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Paying the Price to Become a Doctor: The Impact of Medical School DebtBy Suria Santana 
Andrew Gunter, M.D., 29, still talks passionately about hematology-oncology, a field he wished to go into after finishing his pediatrics residency. A few years ago, he sacrificed his plan of pursuing a fellowship in this area because his educational debt was too high, and the income he would get from the fellowship, too low. "If I didn't have as much debt as I did, I would probably be in a different place right now, possibly working in hematology-oncology," Dr. Gunter said. Instead, he took a private practice job in pediatrics. Although he studied medicine at a public college, Dr. Gunter owed approximately $85,000 at graduation, and at the end of his residency, more than $100,000. Because of his educational debt, he went into economic hardship deferment during his residency and into forbearance in his chief residency year. By then, Dr. Gunter had already changed his mind about the fellowship, so he took a pediatrics private practice job, a field with starting salaries of approximately $80,000. Had he opted to get a fellowship, he would have received a stipend of no more than $40,000. Despite the fact that doctors are among the best-paid professionals in the country, some worry debt and other financial considerations could affect career decisions made at the end of residency, such as was the case with Dr. Gunter. A 2000 Contemporary Issues in Medical Education (CIME) report raised a red flag, stating that "at a $150,000 level of borrowing, a borrower's career decisions such as whether or not to pursue a fellowship program, to subspecialize, to practice in an underserved area, and other practice location decisions may be adversely impacted by their level of educational debt." Such suppositions may be difficult to quantify, but according to Paul Garrard, assistant vice president of AAMC's Division of Student Affairs and Education Services, anecdotal research shows that some young doctors' debt levels are having an influence on their career decisions. "The anecdotal evidence we have gathered over the past years through our work with residents on debt issues clearly indicates this is happening, at least with some of our borrowers," Garrard said. Medical school indebtedness has been growing, with the average debt as of October 2001 at $99,089, a 4 percent jump since 2000. In 1990, the mean debt of medical graduates was $46,220, according to data from the AAMC's Graduation Questionnaire. Increasing tuition and student debt has been on the radar screen of financial aid officers for years. The current numbers alarm Pamela Nyiri, director of financial aid at Yale University School of Medicine for the past 20 years. "It used to be horrible for us to see a student whose debt surpassed $100,000," Nyiri said. "Now it is horrible to see a student whose debt surpasses $200,000." Vickie Ogden, director of financial aid and student services at Brody School of Medicine at East Carolina University, sees similar issues. "Students are coming in with more and more debt," Ogden said. "They're bringing in more credit card and undergraduate debt." Many factors might account for the rising indebtedness of medical school graduates, said Garrard. The lessening of institutional grant and scholarship support at some institutions, increases in the overall cost of attendance, and students who might be tempted to borrow more than needed because of recent drops in loan interest rates, are some examples. "These things taken individually may not account for the increase in debt, but taken together, they might help explain why debt levels continue to climb," Garrard said. St. Louis University School of Medicine Assistant Dean Mary Fenton, M.A., thinks debt has a greater effect on young doctors' career choices than many might want to admit. "I think that when you ask someone outright in a questionnaire if debt had an impact on any of their professional decisions, most of the times, you're going to get a 'no,'" Fenton said. "But when you talk to people anecdotally, that's when the truth comes out. In many cases, the anecdotal information you get is much more important than any quantitative data." Fenton worries that academic medicine could be adversely affected by rising debt rates. As one of the least paid professional options, academic medicine, and other not so-well-remunerated areas, may be negatively affected as more doctors opt for higher-paid practices. "I think debt is having an impact on whether or not young doctors do any subspecialty training and it's also encouraging people away from primary care specialties," Fenton said. "But most importantly, I believe there are going to be some huge ramifications for academic health centers in the future, since the starting salaries aren't going to be able to attract people with high debt levels."
