Educational debt and career choice: every student matters.

TO THE EDITOR: The American Association of Medical Colleges (AAMC) recently published an important report, “Physician Education Debt and the Cost to Attend Medical School: 2012 Update.”1 This publication, an update to a previous report by Paul Jolly, is a comprehensive quantitative analysis capturing the AAMC’s data about medical student debt in the United States. Family physicians will find the report’s discussion of debt and medical student interest in primary care careers (pages 11-12) especially relevant. Youngclaus and Fresne write that educational debt does not “appear to play a determining role for most [students],” and this is undoubtedly true. All medical students make their specialty choices based on a range of factors, and debt probably only plays a significant role for a relatively small number of students: 27%, based on students’ self-assessment at graduation.1 But for a nation that is facing a primary care crisis, a minority of students can make a big difference. We simply do not have enough students who are interested in primary care. We can’t afford to lose a single one. Several studies have demonstrated a relationship between high debt levels and specialization when the population of the study is focused and confounders—particularly socioeconomic status—are carefully controlled.2-4 These findings are congruent with a recent publication demonstrating that students with very high debt are likely to find primary care careers to be financially challenging.5 We cannot continue to saddle students with extraordinary financial obligations and expect them to make choices that are not in their own best interest. Of course, many heavily indebted students do choose primary care careers, understanding that this choice will require them to plan their financial future more carefully. Loan repayment opportunities make a primary care career more financially feasible. But these programs are not for everyone. Every student should have the financial freedom to choose a primary care career, regardless of where they choose to live and practice. It is time for us to stop worrying about the majority. We need to find the students at the margins, for whom debt is a major contributing factor to a decision to avoid primary care. It would only take $150,000 to reduce one student’s debt from an extraordinary $250,000 per year to a much more reasonable $100,000. If that student became a family physician, instead of a specialist, he or she would contribute to a more balanced local physician workforce with lower health care spending.6 Most important, he or she would improve patients’ lives and prolong their life expectancy.7 This physician’s value, over a lifetime of practice, would far exceed the $150,000 financial investment. As family medicine educators, we have a responsibility to advocate for change.