In 1984, 86% of medical students graduated with some amount of debt. While that number has not increased significantly over the past three-and-a-half decades, the amount of debt owed by each individual graduate has increased significantly even when adjusted for inflation, according to Greyson, et. al [1]. In 2012, medical school debt had reached a mean of $158,000 [2]. By 2016, the average medical school graduate owed $190,000, with some residents owing as much as $500,000 [3]. Furthermore, many residents still have unpaid debt from their undergraduate degrees when they finish medical school [4].
This debt creates three primary problems for the medical field as a whole. Firstly, debt discourages students from underrepresented backgrounds from attending medical school. In the first half of the twentieth century, Black students constituted only 2-3% of enrollment at American medical schools. Between 1950 and 1973, that number grew exponentially. However, since 1973, racial diversity has plateaued [1]. Moreover, in 2004, only 10% of medical students came from households in the lowest two quintiles of nationwide income. This represents a decrease of 17% since 1971 [1].
To address this problem, some medical schools have started offering large scholarships to underrepresented groups or have decided to abolish tuition entirely. Columbia University’s Irving Medical Center received a $150 million gift in 2017, which allowed 20% of its students to attend for free, with another 30% receiving significant scholarships [4]. Similarly, in 2018, NYU announced that its medical school would become tuition-free, which it lauded as a way to nurture diversity [5].
According to Steiner, et.al., the rise in debt also affects the disciplines that medical students choose. This leads to fewer students pursuing lower income specialties like pediatrics, which typically pays between $150,000 and $200,000 yearly. In a survey of over 500 anesthesiology residents, those with a higher-than-average amount of debt were 7% less likely to self-report as interested in an academic career. Moreover, these residents reported more interest in working at private practices that offered debt repayment programs [3]. In addition to influencing the chosen fields of medical students, debt affects the locations in which they choose to practice, leading to a lack of doctors in rural or underserved areas. States where high percentages of residents rely on Medicaid find it difficult to attract physicians, leading one such state, California, to develop a debt relief program for doctors who accept Medicaid [6].
Finally, medical residents with large amounts of debt are more likely to take on extra work and report higher rates of emotional stress. The above survey of anesthesiology residents found that those with higher-than-average debt were not only less likely to choose a career in academics but were also 7% more interested in moonlighting during residency or fellowship [3]. In a survey of 3,000 American medical students by Rohlfing, et.al., those with more debt reported more incidents of acting callously towards others than those with less debt. These students were also more likely to report regret about pursuing medicine [7]. Steady increases in medical school debt have influenced the diversity of medical schools, students’ choice of field, and the well-being of medical students, residents, and fellows. In response, states, philanthropists, and universities have responded by establishing debt-relief programs and scholarships, and in some cases by eliminating tuition entirely.
References
[1] Greysen, S. Ryan, et al. “A History of Medical Student Debt: Observations and Implications for the Future of Medical Education.” Academic Medicine, vol. 86, no. 7, 2011, pp. 840–845., doi:10.1097/acm.0b013e31821daf03.
[2] Steiner, Jeffrey W., et al. “Anesthesiology Residents’ Medical School Debt Influence on Moonlighting Activities, Work Environment Choice, and Debt Repayment Programs.” Survey of Anesthesiology, vol. 56, no. 6, 2012, p. 281., doi:10.1097/01.sa.0000422040.29757.47.
[3] Grischkan, Justin, et al. “Distribution of Medical Education Debt by Specialty, 2010-2016.” JAMA Internal Medicine, vol. 177, no. 10, 2017, p. 1532., doi:10.1001/jamainternmed.2017.4023.
[4] Glauser, Wendy. “How Medical School Debt Shapes the Health Workforce.” Canadian Medical Association Journal, vol. 190, no. 29, 2018, doi:10.1503/cmaj.109-5607.
[5] Thomas, Billy. “Free Medical School Tuition.” Jama, vol. 321, no. 2, 2019, p. 143., doi:10.1001/jama.2018.19457.
[6] Rueb, Emily S., and Karen Zraick. “Doctors in Debt: These Physicians Gladly Struck a Deal With California.” The New York Times, The New York Times, 25 July 2019, www.nytimes.com/2019/07/25/health/california-medical-student-loans.html.
[7] Rohlfing, James, et al. “Medical Student Debt and Major Life Choices Other than Specialty.” Medical Education Online, vol. 19, no. 1, 2014, p. 25603., doi:10.3402/meo.v19.25603.
