Medical Student Debt and the US Infectious Diseases Workforce

Abstract

Student debt in the United States is at historically high levels and poses an excessive burden on medical graduates. Studies suggest that financial limitations dissuade some medical trainees from pursuing careers in infectious diseases (ID) and other cognitive specialties, despite their interest in the subject matter. Addressing student debt may have a transformative impact on ID recruitment, diversification of the ID workforce, and contributions of ID physicians to underserved public health needs. Relief of student debt also has the potential to narrow the racial wealth gap because nonwhite students are more likely to finance their postsecondary education, including medical school, with student loans, yet they have a lower earning potential following graduation. An executive order from the Biden-Harris administration announced in August 2022 presents a first step toward student debt relief, but the policy would need to be expanded in volume and scope to effectively achieve these goals.

Addressing medical student debt is important for infectious diseases recruitment, workforce diversification, physician well-being, and addressing underserved healthcare needs. While a recently announced executive order is unlikely to have substantial impact, it is a promising step in the right direction.

Student loan debt in the United States currently exceeds 1.7 trillion dollars [1]. Year after year, this number rises: student debt has grown by approximately 16% per year since 2000 [1], and this debt greatly affects the physician workforce in the United States. Compared with other borrowers, medical students and physicians carry a much larger share of student debt on average [2]. Currently, the average medical school graduate owes more than $240 000 in total student debt, corresponding to a total of $4.35 billion each year [2, 3]. As with other professionals with student loans, a substantial fraction of this debt is in the form of accumulated interest.

On 24 August 2022, the Biden-Harris administration announced new federal loan forgiveness programs that will effectively cancel billions of dollars in existing student debt [4]. In their current form, these landmark programs will forgive up to $20 000 in student debt for individuals who qualified for Pell grants (given to students with exceptional financial need) and $10 000 for other borrowers who currently earn less than $125 000 in individual income [4]. If enacted, millions of individuals, including thousands of medical trainees and physicians, are expected to qualify for debt relief though these initiatives. These programs mark a major change in federal policy after decades of political debate about the growing and seemingly intractable problem of student debt.

Some people have argued that the current proposal of $10 000 relieved per borrower is insufficient and have championed full student debt forgiveness (“cancellation”) by the federal government. There is no clear political consensus on how much student debt should be forgiven, who should qualify, and what income restrictions should apply. Public opinion polls have shown widespread support for federal student debt forgiveness, though opinions still vary about how far such a policy should go [5]. Furthermore, the current proposal does not address the problem of rising tuition fees in US colleges, universities, and medical schools. Proposals on limiting tuition fees and completely cancelling student debt, once at the fringe of political debate, are now in the mainstream and, in the wake of the recent executive order, appear closer to becoming reality through future debt relief legislation and executive orders.

Student debt has wide-reaching consequences for the medical community. Infectious diseases (ID) physicians, being among the lowest-paid medical specialists in the United States [6], could be particularly sensitive to changes in student loan repayment. In this article, we review trends in the ID workforce in the United States, and we consider the impact of debt relief policies on the composition of the ID workforce, including the recruitment of racial and ethnic minorities and people from disadvantaged socioeconomic classes. We also discuss the potential impact on those who choose to pursue ID careers in publicly funded research, public health, and low-income communities. We argue that the ID community has a substantial but currently underappreciated stake in the political debate regarding student debt.

ID WORKFORCE

The need for a robust, diverse, and well-trained ID workforce has long been recognized across spheres of US healthcare [7], especially by the members and leadership of the Infectious Diseases Society of America (IDSA). This need is rooted in a daunting inventory of challenges facing medicine and public health: the ongoing crisis of antimicrobial resistance; an aging and more immunosuppressed population; resurgence of many transmissible respiratory and sexually transmitted pathogens, enabled by an increasingly connected and mobile global society; widespread and persistent structural social inequities; and climate change, which is associated with more frequently observed extreme climate-related events. The list goes on. The critical importance of the ID physician workforce was recognized well before 2020, when the coronavirus disease 2019 (COVID-19) pandemic found its unfortunate and rightful place at the top of this list.

