The numbers are daunting. Consider these statistics from the Association of American Medical Colleges graduate questionnaire and try not to glaze over and fall off your chair in a fit of depression:
- The average educational debt of indebted graduates of the class of 2009 is $156,456.
- 79 percent of graduates have debt of at least $100,000.
- 58 percent of graduates have debt of at least $150,000.
Has it always been this way? No. Medical education debt has increased, and is driven by rising tuition, according to the American Medical Association. AAMC data concurs, showing that median private medical school tuition and fees increased by 50 percent (in real dollars) in the 20 years between 1984 and 2004. Median public medical school tuition and fees increased by 133 percent over the same time period, according to the AAMC.
How Bad Is It?
The good news, if there is any, is that nephrology fellows may have slightly less debt than trainees in other fields, according to Mark G. Parker, MD, director of the Division of Nephrology and Transplantation Program, and director of the Nephrology Fellowship Program at Maine Medical Center.
In 2009, Parker worked with colleagues at several institutions and the American Society of Nephrology to survey the current renal fellow ASN membership and learned that, for instance, only 4.9 percent of fellows had an educational debt burden of greater than $200,000, whereas it was reported in the New England Journal of Medicine earlier that year that nearly 25 percent of U.S. medical graduates report this level of debt burden, Parker said.
“And while 38.4 percent of fellows described little or no educational debt, over 30 percent still described indebtedness in the range of $50,000 to $200,000,” Parker said. “The reasons for this distribution are uncertain, but it’s notable that currently only 40 percent of nephrology fellows are U.S. medical graduates and the nature of a young adult’s financial obligations obviously must, to some degree, reflect socioeconomic background and resources during one’s academic years. Interestingly, when asked why they chose nephrology as a career, only 1 percent of fellows cited ‘earning potential.’”
Parker is not certain that the stress of educational debt or the strategies for managing debt are different for nephrologists than they are for any other young professionals. “In the tenuous economic environment of recent years, I think it may be sensible to utilize the services of a reputable professional financial advisor in order to help one’s short- and long-term personal finance strategies,” Parker said. “Certainly, it should be a high priority to have a plan to pay down one’s pre-existing indebtedness before the additional financial obligations of life (mortgages, cars, children, unanticipated crises, etc.) accumulate. It is clear that ‘credit’ will no longer be extended as liberally as in years past, and that is probably a good thing, but it forces young people embarking on careers and starting families to have a more realistic and prudent approach to ownership and their general purchasing power.”
Consequences
Okay, medical fellows owe a lot of money. But are there ramifications beyond having to wrangle spending the first few years after gradation? Yes, according to Dr. Adam Weinstein, a nephrologist at The Kidney Health Center of Maryland.
“Having student debt is a huge stress for all physicians, nephrologists included,” Weinstein said. “For those of us that have decided to pursue subspecialty fellowships, the delay in loan repayment can mean hundreds to thousands in deferred interest payments. With between $150,000 to $250,000 in debt, on average, it is like starting your first job with a mortgage payment on top of having delayed your life, family, a real mortgage payment and other asset accumulation (think retirement savings, equity in other investments, etc.).”
Whether debt affects where nephrologists decide to work is debatable. According to Weinstein, heavy debt motivates young nephrologists to aim for a lucrative job, which generally requires moving to a densely populated area.
“More importantly, physicians often think of choosing to sub-specialize based on differences in pay,” he said. “For instance, for an extra two to four years of training beyond the three years of internal medicine residency, your salary may go up by 15 percent to 40 percent, sometimes more. Despite the delay in debt repayment, this is a strong incentive to not stay in general internal medicine. Especially since the work-life is not all that different amongst the various internal medicine subspecialties.”
Martin Osinski, president of NephrologyUSA, in Miami, Fla., said numerous factors influence the choice of where a nephrologist ends up working. The vast majority of nephrology fellows Osinski has worked with over the years have not used debt repayment as a motivating factor in choosing a position, Osinski said.
“I believe the fact that the majority of physicians coming out of nephrology fellowships not being U.S. medical school graduates have played a key role in that fact,” he added. “Unless someone feels tremendous stress from the debt and goes out looking specifically for lucrative practices in order to pay them off (I have seen a few), I think most U.S. grad fellows look at the long-term picture, practice potential, place to live, opportunities for spouse and children and time to partnership as more important than how quickly they get their debt paid off.”
Parker agrees. As a fellowship training program director he has advised graduating fellows about the job market for more than 10 years, and does not think educational indebtedness plays a large role in where nephrologists work, either geographically or in terms of practice style.
“Historically, I think that a proportion of trainees have gravitated to private practice for multiple reasons, with higher earning potential being only one contributing factor,” Parker said. “If anything, the choice of work environment is often determined by other factors—for example, many international medical graduates choose positions that will allow them to fulfill specific visa requirements, in turn presenting the opportunity to remain in the U.S. long-term.
