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Legislation to Protect Patients 

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Over the past three decades, concerns about protecting patients’ rights have led to the passage of legislation meant to ensure the safety and privacy of patients. In particular, laws such as HITECH, GINA, HIPAA and EMTALA are meant to protect the privacy of patient data, provide patients with the autonomy to control the distribution of their data, and safeguard against discrimination based on that information.  

 

The Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted in 1986 and required hospitals to care for and treat patients, regardless of their ability to pay. The law was created in response to patient dumping, a practice common in the mid-20th century where poor or uninsured patients were transferred from hospital to hospital because of their inability to pay [1]. A landmark 1984 study by Himmelstein et al. found that 97% of patients transferred to public hospitals had no insurance or were government-insured [2]. With the passage of EMTALA, hospitals were required to treat emergency conditions, as defined by the bill, and stabilize patients before releasing them. Failure to do so can result in a penalty of up to $50,000 for both hospitals and physicians. Importantly, malpractice insurance does not usually cover the fine, meaning that physicians who violate EMTALA must pay the fee out of their own pocket [3]. 

 

The Health Insurance Portability and Accounting Act (HIPAA) was passed in 1996. Building off of the foundational belief that patients have a right to keep personal health information private, HIPAA developed a privacy framework for a digital age. With informational tools such as privacy notices and requirements for detailed authorization requests, HIPAA was meant to inform patients about how their data would be shared [4]. Importantly, the act set a federal minimum for the protection of patient data, which individual states could then develop accordingly. 

 

As genetic testing and sequencing developed in the 1990s and early 2000s, it became apparent that legislation to protect patients would need to cover genetic information, as well. In 2008, lawmakers passed the Genetic Information Nondiscrimination Act (GINA), which prohibited health insurers and employers from requiring genetic tests, requesting genetic information from patients, or discriminating based on that information. While some of these restrictions were set in place by HIPAA, they were strengthened and standardized under GINA. A paper by Hudson et al. noted that GINA would likely reduce the “fear factor” associated with genetic information, making it more likely that patients would participate in studies that collect genetic information [5]. 

 

The Health Information Technology for Economic and Clinical Health Act (HITECH), which was signed into law in 2009, was primarily meant to accelerate the adoption of electronic health records (EHR). The law was fairly successful — a study by Adler-Milstein and Jha found that adoption of EHR among eligible hospitals rose from 3.2% before the passage of HITECH to 14.2% after the law was passed [6]. The HITECH Act also allowed patients to access their EHR which, coupled with increased adoption of EHR at medical facilities, made it easier for individuals to share their health data across organizations. 

 

One of the most recent legislative additions to the patient protection framework is the Patient Protection and Affordable Care Act, which became law in 2010. The law extended Medicaid enrollment to around 15 million people with the ultimate goal of ensuring all Americans were covered by health insurance. While healthcare coverage is the best-known part of the law, ACA also included legislation aimed at improving care to underserved populations and making information about the cost of healthcare more transparent [7]. While parts of the policy, like the individual mandate, have since been rolled back, many of the patient protection measures remain in place. 

 

References 

 

[1] Mayere Lee, Tiana. “An EMTALA Primer: The Impact of Changes in the Emergency Medicine Landscape on EMTALA Compliance and Enforcement.” Annals of Health Law, vol. 13, no. 1, 2004, pp. 145–178., https://lawecommons.luc.edu/cgi/viewcontent.cgi?article=1231&context=annals. 

[2] Himmelstein, D U, et al. “Patient Transfers: Medical Practice as Social Triage.” American Journal of Public Health, vol. 74, no. 5, 1984, pp. 494–497. doi:10.2105/ajph.74.5.494. 

[3] Zibulewsky, Joseph. “The Emergency Medical Treatment and Active Labor Act (Emtala): What It Is and What It Means for Physicians.” Baylor University Medical Center Proceedings, vol. 14, no. 4, 2001, pp. 339–346. doi:10.1080/08998280.2001.11927785. 

[4] Annas, George J. “HIPAA Regulations — A New Era of Medical-Record Privacy?” The New England Journal of Medicine, vol. 348, no. 15, 10 Apr. 2003, pp. 1486–1490. doi:10.1056/NEJMlim035027. 

