Leadership and Resident Satisfaction

It’s residency Rank Order List season, and I thought I’d share a paper published in AJR from 2016 titled, “Radiology Resident’ Satisfaction With Their Training and Education in the United States: Effect of Program Directors, Teaching Faculty, and Other Factors on Program Success.”

It was a small study where the authors surveyed 217 radiology residents.

Of that group, 168/216 (77.8%) of residents were satisfied overall with their residency programs.

You’re always going to have some sour grapes, and it’s not possible from the data to figure out how much of that fraction might be related to noncontrollable factors like the city, the stresses of dealing with student loans, or other factors. But as the authors noted, that’s a big difference from the golden era:

This is lower than reported in similar previous national surveys conducted by the American College of Radiology, which reported a 97.8% level of job satisfaction of radiology trainees in 2003, and 97.6% level of job satisfaction in 1995.

Like with internet comments and product reviews, convenience surveys always lean toward the dissatisfied. But the data are still interesting because they can highlight the causes for dissatisfaction, even if they play an outsize role compared to the general community.

The three sub-categories with the greatest correlation with overall satisfaction were satisfaction with the program director and administrative office, daily workstation experience, and faculty.

So basically everything.

But of the three, the program director and administration were by far the most dominant. I suspect it’s more of a break not make scenario:

The factor with the greatest correlation to satisfaction with the program director and administrative office is how approachable and responsive the administration is to resident concerns.

A good program director may help make a program, but a bad one can definitely tank one.

A good PD is both a boss and an advocate. While not all trainee complaints are necessarily fixable (or even reasonable), accountability, transparency, and attentiveness aren’t something to take for granted in program leadership. Culture colors everything.

It might be impossible to change the culture of the hospital. It might be impossible to reduce RVU pressures on faculty or improve mediocre teachers. So the survey is actually good news because the program leadership is far more mutable.

There was one throwaway statistic they reference from a 2003 study that ties into the daily workstation experience/faculty components:

A survey with 132 junior radiologists revealed that 68% of the responders left academia after an average of 3.28 years because of low pay and lack of academic time.

That was almost 20 years ago, and the RVU pressure and lack of academic time have gotten worse since then. I wonder what that number is now.

My group is extremely stable, but I’ve seen a ton of turnover amounts young attendings in both academia and private practice. I don’t think enough practices of any variety are willing to allow for a Goldilocks approach between productivity and revenue.

The ABR dreams of a low-cost world

The February 2021 issue of the BEAM features a short article with the title, “Board, Staff Working Together to Control Expenses.

As the Board of Governors discussed these new [remote] exam tools, one of the perceived potential benefits was the intuitive opportunity to decrease costs and, by extension, reduce fees. However, there are persistent barriers to fee abatement at the time of this writing, including the absence of proven success of the new exam structure; a lack of dependable forecasts of the future steady-state expense structure; the inherent long-term nature of established financial obligations related to exam center equipment and leases; and the unexpected short-term development costs of the virtual exam platform software.

Proven success? Check.

Does any stakeholder believe that ~$50 million in cash reserves isn’t enough to deal with “a lack of dependable forecasts of the future steady-state expense structure” [sic]?

They continue (emphasis mine):

ABR senior leadership is committed to working with the board to control costs. We are optimistic that this is achievable as we close in on the “new normal,” but we don’t know the extent of potential cost reductions, nor when they might be achieved. The less visible infrastructure elements of board functions, ranging from cybersecurity to volunteer support, are critical to customer service for our candidates and diplomates, as well as fulfillment of our core mission. Despite these obstacles, the board members view themselves as responsible stewards of ABR resources, both financial and otherwise. In this vein, they consistently challenge each other, and the ABR staff, to reduce costs and, subsequently, fees, to the extent possible.

Transparency, transparency, transparency. Anything less is just self-love.

A $310,284.24 PSLF Success Story

People often ask me if I know anybody who has successfully received public service loan forgiveness (PSLF). For the past couple of years, my answer has been that I’ve seen multiple verified examples of PSLF but didn’t know anyone personally (in real life). That’s mostly because I graduated in 2012, so my former classmates are still at least a year away.

That changed recently because last month a colleague of mine had his loans forgiven. He’s given me permission to share some illustrative parts of his story and provided me with a very detailed timeline. It’s a good case study, and I’ve added references to relevant background/discussion throughout.

Without further ado, here is his (annotated) story:

8/94 – First Stafford loan (FFEL) disbursed ($2,625). The local bank immediately sells the loan to Sallie Mae after collecting the origination fee.

