University of Southern California Dissertations and Theses

Medical student loan indebtedness and decision-making in the selection of specialty

(USC Thesis Other)

Medical student loan indebtedness and decision-making in the selection of specialty

PDF

Download a page range

Download transcript

Copy asset link

Request this asset

Transcript (if available)

Content

Medical Student Loan Indebtedness and Decision-Making in the Selection of Specialty
by
Jason T. Murillo

Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the degree requirements for the degree of
Doctor of Education

December 2021

© Copyright by Jason T. Murillo 2021
All Rights Reserved

The Committee for Jason T. Murillo certifies the approval of this Dissertation

Christine Crispen
Anthony Maddox
Patricia Tobey, Committee Chair

Rossier School of Education
University of Southern California
2021

iv

Abstract
This qualitative study summarized the findings from interviews with six medical school
graduates who were, at the time of the interview, in the first year of their residency programs.
The researcher gathered data to address the following research questions: 1) How do fourth year
medical students at the Pacific School of Medicine consider their level of student loan
indebtedness when selecting residencies to which they will apply? and 2) What were these
students’ perceptions of the financial literacy support services they received at the Pacific School
of Medicine? Bronfenbrenner’s Bioecological Framework for Human Development was used to
analyze the findings from these interviews. The main findings from this study suggest that debt,
despite being a source of much anxiety and concern, is not as influential in the decision-making
process as career passion and lifestyle considerations. Debt, and dependency on student loans,
had more impact on a student’s academic experience than on their selection of specialty.
Moreover, participants revealed that financial literacy tools and debt management counseling
were vital to their sense of autonomy and security in the handling of their finances, thus reducing
the significance placed on debt when selecting a specialty.

Key Words: Specialty Selection, Decision-Making, Medical School Debt

v

Dedication
To all my amazing friends and cherished members of my family who accompanied me through
this process. I am eternally thankful for your love, support, and patience.

vi

Acknowledgements
I am grateful to my dissertation committee members, Dr. Patricia Tobey, Dr. Anthony
Maddox, and Dr. Christine Crispen, for their patience, feedback, encouragement, and guidance
throughout this process. A special thank you to my committee chair, Dr. Patricia Tobey, for your
persistence and constant cheerful disposition that assured me this goal could be accomplished.
I would like to thank my classmates who served as cheerleaders throughout this
process—checking in on me and pushing me to the end. The support you have provided to me is
invaluable and was essential to my attainment of this goal. I would like to acknowledge the
support I received from Kristi Culpepper, Debbie Jih, Greg Yamamoto, and Danielle Wilson
Lindor, all of whom played pivotal roles in my time at the Rossier School of Education. I must
also thank my friends and family for their unwavering support and willingness to help in any
way possible.
I honor and thank the women in my life: my mother, Teresa Murillo, my grandmother,
Marcia Simpson, and my great-grandmother, Thelma Walsworth. Their hopes, dreams, and
examples have been foundational to the person that I am today and to the person that I aspire to
be moving forward. I take them with me wherever I go. My accomplishments are theirs.
Finally, I would like to thank the medical students who so graciously shared their
thoughts and insights with me. Their contributions to this work have not only aided me in my
goal of completing this doctoral degree but have also influenced and informed the way I will
move forward in my career as an administrator and educator within higher education.

vii

Table of Contents
Abstract .......................................................................................................................................... iv
Dedication ....................................................................................................................................... v
Acknowledgements ........................................................................................................................ vi
List of Tables .................................................................................................................................. x
List of Figures ................................................................................................................................ xi
Chapter One: Overview of the Study .............................................................................................. 1
Purpose of the Study ................................................................................................................... 2
Background of the Problem......................................................................................................... 3
Evidence of Problem ................................................................................................................... 5
Significance of the Study ............................................................................................................ 6
Theoretical Framework ............................................................................................................... 7
Overview of Methodology ........................................................................................................ 10
Purposeful Sampling ................................................................................................................. 11
Convenience Sampling .............................................................................................................. 11
Interviews .................................................................................................................................. 12
Key Definitions ......................................................................................................................... 12
Chapter Two: Review of the Literature ........................................................................................ 16
Scope of the Problem ................................................................................................................ 16
The Specialty Selection Process ................................................................................................ 17
Promoting Primary Care Specialty Selection ............................................................................ 21
A Brief Historical Overview of Medical Student Debt ............................................................. 22
Medical Student Debt and Tuition ............................................................................................ 24
Medical Student Debt Relief Programs ..................................................................................... 25
Studies on Medical Student Debt and Specialty Selection ....................................................... 27
Potential Effects of Student Loan Debt ..................................................................................... 31
Financial Literacy ...................................................................................................................... 32
Conceptual Framework: Bronfenbrenner’s Bioecological Model of Human Development..... 34
Process-Person-Context-Time ................................................................................................... 35
Bronfenbrenner’s Framework in Educational Contexts ............................................................ 36
Bronfenbrenner and the Current Study ..................................................................................... 36
viii

Key Concepts ............................................................................................................................ 37
Summary ................................................................................................................................... 38
Chapter Three: Methodology ........................................................................................................ 39
Research Approach ................................................................................................................... 39
Participants ................................................................................................................................ 40
Sampling and Site Selection ...................................................................................................... 41
Instrumentation.......................................................................................................................... 41
Data Collection .......................................................................................................................... 42
Interview Protocols ................................................................................................................... 43
Data Analysis ............................................................................................................................ 44
Validity ...................................................................................................................................... 45
Limitations ................................................................................................................................ 46
Chapter Four: Findings ................................................................................................................. 48
Review and Data Collection Methods ....................................................................................... 49
Description of Participants ........................................................................................................ 50
Results: Research Question One ............................................................................................... 53
Discussion: Research Question One ......................................................................................... 69
Results: Research Question Two............................................................................................... 71
Discussion: Research Question Two ......................................................................................... 87
Summary of Theme One ........................................................................................................... 94
Summary of Theme Two........................................................................................................... 95
Summary of Theme Three......................................................................................................... 96
Summary of Theme Four .......................................................................................................... 96
Conclusion ................................................................................................................................. 97
Chapter Five: Discussion .............................................................................................................. 98
Findings ..................................................................................................................................... 99
A Brief Summary of the PPCT Model ...................................................................................... 99
Specialty Selection as a Contextual Process ........................................................................... 100
Specialty Selection: A PPCT Perspective ............................................................................... 104
Financial Literacy and Debt Management Counseling ........................................................... 106
Financial Literacy and Debt Management: A PPCT Perspective ........................................... 108
Perceptions of University Financial Support .......................................................................... 109
ix

Perceptions of University Financial Support: A PPCT Perspective ....................................... 110
Debt and the Academic Experience: A PPCT Perspective ..................................................... 113
Implications for Medical School Administrators .................................................................... 114
Implications for Medical Schools ........................................................................................... 114
Implications for Policymakers ................................................................................................ 116
Future Research ....................................................................................................................... 117
Summary ................................................................................................................................. 120
Conclusion ............................................................................................................................... 121
References ................................................................................................................................... 124
Appendix A: Final Interview Questions and Protocol ................................................................ 141
Appendix B: Email Solicitation: Invitation to Participate in Study ............................................ 143
Appendix C: Survey .................................................................................................................... 144
Appendix D: Conceptual Framework of Questions .................................................................... 145

x

List of Tables
Table 1: Medical Student Average Indebtedness 2015-2019 133
Table 2: Overview of Research Participants 134
Table 3: Debt by Race/Ethnicity 135
Table 4: Debt by Gender 136
Table 5: Debt by Specialty Selection 137
Table 6: Specialty Selection by Race/Ethnicity 138
Table 7: Specialty Selection by Gender 139

xi

List of Figures
Figure 1: Bronfenbrenner’s Bioecological Model for Human Development 140

1

Chapter One: Overview of the Study
The average level of student loan indebtedness among graduates of medical schools has
become an extremely salient topic. According to the American Association of Medical Colleges
(AAMC), the average debt of medical students graduating from public institutions in 2020 was
$199,391 and for students graduating from private institutions $219,829 (AAMC Debt Fact
Card, 2020). These figures are disconcerting, especially when considering the potential negative
impact these levels of indebtedness may have on medical students’ specialty selection. Given the
extremely high levels of debt that many medical school graduates are facing, medical students
are potentially now, more than ever, having to focus much of their decision-making about their
selection of medical specialty on earning potential (i.e., selecting a specialty that is more
lucrative in terms of earning potential in lieu of a career in lower-earning fields like primary
care). This emphasis on earning potential to manage high levels of debt incurred in medical
school has, in turn, the potential to negatively impact the number of primary care physicians
within the workforce each year (Bazargan et al., 2006). Since primary care physicians are
already in short supply, the effects of high levels of student loan debt are of great import to
society at large and medical schools whose aim is to produce high-quality primary care
physicians (Phillips et al., 2014).
Despite these concerns, studies to date have not fully established that the level of student
loan indebtedness is the sole indicator of specialty selection (Youngclaus, 2012). Some studies
have shown that extremely high levels of student loan debt are, indeed, a deterrent to selecting
primary care professions (Adashi & Gruppuso, 2010; Jolly, 2005) while other studies that have
shown that primary care physicians, in many instances, graduate with higher levels of debt than
their counterparts who have chosen to pursue more lucrative specialties (Phillips et al., 2014).
2

Despite these incongruent findings, the preoccupation of medical schools and their accreditation
boards surrounding the impact of student loan indebtedness and specialty selection continues to
be a topic to which they pay much attention.
Purpose of the Study
Given the focus on this issue, its implications for medical school practices, and the
ramifications for society at large, the focus of this study will be to better understand the
considerations that are considered when a student is determining which specialty to select as a
career path after completion of medical school. Specifically, this study will attempt to answer the
following research questions:
1) How did graduates at the Pacific School of Medicine consider their level of
student loan indebtedness when selecting the specialties to which they applied?
2) What were these students’ perceptions of the financial literacy support services
they received at the Pacific School of Medicine?
The aim of these questions is twofold: first, to understand the considerations that are weighed by
medical students when selecting a specialty with the purpose of determining the extent to which
they consider debt; and second, to determine if the practices being implemented by Pacific
School of Medicine around the area of financial literacy and debt management are truly meeting
students’ needs and, possibly, influencing students’ decision-making processes in specialty
selection. In other words, how are environmental factors at the institution facilitating or
inhibiting a student’s ability to decide on a specialty (e.g., career path) that truly interests them
and not one that will merely allow them to quickly repay their educational debt.
3

Background of the Problem
Highlighting the salience of this topic are figures compiled by the AAMC which continue
to show a dramatic increase in the average indebtedness of medical school graduates. According
to their reports, the average level of debt of medical students graduating from public institutions
in 2020 was $199,391 and for students graduating from private institutions in that same year, that
average indebtedness was $219,829 (AAMC Debt Fact Card, 2020). This issue is of import to
the Pacific School of Medicine (PSOM) on a couple of fronts. First, one of the school’s chief
goals is to produce high-quality primary care physicians; however, given the high cost of
attending PSOM, that goal may be becoming increasingly difficult to achieve. Second, the high
cost associated with PSOM, coupled with limited scholarship funding, has resulted in average
student loan indebtedness for a PSOM graduate that is roughly 3% higher than the national
average for medical students from a private institution-approximately $227,000 for the
graduating class of 2020 (US New and World Report, 2021). These problems, in turn, have led to
increased scrutiny by the school’s accreditation board which has cited this as an issue that the
school must monitor and address to maintain continued accreditation. It is important to note that
this challenge is not unique to PSOM. The Licensing Committee on Medical Education (LCME)
has placed increased scrutiny on many medical schools around the matter student loan
indebtedness.
In addition to the mandates imposed by the institution’s accreditation board, this issue has
directly impacted PSOM’s students and staff. Students are placed in a situation in which they
face high levels of debt with limited access to sources of gift aid (i.e., scholarships and grants)
which, in turn, may limit their autonomy in determining which career path they will choose. It
impacts PSOM’s Office of Student Affairs in that it is now, in addition to ensuring that students
4

complete their educational endeavors, accountable for the financial well-being of its students and
creating conditions that mitigate the cost associated with attendance. This mandate on the part of
the Student Affairs Office, in and of itself, is reasonable; however, many of the variables that are
at play and that are crucial to achieving the goal of reducing student loan indebtedness and
(potentially) increasing the number of students pursuing a career in primary care are out of the
control of the Office of Student Affairs. These variables include, but are not limited to, the cost
of attendance, the availability of scholarship/grant funding, and the increase in tuition rates each
academic year.
In addition to these factors, there are also structural factors that must be considered. Bess
and Dee (2008) argued that to effectively address structural and organizational challenges,
coordinated efforts on the part of organizational stakeholders must be established and only then
can organizational improvement be achieved. From this vantage, the issue at hand requires
administrators from other departments at PSOM work together to address the issue in
conjunction with the Office of Student Affairs. These other departments include, but are not
limited to, the Office of Development who is tasked with raising scholarship funds to be used in
the mitigation of debt, the Office of Financial Aid, which processes federal aid and is primarily
tasked with providing the student body with financial literacy resources, the Primary Care
Program which is responsible for exposing students to the primary care fields as well as
professionals within those fields, and the Office of Admission who is the first point of contact
and, therefore, the first provider of information about the costs associated with attending an
institution like PSOM.
5

Evidence of Problem
The Pacific School of Medicine is a private institution located in the western U.S. and,
like many medical schools nationwide, is facing the ever-growing problem of rising student loan
indebtedness. The issue of student loan indebtedness has become an extremely salient issue with
the LCME, which has made the topic, and schools’ approaches to addressing it, one of the
primary factors in determining continued accreditation. This new reality is of utmost importance
to PSOM since its average student loan indebtedness has been consistently higher than that of all
private schools. Moreover, roughly one-third of each year’s class graduates with greater than
$300,000 in debt, reflecting the fact that PSOM’s average indebtedness statistics, while high on
their own, mask an even more disturbing financial reality that faces a large percentage of its
students.
As shown in Table 1, while the growth in the average indebtedness of students at PSOM
has slowed, the average level of indebtedness continues to be higher than the national average.
Part of this drop in the growth of the average indebtedness can be attributed to a concerted effort
by the institution to increase scholarships to graduating students to reduce the level of
indebtedness of the graduating class and to a slightly rate of tuition increase for the last few
years.
In addition to reducing the debt of highly indebted students, PSOM aims to minimize
financial barriers that face graduates who have chosen to pursue careers in primary care by
targeting scholarships at students who express interest in primary care and who ultimately do go
into primary care. The basis for this approach is based highly on anecdotal evidence, as many
students at PSOM have expressed that their high level of student loan debt discourages them
from going into primary care careers since those careers are on the lower end of the
6

compensation spectrum. This is of great importance to the school since it is contrary to its
mission of producing highly effective physicians, particularly in primary care, who work directly
with underserved communities. By reducing such barriers, the school hopes to move toward
achieving one vital component of its mission. For society, this effort, while not directly, has the
potential to address the projected primary care shortage that is facing the nation within the next
few years (AAMC, Complexities, 2020).
Significance of the Study
The significance of this study lies in its potential to provide an understanding of the
factors that influence medical students’ decisions when selecting their selections. This study is
primarily concerned with the role that student loan indebtedness plays in this process. There is
conflicting data on the role of student loan indebtedness and its impact on specialty selection,
with some showing no correlation (Gil et al., 2016; Kahn et al., 2006; Phillips et al., 2010) and
others indicating that higher levels of debt may deter students from going into primary care fields
and to pursue instead specialties that are more highly compensated (Phillips et al., 2014; Phillips
et al., 2016; Webster et al., 2017). Despite this incongruity in the findings, all data reveals an
ever-increasing level of indebtedness incurred by medical students across the board as shown in
Table 1. Given this reality, it is imperative to examine the factors that influence students’
decision-making process as it relates to specialty selection and the significance placed on student
loan indebtedness. The findings of this study have the potential to reveal vital information about
the decision-making process that is employed by highly indebted medical students when
determining their career paths in medicine. Understanding their experiences on this matter can
influence institutional policies and practices related to the dissemination of financial and
educational resources and the utilization of institutional funding to promote greater autonomy in
7

the specialty selection decision-making process. This study seeks to answer the following
research questions: (1) how do high levels of student loan debt impact students’ specialty
selection; and (2) what, as revealed by students’ perceptions of financial literacy and debt
management initiatives, the institution might do to address students’ concerns as they pertain to
debt and specialty selection.
Theoretical Framework
An ecological framework was utilized in the examination of participants’ selection of
specialty. Specifically, Urie Bronfenbrenner’s (1979) ecological framework of human
development provided the model through which this study examined the considerations
participants in this study used when determining their specialty selection. Bronfenbrenner’s
ecological framework was introduced in his seminal work, Ecology of Human Development
(Bronfenbrenner, 1979) and, as the title purports, aimed to describe the complex landscape in
which human development takes place. Bronfenbrenner (1979) viewed human development as
significant changes in an individual over time that result from repeated interactions within their
respective environments. The model, as set forth by Bronfenbrenner, later introduced a four-
component person-environment theory. The four components include Process, Person, Context,
and Time (PPCT) (Bronfenbrenner & Morris, 1998). It is the interaction among these four
components that form a person’s developmental ecology (Bronfenbrenner & Morris, 1998).
Renn and Arnold (2003) adapted this model to the higher education sphere to help
understand the relationship between students and campuses and how this relationship may
impact students’ development. Renn and Arnold (2003) posited that model set forth by
Bronfenbrenner (1979) allows educators and administrators to identify characteristics within
students and how they then interact with the various ecologies found at educational institutions.
8

They contended that through this deeper understanding of the interactions of educational
environments and the students within them, educators and administrators can work intentionally
to influence and shape these interactions to promote positive student development. They
highlighted that the model is most promising within the context of higher education because it
allows educational agents to analyze processes and outcomes (Renn & Arnold, 2003, p. 261)
Bronfenbrenner’s (1998) model acknowledges the role of both nature and nurture in the
development of an individual and contends that human development, like the development of
other organisms, is influenced through interactions between an individual and their environments
or ecologies. Given the focus on interactions, at the core of Bronfenbrenner and Morris’s (1998)
PPCT model is what they refer to as Process. The concept of Process characterizes the nature of
these functional interactions. They viewed these ongoing interactions as the essential foundation
of human development. They further noted that these interactions should become more complex
over time and should be accompanied by support mechanisms that contribute to the development
of an individual (Bronfenbrenner & Morris, 1998, 2006).
The next concept set forth in the model is that of Person. A person’s nature will most
influence their developmental trajectory, either fostering or impeding it from taking place
(Bronfenbrenner, 1993; Bronfenbrenner & Morris, 1998). The degree to which a person will
develop hinges on the individual’s response to and engagement with their environment
(Bronfenbrenner, 1993; Bronfenbrenner & Morris, 1998). Within higher education, Renn and
Arnold (2003) described four manners in which students may respond to their environment. The
first refers to how some students actively engage with their environment. The second refers to
those students who selectively engage with their environment. The third revolves around how
students engage with and within their environments. Finally, the fourth refers to the degree of
9

control students feel they have in shaping their development and, in turn, the control they can
exert over their environments. Bronfenbrenner (1993) and Bronfenbrenner and Morris (2006)
noted that these attributes possessed by individuals, while helpful in determining how one might
respond to environmental situations, do not necessarily determine how an individual will
ultimately develop. Instead, development will be heavily influenced by the other factors within
the environment and the resources available to the individual, thus highlighting the reciprocity
intrinsic to this theory.
The third concept outlined in Bronfenbrenner’s model of human development is that of
Context. Context is concerned with the specific situations in which an individual finds
themselves (Bronfenbrenner, 1993). Bronfenbrenner (1993) divided these contextual components
into four levels branching out from the individual at the center of an interconnected
socialecological system: the microsystem, mesosystem, exosystem, and macrosystem.
Bronfenbrenner (1993) contended that it is within these systems that an individual will develop.
Renn and Arnold (2003) adapted this model to the educational environment, placing the student
at the center of the environment as shown in Figure 1.
Bronfenbrenner (1993) provided the following descriptions of each system. A
microsystem is,
[A] pattern of activities, roles, and interpersonal relations experienced by the developing
person in a given face-to-face setting with particular physical, social, and symbolic
features that invite, permit, or inhibit engagement in sustained, progressively more
complex interaction with, and activity in, the immediate environment. (p. 15)
A mesosystem is comprised of the “linkages and processes taking place between two or more
settings containing the developing person” (Bronfenbrenner, 1993, p. 22). Exosystems are those
10

in which an individual is not necessarily actively involved but that, nonetheless, influence the
development of an individual, because of their impact on microsystems (Bronfenbrenner, 1993).
Finally, macrosystems provide the historical and social contexts within which all the other
systems described in the model operate (Bronfenbrenner, 1993).
The final concept, and later addition to the model, presented in the PPCT model is that of
Time. Bronfenbrenner and Morris (1998) maintained that time is essential to understanding
human development both at the individual level (micro-and mesotime), but also over generations
and society itself (macrotime). Time accounts for how environmental influences are negotiated
over one’s lifespan. Bronfenbrenner (1993) highlighted that this system is best understood as the
changes that take place overtime within an individual and their environment and, therefore,
impact one’s development.
In total, Bronfenbrenner’s (1979,1993) model and, particularly, Renn and Arnold’s
(2003) adaptation to student life provide a constructive lens through which the issue of student
loans indebtedness and its impact on specialty selection can be viewed. By viewing a student’s
development as a process that can be influenced over time by introducing specific forces and
resources, administrators can promote positive student development and reinforce authentic
agency in the specialty selection process. This is vital to medical students as it will impact the
extent to which they feel in control over the financial investment they have made and their ability
to select a career path without solely accounting for financial considerations.
Overview of Methodology
The purpose of this study was to understand, from a medical student’s perspective, the
factors considered when determining which specialty to select and, more specifically, the role in
which their student loan indebtedness may have played in that process. This study was also
11

focused on garnering information regarding their perceptions of financial literacy resources
introduced at PSOM to determine their perceived benefits and effectiveness. Merriam and
Tisdell (2015) argued that qualitative research is concerned with delving into the human
experience to understand how experiences are interpreted and, by extension, how meaning is
created (p. 15). As such, a qualitative research approach was adopted for this study. In this study,
medical students from the PSOM Class of 2020 who had graduated and successfully entered a
residency program were interviewed. The sections that follow provide a brief description of
methods employed in this study.
Purposeful Sampling
The goal of this study was to gain insight into the decision-making process that students
with high levels of debt experienced when selecting a specialty. The study aimed to collect data
from sources that could best provide information about the topic in question by engaging in
purposeful sampling. To garner what Patton (2015) referred to as “information-rich” data,
interviewees in this study were selected based on the following criteria: (a) graduated medical
school and currently in a residency program, and (b) had greater than $250,000 in student loan
debt (p. 53). Ideally, eight to ten graduates would participate in the study.
Convenience Sampling
Medical students were selected from a pool of graduates from the researcher’s home
institution as a matter of convenience. Merriam and Tisdell (2015) noted that convenience
sampling can lead to “information poor” data; however, for this study, students’ experience from
the home institution is vital to understanding how the institution itself is promoting or inhibiting
the development of its students (p. 98). Consequently, a convenience sample was conducive to
the purpose of the study. Students were identified by the researcher and emailed to request
12

participation in the study. Had more than ten students expressed interest in participating in the
study, those with the highest debt would be selected. Of those, a sample that would be most
representative of the student body would be generated.
Interviews
Interviews were semi-structured, as characterized by Merriam and Tisdell (2015). As
such, an interview guide was used to provide an overall structure to the interview. The interview
aimed to elicit responses to the issues being explored by the study. However, the order of the
questions, as well as the wording, were flexible. The interview itself consisted of eleven open-
ended questions that allowed for additional questioning if necessary. Interviews were recorded
using Zoom. Interviews were subsequently transcribed and coded to identify common themes.
The themes that identified were then analyzed to draw relevant conclusions.
Key Definitions
Cost of Attendance (COA): The Cost of Attendance, or COA, is the budget established by the
university for one academic year within a given program. The COA includes direct costs such as
tuition and mandatory fees. It also includes indirect expenses such as housing, food,
transportation, books, supplies, and personal expenses. Non-required educational expenses (as
determined by the Department of Education) cannot be included in the COA; however,
additional educational expenses that may be unique to a particular student may be included on a
case-by-case basis, thus increasing the COA. The total of all student aid received by a student
cannot exceed the established COA unless a student is fully funded through gift aid (i.e.,
scholarships and grants) (U.S. Department of Education, https://studentaid.gov).
Federal Direct Unsubsidized Loan: Formally referred to as the Federal Direct Stafford Loan, is
a federal loan granted to eligible applicants of financial aid regardless of creditworthiness.
13

Unsubsidized loans are those loans for which the government is not paying the interest during
periods of enrollment, grace periods, and periods of economic hardship. The award amount is
based on the duration of the academic year. Typically, a maximum of $40,500 is awarded per
nine-month academic year. However, PSOM students are eligible for $42,722-$47,167 per year
as the academic year is ten to twelve months in duration. The rate of interest is established yearly
by Congress (U.S. Department of Education, https://studentaid.gov).
Federal Direct Graduate PLUS Loan: A federal loan that can be taken out by a graduate
student to cover any costs included in the COA and not covered by the Federal Direct
Unsubsidized (Stafford) Loan and any other sources of aid. This loan is also unsubsidized and
typically has an interest rate that is one percent higher than that of the Federal Direct
Unsubsidized (Stafford Loan). This loan does require credit approval; however, very few
students are denied unless they have a prior bankruptcy or currently have accounts in a
delinquent status. Should a student not qualify based on their credit, a co-borrower, with
approved credit, may submit an application on behalf of the student (U.S. Department of
Education, https://studentaid.gov).
Public Service Loan Forgiveness (PSLF): A federal loan forgiveness program that offers
forgiveness on any remaining federal student loan balance to anyone after 120 qualifying
payments have been made. A qualifying payment is any on-time payment made while employed
full-time at a 501(c)3 organization, government organization, AmeriCorps, Peace Corps, and
under an approved loan repayment plan. As it currently stands, any forgiven debt will be tax-
exempt (U.S. Department of Education, https://studentaid.gov).
Income Driven Repayment Programs (IDR): The umbrella under which loan repayment
programs that base monthly installments on the borrower’s adjusted gross income (AGI) and
14

family size fall. These programs are only offered through the Department of Education for
federally funded loans (U.S. Department of Education, https://studentaid.gov).
Pay As You Earn (PAYE): An income-driven repayment program that calculates payment
based on a borrower’s AGI, family size, and state of residence. The calculation for determining
the borrower’s monthly installment is as follows: (AGI) – (150% the poverty guideline based on
the borrower’s family size) = (Discretionary income) ÷ 12 = monthly installment. Income must
be verified yearly. Under this program, borrowers can obtain forgiveness after 20 years of on-
time payments; however, any forgiven debt is regarded as untaxed income, so the borrower will
be responsible for any subsequent taxes. Finally, this program allows married borrowers to file
their taxes separately to secure lower monthly installments (since only the borrower’s income
will be considered). Moreover, the monthly installments under this program will never exceed
what payments would have been under a Standard Ten-Year Repayment Plan as calculated at the
point at which loan repayment is to begin (U.S. Department of Education,
https://studentaid.gov).
Revised Pay As You Earn (REPAYE): An income driven repayment program that calculates
payment based on a borrower’s AGI, family size and state of residence. The calculation for
determining the borrower’s monthly installment is as follows: (AGI) – (150% the poverty
guideline based on the borrower’s family size) = (Discretionary income) ÷ 12 = monthly
installment. Income must be verified yearly. Unlike PAYE, its predecessor, under this program,
borrowers can obtain forgiveness after 25 years of on-time payments; however, any forgiven
loan is regarded as untaxed income so the borrower will be responsible for any subsequent taxes.
This program does not allow married borrowers to file their taxes separately to secure lower
monthly installments. Thus, spousal income will always be used in the calculation used to
15

determine a borrower’s monthly installment. Despite seemingly fewer desirable terms, this
program, unlike PAYE, offers a potential interest subsidy to borrowers. The subsidy offered
under this program forgives 50% of any interest remaining after the calculated minimum
monthly installment has been applied. This benefit can assist in mitigating the accrual of interest,
especially during residency and fellowship. Unlike PAYE, this program does not cap monthly
installments, so payments will always be 10% of the borrower’s discretionary income (U.S.
Department of Education, https://studentaid.gov).
Loan Consolidation: Process by which a borrower can, under the Department of Education,
consolidate (bundle) all or a portion of his or her loans. The new loan will have a new interest
rate that is the weighted average of all the loans’ interest rates included in the consolidation
rounded up to the nearest one-eighth of a point (U.S. Department of Education,
https://studentaid.gov).
Loan Refinancing: Process by which a borrower can elect to have a private lending institution
purchase their federal and private student loans to secure a lower, market-based interest rate.
Once refinanced, loans are no longer eligible for federal repayment benefits, including loan
forgiveness.

