How medical student loan forgiveness can advance health equity [PODCAST]

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Join us as we welcome Katrina Gipson, an emergency medicine physician, to discuss the intersection of student loan debt and health equity. As the Supreme Court reviews the Biden Administration’s Student Loan Forgiveness Program, Katrina sheds light on the disproportionate impact of student loan debt on underrepresented minorities in medicine. The episode explores how high levels of debt can limit career choices for medical students and worsen health care outcomes for minority communities. We delve into the ways in which systemic racism and lack of access to resources contribute to the student loan debt crisis and how loan forgiveness can serve as a tool for health equity.

Katrina Gipson is an emergency medicine physician.

She shares her story and discusses her KevinMD article, “Student loan forgiveness: a key step in achieving health equity for minority physicians and patients.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have Katrina Gipson. She’s an emergency physician. Her KevinMD article is titled “Student loan forgiveness: a key step in achieving health equity for minority physicians and patients.” Katrina, welcome to the show.

Katrina Gipson: Well, good afternoon or morning, depending upon where you are. Thank you so much for having me, and happy Black History Month.

Kevin Pho: All right, and we’ll get into the article in a little bit. But first off, just briefly share your story and journey to where you are today.

Katrina Gipson: Sure. I was born and raised in Ann Arbor, Michigan, and my path to where I am has not been linear. However, I think that there have been a few recurring themes. I was fortunate enough to be raised by parents who instilled in me the importance of advocacy and social justice, even from a small age. I feel like my first story of that is probably as a first grader, when we went to the elementary school to discuss with my teacher at the time her slavery curriculum. So things started relatively young.

Also, being a racial minority in Ann Arbor, Michigan, I was very aware of who I am and the ways that I stood out, and I was able to use that as a strength, and my support system as an outlet for advocacy and social justice. Before I even graduated high school, I had the opportunity to serve as an appellant and intervener in the Gratz v. Bollinger affirmative action case against the University of Michigan. So as you can see, social justice has been a recurring theme, but what that looks like and how I’ve been able to use my voice and my platform has changed.

After majoring in biomedical engineering, I decided that I actually did want to go into medicine. I chose emergency medicine for a myriad of reasons, and I think it truly is the gateway to the medical field. We see a lot of the things that are public health issues rear their ugly heads in emergency medicine. A lot of our patients, particularly where I work at Grady Memorial Hospital, are either uninsured or underinsured, and they have been at the mercy of, or perhaps victims of, social determinants, or social drivers of health, as we’re now changing the narrative to say. My position as an emergency medicine physician gives me the opportunity to be a voice not only for my patients but for medical students and residents who chose to take this path, to be a voice for the voiceless.

Kevin Pho: So you talk about your role in the emergency department. What are some ways that you can move the needle, especially with your background in advocacy?

Katrina Gipson: Right. So in the emergency department, I think that everybody can, regardless of whether or not you have a focus in health equity or social justice. Each patient encounter in itself is an opportunity to advocate for an individual patient. Being in academia, one of my major outlets for my work is education. As well, my professional organizations, specifically the National Medical Association as well as the Society for Academic Emergency Medicine, have really given me the opportunity to impact the curriculum that we use to educate our learners, as well as inform how we interact with our patients.

For instance, one of the things that I think is important now is implicit bias training, and how that impacts not only how we educate our learners but how we take care of our patients. For instance, a lot of us are probably familiar with the disproportionate use of pain medication for patients depending upon their race and their creed. Of course, there are also disproportionate and inequitable outcomes for women of color, Black women specifically, when it comes to maternal morbidity rates.

So implicit bias, race, social class, all of these directly impact how we take care of our patients. Some of these biases are implicit; others are explicit. But as physicians, it’s important that we recognize these biases and how they impact our patient outcomes. We have a social responsibility to make sure that this is something that’s as intrinsic to our curriculum as cardiology and/or pathophysiology, because these are the things that impact how our patients receive care and where they receive care.

