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Rising educational debt levels in recent dermatology trainees and effects on career choices
BRIEF
REPORTS
Rising educational debt levels in recent dermatology trainees and effects on career choices Sharon A. Salter, MD, and Alexa B. Kimball, MD, MPH Boston, Massachusetts Background: Educational debt levels are outpacing inflation. Objective: To determine whether debt levels influence career choices of graduating dermatology residents. Methods: Anonymous surveys of graduating dermatology residents. Results: The presence of debt was associated negatively with pursuing fellowship training in 1999 and 2004 (P \ .05) but did not affect choices about entering solo practice or job dissatisfaction levels. Limitations: This study relies on self-reported data, and some surveys were incomplete. Conclusion: Debt levels do not appear to significantly influence the career choices of dermatology residents. (J Am Acad Dermatol 2006;54:329-31.)
M
edical education has long been considered an investment—an expense that students have been willing to incur in anticipation of future financial rewards. However, over the last 20 years, costs have increased more rapidly than compensation, leaving many physicians with significant educational debt.1 In the past 2 decades the median cost of medical school has increased 312% (public) and 165% (private).2,3 Not surprisingly, the mean debt level of graduating medical students has also risen from $90,566 in 1999 to $115,219 in 2004, an increase of 5.4% per year.4-6 Somewhat unexpectedly, previous studies have been unable to show a correlation between debt levels and specialty choices of graduating medical
From the Brigham and Women’s Hospital and Massachusetts General Hospital. Funding sources: Galderma provided administrative support for distributing the surveys. American Academy of Dermatology provided administrative support for data entry. Conflicts of interest: None identified. Poster presented at Society for Investigative Dermatology, St Louis, Missouri, May 2005. Oral presented at the International Dermato-Epidemiology Association Americas Chapter (IDEA), St Louis, Missouri, May 2005. Correspondence to: Alexa B. Kimball, MD, MPH, Department of Dermatology, Brigham and Women’s Hospital, 221 Longwood Ave, Boston, MA 02115. E-mail: [email protected]. Reprint requests: [email protected]. 0190-9622/$32.00 ª 2006 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2005.10.047
students.1 However, the effect of debt on career choice after residency training has not been examined. This study was devised to determine if an association could be found between debt levels and the career choices of graduating dermatology residents.
METHODS Anonymous surveys were given to graduating dermatology residents who participated in the Galderma Board Review course from 1999-2004, with the exception of 2001, as has been previously described.7 The surveys included questions about age, gender, marital status, and student debt. Responses were grouped into several categories, which included fellowship status, solo practice, job satisfaction, and job dissatisfaction. Satisfaction levels were evaluated on a 5-point Likert scale with 1 signifying highly satisfied and 5 representing highly dissatisfied. Data from these subsets were analyzed for statistical significance with the use of Analyse-it for Microsoft Excel, version 1.71. P values \ .05 are reported as statistically significant.
RESULTS In total, 959 surveys were collected, with yearly response rates ranging from 62% to 88%. Nine hundred and nine (95%) surveys contained completed information about debt. The proportion of trainees reporting any debt ranged from 58% to 68 % 329
330 Brief reports
J AM ACAD DERMATOL FEBRUARY 2006
Fig 1. Mean debt levels over time.
and did not change significantly over time. Mean debt levels for indebted dermatology residents increased from $78,921 in 1999 to $100,618 in 2004, a 27% increase (Fig 1). During this time of steadily increasing debt, neither the proportion of married residents with debt nor the proportion of trainees with children and debt changed significantly. The proportion of fellowshiptrained dermatologists with debt was more variable, growing from 45% in 1999 to 75% in 2003, but declining in 2004 to 46%. Statistically significant changes in the proportions were noted in 1999 (P # .05) and in 2004 (P # .025) when the presence of any debt corresponded to lower fellowship rates. However, when debt levels were compared, the median/mean debt levels of indebted physicians with fellowship training were similar to those without fellowship training. From 1999 to 2003, 57% to 72% of those who entered solo practice had student debt. This figure declined to 50% in 2004, but these changes in proportions were not statistically significant. Also, debt did not appear to deter trainees from entering into academics. Respondents with and without debt consistently reported low levels of job dissatisfaction, although a slight increase was noted in 2004 (Fig 2). Statistical significance was not observed when dissatisfaction levels (scores 4 or 5) were compared with satisfaction levels (scores of 1, 2, or 3) over time.
