Letters to the Editor
To the Editor: The report by Youngclaus et al1 is an important contribution to the current discourse on medical student debt and the primary care physician shortage. The authors conclude that “Dr. Median,” a student graduating with the median debt level ($162,000), can realistically choose a career in primary care because a financially savvy, two-income married couple with well-timed children can live in an expensive city and pay down the median debt level in 10 years. In addition, they indicate that other feasible repayment options are available for those with the median debt level whose situations are different from the one stated above.
While their conclusions are valid and their model instructive, the authors failed to set Dr. Median in the appropriate context, one that I am acutely aware of as a medical student who will graduate with over $200,000 in debt. In 2002, 4.8% of graduating medical students reported debt of greater than $200,000, but in 2012 that percentage was 36%.2 This means that 36% of graduating medical students have a well-documented financial disincentive to pursue lower-paying careers, including those in primary care. This is because, as the authors point out, “at the $200,000 debt level … a primary care physician would need to consider an extended repayment plan and/or a federal loan repayment program, such as IBR [income-based repayment] or the NHSC [National Health Service Corps].”1 In other words, being in a financially savvy, two-income household would not be enough to avoid either extended repayment scenarios, where the total amount repaid dramatically increases, or noble but demanding service programs, where the freedom to practice where and how one chooses is curtailed.
Another important question to put this report’s findings in context is, “Who are the students with above-average debt levels?” In general, they are more likely to come from lower socioeconomic backgrounds.3 These are precisely the students whom we as a medical education community are encouraging to go into medicine because it is thought that they will preferentially choose primary care. Therefore, the current system is disincentivizing the very people who we hope will help solve the primary care physician shortage.
Youngclaus and colleagues’ “Dr. Median” is a character who is quickly disappearing as debt levels grow and the debt distribution widens. Ultimately, physicians are a very fortunate and well-compensated group, but if debt levels continue to rise, then an ever-growing segment of the physician workforce will experience a serious financial barrier to pursuing the calling our society needs most—that of the primary care physician.
Derek Knight Rogalsky
Second-year medical student, Georgetown University School of Medicine, Washington, DC; firstname.lastname@example.org.
1. Youngclaus JA, Koehler PA, Kotlikoff LJ, Wiecha JM. Can medical students afford to choose primary care? An economic analysis of physician education debt repayment. Acad Med. 2013;88:16–25
2. Rowe S, Wisniewski S AAMC Data Book: Medical Schools and Teaching Hospitals by the Numbers, April 2012. 2012 Washington, DC Association of American Medical Colleges
3. Jolly P. Medical school tuition and young physicians’ indebtedness. Health Aff (Millwood). 2005;24:527–535