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| Journal of the New Zealand Medical Association,
09-May-2008, Vol 121 No 1273
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Female medical students may accrue less student loan
debt than their male colleagues
Karina M McHardy, Anna Janssen, Phillippa J Poole
In an October 2001 issue of the NZMJ, a series of
articles were published focusing upon medical student debt in New Zealand
(NZ).1–3 At that time, it was estimated
that the average anticipated total student loan at the time of graduation was
between $60,000 and $70,000 (all amounts in NZ Dollars), and furthermore, a
significant correlation was noted between the predicted size of total debt and
intentions to practice medicine overseas.1
In the 2007 academic year, the annual medical school fees
paid by NZ domestic students were $11,340 (Medical Programme Directorate,
University of Auckland. Personal Communication, October 2007). Student loans may
be used to cover course fees and living expenses up to $150 per week while
studying.
Additionally, course-related costs of up to $1000 per annum
may be borrowed. In the case of course fees, the borrowed amount is directly
transferred to the education provider.
Since the time of the significant increase in medical school
fees in the late 1990s there has been modest documentation in the NZ medical
literature around the extent of medical student loans. Concerns about
differential debt levels in women and minority groups have been raised
previously1,4 but a clear picture of the
current status of debt distribution remains elusive.
It has been reported that, due to overall lower salaries and
an increased chance of interrupted practice, it will be more difficult for
females than males to repay medical student
loans.5
Despite an increasingly ‘feminised’ workforce,
there is a lack of information about the differing burdens of debt experienced
by males and females entering the profession. Furthermore, following on from the
initial studies, such as the work of Gill et
al2,3 and O’Grady et
al,1 there has been a relative paucity of
information and discussion around the impact that these loans may have on the
work and career intentions of this country’s future medical practitioners.
Although NZ has always produced fewer doctors than required
and, as a consequence, been heavily dependent on overseas-trained physicians,
there is an emerging crisis in doctor
retention.6 A significant factor is the higher
salaries on offer in Australia and beyond.
With the March 2007 release of the Ministers’
Workforce Taskforce report recommending that NZ aims for self sufficiency in
training of doctors,7 the level of financial
commitment to medical training and its potential impact on individuals should be
revisited. It is imperative that this issue is considered in any future
workforce planning strategies.
This study aimed to quantify the current level of actual
student loan debt in Auckland Medical School students at the time of graduation
and to investigate potential variations in the debt burden between the genders
and individuals of different ethnicities. A secondary aim was to investigate
whether or not certain trends regarding student loan debt that were identified
in earlier studies remain evident today.
MethodsParticipants were members of the Tracking Health
Professional Students and Graduates Project, a longitudinal study which is
investigating the characteristics and career patterns of students who studied in
the BPharm, BNurs, BHSc, and MBChB degree programmes at The University of
Auckland. Participants complete questionnaires during their entry and exit years
in the programmes and will be followed up as postgraduates.
The MBChB entry cohort completed the questionnaire at
medical school orientation, while MBChB exit surveys were distributed to
students just prior to qualification.
Ethics approval was obtained from the University of
Auckland’s Human Subjects Ethics Committee. To ensure anonymity, each
student was assigned a generic ID number for the survey. Data obtained from the
questionnaires were entered into an Excel spreadsheet; p values were calculated
using the Chi-squared test.
The purpose of the tracking project is to support the
development of the appropriate range of health care professionals for NZ’s
health needs through informing curriculum and workforce planners regarding
career trends and factors important in career choices. This is a project
separate from the Medical School Outcomes Database project that is sponsored by
the Medical Deans of Australia and New Zealand.
The exit survey is comprised principally of questions
around anticipated future career intentions and investigates factors that may
influence those career decisions, including student debt.
Students were asked to report their current New Zealand
Government Student Loan (NZGSL) debt at the time of the survey by selecting from
a table arranged in $15,000 increments. Other sources of debt were not included.
Although international students were asked to complete
the Exit surveys, their responses were excluded from the analysis of the student
loan data. International students are not eligible to apply for a NZGSL;
therefore these students indicated loan totals of zero. These students comprised
12.2%, or 14 of the Exit study cohort.
ResultsResponse rate—The response rate for
the Exit survey was 88% (n=115). Females made up 61% (n=70) of the study
respondents. The ethnic distribution of the study population is shown
below.
*Mostly of Samoan, Tongan, Niuean, or Cook Islands
origin.
Total NZGSL at graduation—88 of the
101 (87%) NZ resident students surveyed reported that they had taken out a NZGSL
to cover their studies and 13 students (13%) reported that their NZGSL at the
time of graduation was $0.
Over 73% of all NZ resident students (n=74) reported that
their total NZGSL at graduation was over $45,000, with 33% reporting that their
NZGSL would total over $75,000. A NZGSL of greater than $90,000 was reported by
13 (13%) of these students.
