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-The State of Student Finances-UCSF School of Medicine

A special report by the Associated Students of theSchool of Medicine (ASSM)

-June 2015-


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AuthorsGreg Zahner, MS2

Sidra Bonner, MS2Sidney Le, MS2Daniel Novinson, MS2Flavio Oliveira, MS1Brian Shaw, MS2Angela Suen, MS2Chelsea Young, MS4

AcknowledgmentsThis report would not have been possible without the support of our peers and numerous facultyand staff. In particular, we would like to thank Dr. David Wofsy, Dean of Admissions, for histireless advocacy on behalf of students. Carole-Ann Simpson in the Financial Aid Officesupplied much of the data presented in this report and Lisa Raskulinec and Annie Osborne inStudent Academic Affairs were responsible for a very sophisticated forecast of UCSF costs andcumulative debt. Furthermore, Dean Catherine Lucey, Vice Dean for Education, organized keymeetings with administrators and assisted us in gaining access to requested data. She alsoprovided valuable feedback on early drafts. Lastly, we would like to acknowledge ChancellorSam Hawgood who helped initiate the process leading to this report.


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Executive SummaryIn response to student concern over financing their UCSF education, ASSM has conducted thisreport to describe the current state of student finances. Our findings are summarized below.

Cost of Attendance

!

For the 10-year period from 2005-2006 to 2015-2016, the overall Cost of Attendanceincreased 51%, with tuition/fees increasing 78%, and Cost of Living increasing 40% at UCSF.In terms of absolute dollar changes, this means that fees have contributed $69,165 toincreased COA, while COL has contributed $30,831, less than half of the amount.

! According to Student Academic Affairs, from 2005-6 to 2013-14 the total COA has increasedon average 6.0%/year, while the average cumulative debt has increased 5.5% year indicatingthat the financial aid budget will need to increase substantially to keep student debt stable.

! The graduating Class of 2020 is predicted to pay $300,000 for a UCSF medical education andtheir mean debt will be $153,950 a 33% increase from the graduating class of 2014.

! For the average student, top-ranked private schools like University of Chicago and Duke cost

about the same as UCSF when you take grants/scholarships into consideration. Only for

students from wealthier backgrounds that can expect to receive minimal grant/scholarshipsupport is UCSF consistently the cheaper option.Impact on Recruitment and Diversity

! Nationally, ~50% of medical students come from families in the top-quintile by income. Lessthan 5.5% come from the bottom quintile. SES diversity among medical students has beendecreasing since the 1970s.

!

Over the past five years, debt/cost/economy has been by far the #1 reason why acceptedstudents elect not to attend UCSF.

! In the UIM Student Indebtedness Survey, 72% of participants responded that they declinedlarger financial aid awards when deciding to matriculate into UCSF and 76% stated that theyhave considered residency options in more affordable cities. Nearly all (91%) stated that they

had trouble finding affordable housing.Impact on Current Students

!

Prior research indicates that higher levels of debt can adversely affect student performance,well-being, and potentially even specialty choice.

! In the State of Student Finances Survey, 89.7% were concerned about the cost of attendanceat UCSF and 51.2% of students felt that financing their medical education has negativelyimpacted their mental wellbeing. Only 27% feel that the amount of financial aid offered isadequate to cover their costs and 54.7% indicated that educational debt has or may in thefuture influence their specialty choice.

!

At UCSF, our students self-reported level of debt is positively correlated with concern overthe cost of attendance (r(237) = .400,p < .01), impact on specialty choice (r(237) = .389,p $200,000 in debt scored 5 points lower on the Internal Medicine In-TrainingExamination (IM-ITE) for IM residents when compared to residents with no debt. To put thiseffect size in perspective, 2

ndyear residents score 4.1 points higher than 1

styear residents. The

drop in performance associated with debt level is similar in magnitude to the increase in scorethat comes with a years experience on the wards. In a report for the AAMC, Brewer & Grbic(2010) found that although attrition rates were low overall, low SES students were more thantwice as likely to dropout. Fortunately, Cooter et al. (2004) provided some positive news;

although performance among low SES students was lower in the basic science years, thesestudents caught up with their peers during the clinical years. However, their analysis was limitedto students at Jefferson Medical College.

With regards to psychosocial factors, the odds ratio for having 1 symptom of burnout is 1.72 (CI,1.49-1.99) for residents with >$200,000 in debt compared with no debt (West et al., 2011).Students with higher levels of debt are also more likely to depersonalize others and reportedhigher levels of dissatisfaction with becoming a physician. They were also more likely to delaygetting married and having children, and delay buying a home (Rohlfing et al., 2014).

Whether debt influences specialty choice has been the subject of debate and the evidence ismixed. While it seems to make sense that students with higher levels of debt would want topursue higher paying specialties, recent evidence from the AAMC seems to refute this(Youngclaus & Fresne, 2013). Jolly (2005) hypothesizes that the lack of a strong effect might bedue to the fact that some students with high debt might actually prefer lower paying specialtieswith short residencies, so they can earn a steady income more quickly, while others prefer to waitfor the higher paying specialty. Additionally, there is the consideration that low SES andminority students are also more likely to work in underserved communities. In their analysis ofAAMC data, Rosenblatt & Andrilla (2005) found that the majority of students with debts over$150,000 report that debt influences their career choices (p.818).

In conclusion, the literature review makes clear that a medical school education is moreexpensive than ever before, and that student debt, primarily in the form of loans, has increased ata rate far exceeding inflation and physician pay. The increase is particularly steep for publicmedical schools like UCSF. As a result of increasing cost, medical schools have becomeincreasingly homogeneous in terms of socioeconomic status. Additionally, debt levels can havetangible effects on students by leading to increased burnout and potentially decreasedperformance. Our report attempts to apply this prior research to the current state of studentfinances at UCSF.

Policy efforts to improve physician workforce diversity and mitigate shortages in the primary

care workforce are inhibited by rising levels of medical student indebtedness.UCSF Hospitalist, Dr. Greysen, in a 2011 publication.


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Methods

Institutional Data

The Registrars Office keeps a public record of cost of attendance data that was used for ourCOA analysis and compared with national data reported by the AAMC. The Financial Aid

Office and Student Academic Affairs provided additional information on student debt as well asa forecast produced by Lisa Raskulinec and Annie Osborne that shows the projected increase inCOA and student debt over the next several years. Information on housing was providing by theUCSF Housing Office. Dean Wofsy in the Admission Office provided data on the SOM financialaid budget for scholarships/grants as well as the reasons why admitted students dont attendUCSF. Furthermore, the UME office provided data on student zip codes, so we could trackwhether students have had to relocate around San Francisco in response to increasing rent prices.

