Introduction

Financial literacy is the ability to use knowledge and skills to manage financial resources effectively for a lifetime of financial well-being.1,2 Most adults in the United States lack rudimentary financial knowledge, with only one-third of the population being able to answer basic financial questions correctly.2,3 People with poor financial literacy are less likely to plan for retirement and are more likely to use high-cost means of borrowing.2-4

Many medical students, residents, and practicing physicians tend to have poor financial literacy.5-9 A survey of US orthopedic residents found that only 4% of the residents had a formal financial education, but 85% were interested in learning more about finances.10 There are reported attempts to improve financial literacy by implementing a curriculum in personal finance during medical school and residency, but these opportunities are not widely available.5,6,10

Financial illiteracy and increased financial debt have been found to have negative implications on medical professionals and health care. Burnout is common among medical students, residents, and practicing physicians, and financial stress is one of the causes.5,10 Financial pressure increases the severity of burnout and negatively impacts professionalism,5 while the severity of burnout is associated with an elevation in financial debt.5 A survey of internal medicine residents reported Quality of Life (QOL) and satisfaction with work-life balance were both lower among residents with higher educational debt, especially those with debt above $200,000.11 Emotional exhaustion and depersonalization increased as the educational debt increased.11

Worsening student debt is a crisis currently faced by the US, and it is affecting students, parents, and the economy.12,13 Medical students are no exception, with higher amounts of debt compared to other graduate degree professionals.5 Medical school debt is exacerbated by a rapid increase in undergraduate education expenses14 as well as medical education expenses.15,16 The median debt of US medical school graduates has tripled in the last three decades, reaching a level of almost $200,000 in 2018.5,17 Alarmingly, the number of graduates with more than $300,000 debt increased from 2.1% in 2010 to 4.2% in 2016,17 and to almost 12% in 2018.5 Medical school loans' terms are not favorable either, with an average interest rate above 6% and the federal government not providing subsidies to the borrowers with interest during the school years.5,18 The debt increases significantly during residency and fellowship periods by 20% to 50% by the end of the training.5 Once the residents graduate, the physicians will have to pay off the student loans, which will take up 9% to 12% of their post-tax income, and this will add a significant amount of financial stress on an early career physician.15

High levels of student loan debt have an enormous impact on medical students' choices of residency specialty.17,19,20 Ebell et al. reported a strong direct correlation between higher overall salary and higher fill rates with US medical graduates in the residency match (r = 0.82; P = 0.001),19,20 and this has been referred to as "White-follows-green-law."21,22 Thus, high medical school debt results in decreased interest in primary care specialties as the payments are lower, resulting in a shortage of primary care providers.17,19,20,22 There have been many initiatives to improve the crisis of medical school debt, but these proposals have not been implemented widely.15,23 The US is specifically chosen for this review due to the uniqueness of the education system, leading to high amounts of debt compared to other parts of the world.24

The objective of this scoping review is to explore strategies to improve financial literacy and related outcomes among medical students, residents, and fellows in the US. The findings could assist organizations like the Liaison Committee on Medical Education (LCME), Accreditation Council for Graduate Medical Education (ACGME), and Association of American Medical Colleges (AAMC) in their future planning and policy changes to improve financial literacy education during medical school and residency training. A preliminary search of PROSPERO, MEDLINE (PubMed), the Cochrane Database of Systematic Reviews, and the JBI Database of Systematic Reviews and Implementation Reports (Ovid) were conducted, and no current or in-progress systematic reviews on the topic were identified.

Review questions

i. What strategies are used to improve financial literacy?

ii. What outcomes are reported with the strategies?

Inclusion criteria

Participants

The review will consider studies that include medical students and physicians in training (residents and fellows) in the United States. A medical student is defined as a student enrolled in a medical education program leading to the medical doctor or doctor of osteopathy degree.25 A resident is defined as an individual enrolled in an ACGME-accredited residency program.26 A fellow is defined as an individual enrolled in an ACGME-accredited fellowship (subspecialty) program who has completed a residency program in a related specialty.