16

Chapter Two: Review of the Literature
Scope of the Problem
According to the American Association of Medical College as part of the data compiled
on the FIRST analysis of the class of 2020 Graduate Questionnaire, the percentage of students
graduating with medical school debt was 73%. The mean for those graduating with debt at
private institutions was $207,003, and the median debt was $200,000 (AAMC Debt Fact Card,
2020). On that same questionnaire that 44.9% of students were planning to enter a loan
forgiveness program and of those 79.3% were planning to enter the Public Service Loan
Forgiveness program to manage the debt that they had acquired (AAMC Medical School
Graduation Questionnaire, 2020). The effects of these debt levels could be limiting students’
notions of which specialties are viable and perhaps dissuading some highly indebted students
from entering careers they might otherwise pursue—like those in primary care (Rosenblatt &
Andrilla, 2005). Rosenblatt and Andrilla (2005) found specifically that rising debt may
negatively impact the choice of primary care as a specialty, noting a significant adverse impact
on students whose level of debt is greater than $150,000.
The impact of student loan debt on primary care specialty selection is of great import due
to the need for primary care physicians. A study conducted by the U.S. Department of Health
and Human Services (2006) explicitly looking at physician supply and demand projections for
2020 noted that roughly 24,000 residents enter the workforce each year. Of these 24,000
residents, less than 25% will enter a residency to practice as a primary care physician (i.e.,
internist, family medicine, and pediatrics) (Phillips & Turner, 2012). This revealed a steep
decline when compared to data compiled in 1995 showing that roughly 52% of graduates entered
primary care residencies (Petersen et al., 2012). This reduction is disconcerting as projections
17

indicate that a primary care physician shortage is imminent. The AAMC in recently projected
that by 2033 there could be a shortage of 21,400 to 55,200 primary care physicians (AAMC,
Complexities, 2020). They highlight that this is particularly troubling given an ever growing and
aging population that will demand a significant increase in primary care physicians. This
supports the findings of Peterson et al. (2012) that projected that to address this looming shortage
that over 50,000 primary care physicians will need to be added to the physician workforce by
2025.
Given the need for more primary care physicians and the reality of ever-increasing
student loan debt, it is crucial to understand factors that contribute to medical students’ selection
of specialty. While debt does appear to be a significant concern, having consistently been
reported as a strong to moderate factor in specialty selection with approximately 22% of medical
school graduates reporting that it was a consideration and another 23.6% indicating it was at least
a minor influence (AAMC Medical School Graduation Questionnaire, 2020), other factors must
also be considered. These factors include but are not limited to educational opportunities, role
models, socioeconomic influences, gender, race, and anticipated future income. As such, this
chapter will explore these factors to comprehensively understand the medical student decision-
making process related to specialty selection. Additionally, a review of potential interventions
that have been explored on this topic will be conducted.
The Specialty Selection Process
The selection of a specialty is a highly nuanced process that involves many factors that a
student must consider (Bennett & Phillips, 2010; Rao et al., 2017; Weissman et al., 2012). To
understand this process, research conducted by Bennett and Phillips (2010) culminated in a new
theoretical model of specialty choice developed through the application of decision-making
18

theories and an extensive review of literature. Within their model, they identified three categories
of students: 1) students who are committed to primary care during the entire time in medical
school; 2) students who are never interested in primary care; and 3) students whose interest can
change over time or are not defined. Bennet and Phillips (2010) also found that certain factors
played significant roles in students’ selection of specialty and the category to which the student
would belong. Some of the factors they identified included demographics, lifestyle
considerations, specialty characteristics (both real and perceived), and financial objectives.
Weissman et al. (2012) added to these factors the role of clinical experiences in influencing
specialty selection further highlight the environmental component inherent in the specialty
selection process.
Bennet and Phillips (2010) and Weissman et al. (2012) contended that understanding the
factors that influence each category of students’ selection of specialty could empower medical
school faculty and staff in their efforts to provide students with a more comprehensive view of
specialty options. In doing so, they could also promote more positive perceptions of primary care
as a viable choice of specialty through intentional interventions, especially early in the clinical
setting. For example, students interested in primary care, but not committed, might be exposed to
positive examples of primary care physicians who, despite having high debt levels, can share
how they maintain healthy and satisfying lives. Essentially, by understanding contextual factors
that students view as important in a specialty could allow educators and administrators an
opportunity to influence the decision-making process in a way that benefits the student, the
school and society (Weissman et al., 2012).
19

Gender and Specialty Selection
Studies have shown that males and females often have very different approaches to
specialty selection (Barnhart et al., 1996; Bazargan et al., 2006; Dorsey et al., 2005; Kim et al.,
2003; Lambert & Holmboe, 2005; Schieberl et al., 1996; Weissman et al., 2012). Weissman et al.
(2012) found that male students tended to be drawn to higher-compensated, procedure-oriented
specialties while females tended to be drawn more to specialties with shorter training periods and
that afford them with a better work-life balance (i.e., limited work hours). And while women are
more likely to pursue careers in primary care than their male counterparts (Barnhart et al., 1996;
Bazargan et al., 2006; Schieberl et al., 1996), the desire to have more control over their careers
still leads them away from pursuing careers in primary care, as such, the primary care workforce
continues to wane (Lambert & Holmboe, 2005).
Dorsey et al. (2005) developed the concept of “controllable lifestyle specialties” or CLS
as a response to why so many students, both male and female, are choosing not to pursue careers
in primary care. Dorsey et al. (2005) characterized CLSs as those professions that allow an
individual the ability to establish a more structure work-life balance. Careers that fall under the
CLS umbrella include but are not limited to radiology, anesthesiology, and dermatology
(Lambert & Holmboe, 2005). Dorsey et al. (2005) placed primary care professions under the
category of uncontrollable lifestyle specialties (ULS). Dorsey et al. (2005), Lambert and
Holmboe (2005) and Weissman et al. (2012) found that lifestyle control was an important factor
in specialty selection for both males and females noting that there has been a significant
reduction in the percentage of medical school graduates entering into ULS fields. This finding is
further supported by the AAMC’s most recent Medical School Graduation Questionnaire (2020)
20

that found that 77.1% of graduates indicated that work/life balance was a moderate to strong
influence on their selection of specialty.
Despite the decreased interest in ULSs among men and women, Lambert and Holmboe
(2005) still found that women were still slightly more likely to go into a ULS professions than
men and they tend to be overrepresented in many ULS specialties like pediatrics. This
observation was supported by research conducted by Bazargan et al. (2006) who found in their
survey of 668 fourth-year medical students those female respondents showed far more interest in
primary care fields.
Race and Specialty Selection
Regarding race and specialty selection, Saha and Shipman (2006) and Pamies et al.
(1994) noted that underrepresented in medicine (URMs) physicians tend to be overrepresented in
primary care fields given their representation within the physician workforce and
underrepresented in non-primary care fields. Saha and Shipman (2006) and Pamies et al. (1994)
shared that one reason for this may be rooted in the fact that URMs often come from underserved
communities where primary care physicians are in short supply. This, in turn, may lead to them
feeling compelled to address this shortage through service to underserved communities (Saha &
Shipman, 2006; Pamies et al., 1994).
Saha and Shipman’s (2006) argument that minority physicians tend to serve communities
that are reflective of their backgrounds was supported by their survey of statistics compiled by
the Health Resources & Services Administration (HRSA) which provided evidence that URM
physicians are more likely than non-URM physicians to provide medical care to underserved
populations. This held true even when socioeconomic factors were isolated. Saha and Shipman’s
(2006) survey revealed that even URM physicians from more affluent backgrounds provided
21

care to underserved communities at a rate disproportionate to non-URM physicians. This finding
supported a study conducted by Pamies et al. (1994) which found that URM students, regardless
of dependence upon federal student loans (an indicator of financial need), still disproportionately
went into primary care fields. These findings are especially troubling when one considers that
URMs, particularly, African American students, are more likely to have higher levels of debt and
yet still choose to go into lower-compensated fields (Rosenblatt et al., 2005).
Socioeconomic Background and Specialty Selection
There is little research on the impact of the socioeconomic status of a medical student’s
parent(s) on specialty selection. Phillips et al. (2009), however, noted that medical students from
higher socioeconomic backgrounds are more likely to choose non-primary care specialties, while
medical students from lower socioeconomic backgrounds are more likely to enter primary care
professions. Moreover, one study has shown that the socioeconomic status of parents can have a
significant impact on a medical student’s personal and professional development as result of
increased instances of stress, hopelessness, and pessimism which can impact specialty choice
(Fan et al., 2007).
Promoting Primary Care Specialty Selection
As previously noted, Bennett and Phillips (2010) developed a theoretical model that
could potentially address factors that could be identified and used to increase the rate at which
medical students choose primary care specialties. Their model centers around the three
categories of students that their study identified: 1) primary committed throughout; 2) non-
primary committed throughout; 3) those whose interest can change. Bennett and Phillips (2010)
noted that multiple factors affect these students, including but limited to their backgrounds,
academic experiences, obligations, and future goals.
22

Bennett and Phillips (2010) provided suggestions for practices that can be employed to
promote primary care specialty selection or, at least, demonstrate its value. This suggestion is
further supported by Weissman et al. (2012) who noted that it is often students’ perceptions of
specialties that influence their selection of specialty as opposed to actual representations of those
specialties. Accordingly, Bennett and Phillips (2010) contended that for students who are fully
committed to primary care, schools must focus their efforts on providing support systems that
consistently reinforce this commitment, like mentorships. For fully non-primary care committed
students, they note that schools should nurture positive images of primary care fields so that its
importance and relation to other specialties can be highlighted (Bennett & Phillips, 2010).
Bennett and Phillips (2010) stressed, however, that interventions focused on students who have
positive perceptions of primary care but are not committed and on those truly undecided students
are where schools’ efforts have the most potential to steer students into primary care specialties
or, at least, open them up to the possibility of careers within those fields. They argued that for
these students, there are many factors that can impact their choice of specialty such as pay,
lifestyle considerations, location, and healthcare landscape (Bennett & Phillips, 2010). Of course,
many of these factors are out of the control of the medical school; nevertheless, strategic use of
financial programs (e.g., scholarships, grants, low-interest loans, and loan forgiveness programs)
could be useful in promoting primary care specialty selection since.
A Brief Historical Overview of Medical Student Debt
Greysen et al. (2011) noted that medical student debt is a relatively recent topic of
concern, only truly manifesting within the last 60 years. The reason for this, they contended, was
that medical student tuition until that time was manageable and often easily funded by a
student’s family and, therefore, reliance on student loans was not necessary. They supported their
23

assertion with findings compiled by Altenderfer and West (1965) who found that in the 1960s
less than one one-third of medical students had educational debt and that more than three-
quarters were the beneficiaries of financial support provided by the family (Greysen et al., 2011,
para. 1). However, there has since been a dramatic departure from this reality. A medical
education is now viewed as an individual investment—an investment that for many medical
students necessitates a dependence on student loans (Greysen et al., 2011). This argument is
supported by recent statistics that reveal that 73% of all medical students now report having
educational debt, with an average debt level of $207,003 and median debt of $200,000 (AAMC
Debt Fact Card, 2020).
Greysen et al. (2011) attributed the increase in medical student debt to the multiple
factors that have reshaped the medical education landscape. Specifically, they ascribed the
increase is debt to social and economic trends that led to a consumer-driven economy in which
the utilization of loans became much more socially acceptable (Greysen et al., 2011, para. 5).
They also note that a change in the demographics of students going to medical occurred; students
were older, more were women, and less were White (Greysen et al., 2011). These changes
coupled with the rising cost of medical school, greater access to federal student loans, and the
rise of the “professional student” (i.e., a student completely dependent upon loans and who does
not have a source of income), facilitated the growth of debt among medical students (Greysen et
al., 2011).
Another contributing factor to the rise in medical school debt pointed out by Greysen et
al. (2011) was the expansion and increased complexity of higher education institutions. They
noted that this increased complexity resulted in a lack transparency in the cost associated with
running and maintaining medical schools. Additionally, they highlighted those costs not
24

associated with a student’s medical education are, nevertheless, often funded through the tuition
paid by students. As such, students may be bearing incurring debt to support initiatives desired
by medical schools, initiative that do not necessarily directly benefit the student (Greysen et al.,
2011, para. 12).
Medical Student Debt and Tuition
The correlation between rising tuition costs and rising medical student loan indebtedness
is problematic, especially when one considers the rate at which medical tuition has increased. In
addition to increasing student loan debt due to rising tuition costs, there is a lack of financial
assistance available to medical students, especially in the form of scholarships and need-based
grants. This reality is compounded by the fact that increased class sizes make the attainment of
gift aid (i.e., scholarships and grants) much more competitive (Steinbrook, 2008; Weinstein &
Wolfe, 2010). According to data compiled by the AAMC as part of the Financial Aid Summary
Report (FASR) in 2020, student loans comprised 72% of the roughly four billion dollars in total
aid for granted to medical students in the 2019-2020 academic year and only 25% in the form of
grants and scholarships without a service commitment (AAMC FASR, 2020). These loans, it
should be noted, can also be extremely costly to students due to the high interest costs associated
with them. For example, during the 2019-2020 academic year, the interest rate on these loans
was 6.08% (Federal Direct Loan) and 7.08% (Federal Graduate Plus Loan) (U.S. Department of
Education, https://studentaid.gov). Moreover, Weinstein and Wolfe (2010) predicted that
restrictions in federal and state budgets will force medical schools to depend on tuition and fees
from students to remain solvent. Consequently, tuition will continue to rise along with the debt
incurred by students who attend medical school (Jolly, 2005; Steinbrook, 2008; Weinstein &
Wolfe, 2010).
25

Weinstein and Wofe (2010) also noted that rising debt and sluggish increases in the
salaries of primary care physicians compared to non-primary care physicians may also impact
specialty selection. Weinstein and Wolfe (2010) argued that such trends may increase stress
among students who now must worry about paying back their loans and, therefore, may choose
to go into higher earning specialties instead of lower compensated primary care fields.
Phillips et al. (2010) further highlighted this potentiality, offering several reasons why
medical student debt impacts specialty selection. Students with debt are more likely to
understand the impact of specialty selection on their ability to manage their indebtedness.
Medical educators and staff also recognize debt to be a substantial factor in specialty selection.
The return on investment is dramatically higher for non-primary care specialties (Weeks &
Wallace, 2002). Furthermore, AAMC data revealed that specialty residencies fill at higher rates
than primary care specialties (Phillips et al., 2010). This fact reveals an appreciation for
compensation and its ability to raise standards of living by mitigating the debt management
burden.
Medical Student Debt Relief Programs
Multiple programs aim to mitigate the burden of student loan debt while concurrently
strengthening physician workforces in underserved geographic locations or in non-profit
locations. These programs all involve service obligations or strict employment requirements. The
most pursued program types are service-based scholarships, service-based loans, loan repayment
programs, and loan forgiveness programs.
Service-based scholarships and service-based loans are awarded to medical students
during enrollment periods. They require a service obligation after graduation or residency. The
National Health Service Corps, for example, provides a full scholarship to students who commit
26

to working in a primary care capacity in an underserved location. One year of service is required
for each year that the scholarship is received with a minimum of a two-year service commitment.
Suppose a student does not fulfill this obligation. In that case, they are required to repay all funds
received with a substantial penalty and within a strict timeframe. The strict nature of this
scholarship serves to discourage recipients from pursuing non-primary care specialties after
agreeing to the terms of the award.
An example of a service-based loan is the Primary Care Loan, which, in return for
committing to a career in primary care, provides students with low-interest student loans (5%
annually), which do not begin accruing until one year after graduation. This loan mandates that
students enter a primary care profession and continue to practice in that capacity until the loan
has been paid in full. Should a student fail to fulfill the service/repayment obligation, the loan
must be repaid at an increased interest rate in an accelerated timeframe. Because of the service
obligation, this loan cannot be consolidated with other student loans and is not eligible for other
loan forgiveness programs. The strict nature of service-based scholarships and loans results in
apprehension for students who may not be fully confident that a career in primary care is where
they will ultimately find themselves or who are concerned with the limitations it places on their
post-residency career plans.
Loan repayment programs and financial incentive programs offer financial support after
graduation—during or after residency. Loan repayment programs also come with a service
obligation to work in primary care; however, the risk associated with scholarship programs no
longer exists since participants must be in a primary care profession to apply. The National
Health Service Corps also provides a loan repayment program in return for working in a primary
27

care capacity in an underserved area, physicians will receive an additional $25,000 in
compensation each year to be applied directly to their existing educational debt.
Finally, loan forgiveness offered by the federal government allow a student to obtain
forgiveness on any unpaid debt under the Public Service Loan Forgiveness Program (PSLF) after
they have made 120 on-time payments under a qualifying loan repayment plan and while
employed at a qualified location (i.e., a 501(c)3, government agency, AmeriCorps, or Peace
Corps). Students may also receive forgiveness on any unpaid debt even if they are not
participating in the PSLF program after making 20 to 25 years of on-time payments depending
on the loan repayment plan in which they are enrolled.
Studies on Medical Student Debt and Specialty Selection
As has been noted, to date, studies on the topic of medical student loan indebtedness and
its impact on specialty selection have been inconclusive, providing mixed findings (Gil et al.,
2016; Grayson et al., 2012; Kahn et al., 2006; Morra et al., 2009; Phillips et al., 2010; Phillips et
al., 2016; Webster et al., 2017). In their examination of the relationship between educational debt
and primary care practice, Phillips et al. (2014), reviewed data from the AAMC Graduate
Questionnaire for period between 1988 at 2000 and the American Medical Association
Masterfile. Their analysis looked at responses from 136,232 physicians. The questionnaire that
provided the data for their study is used to by the AAMC to capture a multitude of students’
perceptions regarding their medical school experiences. Of interest, of course, for this study was
information reported by respondents concerning their student loan indebtedness. The Masterfile
provided information on students’ specialty selection. The results of their study revealed that for
graduates with debt levels above $100,000, there was a significant decrease in the likelihood that
they would practice in primary care or family medicine. However, when they isolated graduates
28

of private medical schools, there was no evidence that debt levels greater than $100,000
decreased their likelihood of going into primary care or family medicine. Their study also
revealed that for those graduates who had received need-based loans, there was a higher
likelihood of selecting primary care or family medicine if their debt level was below $50,000,
but that for debt levels above $100,000, the likelihood decreased (Phillips et al., 2014).
The findings reveal that debt alone may not be an adequate indicator of a student’s
decision to pursue a primary care career. Socioeconomic considerations might also be at play.
Furthermore, given the difference between graduates of private and public schools, there may be
differences in perceptions of debt at each type of school, which has implications for
administrators. Finally, they note that graduates from lower socioeconomic backgrounds are
often more inclined to pursue primary care careers. However, they are also often those with the
highest levels of debt which could indicate a propagation of an overrepresentation of
disadvantaged, highly indebted students going into lower compensated fields (Phillips et al.,
2014).
Contributing to this area of discussion was research conducted by Phillips et al. (2016).
Their study sought to examine medical students’ perceptions of their debt and its resulting
contribution to approached in career planning. Their qualitative study focused on medical
students in their second year of studies. All participants of the study were located at Michigan
State University College of Human Medicine where graduates had an average student loan
indebtedness of roughly $214K. The data analyzed in this study were compiled from 132
responses to essays medical students submitted as part of a course required as part of their
degree. The essay asked students to reflect on the role of debt and earning potential in their
decision of career (Phillips et al. 2016).
29

The results of the study revealed numerous themes. While the study intended to identify
perceptions of debt in the context of career planning, the researchers found that much of the data
they received revolved around students’ emotional responses to debt and, in turn, how they cope
with it. However, responses that focused on career choice often centered around the notion that
high debt levels have removed their power to forge their futures by limiting the career paths
available to them. Many students indicated that their high levels of debt made it essential for
them to pursue higher-paying specialties despite their desire to work with more underserved
populations (Phillips et al., 2016)
Grayson et al. (2012) sought to understand the role of economic factors in medical
students’ selection of specialty. Specifically, their study considered the relationship between
debt, income, and career choice by comparing data from students planning on entering a primary
care specialty to students who were not. Their longitudinal analysis of first-year and fourth-year
students graduating between 1996-2012 and 1993-2010, respectively, examined changes in
career goals during medical school for students who had completed a survey in both the first and
fourth year. The measures for their study centered around self-reported debt, anticipated income,
and the value each student placed on income. The findings of their study revealed that students’
level of debt influenced the value they placed on anticipated income (Grayson et al., 2012)
In another study, Morra et al. (2009) aimed to understand how students’ perceptions of
remuneration might impact their career choice. Their survey was conducted at one medical
school with a 72% response rate for a total of 560 responses. They found that students were able
to very closely approximate physician incomes. They also found that most students agreed with
the statement that family physicians are paid too little, a possible indicator to their lack of
interest in the specialty. Students reported that remuneration was more important as their level of
30

debt increased. The authors concluded that while debt is a factor in specialty selection, negative
perceptions of compensation may also be serving as a deterrent to students’ desire to pursue a
career in family medicine (Morra et al., 2009).
Gil et al. (2016) conducted a study to determine if medical student debt affected medical
student specialty selection. Their study yielded 415 responses form students at 12 U.S. medical
schools. Of these respondents, 98 students reported that they were pursuing a career in primary
care and 250 students indicated they were not. The study revealed that they there was no
significant difference is the levels of debt reported by each group of students. The study found
that there was no correlation between a student’s level of debt and their choice of specialty even
though students pursuing primary care fields were aware of the lower earning potential.
Another study conducted by Kahn et al. (2006) consisted of a five-year analysis of
student debt and residency choice for graduates from three U.S. medical schools from 2001-
2005. A total of 2,022 students were included in the study. Four predictors were used in the
logistical regression for primary care residency selection: “1) total debt; 2) medical school; 3)
year of graduation (2001-2005); and 4) the number of years of training required for a residency
program” (Kahn et al., 2006, para. 14). The result of the study found that there was no
association between residency selection and debt. Specifically, the study found no significant
difference in total debt between graduates entering a primary care residency and those not
($87,206 vs. $91,430). However, these debt levels are significantly lower than national averages;
therefore, the study’s conclusions are suspect.
Adding more nuance to the issue of medical student debt and its impact on primary care
specialty intentions is a study conducted by Phillips et al. (2010). Their study aimed to look at
debt’s impact on specialty selection and examine the potentially confounding effects of family
31

income, race, and ethnicity. The study itself consisted of a cross-sectional survey distributed to
students at three medical schools. A total of 983 students participated in the survey. Analysis
revealed that students from lower socioeconomic backgrounds and URMs anticipated higher
debt levels. However, that debt did not correlate to their selection of specialty. However, when
disaggregated, it was found that students from middle-income families were less likely to select
primary care specialties if they were anticipating higher debt levels (Phillips et al., 2010).
Webster et al. (2017) explored the relationships between student loan debt, financial
support, and career preferences. Their longitudinal study of 2,405 students found no significant
relationship between debt level and career preferences. Instead, they found that financial support
provided to students had a more significant impact on career choice. However, they concede that
debt level could be a moderating factor.
Potential Effects of Student Loan Debt
The topic of student loan debt is relevant in its relation to specialty selection and in its
impact on student health and academic performance. One study found that students’ perceptions
of their debt levels rather than the actual level of debt could be correlated to academic
performance (Ross et al., 2006). Effectively, students who worry about money tend to have
higher debt levels and perform less well than their peers. These students were also shown to be at
greater risk for mental and physical health problems (Bodvarsson & Walker, 2004; Lyons, 2004;
Lyons & Hunt, 2003). This finding is further corroborated by another study that found that
students with high debt levels are more likely to experience symptoms of depression (Dyrbye et
al., 2008). Mills et al. (1992) found that financial stress is often associated with poor
psychological well-being. In addition to symptoms of depression, Collier et al. (2002) found that
increases in educational debt were associated with increased cynicism and decreased humanism.
32