State of Student Finances Survey

The State of Student Finances survey was a brief instrument designed to take less than 90seconds to complete in order to maximize participation rates. Because of the controversy

surrounding the impact of debt on specialty choice, we decided to measure the association usingan item from Rohlfing et al. (2014) rather than creating our own. Otherwise, all other items werecreated by ASSM and informed by prior research. The survey was coded into Qualtrics anddistributed via class listservs in February 2015. Of the 259 anonymous responses, 243 werecomplete representing about 38% of registered students in the School of Medicine. Alldescriptive statistics and statistical analysis were performed using SPSS.

UIM Student Indebtedness Survey

The UIM Student Indebtness survey was a brief 10-question survey also designed to takeminimal time to complete in order to maximize participation. The leadership board for thestudent organization, Underrepresented in Medicine, comprised of 6 members representing the

Latino Medical Student Association (LMSA), Student National Medical Association (SNMA),and Asian Pacific American Medical Student Association (APAMSA), were contacted for thedistribution of the survey to their respective listservs. The survey was created using GoogleForms and was sent to listserv recipients as a link through which participants could access thesurvey anonymously in February and March 2015. The survey was sent to the APAMSA listservonce, while the LMSA and SNMA listservs were sent the survey two and three timesrespectively. A total of 47 responses were collected representing about 27% of UnderrepresentedStudents within the UCSF SOM. All statistical analyses were performed using Microsoft Excel.

Results

Cost of Attendance & Student DebtCost of Attendance and Indebtedness at UCSF

In 2014, UCSFs tuition for in-state MS1s was $36,427 compared to the national median of$34,540 for public schools and $53,714 for private schools. The one-year cost of attendance(COA) for UCSF for the same year was $60,830, in comparison to the national median of$56,779 for public schools and $76,376 for private schools (AAMC. 2014a). The total 4-yearCOA at UCSF can be seen in Figure XX. The total COA (i.e., tuition + cost of living) has


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increased 84% since 2003 (Figure XX),4far outpacing the rate of inflation. Figure XX puts theincreasing COA in context of increases in fees (including tuition), cost of living (COL), andmean student indebtedness.

The cost of living (COL) in San Francisco is one of the major reasons cited by students and

faculty for why UCSF is so expensive. Each year the Financial Aid Office provides a studentbudget that includes both a monthly cost of living allowance as well as an annual total cost ofattendance (COA), which varies depending on a students medical school year. Between the2004-05 and 2015-16 academic years, the estimated monthly cost of living allowance hasincreased from $1,701 to $2,520, representing a 48% increase. Specifically within the monthlycost of living allowance, the budget for a students off campus housing, including utilities, has

increased from $925 for the 2004-05 academic year to $1,465 for the 2015-16 year, representinga 58% increase.

4For the purposes of this analysis, COA was calculated by adding up the total cost for each year (i.e.,Med1, Med2, Med3, and Med4) at the time point indicated. Students could end up paying more since thetuition and cost-of-living would increase in subsequent years. Currently, the financial aid guarantee fromthe School of Medicine helps protect current students from tuition increases while they are students.Additionally, the 4% annual increase in the Medicine Grant helps provide modest relief from increasesin non-tuition costs.

Figure XX. Tracking the Increase in UCSFs Cost of Attendance


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To look at the relative impact of fees and COL on COA, Figure XX shows the percent increase,year over year for each of these variables. For the 10-year period from 2005-2006 to 2015-2016,COA increased 51%, fees increased 78%, and COL increased 40%. In terms of absolute dollarchanges, this means that fees have contributed $69,165 to increased COA while COL hascontributed $30,831, less than half of the amount. Therefore, despite the common perception thatthe cost of living in San Francisco is driving up the cost of attendance, tuition and fees have hada relatively larger impact. Figure XX shows the year-over-year percent increase in each of thesevariables, demonstrating that until recently, increases in fees outpaced increases in COL.

Despite the common perception that the cost of living in San Francisco is

driving up the cost of attendance, tuition and fees have had a relatively larger

impact.

Figure XX. Absolute increases in COA, fees, COL, and mean student indebtedness atgraduation.


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Additionally, it is important to look at cost of living from multiple sources in order to ensure thatUCSFs estimates for COL are consistent with other graduate institutions in San Francisco.Detailed searches allowed for the acquisition of COL data from the University of San Francisco(USF) School of Law and UC Hastings College of Law for the past six years. 5In figure XX, wesee the COL for all three of the institutions for the years 2010-2011 up to the current academicyear (2015-16). In absolute dollar amounts, UCSF has a COL similar to our neighboringinstitutions. Additionally, in the last five years, UCSFs COL has increased 24% compared to28% at Hastings and 34% at USF.

5Note that the COL for USD and Hastings was calculated using data obtained from each institutionswebsite. For USD, COL was calculated by summing the Room and Board, Personal Expenses andTransportation. For Hastings, COL was calculated by summing the Housing and Utilities, Food,Personal Expenses, and Transportation. Sample budgets for each institution can be seen at thewebsites below (USF: http://www.usfca.edu/law/jd/tuition and Hastings:http://uchastings.edu/about/admin-offices/financial-aid/cost/2015-16/index.php).

Figure XX. Percent increase year-over-year in tuition, fees, and cost of living from 2004-05to 2014-2015.


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While there has been a constant increase in COA, including tuition and fees, over the last decade,the average indebtedness of students has remained relatively stable. Based on Figure XXprovided by Carole Ann Simpson in the Financial Aid Office, the increased discrepancy betweenthe cost of tuition/fees and overall indebtedness will require a rapid increase to the budget forgrants/scholarships in order to keep debt relatively stable, otherwise student debt will increase.According to Student Academic Affairs, from 2005-6 to 2013-14 the total COA has increased onaverage 6.0%/year, while the average cumulative debt has increased 5.5% year.

Figure XX. Cost-of-living allowance at UCSF, UC Hastings, and USF Law from 2010/11to 2015/16.


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For the graduating class of 2013-2014, 83.8% of students had debt with an average of $116,000 well below the national average, though more comparable to many of our competitors for topapplicants. In this class, 48 students graduated with less than $100,000 in debt, 65 graduated with$100,000-175,000 in debt, and 21 graduated with over $175,000 in debt.6

Financial Aid Budget & Effective Cost of a UCSF Education UCSF School of Medicines current financial aid budget is approximately $8 million per year, upsignificantly from about $5 million in 2008-09. This budget represents the amount of financialaid given to students in the form of scholarships and grants. To understand how much theaverage student really had to pay for a UCSF MD, we calculated the effective cost to attendUCSF and compared this to Duke and University of Chicago, representatives of top-tier privateschools.

