Meeting Ourselves Coming and Going: Maldistribution of Veterinarians
Eden Myers, DVM, MS
Ryan G. Gates, DVM
"...it could be worse. Consider the plight of veterinarians. The average tuition and expenses for a veterinary degree at a private school has doubled in the last 10 years...yet their pay remains moribund..."Overview
--Steven M. Davidoff, "The Economics of Law School."1
The veterinary profession is currently suffering the effects of decades of decisions based on unexamined beliefs and subjective surveys rather than objective, statistically valid evidence. With respect to workforce needs and career opportunities, we are operating in the dark. There are signs of potential improvement, most notably the 2013 AVMA-IHS Veterinary Workforce Study . We must improve qualitatively, though, if we are to better the economic condition of our profession- which we must do to maintain the quality of service we provide to society.
In this series of posts, we examine policy decisions made in the absence of sound data. The series consists of:
- Meet the Pink Elephant in the Room: Gender in Veterinary Medicine - 5/2/13; PDF
- Meeting Ourselves, Coming and Going: Maldistribution - 5/13/13; PDF
- Meet Big Veterinary: How the AAVMC Could Serve Students Better - 5/17/13; PDF
- Meet Big Veterinary: How the AVMA Could Serve Its Members Better - 5/22/13; PDF
- Meet Big Ed: Schooling Veterinarians is Big Business - 6/12/13; PDF
Meeting Ourselves, Coming and Going: Maldistribution of Veterinarians
As professionals we do best when we make evidence based decisions. The same holds true for us as a profession as well. Gender disparity is one issue the profession is unable to address due to a lack of evidence.2 Another is supply and demand. Do we have an oversupply? Underdemand? How about a worst case combination of the two?
Oversupply or Underdemand?
Do we have a shortage of veterinarians? To fully appreciate the answer to this question, and how we've arrived at the answer, we must move in chronologic order.
In 2011, the American Association of Bovine Practitioners (AABP) concluded:
...there is not currently a shortage of veterinarians for rural food supply veterinary private practice.... lack of available veterinarians is no longer an issue... there remain underserved rural areas across the country that may not be able to sustain a veterinary practice......the perception by veterinary schools and the public that there continues to be a shortage of rural practitioners is leading to increased class sizes at veterinary schools and the creation of new veterinary schools.3 (emphasis added)
AABP's conclusions are supported by fundamental economic principles.4 In a free market economy, service providers locate where there is adequate incentive. Thus we infer that a lack of veterinary presence in an area is due to a shortage of incentives- financial, social or otherwise. For decades a different inference had been made: that a lack of veterinarians in an area is due to a shortage of veterinarians.5
We find very little sound evidence documenting shortages. A shortage of veterinarians had been the interpretation given to:
- a normal distribution of veterinary practitioners in California,6
- a decrease in hours worked by veterinarians,7
- the lack of utilization of veterinary care by the public.8
In the first example, the fact that half of all counties in California had fewer veterinarians than the average number of veterinarians per county in California is interpreted as half of all counties having a shortage of veterinarians and therefore being underserved. Half the values in a dataset being below average better fits the criteria of normal distribution than of a shortage. It could, in fact, be taken as de facto evidence of lack of demand for veterinary services in those areas, indicating the need to decrease production of graduate DVMs. This is the exact opposite of the interpretation used to justify policy decisions that instead increased the number of veterinarians.
In the second example, a decrease in hours worked per veterinarian is used as evidence of shortage of veterinarians. What is more likely is that there was a shortage of work to be done in those hours or a shortage of money to pay veterinarians to work those hours. Again, however, an interpretation favorable toward creating more veterinarians was used.
In the third example, the study concluded that there weren't enough veterinarians to provide care because half of all pets receive no veterinary care. That is like concluding there aren't enough jewelers to provide diamond rings because half of us don't have diamond rings on our fingers.
