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Health Affairs Editor-in-Chief Alan Weil interviews Louisa Holaday from the Icahn School of Medicine at Mount Sinai who published a paper in the January 2023 issue examining debt burden among medical residents after stratifying by race and ethnicity.
Each week, Health Affairs Editor-in-Chief Alan Weil brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
00;00;00;01 - 00;00;32;13
Alan Weil
Hello and welcome to “A Health Podyssey”. I'm your host, Alan Weil. Having a diverse physician workforce is essential to achieving health equity. A number of studies have demonstrated better patient outcomes associated with a more diverse population of clinicians. But in order to achieve a diverse workforce, we need a diverse student body and a key factor in attracting students to the medical profession is addressing the large levels of debt most students accumulate during their training.
00;00;33;03 - 00;01;01;03
Alan Weil
What do we know about levels of debt among postgraduate medical residents and how that relates to workforce diversity? That's the topic of today's episode of “A Health Podyssey”. I'm here with Louisa Holaday an assistant professor at the Icahn School of Medicine at Mount Sinai in New York. Dr. Holaday and coauthors published a paper in the January 2023 issue of Health Affairs examining debt burden among medical residents after stratifying by race and ethnicity.
00;01;01;11 - 00;01;22;21
Alan Weil
They found that groups that are historically underrepresented in the physician workforce, including black, Hispanic, American Indian, Alaska Native and native Hawaiian/Pacific Islander populations were more likely to have debt than white and Asian Postgraduate Medical residents. We'll discuss these findings in more detail in today's episode. Dr. Holaday, welcome to the program.
00;01;23;18 - 00;01;25;01
Dr. Louisa W. Holaday
Thanks so much. Glad to be here.
00;01;25;14 - 00;01;42;16
Alan Weil
I'm looking forward to talking about this really important topic. I gave a very quick introduction, but I think it is important to set the stage. So I'm going to ask you to provide a little more detail than I did in the opening. Why is it so important that we pay attention to the racial and ethnic composition of the physician workforce?
00;01;43;06 - 00;02;14;08
Dr. Louisa W. Holaday
So great question. I think it's important for multiple reasons. One of these is that research across disciplines not just within medicine, but in business and politics, etc., has shown that a more diverse team comes up with better solutions. So medicine is not unique in that, and we have a lot of big problems that need to be solved. And having a diversity of perspectives, a diversity of backgrounds, is going to help all of us, not just, you know, our patients, but it also helps,
00;02;14;09 - 00;02;41;26
Dr. Louisa W. Holaday
It's been shown, in education that students have a better experience as well. So that's one reason it matters. It also matters because, as we know, you know, talent is equally distributed, but opportunity is not. And when we see that we have a physician workforce that doesn't reflect our population, we know that we're missing out on some talent. And that's a problem for everyone as well.
00;02;42;16 - 00;03;05;22
Dr. Louisa W. Holaday
So if we really want to have the best solutions to these big medical problems, we need to find a way to get equal opportunity to folks so that we can have the best talent in the field. And beyond that, as you mentioned, there are a number of studies now that have shown better outcomes for patients, not just for racial and ethnic concordance, but also for language concordance.
00;03;06;06 - 00;03;11;03
Dr. Louisa W. Holaday
And so having a more diverse physician workforce will help us achieve both of those things.
00;03;12;08 - 00;03;30;19
Alan Weil
Okay. That's a great way to start this. So this is a really critical goal for multiple reasons. Now, your study focuses on debt, which is probably not the first thing people think about when they think about diversity in the physician workforce. So why start here? Why is this relevant to the issue of physician diversity?
00;03;31;26 - 00;04;11;14
Dr. Louisa W. Holaday
So our team, yeah, I think we're a practical group and we wanted to look at something that's both concrete and also amenable to intervention. So the thing about debt is that it's very real. It has real effects on people's lives and we can do something about it, right, both from the policy level in terms of making education more accessible, more affordable, and at the institution level, institutions that really wish to diversify their workforce, which hopefully all do, because again, there are benefits to fellow physicians, you know, medicine is a team sport.
00;04;11;26 - 00;04;40;03
Dr. Louisa W. Holaday
And so having the best teams, having the most diverse teams really helps everyone. And so institutions can also target debt, right? They can help students who come in, whether they do that through financial, actual financial incentives, actual concrete financial help or provide really concrete guidance for managing the different types of debt that trainees have. It's something that, you know, gives people something that they can actually work with and actually do.
00;04;40;12 - 00;05;02;10
Dr. Louisa W. Holaday
You know, there's generations, centuries of exclusion, of exclusion from financial opportunities, from educational opportunities. Those things are challenging to fix. We can't go back in time. We can try to fix things that are happening now. But debt, that's real, it's on the table. We can do something about it.
00;05;02;28 - 00;05;19;02
Alan Weil
Okay. So let's get into the findings of your work. You were looking at debt. First of all, you looked at it across the various characteristics of these medical trainees. How frequently do you find it? How prevalent is it? What's at scale? Just give us a sense of what you learned.