6Consistent with the rest of the report, indebtedness only includes Department of Education and UCSFinstitutional loans taken out while in medical school.

Figure XX: Cumulative Fees Paid and Average Indebtedness

This means that for a student from a high-income family who expects nogrant/scholarship, he/she could save money by attending UCSF, which is great.

However, the same may not be true for a student from a low-income family, who

might save money by attending a private school because these schools have larger

grants/scholarships.


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In 2015-16, UCSFs COA was $275,764, while Dukes was 18% higher at $326,513 andUniversity of Chicagos was 20% higher at $330,910.7However, while the average UCSFstudent can expect to receive $49,000 in scholarships/loans over their 4 years, a Duke studentreceives $86,000 and a UChicago student receives $95,000. Therefore, each of these schools

ends up having a similar effective cost i.e., COA minus grant/scholarship. The effective cost forUCSF is $227,000, while it is only slightly higher for Duke at $241,000 and UChicago at$236,000 (Table XX).

Because Duke and University of Chicago have higher tuition, the students that can afford to paywill provide more revenue for the school, which in combination with the larger per capitascholarship/grant budget, will allow these institutions more financial flexibility to providegenerous financial aid packages to low-income applicants. This means that for a student from ahigh-income family who expects no grant/scholarship, he/she could save money by attendingUCSF which is a good thing. However, the same may not be true for a student from a low-income family, who might save money by attending a private school because these schools havelarger grants/scholarships. For UCSF this is troublesome for two reasons: 1) cost is an importantfactor in accepted students decisions about which school to attend and 2) according to ourliterature review, higher levels of debt adversely affect students. If we are able to increase ourgrants & scholarships, we will have a greater capacity to recruit a socioeconomically diverseclass and reduce the projected debt of our most indebted students, which will reduce the range ofindebtedness at graduation. Because schools do not publically report the SES diversity of theirstudents, we were not able to study whether these differences in COA and averagegrant/scholarship appeared to influence the SES diversity at particular institutions. ASSMrequested data on the SES diversity of the student body at UCSF, but the data was not ready intime from Student Academic Affairs for the writing of this report.

Does UCSFs reported indebtedness for recent grads reflect the situation of current

students?

One of the issues we wanted to address in this report was the feeling expressed by some studentsthat their debt load was not reflected in the official indebtedness data reported by UCSF to theAAMC for recent graduating classes. During the fall 2014 discussions about tuition increases,some members of our schools leadership frequently mentioned the official average of $115,965for the graduating class of 2014. While it is understood that there will always be some outliers

7The 2014-2015 cost of attendance for the University of Chicago was used because the updated 2015-2016 numbers were not available at the time of writing.

Table XX. The Effective Cost at UCSF, Duke and University of Chicago. The effectivecost is calculated by taking the cost of attendance (COA) and subtracting the averagegrant/scholarship per student.

COA Average

Grant/Scholarship

Effective Cost

UCSF $276,000 $49,000 $227,000

Duke $327,000 $86,000 $241,000

UChicago $331,000 $95,000 $236,000


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in fact 21 students from last years graduating class had over $175,000 in debt it did seem thatthere were more current students expecting to have even higher levels of debt. We explored twoexplanations for some of the discrepancy subsidized Stafford loans and the Graduation Gift.

Subsidized Stafford LoansUntil July 1st, 2012 medical students could get subsidized Stafford loans where no interestaccrued during medical school. Until then you could borrow up to $34,000 in these low-costloans over 4 years. These loans were such a bargain that many students from wealthier familiesborrowed them, even though they had family support to pay for school. Therefore, prior to 2012,there were about 15-20 students per class that would borrow $34,000 in these subsidized loans,as they were entitled to do. Unfortunately, the $34,000 figure would drag down the institutionsmean indebtedness figure and held it artificially low. Since 2012 these students are no longertaking any debt and are not considered when calculating average indebtedness i.e., you dont

count a zero when calculating average indebtedness since the national standard is only toconsider indebted students in this calculation. As a result, the mean indebtedness will soonincrease and more accurately reflect the debt of our peers. (Note: All medical schools, not justUCSF, will see the same bump in indebtedness for the Class of 2016.)

The Graduation GiftThrough the process of writing this report, we discovered the existence of scholarships and loanrepayment that were not previously known to any of the authors. For example, near graduation afew of our most indebted peers will receive scholarships created by some of our generousalumni. One such scholarship is specific for students entering surgery. The loan repaymentprograms were created due to a few surpluses in financial aid funding, which the SOM disbursedto help pay down the highest interest loans for the most indebted graduating students. As a resultfrom feedback from students, SOM will try to disburse this additional money to students earlierthrough increased grants/scholarships rather than loan repayment. An example of the newstrategy was the 10% one-time boost to student scholarships announced in May 2015. The neteffect of these programs is that for the students that benefit from them, their actual debt atgraduation will end up being less than they are currently projecting. In other words, while thesubsidized Stafford Loans have held mean indebtedness artificially low, the loan repayments andadditional scholarships have actuallylowered mean student indebtedness, although the impactmay be relatively minor due to the modest size of the program.

Cost of Attendance & Debt ProjectionsIn response to UC Office of the Presidents proposed increase in fees, Chancellor Hawgooddirected Student Academic Affairs (SAA) to create a forecast of how COA and debt willincrease in the coming years. In making their projections, SAA made several assumptions, whichtended to error on the side of over-estimating cost and debt, rather than potentiallyunderestimating the impact of increased fees. They also took into account the ending of thesubsidized Stafford loan program for graduate students, which is mostly responsible for theprojected 16% increase in average debt for the Class of 2016. The graduating Class of 2020 is

The graduating Class of 2020 is predicted to pay $300,000 for a UCSF medical

education and their average debt will be $153,950 a 33% increase from 2014.


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predicted to pay $300,000 for a UCSF medical education and their average debt will be $153,950 a 33% increase from 2014 (Table XX).

Impact on Recruitment and DiversityDiversity is an important institutional ideal, emphasized at this years Deans Leadership Retreat

and enshrined as one of the pillars for UCSF 2.0. The SOM has diversity numbers that comparevery favorably to Californias other medical schools.8Over the last six years, our entering classof medical students has averaged 28% UIM students, with a record of 34% for the entering classof 2015. But the diversity pipeline at the institution tails off dramatically as you climb toresidency and faculty positions, which earned the University a citation from the LiaisonCommittee of Medical Education (LCME). While we await the numbers on SES diversity atUCSF, which wont be available until after this report, the available data does not paint aparticularly encouraging picture with more than half of medical students nationally coming fromthe top quintile by family income. We should be asking is UCSF asdiverse as it couldbe? Is it as diverse as itshouldbe?