Such misinterpretations received widespread coverage.9,10 Schools responded to this publicized perception of shortages by increasing recruiting efforts and class sizes. The increase in applicants created by aggressive recruiting was then used as justification for further expansion of class sizes.11
The steady increase in class size has resulted in a tsunami of new trainees entering the market. Recently, schools have expanded by 16%, 33%, even 71%. Total enrollment in US programs is up 9% over the past four years.12 No data have been released regarding enrollment at veterinary schools outside the US, not even by those institutions which are AAVMC members13 despite the fact that accreditation of such programs has been a source of bitter discord within the profession for the past two years.
| Table 1: Average Veterinary Tuition14 |
Graduates of accredited programs outside the US may incur lower costs than those attending US schools. Meanwhile graduates from unaccredited programs, denied access to federal student loans, potentially incur larger debt loads due to higher interest rates on private student loans in their debt portfolio. New graduates of all programs increasingly find themselves trapped between a Scylla and Charybdis of rising tuition and stagnant compensation, worried that they will not find employment that will pay them enough to pay back their loans.15
Employment: Where the Rubber Meets the Road
Of course only the lucky few even get the chance to feel so trapped. An increasing majority of veterinary graduates report not having a permanent job in the field at graduation. The most recent in a string of highly anticipated, AVMA-commissioned workforce studies seemed to confirm what so many veterinary practitioners had been saying for years,
"Market indicators suggest excess capacity at the national level to supply veterinary services. Recent trends include falling incomes of veterinarians, falling rates of productivity (using various measures), and increased difficulty for new graduates to find employment."
16
We submit that this has been an observable trend and that its impact over time is undeniable- the job market is changing dramatically. We reject the notion of overcapacity and underutilization, however, as this implies the market should meet the supply rather than the other way around.
Take, for example, an imaginary scenario where the authors wave their magic wand and instantly create 90,000 butchers. Leaving the issue of beef, poultry and pork supplies aside, imagine then that after one year the authors complained that not enough of the American public was adequately utilizing the services of the additional butchers and lamented the fact that the butchers in business prior to the creation of the additional 90,000 butchers had seen a decline in utilization. There is little doubt that intelligent minds would focus on the oversupply of butchers. If the authors then claimed before these intelligent minds that there was not, in fact, an oversupply of butchers, but rather an underutilization of butchers on the part of the American public, the authors would be dismissed as crazy. We would never even get the chance to suggest a marketing campaign to encourage Americans to further patronize their butcher, perhpas by dropping prices to increase sales volume. We challenge the reader to itemize how this imaginary scenario is different from what we are enduring at the hands of veterinary medicine and veterinary medical education. Meanwhile the supply of veterinarians in America continues to increase.
Figure 1.17-36 |
This graph (Fig. 1) contains the best data available on veterinary new graduate employment. It is drawn from the data collected annually by AVMA surveying those students expected to graduate from US colleges of veterinary medicine. However, the dataset is seriously flawed- by a small sample size that has no proven correlation to the overall population, by a flat or dropping response rate and by both self-reporting bias and self-reporting error.17-21 This data, while useful for assessing trends, is insufficient for constructing effective interventions to alter those trends.
One of the series' authors is Karl Wise, Ph.D., current AVMA Associate Executive Vice President and former Director of Information Management and of Membership and Field Services. He assured us almost a year ago that, "Your idea to survey veterinarians after the first year to gather compensation data is one of the goals"37 of the AVMA's data gathering efforts. Following a cohort over time to assess their economic welfare should not be a goal which has to be elucidated under public prodding by disgruntled, poorly served, former members.
Yet the first step toward at least preparing to realize this goal was taken by AAVMC in February 2013 with the release of a dataset showing some very basic categorical employment data of recent graduates.38 This open, data driven attitude is also evident in the recently released workforce study.39 The AVMA says the collection of data in a scientific manner is central to the organization's purpose:
"CORE COMPETENCY: Serving as a science-based information resource for the veterinary medical profession and the public"
--AVMA 2012-2015 Strategic Plan40
We submit that there is no area that ought to be more of a priority than that of our own profession. Without objective, timely, comprehensive and relevant information, prevet students cannot evaluate the soundness of a career in veterinary medicine. Without objective, timely, comprehensive and relevant information, admitted and graduating students cannot construct accurate budgets that enable them to stay afloat as they begin their careers. Without objective, timely, comprehensive and relevant information, those guiding the profession cannot know which direction to steer.
