Spring 2009AzMedicine24
Med Students and Residents:Next in line for a Congressional bailout?
K. P. Edmonds & Jeremy Slone, MD
DAILY THERE seems tobe a new financial crisis onthe evening news. Bankscannot lend, car manu-facturers cannot afford tobuild cars, and familiesare struggling to pay theirmortgages to avoid fore-closure. Rarely mentionedis resident and medicalstudent loan debt, anamount that often equatesto the size of a mortgage.A subspecialty fellow atthe University of Arizonarecently stated that her debt,“actually makes me wish Ihad not gone into medicine,but it’s too late now; I havemy loans to pay off.”Robert Steinbrook, MD,recently evaluatedstudentloan data taken from the2008 Association of Amer-ican Medical Colleges(AAMC) Graduation Ques-tionnaire. According tothe survey, the medianpremedical and medicalstudent loan debt for agraduating medical studentin 2008 was $158,061.More shocking is the fact23% of those studentshad debt that was at least$200,000 dollars! Withan average resident salary being just above $43,000dollars, that debt burdencan be quite daunting.Despite these troublingfigures, clear data on howfinances affect career deci-sions can be difficult toobtain. Career decisionsare multi-factorial andit is not easy to quan-tify which factors are themostimportant. Study authors Steinbrook andRosenblatt warned thatthe prospect of such enor-mous debt may discouragethe pursuit of a medicalcareer by a student with alower income background.Students, these authorsincluded, are taking onthis financial burdenwith the hope of future job satisfaction and secu-rity—and the balancesheets are never far fromtheir thoughts when they move to select a specialty.This past year’s gradu-ates reported that, for 81%of them, expected futuresalary played some role intheir decision to pursuea certain specialty andeducational debt weighedon the decision for 48%.The cost of medical educa-tion and the resultanteducationaldebt has beenoutpacing the consumerprice index and the averagephysician compensation,especially payments forprimary care services. TheJAMA recently reported that just 2% of the incomingInternal Medicine intern
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RESIDENTS & MED STUDENTS
How Will AZ PhysiciansPractice in AdverseEconomic Times?
AzMedicineSpring 200925
class of 2007 planned togo into general internalmedicine and, similarly,that only 2% of gradu-ating US medical studentsplanned on a career in aprimary care field. As arecent ACP white paperpointed out, primary carephysicians offered betteroutcomes at a lower costaccompanied by decreasedmortality and hospitalstays and increased conti-nuity of care. The paucity of anticipated physicians inprimary care is particularly troubling given the agingof the American popula-tion and the recent talk inWashington about reen-gineering our health caresystem to be cheaper whileimproving outcomes andoffering a renewed emphasison disease prevention.While studies have yet toshow how important finan-cial debt is when medicalstudents are deciding theircareer path, we need tolook no further than ourown residents in the stateof Arizona to see that theirdebt burden is supremely important. For some,the immediate return of primary care is advanta-geous while some thinkthe higher pay of a sub-specialty is preferable.Darren Siedschlag, a second year internal medicine-pediatrics resident at GoodSamaritan Hospital saidthat “overall I feel the debthas pushed me to primary care.” Ryan Matika, a third year anesthesiology residentat the University of Arizona(UA), says he is “less likely to pursue fellowship… asthe financial burden willlikely not out[weigh] thebenefits.” A third yearpsychiatry resident at UA is“considering a fellowshipin child psychiatry becauseit pays more that generalpsych.” Financial concernsare clearly impacting resi-dents’ career decisions.This being the era of thecongressional bailout,maybe the U.S. Congresswill throw us a lifeline.Unfortunately, it seems theopposite has happened.For years, residents wereable to delay payments onloans while the governmentcovered the interest on allsubsidized federal studentloans via Economic Hard-ship Deferment, also knownas the 20/220 pathway.Nearly 2/3 of residentsbenefited from this option.However, this pathway was not renewed in key educational legislation inSeptember 2007, thereforeletting the federal govern-ment off the hook. Attemptswere made to reinstate the20/220 pathway, includingbills introduced to the U.S.Senate and House of Repre-sentatives but both arestill mired in committee.So on July 1, 2009, the20/220 pathway will beeliminated. In its place, anincome-based repayment(IBR) program will beestablished. While a resi-dent’s loans will no longerbe eligible to be deferred,IBR can be used to makepayments reasonable basedon income. It is sort of likea minimum payment on your credit card, except itis based on your income,not your balance.
