Student Loan Burden and Its Impact on Career Decisions in Dermatology

Dermatology departments in the United States have been facing challenges in recruiting and retaining dermatologists for academic positions. Accordingly, a survey study reported that academic dermatologists were more likely than those in private practice to state that their institutions were recruiting new associates.¹ Several factors could explain this phenomenon. Salary differences between jobs in academic and nonacademic settings may contribute to difficulty in recruiting dermatologists into academia, which is exacerbated by a theoretical shortage of dermatologists, leading to graduates who receive and accept private practice job offers.^1,2 Furthermore, a large survey study reported that challenges unique to academic dermatologists include longer patient wait times in addition to responsibilities such as research, hospital consultations, medical writing, and teaching. These patterns raise concerns for the future of teaching institutions because academic dermatologists not only train future physicians but also conduct clinical and basic science research necessary to advance the field and improve patient care.² Thus, it is important to evaluate the factors that affect career decisions in dermatology and to determine if these factors can be addressed. We hypothesized that student loan burden influences career plans in dermatology and that physicians are not fully educated on loan repayment options. The aims of this preliminary study were to explore the influence of student loan burden on career plans in dermatology and to determine if the Public Service Loan Forgiveness (PSLF) program could potentially encourage more dermatologists to consider academic careers.

Methods

The study aimed to investigate the factors that influence career decisions in dermatology and to assess attitudes toward the PSLF program as an option for student loan repayment. The target population included dermatology residents and attending physicians in the United States. Survey questions were adapted from a previously published study³ and were modified based on feedback from reviewers in the University of California (UC) Irvine department of dermatology. The survey was voluntary and did not collect identifying information. This study was granted exemption from oversight by the UC Irvine institutional review board.

Recruitment materials informed potential participants of the nature of the study and provided a hyperlink to the electronic survey. The UC Irvine department of dermatology emailed US dermatology residency program coordinators, requesting that they forward this study to residents and attending physicians in their programs. The survey also was distributed by one of the investigators (E.S.) on a social networking website for dermatologists. Data were collected from June 2015 to October 2015. A χ² analysis was conducted using SAS statistical software, and P<.05 was considered statistically significant.

Results

Demographics
The survey had 70 respondents including residents (56 [80.0%]) and attending physicians (14 [20.0%]). The mean age (SD) of the respondents was 32.4 (6.1) years, with 31 (44.3%) men and 39 (55.7%) women. The majority were married (38 [54.3%]) and did not have children (48 [68.6%]). Most respondents reported an annual household income of $200,000 or less (55 [78.6%]) and perceived a comfortable annual household income as greater than $200,000 (59 [84.3%])(Table 1).

Financing Medical Education
Most respondents currently had $200,000 or less in student loan debt (40 [57.1%]) and financed more than half of their medical education with student loans (53 [75.7%]). A large majority (61 [87.1%]) indicated that some portion of their medical education was funded by student loans. Other means of financing education included family assistance (29 [40.8%]), scholarships (26 [36.6%]), personal savings (18 [25.3%]), and military benefits (1 [1.4%]); 18.3% (n=13) of respondents did not accrue any educational debt. Respondents endorsed several plans for loan repayment including government-sponsored programs (34 [47.9%]), refinancing with a private company (13 [18.3%]), and the PSLF (1 [1.4%]); 12.7% (n=9) of respondents were uncertain how they were going to repay their student loans.

Career Goals in Dermatology and the Influence of Student Loans
Respondents were asked to specify their career plans before versus after starting dermatology residency training (ie, current career plan). Prior to starting residency, 36 (51.4%) and 34 (48.6%) respondents indicated they were interested in private practice and academia, respectively. After starting residency, the number of respondents interested in private practice increased to 45 (64.3%), and the number of respondents interested in academia decreased to 25 (35.7%). Fifteen (21.4%) respondents changed career trajectories from academia to private practice, 6 (8.6%) changed from private practice to academia, and 49 (70.0%) did not change career goals.

The majority of respondents (39 [55.7%]) indicated that the amount of their student loan debt did not influence their career goals (Table 2); however, those with more than $200,000 in debt were more likely to state that student loans impacted their career goals compared to those with $200,000 or less in debt (70.0% [21/30] vs 25.0% [10/40]; P<.001).