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Letters to the Editor  |   May 2008
Working to Ease Debt Burdens
Author Affiliations
  • Stephen C. Shannon, DO, MPH
    American Association of Colleges of Osteopathic Medicine Chevy Chase, Md
    President
Article Information
Medical Education
Letters to the Editor   |   May 2008
Working to Ease Debt Burdens
The Journal of the American Osteopathic Association, May 2008, Vol. 108, 264-265. doi:10.7556/jaoa.2008.108.5.264
The Journal of the American Osteopathic Association, May 2008, Vol. 108, 264-265. doi:10.7556/jaoa.2008.108.5.264
To the Editor:  
In his letter published in the February 2008 issue of JAOA—The Journal of the American Osteopathic Association, Ethan Wagner, DO,1 raises legitimate concerns regarding the high cost of osteopathic medical education and the rising debt loads confronting osteopathic medical students. However, I take exception to his characterization of colleges of osteopathic medicine (COMs) as unconcerned entities that do not provide adequate financial counseling opportunities for their students. 
The COMs have worked proactively to ensure that their students and graduates are “financially literate” and aware of the services that might help them best manage their education debt. 
Not only are COMs required to provide financial counseling,2-6 most of them go far beyond this requirement in an effort to help their students navigate the early years of debt accumulation and repayment—a time when young physicians feel especially hard hit. The financial education programs of COMs are extensive and include entry-to-exit financial services programs, financial management programs, and even formal seminars on the business aspects of medicine. 
Dr Wagner1 notes that Midwestern University/Chicago College of Osteopathic Medicine (MWU/CCOM) is the alma mater of the physician featured in the Decem ber 2007 Money Magazine article titled “Young doctors in debt.”7 However, as noted by Kathleen H. Goeppinger, PhD,8 MWU/CCOM received the honor of winning a 2006 Excellence in Debt Management Award.9 Obviously, there is a disconnect between Dr Wagner's perceptions derived from the Money Magazine article7 and the realities of financial education programs available at MWU/COM and other osteopathic medical schools. 
This is not to say that osteopathic medical education is inexpensive or that substantial debt burdens are easy for new DOs to shoulder. In May 2007, I explored some particularly worrisome aspects of this topic in Inside OME, the online newsletter of the American Association of Colleges of Osteopathic Medicine (AACOM).10 In the remainder of the present letter, I adapt that piece to help open what I hope will be a constructive dialogue on this critical challenge. 
Debt levels for graduating medical students have been rising for years, spurred by inflationary pressures and associated tuition increases. Under the weight of such factors as increased costs for technology, clinical training, and regulatory requirements—coupled with decreased financial support from states and practice plan earnings—tuition increases at all of the nation's medical schools have long exceeded inflation. In fact, the same can be said for tuition costs throughout higher education. Although COMs work vigorously to contain costs, it is difficult to do so when tuition and fees account for 73% of total revenues at private COMs and 13% of revenues at public COMs.11 
The financial obligations of graduating osteopathic medical students, including all education debts accrued prior to graduation, are especially consequential for those who are entering postgraduate training before beginning their careers as osteopathic physicians. Of course, this has been the case for years, but it is now of increasing concern for several reasons. 
The osteopathic medical profession's primary care roots, which are reflected in the mission statements of most COMs, may be challenged by worsening student debt burdens. Although primary care medicine continues to be the specialty choice of a plurality of COM graduates, the proportion of COM graduates choosing other career paths has been growing for several years.11,12 
The changing career choices of COM graduates may be related to the fact that the salaries of primary care physicians are decreasing. Between 1995 and 2003, the average annual income (adjusted for inflation) of primary care physicians fell by 10.2%, from $135,000 to $121,000.13 The average inflation-adjusted annual income of physicians in other specialties decreased by only 2.1% during that same period, from $179,000 to $175,000.13 The widening gap between income and debt for primary care physicians is also reflected in the relationship between anticipated income and tuition costs. In 1995, the average cost of medical school tuition represented 14% of the average primary care physician's first-year income. By 2003, this proportion had increased to 23%.13 
One result of these troubling developments has been a growing call for increased tuition scholarship and loan-forgiveness programs, particularly in geographic areas where the greatest need for primary care physicians exists. 