Additionally, post-graduation, highly indebted students were more likely to delay marriage,
childbearing, and major purchases (e.g., cars and houses) or they are more likely to regret
pursuing primary care (lower-compensated) professions (Rohlfing et al., 2014).
However, research further complicates the discussion surrounding student loan debt and
its impact on students’ well-being and academic experience. Zhang and Kemp (2009) found that
debt did not significantly impact academic performance and that students with high levels of debt
reported being just as happy as those without debt. But, despite this finding in their research,
they found that students with higher debt did report a significant concern regarding how they
would manage that debt. Students reported that the preoccupation with how they would manage
their debt resulted in overall less satisfaction with life and with their university (Zhang & Kemp,
2009).
Given the impact that student loan debt has on the well-being of students, medical school
administrators must take measures to increase financial satisfaction and, therefore, reduce
financial anxieties that remain even after degree completion. Archuleta et al. (2013)
recommended using financial planners and counselors. These financial experts, they argued, can
equip students with comprehensive financial plans that detail how to finance their educations and
that address the ramifications of student loan borrowing. Moreover, they contended that school
administrators, to effectively employ appropriate interventions, must be sensitive to emotional
symptoms of distress due to debt (Archuleta et al., 2013).
Financial Literacy
Financial literacy, in addition to characterizing one’s knowledge of financial topics and
one’s ability to make informed financial decisions, has been described as “a meaning-making
process” (Mason & Wilson, 2000) which focuses on the individual’s active engagement with
33

their environment to develop their financial knowledge and skills. Anderson et al. (2000)
supported this notion of a “meaning-making process” by highlighting that a truly financially
literate personal is one who possesses the ability to appreciate the full scope of their financial
decisions and who is, therefore, aware of any consequences that stem from those decisions.
Regarding financial literacy as it relates to students, studies of college students have
shown that students often do not appropriately manage their finances (Cude et al., 2006). Cude et
al. (2006) also found that poor financial literacy within students is often associated with a lack of
financial literacy within the home. In other words, students often learn their approach to financial
management from their parents who may be ill-equipped on the matter. Moreover, Cude et al.
(2006) found that effective financial literacy programs must be sensitive to these realities. They
argued that programs must provide students with continuous exposure to financial resources and
explicitly recommend practices that encourage and reinforce wise financial decisions. The
importance of a financial literacy program for health professions graduate students is supported
by research conducted by Mulligan et al. (2020), who found a correlation between financial
literacy and self-efficacy noting that the delivery of financial literacy content was effective in
combatting this deficit (Mulligan et al., 2020). Lyons et al. (2003) also found that financial
literacy programs appear to promote positive decision-making behaviors where students’
finances are concerned and that students tend to have better financial outcomes. Given the
complex nature of students’ relationship to their finances and the decisions they make, Cude et
al. (2006) argued that any effective financial literacy program that an institution adopts should be
comprehensive in its approach considering all the various contexts within which students move.
34

Conceptual Framework: Bronfenbrenner’s Bioecological Model of Human Development
A medical student’s decision-making process related to specialty selection is complex
and is impacted by cultural, educational, demographic, and socioeconomic factors. These
environmental factors have been shown to varying degrees to impact a medical student’s choice
of specialty. It is the interplay of these various influences that shape the development of a
student. Bronfenbrenner (2005) characterized human development as a process that takes place
over the duration of a person’s lifetime and that is constantly changing the characteristics of
person. The factors contributing to a medical student’s choice of specialty can be explored and
better understood utilizing this theoretical framework since it considers a student within the
context of constantly changing, interconnected environmental ecologies.
Bronfenbrenner’s framework for human development understands a person’s
development as the relationship between their experiences within the context of numerous
environmental factors (1979). Development, from this perspective, understands that an
individual is at the center of the developmental process and that it is heavily dependent upon
environmental factors, both immediate and global. Bronfenbrenner categorizes these immediate
and global environmental factors into the following systems: microsystem; mesosystem,
exosystem, macrosystem, and chronosystem (See Figure 1). The microsystem is the most
immediate of the systems and, therefore, has the most direct impact on an individual’s
development. This system is comprised of family, friends, the classroom and is characterized by
face-to-face interactions. The mesosystem is the next system that is characterized by connections
between within microsystems—for example, the connection between an individual’s workplace
and their home. The exosystem refers to larger social systems that influence an individual
indirectly through microsystems. They can include media, law, economics, politics, and
35

governmental agencies whose impact is not necessarily directly felt by an individual, but still
influence more immediate systems. The macrosystem refers to social ideologies and the values
of the cultures and subcultures in which an individual finds him or herself. This system is the
furthest removed from the individual, but like the macrosystem, impacts more immediate
microsystems. For example, if a society views a post-graduate education as a personal good, it
may be less inclined to provide financial support to post-graduate students, thus resulting in the
potential need to take out loans to finance one’s education. The chronosystem is characterized as
the time during which development takes place. An example of the presence of the chronosystem
might be the duration of a student’s enrollment in medical school and the culmination of
experiences they experience during that enrollment that shape their views on specialty
characteristics.
Process-Person-Context-Time
Bronfenbrenner and Morris (1998) went on to develop the Process-Person-Context-Time
(PPCT) model which they noted is practical for its ability to describe the relationships that occur
between an environment and developing person. Given this useful nature of the model, it has
been selected for this study to aid in understanding the various factors that medical students
consider in their choice of specialty. This model provides a framework through which qualitative
data captured from students’ characterizations of their experiences within various systems, both
within medical school and outside of medical school, can be utilized to improve institutional
practices in the hope of promoting positive student development and reducing barriers
encountered by highly indebted medical students in the specialty selection decision-making
process. Bronfenbrenner and Morris (1998) argued that through an analysis of the proximal
36

processes captured within the PPCT model, researchers can more fully appreciate the factors
contributing to a person’s development.
Bronfenbrenner’s Framework in Educational Contexts
While Bronfenbrenner’s framework has not been used explicitly within the context of
medical student specialty selection, it has been used within the context of student academic
advising. Stebleton (2011), in his study of immigrant college students and their unique needs,
utilized Bronfenbrenner’s framework to understand better the multiple contextual factors that
these students encounter. Stebleton (2011) noted that the use of this framework is supported by
the fact that students interact with the environment, including exchanges with academic advisors,
and that these interactions influence student development, success, and retention. As such, he
contends that “the philosophy of a developmental ecology approach parallels the foundational
tenets of developmental, academic advising, mainly through an emphasis on context and working
with the whole student” (Stebleton, 2011, p. 1).
Bronfenbrenner and the Current Study
Bronfenbrenner’s model (1998), with its focus on how individuals interact with their
environments, both shaping and being shaped by them, provides an opportunity for researchers
to appreciate the full scope of student development. By considering the various system set forth
by the framework and their relationship to the development of a student at the center of the
model, educators and administrators can be better equipped to recognize the processes at play
within these systems and enact practices that can promote the positive development of their
students. Bronfenbrenner’s (2005) focus on Process-Person-Context-Time emphasizes the
individual while, at the same time, providing a comprehensive view of the systems that have
been negotiated by and, in turn, influenced, the individual. This study used a qualitative research
37

design to better understand how the systems in which a student finds themselves ultimately
influence their decisions related to specialty selection.
This study utilized this framework to identify and better understand the factors
considered by highly indebted medical students when selecting a specialty. Therefore, this
framework, with its focus wide-ranging environmental systems and their contributions to human
development, can provide insight into how environmental systems might be modified to promote
more positive outcomes—namely, less financial anxiety in the specialty selection process.
Additionally, this framework is helpful in shaping how academic counselors interact with
students and how they influence the educational environment through which the student moves.
Evans et al. (2010) stated:
Ecological models can be considered integrative in the ways that they account for
multifaceted contexts for the development of the whole person. Student affairs educators
can use ecological models to understand how student development may occur and also
consider how campus environments can be shaped to promote optimal growth and
development. (p. 159)
Key Concepts
Because this study aimed to identify the extent to which student loan indebtedness plays
in the selection of specialty and their perceptions/level of satisfaction with the financial literacy
initiatives at the Pacific School of Medicine, interview questions focused on debt, financial
support, and career choice. Also, since debt may not be as influential of an indicator in specialty
selection, the interview questions also addressed emergent themes, such as socioeconomic status,
personal experience, academic experiences, and familial support.
38

Summary
This chapter presented literature surrounding the factors that may contribute to medical
students’ choice of specialty, especially related to selecting primary care career paths. It offered
an explanation of how Bronfenbrenner’s ecological model for human development can provide a
relevant and valuable framework to consider the topic of student loan debt and its impact on
specialty selection. The studies presented in this chapter have revealed the truly complex nature
of the decision-making process as it relates to specialty selection. Additionally, studies presented
in this chapter demonstrated how there is an unavoidable connection between multiple
environmental factors and students. These connections must be acknowledged and understood by
academic advisors and educators for them to be effective in aiding in the positive development of
their students. This is especially vital given the ever-increasing cost associated with pursuing a
medical education and considering the resulting debt that students incur, debt that may heavily
influence their decision-making processes related to specialty selection. As has been discussed,
this issue is of importance not only to students and to the mission of medical schools but also to
society at large. The following chapter will provide a detailed overview of the methodology
employed this qualitative study.

39

Chapter Three: Methodology
As has been noted, multiple studies have attempted to address the degree to which
student loan indebtedness influences specialty selection among medical students (Gil et al., 2016;
Grayson et al., 2012; Kahn et al., 2006; Morra et al., 2009; Phillips et al., 2010; Phillips et al.,
2016; Webster et al., 2017). The results of these studies have been inconclusive, with some
showing no correlation and others finding that there is a definitive relationship. The bulk of
research on the topic has been in the form of quantitative analysis, but little qualitative research
has been performed to understand the processes employed by medical students in their selection
of specialty. Moreover, much research centers around the result of specialty selection (i.e., which
specialties students select) but little on the actual process by which medical students ultimately
selected those specialties.
Research Approach
This study sought to address this gap in the literature and to provide greater insight into
how debt is considered, personally, by highly indebted medical students when selecting their
specialty. Given the emphasis on understanding, a qualitative research approach allowed for a
richer understanding of students’ experiences with debt and its resulting impact on specialty
selection. Through this means of inquiry, this study, in the vein of Bronfenbrenner’s (1993)
ecological model, sought to allow the researcher to gain crucial insight into the environmental
factors confronted by medical student and how students negotiated these factors. Merriam and
Tisdell (2015) stated that qualitative research is “interested in understanding how people
interpret their experiences, how they construct their worlds, and what meaning they attribute to
their experiences” (p. 6). By carefully considering medical students’ experiences with debt and
how these experiences shaped their decisions to pursue the career paths they chose, this study
40

aimed to provide insight into how institutions can tailor their practices to encourage the positive
development of their students. Since educators and administrators are vital forces within
students’ environments, understanding how their actions—or inactions—promote and inhibit
their students’ development is essential for the institution’s development. The potential for
inquiry into this topic includes knowledge about highly indebted medical students’ anxieties,
needs, and desires. This knowledge can influence how educational and monetary resources can
be harnessed to promote positive student development around financial security and maturity.
As has been noted, the framework of this study was grounded in Bronfenbrenner’s (1979,
1993) ecological framework for human development. Therefore, the development of participants
in this study was viewed in relation to environmental factors in a constant state of
interdependence (i.e., family, school, friends, classroom, clinical settings). This assumption
guided the current study by focusing on students’ narratives and how they described the
influence of these environmental factors in their decision to pursue their selected specialty. An
interpretive perspective was utilized since emphasizing student meaning-making was central to
this study. Merriam and Tisdell (2015) noted that an interpretive (constructivist) epistemological
perspective is used when describing, interpreting, and understanding a phenomenon is desired.
Moreover, this perspective is useful as it acknowledges multiple realities bound by context, thus
encapsulating the wide range of influences described by study participants.
Participants
Since the current study was centered around the experiences of highly indebted medical
students and the role their debt has played in their selection of specialty, the following criteria
were established in identifying participants: (a) students with greater than $250,000 in medical
student loan debt; and (b) students who graduated, who applied to, and who ultimately entered a
41

residency program post-graduation. Student loan debt had to be loans reported to the university
(e.g., Federal and Private Student Loans). Therefore, personal loans from parents and relatives
could not be considered as their repayment terms may have varied and ultimate repayment of
these loans could not be established.
Sampling and Site Selection
This study adopted a purposeful sampling based on convenience. All graduates of the
PSOM class of 2020 were invited, via email, to participate in the study. The email invitation
explained that the focus of the study was on those graduates with high levels of student loan
indebtedness and how they arrived at their decision to pursue their chosen specialty. For this
study a high level of indebtedness was defined as a principal balance of greater than $250,000.
For convenience and institutional relevance, all candidates were from the researcher’s home
institution. The researcher had hoped that eight to ten participants would volunteer to participate
in the study. Should more than ten students had expressed a desire to participate in the study, the
researcher would have adopted the following method for selecting participants: (a) those with the
highest levels of debt would be selected, and (b) a sample that most closely approximates the
entire potential participant pool would be created.
Instrumentation
The researcher used a semi-structured interview to garner data. The interview questions
were rooted in Bronfenbrenner’s (1979) model for human development and Bronfenbrenner and
Morris’s (1998) PPCT model. Questions were, therefore, framed to elicit information regarding
potential forces within the various contexts (systems) outlined in the model that may have
impacted a student’s specialty selection. One example of a question posed in the interview was,
“Are you able to describe the kind of support that your family has provided to you as you pursue
42

your medical degree (e.g., emotional, psychological, financial)? The purpose of this question
was to draw out of the participant environmental factors (like the family) that may have shaped
their development in medical school and that could have, in turn, influenced their perception of
student loan debt and their ultimate choice of career path. Another example of such a question
meant to elicit this type of information was, “Can you describe any negative clinical experiences
while a student at PSOM that have impacted you?” See Appendix D for the complete Theoretical
Conceptual Framework of Questions.
Data Collection
Data for this study were generated through interviews with highly indebted (>$250,000 in
federal/private student loan debt) medical students who applied to and were accepted into a
residency program. However, data were also derived from public reports and documents
available to the researcher in order to triangulate data and better understand the phenomenon
while simultaneously placing it within the greater (national) context of student loan indebtedness
and its potential impact on specialty selection. Creswell (2014) noted that qualitative research
often draws upon multiple data sources. In doing so, the researcher is better able to make sense
of themes and patterns that emerge through the data collection process.
Graduates who responded to the email survey expressing interest in participating in the
study were then contacted by the researcher via email. The email conveyed the purpose of the
study, expressed confidentiality measures that would be taken for each participant, and laid out
the interview process (e.g., time, place, duration, and means of recording). Once participants
were secured, interviews were scheduled and took place virtually via Zoom as many of the
participants were no longer local and since the pandemic of 2020 mandated such interactions.
43

Before conducting each interview, the researcher reviewed the interview protocol with
each participant, and consent to record the interview was attained once again. (See Appendix A)
The researcher posed questions directly from the questions detailed in the interview protocol.
However, given the semi-structured nature of the interview, follow-up questions were permitted
and ultimately did emerge from the participants’ responses, so additional questions were, when
necessary, asked. The additional questions allowed for what Creswell (2014) described as
“emergent design,” which describes the fluid nature of qualitative studies (p.186). Since
qualitative studies focus on the full range of human experiences, they must be adaptive, changing
with collection of data that may not have been anticipated by the researcher. The tendency
toward “emergent design” as characterized by Creswell (2014) was present in the current study.
Immediately following each interview, the researcher noted observations that contributed
to the data obtained during the interview. Of particular importance were themes that arose during
the discussion and that aided in the coding during the data analysis. The interview was then
transcribed in preparation for analysis (i.e., coding).
Interview Protocols
The structure for the interview protocol was semi-structured, as characterized by Merriam
and Tisdell (2015). As such, questions were, to a certain extent, structured and placed in a
deliberate order. However, flexibility was allowed for all questions despite specific information
being gathered from all participants. This approach allowed for themes not necessarily
considered before the commencement of the study to emerge. The questions posed to participants
by the researcher were broken into five overarching categories. The first category was meant to
garner information on students’ motivation to pursue a career in medicine and why they chose to
attend PSOM. This information, the researcher hoped, would provide insight into students’ initial
44

goals in medicine and provide a contrast for potential changes in those goals. The second
category meant to capture information on students’ medical school experiences that may have
impacted on their career trajectory in medicine. The third category focused on the types of
support that students received from or provided to family or friends that may have impacted
specialty selection. The fourth category of questions meant to explicitly obtain information about
the factors that went into their decision-making process and determine if financial considerations
were at play. If they were, to what extent did they influence students? Finally, the fifth category
of questions aimed to obtain students’ perceptions of the school’s financial literacy and debt
management program as a potential mitigating factor in their decision-making process.
Moreover, these questions were meant to garner information about its perceived benefits and
effectiveness. These questions were rooted in the conceptual framework that students can often
make specialty selections based on financial considerations (i.e., student loan indebtedness and
earning potential) and the idea that financial literacy programs, clinical experiences, and
emotional, psychological, and financial support can be instrumental in exacerbating or mitigating
the importance given to these financial considerations. (See Appendix D)
Data Analysis
Creswell (2014) recommended adopting a systematic, step-by-step approach to data
analysis. Such an approach will not only help guide the reader as they review the researcher’s
finding, it will also assist the researcher is missing themes present in the data and might be
overlooked This approach, as set forth by Creswell (2014), includes six steps: (1) organize data
in preparation for analysis; (2) review data; (3) code the data and break into relevant themes; (4)
produce descriptions of people and settings; (5) decide how descriptions offered within the
45

narrative, and (6) interpret the findings (p. 197). This framework for data analysis was employed
by the researcher.
Additionally, Merriam and Tisdell (2015) noted that through the simple, yet laborious,
act of transcribing one’s interviews, a researcher affords themself another opportunity to
generate insights and intuitions into the data being collected (p. 132). They noted that this
process of transcription, and the insights it can subsequently generate, is an essential form of data
analysis, useful in its ability to aid in the identification emerging themes in the process of
triangulating data. Accordingly, the researcher reviewed each interview several times to ensure
that identified themes/patterns were truly pronounced and that another investigator would,
therefore, most likely identify the same themes.
Validity
Creswell (2014) defined validity in qualitative research as a process by which a
researcher checks for the accuracy of the findings by employing procedures that include, but are
not limited to, triangulation, member checking, detailed description, clarification of bias, and so
forth. Lincoln and Guba (1985) assert that validity of qualitative research is achieved when it
demonstrates credibility (e.g., plausibility, believability, and accuracy), transferability (e.g., the
extent by which the findings can be applied to other situations), dependability (e.g., the
consistency of the research design), and confirmability (e.g., the replicability of a study).
Maxwell (2013) noted two specific threats two validity within qualitative research:
researcher bias and reactivity. Researcher bias refers to the worldview held by the researcher and
may influence the conclusions drawn in the study. This influence can be found even at the
genesis of the study as research questions are being developed and interview questions
formulated. Since the researcher is an instrument in the study, identifying these biases will help
46

limit their influence on the study and provide transparency to the reader. Reactivity is defined by
Maxwell (2013) as and actual influence that a researcher may exert on a setting or over the
participants of a study and that can influence that data that emerges from the study. Maxwell
(2013) stressed that it is impossible to eliminate the influence a researcher exerts on a study.
Instead, he states it is imperative to acknowledge it and use it constructively. Specifically, the
researcher should avoid leading questions that may influence the data collected while conducting
the interview.
Limitations
This study was site-specific, and interviews were limited to a small number of students.
Consequently, the generalizability of the study was one significant limitation. However, as
Maxwell (2013) stated, qualitative studies do not necessarily concern themselves with external
generalizability. This study was, as a result, focused on internal generalizability. On this note,
Maxwell (2013), again, offered advice, stating that researchers should avoid overgeneralizing
similarities in themes and patterns that emerge from the data. Additionally, researchers must pay
attention to and be receptive to differences in the data. By engaging in such practices, the
researcher decreases the likelihood that they will erroneously apply theories that may not fully
the findings revealed through data analysis.
Another limitation of the study was researcher bias. Since the researcher is an integral
actor within qualitative research, their values and beliefs can never be divorced entirely from the
conclusions drawn from the data. Creswell (2014) noted that this reality need not be a
disadvantage in the study. A researcher, according to Creswell, should, instead, be forthright
about their bias. Through self-reflection, Creswell maintained that a researcher can be clear
about their worldview, as shaped by their background and experiences, and how they, in turn,
47

may influence their interpretation of the data. As it relates to this study, the researcher, in his
capacity at the study site, was responsible for providing students with debt management advice.
As such, the researcher was personally invested in the study at hand. The themes that emerged in
the study could directly impact on the work that the researcher does. Additionally, the researcher
had already established a relationship with the subjects, which may have proved beneficial in
soliciting data from them. However, it could simultaneously inhibit participants from providing
more forthright responses should they feel that their responses could be deemed a critique of the
work conducted by the researcher in his capacity at the institution.
Sample size and the timing of interviews proved to be another limitation of this study.
Since the survey was conducted during the 2020 pandemic, a minimal number of graduates from
the PSOM Class of 2020 took part in the study. A total of six students were ultimately
interviewed for the study. However, interviews with each participant were a minimum of forty-
five minutes to an hour and provided rich sources of information. Nevertheless, the study would
have benefited from more participants to provide more data and ensure saturation.
Finally, the reliance on convenience sampling for this study meant that all participants
self-selected. As a result, the researcher could not ensure a pool of interviewees most
representative of the PSOM graduating class of 2020. Furthermore, since potential participants
for this study had already graduated, dispersed, and begun their residencies; thus, securing
research participants to interview proved difficult.

