We are always
a ladder, but it’s
crashes; easy doors
—Kay Ryan, “Carrying a Ladder”1
Becoming a physician is expensive. In the United States in 2022, the median cost of attending a public medical school for 4 years was $268,476. A private medical school cost more at $363,836.2 Due to this expense, more than two-thirds of current U.S. medical students carry education debt.2 Eight out of 10 U.S. medical school graduates have debt from their premedical and medical education that exceeds $100,000, and more than half (53%) owe more than $200,000.2
The cost of medical education has grown over time. Between 2009 and 2019, cost increased at a rate of 2.3%/year, which was nearly twice the rate of inflation.3 A 2011 article4 from our journal notes that medical education has become “more complex, more technological, and more expensive to support” and that, similarly, the duties and missions of universities have become more complex, with increased responsibility for research and for patient care. For these reasons, the hidden and indirect costs associated with educating undergraduate and graduate medical trainees are not fully known, and it is unclear who should bear this full cost.4 It is clear, though, that our early career colleagues are carrying a lot of the cost—cumulative medical education debt increased by 74.6% between 2004 and 2019.5
Fortunately, medical education debt now appears to have stabilized. In 2009, the median medical education debt was $190,000, and in 2019 and in 2023, it was $200,000, meaning that half of individuals had debt less than this number, and half of individuals had more.2,3 That said, education debt is distributed unevenly amongst graduates. More graduates of public schools have debt, but private school graduates owe more, on average, than do public school graduates.2,3 A larger proportion of medical school graduates who are Black (91%) or Hispanic (85%) incur debt, compared with White (75%) or Asian (63%) graduates.3 In an analysis of 2019 data,3 the median debt burden was highest amongst Black graduates, with $240,000 owed. When analyzed by gender, debt burden was similar, but graduates with families have greater non-education debt burden. More than half of 2019 graduates from families at the very highest incomes, that is, the top 5% (above $300,000 annually), also had education debt, with a median owed of $189,000; these graduates planned on funding nearly half of their education through personal/family support, and planned on covering less of the cost through loans or scholarships, compared with graduates from families with lower incomes.
The data demonstrate that education debt is significant and is carried by the vast majority of physicians-in-training. In 2022, nearly 20% of all graduates with debt, including 29% of private school graduates with debt, owed more than $300,000.2
Debt affects individual physicians-in-training in different ways, and certain subsets of medical students and residents have greater financial challenges. Students attending medical school out of state experience greater debt burden.5 In addition, students who, by necessity or choice, complete clinical rotations away from their home institutions take on considerable additional expense. As noted in a study5 appearing in this issue of Academic Medicine, there was a significant increase in out-of-state matriculants at state-funded medical schools during 2004 to 2019, which may be one cause for the increase in debt during that time.
Unmatched medical students—and their numbers are rising—also encounter serious financial challenges.6,7 An online comment7 posted by a student in this situation states: “Right now I’m 400K in debt and can practice as a medical assistant at best…. Was anything I did the last 10 years worth [it] now?” Graduating students who match in very expensive geographic areas, such as New York or California, may face significant debt during their residency and fellowship training years due to cost of living.8 This challenge has contributed to the phenomenon of unionization amongst postgraduate trainees.9
Physicians-in-training are not alone in struggling with debt. Debt is a reality for all in the health professions, and may be an even greater challenge for students in dentistry, nursing, optometry, pharmacy, psychology, and veterinary medicine.10 Cost of attendance and education debt have grown very rapidly, including in high-need fields such as dentistry. In a recent study,10 researchers comparing several fields found that the average income of physicians increased the most per year, their debt increased the least, and that physicians were in the only health profession with a debt-to-income ratio less than 100%.
Potential consequences of significant debt are perhaps obvious. Individuals with greater debt may experience greater stress, delay having a family, be ineligible to purchase a home, accumulate additional debt (e.g., credit card), opt not to pursue advanced training, or enter more well-paying fields out of financial need. Evidence from the literature suggests that some of these consequences are well established, for example, increased stress, and that some are not, for example, specialty choice.3,4,11–14 Thus far, data from the Association of American Medical Colleges (AAMC)3 do not suggest that debt significantly influences specialty choice, although other authors15–18 have found that medical students make career choices based on financial need rather than personal interests.
