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Original Contribution  |   June 2018
Practice Area Intentions of Graduates of Colleges of Osteopathic Medicine: What Role Does Debt Play?
Author Notes
  • From the University of Kansas Medical Center in Kansas City (Drs Richards and Newman); the Departments of Internal Medicine (Drs Scheckel and Poole) and Biostatistics (Ms Mi) at the Mayo Clinic in Scottsdale, Arizona; and the Midwestern University Arizona College of Osteopathic Medicine in Glendale (Mr Kunz). Drs Richards and Scheckel share first authorship. 
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Jesse R. Richards, DO, University of Kansas Medical Center, 3901 Rainbow Blvd, Mailstop 2017, Kansas City, KS 66160-8500. Email: jrichards4@kumc.edu
     
Article Information
Medical Education
Original Contribution   |   June 2018
Practice Area Intentions of Graduates of Colleges of Osteopathic Medicine: What Role Does Debt Play?
The Journal of the American Osteopathic Association, June 2018, Vol. 118, 384-388. doi:10.7556/jaoa.2018.082
The Journal of the American Osteopathic Association, June 2018, Vol. 118, 384-388. doi:10.7556/jaoa.2018.082
Abstract

Context: Enrollment in colleges of osteopathic medicine continues to increase, as does the need for physicians practicing in underserved areas. The cost of osteopathic medical education is substantial, with students often incurring debt of $200,000 or more. It is unclear whether practice patterns of new graduates will be affected by debt-to-income ratios.

Objective: To determine whether the intended practice location of graduates of colleges of osteopathic medicine is associated with medical education debt.

Methods: Using data from the American Association of Colleges of Osteopathic Medicine's annual survey to graduates of colleges of osteopathic medicine, the authors focused on graduates’ intention to practice in an underserved area, the amount of debt incurred, and plans to enter a loan-repayment program. Survey data from 2007, 2010, 2013, and 2016 were analyzed.

Results: From 2007 to 2016, the percentage of graduates who intended to practice in underserved areas increased (27.5% to 35.3%, respectively). Graduates with the most debt intended to practice in underserved areas at a higher percentage than those with the least amount of debt, and they also planned on using loan-repayment programs at a higher rate.

Conclusion: There is a strong association among the intention to practice in an underserved area, high debt load, and intention to use a loan-repayment program. Therefore, the osteopathic medical community should support increased access to loan-repayment programs to help its graduates surmount economic and social barriers to providing care in underserved areas.

