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JAOA/AACOM Medical Education  |   April 2019
Role of Debt and Loan Forgiveness/Repayment Programs in Osteopathic Medical Graduates’ Plans to Enter Primary Care
Author Notes
  • From the Departments of Internal Medicine (Dr Scheckel) and Biostatistics (Ms Mi) and the Division of Community Internal Medicine (Dr Poole) at Mayo Clinic in Scottsdale, Arizona; the Departments of Internal Medicine (Dr Richards) and Infectious Diseases (Dr Newman) at the University of Kansas Medical Center in Kansas City; the Arizona College of Osteopathic Medicine in Glendale (Student Doctor Kunz); and the Department of Internal Medicine at the University of Texas Southwestern in Dallas (Dr Fangman). Drs Scheckel and Richards contributed equally to the manuscript. 
  • Financial Disclosures: None reported. 
  • Support: This research was supported by internal funding from the Mayo Clinic. 
  •  *Address correspondence to Kenneth G. Poole Jr, MD, MBA, Division of Community Internal Medicine, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259-5452. Email: poole.kenneth@mayo.edu
     
Article Information
Medical Education
JAOA/AACOM Medical Education   |   April 2019
Role of Debt and Loan Forgiveness/Repayment Programs in Osteopathic Medical Graduates’ Plans to Enter Primary Care
The Journal of the American Osteopathic Association, April 2019, Vol. 119, 227-235. doi:10.7556/jaoa.2019.038
The Journal of the American Osteopathic Association, April 2019, Vol. 119, 227-235. doi:10.7556/jaoa.2019.038
Web of Science® Times Cited: 1
Abstract

Context: Osteopathic medicine emphasizes partnering with patients to help them attain or maintain health. This philosophy encourages physicians to practice primary care and a mission of improving community health. However, there is currently a shortage of primary care physicians in many areas of the United States.

Objective: To determine whether intended practice patterns of recent graduates of colleges of osteopathic medicine favor primary care and whether practice patterns correlate with medical education debt.

Methods: Responses were analyzed from the American Association of Colleges of Osteopathic Medicine survey of pending medical school graduates from 2007 through 2016 regarding indebtedness and specialty selection.

Results: The percentage of graduating osteopathic medical students who chose a primary care specialty increased from 28.1% (676 students) in 2007 to 33.2% (1377 students) in 2016. Among graduates, those above the 75th percentile of debt had a general move toward more non–primary care positions, with a value of 74.4% in 2007 and 79.9% in 2016. Graduates below the 25th percentile had a gradual increase in primary care representation, moving from 24.6% in 2007 to 29.4% in 2016. In 2007, graduates with a loan forgiveness/repayment program were more likely to choose primary care over graduates without such a program (OR, 0.681 [95% CI, 0.505-0.920]; P=.02). Analysis of subsequent years showed a declining OR with increasing significance.

Conclusions: Results of this analysis indicated that increased educational debt loan directly influenced physician practice choice. Graduates with high debt burden were more likely to enter primary care fields and use loan forgiveness/repayment programs. Graduates with high debt burden who did not use loan forgiveness/repayment programs were more likely to enter non–primary care specialty fields, with this trend increasing as mean medical school debt increased. This association has implications for policies that could affect choice of primary care. However, further research is needed to fully understand the primary care choice by graduates of colleges of osteopathic medicine.

