Educational Debt in the Context of Career Planning: A Qualitative Exploration of Medical Student Perceptions

Geographic Trends in Ophthalmology Resident Physician Compensation and Cost-of-Living Expenses

Importance

Given that resident physician financial strain has been associated with poor outcomes, objective metrics to forecast financial well-being may be useful to (1) applicants when evaluating ophthalmology residency programs and (2) programs when determining resident benefits.

Objectives

To determine and compare the relative value of ophthalmology resident stipends plus benefits when adjusted for cost-of-living expenses and to analyze program characteristics associated with greater resident net incomes.

Design, Setting, and Participants

In this cross-sectional study, the American Medical Association's Fellowship and Residency Electronic Interactive Database was used to identify US Accreditation Council for Graduate Medical Education-accredited ophthalmology residency programs. Resident physician stipends and stipends plus benefits as well as residency program characteristics from the 2023-2024 academic year were noted for all eligible programs. The Massachusetts Institute of Technology's Living Wage Calculator's required annual income (RAI) was selected as a surrogate to approximate cost-of-living expenses.

Exposure

Residency program characteristics, including affiliation, size, ranking, presence of housing benefit, and training year.

Main Outcomes and Measures

The primary outcome was the annual stipend plus benefits income surplus (SPBIS) for each residency program, defined as the resident's stipend plus benefits (SPB) minus the RAI for the county in which the residency program is located. Secondary outcomes included income surplus variation by program characteristics.

Results

Of 116 ophthalmology residency programs analyzed, 37 (31.9%) were located in the Northeast, 36 (31.0%) in the South, 29 (25.0%) in the Midwest, and 14 (12.1%) in the West. The mean (SD) postgraduate year 1 resident annual SPB was $65 397 ($8205), and the median (IQR) was $63 986 ($59 992-$69 698). After adjusting for the cost of living, the mean (SD) SPBIS was $27 459 ($5734) and the median (IQR) was $27 380 ($23 625-$31 796). Annual cost-of-living expenses varied by as much as $8628 (95% CI, $6310-$10 947) and SPBIS varied by as much as $6283 (95% CI, $3367-$9198) between regions. Resident SPB increased by a mean (SD) of 3.97% (0.98%) for each subsequent training year (range, 0.93%-7.26%). Annual SPBIS increased by a mean (SD) of 9.48% (3.60%) for each subsequent training year.

Conclusions and Relevance

After adjusting for living costs, intraregional and interregional differences in SPBIS among ophthalmology residents can vary by thousands of dollars, impacting residents' financial security. Further discussion regarding compensation may lead to innovative strategies that aim to improve resident well-being and performance.

The Effect of Rural Underserved Opportunities Program Participation on Medical Graduates' Decision to Work in Rural Areas

PURPOSE

There is a persistent rural physician shortage in the United States. Policies to scale up the health workforce in response to this shortage must include measures to draw and maintain existing and newly trained health care workers to rural regions. Prior studies have found that experience in community medicine in rural practice settings increases the likelihood of medical graduates practicing in those regions but have not accounted for selection bias. This study examined the impact of a community-based clinical immersion program on medical graduates' decision to work in rural regions, adjusting for covariates to control for selection bias.

METHOD

Data on sociodemographic characteristics and career interests and preferences for all 1,172 University of Washington School of Medicine graduates between 2009 and 2014 were collected. A logistic model (model 1) was used to evaluate the impact of Rural Underserved Opportunities Program (RUOP) participation on the probability of physicians working in a rural region. Another model (model 2) included the propensity score as a covariate in the regression to control for possible confounding based on differences among those who did and did not participate in the RUOP.

RESULTS

Of the 994 students included in the analysis, 570 (57.3%) participated in RUOP training, and 111 (11.2%) were currently working in rural communities after their training. Regression analysis results showed that the odds of working in a rural region were 1.83 times higher for graduates who participated in RUOP in model 1 ( P = .03) and 1.77 times higher in model 2 ( P = .04).

CONCLUSIONS

The findings of this study emphasize that educational programs and policies are crucial public health interventions that can promote health equity through proper distribution of health care workers across rural regions of the United States.

What Is the Geographic Distribution and Density of Orthopaedic Advanced Practice Professionals in Rural Counties? A Large-database Study

BACKGROUND

Advanced practice professionals, including physician assistants (PAs) and nurse practitioners (NPs), play an important role in providing high-quality orthopaedic care. This role has been highlighted by projections of nationwide shortages in orthopaedic surgeons, with rural areas expected to be most affected. Given that approximately half of rural counties have no practicing orthopaedic surgeons and that advanced practice professionals have been shown to be more likely to practice in rural areas compared to physicians in other medical disciplines, orthopaedic advanced practice professionals may be poised to address orthopaedic care shortages in rural areas, but the degree to which this is true has not been well characterized.

QUESTIONS/PURPOSES

(1) What percentage of rural counties have no orthopaedic caregivers, including surgeons and advanced practice professionals? (2) Is the density of advanced practice professionals greater than that of orthopaedic surgeons in rural counties? (3) Do orthopaedic advanced practice professionals only practice in counties that also have practicing orthopaedic surgeons? (4) Are NPs in states with full practice authority more likely to practice in rural counties compared with NPs in restricted practice authority states?