  • You’ll notice that he is a nontraditional physician who went to school initially back in the 90s but then went back to pursue medicine in the 00s. The Federal Family Education Loan (FFEL) program was created in 1992 as a public/private partnership where “federal” loans were given by private banks in exchange for generous fees from the federal government and a guarantee against cases of default. FFEL supplied 80% of federal student loans until 2008.

8/95 – University converts to the Direct Loan system.

  • The Direct Loan program, which we all currently enjoy, coexisted with FFEL in the 90s. However, individual borrowers didn’t get to choose. The school picked either FFEL or Direct for its federal aid. At this time, due to a combination of purportedly better customer service (and marketing), most schools chose FFEL.

5/98 – Undergraduate graduation followed by consolidation under the Direct program ($11,118, subsidized loans only)

  • This was an optional step for convenience at this point but the beginning of a very helpful pattern. PSLF didn’t exist yet (announced in 2007) but astute borrowers will know that the federal government is only interested in forgiving loans that it actually holds (Direct loans). The only way to make FFEL loans qualify for modern income-driven repayment plans and PSLF is to consolidate them into a Direct Consolidation loan. The same consolidation necessity also applies to the now-defunct “low-interest” Perkins loan program that was shuttered in 2015.

5/05 – Consolidation of undergraduate and (non-medical) graduate school loans under the Direct program ($45,437 subsidized, $24,599 unsubsidized). Direct loans assigned to ACS/Xerox Education Services (“DL Servicer”) for servicing, the only Direct Loans servicer at the time.

  • So after finishing graduate school, he re-consolidates to add his grad school loans to his original undergrad consolidation loan.

9/07 – President George W. Bush signs the College Cost Reduction Act of 2007, establishing the Public Service Loan Forgiveness Program (PSLF)

  • In 2007, the Democrats held the House and Senate. The CCRA passed in the senate 78 – 18, and Bush signed the law. It’s hard to imagine any bill like this not being voted strictly along party lines these days. For further reading, see the first PSLF chapter of my book, available free online here.

7/10 – Consolidates new FFEL medical school loans under the Direct program ($69,707.25 subsidized, $171,973.74 unsubsidized). The consolidation waived the 6-month grace period and signing up for automatic payments lowered the interest rate by 0.25% to 6%.

  • While his older loans were Direct Loans, his medical school chose the FFEL program. You can see what so many people got this wrong. He informed me that back in May 2010, someone from the AAMC actually came to his school to talk about PSLF and what to do to qualify (including consolidation). This was rare golden advice back in the day, as most borrowers either kept the wrong loans (FFEL, Perkins) or used the wrong payment plan (graduated or extended). By consolidating after graduation, he was able to waive the otherwise mandatory 6-month grace period and enter repayment early. Read more about the importance of Direct consolidation here.
  • The interest rate of federal loans changes every year depending on the yield of a 10-year treasury note. During my era, for comparison, it was always 6.8%.

8/10 – Began repayment using the original Income-Based Repayment (IBR) Program.

  • The original IBR was the first modern-day plan within the income-driven repayment (IDR) umbrella, later joined by PAYE and REPAYE. Income-contingent repayment, the less generous original, dates back to 1993. IBR had payments of 15% of discretionary income, capped payments at the 10-year standard repayment amount if income rose sufficiently, and also allowed for loopholes like utilizing “married filing separately” to lower payments and maximize forgiveness.

9/11 – ACS/Xerox (“DL Servicer”) loses Direct servicing contract and loans were transferred to another servicer, which canceled automatic payments without notification and resulted in a “late” payment.

  • While there have been recent plans to consolidate all federal loan servicing with a single company (again), for most of the PSLF-era there have been multiple servicers (e.g. Navient, Nelnet, FedLoan, Great Lakes, etc). Of all the services, only FedLoan processes payments for those intending to utilize the PSLF program.
  • Submitting an employment certification form (ECF) for PSLF automatically switches borrowers to FedLoan, but back in the day, being bounced around wasn’t all that uncommon either. In fact, my loans were transferred to a new servicer a year after I graduated. Each time this happens, you’ll have to set up a new account and auto-pay must be re-established. It’s common to lose a month during the process, and sometimes the servicers themselves might place you on an administrative forbearance if they couldn’t get the job done in the interval between monthly payments.

1/12 – Submitted first employment certification form (ECF) for potential PSLF, triggering the automatic transfer of servicing to Pennsylvania Higher Education Assistance Agency (PHEAA, “MyFedLoan”). The transfer process takes greater than 1 month, resulting in a missed opportunity for a monthly payment.