The value of primary care cannot be overstated. Primary care physicians (PCPs) not only improve individual health outcomes but also provide checks and balances for the use of health care dollars.1-3 An increase of 1 PCP per 10,000 persons was shown to decrease emergency department visits, hospitalizations, and elective operations.4 Despite the added value of PCPs to individual health and the health care system, a shortage remains. According to the 2017 update by the Association of American Medical Colleges,5 the total US physician shortfall is estimated to be between 40,800 and 104,900 physicians by 2030, with projected shortfalls in primary care ranging between 7300 and 43,100 physicians. A primary driver of this shortfall is a growing increase in the number of older persons. Additionally, modeling suggests that even with limited achievement of the nation's Healthy People 2020 goals, increases in patient longevity will further intensify the demand for more physicians.5 
Despite current and projected shortfalls in primary care, the supply of specialty physicians consistently exceeded that of PCPs from 2002 through 2012, according to data from the National Ambulatory Medical Care Survey.6 In 2012, there were 46.1 PCPs and 65.5 specialists per 100,000 persons. Deficits in some areas have been offset by increased numbers of advanced practice registered nurses and physician assistants. This growth in nonphysician health care professionals is expected to continue. By 2030, for example, the ratio of physicians to advanced practice nurses is expected to have declined from a 2017 value of 4:1 to 2:1.5 Fewer physicians, however, raises the question of availability of adequate supervision of the nonphysician health care professionals and overall perpetuity as a solution. 
Meanwhile, medical education in the United States is changing. In osteopathic medicine, the number of medical schools is increasing, as are class sizes, which is affecting the nation's health care system. Today, 1 in 4 US medical students matriculates at a college of osteopathic medicine, and more than 6500 new osteopathic physicians graduate annually from a college of osteopathic medicine.7 Nearly 57% of current osteopathic physicians practice in primary care specialties, such as family medicine, internal medicine, and pediatrics, in contrast to 33% of their allopathic physicians peers.7 In their mission statements, many colleges of osteopathic medicine emphasize the importance of care for medically underserved populations and of primary care, and curriculums are designed to reflect these goals.8-13 
Understanding what motivates medical students to choose one specialty over another is important for addressing gaps in primary care. Various factors have been cited to account for the movement away from primary care among allopathic graduates, including a “controllable lifestyle,” access to ancillary services, prestige, prospective income, and rising educational debt.14,15 Educational debt, in particular, has been the subject of several studies, with results to date being mixed. One study16 found that students with greater debt burdens are more likely to pursue higher-paid specialties, while others17-20 have reported that debt was not a major influence in career decisions. Some authors21 have suggested varied effects of debt on specialty selection depending on underlying sociodemographics. 
Concerns about the impact of rising student debt and selection of a primary care specialty should resonate among osteopathic educators. The mean medical education debt for 2016 osteopathic graduates was $240,331, a 16.9% increase from 2011.22,23 In contrast, graduates from allopathic institutions in 2016 incurred a mean medical education debt of $180,000, which was an increase of 14% during the same time frame.24,25 
Given the increase in the number of osteopathic medicine graduates and their debt burden, coupled with projected primary care shortages, we aimed to examine whether specialty selection of recent osteopathic graduates is evolving because of escalating educational debt. To this end, we sought to answer the following questions: Have specialty selections of osteopathic graduates regarding primary vs non–primary care specialties changed from 2007 through 2016? Does the intended specialty selection change with the accrual of differing levels of indebtedness? 
Methods
The American Association of Colleges of Osteopathic Medicine (AACOM) annually administers a voluntary survey to all graduating students in all colleges of osteopathic medicine. This survey gathers information on graduate demographics, anticipated career path, debt, and other metrics. Questions about anticipated practice location, practice population, and current level of indebtedness have remained consistent over the years; however, questions regarding loan forgiveness or repayment, or both, changed substantially from 2007 through 2016 with the addition of new answer choices to the survey, such as Public Service Loan Forgiveness (PSLF) with federal education policy adoption. We obtained deidentified data, with the permission of AACOM, from 2007, 2010, 2013, and 2016 survey results. This time frame was chosen to specifically examine not only recent data but also how specialty selection has changed longitudinally. The year 2007 also marked the first year that medical trainees could enroll in PSLF, and we were interested in how this loan forgiveness/repayment program would affect decision-making. 
Responses to the following questions from 2007, 2010, 2013, and 2016 were analyzed: 
  • ■ Select 1 specialty in which you are most likely to work or seek training.
  • ■ Indicate the dollar amount you borrowed from each loan source to finance your undergraduate education, osteopathic medical education, or noneducational debt.
  • ■ Do you anticipate participating in a student loan consolidation program for repayment?
  • ■ Do you plan to enter a loan-forgiveness program?
To analyze the potential impact of indebtedness on the selection of a primary care specialty, respondent answers were divided into PCP or non-PCP specialty groups. As defined by AACOM, primary care comprises the disciplines of family medicine, general internal medicine, and general pediatrics.23 Our categorizations are consistent with this definition, with the addition of geriatric medicine because most geriatricians identify as PCPs.26 Student responses to anticipated practice type were divided into quartiles for the 4 years based on summation of undergraduate, graduate, and medical school indebtedness. Top and bottom quartiles were compared and contrasted. Those students who received loan forgiveness/repayment or tuition waivers as part of a service repayment program and graduated with a net indebtedness of $0 were included in the denominator of those with debt to capture the effect of these programs on behaviors. A separate analysis of specialty selection between individuals with top and bottom quartiles of indebtedness (excluding individuals who used a loan forgiveness/repayment program) was performed, the thought being that loan forgiveness/repayment acts as a normalizing external factor between debt extremes.27 
Statistical Analysis
We assessed the univariable associations between amount of medical school debt and the above questions using χ2 and Fisher exact tests with Monte Carlo P values and analysis of variance tests with standard statistical methods.28 We assessed relationships of interest using a multivariable proportional odds ratio model with logistic regression. P<.05 was used to indicate statistical significance. Categorical data are expressed as the number of respondents and percentage of the sample. SAS software, version 3.7 (SAS Institute Inc) was used for statistical analysis. The deidentified data and analysis were stored in a password-protected Excel (Microsoft Corporation) file on a secured network. 
Results
The number of respondents in 2007 was 2402; in 2010, 2892; in 2013, 3655; and in 2016, 4148. The total survey responses increased from 2007 to 2016 as the matriculating osteopathic class size increased nationwide. Although participation in the survey was optional, response rates were fairly consistent, with values between 72% and 77% from 2007 to 2016. 
Mean graduate indebtedness grew consistently over the evaluated period, with graduating seniors in 2007 reporting a mean indebtedness of $155,698 and $240,331 in 2007 and 2016, respectively. The percentage of graduates matriculating without debt was 19.3% in 2007, declined to 6.7% in 2010, and recovered to 12.3% by 2016. The overall distribution of student indebtedness for 2007, 2010, 2013, and 2016 in $50,000 increments is shown in the Figure. 
Figure.
Student loan indebtedness by year among graduates of colleges of osteopathic medicine according to the American Association of Colleges of Osteopathic Medicine's annual survey of graduates.
Figure.
Student loan indebtedness by year among graduates of colleges of osteopathic medicine according to the American Association of Colleges of Osteopathic Medicine's annual survey of graduates.
The number of osteopathic medical students anticipating careers in primary care and non–primary care specialties changed slightly. Selection of a primary care specialty increased from 676 (28.1%) in 2007 to 1377 (33.2%) in 2016. Conversely, the number of osteopathic graduates pursuing a non–primary care specialty decreased from 1726 (71.9%) in 2007 to 2771 (66.8%) in 2016. Among the primary care specialties, gradual growth was seen in family medicine, general internal medicine, and pediatrics. Selection of geriatrics was relatively flat (Table 1). The overall trend of increase in primary care selection and decrease in non–primary care selection for the time studied was significant (P<.001). 
Table 1.
Declared Specialty of Graduates of Colleges of Osteopathic Medicine by Yeara
Specialty 2007 (N=2402) 2010 (N=2892) 2013 (N=3655) 2016 (N=4148)
Primary Care 676 (28.1) 915 (31.6) 1178 (32.2) 1377 (33.2)
 Family practice 457 (19.0) 563 (19.5) 780 (21.3) 870 (21.0)
 General internal medicine 125 (5.2) 218 (7.5) 256 (7.0) 319 (7.7)
 General pediatrics 85 (3.5) 123 (4.3) 128 (3.5) 174 (4.2)
 Geriatrics 9 (0.4) 11 (0.4) 14 (0.4) 14 (0.3)
Non–Primary Care 1726 (71.9) 1977 (68.4) 2477 (67.8) 2771 (66.8)

