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| Journal of the New Zealand Medical Association,
17-February-2006, Vol 119 No 1229
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Student debt amongst junior doctors in New Zealand;
part 2: effects on intentions and workforce
James Moore, Jesse Gale, Kevin Dew, Don Simmers
New Zealand faces worsening problems in its medical
workforce. A recent forecast of population ageing indicated that the number and
type of medical services currently delivered will be insufficient by 2011.1 Of
particular concern is the general practitioner (GP) workforce, which is ageing
and declined by 8% between 2000–2002.2 Other areas of concern include
psychiatry, pathology, general medicine;3 and the medical workforce in rural and
provincial areas, where even mainstream specialties struggle with recruitment.4
New Zealand has the highest proportion of overseas-trained
doctors in the OECD;5 they comprise more than one-third of the active workforce
in 2002,6 and 50% of GPs in rural areas.2 While overseas-trained doctors are
currently vital in our medical workforce, it can be argued that developed
nations such as New Zealand have a moral obligation to train their own doctors,
in order to reduce the emigration of doctors from poorer countries (which have
greater need for those doctors) into New Zealand. It also seems reasonable to
assume that doctors trained in New Zealand would be better prepared to practice
in the unique cultural environment of this country.
New Zealand medical school graduates remain the major source
of doctors in New Zealand. New Zealand medical schools graduate approximately
285 New Zealand citizen/resident doctors each year (to increase to 320 in 2008).
However, the last 15 years has seen the introduction of high tuition fees
(currently approximately NZ$60,000 for an MB ChB) as central funding has not
kept pace with increasing costs of delivery. These fees have resulted in large
personal debts for graduates—our companion paper in this issue of the NZMJ
entitled Student debt amongst junior doctors
in New Zealand; part 1: quantity, distribution, and psychosocial impact
lists the average graduating debt as $65,206. It is important to understand how
these large financial costs impact upon the decisions of graduates and the
medical workforce.
In 2001, a survey of New Zealand medical students found that
82% intended to leave New Zealand shortly after graduation, with 40% citing
student debt as a factor in their decision.7,8 Moreover, the level of debt
correlated positively with students’ intentions to emigrate. Only 16% of
respondents placed general practice as their most preferred speciality. There
was a trend toward respondents with larger debts excluding general practice as a
career. Specifically, these respondents had a mean debt $7,137 greater than
those who were considering general practice.
Indeed, a survey of Auckland medical students in 2001 found
that 25.8% expected to practice mainly or only overseas and that only 13.8% of
students expressed an interest in general practice as a career, compared to 77%
for hospital practice.9 That survey also found that those students with higher
debts were more likely to indicate an intention to emigrate after
graduation.
A survey of medical students in Canada in 2002 suggested
that increasing levels of student debt resulted in more students taking finance
into consideration when choosing their specialty and practice location.10
Research among Resident doctors in the United States in 2001 also showed a
relationship between speciality choice and level of debt, with those in surgical
residencies having significantly greater total debt than those in primary care
residencies.11
Thus there is evidence that student debt affects the medical
workforce, but the only New Zealand data are of medical students’
intentions. For the first time, this study aimed to measure the effect of debt
on New Zealand junior doctors’ career intentions.
MethodsThe survey was based on the same questions as the 2001
Wellbeing, Intentions, Debt and Intentions (WIDE) questionnaire,7,8 and was
delivered to every first-year doctor registered with the Medical Council of New
Zealand at the end of 2004. The survey covered a range of topics including
respondent demographics, level of debt, psychosocial and financial impact of
debt, and the impact of debt on career intentions. The design, delivery, and
analysis of this questionnaire survey are described in the companion paper (part
1).
The present study used Likert scales of agreement
(1=strongly disagree, 5=strongly agree), and both open and closed questions to
explore respondents’ career intentions regarding country of practice,
intended speciality choice, and likelihood of working in rural areas.
Associations between student debt and ordinal Likert scale responses were
measured using Spearman’s rank correlation coefficients. Some respondents
did not answer specific questions, therefore percentages may not add to 100%.
Total debt refers to the total debt at graduation from all sources (excluding
mortgage debt).
ResultsA total of 158 out of 296 questionnaire recipients responded
(53%). Their demographic characteristics are described in the previous
paper.
Location of
practice—Eighty percent of respondents indicated that they intended
to spend the bulk of their careers in New Zealand. The intention to emigrate
away from New Zealand was not associated with the total debt of respondents
(ANOVA; p=0.5), with a large group of undecided respondents (11%) owing the
most. . Sixty-five percent of respondents indicated that they intended to go
overseas within 3 years of graduating. Only 3.8% intended to never leave New
Zealand to practice, and 22.2% remained undecided.
Table 1 shows how respondents rated the importance of
various factors on their decision whether to leave New Zealand, using a Likert
scale of 1–5.
The importance of debt and financial opportunities in
influencing the decision to go overseas were correlated with respondents’
total debt (Level of debt r=0.538, p<0.001; Financial opportunities r=0.352,
p<0.001). That is, doctors with higher debt were more likely to consider
these factors as important in deciding whether to leave New Zealand.
Table 1. Importance of factors
influencing decision whether to leave New Zealand (NZ), correlated to total
debt
*Correlation to total debt
significant at 0.05 level; **Correlation to total debt significant at 0.01
level.
In response to a yes/no question, 55% of respondents (mean
total debt $79,904) stated that they had considered leaving New Zealand
specifically because of their student loan debt, and their debt was
significantly higher than those who had not considered leaving New Zealand (mean
total debt $59,771; p<0.001).