Unfortunately, the current size of ID workforce falls short of what is needed to meet these challenges. For example, in many parts of the country, a deficit in ID specialists and human immunodeficiency virus (HIV) providers threatens gains made in ending the HIV epidemic [8, 9]. The nation's public health workforce, with ID specialists long playing a central role, has been in decline for more than a decade to the detriment of this nation's COVID-19 response [10, 11]. For more than 10 years, ID fellowship training recruitment in the United States has been characterized by an alarming mismatch between surplus training opportunities and low applicant demand [12]. Between 2010 and 2016, the number of applicants to adult ID fellowship training programs fell by 31% [12]. In 2016, ID recruitment hit a particular low point as only 42% of programs participating in the fellowship match filled their available positions [13]. While these metrics have improved in recent years, ID remains among the few subspecialty programs in internal medicine that offer many more training positions than the available pool of applicants.

Multiple factors have contributed to the dearth of new physicians joining the ID workforce, and the reasons behind any individual physician's career decisions are complex and multifaceted. However, there is one consistently identified reason that cannot be ignored: financial concerns related to comparably lower compensation seem to dissuade new physicians from pursuing a career in ID. A nationally representative survey of internal medicine residents found that the most commonly reported dissuading factor for medical trainees who are initially interested in ID is the low salary [14, 15]. A survey of military internal medicine residents recapitulated these results: low salary ultimately dissuaded trainees who were initially considering a career in ID [16]. In fact, the percentage of applicants dissuaded by the low salary offered in ID careers may be underestimated by these surveys owing to social desirability bias (ie, many residents may be reluctant to admit that a low salary motivated them away from their original career choice) [17]. That other low-paying subspecialties in internal medicine have experienced the same trends [18, 19] provides further evidence that financial concerns are an important deterrent among those who may have considered a career in ID.

ID physicians are among the lowest paid subspecialists in medicine. The average adult ID physician earns approximately 60%–70% that of their counterparts in other internal medicine subspecialties [6]. Pediatric ID physicians earn the lowest average salary among all physicians in a recent survey of Doximity members [20]. Lower salaries among nonprocedural “cognitive” specialties are thought to be directly tied to reimbursements, as these specialties bring less relative value units to a hospital or practice, a widespread health systems shortcoming that the IDSA and other professional organizations have worked to address [21]. However, there is arguably a large gap between ID physicians’ salary and the “value” they add to a patient's care [22]. For example, a study of Medicare claims demonstrated that hospitalized patients with ID consultations experienced lower mortality and lower readmission rates than those without an ID consultant involved [23].

The value of the ID physician workforce extends beyond these direct benefits to patients: ID contributions to the public health workforce and ID-trained physician-scientists continue to advance domestic and global public health and generate path-breaking scientific discoveries year after year. Many of the major, life-saving medical and public health interventions developed and deployed during the COVID-19 pandemic and the 2022 monkeypox outbreak would not have been possible without this important group of physicians. That many of these individuals were trained in ID fellowships that are now struggling with low recruitment should give us pause when considering our long-term preparedness for future public health emergencies [11].

MEDICAL STUDENT DEBT IN THE UNITED STATES

In the United States, newly minted physicians typically pay for 8 years of postsecondary school. Approximately 85% of medical school graduates have educational debt: the average graduate currently holds close to a quarter of a million dollars in debt [2, 3]. Unfortunately, these figures are trending in the wrong direction: inflation-adjusted medical student debt has been growing at a compound annual growth rate of 2.9% (Figure 1) [2, 3, 24]. This debt is carried for years and results in many physicians paying off student loans more than a decade into independent practice. Meanwhile, inflation-adjusted medical school tuition continues to increase. This combination of factors makes medical education increasingly inaccessible to people of poor socioeconomic upbringing.

Figure 1.

Median student debt for indebted medical school graduates in the United States, 1992–2019. Data are shown in current currency (diamonds) and inflation-adjusted 2022 US dollars (circles). Source: Association of American Medical Colleges [3, 24].

