Life vs Loans: Does Debt Affect Career Satisfaction in Osteopathic Graduates?

Methods

This study was deemed exempt by the Mayo Clinic institutional review board because no personally identifiable information was used. Data were obtained and analyzed with the permission of American Association of Colleges of Osteopathic Medicine (AACOM). Each year, AACOM invites all accredited colleges of osteopathic medicine to conduct a voluntary survey for graduating students. Similar to AAMC's Graduate Questionnaire,¹ this survey gathers information on demographics, specialty selection, anticipated practice decisions, indebtedness, and other various metrics of undergraduate medical education. Since its introduction, the AACOM survey has evolved to reflect changes in medical education, but questions regarding education and career satisfaction, as well as current level of indebtedness, have remained consistent.¹²

We examined responses to the following AACOM survey questions:

• 1. “Indicate the dollar amount borrowed to finance your osteopathic medical education.”

• 2. “Please rate your overall satisfaction with the quality of your medical education.”

• 3. “At this time, how satisfied are you that you selected osteopathic medicine as a career?”

• 4. “If given the opportunity to begin your medical education again, would you prefer to enroll in: the osteopathic medical school from which you are about to graduate, another osteopathic medical school, an allopathic medical school, or would not have gone to medical school at all?”

The surveys from 2007, 2010, 2013, and 2016 were chosen for the analysis.¹³ We evaluated national trends in perceived education quality, satisfaction in education quality and career selection, satisfaction with financial aid services, choice of same vs different education, and differences in high- vs low-debt respondents (as determined by lowest and highest quartiles of debt).

The software used for these analyses was SAS Studio (release 3.7, basic edition, SAS Institute Inc). We assessed the univariable associations between the amount of medical school debt and the above questions using the χ² test, Fisher exact test with Monte Carlo P value, and analysis of variance. We used a multivariable proportional odds ratio (OR) model with logistic regression to assess relationships of interest. P<.05 indicated statistical significance. Categorical data are expressed as number and percentage. Deidentified data and analyses were placed in a password-protected Excel (Microsoft Corporation) spreadsheet and stored on a secured institutional network.

Results

The number of survey responses ranged from 2403 in 2007 to 4191 in 2016, respectively, reflecting the increased matriculation rate at osteopathic medical schools nationwide. The response rates for the years studied ranged from 72% to 77%, respectively.

We observed consistent increases in the mean educational debt level at graduation (from $155,698 in 2007 to $240,331 in 2016, respectively). The percentage of respondents graduating without debt declined from 19.3% in 2007 to 6.7% in 2010, respectively, but then increased to 12.3% by 2016.

In 2007, the indebtedness quartile variable with debt had a significant effect on satisfaction with student education outcome (P=.0001; using logistic regression analysis). Students with debt in the upper quartile (>75th percentile) were less likely to be satisfied with the quality of their medical education compared with students with indebtedness in the middle debt quartile (25th percentile; P=.75; OR [range], 0.677 [0.528-0.868]). These results were significant in 2007, but not in the other years examined. Quartile variable with debt did not show significant effect on satisfaction with education in 2010, 2013, or 2016 (P=.08, .16, and .052, respectively).

In all years, there was no significant effect of debt quartile on satisfaction with choice of osteopathic medicine as a career in either the low- or high-debt quartiles (Table 2).

In contrast, indebtedness quartile was found to have a significant effect on satisfaction regarding financial aid administration services in all years (all years, P<.0001), with students with lower debt (P≤25) less likely to report a satisfaction rating of “good” in all years (OR, 0.293, 0.480, 0.446, and 0.373, respectively) than those with middle quartile debt (25th percentile, 75th percentile). High debt (>75th percentile) was not associated with consistent differences in satisfaction across years (Table 2).

In 2010 and 2016, students with no debt were more likely to report that if they could begin their education again, they would choose an allopathic medical school (P=.026 and .0379, respectively) with a mean OR (range) of 1.22 (0.904-1.651) in 2010 and an OR (range) of 1.313 (1.086-1.588) in 2016, respectively.

Discussion

Understanding satisfaction with medical training remains a complicated endeavor given the highly individualized and heterogeneous training experience that medical students undergo through classroom, practical, and clinical experiences. However, given the increasing levels of burnout in trainees¹¹ and a concerning projected shortage of physicians, comprehension of factors affecting medical education satisfaction is vital.¹⁴

Despite a consistent increase in median debt over the 10-year period covered in this study, no consistent relationship was found between debt and satisfaction with the choice of osteopathic medical education. One would think that respondents with higher debt burdens graduating after the financial crisis of 2007-2008 would consistently skew toward having a worse experience given interest rate increases and a less than desirable outlook for the economy. Instead, those with higher debt burdens showed no signs of buyer’s remorse. Debt does not appear to reliably affect satisfaction with quality of education. This finding would seem to point away from the cost of education being a deciding factor in trainees’ perceptions of their education.

Additionally, although there was an intuitive theory that larger amounts of debt burden would translate to decrease in satisfaction with financial aid offices, the exact opposite was found, with students with low debt being less likely to rate financial aid offices as “good.” A confounding variable that may have affected this finding is the greater contact that students with financial assistance or scholarships have with financial aid offices. This factor points to a possible different perspective and use of financial aid offices by students with different debt burdens.

In 2 separate years (2010 and 2016), students who had no debt said that they would have preferred to have gone to an allopathic medical school if they were repeating their education again. This is an unexpected finding that warrants further examination. Borrowing a large amount of money to finance education possibly skews an individual’s expectation and opinion of his or her training.¹⁵ Students who are required to incur larger amounts of educational debt seem to place a higher value on their education. Additionally, there are a significant number of social, racial, and socioeconomic factors that have been strongly correlated with student loan debt.¹⁶ Examining socioeconomic background and other factors that may independently contribute to educational satisfaction was beyond the scope of this analysis, but may be an avenue for further research.

Several limitations of this study, including a lack of socioeconomic, ethnic, and other background features, may hinder the ability to generalize these findings. However, to date, little research has been done on this topic and, despite an increase in legislative and medical school focus on educational debt, current students do not seem to be affected by it.

Conclusion

With the progressive rise in both trainee burnout and educational debt, the lack of clear association between student loans and educational satisfaction is a welcome finding. Further research is needed to examine trends in student satisfaction and to help provide support for future medical education policy as a looming physician shortage nears.

Author Contributions

Drs Richards, Scheckel, and Poole provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; Drs Richards, Scheckel, and Newman, and Ms Anderson drafted the article or revised it critically for important intellectual content; Drs Richards, Scheckel, Newman, and Poole, and Miss Anderson 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.