The effect on SOM admissions yield

In the State of Student Finances survey, 50.4% of respondentsindicated that UCSF was not their cheapest option. If you eliminatethe 21.8% of respondents that were not sure, presumably becausethey didnt get other financial aid offers by the time they decided toattend UCSF, then 64% of the remaining respondents turned downcheaper options. While no hard conclusions can be drawn from thisdata, it does show that a majority of current students came here eventhough it has cost them more money. That demonstrates a strongcommitment to the school and a desire to look beyond cost. In thesurvey, respondents were also given the opportunity to write which

other schools were cheaper. The results are included in Figure XX.Although the absolute numbers arent very informative, the relativefrequencies are about what we expected.

8The Deans of Admissions for each of Californias medical schools confidentially share data ondiversity. The data was made available to ASSM but we elected not to include specifics in this report outof respect for the nature of this voluntary data sharing between institutions.

Figure XX. Number of

respondents that indicated a

particular school wascheaper.School Frequency

UCLA 23

UCSD 13

UCD 11

UChicago 11

USC 10

Columbia 9

UCI 8

UMich 8

UPenn 7

WashU 7

Stanford 6Duke 5

Harvard 5

Vanderbilt 5

Table XX. Projected Costs & Average Cumulative Debt 2015-2020 (Source: Student AcademicAffairs).

Graduation Year Cost of Attendance Average Indebtedness2014-2015 $253,058 $118,294

2015-2016 $260,084 $137,378

2016-2017 $268,033 $133,779

2017-2018 $277,522 $138,280

2018-2019 $288,434 $144,073

2019-2020 $299,991 $153,950


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The more conclusive institutional data on recruitment and diversity comes from Dr. DavidWofsy, the Associate Dean for Admissions. For the past few years, UCSF yields 55% of thestudents it accepts. For reference, the national average is 52.8% (Smith-Barrow, 2014), thoughvarious admission strategies can be used to manipulate the numbers thus limiting the value ofyield as a comparison tool to other universities. Considered in isolation, UCSFs yield, while

highlighting many of the successes of our recruitment efforts, still indicates that we are losingmany desirable applicants.

To understand why accepted students choose not to attend UCSF, Dr. Wofsy personally emailseach of them. Over the past five years, debt/cost/economy has been the #1 reason why acceptedstudents elect not to attend UCSF. While UIM students are even more likely to indicatecost/debt/economy as the reason why they dont come, the disparity has been nearly eliminatedin the last three years. While ASSM was granted special access to the data for the purposes ofthis report, we were asked not to include specific figures since they are used internally and maynot be comparable to similar figures reported by other universities due to differences inmeasurement.

Socioeconomic Diversity at UCSFIncome inequality is at an all-time high, with California leading in terms of poverty rate as wellas ultra-wealthy residents (US Census). While UCSF is obviously not responsible for this fact,we believe that UCSF must be responsive to these realities if it wishes to attract a student bodythat fully represents the stunning socioeconomic diversity in the state of California.

To take a closer look at socioeconomic diversity at UCSF, Daniel Novinson, one of the authorsof this report, worked under the supervision of Dr. Rene Salazar, the GME Director of Diversity,as part of a RAPtr summer research project. He found that the mean income and urbanicity ofeach of Californias 58 counties strongly correlates with that countys per capita application rateto UCSF SOM, such that compared to a theoretical application pool in a state of absoluteequality, 25% of the actual application pool is missing altogether. These missing applicants aredisproportionately students from poorer, rural, inland California counties areas most in needof additional medical providers. Second, for students who do apply, higher socioeconomic statusstrongly predicts eventual admission: After controlling for measures of achievement anddemographic variables (MCAT score, undergraduate GPA, age, underrepresented minority statusand gender), students who attended a private high school had admissions odds 2.5 times those oftheir peers, a boost equivalent to nearly six points on the MCAT, or 0.34 on an undergraduateGPA.9(See Table XX below) As lower-SES students are less likely to attend private highschools, the two above findings have a multiplicative effect, with poorer students both less likelyto apply and then disproportionately rejected, further reducing SES diversity.

9The data for this analysis comes from the entering Classes of 2006 and 2007. Under the direction ofDr. Wofsy, the SOM has instituted a new review process and is actively investigating whether studentswho attended public high schools are disproportionately rejected in the admissions process. Of note,requesting a fee waiver had no impact on admissions odds.


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Table XX. Applicant Characteristics and Their Admissions Weight

Variable (SD)B S.E. Sig. Odds Ratio

95% C.I. for Odds Ratio

Lower Upper

HS* GPA

(0.34)1 .758 .179 .000 2.134 1.502 3.032

MCAT*

Private (Ind.)

HS.637 .096 .000 1.891 1.565 2.285

GPA* MCAT

(5.9)1

.857 .108 .000 2.355 1.907 2.908

Age .158 .066 .017 1.171 1.029 1.332

Constant -4.143 .098 .000 .031 ---- ----

Table N. Applicant characteristics ordered by their effect on admissions odds, as determined by logistic

regression.1Variable standardized to allow for comparisons of relative impact, standard deviation in parentheses. Above

statistics reflect effect of one standard deviation increase. One-unit increases in age, MCAT score, and GPA(increase of 0.10), respectively predict 5.1%, 16.3% and 32.0% increase in admissions odds.

Overall Novinsons findings reinforce the prior research demonstrating that students from poorerfamilies are less likely to apply in the first place. As the UCSF SOM community debates tuitionand financial aid policies, it is important to remember that these decisions do not merely changethe numbers on a spreadsheet they are public signals as to the Universitys openness to studentsfrom all socioeconomic backgrounds.

Results from UIM Student Indebtedness SurveyIn the UIM Student Indebtedness Survey, 72% of participants responded that they declined largerfinancial aid awards when deciding to matriculate into UCSF. This data demonstrates that similarto the school-wide State of Student Finances Survey, a majority of students who identify asUnderrepresented in Medicine (UIM) chose to attend UCSF in the presence of cheaper options.When UIM students were asked about the importance of Financial Aid when choosing whichmedical school to attend, 72% of respondents stated it was very or extremely important. Thissuggests that financial aid packages serve as a key determinant in the decision making processfor UIM students choosing a medical school.