DISCUSSION Over the 5 years surveyed, the proportion of indebted residents was substantial and relatively consistent. Mean debt levels were high and increased 27%, a rate nearly identical to that documented by indebted medical students over the same time period.4,5 In comparison, between 1999 and 2004, the consumer price index (CPI) ranged from a low of 1.6 in 2002 to a high of 3.4 in 2000, with a yearly average of 2.5%.8 The 5.4% average annual increase in debt for both medical students9 and dermatology
Fig 2. Job dissatisfaction.
residents was significantly higher than the CPI, outpacing inflation on average by more than 2-fold. Having any debt was positively associated with pursuing a fellowship in some years and negatively associated in others, suggesting no significant impact on the decision making. Furthermore, actual debt levels did not appear to have any significant influence; between 1999 and 2004, the median debt levels of those who entered fellowships were equivalent to those who did not pursue fellowship training. Similar variation was noted when the percent of indebted dermatologists in solo practice was compared with the percent not in solo practice. Several competing factors may be at play; the anticipation of increased earning potential might have influenced some to enter solo practice, but the fear of initial start-up costs might have deterred others. Outside influences, such as insurance reimbursements, governmental regulations, and patient expectations, could influence job satisfaction levels for any given year. Surprisingly, from 1999 to 2003, residents with student debt consistently reported lower levels of job dissatisfaction than those without student debt, which may reflect a difference in job expectations. In determining job satisfaction, physicians with debt may place more emphasis on immediate reimbursements, while physicians without debt may place a higher value on non-monetary factors. In contrast with previous years, in 2004, people with student debt reported higher levels of job dissatisfaction than those without debt. Limitations of this study included self-reported data and incomplete surveys. In addition, this study did not take into account additional influences, such as a spouse’s income or the state of the economy. Future studies may be designed to examine these areas in an attempt to control for these variables. Over the years evaluated, debt levels rose steadily, and yet, statistically, debt did not appear to influence career choices of dermatology residents. However, in 2004 many of the responses received were not consistent with those of the previous 4 years
J AM ACAD DERMATOL
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VOLUME 54, NUMBER 2
surveyed. Two possible factors may account for these differences. First, salaries for dermatologists were reported to increase by approximately 20% in 2004,10 an increase in income that may have influenced career choices. Alternatively, the increase in resident debt levels may have finally reached a threshold above which resident choices were affected. The latter hypothesis, if confirmed, may have profound effects on career plans of graduating residents. With no changes to relieve the burden of medical debt in a substantial way on the horizon, these trends will need to be closely monitored. REFERENCES 1. Chhabra A. Medical school tuition and the cost of medical education. JAMA 1996;275:1372-3. 2. Jolly P. Medical school tuition and young physician indebtedness. Association of American Medical Colleges, March 23, 2004: 1-25. Available at: https://services.aamc.org/Publications/ showfile.cfm?file=version21.pdf&prd_id=102&prv_id=113. Accessed December 27, 2004. 3. American Medical Student Association, December, 27, 2004: 1-6. Available at: http://www.amsa.org/meded/studentdebt. cfm. Accessed December 27, 2004.
4. Association of American Medical Colleges Medical School Graduation Questionnaire, 2001:45(36). Available at: http:// www.aamc.org/data/gq/allschoolsreports/2001.pdf. Accessed December 27, 2004. 5. Association of American Medical Colleges Medical School Graduation Questionnaire, 2004:52(38). Available at: http:// www.aamc.org/data/gq/allschoolsreports/2004.pdf. Accessed December 27, 2004. 6. Environmental Assessment, Educational Debt, April 16, 2004: 1-3. Available at: http://ea.acponline.org/systems/ED.html. Accessed December 27, 2004. 7. Nguyen JC, Jacobson CC, Rehmus W, Kimball AB. Workforce characteristics of Mohs surgery fellows. Dermatol Surg 2004; 30:136-8. 8. US Department of Labor Bureau of Labor Statistics, Consumer Price Index e All Urban Consumers, 1999-2004. Available at: http://data.bls.gov/PDQ/servlet/SurveyOutputServlet. Accessed February 24, 2005. 9. American Medical Association, Medical Student Section (MSS). Medical Student Debt. 2004. Available at: http://www. ama-assn.org/ama/pub/category/5349.html. Accessed December 27, 2004. 10. Tierney E, Kimball AB. Median dermatology base incomes in senior academia and practice are comparable but a significant income gap exists at junior levels. Presented at the Association of Professors of Dermatology meeting, Chicago, Illinois, September 2004.