00;05;19;13 - 00;06;02;08
Dr. Louisa W. Holaday
Overall, about 83% of all graduating medical trainees had at least some debt. But then when you stratify by the type of debt, you see some really dramatic differences for pre-medical education. For example, only 35% of graduating medical students have loans from pre-med education, and only about 25% have debt, consumer debt like credit card debt, things like that. But we saw that these types of debt and the prevalence of these types of debt varied tremendously by race, ethnicity.
00;06;03;05 - 00;06;32;05
Dr. Louisa W. Holaday
And we saw that black trainees consistently were most likely to have every type of debt. And for example, despite only 35% of the overall group having pre-med loans, 60% of black trainees had these loans. And despite only 25% of the overall group having debt from consumer loans like credit cards, etc., over 50% of black trainees had this type of debt.
00;06;32;23 - 00;06;40;08
Alan Weil
And can you give us a little sense of the scale here when you say the share with debt? I mean, you can owe $5. You can owe $5,000.
00;06;40;23 - 00;07;14;11
Dr. Louisa W. Holaday
Yeah, we thought that was really interesting, too. So we found that for medical education loans, unsurprisingly, overall, people owed almost $200,000 when they graduated medical school with a range, of course. But for pre-medical education, loans were almost a 10th of that. So on average, people owed about $25,000 an order of magnitude smaller there. And for consumer debt, the amount of loans was even smaller, you know, only about $10,000 on average.
00;07;14;25 - 00;07;51;05
Alan Weil
So I want to talk a little bit more about the implications of this, and particularly your focus on equity and diversity. We'll dig a little deeper into those topics after we take a short break. And we're back. I'm speaking with Dr. Louisa Holaday about differences in debt among postgraduate medical residents and the study looks at this by race and ethnicity.
00;07;51;18 - 00;08;12;02
Alan Weil
Before the break, we got sort of the top line results of the study. They're really interesting and important. I am particularly struck by the debt that people carry before they go into medical school. And I want to focus a little on that and then we'll talk a little bit more about it in medical school and we'll talk about some solutions because you said you were a practical bunch, so let's take advantage of that.
00;08;13;15 - 00;08;31;13
Alan Weil
You know, when you think about someone applying to medical school and you think they've got debt ahead of them, but if they're already in debt, presumably their attitude toward taking on additional debt is quite different. You said a little bit about the differences and types of debt pre medical training, but I wonder if you could just go a little deeper into that.
00;08;32;00 - 00;08;50;18
Alan Weil
You mentioned consumer debt. You mentioned educational debt and the scale of those and the share across different race and ethnicity. Is there anything we learn about that that has implications for who might feel like they can take on the burden of medical school?
00;08;51;06 - 00;09;31;11
Dr. Louisa W. Holaday
Absolutely. There's also, there's some preexisting research that has looked at graduating college students and has identified that the burden of taking on more debt associated with medical training discourages people who already have debt. And we also saw that, and we've seen that, the cost of application, the cost of interviewing, flying to these different schools, each application adds, you know, another amount of dollars that you have to pay just to even get your foot in the door, plus MCAT preparation, etc..
00;09;31;11 - 00;10;00;27
Dr. Louisa W. Holaday
So even to get to the application phase can be quite expensive. And we've seen that that can be discouraging for folks who already have debt. What we saw in the years where COVID was, had moved interviews from in person to virtual, the AAMC (Association of American Medical Colleges) published data demonstrating that there were increased numbers of applicants from underrepresented groups and also applicants who required fee waivers or qualify for fee waivers.
00;10;01;05 - 00;10;08;08
Dr. Louisa W. Holaday
So this increase diversity of the applicant pool both from a racial and ethnic perspective as well as from a socioeconomic perspective.
00;10;08;19 - 00;10;30;00
Alan Weil
So these barriers are really quite real. Now, when we look at debt, I think some people from the outside would say, you know, okay, it's a lot of debt, but in the end you become a doctor and doctors are pretty well compensated relative to other professions and other positions in this country. So this sort of gets, you know, it works out in the end.
00;10;30;16 - 00;10;51;29
Alan Weil
And then there are others who say, okay, that may be true, but it then affects which specialties people go into because they feel pressured to have a higher earnings to pay off their debt. Did you look at this notion of debt across the types of specialties that people select in their training?
00;10;52;29 - 00;11;16;25
Dr. Louisa W. Holaday
We did, and I want to address both of those points, both the specialty question and this idea that in the end it all works out. And I'll start with that because you started with that. So it's true that physicians are pretty well compensated overall relative to the population. Absolutely. However, it takes a long time to get to that point of being very well compensated.
00;11;17;04 - 00;11;38;10
Dr. Louisa W. Holaday
It requires four years of medical school. It requires at least three years of residency training. So you're pulling off that high salary for quite a long time. You know, when you graduate college, depending on what training you had in college, you can get a job in tech, in engineering, in you know, you can do law school, and that's a shorter training period.
00;11;38;20 - 00;12;12;24
Dr. Louisa W. Holaday
There are other types of additional training programs where you can go into a very well compensated field right out of undergrad. To decide to take on this journey of medical training is also, it's not just a question of financial investment, but also time investment. And depending, you know, who is counting on you, if you come from a family where everyone's pretty well-off, nobody needs your earnings, you know, your parents, your siblings, etc., you know, you have the opportunity to take, hey, let me take as long as I need to train and eventually I'll get that high salary.
