Addressing financial, housing, and food insecurity to help medical trainees achieve their full potential

Training to be a physician is a deeply rewarding yet highly stressful experience. Nurturing learners through this challenging process is a critical objective of medical education. According to Maslow’s hierarchy of needs, basic physiological, safety, and financial security requirements must be met for a learner’s full potential to be achieved. Sen’s1 capability approach further extends this framework to posit that human flourishing depends not merely on the satisfaction of hierarchical needs but also on the substantive freedoms individuals have to pursue valuable endeavors. When a medical trainee cannot afford nutritious food or secure stable housing, not only are their basic needs unmet, but they also experience a fundamental erosion of their ability to engage fully in the intellectual, relational, and professional components of medical education. Recent literature has highlighted that these fundamental human needs are inconsistently satisfied for many medical trainees, who may commonly experience financial, housing, and food insecurity. In this editorial, we briefly summarize current knowledge of trainee experiences with these domains, the implications of gaps in meeting these requirements, and a framework for potential solutions to address these gaps and more effectively aid learners in achieving their greatest potential as health care professionals and human beings. Financial insecurity refers to inability to meet necessary financial expenses and associated distress. The cost of medical training has increased substantially during the past several decades, with an average annual increase of 3%-4% across school types and student residency statuses.2 Four-year cost of attendance for the graduating class of 2025 was nearly $300,000 for public schools and $400,000 for private schools.3 With most students lacking the resources and/or financial aid to cover these costs without loans and with financial aid packages commonly incompletely reflecting actual costs of medical school attendance,4 medical school graduate debt is both substantial and common. For the graduating class of 2025 in the United States, 70% of students reported education debt, with median debt totaling $220,000 for this group.5 Financial stress is particularly common for learners without a financial safety net or robust family resources6 and disproportionately impacts demographic groups historically underrepresented in medicine.3,6,7 Loan repayment programs that require payment during residency and fellowship rather than deferral until after training is complete limit financial resources available for basic needs in the setting of limited income and uncontrolled expenses relating to living location and training requirements. Repaying this debt is therefore difficult during graduate medical education, and debt is often compounded by substantial interest accrual during this time. Financial insecurity has important consequences, including increasing the risk of housing and food insecurity. High debt burden has also been associated with generalized stress, burnout, and challenges to academic performance, such as limiting medical knowledge growth on standardized assessments.7-11 Data on associations of debt burden with specialty choice have been mixed, but some studies have found that medical students with greater debt levels are more likely to pursue higher-paying specialties, less likely to pursue primary care specialties, and less likely to practice in underserved areas.3,9,12 Beyond its effects on specialty selection and burnout, financial insecurity may impose a scarcity mindset, a state of cognitive narrowing in which preoccupation with unmet needs diminishes executive function, long-term planning capacity, and creative thinking.13 In a medical training environment that demands full cognitive capacities, experiences of financial insecurity that add to trainees’ cognitive load inhibit success. For trainees from historically underrepresented backgrounds, financial insecurity may carry an additional identity burden.14 The awareness that one’s presence in medical school was made possible through sacrifice, including familial, communal, and personal, can intensify the pressure to succeed while simultaneously reducing the internal resources available to do so. Housing insecurity is defined as the inability to pay rent or utilities, moving often, or not having a permanent safe place to live.15 Insecurity related to this basic need has been less well characterized among medical students, residents, and fellows but has been identified as highly prevalent among college students, especially in relation to the ability to pay rent or mortgage costs.16,17 Across learner populations, housing insecurity is more prevalent among demographic groups historically underrepresented in medicine and is closely associated with financial insecurity. Academic medical centers are disproportionately situated in urban areas, where housing costs are typically higher. In addition, areas nearest to major hospitals tend to have higher housing costs,18 and medical trainees frequently have limited flexibility to live farther from the hospital due to on-call responsibilities and other duties. Lastly, inherent in medical school selection and residency and fellowship match processes is the expectation of geographic mobility, which creates unique housing burdens, especially for students without a financial safety net. Medical trainees often have limited ability to choose where they live based on affordability. Rather, they may be admitted or matched to locations with housing markets beyond their financial means. The implications of housing insecurity among medical learners have not been clarified, but in other learner populations housing insecurity has been linked with psychological stress and poorer academic outcomes.16 Housing insecurity is also associated with an increased risk of being affected by interpersonal violence19 or another crime.20 Food insecurity, defined as