[5] Hudson, Kathy L., et al. “Keeping Pace with the Times — The Genetic Information Nondiscrimination Act of 2008.” New England Journal of Medicine, vol. 358, no. 25, 2008, pp. 2661–2663. doi:10.1056/nejmp0803964. 

[6] Adler-Milstein, Julia, and Ashish K. Jha. “HITECH Act Drove Large Gains In Hospital Electronic Health Record Adoption.” Health Affairs, vol. 36, no. 8, 2017, pp. 1416–1422. doi:10.1377/hlthaff.2016.1651. 

[7] Rosenbaum, Sara. “The Patient Protection and Affordable Care Act: Implications for Public Health Policy and Practice.” Public Health Reports, vol. 126, no. 1, 2011, pp. 130–135. doi:10.1177/003335491112600118. 

 

 

Image of newborn baby

Intrathecal Morphine vs. Intrathecal Hydromorphone for Post-Cesarean Analgesia 

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Anesthesia for cesarean section commonly involves a single-shot spinal injection of local anesthetic with opioid included to cover postoperative pain as part of a multimodal analgesic pathway. Intrathecal preservative-free morphine is considered the gold-standard for postcesarean analgesia by obstetric anesthesiologists given its low-risk profile; however, hydromorphone has gained attention as an alternate agent due to drug shortages. 

Hydromorphone was chosen partly due to its hydrophilicity, which causes it to persist within the cerebrospinal fluid (CSF) for several hours, providing bimodal analgesia at the segmental and supraspinal levels. Lipophilic opiates such as fentanyl and sufentanil diffuse more quickly, exhibiting a rapid segmental effect with more systemic uptake, making them less ideal in this setting. Dosing studies have shown that the effective intrathecal dose (ED90) for morphine and hydromorphone are 150mcg and 75mcg respectively for post-cesarean analgesia [8]. 

While several retrospective studies have compared the two drugs when administered in the central nervous system, there is only one prospective study published on this subject to date. Observational studies were performed by multiple groups including Beatty et al., who found no significant difference in patient pain between intrathecal morphine 100mcg and hydromorphone 40mcg. However, it is important to note these doses are not necessarily equipotent and standard guidelines for equianalgesic dosing of the two drugs in the intrathecal space are not yet available. The morphine dose was chosen based on prior studies showing absence of analgesic benefit for intrathecal doses above 75mcg, while the hydromorphone dose was merely the most common dose among participating providers [3].

Based on dosing studies by Rathmell et al. and later Sviggum et al., a 2:1 conversion ratio is commonly selected, however this ratio needs further validation [7][8]. In June 2020, Sharpe et al. published a randomized clinical trial comparing intrathecal opioids (150mcg morphine vs. 75mcg hydromorphone), and reported similar pain scores through 36 hours postpartum and no difference in breakthrough analgesics given. Regarding side effects, there was no difference in incidence of nausea/vomiting or moderate or severe sequelae. The median difference in time to first opioid dose was not statistically significant but may be relevant clinically given the 5h span for hydromorphone compared to 12h for morphine. There was also a notable difference in postpartum opioid consumption that did not reach statistical significance, possibly indicating a need for more power in this study [6]. 

It is important to note that, while the pharmacokinetic profile of hydromorphone (hydrophilicity, less rostral spread) would theoretically imply less incidence of nausea or respiratory depression, studies have not supported this hypothesis. Given how infrequent episodes of respiratory depression are in the postpartum setting, there is simply not enough data at this point to properly evaluate the comparative safety of intrathecal hydromorphone. In 2019, the Society of Obstetric Anesthesia and Perinatology published a consensus stating that intrathecal morphine is preferred if readily available given the paucity of data on intrathecal hydromorphone’s safety profile [2]. Furthermore, studies are limited by the lack of a standard method for comparing intrathecal opioid doses. Until a standard conversion ratio for intrathecal opiates becomes available, comparative studies will remain limited by lack of verification that equianalgesic doses of intrathecal opioid are being administered. Statistical differences may be found in future analyses if additional research changes the current 2:1 conversion ratio. 