The osteopathic medical profession has grown rapidly over the past 30 years. Since 2007, the average increase in enrollment in colleges of osteopathic medicine (COMs) has been 6.9% per year.1 Today in the United States, 1 in 4 medical students matriculate to a COM. As of the end of 2016, more than 5000 new DOs graduated annually.2 This number represents an astounding 276% increase from 1986.2 
Of the 34 accredited COMs, 6 are public institutions.2 Fourteen have opened within the past decade, all of which are private institutions.3 Comparison of tuition fees alone between public and private COMs shows a large discrepancy in first-year osteopathic medical student annual tuition (mean, $28,570 vs $47,052, respectively).3,4 These figures, however, do not include institution fees, which can vary considerably from facility to facility, or cost-of-living expenses. Mean osteopathic education debt among 2016 graduates was $240,331, a 16.9% increase from 5 years earlier. National inflation for the same period was only 6.7%.5,6 Public COM graduates reported mean indebtedness of $208,962 vs private COM graduates’ mean indebtedness of $246,941.6 In comparison, students graduating from allopathic institutions in 2016 incurred a mean medical education indebtedness of only $180,000, which was less of an increase compared with 5 years earlier (14%) than for COMs during that period.7,8 
The surge in COM graduates’ indebtedness has occurred simultaneously with a national dialogue that has highlighted both physician shortages and health disparities in the United States. A 2017 Centers for Disease Control and Prevention report9 highlighted some of these gaps in its discussion of higher rates of death among people in rural areas due to conditions such as heart disease, respiratory disease, and stroke compared with people in urban areas. The authors concluded that nonmetropolitan communities have higher age-adjusted death rates from the leading causes of mortality in the United States.9 A zip code analysis of major metropolitan areas in Oklahoma found that people in the same city can have life expectancies that differ by as much as 14 years.10 Although many factors contribute to these statistics, a common theme reverberates: lack of access to medical care in certain geographic areas. These concerns raise questions regarding practice location intentions of medical school graduates. The mission statements of many COMs have themes such as “care for underserved populations,” “fulfilling primary care needs,” and primary care for both rural and urban “communities.”11-16 
In light of the rapid growth of osteopathic medicine, coupled with the increasing burden of debt for COM graduates, we aimed to analyze practice intentions of osteopathic graduates with regard to area (underserved vs nonunderserved), the level of debt incurred during medical school, and the intention to enroll in a loan-repayment program. We also examined the role of indebtedness in graduates’ intention to practice in an underserved vs nonunderserved area. 
Methods
The American Association of Colleges of Osteopathic Medicine (AACOM) annually invites all accredited COMs to administer a voluntary survey to their graduating classes. The survey examines trends among COM graduates in terms of demographics, satisfaction, career choice, and other metrics.5 
The survey has evolved over time, but questions seeking feedback on intended practice area, practice population, and current level of indebtedness have remained consistent. With AACOM's permission, we obtained deidentified responses from the 2007, 2010, 2013, and 2016 AACOM surveys. We examined responses to the following questions: 
  • ■ Are you planning to practice in any underserved or shortage areas?
  • ■ If “Yes” (to practicing with underserved), in what type of underserved or shortage area do you plan to practice?
  • ■ Indicate the principal amount you borrowed from each loan source listed below to finance your osteopathic medical education.
  • ■ Do you plan to enter a loan-repayment program?
For this study, we stored the deidentified data and analysis in a password-protected Excel (Microsoft Corporation) file. χ2 and analysis of variance tests were used with standard statistical methods. P<.05 indicated statistical significance. SAS software (SAS Institute Inc) was used for all analyses. 
Results
For the years 2007, 2010, 2013, and 2016, the overall mean response rate was 76.6%. Total responses increased from 2403 in 2007 to 4191 in 2016 as class size increased. The percentage of graduates who intended to practice in underserved areas was 27.5% in 2007, 32.5% in 2010, 32.2% in 2013, and 35.3% in 2016, which represents a significant increase from 2007 to 2016 (P<.001). In contrast, the percentage of graduates who intended to work with nonunderserved populations decreased, from 25.0% in 2007 to 15.8% in 2016 (P<.001). 
Graduates’ responses were then divided into quartiles based on indebtedness (least debt, quartile 1; most debt, quartile 4), and each quartile was analyzed. For 2007, no statistically significant difference was found between debt quartiles in whether graduates intended to practice in underserved areas. In 2010, 2013, and 2016, however, the percentages of graduates who intended to practice in underserved areas were significantly lower among those with the least debt than among the graduates with the most debt (P=.001, P<.001, and P<.001, respectively) (Table 1). 
Table 1.
Comparison of COM Graduates Intending to Practice in Underserved Areas by Debt Quartilea,b
Year Underserved, No. (%) Nonunderserved, No. (%) P Value
Q1 Q4 Q1 Q4
2007 150 (25.2) 187 (31.5) 156 (26.3) 137 (23.1) .053
2010 195 (26.7) 251 (35.1) 157 (21.9) 124 (17.1) .001
2013 244 (27.3) 349 (39.1) 199 (22.3) 133 (14.9) <.001
2016 307 (30.5) 431 (43.1) 201 (19.9) 106 (10.6) <.001

a Data from American Association of Colleges of Osteopathic Medicine annual surveys of graduates.

b Quartiles (Qs) ranged from 1 to 4, with Q1 having the least debt and Q4 having the most debt.

Abbreviation: COM, college of osteopathic medicine.

Table 1.
Comparison of COM Graduates Intending to Practice in Underserved Areas by Debt Quartilea,b
Year Underserved, No. (%) Nonunderserved, No. (%) P Value
Q1 Q4 Q1 Q4
2007 150 (25.2) 187 (31.5) 156 (26.3) 137 (23.1) .053
2010 195 (26.7) 251 (35.1) 157 (21.9) 124 (17.1) .001
2013 244 (27.3) 349 (39.1) 199 (22.3) 133 (14.9) <.001
2016 307 (30.5) 431 (43.1) 201 (19.9) 106 (10.6) <.001

a Data from American Association of Colleges of Osteopathic Medicine annual surveys of graduates.

b Quartiles (Qs) ranged from 1 to 4, with Q1 having the least debt and Q4 having the most debt.

Abbreviation: COM, college of osteopathic medicine.

