Our health care system is upside down in many ways. One of them is the adminstrative burden of Electronic Health Records. Another is the cost of medical school.

March 20th, 2024 by Tom Lynch

From 2003 through 2020, I was a Founding Director of Commonwealth Care Alliance, a non-profit Massachusetts HMO serving dual-eligible beneficiaries.¹ From 2017 until my retirement at the end of 2020, I was Chair of the Board.

In 2006, we were excited to enter the world of electronic health records, EHRs. Doing so was expensive, but we believed the new technology would allow us to make a giant leap forward in serving our members. Little did we know that the uncharted territory we were about to enter would also resemble a minefield the deeper in we got.

Every health care organization in Massachusetts, as well as the federal government, encouraged every health care provider to make the move to EHRs. This meant that for-profit businesses soon emerged to build bigger and bigger EHR systems, which they could then sell to the nation’s health care community. And so it went.

Eighteen years later, the administration of EHRs is one of the reasons America is losing physicians, especially Primary Care Physicians, PCPs. On average, physicians spend 9.2 hours a week filling in documentation for electronic health records, forcing many of them to stretch workdays into the evenings. This phenomenon is so common that it’s frequently called “pajama time” as doctors continue working on charts after putting their kids to bed. A 2022 JAMA Internal Medicine study estimated, “Assuming a 5-day work week and 47-week work year, US physicians spent 125 million hours documenting outside office hours in 2019.”

And when was the last time you saw your PCP (if you have one; a quarter of the nation doesn’t) without a laptop in hand, into which he or she would stare while entering information throughout your appointment? The one-on-one time is often more with the laptop than the patient. Entries into that laptop have to be precise, because everything is tied to billing. The researchers in the cited study reported, “84.7% of surveyed physicians agreed that documentation solely for billing purposes not only added to their administrative burdens, but was also perceived as onerous.”

Time spent documenting is often time not spent with a patient. The average time a patient spends sitting in a waiting room (20 minutes) now exceeds the average length of a primary care appointment (10 to 15 minutes). Long wait times, general inconvenience, and quick-like-a-bunny appointments drive down patient satisfaction and discourage some people from seeing doctors altogether.

It also weighs heavily on doctors and discourages many from remaining in the profession they worked so hard and paid so much to enter. Moreover, it discourages many young people from entering it in the first place, so much so that the number of America’s primary care physicians has been declining since 2015.

The cost of medical school

Another reason for the steady decline in the number of PCPs is the cost of medical school. It’s expensive.

The annual cost of the average four-year medical school is now more than $58,000.  For a public medical school the cost is nearly $53,000; it’s about $65,000 for a private institution. Elite schools, like ones in the Ivy League, are all around $75,000 per year. The most expensive medical school in the nation for in-state residents is Hackensack Meridien School of Medicine, at $80,203 per year. For out-of-state residents, the University of Washington School of Medicine is the most expensive school at a whopping annual cost of $96,489.

As you can imagine, upon graduation, newly minted physicians  are deep in debt from undergraduate and medical school loans.

According to the Education Data Initiative, medical school graduates owe a median average of $215,100 in total educational debt, undergraduate debt included, when they enter the profession.²  The average physician ultimately pays $135,000 – $440,000 for an educational loan—plus interest. At current interest rates (6.54% as of September, 2023), a $200,000 loan can double over ten years.

Medical school costs in the U.S. are orders of magnitude higher than the costs in European medical schools. For example:

  • France: At about $633 per year, medical school is nearly free;
  • Germany: Medical school is free;
  • Switzerland: The cost is $912 per semester;
  • Spain: Public medical schools charge $3,505 per year (however, private, elite schools are much more, averaging $27,376; still, this is not even half elite school costs in the U.S.); and,
  • United Kingdom: The cost in $9,250 per year, but after year five, there is no cost.

All of which is why physicians in America, both PCPs and specialists, are paid nearly double their peers in the most developed countries in Europe. They owe so much in debt, they have to be.

On top of this seemingly ridiculous paradox is the fact that total health care costs in America are, and have been for many years, nearly double the average for the other 38 developed countries in the OECD.

Despite this, life expectancy in America, at 76.4 years, is lower than two-thirds of all the countries in the OECD, including all of the ones cited above. Yes, uninformed Americans denigrate the UK’s National Health System, but, at 80.4 years, that nation’s citizens manage to live four years longer than we do.

What can be done to right our foundering health care ship?

Perhaps not much. The highly consolidated health care system in the U.S. is so deeply rooted with so many vested interests, doing anything other than nibbling around the edges seems herculean. But that doesn’t mean we shouldn’t try.

For a start, we could make going to medical school easier and cheaper.

We could take a hard look at NYU’s Grossman School of Medicine, which, since 1841, has been nationally recognized for the excellence of its degree program. More important for this discussion—tuition is free. As the school puts it:

We are proud to offer every student enrolled in our MD degree program Full-Tuition Scholarships as part of our tuition-free initiative. We believe providing tuition-free education will lead to better patient care and will benefit society as a whole by turning the best and brightest future physicians into leaders with the potential to transform healthcare.

If a medical school in the heart of New York City can provide free tuition, do you believe it possible for others to do the same?

Well, two others are now. As of August 2024, tuition will be free for all students attending Albert Einstein College of Medicine, also in New York, thanks to a $1 billion donation from Ruth L. Gottesman, chair of the school’s board of trustees — the largest gift ever to a medical school.

And students at the Uniformed Services University’s (USU’s) F. Edward Hébert School of Medicine not only attain a medical degree for free but are paid during their studies.

Those pursuing an MD degree from USU enter the institution as commissioned officers of the Army, Navy, Air Force, or Commissioned Corps of the U.S. Public Health Service. As such, they receive a graduate student stipend while enrolled. They also get other benefits, including free medical care, a housing allowance, and paid time off.

Students at USU receive over $70,000 annually through base pay and other allowances, according to USU. That is in addition to not paying tuition while enrolled.

In return, the program requires a seven-year commitment to active military duty. Time spent in graduate medical education, such as in a residency, does not count toward the required commitment.

These three schools are demonstrating in three different ways that succeeding in medical school does not have to entail being lashed to a long-term, onerous financial anchor.

New physicians from these schools will still have to face the documentation burden that awaits them, but at least they will be spared the added burden of coughing up more than $2,400 per month for ten years to repay loans they did not have to secure.

I am certainly not such a fool as to think that free tuition at  Grossman, Einstein, and USU will cause a radical shift in how we produce the doctors we so dearly need. But it’s a start.

And if we can get beyond three, we may have the beginning of a Movement.


¹ People eligible for both Medicare and Medicaid. Known as “Duals,” these are the sickest of the sick and the poorest of the poor. They make up ~5% of the population, but consume nearly 40% of all health care dollars. Helping them to become healthy also lowers costs, a real win-win.

² In 1978, the average medical school debt in the U.S., adjusted for inflation, was $53,648 (Actual debt in 1978 dollars was $13,500).