How med student loan burdens can deepen health disparities

The following article by Caleb Zimmerschied originally appeared on AMA Wire on April 27, 2017.


The high loan burden associated with medical school can discourage students from underrepresented minority groups or lower-income families from pursuing a career as a physician. This creates a ripple effect of widening health care disparities that disproportionately affect the accessibility of primary care physicians in underserved areas.

Adjusted for inflation, the average medical student graduated in 2014 with a loan burden 3.5 times greater than a medical student in 1978. By 2014, the average loan burden was over $170,000.

Higher interest rates and unsubsidized loans for graduate students mean that they pay off more per dollar owed than undergraduate students. The Association of American Medical Colleges (AAMC) estimates that, accounting for interest under the Pay As You Earn repayment program, a student with $180,000 in loan burdens could pay almost $380,000 in total repayment. During a three-year residency, the AAMC estimates that total repayment to reach nearly $450,000. This amount increases further if a student pursues a specialty care field.

Those kinds of figures may be enough to intimidate any bright student considering a career in medicine. But students in ethnic and racial minority groups that are underrepresented in medicine, and those from lower-income families, can be particularly daunted by the prospect of six-figure loan burdens. According to the most recent AAMC report, 18.2 percent of black high-school sophomores said they aspired to apply to medical school, but only 6.7 percent actually applied. For Hispanic high-school sophomores, 24.4 percent said they wanted to go to medical school but only 6.8 percent applied.

According to 2014 AAMC data, while 13 percent of the U.S. population was black, they only made up 4.1 percent of the physician workforce. Hispanics accounted for 18 percent of Americans, but only 4.4 percent of the physician workforce. This in turn likely contributes to the lack of physicians making direct efforts to serve these communities. According to research published in JAMA, despite making up less than 30 percent of the physician workforce in 2013, physicians from underserved groups are significantly more likely to see nonwhite patients, and “nonwhite physicians cared for 53.5 percent of minority and 70.4 percent of non-English-speaking patients.”

Additionally, the cost of medical school likely deters applicants from lower-income rural communities as well. This could contribute to the fact that while 20 percent of Americans live in rural areas, only 10 percent of physicians practice where people in rural communities can access them. With a shortage of about 4,000 primary care physicians, 77 percent of rural U.S. counties are designated as health professional shortage areas.

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Competencies Needed for Community-Engaged Dissemination and Implementation Research

An article recently published in Translational Behavioral Medicine proposes a conceptual framework for assessing a researcher’s readiness to engage in dissemination and implementation research with community stakeholders. The authors, all affiliated with the North Carolina Clinical and Translational Sciences Institute, started with a table that included community engagement principles as defined by NIH, potential domains areas for competencies, and potential competencies. Through a process of development, evaluation, and refinement, the researchers developed a list of 40 competencies for community-engaged dissemination and implementation (CEDI) research that fit within 9 domains.  These domains were:

  • Perceived value of CE in D&I research: The researcher’s attitude toward the potential for enhancing D&I research processes and outcomes through community engagement
  • Introspection and openness: The researcher’s willingness and/or ability to examine their own preconceptions and to be receptive of others’ beliefs and opinions
  • Knowledge of community characteristics: The researcher’s willingness and/or ability to learn about the community’s characteristics and prior experiences
  • Appreciation for stakeholder’s experience with and attitudes toward research: The researcher’s willingness and/or ability to assess how the community’s research attitudes and experiences may affect the partnership
  • Preparing the partnership for collaborative decision-making: The researcher’s willingness and/or ability to organize the partnership in a way that facilitate dialogues, collective decision-making, and coordinated action
  • Collaborative planning for the research design and goals: The researcher’s willingness and/or ability to adapt to the attitudes and needs of community stakeholders when defining the research process
  • Communication effectiveness: The researchers’ willingness and/or ability to clearly present ideas, listen to community partners, and work through issues
  • Equitable distribution of resources and credit: The researcher’s willingness and/or ability to share resources for conducting the research and credit for outcomes of the research
  • Sustaining the partnership: The researcher’s willingness and/or ability to invest in a long-term relationship with community stakeholders

The individual competencies associated with each of these domains provide specific actions and/or attitudes to help assess readiness to undertake CEDI research. The authors describe this framework as a “first step toward development of a readiness assessment for researchers interested in conducting CEDI.”

The article is available from Translational Behavioral Medicine.