×
2013 and 2016 graduates who intended to practice in underserved areas planned on participating in loan-repayment programs at a significantly higher percentage than did graduates who did not plan to practice in underserved areas (P<.001 for both survey years) (Table 2). 
Table 2.
Comparison of COM Graduates Intending to Use an LRP vs Not Use an LRP While Practicing in Underserved vs Nonunderserved Areasa
Year Underserved, No. (%) Nonunderserved, No. (%) P Value
LRP No LRP LRP No LRP
2013 778 (68.1) 364 (31.9) 190 (31.1) 422 (68.9) <.001
2016 957 (68.5) 440 (31.5) 215 (34.9) 401 (65.1) <.001

a Data from American Association of Colleges of Osteopathic Medicine annual surveys of graduates.

Abbreviations: COM, college of osteopathic medicine; LRP, loan-repayment program.

Table 2.
Comparison of COM Graduates Intending to Use an LRP vs Not Use an LRP While Practicing in Underserved vs Nonunderserved Areasa
Year Underserved, No. (%) Nonunderserved, No. (%) P Value
LRP No LRP LRP No LRP
2013 778 (68.1) 364 (31.9) 190 (31.1) 422 (68.9) <.001
2016 957 (68.5) 440 (31.5) 215 (34.9) 401 (65.1) <.001

a Data from American Association of Colleges of Osteopathic Medicine annual surveys of graduates.

Abbreviations: COM, college of osteopathic medicine; LRP, loan-repayment program.

×
Discussion
Our findings affirm that as modern health care continues to evolve and as national medical practice trends change, an increasing number of COM graduates will complete their degree with intentions to practice in underserved areas, especially among graduates with higher debt burdens. The 42.4% increase in new COMs in the past decade seems to not have slowed the percentage of COM graduates who intended to practice in underserved areas.1 In fact, during that period, the rate at which graduates expressed intent to practice in underserved areas was shown to increase. 
Although conventional wisdom suggests high debt burdens may drive new physicians away from practicing primary care in underserved areas,17 this presumption does not seem to be supported by the findings of the current study. The higher the debt incurred by respondents, the greater the intent to practice in underserved communities. Subgroup analysis of the intent to participate in loan-repayment programs revealed one possible explanation for this trend. Graduates who intended to practice in underserved areas planned to use loan-repayment programs at much higher rates than graduates who intended to practice in nonunderserved areas. This finding may be confounded by the fact that a large number of loan-repayment programs require underserved area location of practice. However, this strong association has not previously been documented, to our knowledge, and presents a topic for future study. 
Some research has detailed the effectiveness of loan-repayment programs in influencing practice patterns, but the evidence remains unclear.18 Graduates have stated that loan repayment is a strong factor that affects their job decision,3,19 although opinions are mixed regarding whether incentives direct those already planning on practicing in rural areas.20 The results of the current study indicate that graduates who intend to practice in underserved areas have both high debt and plan on participating in loan-repayment programs (most of which are directed toward underserved communities). 
One limitation of this analysis is that surveys did not evaluate how specialty choice relates to practice type, location, population, or debt. We recognize that specialty choice may be a substantial contributing factor in the decision to practice in underserved areas, and more research is needed on this topic. Specifically, there may be differences in the recruitment of primary care physicians compared with specialists to underserved areas. In addition, because of the complexities of the decision about practice area, little longitudinal research has been performed assessing the intentions of medical school graduates and how their intentions translate into long-term career choices. Another limitation is that we did not analyze whether students came from underserved areas. Colleges of osteopathic medicine are increasingly opening in and recruiting students from these areas. Could it be that respondents plan to practice in underserved areas because they want to stay in or return to those underserved areas they grew up in? We also acknowledge that survey data are retrospective and have response bias. 
Although determining the impact of COM graduates’ chosen practice or the causal factors behind employment decisions is beyond the scope of this study, the steady increase in medical education cost and loan burdens, combined with the many uncertainties in loan-repayment options or reimbursement for practice, exert continued pressure on medical school graduates’ long-term career decisions.21 A growing body of evidence suggests that the career paths of osteopathic medical graduates can be shaped by finances and incentives. 
The increasing use of programs currently in place to help reduce health care access inequality by attracting physicians to underserved areas seems to provide effective incentives with tens of thousands of dollars a year in student loan repayment. Further research is needed to determine how to optimally manage loan-repayment programs, but continued expansion of these programs and incentives may prove critical to placing newly graduated physicians in areas of greatest need. 
Conclusion
Given the association among the intention to practice in an underserved area, debt load, and plan to participate in a loan-repayment program, the osteopathic medical profession must continue to be aware of and involved in addressing the economic and social pressures on its new graduates to continue to fulfill its public health missions. Understanding how to provide quality health care in areas with critical needs provides an opportunity to attract strong public health–minded applicants to the osteopathic medical profession. 
Acknowledgment
We thank the Mayo Clinic in Scottsdale, Arizona, and AACOM for their support in data provision and analysis for this work. 
References
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American Association of Colleges of Osteopathic Medicine. Tuition and fees: 1st year students. https://www.aacom.org/docs/default-source/data-and-trends/tuition-amp-fees_2017-18_2008-09.pdf?sfvrsn=f2f52b97_6. Accessed April 25, 2018.
AACOM 2015-16 Academic Year Survey of Graduating Seniors Summary. Bethesda, MD: American Association of Colleges of Osteopathic Medicine; 2016. http://www.aacom.org/docs/default-source/data-and-trends/2015-16-graduating-seniors-summary.pdf?sfvrsn=10. Accessed April 16, 2018.
AACOM 2011-12 Academic Year Survey of Graduating Seniors Summary Report. Bethesda, MD: American Association of Colleges of Osteopathic Medicine; 2012. http://www.aacom.org/docs/default-source/archive-data-and-trends/2011-12-GSSSR.pdf?sfvrsn=12. Accessed April 16, 2018.
Association of American Medical Colleges. Medical School Graduation Questionnaire: 2016 All Schools Summary Report. Washington, DC: Association of American Medical Colleges; 2016. https://www.aamc.org/download/464412/data/2016gqallschoolssummaryreport.pdf. Accessed April 16, 2018.
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Rural Americans at higher risk of death from five leading causes [press release]. Atlanta, GA: Centers for Disease Control and Prevention; January 12, 2017. https://www.cdc.gov/media/releases/2017/p0112-rural-death-risk.html. Accessed April 16, 2018.
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Table 1.
Comparison of COM Graduates Intending to Practice in Underserved Areas by Debt Quartilea,b
Year Underserved, No. (%) Nonunderserved, No. (%) P Value
Q1 Q4 Q1 Q4
2007 150 (25.2) 187 (31.5) 156 (26.3) 137 (23.1) .053
2010 195 (26.7) 251 (35.1) 157 (21.9) 124 (17.1) .001
2013 244 (27.3) 349 (39.1) 199 (22.3) 133 (14.9) <.001
2016 307 (30.5) 431 (43.1) 201 (19.9) 106 (10.6) <.001