When students perception about the relationship between financial aid and diversity within the

SOM student body was surveyed, 89% of students agreed or strongly agreed that the cost ofattending UCSF and living in San Francisco has limited student diversity in the SOM.Furthermore, 100% of participants answered that they believed providing subsidized housingwould help increase the recruitment of a diverse student body. In order to understand thepotential impact that finances could have on retention of UIM students for residency, participantswere asked if the cost of attending UCSF and living in San Francisco has caused them to seekpotential residency options in more affordable locations with 53% reporting that it had. If weremove the not applicable respondents, since 90% of them were MS1s or MS2s who


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potentially have not thought extensively about residency, then 76% of UIM students haveconsidered residency options in more affordable locations. Given these responses, it is clear thatUIM students feel as though the cost of living in San Francisco and attending UCSF has not onlyimpeded SOM from being as diverse as possible but has also led them to consider other medicalinstitutions for their graduate medical training.

Finally, students were asked about specific financial barriers, including timing of financial aiddisbursement, providing financial support for family members or relatives and housing that untilnow have only been discussed anecdotally in terms of their impact on UCSF UIM students. Theresults from the survey are listed below in Table XX. Below, we have also listed some specificcomments from UIM students.

The cost of housing is by far the largest obstacle limiting the recruitment of students,

especially UIM students. Our peer institutions not only offer better financial aid

packages, but many offer subsidized housing, especially those in similar housing

market places, such as New York, Chicago, LA, and Boston. It seems extremely

disconnected that the administration and financial aid office believes that $1250 is areasonable amount for financial aid to budget for student's rents.

I turned down a full tuition scholarship and partial tuition scholarship at schools in less

expensive cities to UCSF. As an older student who is interested in primary care or a

"low-paying" specialty & looking at a boat load of debt, I often wonder if I made a

responsible choice.

I remember one very vivid moment when speaking with a financial aid officer about a

gap in my budget. I was told that I wouldn't be able to have my disbursement on time

so I would have to live off of credit cards in the meantime. I was told I should "beg,borrow, and steal" that money for the two month period before money came in. Beg,

borrow, and steal." This is how low-income students are treated at this institution. I

have a master's degree and am told to beg, borrow, and steal for rent. When

administrators and leadership wonder why there's a paucity of low-income, high-

achieving, first-generation students at UCSF or why they're all choosing to go to other

schools, it's because at other schools they don't have to "beg, borrow, and steal.

I declined to go to a school where I would have my entire tuition covered because I

felt like UCSF would make me a better physician. I still believe that I made the right

choice but when I am running low on funds and have to worry about paying my rent or

groceries, I think about how much easier it might have been if I had decided to attend

the other school. I am worried because rent is so expensive and I might not be able to

stay in the student housing for next year. I don't know that I will be able to afford living

close to campus and am concerned that living far from campus will affect my grades

and the extracurricular activities that I am able to take part in. I think having more

student subsidized housing would help but am also concerned about gentrification

and whether the student housing will displace disadvantaged communities.


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It is as if, outside of the UIM community, everyone assumes that family is a source of

emotional and financial support. This is frequently not true! I think that the students

who do have families who provide financial support are throwing off whatever

calculations go into determining how well UCSF is doing at providing Financial Aid.

Maybe many students would answer "no" to whether or not their family providessupport. But are they counting the free flights home, being on their parents' phone

bills and insurance coverage, gifts of books or computers, the stocking of their

refrigerators when family visits... probably not. Do they realize that some of their

classmates need to help support their families? That them entering med school was a

serious blow to their familys financial security? I doubt it.

I love the Bay Area. I have spent my entire adult life here, but it is important to me as a

physician to be able to live in the area in which I serve. Being a physician, for me,

means interacting with my patients in and outside of the clinic/emergency room. That

experience may not be possible as a resident, and it is a really saddening realization.

Do [other students] realize that some of their classmates need to help support their

families? That them entering med school was a serious blow to their familys financial

security? I doubt it.

In summary, not only is cost a major barrier to recruiting a diverse applicants, it createssubstantial burdens for our current students and causes many of them to look elsewhere forresidency. Addressing these issues may serve to further the cause of diversity at UCSF byincreasing the diversity pipeline for our residency and faculty positions.

Impact on Current StudentsResults from State of Student Finances Survey

Survey respondents represented a broad spectrum of the student body with representation fromall four classes as follows: 17.9% MS1s, 25.8% MS2s, 17.5% MS3s, and 38.9% MS4s.

Table XX: Specific financial obstacles for UIM students.

Trouble Receiving Providing Financial Support Trouble FindingFinancial Aid for Family Members/ Affordable Housing

Disbursements on Time Relatives________________________________________________________________________

Yes 36.96% 43.48% 91.49%

No 63.04% 56.52% 8.51%________________________________________________________________________


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Additionally, about a third (34.9%) of respondents self-identified as UIM. The survey had thefollowing key-findings on a scale of 1 (strongly disagree) to 5 (strongly agree):

I am concerned about the cost of attendance at UCSF.

o The average response was 4.40 with 89.7% of students agreeing with the

statement. In fact, the majority of students (56.1%) strongly agreed.

I feel that the amount of financial aid offered is enough to cover tuition, fees, insurance,books & supplies, and cost of living.

o The average response was 2.65 with 26.9% of students agreeing with thestatement and 50.2% disagreeing.

Financing my medical education has negatively impacted my mental well-being.

o The average response was 3.43 with 51.2% of students agreeing with thestatement.

I have already or may in the future make decisions about my medical specialty choicebased on my educational debt.

o The average response was 3.42 with 54.7% of students agreeing.

We failed to find any statistical relationship between any of the items on the survey and UIMstatus. However, there were significant correlations between each of these four items and astudents projected debt level. Projected debt level correlated positively with concern over thecost of attendance (r(237) = .400,p < .01), impact on specialty choice (r(237) = .389,p < .01),and negative impact on mental well-being (r(237) = .396,p < .01). All of these correlationsrepresent medium to large effect-sizes. Additionally, there was a smaller negative correlationbetween projected debt and financial aid satisfaction (r(237) = -.129,p = .048). It should also be

noted that our survey found that UCSF students had very little debt prior to medical school,similar to national trends in national data collected by the AAMC.

Overall, these findings indicate that students have a very high level of concern over the cost ofattendance and slight dissatisfaction with the amount of financial aid. Additionally, somestudents, particularly those with higher levels of debt, report impaired mental wellbeing as aresult of concern over financing their medical education. Lastly, while a majority of studentsagreed that debt influenced their specialty choice, this was particularly true among more indebtedstudents.

Modest yet adequate lifestyle

When determining the cost of living allowance, the Financial Aid Office must comply withfederal guidelines that permit a modest yet adequate lifestyle. However, Annie Osborne andCarole Ann-Simpson will quickly point out that this means a lower standard of living in SanFrancisco relative to Durham, North Carolina because of the astronomically high cost-of-livingin San Francisco. However, we believe they do their best to give us maximum access toDepartment of Education loans. They can also grant us loan increases if we can demonstrateadditional costs in areas that are eligible for government loans such as housing, food, andhealthcare expenses. Furthermore, consistent with what is permitted by federal regulations, they


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left the books & supplies allowance to reflect full retail value, which gives students additionalflexibility to save money in this category and use it for food, housing, etc.