A few strategies for reducing debt burden include, for example, favorable loan programs, tuition-free medical schools, and accelerated or shortened curricular programs. Robust federal loan forgiveness and low-cost loan repayment programs assist thousands of graduates each year. Repayment of loans is within reach (“Any physician can repay any amount borrowed,” as stated in a recent report3 by the AAMC), given the terms of the federal repayment plans, which have a maximum time span of 25 years. Some students are not eligible or able to access these programs, however, such as students attending newly established medical schools that have not yet been accredited.19 More than half of indebted physicians do not pursue loan forgiveness plans, which typically require working for some period of time in underserved communities.3,20 The federal loan forgiveness program announced by the Biden administration in 2022, which, at the time of writing this editorial, is under consideration in the court system, would relieve a small portion of debt for many individuals ($10,000 for those making less than $125,000 a year, and $20,000 for those with Pell Grants), including some medical trainees and clinicians.14
A handful of medical schools offer free tuition or full scholarships to their students, a remarkable and salutary development in medical education.21,22 While these students may still have to shoulder their living expenses, the opportunity to attend medical school tuition-free will clearly reduce their degree of debt.
Other medical schools are offering accelerated training and a 3-year curriculum, which results in less debt and a quicker timeline to a paid position.23 A recent study24 found that accelerated 3-year programs resulted in less debt without negatively affecting the amount of student burnout or academic preparedness, and that accelerated graduates were more likely to enter family medicine and work with underserved patients. A study25 of a combined 5-year program offering joint BS and MD degrees found that students in the accelerated program had less education debt but had less satisfaction with their medical school education and were rated lower on professional attitudes during residency. In this study, there were no significant differences regarding specialty choices of students who completed the combined BS/MD program. These studies give rise to other unanswered questions in medical education and reinforce the importance of long-term follow-up with physicians who have had novel or unique educational experiences.
Given that debt is a nearly unavoidable reality, strengthening the financial literacy skills of physicians-in-training is an important and worthy goal, as discussed by Wesslund et al26 in their systematic review in this issue of Academic Medicine. The authors identified 13 published studies of 13 personal financial wellness curricula for medical students, residents, and/or fellows. Topics covered include student loans, investment, disability and life insurance, retirement savings, budgeting, debt management, and general information on personal finances. Outcomes of the curricula were measured in some of the studies, finding that learners acquired greater knowledge (“financial literacy”), changed or planned to change financial behaviors, and reported greater well-being.
We ask our early career colleagues to set aside years of their lives to study medicine. We ask them to work extremely hard, experience immense stress, and sometimes encounter mistreatment on the journey of becoming a physician. We also ask most physicians-in-training to take on massive financial debt—debt that may take decades to repay. Dear Reader, have we done enough to support them along the way? I wonder and worry about the exceptional students whom we never draw into our field because the cost is too dear. I also wonder and worry about those who enter medicine—the journey is expensive as well as challenging. Caring for those in need, learning to diagnose and treat illness, and cultivating the qualities necessary for the profession of medicine over many years of premedical, undergraduate, and postgraduate medical education are intrinsically difficult. Should it cost as much as it does, too?
1. Ryan K. Carrying a ladder. Poetry. 2004;4:8.
2. Association of American Medical Colleges. October 2022 medical student education: Debt, costs, and loan repayment fact card for the class of 2022. https://store.aamc.org/downloadable/download/sample/sample_id/575
. Accessed February 5, 2023.
3. Youngclaus J, Fresne JA. Physician Education Debt and the Cost to Attend Medical School: 2020 Update. Association of American Medical Colleges. https://www.aamc.org/data-reports/students-residents/report/physician-education-debt-and-cost-attend-medical-school
. Accessed February 5, 2023.
4. Greysen SR, Chen C, Mullan F. A history of medical student debt: Observations and implications for the future of medical education. Acad Med. 2011;86:840–845.
5. Kraus MB, Hasan SH, Buckner-Petty SA, et al. Out-of-state students at state medical schools and increasing medical debt. Acad Med. 2023;98:595–605.