METHODS

We identified orthopaedic surgeons and advanced practice professionals using the 2019 Medicare Provider Utilization and Payment Data, as this large dataset has been shown to be the most complete source of claims data nationwide. Each professional's ZIP Code was matched to counties per the US Postal Service ZIP Code Crosswalk Files. The total number and density of physician and advanced practice professionals per 100,000 residents were calculated per county nationwide. Counties were categorized as urban (large central metropolitan, large fringe metropolitan, medium metropolitan, and small metropolitan) or rural (micropolitan and noncore) using the National Center for Health Statistics Urban-Rural Classification Scheme. Comparisons between rural and urban county caregivers were conducted with the chi-square test and odds ratios. Population densities were compared with the Wilcoxon rank sum test. A bivariate density map was made to visualize the nationwide distribution of orthopaedic caregivers and determine the percentage of rural counties with no orthopaedic caregivers as well as whether orthopaedic advanced practice professionals practiced in counties not containing any surgeons. Additionally, to compare states with NP's full versus restricted practice authority, each NP was grouped based on their state to determine whether NPs in states with full practice authority were more likely to practice in rural counties. We identified a group of 31,091 orthopaedic caregivers, which was comprised of 23,728 physicians, 964 NPs, and 6399 PAs (7363 advanced practice professionals). A total of 88% (20,879 of 23,728) of physicians and 87% (6427 of 7363) of advanced practice professionals were in urban counties, which is comparable to nationwide population distributions.

RESULTS

A total of 39% (1237 of 3139) of counties had no orthopaedic professionals (defined as orthopaedic surgeons or advanced practice professionals) in 2019. Among these counties, 82% (1015 of 1237) were rural and 18% (222 of 1237) were urban. The density of advanced practice professionals providing orthopaedic services compared with the density of orthopaedic surgeons was higher in rural counties (18 ± 70 versus 8 ± 40 per 100,000 residents; p = 0.001). Additionally, 3% (57 of 1974) of rural and 1% (13 of 1165) of urban counties had at least one orthopaedic advanced practice professional, but no orthopaedic surgeons concurrently practicing in the county. There was no difference between the percentage of rural counties with an NP in states with full versus restricted practice authority for NPs (19% [157 of 823] versus 26% [36 of 141], OR 1.45 [95% CI 0.99 to 2.2]; p = 0.08).

CONCLUSION

As advanced practice professionals tended to only practice in counties which contain orthopaedic surgeons, our analysis suggests that plans to increase the number of advanced practice professionals alone in rural counties may not be sufficient to fully address the demand for orthopaedic care in rural areas that currently do not have orthopaedic surgeons in practice. Rather, interventions are needed to encourage more orthopaedic surgeons to practice in rural counties in collaborative partnerships with advanced practice professionals. In turn, rural orthopaedic advanced practice professionals may serve to further extend the accessibility of these surgeons, but it remains to be determined what the total number and ratio of advanced practice professionals and surgeons is needed to serve rural counties adequately.

CLINICAL RELEVANCE

To increase rural orthopaedic outreach, state legislatures may consider providing financial incentives to hospitals who adopt traveling clinic models, incorporating advanced practice professionals in these models as physician-extenders to further increase the coverage of orthopaedic care. Furthermore, the creation of more widespread financial incentives and programs aimed at expanding the experience of trainees in serving rural populations are longer-term investments to foster interest and retention of orthopaedic caregivers in rural settings.

Geographic Trends in General Surgery Resident Compensation Across the United States

OBJECTIVE

To examine the effect of cost of living on general surgery resident salaries and identify factors associated with greater incomes and availability of housing stipends.

DESIGN

Retrospective cross-sectional analysis of Fellowship and Residency Electronic Interactive Database (FREIDA), institutional websites, and Doximity. Program characteristics were compared through Kruskal-Wallis tests, ANOVA, and χ² tests. Multivariable linear mixed modeling and multivariable logistic regression were utilized to determine factors associated with higher salary and availability of housing stipend, respectively.

SETTING

Three-hundred fifty-one general surgery residency programs in the United States.

PARTICIPANTS

Three-hundred-seven general surgery residency programs with available salary data for the 2022 to 2023 academic year.

RESULTS

The average postgraduate year 1 resident annual salary was $59,906.00 (standard deviation [SD] ± $5051.97). After adjustment for the cost of living, the average annual income surplus was $22,428.42 (SD ± $4848.64). Cost of living and resident remuneration varied substantially across regions (p < 0.001). Annual income surplus was the highest for programs in the Northeast when compared to other regions (p < 0.001). Resident annual income increased by $510 (95% confidence interval [CI] $430-$590) for each $1000 increase in the cost of living and $150 (95% CI $80-$210) for each 10-rank increase in Doximity general surgery program reputation ranking. An increased cost of living was associated with a higher likelihood of housing stipend availability (odds ratio 1.17, 95% CI 1.07-1.28).

CONCLUSIONS

General surgery residents are inadequately compensated for the cost of living, indicating the potential for increased compensation to alleviate economic strain of surgical trainees. As financial stress can have implications for mental and physical well-being, further discussion of current resident salaries and benefits is warranted.

