The Problem Set
Medical education currently pits the “morality” of medicine against the “immorality” of money. A critical component of medical education is the ethical importance and responsibility of clinical work. Concerns about profit-driven decision-making, the “greedy” pharmaceutical industry, and “exploitative” insurance companies paint the business of healthcare as contradictory to our mission as care providers. As a result, teaching about how dollars flow in medicine is left out of many curricula. This knowledge gap deprives students of the opportunity to prepare for the daily reality of practicing medicine, where dollars and cents determine the procedures and medications patients can receive, where salary economics determine nurse-to-patient ratios, and where economic pressures determine hospital consolidation and leadership structures.
Medical education must accept the fact that healthcare is a business and integrate lessons on money into medical education. To improve the care environment for patients and the working environment for the entire care team, future physicians must understand the basis of how money works in our healthcare system.
Ignoring money in medical education has complications at four levels: (1) the physician, (2) the patient, (3) the hospital, and (4) the health system.
Physician compensation is a complex topic. While the average physician makes $350,000 per year, providers who enter specialties like family medicine and preventive medicine — which are facing critical shortages — make around $125,000 less than that average. While this salary is significantly higher than the median U.S. income, it comes in the context of an average medical school graduate debt of over $250,000 for 8 years of schooling. This debt impacts specialty choice, can cause loan repayments to drag on for decades, and influences life decisions like buying houses or having kids. Consequently, physicians and physician trainees should understand where their salaries come from and how to manage their personal finances. Such knowledge can improve effective debt management by medical students, minimize financial uncertainty for underpaid residents, and improve agency among attendings.
Furthermore, without a basic understanding of how money flows through the health system and how hospital administrators make decisions, physicians are left feeling powerless in a system they can’t wrap their heads around. This leads to greater frustration, pushes doctors out of clinical care, and increases burnout.
By teaching medical students how money flows through loans, salaries, and patient payments, they can make informed decisions at every stage in their medical journey to stabilize their financial situation, combat burnout, and focus more time on patients.
In a 2020 survey, three quarters of physicians felt obligated to initiate discussions about patients’ out-of-pocket costs, but only half of them understood how their patients’ deductibles work. Furthermore, patients prefer doctors who discuss the costs of care, and patient health insurance literacy increases effective utilization of primary and preventative care services. By bolstering physicians’ knowledge of how patients will pay for care, they can reduce patient uncertainty and ensure treatment plans are actionable.
As a tangible example, approximately 18% of adults do not fill prescriptions due to cost concerns. A physician who is cognizant of their patient’s insurance coverage can develop a cost-conscious treatment plan to boost adherence. This education should begin in medical school because students have more time during patient encounters than physicians, allowing them to properly educate patients and make clinical decisions based on the financial realities of their care.
With an understanding of how money affects healthcare, doctors can begin flipping the script. Physicians can use monetary incentives to their advantage in making a case for change within the system, and they can take on leadership roles that balance clinical priorities with the health system’s financial priorities. For example, a doctor could make the case that adopting a new artificial intelligence platform for note-taking could save $1,000 a day by estimating both the labor cost of physician time, as well as the foregone revenue of clinician time spent on administrative tasks. This case would be more compelling to hospital leadership than the traditional physician case of improved care quality and provider lifestyle. While the latter points should be reason enough, the reality of our system is that money talks. So, teaching future physicians to speak that language will support progress toward a value-based, patient-centered healthcare system.
The Healthcare System
In light of historical and persistent health disparities, which were exacerbated by the COVID-19 pandemic, the American Medical Association has argued that health systems science is a critical component of education for medical students and practicing physicians. We agree with their sentiments and hope that the integration of health systems education into medical school curriculums can teach students about how money is operationalized throughout our healthcare system. Physicians may be perceived as “pawns” whose actions are dictated by financial pressures and non-clinician decision-makers. Giving them strategic knowledge about how the purse strings are pulled in healthcare can turn them into knights or even royals with the power to reclaim medicine as a virtuous service rather than a greedy one. Of course, education alone cannot change our fragmented, profit-driven system into a well-oiled machine, but it can equip physicians with the tools to act rather than acquiesce.
The Solution Set
As physicians begin to develop their professional craft and juggle mounting debt, we encourage medical schools to incorporate education about money in healthcare into their core curriculum. This could take the form of a comprehensive curriculum introducing health system players and incentives (similar to the American Medical Association’s Health Systems Science curriculum), or more integrated approaches, such as including lessons on how to counsel patients on payment into clinical skills training.
While an integrated, comprehensive curricular approach would be the best way to ensure every future clinician understands key components of finances, most medical school curricula are overcrowded, and this approach may not be feasible in every case. As one alternative, we propose either providing flexible curriculum options, such as clerkships focused on health systems innovation, or research opportunities in economics or health systems. As another alternative, medical schools may financially and administratively support extracurricular opportunities for students to engage in these same topics, such as workshops on personal finances, shadowing opportunities with hospital administrators, or lecture series from physicians serving in non-clinical roles.
While no singular solution can fill patient insurance gaps, reduce physician debt and burnout, or completely fix the flawed American healthcare system, educating future physicians on the monetary realities of healthcare will equip the next generation of providers to begin tackling these challenges.
Ryan Leone, MSc, is an MD candidate at Columbia University Vagelos College of Physicians and Surgeons in New York City, a U.S. Army officer, and a former presidential management fellow who worked on healthcare policy and operations at the Department of Defense and Department of State. Kensington Cochran is an MD candidate at Columbia University Vagelos College of Physicians and Surgeons in New York City. She is also a market research fellow at Rock Health, and previously worked as a business analyst in McKinsey and Company’s Healthcare Practice. Kellen Mermin-Bunnell is a third-year MD candidate at Emory University School of Medicine in Atlanta. She is co-founder of Georgia Health Professionals for Reproductive Justice and the National Student Bioethics Association, and a health equity advocate. Maya Roytman is a first-year MD and MA in bioethics and health policy candidate at Loyola University Chicago Stritch School of Medicine in Maywood, Illinois. Ope Akerele is an MD candidate in a joint program between the UCLA David Geffen School of Medicine and the Charles R. Drew University of Medicine and Science in Los Angeles, as well as an MBA candidate at the UCLA Anderson School of Management in Los Angeles.
The authors are members of MD+, a vibrant community of medical students with interests beyond clinical medicine including biotech, venture capital, and health policy. The views expressed are those of the authors and do not reflect any organizations, companies, or institutions with which they are affiliated.