Money on your mind

How student debt can influence physicians’ career choices

Three DOs and two medical students talk about their sizable debt loads and their career decisions.

Lauren Delana, OMS III, will accumulate roughly $275,000 in education debt by the time she finishes medical school. This ulcer-inducing figure has been at the forefront of her thoughts this year.

Like Delana, many medical students faced with choosing a specialty find themselves torn between pursuing their passions or following the most lucrative path toward medical school debt repayment.

“With the amount of debt I will have, I need to make sure I have a career that allows me to pay back those loans,” Delana says.

Financial planners often advise students not to borrow more than they expect to earn in their first year on the job. If Delana wants to follow this advice, she’ll have to forgo lower-paying specialties such as psychiatry and internal medicine and try to land a residency in a more lucrative field, such as urology or pulmonary medicine.

Alternately, Delana could opt for a loan repayment program such as the Public Service Loan Forgiveness (PSLF) program or the National Health Service Corps (NHSC). But the PSLF program is only available to physicians in certain public-service positions, and the NHSC is highly competitive.

Ten years ago, Matt Pflieger, DO, was facing the same choices Delana is now. Dr. Pflieger and his wife, Janelle Maxwell, DO, graduated from medical school with $450,000 of debt in total.

Determined to pursue family medicine despite their debt, the pair moved to Denver, where Dr. Pflieger joined the NHSC and Dr. Maxwell received loan repayment via a Colorado state program. The programs repaid $280,000 of their debt, and the couple paid off the rest by moonlighting and living frugally.

Dr. Pflieger says they would have made the same decisions even if they didn’t obtain loan repayment.

“I was always committed to family medicine,” he says. “If you are committed to something you love, you are going to make it work.”

On the flip side, Hamad Husainy, DO, says his debt load—$263,000 when he graduated—weighed heavily on him when he planned his future.

“There was a time when I wanted to be a family physician or a pediatrician,” he says. “Unfortunately, after having some candid discussions with a few people I trusted, I realized that obtaining financial solvency in those specialties would be very difficult.”

Dr. Husainy eventually chose emergency medicine. After residency, his debt also influenced his decision to work for a rural hospital.

“Your dollar takes you a lot further in rural areas,” says Dr. Husainy, who practices in Florence, Alabama. “And as an emergency physician, you can often get a pay raise to work in a more remote area.”

Similarly, emergency physician Chadd Kraus, DO, accepted a job this year in Columbia, Missouri, partially because the area’s low cost of living will enable him to pay off his loans quickly. Dr. Kraus’ new position is in academic medicine, which he says is a better fit for him than the job he held at a community hospital just after residency. He chose that position to get experience in community medicine, but also to get a head start in paying down his loans, as community hospitals tend to pay more than teaching hospitals.

Whenever possible, medical students should prioritize finances alongside, rather than before, career satisfaction, Dr. Kraus advises.

“While it’s something you need to consider, your debt should not be the driving choice for which specialty you select,” he says.

7 comments

  1. I chose family med and sports med way back in 1964. I did all right and am happy I made that choice then. Now, family medicine is terrible financially and a constant fight with insurance and government regulations. My present satisfaction with the reimbursement and interference spoils my present satisfaction. I teach MD residents from foreign medical schools and the have 0 “zero” student debt. We wonder that our students pick the more lucrative specialties and hospital medicine over primary care. Even that has been userpeted by PA’s and NP’s who even they want the lucrative super specialties. I would advise young Doctors to go where the money is, GI, neuro, Ortho, etc. family med is emotionally rewarding but financially sucks and is a constant fight with insurance and government beaurocrats. Add to that ICD10 and my useless EMR, I would better have pursued a career in professional sports or politics. Heed my words!

  2. This article makes no mention of the military scholarships, where you get paid to go to school, graduate monetarily debt free, and make 2-3 times as much as civilians in residency. Pay back your obligation time (1 year attending for each year you get the scholarship) then you’re free to stay on or go back to the private sector as you see fit.

    I realize the article focuses on students beyond the point of looking for scholarships, and how their decision where to practice is significantly influenced by future compensation, but the military should stand alongside PSLF and NHSC as viable alternatives to crushing debt.

  3. I came out of residency with just under $350,000, but I knew all along that I wanted to be a family medicine doc. I was lucky enough to work with a lot of solo practice family docs and specialists who taught me that not only could I still make it on my own, I’d be better off. They all made more money than those employed so I believed them. I started in indigent care and part time at an urgent care with a plan to open my own clinic in five years, but a local hospital started running it so I left. I got a small business loan, did some light advertising, and opened my clinic with my wife as office manager/reception/billing/IT/etc. I take 60 min with new pts and 30 min with established. I also do OMT, injections, allergy immunotherapy, and more. 10 months later we have 2 more employees, soon to hire another, and we’re making way more than I was making working two jobs before. Our revenue continues to go up each month. Don’t let people dissuade you from your dreams. Just adapt and make them happen!

  4. One major issue that is left out in this article that needs to calculate into the decision is the interest rate. This actually swings the pendulum away from some more time intensive specialties. Newer grads are locked in a criminally high interest rate for federal loans compared to prime – mine is 6.25%. To give context, my car and my home loans are at 2.8% and 3.5% respectively. I actually borrowed – which is to say money dispersed – $160k, this had accrued interest (on the unsubsidized portion to $208k when I graduated. I started paying income based repayment (1/6 of my total take home) during 3 years in residency and it still had grown to close to $275k – day one of being an attending. I don’t make what an ER physician makes as a hospitalist, but I have paid it down in the past 14 months to under $200k. None of that is in any way tax deductible at our salary levels. My advice is, if you lived like a resident once, you can do so again. Be judicious and disciplined and pay every red cent to the loans until they are gone. Student loan debt isn’t the type of debt you should carry. If you’re buying a home (most states a good idea) pay a slightly higher interest rate and get a zero down mortgage if it means you can be disciplined and put that money towards student loans. At least you can deduct mortgage interest.

  5. The unfortunate reality is that family medicine is dead for those looking at a traditional model of practice. There are nurses all over the country taking online classes that will get them independent practice rights as family nurse practioners and will be content to do that job for under 100k a year. You can’t compete with that. There may be a space for concierge practice where people who can pay cash decide they want to see a physician but otherwise look elsewhere.

  6. Finished my residency in IM at more than $250K in debt. Early years thereafter my wife paid the mortgage, and bought the groceries, and ALL of my income went to paying off my debt. Finished that in just about 4.5 years. Kept the same “frugal” model thereafter, but never denying ourselves vacations and such, and paid off the $750K home in December 2014.

    Internists do not make alot of money “working for” anyone. So, though we paid off my debt in that “model” I became a traveling Hospitalist in mid-2007 and have been doing this work since mid-2007. Initially “for a company” then eventually deciding to go out on my own and do 100% Locum Hospitalist work. Never a better decision on my life… both professionally and personally. See my wife much more now that I ever did when “working for” someone… and the income is much better.

    Now, all debts gone, retirement funds building, all is good.

    You can do it. You just have to make the decision to do the things that may not be “easy” and get with it. Life in the USA is all about hard work, and good returns for hard work. For me and for us, the 100% Locum lifestyle has been the perfect way to go longterm and will do it until I retire.

    Hoping everyone else find their niche.

  7. If only the AOA helped DO’s into more competitive residencies and not just FM. Especially with the merger, it will be almost impossible for a DO to be a urologist, derm, rad onc etc. Those AOA spots were the only chance we had.

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