Letters to the Editor  |   May 2008
Mortgaging Our Future, Foreclosing Our Profession
Author Affiliations
  • Chadd K. Kraus, II, MPH, OMS
    Willow Grove, Pa
Article Information
Medical Education
Letters to the Editor   |   May 2008
Mortgaging Our Future, Foreclosing Our Profession
The Journal of the American Osteopathic Association, May 2008, Vol. 108, 231-233. doi:10.7556/jaoa.2008.108.5.231
The Journal of the American Osteopathic Association, May 2008, Vol. 108, 231-233. doi:10.7556/jaoa.2008.108.5.231
To the Editor: Medical school debt is a challenge facing many young physicians, DO and MD alike.1-3 In fact, several authors have suggested that concern about debt, rather than the rigors of medical training, is the leading source of stress among medical students.4,5 Such stress may be severe enough to have an adverse impact on academic performance, especially among students from low-income backgrounds.4,5 
For osteopathic medical students, young DOs, and the profession as a whole, concern about high debt loads is especially important and is related to three other issues: 
  • possible future problems regarding financial solvency of colleges of osteopathic medicine (COMs)
  • potential reductions in applications to, and matriculation into, COMs from individuals of racial or ethnic minority groups
  • negative public perceptions about the quality and scope of osteopathic medical education
High education-related debt loads among osteopathic medical students and young DOs call into question the long-term financial solvency of COMs and their alumni. In the 2008 edition of US News & World Report`s “America's Best Graduate Schools,”6 five of the 10 medical schools with the highest levels of debt among graduates were COMs. In addition, the two schools with the highest graduate debt burdens were COMs. Although COMs and their branch campuses comprise only 16% of all fully accredited medical schools in the United States and Canada, COMs make up half of the medical schools with the highest debt among graduates.7,8 
To say that these data are alarming is an understatement. With the exception of a few federal service (eg, the Department of Health and Human Services' National Health Service Corps, the US Armed Forces' Health Professions Scholarship Program) and highly variable state-level loan repayment programs, students have few choices but to assume greater personal debt to finance an osteopathic medical education. 
Interestingly, three of the five COMs with the highest debt burdens reported for the class of 20056—Kirksville (Mo) College of Osteopathic Medicine-A.T. Still University, Philadelphia (Pa) College of Osteopathic Medicine, and Touro University College of Osteopathic Medicine–California in Vallejo—have opened branch campuses since 2000. It is not clear whether the revenues used for, and generated from, the establishment of new schools of osteopathic medicine and additional branch campuses are being partly funded through student tuition or through the redistribution of other resources (eg, selling land assets where osteopathic hospitals once stood). 
Although some in the osteopathic medical profession justify the explosive growth in class sizes at existing COMs and the opening of new schools—including the for-profit Rocky Vista University College of Osteopathic Medicine in Parker, Colo—by a perceived shortage of physicians,9 the evidence cited for such shortages is based on a series of unproven assumptions about the US healthcare system.10,11 For example, the assumption that demand for physicians will increase as gross national product increases is not absolute.11 
If the osteopathic medical profession chooses to continue its growth through COMs, it is unlikely that the addiction to student tuition as a source of financial well-being can sustain COMs for years to come. It is even more difficult to conceive that current osteopathic medical students will be compelled to become generous alumni donors while also committing large portions of their monthly incomes to repaying long-standing student debt. 
At a time when applications to osteopathic medical schools are at historic highs, medical education is becoming less affordable to many students, especially students from disadvantaged backgrounds.12,13 High tuition costs and the prospect of debt on graduation that far exceeds $100,000 could result in the inability of COMs to recruit and retain students who represent the diverse communities our nation boasts. In fact, data compiled by the Association of American Medical Colleges12,14 reveal that cost was the leading reason for not applying to medical school among qualified African American, Hispanic, and Native American candidates. 
Medical students who are members of racial or ethnic minority groups are most likely to become practicing primary care physicians in our nation's most underserved communities—even in the face of crippling debt.15 Therefore, a decline in the number of these students in our COMs as a result of the prospect of looming debt would be a tragic blow—not only to diversity and cultural understanding in osteopathic medical institutions, but also to our efforts to provide healthcare services in underserved communities. 
Conversely, the promise of lower postgraduate debt at COMs could result in the recruitment of higher quality students to the osteopathic medical profession. Before opening more branch campuses and more new COMs, the American Osteopathic Association and existing COMs should evaluate their missions to determine whether quality or quantity will be the hallmark of osteopathic medicine for the future. 
Finally, the disproportionate debt burden held by young DOs rekindles, at least indirectly, the historic image of COMs as being academically inferior to allopathic medical schools and lacking the research facilities, number of basic science faculty members, and commitment to academic medicine of their allopathic counterparts.16 
Despite high debt among osteopathic medical students, few COMs operate academic hospitals with graduate medical education programs. Fewer still have the research funding needed to support faculty salaries, sustain infrastructure improvements, and contribute to discoveries in osteopathic manipulative medicine or other important areas of science. 
When COMs are compared with allopathic medical schools that have low debt among graduates, the question becomes whether the mission of COMs is to contribute to improving medical education, advancing scientific research, and providing quality clinical care or simply to develop curricula and award diplomas to persons willing to incur six-figure debt. 
Among allopathic medical schools with the lowest debt burdens for graduating physicians are the Johns Hopkins School of Medicine in Baltimore, Md; Stanford (Ca) University School of Medicine; and Mayo Medical School College of Medicine in Rochester, Minn.6 In 2005, the average debt of a graduate from Mayo Medical School was nearly two-thirds less than that held by a graduate from Touro University College of Osteopathic Medicine–California.6 
Many of the same allopathic medical schools with low debt among graduates also have vast research infrastructures to maintain, complex hospital and healthcare systems to finance, and large numbers of basic science and clinical faculty engaged in research, student education, and patient care. Thus, not only are these allopathic medical schools producing physicians with less debt, their institutional resources offer students greater opportunities to prepare for positions of leadership in research, education, and clinical care—positions that will shape healthcare policy at the state and federal levels for decades to come. 
The question among prospective applicants to COMs will eventually (or has already) become: 

What is the additional value of choosing an osteopathic medical school over an allopathic medical school, especially when debt incurred from osteopathic medical education is so high?

I wager that, for many of these applicants, “the osteopathic difference” will unfortunately not be palpable enough to convince them of the merits of becoming a DO. 
If the osteopathic medical profession is to produce leaders who will shape the future of medicine, we must aggressively address the economic realities facing debt-burdened osteopathic medical students and young DOs. Addressing those realities might include structured financial-planning programs and tuition-stabilization initiatives. 
For many new DOs, the cavalier response of academic administrators to “not worry” about future debt17 is myopic and irresponsible. Such a response threatens the health of the osteopathic medical profession. If COMs continue to expect students and young DOs to mortgage their professional and financial futures to finance their education, the result might well be the foreclosure of the osteopathic medical profession. 
 Editor's Note: Student Doctor Kraus states that the views expressed in his letter to the editor are his own and are not intended to represent any positions of the Philadelphia (Pa) College of Osteopathic Medicine.
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