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Enhanced access to care for rural and disadvantaged patients may be a by-product of the high cost of a medical education

Four-year medical school tuition and fees are typically $50,000 to $100,000, and many students and young physicians are worried about their financial situations. In fact, 80 percent of generalist physicians surveyed last year said they obtained loans for all or part of their training, and 25 percent accepted scholarships, loan repayment plans, or similar programs that required medical practice commitments in return, according to a new study.

Since the high costs of medical training prompt these commitments to practice, usually in rural or disadvantaged areas, they promote care for rural and poor patients. However, these positive outcomes of the skyrocketing costs of medical education must be balanced against the negative consequences of discouraging some poor and minority students from pursuing medical careers, cautions Donald Pathman, M.D., M.P.H., of the University of North Carolina at Chapel Hill.

In the study supported by the Agency for Healthcare Research and Quality (HS09165), Dr. Pathman and his colleagues analyzed data from a 1999 mail survey of a national sample of 468 practicing family physicians, general internists, and pediatricians who graduated from U.S. medical schools in 1988 and 1992. The median debt after finishing medical school for doctors with educational loans was $60,000 in 1995 dollars. Nearly three-quarters (70 percent) of the doctors surveyed felt moderate to great financial concerns during medical school, 63 percent during residency, and 55 percent in the years following residency. Physicians who were serving practice commitments were nearly five times as likely to have such concerns as those who were not.

Physicians serving commitments in exchange for training cost support, compared with those without such obligations, were more likely to work in rural areas (33 percent vs. 7 percent) and provide care to more Medicaid-insured and uninsured patients (53 percent vs. 29 percent), but the two groups did not differ in their incomes ($99,600 vs. $93,800). For pediatricians and family physicians, but not internists, higher debt was associated with a greater reported percentage of Medicaid and uninsured patients, ranging from 23 percent for physicians without debt to 37 percent for those with debts over $90,000.

For more details, see "Medical training debt and service commitments: The rural consequences," by Dr. Pathman, Thomas R. Konrad, Ph.D., Tonya S. King, Ph.D., and others, in the summer 2000 Journal of Rural Health 16(3), pp. 264-272.

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