Student loan debt and financial education: a qualitative analysis of resident perceptions and implications for resident well-being

High educational debt is prevalent among resident physicians and correlates with adverse well-being outcomes, including symptoms of stress and burnout. Residents also report low financial literacy levels, affecting financial well-being. Understanding resident viewpoints toward financial well-being initiatives is crucial to develop targeted resident financial well-being programs. This study aims to examine residents' experiences financing their medical education and how these experiences influence well-being and attitudes toward financial education in residency. We recruited residents from a Southern California health system with residency programs in Family Medicine, Internal Medicine, General Surgery, Orthopaedic Surgery, and Psychiatry. We contacted residents by email and text message to participate in semi-structured interviews. We conducted interviews from October 2020 to March 2021 and analyzed 59 resident interviews using reflexive thematic analysis. Among residents, 76% (45/59) had ≥ $200,000 in student loans. Residents perceived mounting medical education debt as unfairly burdensome for trainees engaged in socially beneficial work, leaving residents feeling undervalued - a feeling heightened by the stressors of the COVID-19 pandemic - and hampering well-being. Compartmentalizing debt attenuated financial stressors but often made financial education seem less pressing. A subset of residents described how financial planning restored some agency and enhanced well-being, noting that protected didactic time for financial education was crucial. Resident interviews provide practical guidance regarding designing financial education sessions. Desired education included managing debt, retirement planning, and the business of medicine. How residents framed educational debt and their degree of financial literacy impacted their well-being and sense of agency. Residents proposed that residency programs can aid in stress mitigation by providing residents with skills to help manage debt and plan for retirement. To reduce clinician indebtedness, this approach needs to occur in tandem with systemic changes to financing medical education.

Depression Among Medical Students in the United States During the COVID-19 Pandemic: The role of Communication Between Universities and Their Students

OBJECTIVE

Medical students are vulnerable to stress and depression during medical school and the COVID-19 pandemic may have exacerbated these issues. This study examined whether the risk of depression was associated with COVID-19 pandemic-related medical school communication.

METHODS

A 144 - item pilot cross-sectional online survey of medical students in the US, was carried out between September 1, 2020 and December 31, 2020. Items on stress, depression, and communication between students and their medical schools were included. This study examined associations of student perceptions of universities' communication efforts and pandemic response with risk of developing depression.

RESULTS

The sample included 212 students from 22 US states. Almost 50% (48.6%) were at risk of developing depression. Students felt medical schools transitioned well to online platforms, while the curriculum was just as rigorous as in-person courses. Students at risk of developing depression reported communication was poor more frequently compared to students at average risk. Students at risk of depression were also more than 3 times more likely to report their universities' communication about scholarships or other funding was poor in adjusted analyses.

CONCLUSION

Universities communicated well with medical students during the pandemic. However, this study also highlights the need for ongoing efforts to address student mental health by medical schools.

Student well-being during dedicated preparation for USMLE Step 1 and COMLEX Level 1 exams

BACKGROUND

Nearly all U.S. medical students engage in a 4-8 week period of intense preparation for their first-level licensure exams, termed a "dedicated preparation period" (DPP). It is widely assumed that student well-being is harmed during DPPs, but evidence is limited. This study characterized students' physical, intellectual, emotional, and social well-being during DPPs.

METHODS

This was a cross-sectional survey sent electronically to all second-year students at four U.S. medical schools after each school's respective DPP for USMLE Step 1 or COMLEX Level 1 in 2019. Survey items assessed DPP characteristics, cost of resources, and perceived financial strain as predictors for 18 outcomes measured by items with Likert-type response options. Open-ended responses on DPPs' influence underwent thematic analysis.

RESULTS

A total of 314/750 (42%) students completed surveys. DPPs lasted a median of 7 weeks (IQR 6-8 weeks), and students spent 70 h/week (IQR 56-80 h/week) studying. A total of 62 (20%) reported experiencing a significant life event that impacted their ability to study during their DPPs. Most reported 2 outcomes improved: medical knowledge base (95%) and confidence in ability to care for patients (56%). Most reported 9 outcomes worsened, including overall quality of life (72%), feeling burned out (77%), and personal anxiety (81%). A total of 25% reported paying for preparation materials strained their finances. Greater perceived financial strain was associated with worsening 11 outcomes, with reported amount spent associated with worsening 2 outcomes. Themes from student descriptions of how DPPs for first-level exams influenced them included (1) opportunity for synthesis of medical knowledge, (2) exercise of endurance and self-discipline required for professional practice, (3) dissonance among exam preparation resource content, formal curriculum, and professional values, (4) isolation, deprivation, and anguish from competing for the highest possible score, and (5) effects on well-being after DPPs.

CONCLUSIONS

DPPs are currently experienced by many students as a period of personal and social deprivation, which may be worsened by perceived financial stress more than the amount of money they spend on preparation materials. DPPs should be considered as a target for reform as medical educators attempt to prevent student suffering and enhance their well-being.

"Pulling the Parachute": A Qualitative Study of Burnout's Influence on Emergency Medicine Resident Career Choices

OBJECTIVES

About half of all resident physicians report symptoms of burnout. Burnout negatively influences multiple aspects of their education and training. How burnout may impact residents' career choices remains unclear. The authors explored the role burnout played in residents' career decisions.

