There are multiple factors influencing career plans for physicians trained in the United States. At Indiana University, 1 of the largest medical schools in the nation, we decided to study some of these factors, focusing on current fellows and recent graduates of the hematology and medical oncology specialty in the United States.

We sought to evaluate the effects of student loan debt and visa status as 2 factors affecting the career choices of fellows. We also wanted to evaluate whether fellows were aware of available resources or mentorship to help them deal with these factors. To do so, we surveyed current fellows and recent fellows who graduated from 2017 to 2019 at 159 hematology and medical oncology fellowship programs in the United States. All programs included in the study are accredited by the Accreditation Council for Graduate Medical Education (ACGME).

The survey consisted of 13 questions regarding student loan debt and visa status, research experience, initial career plan, current career for graduates, the influence student loan debt and visa status had on career decision, and whether the respondent was aware of available resources or mentorship that could help them address debt and visa concerns. We used a 5-point scale, from extremely unaffected to extremely affected, to determine how much each factor influenced career choice.

A total of 220 physicians participated, 80% of whom were fellows and 20% were graduates. Thirtyfive percent of graduates reported taking out student loans during their fellowship. Of those, 40% felt their loans strongly affected or extremely affected their career choice. In addition, 93% of graduates who had student loans said they weren’t aware of resources or mentorship programs to address their loans’ effect on their career.

Forty-four percent of graduate respondents were on a J1 visa for students or an H-1B visa that allows US companies to employ graduatelevel workers in specialty occupations that require theoretical or technical expertise in specialized fields during their training. Of those, 74% of respondents felt their visa status strongly affected or extremely affected their career choice. Further, 63% of graduates who were on a visa answered that they weren’t aware of resources or mentorship programs to address visa status as a factor influencing their career options.

For the current fellows, 51% have student loans and one-third of those with loans said their loans strongly affected or extremely affected their career choice. In addition, 77% of fellows with student loans answered that they weren’t aware of resources or mentorship programs to address their loans’ effect on their career.

Sixteen percent of current fellows are on J1/H1-B visas and 66% of reported that their visa status is affecting their career choice. Adding to that, 62% of fellows who are on a visa answered that they weren’t aware of resources or mentorship programs to address visa status as a factor influencing their career options.

The 2 major career paths available for cancer doctors in the United States are academic and community practices. In academia, there are different tracks such as research, educator, and clinical. In hematology/ oncology, the focus is to build a career based on basic, translational and/or clinical research, and/or teaching. Physicians usually work at universities and major cancer centers.

Many academic oncologists find research and teaching deeply rewarding. The drawback to an academic career is that the average compensation is generally lower than in community practice. In addition, physicians in academia often have protected time for research and/or teaching, which offers some flexibility in their schedules compared with physicians in community practice. In other words, those physicians choose a career path with less pay to focus on research and/or teaching in addition to clinical duties because they have a passion for medical science.

Community practitioners, on the other hand, focus on working in the clinic. Although some community practices focus on research, usually clinical research, the majority of physicians in this setting are busy treating patients during most working days.

Hematology/oncology community practices are either hospital-employed or physician-owned groups. On average, the compensation in community practices is considerably more than in academic practice. It is worth mentioning that the greater portion of patients with cancer in the United States are treated in community practices since they are more common than academic medical centers.

Hematology/oncology fellows have the option of pursuing a career in the pharmaceutical/drug development industry. Physicians employed by pharmaceutical companies are directly involved in the development process of new drugs and conducting clinical trials. In addition, compensation at pharmaceutical companies is usually competitive but most of those opportunities are in urban and suburban areas.

From the fellows’ standpoint, student loan debt can push them toward a career with a potential higher income like in community practice, even if they would prefer to go into research and play a role in advancing cancer therapy. On the other hand, fellows on a visa are often pushed to work in community practices in underserved geographic areas due to their visa conditions. For example, fellows on a J1 visa are usually required to go back to their home countries for at least 2 years unless they agree to work in rural areas in the United States. However, a fellow working in a rural area is often unable to pursue research because the vast majority of academic practices that engage in research are clustered in urban or suburban areas.

With our survey analysis we were able to conclude that student loan debt and visa status are important factors affecting hematology and medical oncology fellows’ career paths. The majority of hematology/ oncology fellows in this survey weren’t aware of mentorship programs or resources to help them deal with those factors. Our message is that mentors at training programs need to be aware of these factors to give tailored advice to help fellows achieve their career goals.

There is a desperate need in oncology to develop more clinical trials and invent new therapies to help our patients. Because of concerns over student debt or visa status, we risk losing the talent of a group of physicians who have the ability to become investigators and significantly advance cancer therapy. When physicians are forced to make career decisions based on financial stress or immigration regulations, they may be unable to focus on research work

Al-Issa K, Rangaraju S, Al-Hader AA. Student loan debt and visa status influence on career choices for hematology and medical oncology fellows in the United States. 

. 2020;38:(suppl; abstr 11024). doi: 10.1200/JCO.2020.38.15_suppl.11024

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Investigators from Indiana University decided to study some of the factors influencing career plans for physicians, focusing on current fellows and recent graduates of the hematology and medical oncology specialty in the United States.

Karam Al-Issa, MD

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