48

Chapter Four: Findings
The purpose of this study was to better understand the factors that impact medical
students’ specialty selection and, particularly, the role of student loan debt in that selection. This
study explored factors that influenced their selection of specialty by (a) understanding career
motivations and aspirations; (b) understanding participants’ decision-making processes in
making their final decisions about specialty selection, and (c) understanding how financial
literacy resources and debt-management counseling sessions may have influenced the decision-
making process by possibly mitigating stress surrounding loan repayment. The researcher
interviewed graduates of the Pacific School of Medicine (PSOM). The results of this study
contribute to the knowledge of the role that student loan indebtedness plays in the academic and
post-academic experiences of students who incur high levels of debt because of attending
medical school. This knowledge, in turn, may influence how private medical schools provide
financial support and counseling services to students who are likely to incur high levels of
student loan debt. As such, students may be better informed about the ramifications of their debt
and its potential impact on specialty selection. The study participants will be described, and
qualitative data will be reported. This chapter will discuss the four overarching themes that
emerged in the data: (1) Specialty Selection as a Contextual Process; (2) Debt Management
Counseling and Financial Literacy as a Mitigators of Financial Anxieties; (3) Perceptions of
University Financial Support; and (4) Student Debt and the Academic Experience.
Theme One emerged from the data compiled pertaining to research question one. And
will be further broken down into the following sub-themes: (a) foundations of interest in
medicine; (b) medical school selection; (c) family obligations; (d) clinical experiences; and (e)
the role of debt. Theme Two emerged from data compiled concerning research question two and
49

will be further broken down into the following sub-themes: (a) financial literacy resources; (b)
one-on-one debt management meetings; (c) loan repayment programs; and (d) loan forgiveness
programs. Theme Three emerged from data compiled relating to research question two. It will
discuss students’ perceptions of financial support provided by the university. Theme Four
emerged from the data as an emergent theme that did not directly flow from the research
questions presented in this study. This theme will be further broken down into the following sub-
themes: (a) lack of access to academic resources due to dependence on student loans; and (b)
lack of social engagement due to student loan dependency and financial constraints.
Review and Data Collection Methods
This study used a qualitative research design. Data was collected utilizing a semi-
structured interview. A complete overview of the interview protocol utilized by the researcher
can be found in Appendix A. To participate in this study perspective participants had to meet the
following criteria: (a) 2020 graduate of the Pacific School of Medicine; (b) currently in a
residency program; and (c) greater than $250,000 in debt incurred while enrolled in medical
school. The researcher invited all potential participants in this qualitative study via email. The
researcher sent the email invitation to all graduates of the Pacific School of Medicine Class of
2020. The researcher provided all graduates with a study description and invited them to
complete a survey if they were interested in participating in the study. Each graduate provided
informed consent before the study was conducted. Six graduates ultimately participated in the
study. The researcher conducted all six interviews virtually via Zoom. Interviews were
simultaneously recorded with the consent of each research participant. Audio files were then
transcribed and coded.
50

Description of Participants
For context, the Pacific School of Medicine’s 2020 graduating class consisted of 178
students. The average indebtedness of the PSOM’s class of 2020 was roughly $226,000 (U.S.
News and World Report, 2021). This level of indebtedness was 9.6% greater than the national
average of medical student loan indebtedness among all medical schools and 3.2% greater than
the average among all private medical schools (AAMC Debt Facts Card, 2020). This level of
indebtedness was also an increase of 4% over the prior year’s average indebtedness. In the
previous year, the average increase in the average indebtedness for all medical schools was 3%
and for private medical schools a 2% increase.
Graduates were asked to report their level of debt acquired in medical school. Four of the
six interviewees graduated with greater than $300,000 in medical school debt—one of which had
greater than $400,000 in medical school debt. Two interviewees graduated with greater than
$250,000 in medical school debt. Two participants could offset a portion of their educational
costs by living with their families during medical school. All other participants in this study
financed one hundred percent of their cost of attendance using federal student loans (i.e., Federal
Direct Unsubsidized Loan and Federal Direct Graduate Plus Loan). Finally, of the six graduates
interviewed for this study, only two went into primary care fields, the remaining four participants
chose to pursue emergency medicine. (See Table 2) Table 3 further breaks down medical student
loan indebtedness as it relates to the race and ethnicity of the research participants. Table 4
breaks down debt as it relates to gender. Table 5 breaks down debt at it relates to specialty
selection. Table 6 breaks down specialty selections as it pertains to race or ethnicity and, finally,
Table 7 breaks down specialty selection as it relates to gender.
51

Participant Profiles
The following section provides a brief profile of each graduate who participated in this
study to provide some additional information about their respective backgrounds. Please note
that pseudonyms were be used for each graduate to keep the identities of each participant
anonymous.
Graduate 1: Nancy
Nancy was in her early thirties at the time of the interview. She was also married and had
a young child. Nancy was an immigrant of African descent. She and her family reside in
Southern California. She was the first of her family to graduate from medical school. Nancy
graduated from medical school with roughly $270,000 in student loan debt. She ultimately chose
to pursue a career in primary care as a doctor of family medicine.
Graduate 2: Raymond
Raymond was in his late 20s time of the interview. Raymond was not married but was in
a long-term relationship with another graduate of medical school. Neither had children.
Raymond’s family was of Middle Eastern descent and had immigrated to the U.S. before his
birth and settled in Southern California. Raymond was the eldest child in his family. He was the
first in his family to graduate from medical school. Raymond graduated from medical school
with roughly $345,000 in student loan debt. He ultimately chose to pursue a career in emergency
medicine.
Graduate 3: Tina
Tina was in her mid-twenties at the time of the interview. Tina was from an Asian-
American background and grew up in Southern California. She was married without children.
Tina was the first in her family to attend medical school. She graduated from medical school
52

with roughly $288,000 in student loan debt. She ultimately chose to pursue a career in primary
care as an internist.
Graduate 4: Guillermo
Guillermo was in his late twenties at the time of the interview. He was of Mexican
American descent and from Southern California. He was the first in his family to attend medical
school. Guillermo graduated from medical school with roughly $305,000 in student loan debt.
He ultimately chose to pursue a career in emergency medicine.
Graduate 5: Levy
Levy was in his mid-twenties at the time of the interview. He was of Asian-American
descent and was from Southern California. He was the first graduate of medical school in his
family. Levy graduated from medical school with roughly $315,000 in student loan debt. He
ultimately chose to pursue a career in emergency medicine.
Graduate 6: Sara
Sara was in her mid-thirties at the time of the interview. She was of Caucasian (White)
descent. Sara decided to pursue a career in medicine in her late 20s. She was the first in her
family to attend medical. Sara graduated with roughly $400,000 in student loan debt. She
ultimately chose to pursue a career in emergency medicine.
The sections that follow will provide a narrative analysis of the results of this study.
Primarily, the following two research questions that were presented in this study will be
addressed:
1) How did graduates at the Pacific School of Medicine consider their level of
student loan indebtedness when selecting the specialties to which they applied?
53

2) What were these students’ perceptions of the financial literacy support services
they received at the Pacific School of Medicine?
Additionally, a discussion of the themes that emerged from the data will be offered to more fully
understand the role that debt may play in the various contexts and environments within which
these highly indebted participants found themselves.
Results: Research Question One
The first research question in this study sought to understand the factors that highly
indebted students consider when determining which specialty to select. The purpose of this
question was to determine the extent to which debt plays a role in their decision-making process
since much of the research on this topic has produced mixed findings (Gil et al., 2016; Grayson
et al., 2012; Kahn et al., 2006; Morra et al., 2009; Phillips et al., 2010; Phillips et al., 2016;
Webster et al., 2017). Moreover, should debt not be a determining factor in specialty selection,
which factors are highly indebted graduates of medical school considering? The following
section will present findings on this subject and highlight the highly contextual process
participants in this study utilized when approaching specialty selection.
Theme One: Specialty Selection as a Contextual Process
One major theme that came out of the data relates to the highly contextual process that
participants in this study employed regarding their selection of specialty. All participants in this
study revealed that their choice of specialty was a highly nuanced process that they could not
distill down to one or two factors. Instead, the decision-making process, in many ways, began
even before attending medical school. Factors considered by participants in this study included
initial motivation for going into medicine, clinical experiences in medical school, familial
obligations, and debt. None of these factors, on their own, determined the field into which each
54

participant would enter. Instead, each of these factors would inform one another and be weighed
together in the decision-making process. The following sections will explore the factors that
contributed to participants’ selection of specialty beginning with why they chose to pursue
medicine and why they chose to attend PSOM. Later sections will detail the primary factors that
participants considered when selecting a specialty.
Foundations of Interest in a Career in Medicine
All participants in this study indicated that in addition to love of science, they were drawn
to a potential career in medicine out of a desire to give back to the communities from which they
came. This desire to give back was often rooted in an acknowledgment of the lack of healthcare
resources available to them and their immediate families growing up, or by an encounter with a
healthcare worker who left a lasting impression upon them at a young age.
When she and her family moved to the U.S., Nancy told of how they experienced much
disorientation, especially around healthcare services available to them. She shared that she and
her family could establish themselves through the development of networks at institutions like
her elementary school. While in school, she built a strong relationship with her school nurse who
showed her and her family how to navigate the healthcare system. This relationship was pivotal
to her career aspirations. She said,
She [the school nurse] really changed me…how she helped us with resources made me
think of how I want to be that kind of person for someone. I want to be a point-person,
helping people and letting them know what is available to them. I want to help them meet
their needs.
Nancy went on to say that while growing up in Africa in a small village, she was very much
aware of how few resources were available to her and her family. She stated:
55

I grew up with very few medical resources, and I wanted to solve this problem. And I
don’t want to just write a prescription—I want to provide holistic care to patients. I want
to help my patients be empowered to take control of their healthcare.
Raymond also voiced a desire to help people but in a “meaningful” way. On the topic of
initial motivations for pursuing a career in medicine, he said,
I am good with science, and I majored in biopsychology, but I couldn’t just do research; I
am a social person. I wanted to do work where I interacted with people, and because I am
good at science, I put that concoction together, and I was like, “Okay, medicine.”
He noted that medicine was a career path that would allow him to not “just push papers,” but “to
do a real public service for people who need it.” Medicine, he conveyed, was a profession that
would allow him to be “a part something greater than himself and give back to people truly in
need.”
Tina noted that for as long as she could remember she had always felt that it was
important for her to “contribute to the lives of others and to help those in need.” Medicine,
according to her, allowed for a merging of her two passions: literature and science. Tina stated
that she was fascinated by the idea of a storyline. She noted,
I felt like, growing up, I had a lot of difficult experiences, and so the way I tell that
personal story shapes who I am now. In medicine, not only is there science behind
medicine; there is an art to it. I really wanted to be able to help people and to have that
opportunity to be a part of their story. That is the most rewarding part of helping people,
to know that you maybe had a positive impact on their narrative.
Guillermo attributed his interest in medicine to an early encounter with a pediatrician
who was of Latino descent. He recounted,
56

I was fortunate to have a Latina doctor as a pediatrician. I remember being impressed that
there was someone like me who was a doctor and different from everyone around me
[who were not doctors]. But it let me know that if she could do it, I could do it, too.
He noted that he was always a social and interactive person and that character trait of his, along
with his love of science, furthered his desire to pursue medicine as a profession. He said,
I really appreciate how in medicine you get to impact peoples’ lives. I feel like you can
make a lasting impact. Plus, as a Latino I get to be an example of how other brown kids
can be doctors, too. That is important to me.
Levy noted that a career in medicine was a natural fit because, most of all, it would allow
him “to make a positive impact on peoples’ lives.” However, he went on to say that it was a field
that would be “intellectually challenging and interesting, something that I could get up in the
morning and feel excited about doing every day. I could really touch people’s lives and be
stimulated.” Moreover, Levy shared that a career in medicine would allow him to truly “engage
the community….and give back to the community that you come from.” He explained,
Sometimes it’s really hard if you set your sights on changing the world, that’s not always
a realistic goal and that’s such an abstract and vague and sometimes intangible goal, and
it’s really hard to make tangible steps and progress towards that goal if that’s the goal you
set for yourself, but you can change the realities for those you work with in the
community.
He expressed a strong desire to remain rooted in his community stating that “as a physician I
hold this white-collar job, with that invariably come some status and authority, but I want to
remain true to my roots and fully engaged with my community.”
57

Sara, like all other participants in this study, expressed the fact that medicine, in addition
to speaking to her love of science, allowed her an opportunity to work with communities that are
so often overlooked and, as a result, underserved. She revealed,
I didn’t always know that a career in medicine is what I wanted to pursue. I made the
decision to go to medical school later in life, I was older than almost all of my
classmates. But I chose to come to medical school because I witnessed first-hand how
hard it is to navigate the healthcare system. I had trouble getting the help that I needed. I
could only imagine how people from underserved communities are at a loss. It just
didn’t sit well with me. So, I was already trying to figure out what I wanted to do, not
really getting anywhere. I knew I wanted to help people, but I didn’t really know how.
But I realized as a doctor I could help people. I wanted to have a positive impact, and I
thought that this [a career in medicine] was the best way for me to do that.
Medical School Selection
Participants in this study overwhelmingly indicated a desire to attend PSOM rooted in its
location and in the community it serves. Specifically, an urban setting that serves historically
underserved (i.e., Black and Latino) communities. Participants often expressed that PSOM
afforded its students with opportunities to work with people with whom they identified directly,
and for whom, in many cases, they had specifically chosen a career in medicine to assist.
Nancy’s decision to attend PSOM was grounded in a positive experience at the hospital
affiliated with the university. She recounted explicitly the experience of one of her family
members who gave birth at the hospital. She stated that her cousin, not knowing how to navigate
the healthcare system as an immigrant, was scared, confused, and lost. However, healthcare
58

providers her cousin encountered at the hospital took time to get to know and guide her. Nancy
recalled,
[S]he [her cousin] was so needy because she did not have her foot in the door, she was
practically homeless, or home insecure, she did not have a lot of resources, but the
doctors and mid-wife really helped her and the rest of my family. That really made an
impression on me. When I spoke to the doctors, they told me that they went to PSOM and
I was like, “Wow, I want to be like that. I want to do what they do.” That was really
when PSOM became the place I wanted to go. Not to mention that my family doesn’t live
far from PSOM, so it was like a perfect match.
Raymond stated that PSOM was his first choice in medical school for several reasons. He
explained,
[I]t is a prestigious school. That was a big deal for me. I wanted to go somewhere I would
get a solid education and whatnot. But it also helped that it was in Southern California
near my family and friends which made me feel comfortable and secure.”
However, it was the community that PSOM serves that genuinely appealed to Raymond. He
wanted to help those in need—people who were too often overlooked. During one of his
interviews for admission, his desire to attend PSOM was solidified. He told of a specific time in
which the Dean of Admission was asking interviewees whom PSOM serves. Each interviewee
offered up politically correct responses to characterize the population served by PSOM, all of
which the Dean shot down. It was not until someone said, “Poor people.” that the Dean
approved. Raymond stated,
59

That really made a huge impact on me—the fact that we could just be ourselves and
know that we are helping poor people which is what my motivation was. I like that
PSOM didn’t shy away from that. I wanted to be a part of that.
Having grown up in the community around PSOM, Guillermo was very much aware of
the community it served, which was a primary motivator in his choosing to attend PSOM.
Guillermo stated of the hospital affiliated with PSOM:
It has always been a part of my life. I’ve seen it every day, it was constantly present in
my life, and I was part of the community it served. And, funny enough, my dad was part
of the construction team that built the new hospital. He literally built it. And, so, I was
like ‘Okay, this is where I need to be.’ I am part of this community and I want to give
back to it. [PSOM’s] whole mission of serving the underserved just really attracted me to
it.
Levy spoke to PSOM’s commitment to community service at its primary appeal to him:
I felt that PSOM was a very community-driven institution. PSOM, I feel, their mission
was very community oriented. Just the fact that PSOM is in an underserved urban area, in
and of itself, I felt that was really appealing to me. I really respect that PSOM is situated
[within] the community it aims to serve. Plus, you know, PSOM has a lot of community
engagement programs and initiatives and make a deliberate effort to do outreach in the
community and to really partner with other schools in the community, with other
organizations in the community to make a positive impact. That really appealed to me.
Also, the clinical exposure you get at PSOM starting in your first year I thought was
really cool.
60

Factors Influencing Specialty Selection
Another central theme in the data relates to the complex, multi-faceted process
participants in this study employed when arriving at their chosen specialties. All participants
indicated that although debt was a consideration in their initial decision-making process, and
constantly present in their minds, their decision-making process was a much more nuanced
process that could not be reduced to one factor. Ultimately, all participants in the study indicated
that their passion for their chosen career path took precedence, along with several other factors
that would impact their lives post-medical school. Many revealed that regardless of earnings or
the promise of more structured work schedules that more competitive and highly compensated
fields could provide them, it was far more important for them to pursue a specialty that would
keep them mentally stimulated, interested, motivated, and connected to the communities they
always sought to serve. However, several participants also revealed how they chose to practice in
their chosen fields post-residency was still likely to be highly influenced by their debt and their
ability to pay it off in a reasonable timeframe—within 10 to 15 years of completing their
training. Career passion was in many cases tied to experiences that the participants had both
before attending medical school and while in medical school. In the sections that follow, the
experiences that each participant shared in this study will be shared to provide context to the
ways in which each participant approached a career in medicine and how and why they chose to
pursue their respective fields.
Family Obligations
Several participants in this study noted that they felt a moral obligation to be able to
provide financial support to their families. In some cases, this was due to financial support they
had received while students within their medical studies, and that was explicitly expected to be
61

returned for the good of the family. In other cases, this obligation was born out of an
acknowledgment that given the socioeconomic status of their families (namely, their parents)
they must provide support in the future. Moreover, several participants noted that while long-
term earning potential was not at the forefront of their minds when selecting their specialty, they
acknowledged that shorter training periods were. Specifically, they noted that shorter training
periods post-medical school were appealing because they would allow them to begin earning an
attending’s salary earlier. This would, in turn, allow them to provide more substantial financial
support to their families and financially establish themselves sooner.
Raymond spoke of the need to provide financial support to his family at the request of his
parents. He revealed that he was the eldest of three brothers. His father, the sole income provider
in his family and who has been chronically ill, made explicit that he would need to provide
financial support to his youngest sibling. He said of this obligation:
I got to make sure I’m financially stable and I not going to buy a big fancy house because
I would rather have the financial flexibility to make sure that people in my family are
taken care of. I want to make sure my brother has his education and I want to be able to
save for my parents, so they have a safety net in case things go south.
These considerations made his decision to go into emergency medicine more appealing since he
would have a shorter training period and could, therefore, make a higher salary sooner.
Moreover, he could choose to work more and earn more, so there was more autonomy in
influencing his earning potential.
Tina expressed concern with her ability to provide financial support for her family. She
intimated,
62

I was weighing family medicine and internal medicine, there is not a huge difference in
the earning potential, but I can specialize and make more if I go into internal medicine. I
had to think of that because I feel like as my mom's getting older and my grandma's
getting older, my dad's getting older, and then my brother doesn't work, so then,
ultimately, I'm like the only person who's going to be able to provide if my mom lost her
job... because she's the only one working. So, if she wasn't able to work anymore, if
anything happened, then I would be the only person that would have to provide
financially for all of them. And then that would be medical, housing, and then also just
long-term, if they ever needed a nursing home or if they needed assisted living or if they
needed a caregiver, and all of that is super expensive. So, I think about that all the time
and I'm like, “How am I going to save enough money for this?"
She explained that if needed, she might even forgo a fellowship if it resulted in making money
sooner to support her family. She stated, “I would probably just put it [fellowship] off, so I could
make the additional salary to be able to help my family.”
Guillermo spoke more to a moral obligation to take care of his family as they grow older.
His desire to support his family is rooted in the financial investment they made in his
undergraduate degree. Guillermo stated,
It's not something that's been explicitly said, but it's like I want to be able to take care of
my parents at some point. They could've used this money on themselves. They could
have used this money to invest. So, they invested it in me. I feel like there should be
some return. I just feel there's just something I have to be able to give them financially.
They should be able to get those benefits of this investment.
63

Levy spoke to a desire to provide a better life for his family, who immigrated to this
country. He told of his father and mother, who worked very hard and often in many odd jobs to
put him in a position to attend medical school. Levy shared,
My parents were very frugal and smart with their money. I could see that they were
making specific financial decisions that would benefit me and my future. So, I want to be
in position to be able to help them if needed. So even though I didn’t choose a specialty
that makes a lot of money, I did pick a specialty [emergency medicine] that allows me to
make a higher salary quicker. My residency is only three years, so that was definitely a
plus.
Clinical Experiences
Participants in this study often brought up clinical experiences when describing how they
came to select their respective specialties. These encounters with patients and other healthcare
professionals, both positive and negative, were often crucial to how the participants in this study
felt about certain specialties. Participants indicated that exposure to primary care fields often left
them impressed by the work conducted in those fields and left them lacking the area of
excitement. As a result, all participants who chose to enter emergency medicine did so because
they felt it was a field that allows them to work directly with their patients while providing a
tangential form of primary care. However, unlike primary care, they expressed that emergency
medicine was more dynamic since it does not necessitate long-term, routine care inherent in
many primary care fields. Those who chose to go into primary care were particularly drawn to
the what they deemed as the predictability the field provides and the flexibility it can offer in the
future. These characterizations of primary care versus non-primary care fields were largely
formulated by participants’ clinical experiences.
64

Levy noted that despite going into emergency medicine, he did have an extremely
positive clinical experience while enrolled at PSOM that led him to seriously consider a career in
primary care, specifically pediatrics. He recalled a doctor whom he shadowed:
This doctor I was shadowing, he saw patients from Mexico, from Guatemala, from
Central America, patients who had deliberately traveled to the United States to be seen at
[this specific] hospital because they couldn't get the care that they needed in their home
countries. The specialists' care at [this hospital] was what they needed. I just saw the
impact that he had on those patients' lives, on those patients and on their families as well.
The truly life-changing work that he did and the life-changing treatment that he provided,
that left a really big impact on me and that really inspired me, seeing this guy. Here he
was this white physician, but he spoke Spanish fluently. It was a big part of his job
because a lot of his patients came from Central America. He had the whitest accent ever.
His vocabulary, grammar was all perfect. He was fluent, but his accent was just awful. It
was so Americanized and so English sounding. Regardless of that, he did such amazing
work, and he was so good with the patients. He had such great rapport with the patients
and with the families. He could crack jokes in Spanish. He was so good with the kids and
I thought, ‘Wow. This guy is really making a difference. He's actually, tangibly changing
people's lives.’ That really inspired me and that got me thinking about pediatrics for some
time.
Levy indicated that he ultimately chose emergency medicine because he felt he could have the
same impact as this doctor, but with a greater number of patients. He found this to be exciting.
He intimated, “I really like the work that primary care physicians do, but I like the dynamics of
65

emergency medicine. Every day is something new, but you’re still working with people who
really need you.”
Raymond revealed that he entered PSOM already inclined to pursue a career in
emergency medicine but that he was genuinely open to other fields of medicine. In fact, he
completed research in the field of pediatrics. He had this to say about his rotations:
I loved all of them, especially OB-GYN and pediatrics. I would do the rotations and say
to myself ‘I could do this.’ But always I was thinking about how I could help so many
people in emergency medicine.
He went on to express the role of the attendings in these clinical experiences:
It had a lot to do with the attendings. Like the one in OB-GYN and peds were so
passionate about what they did, and you could feel it. I didn’t get that same impression
for attendings in neuro and cardiology. It kind of reaffirmed that I wanted to have more
of a relationship with my patients…primary care and emergency medicine do that. It was
always going to be pediatrics or emergency medicine for me.
Nancy noted that she was always going to go into a primary care field. It was just a
question of which field within primary care she would ultimately choose to pursue. She stated
that primary care provided her with a career path conducive to the lifestyle that she wanted to
have. She revealed of her clinical experiences:
I had experiences in the E.R. and while I was in my OB-GYN rotations that were not
necessarily negative, but profound. Like we had a guy who came in with a gunshot and
was extremely traumatized. That was a hard situation having to be there to comfort him. I
was happy that I could be there for him, but it was hard. And in OB-GYN having to deal
with babies who were very sick or that died. I could not do that for my mental health.
66

That’s why, I think, family medicine was for me. And I could be more balanced which is
really important to me if I want to have a family. With family medicine I would be able
to have a more stable schedule and have deeper relationships with my patients.
Sara revealed that she was seriously considering family medicine and emergency
medicine. She noted that when she initially entered medical school that she was inclined to go
into primary care. She shared, “When I came to [PSOM] I was already thinking that I was going
to go into primary care because I really wanted to work with underserved communities. That was
my goal.” Sara went on to share that her clinical experiences strengthened her interest in primary
care:
I was amazed by the doctors I worked with, they were all so passionate about patient care
and you could tell they really cared. I had experiences in other rotations that were not
positive mainly because it didn’t feel like the patient was the main priority, they were
more like a task. But with especially my family medicine and emergency medicine
rotations, there was a sense that the patient is first, and we are directly impacting them.
Role of Debt in Specialty Selection
Participants in this study all indicated that debt, while a serious concern, was not the
primary factor in determining the specialty they would pursue. Nevertheless, debt would impact
how they chose to approach their selected specialties. As has been noted, participants indicated
that being passionate about the work they were going to do was far more important to them than
how much money they would make in that profession. The reasons for this approach to specialty
selection and debt management varied. However, they were largely grounded in varying
approaches to lifestyle, debt (acceptance), loan repayment, and forgiveness programs that
67

provide students with a sense of ease concerning the short-term and long-term management of
their debt.
Nancy stated that while there was a concern with her debt and how she would ultimately
pay it off, that would not dictate what kind of medicine she would practice. However, she
revealed that her debt would impact her approach to how she practiced. Nancy revealed,
I think that my debt was enormous that I didn't know exactly what I would do…. [but] I
wouldn't say it affected my specialty selection, but I will say that now that I'm a little bit
more seasoned, I think it'll affect how I choose to practice medicine in future, in terms of
wanting to do inpatient versus outpatient, community versus private institutions, [my
debt] will affect that, but not my specialty.
Nancy also acknowledged that while debt did not ultimately determine which specialty
she would pursue, it would impact the lifestyle that she would potentially have. She confirmed,
I will, as a physician, have a livable wage; I will be okay. But [this debt] will affect other
ways in which the rest of my life will look like: like what kind of house, I end up buying,
or where whether I end up sending my kids to a private school, because I am going to
have these loans. But I don’t feel limited because I wanted to work with low-income
communities. I just may have to be creative with how I can work with them and pay my
loans, but debt is not going stop me from doing that.
Raymond expressed the intangible nature of debt, sharing the following the following
perspective on his view of his debt:
I'm in more debt than my parents' house is worth. And it's hard to imagine. I think a
reason why it was so easy for me to be like, “Yeah, let's take this debt,” is because I
didn't have an understanding of how much money that is. It's like, what is $400,000? I
68

don't even know what that looks like by just looking at a number. It's just a concept, it's
just numbers, it's a concept you don't understand if you've never held $400,000 in your
hand. I feel like had I ever held that much money, I'd feel like, oh, how am I going to pay
for this?
He went on to say the incomprehensible nature of his level of indebtedness almost made him
numb to it and allowed him to be less concerned with the earning potential of his chosen
specialty. So, while debt was not a factor in his specialty selection, it could have been. He
disclosed,
Thinking about it now, I guess I was able to make a decision on specialty selection
without thinking about how much I was going to make because it was so unimaginable
which is kind of a good thing since I am doing was what I wanted to do and what I know
is going keep me motivated. Maybe if I were more concerned with my huge debt, I would
have been more concerned with how much I was going to make.
Tina spoke of being uncomfortable carrying such a high debt burden since it was contrary
to how she was brought up—namely, not to carry debt. She stated, “I was brought up by
hardworking parents who didn’t believe in debt and were always stressing to me the importance
of saving. So, having hundreds of thousands of dollars in debt is definitely something that
weighs on me.” When asked how that financial burden factored into her decision as to what
specialty to pursue, she said:
I knew the earning potential for internal medicine, and it is not as high as something like
surgery or dermatology, but I was also brought up to not need a lot. It is okay to make
enough to provide for you and your family and put a little away. I never had and don’t
69

need a lot to be content. That’s why I am okay with making less, which is still a lot more
than I have ever had and be able to do what I am passionate about.
Sara, who had the highest level of debt of all those who participated in this study,
expressed the same concern for debt but not as a deterrent to pursuing the kind of medicine she
wanted to practice. She intimated,
I have a huge amount of debt and I am an older student, so I have to be more intentional
in my plan moving forward. I know that it would have been wise to go into a higher
earning field, but I just don’t think I would be happy. And I already know what it’s like to
be working and not be happy—that’s why I went back to school.
Nevertheless, she noted that even though being happy in her career was of utmost importance,
she must be sensitive to the significant level of debt that she had incurred while at PSOM. She
elaborated on the role of debt:
I was weighing both family medicine and emergency medicine, I think I would have been
happy in both so that was good, but I did see emergency medicine as a way of making
more money, but still giving me the feeling of having a direct impact on my patients. So,
even though I thought about making more money because I had to, I don’t think that my
debt made that decision for me. I was just lucky to be equally interested in another type
of medicine that had a higher earning potential as a benefit.
Discussion: Research Question One
The findings related to this question revealed that student loan debt, while an ever-present
factor in the specialty selection decision-making process, was not a determining factor. Instead,
career passion, career interest, engagement with, and service to, community, and obligation to
family took precedence. As noted, Phillips et al. (2014) in their examination of more than
70

