Article In Brief
Underrepresented medical students may face a greater financial burden from medical student debt, but the degree to which it affects the pipeline for neurology is not clear. Neurology program directors say early exposure to neurology is key in capturing this group.
Alvin Singh, MS, a fourth-year medical student at Chicago Medical College at Rosalind Franklin University of Medicine and Science, was fortunate enough to come into medical school with prior exposure to neurology.
Between his undergraduate studies and medical school, Singh took two gap years, which he refers to as his “growth years,” to do clinical research in neurology, movement disorders, and Parkinson's disease. He also pursued a master's degree in global health at Northwestern University—motivated in large part by his desire to work with underrepresented, underserved patients.
But as a first-generation college graduate with limited income, Singh told Neurology Today he still had to navigate a number of challenges to pursue that academic path. For one, he did not have family who could guide him through the admissions and financial aid process.
Singh managed to get through his undergraduate and master's degree studies with the help of student loans, Pell grants, scholarships, and by working at his graduate school, which offered employee tuition benefits.
But with medical school tuition and expenses, he has accrued a significant loan burden. Despite this financial burden, Singh still plans to do a residency in neurology.
The National Debt Burden
Singh's financial situation is not unique. The median medical school education debt burden as of 2020 was $200,000, according to Norma Poll-Hunter, PhD, the senior director of workforce diversity with the Association of American Medical Colleges (AAMC).
Notably, the AAMC also reported that in 2019 the median education debt burden was $212,375 for American Indian students, $190,000 for Hispanic students, and $230,000 for Black students, while the average debt for White students was $200,000.
Whether the projected costs of medical school impact the pipeline for medical school is not clear. “We are seeing a national trend of about an 18 percent increase in applications to medical school this year,” Dr. Poll-Hunter said, but there has not been much research yet to understand the trend, specifically as it relates to individuals who are underrepresented in medicine.
That said, the data from the last few years show the early pipeline figures for underrepresented medical school applicants have been relatively flat. In the 2017-2018 academic year, 4,306 Blacks, 3,396 Hispanics or Latinos, and 100 American Indians or Alaskan Natives applied to medical school. The numbers did not budge much and even decreased in some categories several years later: For the 2020-2021 academic year, there were 4,363 Black applicants, 3,331 applicants of Hispanic or Latino origin, and 72 American Indian or Alaska Native applicants, according to a 2020 AAMC report.
The role that projected or realized debt burden plays in drawing underrepresented populations to medical school and even a neurology residency is not clear.
“I think there may be some underrepresented groups who are deterred from medical school,” said Holli A. Horak, MD, FAAN, a neurology clerkship director and professor of neurology at the University of Arizona College of Medicine in Tucson. “When young physicians realize that they will be working for years to repay loans, they may determine that the financial and time cost is too great.”
“The cost of medical school education can be detrimental so I do think loan forgiveness is an important thing for us to pursue nationally,” she added.
This year, in particular, students and their families are facing even greater financial restraints due to COVID-19, said Arielle Kurzweil, MD, an associate professor of neurology and adult neurology residency program director at New York University. “We also know that COVID-19 is disproportionately affecting people of color and thus financial restraints may be particularly disruptive to this population. It is unclear at this time, however, how these financial restraints might impact student selection of a medical field,” or, for that matter, the decision to pursue a neurology residency after medical school, she said.
Dr. Kurzweil noted that other procedural-based subspecialties, such as surgery, have traditionally had higher salaries, and the perception for trainees may be that neurology and other medical subspecialties are not as financially rewarding. But, she said, the messaging needs to be that neurology affords a lot of diversity within the field, good financial stability, intellectual stimulation, and collaboration with colleagues.
A paper published in January in the BMJ Postgraduate Medical Journal suggests, however, that “gender and racial disparity persists in the recruitment of residents in neurology.”
The analysis of data from the Accreditation Council for Graduate Medical found that, between 2011 to 2018, the number of women in neurology residency programs increased by only 3 percent and there were some increases in the numbers of Whites, Asian/Pacific Islanders, and Blacks in neurology residency programs, but also a decrease in Hispanic representation.
In the 2019-2020 academic year, 0.5 percent of neurology residents were American Indian or Alaskan Native, 4.4 percent were Black or African American, and 7.2 percent were of Hispanic, Latino, or Spanish origin, according to the 2020 AAMC report.
Maysaa Basha, MD, an associate professor in neurology at Wayne State University and neurology residency program director at the Detroit Medical Center, observed that debt burden may also influence what underrepresented trainees do after a neurology residency.
“First-generation physicians and other underrepresented trainees are more likely to make specialty decisions based on debt burden in my observation,” she said. “I've seen some residents decide to skip a fellowship, for example, and go straight into practice after residency because they need to address their student debt. I do think we do need to look at these metrics on a national level.”
“At the end of the day you have to make a choice based on what interests you and what you enjoy doing,” she said. Still, she acknowledged, “I graduated in 2005 and am still paying back my debts.”
Student loan debt hasn't necessarily been the only factor shaping the choice of a specialty for underrepresented population, Dr. Poll-Hunter said. “Job security, interest overall in a particular profession have a stronger influence, not necessarily just the debt that can be incurred.”
