What will you earn as a junior doctor?

United States

The Association of American Medical Colleges has compiled a report about the “gloomy” and “bleak” financial situation affecting public and private medical school graduates in the United States. They have found that tuition fees at public medical schools have risen by an “astonishing” 11.1% since 2001. Projections estimate that the debt of private and public graduates will reach $750 000 (£470 000) by 2033.13

Junior doctors in the US, known as residents, are given a stipend—a form of allowance to offset expenses. The amount of stipend varies by region and by type of hospital, but the average annual stipend for a first year resident in 2011 was $49 000. When adjusted by inflation for that year, residents took a $127 pay cut.14 The stipend is “considered a ‘living wage,’ but it is far lower pay than that of the average first year college graduate.”15

Prospective US medical students on social media sites question how residents are able to manage their finances. One user said: “Just curious how residents survive on [their average] salary . . . for 3-5 years, especially those with big loans to pay off?”16

Many US graduates choose to defer their federal loan repayments until after the completion of their three year residency. Unfortunately this deferment is associated with an accrual of interest on any amount over the $34 000 subsidised by the US government. This means that, with deferment, the current median debt of a 2006 public medical school graduate would increase from $120 000 to $151 342, and that of a private medical school graduate would increase from $160 000 to $205 707.

India

In India, the equivalent period after medical school final examinations is called the internship. As this is considered an educational training period, students undertaking their internship continue to pay tuition fees but are called junior doctors, have clinical responsibilities, and are given a stipend. The amount of monthly stipend given varies between regions, with junior doctors in West Bengal receiving 14 000 rupees (£164) a month and those in Madhya Pradesh receiving just 5000 rupees (£59).17 In comparison, a nurse in India receives between 10 000 and 50 000 rupees, depending on experience.18

Strike action over pay is common in India. In 2011, junior doctors in the state of Maharashtra went on a seven day hunger strike to demand an increase in their stipend. At that time, interns received just 2550 rupees a month. Pankaj Nalawade, president of the Maharashtra Association of Resident Doctors, said, “For a decent standard of living, a person should be earning at least 100 every day, but what they get is something between 80 and 85.”

Medical education minister Vijaykumar Gavit assured the doctors that they would be paid a higher amount. The promise went unfulfilled, however, and the doctors were told five months later that their demands were unjustifiable.19 The deal was secured only after a year long dispute that ended in May 2012.

The situation in India has led to a substantial number of doctors leaving the country after training. Among developing countries, India is the biggest exporter of trained doctors, with roughly 700 Indian medical graduates migrating to the US every year. In the US, 4.9% of doctors were originally trained in India, and in Britain the figure is 10.9%.20

At the All India Institute of Medical Sciences, the top ranked medical school in India, nearly 54% of students graduating between 1989 and 2000 left the country to work abroad. Shakti Gupta, the head of hospital administration at the institute, said that a medical student at the institute pays annual fees of about 4500 rupees but that training costs three million rupees. “I think we should ask them to come back and work in India—at least for some years,” Gupta said.21

Posts on online forums suggest that pay is one of the largest factors involved in the Indian “brain drain.” “It’s definitely a huge concern,” said one user. “The best brains in India are moving out of India as the odds of getting the same pay package in India as they are offered in countries like America [and the] UK are astronomical. Money is a big driving force for [the] brain drain.” 22

A recent decision by the Indian health ministry to require medical graduates to return to India for two years has been met with a negative reaction.21

Sub-Saharan Africa

A recent survey of 148 medical schools in 48 sub-Saharan African countries found that tuition fees are comparatively affordable, with 48% charging $1000 or less per annum.23 This is because most medical schools are publicly run and therefore supported financially by their governments. This might suggest that graduate debt is less of an issue here than for other nations.

However, 27% of domestic sub-Saharan medical graduates leave their nation of study within five years, mostly for countries outside of Africa. Many factors can explain why doctors leave their native countries, but the medical schools in the survey report that by far the biggest barrier to the retention of graduates is low wages.23

Sub-Saharan Africa bears 24% of the world’s disease burden but has only 2% of the world’s doctors. Research published in the BMJ calculated that sub-Saharan African countries with a high HIV prevalence lose $2bn a year through the migration of doctors, while destination countries benefit as they do not have to pay for the education of their medical workforce. Savings of at least $621m are estimated for Australia, $384m for Canada, $2.7bn for the UK, and $846m for the US. This amounts to $4.55bn in total.24

Concerned about the impact of the brain drain on achievement of the United Nations’ millennium development goals, members of the World Health Organization signed a resolution in 2010 to ensure the “ethical international recruitment of health personnel.”25

To deal with the problem locally, 69% of sub-Saharan medical schools require doctors to do a period of compulsory or community service after graduation. This can be paid or unpaid, meaning that some doctors are forced to work for nothing after graduation.