Who Bears the Burden? Understanding the Socioeconomic Patterns of Educational Debt in Orthopaedic Surgery Residency Candidates.

BACKGROUND: Educational debt is commonly observed among applicants to orthopaedic surgery residency programs; however, an understanding of the debt burden among minority and nonminority applicants is not well established. Thus, this study aimed to fill these knowledge gaps by examining the extent of and factors shaping educational debt among orthopaedic surgery applicants. QUESTIONS/PURPOSES: (1) What is the educational debt burden among orthopaedic surgery residency applicants? (2) After controlling for relevant confounding variables, what factors are independently associated with increasing levels of educational debt? (3) After controlling for relevant confounding variables, are individuals classified as an underrepresented minority or those with educational debt and socioeconomic disadvantage less likely to match in orthopaedic surgery? METHODS: A retrospective evaluation of orthopaedic surgery residency application data from the American Association of Medical Colleges was analyzed from 2011 to 2021. The American Association of Medical Colleges database was selected because every residency applicant must register and apply through the American Association of Medical Colleges. Therefore, these data exist for every residency applicant, and the sample was comprehensive. Self-reported data including premedical, medical, and total educational debt burden as well as classification as socioeconomically disadvantaged and application fee waiver use were collected. Applicants were dichotomously categorized as an underrepresented minority or a not underrepresented minority based upon self-identified race and ethnicity. Monetary values were reported in USD and inflation-adjusted to 2021 using the Consumer Price Index. We performed t-tests and chi-square tests for continuous and categorical variables, respectively. Significance was considered at p < 0.05. In all, 12,112 applicants were available in the initial cohort, and 67% (8170 of 12,112) of applicants with complete data were included from 2011 to 2021 in the final study cohort. Of these, 18% (1510 of 8170) were women, 14% (1114 of 8170) were classified as underrepresented minorities, and 8% (643 of 8170) were classified as socioeconomically disadvantaged. Sixty-one percent (4969 of 8170) of applicants reported receiving at least one scholarship, 34% (2746 of 8170) had premedical school debt, and 72% (5909 of 8170) had any educational debt including medical school. Among all applicants, the median (IQR) educational debt was USD 197,000 (25,000 to 288,000). Among those with scholarships, the median amount was USD 25,000 (9000 to 86,000). RESULTS: After controlling for the potentially confounding variables of gender and socioeconomic disadvantage, classification as an underrepresented minority applicant was independently associated with higher scholarship amounts than applicants characterized as not underrepresented minorities (ß = USD 20,908 [95% confidence interval (CI) 15,395 to 26,422]; p < 0.001), whereas underrepresented minority classification was not independently associated with a difference in total educational debt (ß = USD 3719 [95% CI -6458 to 13,895]; p = 0.47). After controlling for the potentially confounding variables of gender and classification as an underrepresented minority, socioeconomic disadvantage was independently associated with higher scholarship amounts (ß = USD 20,341 [95% CI 13,300 to 27,382]; p < 0.001) and higher total educational debt (ß = USD 66,162 [95% CI 53,318 to 79,006]; p < 0.001) than applicants not classified as socioeconomically disadvantaged. After controlling for the potentially confounding variables of gender and classification as an underrepresented minority, socioeconomic disadvantage was independently associated with decreased match rates (OR 0.62 [95% CI 0.52 to 0.74]; p < 0.001). CONCLUSION: These findings underscore the need for comprehensive scholarship initiatives to ensure equitable financial accessibility for applicants from all backgrounds. CLINICAL RELEVANCE: In the future, orthopaedic surgery may benefit from research comparing the effectiveness of various initiatives aiming to improve fairness in the burden of debt among applicants to orthopaedic surgery residency programs.

Student Loans and Psychological Distress: A Cross-sectional Study of Young Adults in Japan.

BACKGROUND: Levels of student loan debt have been increasing, but very little research has assessed if this is associated with poor health. The aim was to examine the association between student loans and psychological distress in Japan. METHODS: We conducted a cross-sectional web-based self-administered questionnaire survey in 2017. The sample comprised of 4,149 respondents aged 20-34, with 3,170 graduates and 979 current university students. The independent variables were whether or not current students had student loans, and for graduates, the total amount of their student loan debt. The dependent variable was severe psychological distress assessed using the Kessler Psychological Distress Scale (K6; the cut-off point was 12/13). Covariates were demographic and parents' socioeconomic variables. A Poisson regression analysis with a robust error variance was conducted to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs). Because there was a significant interaction between current student status and the status of borrowing student loans, stratified analyses were conducted. RESULTS: The percentage of those with student loans was 33.8% among graduates and 35.2% among current university students. Among graduates, student loan debt was significantly associated with a high possibility of having severe psychological distress after adjusting for covariates (PR of ≥4 million yen, 1.44; 95% CI, 1.02-2.03). Among current university students, there was no significant association (PR of borrowing student loans, 0.91; 95% CI, 0.60-1.37). CONCLUSIONS: There was a significant association between student loan debt and psychological distress among graduates but not current university students.