The following was noted of the students who were
NZGSL-free:
A conservative
average NZGSL total of all non-international students was $55,660. However,
excluding the students who reported having no NZGSL, the ‘average’
loan rises to $63,880.
Financial support—86% of all
graduating students reported that they had ‘some form’ of financial
support from their parents during their medical school training.
Gender and debt—The NZGSL data were
analysed according to gender. While only 7% of all males in the NZ resident exit
cohort had not taken out a student loan, 21% of all females in this group
indicated that they were student loan-free at the time of graduation (p=0.049).
Males were also more likely to have higher loans than their
female counterparts. Whereas 17 (27%) of NZ resident female exit students had
loans under a total of $30,000, only 4 (8%) of males in this group had a NZGSL
total under this figure (p=0.035). Furthermore, although 14.5% of female
students indicated a total NZGSL of $75,000 - $89,999, 21% of all male students
in this cohort reported a NZGSL of this size. This difference between males and
females in the $75,000-$89,999 category was not statistically significant
(p=0.11).
Ethnicity and debt—In this cohort
there was no suggestion that Māori, Pacific Island, or other
‘minority’ ethnicities were over-represented among the students who
had considerable NZGSL debt, or that they were under-represented in the group
with no NZGSL. Even though Māori made up 5% of the total cohort, nearly 8%
of the students with no student loan were
Māori. Of those with a loan
totalling over $75,000, only 6% identified themselves as Māori.
Pacific Island students, who make up 6% of the total cohort,
are over-represented amongst those with no student loan; 23% of those who were
NZGSL-free were of Pacific Island descent. The proportion of Pacific students
with a loan over $75,000 was 6%.
Debt and career intentions—We
investigated 8 factors that may influence future career decisions; student loan
debt was one of these factors. Only 11% of the exit students reported that their
degree of debt would have a ‘significant’ influence on their career
choice, while 74% reported that their loan would have ‘no effect’ on
this decision. Similarly, the potential for remuneration in a given specialty
was reported by over 65% of students to have ‘no effect’ on their
future career decisions.
The stated career intentions of those reporting a
‘significant effect’ of student loan debt on their future career
choice did not differ significantly from the reported intentions of either the
total exit cohort or those who stated that their loans would have ‘no
effect’ on career decisions.
DiscussionThe majority of University of Auckland medical graduates
accumulate a significant student debt. Since the time of the major increase in
fees nearly a decade ago, medical student debt has been the topic of much
discussion and has received relatively extensive media coverage. However, actual
debt levels for NZGSLs alone have not been well documented as most reports
concentrate on projected debt and often include debt from multiple
sources.1,8
Medical students in NZ do have debts other than their NZGSL,
such as credit card debt and finance company loans. Indeed, these debts are
often unavoidable and significant in size. The figures estimated in the 2001
studies noted above included all these sources of debt, with the exception of
housing mortgages.1 However, it is also
important to document the burden of debt that is attributable to loans incurred
for the purpose of fee-paying and course-related costs.
Our survey looked solely at NZGSL debt. These figures assist
in confirming that for the vast majority of medical students, debt is necessary
in order to cover basic tuition fees. Because this study looked only at NZGSL
debt, the estimated average debt is lower than that seen in the 2001 studies
that estimated total debt.1
For various reasons, including specialty choice, and working
fewer hours on average, females may struggle to a greater degree with their
student debt burden than their male
colleagues.5
Encouragingly, our sub-group analysis showed that female
medical students were significantly more likely to report being free of a
student loan at the time of graduation, and, overall, to have total loans lower
than their male counterparts. The reasons for these findings are unclear and
there is little available information in the international literature around the
relative borrowing habits of males and females.
There was no significant difference between females and
males in terms of reported parental financial support, engagement in part-time
work during medical school, or availability of savings funds. Few women received
spousal financial support. One hypothesis, therefore, is that females are more
wary of the future burden of such debt and are therefore less likely to add to
the loan without significant consideration or need. This warrants further
investigation.
The apparent increase in reported intention to work in a
rural setting seen in those without a student loan is also of particular
interest. However, while this trend was statistically significant (p=0.039), it
is difficult to speculate as to reasons for this because of the small numbers in
these sub-groups.
The overall distribution of the ethnicities in the loan-free
population was essentially as per the total exit cohort. This was also true of
the ethnicity of the students whose loans were greater than
$60,000—meaning that Māori and Pacific Island students have loans of
similar sizes to those of other ethnicities.
Indeed, Pacific Island students made up nearly one-quarter
(23%) of the students with no student loan, despite only representing 6% of the
total study population. These heartening findings are in contrast to results
from an earlier study at Auckland Medical School where it was suggested that
Māori and Pacific Island students would bear a significantly higher level
of student debt.1
It is possible that the discrepancies found between the 2001
study and our findings can be explained by more scholarships being available to
Māori and Pacific Island students. The differences may also be due to the
fact that the 2001 study looked at all sources of student debt, while this
survey concentrated solely on NZGSL debt.