The deleterious effects of student debt on the health and performance of medical trainees are well documented. Medical students with higher debt report feeling stress and anxiety more often than their counterparts with less debt [25]. Internal medicine residents with high debt are more likely to report symptoms of burnout and score lower on their in-training examinations than their colleagues with no debt [26]. Medical graduates with high amounts of debt change their anticipated professional and nonprofessional plans to meet these financial realities. For example, medical trainees with high debt tend to delay certain life decisions, such as marriage, having children, and owning their first home [25]. Importantly, surveys of medical students demonstrate that those graduating with higher debt are less likely to practice medicine in underserved communities or choose careers in primary care [25, 27].

The burden of student debt is greatest on nonwhite people. Existing wealth inequalities across racial lines result in nonwhite families becoming less capable of independently financing their children's postsecondary education [28]. At the start of medical school, students who are black, American Indian/Alaskan Native, or Native Hawaiian/Pacific Islander are more likely than other racial groups to hold debt from premedical education [29]. In fact, 23% of black medical school matriculants will have already accumulated more than $50 000 in premedical school debt, which is more than any other racial or ethnic group [29]. By the time they graduate from medical school, >91% of black medical school graduates have debt, and their average debt is far higher than that of other racial/demographic groups [2]. The important effects of student debt on physicians, particularly minority physicians, and their career trajectories means that student debt has had a wide-reaching, systems-level impact on the US medical system.

ADDRESSING STUDENT DEBT

Of the many ways to address student debt among medical graduates, perhaps the most important are to decrease the costs of premedical and medical education and to cancel existing student loans, which accrue interest each year following graduation. The simplest and perhaps most compelling reason for debt cancellation is formulated as follows: a postsecondary education is a public good and is increasingly seen as a prerequisite for a well-paying job; meanwhile, the costs of a postsecondary education in the United States have been rapidly rising, such that this public good has become inaccessible to many, particularly for people without inherited wealth. Individuals who are relieved of their onerous levels of student debt may be more likely to take on entrepreneurial risks, develop novel ideas, start new businesses, and spur innovation. In addition, student debt cancellation has the potential to greatly narrow the racial wealth divide in the United States [30].

The primary challenge to debt cancellation has been the question, simply put, of “Who is going to pay for this?” Nearly all current student debt is held by the federal government, such that cancellation of student debt will reduce future government revenue. However, the Department of Education projects that more than 30% of student debt will ultimately never be repaid, and this may in fact be an underestimate [31]. Recognition of the high burden and the general inability of many graduates to repay their student loans has resulted in the income-driven repayment system, which includes programs that cap debt repayments based on a percentage of income. Even so, these debts currently weigh heavily on medical graduates and affect their ability to cope with medical training, manage stress and burnout, and make professional and nonprofessional life choices that critically affect them, their families, and other sectors of the healthcare system and economy. Economists estimate that a one-time student debt cancellation is likely to reduce unemployment and increase the real gross domestic product through increased tax revenue [32].

A frequently repeated argument against student debt cancellation is that it is regressive, benefiting individuals who have the advantages, the privilege, and the higher earning potential of a postsecondary education. This argument fails to recognize that with the increase in accessibility of federal student loans, a wider cross-section of society has been able to matriculate into postsecondary education despite that sharp rise in college tuition. In this context, those who carry high levels of student debt are, by definition, the ones who are unable to independently finance their education [33]. Therefore, student debt has become a marker of relative disadvantage among people with postsecondary education [28, 33]. In the case of medical school debt, wide-reaching negative impacts are felt not just on early career physicians but also on the organization and delivery of healthcare in the United States through physician career choice. Accordingly, there are potential systems-level benefits of debt cancellation. Programs such as the Public Service Loan Forgiveness Program are structured around the very logic that removing financial constraints on physicians provides a powerful incentive for working in otherwise low-paying positions that deliver important social benefits. Debt relief is good both for physicians and for the communities they serve.