Will the return of financial support for students improve nurse recruitment?

Emeritus Professor Alan Glasper, from the University of Southampton, discusses a government initiative to increase the number of nurses in the NHS through the reintroduction of student funding.

Academic Anesthesiology Career Development: A Mixed-Methods Evaluation of the Role of Foundation for Anesthesiology Education and Research Funding.

BACKGROUND: In 1986, the American Society of Anesthesiologists created the Foundation for Anesthesiology Education and Research (FAER) to fund young anesthesiology investigators toward the goal of helping launch their academic careers. Determining the impact of the FAER grant program has been of importance. METHODS: This mixed-methods study included quantitative data collection through a Research Electronic Data Capture survey and curriculum vitae (CV) submission and qualitative interviews. CVs were abstracted for education history, faculty appointment(s), first and last author peer-reviewed publications, grant funding, and leadership positions. Survey nonrespondents were sent up to 3 reminders. Interview questions elicited details about the experience of submitting a FAER grant. Quantitative data were summarized descriptively, and qualitative data were analyzed with NVivo. RESULTS: Of 830 eligible participants, 38.3% (N = 318) completed surveys, 170 submitted CVs, and 21 participated in interviews. Roughly 85% held an academic appointment. Funded applicants were more likely than unfunded applicants to apply for National Institutes of Health funding (60% vs 35%, respectively; P < .01), but the probability of successfully receiving an National Institutes of Health grant did not differ (83% vs 85%, respectively; P = .82). The peer-reviewed publication rate (publications per year since attending medical school) did not differ between funded and unfunded applicants, with an estimated difference in means (95% confidence interval) of 1.3 (-0.3 to 2.9) publications per year. The primary FAER grant mentor for over one-third of interview participants was a nonanesthesiologist. Interview participants commonly discussed the value of having multiple mentors. Key mentor attributes mentioned were availability, guidance, reputation, and history of success. CONCLUSIONS: This cross-sectional data demonstrated career success in publications, grants, and leadership positions for faculty who apply for a FAER grant. A FAER grant application may be a marker for an anesthesiologist who is interested in pursuing a physician-scientist career.

Popping the medical education bubble before it forms: It's about dollars and sense.

Headlines have previously acknowledged the risk of a "bubble and crash" phenomenon in the physician workforce pipeline. A growing number of medical career dissatisfiers, including emotional and physical burnout, loss of autonomy and burdensome regulations, compound the longstanding fundamental issue of the prohibitive direct and opportunity costs associated with medical training. For U.S. medical education and, in turn, healthcare to remain robust and high-quality, creative solutions are needed to address the untenable physician debt-to-income ratios and to ensure not only that the quantity and quality of medical school aspirants remains favorable to the profession, but that the profession remains responsible to its future members. Creating fiscally healthy physicians is a societal imperative.

Training the next generation of Canadian Clinician-Scientists: charting a path to success.

Clinician-scientists are physicians with training in both clinical medicine and research that enables them to occupy a unique niche as specialists in basic and translational biomedical research. While there is widespread acknowledgement of the importance of clinician-scientists in today's landscape of evidence-based medical practice, training of clinician-scientists in Canada has been on the decline, with fewer opportunities to obtain funding. With the increasing length of training and lower financial compensation, fewer medical graduates are choosing to pursue such a career. MD-PhD programs, in which trainees receive both medical and research training, have the potential to be an important tool in training the next generation of clinician-scientists; however, MD-PhD trainees in Canada face barriers that include an increase in medical school tuition and a decrease in the amount of financial support. We examined the available data on MD-PhD training in Canada and identified a lack of oversight, a lack of funding and poor mentorship as barriers experienced by MD-PhD trainees. Specific recommendations are provided to begin the process of addressing these challenges, starting with the establishment of an overseeing national body that would track long-term outcome data for MD-PhD trainees. This national body could then function to implement best practices from individual programs across the country and to provide further mentorship and support for early-career physician-scientists. MD-PhD programs have the potential to address Canada's growing shortage of clinician-scientists, and strengthening MD-PhD programs will help to effect positive change.

What will it take? Pathways, time and funding: Australian medical students' perspective on clinician-scientist training.