The American Association of Colleges of Osteopathic Medicine is advocating its support for such programs with federal agencies and legislators. We are also working to expand other mechanisms of scholarship and low-interest or loan-forgiveness programs—as well as to implement changes in federal tax laws that would maintain and expand deductions for medical student loan interest. Furthermore, we are working with a variety of other physician and medical education organizations to prevent the type of downward pressure on physician income represented by the current Medicare payment formulas. 
The bottom line is that AACOM and our member colleges recognize the difficult financial burdens imposed on today's osteopathic medical students, and we are working on many fronts to help ease these burdens. We welcome constructive suggestions that might add to the effectiveness of our efforts. 
 Editor's Note: In an upcoming issue of JAOA—The Journal of the American Osteopathic Association, the executive director of the American Osteopathic Association, John B. Crosby, JD, will respond to this series of letters on debt management for osteopathic medical students.
 
Wagner E. Debt control for young DOs [letter]. JAm Osteopath Assoc. 2008;108:53,81. Available at: http://www.jaoa.org/cgi/content/full/108/2/53. Accessed April 14, 2008.
Federal Family Education Loan Program: processing the borrower's loan proceeds and counseling borrowers (codified at 34 CFR § 682.604 [f] and [g]). Available at: http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=bba21df8388e3a9eaccf8cc8c0fa9f3a&rgn=div8&view=text&node=34:3.1.3.1.40.6.40.5&idno=34. Accessed May 16, 2008.
Public Health Service Act: repayment and collection of health professions student loans (codified at 42 CFR § 57.210). Available at: http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=80351b973012aba5865c65e7bab62f52&rgn=div8&view=text&node=42:1.0.1.4.39.2.19.10&idno=42. Accessed May 16, 2008.
Public Health Service Act: repayment and collection of nursing student loans (codified at 42 CFR § 57.310). Available at: http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=80351b973012aba5865c65e7bab62f52&rgn=div8&view=text&node=42:1.0.1.4.39.3.19.10&idno=42. Accessed May 16, 2008.
Federal Perkins Loan Program: making and disbursing loans (codified at 34 CFR § 674.16 [a]). Available at: http://edocket.access.gpo.gov/cfr_2007/julqtr/34cfr674.16.htm. Accessed May 16, 2008.
Federal Perkins Loan Program: contact with the borrower (codified at 34 CFR § 674.42 [b]). Available at: http://edocket.access.gpo.gov/cfr_2007/julqtr/34cfr674.42.htm. Accessed May 16, 2008.
Mannes G. Young doctors in debt. Money Magazine. December 2007:120-126. Available at: http://money.cnn.com/2007/11/16/pf/young_doctors.moneymag/?postversion=2007111611. Accessed April 14, 2008.
Goeppinger KH. Award-winning debt-management education [letter]. J Am Osteopath Assoc. 2008;108:233 ,264.
2006 USA Funds Excellence in Debt Management Awards: Midwestern University; June 20, 2006. USA Funds Web site. Available at: http://www.usafunds.org/financial_aid/debt_management/best_practices/2006_award_winners/midwestern_university.htm. Accessed April 14, 2008.
Shannon SC. From the president. Inside OME [serial online]. Chevy Chase, Md: American Association of Colleges of Osteopathic Medicine; May 2007. Available at: http://www.aacom.org/resources/ome/Pages/May2007.aspx. Accessed March 27, 2008.
American Association of Colleges of Osteopathic Medicine. 2006 Annual Statistical Report on Osteopathic Medical Education. Chevy Chase, Md: American Association of Colleges of Osteopathic Medicine; February 2007. Available at: http://www.aacom.org/resources/bookstore/2006statrpt/Pages/default.aspx. Accessed April 14, 2008.
Ramirez AF, Bell EC. Osteopathic specialty board certification. J Am Osteopath Assoc. 2007;107:117-125. Available at: http://www.jaoa.org/cgi/reprint/107/3/117. Accessed April 14, 2008.
Tu HT, Ginsburg PB. Losing ground: physician income, 1995-2003. Tracking Report No. 15 [serial online]. Washington, DC: Center for Studying Health System Change; June 2006. Available at: http://www.hschange.com/CONTENT/851/. Accessed April 14, 2008. ♦