A young doctor with substantial debt herself, Shamiram Feinglass, M.D., 34, has a different opinion. Dr. Feinglass is finishing up a Robert Wood Johnson Clinical Scholars fellowship, and argues that academic medicine professionals are a very special breed, and likely don't let financial considerations affect their decision to become professors or researchers. "Most people who want to go into academic medicine make a conscious decision about taking a lower salary," Dr. Feinglass said. "The person who goes into academic medicine is much different from the one who goes into private practice. Every once in a while, they may look with envy upon their private practice doctor friends, but they know going into academic medicine will bring less money and they do it anyway." Dr. Feinglass' six-digit debt figure hasn't kept her from following her passion and pursuing a fellowship. "I am in the higher end of debt myself, owing more than $100,000 for educational incurred expenses," Dr. Feinglass said. "But I found out through my own experience that despite debt, doctors are generally more likely to do what they're really interested in." Jack Murphy, M.D., 30, a pediatrician practicing in Children's Hospital, Philadelphia, is another doctor who has persevered despite financial burdens. Dr. Murphy graduated from Georgetown University School of Medicine in 1997, with a debt of nearly $155,000. During his three-year residency some of his loans accumulated interest, leaving him with a staggering $180,000 debt. "I know that for many people financial considerations are factors that influence professional decisions, but that wasn't the case for me," Dr. Murphy said. "Pediatrics is one of the least paid practices, but I went for it despite my debt." Programs like the AAMC's Careers in Medicine help ensure that the ultimate professional decisions of medical students and residents are compatible with their interests and skills. George Richard, Ph.D., the AAMC's director of Careers in Medicine, is in charge of this three-year-old program. "Our program has information to guide students through their career planning process, helping them assess who they are, what their values and skills are, and comparing that information to different specialties to find a good match," Dr. Richard said. The AAMC Careers in Medicine Web site provides information such as salary and employment data on the different medical specialties. While residents also have access to a variety of financial aid and financial planning resources, many do not take advantage of them. Mercer University School of Medicine's Director of Financial Aid Youvette Hudson said that especially during residency, young doctors don't have time to deal with all the paperwork. "I know residents who could qualify for certain programs, but they simply haven't taken the time to apply," Hudson said. "I write residents letters asking them to get in touch with their loan servicers immediately, and in the next months after I send the letter, I still receive pre-claims assistance requests from the Department of Education." Due to the elimination of the Internship Residency Deferment many years ago, the majority of medical school borrowers now apply for the Economic Hardship Deferment on their Stafford Loans during their residency. However, Garrard said, with a limit of three years on "hardship," they may still need help in residency when their deferment options run out. Forbearance is available in residency, but it is a costly option for young doctors. Besides the possible effect on professional decisions, young doctors' increasing educational debt can inconvenience other aspects of their lives. Dr. Murphy complains that unlike most of his friends, he hasn't been able to purchase a home yet. "I definitely had to sacrifice some plans after residency because of debt," Dr. Murphy said. "I make a decent salary now, but because of my debt and monthly loan payments, I am unable to buy a house or take expensive vacations." Dr. Feinglass is in a similar situation. "I look at my friends who are able to buy houses and cars and pay them off sooner and think: 'I certainly can't do that,'" she said. Because of her debt, she says that she thinks long and hard before putting anything on her credit card. But Dr. Feinglass insists that it is worth putting yourself in debt to pay for an education. "There's no problem going into debt in order to go to medical school," she said. "Our salaries are certainly higher than most other professionals' salaries in the country, so it pays off in the long run." But with that in mind, don't ever take out any more loans than you need, she warned. "It's a good idea to live less expensively during medical school, since you'll be less in debt after you're done." |
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The
AAMC's nationally recognized MEDLOANS Debt Management Program provides debt management help for students and the financial aid
profess-ionals who counsel them, said Garrard. "Additionally,
DEBTHELP, the AAMC's Educational Debt Management Services for Residents
provides help specifically for residents, and is a great way to
get timely information on everything from deferment and forbearance
to detailed information on loan consolidation," he added.