Assessing the Value of Completing an Internship

According to the AVMA's annual survey of graduates of the 28 veterinary medical colleges in the United States,¹ the mean full-time starting salary for year-2011 graduates who had accepted a position in private practice was $66,714, whereas the mean full-time starting salary for year-2011 graduates who had accepted a position in an advanced education program (including 696 graduates who had accepted an internship, 59 who had accepted a residency, and 44 who had accepted a position in another type of advanced education program) was only $29,116. Of the 1,537 respondents who had accepted a position by the time of the survey, 696 (45.3%) had accepted an internship, representing 26.6% of the 2,618 veterinary medical students expected to graduate in spring 2011; whereas according to data from the VIRMP and the AAEP Avenues database, > 1,000 students entered internships in 2011.^2,3 When respondents to the AVMA survey were asked their primary reason for undertaking an internship, 36.9% (254/688) indicated that they planned to pursue residency training, 36.9% (254) indicated that they wanted to practice better-quality veterinary medicine, 22.1% (152) indicated that they believed they needed more training before entering veterinary practice, and 4.1% (28) provided another reason.¹

For the 2011 AVMA annual survey of fourth-year veterinary students,¹ 799 of the 1,537 (52.0%) respondents who had accepted a position by the time of the survey had selected a position in advanced education, representing an all-time high. By contrast, for the 2001 survey,⁴ only 293 of the 1,252 (23.4%) respondents who had accepted a position by the time of the survey had selected a position in advanced education (importantly, these values represent percentages of students who had accepted a position by the time of the survey, not percentages of students expected to graduate). At the same time, the percentage of respondents seeking employment who had received one or more offers of employment decreased from 91.8% (1,463/1,594) in 2001 to only 74.3% (1,798/2,421) in 2011, and mean starting salary for respondents who had accepted a full-time position in private practice decreased from $67,548 in 2010 to $66,714 in 2011, the first time a decrease was reported for this survey. More data is needed to determine whether the decrease in the percentage of students receiving job offers is in fact leading more of them to consider internship programs. However, we believe that it is playing a role. If so, comprehensive solutions that address both internship quality and the oversupply of veterinarians must be identified.

Basic business principles indicate that the value of a good or service represents the benefit of that good or service divided by the price. A conservative estimate of the price of an internship can be calculated as the foregone earning power plus the accrued interest on outstanding student loans and other associated costs (eg, relocation costs associated with a single-year position). In this instance, the foregone earning power would be the salary one could earn in private practice minus the salary one would earn during the internship, or approximately $40,000. Given that mean educational debt for the 89.6% of year-2011 graduates who reported having debt was $142,613,¹ accrued interest during the internship year could be as much as $10,000. Thus, the price of a 1-year veterinary internship can be calculated as approximately $50,000.

Given this, the sum of the tangible and intangible benefits associated with completing an internship would have to, on average, exceed approximately $50,000 for the internship to be considered time and money well spent (ie, for the value to be > 1). The most obvious tangible benefit of completing an internship would be a subsequent increase in salary as a result of the increased clinical training received during the internship year. According to the most recent AVMA Biennial Economic Survey,⁵ however, veterinarians who had completed an internship earned a mean of $10,107/y less than did veterinarians who had graduated the same year but did not pursue an internship. Linear regression analysis of data from that survey found that completion of an internship, regardless of the type of internship (ie, academic vs private practice) or species focus of the internship, did not have a significant effect on annual veterinarian income, indicating that completion of an internship did not lead to significantly higher or lower salaries.⁶

Results of the AVMA Biennial Economic Survey⁵ do suggest that veterinarians who complete a residency earn significantly more than those who do not. In this regard, completion of an internship could be considered a cost of gaining entrance to a residency program. However, not all veterinarians who complete an internship have the desire to go into a residency program, and some of those who do wish to enter a residency program may not be accepted. In 2011, for instance, there were 906 internship positions listed in the VIRMP (compared with 822 positions listed in 2010) but only 264 residency positions (compared with 248 positions listed in 2010).

Owing to the current lack of evidence that completing an internship will result in subsequent financial benefits, the intangible benefits of an internship must be high for the internship to be considered time and money well spent. To our knowledge, however, no surveys have been done to determine whether internships are providing substantial intangible benefits for those who participate in them.

Confusion About Internship Quality

To maximize the benefits of their internship year, candidates would naturally prefer to apply only to those programs that provide a high-quality internship experience. For individuals who participate in the VIRMP, however, it generally is impossible for them to physically visit all of the programs they are interested in, and many will be matched with a program with which they have had little or no direct experience. Although written descriptions of the programs are available, there is no control over the descriptions that are provided, and the advertised program experience may not be what is provided when new interns show up.

In 2011, the AVMA Task Force on Veterinary Internships recommended more robust, standardized information disclosure for internship providers. The AAVC reviewed these recommendations and implemented some of the recommendations for the 2012 internship application cycle. Although we believe this is a step in the right direction, we also believe that the information posted on the AAVC's VIRMP website lacks adequate quality assurance to allow applicants to make informed decisions about these programs. Missing ingredients include information about the amount of mentorship supervision, the duration of work shifts, the number of emergency duty shifts interns are expected to work each week, the typical number of hours scheduled to be worked per week (and the corresponding hourly wage), the availability and quality of support staff when providing emergency care, any requirements to staff affiliated facilities and the support provided at these facilities, and whether the program requires interns to sign a restrictive covenant (and if so, the time and distance provisions of the covenant). In addition, we believe that all programs should provide contact information for former interns so that applicants can contact them for comments.