Kevin Pho: All right, let’s talk about your KevinMD article titled “Student loan forgiveness: a key step in achieving health equity for minority physicians and patients.” Now, tell us, how did this article come together?

Katrina Gipson: Sure. Among our circles, we always hear people talking about student loan debt. However, the general public doesn’t really want to hear about a bunch of physicians who are going to be making six figures and their debt. That doesn’t seem to resonate. However, what we don’t discuss to the same extent is the disproportionate and/or inequitable distribution of that debt. People of color, Black and Hispanic people, tend to have more educational debt even prior to entering medical school, even at the undergraduate level, when compared to their white counterparts. So what does that mean, and why should I care if I’m not a physician, people may ask? This article helps to explore that.

Before students even get to the point where they’re a candidate for medical school, just based upon their ZIP code, their social determinants or drivers of health may dictate whether or not they even have the opportunity, or feel like they have the opportunity, to enter medical school. So this affects the diversity of the medical school pipeline. Of course, that dictates who goes into academic medicine, who performs research, and whether or not certain patients are likely to have physicians who look like them.

Now, as much as we like to laud ourselves as enlightened and sophisticated, we still have implicit biases. I have them myself, and it’s important to realize that these have real consequences for real patients. We know that patients receive better care from those who look like them. However, if student loan debt is a barrier for entering the medical field, or even certain specialties, then this can have impacts on the outcomes, the health care outcomes, of our patients. This disproportionately affects, for instance, lower-paying fields such as primary care, and these are where patients have the most needs. I mean, having insurance, if you don’t have access to a primary care physician, if wait times are six, seven, eight months, that doesn’t necessarily mean that you have access. So that’s fodder for another discussion, I’m sure. Insurance doesn’t equal access.

However, student loan debt has provided barriers for entering the medical school pipeline. It provides barriers for diversity in academic medicine across all fields, and it has real impacts for people who are not in areas where they have access to primary care physicians. So I think COVID really opened our eyes to a lot of health care inequities. With the racial violence that has been getting a lot more attention in the last several years, it’s given us the opportunity to add a new voice and change the narrative on facts and figures that we’ve been discussing for years, but in a manner that has less of an emphasis on what that looks like for the pocketbooks of physicians, and more so what that looks like for diversifying our pipeline, as well as what type of outcomes we can expect for certain patients, particularly those who are underrepresented in medicine.

Kevin Pho: Just so we can understand the scope and depth of the issue, what are some numbers when it comes to the disparity in educational debt between minorities and non-minorities?

Katrina Gipson: Sure, that’s an excellent question, and my article touches on that. For instance, the Association of American Medical Colleges puts out these types of numbers, and they showed us that about 40.5 percent of Black matriculants had $25,000 or more in premedical education debt, and this is compared to only 18.7 percent of their white counterparts. So we’re talking about debt before students even matriculate into medical school.

That burden worsens after students have completed their four years of medical school and undergraduate training, with 91 percent of Black graduates having a median debt of $230,000, and this is compared to 70 percent of white students, who had a median debt of $200,000. So from a practical standpoint, we ask ourselves, what does that mean? Unfortunately, regardless of what your passions may be, people have bills to pay and families to support, and this can directly impact what type of specialty you may want to go into, or where you’re able to practice.

For instance, maybe entering medical school, your goal was to enter an area that was underserved in the South, or other rural Midwestern areas. However, if you have debt, that may not make that a realistic choice for you and your family. You might have to think about where you’re going to practice, and possibly choose a more lucrative field. Of course, all of our specialties contribute to the health care outcomes of our patients. However, there are certain areas and certain specialties where we just need more physicians, and that tends to be in primary care and in mental health areas.

Kevin Pho: Now, in your interactions with medical students, whether you’re a mentor to them, has that issue of educational debt influenced their career path?