6. Aagaard EM, Moscoso L. Practical implications of compassionate off-ramps for medical students. Acad Med. 2019;94:619–622.
7. Morrissette A, Morrissette M. “The feeling of failure is immense”: A qualitative analysis of the experiences of unmatched residency applicants using Reddit. Acad Med. 2023;98:623–628.
8. Velsey K. After “The Match”… the housing match: Medical residents hustle to find homes in NY. Observer. https://observer.com/2015/04/after-the-match-the-housing-match-medical-residents-hustle-to-find-homes-in-ny
. Published 2015. Accessed February 5, 2023.
9. Lin GL, Ge J, Pal R. Resident and fellow unions: Collective activism to promote well-being for physicians in training. JAMA. 2022;328:619–620.
10. Chisholm-Burns MA, Spivey CA, Stallworth S, Zivin JG. Analysis of educational debt and income among pharmacists and other health professionals. Am J Pharm Educ. 2019;83:7460.
11. Rajapuram N, Langness S, Marshall MR, Sammann A. Medical students in distress: The impact of gender, race, debt, and disability. PLoS One. 2020;15:e0243250.
12. Krumer-Nevo M, Gorodzeisky A, Saar-Heiman Y. Debt, poverty, and financial exclusion. J Soc Work. 2017;17:511–530.
13. West CP, Shanafelt TD, Kolars JC. Quality of life, burnout, educational debt, and medical knowledge among internal medicine residents. JAMA. 2011;306:952–960.
14. Mohareb AM, Brown TS. Medical student debt and the US infectious diseases workforce [published online ahead of print November 1, 2022]. Clinical Infectious Diseases. doi:10.1093/cid/ciac862.
15. Phillips JP, Peterson LE, Fang B, Kovar-Gough I, Phillips RL Jr. Debt and the emerging physician workforce: The relationship between educational debt and family medicine residents’ practice and fellowship intentions. Acad Med. 2019;94:267–273.
16. Phillips JP, Wilbanks DM, Salinas DF, Doberneck DM. Educational debt in the context of career planning: A qualitative exploration of medical student perceptions. Teach Learn Med. 2016;28:243–251.
17. Rohlfing J, Navarro R, Maniya OZ, Hughes BD, Rogalsky DK. Medical student debt and major life choices other than specialty. Med Educ Online. 2014;19:25603.
18. Pisaniello MS, Asahina AT, Bacchi S, et al. Effect of medical student debt on mental health, academic performance and specialty choice: A systematic review. BMJ Open. 2019;9:e029980.
19. Fernandez B. These students borrowed $35K plus for an unaccredited program that closed. Years later, their debts remain. Seattle Times. https://www.seattletimes.com/business/these-students-borrowed-35k-plus-for-an-unaccredited-program-that-closed-years-later-their-debts-remain
. Published 2019. Accessed February 5, 2023.
20. Pathman DE, Sewell RG, Rauner T, et al. Outcomes of states’ loan repayment and forgiveness programs from the perspective of safety net practice administrators. J Amer Board of Family Med. 2022;35:1015–1025.
22. Pentis A. 7 top medical schools with tuition-free programs. LendingTree. https://www.lendingtree.com/student/tuition-free-medical-schools
. Published 2020. Accessed February 5, 2023.
23. Weiner S. Med school in 3 years: Is this the future of medical education? AAMC News. https://news.aamc.org/medical-education/article/med-school-3-years-future-medical-education
. Published 2019. Accessed February 5, 2023.
24. Leong SL, Gillespie C, Jones B, et al. Accelerated 3-year MD pathway programs: Graduates’ perspectives on education quality, the learning environment, residency readiness, debt, burnout, and career plans. Acad Med. 2022;97:254–261.
25. Gonella JS, Callahan CA, Erdmann JB, et al. Preparing for the MD: How long, at what cost, and with what outcomes? Acad Med. 2021;96:101–107.
26. Wesslund HM, Payne JS, Baxter JD, et al. Personal financial wellness curricula for medical trainees: A systematic review. Acad Med. 2023;98:636–643.