Career
intentions—In response to a yes/no question, 43% of respondents
with a student loan stated that their student debt had influenced their intended
specialty, and these respondents had a significantly higher total debt ($65,281
compared to $57,120; p=0.03).
Table 2 shows the intended specialty intentions of
respondents alongside the proportion of the New Zealand workforce in 2002 (from
Medical Council of New Zealand), and the first-choice responses from the 2001
WIDE survey of Christchurch medical students.7
Table 3
shows how respondents rated the importance of various factors on their career
intentions. The importance of debt, and financial opportunities in determining
career intentions was correlated with respondents’ total debts (level of
debt r=0.304; p<0.001; Financial opportunities r=0.189; p=0.02). That is,
respondents owing more found debt and financial considerations had a larger
influence over their choice of specialty. However, level of debt was not a
strong influence over specialty choice for most respondents, as indicated by the
median rating. The strongest influences over speciality choice were
interest,
lifestyle,
family,
and
intellectual
challenge,
respectively.
*Correlation to total debt
significant at 0.05 level; **Correlation to total debt significant at 0.01
level.
Table 4 shows how respondents rated potential incentives for
them to stay in New Zealand. Respondents considered increased salaries, employer
repayments towards student loans, training opportunities in New Zealand, and
shorter working hours as the most important incentives to staying in New
Zealand. Again, those with higher debts were more likely to find increased
salaries and employer contributions towards student loans as important
incentives.
‡Bonded training
would be a scholarship towards fees etc in exchange for a guarantee of work for
a set number of years in a particular hospital after graduation; *Correlation
with total debt significant at 0.05 level; **Correlation with total debt
significant at 0.01 level.
 Rural
intentions—As illustrated in Figure 1, the majority of respondents
stated that they definitely would not, or were unlikely to practice in rural New
Zealand during their career. Total debt was not associated with the intention to
practice in rural New Zealand (ANOVA p=0.3).
DiscussionThese results demonstrate that student debt had a strong
influence over the decisions of the first-year house officers (PGY1s) in New
Zealand. These influences are likely to affect the medical workforce, as the
majority considered emigration due to their debt, and a substantial number
claimed debt affected their specialty choice. These findings have implications
for medical workforce development, and the tertiary education sector.
It is notable that only 9% of applicants indicated that
general practice was their preferred specialty, when considering GPs currently
make up over 40% of the medical workforce in New Zealand. With primary care as a
central focus in current government health policy, and the GP workforce already
declining, this result is potentially alarming. It was also notable that
psychiatry and public health were the only areas besides general practice in
which a smaller proportion of respondents intended to work than currently do so
amongst the New Zealand medical workforce.
Twenty percent of respondents did not intend to practice in
New Zealand for the majority of their career. Between 1998 and 2002, the
percentage of medical graduates remaining practicing in the New Zealand medical
workforce after 3 years has ranged from 69 to 78%.12 The comparable figure from
the present study (35% intending to remain in New Zealand beyond their third
year) would represent a large increase in emigration. Historically, doctors have
emigrated to gain experience and specialist training, but the present results
indicate that debt is now a factor in this decision, particularly for those with
the bigger debts. In constrast, debt as a driver of medical emigration did not
exist 20 years ago.
This new motive for doctors to leave New Zealand may
represent a change in professional motivation. Indeed, the sense of obligation
felt by many past graduates may have been undermined by personal debts, and a
focus on repayment. While doctors have tended to return from travel in the past,
those who travel to repay (or escape) debts of $100,000 may not.13
Forty-three percent of respondents with student loans stated
that their student loan debt had influenced their choice of specialty. This
indicates that student debt may have long-term consequences for the structure of
the medical workforce—this is an unintended and potentially detrimental
consequence of the student loan scheme.
Intentions do not always equate to actions. However these
doctors were surveyed at a time in their careers when they were beginning to
make choices about their future specialties. A regular intentions survey of
junior doctors in PGY1 and 2 would be a useful tool for monitoring trends in
career intentions.
This paper describes associations between emigration from
New Zealand, altered patterns of speciality choice, and student debt. This
illustrates the unintended, yet potentially serious effect that student debt may
be having on the public health system in New Zealand.
Author information:
James Moore, Trainee Intern, Wellington School of Medicine, University of Otago,
Wellington; Jesse Gale, House Officer, Nelson Hospital, Nelson; Kevin Dew,
Senior Lecturer, Department of Public Health, Wellington School of Medicine
& Health Sciences, University of Otago, Wellington; Don Simmers, Chairman,
Medical Workforce Subcommittee, NZMA, Wellington
Acknowledgements:
Data collection was funded by the New Zealand Medical Association (NZMA), New
Zealand Medical Students Association (NZMSA), and New Zealand University
Students Association (NZUSA). Analyses were performed under a summer studentship
funded by the New Zealand Medical Association, and Medical Assurance Society
provided the incentive prize for respondents.
The authors also acknowledge the contributions of Fleur
Fitzsimons, Kane O’Connell, Camilla Belich, and Andrew Kirton of New
Zealand University Students’ Association; Don Simmers, Cameron McIver,
Richard Pole, and Raewyn Whitehead of New Zealand Medical Association; Jess
Allen of New Zealand Medical Students’ Association; and Tony Blakely,
David Abernethy, and Mary Newman of Wellington School of Medicine, University of
Otago.
Correspondence:
James Moore, Trainee Intern, Wellington School of Medicine, University of Otago,
PO Box 7343, Wellington South. Email: mooja074@student.otago.ac.nz
References
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