  

 

References 

 

  1. Abboud TK, Dror A, Mosaad P, et al. Mini-dose intrathecal morphine for the relief of post-cesarean section pain: Safety, efficacy, and ventilatory responses to carbon dioxide. Anesth Analg. 1988;67(2):137-143. 
  2. Bauchat JR, Weiniger CF, Sultan P, et al. Society for obstetric anesthesia and perinatology consensus statement: Monitoring recommendations for prevention and detection of respiratory depression associated with administration of neuraxial morphine for cesarean delivery analgesia. Anesth Analg. 2019;129(2):458-474. doi:10.1213/ANE.0000000000004195.
  3. Beatty NC, Arendt KW, Niesen AD, Wittwer ED, Jacob AK. Analgesia after cesarean delivery: A retrospective comparison of intrathecal hydromorphone and morphine. J Clin Anesth. 2013;25(5):379-383. doi:10.1016/j.jclinane.2013.01.014.
  4. Marroquin B, Feng C, Balofsky A, et al. Neuraxial opioids for post-cesarean delivery analgesia: Can hydromorphone replace morphine? A retrospective study. Int J Obstet Anesth. 2017;30:16-22. doi:10.1016/j.ijoa.2016.12.008.
  5. Rathmell JP, Lair TR, Nauman B. The role of intrathecal drugs in the treatment of acute pain. Anesth Analg. 2005;101(5 Suppl):30. doi:10.1213/01.ane.0000177101.99398.22.
  6. Sharpe EE, Molitor RJ, Arendt KW, et al. Intrathecal morphine versus intrathecal hydromorphone for analgesia after cesarean delivery: A randomized clinical trial. Anesthesiology. 2020;132(6):1382-1391. doi:10.1097/ALN.0000000000003283.
  7. Sultan P, Halpern SH, Pushpanathan E, Patel S, Carvalho B. The effect of intrathecal morphine dose on outcomes after elective cesarean delivery: A meta-analysis. Anesth Analg. 2016;123(1):154-164. doi:10.1213/ANE.0000000000001255.
  8. Sviggum HP, Arendt KW, Jacob AK, et al. Intrathecal hydromorphone and morphine for postcesarean delivery analgesia: Determination of the ED90 using a sequential allocation biased-coin method. Anesth Analg. 2016;123(3):690-697. doi:10.1213/ANE.0000000000001229.

Dexmedetomidine: Physiology, Applications, and Efficacy 

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Dexmedetomidine (DEX) is an α2 adrenoceptor agonist that is commonly administered before general anesthesia as a short-term sedative [13]. In this setting, dexmedetomidine has several well-studied benefits, most notably a reduction in the need for opioids during surgical procedures while producing sedation and analgesia throughout the entire perioperative period, as well as an elimination of otherwise common post-surgical respiratory depression [12]. Patients under the effect of dexmedetomidine retain psychomotor functions without sacrificing comfort, allowing for cooperation and physiological arousal [2]. First approved for ICU use in December 1999 and used at Baylor University Medical Center in August 2000, dexmedetomidine is commonly sold under the trade name Precedex today [23]. 

 

As an α2 adrenoceptor agonist, dexmedetomidine targets presynaptic receptors in the peripheral and central nervous systems, as well as in platelets, the pancreas, eyes, kidneys, and liver [2]. Via a negative feedback mechanism, this imidazole compound regulates norepinephrine and adenosine triphosphate levels [2]. α2 receptor agonists activate guanine-nucleotide regulatory binding proteins that activate cellular responses through two primary methods: the modulation of ion channel activity or the firing of a second messenger system [2]. The former of these methods produces the hyperpolarization of the cell membrane, facilitating the expulsion of potassium and, consequently, suppressing neuronal activity [2]. 

 

Dexmedetomidine differs from other means of sedation because of the combined effects of presynaptic and postsynaptic α2 adrenoceptor activation [2]. Presynaptic activation preserves norepinephrine levels, effectively stifling pain signals, while postsynaptic activation centralized in the central nervous system contributes to reduced sympathetic activity [2]. These two forms of activation enable dexmedetomidine to become a singular source of sedation, anxiolysis, and analgesia [2]. Consequently, some of the challenges associated with the administration of several disparate medications are eliminated [2]. However, despite this knowledge, dexmedetomidine’s analgesic mechanisms are not yet fully understood [4]. 