Concept

The concept of this review is to identify strategies used to improve financial literacy and related outcomes among medical students, residents, and fellows in the United States. Strategies may include, but not be limited to, course lectures, curriculum changes focused on financial literacy, or intensive courses. Outcomes may include, but not be limited to, improved financial literacy and decreased student loan debt.

Context

This review will consider studies involving medical students, residents, and fellows in the United States.

Types of Sources

This scoping review will consider both experimental and quasi-experimental study designs, including randomized controlled trials, non-randomized controlled trials, before and after studies, and interrupted time-series studies. Analytical observational studies, including prospective and retrospective cohort studies, case-control studies, and analytical cross-sectional studies, will be considered for inclusion. This review will also consider descriptive observational study designs, including case series, individual case reports, and descriptive cross-sectional studies for inclusion. Qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative description, action research, and feminist research will be considered.

Systematic reviews that meet the inclusion criteria will be considered. Text and opinion papers will also be considered for inclusion in this scoping review. Studies published in the English language will be included. Studies published from inception to present will be included.

Methods

The proposed systematic review will be conducted as per the JBI methodology for scoping reviews.27,28

Search strategy

The search strategy will aim to locate both published and unpublished studies. An initial limited search of MEDLINE (PubMed) was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a proposed search strategy for PubMed (see Appendix I). The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference list of all studies included in the review will be screened for additional studies.

Information sources

The databases to be searched include PubMed (US National Library of Medicine), Embase (Elsevier), the Cochrane Library (Wiley), Scopus (Elsevier), Academic Search Premier (EBSCOhost), and Web of Science (Clarivate Analytics). MedNar (mednar.com), ProQuest Dissertations and Theses Sciences and Engineering Collection (ProQuest), OpenGrey (opengrey.eu), Open Access Theses and Dissertations (oatd.org), Directory of Open Access Journals (doaj.org), and PapersFirst (OCLC) will be used as the source of unpublished studies and gray literature.

Study selection

Following the search, all identified citations will be collated and uploaded into EndNote v.X9 and duplicates removed. Two independent reviewers will then screen titles and abstracts for assessment against the inclusion criteria for the review. Studies that may meet the inclusion criteria will be retrieved in full and their details imported into the JBI System for the Unified Management, Assessment, and Review of Information (JBI SUMARI; JBI, Adelaide, Australia).29 The full text of selected studies will be retrieved and assessed in detail against the inclusion criteria. Full-text studies that do not meet the inclusion criteria will be excluded, and reasons for exclusion will be provided in an appendix in the final systematic review report. The results of the search will be reported in full in the final report and presented in a PRISMA flow diagram. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.

Data extraction

Data will be extracted from papers included in the scoping review using the draft data extraction tool listed in Appendix II by two independent reviewers. The data extracted will include specific details about the populations, concept, context, and study methods of significance to the scoping review questions and specific objectives. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data where required. The draft data extraction tool will be modified and revised as necessary during the process of extracting data from each included study. Modifications will be detailed in the full scoping review report.

Data presentation

The extracted data will be presented in diagrammatic or tabular form in a manner that aligns with the objective of this scoping review. A narrative summary will accompany the tabulated and charted results and will describe how the results relate to the review's objective and questions.

Appendix I: Search strategy

The search date on October 17, 2019. 342 results received.

PubMed

1. "finance literacy" [tiab] OR "financial literacy" [tiab] OR finance[tiab] OR "money management" [tiab] OR "financial education" [tiab] OR "student debt" [tiab] OR "student loan" [tiab]

2. "medical student" [tiab] OR "Students, Medical" [Mesh] OR fellow[tiab] OR fellowship[tiab] OR resident[tiab] OR residency[tiab] OR "graduate medical student" [tiab] OR "graduate medical education" [tiab] OR "medical trainee" [tiab] OR intern[tiab] OR internship[tiab] OR "Education, Medical, Graduate" [Mesh] OR "Internship and Residency" [Mesh] OR housemanship[tiab] OR "house staff" [tiab] OR "house officer" [tiab] OR "medical education"[tiab] OR "Education, Medical, Undergraduate" [Mesh] OR "Education, Medical" [Mesh]

3. 1 AND 2

Appendix II: Data extraction tool

References