K. P. Edmonds comments
As a soon-to-be graduate of the University of ArizonaCollege of Medicine, I haveenjoyed tuition and feesin the top of the bottomone third of US medicalschools and, as such, havebeen able to meet my goalof keeping my educationaldebt less than $100,000. If I hadn’t, or if I had beenattending the MidwesternAzCOM campus wheremy tuition and fees wouldhave been much greater,I can’t be certain that Iwould have been as freeto follow my passion intoFamily Medicine. This isespecially true at a timewhen the difficulties of primary care have beenhighlighted by the closingof two Family Medicineresidencies in MaricopaCounty and the resultantloss of 8 potential Arizonafamily physicians a year.Much like the AAMCnumbers highlighted above,my classmates generally assure me that their educa-tional debt does not affecttheir specialty selection,but, in the next breath,they mention that expectedfuture salary played animportant role. Perhapsthe best way to close outthese musings is with thisthought from my class-mate, Amber May, “For mepersonally, the issue of debtwas not a consideration…Ido feel affected though by the cost of medical educa-tion because I feel I’ve lostcolleagues (who initially were interested in primary care) to [other] fields.”
Jeremy Slone’s comments
Recently, I contacted resi-dents all over the state of Arizona to see how they will be affected by theelimination of the 20/220pathway and establishment
Continued on page 33
The cost of medical educationand the resultant educationaldebt has been outpacing theconsumer price index and theaverage physician compensation.
AzMedicineSpring 200933
of the IBR program. To my surprise, the majority of responders were completely unaware of what will behappening to them in justa few months! Those thatwere aware recognize theenormous impact thischange will have on them.Resident debt continuesto climb and is a factor incareer decisions; meanwhile,an important managementtool is being eliminated ina few months. The impacton our healthcare system,if any at all, remains to beseen. Continuing the avail-ability of economic hardshipdeferment, increasing theamount of federal grantsand developing loan repay-ment programs are just afew of the remedies beingdiscussed. However, justcreatinga dialogue amongstinterested parties might bethe most important firststep. Regardless, in today’stroubled economy, resi-dents are facing toughdecisions with an alba-tross that will hang on theirneck through the majority of their career. We willnot be holding our breathwaiting on that congres-sional bailout of our loans.
Kyle P. Edmonds is a 4th year stu-dent at the University of ArizonaCollege of Medicine soon to beginresidency at an Arizona Family Med-icine program. He proudly serveson the AzMedicine Advisory Coun-cil, the Board of Directors of ArMAand the Governing Council of the AMA Medical Student Section.Jeremy Slone, MD, is a PediatricResident at Phoenix Children’s Hos-pital and Maricopa Medical Center,and a member of the ArMA Boardof Directors and the AzMedicine Ad- visory Council. In July, he will begina pediatric hematology-oncology fel-lowship at Vanderbilt University.References: American College of Physicians.How Is a Shortage of PrimaryCare Physicians Affecting theQuality and Cost of Medical Care?Philadelphia: American College ofPhysicians; 2008: White Paper.(Available from American College ofPhysicians, 190 N. IndependenceMall West, Philadelphia, PA 19106.)Ebell, Mark H. “Future Salaryand US Residency Fill Rate.”
Journal of the American Medical Association
300 (2008): 1131-132.Hartzband, Pamela, and JeromeGroopman. “Money and theChanging Culture of Medicine.”
New England Journal of Medicine
360 (2009): 101-03.Hauer, Karen E, et al. “Factors Associated with Medical StudentCareer Choices RegardingInternal Medicine.”
Journal of the American Medical Association
300 (2008): 1154-164.Morra, Dante J., MD, et al.“Medical Students, Money, andCareer Selection: Students’Perception of Financial Factorsand Remuneration in FamilyMedicine,”
Family Medicine
2009; 41 (2): 105-110.Rosenblatt, MD, MPH, et al, “TheImpact of U.S. Medical Students’Debt on Their Choice of PrimaryCare Careers: An Analysis of Datafrom the 2002 Medical SchoolGraduation Questionnaire,”
Academic Medicine
, Vol. 80, No.9/September 2005, 815-819.Steinbrook, Robert. “MedicalStudent Debt -- Is There aLimit?”
New England Journal of Medicine
359 (2008): 2629-632.
Med Students and Residents: Next in line for a Congressional bailout?
Continued from page 25
So on July 1, 2009, the 20/220pathway will be eliminated.In its place, an income-basedrepayment (IBR) programwill be established.
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Medical Students & Residents: Next in line for a Congressional bailout?
Article from Spring 2009 AzMedicine magazine, produced by the Arizona Medical Association, exploring the economics of medical school and residency for future physicians.
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