a Data, given as No. (%), are from the American Association of Colleges of Osteopathic Medicine's annual survey of graduates. P<.001 for the overall trend of growth in primary care selection and drop in non–primary care selection.

Table 1.
Declared Specialty of Graduates of Colleges of Osteopathic Medicine by Yeara
Specialty 2007 (N=2402) 2010 (N=2892) 2013 (N=3655) 2016 (N=4148)
Primary Care 676 (28.1) 915 (31.6) 1178 (32.2) 1377 (33.2)
 Family practice 457 (19.0) 563 (19.5) 780 (21.3) 870 (21.0)
 General internal medicine 125 (5.2) 218 (7.5) 256 (7.0) 319 (7.7)
 General pediatrics 85 (3.5) 123 (4.3) 128 (3.5) 174 (4.2)
 Geriatrics 9 (0.4) 11 (0.4) 14 (0.4) 14 (0.3)
Non–Primary Care 1726 (71.9) 1977 (68.4) 2477 (67.8) 2771 (66.8)

a Data, given as No. (%), are from the American Association of Colleges of Osteopathic Medicine's annual survey of graduates. P<.001 for the overall trend of growth in primary care selection and drop in non–primary care selection.

×
The use of various loan or service forgiveness programs differed from 2007 through 2016. Of the years we examined, 2013 was the first for which PSLF was listed as an answer choice for respondents. For the purposes of our study, program use for each year was recorded only for the top and bottom quartile of indebtedness. These expanded results are shown in Table 2. For 2013 and 2016, the number of students participating in a loan forgiveness/repayment program differed significantly between the highest and lowest quartiles of debt (2013: Q<P [percentile] 25, 27.9%; Q>P75, 68.8%; P<.001) (2016: Q<P25, 25.7%; Q>P75, 73.1%; P<.001). 
Table 2.
Graduates of Colleges of Osteopathic Medicine Use of Loan Forgiveness/Repayment Programs by Level of Indebtednessa
Primary Care Loan Scholarship/Grant/Fellowship Armed Forces Osteopathic Association Scholar Public Service Loan Forgivenessb
Year Q<P25 Q>P75 Q<P25 Q>P75 Q<P25 Q>P75 Q<P25 Q>P75 Q<P25 Q>P75 Total With Debt
2007 0 (0.0) 25 (1.0) 11 (0.5) 2 (0.1) 178 (7.4) 3 (0.1) 15 (0.6) 21 (0.9) 2395
2010 1 (0.03) 14 (0.5) 9 (0.3) 0 (0.0) 163 (5.7) 5 (0.2) 24 (0.8) 8 (0.3) 2869
2013 6 (0.2) 13 (0.4) 8 (0.2) 3 (0.1) 172 (4.8) 2 (0.1) 15 (0.4) 26 (0.7) 95 (2.6) 342 (9.5) 3602
2016 2 (0.1) 16 (0.4) 10 (0.3) 2 (0.1) 120 (3.0) 1 (0.02) 16 (0.4) 21 (0.5) 119 (3.0) 474 (11.8) 4029