Relatively few students (11%, 13 students) reported that the
debt from their student loan would significantly influence their future
specialty choice, with almost three-quarters of students in this cohort
indicating that it will have ‘no effect’ on this decision. This
initial figure is in keeping with that of a similar study from Gill et al in
2001 where 16% of students at the Christchurch School of Medicine reported that
their level of debt would be a ‘strong motivator’ influencing
decisions around career choices.3 However, it
should be noted that a nationwide study of first-year postgraduates (PGY1s)
found recently that a significant number of respondents (43%) indicated that
their student debt would impact on decisions around specialty
selection.8
The study participants in the nationwide PGY1 survey were in
a position where they were actually required to make payments on their loans,
while those in the 2001 Wellbeing, Intentions, Debt and Experiences (WIDE)
survey and the current study remain within the relatively
‘protected’ environment of the medical school. The timing of the
survey may be a factor contributing to the different findings reported by the
respective studies.
Regardless of whether the impact of medical student debt
extends to influencing career decisions, the reality remains that the true
consequences of the debt burden in this country are largely unknown.
Furthermore, it is obvious that career choices incorporate more than merely a
decision on specialty.
The chosen work place, whether urban, rural, or beyond
NZ’s waters; type of practice, including the decision to work as a
highly-paid locum; and the timing of engagement in a vocational training program
all influence one’s ultimate career path.
There are also family issues to consider. For some women, a
‘trade off’ of career aspirations for flexibility has been
noted.9 The question of whether the current
significant retention issue seen in the junior doctor workforce in NZ is
associated with the medical student debt burden should be considered. While
there is the suggestion that the speed at which junior doctors are resigning
from the District Health Boards to take up highly-paid locum positions is in
part due to generational factors and a changing work ethic, thought should also
be directed to whether such decisions are brought on by a strong desire or need
to reduce the burden of debt. Additionally, career satisfaction, work-life
balance and levels of stress are important things to consider.
There is little data around how the debt accrued during the
medical school years influences these factors in early postgraduate doctors.
The limitations of this study included the possible
introduction of ‘social desirability bias’ into the responses around
the importance of remuneration and student loan debt in career decisions. The
drive to produce a response that is perceived as more socially responsible may
have altered some answers. We feel this is unlikely, however, as students were
informed that surveys would be analysed anonymously. Furthermore, previous
research supports the theory that students are open and forthright when
discussing the impact of their loans on their lives and career
intentions.1–3
Additional limitations include that the NZGSL amounts were
not independently verified, and that the data has been obtained from only one
student cohort. Despite these limitations, there were clear differences observed
in the borrowing habits of male and female medical students, and the study had a
high response rate.
The University of Auckland’s tracking project will
continue to gather information around loan totals over time to obtain a broad,
consistent view of borrowing habits and trends. Additionally, there are plans to
link with the Medical Council of New Zealand databases to follow graduates to
career destinations. It is hoped this will provide a more accurate depiction of
the effect of loans on career choices and whether our observations persist over
time.
In conclusion, our study has shown that the NZGSL debt level
in NZ medical students remains high. There is a significant difference in the
borrowing behaviours of female medical students resulting in lower overall NZGSL
totals, although the reasons for this trend are unclear.
Encouragingly, Māori and Pacific Island students do not
seem to have a disproportionately higher level of debt and are just as likely to
be NZGSL-free at the time of graduation as their peers.
An individual’s student loan does not greatly
influence decisions around specialty career choices, however much remains
unknown about the wider implications of the burden of medical school
debt—both for the individual doctors and the professional as a whole. The
door of opportunity for further research in these areas is open.
Competing interests: None known.
Author information: Karina McHardy,
Clinical Medical Education Fellow, Medical Programme Directorate, Faculty of
Medical and Health Sciences, University of Auckland; Anna Janssen, Lecturer,
Centre for Medical and Health Sciences Education (CMHSE), Faculty of Medical and
Health Sciences, University of Auckland; Phillippa Poole, Associate Dean
(Medical Programme), Medical Programme Directorate, Faculty of Medical and
Health Sciences, University of Auckland, Auckland
Correspondence: Associate Professor
Phillippa Poole, University of Auckland, Faculty of Medical and Health Sciences,
Private Bag 92019, Auckland, New Zealand. Email: p.poole@auckland.ac.nz
Acknowledgements: Dr Karina McHardy along
with the Tracking Health Professional Students and Graduates Project receive
funding from the Faculty of Medical and Health Sciences of The University of
Auckland. The authors also thank the study participants, the research staff of
the Tracking Project, and especially Deanna Sanders and Ian Wood for their help
with this project.
References:
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