Medical student debt has been growing steadily over the past several years, and there is increasing concern that this financial burden is biasing students’ career choices and discouraging economically disadvantaged students from applying to medical school. HMS dean Jeffrey Flier, the Strategic Advisory Group on Education (SAGE), and the Program in Medical Education recently took an important step toward reducing this burden. They have initiated a plan to eliminate the family contribution entirely for students whose parents make $120,000 or less each year; one in three HMS students will benefit from this reform. Their proposal follows another policy change enacted last year, which reduced the family contribution expected of HMS students aged 29 years or older.
These reforms are welcome steps toward an elusive solution. The inexorable rise of medical school tuition, coupled with physician salaries that are struggling to keep pace with inflation, hints that the financial relief they afford may soon be eroded. More transformative measures are sorely needed—not just at HMS, but in medical schools nationwide.
Nine out of every 10 U.S. medical students are in debt at the time of graduation, and they each carry an average of $140,000 in loans. This amount is made up of both undergraduate and graduate financial aid, and its steady growth over time is largely due to high and ever-rising tuition fees. The financial scenario is even bleaker for one in 10 medical students with debt, since their total loans exceed the $200,000 mark. Not surprisingly, the American Medical Association (AMA) and other groups are concerned that this burden could be driving graduates to base their specialty choices on financial remuneration rather than personal or altruistic interests.
Indeed, the career fields that are widely considered to be casualties of students’ heavy financial burdens also happen to be those that are in most desperate need of talented physicians. Specifically, the AMA is concerned that high indebtedness is biasing students away from careers in primary care and also discouraging them from working in rural, low-income, and other underserved settings. Empirical research has also uncovered evidence in support of this claim.
To better understand local sentiments about educational debt, I spoke with several graduating HMS students. None of them asserted that debt was a major driver of their specialty choice, but this must be considered in the context of the issue’s sensitivity. Many of their comments did suggest that indebtedness does influence some students’ choices. I highlight a few of the more representative responses below.
Anna Chodos, who will be an intern in the internal medicine/primary care residency program at the University of California-San Francisco, encountered residents, attendings, and others who voiced concerns about loan repayment to her upon hearing her plan to pursue primary care. “I have some fears about educational loan debt being a problem for me, but I did not allow this to affect my choice of residency. Primary care is the channel through which I can contribute most to the field of medicine and patients.” She added, however, that some of her colleagues were in more challenging positions. “I have seen medical students make career decisions out of concern for their financial security. Many students in their early years believe that debt burden won’t affect their specialty choices, but by third or fourth year, many others succumb to suggestions that they should be going into lucrative fields.”
Taniqua Alexander, who will train in an obstetrics and gynecology residency program at the University of Virginia, echoed similar sentiments. “The high cost of medical school sometimes forces students’ altruistic reasons for pursuing medicine to take a back seat to the need for greater earning potential.” Like Chodos, she expressed concerns about indebtedness, but remains optimistic about the future. “I plan to focus on the prevention and primary care aspects of obstetrics and gynecology, as opposed to the surgical aspects of the field. I know that my income may be substantially lower because of this, but I’m hoping to find avenues for debt relief.”
Another graduating student, Thomas Hocker, will be starting a dermatology residency at the Mayo School of Graduate Medical Education next summer after finishing a transitional year at the Santa Clara Valley Medical Center in San Jose. His career choices were not influenced by debt worries, but he voiced similar concerns about the overall effect of heavy loan burdens. “I chose dermatology primarily because of my research interest in cancer genetics, namely melanoma,” he said. “However, I do feel that excessive debt from medical school may impact some students’ residency choices and that efforts must be made by medical schools across the country to reduce the amount of loans with which medical students are burdened.”
The recent HMS policy change marks an important step toward reducing the heavy debt burden faced by students. Among the HMS students I spoke to, most noted that personal interest and altruism were the major drivers of their specialty choices, but concerns about the influence of indebtedness on career decision-making remain strong. As medical tuition continues to rise, the problem is likely to worsen. Ultimately, innovative ideas and approaches are needed to craft a lasting solution on a national level.
Joseph Ladapo is a Harvard medical student and a PhD student in health policy.
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.
