Confronted with ever-increasing tuition bills and immersed in a culture of promissory notes and delayed gratification, the realm of indebtedness in seemingly intrinsic to the physician-in-training. Medical student debt has been increasing at an alarming rate over the past decade. While medical students have always had problems with high debt, today’s generation of young physicians have seen their debt become unmanageable.
Furthermore, medical student debt is a major social justice issue. For medicine to really be able to provide for the needs of our complex society, it has to match the diversity found in our complex society. The cost of medical education and subsequent debt makes accessing medical education prohibitive for quality students of color and/or of working class background.
THE CURRENT STATE OF AFFAIRS
The latest statistics on medical student debt are staggering. According to a recent report published by the Association of American Medical Colleges (2006):
- It is estimated that over 86% of graduates carry educational debt.
- The median debt burden for graduates of public medical institutions has risen to over $119,000 while that for private school graduates has increased to nearly $150,000.
- 41% of students with educational debt report principle in excess of $150,000 and a significant minority reports debt as high as $350,000.
- Medical education debt is 4.5 times as high in 2003 as it was in 1984, growing well beyond the consumer price index.
While there are a multitude of causes for the growing debt burden, the most significant remains the massive increase in tuition costs across the country’s medical institutions:
- Over the past twenty years, median medical school tuition and fees have increased by 165% in private schools and by 312% in public schools.
- From 2002 to 2003, students saw some of the largest tuition increases in history. Private school tuition increased by 5.7% while public school tuition increased by 17.7%.
- With the recent downturn in the economy and the resultant tightening of federal and state budgets, funding for medical education has been compromised, particularly for public schools. This has provoked an array of responses including the rescinding of scholarships, record increases in tuition, as well as the institution of mid-year and retroactive tuition hikes.
Average Educational Debt for Indebted Medical School Graduates 1994-2003
Source: AAMC Graduate Questionnaire
Median U.S. Medical Tuition for First Year Students
About Much More Than Dollars And Cents
While it is without question that educational debt places a significant burden on students and their families, it is important to realize that the current system of financing undergraduate medical education has far-reaching implications for the American health care system. Critical issues in American health care such as access to care, diversity and cultural competency in the workforce, and health disparities are all affected by the debt burden carried by today’s physicians-in-training:
- African Americans, Hispanic Americans, and Native Americans are considered underrepresented minorities as they make up approximately 25% of the U.S. population but only about 12% of medical students. A recent AAMC national survey showed that the cost of attending medical school was the #1 reason why qualified minority students chose not to apply to medical school.
- The composition of the physician workforce is also changing in that more and more students are coming from wealthy families. Today, the fraction of medical students that come from families in the top 20% of annual income exceeds 60%. On the other hand, students from families in the bottom 20% of annual income make up less than 3% of medical students.
- There are an array of studies documenting that minority medical students and those from modest financial backgrounds are more likely to enter primary care fields and also serve in underserved communities where lack of access and disparities in care are most apparent.
- A study done at Mount Sinai Medical Center reports, “Minority graduates entered internal medicine, pediatrics, and family medicine in far greater numbers than any other specialty. Also, the percentage of minorities who entered these fields was greater than the percentage of non-minorities.” Thus the debt crisis serves to exacerbate the shortage of minority physicians and severely hamper improvement in the care of underserved populations.
- The Department of Health and Human Services has made increasing the number of underrepresented minorities in medicine a priority in its Healthy People 2010 campaign as it has profound consequences on health care disparities. According to the Healthy People 2010 Companion Document on Workforce Development, minority physicians are more likely than their Caucasian counterparts to serve in communities where there is a shortage of physicians, to treat minority patients, and to research those diseases that disproportionately affect minorities.
- A paper published in the American Journal of Public Health similarly states that workforce demographics have, “implications for the health of poor, minority, and underserved communities, which are most likely to be cared for by underrepresented minority physicians.”
- In September 2004, the Sullivan Commission report on “Missing Persons: Minorities in the Health Professions,” emphasized the profound influence debt has on minority applicants and called for a significant increase in scholarships, loan forgiveness programs and tuition reimbursement to help develop a more diverse workforce.
What About Physician Income?
We have seen that both student debt and medical school tuition have increased dramatically, so how about physician incomes over the same time period? Well, the numbers just don’t seem to add up. The mean starting salary for general internists in 2002 was $124,000 and for pediatricians it was $109,000. When looking at the trends in income, the AAMC reports, “In recent years, physician incomes have increased only slowly, and in constant dollars, the amounts have trended slightly downward.” So, while tuition and debt continue to outpace inflation, physician incomes continue to lag far behind. This has made medical education less and less affordable to students and their families. Given the current figures on income and debt burden, a starting primary care doctor could be paying between 8 and 15% of income solely to manage their debt.
Does The Debt Burden Affect Specialty Choice?
Whether the debt carried by students affects their choice of specialty has been at the center of a contentious debate. While there is no empirical evidence illustrating the precise relationship between debt level and specialty choice, intuition has led many in the medical community to accept the supposition that there is some genuine interaction. Leon Johnson, chief executive officer of EAS Group LLC, believes that levels of educational debt will impact borrower’s career and personal decisions, either consciously or unconsciously. In the 2002 AAMC Graduate Questionnaire, 32% of medical students cited that debt level influenced their specialty choice. According to the National Resident Matching Program the number of graduating U.S. medical school seniors who chose residency programs in family medicine has dropped for the sixth year in a row. According to one analysis of the 2004 National Residency Matching Program results, “the movement of U.S. seniors away from family practice and internal medicine (primary care track) continues.” Thus, AMSA believes that the debt burden may be partly responsible for the measurable decline in students entering primary care fields in favor of more lucrative specialties and believes more research must be undertaken to decipher a more precise relationship.
Summing Up AMSA’s Big Picture On Student Debt:
Medical student debt has reached a critical point. It places a significant burden on students and their families and also has far-reaching implications, many of which threaten to undermine the fundamental tenants of the profession. Achieving diversity in medicine, improving access to care, and addressing disparities in care are common missions for medicine, yet the current financing model continues to mitigate the modest gains that have been made in these critical areas.
What Is AMSA Doing About Student Debt?
AMSA has a rich history of activism on this issue. Years ago, when the advocacy of others’ was limited to rhetoric, AMSA lobbied successfully to get federal student loans for medical students. Furthermore, AMSA developed the Heal Deal Program, the first nationally discounted educational loan program available to medical students. AMSA’s visionary leadership on this issue continued in 1991 when in conjunction with the Robert Wood Johnson Foundation, it organized the 1st national conference on Financing Medical Education. This conference marked the first formal attempt to bring educators, legislators, financial leaders, loan servicers and students together to better define the landscape for reforming the cost structure of medical education.
Medical student debt has become the unifying issue of a broad coalition aligning AMSA with AMA-MSS and AAMC among others. As the medical community works to develop a comprehensive solution to medical student debt, AMSA again finds itself a vanguard for activism and advocacy.
- Federal Student Aid
- Federal Student Aid for Graduate Students
- AAMC – Financing your Medical Education
- AAMC Debt Resources
- AAMC Loan Repayment/ Forgiveness and Scholarship Programs
- The Big Squeeze: What’s being done about medical student indebtedness? (The New Physician, Sept 2006)