Katrina Gipson: Absolutely. There are a lot of people, and I’m speaking from anecdotal experience as well as what studies show, who take their medical debt into consideration when they’re choosing a specialty. For instance, maybe someone wanted to go into primary care and/or family medicine, but unfortunately, reimbursement rates and/or compensation for those specialties may not be all that realistic. So once again, that sets their sights on differently paying fields.

Some of this, of course, can also shed some light on the inequities in the representation of physicians in certain specialties. For instance, some of the higher-paying, more competitive specialties are less likely to be as diverse, whether that be racial diversity or gender diversity. And of course, it’s a little bit more difficult to achieve a certain position if you haven’t seen someone who looks like you in those fields, and it can be that much more difficult to find mentorship and to find opportunities.

So there are a lot of barriers to this pipeline, whether it be from medical school or even college. But let’s be honest: If our students don’t have these opportunities by the time they’re college age, they’re already at a disadvantage to place themselves in positions where they can be competitive for medical school.

Kevin Pho: Now, when someone talks to you and tells you that their educational burden is influencing what they can and can’t do going forward, and you’re speaking as a physician and a public health professional, how does that make you feel?

Katrina Gipson: I mean, it’s not surprising, but it’s a problem that’s unique to the United States in many ways. For some of our counterparts, college debt is not an issue. It’s this whole idea that college should be for certain people, and usually those certain people, of course, are going to be less likely to be underrepresented in medicine, due to our country’s sordid history with racism, with all types of discrimination, that made it that much more difficult for certain people to be in areas where they have access to public schools that can prepare them for certain colleges and universities, and make these opportunities available for all.

So it’s something that I realize is a continued burden. I don’t think that it has to be an insurmountable one. However, we need, and when I say we, I don’t just mean physicians and members of the public health care field, but just citizens in general, to understand how all of our fates are interwoven, and who’s able to access higher education, and what that means for the greater good. So I think that despite the fact that it’s a pervasive issue that can be fought from a legal standpoint and a medical standpoint, I think it can be disheartening, but it just means that there’s that much more work to do, and we need to explore what our outlets look like for addressing those issues.

Kevin Pho: So let’s talk about next steps. I’m sure that you’re aware that there are a variety of options in terms of tackling this issue. It could be medical schools that forgive tuition. It could be programs that forgive educational debt if they serve in underserved areas. So among the menu of options, what do you think is the best path forward?

Katrina Gipson: Yeah, that’s an excellent question. I think that this is something that we need to address not only in the short term but in the long term as well. One of the things that inspired my article was the Biden administration’s student loan debt relief plan. This was something that brought a lot of joy, temporarily, to many people. While some of this may not apply directly to physicians due to their likely income, I think that in the short term, this is something that can address that issue: people who have a significant amount of debt that, as we just talked about before, can impact the types of fields that they enter, whether they be medical or not, as well as where they live, whether or not they’re able to purchase a home, and engage in other activities that stimulate the economy for us all.

Kevin Pho: Let me jump in there. Specifically, for those who aren’t familiar with the details of the Biden debt relief plan, how does that specifically impact prospective or current medical students?

Katrina Gipson: Sure. So there are several parts to this student loan relief program. The first part: The pandemic-related economic challenges led to a pausing of these federally held loans. I know that plenty of people, myself personally, have been able to benefit from that.

The second part of this, targeted debt relief, would allow for up to $20,000 in relief to Pell Grant recipients with loans held by the Department of Education, and up to $10,000 in relief to non-Pell Grant recipients. There’s also the Public Service Loan Forgiveness program, for people who made 120 eligible payments while working at nonprofit organizations, and this also means academic institutions as well. This would result in them being able to have their debt forgiven after those 120 payments are made.

