According to the Association of American Medical Colleges (AAMC), 87% of graduating medical students carries outstanding loans, and the average educational debt of indebted graduates of the class of 2009 was $156,456. Of those students graduating with debt, 79% of graduates have debt of at least $100,000, and 58% of graduates have debt of at least $150,000. These numbers have taken a significant toll on medical students and the health care system itself, which has led to:
– Decreases in primary care physicians because students with high debt are less likely to pursue family practice and primary care specialties and instead seek specialties with higher income or more leisure time.
– A decrease in students from low-income/minority and those with other financial responsibilities from attending medical school. Such an effect harms physician diversity, which is necessary to address the needs of heterogeneous, multicultural patient populations.
– Residents with high debt being more likely to moonlight, and leading to more cynicism and depression among residents.
While health care reform attempted to address shortage of primary care physicians by increasing reimbursement from federal health care programs like Medicare, and also through loan incentives to go into primary care, the fact still remains that medical students are under a significant amount of financial pressure.
Taking advantage of the fact that medical residents are often vulnerable to their financial situation, a recent study published in the Journal of the American Medical Association (JAMA) examined the “Effect of Reminders of Personal Sacrifice and Suggested Rationalizations on Residents’ Self-Reported Willingness to Accept Gifts.”
In carrying out the study, the authors hoped to bring more attention “to the psychological processes that enable physicians to rationalize the acceptance of gifts.” To do so, the authors set out “to determine whether reminding resident physicians of the sacrifices made to obtain training, as well as suggesting this as a potential rationalization, increased self-stated willingness to accept gifts from industry.”
Essentially, the authors created a survey to go around asking starved, fatigued, underpaid, underappreciated, and sleepless residents how the pressure of $150,000 debt may lead them to accept a free pen or meal.
To carry out the study, the authors surveyed 301 US resident physicians about their quality of life and values. The respondents were taken from 2 sample populations: pediatric residents from the University of Pittsburgh Medical Center and family medicine residents from across the country. They were recruited between March and July 2009, and were then randomly assigned to receive 1 of 3 different online surveys:
– The sacrifice reminders survey asked questions about sacrifices made in medical training, followed by questions regarding the acceptability of receiving gifts from industry.
– The suggested rationalization survey presented the same sacrifice questions, followed by a suggested possible rationalization (based on sacrifices made in medical training) for acceptance of gifts, before the questions regarding the acceptability of gifts.
– The control survey asked about the acceptability of gifts before asking questions about sacrifices or suggesting a rationalization.
After analyzing the results, the authors found that reminding physicians of sacrifices made in obtaining their education resulted in gifts being evaluated as more acceptable: 21.7% in the control group versus 47.5% in the sacrifice reminders group. Is this really a scientific finding though?
When you remind someone of the sacrifices they make, it’s human nature to find certain things more acceptable. When soldiers come home, local establishments usually honor their service with free meals or drinks. When police officers catch a criminal, or fire and rescue save someone from dying, communities usually thank them for their service. If you reminded any of these individuals of the sacrifices they make, would it be a surprise that they found such events acceptable?
But the reality is doctors and medical residents aren’t walking around looking for free lunches and pens or pads, thinking “I deserve this.” The overwhelming majority of residents are there to practice medicine and to serve patients. They are too busy to worry about the sacrifices they have made, and so it should come as no surprise that when someone reminds them, they feel entitled for their sacrifice.
In fact, looking at the data in a different light produces a much different conclusion. If, as the study asserts, “most residents disagreed with the suggested rationalization,” this would confirm that they are in fact not thinking about the sacrifices they are making. For example, if residents were constantly thinking about the sacrifices they made to achieve their medical education, one would presume that over time they would rationalize this by thinking of reasons why they made the sacrifices (i.e. gifts, money, service, etc.). But as the study acknowledges, residents disagreed with the suggested rationalization. It was only until they were exposed to it that further increased the perceived acceptability of gifts to 60.3% in that group.
Consequently, the authors believe that the results show evidence that “physicians are going to find a way to rationalize accepting these bribes as long as they are offered and are legal.” The problem with this assertion is that for the most part, all companies have stopped offering any kind of gifts, and many states and institutions have outlawed or prohibited such gifts. So in that respect, they are really not offered or legal anymore. Another problem with this study is that residents are just beginning to pay off their debt. Physicians who have completed their residencies have paid some of their debt down and therefore, generalizing about the acceptance and rationalization of gifts from residents is problematic.
Accordingly, attempting to outlaw gifts based on some “powerful human capacity to rationalize” is farfetched. With companies disclosing all of their gifts, including free samples, and payments to physicians, transparency will let the public determine whether conflicts exist or not. In the future, our resources should be focused on how to help residents with their debt, not to waste their time reminding them about it.
You averred, “The overwhelming majority of residents are there to practice medicine and to serve patients.”
But I’m not convinced of that on its face. I’m inclined to think that a significant number of residents use patients as a means to an end over service to them. And that this likely occurs on a continuum where there is rarely an extreme of either of those behaviors.