By: James “Jay” Youngclaus, AAMC
In his recent book, Thinking, Fast and Slow, Daniel Kahneman, a Nobel Prize winner in Economics, explains the two systems central to thinking. He depicts “System 1” as “fast, intuitive, and emotional” while “System 2 is slower, more deliberative, and more logical.” The book “is about the working of System 1 and the mutual influences between it and System 2.” This fascinating work has affected how I think about debt and specialty choice.
I think most people are quick to believe that debt plays a key role in specialty choice, driving physicians away from primary care with its comparatively lower salaries versus specialists. It seems to make such intuitive sense. The current median debt level is $170,000; with the interest that accrues during residency, this will be expensive and time-consuming to repay. Most specialties have a starting salary after residency one and a half to two times that of primary care. How can that difference not play a critical role? This is classic System 1 thinking.
But, is it really so simple? First, if the link were so direct, why would any indebted physician choose primary care? How do you explain those physicians with significant debt levels who do choose primary care? Also, isn’t medicine a profession driven by altruism? If an applicant seems primarily motivated by financial gain, isn’t it more difficult for him or her to get accepted into medical school in the first place? Are physicians really choosing how they will spend the rest of their professional lives mainly based on the money? Finally, how challenging is it for an indebted physician, regardless of specialty, to actually repay her or his education debt? These questions characterize System 2 thinking.
Our recent report tries to take a more System 2 approach to the question of debt and specialty choice. We tracked the future income and expenses of a physician household to see how manageable repaying different debt levels would be. This approach has not been used before in such a comprehensive way according to our thorough review of the academic literature. My interpretation of our findings are twofold–they suggest that education debt need not play a determining role in specialty choice and illustrate the capacity of physicians to repay current education debt levels.
So, if it’s not just about debt, what drives specialty choice? I believe there is compelling evidence that, for most medical students, specialty choice is a complex and personal decision more responsive to factors such as interest in a specialty’s content and level of patient care, desire for the “controllable lifestyle” offered by some specialties, or exposure to a strong role model in the specialty. Education debt and/or potential income may play a role when some physicians choose their specialties, but these factors do not appear to play a determining role for most.
Many people have an older relative–a parent, grandparent, aunt or uncle–who at one point offered life advice similar to “Don’t make decisions just based on the money, follow your heart.” Shouldn’t such advice apply to specialty choice as well?