The ‘Jack of all trades’ nature of being a trauma surgeon requires clinicians to have a working knowledge across a broad range of subspecialties. From orthopaedics and plastics, to neurosurgery and cardiothoracics, the general-surgeon-come-trauma-surgeon will often need to undertake additional fellowships and specialist courses to ensure they are adequately equipped to deal with the unique challenges that trauma patients pose. American trauma surgeons in many ways have it easy, with dedicated and defined residency programmes in high-volume urban areas that focus on trauma and surgical critical care. Elsewhere, in places such as the UK, surgical trainees mostly still have to carve out a bespoke career path for themselves and will often require a period of time abroad in high-volume trauma settings in order to fill in the gaps in their technical skills. All of this comes with a financial burden that many struggle to cope with.
A British surgical trainee having left medical school with tuition fee debts in excess of $65,000 can expect to spend an average of $34,000 on courses, exams and conference attendance throughout the duration of their residency. Specialist trauma surgery courses offered by the Royal College of Surgeons include Definitive Surgical Trauma Skills ($1800) and the Pre-Hospital and Emergency Department Resuscitative Thoracotomy Course ($900).
US medical graduates with an average student debt of $180,000 will of course shed no tears for their less heavily-burdened counterparts overseas, however the issue of surgeons in financial difficulty both inside and outside of the USA is likely to be more prevalent than ever. A survey of over 100 surgical residents at the University of Wisconsin in 2015 reported 38% of respondents having more than $200,000 in educational debt, and 82% had a moderate or high risk debt-to-asset ratio. A lack of financial literacy, the desire to play catch-up with their peers who qualified in other professions at earlier ages and salespeople trying to push any number of burdensome financial products on young residents are some of the key issues. A recent systematic review detailed the negative association between medical student debts and mental-wellbeing and academic outcomes. More worrying still is the ample evidence pointing to debt as a leading risk factor in suicide.
There is an urgent need for more training in financial planning throughout medical school and residency. At Johns Hopkins University in Baltimore, Maryland, for example, the finance faculty created the Pillars of Wealth financial literacy initiative, aimed at teaching medical professionals to make better financial decisions. It is now offered to fellows, residents and staff physicians throughout the Johns Hopkins medical system.
Aside from greater personal financial education and responsibility, one would expect that state or government-led loan forgiveness schemes and greater regulation of the student loan industry may go some way towards easing the burden. Ironically, the fear of undergraduate and postgraduate debt burdens may push relatively higher numbers of medical students towards a surgical career path due to the higher earning potential compared to some other medical specialties. Although trauma surgery with its high emergency to elective work ratio and relatively low remunerations compared to other surgical subspecialties may not see the same staffing benefits. Ultimately, the long-term impact of student debt will have a negative impact on the overall numbers of people entering medical school, which will be to the detriment of society as a whole.
Obi Nnajiuba is a British surgical resident with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.
