Letters to the Editor
To the Editor: Mr. Youngclaus and Ms. Fresne1 should be commended for their comprehensive report describing the cost of medical education. Graduate debt is a major concern for medical educators, and the Association of American Medical Colleges plays a critical role in describing its scope and impact.
I was disappointed, however, in the report’s lack of attention to the negative impact of educational debt on the culture of medical school. I believe debt begins to shape students’ attitudes from the moment they accept their first loan disbursements and attend their first financial aid sessions. They learn about compounded interest and compare the 25-year-repayment plan to the 10-year-repayment plan. They think about where they want to live, whom they might marry, and the cost of their (future) children’s college education. Right or wrong, too many seem to come to a consensus: A primary care career is not financially feasible.
From that point forward, students with a spark of interest in primary care start working to suppress that interest. Students who cannot or will not suppress their interest become part of a minority and experience the “differentness” of joining a lower-status group. Relatively few students acknowledge this financial acculturation as a major part of their career planning, but we are naïve to pretend that it does not exist.
Further, educational debt contributes to students’ belief that their medical education is a process of sacrifice, in which they are victims of a “system” that takes advantage of their powerlessness. My students talk about “winning the game”: paying their money, passing their exams, and competing for the most prestigious opportunities until they can achieve a “controllable lifestyle” and financial freedom. High debt contributes to a shared sense of entitlement. Those who choose lower-income, lower-prestige specialties haven’t “won the game.” And if you’re not a winner, you’re a loser.
There is a clear relationship between specialties’ potential income and U.S. graduates’ preferences.2 By requiring most students to acquire high debt, our educational institutions bear real responsibility for fostering this value system. It is time for us to acknowledge our responsibility and work to make the cost of medical education reasonable for everyone.
Julie P. Phillips, MD, MPH
Associate professor of family medicine, Michigan State University College of Human Medicine, East Lansing, Michigan; Julie.firstname.lastname@example.org
2. Ebell MH. Future salary and US residency fill rate revisited. JAMA. 2008;300:1131–1132