Introduction

The increasing ease of debt accessibility has changed the landscape of higher education in the US over the past 5 decades, which has grown increasingly more expensive. In human medicine, as recent as the 1960s, only 31% of medical students incurred any educational debt.¹ In 2021, this number was as high as 76% to 89%.² Although the availability of government-backed loans has made higher education more accessible to students of lower socioeconomic status and underrepresented minorities, increasing debt levels have been posited to be deterring new medical school graduates from choosing careers in primary care—a field in which substantial shortages are projected by 2034³—in favor of higher-paying specialties.⁴ Although findings are mixed, some evidence suggests that the lower income associated with primary versus specialty practice likely plays a role in this choice.⁵

In veterinary medicine, tuition fees and educational debt are also rising. The 2019 American Association of Veterinary Medical Colleges Cost Comparison Tool indicates that the total cost of a 4-year program for residents of the state in which their school is located ranges from $170,742 to $289,597 and for residents of other states ranges from $222,612 to $481,514.⁶ Also notable, the educational debt of students about to graduate from veterinary school (ie, new DVM graduates) is growing 4.5 times as fast as their starting salaries, reaching a mean of $157,146 in 2020.⁷

The veterinary profession is among the most-varied professions in terms of possible career paths; however, a trend has emerged whereby the majority of new DVM graduates are choosing to pursue private practice—particularly companion animal medicine—over population health or public practice, in which starting salaries are typically lower.⁸ This trend is important to understand given the unique contributions veterinarians could make to these fields with their training in multiple species, epidemiology, zoonotic disease, biosecurity, food safety, comparative, preventive, and population medicine, and other subjects. Indeed, Maccabe et al⁹ wrote of the fast-growing demand for public practice veterinarians in 2008, and that need is no less relevant today given current emerging zoonotic threats such as SARS-CoV-2. As Dr. Lonnie King, former director of the CDC’s National Center for Zoonotic, Vector-Borne and Enteric Diseases, wrote, “Veterinarians are essential to the detection and diagnosis of and response to these threats and are integral to the first-line defense and surveillance for bioterrorism agents.”¹⁰

To the authors’ knowledge, no studies have been conducted to expound on the relationship, if any, between career choice and educational debt in the veterinary profession. The purpose of the present study was to determine whether career choices of new DVM graduates in the US were associated with the level of educational debt they accrued during veterinary school. We hypothesized that career choice (ie, private practice, public practice, or advanced education) would be significantly associated with educational debt level, while controlling for other factors, and that educational debt and starting salary would be correlated within this population. Our primary research question was whether graduates choosing private practice or advanced education had more educational debt, on average, than graduates choosing public practice, which might in part explain the unmet need for public practice veterinarians.

Materials and Methods

The data source for the study was the annual AVMA Survey of Graduating Seniors (commonly known as the Senior Survey). This online survey is distributed to each veterinary school in the US with a graduating class to collect information on student demographics, plans for employment or advanced education, educational debt, tuition, and other variables. Fourth-year veterinary students from 28 schools were surveyed from 2001 through 2017 and from 30 schools in 2018 through 2021. The timing of the survey was approximately 2 weeks prior to anticipated graduation of senior (fourth year) veterinary students. Over the 21-year period from 2001 through 2021, responses were received from 48,864 prospective graduates who represented, on average, 89.8% of all graduates from US veterinary schools. Only respondents who reported accepting a full-time position or advanced education opportunity were included in the analyses.

Variables used for analyses included demographic variables previously shown to be associated with educational debt level¹¹ (respondent’s age, gender, marital status, and having children), zip code of veterinary school (schools grouped by the first number of the zip code to designate geographic region), graduation year; tuition level (categorized as described below), career choice (private practice, public practice, or advanced education), amount of educational debt incurred during veterinary school, and starting salary. For study purposes, private practice was considered to include food animal practice (exclusive or predominant), companion animal practice (exclusive or predominant), mixed animal practice, and equine practice. Advanced education was defined as internships, residencies, and graduate studies (eg, master’s degree and PhD programs). Grouping of these choices into a single category was necessary because the nature of the survey questions about these options changed over the study period, and this would have confounded interpretation. Public practice was defined as positions within federal government (or civil service), uniformed services, colleges or universities, state or local government, industry or commercial organizations, and not-for-profit organizations.

Tuition levels were defined as follows. First, the mean (µ) tuition fee for all veterinary schools over the study period (calculations included both state resident and nonresident tuition fees for each school each year) was determined, and then the SD (σ) was determined. The first tuition level (considered “very low”) included values < µ – 2σ, the second level (considered “low”) included values from µ – 2σ to < µ, the third level (considered moderate) included values from µ to < µ + 2σ, and the fourth level included values ≥ µ + 2σ (considered “high”).

