AAOS Now

Published 12/20/2020
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Kaitlyn D’Onofrio

Survey Asks Orthopaedic Fellows How Medical Debt Impacts Life and Career

Large educational debts affect fellowship-trained orthopaedic surgeons’ decisions

Editor’s note: The following content was originally scheduled for the AAOS Now Daily Edition, which publishes each year onsite at the AAOS Annual Meeting, but this year’s meeting in March was canceled due to COVID-19. Despite the cancellation, members can access virtual content from the Annual Meeting by visiting the Academy’s Annual Meeting Virtual Experience webpage at aaos.org/VirtualAAOS2020.

The cost to attain an education in the field of medicine has been rising and outpacing the rate of inflation. Medical students who graduated in 2018 did so with about $200,000 in educational debt; a four-year, private school medical education costs more than $330,000. In a new study, researchers discovered that the massive burden of educational debt not only severely impacts orthopaedic fellows’ bank accounts and career choices, but also plays a significant role in their life decisions. J. Logan Brock, BA, a fifth-year MD/MBA student at the Perelman School of Medicine and the Wharton School at the University of Pennsylvania, presented the study as part of the Annual Meeting Virtual Experience.

According to Mr. Brock, the study was inspired by what he and his colleagues were witnessing firsthand in medical education. “My coauthors and mentors on this project are fellowship directors, and, in that capacity, they have learned in recent years that their fellows are completing their training with debt loads that are huge and growing,” he explained to AAOS Now. “The rising level of debt that they saw among their fellows, coupled with declining reimbursement, made them concerned about the effects that these trends may have on the ability to attract talented young students to careers in medicine. As my classmates and I realized during medical school, while we are entering a field that promises a comfortable life financially, that can feel very far away as debt accumulates during school. As such, we wanted to gain a better understanding of the debt load orthopaedic surgeons face at the end of their training and how that debt is affecting their career and life decisions.”

The researchers conducted an anonymous survey, completed by orthopaedic sports medicine and total joint reconstruction fellows from the 2017–2018 and 2018–2019 fellowship classes. The survey contained 34 questions pertaining to educational debt and its effect on career and life choices. Questions covered:

• undergraduate and medical education costs

• how fellows financed their education (scholarships, debt, family support, working, etc.)

• how long they predicted it would take to repay their educational debt and what repayment options they would use

• initial perception of what their debt would be upon starting medical school

• marital status

• whether they have children

• how debt influenced life choices such as specialty and subspecialty, marriage, and when to have children

The authors calculated expected monthly loan payments using average repayment time per respondent answers with a 6.8 percent interest rate, per the Federal Direct Loans rate at the time of the study—which the researchers noted is likely an underestimate, as there is a cap on federal direct loan borrowing, and other federal loans carry higher interest rates.

Of 253 surveys sent, 99 fellows responded, for a 39.1 percent response rate. Most respondents were sports medicine fellows (n = 54; 55 percent); the rest were total joint fellows (n = 45; 45 percent). Upon completion of medical school, fellows reported $213,510 in educational debt; after completing residency, debt increased to $242,677. Only eight respondents (8 percent) graduated medical school without debt, and only one physician who graduated with debt (1 percent) paid it off completely during residency. Fewer than half of fellows (n = 42; 42.0 percent) reported receiving scholarships for medical school, which covered 19.3 percent of medical school costs on average. Two respondents received full scholarships.

Less than half (43 percent) of fellows said they had an understanding of what their actual debt would be when they began medical school. Most (71 percent) said they considered other career options before enrolling in medical school, whereas 61 percent said cost was a consideration when deciding whether to enroll. About two in five fellows (42 percent) said they would have foregone medical school for a sufficiently high starting salary in another field; for 25 percent of those fellows, that salary would have been $150,000 or less.

Forty percent of respondents said that debt influenced their specialty choice, 22 percent said it affected their subspecialty choice, and 49 percent said it affected their practice setting choice. Most fellows (n = 81; 82 percent) were married, and more than half (n = 55; 56 percent) had children. About one in five fellows (n = 21; 21 percent) said their educational debt influenced their choices regarding whether or when to marry, and a greater proportion (n = 29; 29 percent) said their debt affected their choices regarding whether or when to have children.

Fellows expected their starting salary to be $382,702 pretax ($229,621 post-tax), and they expected those earnings to grow to $621,389 after five years of practice and $728,409 after 10 years of practice—a prediction that surprised Mr. Brock and his colleagues. “In general, we found that fellows were likely overestimating their future earning potential and using these overestimates to guide important financial decisions,” he said.

The study’s findings are significant in terms of the attractiveness of a career in medicine for the next generation of medical students, according to Mr. Brock. “As debt continues to rise and reimbursement falls, we worry that some aspiring physicians may opt to pursue careers outside of medicine. That said, there are promising trends that could combat this, such as some medical schools offering free tuition or three-year programs.”

A limitation of the study is that the survey respondents may not have been representative of the general fellow population. Also, although the survey asked whether debt affected certain decisions, it did not specifically ask how it affected those decisions, which could have changed the trajectory of fellows’ responses.

Mr. Brock’s coauthors of “Educational Debt Affects Career and Life Decisions for Orthopaedic Fellows” are Jennie O’Grady, DC; Douglas Dennis, MD; and Theodore F. Schlegel, MD.

Kaitlyn D’Onofrio is the associate editor for AAOS Now. She can be reached at kdonofrio@aaos.org.