Education Research: Observational Study of Educational Debt Among US Medical Graduates Entering Neurology, 2010-2021

Abstract

Background and objectives: To identify trends in educational debt for US medical school graduates entering neurology and compare debt to anticipated compensation.

Methods: Data of 148 accredited medical schools were obtained from the Association of American Medical Colleges Graduation and Matriculating Student Questionnaires to identify self-reported educational debt for graduates pursuing neurology training. Trends were assessed in a 2-year interval from 2010 to 2021. Descriptive statistics were used to assess characteristics associated with debt. Dollar amounts were adjusted to 2021 US dollars. Total compensation by subspecialty from the 2021 American Academy of Neurology Compensation and Productivity Survey was used to calculate debt-to-income ratios by subspecialty.

Results: There were 182,738 responses recorded from medical graduates from 2010 to 2021, of which 4,466 planned on neurology training. The percentage of medical graduates entering neurology with debt decreased from 82% in 2010-2011 to 71% in 2020-2021. Among indebted, the median educational debt increased 9% from $192,613 (interquartile range [IQR] $140,908) in 2010-2011 to $209,396 (IQR $159,128) in 2020-2021 (p < 0.001). Medical graduates with debt more often reported family income in the bottom 3 quintiles of US household income (18% with debt vs 7% without debt; p < 0.001). Graduates from self-identified race and ethnicity groups who are underrepresented in medicine (URiM) were more likely to have debt (15% vs 9%; p < 0.001) and had greater debt when compared with graduates not self-identifying as URiM (median $211,616 [IQR $152,760] vs $202,379 [IQR $153,340]; p < 0.001). In 2021, 46% of indebted neurology-bound graduates indicated plans to use Public Service Loan Forgiveness, which increased from 16% in 2010. In 2021, the median debt for neurology graduates represented between 70% and 93% of total annual compensation with the highest debt-to-income ratios among behavioral neurology (0.93), child neurology (0.91), and movement disorders (0.89).

Discussion: The burden of educational debt for neurology-bound graduates is increasingly concentrated among those from lower-income families and racial and ethnic groups who are URiM. Subspecialties that often manage patients in the outpatient setting, as compared with those that are primarily inpatient/procedural, may have greater debt with respect to their compensation. Nearly half of 2021 graduates pursuing neurology plan to use tax-payer funds for loan forgiveness.

Figure 1. US Medical Graduate Selection Methods

For an analysis comparing educational debt among graduates entering Neurology to those entering other specialties, we examined responses from 156,886 US medical graduates. For an analysis of trends of medical education debt and characteristics associated with debt, we examined responses from 4,466 US medical graduates indicating Neurology as their chosen specialty.

Figure 2. Educational Debt for US Medical Graduates by Specialty

(A) Proportion of medical graduates with educational debt. (B) Boxplot of educational debt among those with debt adjusted to 2021 US dollars. Box represents median and interquartile range. Educational debt includes both premedical and medical educational debt. Figure represents n = 146,901 medical graduates classified into specialties based on postgraduate plans. There were n = 9,985 graduates who were not classified, reported “other” specialties, or did not intend to pursue medicine. Neurology is indicated in dark green. All specialties were compared with Neurology with asterisk indicating differences, p < 0.05.

Figure 3. Trends in Educational Debt Among US Medical Graduates Entering Neurology, 2010–2021

(A) Percent with and without educational debt. (B) Box and whisker plot of educational debt among those with debt adjusted to 2021 US dollars. Mean values shown as diamonds. Trends were consolidated into a 2-year interval due to size of the categories. A Cochran-Armitage test of trends demonstrated increasing debt over time, p < 0.001.

Figure 4. Ratio of Debt-to-Income by Neurologic Subspecialty and Practice Setting, 2021

We calculated debt as a proportion of total annual compensation by neurologic subspecialty and practice setting assuming the median debt amount for US medical graduates entering Neurology in 2021 and total compensation from the American Academy of Neurology Compensation and Productivity Survey. Subspecialties with fewer than 50 responses were excluded (Neuro-Ophthalmology, Pain Medicine, Endovascular Neurology, Autonomic Disorders, Geriatric Neurology, Other).