Socioeconomic status influences care of patients with acne in Ontario, Canada Aamir Haider, MD, PharmD,a Muhammad Mamdani, PharmD, MA, MPH,a,b James C. Shaw, MD, FRCPC,a,c David A. Alter, MD, PhD, FRCPC,a,b,d and Neil H. Shear, MD, FRCPCa,d Toronto, Ontario, Canada
Background: Canada’s universal health care system is designed to ensure equitable access to medical care based on need rather than socioeconomic status, although a number of studies indicate a preferential access and greater use of specialist services for those patients in higher socioeconomic groups. Objectives: The primary objective of this study was to determine whether socioeconomic status influences access to specialist care by a dermatologist for the management of acne in Ontario, Canada. A secondary objective was to determine whether the urban-rural dwelling status of patients affects access to specialty care. Methods: We conducted a population-based cohort study using administrative health care databases covering more than 12 million residents of Ontario. Individuals age 12 to 27 years with a new diagnosis of acne by a general practitioner were identified as belonging to 1 of 5 socioeconomic groups based on
From the Division of Dermatology, University of Torontoa; Institute for Clinical Evaluative Sciencesb; University Health Network, Toronto Western Hospitalc; Sunnybrook and Women’s College Health Sciences Centre.d Funding sources: None. Disclosure: Dr Shear is an advisory board member and consultant for Galderma, is an advisory board member for Berlex, and is a consultant and performs clinical trials for Hoffman La Roche.
Presented at the Canadian Dermatology Association annual meeting in Victoria, BC, Canada in June 2004. Reprint requests: Aamir Haider, MD, PharmD, 135 Union St East, Waterloo, Ontario, Canada N2J 1C4. 0190-9622/$32.00 ª 2006 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2005.03.029
REPORTS
Rising educational debt levels in recent dermatology trainees and effects on career choices Sharon A. Salter, MD, and Alexa B. Kimball, MD, MPH Boston, Massachusetts Background: Educational debt levels are outpacing inflation. Objective: To determine whether debt levels influence career choices of graduating dermatology residents. Methods: Anonymous surveys of graduating dermatology residents. Results: The presence of debt was associated negatively with pursuing fellowship training in 1999 and 2004 (P \ .05) but did not affect choices about entering solo practice or job dissatisfaction levels. Limitations: This study relies on self-reported data, and some surveys were incomplete. Conclusion: Debt levels do not appear to significantly influence the career choices of dermatology residents. (J Am Acad Dermatol 2006;54:329-31.)
M
edical education has long been considered an investment—an expense that students have been willing to incur in anticipation of future financial rewards. However, over the last 20 years, costs have increased more rapidly than compensation, leaving many physicians with significant educational debt.1 In the past 2 decades the median cost of medical school has increased 312% (public) and 165% (private).2,3 Not surprisingly, the mean debt level of graduating medical students has also risen from $90,566 in 1999 to $115,219 in 2004, an increase of 5.4% per year.4-6 Somewhat unexpectedly, previous studies have been unable to show a correlation between debt levels and specialty choices of graduating medical
From the Brigham and Women’s Hospital and Massachusetts General Hospital. Funding sources: Galderma provided administrative support for distributing the surveys. American Academy of Dermatology provided administrative support for data entry. Conflicts of interest: None identified. Poster presented at Society for Investigative Dermatology, St Louis, Missouri, May 2005. Oral presented at the International Dermato-Epidemiology Association Americas Chapter (IDEA), St Louis, Missouri, May 2005. Correspondence to: Alexa B. Kimball, MD, MPH, Department of Dermatology, Brigham and Women’s Hospital, 221 Longwood Ave, Boston, MA 02115. E-mail: [email protected]. Reprint requests: [email protected]. 0190-9622/$32.00 ª 2006 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2005.10.047
students.1 However, the effect of debt on career choice after residency training has not been examined. This study was devised to determine if an association could be found between debt levels and the career choices of graduating dermatology residents.