METHODS

This was a qualitative study among a sample of 29 emergency medicine residents from four institutions. Qualitative data were generated through four semistructured focus groups. The authors employed a constructivist approach to thematic analysis. Transcripts were coded and organized into major themes.

RESULTS

Five major themes connecting burnout with residents' career choices emerged: 1) residents' current burnout and the prevention of future burnout figured prominently in their career considerations, 2) residents aimed to mitigate sources of burnout through their career choices, 3) residents' view of clinical work as a burden and a burnout contributor spurred the pursuit of other interests, 4) faculty advice and role modeling in relation to burnout shaped residents' career perspectives, and 5) residents weighed long-term burnout concerns with short-term financial needs.

CONCLUSION

Burnout played an important role in multiple aspects of residents' career considerations. Educators, program directors, and organization leaders can focus on identified target areas to address burnout's influence on residents' career decisions.

The Great Gamble? A Mixed-Methods Study of Factors In˜fluencing Medical Students in Specialty Choice

BACKGROUND

Career planning remains relatively unexplored as a domain of medical education. Our aim was to explore the career planning journey undertaken by medical students. Results Approximately one third of participants had decided their future specialty. Important factors in career choice were 'interest in specific [specialty] aspects,' 'work-life balance,' 'personality type' of others in the specialty, an enjoyable experience on rotation and role models. Negative influential factors included poor conduct of doctors encountered and negative portrayals of specialities by practicing doctors. Conclusion The undergraduate and early postgraduate periods are formative times in career planning for junior doctors. Students and interns/FY1s are strongly influenced by doctors in the clinical setting, and clinicians should be aware of this power to exert both positive and negative influence.

Regional Variations in Diagnostic Radiology Residency Stipends Are Accentuated When Correlated With Cost of Living

OBJECTIVES

To determine and compare the relative value of diagnostic radiology resident stipends when adjusted for regional cost of living.

METHODS

The ACGME database was queried for a list of accredited allopathic diagnostic radiology residency programs for academic year 2017-2018. Stipend information for R1 positions (post-graduate year 2) was identified through each program's website. Data was grouped and analyzed by city, state, and geographical region. Stipends were then correlated with the 2017 annual region-specific average cost of living index (COLI).

RESULTS

There were 194 programs identified, of which 118 (60.8%) were analyzed after exclusions for lack of stipend or corresponding COLI data. The average annual stipend was $57,161±$4,242 (range, $49,547-$72,000). The COLI-adjusted value was $51,357±$9,927 (range, $26,915-$68,827). The average difference between stipend and cost-ofliving adjusted value was -$5,804±$12,610 (range, -$40,953-$10,958), corresponding to an average -9.1% stipend value loss (range, -58.1%-21.7%, P = .00000004). Value loss in large metropolitan cities was as high as 53.8%.

DISCUSSION

Financial issues are one of the biggest challenges faced by trainees and have been correlated with increased stress as well as poor academic performance. The pressures of debt can also play a significant role in ultimate subspecialty career choice. Discrepancies between resident stipends, which are not adjusted based on the local COLI, are exacerbated by large regional variations in cost of living. Residency applicants should not discount regional cost of living when deciding where to train, and training programs should consider cost of living when setting stipend levels for their trainees.

Reasons geriatrics fellows choose geriatrics as a career, and implications for workforce recruitment

Objectives: Although the population of older adults is rising, the number of physicians seeking geriatrics training is decreasing. This study of fellows in geriatrics training programs across the United States explored motivating factors that led fellows to pursue geriatrics in order to inform recruitment efforts. Design: Semi-structured telephone interviews with geriatrics fellows. Setting: Academic medical centers. Participants: Fifteen geriatrics fellows from academic medical centers across the United States. Measurements: This qualitative telephone study involved interviews that were transcribed and descriptively coded by two independent reviewers. A thematic analysis of the codes was summarized. Results: Fellows revealed that mentorship and early exposure to geriatrics were the most influential factors affecting career choice. Conclusion: The results of this study have the potential for a large impact, helping to inform best practices in encouraging trainees to enter the field, and enhancing medical student and resident exposure to geriatrics.

"This Isn't Being a Doctor."-Qualitative Inquiry into the Existential Dimensions of Medical Student Burnout

Recent studies report that up to 50% of medical students feel burned out. Medical student burnout has significant public health consequences-as students detach, the quality of patient care is impacted, and students themselves suffer, as evidenced by the increased risk in substance use and suicide. While some theorize that medical student burnout is due to an inability to confront suffering, death, and their own mortality, this hypothesis fails to explain why pre-clinical students also experience burnout despite having minimal clinical exposure. /r/medicalschool, a news-aggregating website for medical students, was queried for posts from the creation of the subreddit, December 11, 2009, to July 1, 2018, for the term "burnout" and its grammatical variations. Three hundred fifty-two posts and their comment threads were analyzed using a grounded theory approach. When the causes of burnout were interpreted using an existential psychodynamic framework, the predominant themes that arose were difficulties dealing with freedom (groundlessness), existential isolation, and meaninglessness, rather than death anxiety stemming from witnessing the suffering of patients. Students feel as if they are not living up to their own values of what a physician should be like and are troubled by the inconsistent values within the hidden, informal, and formal curriculum. Individualized interventions are temporary fixes that allow people to withstand their environment and complete their training; however, the learning environment needs change to better empower students to live a life full of existential meaning.

