A Retrospective Analysis of the Relationship Between Medical Student Debt and Primary Care Practice in the United States

Abstract

PURPOSE We undertook a study to reexamine the relationship between educational debt and primary care practice, accounting for the potentially confounding effect of medical student socioeconomic status. METHODSWe performed retrospective multivariate analyses of data from 136,232 physicians who graduated from allopathic US medical schools between 1988 and 2000, obtained from the American Association of Medical Colleges Graduate Questionnaire, the American Medical Association Physician Masterfile, and other sources. Need-based loans were used as markers for socioeconomic status of physicians' families of origin. We examined 2 outcomes: primary care practice and family medicine practice in 2010.RESULTS Physicians who graduated from public schools were most likely to practice primary care and family medicine at graduating educational debt levels of $50,000 to $100,000 (2010 dollars; P <.01). This relationship between debt and primary care practice persisted when physicians from different socioeconomic status groups, as approximated by loan type, were examined separately. At higher debt, graduates' odds of practicing primary care or family medicine declined. In contrast, private school graduates were not less likely to practice primary care or family medicine as debt levels increased.CONCLUSIONS High educational debt deters graduates of public medical schools from choosing primary care, but does not appear to influence private school graduates in the same way. Students from relatively lower income families are more strongly influenced by debt. Reducing debt of selected medical students may be effective in promoting a larger primary care physician workforce.

US Federal Policies Should Better Support the Primary Care Physician Workforce

“…28 Many students with the strongest interest in primary care, including underrepresented minority students and students from disadvantaged backgrounds, also have the highest debt levels. 29,30 The PSLF thus serves an important function in reassuring these students.…”

The Impact of Debt on Young Family Physicians: Unanswered Questions with Critical Implications

“…5 In a large, retrospective study of 136,232 physicians, those who had graduated from public schools with more than $100,000 of debt (2010 dollars) were less likely to practice family medicine. 6 In a qualitative study students described their debt as making them feel more cynical, less altruistic, and entitled to a high income. 7 High debt has also been correlated with callousness, 8 stress, 8,9 suicidal thoughts, 10 failing medical licensing exams, 11 and leaving or being dismissed from medical school.…”

Money and Medicine: Indivisible and Irreconcilable

“…This conclusion appears to be particularly applicable to the "cash-only" segment of medicine exemplified by the subspecialties of plastic surgery and cosmetic dermatology and some subspecialties of assisted reproductive care, to name a few. As such, it is hardly surprising that a body of peer-reviewed contributions highlights the role of debt in the career choices made by medical school graduates [16,17]. It follows that decisions at the earliest stages of a medical career may be guided not only by professional preferences but also by the need to address financial realities and goals.…”