having uncertain access to food or not having enough food at some point in the last year, affects approximately 1 in 7 households in the United States, representing nearly 50 million people.21 Physicians as a group are at low risk of food insecurity given their typical incomes, but medical students typically have little or no income, and residents and fellows have lower salaries and commonly experience financial strain as previously noted. Up to 25% of medical students experience food insecurity, with even higher rates among groups historically underrepresented in medicine, those from low-income backgrounds, and those with a disability.6,22 In addition, increasing medical student debt is also associated with a greater risk of food insecurity.22 Among trainees in graduate medical education, Thomas et al.21 found a food insecurity prevalence of 13.5%, a frequency similar to that of the general population. Furthermore, certain groups, including those identifying as Black or African American, early-year trainees, and those in large metropolitan areas, were at markedly greater risk, echoing the results for medical students. The consequences of food insecurity for medical trainees are serious. Medical students experiencing food insecurity report guilt and social isolation.23 Food insecurity among residents and fellows is strongly associated with burnout, social isolation, and lower intent to stay at one’s institution for further training or to practice.21 The overlap across the different domains of basic needs insecurity discussed in this editorial further highlights the adverse implications of each domain for learners. The experience of basic needs insecurity among medical trainees exists within a paradoxical institutional context. Trainees are simultaneously entrusted with the care of the most vulnerable members of society while themselves experiencing vulnerability that often remains largely invisible to their educators, peers, and institutions. The learner who skips meals before a clinical rotation, who cannot afford the professional attire expected in a clinical setting, or who commutes 2 hours to work because affordable housing near the clinical site is unavailable does not face only logistical inconvenience but also a daily cognitive and emotional tax that compounds the already challenging demands of medical training. Qualitative studies have revealed that medical students experiencing food insecurity describe pervasive feelings of shame and concealment, often masking their economic hardships to belong and to avoid judgment from peers and faculty.14 This phenomenon constitutes a hidden curriculum of scarcity, an unspoken lesson that need is a personal failing to conceal rather than a systemic condition to address. When institutions fail to acknowledge and attend to these realities, they inadvertently reinforce a culture in which vulnerability is stigmatized and help-seeking is suppressed, precisely the opposite of the values the medical profession espouses in its approach to patient care. Taken together, many medical trainees are at risk of financial, housing, and food insecurity. Although on completion of training these learners can be expected to enjoy much higher incomes, the strain from these experiences during training has important consequences that demand we do better to support medical trainees while they are vulnerable. In addition, these experiences are associated with stigma that may interfere with self-identification for support, emphasizing the need for systemic approaches to identify and address these risks. These issues reflect a complex interplay of sociodemographic, professional, and financial factors. Solutions must be mindful of these relationships for both medical trainees and other health professional trainees who may experience similar or even greater risk.24 Ideally, solutions would be developed that support all individuals in their personal growth in their medical careers. Broadly speaking, we recommend efforts to reduce costs raise awareness and leverage policies relating to learner experiences; and target interventions for notably at-risk groups. Each of these focus areas can be influenced at both the training site and external levels (Table 1). Sample approaches to address basic needs insecurity among medical trainees. Establish a learner advisory council focused on basic needs insecurity Implement education and awareness programs for basic needs insecurity and resources Create a dedicated basic needs navigator role (analogous to patient navigators) to connect trainees confidentially to institutional and community resources Integrate anonymous basic needs insecurity screening into existing institutional well-being surveys, with results reported to institutional leadership and tied to action plans Strengthen accrediting body policies in support of financial education, affordable housing, and access to affordable and appropriate nutrition Reframe basic needs support as educational infrastructure not charity; institutional investment in trainee basic needs should be positioned alongside simulation laboratories, libraries, and clinical facilities as essential to the educational mission Expand grants and scholarships, including emergency funds with streamlined, low-barrier applications with rapid turnaround for trainees facing acute financial crises (eg, car repairs, medical bills, unexpected relocation costs). Reduce costs of attendance, including tuition, health plan fees, and other expenses Offer low- or no-interest loans Provide adequate salaries and stipends to meet costs of living Offer transportation passes and income-based sliding-scale fees for institutional costs, such as parking rather than flat fees that disproportionately burden lower-income trainees Expand grant and scholarship options for medical training Maintain flexible and deferred nonpredatory loan repayment plans Advocate for federal legislation to exclude stipends from income calculations for need-based benefit programs (SNAP, Medicaid, childcare subsidies), recognizing that trainee salaries are training wages