136,000 medical school graduates found that those from private institutions, even at levels of
debt greater than $100,000, showed no decreased likelihood of practicing in primary care. The
results of this study align with these findings as even those participants who did not pursue a
career in primary care expressed that debt, on its own, would not have served as a deterrent.
Responses from participants in this study also aligned with findings compiled by Gil et al. (2016)
and Webster et al. (2017), studies that found no correlation between debt and specialty selection.
The results of this research question did, however, counter the findings of research
conducted by Phillips et al. (2016), who found that highly indebted medical students felt limited
in their specialty selection prospects. Participants in their study overwhelmingly expressed the
need to go into higher-paying specialties to manage their debt. Conversely, while concerned with
debt, participants in this study did not allow it to deter them from a career that most interested
them—even if it was on the lower end of the earning spectrum. This determination to pursue a
potentially lower compensated specialty despite high levels of debt was not completely
surprising when one considers findings presented in the research of Bennett and Phillips (2010),
who found that motivations for going into medicine have a strong correlation with the type of
medicine that students will ultimately pursue. Participants in this study expressed a strong desire
to work in either primary care or emergency medicine very early on in their medical education
and, in some cases, even before starting medical school. This initial motivator proved to be a
constant factor in their decision-making process.
Findings on this topic also aligned with other studies on specialty selection and gender
which have shown that females are more likely to enter primary care fields due to lifestyle
considerations such as family planning and care (Dorsey et al., 2005). Two of the three female
participants in this study chose to go into primary care fields, citing lifestyle considerations
71

(family concerns) as one of their primary considerations. Conversely, none of the male
participants, nor the one female participant in this study who went into emergency medicine,
cited lifestyle considerations (such as starting a family) as a decision-making factor. This, of
course, does not mean they were not a consideration, but perhaps simply a consideration that
carried less weight.
Finally, all participants in this study were first-generation medical students from
working-class families. Research has shown that students from more affluent backgrounds and
backgrounds in which one or both parents were physicians are less likely to go into lower-
earning specialties (Phillips et al., 2009). These same studies find that graduates from less
affluent backgrounds are more likely to go into lower-earning fields and be motivated by a desire
to work with underserved communities. Participants in this study aligned with these findings,
having all gone into lower-earning fields out of an expressed commitment to community service.
Results: Research Question Two
The second research question in this study sought to garner information about how, if at
all, financial literacy and support resources impacted highly indebted graduates’ relationships
with their debt. Moreover, it sought to understand if these forms of support allowed students to
place less emphasis on their level of debt when making their choice of specialty. The
participants’ perceptions of these resources would be helpful in determining the effectiveness of
such programs employed at PSOM and potentially other private medical schools.
Theme Two: Financial Literacy and Debt Management as Mitigators of Financial Anxieties
Participants were asked to characterize the impact of the financial literacy resources and
debt-management counseling offered through PSOM and its role, if any, on their specialty
selection. Participants overwhelmingly indicated that the financial literacy resources and,
72

particularly, the one-on-one debt-management counseling sessions offered at PSOM were
instrumental in providing them with tools and knowledge that served to ease some of the
anxieties that they had surrounding the level of debt they had incurred while at PSOM.
Additionally, federal loan repayment programs were overwhelmingly noted as a mitigating factor
in debt-related stress as were federal loan forgiveness options, specifically the PSLF program.
Financial Literacy Resources
PSOM has, over the last six years, implemented the use of financial literacy resources
offered through the American Association of Medical College’s (AAMC) FIRST program
(Financial Information, Resources, Services, and Tools). This program offers financial literacy
resources to all medical schools and to all students who attend medical school to strengthen
students’ knowledge and abilities in managing the significant financial investment associated
with attending medical school. The topics covered in this program are meant to carry students
through the entire duration of their medical education (pre-matriculation, during matriculation,
and post-graduation). Topics covered include how to pay for medical school, managing finances
during medical school and after, determining repayment plan options, building creditworthiness,
managing student loans, and exploring loan forgiveness options (AAMC FIRST, n.d.). All
participants in this study noted that these resources were vital to their financial well-being. They
also noted that these resources served to empower them in areas that most admitted were not
their strongest.
Nancy explicitly stated that she was grateful for the First Friday Financial Wellness
emails sent out on the first Friday of each month. She stated,
I used to just think to myself, “I will just figure out the money [how to manage debt]
when the time comes.’ Maybe not the best way to do it.” But then they [PSOM] would
73

send out these emails every month that would tell me about scholarships when there were
coming up and about loan repayment. I think that those small things matter so that you’re
not out fending for yourself. I think the school supported us in that way and that made me
be more involved and not ignore my debt.
Nancy explained that having more knowledge of her finances made her realize that she would
manage and even thrive in a lower earning specialty. She stated, “I feel like the emails that were
sent out got me thinking about how I could make it [making less money] work and even though I
wasn’t going to change my specialty, I would be okay.”
Tina expressed an appreciation for the financial literacy resources brought to her attention
by the administration at PSOM. She stated,
The emails that were sent out were really useful. A lot of financial stuff you find doesn’t
really speak to medical students because our financial situation is so different. But I
remember one email that talked about the White Coat Investor and that really helped me.
It was a really good resource and, I read it. It made me feel more prepared. But it also
made me think that the school should make it more formal—like make it part of the
curriculum. I think that part of being successful as a physician is being fiscally
responsible.
Tina noted further that the resources disseminated monthly made her feel less anxious about her
debt. She stated, “All the information that was in those emails really showed me that it could be
done—that I could handle my debt and still have a life even better than I thought I could have.”
Guillermo said that the financial literacy resources provided by PSOM were instrumental
in giving him a real sense of what the loans he was taking out were: money to be repaid.
Guillermo explained, “I mean, it’s like you’re taking out all of this money, and it’s not real, it’s
74

like Monopoly money. Seriously, it just shows up in your account each semester.” He went on
to say that the nature of how funds are disbursed diminish the fact that they are real dollars that
will have to be paid with interest. He shared,
I used to look at the funds and be like, “Why am I going to try to take out less loan if I am
already going to be $400,000 in debt?” But then, when I started to use some of the
resources that were sent out, I realized how you can’t look at it that way. Like $15,000
less in loan is like two or three times that amount by the time you paid it off. When I
looked at it that way, I started to change how I borrowed.
He went on to explain how the resources prepared him for the reality of selecting his specialty.
He shared that by looking into the resources that were shared, he could see how emergency
medicine would likely not be eligible for loan forgiveness programs, so he went into his selection
fully informed on that front. As such, he explained that he was able to think of other means of
managing his loans. He stated, “Emergency medicine doctors don’t qualify of much loan
forgiveness because we are often employed by private entities. So, now I know that I need to
look into things like bonuses and loan refinancing.”
Levy conveyed that he, due to the example set by his parents, felt comfortable with
managing his finances, but that medical school and the amount of debt that he was incurring was
utterly “out of his league” and that he, as a result, experienced much stress. He explained,
I was always confident in my ability to manage my finances, and that was part of the
reason that I didn’t really feel too concerned about my debt and choosing whatever
specialty I wanted. But then you start seeing these huge numbers and you get stressed.
75

Levy felt his confidence where the management of his finances was concerned was restored by
the exposure to financial tools tailored for medical students, “The resources helped me to realize
that I can still manage my finances.”
One-on-One Debt Management Sessions
In addition to disseminating financial literacy resources to its student body, PSOM
employs a full-time staff member who meets with students one-on-one to discuss their financial
circumstances. These meetings are open to all students yearly but mandated for all graduates of
PSOM who have a student loan indebtedness greater than $150,000 at the time of graduation.
Topics covered in these meetings include, but are not limited to budgeting, scholarship searches,
loan management, loan repayment plans, loan forgiveness options, loan refinancing, financial
planning resources, home purchasing etc.
All participants in this study indicated that these sessions were the most vital component
to their overall feelings of financial well-being. Specifically, participants expressed that these
sessions forced them to acknowledge the debt that they were incurring while, at the same time,
providing them with a plan of action for how to manage it. The active confrontation and
engagement with their loans coupled with a reinforcement of potential management plans, it was
noted, eased their anxieties about their debt and encouraged them to address them head-on.
Nancy expressed the appreciation she had for the opportunity to sit down with a
counselor and discuss her student loans and how she would approach them after she graduated.
She stated,
I felt really supported in that way. To be able to sit down and have a conversation about
my loan and be like, “Okay, these are the options that are available to you.” I really liked
76

that aspect [because] these are important conversations that really let us know how we
can pay our loans and know that we will be okay.
She attributed these conversations and the financial literacy emails sent out to introduce her to
options she would otherwise not know about. She revealed, “I wouldn’t have known about the
payment plans that are available or the National Health Service or the [Steven M.] Thompson
Loan Repayment Program without the support of the school. It made me feel like I wasn’t
alone.”
Raymond expressed how the one-on-one meetings were instrumental in alleviating some
of his feelings of helplessness where his loans were concerned. He revealed,
There's a learned helplessness to it [to taking out loans]. I appreciated having the time to
talk about my loans once or twice a year. Then like at the end of fourth year where it was
like most useful just to have a general perspective on things. I did feel like, “Okay, it’s a
huge amount of money, and it is what it is and there is nothing I can do about that, but at
least I know how I pay it off moving forward.
Despite feeling less helpless about his debt incurred while in medical school, Raymond noted
that there remained a slight feeling of helplessness in that there were limited mechanisms in
place to help him not incur so much debt in the first place. He noted,
I just wish I could have been able to have more control over my debt while in medical
school. I mean I don’t resent the school or anything, but I feel like debt management
should have a component of scholarship that reduces debt in the first place.
Tina said of the one-on-one meetings:
Before these meetings I would, and I heard this from a lot of my peers, be stressed about
my debt and I feel like it was weighing on my decision [of specialty], but then when you
77

meet and you go through the math of it, it’s like, “Well, I am going to pay it off at some
point. It’s a lot, but I’ll pay it off some point.” That’s what I got.
She went on to say that having the meetings in which repayment plans and strategies
were discussed and put into the context of how much she was going to earn as a primary care
(internal medicine) physician, made her feel more secure in her career path. She remarked, “I
realized that even family medicine or internal medicine, [where] it’s less money than other
specialties, it’s still a lot of money if you use it right.” She summed up the utility of the
meetings, saying:
[The meetings] made me feel a little more stable, carrying so much debt. And I think a lot
of it also has to do with the way I deal with things, but it seems so overwhelming, but if
you're able to break it down and come up with a solid plan, and a plan that's actually
feasible, then I think it's okay, not that it justifies having that amount of debt, but it was
easier to cope with.
Guillermo reflected on the benefit of the one-on-one meetings. He shared,
[T]hey were really useful because as you've maybe gathered now, I'm not the most
financially literate person. So, and I know in other schools they don't have that at all or
not even close. And so, whenever I'd tell other friends who are in other programs, I'd be
like, “Oh, I met with our financial counselor person that tells us X, Y, Z.” They don't
know about it. They don't know to submit taxes in their fourth year so that their loan
repayment could be zero for the first year. So, I realized that I am lucky to have this help.
Guillermo went on to say of the meetings:
It definitely helped having those meetings and releasing that stress. Because we’d get a
reasonable plan for repayment, where like in 10 years, if you pay this much, you will
78

have it paid. And I think having it [made] into a concrete timeline was really helpful,
because it's hard to visualize like I said, what $400,000 looks like. But having it broken
down, it definitely helped ease the anxiety of it. Knowing that, okay, it is possible. I
already took on this debt, and it’s definitely possible to pay it back.
Levy shared the sentiment that the one-on-one meetings were critical to reducing his
anxiety. He remarked,
I found those talks really comforting when [the counselor] laid out the actual numbers
and showed me, “Hey, look. Here's a viable path to paying off your student loans. You
can do so within eight years, or within six years.” Even with my level of indebtedness,
[the counselor] showed me, “Here are some strategies for how you could, if you want to
prioritize paying off your loans, here's a reasonable way to go about doing that.” I found
that really comforting and helpful because I didn't have the knowledge or the know-how
to go through those numbers myself and [the counselor] showed me the tools and showed
me the calculations and that really helped to relieve my stress and anxiety about that. I
thought that was extremely helpful.
Levy expressed further how the introduction to financial literacy and debt management
strategies had instilled in him a desire to continue to take a proactive stance on his finances
during residency. He shared the following reflection:
I have already been exposed to financial planners from my residency which is really
helpful. I feel like in medical school, we’re young and maybe thinking about finances and
how they affect our futures is further off in our minds, but by exposing us to those
conversations while in school it was laying the seeds and foundation for a better financial
79

future for us. I know that I am now more willing to be active and I know that it helped me
make wise decisions now just by thinking about it.
Sara expressed how the one-on-one debt management meetings were a resource that she
took full advantage of by meeting much more frequently than what was mandated by PSOM.
Sara shared,
I really benefited from the debt-management meetings. I would meet like three or four
times a year to just to talk things through. I was super stressed about my debt because I
was an older student, and I am sure I had one of the highest debts.
She went on to say of the meetings:
I really appreciated sitting down and seeing in front of me how much debt I had and how
it would look over time depending on the path I chose. That would set my mind at ease
every time which is why I came in so often. I like seeing how I could pay down my debt
or have it forgiven.
She noted that these conversations were also instrumental in developing her career plans. She
explained,
These conversations helped me decide my career path. Like I was seriously considering
going into family medicine because of all the forgiveness options, but I realized, when I
did the math, that I could do emergency medicine and still maybe get forgiveness. That
was liberating because I think that emergency medicine is a better fit for me.
Loan Repayment Programs
Loan Repayment Programs include the various repayment structures available to
borrowers once their loans are no longer in a deferment status or grace period. By default, loans
are placed into a standard 10-year repayment plan. Given the high level of debt incurred by many
80

medical school graduates and by all the participants of this study and the relatively low incomes
they will have during their residencies, the payments calculated under a standard 10-year
repayment plan would not be feasible. In many cases, payments under this default repayment
plan could approach three to four thousand dollars per month—more than the take-home
earnings of most residents. Consequently, most highly indebted graduates must enroll in income-
driven repayment programs that calculate payments as a percentage of discretionary income (i.e.,
PAYE and REPAYE), thus making repayment in the short-term manageable. All participants in
this study indicated that they would be taking advantage of these programs and that they
provided them with a sense of relief and quelled anxieties about paying back their loans even
after residency.
Nancy, on the topic of loan repayment programs and their usefulness in her financial
planning, explained:
I know because of my meetings that I will be able to pay my loans. Seeing that, you
know, I could have a zero-dollar payment at first made me happy because it’s scary. All
the things you get show a big payment and you’re like, “How can you pay that?” But
having the meetings and seeing that there are ways to lower your payment and maybe get
forgiveness after like 20 years, that really makes you less stressed. I know I am not going
to be making a huge salary, and I have a family, so that is important for me.
Tina expressed a persistent uneasiness with her debt but stressed that being exposed to
the payment plans through the federal government was reassuring. She stated,
I mean I don’t know that I’ll ever be totally okay with the amount of debt that I have, but
at least I know what I can do to manage it. Just going through the calculations for each
option made me feel a lot better, like I am going to be okay.
81

Guillermo noted that the repayment plans available to students gave him a sense of
reassurance that his approach to specialty selection was justified. He stated,
I would speak to a lot of my friends—all Latinos—about debt and specialty selection and
how it would make sense to go into a field that pays more because we have so much debt,
but then we would always say, “We are still going to be making three or four times more
than our families made growing up.” When I looked at it that way, I was like, in the
grand scheme of things, what’s really the difference between $200,000 to $250,000 and
$400,000 if you’re doing what you love? So, when I see that there are ways to make the
payments affordable and I can look into contracts with bonuses, I felt good about my
selection.
Levy echoed many of these sentiments but added that debt for him was often just an
afterthought. He shared,
I remember having so many discussions about student loan indebtedness and about how
expensive medical school is and how so many graduates have such a large amount of
student loans when they graduate. I think, thereafter, after hearing it so much, it just
became an expectation that you would come out with a lot of student loans. And it was
like, “Whatever. You’ll figure it out.” But that’s why it was good to have the meetings
and go over the plans, you got to figure it out before you graduate even though things
change. Knowing the plans and what I had to do made a huge difference for me. I felt in
control.
Sara spoke of the strategic approach she took to the payment plans. She shared,
The payment plans, especially the REPAYE plan, is the one I am going to pursue. It was
confusing trying to compare them but having the final exit loan counseling before I
82

graduated really broke down which one was the best for me. I was going to go into
primary care to get the PSLF forgiveness but didn’t end up doing that and going into
emergency medicine instead. But here is this program that I can get forgiveness in, too. I
still plan on trying to get forgiveness under PSLF by opening a non-profit if I can. But I
have REPAYE as a backup since I do have so much debt.
Loan Forgiveness Options
Participants overwhelming indicated that the potential for loan forgiveness was a
mitigating factor in alleviating stress where their debt was concerned. Moreover, participants,
especially those who entered primary care fields, indicated that the existence of these programs,
while not the reason they chose their specialty, did provide them with some sense of security.
Moreover, they expressed that the existence of these programs provided them with some options
depending on their career and life trajectories.
Nancy noted on the topic of loan forgiveness:
I do feel like going into family medicine was possible because there are forgiveness
programs for primary care. I didn’t really know about them until I started receiving
emails from the school. Like National Health Service Corps and Steven [M.] Thompson
Loan Forgiveness Programs, I am going to apply to those because I am working in
underserved communities. I so appreciated getting information about them and knowing
that there is support out there that can remove some of the barriers to entering this kind of
medicine.
Nancy also revealed that she is hoping to receive loan forgiveness under the PSLF Program. She
shared,
83

I know that the NHSC Program and Steven [M.] Thompson Program are competitive, so I
am also doing the PSLF Program like I was told to do in my debt counseling session. I
am pretty sure that will be able to get the forgiveness in ten years because I am going to
try to stay at non-profits if I can.
When asked how the existence of these programs impacted her decision-making process, Nancy
intimated that she would have gone into family medicine regardless but that these programs
made her more at ease. She stated, “I just like knowing there are these resources I can tap into
and may help me do the kind of work I want to do.”
Tina noted that she was seriously considering the National Health Service Corps and the
Steven M. Thompson Program. She revealed,
It was already good to sit down and see that all this debt was manageable, but it was
really good to know that there are programs that can help me make it more so and maybe
even get it paid off sooner by doing what I am already going to be doing.
She revealed that even though her family did not expect her to go into more competitive, higher-
earning fields, it was in the back of her mind because of her debt. She revealed,
Sometimes you think maybe a more competitive, higher-earning specialty would be the
smartest move, but like I said, you’re still going to make a lot of money and when you
factor in these programs it reminds you that there are multiple ways to go about paying
off your loans.
Sara made explicit that loan forgiveness programs, and specifically the PSLF Program,
are integral to her loan repayment strategy. Sara shared,
I made it a point meet with [the financial counselor] often so I could discuss how I could
take advantage of the PSLF Program and make it work for me. I already know that I was
84

not going go into a high-earning specialty, so I had to really think about what I was going
to do.
Sara noted that her decision to pursue her career path was mitigated by the fact that there were
ways for her to have loan forgiven by simply working in a particular setting. She stated,
I am going to form a non-profit and help the people the people that I wanted help
anyway, but it’ll also help me get forgiveness under PSLF. I just have to be strategic
about what I do from now on.
Theme Three: Perceptions of University Financial Support
Participants were asked about their perceptions of financial support from the university
and how it may have influenced their decision-making process. Participants overwhelmingly
expressed frustration with the lack of financial support that the university offered. However, the
frustration was not limited to the lack of scholarships and grants available to students at PSOM
but also to the perceived lack of transparency regarding the availability of these funds.
Additionally, some participants noted that they felt that the university was not fulfilling its
commitment to the community in which it is situated by failing to provide scholarships to
students from that very community. In doing so, they contended, the university was failing to
facilitate the likelihood that graduates from PSOM might work in the surrounding area.
Lack of Scholarships and Grants
When asked how the university might support its students, all participants noted that
greater availability of merit-based scholarships and need-based grants was needed. They also
noted that the limited availability of such funds was the source of much dissatisfaction. Most
noted that despite having applied for many of the scholarship opportunities provided by PSOM,
85

they had not received many, if any at all. They shared that this was not only frustrating but
disheartening.
Nancy shared that although she found the financial literacy program very helpful and
attributed it to easing many of her anxieties surrounding her student loan debt, it was not enough
to fully address the issue of student loan debt. She stated,
It was great to have all of this information sent out about loan repayment and forgiveness
programs so that we knew how to manage our loans, but what about scholarships? The
school needs to give more scholarships and I say this even though most of the
scholarships that are sent out for primary care. There are still not enough. The school
should give [students] more scholarships so they don’t have as much debt.
Raymond echoed these sentiments. He expressed frustration about the scholarship
program at PSOM. He said,
I appreciated all the emails about scholarships at [PSOM], but they were mostly for
primary care interests which I had but couldn’t commit to. So, it felt like there just wasn’t
a lot of funds for people going into other areas of medicine even though they have really
high levels of debt and are going to be working in underserved areas.
He expressed frustration with what he viewed as a misguided impression that he was given
before attending PSOM regarding the availability of scholarships to students. He shared,
It was also kind of frustrating that we were told of all these scholarships that the school
has when we are interviewing, but then you get here and there really aren’t that many and
they are so specific. I would always apply, but I got hardly anything from the school.
He capped off his remarks by noting that while financial literacy was essential and needed, “it
would be good to limit the debt from the start.”
86

Guillermo added to this topic that he felt, as a student who came from the community in
which PSOM is situated, financially unsupported. Moreover, he shared that although he chose to
stay in the area around PSOM, he contemplated pursuing residencies with better pay. He shared,
I know that I and many of my classmates who came to [PSOM] came because we wanted
to serve this community—the community we came from—but because we didn’t get
scholarships, we have to consider other places [communities] that pay more [after
graduation].
He went on to say that the lack of scholarships was made even more frustrating by the fact that
he, and others from the community around PSOM, were often used as recruitment
representatives by the school “to recruit other black and brown students.” He shared,
I kind of resented the fact that they [PSOM] recruit from the community by telling us that
we would be giving back to the community, which is true, so they capitalize on that.
Then they have us at the school and want us to act as recruiters to other students from the
community, but there is no compensation. There are no scholarships for us and we are
taking on all this debt, helping the school, but we are not getting helped back.
Sara shared that she was dismayed that, despite having over $400,000 in debt, she was
still not granted more scholarships to offset her debt and reduce her loan burden. She noted,
I would apply to all of these scholarships. They would say that they were for financially
needy students, but I still wouldn’t get any. I was like, “I probably have the highest debt,
but I am still not getting any awards.” It was confusing and kind of made me want to give
up. But I kept applying. The only scholarship I got was in my last year for debt reduction.
I was grateful for it, but it was so small in the grand scheme of things. I would have
preferred something throughout the program.
87

Discussion: Research Question Two
Research on the topic of student loan debt has revealed that it carries with it the potential
to impact student health (Dyrbye et al., 2008). Specifically, students with high levels of debt are
more likely to experience symptoms of depression, pessimism, and decreased compassion
(Collier et al., 2002). Moreover, (Rohlfing et al., 2014) found that high levels of debt could result
in a medical school graduate regretting their choice of a primary care career due to the relatively
low-earning potential associated with it. The findings of this study on the issue of the efficacy of
financial literacy resources and debt management counseling show that it is an appreciated
resource. Participants expressed that such resources and services helped mitigate financial
anxieties by providing them with a framework with which they can approach their debt with
authority.
Additionally, participants expressed that knowing the various ways in which they could
manage their debt allowed them to feel less helpless and to feel more confident in choosing to
pursue a career with lower-earning prospects. Furthermore, it allowed them to feel more
confident in choosing a career that was more rewarding and more aligned with their initial
motivations for pursuing a career in medicine. However, despite the empowerment expressed by
participants in this study stemming from financial literacy and debt management counseling
initiatives, participants still expressed that they felt under-supported by the university in the
realm of financial assistance. They particularly cited the lack of scholarships and grants as
disheartening and as being a contributing factor to their high levels of debt. They shared that they
felt that a truly robust financial wellness plan should incorporate funds to decrease student loan
debt.
88

