Burnout, depression, and even thoughts of suicide can start early in physicians’ careers. The seeds are often planted in medical school. A big contributor is the financial burden that many medical students take on, which gets compounded as they move into poorly paid residencies.
Over the last 30 years, tuition nearly tripled for private medical schools and quadrupled for public medical schools, increases that drastically outpace inflation. During that time, the average student debt at graduation increased from $25,000 to $166,750, while salaries for resident physicians have remained stagnant and physicians’ salaries have been declining.
As a fourth-year medical student and an advisory dean at the Perelman School of Medicine at the University of Pennsylvania, we have seen burnout and depression take root during medical school. Curious about how they might be affected by financial pressures, we surveyed medical students at US News and World Report’s top 10 ranked private and public US medical schools. The survey focused on finances and medical education.
Six of the 20 schools allowed us to survey their students; 812 of the 3,752 students surveyed responded. To look at the impact of financial pressures, we compared responses from first- and second-year students with those of third- and fourth-year students. Here are two of the key findings:
- 6 percent of first- and second-year students said they had stopped pursuing certain medical specialties based on their projected income as physicians. That increased to 43.3 percent for third- and fourth-year students.
- 6 percent of first- and second-year students said that medical school was a poor financial investment, compared to 17.5 percent of third- and fourth-year students.
Our results indicate that medical students feel more financial pressure as they advance through their medical training. Their prospects for paying off debt or making money don’t improve in residency, which is essentially a paid apprenticeship. These training positions, which are required for all medical school graduates who want to become board certified and practice clinical medicine, offer relatively meager salaries in exchange for long and highly stressful workdays.
As a result, when physicians complete these residency programs and become attending physicians, they are already burdened with a mountain of debt and years of banked financial stress. On top of this, they then must deal with a surge of regulatory and administrative stressors — more paperwork, dealing with insurer reimbursement and malpractice insurance, and maintaining certification to name a few — plus those imposed by clinical practice.
With this combination, it’s no wonder that burnout and depression are common among physicians, and the numbers are getting worse. Researchers from the Mayo Clinic and the American Medical Association surveyed doctors in 2011 and 2014. In just three years, the number of physicians reporting one or more symptoms of burnout increased by almost 20 percent and the number reporting suicidal thoughts jumped by 80 percent. Nearly 40 percent of physicians screened positive for depression.
We suggest focusing on six strategic solutions to financial stress, burnout, and depression:
Improve financial counseling programs for premedical students. Undergraduate or post-baccalaureate students need solid, accurate information before applying to medical school. This can help guide their choices, including the medical schools they apply to.
Limit tuition increases. Medical schools should consider capping tuition and increase it only with inflation.
Targeted philanthropy. Medical schools should work to make alumni and philanthropic donors more aware of the financial stress that plagues many physicians and encourage those who are concerned about this issue to earmark donations for tuition relief.
Incentive programs. Improving incentive programs for physicians who enter shortage fields like primary care can help ease financial stress. This could include expanding existing loan forgiveness programs for those who complete residency training in one of the shortage fields.
Increase federal funding. It would cost less than one-one thousandth of what the US spends on health care every year to make medical school free. Alleviating even a portion of medical school tuition would pay dividends by promoting a healthier physician workforce and letting trainees select lower-salary fields. Both of these would help address our primary care physician shortage and provide better access to health care for many patients.
Protect and expand graduate medical education funding. A proposal by the Institute of Medicine (now the National Academy of Medicine) suggests maintaining the current level of funding for residency programs and transferring up to 35 percent of that funding to a transformation fund, which would support innovative new programs. Though laudable in its intent, this could mean diverting funding from the already limited amount being used to pay residents’ salaries.
Medical schools aim to attract high-caliber students and prepare them to be capable, competent, high-quality physicians. Saddling medical students with huge amounts of debt doesn’t dovetail with that mission. One conclusion we drew from our survey is that decreasing student debt would help students be less pressured by their financial situation and less constrained when choosing a specialty, and so more able to prioritize what is most fulfilling rather than most lucrative.
Medical students are repeatedly taught to treat the cause of a symptom and not just the symptom itself. So instead of just treating burnout and depression among physicians, let’s also treat some of their root causes — debt and financial stress.
Giffin Daughtridge is a fourth-year medical student at the Perelman School of Medicine, and a candidate for a master’s degree in public administration and a Zuckerman Fellow at the Harvard Kennedy School. Neha Vapiwala, MD, is a specialist in radiation oncology and an advisory dean at the Perelman School of Medicine.
Finances are one of many factors that contribute to physician burnout. Other factors include:
1) lack of adequate coping skills (could/should be trained in school)
2) low levels of resilience (could/should be trained in school)
3) Increased mandates from government, employers, insurance companies, regulating bodies (i.e. medical boards)
4) malpractice stress (fear of making an error which actually increases the likelihood since stress reduces cognitive function)
5) Increased paperwork (22 – 40+% of physician time)
6) Income uncertainty due to gov’t mandates, increased arduous medical board certification requirements, insurance company mandates, PQRS related reductions, medical necessity reviews, clinical decisions being made by insurance companies, MIPS, HIPAA updates and increased policing, ICD10, EHR and the cost of establishing EHR, not knowing how to effectively negotiate contracts with insurers, marketplace contracts accepted without understanding reimbursements, Medicaid managed care, straight Medicaid, etc.
7) reduced autonomy
8) long work hours
9) health insurance interferes with developing long-term relationships with pts (insurance may require a change of provider)
10) inconsistent shifts
11) culture that discourages use of earned vacation time
12) stigma surrounding obtaining mental health help
13) Secondary trauma and compassion fatigue
14) lack of training about the business requirements of medicine (labor laws, contract law, etc.)
15) co-worker incivility
16) Lack of understanding of how to negotiate their own employment contract, contract clauses to have and avoid, etc.
Finances have a role in burnout but they are only one leg on a centipede. Your suggestions are good for medical school but there are many more financially related solutions they need when they enter the business of medicine.
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