Pauline Chen had a compelling piece in the New York Times recently about medical student debt and it’s unappreciated costs. It draws on a recent publication in Academic Medicine which highlights the diverse drivers of medical student indebtedness. These include an expansion of the medical school’s research enterprise, a lack of accountability on the part of medical school administrators, who can increase tuition to support the research mission, and the advent of medical students who want to live like young professionals not professional students.
Dr. Chen argues that high levels of medical student debt are, at least in part, responsible for the shortage of primary care doctors and those willing to take care of poorer patients. She writes that “looming debts mean eschewing a calling to serve a particularly needy, less lucrative patient population or practice, and instead pursuing a well-compensated subspecialty that caters to the comfortably insured.”
I’d like to suggest that something more complicated is going on. As both articles point out, high medical school tuition acts as a deterrent to students from underrepresented minorities and lower socioeconomic status. Since the 1970s, enrollment of underrepresented minorities in American medical schools has stagnated (see figure). The percentage of students coming from the lowest 40% of the income spectrum has dropped from 27% to 10% from 1971 to 2004. The percentage of medical students from the top 40% of earners has increased from 66% to 75%. Our profession is increasingly made up of people who come from the upper and upper-middle classes.
As this AAMC report points out, “physician diversity contributes to increased access to health care for underserved populations.” The converse is true as well— the less our profession represents the demographics of the U.S. population, the less well we’re able to care for it.
No doubt, students are justifiably concerned with their debt burdens, but it’s frequently forgotten that one can make a good living in primary care or caring for the underserved. Personally, I wonder if students eschew this work because of their loans or if they never really consider it in the first place. A recent study highlights that sustaining a practice in an underserved area requires a deep personal motivation or strong sense of identification with the community. If most students don’t bring these characteristics to medical school, and schools don’t nurture them, it’s no wonder that students choose lucrative subspecialties where their income can keep pace with their peers outside of medicine.
This is all just to say that increases in tuition and debt for medical students are only a part of the problem. They reduce our ability to recruit and train a diverse workforce. This in turn contributes to skewed values within the profession—and it is our values, not the debt itself, that most frequently drives graduating doctors into subspecialties and suburban practices.
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