Medical training debt and service commitments: The rural consequences

This study assesses how student loan debt and scholarships, loan repayment and related programs with service requirements influence the incomes young physicians seek ann attain, influence whether they choose to work in rural practice settings and affect the number of Medicaid-covered and uninsured p atients they see. Data are from a 1999 mail survey of a national probabilit y sample of 468 practicing family physicians, general internists and pediat ricians who graduated from US. medical schools in 1988 and 1992. A majority of these generalist physicians recalled "moderate" or "great" concern for their financial situations before, during and after their training. Eighty percent financed all or part of their training with loans, and one-quarter received support from federal, state or community-sponsored scholarship, lo an repayment and similar programs with service obligations. In their first job after residency, family physicians and pediatricians with greater debt reported caring for more patients insured under Medicaid and uninsured than did those with less debt. For no specialty was debt associated with physic ians' income or likelihood of working in a rural area. physicians serving c ommitments in exchange for training cost support, compared to those without obligations, were more likely to work in rural areas (33 vs. 7 percent, re spectively p<0.001) and provided care to more Medicaid-covered and uninsure d patients (53 vs. 29 percent, p<0.001) but did not differ in their incomes ($99,600 vs. $93,800, p=0.11). Thus, among physicians wire train as genera lists, the high costs of medical education appear to promote, not harm, nat ional physician workforce goals by prompting participation in service-requi ring financial support programs and perhaps through increasing student borr owing. These positive outcomes fbr generalists should be weighed against ot her known and suspected negative consequences of the high costs of training , such as discouraging some poor students from medical careers altogether a nd perhaps influencing some medical students with high debt not to pursue p rimary care careers.