a Data from American Association of Colleges of Osteopathic Medicine annual surveys of graduates.

b Quartiles (Qs) ranged from 1 to 4, with Q1 having the least debt and Q4 having the most debt.

Abbreviation: COM, college of osteopathic medicine.

Table 1.
Comparison of COM Graduates Intending to Practice in Underserved Areas by Debt Quartilea,b
Year Underserved, No. (%) Nonunderserved, No. (%) P Value
Q1 Q4 Q1 Q4
2007 150 (25.2) 187 (31.5) 156 (26.3) 137 (23.1) .053
2010 195 (26.7) 251 (35.1) 157 (21.9) 124 (17.1) .001
2013 244 (27.3) 349 (39.1) 199 (22.3) 133 (14.9) <.001
2016 307 (30.5) 431 (43.1) 201 (19.9) 106 (10.6) <.001

a Data from American Association of Colleges of Osteopathic Medicine annual surveys of graduates.

b Quartiles (Qs) ranged from 1 to 4, with Q1 having the least debt and Q4 having the most debt.

Abbreviation: COM, college of osteopathic medicine.

×
Table 2.
Comparison of COM Graduates Intending to Use an LRP vs Not Use an LRP While Practicing in Underserved vs Nonunderserved Areasa
Year Underserved, No. (%) Nonunderserved, No. (%) P Value
LRP No LRP LRP No LRP
2013 778 (68.1) 364 (31.9) 190 (31.1) 422 (68.9) <.001
2016 957 (68.5) 440 (31.5) 215 (34.9) 401 (65.1) <.001

a Data from American Association of Colleges of Osteopathic Medicine annual surveys of graduates.

Abbreviations: COM, college of osteopathic medicine; LRP, loan-repayment program.

Table 2.
Comparison of COM Graduates Intending to Use an LRP vs Not Use an LRP While Practicing in Underserved vs Nonunderserved Areasa
Year Underserved, No. (%) Nonunderserved, No. (%) P Value
LRP No LRP LRP No LRP
2013 778 (68.1) 364 (31.9) 190 (31.1) 422 (68.9) <.001
2016 957 (68.5) 440 (31.5) 215 (34.9) 401 (65.1) <.001

a Data from American Association of Colleges of Osteopathic Medicine annual surveys of graduates.

Abbreviations: COM, college of osteopathic medicine; LRP, loan-repayment program.

×