Keywords
physician burnout - personal financial planning - financial literacy - physician wellness
The heart of medicine has been improving patient's health and overall well-being but
over the last 10 to 15 years, there has been an added focus on the well-being of the
physicians who take care of these patients.[1] As physician burnout and a poor sense of well-being can lead to worse patient outcomes
and patient dissatisfaction, many professional organizations have implemented programs
to help improve physician job satisfaction.[2] Although many programs have been shown to improve physician well-being, none have
focused on improving financial literacy.[3]
Physicians in training have previously demonstrated a strong desire for a personal
finance curriculum within their training programs.[4]
[5] This absence of financial literacy education is concerning as financial stress is
associated with greater anxiety, depression, and alcohol dependency,[6] and also conditions that residents and fellows are already more at risk for than
the general population.[7]
Expanding financial literacy could be a part of the solution, as more than 90% of
resident physicians feel that they are unable to handle their finances.[8] This number is alarming as financial stressors lead to higher job dissatisfaction.[9] Other industries have already shown that formulized personal finance education improves
financial literacy and in turn one's sense of prosperity and job satisfaction.[10] However, there has yet to be any study examining the effects of a personal finance
curriculum on a physician's sense of well-being and financial stress.
We hypothesize that when a personal finance curriculum is provided to residents and
fellows, they will demonstrate an improvement in their sense of well-being and experience
a decreased amount of financial stress.
Materials and Methods
This was a prospective cohort study that measured obstetrician/gynecologist (OB/GYN)
resident and fellow's sense of well-being and financial stress through validated surveys
before and after implementation of a personal finance curriculum. All 46 OB/GYN residents
and fellows at a single institution and currently enrolled in the graduate medical
education (GME) program were invited to participate in the personal finance curriculum.
Our intervention consisted of a five-part personal finance curriculum (45 minutes
each) that was performed by the primary author throughout the 2019 to 2020 academic
year. The primary author has spent the last 5 years in both a formal and informal
capacity for advising physicians on their finances. The covered topics were chosen
based on the primary authors experience, as well as what trainees have previously
expressed interest in learning.[5]
[11] These included the following: (1) personal finance education and its relationship
to well-being, (2) an overview of financial terms and principles, (3) budgeting, (4)
debt planning, and (5) investing and giving ([Fig. 1]). The first three topics were given in a live round-table discussion format. A formal
presentation was used as the background with free-flowing discussion throughout. The
final two presentations were moved to a video-conferencing application (due to the
novel coronavirus disease 2019 [COVID-19] pandemic) and involved a lecture format
followed by question and answer (Q&A) session. Following each lecture, the presentation
was provided in a PowerPoint PDF document with a modified transcript of what was discussed.
This was available to all residents and fellows to educate those who were unable to
participate in the live sessions and review at their own discretion.
Fig. 1 The list of covered topics that topics were chosen based on the primary authors experience,
as well as what trainees have previously expressed interest in learning.
All OB/GYN trainees who were able and willing to participate in the study were asked
to take a pre- and postintervention survey. The primary outcomes were trainee financial
health and stress as measured by both the previously validated the 9-Item Expanded
Well-Being Index (E-WBI) and the 13-question Financial Stress Scale-College Version
(FSS-CV) survey.[12]
[13] Two primary outcomes were included as well-being can be multifactorial and not directly
related to financial stress.[12] Secondary outcomes included resident and fellow attitudes and comfort levels on
the role of financial education in a medical curriculum. These attitudes were recorded
based on a 7-point Likert's scale. Questions were chosen based on previously described
physician attitudes toward financial education.[4]
[5]
[8]
[11] Those who declined to take the surveys were excluded from analysis but were still
be able to actively participate in all facets of the personal finance curriculum.
Our sample size was limited by the set number of OB/GYN trainees, 46 total. However,
with a mean FSS-CV score of 22.54 ± 7.39, we calculated the ability to detect a 20%
improvement in FSS-CV score with 80% power and 0.05 α if 43 residents/fellows participate. Given this would involve a difficult to achieve
95% participation rate, we acknowledged our limitations beforehand in failing to reject
the null hypothesis in the event; no statistical significance was achieved.
All data were captured directly into the study database developed with the Research
Electronic Data Capture (REDCap).[14] Exposure groups were compared using Chi-square, Fisher's exact, and Wilcoxon's tests
as appropriate. The statistical analysis was performed using SAS 9.4 (Cary, NC) with
significance level at 0.05. Institutional review board review was provided and obtained
given all residents could opt out of study participation by not completing the surveys.
Results
Out of the eligible resident and fellows, 35 agreed to participate in the study by
taking the initial survey. The representation included a majority of those who identify
as predominantly female which is representative of the GME program's demographics.
They also were well distributed between lower level residents, upper level residents,
and fellows ([Table 1]). Of those who agreed to participate in the study by taking the first survey, 21
of 35 (60%) took part in the follow-up survey. The mean number of individual course
lectures attended during a live session was around 3 ([Table 2]).