a Data, given as No. (%), are from the American Association of Colleges of Osteopathic Medicine's annual survey of graduates. Percentages are a proportion of all students with debt.

b Data for use of public service loan forgiveness/repayment was available only for 2013 and 2016.

Abbreviations: P, percentile; Q, quartile.

Table 2.
Graduates of Colleges of Osteopathic Medicine Use of Loan Forgiveness/Repayment Programs by Level of Indebtednessa
Primary Care Loan Scholarship/Grant/Fellowship Armed Forces Osteopathic Association Scholar Public Service Loan Forgivenessb
Year Q<P25 Q>P75 Q<P25 Q>P75 Q<P25 Q>P75 Q<P25 Q>P75 Q<P25 Q>P75 Total With Debt
2007 0 (0.0) 25 (1.0) 11 (0.5) 2 (0.1) 178 (7.4) 3 (0.1) 15 (0.6) 21 (0.9) 2395
2010 1 (0.03) 14 (0.5) 9 (0.3) 0 (0.0) 163 (5.7) 5 (0.2) 24 (0.8) 8 (0.3) 2869
2013 6 (0.2) 13 (0.4) 8 (0.2) 3 (0.1) 172 (4.8) 2 (0.1) 15 (0.4) 26 (0.7) 95 (2.6) 342 (9.5) 3602
2016 2 (0.1) 16 (0.4) 10 (0.3) 2 (0.1) 120 (3.0) 1 (0.02) 16 (0.4) 21 (0.5) 119 (3.0) 474 (11.8) 4029

a Data, given as No. (%), are from the American Association of Colleges of Osteopathic Medicine's annual survey of graduates. Percentages are a proportion of all students with debt.

b Data for use of public service loan forgiveness/repayment was available only for 2013 and 2016.

Abbreviations: P, percentile; Q, quartile.

×
Primary care and non–primary care respondents were further organized by quartiles of indebtedness (Table 3). The upper half of the table shows respondents regardless of loan forgiveness/repayment plan use. In the group with indebtedness above the 75th percentile, a gradual change was observed in specialty representation, with primary care moving from 28.0% in 2007 to 34.7% in 2016. For those in the bottom quartile of debt, representation by primary care grew from a 2007 value of 25.7% to a peak of 31.0% in 2013. The value has since plateaued. The difference in specialty selection between top and bottom quartiles of debt was not statistically significant for any of the 4 years examined. 
Table 3.
Effect of Loan Forgiveness/Repayment Programs on Choice of Primary vs Non–Primary Care for College of Osteopathic Medicine Graduates With Debta,b
Primary Care, No. (%) Non–primary Care, No. (%)
Year Q<P25 Q>P75 Q<P25 Q>P75 Total With Debt P Value
With Debt
 2007 154 (25.7) 167 (28.0) 445 (74.2) 429 (72.0) 2395 .37
 2010 218 (30.1) 217 (30.3) 507 (69.9) 499 (69.7) 2869 .92
 2013 279 (31.0) 294 (32.6) 621 (69.0) 607 (67.4) 3602 .46
 2016 313 (30.7) 349 (34.7) 706 (69.3) 658 (65.3) 4029 .058
With Loan Forgiveness/Repayment Exclusion
 2007 97 (24.6) 140 (25.6) 298 (75.4) 406 (74.4) 2026 .70
 2010 150 (28.3) 201 (29.1) 380 (71.7) 489 (70.9) 2534 .75
 2013 135 (28.1) 63 (22.8) 345 (71.9) 213 (77.2) 1532 .11
 2016 189 (29.4) 53 (20.2) 454 (70.6) 210 (79.9) 1696 .004

a Data are from the American Association of Colleges of Osteopathic Medicine annual survey of graduates.

b Percentages are based on those in their quartile.

Abbreviations: P, percentile; Q, quartile.

