Debt and the Emerging Physician Workforce: The Relationship Between Educational Debt and Family Medicine Residents’ Practice and Fellowship Intentions

Abstract

Purpose Educational debt is increasing and may affect physicians’ career choices. High debt may influence family medicine residents’ initial practice setting and fellowship training decisions, adversely affecting the distribution of primary care physicians. The purpose of this study was to determine whether debt was associated with graduating family medicine residents’ practice and fellowship intentions. Method The authors completed a cross-sectional secondary analysis of 2014 and 2015 American Board of Family Medicine (ABFM) examination registration questionnaire data and ABFM administrative data. They used multivariate logistic regression to determine whether educational debt was associated with graduating residents’ practice (ownership and type) and fellowship intentions. Results Most residents (89.7%; 3,368) intended to pursue an employed position, but this intention was not associated with their debt. Residents with high debt ($150,000–$249,999) had lower odds of intending to work for a government organization (odds ratio [OR] 0.57; confidence interval [CI] 0.41–0.79). Those with high or very high debt (> $250,000) had lower odds of choosing academic practice (OR 0.55, CI 0.36–0.85 and OR 0.62, CI 0.40–0.96, respectively) or a geriatrics fellowship (OR 0.36, CI 0.20–0.67 and OR 0.29, CI 0.15–0.55, respectively). Conclusions High educational debt may contribute to national shortages of academic primary care physicians and geriatricians. Existing National Health Service Corps loan repayment opportunities may not offer adequate incentives to primary care physicians with high debt. The medical community should advocate for policies that better align financial incentives with workforce needs.

Effect of medical student debt on mental health, academic performance and specialty choice: a systematic review

“…Several articles fell under one or more of these categories. All but one27 of the additional articles from the 2019 review examined the effect on (c) specialty choice 64–69…”

“…Similarly, Schwartz et al 12 found greater debt in 2007 compared with 1990, and students in 2007 were more likely to report that debt repayments pushed them away from primary care careers. More recently, high debt levels (US$150 000–US$249 999) of family medicine residents were associated with decreased odds of working in a government organisation, and very high debt levels (>US$250 000) associated with decreased odds of academic practice or geriatric fellowships 64…”

“…This more recent search revealed similar findings to those already concluded, in particular the majority of articles being related to specialty choice. Examples of the most recent studies64–69 are included throughout the ‘Results’ and ‘Discussion’ sections.…”

<p>Chronic Noncancer Pain Management and Systemic Racism: Time to Move Toward Equal Care Standards</p>

“… 171 Additionally, it is in hospitals’ best financial interests to train subspecialists for whom their reimbursements will be higher as opposed to primary care residents. 172 Accordingly, recent calls for a more direct financial benefit are being made, 173 with Ahmed and Carmody recently opining that providing financial compensation or expanding loan forgiveness programs for physicians entering practice in the most needed specialties or areas would create a powerful incentive to encourage doctors to work in the areas of greatest societal need. (p. 5) 172 Given the relative shortage of BIPOC pain physicians, we posit that such direct financial incentivization for BIPOC physicians to enter pain medicine training programs will be imperative as a step toward reducing systemic racism in pain medicine and improving the care that BIPOC patients receive.…”

Specialty income and career decision making: a qualitative study of medical student perceptions

“…This approach was chosen, in part, because the topic of study, the role of education-related debt in physician specialty choice, was one of personal interest to the researchers(JPP, DMW, DFR-S and DMD), who had personal experience with education debt. 29 Hermeneutic inquiry also allows researchers to explore issues that are 'taken for granted', 29 such as the observation, noted in multiple previous studies [13][14][15]20,21,26,31 that students and residents are influenced by debt and income when making career decisions. Through hermeneutic inquiry, researchers identify contextual influences of participant experiences that would otherwise 'lie beneath the surface'.…”