Nevertheless, students tend to complain specifically about trying to find housing, though thismay become a little easier with the big jump in the housing allowance to 1,465/month for the

2015-2016 academic year. However, even with the big increase, it will still be difficult forstudents to find housing in the Inner Sunset, one of San Franciscos cheaper neighborhoods.The average cost for a single room in San Francisco is $2,200 according to the UCSF HousingServices Manager. In the Inner Sunset, the average costs are as follows: $2,122 for a studio,$2,800 for a 1-bedroom, $3,355 for a 2-bedroom, and $3,900 for a 3-bedroom. So with a $1,465the average apartments are simply unaffordable in the neighborhoods around Parnassus (ColeValley is even more expensive). This reality gives students a strong incentive to move in withsignificant others, find a 3-bedroom apartment, or convert common rooms like living rooms intomakeshift bedrooms.

In order to find affordable housing, many students have wondered whether students are

increasingly moving further and further away from campus to places such as the Richmond,Outer Sunset, and Daly City. ASSM was provided with local zip codes of students from theClasses of 2006, 2012, and 2018. Based on the data we were able to collect (Table XX), theseconcerns appear unwarranted thus far. However, our analysis is limited by the lack of detailedinformation on the exact location of student residences. For example, the 94122 zip codeincludes UCSF as well as places in the Outer Sunset that are a 30+ minute commute by publictransportation.

The role UCSF has played in helping students find housing has been relatively minimal. Weprovide no housing guarantees, and with the exception of single bedroom in a shared unit, ourhousing options tend to be more expensive than many of our peer institutions. Since UCSFprovides housing for


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Finances While Doing ResearchSince the government no longer provides subsidized loans to graduate students, UCSF studentswith high levels of debt had to consider whether or not taking a research year was worth havinganother year of unpaid interest accumulate on the loans they had taken out during the first threeyears of medical school. To address this issue, Associate Dean for Curriculum, Susan Masters,was credited with recently starting a program to pay for a students loan interest during the yearthey are conducting research. For example, for a student with $100,000 in federal loans at theend of their 3rdyear, this program will save them approximately $6,000 in unpaid interest duringthe research year. This guarantees that all students are on a more equal playing field whenconsidering the costs versus benefits of taking time off to do research.

In contrast, the summer Pathway to Explore program was less student-friendly in terms offinances. This past year disbursements for $3,000 went out halfway through summer leavingmany students scrambling to pay rent in advance of the disbursement. Additionally, students

Table XX. Where students are living by zip code for the class of 2006, 2012, and 2018.


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didnt receive the final $500 until over 7 months after the summer ended. Additionally, the$3,500 does not cover the cost-of-living for a 10-week period as determined by the Financial AidOffice. Fortunately, Dean Lucey has already begun taking steps to address these issues.

Loan Repayment Programs & Debt During Residency

Graduates must start repayment during residency on an average salary that starts at $51,586 for aPGY1 and gradually increases to $67,238 for a PGY8 (AAMC, 2014b). For a first year residentwith the average public indebtedness of $167,763 at an interest rate of 6.0%, they would owe$10,066 in interest. Luckily, several federal repayment programs and loan forgiveness programsexist to minimize the burden.10For example, the popular Pay-As-You-Earn (PAYE) programwould reduce that interest rate to ~$3,360. There is also the Public Service Loan ForgivenessProgram, which forgives all remaining debt after 10-years of service for non-profit and publicsector employees. That means that after 7 years of residency/fellowship at UCSF and 3 years ofworking for the VA (as an example), while making 120 minimum payments under PAYE, youwould be eligible to have the remaining balance of your loans forgiven.11This is potentially ahuge savior for our most indebted students, which could walk away from medical school having

paid relatively little for their UCSF education. However, the 2015 budget proposal from theObama Administration proposed capping the amount forgiven at about $60,000 (U.S. Dept. ofEducation, 2014) and the prospects for the program look even worse in the context of ourshifting political environment. Furthermore, the program was enacted in 2007, which means itwill start hitting the Department of Educations budget in 2017. This hit to the budget maytrigger legislative action from Congress to cut the program. Ultimately, the fate of this programis a huge wild card for our peers.

If we assume that the Public Sector Loan Forgiveness Program will be eliminated, students willstill have access to the PAYE program. However, by lowering the minimum payments, the restof the unpaid interest will be added to your principal, as it did in medical school. This means thatthe debt you graduate with may be less than the debt you end up with after residency. This effectis even more drastic for students with high levels of debt, as illustrated in Table XX.12Thisshows that for the 21 students with over $175,000 in debt in last years graduating class, many ofthem can expect to have well over $200,000 in debt by the end of residency.13Even a student

10A small minority of UCSF graduates will choose forbearance and delay payment, though this option isnot recommended by ASSM because it will cause your outstanding debt to compound during residency.11The forgiven amount may have to be reported as income, causing a significant tax penalty during theyear the loans were forgiven.12The calculator created to make this table was produced by Greg Zahner in consultation with Carole-Ann Simpson in Financial Aid. We plan to eventually make it publically available, but if youd like it inadvance, please email [email protected] to receive the excel file.13The calculations use the interest rate for Stafford loans in 2014-15 and assume a monthly increase inthe minimum PAYE payment of $17/month for each subsequent year of residency due to increasingresident income.

A UCSF graduate with $175,000 in debt that wants to become an interventional

cardiologist will have at least $230,000 in debt by the end of her residency.


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with $150,000 in debt - the projected average for the Class of 2020 can expect to have$175,000 to $200,000 in debt by the end of residency.

ConclusionIn conclusion our review of the State of Student Finances reviews several areas of concern. TheCOA has increased 84% since 2003 and will soon reach $300,000. While strong leadership fromthe administration has kept mean indebtedness relatively stable, shielding our students from thefull extent of financial pressure facing students nationally, our mean indebtedness is projected toincrease 33% by 2020 to over $150,000. Even with the projected increase, it is important to alsoconsider that UCSF still compares favorably with national averages. Yet ASSM argues that weare no average institution and even in the Class of 2014 a class with a mean indebtedness morethan $30,000 lower than the national average 21 students graduated with over $175,000 indebt, highlighting how averages can ignore the hardship faced by individual students.

