Educational Debt Linked to Lower Test Scores for Residents

September 06, 2011

September 6, 2011 — Physicians may pay a price for taking out hundreds of thousands of dollars in educational loans that goes beyond the monthly payments.

A study published today in the Journal of the American Medical Association (JAMA) found that internal medicine (IM) residents experienced more symptoms of burnout and scored lower on a standardized medical test if their educational debt was higher.

The study looked at scores on the Internal Medicine In-Training Examination (IM-ITE) completed by 16,394 IM residents in 2008 and 2009, along with the results of an accompanying survey. The IM-ITE is an annual multiple-choice test designed to assess a resident’s progress and identify areas of deficiency.

Of the residents who completed the test and survey, 1.5% said their quality of life was "as bad as it can be" while another 13.3% described it as "somewhat bad." Residents were more likely to give either answer as their debt level increased. Almost 19% of residents with more than $200,000 in debt answered this way, compared with almost 12% of those with no debt.

The same pattern emerged for 2 manifestations of burnout: emotional exhaustion and depersonalization, which presents itself as a calloused, cynical mindset. Nearly 46% of residents reported feeling emotionally exhausted at least once a week, while roughly 29% said that about depersonalization. Almost 52% had one symptom or the other. Again, these scores climbed in tandem with educational debt.

Moonlighting Residents No More Prone to Burnout Than Others

The combination of low quality of life, emotional exhaustion, and educational debt, in turn, were associated with lower IM-ITE scores, according to lead author Colin P. West, MD, PhD, an associate professor of biostatistics and medicine at the Mayo School of Medicine in Rochester, Minnesota, and coauthors. Residents shouldering more than $200,000 in loans scored 5 points lower than those who were debt-free.

Dr. Colin P. West

The connection between test scores, burnout, and educational debt makes sense to Michael Myers, MD, a psychiatrist who has written extensively about physician well-being.

"It’s hard to study when you’re demoralized — why bother?" said Dr. Myers, a professor of clinical psychiatry at SUNY Downstate Medical Center in Brooklyn, New York, in an interview with Medscape Medical News. "And your studying efficiency isn’t as good. Depressed physicians tell me they don’t seem to retain what they read."

One finding in the JAMA article is counterintuitive — moonlighting as a resident was not linked to burnout. Moonlighting trainees were no more prone to symptoms of burnout than anyone else, and only 9.9% of them reported a low quality of life.

Dr. Michael Myers

The authors also discovered that international medical graduates were less likely to report high levels of burnout regardless of debt than their domestic counterparts.

"One possible explanation is that internal medical graduates...are more resilient and less prone to burnout owing to their successful navigation through the complex and highly competitive selection process for US residency positions as foreign graduates," write Dr. West and coauthors.

The authors acknowledge that their study did not take into account many demographic variables, such as race, socioeconomic status, or marital status, that may be associated with well-being, debt, or medical knowledge. They also caution that the study does not permit them to determine causation, "so the observed relationships between [quality of life], symptoms of burnout, debt, and medical knowledge are best interpreted as associations."

JAMA. 2011;306:952-960. Abstract

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