Table 3.
Effect of Loan Forgiveness/Repayment Programs on Choice of Primary vs Non–Primary Care for College of Osteopathic Medicine Graduates With Debta,b
Primary Care, No. (%) Non–primary Care, No. (%)
Year Q<P25 Q>P75 Q<P25 Q>P75 Total With Debt P Value
With Debt
 2007 154 (25.7) 167 (28.0) 445 (74.2) 429 (72.0) 2395 .37
 2010 218 (30.1) 217 (30.3) 507 (69.9) 499 (69.7) 2869 .92
 2013 279 (31.0) 294 (32.6) 621 (69.0) 607 (67.4) 3602 .46
 2016 313 (30.7) 349 (34.7) 706 (69.3) 658 (65.3) 4029 .058
With Loan Forgiveness/Repayment Exclusion
 2007 97 (24.6) 140 (25.6) 298 (75.4) 406 (74.4) 2026 .70
 2010 150 (28.3) 201 (29.1) 380 (71.7) 489 (70.9) 2534 .75
 2013 135 (28.1) 63 (22.8) 345 (71.9) 213 (77.2) 1532 .11
 2016 189 (29.4) 53 (20.2) 454 (70.6) 210 (79.9) 1696 .004

a Data are from the American Association of Colleges of Osteopathic Medicine annual survey of graduates.

b Percentages are based on those in their quartile.

Abbreviations: P, percentile; Q, quartile.

×
Responses were reevaluated after removing graduates who participated in a loan forgiveness/repayment program. Among graduates above the 75th percentile of debt, a general move toward more non–primary care positions was observed, with a value of 74.4% in 2007 and 79.9% in 2016. Graduates below the 25th percentile had a gradual increase in primary care representation, increasing from 24.6% in 2007 to 29.4% in 2016. These differences achieved statistical significance in 2016 only (P=.004) (Table 3). 
Logistic regression consistently showed that graduates with a loan forgiveness/repayment program were more likely to choose primary care over graduates without such a program when data for all respondents with debt were analyzed for primary care vs non–primary care selection, with and without loan forgiveness/repayment. For example, in 2007, the odds ratio for selecting a non–primary care specialty among those enrolled in a loan forgiveness/repayment program was 0.681 (95% CI, 0.505-0.920; P=.02). Analysis of subsequent years showed a declining OR with increasing significance (Table 4). 
Table 4.
Odds Ratio Analysis for Specialty Selection by Graduates of Colleges of Osteopathic Medicine With and Without Loan Forgivenessa
Repaid, No. (%)
Year Specialty Yes No Total Odds Ratio (95% CI) P Value
2007 Non–primary care 170 (67) 704 (75) 874 0.681 (0.505-0.920) .01
Primary care 84 (33) 237 (25) 321
Total 254 941 1195
2010 Non–primary care 137 (62) 869 (71) 1006 0.659 (0.489-0.888) .006
Primary care 84 (38) 351 (29) 435
Total 221 1220 1441
2013 Non–primary care 670 (64) 558 (74) 1228 0.634 (0.516-0.779) <.001
Primary care 375 (36) 198 (26) 573
Total 1045 756 1801
2016 Non–primary care 700 (63) 664 (73) 1364 0.607 (0.502-0.735) <.001
Primary care 420 (38) 242 (27) 662
Total 1120 906 2026

a Data are from the American Association of Colleges of Osteopathic Medicine annual survey of graduates.

Table 4.
Odds Ratio Analysis for Specialty Selection by Graduates of Colleges of Osteopathic Medicine With and Without Loan Forgivenessa
Repaid, No. (%)
Year Specialty Yes No Total Odds Ratio (95% CI) P Value
2007 Non–primary care 170 (67) 704 (75) 874 0.681 (0.505-0.920) .01
Primary care 84 (33) 237 (25) 321
Total 254 941 1195
2010 Non–primary care 137 (62) 869 (71) 1006 0.659 (0.489-0.888) .006
Primary care 84 (38) 351 (29) 435
Total 221 1220 1441
2013 Non–primary care 670 (64) 558 (74) 1228 0.634 (0.516-0.779) <.001
Primary care 375 (36) 198 (26) 573
Total 1045 756 1801
2016 Non–primary care 700 (63) 664 (73) 1364 0.607 (0.502-0.735) <.001
Primary care 420 (38) 242 (27) 662
Total 1120 906 2026

a Data are from the American Association of Colleges of Osteopathic Medicine annual survey of graduates.