Theme Four: Student Debt and the Academic Experience
Another major theme that was not anticipated at the onset of the study, but that emerged
in the data and that is tangentially related to research question two, revolves around the role that
student loan debt plays in the academic experiences of students who are highly dependent upon
student loans to finance their cost of attendance. Every graduate interviewed stated that their
dependence on student loans limited their access to academic resources that might have
facilitated their learning and limited their ability to fully engage socially with classmates. Each
participant in this study indicated that they did not purchase recommended study materials that
would have potentially facilitated or enhanced their academic success and often decided not to
participate in many social activities that would have facilitated their integration into the PSOM
community. The decision to not purchase such academic resources and not to engage in social
activities was out of concern for the additional financial burden it would impose upon them. In
addition to potential feelings of depression as set forth by studies conducted by Dyrbye et al.
(2008), Ross et al. (2006) found that stress about debt and perceptions about what that debt
means to their experience could hinder academic performance. Therefore, this emergent theme in
the findings carries great importance for institutions that are concerned with the well-being of
their students, especially those with high levels of debt.
Lack of Access to Academic Resources Due to Student Loan Dependence
Each student, when characterizing the role that debt played on their academic experience
at PSOM, noted that they often felt at a disadvantage when it came to accessing supplemental
academic resources such as study guides and prep courses. They often indicated that access to
such resources could have potentially improved their academic performance or, at least,
facilitated it. These supplemental academic resources, apart from being expensive, are also not
89

mandated by the university. As such, these supplemental resources cannot be included in the
Cost of Attendance (COA), even if a student is willing to incur additional debt to acquire them.
Tina indicated that being dependent upon federal loans with no outside financial support
led to feelings of frustration at having to choose between having study aids recommended by her
professors and having fewer funds available to her for living expenses. Tina noted, “when we did
each of the blocks, there were books that they recommended to us, and I never really got them
because they were so expensive.” She noted that she would often spend much time trying to find
alternative study guides that were free. She said,
I would try to find a PDF version or something, or I'd just look at the ones from my
friend. But I know people would buy those as well. And then also with our clerkship,
these clerkship study guides with questions and stuff, I never got those, but I know a lot
of people did and it probably helped them a lot on their shelf, honestly. They could have
helped me, too.
Tina went on to say on the topic of study materials:
And things like Netter's Flash Cards and stuff, I was like, "I can go without, I'll make do
without, I'll learn without it," and I know a lot of people had them, but I was just like,
“That's money.” Even getting the anatomy books was really a struggle for me because
there were two and I didn't want to buy both because it was expensive, and even getting
one was expensive. But I know other people who got both of the books so that they could
compare, and then I was like maybe that helped their learning more.
When asked how this reality and the need to decide between items that might facilitate
learning processes and improve their academic performance impacted her, Tina lamented being
placed in that situation. She said,
90

If the school is going to recommend these books and things, they should make them
available for students who can’t afford them. It’s kind of a disservice to people like me
who have to put so much more time and effort into finding these resources. I mean, I still
did well, but who knows if I might have done better.
Guillermo noted that he often had to consider costs of academic resources, stating:
[Lack of] money definitely impacted my decisions while I was a medical student. When
it came to things, even as small as purchasing study guides and study tools and
supplemental materials to help in medical school, I always had to pause and think about it
before I purchased something like that because these study guides weren't cheap. Some
study resources, like Uworld, the question bank that we used, were several hundreds of
dollars for a six-month subscription. Some of the study books, and for every single
rotation there were books recommended, study guides recommended for every single
block during first and second year. The educational expenses for all these supplemental
materials really build up. I had to skip out on so many of the suggested materials because
it was too much.
When asked how this made him feel and to describe the impact this reality may have had,
Guillermo was adamant that it put him, and students like him, at a disadvantage, but that he was
able to overcome that hurdle. He explained,
I was definitely upset sometimes that I had to make these decisions, but that’s life, right?
I mean maybe I would have done better with them, but I still did well without them, but,
like, who knows? I mean it’s just one more challenge, but you manage.
91

Levy noted that his debt played a significant factor in his ability to access study aids that
were recommended. He lamented his inability to secure supplemental academic resources,
stating:
I didn't purchase all the study materials that I wished I could have purchased because I
felt that maybe I can do without this, maybe I can save the money and not purchase this. I
feel like that did impact my academic performance. That is a small regret that I do have.
Sometimes I wish, “Man, I wish I didn't have to worry about money.” I wished I could
just purchase all the things I need to do as well as I could in medical school. I've thought
about that, and I've thought about how I feel like I might have done better in medical
school had I been able to afford all these study materials that I feel like a lot of my
classmates had access to [and] that I was refraining from [buying] because I was
concerned about my finances. I've thought about how maybe I could have done better in
medical school and been a better candidate for residency. Not that it matters now,
because I'm really happy where I ended up, thankfully. But maybe I would have been less
stressed.
Sara was open about her frustration with the limitations she felt around academic
resources. She said on the topic:
It was really hard to accept that they [professors] recommend all these study guides and
books, but they cost so much. I went to the Office of Financial Aid to ask for additional
loan which I didn’t want to do, but I felt like I needed the additional help because I had
repeated a year. But [the Office of Financial Aid] denied my request. And I don’t have
anyone that I can ask for money from. I am on my own. So, I had to use the money that I
92

had to get the materials which left me short for other expenses. It puts you in this vicious
circle of never having what you need or being tight on funds in another area.”
Sara recalled the constant stress she experienced about her academic performance sharing
that her dependence on federal student loans compounded that stress. She stated,
“I was already stressed because I had to repeat my first year so I really needed all the help
I could get, but I also had to face the fact that I was facing another year of loans. I was
like, “How am I supposed to improve my academic performance if I can’t even afford the
things I need even when I willing to take out more loans?’ I didn’t want to take out more
loan, but it was like just a drop in the bucket for me.
Lack of Social Engagement due to Student Loan Dependence
Interestingly, most participants, in addition to noting the disadvantage they felt where
access to supplemental study guides and materials was concerned, also highlighted their inability
to participate in many of the social activities that arose while enrolled at PSOM. These were not
only activities organized by the institution itself but also those organized by their peers. The
extra consideration they had to put on the financial component of participating in social activities
was often characterized as disheartening and often led to a sense of social isolation. Nancy and
Guillermo were able to evocatively articulate the isolation that arose as a result of these financial
restrictions.
When characterizing how her dependence on federal student loans to cover her expenses
impacted her academic experience, Nancy explained that it extended beyond her inability to
access supplemental academic resources. She related,
It’s not just [the academic resources] that it affects, believe me or not, it even affects your
friendships because if you can't afford to buy... If you go out with friends and you don't
93

have money for lunch, okay. To eat out versus eating at home, or like all [these] very
social events that we go to that require money like skiing trips or camping trips, it will
affect your friendships and relationships and how you're able to navigate socially from
then on.
Nancy went on to express how financial constrictions contributed to her feelings of isolation. She
explained,
People get to know one another and solidify their friendships, but if you can't afford that,
you miss out on that experience. So, people don't know who you are and they already
made friends, they already met and had great time but you couldn't afford to go because
the only money you have is loans. It can make you feel alone.
In addition, to expressing a certain level of social isolation due to financial constraints,
Guillermo noted that he would sometimes become frustrated with classmates who were
insensitive to the fact that he had to be budget conscious when it came to social engagements. He
said that many of his classmates were able to “drop money to go on a trip or out to lunch”
without giving it any thought. In contrast, he had to weigh the cost associated with every social
engagement. Guillermo also reflected that the lack of financial resources contributed to his
isolation from his family since he was not able to visit them as often as he would have liked
revealing, “It’s hard not being able to see your family as much as you want because you have to
think about the extra money it takes to see them.” For him, family was a support system that he
would have benefited from but that he had to limit, “I am really close to my family and there
were times that I could have really used their company when I was really stressed with school
and just life.”
94

Guillermo noted that this financial tension limited his ability to fully engage with his
classmates and with certain segments of his family. Nonetheless, despite these constraints, he
was still able to build meaningful relationships and was still able to thrive academically. He
noted, “Of course not having money is something that keeps you from being as involved as you
want to be because you’re always thinking about the cost of things, so it limits you. But I made it
work.” On the topic of social engagement, he noted, “I had to sit out on trips and things like that,
but I was able to find friends like me, so we would do things that didn’t cost a lot.”
Nevertheless, he wondered if these barriers had been alleviated, would he have had a
better academic experience. He shared,
You’re constantly having to make all of these financial considerations that kind of put
into tension your financial and social well-being. To make the financially responsible
decision you suffer socially, but in the end, I made the decisions that were best for me,
and over time, I was able to find a balance and what worked for me.
Summary of Theme One
Interview results indicated that participants in this study were primarily drawn to a career
in medicine out of a desire to serve their respective communities, specifically those typically
underserved communities. No participants indicated earning potential or the prospect of a more
affluent lifestyle as motivation to pursue a career in medicine. In fact, all participants expressed
that their potential future earnings were of little import upon entering medical school. This
reality for participants in this study would be vital in their ultimate consideration of specialty
selection even after substantial medical school debt had been incurred. This is supported by the
fact that all indicated that their initial passion for serving their communities was the primary
factor in determining the type of medicine they would pursue. This finding revealed that debt,
95

while a concern for all participants, was not a deterrent to pursuing a career path with a lower
earning potential. Moreover, it was evident that for participants in this study, original
motivations for pursuing a career in medicine were persistent and carried the most weight when
selecting a specialty at the end of their program.
Participants in the study revealed that their decision to pursue their respective specialties
was multi-faceted and could not be isolated to one specific factor like debt. So, despite an
overwhelming adherence to the original motivation to pursue a career in medicine, participants
were also engaged in a nuanced process of reflection when determining their selection of
specialty. As such, the interview results reflected that the process for specialty selection factored
in many considerations such as, original motivation for a career in medicine, area of interest,
level of engagement with the community, lifestyle considerations (i.e., schedule flexibility, fixed
hours, ability to moonlight etc.), duration of training, ability to manage debt, ability to provide
for the family, and ability to influence earning potential.
Summary of Theme Two
Interview results of this study also indicated that all participants felt that the financial
literacy resources and, particularly, one-on-one debt management sessions were essential to their
overall financial well-being. All participants revealed that exposure to financial tools to be used
in the management of their loans and the ability to map out short-term and long-term financial
plans as they relate to the repayment and management of their student loans were mitigating
factors in the significance that debt factored into their specialty selection process. Participants
revealed that understanding how their debt could be repaid or forgiven, coupled with seeing how
this would impact their finances and lifestyles as physicians, reduced their anxieties. No longer
did they feel that their debt would be crippling to their futures. They indicated that seeing the
96

mechanisms at their disposal to manage debt revealed that they would be able to flourish
economically despite their substantial medical school debt. All participants expressed that they
felt equipped to take an active role in managing their student loans because of the financial
literacy initiatives offered at PSOM.
Summary of Theme Three
Another revelation from the interview data was the dissatisfaction participants had with
financial support in the form of scholarships and grants offered by the university. Most expressed
how little opportunities there were to secure these forms of gift aid and how they felt that
applying for them was an exercise in futility. Participants attributed the lack of scholarship and
grant funding to a high dependence on student loans which, in turn, led to higher levels of debt.
While participants were positive in their characterizations of the benefits of access to financial
literacy resources and debt management counseling, they lamented that it was not coupled with
what they perceived to be a more robust scholarship and grant program. Hence, financial literacy
initiatives were viewed as essential but incomplete. Consequently, financial anxieties persisted
even if significantly reduced.
Summary of Theme Four
Theme four sprang out of an emergent theme not anticipated at the outset of the study.
The theme was attributed to the lack of gift aid and reliance on student loans and their resulting
roles as barriers to academic resources and social engagement. Participants expressed that being
dependent upon limited loan funds often prohibited them from acquiring study materials that
may have facilitated their learning. Additionally, they expressed that lack of funding also limited
their ability to fully engage socially with classmates leading to feelings of social isolation.
97

Conclusion
The ever-increasing debt incurred by medical school graduates and the detrimental
impact in can have on them is evident. This study has revealed that special attention needs to be
paid to how this debt impacts not only graduates’ approach to specialty selection, but also how it
impacts their educational experiences. Participants interviewed for this study revealed the
following relevant themes related to medical student loan indebtedness, its impact on the
academic experience and, of course, specialty selection: (1) specialty selection as a contextual
process; (2) financial literacy and debt management as mitigators of financial anxieties; (3)
perceptions of university financial support; and (4) student debt and its impact on the academic
experience.
The findings set forth in this study have implications on both policy and practice;
specifically, in how students experience the management of their debt and how educators and
policymakers address it. Findings of this study also reveal future research opportunities in
exploring how medical student loan debt is experienced throughout the academic experience and
how it shapes graduates’ future goals once out of medical school. Moreover, there are
opportunities to explore how institutions might address the topic of student loan debt and
promote financial support mechanisms to support their students’ goals during periods of
enrollment and after graduation. These implications and potential future research opportunities
will be addressed in the following chapter.

98

Chapter Five: Discussion
This study aimed to better understand the decision-making process employed by highly
indebted medical school graduates when determining the selection of specialty. Additionally, this
study sought to garner information about graduates’ perceptions of the effectiveness of the
financial literacy initiatives implemented at PSOM. The goals of this study were as follows: (1)
to shed light on the factors that medical students take into consideration when selecting a
specialty and the potential role that debt may play in that process; and (2) to gather information
on how financial literacy programs may mitigate the emphasis placed on debt in the specialty
selection process. While not explicit in the study’s research questions, the researcher also was
interested in the potential role that debt may play in medical students’ considerations of pursuing
a career in lower-compensated, primary care fields.
The researcher conducted six in-depth interviews with graduates of the PSOM Class of
2020, all of whom had greater than $250,000 in medical student loan debt and who had been
accepted into a residency program post-graduation. The interviews consisted of eleven questions
developed using the Process-Person-Context-Time (PPCT) model. Interview questions covered
interest in medicine, career objectives, medical school experiences, support systems, obligations,
decision-making factors in specialty selection, perceptions of debt, and perceptions of
institutional support and highlight the interaction between students and their various
environments. The questions sought to elicit information to address the following research
questions:
1) How did graduates at the Pacific School of Medicine consider their level of
student loan indebtedness when selecting the specialties to which they applied?
99

2) What were these students’ perceptions of the financial literacy support services
they received at the Pacific School of Medicine?
Findings
The findings of this study produced four themes: (1) specialty selection as a contextual,
multi-faceted process; (2) debt management counseling and financial literacy as mitigators of
financial anxieties; (3) students’ perceptions of university financial support; and (4) student debt
and its impact on the academic experience. These themes will be used to answer the two research
questions presented in this study. Additionally, these themes will be discussed and evaluated
using Bronfenbrenner and Morris’s (1998, 2006) PPCT model.
A Brief Summary of the PPCT Model
The PPCT model (Bronfenbrenner & Morris, 1998, 2006) consists of four
elements that work in conjunction with one another to influence the development of an
individual. When considered individually and together, they can provide insight into how
educational institutions can potentially support their students in their development (Renn &
Arnold, 2003). Process is the first element and refers to the relationship between an individual
and their environment. Person is the second element and refers to the characteristics that make up
an individual and influence how and individual will interact with their environment. The third
element is Context and refers to interconnected systems within which an individual finds
themself. The final, and most recent addition to the model, is Time, which, as its name implies,
refers to the duration of experience and development within multiple social and historical
contexts (Bronfenbrenner & Morris, 1998, 2006).
100

Specialty Selection as a Contextual Process
This section examines the findings of this study about specialty selection as a contextual
process that is dependent upon multiple factors that inform one another. All participants in this
study described a decision-making process about specialty selection that was highly nuanced and
dependent upon multiple factors. All participants also noted that debt was an ever-present
peripheral consideration but not the ultimate decision-making factor when determining their
specialty. In this peripheral position, debt influenced or further informed how participants
viewed other factors. Thus, debt, while not serving as a deterrent from going into lower-earning
specialties, did impact how participants in this study said they would approach practicing
medicine post-residency within their respective fields and how they would approach the
management of their loans.
Interest in Medicine, Medical School Selection, & Clinical Experiences
To understand if any changes occurred in students’ approaches to a career in medicine
throughout their enrollment in medical school, this study sought to collect information about
participants’ initial motivations for going into medicine. The initial supposition was that
participants would reveal that as they moved through their academic program and incurred more
debt, their concern with repaying that debt would perhaps lead participants to pursue higher
earning specialties. All participants in this study indicated that they were drawn to a career in
medicine out of a love of science and a desire to serve underserved communities. No participants
noted earning potential as a motivation for going into medicine. They expressed that a career in
medicine was a way for them to merge these two passions and “make a difference.”
Additionally, most participants in this study indicated that they primarily chose to attend
PSOM because of its mission and location. They indicated that PSOM, with its mission to serve
101

underserved urban communities and given its location within the very community it aimed to
serve, was appealing to them, and aligned with their goals. They revealed in their narratives that
these original motivations for pursuing a career in medicine persisted through their enrollment at
PSOM and were reinforced by their clinical experiences while enrolled at PSOM.
Bennet and Phillips (2010) attributed multiple factors to a student’s decision to pursue
their specialty. These factors include demographic characteristics and predisposition, student
interest in specialty selection, curriculum, and school experience. Participants in this study
reflected these observations detailed by Bennet and Phillips (2010) in that they explicitly stated
that they chose medicine out of a desire to help people like themselves (demographics and
predisposition) and found PSOM to be a place where they could realize this goal (curriculum).
They also noted that they were drawn to their respective specialties due to characteristics that
matched their initial motivations and provided a lifestyle conducive to their personal goals
(student interest). Furthermore, their decisions to pursue their chosen specialties were reinforced
by their clinical experiences and demonstrated what their realities would look like after medical
school (school experiences). Interestingly, participants in this study did not cite debt as a
deterrent from these original motivations. Instead, there was an adherence to a career in medicine
that would fulfill their desire to provide what they viewed as meaningful care to their patients.
Familial Obligations
Several participants in this study noted that they were highly concerned with providing
financial support and (re)compensation to their families. One reason for this concern was that
participants knew that they might have to provide financial support to their parents in the future.
Another concern was that they had a moral obligation to return funds to their family for the
support received or to assist other siblings in their educational endeavors. Participants revealed
102

that, while financial in nature, these considerations did not impact their selection of specialty
(i.e., the need to enter a higher-earning specialty), but it did impact how they would approach the
specialties they selected. Specifically, participants repeatedly noted that specialties with shorter
training periods were desirable as they would allow them to start earning a higher (e.g.,
attending’s) salary sooner, thus allowing them to begin the process of establishing themselves
financially and providing support to their families sooner.
All participants from this study were the first in their families to attend medical school
and noted that they came from modest economic backgrounds. Phillips et al. (2009) found a
correlation between the socioeconomic status of medical students’ families and the type of
medicine they would pursue. Specifically, they found that students from lower socioeconomic
backgrounds were more likely to go into lower-earning, primary care fields. Grbic et al. (2010)
suggest that students from lower socioeconomic backgrounds are disproportionately represented
in lower-compensated specialties. The findings of this study align with these findings. All
participants in this study went into either primary care or emergency medicine. Of those that
went into emergency medicine it was noted that they appreciated the fact that it allowed them to
be “short-term” primary care physicians, providing primary care type services but not over a
long period of time.
Additionally, when discussing the lower compensations associated with their chosen
fields, participants noted that they were still positioned to earn far more than with which they had
grown up. This view of their earning potential further aligned with research conducted by
Phillips et al. (2009) that found that students from higher socioeconomic backgrounds felt
compelled to pursue highly compensated fields to maintain livings standards to which they were
103

accustomed. This concern to maintain a particular lifestyle was explicitly not a concern for
participants interviewed in this study.
Role of Debt
All participants in this study, when addressing the role of debt when considering specialty
selection, indicated that it was not a primary factor in their decision-making process. However,
this was not to diminish the seriousness with which they viewed their debt. It was a serious
concern that participants revealed would significantly impact how they would approach their
careers within their chosen specialties. Specifically, for the two participants who went into
primary care it would impact going into private practice, working outside of underserved
communities, or choosing to further specialize within their fields to increase their earning
potential. Those participants who went into emergency medicine conveyed that they would
“hustle” and earn more by working more hours. It was shared that these possibilities to
potentially earn more within fields for which they are passionate but that are on the lower end of
the compensation spectrum were serious considerations given their high debt levels.
These revelations stand in contrast to assertions compiled by Weinstein and Wolfe
(2010). They contended that the increasing debt levels among medical students and somewhat
stagnant physician compensations would, in addition to increasing stress experienced by medical
students, would also serve as a deterrent to them going into lower compensated fields.
Participants in this study revealed that while financial anxieties related to their debt are real, they
would simply renegotiate how they would approach their specialties. They also did not support
findings from a study conducted by Phillips et al. (2006) that found that students felt high levels
of limited career paths due to emphasis that had to be placed on debt repayment. Participants in
this study expressed a priority of career passion over earning potential when approaching
104

specialty selection. This also contrasted with a study conducted by Grayson et al. (2012) that
found that students place a higher emphasis on earning potential as their debt levels rise. The
findings of this study do, however, support the findings of Phillips et al. (2014) that found that
graduates of private medical schools with debt levels greater than $100,000 showed no decrease
in the likelihood of entering primary care (lower earning fields).
Specialty Selection: A PPCT Perspective
All participants revealed that specialty selection was a highly nuanced process that
involved a consideration of multiple factors but that primarily focused on original career
motivations. So, while participants in this study were most motivated to pursue a specialty that
would allow them to fulfill their original goals within a career in medicine, the decision-making
process was still influenced by a consideration of contextual factors like clinical experiences,
family considerations, and the ability to manage debt post-graduation.
Examining specialty selection as a contextual, or multi-faceted, process dependent upon
numerous factors through a consideration of Bronfenbrenner’s PPCT model provides some
insight into the decision-making process that participants of this study employed. The primary
factor that affected the decisions made by participants in this study is the developing Person.
Specifically, the characteristics that each participant possessed impacted how proximal processes
occurred (Bronfenbrenner, 2005). These characteristics can be biological, emotional, cognitive,
and social and can be broken into three groups: demand characteristics, resource characteristics,
and force characteristics (Bronfenbrenner & Morris, 2006). For this analysis, it is apparent that
force characteristics of the participants were heavily at play in their approach to specialty
selection.
105

Force characteristics are defined as those that represent a person’s disposition,
motivation, and persistence (Bronfenbrenner and Morris, 1998). These characteristics are
attributed to the ability to influence the initiation and maintenance of proximal processes within
the development of a person (Bronfenbrenner & Morris, 1998). No participants in this study
deviated from their original career motivations demonstrating that their persistence in pursuing
the career that most aligned with their original goals. Participants also did not they waver in their
initial objective despite the multiple environmental influences within the micro and mesosystems
while enrolled at PSOM. For example, the familial obligations described by several participants
could have served as a deterrent from going into a lower-earning specialty given the pressure that
these participants felt to provide financial support to parents or siblings. However, given the
backgrounds of the participants in this study, it was made clear that what could have been a
strong emphasis placed on higher earning potential was mitigated by an upbringing that did not
prioritize high earnings and that further enforced participants’ persistence. Consequently,
participants viewed service to the community through medicine as more important than earnings
despite ever-present concerns about financial obligations to the family. Moreover, participants
acknowledged that they were still positioned to earn a highly sustainable salary even in typically
lower compensated fields.
The ability to approach specialty selection in this manner may also be attributable to the
participants’ exposure to financial literacy resources and access to counseling. These resources
allowed them to develop concrete plans for managing loan repayment and personal goals given
their respective situations. This will be addressed in the next theme identified in the findings of
this study.
106

Financial Literacy and Debt Management Counseling
This section examines study participants’ responses relating to their perceived benefits of
financial literacy resources and debt management counseling as they relate to their financial
anxieties and abilities to manage their indebtedness. The participants in this study demonstrated
an appreciation for financial literacy resources providing information about loan management,
loan repayment, loan forgiveness programs, building credit, and home-buying. Additionally, they
expressed positive feedback regarding one-on-one debt management sessions that provided them
with tangible examples of how to approach their loans post-graduation depending on their
personal circumstances and career objectives. All participants noted that these initiatives proved
beneficial to their understanding of loans by providing a more in-depth analysis of structures in
place to assist them. They also noted that developing a personalized loan repayment plan was
empowering and instrumental in alleviating much of the stress surrounding their high levels of
debt.
Financial Knowledge as a Mitigator of Financial Anxieties
Mulligan et al. (2020) found that effective financial literacy programs strongly correlate
to higher levels of self-efficacy among students. Specifically, they found that financially literate
students show a greater belief in their ability to make sound financial decisions to support their
goals. Their findings are especially relevant when one considers the multiple findings revealing
that student loan debt has a significant impact on a student’s physical, emotional, financial, and
academic well-being (Bodvarsson & Walker, 2004; Dyrbye et al. 2008; Lyons, 2003; Lyons &
Hunt, 2004; Ross et al., 2006). The ability to promote self-efficacy through financial literacy
programs may be effective in combatting these tendencies and in reducing the potential for
increased pessimism and decreased compassion as described by Collier et al. (2002).
107

Participants in this study overwhelmingly expressed that financial literacy resources
made available to them by PSOM were instrumental to their financial well-being. They shared
that not only did these resources provide them with knowledge about loan repayment plans, loan
forgiveness options, scholarship opportunities, and general financial wellness information that
served to boost their knowledge and familiarity with financial terms, but they also served to ease
their anxieties related to debt and their abilities to manage it post-medical school. Participants
were significantly positive in their characterizations of one-on-one debt management sessions
required of them yearly. Participants repeatedly revealed that these resources were
“empowering,” “enlightening,” and “stress-reducing,” noting that without these resources they
would have been “lost.”
Participants also shared that being introduced to practical approaches to debt
management made them feel more confident in their ability to effectively manage their loans and
thrive even on the lower end of the compensation spectrum. This finding supports research
conducted by Lyons et al. (2003), who found that financial literacy programs promote better
financial decisions. Participants in this study demonstrated a propensity to make better financial
decisions in their descriptions of how they planned to approach their student loan debt after
graduation. Instead of acquiescence to their student loans, participants demonstrated an active
engagement in their approaches to debt management. This active role taken on by participants is
represented by the fact that all participants in this study explicitly detailed how they would
strategically utilize federal loan repayment plans and loan forgiveness options in the
management and ultimate repayment of their loans. Additionally, the fact that graduates were
already actively contemplating how to practice medicine to achieve their personal and
professional goals demonstrated an ability and willingness to make wise financial decisions.
108