Additionally, cost is a major deterrent to potential applicants, which costs the school diversity.Although the data on the SES makeup of UCSF students is not yet available, we anticipate thatthese data will show a strong overrepresentation of the top quintile by family income, consistentwith what is seen across the rest of the nation. Furthermore, the effective cost analysis shows thatfor many students, private schools like Duke and University of Chicago cost about the same.Only for the wealthiest families is UCSF most likely to be the cheapest option. In order for us tocompete with these private schools for highly qualified, low-income students, we will need alarger financial aid budget for grants/scholarships.

Possibly the most troubling issue that we found is the impact that debt is having on our current

students. More indebted UCSF students report that debt influences their specialty choice as wellas adversely affects their mental wellbeing. They are more concerned about the increasing costof attendance and less satisfied with the financial aid offered.

We would be remiss not to recognize the common counter-argument that if physicians make somuch money, why do they need more scholarships? After all, Net Present Value calculations of amedical education show that it a great long-term investment. However, NPV doesnt fully takeinto account the short and medium-term costs of making that investment while students are in

Table XX.What happens to debt during residency? Debt will drastically increase duringresidency for a student with $175,000 in debt at graduation that is making minimum payments under

the Pay As You Earn loan repayment program.Year Starting Debt InterestRate

Interest Owed PAYE

Payment

Unpaid Interest Ending Debt

PGY1 175,000 0.0621 10,868 3,360 7,508 182,508

PGY2 182,508 0.0621 11,334 3,576 7,758 190,265

PGY3 190,265 0.0621 11,815 3,780 8,035 198,301

PGY4 198,300 0.0621 12,314 3,996 8,318 206,619

PGY5 206,619 0.0621 12,831 4,200 8,631 215,250

PGY6 215,250 0.0621 13,367 4,404 8,963 224,213

PGY7 224,213 0.0621 13,924 4,608 9,316 233,529

PGY8 233,523 0.0621 14,502 4,812 9,690 243,219


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training. Students face the decision of whether to make nothing for 4-5 years followed byrelatively little for another 3-8 years, or enter the workforce immediately. This presents a hugedilemma for all students and particularly lower income students for whom cash flow andfinancial flexibility is a particularly big concern. Entering the workforce gives them financialflexibility to support their families and build up savings so that they can weather an emergency

like unexpected medical bills or death of a parent. For the students that enter medical school,they have relatively few financial options if such emergencies arise. Imagine the stress of livingdisbursement to disbursement knowing that if you get sick, get into a car accident, receive anexpensive parking ticket, need to fly home for a family emergency, or need to pay copays forphysical therapy or psychiatry appointments, that your financial aid disbursement does not havean allowance for these expenses and you will need to cut from food, books & supplies, or themodest catch-all miscellaneous. Additionally, their income is constrained during a time in lifewhen many are getting married, starting families, or supporting elderly parents. Furthermore, thedebt burden is higher and more expensive than ever before, even when adjusting for inflation andchanges in physician salaries. For these reasons, debt is an increasing burden on allstudents anda major cause of the decreasing SES diversity in medical schools.

While UCSF might have one of the most diverse medical student bodies, available data indicatesthat we are still falling short. Unfortunately, as long as we continue to compare favorably toother medical schools at the UME level in terms of percentage of UIM students, there may belittle incentive for the University to prioritize increasing SES diversity. Additionally, we cannotidly accept the finding that projected student indebtedness at UCSF is negatively correlated withmental wellbeing especially considering the enormous concern we have for the mental healthof our students. In 2014 a survey of first year medical students, found that 30% reportedcurrently dealing with a mental illness.14Therefore, it is incumbent upon students and visionaryleaders within the University to push for allocating more financial resources toward financial aid.We must truly innovate and lead the change to make medicine more diverse, and this processcannot happen without greater financial support for students that allows for greatersocioeconomic diversity, equity, and student wellbeing. As a public medical school, it isparticularly incumbent upon us to educate students of all backgrounds, so that students regardlessof socioeconomic status all have the opportunityto join in the privilege of receiving a UCSFMD.

Recommendations Increase the financial aid budget to a new minimum baseline of $10 million for 2015-16 and

subsequently increase it to keep increases in mean indebtedness at the level of inflation. For the upcoming year the financial aid budget for grants/scholarships should be increased to at

least $10 million to help counteract projected increases in student indebtedness and preferably$12-13 million/year to help reduce baseline levels of student indebtedness, a stated desire ofseveral UCSF leaders we consulted. These new funding levels would need to be increased insubsequent years to keep increases in student indebtedness at the level of inflation.Unfortunately, declining state support means that the University will need to raise most of this

14The survey was conducted as part of the Mental Illness Among Us event and had a 73% participationrate.


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money on its own. While we encourage continued advocacy at the state and federal levels, wemust face the reality that while UCSF is a public institution, it must increasingly behave like aprivate school when it comes to funding financial support for its students.

According to information provided by Vice Chancellor Jennifer Arnett in the Development

Office, UCSF has an endowment of ~$61,371,830 for medical student scholarships, whichprovides an annual payout of ~$3 million. In the last fiscal year, they raised $1,336,950 forscholarships, with $451,128 for immediate use. The rest was added to the endowment. Whilethese totals are the result of years of hard work and carefully forged relationships with donors, itis clear that fundraising will need to dramatically increase in order to meet the demand forfinancial aid resources. Students should take an important role in helping the University raise theadditional funds.

How should the money be spent? The answer requires an ongoing discussion between

students and administrators, though we would argue that increased funding for need-based

grants/scholarships is the most progressive option.

The literature provides limited advice on this issue. For example, Steinbrook (2008) recommendsthe following: capping tuition increases at CPI, providing majority of financial assistance asscholarships, and expanding loan-repayment programs.

In the State of Student Finances survey, students were asked how they would want SOM tospend a $200 million endowment in support of student finances. Students were pretty evenlysplit between wanting lower tuition/fees for all students, building subsidized housing forstudents, and increasing need-based scholarships. Other less popular options included merit-scholarships and offering loan forgiveness to students matching in primary care/working inunderserved areas. The results are shown in Figure XX.

Our effective cost analysis indicates that decreasing tuition for all students preferentially favorsstudents from higher income backgrounds. While an argument can easily be made that this ismost fair and that all students are facing difficulties due to the high COA, the counterargumentwould point out that this would be a relatively regressive policy compared to concentratingadditional financial support among the highest need students. Since ASSM represents allstudents, we do not wish to pit one group of students against another. Instead, we want tohighlight the differing opinions among students and encourage greater dialogue about how the

university can bestsupport us.Figure XX. If UCSF raised $200 million to support student finances, how

should it spend it?


