CASE STUDIES IN TRAINING AND EDUCATION
Financial Education for Radiology
Residents: Significant Improvement in Measured
Financial Literacy After a Targeted Intervention
Mitchell Boehnke, MD, Sajal Pokharel, MD, Eric Nyberg, MD, Toshimasa Clark, MD
PROBLEM
Financial literacy is an important
concept that has direct bearing on
individuals’ behavior and financial
outcomes [1]. It is particularly
relevant for students and trainees, as
cumulative student loan debt is at
record levels. For instance, in 2016,
student loan debt for Americans
reached $1.31 trillion, credit card
debt $779 billion, and mortgage
debt $8.48 trillion [2]. Moreover,
median debt for medical school
graduates in 2015 was $180,000
[3]. Despite these staggering
numbers, disproportionately lower
financial literacy has been
demonstrated in numerous groups,
including those with lower
educational attainment, younger
age, female gender, and African
American and Hispanic ethnicity
[4]. This lack of financial literacy
has quantifiable effects, resulting in
households demonstrating lower
financial literacy shown to have less
wealth, to be less likely to plan for
retirement, to be less likely to invest
in the stock market, and to be more
likely to accumulate debt with high
interest rates [4].
Not only have these findings
been demonstrated in the general-
ized population worldwide but they
also pertain directly to radiology
residents. One study demonstrated
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that medical interns had rates of
financial literacy on par with those of
the general population [5,6]. Indeed,
financial literacy has particular
relevance to medical trainees
because financial stressors are
correlated with burnout [7,8]. One
group found that medical students
in their cohort who had more than
$100,000 in debt had an odds ratio
of 1.47 for suicidal ideation
compared with medical students
with less than $49,999 in debt [9].
Another group found that financial
stress during the first year of
medical school was a significant
predictor of burnout symptoms
exhibited in the third year of
training [10]. The association
between financial stress and
burnout in medical trainees is not
limited to the United States, as
similar correlations have been
shown in New Zealand despite
their junior house staff having
significantly lower absolute debt
burdens compared with those in
the United States [11].
Interventions with the goal of
improving financial literacy have
been developed, although the evi-
dence suggests that the effectiveness
of such interventions declines dur-
ing the time between education and
action [12]. One group examined
the effect of a 90-min seminar on
the financial literacy and behaviors
of a class of medical interns in Cal-
ifornia. They found that after the
seminar, interns made changes in
allocation of tax-deferred retirement
savings [6]. We believe that we are
the first group to assess the
effect of a similar intervention on
the financial literacy of radiology
residents.
WHAT WE DID
We reviewed the literature to isolate
the key concepts on which to focus
our financial literacy survey instru-
ment. An analysis by Huston [13] of
71 prior surveys of financial literacy
emphasized four main topics:
money basics (eg, the time value of
money and numeracy), investing
(eg, stocks, bonds, mutual funds),
borrowing (eg, mortgages and
consumer debt), and protecting
resources (eg, insurance) [13].
Using these topics as a basic
framework, we created a pre- and
posttest pertaining to financial
literacy targeted specifically to
radiology residents, with domain-
specific content added including
discussion of student loan forgive-
ness programs such as Public Service
Loan Forgiveness. To test retention
of knowledge, we planned a 6-
month follow-up test using the
same list of questions.
1
 We obtained institutional review
board approval of our survey in-
strument and our plan to administer
the survey to a representative sample
of radiology residents and fellows at
our institution. Particular care was
made in the materials to emphasize
that the results of this survey would
not be used in the residents’ formal
rotation evaluations and that partic-
ipation was entirely voluntary. We
created a 60-min noninterpretative
skills lecture covering the core
financial literacy topics from the
survey in more depth. This presen-
tation is available from the corre-
sponding author upon request and
was distributed via e-mail to at-
tendees after the lecture. All resi-
dents and fellows onsite were invited
to the presentation. Specific topics
covered in the lecture included the
time value of money, mortgages,
investment, tax-preferred retirement
vehicles, student loan forgiveness
programs, life insurance, and
health insurance. Pre- and posttest
survey questions are presented in
Appendix 1.
OUTCOMES
A total of 23 residents and fellows
attended the resident finance lecture,
with 3 declining to complete the
Fig 1. Percentage of correct answers on the pretest, posttest (immediately after the
financial education lecture), and 6 months after the administration of the lecture.
2 Journal of the American College of Radiology
pre- and posttest evaluations. There
were eight knowledge-based ques-
tions assessed on both the pre- and
posttests, which were answered