not full professional compensation Establish matched savings programs seeded by institutions or specialty societies to help trainees from low-income backgrounds build financial stability during training Offer subsidized housing and relocation stipends and bridge housing for incoming trainees, particularly those matching from distant locations or those without savings for security deposits and moving costs Enact housing location policies that include affordable housing options Develop financially viable housing loan options for medical trainees Enact federal housing assistance carve-outs for medical trainees, similar to military housing allowances, recognizing that trainees are geographically constrained by their training and provide essential health care services Ensure adequate food allowances and meal vouchers Support food pantries and pop-ups Enable community partnerships with restaurants and markets Provide food consistently at conferences and lectures Provide hospital cafeteria subsidies for trainees, analogous to common subsidies for physician lounges Advocate for extending SNAP and similar benefits for medical trainees Advocate for federal and state tax credits for teaching hospitals that provide free meals to trainees, similar to existing tax incentives for employer-provided meals Abbreviation: SNAP, Supplemental Nutritional Assistance Program. To reduce costs, approaches include expanding financial support through grants, scholarships, and loan reform. Notably, many medical schools have eliminated tuition fees in recent years,2 although this requires substantial philanthropy and is not universally feasible. Subsidizing housing and food programs in partnership with local communities is an additional strategy, and providing food consistently at education conferences and lectures can further demonstrate organizational commitment to learner needs. Ensuring that salaries reflect local costs of living is an important concurrent approach, particularly appropriate given the tuition and clinical revenues medical students, residents, and fellows contribute as they form an essential core of patient care at their training sites. Turning to solutions based on elevating awareness and implementing policy-based support, curricular guidance to identify and address basic needs insecurity among medical students is available and can be adapted to other medical trainees.15 Policies at the local level that restrict housing options to more expensive locations typically close to hospitals should be reviewed for their necessity. Relaxing time-to-site requirements could make more affordable food and housing options available. At the national level, accrediting bodies, such as the Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME), should review policies affecting student and trainee costs for clarity and intent. For example, the current ACGME policy on food availability indicates only that training programs must ensure that food is available at all times. Asserting or clarifying that this policy intends for food to have sound ­nutritional value and be affordable would be a step forward. Advocacy for extending Supplemental Nutritional Assistance Program (SNAP) and similar benefits for medical trainees would also be helpful. Financial education should be universally available to medical trainees. Although LCME Standard 12.1 requires financial aid and debt management counseling for medical students,25 this standard should be extended to encompass other dimensions of basic needs insecurity. Similarly, ACGME Common Program Require­ments26 should explicitly require financial education rather than leaving support to local interpretation. Finally, targeted interventions should be thoughtfully designed to minimize stigma while reaching high-risk groups. For example, sharing resources during new trainee orientations alongside data on how common these experiences are can normalize help-seeking. The produce pop-ups at the Perelman School of Medicine at the University of Pennsylvania27 illustrate how efforts to address basic needs insecurity can be designed for professional student populations. In addition, free or reduced-price public transportation passes could be made available to all trainees, understanding that those with a particular need will be more likely to benefit. Critically, solutions should be codesigned with trainees themselves. Learner advisory councils focused on basic needs security, analogous to existing well-being committees but with explicit mandates around financial, housing, and food security, would ensure that interventions are responsive to lived experience rather than imposed from institutional vantage points that may be disconnected from the realities of trainee life. Participatory approaches also carry the benefit of reducing stigma when learners are architects of the solution because the act of seeking help can be normalized as collective advocacy rather than individual deficiency. As medical trainees pursue the arduous path of their training, an increasing body of evidence has identified that many struggle not just with the challenge posed by their academic journey but also with basic needs insecurities, including financial, housing, and food insecurity. These issues adversely affect their training experiences and inhibit their ability to achieve their full personal and professional potential. Medical education aspires to develop physicians who dedicate their careers to alleviating human distress. It is a stark institutional contradiction when the very systems charged with this formation do not protect their learners from preventable distress born of unmet basic needs. More robust solutions at the system and local levels are needed to address these essential needs of learners who have entrusted themselves into medical education’s care. C.P. West is a deputy editor for Academic Medicine. The opinions expressed in this editorial do not necessarily reflect the opinions of the AAMC or its members. None declared. M.N. is supported by the National Institutes of Health Medical Scientist Training Program.