Pediatric Residents Pushed to Primary Care Because of Debt

Laurie Barclay, MD

January 07, 2013

Educational debt is high and increasing among pediatric residents, according to a survey study published online January 6 in Pediatrics. These financial pressures could motivate pediatric residents to choose a primary care or hospitalist career rather than fellowship training needed for a subspecialist career.

"Educational debt is an important topic in medicine, particularly to young physicians who have accrued substantial debt and are unable to start paying it back for many years, depending on their length of training," write Mary Pat Frintner, MSPH, from the Department of Research at the American Academy of Pediatrics in Elk Grove Village, Illinois, and colleagues. "Approximately half of medical school graduates have student debt of at least $150 000, and debt levels are increasing among graduating pediatric residents."

The study goal was to determine current levels of educational debt among pediatric residents and to evaluate the association between educational debt and choice of career path.

The investigators combined responses from annual national random samples of 1000 pediatric residents graduating from 2006 through 2010. Overall response rate was 61%. Statistical analyses included t tests and one-way analysis of variance to compare debt, linear regression to identify factors linked to educational debt, and logistic regression to examine the effect of debt on resident choice of clinical career path.

Educational debt from medical school and college, including the spouse's debt for married residents, affected 75% of residents. Among those residents with educational debt, the mean debt (in 2010 dollars adjusted for inflation) rose by 24% from 2006 to 2010, going from $146,000 to $181,000. Among all residents, the debt increase during the same period was 34%, going from $104,000 to $139,000.

Less than half (43%) of residents had clinical practice goals mandating fellowship training for subspecialty or combined primary-subspecialty careers. The remaining 57% opted for primary care, hospitalist, or other career paths that generally would not require fellowship training.

Debt level independently predicted practice goals, even in multivariate analyses controlling for resident age, sex, race, and marital status. Odds of having a practice goal that does not typically require fellowship training were higher in residents with either medium debt level (adjusted odds ratio [OR] 1.46, 95% confidence interval [CI] 1.16 - 1.84) or high debt level (adjusted OR, 1.51; 95% CI, 1.20 - 1.90) than in residents with low debt level.

Other independent predictors of non–fellowship requiring career choices were female sex, Black or Hispanic race, being married, and having children.


"Educational debt among graduating pediatric residents is high and continues to increase," the authors write. "Higher debt is one factor that may lead residents toward a career in primary care or hospitalist practice, rather than pursuing fellowship training and a subspecialist career."

Limitations of this study include an overall response rate of 61% and a reliance on self-report, which may create recall bias. The higher response rate among women than among men could have resulted in overestimation of the debt level because women reported higher degrees of debt. In addition, the debt load for married respondents could not be separated from that of their spouse, and other socioeconomic data were not available.

"Deciding on a career path is a critical personal decision for each graduating pediatric resident; multiple factors will shape this decision," the study authors conclude. "Additional studies on these practice trends are needed to better anticipate supply and demand as well as what is needed to achieve a balance between pediatric primary and individual subspecialty medical services to meet the needs of America's children."

The American Academy of Pediatrics supported this study. The study authors have disclosed no relevant financial relationships.

Pediatrics. Published online January 7, 2013. Abstract