Furthermore, many current internship programs are not offered through the VIRMP. Most equine internships, for example, are listed through the AAEP's Avenues program.³ Although this database provides ample information about individual internship programs, the quality and consistency of that information, particularly with regard to compensation, benefits, and responsibilities, are quite variable, and information about whether interns are required to sign restrictive covenants is often missing.

Beyond this, an indeterminate number of internship programs exist outside the VIRMP and the AAEP's Avenues program. These programs are typically advertised in veterinary journals, through veterinary college job postings, by word of mouth, and via other marketing channels. Because there are no standards, the information provided to applicants regarding these other internship programs varies even more than the information provided for internships listed in the VIRMP or AAEP Avenues program.

Developing Model Internship Guidelines and Standards

Because the quality of internship programs currently offered likely varies quite widely and because applicants to internship programs often have limited knowledge about the quality of these programs, we believe that a system should be developed to ensure that internship programs meet minimum quality guidelines and standards and that interns receive sufficient training to justify the economic cost of the internship year. This would be analogous to the way that the AVMA Council on Education uses the accreditation process to ensure that veterinary colleges meet minimum standards for veterinary medical education and that students enrolled in those colleges are adequately prepared for entry-level positions in the profession at the time of graduation.

For example, we believe that an internship program should meet minimum standards with regard to the quality of the internship training facilities and the availability and quality of mentorship opportunities. Additional guidelines and requirements should be determined with regard to number of training weeks, core curriculum, knowledge requirements, hands-on exposure to medical and surgical procedures, and independent study requirements.

We also suggest that reasonable limits for duty hours be established. The ACGME publishes duty hour standards for physician residency and fellowship programs,⁷ and the Student AVMA House of Delegates recently passed a resolution regarding duty hours for veterinary students.⁸ Overseers of internship programs and internship providers could adapt these documents to develop veterinary internship duty hours protocols.

Accreditation Solutions

Umbrella accreditation—Within the human health-care profession, the quality of postgraduate (ie, after medical school) medical training programs is overseen by the ACGME. The ACGME is a private, nonprofit organization that evaluates and accredits residency programs in the United States through a peer-review process that is based on established standards and guidelines.⁹ Organizations that are members of the ACGME include the American Board of Medical Specialties, American Hospital Association, American Medical Association, Association of American Medical Colleges, and Council of Medical Specialty Societies.

Given the increases in the number of veterinary graduates entering internships and the number of veterinary internship programs, we believe that the time is favorable for the veterinary profession to have an ACGME counterpart. Except for the Council of Medical Specialty Societies, the veterinary profession has equivalents of all of the organizations that make up the ACGME, including the American Board of Veterinary Specialties, the AAHA, the AVMA, and the Association of American Veterinary Medical Colleges, although representatives from the AAEP, American Association of Bovine Practitioners, and Student AVMA should also be included. This group could then work to develop guidelines and standards to ensure that veterinary internships meet minimum quality standards.

Fragmented accreditation—Alternatively, internships could be accredited by designated veterinary associations and the individual veterinary specialty colleges. For example, an AAHA-certified hospital could offer an AAHA-certified general or specialty practice internship. Interestingly, an AAHA task force is currently discussing the possibility of AAHA certification of internship programs. Similarly, internship programs focused on a particular specialty could be accredited by the specialty college dedicated to the specialty. As an example, the Veterinary Emergency and Critical Care Society has recently released specific guidelines for internship programs focused on emergency and critical care.¹⁰ Potentially, the American Board of Veterinary Practitioners could certify any internship at a hospital staffed by its diplomates, just as the American College of Veterinary Internal Medicine and the American College of Veterinary Surgeons could certify internships focused on internal medicine and surgery.

Alternative Accreditation and Evaluation Methods

We believe that without action by organized veterinary medicine, student-derived rating systems for internship programs likely will emerge. Through the use of social media and other online methods, students could develop a system whereby current and previous interns rate and evaluate internships. As an example, the Veterinary Information Network has been surveying interns since 2008 and has made the results of these surveys available to senior veterinary students and respondents. Similarly, a star-based rating system similar to the rating systems used by Amazon, eBay, and Yelp could be created to allow current and previous interns to rate the quality of their internship program. Although rating systems such as these are heavily influenced by self-selection bias and other problems, a star-rating system could pressure internship providers to improve the quality of their internship programs because of concerns that veterinary students would be less likely to apply to low-rated programs.

Mandatory Internships

Currently, all new veterinary graduates with < 1 year of qualifying experience who wish to practice veterinary medicine in Oregon must obtain a permit to practice through the state's Veterinary Intern Permit program.¹¹ Importantly, the colleagues and employers of these recent graduates accept some responsibility for providing supervision and mentoring, and participants in the permit program who wish to obtain licenses to practice independently must provide verification from a supervising colleague that they have obtained sufficient practice experience. Although other states do not currently have this requirement, its adoption in Oregon raises concerns that other states may follow suit or may, at some time in the future, mandate that new veterinary graduates complete an internship prior to being allowed to practice independently. This possibility further underscores the need for an accreditation process to ensure the quality of internships that are being offered.

Conclusion

There is a gap in the continuum of excellence in veterinary education. An increasing number of veterinary graduates are entering internships without any assurance that their expectations will be met or their economic sacrifice justified. Inconsistent mentorship, unreasonable working conditions, and overly broad, restrictive covenants devalue many internships. Now is the time for the AVMA and other veterinary organizations to develop an effective system of accreditation and oversight to ensure the quality of veterinary internship programs.