But, she added: “I think what we find particularly for communities who are underrepresented and or first-generation is they often are not aware of certain opportunities early on to help them with career decision-making. They may not have the mentorship to help with exploring and making career choices.”
A Neurologist Steps In
Alyx Porter, MD, a neuro-oncologist and associate professor of neurology at Mayo Clinic in Scottsdale, AZ, is seeking to change that trend. Dr. Porter, who is Black, said she understands firsthand the toll medical student debt can take on prospective neurologists from underrepresented backgrounds.
“When I got to medical school on the first day before we had even taken any classes immediately I remember our class being separated into what felt like the ‘haves’ and the ‘have nots’—those who needed financial support and those who didn't. I was in the group that needed financial support.”
Dr. Porter noted that the financial support offered was for those interested in primary care or joining the military. She said she was interested in neurosurgery at the time and knew that none of those financial aid options would help her to achieve that goal, so she opted to take out a combination of private and federal loans to give herself more flexibility.
After paying off a half-million dollars in student loan debt, she and her husband, who is also a physician, started a nonprofit organization, ElevateMeD in May 2019 to address the debt burden.
The organization aims to increase ethnic and racial diversity in medicine and to capture a demographic of underrepresented students, who are often deterred from medicine due to the unprecedented levels of student debt. “What we did with ElevateMeD was create the thing we wished we always had,” Dr. Porter said.
The program provides underrepresented students with financial support through scholarships, mentorship from other underrepresented physicians, financial wellness education, and leadership development. Its board of directors and advisory board consists of clinicians across a variety of medical specialties including neurology, cardiology, anesthesiology, physical medicine and rehabilitation, sports medicine, and gastroenterology, among others. The board also includes professionals in leadership, law and accounting.
The program works with a select group of partner medical schools including Howard University College of Medicine, Charles Drew University, University of Arizona and Wayne State School of Medicine.
“In order to apply to be a part of our program, you have to attend one of our partner schools and then you have to be a rising M3 or M4 and be nominated by the school for our program. Outside of the actual scholarship process, students are encouraged to follow our social media and sign up for our monthly newsletter. We use our social media and links on our website to continue to raise awareness to issues pertaining to medical education and students that are underrepresented. We talk about issues pertaining to health equity and health disparities and share various resources through our newsletter as well,” Dr. Porter added.
A unique aspect of the program that distinguishes it from other mentorship initiatives is its use of concordant mentorship. “When we have our students tell us that they want to go into interventional radiology, we work our networks to find someone in that specialty. If a student is a Black man, we try to find a Black interventional radiologist who would be willing to serve as a mentor,” Dr. Porter noted.
She pointed out that the program places a strong emphasis on financial education. “What we hear from our students within ElevateMeD is that they just don't get much of anything in terms of advice on how to navigate their financial futures. We give our students access to a financial planner and that's something that might be helpful, but I think the more education in this regard, the better.”
“In May 2020, we awarded our first $100,000 in scholarship support to 10 incredible medical students. This year, we are looking to give $150,000 in scholarships,” she said.
The program has recently provided funding for two rising neurologists, who are current medical students at Temple University and the University of Texas Southwestern.
Earlier Outreach is Needed
Indeed, in interviews with Neurology Today, neurology program directors agreed that outreach to underrepresented students should start earlier, even before medical school.
“I think the major goal should be to really expose people early and get them excited about neurology because ultimately students should be pursuing a field based on intellectual and emotional reward rather than a purely monetary one,” Dr. Horak said. “We are noticing that with efforts aimed to bring more awareness to the field of neurology among students, there has been more interest among underrepresented students.”
Dr. Basha agreed that greater efforts should be made by institutions to foster early exposure to neurology to ensure underrepresented students are fully aware of all clinical neurology has to offer.
They also need to be aware of resources available to them. Dr. Poll-Hunter said numerous programs can help students navigate the financial burden, including the National Medical Fellowship, the National Health Service Corps, repayment programs through Health Resources and Service Administration, the VA, Department of Defense, and Health and Human Services.
“These programs provide financial support for physicians, who oftentimes repay through service after they complete their training and many times they are working in underserved communities and institutions have their own financial aid packages that they offer students,” Dr. Poll-Hunter told Neurology Today.
The AAMC also has several resources available on financing a medical education and offers a fee assistance program to help to cover a substantial portion of the costs of applying to medical school, Dr. Poll-Hunter noted.
Singh, for one, said he intends to pursue a career in academic medicine and plans to turn to resources like Public Student Loan Forgiveness (PSLF), a program in which students who work in a public sector job are eligible to have the remaining balance of their direct loans repaid after they have made 120 payments under a qualified repayment plan while working full-time.
“I think that a lot of us are considering PSLF, that's a big thing, among my peers,” he said. “I can think of a few people that may be choosing a specialty based on income. I don't particularly agree with that, but I do think it's there,” he said.
“For me, it's kind of amplified coming from a low-income background, but I don't think that income should be a high priority when choosing a specialty and life-long career. I think that not choosing something that you are really passionate about could backfire,” he said.