ANTICIPATED EFFECTS OF DEBT CANCELLATION ON THE ID WORKFORCE

Given that medical trainees are frequently dissuaded from pursuing careers in primary care and “cognitive” specialties, even if they find those fields intellectually and professionally fulfilling [14, 16], we reason that a policy of full debt cancellation will improve the likelihood that trainees will pursue careers in ID. Medical residents will be the trainee group most likely to be influenced by debt cancellation, as they are in a stage of accumulating interest without earning a high salary. Debt cancellation would also affect the career trajectories of premedical and medical students. A policy of one-time student debt cancellation may have the immediate effect of enhancing recruitment into ID fellowship training programs for several years after enactment, but its long-term impact will be limited without concomitantly addressing rising medical school tuition fees. Using similar reasoning, we may also expect to see a diversification of the ID workforce by attracting more racial and ethnic minorities and students from underprivileged backgrounds who carry high levels of student debt. Black or African American physicians account for <5% of IDSA members and even lower proportions of the Society for Healthcare Epidemiology of America and the Pediatric Infectious Diseases Society [34]. Relieving the burden of student debt may be a critical, albeit insufficient, component of efforts to diversify both the ID and primary care workforces in the short-term.

Practicing ID physicians, and those currently in ID fellowship training programs, will also be greatly affected by a policy of full student debt cancellation. ID physicians-in-training and early career faculty may be more likely to practice in underserved settings if they are relieved of the need for higher remuneration to pay off debt. For many, they will be more likely to continue working as ID specialists rather than leaving specialty practice for more lucrative nonspecialist roles, such as hospitalists, healthcare administrators, or industry consultants. They may also be more likely to pursue publicly funded investigative careers. Midcareer ID physicians who still hold student debt may be able to adopt public health or service-oriented roles following debt cancellation, directing their work into much needed but relatively less lucrative fields that have wide-reaching positive social impacts.

Will the recently announced Biden-Harris policy of student loan relief have any of these anticipated effects? Unfortunately, the current proposal relieves only up to $20 000 of student debt for Pell grant recipients and up to $10 000 for non–Pell grant recipients [4]. For the average medical graduate, these amounts represent less than 10% and 5%, respectively, of their student debt. To be eligible for debt relief under this policy, borrowers must have less than $125 000 in individual or $250 000 in joint income [4]. Medical graduates at the residency and fellowship level will likely meet these income thresholds, but most practicing ID physicians will not. Current medical and graduate students are unable to benefit from this policy as they are not in a state of loan repayment, which is a condition of this executive order. Therefore, we hypothesize that this current policy is unlikely to unleash the potential of benefits for the ID workforce that we outline above.

Despite its near-term benefits, one-time debt cancellation is not a sustainable solution to the long-term problem of rising tuition fees in colleges, universities, and medical schools. Implementation of debt-free medical education, particularly for those with demonstrated financial need, could yield more long-term gains, though it would likely cost more to sustain at a societal level [35]. Alternatively, a policy of focused debt relief or subsidized loan repayments for trainees in specific fields may be a more viable solution [36]. Under this framework, physician graduates who undertake training in primary care and select specialty programs would have their loan repayments subsidized and interest paused during training. This policy could serve as a powerful incentive in career decision making, particularly for those trainees who are equally passionate about specialties with disparities in anticipated compensation. This policy may also strike a more viable long-term balance between the program costs and the societal benefits it accrues.

CONCLUSIONS

Student debt in the United States has been rapidly increasing and represents an excessive burden on physicians. As policy makers continue to debate the merits of student debt cancellation, it is important for those in the ID community to explore effects of various levels of debt cancellation on our workforce, profession, health systems, and patient population. At the same time, the IDSA should incorporate legislative advocacy in support of student debt relief and medical school tuition control into their efforts to improve the welfare of the ID workforce to meet emerging patient care and public health challenges.

The recently announced executive order allows for limited debt relief within restrictive income restrictions. This may greatly improve the quality of life for a large number of current medical trainees. However, a policy of full student debt cancellation would have a much greater impact on the entire physician workforce. It could potentially enhance recruitment for ID training programs and motivate ID physicians to work in public health roles, in underserved communities, and in publicly funded scientific careers. Despite these potential far-reaching effects, a policy of one-time student debt cancellation is clearly not a sustainable solution to long-standing workforce problems in ID, primary care, and other similar fields. Long-term changes are urgently needed in both the structure and financing of postsecondary education and in disparities of remuneration across medical specialties.