Financial Literacy and Debt Management: A PPCT Perspective
In considering financial literacy and debt management through the view of the PPCT
model, it is important to refer, once again, to Mason and Wilson’s (2000) definition of financial
literacy, which characterized it as a “meaning-making process” that involves an individual’s use
of skills, resources, and knowledge to make decisions regarding their finances with an
appreciation for the costs associated with those decisions. This view of financial literacy aligns
well with the PPCT model for human development. It highlights the role of the individual in
their process of meaning-making through the utilization of resource and force characteristics as
set forth by Bronfenbrenner and Morris (1998, 2006). Moreover, it accounts for the processes
between the microsystems in which the participants found themselves and were active
participants (Bronfenbrenner, 1979). This active participation is revealed through a
demonstration of: (a) behavior regulation; (b) stress management; (c) attaining resources; and (d)
actively shaping one’s environments (Bronfenbrenner & Ceci, 1994). Mulisa (2019) added to
this theme, noting that within the context of higher education, the specific microsystems that can
impact student outcomes include supportive and educational resources, teaching methods, and
family. Participants in this study, through their descriptions of how financial literacy resources
and debt management sessions impacted their decision-making process, noted that, while they
would have pursued their chosen specialties despite their levels of debt, they could shift the
narrative regarding their debt. In essence, participants noted that financial literacy initiatives
made them feel more prepared to manage the debt they had incurred and still lead fulfilling lives.
This ability to confidently approach their debt demonstrated the development of force
characteristics within the participants through active engagement with the microsystems to which
they were exposed (e.g., the student affairs office, the office of financial aid, their loan servicers,
109

and their peers). Participants shared that being provided with relevant information about debt
management and financial literacy allowed them to alleviate the uncertainty about how they
would approach their debt after graduation. They also revealed that it allowed them to feel more
confident and secure in their selection of specialty since they had a framework within which to
manage and, eventually, repay their loans. This confidence, in turn, allowed them to imagine a
future in which they could practice the type of medicine they wanted, manage their debt,
establish themselves financially, and fulfill financial obligations, both explicit and perceived, to
their families. These developments happened over time through concerted and intentional
interventions by the university and sometimes through active solicitation by the participants.
This reciprocal engagement within the micro and mesosystems improved participants’ emotional
states, cognitive abilities, and financial practices.
Perceptions of University Financial Support
Despite having positive feedback regarding the financial literacy program at PSOM, all
participants in this study intimated that they were both frustrated and discouraged by what they
perceived as a lack of financial support in the form of scholarships and grants. This finding
aligns with findings presented by Zhang and Kempt (2009) who found that debt, while not
necessarily an impediment to happiness, did relate to students’ dissatisfaction with their school.
While displaying confidence in their ability to manage their student loan debt, participants noted
that lack of gift aid and its subsequent contribution to their level of debt were sources of great
concern leading them to feel insufficiently supported by the university.
Furthermore, several participants shared that, in their opinions, a genuinely robust or
comprehensive financial literacy program should promote knowledge in the realm of financial
decision-making as well as provide financial assistance as a means of curbing the level of debt
110

with which students graduate. One participant noted that she received a scholarship before
graduating that was meant to reduce her debt, but that it effectively only reduced a portion of the
interest she had incurred. She felt that it might have been more beneficial had it been awarded
earlier in her enrollment. So, while anxieties were alleviated, participants felt that additional
support in the form of gift aid would have further eased these concerns. Another interesting
revelation shared by one participant was that scholarship support would have made him feel
appreciated for the “work” he conducted on behalf of the university in its efforts to recruit Black
and Latino students. So, in his view scholarships were viewed as a form of financial support and
as well as a form of compensation that would have served to improve his perception of the
university’s commitment to its current and prospective students.
Perceptions of University Financial Support: A PPCT Perspective
While positive developments were reported and demonstrated through participants’
narratives in this study, there was an over-arching dissatisfaction with the level of financial
support offered by the university in the form of gift aid. Participants’ ability to articulate the
existence of this deficit in PSOM’s financial literacy program also spoke to their development.
Although disheartened by what they perceived as a lack of financial support from the university
to offset debt, participants acknowledged how external programs would be used to address their
indebtedness. So, far from feeling helpless in managing their debt, they described fundamental,
actionable steps they could take themselves to address it.
Bronfenbrenner (1979) defined human development as “a lasting change in the way in
which a person perceives and deals with his environment” (p. 3). Within the context of a
perceived lack of university financial support, participants demonstrated a capacity to actively
engage with proximal processes, like meeting with PSOM’s financial planner, that afforded them
111

resources and exposure to programs that could mitigate this deficit in gift aid. In doing so, the
participants in this study demonstrated cognitive and social characteristics (e.g., force
characteristics) that permitted them to seek out other means of addressing their financial
concerns. These processes, of course, took place over their time at PSOM as they were
consistently exposed to financial literacy resources and allowed to meet, at a minimum, four
times with a financial planner.
Debt and Its Impact on the Academic Experience
This section examines study participants’ responses relating to the impact that student
loan debt had on their academic experiences while at PSOM. Participants in this study conveyed
the detrimental impact of reliance on student loans on their ability to access academic materials
and how it served as an impediment to full social engagement. Most students indicated
frustration with being unable to access recommended academic resources due to financial
constraints. Moreover, several revealed that social engagements with peers was often not
possible because they were cost-prohibitive and could result in deficits for other educational and
living expenses. This revelation demonstrated that debt for participants in this study had a real-
time impact on students’ academic experiences. As before, this section will the PPCT model as
the framework for evaluating these themes.
Debt as an Inhibitor to Academic Resources and Social Engagement
Harrison et al. (2013) and Nissen et al. (2015) found that financial anxieties significantly
impact the social well-being of a student while at a university. Specifically, debt places students
at risk of experiencing higher levels of loneliness and isolation during their studies, which, in
turn, can lead them to feel excluded from campus life. These findings are further supported by
research conducted by Antonucci (2016), who found that highly indebted students can have
112

difficulties developing social networks and friendships during enrollment. Regarding lack of
access to academic resources due to financial limitations, there is a gap in the literature.
However, this theme within this study was often characterized as an obstacle to academic
success. As such, this theme can be understood in terms of academic performance. Ross et al.
(2006) found that students with higher debt levels often experience preoccupations about money.
Also, these students are more likely than their peers to perform less well academically.
Furthermore, Dyrbye et al. (2008) found that more highly indebted students were more likely to
experience symptoms of depression resulting from their financial anxieties.
Participants across the board in this study spoke to these challenges and the real sense of
isolation and helplessness they felt at times while in school. Participants lamented they could not
participate as easily in social engagements because a cost analysis was always involved in the
decision-making process. The same was true of the decision-making process as it related to
acquiring academic resources. This finding stood in stark contrast to the characterizations
participants had relating to their debt post-graduation. For example, participants all expressed
confidence in their ability to manage their debt out of school by making wise financial decisions
and by strategically utilizing the programs offered by the Department of Education. Whereas,
while enrolled at PSOM, they felt more restricted in their abilities to influence their options. So,
while they were able to make calculations as to the use of their financial resources (i.e., going out
versus staying home, or reducing funds for living expenses to purchase study aids), the need to
do so led to feelings of isolation and frustration. Furthermore, while participants overwhelming
indicated that they still performed well academically, several wondered if they might have
performed better or if, at the very least, their learning might have been facilitated through access
to supplemental academic resources.
113

Debt and the Academic Experience: A PPCT Perspective
Examining debt and its impact on the academic experience of participants in this study
through the lens of Bronfenbrenner’s PPCT models provides some insight into the influence that
debt plays in the day-to-day experiences of students and the difficult decisions that they must
often make. While primarily concerned with the impact that debt might play in students’
decision-making process in their selection of specialty, this study found that it played a far more
significant role in the everyday decisions that participants in this study had to make. As
discussed, participants revealed that financial considerations related to debt were often made
about the acquisition of supplemental study materials or when determining whether to participate
in social engagements.
Through their cost considerations, participants demonstrated what Bronfenbrenner and
Morris (1998, 2006) refer to as their resource characteristics that reside within the Person. Within
the context of this study, resource characteristics refer to a students’ ability to reflect upon and
utilize their social and material resources in decision-making. For example, participants often
spoke of not buying study aids and instead of trying to find peers who had the desired aids and
who might be willing to share them. Or they described creating social circles of peers who also
could not afford to participate in more expensive social activities and who instead created
activities sensitive to their shared financial constraints.
Moreover, the role of debt influenced contextual factors within the micro and
mesosystems. This influence was made evident in participants’ descriptions of how the
university’s planning of certain social activities impacted how immersed they were within the
school’s culture. For example, one result of not having funds to participate in university-
sponsored social events was to spend more time at home with family to contain costs. The
114

decision to do so was wise from a financial perspective but led to feelings of isolation. Thus,
while decision-making related to financial well-being was apparent, the cost of these decisions
and their potential negative impact on the student was not.
Implications for Medical School Administrators
Administrators, especially those within the areas of student affairs and financial aid, need
to be sensitive to the significant financial investment their students face and how it impacts their
lives both post medical school and during times of enrollment. As this study has revealed,
dependence on student loans, in addition to being a source of anxiety post-medical school,
influenced the academic experience relating to access to academic resources and materials and in
the ability to participate in social activities.
Administrators should also be well-versed in the guidance provided by the AAMC in the
areas of financial planning, budgeting, loan repayment programs, and loan forgiveness programs.
Presentations and documents on these topics are available on the AAMC’s website as part of
their FIRST Program could be used to provide training to all student affairs staff since the
financial component of the educational endeavor impacts all other facets (i.e., career planning,
research, away rotations, dual degrees, and leaves of absence).
Implications for Medical Schools
It is often assumed that education for professional students is a personal good because it
serves to benefit the student’s future career options and earning potential. Accordingly, medical
schools could simply adopt an attitude toward student loan debt based on this assumption.
However, given the type of education that medical schools provide and the types of professionals
that they produce (i.e., professionals that, by their very essence, provide a social good), it is
compulsory that medical schools be more sensitive to the financial wellness of their students.
115

This is especially true if debt might influence the kind of medical careers medical school
graduates pursue, even to a small extent. Therefore, medical schools must provide proactive and
sustained financial literacy resources and in-depth debt-management counseling.
Despite the importance of a strong financial literacy and debt-management program,
medical schools must also make a concerted effort to provide meaningful financial assistance.
However, financial assistance should not only be in the form of scholarships and grants, but it
should also provide access to supplemental academic resources for those who cannot afford them
and to social activities facilitated and sponsored by the institution. Should scholarships and
grants be available, the timing of these awards should be strategic. Specifically, awards should
be made earlier in a student’s medical school career. The benefits of this approach would be the
containment of student loan interest and the potentially diminished role of debt in anxieties
experienced by students during enrollment. This would also potentially lead students to feel more
supported by their school which, in turn, could lead to increased satisfaction.
Additionally, medical schools must actively investigate the ways in which the cost
associated with them can be capped or, at least, curbed. The consistent four to six percent
increase in tuition each academic year only serves to increase the level of indebtedness with
which graduates are leaving medical school. This increase in debt, in turn, is counterproductive
to the goal of medical schools as it relates to continued accreditation given the scrutiny placed on
students’ average indebtedness and institutional efforts to address and contain it.
Finally, it might be wise to reconsider the practice of not allowing medical students to
work and, therefore, not be able to earn an income during enrollment times. By allowing students
to work while enrolled through a program like federal work-study, institutions could offset the
debt with which their students graduate. Work conducted by students could be related to their
116

coursework or research that advances the science of medicine. Such work could contribute to
their learning as opposed to acting as a distraction from it.
Implications for Policymakers
Lewin (2011) noted that policymakers must pay attention to the problematic nature of
student loan debt has surpassed credit card debt and saddled graduates with debt that they will
carry for many years. As it stands, student loans are easy to obtain and require little counseling
by the federal government to secure. Moreover, since there is technically no aggregate limit to
the amount of Federal Graduate Plus Loans that a student can request, students who are fully
dependent upon loans to cover their educational costs are being placed precariously into a
position in which they may incur astronomical amounts of debt. This reality raises several issues
that need to be addressed. First, while medical schools should be actively involved in promoting
the financial welfare of their students by using financial literacy and debt-management
counseling, the federal government should provide more comprehensive and frequent tutorials on
the ramifications of borrowing federal loans. As it stands, students are only required to complete
one entrance loan counseling session before borrowing a loan and one exit loan counseling
session upon withdrawing from the university (U.S. Department of Education,
https://studentaid.gov). These counseling sessions are extremely brief, lasting only roughly thirty
minutes and not requiring much active engagement. Additionally, the tutorials are not tailored to
the specific needs of medical school graduates who complete their studies with much higher debt
levels than the average graduate student and whose income significantly increases upon
completion of their training programs.
Second, while income-driven repayment programs, specifically PAYE and REPAYE,
provide significant benefits to borrowers and are vital to their short-term financial plans (i.e.,
117

making payment manageable during times of low earnings), they do not go far enough. It would
be beneficial to further improve the federal loan program by extending interest subsidies to
graduate and professional students, at least during periods of enrollment. Moreover, it would
further benefit graduate and professional students to advocate for lower interest rates. This last
note may even be the most fruitful given current attitudes about loans for graduate and
professional students that center around the idea of post-graduate work as a personal benefit and,
of course, misconceptions regarding the earning potential of medical school graduates.
Finally, eligibility guidelines for the Public Service Loan Forgiveness Program (PSLF)
should be expanded further to facilitate its benefits to graduates of medical school. As it
currently stands, the PSLF Program mandates that a student be employed by a 501(c)3
government agency, AmeriCorps, or Peace Corps, full-time to qualify (U.S. Department of
Education, https://studentaid.gov). The mechanisms by which physicians are employed (i.e., by
third-party, for-profit physician groups) often prohibit them from continuing in the program at
the conclusion of their residencies. Policymakers should advocate for expanding of employment
eligibility criteria, particularly for those physicians going into lower-earning specialties (like
those under the primary care umbrella) or those serving in underserved communities.
Future Research
The data gathered in this study provides insight into how student loan debt influences the
specialty selection process for medical students. It also provides insight into how financial
literacy and debt management programs can help mitigate the anxieties medical school graduates
have regarding the management of the debt they have incurred. While participants’ stories shed
some light on debt and its impact on specialty selection, their narratives also revealed the need
for additional research to address other questions that arose in this study. The recommendations
118

that follow in this section were developed as an extension of the findings presented in this study:
the influence of debt on the academic experience, the relationship that exists between medical
students and the debt they incur, and the feasibility of the Public Service Loan Forgiveness
Program (PSLF) as a viable option for loan management and forgiveness post-residency.
The Influence of Debt on the Academic Experience
While demonstrating that debt is not a deciding factor in specialty selection—a finding
supported by much of the quantitative data on the issue—this study did shed light on the highly
influential role that debt had on the academic experience. Specifically, this study revealed that
students might feel disadvantaged because of their dependence on federal student loans since
they do not necessarily provide access to supplemental study aids. Moreover, debt may be
limiting students’ engagement with their peers and perhaps the community at large since
engagement often has a cost associated with it. The students in this study did complete their
degrees; however, they expressed concerns that they may have had to work additionally hard to
do so. The social isolation that can be associated with dependence on student loans may have
further compounded their stress and anxieties.
Given these findings and their potential negative impact on students’ academic
experiences, future research might involve a close analysis of how students navigate these
barriers and the potential impact they have on their educational outcomes. This research would
consist of longitudinal studies that would follow students throughout the four years of their
medical educations. A potential research question in this area could be: How do students
supplement in-class learning without financial access to recommended, non-required study aids?
It may be additionally valuable for institutions to examine how they might mitigate and
exacerbate these barriers. The institution could, for example, disseminate a survey to its student
119

body to garner information from students on the matter. Based on the feedback received from
this survey, institutions could implement initiatives that attempt to address the concerns that were
expressed. Surveys could be given periodically over time to gather information about how the
student body perceives the initiatives to determine if they are positively affecting their academic
experiences both in and out of the classroom. A potential research question could be: How do
institutionally provided supplemental study resources impact students’ perceptions of
institutional support and educational outcomes?
Relationship Between Medical Students and Loans
A second possible topic for research could focus on the relationship between medical
students and the loans they take out to finance their educations. Participants in this study
revealed that their loans were initially a source of great anxiety but that as they became more
demystified, their anxieties, while not eliminated, were eased. The demystification process was
often simply a matter of providing students with in-depth information about repayment and
forgiveness plans available to them post-graduation. These efforts were especially appreciated
when presented within the context of their earning potential as physicians. When provided with
actionable plans and real-world scenarios, students indicated that they felt empowered. No longer
did they feel like prisoners to their loans but, instead, creators in their financial health. As such, a
future research study could monitor students’ perceptions of loans and how those perceptions
change over time after being provided with frequent (semesterly) loan management sessions. A
potential research question for this type of study could be: How do frequent financial literacy and
debt-management sessions impact students’ anxieties surrounding student loans? In addition to
tracking any potential changes in their relationships to loans, it would be fruitful to determine if
it impacts students’ borrowing habits.
120

The Feasibility of the PSLF Program as a Viable Option for Loan Management
All participants in this study noted that the Public Service Loan Forgiveness Program
(PSLF) was an instrumental component to their short-term and, potentially, to their long-term
financial plans for their loan repayment and forgiveness. Moreover, the program’s existence was
often cited as a mitigating factor in the anxiety surrounding borrowing loans. Given the reliance
that many students place on the program as a potential source of forgiveness, especially when
going into lower-earning fields or extended training programs, it would be a fascinating topic for
future research. An analysis of how the PSLF Program impacts medical students’ borrowing
habits and perhaps their willingness to go into lower-earning fields or programs with longer
training periods would be an interesting area of study. Furthermore, it would be beneficial to do a
longitudinal study of medical school graduates to determine the feasibility of taking the program
to its ten-year end. Suppose the data reveals that forgiveness under the program is not easily
acquired by healthcare professionals (specifically physicians), the guidance provided by medical
school institutions should be altered to reflect this reality.
Summary
This study contributes to our understanding of how highly indebted students approach the
topic of specialty selection, how financial literacy and debt-management programs mitigate
anxieties surrounding student loans, and how dependence on student loans (i.e., carrying debt)
can negatively impact the academic experience. However, it focused solely on a small sample of
students from one high-cost, private medical school. The recommendations for future research
described in this section should be conducted with larger populations of students and perhaps
even on a national scale using quantitative measures. The results of these new research studies
would potentially provide a deeper understanding of how debt among medical students impacts
121

not only decision-making as it relates to specialty selection but how it impacts the academic
experience, students’ perceptions of debt, and how they approach short-term and long-term
financial planning. Medical schools stand to benefit from the data garnered by these proposed
future studies by proactively addressing students’ concerns and tailoring their practices to better
serve the students in their care. Finally, in addition to institutional changes, these studies could
potentially result in policy changes at the state and federal levels.
Conclusion
Despite previous research suggesting that that debt does not, in the end, impact specialty
selection, the results have primarily been compiled from quantitative data. As a response to
previous research on the topic, this study sought to understand, through the stories from highly
indebted graduates, the factors that influenced their decisions to pursue their respective
specialties. Ultimately, this study attempted to answer the following questions:
1) How did graduates at the Pacific School of Medicine consider their level of
student loan indebtedness when selecting the specialties to which they applied?
2) What were these students’ perceptions of the financial literacy support services
they received at the Pacific School of Medicine?
Using a qualitative approach, the researcher collected individual stories of medical
students’ experiences with debt and their perceptions of the university’s attempts to address this
debt utilizing financial literacy and debt management programs. After an in-depth analysis of the
data, results indicated the following four dominant themes: (1) specialty selection as a contextual
process; (2) financial literacy and debt management counseling as a mitigator of financial
anxieties; (3) students’ perceptions of university financial support; and (4) debt and its impact on
the academic experience.
122

The study ultimately produced three assumptions: First, specialty selection cannot be
reduced to one factor. Instead, it is a process heavily dependent upon a person’s disposition,
motivation, persistence, academic and clinical experiences, financial knowledge, and access to
educational and financial resources. Nevertheless, debt is a factor that interacted with all other
factors that participants considered. Second, financial literacy and debt management counseling
are vital to mitigating financial anxieties and to providing more assurance through the specialty
selection decision-making process. However, it must be combined with additional support in the
form of gift aid to be perceived as genuinely effective. Third, debt, while an omnipresent factor
in the specialty selection decision-making process, may also dramatically impact students’
decision-making processes during enrollment. These decisions include, but are not limited to,
whether to acquire study aids and whether to participate in social activities, which may result in
negative financial consequences.
The results of this study are varied. While it established that debt, for participants in this
study, was not the ultimate decision-making factor in the specialty selection process and,
moreover, that it did not deter them from pursuing specialties that they were most interested in, it
did often contribute to negative experiences of those interviewed. Furthermore, while financial
literacy and debt management initiatives were vital to the positive development of participants
interviewed, they could not fully address wide the range of needs participants described. Despite
being designed to inform and empower students in the management of their finances once in
repayment, they must also address the importance of support during times of enrollment beyond.
Moreover, even if debt does not influence specialty selection, it does not follow that medical
schools do not have an obligation to address it. It may even necessitate a more concerted effort to
123

curb debt since it appears that medical students determined to pursue lower-compensated,
primary care fields do so despite their high levels of debt.
As the debt of medical school graduates continues to grow and continues to be the source
of scrutiny, all stakeholders need to make a concerted effort to ensure that students who are
facing significant levels of debt are equipped with the necessary resources and supports system
to ensure their positive development. Students should feel confident in their ability to make
sound decisions about their borrowing, how to manage their debt, and their selection of specialty.
This objective not only serves to empower students as they move through their academic
program, it also serves to provide them with greater autonomy in their long-term, post-
graduation financial plans. As for medical teaching institutions, it provides them with the
opportunity to alter their educational environments into those that are sensitive to the needs of
their students before, during, and after periods of enrollment. This can only occur when
administrators take the time to fully understand the experiences of highly indebted students and
the challenges they encounter in pursuit of their academic and professional goals.