Also, the third part of this debt relief program is hoping to keep the gaze moving forward, making sure that student loan systems are more manageable for current and future borrowers. But let’s be honest: When a lot of us are taking out this debt, we’re 17- and 18-year-old teenagers, many of whom may not have ever even had a credit card. So I think that it’s important for people to not only understand the ramifications of this debt, but make sure that they have all of the information that they need, whether it be what types of scholarships they’re eligible for, as well as what types of institutions might be more favorable for them from an economic standpoint as far as educational opportunities.

These are all things that we need to think about to not just impact medical student debt, but make debt more manageable and understandable regardless of what field you’re going into, for students and their families who want to pursue higher education. Particularly for students who might be the first generation going into college, they may not have the same tools and education or advice regarding these types of decisions, and they will wake up five to 10 years later with six figures in debt, maybe not really understanding what that may look like for their future career choices.

So those are three of the parts of the Biden debt relief program, plus Public Service Loan Forgiveness, which preceded that, that’s in question right now. As you alluded to before, a lot of institutions are offering debt-free education for students whose families may make under a certain amount of money. That’s a short-term fix that both private and public institutions can take into consideration, to make sure that a price tag is not a barrier for students who otherwise have so much to offer the institution and their future respective fields, and that debt and tuition not be something that students have to take into consideration when choosing where they want to go to school and what it is that they want to do to contribute to the world.

Kevin Pho: Now, for those underrepresented minorities in undergrad who are considering a career in medicine, from a financial and student debt standpoint, what kind of advice do you have for them as they’re looking potentially to medicine as a career?

Katrina Gipson: That’s an excellent question. I acknowledge that everybody’s situation is different, and I think it’s important to be realistic when we approach these matters, but make sure that students don’t take these debt barriers into consideration, or at least don’t use them as a complete deterrent. For instance, I’ll tell students that they should look into their state schools, look into HBCUs, and also, as soon as they get to college, or I’m sorry, to high school, even by their sophomore or junior year, make sure that they are familiar with whomever their college advisors are, to see if they can maximize scholarships, which are available.

It’s a lot to understand. A lot of the high schools don’t have the same type of resources as far as preparing their students academically, whether it be for scholarships or SATs. So I think that a lot of times, unfortunately, students have to seek those opportunities out themselves, and also look into areas like, as you mentioned before, no-loan schools, and really just have to be a little bit more cunning about these types of opportunities, because not everyone is going to tell you about them.

Also, look for mentorship, whether it be from people within fields who look like you, but also look for mentors and opportunities from anyone, because don’t be afraid to learn from anyone. These mentors may not have the same experiences that you have had, but they definitely can shed some sort of light on the process, and if they are where you want to be, then it’s important for you to learn from their journey. As you enter college, definitely make sure that you start to seek mentorship from medical students, residents, and physicians, because they can also make you aware of opportunities as far as scholarships, and what it takes to get to where you need to be.

Kevin Pho: We’re talking to Katrina Gipson. She’s an emergency medicine physician. Her KevinMD article is titled “Student loan forgiveness: a key step in achieving health equity for minority physicians and patients.” Katrina, tell us some of your take-home messages that you want to leave with the KevinMD audience.

Katrina Gipson: Sure. I think that one thing that I share, particularly with residents and medical students, is that health equity truly is social justice, and even if this is not your life’s work, it’s something that can be interwoven into whatever it is that you do. All of our fates and our stories come together, and we all benefit when everyone is winning.

Also, I think it’s important to realize, particularly early on in your career, that success is not a linear path. I myself am a work in progress. Don’t be discouraged by obstacles and pitfalls. Always be willing to invest in your network and ask for help and guidance, because, as I mentioned before, no one else’s journey is yours. Just because your journey doesn’t look like someone else’s doesn’t mean that it’s less impactful. It doesn’t mean that you’re less successful. Your timeline is your own, and everyone can benefit from whatever contributions it is that you have to make to the field.

Kevin Pho: Katrina, thank you so much for sharing your time and insight, and thanks again for being on the show.

Katrina Gipson: Thank you so much for having me.

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