BACKGROUND: Clinician-scientists are in decline worldwide. They represent a unique niche in medicine by bridging the gap between scientific discovery and patient care. A national, integrated approach to training clinician-scientists, typically programs that comprise a comprehensive MD-PhD pathway, are customary. Such a pathway is lacking in Australia. The objective was to gather perceptions from Australian medical students on factors they perceive would influence their decision to pursue clinician-scientist training. METHODS: A cross-sectional mixed methods design used quantitative and qualitative questions in an online self-report survey with medical students from a four-year MD program. Quantitative measures comprised scaled response questions regarding prior experience and current involvement in research, and short- and long-term opinions about factors that influence their decisions to undertake a research higher degree (RHD) during medical school. Qualitative questions gathered broader perceptions of what a career pathway as a clinician-scientist would include and what factors are most conducive to a medical student's commitment to MD-PhD training. RESULTS: Respondents (N = 418; 51% female) indicated Time, Funding and Pathway as the major themes arising from the qualitative data, highlighting negative perceptions rather than possible benefits to RHD training. The lack of an evident Pathway was inter-related to Time and Funding. Themes were supported by the quantitative data. Sixty percent of students have previous research experience of varying forms, and 90% report a current interest, mainly to improve their career prospects. CONCLUSIONS: The data emphasise the need for an MD-PhD pathway in Australia. A model that provides an early, integrated, and exclusive approach to research training pathways across all stages of medical education is suggested as the best way to rejuvenate the clinician-scientist. A national pathway that addresses factors influencing career decision making throughout the medical education continuum should include an appropriate funding structure, and provide early and continuing advice and mentoring. It should be flexible, gender equitable, and include post-graduate training. The implications of implementing MD-PhD programs represent a substantial investment. However this should not be a deterrent to Australia's commitment to an MD-PhD pathway, but rather a challenge to help ensure our future healthcare is guided by highly trained and competent clinician-scientists.

A Fulbright Specialist in Poland.

One of the greatest rewards in cancer education is working with colleagues from around the world. This manuscript reports on the development and conduct of a cancer research training program in Wroclaw, Poland, supported by the Fulbright Commission. The precipitating need for this program was the desire and lack of opportunity for medical trainees to develop skills necessary to conduct cancer education research. A 2-week program was developed consisting of didactic, Socratic, and individual/group consultations. Support from the Fulbright Commission was essential to the success of this program. Information will be presented in this paper on the completion of the funding application as well as lessons learned in the development and implementation of this program.

Child Care and Development Fund (CCDF) Program. Final rule.

This final rule makes regulatory changes to the Child Care and Development Fund (CCDF) based on the Child Care and Development Block Grant Act of 2014. These changes strengthen requirements to protect the health and safety of children in child care; help parents make informed consumer choices and access information to support child development; provide equal access to stable, high-quality child care for low-income children; and enhance the quality of child care and the early childhood workforce.

Improving Primary Care Retention in Medically Underserved Areas: What's a Clinic to Do?

To reduce health professional shortage areas, the National Health Service Corps has attempted to increase the number of primary care providers in underserved communities through scholarships and loan repayment. Program evaluations assessed Loan Repayment Program (LRP) propensity to work in underserved communities. The National Health Service Corps LRPs were asked about preferences for particular retention strategies and which strategies were utilized by their clinical sites. Loan Repayment Programs were asked to rank retention strategies. Loan Repayment Program top choices were competitive salary, 88%; professional development, 70%; knowledgeable/competent support staff, 59%, and professional support, 58%. Loan Repayment Programs were also asked to rank retention strategies provided by their clinical sites: professional development, 74.2%; competitive salary, 71.2%; policies that prohibit abusive behavior, 63.6%, and knowledgeable/competent support staff, 60.6%. Loan Repayment Programs indicated professional support was an important retention element. However, when asked if professional support opportunities were offered, LRP indicated that these were not in the strategies offered by sites.

Funding nurse education in a climate of austerity.

Emeritus Professor Alan Glasper, from the University of Southampton, discusses the Government's plan to increase health professional student numbers, which is also linked to the abolition of student nurse bursaries.

Scholarly productivity and national institutes of health funding of foundation for anesthesia education and research grant recipients: insights from a bibliometric analysis.

BACKGROUND: The Foundation for Anesthesia Education and Research (FAER) grant program provides fellows and junior faculty members with grant support to stimulate their careers. The authors conducted a bibliometric analysis of recipients of FAER grants since 1987. METHODS: Recipients were identified in the FAER alumni database. Each recipient's affiliation was identified using an Internet search (keyword "anesthesiology"). The duration of activity, publications, publication rate, citations, citation rate, h-index, and National Institutes of Health (NIH) funding for each recipient were obtained using the Scopus (Elsevier, USA) and NIH Research Portfolio Online Reporting Tools (National Institutes of Health, USA) databases. RESULTS: Three hundred ninety-seven individuals who received 430 FAER grants were analyzed, 79.1% of whom currently hold full-time academic appointments. Recipients published 19,647 papers with 548,563 citations and received 391 NIH grants totaling $448.44 million. Publications, citations, h-index, the number of NIH grants, and amount of support were dependent on academic rank and years of activity (P < 0.0001). Recipients who acquired NIH grants (40.3%) had greater scholarly output than those who did not. Recipients with more publications were also more likely to secure NIH grants. Women had fewer publications and lower h-index than men, but there were no gender-based differences in NIH funding. Scholarly output was similar in recipients with MD and PhD degrees versus those with MD degrees alone, but recipients with MD and PhD degrees were more likely to receive NIH funding than those with MDs alone. CONCLUSION: Most FAER alumni remain in academic anesthesiology and have established a consistent record of scholarly output that appears to exceed reported productivity for average faculty members identified in previous studies.