  • When you file for your Direct consolidation, you are able to choose your servicer. If you are considering PSLF at all, you want to select FedLoan to prevent any delays from an unnecessary transfer down the road.
  • Additionally, while you would think that the transfer of your payment records would be easy-peasy, it isn’t. Apparently, at least in the recent past, actual paper was involved. Achieving PSLF on-time relies on a correct payment count, and the source of many folks’ incorrect payment counts is the payment information from old servicer accounts prior to the transfer. While FedLoan is objectively not a good company, they do better with their own counting.

1/14 – Employment verified but payment counts were inaccurate. Submitted complaint with bank statements to show the error. While there was no response, it seemed to be fixed in later iterations.

  • Incorrect payment counts are a common headache source for borrowers and are often off by years due to small errors in the data. And while it’s easy to request a manual recount, they’ll tell you upfront that the process might take two years. For obvious reasons, they also prioritize those who are closer to the 120 payment number.
  • When there are payment count or processing issues and FedLoan doesn’t fix them promptly, there are now a few ways to call in bigger guns. You can file a complaint with the Office of Federal Student Aid here and with the Consumer Finance Protection Bureau here. If neither one of those works, then contact the FSA Ombudsman.

6/15 – Residency complete; employment verified.

  • While it’s considered good practice to submit ECFs annually, at the minimum you want to do so as you leave a qualifying institution. You don’t want to be trying to track down someone at HR willing to sign your form years down the line.

6/16 – First fellowship complete, employment verified.

  • He’s doing a great job.

11/16 – Switched from IBR to the new Revised Pay as You Earn (REPAYE) payment plan created through an executive order by President Barack Obama in 2015. Annual income verification timing was moved to the end of the calendar year, and one qualifying monthly payment opportunity was lost; 2017 payments now based on 2015 (trainee) income.

  • Note that because he didn’t meet the eligibility criteria for PAYE, REPAYE was his only chance to lower his payments from 15% to 10% of discretionary income, resulting in significant savings.
  • During the switch, his annual recertification timepoint moved later in the year. Recall that payments are based on your most recent tax return, which is in turn based on the previous year’s income, so there is a considerable lag between when your income goes up and when you start paying for it with regards to student loans.
  • You should expect to always lose a month when switching between repayment plans. Your interest also capitalizes, though that is irrelevant with regard to loan forgiveness. With IBR, in particular, the lost month was specifically included in the process.

6/17 – Second fellowship complete; employment verified.

  • The more training you do, the better deal PSLF becomes. Because of the lag in payment increases, some physicians will almost certainly receive loan forgiveness after never making an attending-sized payment.

8/17 – Graduate school (MPH) enrollment triggers automatic deferment (without notification), another month lost while the deferment waiver was submitted and processed.

  • Most people who are full-time students cannot meaningfully make student loan payments on prior debt (and they’re usually taking on more!), so any time you become a full-time student, the system is set up so that you are automatically placed on an in-school deferment.
  • You can waive this and continue repayment on loans from prior schooling, which is very helpful for PSLF for those who go back to school but are still working full-time at a qualifying institution. (But no, in case you’re wondering, you can’t simply waive this on new/current loans and start making qualifying PSLF payments on those new loans while still in school even if you somehow were also working full-time.)

8/18 – Employment verified with 4 payments not appropriately counted; request submitted for a manual recount (which would take almost 2 years to complete).

  • Two years is what FedLoan considers par.

3/20 – President Donald Trump signs the Coronavirus Aid, Relief, and Economic Security (CARES) Act, essentially canceling the final 7 payments and neutralizing the effects of the prior errors.

  • The CARES act (which included 0% interest and $0 payments) has benefited a lot of people. In addition to helping keep less fortunate borrowers financially afloat, it’s also been a boon for those going for loan forgiveness, in particular those near the end of their journey currently enjoying larger salaries and consequent larger payments. Further discussion here.
  • An intern is often looking at $0 payments anyway. A resident may be saving a few hundred bucks per month. But many attendings are saving thousands of dollars per month through the CARES act forbearance, which counts these no-pay months as qualifying payments for PSLF.

10/20 – FedLoans sent notification that 120 payments had been reached (during the CARES forbearance); PSLF application/final ECF submitted, but an employer error on the application results in a 1-month delay.

  • The language of the CARES act was clear, but some folks were still petrified that somehow the CARES act forbearance wouldn’t count for PSLF. It does.
  • The HR department has a tendency to sign these forms incorrectly. Every signature should be legible and every date completely clear for an ECF to be accepted.

1/21 – PSLF application approved. $82,438.65 subsidized and $227,845.59 unsubsidized forgiven.

  • Congratulations!
  • (Note that subsidized loans are no longer given out for graduate school like medical school, but regardless the interest is only subsidized while still in school.)