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Create a special task force to explore alternative forms of financing a UCSF medical

education.We are acutely aware of how difficult it will be to increase the budget for studentscholarships/grants in order to keep pace with the increasing COA. To fund a new baselinescholarship/grant budget of $12 million/year, as we recommend, it will require an endowment of~$250 million or a substantial amount of annual fundraising/reallocation of funds from other

areas. If the COA continues to increase at current rates, that budget would need to quicklyincrease to $15-20 million/year.

Therefore, it would be well worth going back to the drawing board and asking some fundamentalquestions. For example, what really matters in financing a medical education? Should studentshave skin in the game? What is the right amount of debt? Are their other ways to fund a UCSFeducation? Are there any ways to make it cheaper, like a 3-year accelerated program? A taskforce of some of UCSFs brightest minds in medical education, health policy, finance, anddevelopment could begin to answer these questions and come up with more creative andsustainable long-term solutions.

UCSF should disburse funds in a timelier manner that is consistent with the world studentslive in.Disbursement of funds needs to occur at equal and regular intervals that allow students to payrent and other bills. For example, disbursement should occur before the end of the month so thatstudents have funds to pay for the next months rent. Unfortunately, this recommendation runsinto Department of Education regulations that state loans can be disbursed a maximum of 7 daysbefore the start of a quarter. We strongly encourage the schools leadership to work with federalregulators and available school resources to develop a creative solution to this problem.Additionally, since holds on student accounts delay disbursement, we encourage a better systemfor notifying students of holds and making sure that no holds are placed on an account too closeto a scheduled disbursement date so that students have adequate time to respond and comply.

Maintain progressive programs like the tuition guarantee to protect students from tuition

increases while they are students and loan interest support during an optional research

year.

The tuition guarantee spearheaded by Dean Lucey and Dean Wofsy helps provide predictabilityonce students have matriculated at UCSF. Students can rest assured that if the Regents increasetuition/fees, UCSF will shoulder the additional cost for students that receive financial aid.Additionally, providing financial support to cover the unpaid interest on student loans during a


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research year is a very progressive program started under the direction of Dean Masters. ASSMencourages UCSF to continue subsidizing the interest of student loans during the optionalresearch year.

Students should be aware that they are entitled to ask for loan increases if they can

demonstrate that their costs exceed UCSF cost of living estimates.Students can successfully request more loans from the Office of Financial Aid if they candemonstrate that their costs for things like books, food, and rent reasonably exceed theallowances provided by UCSF. More information is available online:http://finaid.ucsf.edu/continuing-students/student-budget-increases

Financial advice for students: budget and track your expenses while in medical school and

project your costs during residency so you can select the repayment program that makes

the most sense for you.

The University already offers a lot of assistance for students, including budgeting tools that canhelp students make ends meet from disbursement to disbursement. ASSM has also worked with

the Financial Aid Office to create a debt during residency calculator. We encourage morestudents to take advantage of these resources and meet with advisors in Financial Aid.

Students should have frank conversations about class, SES diversity, and privilege.

While not explored formally in this report, the research that we conducted highlighted manydiffering views among students best highlighted by this comment from the UIM survey: Do[other students] realize that some of their classmates need to help support their families? Thatthem entering med school was a serious blow to their familys financial security? I doubt it. Thediffering comments in the UIM Survey and the State of Student Finances Survey highlighted thevast differences in attitudes among students toward financing their medical education. Theresults in Figure XX above, further illustrate this point.

Our education has gotten so expensive that all of us feel it. Even for the majority of us from thefirst or second quintile by family income, paying for our education has been difficult andstressful, requiring us to take well over $100,000 in debt to graduate. These difficulties can makeit easy for us to ignore the privileges many of us still have. For example, some may have familiesthat pay for trips home, for phone bills, insurance, or copays for unexpected medical bills.Perhaps their parents bought them a house in SF, pay for their rent, or provided a car for thirdyear rotations. For others, these privileges were not a part of their reality. They cant count ontheir family to provide a safety net in case of an emergency or on future inheritance to pay downstudent debt. There is also inequity and unfairness inherent to the system of financial aid.Students that worked hard and saved money before medical school feel penalized because their

savings may have led to less financial aid. In recent years, some students who budgeted morestrictly during school didnt qualify for loan repayments from UCSF because they didnt borrowas much as some of their less thrifty peers. We encourage all students to discuss and explorethese issues so that financing our education becomes something that unites rather than divides us.

Citations


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AAMC. 2006. Diversity in the physician workforce: Facts & figures 2006.Association of American Medical

Colleges.

AAMC. 2014a. Medical student education: Debt, costs, and loan repayment fact card.AAMC.org/FIRST

AAMC. 2014b. Survey of resident/fellow stipends and benefits report.Association of American MedicalColleges.

American Medical Student Association/Foundation 1996. Study group on minority medical education:

Findings from literature search and anecdotal data. Sponsored bythe U.S. Department of Health and Human

Services.

Brewer, L., & Grbic, D. 2010. Medical students socioeconomic background and their completion of the first

two years of medical school.AAMC Analysis in Brief, 9(11).

Cooter, R., Erdmann, J.B., Gonnella, J.S., Callahan, C.A., Hojat, M., & Xu, G. 2004. Economic diversity in

medical education: The relationship between students family income and academic performance, career

choice, and student debt.Evaluation & The Health Professions27(1), pp. 252-264.

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), pp. 840-845.

Jolly, P. 2004. Medical student tuition and young physician indebtedness.Association of American MedicalColleges.

Jolly, P. 2005. Medical school tuition and young physicians indebtedness.Health Affairs 24(2), pp.527-535.

Jolly, P. 2008. Diversity of U.S. medical students by parental income.AAMC Analysis in Brief 8(1).

OReilly, K.B. 2013. Black men increasingly hard to find in medical schools. amednews.com

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.

Rosenblatt, R.A., & Andrilla, C.H.A. 2005. The impact of U.S. medical students debt on their choice of

primary care careers: An analysis of data from the 2002 medical school Graduation Questionnaire.Academic

Medicine, 80, pp. 815-819.

Smith-Barrow, D. 2014. 10 medical schools where accepted students usually enroll. USNews, May 16th.

Available at: http://www.usnews.com/education/best-graduate-schools/the-short-list-grad-

school/articles/2014/05/06/10-medical-schools-where-accepted-students-usually-enroll

Steinbrook, R. 2008. Medical student debt Is there a limit?New England Journal of Medicine359(25), pp.

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U.S. Census Bureau. Historical income tables: income inequality. Available at:http://www.census.gov/hhes/www/income/data/historical/inequality/

U.S. Department of Education. 2014. Student loans overview: Fiscal year 2015 budget proposal.

West, C.P., Shanafelt, T.D., & Kolars, J.C. 2011. Quality of life, burnout, education debt, and medical

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