Student Loan Burden and Its Impact on Career Decisions in Dermatology

Comment

In 2015, 76% of medical school graduates in the United States accrued educational debt, with an average of $189,165, a number that has continued to increase over the years.⁴ In addition to the increasing cost of medical education, higher interest rates on federal student loans contribute to debt burden. Over the last 2 decades, some research has posited that debt may influence medical specialty selection, with most studies focusing on primary care.^5-9 However, there is limited information on the effect of student loan debt on career decisions within dermatology.

The results of our study suggest that financial factors including income and amount of educational debt may influence career decisions in dermatology. There is a known income gap between academic and nonacademic settings. According to the Association of American Medical Colleges, the median salaries for an assistant professor and associate/full professor in dermatology are $266,000 and $331,000, respectively.¹⁰ In contrast, for dermatologists in private clinical practice, the overall median salary is more than $450,000. These salary differences may impact career plans, as 73.3% (33/45) of survey respondents in our study who were interested in private practice stated that higher income was one of the primary motivating factors behind their career goals. Student loan burden also may impact career decisions in dermatology. Compared to those with lower student loan debt (≤$200,000), respondents with higher student loan debt (>$200,000) showed greater interest in pursuing positions in private practice and were more likely to change career goals from academia to private practice after starting residency. Thus, academic institutions are potentially losing physicians who are interested in academic careers but ultimately decide against it, at least partially due to high student loan debt.

The PSLF can potentially address this issue and be used as a recruiting tool for dermatology positions in academia. Under PSLF, borrowers can have the remainder of their loan balances forgiven after making 120 monthly payments while employed full time by public service employers, including some academic medical institutions. In our study, a large majority of respondents indicated that they are aware of the PSLF, and more than half said they would consider pursuing positions in academia if their loans could be forgiven through the program; however, when asked about plans for loan repayment, only 1 respondent endorsed current plans to enroll in PSLF. Thus, despite high interest in PSLF among the survey respondents, few had actual plans to use the service, suggesting that perhaps dermatologists are not provided enough information about PSLF to motivate enrollment. In the same way, almost a quarter of respondents were not familiar with the PSLF as a repayment option, further signifying that distribution of information about financial planning may be inadequate. If student loan burden is a notable factor in career decisions in dermatology, it is important that academic institutions provide sufficient information about repayment to encourage informed decisions. As such, it is possible that educating physicians about options such as PSLF can potentially recruit more dermatologists to academic positions.

Aside from financial reasons, residency program experience and differences in practices in academic and nonacademic settings may impact career trajectories. The majority of respondents stated their residency program experience influenced their career decisions; however, the majority of respondents did not change their minds about career goals since starting residency, suggesting that residency program experience may reinforce but not necessarily alter these choices. Interests in specific focuses within dermatology also may influence career decisions. This study suggests that those pursuing private practice positions are more interested in dermatologic surgery, lasers, and cosmetics. Roles in research, mentoring, and patient care differ between academic and nonacademic settings and also may be influential in career decisions in dermatology, mirroring the implications of other studies that posited that career decisions within medicine are complex and involve multiple factors.¹¹

In this study, we did not find an association between gender and career plans in dermatology. In 2013, more than 60% of dermatology resident physicians were female.¹² However, a recent study suggested that women face challenges in academic dermatology, including a downtrend in the number of female investigators with grants from the National Institutes of Health.¹³Taken together, female dermatologists, who currently represent the majority of resident physicians training in dermatology, may face unique challenges in academia, further highlighting the potential difficulties with recruitment of dermatologists by academic institutions in the future.

This preliminary study has several limitations. First, the small sample size limited generalizability to all dermatologists. Second, responder bias was possible, as those who have stronger opinions about this topic may have been more inclined to participate in this voluntary survey. Future studies with larger sample sizes are needed to further explore the factors that influence career decisions within dermatology and to determine if there are additional means to increase recruitment into academia.

Conclusion

It is recognized that there are challenges in recruiting dermatologists into academic positions. This study suggests that student loan burden influences career decisions in dermatology. Dermatologists may not be fully educated on options for student loan repayment. With increased awareness, the PSLF can potentially be used as a recruitment tool for positions in academic dermatology.