Author + information
- C. Michael Minder, MD∗ ()
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
- ↵∗Reprint requests and correspondence:
Dr. C. Michael Minder, Duke University Medical Center, 2301 Erwin Road, Durham, North Carolina 27710.
For most students, medical training began as a labor of love. The further I advance, however, the more keenly aware I become of the financial “hole” from which I will eventually need to extract myself. When I pause to survey my progress, I realize I am 32 years old, with an additional year of training on the horizon. My wife (a nonphysician) and I have >$250,000 in educational debt. I have never been anything other than a student, resident, or fellow trainee except for a 1-year gap between residency and fellowship during which time we managed to squirrel away a small nest egg to fund a wedding, a down payment for a modest home, and actually begin to think seriously about starting a family. Despite the fact that I have been practicing medicine for >6 years, I still require additional training as a prerequisite for entry into my future career.
Cardiology is unique in that it requires years of apprenticeship before allowing independent practice. On the other hand, the vast majority of my college peers have been in the workforce more than a decade. Those who completed law school or business school are now assuming mid-career positions with corresponding compensation, whereas my career as an attending has yet to begin. That is not to say that on-the-job learning ceases after completion of training—rather, it occurs in a less formalized manner irrespective of profession.
Growing Concern Among Trainees
Physicians are often regarded as highly paid professionals by societal standards; however, an oft-overlooked aspect of medical training is the upfront personal and financial sacrifice we assume by pursuing medical training. Although higher education has historically been considered a safe investment, continued growth of student loan debt, increasing duration of specialty training, and uncertainties in provider reimbursement in the era of the Affordable Care Act have made the economic implications of medical training riskier than ever.
According to the American Association of Medical Colleges, the median education debt of medical school graduates in 1992 was $81,729 (amounts adjusted for inflation to reflect 2012 costs) (1). In 2012, the median educational debt more than doubled to $170,000 with 86% of graduates reporting educational debt. Between 2000 and 2012, the cost of medical school increased for public and private institutions at annual rates of 5.8% and 4.5%, respectively, compared with an average annual inflation rate of 2.4% over the same time period. In 2015, the median educational debt increased to >$180,000 with 45% of graduating medical students owing ≥$200,000 (2).
In addition to rising medical school tuition, changes in the structure of the federal student loan program make it increasingly more expensive to finance education. Between 2006 and 2015, rates for medical students with Direct Unsubsidized Loans fluctuated between 6.21% and 6.8% for 8 of 9 years (3). Interest rates for Direct Plus Loans were even higher ranging from 6.41% to 7.9% over the same time frame. For comparison, the average annual rate of a 30-year fixed-rate mortgage ranged from 3.66% to 6.41% over the same time span with rates ≤5.04% for 7 of 10 years and ≤4.69% every year since 2010 (4). Starting in 2012, medical students no longer qualified for federally subsidized loans, which have been predicted to cost an additional $10,000 to $20,000 over the duration of loan repayment (1).
As physician indebtedness continues to increase, wages for house staff have essentially remained flat over the same time interval. From 1992 to 1993, the mean post-graduation year 1 stipend was $48,677 (adjusted for inflation) compared with $51,586 for 2014 to 2015 (5). Some might contend that lower rates of reimbursement are necessary to offset inefficiencies in patient care and added expenditures incurred by trainees, such as unnecessary medical testing. Although this argument may hold some truth in the very early stages of training, recent data suggest that teaching hospitals are benefitting economically from the discounted labor provided by seasoned medical trainees (6). Fellows, in particular, represent a special case in that most are board-certified physicians who are capable of practicing independently, and yet their salaries continue to lag behind those of other health care professionals. According to the Association of American Medical Colleges and Bureau of Labor Statistics, the mean salary of a first-year (post-graduate year 4) medical subspecialty fellow in 2014 was $57,682—lower than health care professionals with substantial job overlay, including general internists (mean annual wage $190,530), nurse practitioners ($97,990), and physicians assistants ($97,280) (7).
Compensation also takes the form of employer-sponsored benefits and subsidies. In 2014 and 2015, only 73.5% of surveyed training programs offered a retirement plan to house staff (5). By comparison, data from the National Compensation Survey of workers in the United States from March 2015 indicate 80% of full-time workers in the civilian, 76% in the private, and 99% in the state and local government sectors had access to retirement plans through their employer (8). Nearly all training institutions offer health care coverage; however, the amount of employer subsidy varies widely among institutions with 31% providing fully paid individual coverage and 64% offering cost-shared coverage. Relatively few teaching institutions (∼30%) offer childcare and even fewer programs (7%) subsidize childcare despite long work hours and call requirements (5).
