Weigh Medical Student Debt, Specialty Choice

Consider the financial implications of choosing to be a specialist or primary care physician.

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As the United States recovers from the recent recession, it is not surprising that the longterm effects of the economic belt-tightening we see all around us will affect health care spending as much, or perhaps more, than other sectors of the economy. Nevertheless, future doctors can take comfort in the relative job stability and high earnings achieved by medical professionals: The U.S. Bureau of Labor Statistics reports that doctors and dentists represent four of the top five highest-earning professions in the United States ("chief executives" are fifth).

Given this context, I'm sure many people were caught off guard by an op-ed, "Why Medical School Should Be Free," that recently appeared in the New York Times.

Written by two health policy experts who happen to be doctors themselves, the authors call attention to the shortage of primary care physicians predicted in the coming decades. They argue that, "Fixing our health care system will be impossible without a larger pool of competent primary care doctors who can make sure specialists work together in the treatment of their patients—not in isolation, as they often do today."

[See U.S. News's rankings of Best Medical Schools.]

However, the number of U.S. medical school graduates choosing primary care has been declining dramatically; this reduction in supply is compounded by a simultaneously growing and aging U.S. population, as well as the expansion of government-financed health care access mandated under Obamacare. All told, the American Academy of Family Physicians predicts a shortfall of almost 40,000 primary care providers by the year 2020.

The authors identify rapidly ballooning student debt as the motivator for this retreat from primary care. According to 2010 statistics compiled by the American Association of Medical Colleges, approximately 86 percent of U.S. medical students graduated with some debt, and of those, the average debt was almost $160,000, up from $129,000 in 2006 (and $87,000 in 2002). Meanwhile, the income gap between primary care doctors and specialists has continued to widen, with specialists' annual income averaging more than $300,000 as opposed to less than $200,000 for primary care doctors.

The op-ed proposes an ambitious scheme to drive medical students away from specialties and into primary care, by having postgraduate specialty trainees (who are "virtually assured lucrative jobs") forgo their stipends (i.e., salaries) for the duration of their training in order to finance universal free medical education. Primary care trainees would continue to receive their stipends without interruption.

[See which medical schools are investing in primary care.]

I think this proposal is fundamentally flawed on multiple levels, the most important being the fact that most of the rigorous studies conducted to identify factors that influence specialty choice amongst U.S. medical students have concluded that medical debt is a minor contributor. For instance, an analysis of the 2002 AAMC nationwide survey of graduating U.S. medical students showed that debt levels were independently associated with less than 5 percent of students' career choices, whereas demographic factors such as gender and ethnicity accounted for around 10 percent to 30 percent of those choices

Nevertheless, the issues of physician supply, specialty choice, and exorbitant debt bear considering. Without question, many of the most highly compensated specialties (e.g., radiology, anesthesia, orthopedics) also tend to be amongst the most competitive. Even at the early stage of medical school application, this might be relevant: Might it be worth going to a more prestigious medical school, even if it means passing on the low tuition of a state school or generous financial aid package at a lesser-known institution? Then again, are you prepared to face six-figure debt by the time you graduate without any guarantee you'll be able to secure one of the highly lucrative positions many are seeking?

As with most aspects of medical school admissions, and career planning in general, considering your options—and these questions—carefully is your surest way to maximize your chance of achieving the medical career you desire.

Joshua Klein is a Board Certified OB/GYN and a Clinical and Research Fellow in Reproductive Endocrinology and Infertility at Columbia University Medical Center in New York City. After earning his medical degree at Harvard Medical School, he completed residency at Harvard’s Brigham and Women’s Hospital and Massachusetts General Hospital.