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Emily P. Tierney, MD; Sunil Kalia, MD; Alexa Boer Kimball, MD, MPH

Arch Dermatol. 2009;145(2):208-209.

The shortage and geographic maldistribution of dermatologists substantially affects patient access to dermatologic care.¹ At the same time, student loan debt has been rising at a rate far surpassing that of inflation.² In light of the oft-cited proposal to use debt repayment to influence physician maldistribution,^3-4 we designed survey questions to discover whether recent dermatology residency graduates would be willing to practice in underserved areas in exchange for student loan debt repayment.

Methods
Data were collected at a board review course attended by many recent residency graduates, as previously described.⁵

Results
In 2006 and 2007, 52.0% (n = 139 of 261) and 66.0% (n = 162 of 266) of attendees completed the survey (Table). In 2006 and 2007, location was described by 73.1% as "very important" in job selection (n = 220). In 2006, 60.6% of respondents graduated with student loan debt (n = 84) (Table), increasing to 69.1% in 2007 (n = 112). The average student loan principal was $108 411 (aggregated over 2006 and 2007).

View this table: [in this window] [in a new window] [as a PowerPoint slide]   Table. Characteristics of Dermatology Residency Graduates With Regard to Willingness to Relocate in Exchange for Student Loan Repayment

A greater proportion of respondents with debt planned to practice in a rural or inner city area (n = 43, 14.3%) compared with those without debt (n = 28, 9.3%) P = 0.5). When questioned whether they would be willing to move to a rural or inner city area for student loan debt repayment, 39.8% of respondents reported that they would b4e willing to move *81 of 203) (aggregated average over 2006 and 2007). The minimum repayment amount they would accept was $202 254, paid over a 3-year interval (aggregated average for 2006 and 2007, reported by the 81 respondents who were willing to move in exchange for debt repayment [29.8%]). There was a greater percentage of women among the group unwilling to relocate (n = 74, 67.7%) relative to the group willing to relocate (n = 45, 63.3%) (P = .05). Age, marital, and parental status were not different between groups. Loan debt levels of respondents willing to relocate ($125 160) were significantly greater than those for graduates not willing to move ($106 218) (P<.05).

Comment
Limitations of this analysis include overall response rates and the self-reported nature of the data. In addition, in 2006 and 2007, only 67.8% of survey respondents answered the question on willingness to relocate in exchange for debt repayment (203 of 299).

Current loan repayment programs,⁶ which provide $25 000 to $30 000 per year, are not likely to influence the decisions of dermatology graduates who cite higher amounts needed for them to move to an underserved area.^{4, 6} In addition, the minimum amount required for recent trainees to move ($202 254, paid over 3 years) was significantly greater than the education loan principal at graduation, suggesting that graduates may have other loans that may be burdensome.

Other solutions to address geographic maldistribution include increased incentives, research funding, accelerated tenure tracks, community health projects, and expanded telemedicine access. The Department of Education plans to eliminate the Economic Hardship Deferment program in 2009, which allows deferment of educational loans during residency. Given rising debt levels, subspecialty organizations need to exert their influence to encourage continuation of these programs.

AUTHOR INFORMATION
Correspondence: Dr Kimball, Clinical Unit for Research Trials in Skin (CURTIS), Massachusetts General and Brigham and Women's Hospitals, Harvard Medical School, 50 Staniford St, No. 246, Boston, MA 02114 (harvardskinstudies{at}partners.org).

Financial Disclosure: None reported.

Author Contributions: Study concept and design: Tierney and Kimball. Acquisition of data: Tierney, Kalia, and Kimball. Analysis and interpretation of data: Tierney and Kimball. Drafting of the manuscript: Tierney. Critical revision of the manuscript for important intellectual content: Tierney, Kalia, and Kimball. Statistical analysis: Tierney and Kimball. Obtained funding: Tierney. Administrative, technical, and material support: Tierney, Kalia, and Kimball. Study supervision: Tierney, Kalia, and Kimball.

Previous Presentation: Portions of this work were presented at the Association of American Medical Colleges workforce conference, April 30, 2008; Crystal City, Virginia.

REFERENCES
1. Resneck J Jr, Kimball AB. The dermatology workforce shortage. J Am Acad Dermatol. 2004;50(1):50-54. FULL TEXT | WEB OF SCIENCE | PUBMED 2. Salter SA, Kimball AB. Rising educational debt levels in recent dermatology trainees and effects on career choices. J Am Acad Dermatol. 2006;54(2):329-331. FULL TEXT | WEB OF SCIENCE | PUBMED 3. Tierney E, Kimball AB. Median dermatology base incomes in senior academia and practice are comparable, but a significant income gap exists at junior levels. J Am Acad Dermatol. 2006;55(2):213-219. FULL TEXT | WEB OF SCIENCE | PUBMED 4. Gronski TJ Jr. Debt repayment for trainees. N Engl J Med. 2002;346(25):2013-2014. FREE FULL TEXT 5. Salter SA, Kimball AB. Rising educational debt levels in recent dermatology trainees and effects on career choices. J Am Acad Dermatol. 2006;54(2):329-331. FULL TEXT | WEB OF SCIENCE | PUBMED 6. Ley TJ, Rosenberg LE. Removing career obstacles for young physician-scientists–loan-repayment programs. N Engl J Med. 2002;346(5):368-372. FREE FULL TEXT

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