Implications for a Future Generation of Trainees
Calm waters do not make for seasoned sailors—and medical training is no exception. There is no replacement for rigorous training including internship, residency, and fellowship to shape young physicians into astute clinicians and future health care leaders. That being said, a growing number of economic factors have the potential to negatively impact quality of fellowship training and deter trainees from pursuing careers that require longer training without necessarily guaranteeing higher reimbursement. Trainees are particularly vulnerable to economic stresses related to raising a young family, saving for an unexpected emergency, or planning for retirement. Among 16,394 internal medicine residents surveyed in the United States, educational debt was associated with higher rates of burnout, lower quality of life, and low satisfaction with work-life balance (9). Another survey of 4,128 medicine residents from 415 U.S. residency programs reported that 43% of respondents had a monthly disposable income ≤$100, another 16% felt they could not afford safe housing, 52% had insufficient funds to purchase books and equipment, and 29% could not afford fees for board-certification exams (10). Further complicating matters, financial literacy among trainees is highly variable, which can limit overall financial health. One survey of 52 medical interns found that the average score on an investor literacy test was 40%--on par with the general population. The investigators estimated that educational interventions focused on retirement savings during 3 years of residency could result in an additional $53,000 to $251,000 in tax-deferred savings at the time of retirement (11).
On a larger scale, the prospect of longer training, increasing debt, and lower projected reimbursement may deter many of the best and brightest students from pursuing a career in medicine as pointed out in a 2008 report by the U.S. Department of Health and Human Services (12). Programs such as the National Institutes of Health Loan Repayment Program and Public Student Loan Forgiveness have been implemented by the federal government to mitigate student load debt while encouraging medical professionals to enter academic and public service careers. While these programs do help defray expenses for some fellows, only 51% of extramural National Institutes of Health Loan Repayment Program applicants were funded (13). Details surrounding the Public Student Loan Forgiveness remain vague as the program requires a minimum of 10 years of income-based repayments before qualifying. The first applicants will not be eligible until October 2017 and it remains to be seen whether the program will be capitated.
Changes to Reform Medical Training: The Road Ahead
Even though current fellows experience many of the same challenges faced by generations of former trainees, the continued trend of increasing student loan indebtedness threatens to disrupt the financial model on which graduate medical education is predicated. Mounting educational debt is by no means unique to physicians and is reflective of a national trend among American students attending college (14). Despite increasing awareness of the problem, unchecked educational debt is part of a larger economic issue for which a comprehensive solution remains elusive. Within cardiology, there has been a shift toward competency-based medical education as part of COCATS (Core Cardiovascular Training Statement) 4 as well as development of “blended” Internal Medicine–Cardiology training programs currently undergoing pilot evaluation at select institutions across the country (15–18). These pragmatic approaches offer much needed hope for future generations of cardiology trainees. Nonetheless, continued growth of educational debt remains unsustainable. Asking students to assume ever increasing amounts of debt early in training allows for little flexibility later in their careers when they may be forced to decide between passion and financial obligation.
- Marc R. Dweck, MD and
- Zahi A. Fayad, PhD ()
RESPONSE: The Shifting Economics of Medical Training
Can We Afford Not to Listen?
What drives young people to become the doctors, physicians, and cardiologists of the future? Few would consider ice-cold finance to be the primary influence to what is often a conscious or unconscious desire to help those around us. Indeed, there are many simpler and more rapid routes to fortune than medicine. Yet, to completely deny the importance of financial stability in this decision-making process would be naive. The reality is that if the numbers fail to stack up, then many talented young people will reluctantly choose an alternate profession rather than medicine if it is accompanied by a life of economic uncertainty.
In many ways, the economics underlying cardiology training in the United States are simple. Young, aspiring doctors are asked to make a heavy, upfront investment in their education starting at medical school. This then continues into their residency and fellowship programs over a period of at least a decade. The debt that follows is substantial and increasing (currently ∼$200,000) but this path is taken with the understanding that the acquired skills and credentials will ultimately generate enough money to justify the original down payment. In that way, the high starting salaries traditionally afforded to attending cardiologists (again ∼$200,000) have been critical in maintaining the economic sustainability of this model and in providing a degree of reassurance during the years of debt-laden training.
