The need to address debt accumulated from years of higher education tuition is more apparent than ever. Dr. Williams is like 73% of all U.S. medical graduates who carries student loan debt that totals $241,000, a figure that places them at the mean debt level for all indebted U.S. medical graduates.¹ By comparison, in 1978 the average physician graduated with $13,500 in total student loan debt ($53,648 in today’s dollars).¹ Like many physicians, there has been no formal or meaningful financial education during undergraduate, graduate, or post-graduate education. The loans carry an overall 5.8% interest rate (again average). Using a 20-year payback period, this will equate to $407,738 paid in total. Dr. Williams has never faced this amount of debt before and is unsure on how to proceed.

This scenario begs the following question: How does debt affect overall physician well-being? This column presents a brief history of education loan debt, a quick literature review of the relationship of debt to wellness, and areas of need for further investigation.

Brief History of Educational Debt

In 1840, Harvard University is reportedly the first U.S. university to offer a private student loan.² Following this was a relatively dormant period with regards to change until legislative actions functioned to improve access to higher education by allowing more people to access financing. The period following World War II, spurred by the GI Bill, increased the number of people who wanted to attend college—a service that remains available today and is still frequently used by veterans.In the 1980s and 90s, the burden of student debt started to be tracked more closely. The average undergraduate debt increased from 25% of students carrying up to $10,000 to all students with a bachelor’s degree carrying an average of $15,000 in debt. In 2012, the average debt was $30,000, for a total of over one trillion dollars in total debt.² By 2021, the average debt is $39,351 and over $1.56 trillion in total debt.¹

For physicians, the numbers are more dramatic. Of all U.S. medical school graduates, 73% have student loan debt. The average debt is an astounding $241,000.¹ While the percentage of indebted students has decreased since 2012 from 86% to 73%, the average total dollar amount of debt per indebted physician continues to climb. Furthermore, this rate has and continues to accelerate faster than inflation (2.3% versus 1.7%).³

Currently, there are bills proposed looking to improve federal repayment plans, enhance existing federal loan forgiveness programs, cancel up to $50,000 in debt per borrower which is the Student Loan Debt Relief Act of 2019, and fully privatize the student loan industry.

Review of the Literature

PubMed and SCOPUS search engines utilizing the phrase “physician well-being” from the year 2000 through June 2021 produced greater than 250,000 results. We then added the filter of debt and finance to the search, and filtered for clinical trials, meta-analysis, and systematic reviews. We did not find any interventional studies directed at lowering student loan debt and its effect on physician well-being.

Using the above search parameters, only three articles were identified:

• Effect of medical student debt on mental health, academic performance and specialty choice: a systematic review
• Determinants of an urban origin student choosing rural practice: a scoping review
• Effectiveness of financial incentives in exchange for rural and underserviced area return-of-service commitments: systematic review of the literature

The topics of the second and third are out of scope for this discussion. The first review, however, published in 2019 in BMJ Open, identified 678 potential articles, of which 52 met inclusion criteria. The results showed that medical student debt levels were negatively associated with mental well-being and academic outcomes. Additionally, high debt likely drives people to higher paying subspecialties. Interestingly, students from urban backgrounds were more likely to report the influence of debt on specialty choice compared to students from rural backgrounds. This, despite rural students often carrying higher debt loads compared to their urban peers. One important limitation of this systematic review was the noted paucity of prospective trials compared to cross-sectional studies. This has particular importance as debt and debt burden changes over time.⁴

Since 2019, Ahmed, et al., found that debt burdens exceeding $150,000 (lower than the aforementioned average debt) was directly associated with burnout among Oncology trainees (Odds Ratio 2.14).⁵ Additional data is emerging with similar findings linking educational debt and burnout across multiple specialties.

Knowledge Gaps

Based on the above, we were able to identify knowledge gaps that would serve as areas of interest for research, policy change, and/or education moving forward:

1. What can professional societies, like SGIM, do to promote visibility around the issue of the costs of medical education or the burdens of debt repayment and its potential effects on subspecialty choice?
2. How can undergraduate and graduate medical education programs prepare trainees to face these mounting financial stressors upon graduation?
3. Comparative effectiveness educational trials evaluating best practices to address knowledge gaps and their effect on physician well-being and patient outcomes are needed.
4. Prospective cohort studies evaluating changes in debt level over time and its association with well-being and academic output are needed.
5. Funding opportunities to support targeted intervention to lower student debt to less than $150,000 and evaluate its effect on standardized wellness evaluations are needed.
6. Trials evaluating the effectiveness of lowering student loan debt as a recruitment strategy to GIM and other lower paying subspecialties and as a targeted intervention to reduce burnout are needed.

Conclusion

There is an urgent need to address snowballing medical education debt, specifically as a driver of burnout and well-being. Our suggested approaches include: (1) research to better define these relationships and evaluate prospective interventions effect; (2) policy enhancement strategies to address both the cost of education and improve access or eligibility for public service loan repayment programs; (3) physician education to address known gaps in financial literacy, with the aim of empowering physicians and aiding them in combatting the stress of debt; and (4) normalizing discussion around finance and its effect on physician well-being. Focusing on these approaches would enhance basic financial understanding and education, while also building opportunities to stop the snowball from growing out of control. Finally, the authors would encourage anyone interested in learning more to reach out directly for a list of resources or further discussion.