The Business of Medicine: A Course to Address the Deficit in Financial Knowledge of Fourth-Year Medical Students

Despite a documented need for physician education on financial principles, traditional medical education rarely provides students or residents with formal educational opportunities to improve their financial literacy and gain competence to manage personal or business finances.(1-12) As a result, medical student financial literacy is low,(13) financial changes occurring in U.S. healthcare often are poorly understood by trainees, and many believe these factors have led to insufficient physician engagement in healthcare reform, inefficient financial practices in medical business, and decreased reimbursement.(14-16) Furthermore, the average debt incurred to finance medical education is climbing, now on the order of approximately $190,000 per student.(17) This debt and lack of preparedness for future financial challenges have been associated with increased trainee stress and burnout, negative effects on wellness, and possibly even students’ choice of medical specialty.(18,19) Low financial literacy and limited educational offerings on financial topics are not isolated to medical education, however.(20) Other health professions, including veterinary programs, pharmacy programs, and a range of graduate medical education programs also report similar curricular deficits and low rates of financial literacy among their students.(3,21-23)

Efforts to address these deficiencies may explain, in part, why there has been an increasing trend of students and physicians electing to pursue degrees such as an MD/MBA or Executive MBA.(24-26) Several studies describe the competitive advantages for those who earn dual MD/MBA degrees, including as higher starting salaries, better job satisfaction, and leadership and career advancement opportunities.(10,26,27) Downsides to pursuing additional degrees also have been reported, including additional costs and time as a student (usually about one to two years), as well as lack of integration between business schools and medical schools.(28) A handful of medical schools and residency programs have pursued alternative approaches to address these deficits by offering business or personal finance programs, either as an elective or, less often, as an integrated part of the standard curriculum.(6,29-42)

In response to these profound deficits in healthcare and finance education and the associated detrimental effects on wellness, we designed a business of medicine course to address the needs of medical students at the University of Arkansas for Medical Sciences (UAMS). The course was modeled after a business of medicine course for surgery residents that had been implemented at the same school.(6) We hypothesized that completion of the course would improve students’ knowledge of personal and business financial topics and enable them to make sound financial decisions.

Methods

Course Design and Overview

During each spring from 2015 to 2018, an elective 20-hour Business of Medicine (BoM) course for M4 medical students (n=66, n=93, n=125, n=127, respectively) lasting for 10 weeks was held at UAMS. The host institution is a mid-size, public medical school and the only academic health center in the state, with approximately 160 fourth-year medical students per class. UAMS offers no MD/MBA programs.

The BoM curriculum was designed and is led each year by the same course director (JM), a faculty member in the Department of Surgery. The course is advertised in the M4 student course catalog, as with other courses, but interest also is generated by word of mouth. Students who enroll receive 2 credit hours toward the 33 total required to graduate, and they are required to attend no less than 80% of the lectures. Students who desired to take the course but were unable to attend the required number of lectures (e.g., due to away rotations) were required to watch video recordings of the missed lectures and write a summary of the content presented to receive credit. The spouses and partners of medical students also were encouraged to attend the course. Additionally, all resident and fellow physicians from the College of Medicine were invited to attend on their own volition if any topics were of interest to them.

Topics for the curriculum were chosen from those considered to be critical to development of a well-rounded student, inadequately taught in student education, or of special interest to our students as assessed by baseline interest survey items. Content was delivered by physician and lay experts from both public and private sectors, all of whom were invited by the course director (Table 1). Other than a single visiting keynote speaker each year, no speakers were given financial compensation for their presentations. Presenters used a variety of teaching methods, including interactive discussions and lectures, panel discussions, keynote-style presentations by invited guest speakers, and small group discussions. The annual costs of running the course are approximately $3500 for supplies, audiovisual fees, room charges, and keynote speaker fees. More recently, the course director has received dedicated time/salary support at .15 FTE. All of these costs have been provided by the College of Medicine.

Before the course was implemented, institutional review board approval was obtained to allow for survey completion and course evaluation activities. At the beginning of the course, students completed a 45-item survey via Survey Monkey with response options that included Likert-type scales (ranging from 1–Strongly Disagree to 5–Definitely Agree), short answer, and yes/no responses. Survey items assessed their interest and knowledge of personal and business financial topics, baseline financial status, confidence in managing their finances, and anticipated career plans. After finishing the course, students completed a similar post-survey, which included items to obtain feedback on speakers and course content, as well as open-ended items to assess students’ greatest financial concerns and the most important lessons learned in the course. Beginning in 2018, an item also was added to assess whether students had made or planned to make any personal financial changes.

