greatly reduce education-related debt.
* This approach would eliminate financial barriers for economically disadvantaged applicants to medical school.
* Those funds currently used to provide scholarships to students could be used for other purposes.
* Fundraising efforts (which are an expense in and of themselves) currently directed at raising money for student scholarships could be refocused on other priorities.
* Deans would no longer need to make the morally difficult choice between funding need-based or merit-based scholarships, since students would not require scholarship money for tuition and fees.
* A school's effort and expense to provide financial aid services for students likely would be reduced.
* Deans currently face the intractable dilemma of trying to admit a diverse class and control student debt while being under tremendous fiscal pressure to increase revenue, one source of which is tuition. As the dean increases tuition, students' educational debt goes up, and attracting a socioeconomically diverse group of applicants becomes that much harder. Under an education-service exchange program, deans' efforts, individually or collectively, to secure additional tuition funds would be directed at a service agency, government body, or other institution, but not at students.
* The high cost of medical education has led a number of opinion leaders to suggest that one approach to controlling educational debt lies in shortening the number of years a student spends in medical school. But we know so little about the cognitive, emotional, and moral development of young adults during their medical school years, and we know even less about the mechanisms of intellectual growth, professional identity formation, and other changes that may or may not occur during the senior year, that we do not have enough information to make an informed decision about the optimal length of a medical school education.6 Rather than limiting the length of training based on cost issues, an education-service exchange program could enable students to spend the time they need in medical school without accumulating debt.
* An education-service exchange program could benefit the greater society by fulfilling important service needs in rural and underserved regions, by improving access to care in physician shortage areas, and by reinforcing the value of a culture of service.
* A program to exchange public service for tuition and fees could be an important approach for institutions besides medical schools. While it is easy to imagine how such a system could benefit a nursing or dental school,7 I can envision how such an exchange could be used in new and innovative ways in schools of law, business, or engineering as well as in other areas.
Criteria and Instructions
I invite responses to the 2010 Question of the Year in the form of an essay with a maximum of 750 words and no more than three references. I welcome submissions about new ideas or about existing approaches that have been implemented in any discipline anywhere in the world and that are applicable to the exchange of service for the cost of a medical education in any country.
If a submission is based on an existing program that offers education in exchange for service (e.g., several branches of the U.S. military offer a Health Professions Scholarship Program), it must be more than a program description or promotional piece. Authors of such submissions may wish to explore why, and to what degree, the existing program has been effective, how it could be or should be expanded in scope, what kinds of barriers have precluded broader application, how it could evolve into a better program, how it would fare in a system with other education-service exchange options, and what advantages have accrued to individuals and society. Also, in some countries, governments subsidize all or most of the cost of medical students' education. I welcome submissions about those programs that meet the aforementioned criteria.
It is unreasonable to expect medical schools to operate without the revenue from tuition and fees. So, responses should include a mechanism for medical schools to recover an amount approximately equivalent to that revenue. At the same time, responses should include a mechanism that precludes medical schools from recovering lost tuition by creating new categories of charges or special fees, or by charging students in other ways. The idea is that students should not incur out-of-pocket costs for tuition and fees in exchange for substantive public service.
Anyone is eligible to submit an essay (i.e., one does not need to have a formal role at a medical school or teaching hospital), and an individual may be an author or coauthor of more than one essay.
The guidelines of this journal's “Complete Instructions for Authors” (http://journals.lww.com/academicmedicine/Pages/InstructionsforAuthors.aspx) should be followed to determine eligibility for authorship. The deadline for submitting an essay is May 1, 2010. All essays must be written in English and submitted through the journal's Web-based manuscript submission system (www.editorialmanager.com/acadmed/); there is a special category on the submission form, Response to 2010 Question of the Year.
The journal's professional editorial staff and editorial board will work with me to select as many as five essays to publish later this year in the journal. We will select essays that present responses to the 2010 Question of the Year that are creative, imaginative, innovative, and feasible.
It makes no sense to saddle a medical student with tuition and fees that, by the time of graduation from medical school, result in a debt that is greater than many individuals' home mortgages. And it makes even less sense for a medical school to charge tuition and fees that are so high that most students cannot afford to pay them, and that thereby compels the school to spend money to weave a complex web of financial aid programs, scholarship funds, and debt forgiveness initiatives.
It is time to stop complaining about high tuition and to put forth a serious set of ideas so we can make real progress. An education-service exchange program could offer philosophic, moral, social, financial, and practical benefits. And a commitment on the very first day of medical school to one's community, region, or nation, in exchange for a professional education, is just the right way to begin a lifetime of service.
Steven L. Kanter, MD
1AAMC Division of Operational Studies. Trends in medical school tuition levels: 1952–53 to 1972–73. J Med Educ. 1971;46:175–176.
2Ayers WR, Stangert AC, Dennis MJ, Henry JB. Impact of high tuition on medical school applicants and enrollees. J Med Educ. 1981;56:795–802.
3Petersdorf RG. Financing medical education. Acad Med. 1991;66:61–65.
4Tonkin P. Effect of rising medical student debt on residency specialty selection at the University of Minnesota. Minnesota Med. 2006;89(6):46, 47, 49.
5Morra DJ, Regehr G, Ginsburg S. Anticipated debt and financial stress in medical students. Med Teach. 2008;30:313–315.
6Mahoney JF, Littleton EB, Kanter SL. What can theories of adult development offer medical education? Educación Médica. 2009;12(2 suppl):S19.
7Matthew IR, Walton JN, Dumaresq C, Sudmant W. The burden of debt for Canadian dental students: Part 3. Student indebtedness, sources of funding and the influence of socioeconomic status on debt. J Can Dental Assoc. 2006;72:819.