124

References
Adashi, E.Y., & Gruppuso, P.A. (2010). Commentary: the unsustainable cost of undergraduate
medical education: an overlooked element of US healthcare reform. Academic Medicine,
85(5): 763-765.
Altenderfer, M., West, M. (1965). How medical students finance their education: results of a
survey of Medical and osteopathic students, 1963-1964. Washington, DC: U.S.
Department of Health, Education and Welfare; 1965.
Anderson, C., Kent, J., Lyter, D. M., Siegenthaler, J. K., & Ward, J. (2000). Personal Finance
and the Rush to Competence: Financial Literacy Education in the US. Journal of Family
and Consumer Sciences, 107(2).
Antonucci, L. (2016). Student lives in crisis: Deepening inequality in times of austerity.
Archuleta, K. L., Dale, A., & Spann, S. M. (2013). College students and financial distress:
exploring debt, financial satisfaction, and financial anxiety. Journal of Financial
Counseling and Planning, 24(2), 50-62.
Association of American Medical Colleges. (2020). AAMC data book: The complexities of
physician supply and demand: projections from 2018 to 2033. Washington, D.C.:
AAMC.
Association of American Medical Colleges. (2020). Financial aid summary report (FASR)
2019-2020.
Association of American Medical Colleges. (n.d.). FIRST (financial, information, resources,
services, and tools). https://students-residents.aamc.org/financial-aid
Association of American Medical Colleges. (2020). Medical school graduation questionnaire:
2020 all schools summary report. https://www.aamc.org/system/files/2020
125

07/2020%20GQ%20All%20Schools%20Summary.pdf
Association of American Medical Colleges. (2016). Medical student education: debt, costs, and
loan repayment fact card for the class of 2016.
https://www.med.wmich.edu/sites/default/files/2015_Debt_Fact_Card.pdf
Association of American Medical Colleges. (2017). Medical student education: debt, costs, and
loan repayment fact card for the class of 2017.
https://www.med.wmich.edu/sites/default/files/2016_Debt_Fact_Card.pdf
Association of American Medical Colleges. (2018). Medical student education: debt, costs, and
loan repayment fact card.
https://medsis.urmc.rochester.edu/Global/Documents/financial-lit/aamc-debtfactcard.pdf
Association of American Medical Colleges. (2019). Medical student education: debt, costs, and
loan repayment fact card.
https://store.aamc.org/downloadable/download/sample/sample_id/296/
Association of American Medical Colleges. (2020). Medical student education: debt, costs, and
loan repayment fact card.
https://store.aamc.org/downloadable/download/sample/sample_id/374/
Barnhart, J., Shekelle, P., Lewis, C. (1996). The effect of a medical school’s admission and
curriculum policies on increasing the number of physicians in primary care specialties.
Acad Med. 71(3):293-295.
Bazargan, M., Lindstrom, R. W., Dakak, A., Ani, C., Wolf, K. E., & Edelstein, R. A. (2006).
Impact of desire to work in underserved communities on selection of specialty among
fourth-year medical students. Journal of the National Medical Association, 98(9), 1460.
Bennett, K.L., Phillips, J.P. (2010). Finding, recruiting, and sustaining the future primary care
126

physician workforce: a new theoretical model of specialty choice process. Acad Med.,
85 (10 Suppl): S81-88.
Bess, J. L., & Dee, J. R. (2008). Understanding college and university organization: Dynamics
of the system (Vol. 2).
Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and
design.
Bronfenbrenner, U. (1989). Ecological Systems Theory. In R. Vasta (Ed.), Six theories of
development. Greenwich, CT, 187-249.
Bronfenbrenner, U. (Ed.) (2005). Making human beings human: Bioecological perspectives on
human development. Thousand Oaks, CA.
Bronfenbrenner, U. (1993). The ecology of cognitive development: Research models and
fugitive findings. In R.H. Wozniak & K. W. Fischer (Eds.), Development in
context: Acting and thinking in specific environments (pp. 3-44). Hillsdale, NJ.
Bronfenbrenner, U., & Ceci, S. J. (1994). Nature-nuture reconceptualized in developmental
perspective: A bioecological model. Psychological review, 101(4), 568.
Bronfenbrenner, U., & Morris, P. A. (1998). The ecology of developmental processes.
Bronfenbrenner, U. & Morris, P.A. (2006). The bioecological model of human development. In
W. Damon & R.M. Lerner (Eds.), Handbook of child psychology (6
th
ed.), pp. 793-828.
Hoboken, NJ.
Bodvarsson, Ö. B., & Walker, R. L. (2004). Do parental cash transfers weaken performance in
college?. Economics of Education Review, 23(5), 483-495.
Collier VU, McCue JD, Markus A, Smith L. (2002). Stress in medical residency: status quo after
a decade of reform? Ann Intern Med., 136:384–90.
127

Creswell, J. W. (2014). Research design: Qualitative, quantitative, and mixed methods
approaches (4
th
ed.).
Cude, B., Lawrence, F., Lyons, A., Metzger, K., LeJeune, E., Marks, L., & Machtmes, K. (2006).
College students and financial literacy: What they know and what we need to
learn. Proceedings of the Eastern Family Economics and Resource Management
Association, 102(9), 106-109.
Dorsey, E.R., Jarjoura, D., Rutecki, G.W. (2005). Influence of controllable lifestyle and sex on
the specialty choices of graduating U.S. medical students, 1996-2003. Acad Med.,
85(11): 1692-1697.
Dyrbye, L. N., Thomas, M. R., Massie, F. S., Power, D. V., Eacker, A., Harper, W., & Sloan,
J. A. (2008). Burnout and suicidal ideation among US medical students. Annals of
internal medicine, 149(5), 334-341.
Evans, N. J., Forney, D. S., Guido, F. M., Patton, L. D., & Renn, K. A. (2010). Student
development in college: Theory, research, and practice (2nd ed.). San Francisco, CA.
Fan, A. P., Chen, C. H., Su, T. P., Shih, W. J., Lee, C. H., & Hou, S. M. (2007). The association
between parental socioeconomic status (SES) and medical students' personal and
professional development. Annals-academy of medicine singapore, 36(9), 735.
Gil, J. A., Waryasz, G. R., Liu, D., & Daniels, A. H. (2016). Influence of medical student debt on
the decision to pursue careers in primary care. Rhode Island Medical Journal, 99(7), 19.
Grayson, M. S., Newton, D. A., & Thompson, L. F. (2012). Payback time: the associations of
debt and income with medical student career choice. Medical education, 46(10), 983-991.
Grbic, D., Garrison, G., Jolly, P. (2010). Diversity of U.S. medical school students by parental
education: Analysis in brief. Acad Med., 9(10).
128

Greysen, S. R., Chen, C., & Mullan, F. (2011). A history of medical student debt: observations
and implications for the future of medical education. Academic Medicine, 86(7), 840-845.
Harrison, N., Agnew, S., & Serido, J. (2015). Attitudes to debt among indebted undergraduates:
A cross-national exploratory factor analysis. Journal of Economic Psychology, 46, 62-73.
Jolly, P. (2005). Medical school tuition and young physicians’ indebtedness. Health Aff
(Millwood), 24(2):527-535.
Kahn, M. J., Markert, R. J., Lopez, F. A., Specter, S., Randall, H., & Krane, N. K. (2006). Is
medical student choice of a primary care residency influenced by debt?.Medscape
General Medicine, 8(4), 18.
Kim, H., Park, S., Kim, J., Park, E., & Lee, H. (2003). Factors influencing the specialty selection
of medical students. Korean Journal of Medical Education, 15(2), 151-161.
Lambert, E.M., Holmboe, E.S. (2005). The relationship between specialty choice and gender of
U.S. medial students, 1990-2003. Acad Med., 80(9):797-802.
Lewin, T. (2011). College graduates’ debt burden grew, yet again, in 2010. New York Times, 2.
Lincoln, Y. S. & Guba, E. G. (1985). Naturalistic Inquiry. Beverly Hills.
Lyons, A. C. (2004). A profile of financially at‐risk college students. Journal of consumer
affairs, 38(1), 56-80.
Lyons, A. C., & Hunt, J. (2003). The credit practices and financial education needs of
community college students. Journal of Financial Counseling and Planning, 14(2).
Mason, C. L. J., & Wilson, R. M. S. (2000). Conceptualising fi-financial literacy. Occasional
paper, 7.
Maxwell, J. A. (2013). Qualitative research design: An interactive approach (3
rd
ed.).
Merriam, S. B., & Tisdell, E. J. (2015). Qualitative research: A guide to design and
129

implementation.
Mills, R. J., Grasmick, H. G., Morgan, C. S., & Wenk, D. (1992). The effects of gender, family
satisfaction, and economic strain on psychological well-being. Family Relations, 440-
445.
Morra, D. J., Regehr, G., & Ginsburg, S. (2009). Medical students, money, and career selection:
students' perception of financial factors and remuneration in family medicine. Family
medicine, 41(2), 105.
Mulisa, F. (2019). Application of bioecological systems theory to higher education: Best
evidence review. Journal of Pedagogical Sociology and Psychology, 1(2), 104-115.
Mulligan, E. P., Dickson, T., & DeVahl, J. (2020). Financial Literacy Among Health Professions
Graduate Students. Journal of allied health, 49(3), 181-189.
Nissen, S., Hayward, B., & McManus, R. (2019). Student debt and wellbeing: a research
agenda. Kōtuitui: New Zealand Journal of Social Sciences Online, 14(2), 245-256.
Pamies, R. J., Lawrence, L. E., Helm, E. G., & Strayhorn, G. (1994). The effects of certain
student and institutional characteristics on minority medical student specialty
choice. Journal of the National Medical Association, 86(2), 136.
Patton, M. Q. (2015). Qualitative research and evaluation methods. (4
th
ed.). Thousand Oaks,
CA.
Petterson, S.M., Liaw, W.R., Phillips, R.L., Jr.,Rabin, D.L., Meyers, D.S., Bazemore, A.W.
(2012). Projecting US primary care physician workforce needs: 2010-2025. Ann Fam
Med., 10(6): 503-509.
Phillips, J. P., Weismantel, D. P., Gold, K. J., & Schwenk, T. L. (2010). Medical student debt
and primary care specialty intentions. Family medicine, 42(9), 616.
130

Phillips, J. P., Petterson, S. M., Bazemore, A. W., & Phillips, R. L. (2014). A retrospective
analysis of the relationship between medical student debt and primary care practice in the
United States. The Annals of Family Medicine, 12(6), 542-549.
Phillips, J. P., Wilbanks, D. M., Salinas, D. F., & Doberneck, D. M. (2016). Educational debt in
the context of career planning: a qualitative exploration of medical student
perceptions. Teaching and learning in medicine, 28(3), 243-251.
Phillips, R.L., Dodoo, M.S., Petterson, S., Xierall, I., Bazemore, A., Teevan, B., Bennett, K.,
Legagneur, C., Rudd, J., Phillips, J. (2009). Specialty and Geographic Distribution of the
Physician Workforce: What Influences Medical Student and Resident Choice. Robert
Graham Center; March 2, 2009.
Phillips, R.L., Jr., Turner, B.J. (2012). The next phase of Title VII funding for training primary
care physicians for America’s health care needs. Ann Fam Med., 10(2): 163-168.
Rao, R. D., Khatib, O. N., & Agarwal, A. (2017). Factors motivating medical students in
selecting a career specialty: relevance for a robust orthopaedic pipeline. JAAOS-Journal
of the American Academy of Orthopaedic Surgeons, 25(7), 527-535.
Renn, K.A., & Arnold, K.D. (2003). Reconceptualizing research on peer culture. Journal of
Higher Education, 74, 261-291.
Rohlfing, J., Navarro, R., Maniya, O. Z., Hughes, B. D., & Rogalsky, D. K. (2014). Medical
student debt and major life choices other than specialty. Medical education online, 19(1),
25603.
Rosenblatt, R. A., & Andrilla, C. H. A. (2005). The impact of US medical students' debt on their
choice of primary care careers: an analysis of data from the 2002 medical school
graduation questionnaire. Academic Medicine, 80(9), 815-819.
131

Ross, S., Cleland, J., & Macleod, M. J. (2006). Stress, debt and undergraduate medical student
performance. Medical education, 40(6), 584-589.
Saha, S.S., Shipman, S.A. (2006). The rationale for diversity in the health professions: a review
of the evidence. U.S. Department of Health and Human Services 2006.
Schieberl, J.L., Covell, R.M., Berry, C. Anderson, J. (1996). Factors associated with choosing a
primary care career. West J Med., 164(6):492-496.
Stebleton, M. J. (2011). Understanding immigrant college students: Applying a developmental
ecology framework to the practice of academic advising. NACADA Journal, 31(1), 42-54.
Steinbrook, R. (2008). Medical student debt—is there a limit? N Engl J Med.,
359(25):2629-2632.
U.S. Department of Education. (n.d.). Federal Student Aid. https://studentaid.ed.gov
U.S. Department of Health and Human Services. (2006). Physician supply and demand:
projections to 2020. Washington DC: Health Resources and Service Administration.
U.S. New and World Report. (2021). Which medical graduates have the most debt?
https://www.usnews.com/best-graduate-schools/top-medical-schools/debt-residents-
rankings
Webster, C. S., Ling, C., Barrow, M., Poole, P., & Henning, M. (2017). A cross-disciplinary
assessment of student loans debt, financial support for study and career preferences upon
graduation. Medicine, 60(79), 40.
Weeks, W.B., Wallace, A.E. (2002). The more things change: revisiting a comparison of
educational costs and incomes of physicians and other professionals. Acad Med.,
77(4):312-319.
Weinstein, L., Wolfe, H. (2010). A unique solution to solve the pending medical school tuition
132

crisis. Am J Obstet Gynecol, 203(1):11-13.
Weissman, C., Zisk-Rony, R. Y., Schroeder, J. E., Weiss, Y. G., Avidan, A., Elchalal, U., &
Tandeter, H. (2012). Medical specialty considerations by medical students early in their
clinical experience. Israel journal of health policy research, 1(1), 1-10.
Youngclaus, J.A., Koehler, P.A., Kotlikoff, L.J., & Wiecha, J.M. (2013). Can medical students
afford to choose primary care? An economic analysis of physician education debt
repayment. Academic Medicine, 88(1), 16-25.
Zhang, J., & Kemp, S. (2009). The relationships between student debt and motivation, happiness,
and academic achievement. New Zealand journal of psychology, 38(2), 24-29.

133

Table 1
Medical Student Average Indebtedness 2015-2019
Academic Year Public Institutions Private Institutions
a
PSOM
2019-2020 $199,391 (↑3%) $219,829 (↑2%) $227,000
2018-2019 $193,186 (↑2%) $215,005 (↑3%) $218,000
2017-2018 $188,758 (↑4%) $209,367 (↑2%) $218,000
2016-2017 $181,179 (↑0%) $206,204 (↑1%) $216,000
2015-2016 $180,610 (↑5%) $203,201 (↑5%) $221,000
Note. Adapted from the AAMC Medical Student Education: Debt, Costs, and Loan Repayment
Fact Card (2016-2020). Copyright 2016-2020 American Association of Medical Colleges.
a
Figures rounded to the nearest $1,000.

134

Table 2
Overview of Research Participants
Female Male African
American
Asian-
American
Latino White Other >$300K
In Debt
<$300K
In Debt
Number 3 3 1 2 1 1 1 3 3
Percentage 50% 50% 16.5% 33% 16.5% 16.5% 16.5% 50% 50%

>30yrs <30yrs First Generation
in Medicine
Married Children
Number 1 5 6 2 1
Percentage 17% 83% 100% 34% 17%
Note. Figures may not add to 100% due to rounding.

135

Table 3
Debt by Race/Ethnicity
$250,000-
$275,000
$275,001-
$300,000
$300,001-
$350,000
$350,001-
$400,000
African
American
1 (16.5%) 0 (0%) 0 (0%) 0 (0%)
Asian American 0 (0%) 1 (16.5%) 1 (16.5%) 0 (0%)
Latino 0 (0%) 0 (0%) 1 (16.5%) 0 (0%)
White 0 (0%) 0 (0%) 0 (0%) 1 (16.5%)
Other 0 (0%) 0 (0%) 0 (0%) 1 (16.5%)
Note. Figures may not add to 100% due to rounding.

136

Table 4
Debt by Gender
$250,000-
$275,000
$275,001-
$300,000
$300,001-
$350,000
$350,001-
$400,000
Female 1 (17%) 1 (17%) 0 (0%) 1 (16.5%)
Male 0 (0%) 0 (0%) 2 (33%) 1 (16.5%)
Note. Figures may not add to 100% due to rounding.

137

Table 5
Debt by Specialty Selection
$250,000-
$275,000
$275,001-
$300,000
$300,001-
$350,000
$350,001-
$400,000
Family Medicine
(Primary Care)
1 (17%) 0 (0%) 0 (0%) 0 (0%)
Internal Medicine
(Primary Care)
0 (0%) 1 (17%) 0 (0%) 0 (0%)
Emergency
Medicine
(Non-Primary
Care)
0 (0%) 0 (0%) 2 (33%) 2 (33%)
Note. Figures may not add to 100% due to rounding.

138

Table 6
Specialty Selection by Race/Ethnicity
African
American
Asian
American
Latino White Other
Family
Medicine
(Primary Care)
1 (16.5%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Internal
Medicine
(Primary Care)
0 (0%) 1 (16.5%) 0 (0%) 0 (0%) 0 (0%)
Emergency
Medicine
(Non-Primary
Care)
0 (0%) 1 (16.5%) 1 (16.5%) 1 (16.5%) 1 (16.5%)
Note. Figures may not add to 100% due to rounding.

139

Table 7
Specialty Selection by Gender
Female Male
Family Medicine
(Primary Care)
1 (16.5%) 0 (0%)
Internal Medicine
(Primary Care)
1 (16.5%) 0 (0%)
Emergency
Medicine
(Non-Primary
Care)
1 (16.5%) 3 (49.5%)
Note. Figures may not add to 100% due to rounding.

140

Figure 1: Bronfenbrenner’s Bioecological Model for Human Development

Note: Adapted from Reconceptualizing research on peer culture, by K.A. Renn and K.D.
Arnold, 2003. Journal of Higher Education. Copyright 2003 by Ohio State University.

141

Appendix A: Final Interview Questions and Protocol
Introductions
Thank you for coming in today to meet with me. I look forward to learning about your
experience as it pertains to your decision-making process as it relates to your specialty selection.

Brief explanation of the purpose of interview
As you stated in my invitation, the purpose of this interview is to learn more about the factors
that went into your specialty selection.

Explanation of confidentiality
Also, I would like to reiterate the fact that this interview is part of a research project that I am
conducting as part of my Doctor of Education program. I am interviewing several students about
their experiences as well. The insights gained through these interviews will be shared, however,
your identity will be kept confidential.

Request to record
Since I would like to be fully present during this interview, I would like to ask for your
permission to record our session so that

I can later transcribe it. Once transcribed, the recording will be deleted. Also, I would like to
assure you that the recording will not be shared with anyone.

Freedom not to answer
Please note that you are free to not answer any question that is posed to you. Also, if you would
like to skip any question at any time, feel free to let me know. If you would like to come back to
it, we can do so.

Timeframe for interview and other logistical considerations
I anticipate that this interview will take between 45 minutes to 1 hour.
Before we begin, do you have any questions that you would like to ask of me?

Okay, we will move into the interview now.

Questions
First, I have some questions to get to know a little about you.
1. What drew you to a career in medicine?
a. What personal experiences did you have?
b. What did you hope to accomplish with a career in medicine?
2. Is there anything in particular that led you to enroll at the PSOM?
142

a. Their mission?
b. Their location?
c. The population it serves?
3. Can you describe any positive clinical experiences while a student at PSOM that have
impacted you?
a. Did that/those experience(s) have an impact on your specialty selection? If yes,
how?
4. Can you describe any negative clinical experiences while a student at PSOM that have
impacted you?
a. Did that/those experience(s) have an impact on your specialty selection? If yes,
how?
5. Are you able to describe the kind of support that your family has provided to you as you
pursue your medical degree?
a. Emotional
b. Psychological
c. Financial
6. Do you, in any way, feel responsible for providing support for your family? If so, in
what ways?
a. Emotional
b. Psychological
c. Financial
7. What factors did you consider in determining to which specialty to pursue?
8. If your indebtedness was a factor in your specialty selection, is there anything that you
feel could have been done to mitigate it as a factor?
a. Loan/repayment programs?
9. How effective do you think the financial literacy program at PSOM was (credit
workshops, financial wellness email campaign, one on one counseling sessions etc.)
10. How has PSOM helped or hindered you in your career aspirations in medicine?
a. What do you now hope to accomplish with your career in medicine?
11. Is there anything else that you would like to state about your decision-making process as
it pertains to your specialty selection?
Closing
Thank you, again, for coming in today. I appreciate your contribution to this research project.
Before you leave, do you have any final questions and/or concerns for me?

143

Appendix B: Email Solicitation: Invitation to Participate in Study

Dear graduates of the Class of 2020,

I am a third-year doctoral student completing my dissertation on the topic of medical student
loan indebtedness and its potential impact on specialty selection in the Ed.D. program at the
Rossier School of Education at USC. The final component needed to complete my dissertation
requires a series of interviews of graduating students to acquire their insight on the research
topic. It is on this front that I ask for your assistance. I am looking to have 8-10 students
interviewed as part of this study to garner information on their experiences on this topic.
If you have significant student loan debt (>$250,000) that you have acquired while in medical
school and would be willing to be interviewed about your medical school experience through this
financial lens, please complete the following survey to determine eligibility criteria. The data
from this survey will only be viewed by the primary researcher who will use the data to screen
for eligible participants and contact them to set up an interview time.
The interview would be confidential, and your identity would be anonymous. I would anticipate
that the interview would be no longer than 45 minutes to one hour in duration. Students who are
ultimately selected to be interviewed will receive a $10 Starbucks gift card.
Please note, participation in this study is completely voluntary and you can choose to withdraw
your participation at any time. All identifying characteristics such as names and residency
locations will be changed by the interviewer to protect your identity. Also, all recordings and
transcriptions will be destroyed at the completion of the study.
If you have any questions regarding this study, please feel free to reach out to Dr. Patricia Tobey
who is the faculty chair for my committee. She can be reached via email at tobey@usc.edu. She
can address any questions or concerns.
I appreciate your time and consideration of my request.

Thank you!
Jason Murillo
Rossier School of Education
Doctor of Education, Education Leadership Program

144

Appendix C: Survey

Survey Title: Student Loan Indebtedness and Specialty Selection
Questions:
1. Full Name
2. Email Address
3. Date of graduation.
4. Have you applied to and been accepted into a residency program?
Yes
No
5. Anticipated level of indebtedness at graduation.
$150K-$199,999
$200K-$249,999
$250K-$299,999
>$300K

Thank you for completing this survey.

Please note, once again, that participation in this study is completely voluntary and you can
choose to withdraw your participation at any time. All identifying characteristics such as names
and residency locations will be changed by the interviewer to protect your identity. Also, all
recordings and transcriptions will be destroyed at the completion of the study.
If you have any questions regarding this study, please feel free to reach out to Dr. Patricia Tobey
who is the faculty chair for my committee. She can be reached via email at tobey@usc.edu. She
can address any questions or concerns that you may have.

145

Appendix D: Conceptual Framework of Questions
Bronfenbrenner and Morris’s PPCT Model
Concept Features Questions
Process Primary Mechanism for
development. Comprised of
complex and reciprocal
interactions between a
person and the
environment.
Q3: Can you describe any
positive clinical experiences
while a student at PSOM that
have impacted you?
a. Did that/those experience(s)
have an impact on your
specialty selection? If yes,
how?
Q4: Can you describe any
negative clinical experiences
while a student at PSOM that
have impacted you?
a. Did that/those
experience(s) have an
impact on your
specialty selection? If
yes, how?
Q11: Is there anything else that
you would like to state about
your decision-making process
as it pertains to your specialty
selection?
Person Captures the
characteristics possessed
by a person that help shape
and influence proximal
processes
Q1: What drew you to a career
in medicine?
a. What personal experiences
did you have?
b. What did you hope to
accomplish with a career in
medicine?
Q2: Is there anything in
particular that led you to enroll
at the PSOM?
a. Their mission?
b. Their location?
c. The population it serves?
146

Q10: How has PSOM helped or
hindered you in your career
aspirations in medicine?
a. What do you now hope to
accomplish with your career in
medicine?
Q11: Is there anything else that
you would like to state about
your decision-making process
as it pertains to your specialty
selection?
Context Involves the five
interconnected systems
within which a person is
situated and where
interactions take place.
Q5: Are you able to describe
the kind of support that your
family has provided to you as
you pursue your medical
degree?
a. Emotional
b. Psychological
c. Financial
Q6: Do you, in any way, feel
responsible for providing
support for your family? If so,
in what ways?
a. Emotional
b. Psychological
c. Financial
Q7: What factors did you
consider in determining to
which specialty to pursue?
Q8: If your indebtedness was a
factor in your specialty
selection, is there anything that
you feel could have been done
to mitigate it as a factor?
a. Loan/repayment
programs?
Q9: How effective do you think
the financial literacy program
at PSOM was (credit
workshops, financial wellness
147

email campaign, one on one
counseling sessions etc.)
Q11: Is there anything else that
you would like to state about
your decision-making process
as it pertains to your specialty
selection?
Time Refers to what is occurring
during proximal processes
and the duration of these
processes.
*Pertains to all questions

Abstract (if available)

Abstract This qualitative study summarized the findings from interviews with six medical school graduates who were, at the time of the interview, in the first year of their residency programs. The researcher gathered data to address the following research questions: 1) How do fourth-year medical students at the Pacific School of Medicine consider their level of student loan indebtedness when selecting residencies to which they will apply? and 2) What were these students’ perceptions of the financial literacy support services they received at the Pacific School of Medicine? Bronfenbrenner’s Bioecological Framework for Human Development was used to analyze the findings from these interviews. The main findings from this study suggest that debt, despite being a source of much anxiety and concern, is not as influential in the decision-making process as career passion and lifestyle considerations. Debt, and dependency on student loans, had more impact on a student’s academic experience than on their selection of specialty. Moreover, participants revealed that financial literacy tools and debt management counseling were vital to their sense of autonomy and security in the handling of their finances, thus reducing the significance placed on debt when selecting a specialty.

Linked assets

University of Southern California Dissertations and Theses

Conceptually similar

PDF

The relationship between the campus climate and under-represented students’ experiences on campus and the influences on fit, self-efficacy, and performance: a qualitative study

PDF

Student loan debt and the impacts on first-generation student success

PDF

Effective strategies used by general education teachers to address the learning needs of students with selective mutism

PDF

Decision-making and graduate school debt: a focus on master's degree students

PDF

Knowledge sharing among student affairs professionals at a small faith-based higher education institution

PDF

Double jeopardy: the influence of prevalent race and gender bias on women of color executive leadership promotions

PDF

Chinese-Vietnamese American college students: narratives of educational experiences and college success

PDF

Female graduate student decision-making and graduate student loan debt

PDF

Oppression of remedial reading community college students and their academic success rates: student perspectives of the unquantified challenges faced

PDF

Black male experience on a community college campus: a study on sense of belonging

PDF

Sense of belonging and inclusion among non-Christian students at Jesuit Catholic universities: a qualitative study

PDF

Making meaning: using constructivism to understand students' relationship to engineering

PDF

Departure from the student affairs profession: a study of professionals who left the field

PDF

Decision-making and graduate school debt: a focus on master's degree students

PDF

College-educated older adults and information and communications technology

PDF

The role of race and racism in Black male medical students’ specialty selection process

PDF

An exploration of student experiences in a preparation program for online classes in the California community college system

PDF

Decision-making and graduate school debt: a focus on master's degree students

PDF

Barriers that prevent people experiencing homelessness from utilizing employment services

PDF

Pay to play: a qualitative study on how the perception of the continued rise in college tuition impacts first-generation, loan-borrowing graduates and their financial well-being

Asset Metadata

Creator Murillo, Jason Travis (author)

Core Title Medical student loan indebtedness and decision-making in the selection of specialty

School Rossier School of Education

Degree Doctor of Education

Degree Program Education (Leadership)

Degree Conferral Date 2021-12

Publication Date 12/09/2021

Defense Date 09/14/2021

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag decision-making,medical school debt,OAI-PMH Harvest,specialty selection

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Tobey, Patricia (committee chair), Crispen, Christine (committee member), Maddox, Anthony (committee member)

Creator Email jmurillo@usc.edu,jtmurillo@me.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC18010015

Unique identifier UC18010015

Legacy Identifier etd-MurilloJas-10288

Document Type Dissertation

Format application/pdf (imt)

Rights Murillo, Jason Travis

Type texts

Source 20211210-wayne-usctheses-batch-903-nissen (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright. The original signature page accompanying the original submission of the work to the USC Libraries is retained by the USC Libraries and a copy of it may be obtained by authorized requesters contacting the repository e-mail address given.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu