Medical Student Conundrum: Loan Repayment or Public Service? Lessons from the Judgment of Paris

By Paul Katz, MD

According to Greek mythology, the god Zeus called upon a young shepherd named Paris to make a determination of which goddess was the most beautiful: Hera, Athena, or Aphrodite. Each of the goddesses tempted Paris with a special gift if he selected them. Hera offered strength as a ruler; Athena proposed wisdom and might in battle; and Aphrodite promised the love of the most beautiful mortal woman in the world, Helen.

Paris succumbed to Aphrodite’s proposition and selected her as the most stunning of the goddesses. His selection came to be known as the “judgment of Paris.” Paris subsequently ran away with the already married Helen, who happened to be from Troy, and the resulting war was, as they say, history — or at least mythology.

A similar difficult choice faces many of today’s medical students. Much has been written about student debt; it is unlikely that any reader needs a refresher. Despite the smaller amount of debt accumulated by the Class of 2011, the mean of $160,000-plus in accrued financial commitment of graduates with medical school debt is staggering. Much has also been published about the impact of this obligation on specialty and career selection; published studies show no cause-and-effect consensus and, undoubtedly, other variables contribute to this choice. Nonetheless, we should not discount the potential influence of debt on ultimate career choices.

While a significant component of the conversation about the worsening physician shortage has focused on primary care, workforce gaps exist across most specialties, with particular challenges in those urban and rural communities with uninsured or underinsured populations. While these populations have significant primary care needs, they also obviously need access to orthopedists, ophthalmologists, and dermatologists.

I will take the liberty of assuming that the provision of care to the underserved is and will be frequently delivered by providers outside of the “typical” private practice environment where patients usually have commercial or governmental insurance. I also submit that care provided in the “public” service environment (city hospitals, county clinics, academic medical centers, and so forth), where many of the underserved access the medical community, generally provides lower compensation to physicians than the “private” arena.

Choosing a medical career that offers health care to those least able to pay will likely result in a lower salary regardless of whether or not the physician is a family physician or a cardiothoracic surgeon. Therefore, specialty selection, as well as practice venue, may both be influenced by medical school debt.

How can we provide other options to students that will help mitigate the “either/or” scenario? What factors might alter students’ selection of a higher paying career path or a more lucrative practice location? Pathways exist, although none has been singularly successful in changing these trends.

Public service obligations in return for tuition remission and loan forgiveness programs have some traction, obviously, but seemingly not enough to resolve our national dilemma; physician recipients frequently leave for richer pastures once the obligation has been fulfilled. Further, the issues surrounding reimbursement “inequities” are well known and unlikely to resolve any time soon; even so, such changes may still not close the existing specialty payment differences.

Reducing the somewhat “magical” four-year medical curriculum for students agreeing to enter primary care residencies has also begun, and support from undergraduate and graduate medical education accrediting agencies is needed to develop more of these programs. Delivery of care by non-physician providers will also diminish the voids in primary care and public health service; overcoming physician resistance to such care delivery pathways will be needed to widen the scope of practice of allied health professionals.

But there are other ways too, approaches that try to identify medical school applicants who may be committed to public service and who may eschew higher paying specialties for generalist careers that will help reduce health disparities. While GPAs and MCAT and USMLE scores are now recognized as having less predictive value for “success” than once thought, medical schools and residency programs are struggling to not only acknowledge but renounce these parameters as coins of the realm for the recognition of “excellence.” We are certainly receiving encouragement to do so by our professional organizations (see more on AAMC’s Holistic Review process here).

Medical schools need to move beyond the historical “ranking” markers of NIH funding and national periodical ratings when they select medical students. Institutions with strong and real social missions must be willing to enroll students who may have been overlooked in the past. We must seek applicants with robust service experiences who can forcefully demonstrate a desire to give back. We must seek applicants who were raised in urban and rural locations in which access to care is difficult; they may be more attracted to return to similar communities in the future.

At Cooper, we have focused on diversity within our student body: 24 percent of our charter class is students who are “underrepresented in medicine” — about double the national average. We have accepted nontraditional students with varied backgrounds and a special enthusiasm for service and renewal.

In doing so, we have accepted some students who may not have the same metrics that medical students have valued for so long. We understand that we may need to provide additional resources for those students, such as tutoring for example. We held a four-week “pre-matriculation” program for a cohort of students whom we felt needed slightly different preparation from that of their colleagues.

A quarter of the class is self-declared “disadvantaged,” a question posed to all applicants on their AMCAS application. While it does not necessarily imply economic hardship, in the majority of cases we believe that it does. The percentage of our students who have declared themselves as disadvantaged is also about double the national average. We tried very hard to provide scholarship money to these students and, in many instances, it made the difference in them choosing to come to CMSRU.

Finally, we must demonstrate that we value public service and create an overall brand that can be defended by data demonstrating our success. The differences among the graduates of most medical schools are indiscernible in terms of knowledge and skills — not that there is anything wrong with this. I would propose, however, that funding agencies, municipal governments, accrediting groups, national professional organizations, and most importantly, medical schools themselves must work collaboratively and creatively to solve this problem.

Like Paris, medical students are confronted with tempting options for their future. While medical schools will not be able to control all of the variables that influence career decisions, we need to pledge to manage those within our purview. Let us ensure that the opportunity for public service is one that is made available and enticing to those most likely to make such an important commitment.

—Paul Katz, MD, is dean of Cooper Medical School of Rowan University in Camden, New Jersey. He can be reached at

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