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Total Educational Debt May Be More Important than Monthly Debt Payments on Career Choices

I enjoyed reading Weinert and colleagues' recent study of factors that influence decisions to pursue academic careers in pulmonary and critical care medicine (1). However, I am troubled by the authors' decision to analyze debt according to a monthly dollar analysis as opposed to total educational debt. Most lenders offer multiple payment plans that are adjusted for an individual's current and future income, so that payments are not overly burdensome during training. Therefore, monthly debt payments are more reflective of what borrowers can afford to pay based on their current income, rather than their total educational debt. This was nicely demonstrated in Weinert and colleagues' Figure 2, which showed that monthly debt payments for fellows roughly correlated with median household income. In addition, by focusing on monthly payments, there is no insight gained from individuals who are in deferment and who may have anywhere from $10,000 to $200,000 in debt.

One reason the authors pursued this type of analysis was because they believed respondents were more likely to remember their monthly debt payment compared with their total loan balance. I am fairly certain, however, that most borrowers readily know their total debt balance within a small margin of error. Unfortunately, focusing on monthly debt payments has the confounding effect of normalizing an individual's debt burden to their current income, and may explain why debt had only a modest effect on career decisions in this study, which differs from the findings of others (2, 3).

Brian D. Gelbman

New York Presbyterian Hospital, Weill Cornell Medical College, New York, New York

FOOTNOTES

Conflict of Interest Statement: B.D.G. does not have a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

REFERENCES

1. Weinert CR, Billings J, Ryan R, Ingbar DH. Academic and career development of pulmonary and critical care physician-scientists. Am J Respir Crit Care Med 2006;173:23–31.[Abstract/Free Full Text]
2. Marci CD, Roberts TG. The increasing debt of medical students: how much is too much? JAMA 1998;280:1879–1880.[Medline]
3. Rosenblatt RA, Andrilla CHA. The impact of US medical students' debt on their choice of primary care careers: an analysis of data from the 2002 Medical School Graduation Questionnaire. Acad Med 2005;80:815–819.[CrossRef][Medline]

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