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SERVICE: Selecting Educational Residencies with Value, Incentives, Cost, and Effectiveness

Vohra, Sameer S.; Sylla, Ricci MD

doi: 10.1097/ACM.0b013e3181f593be
Response to 2010 Question of the Year

Mr. Vohra is in the final year of a medicine and law dual degree program, Southern Illinois University Schools of Medicine and Law, Springfield, Illinois.

Dr. Sylla is a first-year obstetrics–gynecology resident, Kaiser Permanente Santa Clara Medical Center, Santa Clara, California.

Correspondence should be addressed to Mr. Vohra; e-mail:

The average debt of a medical school graduate in the United States reached $143,870 in 2009.1 Twenty-five percent of these graduates have debt exceeding $200,000.1 This amount of debt is crippling, and new physicians must keep their indebtedness in mind when making decisions on what and where to practice. It is no secret that there is a geographic maldistribution of physicians in this country. Underserved areas exist in mass, and the discrepancy in care continues to grow. These two problems—lessening the debt burden for medical students and filling physician shortage areas—may not seem connected. Yet, an answer to one could very well lead to a solution to the other.

The readers of this journal were challenged to find effective ways to make medical school tuition free to students in exchange for public service. This question seeks to tie free medical tuition to individual students for greater service to our country. However, should we not aim higher by attempting to forgive, or at least reduce, the debt burden for as many medical students as possible? The authors aim to propose one such possible enterprise: Selecting Educational Residencies with Value, Incentives, Cost, and Effectiveness (SERVICE).

SERVICE works by providing physicians with various degrees of debt forgiveness/reduction through a point system that factors in physician specialty choice, the medical shortage in a particular geographic area, and the amount of time spent working in these communities. Medical students already have the option to enter education–service exchange programs, the most prominent being the National Health Service Corps (NHSC) scholarship program. Yet, these programs require students to choose specialties before their first day of medical school and are targeted only to those students choosing primary care specialties.

SERVICE appreciates the need for primary care physicians and allots more points to those choosing primary care specialties. However, many medically underserved areas also need a wider variety of physicians. This new program would broaden the definition of Health Professional Shortage Areas (HPSAs) designated by the Department of Health and Human Services to include other specialties that are also in shortage. This change allows medical students to choose their career based on what they are passionate about and avoid a penalty if they change their career choice during medical school. Additionally, SERVICE recognizes that not all HPSAs are the same and that certain locations are in greater need of physicians. More points will be allotted to the physicians serving these areas. With these changes alone, SERVICE expands the pool of possible candidates who can help serve this country.

SERVICE also accounts for the fact that a stringent formula of public service does not lead to the most individuals receiving the help they need. The NHSC asks graduates to devote years of full-time public service in exchange for free tuition. Instead, SERVICE would allow new graduates to participate part-time. This modification allows physicians to gain credit toward their medical school tuition while not feeling as if their early working careers will be defined solely by repaying their obligations. This feature will attract more young physicians to help those in need.

A program of this magnitude will cost a significant amount of money. One manner to fund SERVICE could mirror the Steven M. Thompson Physician Corps Loan Repayment Program (STLRP) in California. STLRP assesses a small surcharge at the time of initial licensure and renewal from physicians by the Medical Board of California and uses private donations and monies transferred from the Managed Care Administrative Fines and Penalties Fund.2 SERVICE could assess a similar fee through the Federation of State Medical Boards and collect extra money through private donations. This plan would ensure a steady source of funds in order to increase the number of scholars in the program. Currently, NHSC can only fund 39 new scholars yearly with 114 additional scholars for 2009–2011 as a result of the American Recovery and Reinvestment Act.3 The U.S. government can and should do more to benefit those doctors providing public service.

SERVICE is one attempt to link medical education debt relief with public service. A system in which a Bentley convertible is less expensive than four years of medical education is neither right nor sustainable. SERVICE provides a solution in which every medical student has a choice to ease his or her debt and impact those in need without sacrificing the specialty that he or she chooses. Programs like SERVICE are how we promote action. Programs like SERVICE are how we promote public service. Now, our country needs the motivation and action of our leaders to make it happen.

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1 Association of American Medical Colleges. 2009 GQ Medical School Graduation Questionnaire: All Schools Summary Report: Final. Available at: Accessed July 25, 2010.
2 Health Professions Education Foundation. Steven M. Thompson Physician Corps Loan Repayment Program (STLRP). Available at: Accessed July 25, 2010.
3 U.S. Department of Health and Human Services. Health Services and Services Administration, National Health Service Corps. Facts and Figures. Available at: Accessed July 25, 2010.
© 2010 Association of American Medical Colleges