Kevin Kuo, MD, Martin Palmeri, MD, and Jennifer Woyach, MD
Dr. Kuo is Clinical Fellow, Division of Hematology, Department of Medicine, University of Toronto
Dr. Palmeri is Fellow and Instructor, Department of Hematology/Oncology, Dartmouth-Hitchcock Medical Center
Dr. Woyach is Clinical Fellow, Hematology and Oncology, The Ohio State University
“But I’m already 34, and I feel like I have been training forever!” remarked the character in an introduction video played at this year’s ASH annual meeting trainee reception. This sentiment resonates for many trainees, as post-graduate medical education has lengthened considerably since the creation of the first U.S. residency program in 1889. Current trainees wishing to pursue an academic career feel increasing pressure to obtain additional clinical and research training beyond their hematology/oncology fellowship in the form of “fourth-year options,” additional fellowships, or advanced degrees. Trainees also face rising debts from medical education and the need to support their families, while shouldering the cost of caring for their aging parents, following in the footsteps of the “sandwich generation.” Increasing financial constraints, prolonged training, reduced grant funding, delayed retirement savings, and deferred investment opportunities can greatly affect a hematology/oncology fellow’s career choices and could potentially drive fellows out of academics.
Despite what appears to be an increasing number of trainees extending fellowship, there is a dearth of literature describing its personal, financial, and societal impact. We therefore informally calculated the economic ramifications of pursuing a career in academic hematology, using basic financial planning techniques and previously published assumptions.1 These assumptions included starting fellowship at age 30, average medical student debt of $162,500, a home mortgage of $250,000, two children with associated college savings expenses, industry-recommended retirement savings parameters, and other average expenses based on the Bureau of Labor Statistics data for a professional cohort. A similar analysis focusing on primary-care careers was recently published in Academic Medicine (reference below), which includes the rationale for the assumptions, possible limitations, and a supplemental online calculator for individualized modeling. For our model, the parameters that differed between the career cohorts were time to starting one’s career and salary.
The primary drivers for these budgetary deficits are rising medical student debt and delayed savings and investing expenses.
Besides the financial impact on trainees, prolongation of subspecialty training can have a substantial impact on patients. It is projected by the American Association of Medical Colleges that there will be a shortage of 27,000 internal medicine subspecialists by the year 2020. The American Society of Clinical Oncology estimates a shortage of 2,550 to 4,080 oncologists, including hematology/oncology specialists, by 2020. This estimation has not taken into account the potential shortage of non-malignant hematologists. If trainees choose to prolong subspecialty training, it will likely intensify the shortage.
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The decision to pursue academics is often stimulated by a drive and desire to advance the field. Additional research training helps young investigators develop their ideas and drive discovery, and opportunities for additional training are rare outside of a fellowship setting. However, the harsh financial reality that many fellows face, particularly in regard to medical education debt and declining grant opportunities, can make a career in academic hematology untenable and drive them into more lucrative career options. Prevalent prolongation in subspecialty training may also intensify an already-looming physician shortage and create an unacceptable environment for patients requiring hematology care. Addressing these issues through research and coordinated policy development is necessary to ensure the recruitment and retention of hematologists to meet society’s growing health-care needs. Expanding medical student debt forgiveness programs and assisting residents and fellows with financial planning could help to alleviate some of the financial challenges that a career in academics and extended training pose.
- Palmeri M, Pipas C, Wadsworth E, et al. Economic Impact of a Primary Care Career: A Harsh Reality for Medical Students and the Nation. Acad Med. 2010;85:1692-1697.