Results

From 2001 through 2021, 86.9% (37,276/42,914) of fourth-year students at US veterinary schools who responded to the AVMA Senior Survey and answered the question reported having accepted a full-time position or advanced education opportunity (including internships and residencies) 2 weeks prior to graduation. A mean of 60.5% of these new DVM graduates reported accepting positions in private practice. Of those in private practice, a mean of 71.5% secured positions in companion animal practice, representing 43.7% of respondents securing postgraduate opportunities.

A mean of 36.2% of new DVM graduates accepted advanced education opportunities. These opportunities consisted of internship positions (76.1%), residencies (6.1%), or graduate studies (17.8%). Among internship positions, 73.0% were in private or private referral practice. Overall, 70.8% of new DVM graduates pursuing internships indicated that they planned to pursue an AVMA-recognized specialty now or in the future, and 29.2% had no such plans.

A mean of 3.3% of new DVM graduates accepted full-time positions within public practice (2.8% [n = 35] in 2001 and 3.7% [92] in 2021). Among choices in public practice, uniformed services was the most common (44.6% of those in public practice) and state and local government was the least common (2.8% of those in public practice).

From 2001 through 2021, 48,527 of 48,864 (99.3%) respondents provided data on their educational debt. On average, mean educational debt increased by $6,110 each successive year. Mean ± SD starting salaries for new DVM graduates choosing private practice increased from $44,513 ± $8,837 in 2001 to $98,705 ± $23,713 in 2021, compared with $42,316 ± $15,253 to $84,872 ± $26,213, respectively, for respondents choosing public practice and $21,779 ± $5,028 to $39,621 ± $12,763, respectively, for those choosing advanced education.

Results of multiple linear regression to determine whether career choice was associated with educational debt were summarized (Table 1). Debt level increased significantly (P ≤ 0.002) with older age, later graduation year, having children (vs no children), being divorced (vs single or never married), moderate or high (vs low) tuition level (as defined), and schools in postal code regions beginning with 4, 5, and 6 (vs 3). Debt level decreased significantly (P ≤ 0.01) with being male (vs female), being married (vs single or never married), very low (vs low) tuition level, and schools in postal code regions beginning with 0, 1, 2, and 7 (vs 3) and being married (vs single or never married). As for career choice, respondents choosing public practice had a mean of $24,913 less debt than those choosing advanced education (referent group), but the difference in mean debt between respondents choosing advanced education and private practice was not significant. Post hoc analysis showed that mean debt was also significantly (P < 0.001) lower for respondents choosing public practice versus private practice.

Bivariable analysis revealed a significant (P < 0.001) correlation (r = 0.177) between educational debt and starting salary.

Discussion

In the present study, a significant association was found between career choices of new DVM graduates and their educational debt over the 21-year study period. In addition, a significant, albeit relatively low, correlation was found between educational debt and starting salary. Although respondents were not asked which factors they considered when making employment decisions, both findings suggested that the amount of debt incurred during veterinary school has at least some influence on new veterinarians’ career paths. Notably, graduates with higher debt levels appeared to gravitate toward higher paying jobs or generally low-paying advanced education opportunities (eg, internships and residencies) that typically serve as stepping stones to higher paying jobs in fields other than public practice (eg, referral or specialty practice). Indeed, as shown in the AVMA’s 2018 Report on the Market for Veterinarians,¹² board-certified veterinarians generally earn substantially more (median annual income in 2017, $145,000; n = 285) than their non–board-certified counterparts ($88,000; 1,934).

All else held constant, new DVM graduates who chose positions in public practice reported on average $24,913 less debt than those who chose advanced education and less debt and lower starting salaries than those who chose private practice. We were unable to determine from the available data whether some of the graduates choosing public practice were obliged to do so owing to financial arrangements with their future employer. An example of such an arrangement is the full-tuition scholarship and monthly allowance available from the US Army Veterinary Corps in return for military training and reserve service.¹³ Although the surveys lacked information on specific funding sources, we were able to use data from the 2020 and 2021 surveys (that included a question about general funding sources) to establish that, on average, new DVM graduates choosing full-time employment in uniformed services (the most common selection among public practice options) had 63.4% of their tuition and fees covered by scholarships or grants, compared with a mean of 8.2% for all graduates combined during this period (P < 0.001). These post hoc findings suggested that graduates choosing uniformed services had, on average, taken advantage of substantial funding opportunities—possibly from uniformed services—at some point during their veterinary education. We do not believe this weakens our hypothesis that educational debt is associated with career choice because even if all graduates who chose public practice had their educational debt covered to some degree by uniformed services (who advertise “zero or little debt” as a means of recruitment¹⁴) or other public practice sources, those graduates were still likely drawn to public practice to at least some extent as a means of minimizing their educational debt.