 

In anesthetic contexts, dexmedetomidine can be administered intravenously or intrathecally, although intravenous administration is more common [1]. Numerous studies have revealed that dexmedetomidine can result in as much as a 50% decrease in opioid consumption through the surgical process [45]. When managing refractory cancer pain, combined treatments consisting of dexmedetomidine and opioids have even been considered optimal in terms of analgesic effects in comparison to opioid-only treatments [6]. Additional noted effects, including diminished delirium in non-cardiac surgeries in elderly patients [7], improved recovery after laparoscopic colectomy [8], and reduced depression rates following cancer treatment [1], demonstrate the widespread benefits of this agonist. 

 

However, it is important to note the side effects previously observed following dexmedetomidine administration, including hypotension, hypertension, nausea, bradycardia, and dry mouth [2]. These side effects were observed immediately during or following loading; consequently, they can be diminished by controlling the loading dose [2]. Additionally, patients might be afflicted by withdrawal, similar to that associated with clonidine, following treatment [2]. 

 

Scientists continue to investigate the power of dexmedetomidine use, particularly concerning its effects on children. A notable recent study [9] demonstrated how dexmedetomidine can reduce inflammatory factors and ameliorate cardiopulmonary bypass-resultant neurodevelopmental damage when treating adolescent congenital heart disease. Another study [10] compared how minimal dosages of dexmedetomidine and midazolam prevented emergency delirium in children following exposure to sevoflurane anesthesia. Although both medications had equal efficacy when administered at the end of surgical procedures, dexmedetomidine had significantly higher postoperative efficacy. 

 

Evidently, the extent of dexmedetomidine’s potential is still being discovered by the scientific community and, thus, the medication remains a powerful tool in the anesthetic sphere. 

 

References 

 

[1] Huang, G., Liu, G., Zhou, Z. et al., “Successful Treatment of Refractory Cancer Pain and Depression with Continuous Intrathecal Administration of Dexmedetomidine and Morphine: A Case Report,” Pain and Therapy, vol. 9, no. 1, July 2020. [Online]. Available: https://doi.org/10.1007/s40122-020-00183-3. [Accessed Aug 9, 2020]. 

 

[2] Gertler, R., Brown, H. C., Mitchell, H., Silvius, E., “Dexmedetomidine: A Novel Sedative-Analgesic Agent,” Baylor University Medical Center Proceedings, vol. 14, no. 1, p. 13-21, 2001. [Online]. Available: https://doi.org/10.1080/08998280.2001.11927725. [Accessed Aug 9, 2020]. 

 

[3] Sassi, M. et al, Safety in the Use of Dexmedetomidine (Precedex) for Deep Brain Stimulation Surgery: Our Experience in 23 Randomized Patients,” Neuromodulation: Technology at the Neural Interface, vol. 16, no. 5, p. 401-407, Jan 2013. [Online]. Available: https://doi.org/10.1111/j.1525-1403.2012.00483.x. [Accessed Aug 9, 2020]. 

 

[4] Sadhasivam, S., Boat, A., Mahmoud, M.., “Comparison of patient-controlled analgesia with and without dexmedetomidine following spine surgery in children,” Journal of Clinical Anesthesia, vol. 21, no. 7, p. 493-501, Dec. 2009. [Online]. Available: https://doi.org/10.1016/j.jclinane.2008.12.017. [Accessed Aug 9, 2020]. 

 

[5] Wallace, S., Mecklenburg, B., Hanling, S., “Profound Reduction in Sedation and Analgesic Requirements Using Extended Dexmedetomidine Infusions in a Patient With an Open Abdomen,” Military Medicine, vol. 174, no. 11, p. 1228-1230, Nov. 2009. [Online]. Available: http://doi.org/10.7205/MILMED-D-00-6009. [Accessed Aug 9, 2020]. 

 

[6] Roberts, S, Wozencraft, C., Coyne, P., Smith, T.., “Dexmedetomidine as an Adjuvant Analgesic for Intractable Cancer Pain,” Journal of Palliative Medicine, vol. 14, no. 3, p. 371-373, Mar. 2011. [Online]. Available: http://doi.org/10.1089/jpm.2010.0235. [Accessed Aug 9, 2020]. 