×
Discussion
With the current shortage of PCPs in the United States, we believe it is important to understand the factors that influence osteopathic medical graduates’ preferences for primary care. A previous study29 analyzed the economic feasibility of primary care careers; however, the effect of educational debt and loan forgiveness/repayment use on choice of primary care remains poorly understood. Our results showed that during a 10-year period (2007-2016), graduates of colleges of osteopathic medicine have increasingly anticipated practicing in primary care. These results affirm a reversal of the previous downward trend for primary care as a specialty choice by osteopathic graduates, which was lowest around 2007, and show that the osteopathic medical profession is successfully increasing the numbers of osteopathic PCPs. However, further research is needed to determine what other factors may be influencing this increase, such as specialty tracks for greater exposure, securing primary care clinical mentors, and requiring students to spend time training in primary care or underserved areas. 
In 2016, there appeared to be a paradoxical association of increased choice of primary care by graduates with large loans. However, subgroup analyses showed a significant difference in use of loan forgiveness/repayment programs for graduates at different debt levels. Intuition suggests that debt burden may drive new physicians away from primary care in lieu of higher-reimbursing subspecialties. However, a previous study designed to answer this question produced mixed data, with no clear answer.30 
As debt increased for osteopathic medical graduates, so did anticipation of using loan forgiveness/repayment programs, such as the PSLF program or the National Health Service Corps. These programs offer various loan forgiveness/repayment options in exchange for a graduate's working in public service organizations—at nonprofit entities for the PSLF program and in medically underserved areas for the National Health Service Corps. In addition to using federal programs, graduates also stated increased intent to use employers’ loan forgiveness/repayment programs. 
The significant reversal of graduates from being more likely to less likely to choose primary care after loan forgiveness/repayment program effects were removed from analysis showed that incentives to enter primary care can substantially help shape graduates’ choices. The inverse relationship between increased debt and primary care choice corresponds to data from a similar study21 and is concerning given projected shortages in primary care medicine. As costs of and debt from medical education continue to grow, primary care will become a less economically attractive specialty choice. 
Some articles32 have discussed the effectiveness of loan forgiveness/repayment programs, but whether such programs directly affect specialty choice was previously unclear. However, the findings of the current study indicate that increased use of loan forgiveness/repayment programs is associated with increased debt and primary care specialization choice. Many programs, such as state loan incentives and the National Health Service Corps, are available only for primary care fields, and more research is needed to fully understand the relationship between loan forgiveness/repayment options and specialty choice for osteopathic medical graduates. 
This study has several limitations. The survey questions asked about intended practice plans, which may not reflect actual residency choice or practice pursued after residency. However, most surveys are administered near the end of year 4 and after Match Day, so responses should be largely congruent with final specialty destination. The survey is retrospective, and detailed loan forgiveness/repayment program data were available only for 2013 and 2016. In addition, despite a high response rate of approximately 75%, the survey is vulnerable to inherent response bias. Furthermore, while loan forgiveness/repayment in the context of debt was examined, we did not analyze intent to use loan forgiveness/repayment programs by specialty, which may have shown other differences. Finally, although a previous study has shown that demographics influence practice type, no demographic information was included in our analyses.33 Childhood socioeconomic status, race, sex, marital status, and even Medical College Admission Test scores are variables that could certainly influence both physician specialty selection and use of loan forgiveness/repayment programs. 
Because of the multifactorial nature of physicians’ career planning, we cannot make conclusive predictions based on this study, even with multivariate data analysis. Further studies that assess specialty choice of physicians in residency and longitudinal matching of respondents with records of practice patterns would offer a method for determining whether intended plans matched actual career choices. 
Making causal determinations is beyond the scope of this study. However, our data showed an association between high loan debt and decisions not to enter primary care and an association between use of loan forgiveness/repayment programs and a decision to enter primary care. These results and results of ongoing studies can be used to help address the projected shortage in PCPs. This research also helps answer the question “What effects do loan forgiveness/repayment programs have on graduate practice patterns?”31,34 Research to this point has shown that financial incentives can have some effect on physician practice patterns,35 but more research is needed to understand the complex nature of these relationships. Additionally, little research has been done regarding the effectiveness of loan forgiveness/repayment programs on specialty choice. As medical school graduate debt increases and economic pressures mount,36 loan forgiveness/repayment programs may be an incentive to keep primary care attractive to graduates. 
Conclusion
The current study showed that higher educational debt directly influenced physician practice choice. Graduates with high debt burden were more likely to enter primary care fields and participate in loan forgiveness/repayment programs. Graduates with high debt burden who did not participate in loan forgiveness/repayment programs were more likely to enter non–primary care specialty fields, with this trend growing as mean medical school debt increased. We believe that the medical education community should continue to explore economic stressors that affect new graduates and the effects that loan forgiveness/repayment programs have on specialty choice, as well as advocate for national programs that support new graduates, such as continued income-based loan repayment, continuation of PSLF, and expansion of the National Health Service Corps. Understanding how to promote practice in primary care is fundamental to addressing the changing demographics of the US population. 
Author Contributions
All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; all authors drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. 
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Figure.
Student loan indebtedness by year among graduates of colleges of osteopathic medicine according to the American Association of Colleges of Osteopathic Medicine's annual survey of graduates.
Figure.
Student loan indebtedness by year among graduates of colleges of osteopathic medicine according to the American Association of Colleges of Osteopathic Medicine's annual survey of graduates.
Table 1.
Declared Specialty of Graduates of Colleges of Osteopathic Medicine by Yeara
Specialty 2007 (N=2402) 2010 (N=2892) 2013 (N=3655) 2016 (N=4148)
Primary Care 676 (28.1) 915 (31.6) 1178 (32.2) 1377 (33.2)
 Family practice 457 (19.0) 563 (19.5) 780 (21.3) 870 (21.0)
 General internal medicine 125 (5.2) 218 (7.5) 256 (7.0) 319 (7.7)
 General pediatrics 85 (3.5) 123 (4.3) 128 (3.5) 174 (4.2)
 Geriatrics 9 (0.4) 11 (0.4) 14 (0.4) 14 (0.3)
Non–Primary Care 1726 (71.9) 1977 (68.4) 2477 (67.8) 2771 (66.8)

a Data, given as No. (%), are from the American Association of Colleges of Osteopathic Medicine's annual survey of graduates. P<.001 for the overall trend of growth in primary care selection and drop in non–primary care selection.

