Clinical and Health Affairs
Effect of Rising Medical Student Debt on Residency Specialty Selection at the University of Minnesota
By Paul Tonkin
Abstract
The cost of a medical education continues to increase while the real value of physician compensation is decreasing. The University of Minnesota Medical School is the most expensive public medical school in the country. Rising tuition costs combined with a relative decrease in scholarship money is resulting in dramatic increases in medical student debt. The average debt load of a medical student graduating from the University of Minnesota was $119,868 in 2004 and $132,988 in 2005. Experts in medical education speculate that such heavy debt affects medical students’ career choices. However, prior to this study, the relationship between student debt and residency specialty selection at the University of Minnesota had not been analyzed. This study found a significant correlation between debt and specialty selection at the University of Minnesota, Duluth campus, and no significant correlation at the Twin Cities campus in Minneapolis.
The University of Minnesota Medical School is unique because it has 2 campuses—Duluth and the Twin Cities—with different missions. Applicants to the Duluth program are screened for their interest in rural medicine and family medicine/primary care. Forty-four percent of graduates enter family medicine, and 65% enter primary care residency programs following graduation.1 The Twin Cities campus in Minneapolis is more traditional in that students are encouraged to consider all fields of medicine. Students pay the same tuition and have the same financial aid resources available to them at both facilities.
The University of Minnesota Medical School is the most expensive public medical school in the country with an annual tuition cost of $26,607 (not including $16,000 on average for annual living expenses).2 The average debt of a medical student graduating from the University of Minnesota was $119,868 in 2004 and $132,988 in 2005.3 Rising tuition combined with a relative decrease in scholarship money is resulting in dramatic increases in medical student debt (Figure 1).
Methods
This study analyzed data from 326 medical students from the University of Minnesota. Subjects were divided equally between the graduating classes of 2000, 2001, 2002, and 2003. One hundred fifty-eight students started their medical training on the Duluth campus, and 168 students started on the Minneapolis campus. Data on each student including gender, age at graduation, marital status, number of dependents, ethnicity, medical school debt, and residency selection was collected.
Students were divided into 3 groups based on their residency selection. The first group consisted of students who chose family medicine residencies. The second group was a primary care subgroup that included students who chose internal medicine, pediatrics, or internal medicine/pediatrics residency programs. The third group was made up of students who chose all other residencies including general surgery, surgical specialties, OB/GYN, dermatology, radiology, anesthesiology, etc. It should be noted that fellowship data were not collected or analyzed because the majority of the subjects had not completed their residencies at the time of this study. Students were randomly selected and data were analyzed using Statview. Chi-square tests were used for discrete data, t-tests for 2-group comparisons, and 1-way analyses of variance for comparison of multiple groups.
Results
Data analysis showed no statistical correlation between marital status and residency specialty selection (P=0.4090). There was no correlation between age at graduation or ethnicity with specialty selection (P=0.9172 and 0.4969, respectively). A statistically significant correlation did exist between gender and specialty selection, as women graduates chose primary care specialties more often than men (P<0.0001). The campus on which students started their training also correlated with residency selection. Students who spent their first 2 years of medical school in Duluth entered family medicine and other primary care specialties more often than students who began their medical training in Minneapolis (P<0.0001). Approximately 60% of Duluth students go into primary care specialties. Finally, Duluth students who entered surgical specialties or who chose a subgroup of primary care specialties including internal medicine had significantly more debt than those students who entered family medicine residencies (P<0.05). Conversely, there was no correlation between debt and residency selection among Minneapolis graduates (P= 0.423) (Figure 2).
