A Retrospective Analysis of the Relationship Between Medical Student Debt and Primary Care Practice in the United States

Julie P. Phillips; Stephen M. Petterson; Andrew W. Bazemore; Robert L. Phillips

doi:10.1370/afm.1697

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Figure 1
Percent of graduates practicing primary care, by medical school debt level and type of loan received (unadjusted analyses).
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Figure 2
Percent of graduates practicing family medicine, by medical school debt level and type of loan received (unadjusted analyses).
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Figure 3
Theoretical relationships between debt, socioeconomic status, and primary care specialty choice.

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Table 1

Characteristics of Medical School Graduates Overall and Among Those With Loans

Characteristic	All	Type of Loan Received
Characteristic	All	Perkins/Disadvantaged Student Loans	Health Professions Student Loans	Loans Not Based on Parents’ Income
Graduates, No. (%)	136,232 (100)	42,389 (31.1)	6,568 (4.8)	58,309 (42.8)
Debt category, %
None	20.6	0	0	0
$1–$50,000	17.9	10.0	12.7	32.7
$50,001–$100,000	28.6	41.0	48.9	32.8
$100,001–$150,000	20.2	31.3	26.8	22.2
$150,001–$200,000	7.5	11.7	8.8	8.4
≥$200,001	3.6	6.0	2.8	3.9
Debt amount, $^a
Mean	92,689	105,407	94,135	83,281
Median	85,471	97,484	87,757	73,296
Graduation era, %
1988–1992	37.0	32.2	59.9	35.2
1993–1996	33.6	34.5	35.7	32.2
1997–2000	29.4	33.3	4.4	32.7
Demographics
Married at graduation, %^b	33.4	33.1	43.8	33.6
Male, %	60.2	58.1	61.8	60.4
Born in a rural county, %	0.74	0.93	1.00	0.73
Age at graduation, mean, y	27.7	27.8	27.7	27.8
Medical school
Rural, %	0.42	0.38	0.23	0.45
Public, %	62.1	67.8	65.3	59.1
NHSC scholarship, %	0.42	0.37	0.35	0.53
Community based, %	5.8	8.2	3.6	5.1

NHSC = National Health Service Corps.
Note: Percentages may not sum to 100% because of missing data fields. In particular, debt level was unknown for 3.3% of the study sample.
↵a Mean and median debt levels exclude students with no debt. Debt levels are adjusted to 2010 dollars.
↵b Marital status was unknown for 29.9% of the study sample. Unknown marital status did not predict any study outcomes in multivariate models.

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Table 2

Multivariate Odds of Practicing Primary Care or Family Medicine by Type of Loan

Characteristic	Practicing Primary Care, Odds Ratio				Practicing Family Medicine, Odds Ratio

	All (Model 1) (N = 136,232)	All (Model 2) (N = 136,232)	Public (n = 84,739)	Private (n = 51,493)	All (Model 1) (N = 136,232)	All (Model 2) (N = 136,232)	Public (n = 84,739)	Private (n = 51,493)
Type of loan
Loan not based on parents’ income (ref)	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00
Perkins/Disadvantaged Student Loans	1.09^a	1.12^a	1.12^a	1.02	1.11^a	1.20^a	1.11^a	1.07
Health Professions Student Loans	1.18^a	1.21^a	1.16^a	1.21^a	1.28^a	1.35^a	1.19^a	1.54^a
Debt category
None	0.78^a	0.76^a	0.79^a	0.83^b	0.69^a	0.65^a	0.67^a	0.91
$1,000–$50,000	0.89^a	0.89^a	0.90^a	0.88^a	0.87^a	0.87^a	0.87^a	0.91
$50,001–$100,000 (ref)	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00
$100,001–$150,000	0.96^a	0.92^a	0.94^a	1.02	0.99	0.91^a	0.99	1.04
$150,001–$200,000	0.97	0.85^a	0.89^a	1.04	1.06	0.76^a	0.97	1.15^a
≥$200,001	0.95	0.80^a	0.84^b	0.99	1.05	0.66^a	0.89	1.11
Graduation era
1988–1992 (ref)	1.00	1.00	1.00	1.00	1.00	1.00	1.00	1.00
1993–1996	1.29^a	1.31^a	1.30^a	1.29^a	1.32^a	1.36^a	1.29^a	1.42^a
1997–2000	1.76^a	1.83^a	1.93^a	1.58^a	1.99^a	2.21^a	1.83^a	2.44^a
Demographics
Married at graduation	1.25^a	1.27^a	1.26^a	1.22^a	1.51^a	1.58^a	1.51^a	1.52^a
Male	0.49^a	0.49^a	0.50^a	0.46^a	0.78^a	0.79^a	0.81^a	0.71^a
Born in rural county	1.46^a	1.53^a	1.55^a	0.98	1.95^a	2.16^a	2.00^a	1.45
Age at graduation (per year)	1.02^a	1.02^a	1.02^a	1.02^a	1.04^a	1.04^a	1.04^a	1.05^a
Medical school
Rural	1.40^a	1.20^b	–	–	1.67^a	1.06	–	–
Public	1.30^a	–	–	–	2.05^a	–	–	–
NHSC scholarship	5.83^a	5.35^a	5.50^a	6.15^a	5.44^a	4.26^a	4.53^a	6.25^a
Community based	1.28^a	1.36^a	1.31^a	1.08	1.37^a	1.59^a	1.43^a	0.99