Table 1.
Declared Specialty of Graduates of Colleges of Osteopathic Medicine by Yeara
Specialty 2007 (N=2402) 2010 (N=2892) 2013 (N=3655) 2016 (N=4148)
Primary Care 676 (28.1) 915 (31.6) 1178 (32.2) 1377 (33.2)
 Family practice 457 (19.0) 563 (19.5) 780 (21.3) 870 (21.0)
 General internal medicine 125 (5.2) 218 (7.5) 256 (7.0) 319 (7.7)
 General pediatrics 85 (3.5) 123 (4.3) 128 (3.5) 174 (4.2)
 Geriatrics 9 (0.4) 11 (0.4) 14 (0.4) 14 (0.3)
Non–Primary Care 1726 (71.9) 1977 (68.4) 2477 (67.8) 2771 (66.8)

a Data, given as No. (%), are from the American Association of Colleges of Osteopathic Medicine's annual survey of graduates. P<.001 for the overall trend of growth in primary care selection and drop in non–primary care selection.

×
Table 2.
Graduates of Colleges of Osteopathic Medicine Use of Loan Forgiveness/Repayment Programs by Level of Indebtednessa
Primary Care Loan Scholarship/Grant/Fellowship Armed Forces Osteopathic Association Scholar Public Service Loan Forgivenessb
Year Q<P25 Q>P75 Q<P25 Q>P75 Q<P25 Q>P75 Q<P25 Q>P75 Q<P25 Q>P75 Total With Debt
2007 0 (0.0) 25 (1.0) 11 (0.5) 2 (0.1) 178 (7.4) 3 (0.1) 15 (0.6) 21 (0.9) 2395
2010 1 (0.03) 14 (0.5) 9 (0.3) 0 (0.0) 163 (5.7) 5 (0.2) 24 (0.8) 8 (0.3) 2869
2013 6 (0.2) 13 (0.4) 8 (0.2) 3 (0.1) 172 (4.8) 2 (0.1) 15 (0.4) 26 (0.7) 95 (2.6) 342 (9.5) 3602
2016 2 (0.1) 16 (0.4) 10 (0.3) 2 (0.1) 120 (3.0) 1 (0.02) 16 (0.4) 21 (0.5) 119 (3.0) 474 (11.8) 4029

a Data, given as No. (%), are from the American Association of Colleges of Osteopathic Medicine's annual survey of graduates. Percentages are a proportion of all students with debt.

b Data for use of public service loan forgiveness/repayment was available only for 2013 and 2016.

Abbreviations: P, percentile; Q, quartile.

Table 2.
Graduates of Colleges of Osteopathic Medicine Use of Loan Forgiveness/Repayment Programs by Level of Indebtednessa
Primary Care Loan Scholarship/Grant/Fellowship Armed Forces Osteopathic Association Scholar Public Service Loan Forgivenessb
Year Q<P25 Q>P75 Q<P25 Q>P75 Q<P25 Q>P75 Q<P25 Q>P75 Q<P25 Q>P75 Total With Debt
2007 0 (0.0) 25 (1.0) 11 (0.5) 2 (0.1) 178 (7.4) 3 (0.1) 15 (0.6) 21 (0.9) 2395
2010 1 (0.03) 14 (0.5) 9 (0.3) 0 (0.0) 163 (5.7) 5 (0.2) 24 (0.8) 8 (0.3) 2869
2013 6 (0.2) 13 (0.4) 8 (0.2) 3 (0.1) 172 (4.8) 2 (0.1) 15 (0.4) 26 (0.7) 95 (2.6) 342 (9.5) 3602
2016 2 (0.1) 16 (0.4) 10 (0.3) 2 (0.1) 120 (3.0) 1 (0.02) 16 (0.4) 21 (0.5) 119 (3.0) 474 (11.8) 4029

a Data, given as No. (%), are from the American Association of Colleges of Osteopathic Medicine's annual survey of graduates. Percentages are a proportion of all students with debt.

b Data for use of public service loan forgiveness/repayment was available only for 2013 and 2016.

Abbreviations: P, percentile; Q, quartile.

