Financial Literacy and Wellbeing among Medical Students, Residents, and Attending Physicians in Lebanon: Results from A Nationwide Multi-Centered Survey

Thank you all for joining me today. My name is Dr. Mohammed Ali Jardaly, a family medicine physician and population health manager in Saudi Arabia. This presentation is special to me as it originated from a passion project I started during my residency. I aim to inspire you to focus on financial wellbeing, encourage you to be proactive in managing your finances, and promote organization in your financial planning.

The title of our paper is "Financial Literacy and Wellbeing among Medical Students, Residents, and Attending Physicians in Lebanon." I will be presenting the results of this nationwide, multi-centered study. I would like to thank my collaborators, Dr. Juman Antoun, Dr. Anna Saad, Dr. Hassan Doumiati, and my mentor, Dr. Isam Sharani, for their contributions to this project. It took over two years to conceptualize and conduct the research, and I am pleased that it is now published for others to learn from.

You can find me online on X (formerly Twitter) at MAJ AAP and I also host a podcast called the Lebanese Physicians Podcast. Please feel free to reach out to me. So why is a family doctor discussing finance with you today? This research is influenced by the current events in my home country of Lebanon.

My motivation for pursuing family medicine was personal - I was struggling with finances and student loans. I knew I wouldn't become wealthy in this field, but I didn't want to be in debt for the rest of my life. Graduating with over $100,000 in student loans added to the financial stress. Starting residency with low pay while preparing to get married and start a family made me realize the financial challenges ahead, such as buying a home, car, or clinic.

Talking about money was uncomfortable at first, but discussing it with friends and colleagues made me realize I wasn't alone. I noticed a lack of data on student loans outside the US, which motivated me to start a project focusing on financial wellbeing. This project was meant to be a building block for a larger initiative.

Financial wellbeing became a significant focus for me when I participated in a wellness program during my residency. The wellness director often asked us about interventions that could improve our overall wellness, sparking my interest in addressing financial health as part of a holistic approach.

The traditional wellness program included activities like yoga, hiking, pizza parties, and movie nights. I suggested to use the money spent on this program to increase our salaries instead. I believe that financial wellbeing is a crucial aspect of wellness and burnout, often overlooked in discussions. This research project aims to highlight the importance of financial wellbeing in addressing burnout. In Lebanon, my home country, there are seven medical schools.

There is one public medical school and six private medical schools included in our study. Financial literacy is not currently included in the curriculum of medical schools. Our research did not find any data on the financial debt incurred by Lebanese medical students to fund their education. The list below includes the six private medical schools we focused on in our study, along with their affiliated university hospitals.

Medical school tuition in Lebanon varies depending on whether you attend a Public or Private school. Public schools charge around $200 per month, while Private schools can range from$15,000 to $40,000 per year. These figures are subject to change annually, with some schools increasing tuition by 4$47,000 per year with a 4% annual increase.

By 2018, tuition was close to $40,000. If it continued at that rate, by 2030 it would reach$60,000. This would mean a doubling of tuition in less than 20 years, which is not sustainable. This is especially concerning given the disconnect between tuition costs and wages in Lebanon. For example, in 2009 when we started the study, the minimum wage in Lebanon was only $400 per month and the median wage was$1300 per month.

In Lebanon, the annual Minimum wage is close to $5000 and the Median wage is close to$16,000. Some medical schools are charging $40,000 for one year, making it unaffordable for many people. To make matters worse, Lebanon was hit by the worst economic crisis in October 2019. The currency was devaluated by more than 1000%.

The COVID-19 pandemic brought about unprecedented crises one after another, prompting us to revise our survey to include components that study behavior before these crises occurred. Our study was conducted in the midst of the pandemic and economic collapse, during which the Lebanese Pound lost over 90% of its value. People's savings were wiped out, social security and retirement plans were decimated, and obtaining loans became difficult. Rising prices, unemployment, and food insecurity added to the hardships faced by many. This grim situation presented both challenges and opportunities for our study, allowing us to document a sharp decline in financial wellbeing and recognize the global impact of these events.

Despite the difficulties, studying during such a crisis provided valuable insights into the effects on medical students. Our primary objective was to assess the financial literacy and wellbeing of final year medical students. We selected this group to ensure uniformity across different medical schools due to variations in curricula. This study sheds light on how crises like the COVID-19 pandemic can influence the financial situations of physicians in training and practicing physicians.

We included all residents and fellows from six private medical schools and attending physicians in the affiliated University hospitals of those schools in our nationwide study in Lebanon. Our study is ambitious, with multiple objectives for the second year. In today's presentation, I will briefly discuss the financial wellbeing of the students, residents, and physicians.

In another paper, we discussed the state of medical student loans and the impact of the financial crisis and the COVID pandemic on the financial wellbeing behavior of our cohort. The study took place within the framework of financial wellbeing, which includes multiple components that affect wellbeing. At the base level, there is the socio-economic environment and the demographics of the people.

Your socio-economic background can influence your financial wellbeing. Factors like your socio-economic status and environment play a role in this. While these are not easily changed, there are other factors that can be modified, such as Financial Knowledge. There is a validated Scale used to measure this. Additionally, Financial attitude and behaviors also impact financial wellbeing, measured by validated tools. Financial wellbeing is influenced by socio-economic factors, knowledge, attitudes, and behaviors. There is a validated Scale to measure financial wellbeing as well. High financial wellbeing indicates financial resilience and the ability to meet commitments. This framework was developed by Kempson et al. in 2017 and guides our survey approach. The survey is comprehensive, covering different components of financial wellbeing with 51 questions divided into six sections. It only takes 10 minutes to complete.

We sent the email to all final year medical students, residents, fellows, and attending physicians at six affiliated medical schools and their medical centers in Lebanon. Initially, we hoped for a 10% response rate, but we were pleasantly surprised to receive a 20% response rate. This is considered a high rate compared to other national surveys, which typically only reach 5%. In total, 330 individuals took the time to respond to our survey despite the challenges posed by the COVID pandemic and financial crisis.

The survey was answered by a younger cohort, as we specifically targeted students, residents, and attending physicians in medical centers.

The survey results showed that 20% of participants were students, 44% were residents, and 34% were attending. This distribution was close to a third for each group. The sample was representative, with a mean age of 35 and a standard deviation of 13, and nearly equal gender distribution. Most respondents reported being middle to upper middle class, but two-thirds mentioned having at least one loan.

These demographics could be predictors of financial well-being, which will be discussed later. The next section of the survey focused on financial literacy, using the industry standard Big Five questions. Let's see how you're doing.

The following are the five questions that determine your Financial Knowledge, based on industry standards. This survey has been validated on the general population and various professionals. Let's see if you can answer these questions correctly.

First question: If you have $100 in savings with a 2$102, exactly $102, or less than$102?

Second question: If the interest rate on your savings account is 1% per year, but inflation is 2% per year, how much would you be able to buy with the money in this account after one year? More than today, exactly the same as today, or less than today?

Third question: If the interest rate rises, what would happen to bond prices? Would they rise, fall, or stay the same?

Fourth question: When buying company stock, does it usually provide a safer return than a stock mutual fund? True or false?

Fifth question: A 15-year mortgage typically requires higher monthly payments than a 30-year mortgage, but the total interest paid over the life of the loan will be less. True or false?

These questions are part of a sample Financial Literacy questionnaire, and the correct answers are as follows.

For the first question, the answer is more than $102. For the second question, the answer is less than today. The third question should result in a fall. The fourth statement is false, and the fifth statement is true. How many questions did you answer correctly? Did you get two out of three, three out of five, or five out of five? Don't be discouraged if you did not get all the answers correct, as the passing grade is three out of five.

The results of the responses are as follows: Only 9% of students received a passing grade. For residents, 26% achieved a passing grade, and for physicians, 64% received a passing grade.

There is variation depending on the group. However, when looking at all the groups together, they performed worse than the general Lebanese population. The study was conducted on the general Lebanese population and compared to physicians in our group, both current and future, they performed worse than the general public. This highlights an oxymoron in financial literacy within this highly educated and literate population.

Only 1/4 of the participants were able to answer three or more questions correctly. They performed poorly in terms of diversification of risk. Another question about mortgages was saved for later, as well as one about housing prices in Lebanon. Surprisingly, 40% of participants falsely believed that prices could not fall during an economic collapse. This highlights the importance of not relying solely on self-taught financial literacy. There seems to be a general denial about the state of the economy, indicating a need for financial education in medical school curriculums. This data is from an OECD survey conducted on the German population in Lebanon.

I find it interesting to share the results of our therapy on financial attitudes and behaviors. However, the most important aspect we were focusing on is financial wellbeing. Here is a summary of the financial wellbeing before the crisis.

During the crisis, it was observed that attending physicians had better financial wellbeing compared to students and residents. Despite having low financial knowledge, attending physicians still had relatively high financial wellbeing. This indicates a dissociation between knowledge and wellbeing among physicians. A diagram best visualizes this difference in scores. Before the crisis, students and residents had a medium-high financial wellbeing score while attending physicians had a high score. However, during the crisis, both students and residents shifted to a medium-low financial wellbeing scale.