 

[7] Pan, Hao, Chengxiao Liu, Xiaochun Ma, Yanbing Xu, Mengyuan Zhang, and Yan Wang, “Perioperative Dexmedetomidine Reduces Delirium in Elderly Patients after Non-Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized-Controlled Trials,” Canadian Journal of Anesthesia/Journal Canadien d’anesthésie, vol. 66, no.12, p. 1489, Dec. 2019. [Online]. Available: http://doi.org/10.1007/s12630-019-01440-6. [Accessed Aug 9, 2020]. 

 

[8] Pan, W., Liu, G., Li, T., Sun, Q., Jiang, M., Liu, G., et al., “Dexmedetomidine combined with ropivacaine in ultrasound-guided tranversus abdominis plane block improves postoperative analgesia and recovery following laparoscopic colectomy,” Experimental and therapeutic medicine, vol. 19, no. 4, p. 2535-2542, Apr. 2020. [Online]. Available: http://dx.doi.org/10.3892/etm.2020.8508. [Accessed Aug 9, 2020]. 

 

[9] Yongsheng Qiu et al., “Effects of Dexmedetomidine on the Expression of Inflammatory Factors in Children with Congenital Heart Disease Undergoing Intraoperative Cardiopulmonary Bypass: A Randomized Controlled Trial,” Pediatric Investigation, vol. 4, no. 1, p. 23-28, Mar. 2003. [Online]. Available: http://doi.org/10.1002/ped4.12176. [Accessed Aug 9, 2020]. 

 

[10] Cho, E., Cha, Y., Shim, J. et al., “Comparison of single minimum dose administration of dexmedetomidine and midazolam for prevention of emergence delirium in children: a randomized controlled trial,” Journal of Anesthesia, vol. 34, p. 59-65, 2020. [Online]. Available: Springer Link, http://link.springer.com. [Accessed Aug 9, 2020]. 

 

 

Results of Clinical Trials for Remdesivir, Chloroquine, Lopinavir/Ritonavir, and Arbidol to Treat Patients with COVID-19

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COVID-19 has become the most pressing global public health crisis in decades, with more than 3.6 million cases recorded in the United States alone as of the writing of this article. The biggest challenge of the pandemic is the novelty of this coronavirus and the absence of an approved drug or vaccine. Under extreme time pressure to treat patients with severe symptoms, several pre-existing drugs including remdesivir, chloroquine, lopinavir/ritonavir, and arbidol have caught the attention of researchers. Clinical trials were conducted in the hopes that they show clinical efficacy against the highly infectious SARS-CoV-2 strain.

 

Remdesivir is an adenosine analogue prodrug that inhibits viral RNA polymerases, including SARS-CoV-2 in vitro1.Although not FDA-approved to treat COVID-19, healthcare providers have initiated compassionate use of remdesivir for patients with confirmed SARS-CoV-2 and low oxygen saturation. In a cohort study published in April, researchers administered a 10-day course of intravenous remdesivir to patients with COVID-19 and reported clinical improvement in 36 of 53 patients (68%)2. This study showed promise for the use of remdesivir but lacked a control group to conclude the efficacy of the drug. In another trial reported in May, researchers conducted a randomized, double-blind, placebo-controlled trial with 236 patients. However, the results of this particular trial showed no significant difference between clinical improvement rates of the remdesivir group and placebo group3. The results of the most recent phase three trial conducted by Gilead indicated that the 5-day remdesivir course group was 65% more likely to have clinical improvement compared to the control group, which only received standard care. The 10-day remdesivir course group did not show statistical significance when compared to the control group4.

 

Chloroquine is another example of a drug that quickly gained interest during the early days of the pandemic. It is normally used to treat malaria and arthritis, and its antiviral effects have resulted in its administration to patients with COVID-19 without much evidence of clinical efficacy. In an observational study, researchers followed 1376 patients at a medical center in New York City and compared the results between those who received hydroxychloroquine and those who did not. The study concluded that there was no significant difference between the two groups5. The Recovery trial run by Oxford University followed a greater sample size, but ultimately also issued a statement announcing that chloroquine has no beneficial effect when used to treat COVID-196. FDA has also cautioned use of chloroquine due to side effects such as serious heart rhythm problems7.

