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LETTER |
Willow Grove, Pa
To the Editor: Medical school debt is a challenge facing many young physicians, DO and MD alike.1-3 In fact, several authors have suggested that concern about debt, rather than the rigors of medical training, is the leading source of stress among medical students.4,5 Such stress may be severe enough to have an adverse impact on academic performance, especially among students from low-income backgrounds.4,5
For osteopathic medical students, young DOs, and the profession as a whole, concern about high debt loads is especially important and is related to three other issues:
High education-related debt loads among osteopathic medical students and young DOs call into question the long-term financial solvency of COMs and their alumni. In the 2008 edition of US News & World Report`s "America's Best Graduate Schools,"6 five of the 10 medical schools with the highest levels of debt among graduates were COMs. In addition, the two schools with the highest graduate debt burdens were COMs. Although COMs and their branch campuses comprise only 16% of all fully accredited medical schools in the United States and Canada, COMs make up half of the medical schools with the highest debt among graduates.7,8
To say that these data are alarming is an understatement. With the exception of a few federal service (eg, the Department of Health and Human Services' National Health Service Corps, the US Armed Forces' Health Professions Scholarship Program) and highly variable state-level loan repayment programs, students have few choices but to assume greater personal debt to finance an osteopathic medical education.
Interestingly, three of the five COMs with the highest debt burdens reported for the class of 20056—Kirksville (Mo) College of Osteopathic Medicine-A.T. Still University, Philadelphia (Pa) College of Osteopathic Medicine, and Touro University College of Osteopathic Medicine–California in Vallejo—have opened branch campuses since 2000. It is not clear whether the revenues used for, and generated from, the establishment of new schools of osteopathic medicine and additional branch campuses are being partly funded through student tuition or through the redistribution of other resources (eg, selling land assets where osteopathic hospitals once stood).
Although some in the osteopathic medical profession justify the explosive growth in class sizes at existing COMs and the opening of new schools—including the for-profit Rocky Vista University College of Osteopathic Medicine in Parker, Colo—by a perceived shortage of physicians,9 the evidence cited for such shortages is based on a series of unproven assumptions about the US healthcare system.10,11 For example, the assumption that demand for physicians will increase as gross national product increases is not absolute.11
If the osteopathic medical profession chooses to continue its growth through COMs, it is unlikely that the addiction to student tuition as a source of financial well-being can sustain COMs for years to come. It is even more difficult to conceive that current osteopathic medical students will be compelled to become generous alumni donors while also committing large portions of their monthly incomes to repaying long-standing student debt.
At a time when applications to osteopathic medical schools are at historic highs, medical education is becoming less affordable to many students, especially students from disadvantaged backgrounds.12,13 High tuition costs and the prospect of debt on graduation that far exceeds $100,000 could result in the inability of COMs to recruit and retain students who represent the diverse communities our nation boasts. In fact, data compiled by the Association of American Medical Colleges12,14 reveal that cost was the leading reason for not applying to medical school among qualified African American, Hispanic, and Native American candidates.
Medical students who are members of racial or ethnic minority groups are most likely to become practicing primary care physicians in our nation's most underserved communities—even in the face of crippling debt.15 Therefore, a decline in the number of these students in our COMs as a result of the prospect of looming debt would be a tragic blow—not only to diversity and cultural understanding in osteopathic medical institutions, but also to our efforts to provide healthcare services in underserved communities.
Conversely, the promise of lower postgraduate debt at COMs could result in the recruitment of higher quality students to the osteopathic medical profession. Before opening more branch campuses and more new COMs, the American Osteopathic Association and existing COMs should evaluate their missions to determine whether quality or quantity will be the hallmark of osteopathic medicine for the future.
Finally, the disproportionate debt burden held by young DOs rekindles, at least indirectly, the historic image of COMs as being academically inferior to allopathic medical schools and lacking the research facilities, number of basic science faculty members, and commitment to academic medicine of their allopathic counterparts.16
Despite high debt among osteopathic medical students, few COMs operate academic hospitals with graduate medical education programs. Fewer still have the research funding needed to support faculty salaries, sustain infrastructure improvements, and contribute to discoveries in osteopathic manipulative medicine or other important areas of science.
When COMs are compared with allopathic medical schools that have low debt among graduates, the question becomes whether the mission of COMs is to contribute to improving medical education, advancing scientific research, and providing quality clinical care or simply to develop curricula and award diplomas to persons willing to incur six-figure debt.
Among allopathic medical schools with the lowest debt burdens for graduating physicians are the Johns Hopkins School of Medicine in Baltimore, Md; Stanford (Ca) University School of Medicine; and Mayo Medical School College of Medicine in Rochester, Minn.6 In 2005, the average debt of a graduate from Mayo Medical School was nearly two-thirds less than that held by a graduate from Touro University College of Osteopathic Medicine–California.6
Many of the same allopathic medical schools with low debt among graduates also have vast research infrastructures to maintain, complex hospital and healthcare systems to finance, and large numbers of basic science and clinical faculty engaged in research, student education, and patient care. Thus, not only are these allopathic medical schools producing physicians with less debt, their institutional resources offer students greater opportunities to prepare for positions of leadership in research, education, and clinical care—positions that will shape healthcare policy at the state and federal levels for decades to come.
