Many Family Medicine Residents Have $150,000 in Student Debt

Diana Swift

April 28, 2016

With the United States facing growing shortfalls in primary care physicians, high educational debt loads are being deemed as much a deterrent to entering family medicine as lower remuneration.

A new policy brief from the Robert Graham Center for Policy Studies in Family Medicine & Primary Care, based in Washington, DC, reports that in a census of 3083 graduating family medicine residents, 58% had accumulated more than $150,000 in educational debt, and for 26%, debt reached more than $250,000.

The fear is that such liability levels are directing students' interest away from primary care, which is the practice area with the greatest return for the national healthcare dollar, according Andrew Bazemore, MD, MPH, and colleagues.

The policy brief was published in the April-May issue of the Journal of the American Board of Family Medicine.

For those who do plan to enter primary care, debt may also limit their choices for practice location and hours worked.

Dr Bazemore and colleagues call for reforms to ease debt repayment and narrow the remuneration gap between primary care and more lucrative medical specialties.

That point is reflected in findings from the "Medscape Medical News Physician Debt and Net Worth Report 2016," which found that 33% of primary care physicians are still paying off educational loans, sharing the top spot with emergency physicians. In contrast, just 16% of rheumatologists and gastroenterologists were still paying down educational debt.

Interestingly, 5% of third-year residents in the Robert Graham census faced school debt of less than $25,000, and a somewhat surprising 18% owed no educational debt at all.

The policy brief pointed to American Association of Medical Colleges findings that an educational debt level of $200,000 required measures such as programs for extended loan repayment and/or service-related loan forgiveness programs. An additional $50,000 in debt necessitated an extended repayment period of 25 years, as well as the location of practice in areas of physician shortage. Debt also limited a physician's chance of residing in a desirable neighborhood.

"Published student reactions to the American Association of Medical Colleges' findings affirmed suspicions that high debt levels help to explain why students are less likely to choose family medicine and raise concerns for those who still do," Dr Bazemore and colleagues write. They add that those from disadvantaged backgrounds may be even less likely to opt for primary care.

The authors stress that boosting the number of graduates choosing primary care will likely require debt-easing strategies including extended repayment plans, small business loans, practice transformation support, and reforms to correct the remuneration gap between primary care and higher-paying specialties.

Julie Phillips, MD, MPH, from the Sparrow-MSU Family Medicine Program at Michigan State University in East Lansing, agrees that medical school debt pressures some graduates to enter higher-income specialties. "[W]e are now facing a paradox in the United States: family medicine — the specialty that creates the greatest health value for the nation — is viewed by medical students as the specialty that offers the least personal financial security," she writes in a related commentary.

She points to research showing residents with heavy debt loads may suffer from depression or delay marriage, childbearing, and major purchases. They may also switch careers. Data also link high debt to increasing risk for callousness, stress, suicidal ideation, failing licensing exams, and leaving medical school.

According to the Bureau of Labor Statistics, Dr Phillips notes, family physicians' salaries have managed to beat inflation by increasing from $138,490 in 2004 to $186,320 in 2014. Still, a 2009 Robert Graham Center study showed that a high-income specialty vs primary care translates to an additional $3.5 million in lifetime income.

"The gap in payment between primary care and specialty physicians is not primarily the result of a difference in market value. It is caused and sustained by Medicare reimbursement policy, which must be reformed to value primary care in a real way," Dr Phillips writes. "Debt forces medical students, residents, and young physicians to make their future income a high priority, regardless of other values, hopes, and dreams."

This study received no funding. Two study authors are affiliated with the American Board of Family Medicine. The other authors and the editorial commentator have disclosed no relevant financial relationships.

J Am Board Fam Med. 2016;29:177-181. Brief full text, Commentary full text

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