 

Lopinavir and ritonavir are combined antiretroviral medications used to control HIV infection. A randomized, controlled study published in May assigned 199 patients to either the lopinavir-ritonavir group or the control group that only received standard care. Mortality rates at 28 days for the experimental group was slightly but not significantly lower than the control group. The percentage of patients with detectable viral RNA was similar in both groups. Ultimately, it was concluded that use of lopinavir and ritonavir did not provide any benefits for treating COVID-198. WHO announced in July that it would discontinue its hydroxychloroquine and lopinavir/ritonavir trials due to evidence that neither of these medications benefit patients with COVID-199.

 

Arbidol is commonly used in China and Russia to treat influenza by blocking virus-cell membrane fusion10. Li et al. conducted a randomized trial with 35 patients who received arbidol orally and 17 who received no antiviral medication. The rate of positive-to-negative conversion of SARS-CoV-2 nucleic acid was similar in both groups. The arbidol group exhibited adverse effects, while the control group did not. Arbidol presented no benefit to patients with COVID-1911.On the other hand, another study concluded that arbidol significantly reduced COVID-19 infection among health professionals. Arbidol may not be effective in treating COVID-19, but this study sheds light on its possible preventative abilities12.

 

No therapeutics have been proven to effectively treat COVID-19 at this stage, but studies are taking place globally to further explore the efficacy of the drugs mentioned.

 

 

 

References:

 

 

  1. Sheahan TP, Sims AC, Graham RL et al. (2017). Broad-spectrum antiviral GS-5734 inhibits both epidemic and zoonotic coronaviruses. Sci Transl Med.

 

  1. Grein, Jonathan, et al. (2020). Compassionate Use of Remdesivir for Patients with Severe Covid-19. New England Journal of Medicine, vol. 382, no. 24, pp. 2327–2336. doi:10.1056/nejmoa2007016.

 

  1. Wang, Yeming, et al. (2020). Remdesivir in Adults with Severe COVID-19: a Randomised, Double-Blind, Placebo-Controlled, Multicentre Trial. The Lancet, vol. 395, no. 10236, pp. 1569– 1578. doi:10.1016/s0140-6736(20)31022-9.

 

  1. Gilead Announces Results From Phase 3 Trial of Remdesivir in Patients With Moderate COVID-19. (2020) Gilead, Gilead Sciences.

 

  1. Geleris, Joshua, et al. (2020). Observational Study of Hydroxychloroquine in Hospitalized Patients with Covid-19. New England Journal of Medicine, vol. 382, no. 25, pp. 2411–2418. doi:10.1056/nejmoa2012410.

 

 

  1. No Clinical Benefit from Use of Hydroxychloroquine in Hospitalised Patients with COVID-19 (2020) RECOVERY Trial.

 

  1. Center for Drug Evaluation and Research. FDA Cautions Use of Hydroxychloroquine/Chloroquine for COVID-19. (2020). U.S. Food and Drug Administration, FDA

 

  1. Cao, Bin, et al. (2020). A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19. New England Journal of Medicine, vol. 382, no. 19, pp. 1787–1799. doi:10.1056/nejmoa2001282

 

  1. WHO Discontinues Hydroxychloroquine and Lopinavir/Ritonavir Treatment Arms for COVID-19. World Health Organization, 4 July 2020

 

  1. Villalaín J. (2010). Membranotropic effects of arbidol, a broad anti-viral molecule, on phospholipid model membranes. J Phys Chem B. 2010;114(25):8544–8554. doi:10.1021/jp102619w.

 

  1. Li, Yueping, et al. (2020). Efficacy and Safety of Lopinavir/Ritonavir or Arbidol in Adult Patients with Mild/Moderate COVID-19: An Exploratory Randomized Controlled Trial. Med, doi:10.1016/j.medj.2020.04.00

 

 

  1. Yang, Chunguang, et al. (2020). Effectiveness of Arbidol for COVID-19 Prevention in Health Professionals. Frontiers in Public Health, vol. 8, 2020, doi:10.3389/fpubh.2020.00249.

The Effects of Medical School Debt

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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.