correctly 60.0%  25.3% on the
pretest and 84.8%  15.8% on the
posttest. A 6-month follow-up test
was made available through an
online survey using the same
eight knowledge-based questions
(Appendix 1). A total of 7 of the
original 20 respondents responded
to the survey and answered
76.8%  20.1% of the questions
correctly. A graphic representation
of these results is shown in Figure 1.
Although our data are limited
because of the small sample size, our
results are concordant with the
literature: a targeted intervention can
help increase basic financial literacy
among radiology residents when
measured in the short term. The
evidence suggests that the effective-
ness of such a strategy decreases with
increased time between intervention
and action. However, our in-
tervention’s effectiveness may be
amplified in that it may have
increased these subjects’ self-
awareness about their lack of
knowledge in this domain and,
through this, inspired a course of
subsequent self-directed learning
[12]. Relevant to this is that on the
posttest, 13 of 20 respondents
answered that they “definitely will”
and 5 of 20 respondents answered
that they “probably will” apply
strategies and knowledge acquired
during the lecture to their own
finances.
General financial education pro-
grams have been developed in the
past, with varying levels of success in
affecting future financial behavior
and success. One meta-analysis
showed a small effect of finance
education on future financial
behavior [12]. Timing of the
information may be important; one
study suggested that providing
prepurchase counseling (eg, before
a home purchase) may have a
greater chance of affecting
behavioral change [14]. Applying
this to radiology resident education,
offering on-demand educational
materials on student loan refinanc-
ing, mortgage basics, or insurance
products may be helpful for residents
considering the same. Given that we
made our slides freely available to the
attendees after the fact, our one-time
intervention may also serve a dual
role as a just-in-time resource in the
future.
A single intervention cannot
address the systemic lack of financial
literacy in the general population,
including radiology trainees. Future
studies using larger sample sizes may
better elucidate the effects that
resident-specific financial education
has on financial literacy, and follow-
up testing at intervals greater than
6 months would be useful to
demonstrate long-term knowledge
retention and concrete effects on
personal finance behaviors.
Increasing financial literacy is a
desirable goal in that it may posi-
tively affect residents’ well-being,
reduce financial stress, and thus
Volume - n Number - n - 2017
potentially reduce future burnout. In
this work, we demonstrate how such
an intervention may increase short-
term financial knowledge and posit
that the true benefit from such an
endeavor may be the self-directed
learning it may inspire.
ADDITIONAL RESOURCES
Additional resources can be found
online at: http://dx.doi.org/10.1016/
j.jacr.2017.06.020.
REFERENCES
1. Lusardi A, Mitchelli OS. Financial literacy
and retirement preparedness: evidence and
implications for financial education. Bus
Econ 2007;42:35-44.
2. Federal Reserve Bank of New York.
Quarterly report on household credit and
debt. Available at: https://www.newyork
fed.org/medialibrary/interactives/house
holdcredit/data/pdf/HHDC_2016Q4.pdf.
Accessed March 1, 2017.
3. American Association of Medical Colleges.
Medical student education: debt, costs, and
loan repayment fact card. Available at:
https://members.aamc.org/eweb/upload/
2015%20Debt%20Fact%20Card.pdf.
Accessed March 1, 2017.
4. Lusardi A. Financial literacy: an essential
tool for informed consumer choice? Avail-
able at: http://www.nber.org/papers/w14
084.pdf. Accessed July 15, 2017.
5. Lusardi A, Mitchell OS. Financial literacy
around the world: an overview. Available
at: http://www.nber.org/papers/w17107.
pdf. Accessed July 15, 2017.
6. Dhaliwal G, Chou CL. A brief educational
intervention in personal finance for medical
residents. J Gen Intern Med 2007;22:
374-7.
7. Brown SD, Goske MJ, Johnson CM.
Beyond substance abuse: stress, burnout,
and depression as causes of physician
impairment and disruptive behavior. J Am
Coll Radiol 2009;6:479-85.
8. Collier VU, McCue JD, Markus A, et al.
Stress in medical residency: status quo after
a decade of reform? Ann Intern Med
2002;136:384-90.
9. Dyrbye LN, Thomas MR, Massie FS, et al.
Burnout and suicidal ideation among U.S.
medical students. Ann Intern Med
2008;149:334-41.
10. Dahlin ME, Runeson B. Burnout and
psychiatric morbidity among medical stu-
dents entering clinical training: a three year
prospective questionnaire and interview-
based study. BMC Med Educ 2007;7:6.
11. Henning MA, Hawken SJ, Hill AG. The
quality of life of New Zealand doctors and
medical students: what can be done to
avoid burnout? N Z Med J 2009;122:102.
12. Fernandes D, Lynch JG Jr, Netemeyer RG.
Financial literacy, financial education, and
downstream financial behaviors. Manage
Sci 2014;60:1861-83.
13. Huston SJ. Measuring financial literacy.
J Consum Aff 2010;44:296-316.
14. Hilgert MA, Hogarth JM. Household
financial management: the connection be-
tween knowledge and behavior. Fed Res
Bull 2003;July:309-22.