00;12;13;06 - 00;12;36;23
Dr. Louisa W. Holaday
Right? But for people who may be supporting their families back home, for people who already have debt from credit cards with, you know, the interest rates on those being quite high, waiting this very long time to actually hit that, you know, high paycheck may not be a good option. The opportunity cost is really high there. So that's just one piece of things.
00;12;37;10 - 00;13;05;08
Dr. Louisa W. Holaday
And as far as specialties, there have been a number of studies and a number of people, you know, suggesting that because of the high costs of medical education, students may prefer, students with debt, might prefer a higher paying specialty, and we might be shaping our workforce through these high costs of education. What we found was actually counter to that, and we found that family medicine residents were the most likely to have debt.
00;13;06;04 - 00;13;41;08
Dr. Louisa W. Holaday
And this was true across all racial and ethnic groups. Family, medicine residents, almost all had debt, and family medicine is unique in that it's one of the training programs which almost everyone goes into primary care. Very few people subspecialize and do any additional years of training, and it's the shortest residency, so it's three years. So again, if you're thinking about this opportunity cost in terms of time and, you know, do you want to get out into the workforce and make that attending salary three years from now or seven years from now?
00;13;41;23 - 00;14;04;05
Dr. Louisa W. Holaday
You know that makes a big difference. And so what we saw was that people going into the shortest residencies were the most likely to have debt. We can't say for sure, you know, what led to what there, right? Is it that people said, “Hey, I got to get out, I got to make money”? Or is it that the same people who have debt also are interested in primary care?
00;14;04;17 - 00;14;20;05
Dr. Louisa W. Holaday
You know, we're trying to do some further work on that. And I think there are a lot of open questions. But it was very clear from our sample, which was, you know, 120,000 residents over six years, that people doing the shortest residencies, primary care residencies, were most likely to have debt.
00;14;21;00 - 00;14;49;26
Alan Weil
That's a really interesting question to get more information on. So as we close, I want to go back to where you started, which is you’re practical bunch. And we have lots of historical barriers to equitable participation in the workforce, but debt is right there in front of you and there's something you can potentially do about it. You alluded to a little bit earlier, but I'd love to hear more about what your team thinks is possible with respect to debt so that we can achieve a more diverse physician workforce.
00;14;51;00 - 00;15;25;25
Dr. Louisa W. Holaday
Yeah, great. Thanks. This is really our goal is that, you know, provide some data that's actionable and can lead to some solutions. And we think that our data suggests a number of different solutions, some that could be implemented at the policy level, some by institutions. What was interesting and we haven't talked a lot about is that the biggest disparities that we saw, the biggest disparities by race/ethnicity in terms of the likelihood of having debt were for pre-med loans and for consumer debt.
00;15;26;23 - 00;16;11;05
Dr. Louisa W. Holaday
So medical school is tremendously expensive. The majority of people across all ethnic groups have loans from med-ed (medical education). But for pre-medical education, there were much greater differences. And the amount of money that people owed was much smaller. So for both of those reasons, addressing college undergraduate education, making it either more affordable to start with, having there be more pathways for people who would need loans to get, you know, scholarships, to get aid, to get alleviation of that debt, to have it paid back before they go on to medical training.
00;16;11;29 - 00;16;40;15
Dr. Louisa W. Holaday
All of those things targeting that early debt, that debt that is obtained before and during medical school and the workforce. That seems to be one of the places really to start and also figuring something out with regard to this consumer debt. So this is credit cards, car payments, anything outside of educational loans. We really saw wide disparities there across racial and ethnic groups.
00;16;41;08 - 00;17;26;00
Dr. Louisa W. Holaday
And so targeting that somehow, whether it's through minimizing, you know, how predatory these interest rates can be for, these are kids taking out these loans, presumably, you know, people who are in college, they may be teenagers. Right? So figuring out a way to target that. Also, at the institution level, you know, medical schools talk a lot about sort of loans overall and debt overall, but really thinking about these different types of debt and how can we assist students that are coming in or who want to come in, who have debt from things like consumer loans that they took out, you know, years before or even from their college loans that are much lower than these
00;17;26;00 - 00;17;40;19
Dr. Louisa W. Holaday
years of debt that they take out for medical school. So figuring out ways to help students, to provide guidance, to alleviate that debt. Scholarships, pathways to paying things off. All of those things could be beneficial.
00;17;41;19 - 00;18;04;12
Alan Weil
Well, Dr. Holaday, thank you for such a clear explanation of the issues here and how important it is to address these challenges and for shedding light on the barriers to having an equitable workforce that may not be exactly the ones that people would have thought of or understood before this work. So we appreciate your efforts in this area and creativity you and your team are bringing to them.
00;18;04;12 - 00;18;07;11
Alan Weil
I thank you today for being my guest on “A Health Podyssey”.
00;18;08;02 - 00;18;11;18
Dr. Louisa W. Holaday
Thanks so much. It was great to be here.