Several words typically come to mind when we hear the word "intern": naive, coffee, and free labor might be some of them. Most internships pay nothing or, at the very most, minimum wage.
However, there are actually internships out there with a less than 50 percent acceptance rate that require interns to pay thousands of dollars just to participate. No stipend is offered for housing, food, materials, transportation, or any other miscellaneous internship costs. The internship consists of at least 1200 hours of practical experience across three to ten different sites and can last anywhere between eight months and two years. Hours range from forty to fifty hours a week, giving interns very little leeway for a part-time job, assuming their internship director even allows them to get one.
Welcome to the confusing, costly, and demanding world of dietetics.
Similar to a medical residency, the dietetic internship is necessary for students in the field to receive licensure and practice legally. One difference, though, is that medical residents get paid about $40,000 a year—a "minimal salary…to help pay the bills" (emphasis added), while these other interns are paying almost that much to earn their credential. Once they acquire it and enter the workforce, they are lucky if they can find an entry-level job that offers the same "minimal" salary that medical residents receive. According to the Bureau of Labor Statistics, the median salary for dietitians and nutritionists in May 2016 was about $59,000.
The internships can have quite a hefty cost. I surveyed all the dietetic internships offered in the United States during my application process and found that the average cost is about $15,000 in tuition alone.
Unpacking the embedded fees
Beyond the upfront cost of tuition, doing a dietetic internship (DI) incurs costs that most students don’t even think about! Let’s break down everything an intern needs for a DI to account for all the embedded fees.
Transportation
Let’s be honest, you’re going to need a car. This can be a pretty hefty cost if you don’t have one already.Average expense: $5,000 (not including insurance).
Gas
Internship sites can be anywhere from 5 to 50 miles away from an intern’s humble (and it will be humble) abode.Average expense: $20–30/week; $100/month; $1,200/year.
Parking
Most sites will have free parking, but some hospital parking ramps require daily payments as little as $4 or as much as $12. It can add up during your clinical rotation, which is typically the longest rotation of a DI.Average expense: $50–$800 (upper end based on $12/day for a 3-month clinical rotation, plus parking fees at other rotation sites).
Humble abode
Apartment, condo, rented house with eleven other people—whatever floats your boat and doesn’t sink your budget. Varies relative to the area, of course.Average expense: $600–$800/month; $7,000–$9,000/year.
Furniture
Bought or shipped from a former home, they’re both a good hunk o’ change. IKEA and Craigslist are lifesavers, no matter the level of reluctance.Average expense: $1,500.
Groceries
Because most internship sites don’t provide meals.Average expense: $50/week; $200/month; $2,400/year.
Membership fees and seminar costs
Whether it’s dues for the Academy of Nutrition and Dietetics, DPG (dietetic practice groups) dues, your state’s individual association dues, or FNCE (Food and Nutrition Convention and Exposition) costs, you will be paying fees for some kind of alphabet soup.Average expenses: $100–$500.
Clothes and shoes
Because now you’re a professional, and you have to dress like one! Well, semi-professional. Glorified student? Whatever you are, jeans and a nice scarf are no longer considered ‘classy.’ Thrift stores are your friends.Average expense: $100–$500 (upper end based on if you don’t want “new” friends).
Which leads us to...
Total potential fees: $19,125 (average of lowest and highest costs listed).
Add this to a DI’s standard tuition cost of $15,000 and you have about $34,000 on average for an internship that kids fresh out of their undergraduate education are expected to pay for.
What even is an 'internship'?
Should this experience even be called an internship? The definition of an internship, according to Oxford Dictionary, is: "The position of a student or trainee who works in an organization, sometimes without pay, in order to gain work experience or satisfy requirements for a qualification." The Department of Labor gets even more specific about internships, laying out six criteria that must be met in order for internships to qualify as “unpaid.” These definitions sound fair, except for the lack of "sometimes with fees" mention.
What many of us students and interns (and even professionals) in dietetics want to know is: Where are these fees going, and can they be reduced? Why do some internships cost more than others, while some manage to offer a stipend to interns? Do the internship directors get salaries out of internship tuition? Do the associated universities get a piece, even if we don’t use any services from those facilities?
Some internships are combined with master’s degrees, which means interns do their Master of Science and internship programs at the same time. Since these interns are also considered students of the university, they may be eligible for federal loans, but there is no "financial aid" offered at the master’s degree level like there is at the undergraduate level (based on FAFSA).
