10 April 1990 The New York Times Company 229 West 43rd Street New York, NY 10036 To the Editor: In "M.D. ~ Mired in Debt" (Apr. 9) Dr. Howard Hiatt clearly and effectively points out that the debt burden of medical education in large part drives many young doctors to lucrative specialties rather than primary care. Solving this problem by "system- tinkering" (readjusting physician incomes, increasing student loans, etc.) is not only economically inefficient but also tends to divert scare health care monies towards bureaucracies and banks. Instead, a more radical and ultimately effective solution would be to create a state and federally funded system of free medical education with a post-graduate service requirement of two years in primary care or three in research. Although funding for this program (roughly estimated at $1 billion should be intrinsic to the budget, supplemental financing may be derived from increased taxes on cigarettes and reduced military spending. Ultimately and most ideally, funds should be generated as part of national health insurance. What are the advantages of a free medical education with a service requirement? First, the debt burden that distorts career choice and future earnings is effectively eliminated. Second, since wealth will no longer be an "implicit" criterion for application to medical school one can expect a higher quality and more socially just pool of doctors. Third, the system creates a flexible vehicle for eliminating physician shortages both regionally as well as in medical research. Finally, such a system provides for a richer and more rigorous grounding of all physicians (future specialists, or not) in the philosophy and fundamentals of the general approach to medicine. In summary, free medical education with a service requirement can lower costs, increase quality, and eliminate physician shortages. Most importantly, however, is that when the newly-graduated M.D. meets his first patient, he will not be "mired in debt" but rather “ennobled in ideals. Sincerely, on Geer ogan Gurel MD/PhD student Columbia University College of Physicians & Surgeons Box 697 New York, NY 10032 (212) 694-5690