Dr. J.B. Wharton, a new pediatrician at Bend Memorial Clinic, always knew she would choose a career in primary care medicine. Growing up, she followed her dad, a family practice doctor, on his rounds.

“I grew up with that model of taking care of the whole family and being involved through all the stages of life,” she said. “I didn't particularly know I was going to do pediatrics, I just fell love with it in med school.”

That decision likely cost Wharton hundreds of thousands of dollars in potential career earnings. Primary care physicians, such as family practice doctors or pediatricians, on average earn half the salary of specialists such as radiologists or dermatologists. The potential income disparity is so great that medical students often feel both economic and academic pressure to avoid a primary care career path.

“I had one professor in med school that sat down with me at one point and said, ‘You have great grades. You have great scores. You could get into ophthalmology. Why would you pick pediatrics?'” Wharton recalled.

With the costs of attending medical school increasing, new doctors can begin their medical practices with student loan debts bigger than their mortgages. A recent analysis suggests that despite six-figure salaries, primary care doctors could struggle to make ends meet in their first years of out of residency. Many experts are concerned the disparity in income may be discouraging medical students from entering the primary care field and could be exacerbating an already worrisome access problem.

Balancing budgets

The analysis from researchers at Dartmouth Medical School quantified average salaries and expenses faced by doctors, factoring in such costs as mortgage payments, retirement savings and college savings for children. Many of those costs were higher because doctors spend a minimum of 11 years in training and must take on higher rates of savings to make up for lost time.

But the single biggest expense faced by those new physicians was their student loan payments, averaging $2,261 per month if amortized over 10 years. According the American Association of Medical Colleges, the average medical school senior in 2010 graduated with $157,944 in school loan debt. Many will defer payment on those loans for their three or more years of residency, during which interest begins to accrue. As a result, the average physician will begin medical practice with about $200,000 in student loan debt.

For a new primary care physician earning about $130,000 a year, that debt payment would account for 28 percent of his or her take-home pay. By contrast, the same debt load would account for 23 percent of the take home pay of a psychiatrist, and only 12 percent for a radiologist, despite having a longer residency and a higher average debt load.

The researchers suggested primary care physicians would lose $800 a month unless they reduced their contributions to retirement or college savings plans. Another recent study found that primary care physicians do not begin to have a positive net worth until an average age of 33.

“It's unfortunate because we are in desperate need of primary care docs,” Wharton said. “It's definitely a burden on primary care docs and it weighs heavily on our decision.”

Choosing specialties

Studies have shown that higher-salary specialties, such as orthopedic surgery or radiology, tend to have a higher percentage of residency positions filled than lower paying specialties. A recent analysis published in the journal Family Medicine found that among students from middle income families, there was a strong correlation between the amount of medical debt at graduation and the mean salaries of the specialties chosen by those students.

It's why medical students talk about the “R.O.A.D. to happiness,” an acronym created from four highly sought-after specialties: radiology, ophthalmology, anesthesiology and dermatology.

“You don't work long hours, you get paid really well and there's no (emergency room) call,” said Dr. Andrew Janssen, a primary care doctor in John Day.

“Everyone enters medical school fairly naive and fairly idealistic,” he said. “But by the end of your third year, you've met a lot of residents who are working like crazy, you're burned out and your loans are stacking up, and you have to make a decision on your residency.”

When medical students know they can add on a year or two of residency to become a specialist and double their income, it's hard to pass up that opportunity.

“I think human nature being what it is, we all get to the point where we say, ‘The system owes me something. I put in all this time. The more I can get the better,'” he said. “It's fairly insidious, but it's there, and I think that doctors are as vulnerable to it as anybody else, despite our high ideals.”

Janssen acknowledges that increasing debt loads may indeed be discouraging medical students from applying for primary care residency slots if they can help it. Just as the Ivy League schools are open only to the top students in high schools, the more lucrative specialties have become more competitive and only the top med school students can hope to get into those residencies. That may further dilute the quality of primary care.

“The bottom line is that family medicine and a few other (specialties) are less competitive and so people who aren't at the top of their class are more likely to go into the less competitive fields,” he said. “I'm a family doc and that doesn't speak well about my field, but it's probably true.”

Making it work

Many doctors like Janssen and Wharton who do want to pursue a primary care field try to do what they can to limit accruing debt and find additional revenue streams to help pay down their debt after graduation. Janssen chose to practice in John Day, in part because the region qualified for National Health Service Corp. loan repayment. That helped to pay off his $90,000 to $100,000 in medical school loans in only three years. He also supplements his primary care income by covering the emergency room at night.

Dr. Matthew Rode completed his residency in 2005, and set up a family practice in Bend. But he travels to Burns to work as an emergency room doctor twice a month to help make ends meet.

“You can certainly look past the debt, which is essentially what I did, and say, ‘I'm going to earn a good wage, this is the specialty I want to practice, and so I'm willing to be at a financial disadvantage compared to some of my colleagues in other specialties,'” he said. “I've found other ways to make it work. I practice emergency medicine to support my primary care practice. That's the reality.”

The trend lines, however, suggest the situation may worsen. Each year, the medical schools train fewer and fewer primary care doctors, while medical school costs continue to increase.

According to the American Association of Medical Colleges, private medical school tuition and fees increased by 50 percent from 1984 to 2004, while public medical school tuition and fees increased by 133 percent. Oregon Health&Science University, Oregon's only medical school, now has the highest tuition for in-state students in the country, at $40,684 per year. Factoring in room and board, freshman medical students in 2011 could be facing debt loans of $250,000 or more by the time they graduate.

“I'd like to think that most physicians are fairly altruistic, following their desires as far as what they'd like to do, rather than how much money they'd like to make,” Rode said. “But when you're looking down the barrel of being $200,000 in debt, that can certainly be a motivating factor for choosing one of the higher-paying specialties.”