Table 3

Articles investigating the effect on specialty choice

StudyYearSample sizeStudy designSignificant FindingsOxford level of evidence
USA studies associating debt with high paying specialties
Hafferty and Boulger5198696Cross-sectional surveyHigher debt led to specialist medical fields over generalist.4
Colquitt et al111996N/ACross-sectional (American Medical Colleges' (AAMC)
Medical Student Graduation Questionnaire (GQ)
and Matriculating Student Questionnaire (MSQ)))
High debt led to high paying specialties.4
Schwartz et al1220112421Longitudinal surveyGreater debt in 2007 compared with 1990 and students in 2007 were more likely to report that debt repayments pushed them away from primary care careers like internal medicine.3
Andriole et al3020081833Cross-sectional survey (AAMC)Lower debt led to high paying specialties.4
Azizzadeh et al312003111Cross-sectional surveyLower concern about debt led to high paying specialties.4
Bazzoli3219853855Cross-sectional surveyHigher subsidised debt led to primary care (PC) specialties (US$10 000 increase in debt increases PC by 5.3%).
Higher HEAL debt led to high paying specialties (US$10 000 increase decreased PC by 7.5%).
Curran et al33201527Cross-sectional surveyIn those not pursuing academic careers due to financial issues, the cited a need for adequate compensation due to debt.4
Grayson et al3720124916Longitudinal surveyHigh debt led to high paying specialties. Placed more value on anticipated higher income.3
Hauer et al3920081177Cross-sectional survey26.1% stated debt led to less attracted to internal medicine careers (generalist specialties).4
Andriole and Jeffe282010N/ALongitudinal survey (AAMC)Higher debt led to less generalist/primary care specialty choices, but not associated with family medicine specialty choices.3
Kassebaum and Szenas44199312 131Cross-sectional survey (AAMC)Debt had a greater influence in those choosing surgical and support specialties compared with generalist and medical specialties. There was also a higher number of students citing an influence in the 1993 graduate class compared with the 1992 class. However, interest in generalist specialties increased during this time compared with the other specialties.4
Kassebaum and Szenas4519948128Cross-sectional survey (AAMC)Limited influence but slightly higher for surgical (0.93) compared with generalist (0.54).4
Kassebaum and Szenas46199312 096Cross-sectional survey (AAMC)Under-represented minority students were more likely to have debt than white and other non-under-represented minorities (majority students). Minority cited debt as a strong or major influence more frequently, particularly in those wanting to pursue medical/surgical/support specialties compared with generalist certifications.4
Nguyen and Bounds67201974Cross-sectional surveyPhysicians who received full tuition and fee scholarships for college and medical school were surveyed for their specialty choice. Of the 74 respondents (54% response rate), only 18 went into primary care despite having no student debt.4
Park55199033 499Longitudinal survey (AAMC)Highest mean debt in those who chose emergency medicine and surgical subspecialties in 1986 and 1989.3
Phillips et al6420196229Cross-sectional surveyHigh debt (US$150 000–US$249 999) was associated with lower odds of intention to work for government organisations in family medicine residents. Those with high debt or very high debt (>US$250 000) had lower odds of intention to pursue academic practice or a geriatrics fellowship.4
Richards et al6620186594Longitudinal surveyThe proportion of students intending to practice in underserved areas from between 2007 and 2016 (27.5%–35.3% and those with more debt were more likely to practice in underserved areas. These students also intended on using loan-repayment programmes at a higher rate.3
Rosenblatt and Andrilla57200514 240Cross-sectional survey (AAMC)Increasing debt inversely correlated with choosing a PC specialty, greatest effect in debt exceeding US$150 000. However, only modest relationship after controlling for other characteristics. Factors like demographic (race, age, gender) has a more significant effect.4
Rosenthal et al591996326Longitudinal surveyHigher debt associated with not choosing family practice specialties.3
Scheckel et al65201913 097Longitudinal surveyGraduates who were above the 75th percentile of debt moved more towards non-primary care (NPC) positions, with an increase from 74.4% to 79.9% from 2007 to 2016. Over the same time period, there was greater interest in primary care positions in those below the 25th percentile of debt, increasing from 24.6% to 29.4%. Graduates with a loan forgiveness/repayment programme were more likely to choose primary care over graduates without such a programme.3
USA studies associating debt with low paying specialties
Phillips et al212010983Cross-sectional surveyThose with any level of debt were two-times as likely to choose PC compared with no debt, but those with no debt were less likely to be under-represented minorities and their families had higher incomes. Also, those from middle-income families were less likely to choose primary care as their debt levels increased.4
Rohlfing et al2220143032Cross-sectional surveyEach decrease in relative debt decreased salary of desired specialty by US$21 000, there was not a statistically significant relationship with an increase in relative debt.
An increase in premedical student loan debt by US$20 000 increased chance of choosing a PC specialty. Contrarily, a decrease in relative debt as measured by an increased proportion of estimated cost of attendance saved was also associated with choosing PC.
Bazzoli3219853855Cross-sectional surveyHigher subsidised debt led to primary care specialties (US$10 000 increase in debt increases PC by 5.3%).
Higher HEAL debt led to high paying specialties (US$10 000 increase decreased PC by 7.5%).
Greenberg et al382013239Cross-sectional surveyHigher debt led to academic medicine.4
Henderson et al401996144Longitudinal survey (preclerkship and postclerkship survey)High debt led to primary care specialties.3
Jeffe et al42200887 763Retrospective longitudinal (AAMC)Lower debt led to more likely to stay with academic medicine if considered initially. But does not increase chance of changing to academic medicine if did not initially consider it.3
Kassebaum and Szenas4419948128Cross-sectional surveyHigher debt led to more generalist/primary care specialty choices.