×
Table 3.
Effect of Loan Forgiveness/Repayment Programs on Choice of Primary vs Non–Primary Care for College of Osteopathic Medicine Graduates With Debta,b
Primary Care, No. (%) Non–primary Care, No. (%)
Year Q<P25 Q>P75 Q<P25 Q>P75 Total With Debt P Value
With Debt
 2007 154 (25.7) 167 (28.0) 445 (74.2) 429 (72.0) 2395 .37
 2010 218 (30.1) 217 (30.3) 507 (69.9) 499 (69.7) 2869 .92
 2013 279 (31.0) 294 (32.6) 621 (69.0) 607 (67.4) 3602 .46
 2016 313 (30.7) 349 (34.7) 706 (69.3) 658 (65.3) 4029 .058
With Loan Forgiveness/Repayment Exclusion
 2007 97 (24.6) 140 (25.6) 298 (75.4) 406 (74.4) 2026 .70
 2010 150 (28.3) 201 (29.1) 380 (71.7) 489 (70.9) 2534 .75
 2013 135 (28.1) 63 (22.8) 345 (71.9) 213 (77.2) 1532 .11
 2016 189 (29.4) 53 (20.2) 454 (70.6) 210 (79.9) 1696 .004

a Data are from the American Association of Colleges of Osteopathic Medicine annual survey of graduates.

b Percentages are based on those in their quartile.

Abbreviations: P, percentile; Q, quartile.

Table 3.
Effect of Loan Forgiveness/Repayment Programs on Choice of Primary vs Non–Primary Care for College of Osteopathic Medicine Graduates With Debta,b
Primary Care, No. (%) Non–primary Care, No. (%)
Year Q<P25 Q>P75 Q<P25 Q>P75 Total With Debt P Value
With Debt
 2007 154 (25.7) 167 (28.0) 445 (74.2) 429 (72.0) 2395 .37
 2010 218 (30.1) 217 (30.3) 507 (69.9) 499 (69.7) 2869 .92
 2013 279 (31.0) 294 (32.6) 621 (69.0) 607 (67.4) 3602 .46
 2016 313 (30.7) 349 (34.7) 706 (69.3) 658 (65.3) 4029 .058
With Loan Forgiveness/Repayment Exclusion
 2007 97 (24.6) 140 (25.6) 298 (75.4) 406 (74.4) 2026 .70
 2010 150 (28.3) 201 (29.1) 380 (71.7) 489 (70.9) 2534 .75
 2013 135 (28.1) 63 (22.8) 345 (71.9) 213 (77.2) 1532 .11
 2016 189 (29.4) 53 (20.2) 454 (70.6) 210 (79.9) 1696 .004

a Data are from the American Association of Colleges of Osteopathic Medicine annual survey of graduates.

b Percentages are based on those in their quartile.

Abbreviations: P, percentile; Q, quartile.

×
Table 4.
Odds Ratio Analysis for Specialty Selection by Graduates of Colleges of Osteopathic Medicine With and Without Loan Forgivenessa
Repaid, No. (%)
Year Specialty Yes No Total Odds Ratio (95% CI) P Value
2007 Non–primary care 170 (67) 704 (75) 874 0.681 (0.505-0.920) .01
Primary care 84 (33) 237 (25) 321
Total 254 941 1195
2010 Non–primary care 137 (62) 869 (71) 1006 0.659 (0.489-0.888) .006
Primary care 84 (38) 351 (29) 435
Total 221 1220 1441
2013 Non–primary care 670 (64) 558 (74) 1228 0.634 (0.516-0.779) <.001
Primary care 375 (36) 198 (26) 573
Total 1045 756 1801
2016 Non–primary care 700 (63) 664 (73) 1364 0.607 (0.502-0.735) <.001
Primary care 420 (38) 242 (27) 662
Total 1120 906 2026

a Data are from the American Association of Colleges of Osteopathic Medicine annual survey of graduates.

Table 4.
Odds Ratio Analysis for Specialty Selection by Graduates of Colleges of Osteopathic Medicine With and Without Loan Forgivenessa
Repaid, No. (%)
Year Specialty Yes No Total Odds Ratio (95% CI) P Value
2007 Non–primary care 170 (67) 704 (75) 874 0.681 (0.505-0.920) .01
Primary care 84 (33) 237 (25) 321
Total 254 941 1195
2010 Non–primary care 137 (62) 869 (71) 1006 0.659 (0.489-0.888) .006
Primary care 84 (38) 351 (29) 435
Total 221 1220 1441
2013 Non–primary care 670 (64) 558 (74) 1228 0.634 (0.516-0.779) <.001
Primary care 375 (36) 198 (26) 573
Total 1045 756 1801
2016 Non–primary care 700 (63) 664 (73) 1364 0.607 (0.502-0.735) <.001
Primary care 420 (38) 242 (27) 662
Total 1120 906 2026

a Data are from the American Association of Colleges of Osteopathic Medicine annual survey of graduates.

×