Figure 2.17-36,41,a |
Anecdotally, many of our students and freshly minted colleagues are battling anxiety and depression over their high post-graduate debt and low compensation.b,42 Faced with elevated costs of a degree and depressing earnings, many desirable candidates may eschew veterinary medicine for other careers.43
Equally likely is that while new graduates fill the practitioner pool faster than ever, the pool that they are entering is draining more slowly as existing practitioners defer retirement to recover from their losses in the Great Recession. One large practice brokerage affirmed that anecdotally this seems to be the case.c
To briefly reprise the gender shift, the brokerage reports roughly half the clients seeking to purchase practices in today's market are female, while half of those selling are female.d As far more than half of all graduates are female, and far fewer than half of all existing practice owners are female, the gender disparity in practice ownership appears to be growing. What implications does this growing imbalance have for the continuing impact of gender on the conduct of veterinary medicine?
While practice succession is clearly occurring, we simply have no data on how the shifting gender composition of the profession may be affecting that. We don't even have a publicly available source of data on the rate of veterinary withdrawals from practice via death, retirement or other reasons. We don't know how many veterinarians leave practice every year, or have a calculation from real world data of how long the average veterinary career is so we could estimate that number with any confidence. Just as we don't know how gender may be affecting the rate of veterinarians leaving the workforce, we have no assessment of how the recession is affecting it. We don't know if or how many veterinarians have put off retirement recently.
Anecdotally, some practitioners who sell their practices continue to provide service, creating competition their practice buyers were not expecting,e and some practitioners who would like to retire feel they cannot do so as their practices have lost so much value. The existing central documentation of practice sales data, VeterinaryMLS.com, remains poorly populated. To leverage the most information out of available data, this database of practice sales could be correlated with school collected demographic data transmitted via national licensing exam identification through state licensure databases to track the impact of such demographic factors as age, gender, race, school and background on the patterns of such transactions over time.
In conclusion, we do not know how many veterinarians there are, where they came from, what they gave tangibly and intangibly to pursue the profession, what they do, how much they get paid, or where they are located. This is despite the fact that the data already exists. Without a system to generate such basic information through coordination of existing data, we cannot quantify or qualify the capacity to provide veterinary services. If we want to get out of the deep water we're in, and keep ourselves from getting everybody else into similar straits again in the future, the profession will invest in constructing such a system.
Footnotes
(a) IPEDS Tuitions. Data collected by searching for 28 veterinary colleges with variable set for fees and charges for DVM program. Available at:
(b) Givens, D. Personal telephone communication with Myers, E. 18 August 2012. Givens is the Interim Associate Dean of Academic Affairs at Auburn University's College of Veterinary Medicine.
(c) McCormick, DF. Telephone interview with Gates, RG. 7 Nov 2012. McCormick is a Charter Member of Association of Veterinary Practice Management Consultants and Advisors (AVPMCA) and is currently the Immediate Past President.
(d) Ibid.
(e) Whitney, L. Personal communication via internet. Whitney recounted her own experience with a veterinarian attempting to breach the non-compete clause in their contract post-retirement.
References
(1) Davidoff, SM. "The Economics of Law School." Deal B%k, 24 September 2012. Web. Accessed: 11/13/2012. Available at: <http://dealbook.nytimes.com/2012/09/24/the-economics-of-law-school/>
(2) Myers, E., DVM, MS; Gates, R.G., DVM. "Meet the Pink Elephant in the Room: Gender in Veterinary Medicine." 5 May 2013. Web. Accessed 5/2/2013. Available at: <http://www.justvetdata.com/meet_the_pink_elephant_in_the_room_gender_in_veterinary_medicine>
(3) Summary Opinion of AABP Ad Hoc Committee on Rural Veterinary Practice, May 2011. Web. Accessed: 1/13/2013. Available at: <http://www.aabp.org/resources/pdfs/Summary_Opinion_of_the_AABP-Rural_Vet_Practice-5.19.11.pdf>
(4) Smith, A. Wealth of Nations. 1776. especially Book 1., Ch. 1, "Of the Division of Labour," for elaboration on this philosophy.
