American Medical News
By — Posted March 11, 2013
Graduating medical students rate their level of education debt as the least influential factor in their choice of specialty, according to an Assn. of American Medical Colleges survey of nearly of 14,000 students. But others said money is a driver among many of the reasons students named for picking their career path.
The top two factors that students listed as having a “strong” or “moderate” influence on their choice of specialty were personality fit and the content of the specialty, with 98% listing both of those. Three-quarters of students — who could select as many items as they believed were applicable — cited the influence of role models and work-life balance as significant factors.
Forty-seven percent of respondents said income expectations were a factor, and 27% listed educated debt as a big factor.
“A thorough review of the academic literature shows little to no connection between economic factors such as debt/income potential and specialty choice,” said the AAMC report, released in February.
However, Elizabeth Wiley, MD, MPH, said the AAMC survey responses show that, despite appearances, money is very much on medical students' minds.
“While education debt as a factor in isolation is not ranked high, a lot of the other factors are at least indirectly associated with issues of reimbursement or earning potential,” said Dr. Wiley, national president of the American Medical Student Assn. “With things like work-life balance, certain specialties such as dermatology, radiology or anesthesiology — the reason that work-life balance is possible there is the way that subspecialty care is compensated in our system. To say that debt or earning potential isn't a factor compared with cultural issues may not paint a completely accurate picture.”
Specialists earn two to three times more than primary care physicians, according to the American Academy of Family Physicians.
The AAMC's findings on student debt as a factor in picking a specialty come as 86% of medical students graduated with debt in 2012, with the median debt at $170,000. That total did not differ notably by family income, the AAMC report said.
It is possible that medical students discount the effect of debt out of embarrassment, said Dr. Wiley, who plans to enter primary care. “In my experience, my debt is astronomical to the point where it's a personal issue that's almost embarrassing,” she said. “Who wants to talk about how indebted they are, or acknowledge it as a factor? I avoid looking at my loan statements because they're that terrifying.”
Targeting debt as a principal factor discouraging students from entering primary care misses other motivations, said Elbert S. Huang, MD, associate professor of medicine at the University of Chicago Pritzker School of Medicine.
“The depressing part of the problem is that there are just generational differences in what people want in their lives that are creating some of this continued move away from primary care,” he said. “Young professionals want a lot of control over their lifestyles, and the way primary care is arranged right now makes it look really unattractive, where you're working hard to take care of a lot of people.”
As many as 40% of U.S. physicians chose primary care in the late 1990s, but that share has fallen to about 30%. There were slight increases in students picking primary care residencies during the 2010 and 2011 Matches, with 44.1% selecting such training in 2011. The share fell to 43.6% in the 2012 Match. Figures from the Match do not perfectly predict how many physicians will pick primary care, because many applicants who opt for internal medicine residencies later choose to subspecialize rather than go into practice as general internists.
Medical schools should be doing more to encourage primary care among students, said Jeffrey J. Cain, MD, AAFP president. They should recruit students who are likelier to choose primary care, especially in shortage areas. These are students from rural areas, minority students and those who have expressed an interest in working in underserved areas. He added that medical schools ought to give students experience with primary care where it shines brightest.
“Medical schools by their nature are tertiary or quaternary care facilities, and thriving primary care tends to be in places outside of those facilities,” said Dr. Cain, chief of family medicine at Children's Hospital Colorado in Aurora. “It's important that students are exposed to thriving primary care practices in outpatient settings.”
A February study in Health Affairs estimates that the Affordable Care Act's insurance expansion in 2014 will produce a shortage of 7,200 primary care physicians, nurse practitioners and physician assistants. Seven million Americans will live in areas where the demand for primary care outstrips supply by more than 10% in 2014, said the study, whose lead author was Dr. Huang. Meanwhile, the AAMC projects a shortage of about 45,000 primary care doctors by 2020.
The American Medical Association has several policies on medical school tuition and debt. The high debt burden of medical school may dissuade students from diverse ethnic and socioeconomic backgrounds from pursuing careers in medicine, the AMA says. To relieve medical students' debt burden, the AMA favors capping loan interest rates at 5%, offering income-tax exemptions for scholarships, making loan interest fully tax-deductible, and creating more tuition assistance and loan-forgiveness programs.
The Affordable Care Act contains elements aimed at addressing the looming primary care shortage. Through 2015, primary care physicians and general surgeons who work in shortage areas are getting a 10% pay bump for certain services. In February, $10 million in federal funding went to help 87 medical students repay their loans. In exchange, these students will work full time for three years or part time for six years under the National Health Service Corps' Students to Service Loan Repayment Program.