In defense of veterinary internships

The May dvm360 article by Mike Dicks, PhD, titled “Internships: A tax on new veterinarians?” was enlightening and provocative. But in viewing new grads' decision to pursue an internship as primarily an economic one, he does a disservice to those universities and tertiary-care veterinary hospitals that administer internship programs, as well as the young veterinarians who seek them. 

Internships can indeed be an additional financial burden for those students who have considerable debt at graduation. What Dr. Dicks calls a “tax” may add to student debt and contribute to the increasing belief that only the economically privileged will have the opportunity to pursue a veterinary career. Since fewer than 50 percent of interns end up pursuing residencies and board certification, it is an appropriate exercise to question these interns' economic judgment.

There are a number of reasons for new grads to pursue a veterinary internship beyond specialization. Many are still undecided as to whether they are interested in general practice, emergency medicine or board certification. Others want to be able to hit the ground running when they take their first job, and still others want to increase their skill set. As Dr. Dicks noted, some believe (rightly or wrongly) that their veterinary education has not prepared them adequately for private practice.

In the same issue as Dr. Dicks' column is a news article summarizing U.S. News' periodic ranking of veterinary school programs. Interestingly, of the five schools with the highest percentage of students pursuing internships, four are ranked in the top 10 schools in the country. Dr. Dicks notes that students with lower perceptions of their competence are more likely to pursue internships. Do we thus conclude that students from some of the best schools in the country are the least competent at graduation?

Another possibility is that these schools understand the limitations present in their curricula and the benefit of an additional year of training. As many veterinarians have noted, “You learn more your first year out of vet school than in your four years in vet school.” Many of us looking back on our careers jokingly refer to our first year in practice as “007-a license to kill.” The problem is that at the time, we didn't know what we didn't know. And we would now posit that some of the self-confident students who forego internships fall into this same characterization. It strains credulity to think that new grads who do not do internships are more prepared to take a medical history, diagnose and treat disease, and interpret medical literature than those who do. Yet this is precisely what the survey responses in the AVMA's economic research seem to indicate.

In our view, students who feel prepared to practice at graduation don't know what they don't know. Supporting our belief is a 1994 study by Smeak and colleagues in Veterinary Surgery that found that those “who ranked themselves above average consistently performed below average in [surgical skill] scores. … Conversely, the student whose self assessment skill level was below average performed above average.”

In human medicine, internships are no longer required, but residencies are. The reason for this postgrad education is likely that despite four years of intensive medical school training, these new grads are simply not prepared for clinical practice. We do not hear any voices suggesting that medical schools are failing their students by not allowing them to practice right after graduation.

One of the most challenging aspects of being a veterinarian is the need for top-notch client communication skills. Being able to talk to clients about their pet's illness in a thorough yet easily understood manner, being able to discuss euthanasia and quality of life factors, learning how to address the financial aspects of our relationship with clients and their pets-these skills can make the difference between a successful veterinarian and one doomed to fail. Most interns have a rapid and complete immersion in these aspects of client communication, making them much better at this often difficult and stressful aspect of private practice.

Dr. Dicks seems to equate the on-the-job training, what he calls “a professional obligation,” with the incredibly intensive and time-consuming mentoring that occurs in a well-run internship program. Hospitals and doctors who train interns devote considerable time to educational efforts that include rounds, seminars, labs and, in some cases, clinical research, often in lieu of revenue production for the hospital. This level of mentoring, even with the best of intentions, is practically and economically impossible in most general practice settings.

Dr. Dicks also notes that the “surge of internships after 2008 may have been concentrated in private practice because owners wanted to maintain profits during the sharp decline in business.” We can speak only to the economics of our own longstanding internship program. An annual salary of $30,000, dues, licenses, and healthcare and malpractice coverage represent only part of our “costs” for an intern. In some clinical rotations such as radiology and clinical pathology, interns spend weeks generating no money for the hospital at all.

Our lost opportunity costs involve having our specialists dedicate some of their workweek to teaching, appointments prolonged by involving interns in the history and exam process, and experienced ER doctors taking time to talk floundering interns through difficult cases. This decreases the efficiency and productivity of experienced emergency doctors and specialists who accept the responsibility of training interns, and we disagree with Dr. Dicks' insinuation that internship programs are not paying a “fair wage.” Many hospitals such as ours see their internship programs as a financial “wash” when fairly evaluated.

Students considering internships are appropriately nervous about dealing with their first bloat or first proptosed eye when that pet is attached to a real, paying owner. Internships not only provide a level of clinical comfort for veterinarians but likely enhance the level of care these veterinarians provide when they take jobs after their internships. We maintain that completing an internship is roughly equivalent to five years of general practice with regard to dealing with sick and injured animals.

One factor that has not to our knowledge been studied is an internship's long-term impact on compensation. By being more efficient, seeing more cases, being able to do more procedures, requiring less mentoring and needing to refer less often, intern-trained veterinarians are likely to see greater compensation, assuming their compensation is related to production. The 2015 AVMA Report on Veterinary Debt and Income explicitly notes that the AVMA has no data “on the lifelong value added to the earning path of a veterinarian that has elected an internship versus full time employment.” This is a much more important piece of information for those considering internships because it has a potentially larger role on lifetime earnings and ability to pay off their debt. These future economic benefits may well exceed the $40,000 in lost opportunity costs that Dr. Dicks notes.

Job satisfaction is another aspect of the discussion that should not be minimized. Intern-trained veterinarians in general practice are more likely to manage complicated cases, more likely to have skills that allow advanced diagnostics to be undertaken, and less likely to have to refer cases to specialists. Interestingly, one of the factors in the AVMA data that appears most relevant to job satisfaction is “opportunities for learning and professional growth.” Surely internships would fall under such a heading.

Our experience with graduating interns is that they command $10,000 to $20,000 more in starting salary than new grads without internships. Even if we accept the AVMA data that starting salaries for intern-trained doctors are comparable to those of doctors who have not completed an internship, how do we reconcile that with the finding that these same intern-trained veterinarians are less likely to obtain employment? These two “facts” require us to conclude that a potential employer would, when given the opportunity, hire a new grad with no practice experience over a veterinarian with a year of intensive training who will need less mentoring, be more clinically proficient, and be more adept with client communications. Common sense would argue that one of these conclusions has to be wrong. The AVMA has stated that “results should not be taken to mean that internships cause unemployment,” yet the dvm360 article implies this very conclusion.

There are undeniably crummy internship programs out there, and for those practices that have looked to internships as a financial opportunity, we suggest an honest look in the mirror. But Dr. Dicks' across-the-board recommendation that new graduates “vote with their feet against this enormous tax on entering the profession” unfairly tars many wonderful internship programs that have trained some of the best and brightest in our profession.

Dr. Dicks states that his article “isn't meant to be an indictment” of internships but also concludes that “veterinarians should steer clear of internships for now.” For all the reasons above and without additional information on the long-term value of internships, this seems to be a simplistic conclusion and premature recommendation.

Drs. Gary Block and Justine Johnson practice at Ocean State Veterinary Specialists in East Greenwich, Rhode Island.