Table 1
Personal characteristics of the OB/GYN residents and fellows
|
Presurvey (n = 35)
|
Postsurvey (n = 21)
|
p-Value
|
|
Level of training (n = 47)
|
|
Lower level resident (PGY 1–2)
|
14 (40.0)
|
10 (47.6)
|
0.16
|
|
Upper level resident (PGY 3–4)
|
10 (28.6)
|
9 (42.9)
|
|
Fellow (PGY 5–7)
|
11 (31.4)
|
2 (9.5)
|
|
Female (%)
|
27 (77.1)
|
16 (76.2)
|
> 0.99
|
|
Shares finances with partner
|
22 (62.9)
|
14 (66.7)
|
0.77
|
|
Manages self/household finances
|
23 (65.7)
|
13 (61.9)
|
0.77
|
Abbreviations: OB/GYN, obstetrician/gynecologist; PGY, postgraduate year.
Note: Data presented as
n
(%).
Table 2
OB/GYN resident/fellow exposure and participation in the personal finance curriculum
|
Trainees who participated in the follow-up survey
|
21/35 (60)
|
|
Average number of presentations they attended live
|
2.8 ± 1.2
|
|
Average number of watched on own when missed live
|
0.6 ± 1.1
|
|
Trainees who revisited any presentation they attended in person
|
7/21 (33.3)
|
Abbreviation: OB/GYN, obstetrician/gynecologist.
Note: Data presented as
n
(%) or mean ± standard deviation as appropriate.
There was a significant improvement in the median expanded well-being index score
after exposure to the personal finance curriculum (2 vs. 1, p ≤ 0.05). There was no significant difference in the median financial stress scale
survey before and after the personal finance curriculum (22 vs. 20, p = 0.06; [Table 3]). Residents and fellows expressed a better understanding of financial planning topics
(4 vs. 5, p = 0.007) and the financial industry (3 vs. 5, p ≤ 0.001). After completing the curriculum, there was a significantly stronger agreement
that financial literacy improves their sense of well-being (4 vs. 5, p = 0.018; [Table 4]).
Table 3
Expanded well-being index and financial stress scores before and after exposure to
the personal finance curriculum
|
Presurvey (n = 35)
Median (Q1–Q3)
|
Postsurvey (n = 21)
Median (Q1–Q3)
|
p-Value
|
|
The Expanded Well Being Index
|
2 (1–5)
|
1 (0–3)
|
0.049
|
|
The Financial Stress Scale-College Version Survey
|
22 (17–26)
|
20 (18–23)
|
0.06
|
Table 4
Trainee attitudes on financial education
|
Presurvey (n = 35)
|
Postsurvey (n = 21)
|
p-Value
|
|
Education in personal financial planning is important to me
|
5 (4–6)
|
6 (5–6)
|
0.14
|
|
I believe I will be able to meet my financial goals within a reasonable time
|
4 (4–5)
|
5 (5–6)
|
0.007
|
|
I have a working understanding of personal financial planning topics
|
4 (3–5)
|
5 (4–6)
|
0.012
|
|
I have a working understanding of the financial services industry
|
3 (2–5)
|
5 (4–5)
|
< 0.001
|
|
Education in personal financial planning helps my sense of well-being
|
4 (4–5)
|
5 (5–6)
|
0.018
|
|
I am personally comfortable handing my own finances
|
4 (3–5)
|
5 (4–5)
|
0.08
|
Note: Data presented as median (Q1–Q3) based on 7-point Likert's scale (1, very strongly
disagree; 2, strongly disagree; 3, disagree; 4, neutral; 5, agree; 6, strongly agree;
and 7, very strongly agree).
Discussion
In this prospective study, OB/GYN residents and fellows who participated in a personal
finance curriculum showed improved well-being as scored by the E-WBI. In addition,
the trainees agreed that financial education improved their sense of well-being.
Financial literacy programs are a common occurrence across multiple groups and industries,
including those within health care.[10]
[15]
[16]
[17] Although measured outcomes and goals of programs differ, common findings include
the desire for financial literacy and an appreciation for the obtained knowledge.
Programs that have specifically assessed physician attitudes toward a personal finance
curriculum have all consistently showed residents' and fellows' desire to improve
their financial literacy.[4]
[5]
[8]
[11]
[18] As studies have shown the appetite for financial literacy is apparent, ours is the
first to directly measure its association with physician well-being and financial
stress.
Physician well-being is a complex concept that involves multiple inputs, including
work–life balance, quality of life, resilience, mindfulness, coping strategies, and
mood.[19] Financial well-being is not included in this list; however, financial stress and
strain play a direct roll on our self-efficacy beliefs and mental health.[20] With improved financial literacy, it is logical that financial stress will decrease[9] and in turn improve most of the components of physician well-being.