NHSC = National Health Service Corps; ref = reference group.
Notes: Multivariate logistic regression analyses. All variables listed were included. Model 1 controlled for public school attendance; model 2 did not.
↵a P <. 01.
↵b P <. 05.

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Table 3

Multivariate Odds of Practicing Primary Care or Family Medicine by Type of Loan

Characteristic	Practicing Primary Care, Odds Ratio			Practicing Family Medicine, Odds Ratio

	Perkins/Disadvantaged Student Loan (n = 42,389)	Health Professions Student Loan (n = 6,568)	Non–Income-Based Loans (n = 58,309)	Perkins/Disadvantaged Student Loan (n = 42,389)	Health Professions Student Loan (n = 6,568)	Non–Income-Based Loans (n = 58,309)
Debt category
$1,000–$50,000	0.93^a	0.86	0.88^b	0.85^b	0.85	0.89^b
$50,001–$100,000 (ref)	1.00	1.00	1.00	1.0	1.00	1.00
$100,001–$150,000	0.91^b	0.86^a	0.94^b	0.89^b	0.84^a	0.92^b
$150,001–$200,000	0.82^b	0.77^b	0.90^b	0.75^b	0.67^b	0.77^b
≥$200,001	0.73^b	0.71^a	0.88^b	0.65^b	0.52^b	0.69^b
Graduation era
1988–1992 (ref)	1.00	1.00	1.00	1.00	1.00	1.00
1993–1996	1.33^b	1.58^b	1.31^b	1.38^b	1.63^b	1.41^b
1997–2000	1.94^b	1.20	1.95^b	2.58^b	1.74	2.35^b
Demographics
Married at graduation	1.25^b	1.32^b	1.30^b	1.66^b	1.48^b	1.60^b
Male	0.50^b	0.51^b	0.49^b	0.77^b	0.90	0.80^b
Born in rural county	1.37^b	1.86^a	1.60^b	1.84^b	2.23^b	2.32^b
Age at graduation (per year)	1.02^b	1.01	1.02^b	1.05^b	1.04^b	1.04^b
Medical school
Rural	1.01	1.05	1.25	1.07	2.17	0.85
NHSC scholarship	3.58^b	6.24^b	6.15^b	2.99^b	3.08^b	4.49^b
Community based	1.30^b	1.68^b	1.38^b	1.62^b	1.72^b	1.50^b

NHSC = National Health Service Corps; ref = reference group.
Notes: Multivariate logistic regression analyses showing the odds of physicians who graduated from allopathic US medical schools between 1988 and 2000 practicing primary care or family medicine in 2010. Physicians are grouped into 6 different analyses, based on their types of educational loans. Data from 136,232 physicians were analyzed. All variables listed were included.
↵a P <. 01.
↵b P <.05.

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In Brief

A Retrospective Analysis of the Relationship Between Medical Student Debt and Primary Care Practice in the United States

Julie P. Phillips , and colleagues

Background The study re-examines the relationship between educational debt and primary care specialty choice, with a particular focus on how debt interacts with students' socioeconomic status.

What This Study Found High medical school debt discourages graduates of public medical schools from pursuing careers in primary care, but does not appear to influence private school graduates in the same way. Analysis of data from 136,232 physicians who graduated from US medical schools between 1988 and 2000 found physicians who graduated from public schools were most likely to practice primary care and family medicine at graduating educational debt levels of $50,000 to $100,000. At higher debt, graduates' odds of practice primary care or family medicine declined. In contrast, private medical school graduates were not less likely to practice primary care or family medicine as debt levels increased. They authors offer two possible explanations: 1) graduates with little or no debt may be less likely to choose primary care because they often come from wealthier families, and 2) public school graduates with very high debt are less likely to choose primary care because they perceive a need for the higher financial return of specialization to finance their debt.

Implications

Reducing the debt of selected medical students may be effective in promoting a larger primary care physician workforce.