METHODS Anonymous surveys were given to graduating dermatology residents who participated in the Galderma Board Review course from 1999-2004, with the exception of 2001, as has been previously described.7 The surveys included questions about age, gender, marital status, and student debt. Responses were grouped into several categories, which included fellowship status, solo practice, job satisfaction, and job dissatisfaction. Satisfaction levels were evaluated on a 5-point Likert scale with 1 signifying highly satisfied and 5 representing highly dissatisfied. Data from these subsets were analyzed for statistical significance with the use of Analyse-it for Microsoft Excel, version 1.71. P values \ .05 are reported as statistically significant.
RESULTS In total, 959 surveys were collected, with yearly response rates ranging from 62% to 88%. Nine hundred and nine (95%) surveys contained completed information about debt. The proportion of trainees reporting any debt ranged from 58% to 68 % 329
330 Brief reports
J AM ACAD DERMATOL FEBRUARY 2006
Fig 1. Mean debt levels over time.
and did not change significantly over time. Mean debt levels for indebted dermatology residents increased from $78,921 in 1999 to $100,618 in 2004, a 27% increase (Fig 1). During this time of steadily increasing debt, neither the proportion of married residents with debt nor the proportion of trainees with children and debt changed significantly. The proportion of fellowshiptrained dermatologists with debt was more variable, growing from 45% in 1999 to 75% in 2003, but declining in 2004 to 46%. Statistically significant changes in the proportions were noted in 1999 (P # .05) and in 2004 (P # .025) when the presence of any debt corresponded to lower fellowship rates. However, when debt levels were compared, the median/mean debt levels of indebted physicians with fellowship training were similar to those without fellowship training. From 1999 to 2003, 57% to 72% of those who entered solo practice had student debt. This figure declined to 50% in 2004, but these changes in proportions were not statistically significant. Also, debt did not appear to deter trainees from entering into academics. Respondents with and without debt consistently reported low levels of job dissatisfaction, although a slight increase was noted in 2004 (Fig 2). Statistical significance was not observed when dissatisfaction levels (scores 4 or 5) were compared with satisfaction levels (scores of 1, 2, or 3) over time.
DISCUSSION Over the 5 years surveyed, the proportion of indebted residents was substantial and relatively consistent. Mean debt levels were high and increased 27%, a rate nearly identical to that documented by indebted medical students over the same time period.4,5 In comparison, between 1999 and 2004, the consumer price index (CPI) ranged from a low of 1.6 in 2002 to a high of 3.4 in 2000, with a yearly average of 2.5%.8 The 5.4% average annual increase in debt for both medical students9 and dermatology
Fig 2. Job dissatisfaction.
residents was significantly higher than the CPI, outpacing inflation on average by more than 2-fold. Having any debt was positively associated with pursuing a fellowship in some years and negatively associated in others, suggesting no significant impact on the decision making. Furthermore, actual debt levels did not appear to have any significant influence; between 1999 and 2004, the median debt levels of those who entered fellowships were equivalent to those who did not pursue fellowship training. Similar variation was noted when the percent of indebted dermatologists in solo practice was compared with the percent not in solo practice. Several competing factors may be at play; the anticipation of increased earning potential might have influenced some to enter solo practice, but the fear of initial start-up costs might have deterred others. Outside influences, such as insurance reimbursements, governmental regulations, and patient expectations, could influence job satisfaction levels for any given year. Surprisingly, from 1999 to 2003, residents with student debt consistently reported lower levels of job dissatisfaction than those without student debt, which may reflect a difference in job expectations. In determining job satisfaction, physicians with debt may place more emphasis on immediate reimbursements, while physicians without debt may place a higher value on non-monetary factors. In contrast with previous years, in 2004, people with student debt reported higher levels of job dissatisfaction than those without debt. Limitations of this study included self-reported data and incomplete surveys. In addition, this study did not take into account additional influences, such as a spouse’s income or the state of the economy. Future studies may be designed to examine these areas in an attempt to control for these variables. Over the years evaluated, debt levels rose steadily, and yet, statistically, debt did not appear to influence career choices of dermatology residents. However, in 2004 many of the responses received were not consistent with those of the previous 4 years
J AM ACAD DERMATOL
Brief reports 331
VOLUME 54, NUMBER 2
surveyed. Two possible factors may account for these differences. First, salaries for dermatologists were reported to increase by approximately 20% in 2004,10 an increase in income that may have influenced career choices. Alternatively, the increase in resident debt levels may have finally reached a threshold above which resident choices were affected. The latter hypothesis, if confirmed, may have profound effects on career plans of graduating residents. With no changes to relieve the burden of medical debt in a substantial way on the horizon, these trends will need to be closely monitored. REFERENCES 1. Chhabra A. Medical school tuition and the cost of medical education. JAMA 1996;275:1372-3. 2. Jolly P. Medical school tuition and young physician indebtedness. Association of American Medical Colleges, March 23, 2004: 1-25. Available at: https://services.aamc.org/Publications/ showfile.cfm?file=version21.pdf&prd_id=102&prv_id=113. Accessed December 27, 2004. 3. American Medical Student Association, December, 27, 2004: 1-6. Available at: http://www.amsa.org/meded/studentdebt. cfm. Accessed December 27, 2004.