The question among prospective applicants to COMs will eventually (or has already) become:
What is the additional value of choosing an osteopathic medical school over an allopathic medical school, especially when debt incurred from osteopathic medical education is so high?
I wager that, for many of these applicants, "the osteopathic difference" will unfortunately not be palpable enough to convince them of the merits of becoming a DO.
If the osteopathic medical profession is to produce leaders who will shape the future of medicine, we must aggressively address the economic realities facing debt-burdened osteopathic medical students and young DOs. Addressing those realities might include structured financial-planning programs and tuition-stabilization initiatives.
For many new DOs, the cavalier response of academic administrators to "not worry" about future debt17 is myopic and irresponsible. Such a response threatens the health of the osteopathic medical profession. If COMs continue to expect students and young DOs to mortgage their professional and financial futures to finance their education, the result might well be the foreclosure of the osteopathic medical profession.
Footnotes
Editor's Note: Student Doctor Kraus states that the views expressed
in his letter to the editor are his own and are not intended to represent any
positions of the Philadelphia (Pa) College of Osteopathic Medicine.
References 2. Fuchs E. With debt on the rise, students and schools face an uphill
battle. AAMC Reporter [serial online]. January 2008. Available at:
http://www.aamc.org/newsroom/reporter/jan08/debt.htm.
Accessed March 10, 2008. 3. Santana S. Paying the price to become a doctor: the impact of
medical school debt. AAMC Reporter [serial online]. January 2002.
Available at:
http://www.aamc.org/newsroom/reporter/jan02/medschooldebt.htm.
Accessed March 10, 2008. 4. Cooter R, Erdmann JB, Gonnella JS, Callahan CA, Hojat M, Xu G.
Economic diversity in medical education: the relationship between students'
family income and academic performance, career choice, and student debt.
Eval Health Prof.2004; 27:252
-264.[Abstract] 5. Ross S, Cleland J, Macleod MJ. Stress, debt, and undergraduate
medical student performance. Med Educ.2006; 40:584
-589.[Medline] 6. America's best graduate schools 2008. US News & World Report
Web site. Available at:
http://www.usnews.com/usnews/edu/grad/rankings/rankindex_brief.php.
Accessed March 10, 2008. 7. Member colleges; 2008. American Association of Colleges of
Osteopathic Medicine Web site. Available at:
http://www.aacom.org/people/colleges/Pages/default.aspx.
Accessed April 17, 2008. 8. Medical schools, 2008. Association of American Medical Colleges Web
site. Available at:
http://www.aamc.org/medicalschools.htm.
Accessed April 17, 2008. 9. Martin RB. RVUCOM: striving to meet the needs of the osteopathic
medical profession [letter]. J Am Osteopath Assoc. 2007;107:426-428.
Available at:
http://www.jaoa.org/cgi/reprint/107/10/426.
Accessed April 15, 2008. 10. Weiner JP. Expanding the US medical workforce: global perspectives
and parallels. BMJ.2007; 335:236
-238. 11. Weiner JP. A shortage of physicians or a surplus of assumptions?
Health Aff (Millwood). 2002;21:160-162. Available at:
http://content.healthaffairs.org/cgi/content/full/21/1/160.
Accessed April 15, 2008. 12. Jolly P. Medical student tuition and young physicians'
indebtedness. Health Aff (Millwood). 2005;24:527-535. Available at:
http://content.healthaffairs.org/cgi/content/full/24/2/527.
Accessed April 15, 2008. 13. Kwong JC, Dhalla IA, Streiner DL, Baddour RE, Waddell AE, Johnson
IL. Effects of rising tuition fees on medical school class composition and
financial outlook. CMAJ. 2002;166:1023-1028. Available at:
http://www.cmaj.ca/cgi/content/full/166/8/1023.
Accessed April 15, 2008. 14. McInturff B, Frontczak E. Medical school applicant survey.
Unpublished report prepared for the Association of American Medical Colleges
by Public Opinion Strategies; February 11,2004
. 15. Rosenblatt RA, Andrilla CH. The impact of US medical students' debt
on their choice of primary care careers: an analysis of data from the 2002
medical school graduation questionnaire. Acad Med.2005; 80:815
-819.[Medline] 16. Flexner A. Medical Education in the United States and
Canada. New York, NY: Carnegie Foundation for the Advancement of
Teaching; 1910. Available at:
http://www.carnegiefoundation.org/files/elibrary/flexner_report.pdf.
Accessed March 10, 2008. 17. Mannes G. Young doctors in debt. Money Magazine. December
2007:120-126. Available at:
http://money.cnn.com/2007/11/16/pf/young_doctors.moneymag/?postversion=2007111611.
Accessed March 10, 2008.
1. Association of American Medical Colleges. Medical Student
Tuition and Young Physician Indebtedness: An Update to the 2004 Report.
Washington, DC: Association of American Medical Colleges; October 2007.
Available at:
https://services.aamc.org/Publications/showfile.cfm?file=version103.pdf&prd_id=212&prv_id=256&pdf_id=103.
Accessed March 10, 2008.
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