Burnout and work-related stress have been described as a “mismatch between the perception
of what is expected and the reality of what is possible.”[21] We would concur that all stress can be decreased when expectations and reality become
more in line. When a resident or fellow goes through a personal finance curriculum,
they are exposed to the reality of the financial world. This in turn creates more
realistic financial expectations and in turn decreases financial stress. Although
we did not show a significant difference in the course decreasing financial stress,
this was likely due to being underpowered and not due to the lack of association.
Limitations
Although our study is the first to demonstrate an association with financial education
and physician well-being, it is not without limitations. The first involves the unmasking
of the participants. The residents and fellows in our GME program were notified beforehand
that they were participating in a study assessing the potential benefits of a personal
finance curriculum. This knowledge could have led to the Hawthorne effect. However,
the participants were not aware of the specific outcomes being measured or the scoring
system, limiting result bias. In addition, those who saw no benefit to the course
may have declined to participate in the postintervention survey biasing our intervention
results away from the null hypothesis. Another notable limitation relates to the generalizability.
This education initiative was given at a single site, to a single specialty, and specific
to residents and fellows. Both medical students and faculty have a different set of
financial needs and our personal finance curriculum may not show the same association
in these groups. Plus pay differs substantially between subspecialties and geographic
regions which could have a bearing on how applicable the curriculum may be to all
GME programs.[22] In addition, the external validity of this study is not apparent. This course consisted
of five parts and given by one individual. Our study is unable to distinguish if the
association between the personal finance curriculum and improved well-being is due
to the instructor and specific course design or becoming more financial literate in
general. A final limitation is that surveys were given during an unprecedented time
for medical education. The distribution to program structures and resident and fellow
schedules due to the COVID-19 pandemic cannot be quantified. It is difficult to evaluate
if the improvement in scores was due to the personal finance curriculum or other circumstantial
changes. Despite the fact that stress and anxiety levels of residents/fellows were
increasing during the COVID-19 pandemic,[23] our trainees showed an improvement in the well-being index. This may further substantiate
our findings that financial literacy improves one's sense of well-being. We also witnessed
that residents or fellows do not need to be exposed to a whole personal financial
curriculum to see benefit. The median attendance for residents and fellows were 2.8
lectures, just over 50% of the entire curricula. Even a small amount of an exposure
to monetary topics can improve one's financial literacy and well-being.
Given the overarching limitations of our study, further studies must be done. It should
be evaluated at other GME sites and in different specialty programs which we are evaluating
following this pilot. In addition, separate studies should be done to assess the effect
on medical students. Furthermore, other curricula need to be evaluated to discover
if improvement is due to a specific course structure or if it is the financial education
itself that is associated with an improved sense of well-being.
Conclusion
In conclusion, we demonstrated that a personal financial course is associated with
an improvement in a resident and fellow's sense of well-being. Incorporation and further
study of a personal finance component into the wellness curriculum should be considered
by all OB/GYN programs.
Expanded Well-Being Index (Dyrbye et al12)
Expanded Well-Being Index (Dyrbye et al12)
-
During the past month, have you felt burned out from work? (Y/N)
-
During the past month, have you worried that your work is hardening you emotionally?
(Y/N)
-
During the past month, have you often been bothered by feeling down, depressed or
hopeless? (Y/N)
-
During the past month, have you fallen asleep while sitting inactive in a public place?
(Y/N)
-
During the past month, have you felt that all things you had to do were piling up
so high that you could not overcome them? (Y/N)
-
During the past month, have you been bothered by emotional problems (such as feeling
anxious, depressed or irritable)? (Y/N)
-
During the past month, has your physical health interfered with your ability to do
your daily work at home and/or away from home? (Y/N)
-
7 Point liget scale (1, very strongly disagree; 2, strongly disagree; 3, disagree;
4, neutral; 5, agree; 6, strongly agree; and 7, very strongly agree)—add 1 point for
1 or 2 and subtract 1 point for 6 or 7.
-
“The work I do is meaningful to me”
-
“My work schedule leaves me enough time for my personal/family life.”
Financial Stress Scale-College Version Survey (Northern et al13)
Financial Stress Scale-College Version Survey (Northern et al13)
In the past 6 months, please rate how often you've thought about the following financial
events using the following scale: (1) never, (2) sometimes, (3) often, or (4) all
the time.
Financial Stability Factors
-
Not having any emergency money (e.g., savings accounts or investments).
-
Living paycheck to paycheck.
-
Being in a job where work isn't steady/predictable.
-
Barely making enough money to cover expenses.
-
Not making enough money to be able to cover unexpected expenses.
Credit Factors
-
Having a low credit score.
-
Having a large debt.
-
Having loans with high interest rates.
Predictable Future Stressor Factors
-
Knowing you make less money than most of your peers.
-
Christmas/holiday expenses.
-
Paying taxes.
-
Having to borrow money from family or friends.
-
Being behind on payments.