Mitchell Boehnke, MD, Sajal Pokharel, MD, Eric Nyberg, MD, and Toshimasa Clark, MD, are from the Department of Radiology,
University of Colorado Anschutz Medical Campus, Aurora, Colorado.

The authors have no conflicts of interest related to the material discussed in this article.
Mitchell Boehnke, MD: Department of Diagnostic Radiology, University of Colorado Anschutz Medical Campus, 12631 East
17th Avenue, Mail Stop 8200, Aurora, CO 80045; e-mail: mitchell.boehnke@ucdenver.edu.

Journal of the American College of Radiology 3

Boehnke et al n Case Studies in Training and Education
APPENDIX 1
Survey questions used for the pretest, posttest, and 6-month follow-up assessments of financial literacy. Topics were
chosen to cover four main financial topics: money basics, investing, borrowing, and protecting resources.

PRE-TEST SURVEY
Basic Financial Issues for Trainees
Please complete the following survey regarding your current knowledge and understanding of these financial principles.
Completing this survey is entirely optional and will not affect your evaluations or ability to stay for the lecture
content. By filling out this form, you are providing your consent.

1. What is the time value of money?

, Money available now is worth more than , Money available now is worth less than , On-time payments are important
money available in the future money available in the future for a good credit score
2. What is a typical interest rate for a mortgage?
, 1% , 4% , 10%
3. If you have an ARM, what is its effect on your mortgage payments over time?
, Payments do not change but the , Payments may go up but never down , Payments may vary with the
amount of principal and interest does interest rate
4. How does active versus passive management of mutual funds and exchange traded funds differ?
, Passive funds track stock or sector , Active funds are favored by Warren , Active funds actively reduce their
indices Buffett expenses to below that of passive
funds
5. How do a Traditional and Roth IRA differ?
, Traditional IRAs allow contributions to , Roth IRAs may cause one to be in a higher , Roth IRAs have no income limit
be deducted if your income is below a income tax bracket when making above which one cannot contribute
threshold withdrawals to it
6. How many qualifying payments must one make to achieve Public Service Loan Forgiveness?
, 120 (10 years) , 240 (20 years) , 30 (25 years)
7. Is a payout from a life insurance policy taxable?
, If premiums were pre-tax then the , If premiums were pre-tax then the payout , If premiums were pre-tax then the
payout is taxable is taxed over a certain threshold payout is also exempt from taxes
8. Can a Health Savings Account be paired with a regular (non-high deductible) health insurance plan?
, No , Sometimes, depending on which state , Yes
one lives in
9. (For post-test only) Do you plan on applying strategies and knowledge acquired during this lecture to your own finances?
, No , Probably not , Maybe , Probably will , Definitely will
10. Comments:

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