However, as Dr. Minder eloquently describes, a very real concern exists that these once-dependable goalposts are now shifting. Indeed, in an era of increasing education costs, exorbitant debt interest, and fears over declining remuneration, the figures are slipping, potentially forcing an entire generation of young gifted people away from less lucrative academic pathways or indeed medicine altogether. Those from less affluent backgrounds will be particularly affected with the risk that medicine will emerge not as a profession for the most talented but rather as a privilege for the wealthy. So, what are the potential solutions to this looming issue? None are easy. Rising costs and the intense pressure on health care budgets means that major salary increases for doctors are unlikely. Also, the level of expertise and experience required to deliver high-quality clinical care makes reductions in training duration largely impractical. Tackling the exorbitant interest charged on student loans would be an important start; however, ultimately if physician remuneration does indeed fall, then the costs of medical education will have to come down in line. That or the bubble will inevitably burst.
Although money should never be the primary driver to a career in medicine, the promise of financial security at the end of a prolonged and arduous period of training remains integral to the recruitment of the brightest and ablest young minds. If this paradigm becomes challenged, then the impact on the development of cardiology as a profession and the quality of care provided to our patients will be devastating. The concerns expressed by Dr. Minder are genuine and widely held, with major implications for the medical profession as a whole. We dismiss his stark warnings at our peril.
Dr. Minder has reported that he has no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- ↵Association of American Medical Colleges. Physician Education Debt and the Cost to Attend Medical School: 2012 Update. Available at: https://members.aamc.org/eweb/upload/Physician%20Education%20Debt%20and%20the%20Cost%20to%20Attend%20Medical%20School,%202012%20Update.pdf. Accessed September 3, 2015.
- ↵Association of American Medical Colleges. Medical Student Education: Debt, Costs, and Loan Repayment Fact Card. Available at: https://www.aamc.org/download/447254/data/debtfactcard.pdf. Accessed January 10, 2016.
- ↵Federal Student Aid. Federal Student Aid: Understand How Interest Is Calculated and What Fees Are Associated With Your Federal Student Loan. Available at: https://studentaid.ed.gov/sa/types/loans/interest-rates#what-are-the-interest-rates-of-federal-student-loans. Accessed September 3, 2015.
- ↵FreddieMac. Primary Mortgage Market Survey Archives. Available at: http://www.freddiemac.com/pmms/pmms30.htm. Accessed September 3, 2015.
- ↵Association of American Medical Colleges. Survey of Resident/Fellow Stipends and Benefits Report 2014-2015. Available at: https://www.aamc.org/download/412558/data/2014stipendsurveyreportfinal.pdf. Accessed September 3, 2015.
- ↵Bureau of Labor Statistics. Occupational Employment Statistics: May 2014 Occupation Profiles. Available at: http://www.bls.gov/oes/current/oes_stru.htm#29-0000. Accessed September 3, 2015.
- ↵Bureau of Labor Statistics. Employee Benefits in the United States—March 2015. News release. July 24, 2015. Available at: http://www.bls.gov/news.release/pdf/ebs2.pdf. Accessed September 3, 2015.
- ↵U.S. Department of Health and Human Services, Health Resources and Services Administration. The Physician Workforce: Projections and Research into Current Issues Affecting Supply and Demand. December 2008. Available at: http://bhpr.hrsa.gov/healthworkforce/reports/physwfissues.pdf. Accessed September 3, 2015.
- ↵National Institutes of Health. FY 2014: The NIH Extramural Loan Repayment Programs Data Book: Fiscal Year 2014 Highlights: October 1, 2013 to September 30, 2014. Available at: http://www.lrp.nih.gov/lrpdatabook/pdf/FY2014_Extramural_Data_Book_Final.pdf. Accessed September 3, 2015.
- ↵U.S. Department of Education, National Center for Education Statistics. Fast Facts: Tuition Costs of Colleges and Universities. Available at: https://nces.ed.gov/fastfacts/display.asp?id=76. Accessed November 19, 2015.
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- American Board of Internal Medicine. Competency-Based Medical Education Pilot Programs. Available at: http://www.abim.org/program-directors-administrators/competency-based-medical-education-pilot-programs/default.aspx. Accessed September 8, 2015.
- American Board of Internal Medicine. Internal Medicine—Cardiology Pilot Program. Available at: http://www.abim.org/program-directors-administrators/competency-based-medical-education-pilot-programs/internal-medicine-cardiology.aspx. Accessed November 19, 2015.