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      Effect of medical student debt on mental health, academic performance and specialty choice: a systematic review

      systematic-review

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          Abstract

          Objectives

          With the high and rising total cost of medical school, medical student debt is an increasing concern for medical students and graduates, with significant potential to impact the well-being of physicians and their patients. We hypothesised that medical student debt levels would be negatively correlated with mental health and academic performance, and would influence career direction (ie, medical specialty choice).

          Design

          We performed a systematic literature review to identify articles that assessed associations between medical student mental health, academic performance, specialty choice and debt. The databases PubMed, Medline, Embase, Scopus and PsycINFO were searched on 12 April 2017, for combinations of the medical subject headings Medical Student and Debt as search terms. Updates were incorporated on 24 April 2019.

          Results

          678 articles were identified, of which 52 met the inclusion criteria after being reviewed in full text. The majority of studies were conducted in the USA with some from Canada, New Zealand, Scotland and Australia. The most heavily researched aspect was the association between medical student debt and specialty choice, with the majority of studies finding that medical student debt was associated with pursuit of higher paying specialties. In addition, reported levels of financial stress were high among medical students, and correlated with debt. Finally, debt was also shown to be associated with poorer academic performance.

          Conclusions

          Medical student debt levels are negatively associated with mental well-being and academic outcomes, and high debt is likely to drive students towards choosing higher paying specialties. Additional prospective studies may be warranted, to better understand how educational debt loads are affecting the well-being, career preparation and career choices of physicians-in-training, which may in turn impact the quality of care provided to their current and future patients.

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          Most cited references63

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          Burnout and Alcohol Abuse/Dependence Among U.S. Medical Students.

          To explore the relationship between alcohol abuse/dependence with burnout and other forms of distress among a national cohort of medical students.
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            Factors associated with medical students' career choices regarding internal medicine.

            Shortfalls in the US physician workforce are anticipated as the population ages and medical students' interest in careers in internal medicine (IM) has declined (particularly general IM, the primary specialty serving older adults). The factors influencing current students' career choices regarding IM are unclear. To describe medical students' career decision making regarding IM and to identify modifiable factors related to this decision making. Web-based cross-sectional survey of 1177 fourth-year medical students (82% response rate) at 11 US medical schools in spring 2007. Demographics, debt, educational experiences, and number who chose or considered IM careers were measured. Factor analysis was performed to assess influences on career chosen. Logistic regression analysis was conducted to assess independent association of variables with IM career choice. Of 1177 respondents, 274 (23.2%) planned careers in IM, including 24 (2.0%) in general IM. Only 228 (19.4%) responded that their core IM clerkship made a career in general IM seem more attractive, whereas 574 (48.8%) responded that it made a career in subspecialty IM more attractive. Three factors influenced career choice regarding IM: educational experiences in IM, the nature of patient care in IM, and lifestyle. Students were more likely to pursue careers in IM if they were male (odds ratio [OR] 1.75; 95% confidence interval [CI], 1.20-2.56), were attending a private school (OR, 1.88; 95% CI, 1.26-2.83), were favorably impressed with their educational experience in IM (OR, 4.57; 95% CI, 3.01-6.93), reported favorable feelings about caring for IM patients (OR, 8.72; 95% CI, 6.03-12.62), or reported a favorable impression of internists' lifestyle (OR, 2.00; 95% CI, 1.39-2.87). Medical students valued the teaching during IM clerkships but expressed serious reservations about IM as a career. Students who reported more favorable impressions of the patients cared for by internists, the IM practice environment, and internists' lifestyle were more likely to pursue a career in IM.
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              Characteristics and career intentions of the emerging MD/PhD workforce.

              MD/PhD program participants represent only a small proportion of all US medical students, yet they are expected to play a major role in the future physician-scientist workforce. The characteristics and career intentions of recent MD/PhD program and other MD program graduates have not been compared. To identify factors associated with MD/PhD program graduation among recent medical graduates. Deidentified data were obtained from a nationally representative sample of 88,575 US medical graduates who completed the national Association of American Medical Colleges Graduation Questionnaire from 2000-2006. Multivariate logistic regression was used to test responses to items regarding graduates' characteristics and career plans in association with program graduation, reporting adjusted odds ratios (ORs). MD/PhD program graduation. Of the 79,104 respondents with complete data (71.7% of all 2000-2006 graduates), 1833 (2.3%) were MD/PhD program graduates. Variables associated with greater likelihood of MD/PhD program graduation included planned substantial career involvement in research (OR, 10.30; 95% confidence interval [CI], 8.89-11.93); lower educational debt (compared with > or = $150,000: $100,000-$149,999, OR, 1.85; 95% CI, 1.35-2.52; $50,000-$99,999, OR, 5.50; 95% CI, 4.14-7.29; $1-$49,999, OR, 17.50; 95% CI, 13.30-23.03; no debt, OR, 17.41; 95% CI, 13.22-22.92); and receipt of medical school scholarships or grants (OR, 3.22; 95% CI, 2.82-3.69). Compared with planned training in internal medicine, MD/PhD graduation was positively associated with planned training in dermatology, neurology, ophthalmology, pathology, pediatrics, or radiology. Variables associated with lower likelihood of MD/PhD graduation included female sex (OR, 0.68; 95% CI, 0.60-0.77); race/ethnicity underrepresented in medicine (OR, 0.64; 95% CI, 0.52-0.80); and, compared with internal medicine, planned training in emergency medicine (OR, 0.58; 95% CI, 0.40-0.84) or surgery (OR, 0.70; 95% CI, 0.57-0.85). Compared with graduates of other MD degree programs, MD/PhD graduates tend to be less demographically diverse, have a lower debt burden, favor different medical specialties, and have greater planned career involvement in research.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2019
                2 July 2019
                : 9
                : 7
                : e029980
                Affiliations
                [1 ] departmentSchool of Medicine , The University of Adelaide , Adelaide, South Australia, Australia
                [2 ] Royal Adelaide Hospital , Adelaide, South Australia, Australia
                [3 ] State University of New York Upstate Medical University , Syracuse, New York, USA
                [4 ] departmentDepartment of Psychiatry , State University of New York Upstate Medical University , Syracuse, New York, USA
                Author notes
                [Correspondence to ] Miss Monique Simone Pisaniello; monique.pisaniello@ 123456student.adelaide.edu.au
                Article
                bmjopen-2019-029980
                10.1136/bmjopen-2019-029980
                6609129
                31270123
                7dd8a6cf-1b47-4de1-a65c-a629b42c1345
                © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

                History
                : 22 February 2019
                : 30 April 2019
                : 30 May 2019
                Categories
                Mental Health
                Research
                1506
                1712
                Custom metadata
                unlocked

                Medicine
                medical student,debt,stress,mental health,academic performance,specialty choice,physician,well-being,vocation,loans,financial

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