Analyses

Descriptive statistics were computed to generate mean item responses for continuously scaled items and frequencies and percentages for categorically scaled items. Because the pre- and post-test surveys were anonymous and, therefore, not completed in a way to allow for pairing, independent groups nonparametric Mann Whitney U-tests were computed to compare the Likert-type scaled pre- and post-test responses. All statistical analyses were completed using SPSS 25.0. Content analysis of open-ended survey comments for two items (greatest financial concerns and financial changes made by students) was performed using hand-coding and search word features in Excel to group responses into common categories. The categories were reached via consensus by two coauthors. To ensure consistency and accuracy, the coding of students’ comments was performed first by one author (CT) and again by a second author (JM).

Results

Course enrollment has grown each year, increasing from 43% of M4 students in the initial year to 77% of M4 students in 2018 (n=66/153, n=93/156, n=125/172, and n=127/164, respectively). All students who enrolled in the course completed the course. All course participants completed the pre-course survey each year, and 66% (n=274/412) completed post-course surveys (n=66, n=47, n=81, n=80, respectively). About one quarter of the students (27%, n=111) reported they had previously taken at least one college-level finance course.

With regard to debt, 88% (n=361) of course participants reported carrying debt related to medical school:

• $125,000 to $200,000—41%;

• $200,001 to $300,000—36%;

• $300,001 to $400,000—2.5%; and

• More than $400,000—1.6%.

Thirty-five percent of students reported having non–education-related debt:

• $0 to $5,000—42%;

• $5,001 to $10,000—16%;

• $10,001 to $20,000—22%;

• $20,001 to $40,000—9%;

• $40,001 to $60,000—2%; and

• More than $60,000—9%.

Tables 2 and 3 present results comparing pre- and post-course survey responses. Initial low mean scores were observed for the items “Currently feel competent to manage current personal finances” (3.07) and “Currently feel competent to manage future personal finances” (2.42); both of these increased significantly after the course, to 3.95 and 3.65, respectively (p < .001). The mean score for the question “Anticipate having significant amount of debt for the rest of my life” decreased from 1.91 to 1.71, indicating they agree less with this statement at post-test. Students strongly felt the “Business aspects of medicine should be taught throughout medical school” (4.20), and this further increased significantly after taking the course (4.46). This point also was reflected in the high pre- and post-course mean values on the question “I cannot reach my full potential as a physician without an understanding of the business aspects of medicine” (4.36 and 4.50, respectively.)

Table 3 summarizes of students’ responses to the interest and knowledge survey items. Baseline interest in each topic for the course started very high and increased further in 7 out of 16 topics. The only item for which interest decreased significantly was How to effectively negotiate future contract. Two items showed statistically higher interest at the post-course assessment: Investment strategies, types, and general risks associated with each and Strategies to effectively balance monthly expenses with potential future salary. Baseline knowledge at the beginning of the course was very low, but significantly increased in each topic area assessed (p < .001). Areas that showed the most improvement included topics related to financial principles needed to start a medical practice, metrics used to determine efficiency of a practice, effective negotiation of a future contract, and deferred compensation and retirement planning. In response to Knowledge I gained in this course will be helpful for me, 22.5% of students rated this as “agreed,” and 76.4% of students rated this as “definitely agree.”

Table 4 provides a summary of students’ open-ended responses about the most important lessons learned during the course, with the two most common being “Loan repayment strategies” and “Personal finance/budgeting.” Exemplar statements for each category of the students’ responses also are provided in Table 4. Additionally, student comments to provide feedback about the course indicate increased confidence and less anxiety, as expressed by statements such as “I feel much more confident to manage my finances after this course,” “I feel much more prepared to handle my future finances,” “I feel better equipped to know what resources are available to help me,” and “I was able to take knowledge learned from multiple lectures and immediately apply them to real life situations.”

With regard to specific behavioral changes, 95% of students who responded to the post-test survey in 2018 (n=76) stated they had made some type of change. Forty-six percent of students indicated they had created a budget, 20% started a retirement plan, 18% changed their spending habits, 8% changed their social media practices, 5% had met with a financial planner, 3% created a will or trust, and 1% opened a savings account. Data currently are being collected to assess more long-term behavioral changes by previous course graduates.