We* are asking for some transparency and explanations that seem to be lacking in a very important area of our career development. This is especially important since it will be necessary to have a graduate degree before one can even sit for the certification exam, starting January 1, 2024 (See the Commission on Dietetic Registration, or CDR, Graduate Degree Registration Eligibility Requirement: Frequently Asked Questions, 2013 [PDF].)
It seems clear to me that this change would further increase the cost to become a registered dietitian. However, the Accreditation Council for Education in Nutrition and Dietetics (ACEND, the accrediting agency for the Academy) argues that although the "exact cost of future education model programs is not yet known, […] the cost of requiring a master degree for entry-level practice potentially may not exceed what students are currently paying to complete a master degree in a coordinated program or with a dietetic internship." (See Future Education Model Accreditation Standards for Programs in Nutrition and Dietetics: Frequently Asked Questions, 2017 [PDF].)
This statement is based on their findings that about 65 percent of students completing coordinated programs and DIs currently pay tuition to simultaneously pursue a master’s degree or some graduate-level courses.
While it is well-known that our profession lacks diversity in gender and in color, ACEND predicts that this future education model will not negatively impact diversity in the dietetics profession. Other health professions such as physical therapy, pharmacy, and occupational therapy have transitioned their education requirements to a graduate level and have not seen a decrease in student diversity. The same trend is expected in the dietetics pool.
One significant difference between dietetics and the aforementioned professions, however, is the pay rate: In the same document that lists physical therapy, pharmacy, and occupational therapy as having comparable retention rates to dietetics, CDR reports, "In 2010, RD salaries were 40-45% less than salaries of other non-physician health professionals." Will students really not mind paying more so that they can practice in a field that earns considerably less than their healthcare counterparts? Sure, earning a graduate degree provides opportunities for higher salaries (by about $5,000 annually, according to the CDR FAQ document) and possibly more respect in the workplace (old dogs may not be able to learn new tricks, but can they learn new opinions…?), but the main benefit of requiring a graduate degree is really for the student to specialize in their preferred area of nutritional sciences.
There's got to be a better way
Considering the myriad of workplace options for RDNs, I don’t think requiring a graduate degree is a bad idea at all. However, if the concern is validating and improving RDNs’ education and training, we need to start thinking outside the box and coloring outside the lines. There have to be better options to legitimize RDNs’ positions in certain fields, such as inpatient care and obesity counseling, without jeopardizing the future of dietetics by discouraging people from entering the field because of the costs associated with it.
One stepping stone that some fellow RDNs and I have discussed is to have a more pro-active approach and re-mold the framework at the undergraduate level: create the undergraduate Dietetics Program, one that students have to apply for and get into, similar to that of a Nursing Program. This would save students and professors time and money! It would also weed out the students who aren’t sure about entering the dietetics profession. Those who do apply and get accepted into the program probably have a good idea of what they’re getting themselves into with all the science classes, and hopefully will be informed of the post-graduate internship by this point as well. It would also ensure a higher standard of the Didactic Program in Dietetics (DPD), and thus a higher quality pool of dietetics graduates and DI applicants. Some schools, such as the University of Minnesota, currently have this policy. See the U of M's Department of Food Science and Nutrition DPD Admission Process.
While this would decrease the number of students who could potentially “waste” four years of college—those who aren’t sure about, or have a very slim chance of being matched to, a DI—it still doesn’t address those students who are passionate about food and nutrition, have potential to be stand-out dietitians and a good shot at getting matched, but are unfortunately not in an financial position to pursue that route.
I’m not exactly sure how to modify the whole DI process, because I do not have enough experience or widespread knowledge to take all necessary factors into account. However, I do know that many past and present interns, and even practicing professionals, are extremely frustrated by the whole application and internship process. Instead of accepting old ways as the be-all and end-all, we should be engaging the future leaders of our career field and getting them involved in how to better our profession. It’s time we started talking, sharing experiences, and coming up with more possible solutions to improve the path to such a giving and beneficial career choice.
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*Those that I have talked to about this topic do not want their names mentioned for fear of being flagged as “bad-mouthing” the Academy and possibly jeopardizing their reputation in the field.
You can reach Lizzie for civil discourse at elizabeth.briasco [AT] gmail [DOT] com.
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