Life vs Loans: Does Debt Affect Career Satisfaction in Osteopathic Graduates?

Background

The cost of undergraduate osteopathic medical education continues to grow. It is important to understand how the rising cost of matriculation negatively affects training and career satisfaction of entering students.

Objective

To better understand any association between level of educational debt and satisfaction with osteopathic medical education, career choice, and financial services.

Methods

Responses were analyzed from the American Association of Colleges of Osteopathic Medicine survey of pending medical school graduates from 2007 through 2016 regarding indebtedness and specialty selection.

Results

From 2007 to 2016, the mean educational debt level at graduation rose consistently among osteopathic graduates (from $155,698 to $240,331, respectively). In all years, there was no significant effect of debt quartile on satisfaction with choice of osteopathic medicine as a career. Quartile variable with debt did not show a significant effect on satisfaction with education experience in 2010, 2013, and 2016. Top quartile debt was associated with higher satisfaction with financial service departments in all years.

Conclusion

Although debt has consistently increased for osteopathic medical graduates, it does not affect their satisfaction with either their educational experience or their choice of osteopathic medicine as a career.

Assessment of Diversity Outcomes in American Medical School Admissions: Applying the Grutter Legitimacy Principles

In the last 30 years, except for female participation, the enrollment of Latinx, African Americans, Native Americans, Alaskan natives, and disadvantaged students in medical school has been constant; however, increasing enrollment of these minority populations is feasible, if admissions committees make two changes in approach. First, the traditional belief that matriculation merit is a linear function of past academic performance must be rejected. Second, once the threshold needed to complete medical school in four years and to pass licensing examinations at the first attempt has been met, all candidates are equally qualified, and matriculation decisions must be based, in part, on societal interests. In Grutter vs. Bollinger, the United States Supreme Court determined that graduate admission committees can and should consider societal interests. Each admission decision represents a substantial government investment in each student, as the Medicare Act directly subsidizes much of the cost of medical education. As Grutter explained, there is a societal interest in the public having confidence in, and access to, the medical school training that will prepare tomorrow’s medical, professional, and political leaders. Our analysis suggests that medical school admissions are biased towards academic achievement in matriculants, beyond acceptable thresholds for graduation and licensure. We believe medical schools must shift their admissions strategies and consider noncognitive factors in all candidates as determinative once minimum acceptable academic standards have been met.

How Trainees Finance Their Medical Education: Implications of Higher Education Act Reform

Context

The Public Service Loan Forgiveness (PSLF) program is among several repayment programs currently available for recipients of federal student loans. Medical education debt has continued to expand at a rapid pace in the decade since PSLF was created. Proposed changes to the Higher Education Act would substantially transform how future medical trainees finance and repay medical education debt.

Objective

To better understand relationships between debt and personal stress, as well as between repayment- and forgiveness-program use, in the context of competing legislation.

Methods

Surveys were sent to all Accreditation Council for Graduate Medical Education−accredited internal medicine residency programs (osteopathic and allopathic).

Results

From a potential pool of 579 residents, data were obtained from 403 unique respondents (response rate, 69.6%) at 12 residency programs, for a program response rate of 2.2%. Of these respondents, 290 (71.9%) completed the demographic portion of the survey. Median education debt was $225,000. Residents with the top quartile of debt burden were more likely to use PSLF (odds ratio [OR], 3.27; P=.02), more likely to enter loan forbearance (OR, 2.14; P=.03), and indicated a higher level of stress (OR, 5.94; P<.001) compared with those in the second and third quartiles.

Conclusion

Proposed legislative changes to the Higher Education Act would scale back loan repayment options and also eliminate PSLF for future borrowers. Our data suggest that higher debt burdens are associated with increased debt-related stress. Given program popularity and growing use, along with growing concerns of physician burnout, policy makers should weigh the potential downstream effects of policy change on prospective future physicians.

National prospective cohort study describing how financial stresses are associated with attrition from surgical residency

BACKGROUND

Attrition from general surgery residency is high with a national rate of 20%. We evaluated potential associations between financial considerations and attrition.

METHODS

National prospective cohort study of categorical general surgery trainees.

RESULTS

Of the 1048 interns who started training in 2007, 681 (65%) had complete survey and follow-up data. In logistic regression, those with higher starting attending salary expectations (>$300K) were more likely to leave training (OR 2.9, 95% CI 1.2-6.9). Women with a partner who earned more (>$50K/year) were more likely to leave training (OR 4.1, 95% CI 1.6-10.5). In a subgroup of interns undecided about their future practice setting (academic, community, private practice, industry), those with less debt (≤$100K) were more likely to leave training (OR 2.4, 95% CI 1.1-5.2).

CONCLUSIONS

Several financial matters were associated with attrition. Addressing these financial concerns may help decrease attrition in surgical training and improve surgical training.