Discussion
The results of this study demonstrated significant correlations between gender and choice of specialty and between the campus on which students began their training and specialty selection. These correlations have been reproduced in many other studies, therefore supporting the validity of this data set.4 This study also demonstrated a significant correlation between medical student debt load and specialty selection at the University of Minnesota, Duluth campus. Between 2000 and 2003, Duluth students who chose surgical specialties and a subgroup of primary care specialties including internal medicine had significantly more debt than those who chose family medicine residencies. In short, medical students from Duluth with more debt chose specialties with increased earning potential more often than students who graduated with less debt. It is worth noting that physicians entering family medicine or internal medicine are compensated similarly; however, nationally cited figures indicate two-thirds of internal medicine residents subspecialize in fields such as cardiology, gastroenterology, pulmonology, and infectious disease. Internal medicine residents who subspecialize increase their earning potential by 2 or 3 times that of a family physician.5,6
Prior to gaining admission to the University of Minnesota Medical School, Duluth campus, students are extensively screened for their interest in rural medicine and family medicine. It would be reasonable to think that students who pass the test would be less likely to be affected by the burden of debt because of their strong interest in family medicine. Therefore, it is surprising that a significant correlation exists between debt load and specialty selection among students from the Duluth campus and not among those from the Minneapolis campus. One explanation for Duluth students pursuing higher-paying specialties is that they are more likely to come from a rural area and from a blue-collar family. Consequently, these students may better understand the implications of assuming a 6-figure debt and may be solely responsible for paying it off.
Another explanation is that the data on Duluth students may indicate the beginning of a national trend. It is possible that schools with a strong history of producing family and primary care physicians will be the first ones to feel the effects of dramatically increasing student debt. These medical schools may likely be the first to demonstrate a statistically significant correlation between student debt and specialty selection because they have enough students choosing primary care to detect a statistically significant change. Therefore, it would be worthwhile to evaluate debt data from other medical schools that produce a large percentage of primary care and family physicians.
Conclusion
Students choose a medical specialty for a variety of reasons including personal interest, lifestyle, and prestige. It is of concern that students at a medical school designed to produce rural family doctors are now being influenced by educational debt imposed by that very institution. Furthermore, demand for primary care physicians in Minnesota continues to increase while the number of students choosing family medicine and primary care specialties is decreasing.7 This leaves many unanswered questions: What will be the consequences of average debts of $200,000? Will the burden of debt ultimately affect the profession’s moral obligation to serve all? How many qualified and diverse applicants are choosing not to apply to medical school because of the overwhelming debt?
Those questions will need to be addressed sooner rather than later as the University of Minnesota Medical School, Duluth campus, attempts to fulfill its mission to serve the primary care needs of rural Minnesota while burdening its students with the most expensive public medical school tuition in the country. MM
Paul Tonkin is a fourth-year medical student at the University of Minnesota Medical School.
The author would like to thank Jim Boulger, Ph.D., and Ruth Westra, D.O., for their hard work throughout each phase of this project. This study was supported by a grant from the Minnesota Academy of Family Physicians.
References
1. Boulger J. Analysis of Residency Selection at the University of Minnesota School of Medicine-Duluth. 2001.
2. Association of American Medical Colleges. Public Medical Schools Tuition and Fees First-Year Medical Students 2005-2006. Available at: http://services.aamc.org/tsfreports/report.cfm?select_control=PUB&year_of_study=2006. Accessed May 10, 2006.
3. Gibson BJ. University of Minnesota Annual Financial Aid and Student Debt Analysis; 2004 and 2005.
4. Pugno PA, McPherson DS, Schmittling GT, Fetter GT Jr, Kahn NB Jr. Results of the 2004 national resident matching program. Fam Med. 2004;36(8):562-70.
5. Grosso U, Goode LD, Kimball HR, Kooker DJ, Jacobs C, Lattie G. The subspecialization rate of third year internal medicine residents from 1992 through 1998. Teach Learn Med. 2004;16(1):7-13.
6. Allied Physicians, Physician Salaries and Salary Surveys. 2004.
7. Martin JC, Avant RF, Bowman MA, et al. Future of Family Medicine Project Leadership Committee.The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med. 2004;2:S3-S32.