(5) Brown, E. "Here we go again." Externs On The Hill. 16 September 2008. Web. Accessed: 1/13/2013. Available at: <http://www.externsonthehill.com/2008/09/here-we-go-again/> This blog identifies a meeting at the USDA to discuss the National Veterinary Medical Service Act's Veterinary Medicine Loan Repayment Program. Of specific note is the acknowledgement, "The purpose of the meeting was to open up a public forum to discuss how to define these underserved areas."
(6) Final Report of the Health Sciences Committee -- November 2004: an update to the Report of the Universitywide Health Sciences Committee - Subcommittee on Veterinary Medicine: Veterinary Medicine- An Overview of Professional Education and Assessment of Future Workforce Needs in California. p. 3. Web. Accessed: 1/3/2013. Available at: <http://www.ucop.edu/health-sciences-services/_files/vet_medicine.pdf>
(7) Veterinary Medical Education And The University Of California, Final Report of the Health Sciences Committee. Projected Workforce Needs, Page 5. November, 2004. Web. Accessed: 1/13/2013. Available at: <http://www.ucop.edu/health-sciences-services/_files/vet_medicine.pdf>
(8) Bayer HealthCare LLC, Animal Health Division, Bayer Veterinary Care Usage Study. Web. Accessed: 1/13/2013. Available at: <http://www.bayer-ah.com/nr/45.pdf>
(9) Jacob, S. "No One Else for Animals, So Retirement Must Wait." New York Times. 31 March 2012. Web. Accessed: 12/16/2012. Available at: <http://www.nytimes.com/2012/04/01/us/a-shortage-of-rural-veterinarians-means-retirement-must-wait.html>
(10) Mach, A. "Alarm over Rural Veterinarian Shortage." ABC News. 12 May 2011. Web. Accessed: 12/16/2012. Available at: <http://abcnews.go.com/Health/alarm-rural-veterinarian-shortage/story?id=13573184#.UM0XVXPjn84>
(11) Projecting the Need for Veterinary Medical Education in Texas: A Report to the Texas Legislature, January 2009. Web. Accessed: 1/13/2013. Available at: <http://www.thecb.state.tx.us/Reports/PDF/1701.PDF>
(12) AAVMC Annual Data Report. 2011-2012. Web. Accessed: 1/13/2013. Available at: <http://www.aavmc.org/Public-Data/Annual-Data-Report.aspx>
(13) AAVMC Members. Accessed 3/4/2013. Available at: <http://www.aavmc.org/aavmc-members/full-member-listing.aspx>
(14) Costs to obtain a 2016 DVM. Data compilation by Myers, E. Web. Accessed 3/4/2013. Available at: <http://www.justvetdata.com/2016_tuition_sheets>
(15) Segal, D. "High Debt and Falling Demand Trap New Vets." New York Times. 23 February 2013. Accessed 2/24/2013. Available at: <http://www.nytimes.com/2013/02/24/business/high-debt-and-falling-demand-trap-new-veterinarians.html>
(16) Center for Health Workforce Studies. 2013 U.S. Veterinary Workforce Study: Modeling Capacity Utilization. vi. Accessed 4/23/2013. Available at: <http://d3n8a8pro7vhmx.cloudfront.net/eden/pages/82/attachments/original/1366811373/AVMA-IHS_2013_US_Veterinary_Workforce_Study.pdf?1366811373>
(17) Shepherd, AJ. "Employment, starting salaries, and educational indebtedness of year-2008 graduates of US veterinary medical schools and colleges." J Am Vet Med Assoc, 2008;233:1067-1070
(18) Shepherd, AJ. "Employment, starting salaries, and educational indebtedness of year-2009 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 2009;235:523-526
(19) Shepherd, AJ. "Employment, starting salaries, and educational indebtedness of year-2010 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 2010;237:795-798
(20) Shepherd, AJ; Pikel, L. "Employment, starting salaries, and educational indebtedness of year-2011 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 2011;239:953-957
(21) Shepherd, AJ; Pikel, L. "Employment, starting salaries, and educational indebtedness of year-2012 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 2012;241:890-894
(22) "Employment, starting salaries, and educational indebtedness of year-1993 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 1993;203:1687-8
