AAMC Reporter: December 2008

Graduates Report Higher Debt, Primary Care Interest

New medical school graduates reported higher debt and concern over the demands of the health care system, but at the same time expressed more interest in primary care specialties and in working with needy and vulnerable populations, according to results from the 2008 AAMC Graduate Questionnaire (GQ).

Approximately 13,400 students responded to the questionnaire, which covers topics ranging from satisfaction over medical school coursework to financial aid to career choices.

For the fifth consecutive year, graduates said they will carry a greater educational debt load than their predecessors. All told, 17.7 percent of graduates had educational loans of $200,000 or more—more than triple the 4.9 percent who had that amount in 2004. Students with debt levels between $175,000 and $199,000 rose a full percentage point from 2007 to 2008, with nearly nine percent of 2008 graduates in this category. Students reported an average debt load of $141,751, more than $10,000 higher than 2007 GQ data.

Carrie Steere-Salazar, director of student financial services at the University of California, San Francisco, School of Medicine, said the relatively strong U.S. economy of four years ago played a large role in the financial aid decisions of this year's graduates.

"We've seen a jump in debt because the cost of getting the funds was very low," she said. "Interest rates were low, and the loans were readily available. Where once they may have relied on their parents for this money, instead at that point they saw a loan as easy cash. Obviously, that's no longer the case, so it will be interesting to see where these trends go."

Meanwhile, debt and salary expectations do not appear to heavily influence new graduates as they begin choosing a specialty. Although GQ coordinators stress that it is impossible to draw definitive conclusions from the data, the survey revealed a spike in interest in primary care specialties and in working with underserved populations. Only 9.2 percent of responding students said that debt would hold a "strong influence" on specialty choice, with large majorities citing the content of the specialty, its fit with personal interests and skills, and a mentor or role model's influence as the top three determining factors. Internal medicine assumed the top spot as the most popular specialty choice among 2008 respondents, with 16 percent reporting it as their intended choice—a major jump over the 5.1 percent who chose the same specialty last year. Obstetrics/gynecology and pediatrics also enjoyed significant growth in interest.

Additionally, 29.7 percent of graduates are interested in practicing in an underserved area—a five-year high and more than eight percentage points higher than in 2007—and more students than ever reported voluntary participation in a global health experience.

"There could be many factors playing into this," said Tom Koenig, M.D., associate dean for student affairs at Johns Hopkins University School of Medicine. "Are medical schools accepting more students with a broader view of the world? Are schools doing a better job of educating students? Are students simply more aware of these problems, and more willing to address them? It will be interesting to compare this data with what actually happens in the coming years."

This year's medical graduates seem to place greater value on having a more diverse set of backgrounds and educational experiences. Almost 7 percent more students in 2008 than in 2007 chose to undergo an experience in cultural awareness or cultural competence. More students also indicated that, on average, medical schools are doing more to educate them on culturally appropriate care for diverse populations.

On the other end of the spectrum, graduates who answered the survey indicated that they did not always receive enough instruction on the inner workings of the health care system. Respectively, 3.2 percent and 3.9 percent more students in 2008 as in 2007 felt that their training in health policy and health services financing was "inadequate." These increases come in tandem with a 3.2 percent increase in students who "strongly agreed" that the health care financing system was "too burdensome on physicians," and a smaller increase in students who "strongly agreed" that "changes in the health care system are impairing physician independence."

The GQ is completed by graduating medical students at all accredited U.S. medical schools. The resulting data are primarily used to track national trends and provide feedback to medical schools. The GQ is divided into two parts: one that evaluates a student's medical school experiences and is completely anonymous, and a second that includes questions related to educational and a noneducational debt, specialty choice, and a medical school's cultural environment. The responses to this survey include personally identifiable information; however, the students are given the option to release their identifiable information back to the medical schools.

—By Scott Harris