Effect of medical student debt on mental health, academic performance and specialty choice: a systematic review

OBJECTIVES

With the high and rising total cost of medical school, medical student debt is an increasing concern for medical students and graduates, with significant potential to impact the well-being of physicians and their patients. We hypothesised that medical student debt levels would be negatively correlated with mental health and academic performance, and would influence career direction (ie, medical specialty choice).

DESIGN

We performed a systematic literature review to identify articles that assessed associations between medical student mental health, academic performance, specialty choice and debt. The databases PubMed, Medline, Embase, Scopus and PsycINFO were searched on 12 April 2017, for combinations of the medical subject headings Medical Student and Debt as search terms. Updates were incorporated on 24 April 2019.

RESULTS

678 articles were identified, of which 52 met the inclusion criteria after being reviewed in full text. The majority of studies were conducted in the USA with some from Canada, New Zealand, Scotland and Australia. The most heavily researched aspect was the association between medical student debt and specialty choice, with the majority of studies finding that medical student debt was associated with pursuit of higher paying specialties. In addition, reported levels of financial stress were high among medical students, and correlated with debt. Finally, debt was also shown to be associated with poorer academic performance.

CONCLUSIONS

Medical student debt levels are negatively associated with mental well-being and academic outcomes, and high debt is likely to drive students towards choosing higher paying specialties. Additional prospective studies may be warranted, to better understand how educational debt loads are affecting the well-being, career preparation and career choices of physicians-in-training, which may in turn impact the quality of care provided to their current and future patients.

Specialty income and career decision making: a qualitative study of medical student perceptions

CONTEXT

Medical educators in the USA are interested in the ways medical students make career choices because shortages in key specialties, particularly primary care specialties, limit access to care. Although anticipated specialty income is a strong predictor of student interest, no studies have qualitatively explored the reasons why income is important to students. By better understanding students' perspectives on income and specialty choice, educators can help students make choices that fit their goals and better educate students about the specialties in which the need for expansion is greatest.

METHODS

In 2012, Year-2 students at one USA medical school were invited to write an essay about how debt and anticipated income levels influence their career choices. A total of 132 essays (response rate: 67%) were qualitatively analysed using a hermeneutic phenomenology approach to conventional content analysis, in which themes emerge inductively from the data. Researchers employed peer debriefing, modified member checking, thick description, code-recode strategies, audit trails and reflexivity to ensure quality and rigour. Although this analysis initially focused on student perceptions of specialty income, prestige also emerged as an important related theme.

RESULTS

Three major findings emerged. Income is of varying importance to different students. Students value income because it provides freedom and flexibility, and power and security. Students recognise that high income confers social prestige. Students also define specialty prestige in other ways, including match competitiveness, perceived expertise, opportunities for advancement through fellowships, and power and autonomy.

CONCLUSIONS

Medical students' perspectives of specialty income, specialty choice and prestige are more complex than previously reported. Medical educators should frame conversations about specialty choices in ways that incorporate varied perspectives on income and prestige. Health policymakers should recognise that income and prestige influence medical students' decisions in complex ways. These insights may inform strategies to counteract shortages in key specialties, including primary care specialties.

Role of Debt and Loan Forgiveness/Repayment Programs in Osteopathic Medical Graduates’ Plans to Enter Primary Care

Context

Osteopathic medicine emphasizes partnering with patients to help them attain or maintain health. This philosophy encourages physicians to practice primary care and a mission of improving community health. However, there is currently a shortage of primary care physicians in many areas of the United States.

Objective

To determine whether intended practice patterns of recent graduates of colleges of osteopathic medicine favor primary care and whether practice patterns correlate with medical education debt.

Methods

Responses were analyzed from the American Association of Colleges of Osteopathic Medicine survey of pending medical school graduates from 2007 through 2016 regarding indebtedness and specialty selection.

Results

The percentage of graduating osteopathic medical students who chose a primary care specialty increased from 28.1% (676 students) in 2007 to 33.2% (1377 students) in 2016. Among graduates, those above the 75th percentile of debt had a general move toward more non–primary care positions, with a value of 74.4% in 2007 and 79.9% in 2016. Graduates below the 25th percentile had a gradual increase in primary care representation, moving from 24.6% in 2007 to 29.4% in 2016. In 2007, graduates with a loan forgiveness/repayment program were more likely to choose primary care over graduates without such a program (OR, 0.681 [95% CI, 0.505-0.920]; P=.02). Analysis of subsequent years showed a declining OR with increasing significance.

Conclusions

Results of this analysis indicated that increased educational debt loan directly influenced physician practice choice. Graduates with high debt burden were more likely to enter primary care fields and use loan forgiveness/repayment programs. Graduates with high debt burden who did not use loan forgiveness/repayment programs were more likely to enter non–primary care specialty fields, with this trend increasing as mean medical school debt increased. This association has implications for policies that could affect choice of primary care. However, further research is needed to fully understand the primary care choice by graduates of colleges of osteopathic medicine.

Family Medicine Residents' Debt and Certification Examination Performance

Introduction

Previous studies have found that medical students and internal medicine residents with high educational debt perform less well on examinations. The purpose of this study was to examine the relationship between educational debt and family medicine residents' performance on initial in-training and board certification examinations.