Discussion

Survey results support the initial hypothesis that completion of the BoM course would improve students’ knowledge of personal and business financial topics and lead to sound financial decisions. The results also revealed several thought-provoking findings. First, we confirmed that student loan debt burden for our students is substantial, but in line with national averages. Because debt may cause stress and significantly influence students’ career choices,(19) this finding highlights the need for vigilance in helping students manage debt. Our students also had great interest in personal and medical financial matters, but very little knowledge initially regarding these concepts. This finding is consistent with results from a recent national study of medical students that found only 3% considered themselves very knowledgeable about personal financial issues.(13) A mere 5% in that study reported being “very knowledgeable” about effective ways to manage debt and loan repayment options.

The Business of Medicine course is now the highest-attended elective on campus.

In light of the significant transitions that occur financially between medical school and residency and thereafter, it was not surprising to discover students had decreased levels of confidence regarding effectively managing their future finances. However, it also was concerning how little confidence students had to handle their current personal finances. Students unfortunately rarely receive education on finance topics during medical school to gain knowledge and confidence to address these deficits.(43,44)

The BoM course has, therefore, been highly rewarding from the perspective of the course director, who regularly hears anecdotal comments from students regarding the steps they have taken to improve their financial situations, ranging from starting retirement plans to creating budgets and estate planning. The course is now the highest-attended elective on campus.

The overarching finding of this study indicates that a 20-hour BoM course can have a significant impact on student knowledge and understanding, leading to behavioral changes to improve their financial situation. Programs such as this may provide a viable, low-cost, time-efficient approach to help students address their knowledge deficit, as opposed to the extra time and cost incurred to pursue an MBA or other forms of outside financial education.

Several changes have been made to the course based on student feedback over its first four years. For example, initially the course contained approximately 50% business content and 50% personal finance content. However, as a result of students’ requesting more topics related to personal finance, there has been a gradual shift toward including more personal finance content, so that now the course is approximately divided into 40% business and 60% personal finance. Topics that initially were included but proved to be of little interest and subsequently have been replaced were Medicare/Medicaid basics, Setting up Your Practice, HIPAA, Use of Midlevel Providers, How Hospitals Get Paid, and Retirement Portfolio Theory. Topics that have been added or expanded include Insurance 101, Life and Disability Insurance, Budgeting, and Debt Reduction. We hope that other schools may be inspired to implement programs such as this, and we think the core topics in our BoM course would be applicable and add value to the medical school curriculum. As with any educational innovation, however, formal needs assessment data may help schools in tailoring their curriculum to their own student populations. We will gladly provide access to the survey tool used in this study and suggest that assessing the interest and knowledge level of potential course participants may be helpful to inform program development needs.

Furthermore, due to interest in the course expressed by our first- through third-year medical students, we recently have developed an Honors in Finance track. Entering first-year students can sign up for the track, and each year has specific requirements intended to enhance their knowledge of business and finance topics. One of the many requirements is participation in the BoM course as a first- or second-year medical student, thereby providing exposure to finance topics earlier in medical school. Students who complete the track requirements will graduate with the designation “Honors in Finance” on their diploma.

Finally, certain limitations to this study should be noted. The study results represent a successful innovation at a single medical school, and thus may not be generalizable to other schools. Nonetheless, we believe that the ease, cost, and portability of this curriculum would make it of interest to other schools. The survey was designed by the authors (some of whom have extensive survey development experience) in an effort to assess the impact of the curriculum, but it was not a validated instrument. It is possible that students who attended the course had a greater baseline interest in finance that led them to electively take such a course and that those who completed the post-course surveys may have been the most engaged students. Therefore, there may be an element of selection bias. However, the low number of students who had had a finance course previously (thereby assuming a baseline interest) combined with the fact that the majority of the medical school class participated in the course (at least in the last two years) suggests course participants may not be uniquely different from course non-participants. It is also worth noting that the medical students represented in this study appear to be very similar in many parameters to other recent national surveys of medical students.

As the art and science of medicine continue to advance, so do the intricacies of the practice of medicine as a business. Additionally, with falling reimbursement rates and rising costs of medical education, it is critical for students to be able to manage their personal finances appropriately. Addressing these knowledge deficiencies can substantially benefit students as they make the critical transition to finally receiving a salary and shouldering the responsibility of providing healthcare.

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Portions of the work described in this paper have been supported with modest annual contributions by the UAMS College of Medicine to implement and sustain this project.

Portions of this work have been presented at the 2017 AAMC SGEA/GSA/SOSR Regional Conference, April 19-22, 2017, Charlottesville, VA, and The Generalists in Medical Education Annual Conference, November 1-2, 2017, Boston, Massachusetts.