The survey was also unable to tell us whether new DVM graduates who chose a path other than public practice lacked knowledge of or interest in public service positions, had concerns about what public service might entail (eg, bureaucratic environment), realized they could earn better wages finding employment in the private sector, or had other motivations. A different survey would be required to obtain this information. In their 2008 commentary on the need for public health veterinarians, Mccabe et al⁹ noted the relatively little attention the veterinary profession has paid to public practice (vs private practice). Our data strengthen this observation, with a mean of only 3.3% of new DVM graduates choosing full-time positions within public practice, compared with the minimum of 20% (500/2,500 graduates, for both public practice and population health) suggested to be necessary to fill the growing national need.¹⁵ More specifically, the percentage of new DVM graduates choosing public practice differed by only 0.9% between 2001 (2.8%; n = 35) and 2021 (3.7%; 92). Although these statistics indicate that the actual number of graduates choosing public practice more than doubled over the 21-year period, Mccabe et al indicates⁹ this number remains insufficient to meet the demand for future employers of public-health veterinarians. Hoblet et al¹⁵ noted that if new DVM graduates forgo employment in public practice (and population health), the jobs available to veterinarians in these fields will instead be filled by foreign-trained veterinarians or nonveterinarian workers, thereby reducing opportunities for veterinarians. More current information is needed in this regard to better appreciate the present demand (perceived and actual) and missed opportunities for veterinarians in public practice.

In theory, high educational debt should not be deterring veterinary students from choosing careers in public practice if such careers interest them. Mccabe et al⁹ suggested that the notion that public health jobs for veterinarians do not pay well is a myth, and previously published income data⁷ for US veterinarians support this position, at least for selected groups. In 2020, the mean salary for veterinarians in federal government positions was approximately $130,000, which is higher than in companion animal exclusive practice (approx $120,000). On the other hand, veterinarians in uniformed services earned only approximately $90,000 on average. Furthermore, pursuing a career in public service, nonprofit work, or rural practice is a proposed strategy for managing educational debt given the loan forgiveness programs available to such workers.¹⁶ The US Public Service Loan Forgiveness program, created under the College Cost Reduction and Access Act of 2007, forgives any remaining balance on student loans following 10 years of full-time work by eligible individuals in US government (federal, state, local, or tribal) or not-for-profit organizations.¹⁷ Although this loan forgiveness program is not without controversy, with only 3,376 of 180,798 (1.9%) applications for debt relief approved as of April 30, 2020,¹⁸ a new expansion of the program was recently announced, relaxing some of the previously confusing eligibility criteria and finally providing relief to thousands of borrowers.¹⁹ Students should be advised about such loan forgiveness programs early in their veterinary education to allow them ample time and opportunity to consider public practice and other fields in which veterinarian shortages have been identified, before they start applying for jobs.

The correlation between educational debt and starting salary in the present study was interesting due to the previously reported lack of correlation between tuition level—a factor associated with educational debt in the present study—and starting salary of new DVM graduates.²⁰ We considered the correlation in the present study remarkable, despite its low value, given the observed low starting salaries yet high debt (not significantly different from private practice) of people pursuing advanced education, which would have biased this correlation toward the null hypothesis (ie, no correlation). To investigate this possibility on a post hoc basis, we reran the bivariable correlation analysis to exclude new graduates who chose advanced education and found that the correlation almost doubled to 0.322 (P < 0.001). The relationship between educational debt and starting salary was not surprising since, as discussed, many students pursuing advanced education programs do so in the hopes of having higher earning potential in the future. In the long term, a correlation between educational debt and starting salary has the potential to create a homogeneous veterinary profession with less variety in career paths, thereby reducing the profession’s breadth of impact on society as a whole.

Because survey respondents were not asked about the factors they considered when accepting their first position and starting salary after graduation, the role of educational debt in those decisions could not be confirmed. This represents an important limitation to our study. If shortages in public practice and other fields are to be adequately addressed, such information would be important to collect and analyze. Another limitation was that jobs for veterinarians in public practice often require a master’s degree, clinical experience, or additional training, and it was possible that some new graduates in our study who chose advanced education or private practice would later go on to pursue a public practice position. Whether some of the included new DVM graduates were simultaneously receiving another graduate degree, such as through a combined MPH/DVM program, could not be determined from the survey.

In conclusion, we believe it is critical for decisionmakers to assess whether the availability and use of student loan programs are having negative, unintended consequences on the veterinary profession, turning new DVM graduates away from public service jobs. The social repercussions of these consequences should also be determined. If graduates are in fact motivated by debt in the pursuit of specific career paths, then investments in recruiting students of diverse career interests could prove futile if the rise in debt levels is left unresolved. We therefore recommend increasing efforts to promote loan forgiveness programs accessible to veterinarians considering or pursuing work in the public sector. Attraction of new DVM graduates to positions in public practice is not only much needed within the veterinary profession, but also targeted attraction efforts stand to present huge gains for society as we strive to understand, detect, control, and prevent threats to public and animal health—roles for which veterinarians are uniquely qualified.