Kyle Fulton graduated from the University of Arkansas for Medical Sciences on Sunday with a new car, plans to start a pediatric residency program in New Orleans and $155,000 in student-loan debt.

Or is it $160,000?

“I’m kind of scared to look at it, actually,” Fulton said.

Fulton, a Jonesboro native, joined thousands of medical-school graduates across the country with admirable academic track records, a commitment to helping people and a sizable financial burden. After fully financing his undergraduate degree at Arkansas State University at Jonesboro with scholarships, he had to take out loans to cover tuition and living expenses at UAMS in Little Rock.

Before he can collect a full physician’s salary, Fulton will complete a three year residency program with an annual salary around$45,000, which makes the repayment of that debt seem more daunting initially.

“It’s worked out for others before,” he said. “It will work out for me. It’s got to.”

As states expand Medicaid, offering medical coverage to previously uninsured residents, and as a growing aging population places a strain on the U.S. health work force, the country will need more doctors like Fulton, who plan to practice in relatively low-paying primary-care fields, such as family medicine, public-health leaders said.

But some fear that indebtedness may one day create an incentive for soon-to-be physicians to pursue more lucrative specialities, such as surgery or orthopedics, in hopes of paying down that debt sooner. While national surveys show debt doesn’t top the rankings in factors that influence specialty choice, students said it is something they consider.

Medical-school applicants with an interest in primary care are increasingly considering low cost as a top priority when selecting a school, they said.

Class of 2012 graduates from U.S. medical schools completed their educations with a median total education debt of $170,000, according to a study released in February by the Association of American Medical Colleges. That’s a 5 percent increase over the previous year’s class, the study said. Since 1992, when graduates had a median debt of $50,000, debt load of medical-school graduates has increased 6.3 percent a year, outpacing inflation alongside tuition rates, the study said. In the same time period, the Consumer Price Index increased an average of 2.5 percent each year.

UAMS expects the average debt load of 2013 graduates, which it hasn’t officially calculated, to be higher than that of 2012 graduates, who had an average indebtedness of $139,044, said Tom South, assistant dean for medical student finance and admissions.

Leaders at the state’s only medical school have said that having a cost of attendance that’s lower than at many peer institutions will help it pursue a goal of training primary-care physicians and keeping them in the state after they graduate. But the cost of becoming a doctor is high at any institution, said South, who helps UAMS graduates develop a plan for tackling their debt.Students have options for repayment, including deferment during residency, he said.

“Looking at the figures, it’s incredible,” he said. “These are large amounts, that’s why most students can’t even begin to pay it in residency training.”

UAMS expects costs to continue to increase.

The University of Arkansas board of trustees will consider increasing in-state tuition and fees for a UAMS medical student to $24,221 for the 2013-14 academic year, an 8.5 percent increase over current levels, South said.

Presidents and chancellors of the state’s higher-education institutions have said they have little choice but to raise tuition. State appropriations have remained stable in recent years, leaving fewer resources to pay larger numbers of faculty or cover other growing costs as enrollment increased, they said.

And the problem is more complicated at UAMS, Chancellor Dr. Dan Rahn told trustees at a retreat in March. Teaching hospitals have traditionally subsidized costs of education and research with excess clinical revenue, he said. But growth in that revenue has slowed as rates of uncompensated care and other costs have continued to grow in recent years, he said.

Fulton said medical students may fear debt more because residency positions, the final step in the path to becoming a fully independent physician, are increasingly limited. The number of federally funded positions has been capped for years. Meanwhile, medical-school admissions continue to grow, and foreign graduates are increasingly competing for U.S. positions.

This spring, 34,355 students nationwide were “matched” with residency positions based on students’ preferences and positions availability, according to the National Residency Matching Program, and 8,800 others nationwide failed to get accepted through the program. As many UAMS graduates learned of their positions this year, nine of their peers did not have residency positions. Many of those students will complete research work and try to match again in the future, but there are no guarantees they will find a placement.

“We have several people in my class who did not match, and they have $150,000 worth of loans,” Fulton said. “It’s another scary aspect of going into medicine. None of these factors would change my path, but it’s a broken system.”

To help students tackle growing costs, UAMS raises funds for scholarships targeted at students who plan to enter residency in primary-care fields. And through the Rural Practice Scholarship and Community Match programs small rural communities and the state commit to help finance part of the education for some UAMS students in exchange for a commitment to practice in those areas after they complete their residency programs.

Arkansas will need a creative, multipronged approach that includes financial incentives to meet its medical workforce needs, according to the Arkansas Center for Health Improvement.

To match current estimated demand, Arkansas needs to increase its work force of 2,077 primary-care physicians by 15 percent, according to a recent study coordinated by the independent, nonpartisan health-policy center, which is led by the state’s surgeon general. Much of that need is concentrated in rural areas, the study found.

That need will grow as about 450,000 previously uninsured Arkansans buy health insurance through provisions of the Patient Protection and Affordable Care Act and through a bill passed by lawmakers this session that will allow residents with incomes under 138 percent of the federal poverty level to purchase private insurance that will be paid for with federal Medicaid funds, state Surgeon General Dr. Joe Thompson said as he released the report. That coverage expansion will create the need for about 60 additional primary-care providers, and the state’s relatively unhealthy and aging population will create a need for 261 more providers by 2020, the study said.

Emily Neaville might be one of them.

After graduating from Stanford University free of debt, the Rogers High School graduate worked in public-health jobs for six years before deciding to return to school to become a physician.

Neaville, in her second year at the UAMS college of medicine, hasn’t selected a specialty yet. But growing up watching her father, a family doctor, build relationships with his patients and treat several generations of the same family has led to a strong interest in primary care, she said.

Returning to school after years in the work force will give Neaville fewer years to tackle her debt, so “money was definitely a factor” in picking a school.

Neaville, who is covering most of her educational costs through loans, chose UAMS to keep her total debt down and keep the door open to primary care.

South said most UAMS students successfully pay off their loans on time. Annually calculated default rates for UAMS medical students are usually around 1 percent, and those who fail to repay their loans are often former students who didn’t complete school or didn’t pass their medical licensing exams, he said.

“Students are still able to command the salaries necessary to repay the loans,” South said. “We just have to couch it in terms that it’s an investment, not an expense.”

But pay varies widely between specialties, and physicians in primary-care fields earn the lowest amounts of income, according to a report released in January by the American Medical Group Association, a national trade group, which based its findings on 2011 data.

That report showed that family-medicine doctors had a median compensation of $219,362 and internal medicine doctors had a median compensation of $224,417. Pediatricians, - Fulton’s chosen specialty - earned a median compensation of $220,644 in 2011, the report said. Income varies depending on geographic region, size of practice and hospital affiliation.

Physicians with the highest compensation levels included neurosurgeons, who earned a median income of $625,000; orthopedic surgeons, who earned a median income of $515,759; and cardiologists, who earned a median salary of $430,316, the report said.

“Medicine is not a field I chose to go into for money one way or another,” Fulton said. “However, I do understand how it can affect what specialty you want to go into.”

For Neaville, choosing a less expensive medical school in a region with a lower cost of living means finances will be less of a factor when it’s time to commit to a practice field.

Her debt is still relatively large compared with most undergraduate loans, but it’s much smaller than it may have been if she had gone to the other schools that accepted her, which were on the East Coast, she said.

“To me, this kind of debt sounds like imaginary money. It’s such a high number. I can’t look at that number and make it make sense in my head,” Neaville said. “But I know it’s possible to pay off this debt. It might be challenging at times, but it’s worth it to me.”

Front Section, Pages 1 on 05/13/2013