Methods

Our study was a cross-sectional secondary analysis of American Board of Family Medicine (ABFM) data collected from residents (N=5,828) who registered for the Family Medicine Certification Examination (FMCE) in 2014 and 2015, representing 85.8% of graduating family medicine residents in the United States in those years. Multivariable linear and logistic regression modeling was used to examine the relationship between debt level and examination scores, and also to explore the relationship between debt level and passing the initial FMCE.

Results

After controlling for demographic variables, residents with high debt ($150,000 to $249,999) and very high debt (more than $250,000) performed significantly worse than those with no debt on the initial in-training examination (score differences of 14.2 [CI 8.6, 19.8] and 15.8 [CI 10.3, 21.4] points, respectively) and FMCE (score differences of 19.3 points [CI 13.4, 25.3] and 30.4 points [CI 24.6, 36.3], respectively). Additionally, those with debt above $250,000 had half the odds of passing their initial FMCE (OR 0.45; CI 0.27-0.75).

Conclusions

High educational debt is associated with lower examination performance among family medicine residents. This may be because residents with more debt have more stress or fewer day-to-day financial resources. However, confounding factors may also contribute to this association.

Debt and the Emerging Physician Workforce: The Relationship Between Educational Debt and Family Medicine Residents' Practice and Fellowship Intentions

PURPOSE

Educational debt is increasing and may affect physicians' career choices. High debt may influence family medicine residents' initial practice setting and fellowship training decisions, adversely affecting the distribution of primary care physicians. The purpose of this study was to determine whether debt was associated with graduating family medicine residents' practice and fellowship intentions.

METHOD

The authors completed a cross-sectional secondary analysis of 2014 and 2015 American Board of Family Medicine (ABFM) examination registration questionnaire data and ABFM administrative data. They used multivariate logistic regression to determine whether educational debt was associated with graduating residents' practice (ownership and type) and fellowship intentions.

RESULTS

Most residents (89.7%; 3,368) intended to pursue an employed position, but this intention was not associated with their debt. Residents with high debt ($150,000-$249,999) had lower odds of intending to work for a government organization (odds ratio [OR] 0.57; confidence interval [CI] 0.41-0.79). Those with high or very high debt (> $250,000) had lower odds of choosing academic practice (OR 0.55, CI 0.36-0.85 and OR 0.62, CI 0.40-0.96, respectively) or a geriatrics fellowship (OR 0.36, CI 0.20-0.67 and OR 0.29, CI 0.15-0.55, respectively).

CONCLUSIONS

High educational debt may contribute to national shortages of academic primary care physicians and geriatricians. Existing National Health Service Corps loan repayment opportunities may not offer adequate incentives to primary care physicians with high debt. The medical community should advocate for policies that better align financial incentives with workforce needs.

Prevalence of stress and its determinants among residents enrolled in China Standardized Training Program for Resident Doctor (C-STRD) program: A cross-sectional study

BACKGROUND

It has been widely understood that well-trained doctors are crucial for a high-quality public health system and safe patient care. Thus, in 2011, China initiated its first national residency training program, called the China Standardized Training for Resident Doctor (C-STRD), for medical graduates to prepare qualified doctors for the medical care system with increasing demands. So far, no studies have specifically address the prevalence of stress and its determinants among residents enrolled in the C-STRD.

PARTICIPANTS AND METHODS

The research is performed in two stages. In stage I, the authors conducted a pilot study and met 112 C-STRD residents in person. Based on the preliminary data, a revised questionnaire was adopted in stage II, during which the authors conducted a multi-institutional, cross-sectional survey of 340 participants from 11 hospitals in Shanghai in a self-administered manner.

RESULTS

The results showed that C-STRD residents were overall under severe stress as their mean PSS score was 27.5 ± 4.9, which was higher than the threshold of high stress (PSS = 20). Specifically, the PSS score for the residents with Bachelor (MB), Master (MM) and Doctoral of Medicine (MD) educational degree were 26.6 ± 4.1, 27.8 ± 3.5 and 27.1 ± 5.2, respectively (P>0.05). Their stress was mainly associated with their financial income status and workload, as these two factors caused more severe burden than other listed stressors (P<0.05). Specially, the residents indicated that their montly payroll amout were as low as $590.2 ± 127 while no benefit package and allowance were given. Surprisingly, wage arrears up to 5.3 month were reported by 36 (10%) participants. Workload survey showed the residents has high work intensity and inadequate rest. Since no stress management program was provided, the majority of residents tended to cope their stress with unhealthy strategies, such as mesmerizing in TV/computer (88.2%) and overeating (59.7%).

CONCLUSION

The C-STRD residents are at high risk of perceived stress. Although there was a difference in perception of stress for workload and career future among different educational degree owners, low financial income is the major stressor among all C-STRD residents. Unhealthy stress management strategies were adopted by all residents due to lack of appropriate stress-relieving intervention.

Practice Area Intentions of Graduates of Colleges of Osteopathic Medicine: What Role Does Debt Play?

Context

Enrollment in colleges of osteopathic medicine continues to increase, as does the need for physicians practicing in underserved areas. The cost of osteopathic medical education is substantial, with students often incurring debt of $200,000 or more. It is unclear whether practice patterns of new graduates will be affected by debt-to-income ratios.