Verdict

In the end, this story demonstrates most of the classic PSLF teaching points. It’s a real program. It can be administratively complex, especially for older borrowers, but it boils down to making sure you have Direct Loans and picking an IDR plan. Everything else is just optimization to maximize forgiveness by paying as little as possible over the course of the 120 qualifying payments, keeping records, and complaining if someone else messes something up.

It can provide a very large amount of tax-free loan forgiveness.

However, for some borrowers, this forgiveness does not result in significant cash savings given the relative compensation differences between academic positions and private practice.

People who borrow in the neighborhood of 1x their annual salary or less can feel more or less confident in picking whatever job they want and know that they will be able to service their debt. For these people, PSLF is a great benefit to pursuing your passion for public service but not a reason to take a job you don’t want. For those that borrow 2x or more, PSLF is a real reason to consider a qualifying job.

The ABR’s virtual Core Exam worked

Last year as the pandemic spiraled out of control, the ABR resisted–as they have for years–calls for disseminated exams away from their centers in Chicago and Tuscon. The lack of a foreseeable endpoint and pressure from advocates was finally enough for the ABR to make the switch. And to their credit, when the ABR came around, they went all the way: all exams are to be virtual from this point forward.

And guess what? It worked.

Apparently, it worked really well.

And I, for one, am not surprised.

People I’ve spoken to were overall very pleased with the remote experience. Were there rare technical difficulties? Sure. But reports are that the ABR was generally responsive and helpful in aiding candidates when issues cropped up, and multiple residents I spoke to gave ABR customer service high marks.

So while perhaps they shouldn’t have needed the worst pandemic in a century to make these changes, credit where it’s due: the ABR successfully pulled off the transition to at-home testing.

The ABR’s testing centers, though physically inconvenient, were always pretty nice compared with most commercial centers. But the ability to take the exam from a location of your choosing with no travel required and your choice of preferred snacks, clothing, thermostat settings, and bathroom is pretty nice. Having the exam over three days also probably helped with test-fatigue.

Future Fix Requests

There were a few complaints the ABR should address in future administrations:

  • Answer choice strikethrough. This was a common request, and it’s a common feature including one available on the USMLE exams that residents are all used to.
  • Cine clip optimization. This has been a longstanding complaint, but in this case, at least sometimes clips are presented in a separate window from the question and answer choices. They should be embedded the same way as normal images with easily controllable playback speed and the ability to manually scroll.
  • Remove the 30 question auto-lock. The need to lock previously seen questions makes perfect sense at the end of a 60-question block and whenever a candidate takes an optional break. But I’m not sure I buy any justification for auto-locking mid-section. This is a true functional change from prior exam administrations that has a negative impact on those who would like to review all related questions before moving on. It’s also difficult to know how much time to allot to question review when you break up 120 questions into 4 blocks instead of two, making time management more difficult.
  • Announce the section order. This was a big complaint I heard and one I agree completely with. For years the ABR has avoided publicizing the section order (e.g. Breast, then Cardiac, then GI) despite keeping it consistent across testing administrations. While people obviously aren’t supposed to discuss the exam, in the real world this has meant that candidates taking the exam later always know what sections are coming on which days, allowing them to cram most effectively. Unless every candidate has a randomized order, keeping this information semi-hidden in this setting just isn’t appropriate and should be a no-brainer to fix. Knowing you’re going to have ridiculous radioisotope safety microdetails on a specific day means you can prepare for that much more effectively and seriously jeopardizes the exam integrity. Again, this is not a new issue.

The Core Exam is still the Core Exam

Ultimately, the biggest complaint–no surprise–wasn’t the software but the test itself. It’s not as though the content magically became more on-point just because you got to wear pajamas.

If I were to limit myself to one content suggestion, it’s this:

I feel very strongly that the ABR’s reduction of physics and radiation safety to nonsense microdetails does our specialty a disservice. Residents constantly complain that the test material seems random and is not found in most review materials. This means either the Core Exam treats this material poorly or that the residents are studying the wrong information.

The problem is that this material is important. The ABR needs to make it clear what information candidates should know and release it as a packet of specific information like non-interpretive skills (NIS). In its current form, the combination of physics/radiation biology/radiation safety/nuclear medicine/RISE is a limitless almost black-box from which residents have no idea what to focus on or what material is high-yield. The end result is that most radiologists are taught low-yield or confusing information from physicists and end up with a poor understanding of these concepts. Candidates simply don’t really know what they should know and so don’t really know anything.

MR safety and contrast safety are included in the NIS study guide already (in addition to mission-critical information like the ACGME core competencies and how to create a “Culture of Safety”). The vast majority of the information I just described is also “non-interpretive” and needs to be included.