Medical resident trainees bear the burden of debt inequitably along racial and ethnic lines, according to a cross-sectional study.
Among over 120,000 trainees who were active from 2014 to 2019, Black trainees were significantly more likely to have every type of debt than the overall sample (95.5% vs 82.7%, respectively), reported Louisa W. Holaday, MD, of the Icahn School of Medicine at Mount Sinai in New York City, and colleagues in Health Affairs.
For example, Black trainees were more likely to have debts from premedical education loans compared with the overall sample (59.9% vs 35.0%, respectively), as well as consumer debt (50.4% vs 25.3%).
Of note, prevalence of debt did not change much over 6 years for Black trainees, while it decreased slightly overall for other racial and ethnic groups, Holaday and team said.
“As dramatic as these findings are, on some level, they’re not so unexpected, based on historical access to wealth and financial opportunities across racial groups in the United States,” Holaday told MedPage Today. “But the good thing is that there’s something that we can do about this.”
While American Indian/Alaska Native, Hispanic, and Native Hawaiian/Pacific Islander trainees were more likely to have any debt than the least indebted groups — white and Asian trainees — their debt prevalence decreased more than Black trainees’ over time.
Differences in debt also varied by specialty, the researchers found, with more trainees in higher-paying specialties indicating they had no debt. Family medicine residents were the most likely to have debt (89.2%), while internal medicine residents were the least likely (78.5%).
Holaday and colleagues noted that previous studies have come to mixed conclusions on how debt might affect specialty selection. “Some of the studies have shown that people who have a lot of debt [have said they] prefer to choose higher-paying specialties,” said Holaday, though this hasn’t actually been demonstrated. “And then there’s some studies that show that people who have a lot of debt prefer to just finish training as soon as possible so they can get on to be making an attending salary.”
However, for some racial and ethnic groups, debt didn’t change much from one specialty to the next. Only about 4-5% of Black trainees indicated they were debt-free, and this proportion was consistent across family medicine and internal medicine. On the other hand, around 30% of Asian internal medicine trainees indicated they had no debt compared with about 20% of Asian family medicine trainees.
Amounts of debt taken on also varied by race and ethnicity, with the largest differences in premedical education debt and consumer debt. Black trainees and those who self-identified as “other” reported taking on a median of $25,000 in loans, and American Indian/Alaska Native trainees took on the least, with a median of $17,000. White and Native Hawaiian/Pacific Islander trainees reported a median of $10,000 in consumer debt, while Asian trainees reported a median of $7,000.
“[For] all the populations underrepresented in the medical workforce, the amount of debt people had from college loans and consumer debt — I don’t think that that’s getting enough attention, in terms of if we could even the playing field earlier on,” said Holaday, noting that it could make a difference in who applies to medical school to begin with.
She pointed out that the financial hurdles to entering medicine can be greater for Black students, who might start their journey without as much family financial support and might be expected to support family financially more often. This, on top of higher rates of discrimination, harassment, and other non-financial barriers, all stand in the way of their representation in medicine.
Those that do overcome those hurdles, Holaday said, might be more likely to want to end training sooner by entering specialties with fewer years of training. “It certainly makes sense that if you don’t have debt, you’re not feeling the same level of pressure to get out into the workforce, especially because if you don’t have debt, not only does that mean you’re not feeling those pressures, but it likely says something about your family and your circumstances,” she noted.
The researchers recommended policies to combat debt disparities among racial and ethnic groups, like loan forgiveness programs and more scholarships. For example, they suggested that programs like the National Health Service Corps, which forgives loans for trainees providing primary care in underserved areas, expand to include specialty care.
Holaday said diversity is a matter of solving some of the biggest medical problems that still plague society. “Even if you’re someone who has never had any debt … you can also get cancer. You can also have all these medical problems,” she said. “Don’t you want everyone to have access to the best minds, to have access to solve these problems?”
For this study, the researchers analyzed data from the Medical School Graduation Questionnaire and the Graduate Medical Education Track Resident Survey, both administered by the Association of American Medical Colleges, from 2014 to 2019. The sample included 120,866 allopathic medical school graduates who went on to become medical resident trainees.
Of the respondents, 61.2% were white, 20.2% were Asian, 5.2% were Black, 4.3% were Hispanic, and 0.1% each were American Indian/Alaska Native and Native Hawaiian/Pacific Islander. Over 50% were men.
Study limitations included not using data for students who graduated medical school but did not go on to residency, and not including family income or public/private status of medical schools, Holaday and team noted. Response rates also differed by race and ethnicity.
This study was supported by the National Clinician Scholars Program at Yale University and by a grant from the Clinical and Translational Science Awards from the National Center for Advancing Translational Science, as well as the Department of Veterans Affairs Office of Academic Affiliations through the VA/National Clinician Scholars Program and Yale University.
Holaday disclosed grant funding from the National Institute on Aging.
Co-authors disclosed relationships with the National Institute on Drug Abuse, Yale University, Johnson & Johnson, the Medical Device Innovation Consortium, the FDA, the Agency for Healthcare Research and Quality, the National Heart, Lung, and Blood Institute, and Arnold Ventures. One co-author also disclosed a role as an expert witness for Greene Law Firm in a lawsuit against Biogen.
Source Reference: Holaday LW, et al “Differences in debt among postgraduate medical residents by self-designated race and ethnicity, 2014-19” Health Affairs 2023; DOI: 10.1377/hlthaff.2022.00446.