4. Association of American Medical Colleges Medical School Graduation Questionnaire, 2001:45(36). Available at: http:// www.aamc.org/data/gq/allschoolsreports/2001.pdf. Accessed December 27, 2004. 5. Association of American Medical Colleges Medical School Graduation Questionnaire, 2004:52(38). Available at: http:// www.aamc.org/data/gq/allschoolsreports/2004.pdf. Accessed December 27, 2004. 6. Environmental Assessment, Educational Debt, April 16, 2004: 1-3. Available at: http://ea.acponline.org/systems/ED.html. Accessed December 27, 2004. 7. Nguyen JC, Jacobson CC, Rehmus W, Kimball AB. Workforce characteristics of Mohs surgery fellows. Dermatol Surg 2004; 30:136-8. 8. US Department of Labor Bureau of Labor Statistics, Consumer Price Index e All Urban Consumers, 1999-2004. Available at: http://data.bls.gov/PDQ/servlet/SurveyOutputServlet. Accessed February 24, 2005. 9. American Medical Association, Medical Student Section (MSS). Medical Student Debt. 2004. Available at: http://www. ama-assn.org/ama/pub/category/5349.html. Accessed December 27, 2004. 10. Tierney E, Kimball AB. Median dermatology base incomes in senior academia and practice are comparable but a significant income gap exists at junior levels. Presented at the Association of Professors of Dermatology meeting, Chicago, Illinois, September 2004.
Socioeconomic status influences care of patients with acne in Ontario, Canada Aamir Haider, MD, PharmD,a Muhammad Mamdani, PharmD, MA, MPH,a,b James C. Shaw, MD, FRCPC,a,c David A. Alter, MD, PhD, FRCPC,a,b,d and Neil H. Shear, MD, FRCPCa,d Toronto, Ontario, Canada
Background: Canada’s universal health care system is designed to ensure equitable access to medical care based on need rather than socioeconomic status, although a number of studies indicate a preferential access and greater use of specialist services for those patients in higher socioeconomic groups. Objectives: The primary objective of this study was to determine whether socioeconomic status influences access to specialist care by a dermatologist for the management of acne in Ontario, Canada. A secondary objective was to determine whether the urban-rural dwelling status of patients affects access to specialty care. Methods: We conducted a population-based cohort study using administrative health care databases covering more than 12 million residents of Ontario. Individuals age 12 to 27 years with a new diagnosis of acne by a general practitioner were identified as belonging to 1 of 5 socioeconomic groups based on
From the Division of Dermatology, University of Torontoa; Institute for Clinical Evaluative Sciencesb; University Health Network, Toronto Western Hospitalc; Sunnybrook and Women’s College Health Sciences Centre.d Funding sources: None. Disclosure: Dr Shear is an advisory board member and consultant for Galderma, is an advisory board member for Berlex, and is a consultant and performs clinical trials for Hoffman La Roche.
Presented at the Canadian Dermatology Association annual meeting in Victoria, BC, Canada in June 2004. Reprint requests: Aamir Haider, MD, PharmD, 135 Union St East, Waterloo, Ontario, Canada N2J 1C4. 0190-9622/$32.00 ª 2006 by the American Academy of Dermatology, Inc. doi:10.1016/j.jaad.2005.03.029