The Financial Crisis and the Covid-19 pandemic have been confounding factors affecting our survey objectives. To assess the impact of these crises, we adjusted our survey goals accordingly. Conducting an online survey was the most practical choice during the pandemic, allowing for easier data collection and analysis.

We focused on private schools with a higher burden of student loans, excluding public schools. In private schools, we found that 50% of students come from households making over $10,000, putting them in the top percentile nationally. We did not study students from lower socio-economic backgrounds in public schools. We excluded premedical and preclinical medical students due to varying curriculums in Lebanese medical schools. We only included final year medical students for consistency. Attendings working in the private sector with their own clinics were also excluded. We did not have a comparison group from the local population for the tools used, except for financial literacy. The financial crisis and COVID-19 pandemic were considered complex factors. This led us to question if medicine is a career only for the wealthy, which we discuss in our second paper. This brings to mind a quote from Atul Gawande.

No one teaches you how to think about money in medical schools or residency. But from the moment you start practicing, you must think about it. This includes the moment you enter medical school and take on student loans if your family cannot support you. In the USA, many students are taking financial loans, and there is a global trend towards privatizing medical schools. Even in countries like the UK, where tuition was traditionally low, costs are increasing, leading to more student loans and impacting the workforce.

We need to have a larger discussion about the role of finance in medical education, starting at the student level. Student loans have significant implications on residency and career choices, with extensive literature on the subject. The first step in solving this issue is recognizing that there is a problem. As a community of healthcare workers and providers, we must acknowledge the financial challenges in the medical profession and be proactive.

A study in 2019 highlighted the oxymoron of financial illiteracy in a highly educated population, inspiring the need for change.

The authors concluded that despite being highly literate, there is a concerning level of financial illiteracy. In today's industrialized and globalized society, having financial literacy is essential. Lazar Gal, a pioneer in financial literacy, emphasizes that it is necessary for making sound financial decisions and being a responsible citizen. This applies not only to doctors and physicians but to everyone in modern society.

Studying financial literacy has real world benefits, especially in the healthcare field. It is important as it correlates with burnout, which in turn affects patient safety.

I encourage everyone to improve their financial literacy, including students, residents, and attending physicians. This can be achieved through financial literacy training, advocacy, support groups, and resilience groups within the medical community. Protections should also be put in place for vulnerable populations. It is important to promote diversity, equity, and equality in the medical workforce and to reform the overall system. The current system, not only in Lebanon but also in other countries, is undergoing significant changes in medical education and healthcare. Universal healthcare and education, including medical education, should be a priority. The financial recession of 2007 highlighted the impact on doctors, and efforts such as hazard pay for responders during the COVID-19 pandemic are steps in the right direction. Loan forgiveness for medical students, free housing for residents and students, and financial assistance during times of crisis should also be considered.

It is important to consider finance as a secondary job after medicine. Taking the time to educate yourself on finance and business is crucial, as being solely focused on clinical work is not sustainable. Having some financial responsibility and action points is necessary. To further your financial education, there are several books, online resources, podcasts, and YouTube channels available for learning. I encourage you to start by expanding your knowledge in this area and then work towards implementing changes and organization in your financial responsibilities.

I spend a lot of time on Twitter reading about Burnout and Continuing Financial Education. Here are four books I recommend reading:

• "Personal Finance for Dummies" by Eric Tyson
• "The Bogleheads Guide to Investing" by Taylor Larimore et al
• "How to Think About Money" by Jonathan Clements
• "The White Coat Investor" or "Financial Boot Camp" by Jim Dahle

For a quick and easy read, check out "If You Can" by William Bernstein, which is a 16-page free PDF available at https://www.etf.com/docs/IfYouCan.pdf

Make sure to put a written financial plan in place and don't hesitate to seek help if needed.

My main message for you today is to be an agent of change. I would like to express my gratitude to everyone who contributed to making this research possible. I am thrilled that it has been published and is now available to the public, as it has been a project that I am very passionate about. If you are interested in collaborating on a similar study in your own country, please feel free to contact me. You can reach me via email, Twitter, or the podcast. Let's work together to bring about positive change.

My take home message for you today is to be an agent of change. I want to thank everyone who contributed to making this research possible. I am thrilled that it is now published and available to the world, as it has been a passion project of mine. If you are interested in collaborating on a similar study in your home country, please contact me through email, Twitter, or the podcast.