Objective

To determine whether the intended practice location of graduates of colleges of osteopathic medicine is associated with medical education debt.

Methods

Using data from the American Association of Colleges of Osteopathic Medicine's annual survey to graduates of colleges of osteopathic medicine, the authors focused on graduates’ intention to practice in an underserved area, the amount of debt incurred, and plans to enter a loan-repayment program. Survey data from 2007, 2010, 2013, and 2016 were analyzed.

Results

From 2007 to 2016, the percentage of graduates who intended to practice in underserved areas increased (27.5% to 35.3%, respectively). Graduates with the most debt intended to practice in underserved areas at a higher percentage than those with the least amount of debt, and they also planned on using loan-repayment programs at a higher rate.

Conclusion

There is a strong association among the intention to practice in an underserved area, high debt load, and intention to use a loan-repayment program. Therefore, the osteopathic medical community should support increased access to loan-repayment programs to help its graduates surmount economic and social barriers to providing care in underserved areas.

Developing a novel international undergraduate surgical masterclass during a financial crisis: our 4-year experience

BACKGROUND

Essential Skills in the Management of Surgical Cases (ESMSC) is a novel 3-day international undergraduate surgical masterclass. Its current curriculum (Cores integrated for Research-Ci4R) is built on a tetracore, multiclustered architecture combining high-fidelity and low-fidelity simulation-based learning (SBL), with applied and basic science case-based workshops, and non-technical skills modules. We aimed to report our experience in setting up ESMSC during the global financial crisis.

METHODS

We report the evolution of our curriculum's methodology and summarised the research outcomes related to the objective performance improvement of delegates, the educational environment of the course and the use of mixed-fidelity SBL. Feedback from the last three series of the course was prospectively collected and analysed using univariate statistics on IBM SPSS V.23.

RESULTS

311 medical students across the European Union (EU) were selected from a competitive pool of 1280 applicants during seven series of the course between 2014 and 2017. During this period, curriculum 14 s evolved to the final Ci4R version, which integrates a tetracore structure combining 32 stations of in vivo, ex vivo and dry lab SBL with small group teaching workshops. Ci4R was positively perceived across different educational background students (p>0.05 for any comparison).

CONCLUSIONS

ESMSC is considered an innovative and effective multidisciplinary teaching model by delegates, where it improves delegates objective performance in basic surgical skills. Our experience demonstrates provision of high-quality and free surgical education during a financial crisis, which evolved through a dynamic feedback mechanism. The prospective recording and subsequent analysis of curriculum evolution provides a blueprint to direct development of effective surgical education courses that can be adapted to local needs.

Feasibility and Usability of Tele-interview for Medical Residency Interview

Every year in the United States, medical students and residency programs dedicate millions of dollars to the residency matching process. On-site interviews for training positions involve tremendous financial investment, and time spent detracts from educational pursuits and clinical responsibilities. Students are usually required to fund their own travel and accommodations, adding additional financial burdens to an already costly medical education. Similarly, residency programs allocate considerable funds to interview-day meals, tours, staffing, and social events. With the rapid onslaught of innovations and advancements in the field of telecommunication, technology has become ubiquitous in the practice of medicine. Internet applications have aided our ability to deliver appropriate, evidence-based care at speeds previously unimagined. Wearable medical tech allows physicians to monitor patients from afar, and telemedicine has emerged as an economical means by which to provide care to all corners of the world. It is against this backdrop that we consider the integration of technology into the residency application process. This article aims to assess the implementation of technology in the form of web-based interviewing as a viable means by which to reduce the costs and productivity losses associated with traditional in-person interview days.

Associations Between Pharmacy Students' Attitudes Toward Debt, Stress, and Student Loans

Objective. To assess graduating pharmacy students' attitudes toward debt and determine associations with stress, student loan debt, financial need, current employment, post-graduation plans, and expected length of time to repay loans. Methods. Survey was conducted using an attitudes-toward-debt scale (sub-scales: tolerant attitudes toward debt; contemplation and knowledge about loans; fear of debt), Perceived Stress Scale, and questions concerning current employment, estimated total student loan debt, post-graduation plans, and expected length of time to repay loans. Federal loan data were collected using financial aid records. Independent samples t-test, ANOVA, and Pearson's r correlations were conducted. Results. There were 147 students (96.7%) who participated. The majority were female (59.2%), white (69.4%), and had federal student loans (90.5%). Mean total loan amount was $153,276 (SD $59,810), which included federal students loans accumulated before and during pharmacy school. No significant differences were noted on attitudes toward debt or stress based on whether respondents had federal student loans. Greater "fear of debt" was correlated with increased stress, estimated total student loan debt, total federal loan debt, and pharmacy school loan debt. Greater "contemplation and knowledge about loans" was correlated with lower estimated total student loan debt, total federal loan amount, and pharmacy school loan amount. Students with higher "contemplation and knowledge" scores expected to repay loans within a shorter time frame than students with lower scores. Conclusion. Increased fear of debt was related to greater perceived stress and higher student loan amounts borrowed, while increased contemplation and knowledge about loans was associated with lower amounts borrowed. Educational programming concerning loans, debt, and personal financial management may help reduce stress and amount borrowed.