(23) "Employment, starting salaries, and educational indebtedness of year-1994 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 1994;205:1687-1688
(24) "Employment, starting salaries, and educational indebtedness of year-1995 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 1995;207:1290-1291
(25) "Employment, starting salaries, and educational indebtedness of year-1996 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 1996;209:2022-2023
(26) "Employment, starting salaries, and educational indebtedness of year-1997 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 1997;211:1519-1520
(27) "Employment, starting salaries, and educational indebtedness of year-1998 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 1999;214:488-940
(28) "Employment, starting salaries, and educational indebtedness of year-1999 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 1999;215:1783-1784
(29) "Employment, starting salaries, and educational indebtedness of year-2000 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 2001;218:710-712
(30) Wise, JK; Gonzalez, ML. "Employment, starting salaries, and educational indebtedness of year-2001 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 2002;220:179-181
(31) Wise, JK. "Employment, starting salaries, and educational indebtedness of year-2002 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 2003;222:312-314
(32) Wise, JK; Shepherd, AJ. "Employment, starting salaries, and educational indebtedness of year-2003 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 2004;224:212-215
(33) Shepherd, AJ. "Employment, starting salaries, and educational indebtedness of year-2004 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 2004;225:1677-1679
(34) Shepherd, AJ. "Employment, starting salaries, and educational indebtedness of year-2005 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 2005;227:1084-1086
(35) Shepherd, AJ. "Employment, starting salaries, and educational indebtedness of year-2006 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 2006;229:1087-1089
(36) Shepherd, AJ. "Employment, starting salaries, and educational indebtedness of year-2007 graduates of US veterinary medical colleges." J Am Vet Med Assoc, 2007;231:1813-1816
(37) Wise, JK. Web comment. "JAVMA News Express: Study examines veterinary workforce needs." 26 June 2012 12:43pm. Accessed 1/3/2013. Available at: <http://atwork.avma.org/2012/05/30/javma-news-veterinary-workforce-study/#comments>
(38) Association of American Veterinary Medical Colleges. "Survey of Recent DVM Graduates of Schools and Colleges of Veterinary Medicine in the United States." Accessed 4/26/2013. Available at: <http://www.aavmc.org/data/images/research/aavmc%20data%20reports/aavmcsurveyofrecentdvmgraduates.pdf>
(39) Center for Health Workforce Studies. "2013 U.S. Veterinary Workforce Study: Modeling Capacity Utilization." vi. Accessed 4/23/2013. Available at: <http://d3n8a8pro7vhmx.cloudfront.net/eden/pages/82/attachments/original/1366811373/AVMA-IHS_2013_US_Veterinary_Workforce_Study.pdf?1366811373>
(40) American Veterinary Medical Association. Strategic Plan 2012-2015. 7 June 2011. Web. Accessed 1/3/2013. Available at: <https://www.avma.org/About/Governance/StrategicPlanning/Documents/strategic_plan_2012-2015.pdf>
(41) Social Security Administration website. Average Wage Index. Web. Accessed: 1/13/2013. Available at: <http://www.ssa.gov/oact/cola/awidevelop.html>
(42) Skipper GE, Williams JB. Failure to acknowledge high suicide risk among veterinarians. J Vet Med Educ. 2012 Spring;39(1):79-82. Web. Accessed: 2/5/2013. Available at: <http://www.ncbi.nlm.nih.gov/pubmed/22433743>
(43) Multiple Authors. "NY Times article on vet med profession." Online posting. 23-24 February 2013. Web. Accessed 3/5/2013. Student Doctor Network. Available at: <http://forums.studentdoctor.net/showthread.php?t=986670&referrerid=385472> Of particular interest are posts #22 and #33, where students acknowledge considering alternatives to veterinary medicine because of the economic climate.