Kieran Walsh: Free medical education would deliver savings in the long term

“Even in comparatively poor countries we find scientific knowledge and trained intellects regarded as sound public investments, and the popular voice applauding a liberal application of public money to secure them.”

Isambard Owen, 1904

Owen would be horrified by the current financing of medical education in the UK. His vision of an enlightened public viewing medical education as a sound long term economic investment has largely disappeared from the 21st century. It is now common for UK students to graduate with debts of over £50 000. In the US, average student debt at graduation is $200 000. Protests are met with the seemingly inarguable fact that we are in recession—that we cannot afford to do things the way that we used to. How then I wonder did the Irish state manage to fund my medical education in the 1980s? Is the recession in the UK today worse than it was in Ireland then? I think not and I think that it is not money that is lacking but political will.

And what effect will student debt have on our students, graduates, and the healthcare system? First of all the students—there is little doubt that students from poorer socio-economic backgrounds will be put off the study of medicine. There is the financial burden of debt, but also the psychological burden. The psychological one will likely be much more easily borne by young people from middle or upper class backgrounds who will not see these sums as such a massive amount of money and whose parents will convince them to make long term strategic decisions about their future.

Next the graduates—once again high level of debts have consequences on their behaviour. There is growing evidence from the US that students will choose specialties that are most likely to help them pay back their debts as soon as possible. Graduates will flock to specialties like cardiology or surgery that will enable them to earn money fast. Specialties where there is a lot of private practice will be attractive.

Finally the system—workforce planners may want geriatricians to care for the ageing population, public health doctors to cope with new epidemiological threats, and frontline staff to offer basic care to patients with non-communicable chronic diseases, but they will end up with doctors whose first thoughts are—how do I get a high earning job and pay back my debts? Doctors who maybe don’t feel obliged to meet public needs—after all, what did the public do for them when they were in need?

The current system of funding of medical education is perverse—it is set up to deliver the opposite of a patient centred healthcare system. What should we do about it? Radically reduce student fees, maybe reintroduce grants, maybe means-test—anything is better than what we have now. Free medical education costs in the short term, but would deliver long term savings.

Competing interests: Kieran Walsh works for BMJ Learning—the medical education division of the BMJ Group. He has written a book on cost and value in medical education published by Radcliffe.

Kieran Walsh is clinical director of BMJ Learning—the education service of the BMJ Group. He is responsible for the editorial direction of BMJ Online Learning, BMJ Masterclasses, and BMJ onExamination. He has written two books—the first on cost and value in medical education and the second a dictionary of medical education quotations. He has worked in the past as a hospital doctor – specialising in care of the elderly medicine and neurology.

  • Could not agree more. How very true. How are we going to bring about the appropriate change Kieran?

  • jfreeman

    It is the will, indeed. In the US it is somewhat different, as there is no tradition of free medical schools. However, we arguably, in the US, have a slightly better mix of socioeconomic class as admissions are not solely based on an exam, but with an effort to get doctors who will practice will all populations.