Increased citing debt as minor or moderate influence from 1992 to 1993 (23.6% → 28.5%) and strong/major (6.2% → 11.9%). However, increased interest in generalist specialties and decline in medical and support specialties. Declined interest in surgical specialties from public school graduates but increase from private school graduates.
McLaughlin et al631991983Longitudinal surveyMean debt rising correlated with effect on ‘choice of specialty’, but weak relationship. Ratings of effect of debt greater in lower pay specialties compared with higher paying.3
USA studies which found no or minimal association between debt and specialty choice
Diamond et al341994104Cross-sectional survey (conjoint analysis)Out of 6 factors asked for influencing specialty choice, loan repayment contributed 5% and debt 4% of variance in specialty choice. The other factors were more influential.4
Gil et al352016415Cross-sectional survey (12 centres)No significant influence.4
Kahn et al4320062022Retrospective longitudinal studyNo significant influence.3
Kassebaum et al4719967848Cross-sectional study (AAMC)No significant influence.3
Kassler et al481991293Cross-sectional survey (eight medical schools)No significant influence.4
Mutha et al52199752Cross-sectional study (group discussion)No significant influence.4
Paiva et al541982144Cross-sectional studyLevel of education debt did not have a significant influence on career choices: 1.7% rating it as very important compared with approximately 73% rating it as none.4
201629 227Cross-sectional study (AAMC 11–13)Educational debt was ranked as the least influential factor in choosing a specialty out of the factors listed.4
Rosenthal et al581994688Cross-sectional studyLittle difference in mean debt between those selecting PC and NPC. However, 10% of NPC students said they would change to PC if medical school loans were repaid.4
USA studies finding an association between debt and specialty choice but did not specify direction
Marci and Roberts181998400Longitudinal surveyAt debt <US$75 000 and influence on specialty choice not correlated.
At debt US$25 000–US$75 000 increasing debt correlated with increasing influence.
At debt >US$75 000 had more influence on specialty choice.
Mader et al492014500Longitudinal surveyInfluence on specialty choice for “amount of educational debt I have” rose in importance from the beginning of first year to third year, while interest in content declined.3
Phillips et al562016132Cross-sectional qualitative (essays)48% said debt limited career choice preferences.4
Teitelbaum et al6020092345Cross-sectional survey (21 colleges of osteopathic medicine and 2 branch campuses)As average debt increased, students were more likely to say it had an impact on specialty choice. However, 62.8% said debt had no impact.4
Studies outside the USA finding an association between debt and specialty choice
Kwong et al1720052994Cross-sectional surveyMore urban students reported that financial considerations around debt would be a major influence on specialty choice.
However, more rural students than urban students enter with debt and among those with debt have greater debt at both entry and completion of medical school.
Kwong et al2520022994Longitudinal surveyStudents reported debt being a major influence on choice of specialty and was higher in first- year students compared with fourth-year students.
More students in 2000 (28.5%) compared with 1997 (21.2%) stated financial considerations would be a major influence on chosen practice location.
Gill et al362012280Cross-sectional surveyMedical students with urban background: specialty choice influenced by current debt load.4
Morra et al512009560Cross-sectional surveyHigher debt→ higher paying specialty: 54%–64% of students agreed with the statement that “it is better to do a specialty as you will make more money and be able to pay off your debt faster”, with remainder agreeing that a student should “Do family medicine as the residency is shorter so you can start paying off your debt faster”.4
Vanasse et al6120111776Cross-sectional descriptive surveyIn the preclinical years, 30% of those intending to practise family medicine said doing a shorter residency is better to start paying off debt sooner while 28.8% of those intending to practise other specialties said it is better to do a specialty to make more money and pay off the debt. Similar results were found in the clinical years with 39.4% and 35.2%, respectively.4
New Zealand
Gill et al42001179Cross-sectional surveyIn sixth-year students, there was a slight trend those with higher debt to exclude GP from their top three preferences, however this was not statistically significant.
16% stated level of debt as a very important and strong influence on career choice.
Ling et al6820183121Cross-sectional surveyMedical and pharmacy students with higher debt were more likely to prefer rural practice. Medical students exhibited little influence of debt on career choice, and those with higher levels of debt were less concerned over career financial prospects. There was no correlation between debt level and interest in a primary care specialty.4
Perry and Wilkinson262010372Cross-sectional survey36% said debt influence specialty choice to at least a moderate amount or more; 13% said less debt would change specialty decision, location of work or doing locum work. Those with greater debt were more likely to say having less debt would affect their career choice.4
McHardy et al502008115Cross-sectional survey11% reported degree of debt would have a significant influence on their career choice.4
O’Grady and Fitzjohn532001407Cross-sectional surveyNo significant influence, association between debt and likelihood of practising overseas: 31.3% of students with debt >60 000 planning to mainly or only practise overseas, compared with 20.3% of those with debts <60 000.4
Fong, et al692018Cross-sectional survey40.5% of the 1241 students studied were to graduate with debt. Those with debt (unadjusted OR 1.623, 95% CI 1.261 to 2.090, p<0.001; adjusted OR 1.393, 95% CI 1.048 to 1.851, p=0.022) were more likely to have an economic factor very significantly influencing postgraduate training choices.4
  • HEAL, health education assistance loans; N/A, not available.