Health Care’s Broke: Med School Debt
Medical students spend an average of $139,000 on medical school in the United States, while other nations provide either fully-funded medical school education or at least greatly subsidized medical education. When you add in the costs of an undergradate degree (which is often either not necessary for other countries’ medical school admission or again tax payer-funded), it’s not uncommon to have medical students starting residency in $200,000 of educational debt.
Often medical students also need to purchase or own a car in order to work at the multiple hospitals which will comprise their clinical training. This adds significantly to their expenses (as they have to take out separate car loans at higher interest rates than most of their student loans, and any car loan debts they have get subtracted from their eligible financial aid amount as well). In order to match in certain specialties, students may have to apply to 50 or more programs and interview at a huge number of them. This enormous amount spent applying, booking flights and hotel rooms and meals on the road can easily add up to $10,000 — and unless the student has $10,000 sitting around, it all goes on the credit card, at an even higher interest rate.
Because interest accrues immediately following graduation, even a low interest loan at 2-3% grows quickly when the principal is $100,000 or $200,000.
While these are just numbers on a piece of paper for most of us medical students (translation: I can’t really fathom owing $200,000, so I just pretend it doesn’t exist), we understand it well deep in our financial souls. Most medical students would be lying if they said this doesn’t at all cross their minds when they consider a specialty and future salary. Being in the hole $200,000 is a gigantic Sword of Damacles that scares the crap out of me.
As I’ve said before, i would much rather have medical school be free (read: tax-payer financed) and either have an expectation of:
- making less money after residency or
- required service time to the taxpayers who financed my education
Maybe we make it a choice. You can choose to pay full price, or pay no price, with either a guarantee that you make less money for life or have required service time for the country.*
I know the government has made unsuccessful attempts to do this in the past by essentially providing too little of a sudsidy for physicians; I would recommend improving this strategy by altering tuition reimbursement based on specialty need and location served. (For example, a primary care physician working in a rural area might be reimbursed 75% of tuition per year, while a pediatrician in the Bronx might be reimbursed 60%.) Perhaps physicians who continue to practice in these settings might receive bonuses for 5 years served, 10 years served, etc. (Yes, I realize the military does offer some programs like this for tuition reimbursement, however it is not available to some physicians *ahem, me* because of don’t ask, don’t tell.)
* Many medical training programs in other countries already require their trainees to essentially complete a medical internship in a rural or underserved area of their country where they are the doctor for the entire community; only then can they go on to specialize in surgery, radiology, obstetrics and gynecology, etc.
Excellent points, all.
One of my great fears is that at some point in the next few years, we will in fact greatly reduce the cost of medical education as you suggest in exchange for national service or as part of a universal singly payer health care system where physicians may make less money (but graduate with no debt). It would be great, as long as it doesn’t leave those of us who have graduated or will soon graduate with large amounts of debt stranded. In other words, the changes you suggest would work great for future medical school applicants, but what happens to those of us who have already accumulated are quarter million dollars in debt?
I’ll be starting medical school in the fall and I must say that, as a non-traditional student (I’m 31), this scares the bejesus out of me. I actually *know* what it’s like to have > $150,000 in debt (it sucks) and the prospect of knowing again is one of the big reasons I’ve ignored a calling to medicine for several years.
I will likely enter an agreement with a rural hospital that will allow me to eliminate this debt within a few years after graduation.
In the end, I think your point, “Most medical students would be lying if they said this doesn’t at all cross their minds when they consider a specialty and future salary.” makes a huge contribution to the “broken-ness” of our healthcare system in that it contributes to the downward spiral in primary care.
I’m hopeful that the current generation of medical students and young physicians will be the driving force for change (guess which democrat I support?) on all these fronts. Thanks so much for this series. I’ve really enjoyed it. AND, it should be required reading for medical school applicants to the class of 2013.
@Ryan–one of the nice things is that you won’t be required to file financial aid paperwork for your parents since you’re over 30.
@Brian–you’re absolutely right, I forgot to mention this. We’ve certainly got to figure out a way to fairly transition this for doctors who are already slowly trying to pay off their debts.
Those are some excellent points Graham, but there are already programs like that out there to serve the underserved, such as the National Health Services Corps.
Fortunately, myself and others in my med school have decided that medical school is not about helping people. The poor are disgusting and only depress you. Although, personally I think they exist to make you feel better about your lifestyle. Any who, my class and I have decided that medical careers should be about other things, like a good comfortable lifestyle, power, influence and respect. These make you feel good about yourself and help with picking up chicks at a bar.
That’s why, when I graduate medical school, I hope to whore myself out to an insurance company and become one of those ridiculously well-paid doctors who make extra bonuses when they deny patients access to chemotherapy.
The pain of being in med school, getting in, and being shat on royally by the hierarchy we serve has made my pain sharp and constant. I hope to share it with the world.
Today Harvard announces it will waive tuition for 3rd year law students who agree to work in public service for 5 years.
@Boy: I’m going to assume that’s satire there. While I’m aware of the NHSC, I don’t think these programs should be limited to primary care. The waiting times to see specialists for those with Medicaid are atrocious.
“The waiting times to see specialists for those with Medicaid are atrocious.”
I’ve mentioned this before, but as a generally reviled (at least on-this-board)specialist, I do see Medicaid patients (about 10% of my practice). A recent audit of our practice found that for each patient I see, the practice (read: me) PAYS $5. This because Medicare/and next Medicaid has lowered our reimbusements every year for the past 5 years (and by over 75% in the past 20).
Now after 4 years of private college, 4 years public med school, 6 years of residency, 1 year fellowship and then marrying an ER doc with 4 private/ 4 public/ 4 residency, we started our lives together with close to a half million JUST in educational debt (not to mention all the other costs that Graham adeptly outlined). Since the gubment has effectively decreased our salaries every year in practice (by either direct reduction or by not increasing even by cost-of-living), the future is indeed scary.
We’ve actually got a program like that at my school, Graham; the problem is that it’s far too restrictive. You have to decide to do it at the beginning of your first year, and then it locks you in to either family practice or pediatrics in a rural location far before you’re ready to make that decision. It prevented all but one of my classmates from doing the program.
I oppose any program that “forces” people to work in particular areas of the country in order to pay back debt, or anything else. I can’t imagine forcing my family to move to Kansas, where my husband could never get a job, in order to fulfill some service requirement for med school. I think that would drive me away from the field entirely.
On the other hand, I COMPLETELY support generous loan forgiveness programs for people who go into primary care in underserved areas.
As a side note, you are aware that medical school costs us more than they charge us for tuition, right? A significant contributor to the cost of medical education (and undergraduate education I might add) is that the federal government DOES provide loans to people. That allows the universities to price discriminate more effectively, i.e. they charge each student as much as he/she is “willing to pay.” It’s a model of operations most businesses would love to be able to do that allows them to maximize tuition revenue. This problem would be solved by LESS government intervention, not more.
@Old MD: I certainly am aware. Stanford tells me that while their tuition is $30/year, the cost is more like $50 a year.
Also, Medicare pays hospitals more $$/resident than residents get paid, so hospitals certainly take a cut as well.
Old MD girl. Some of us do not get significant federal loans. Most get zero scholarships and grants. So, we resort to private lenders because in reality(like Graham pointed out), you need the money as the estimates are never accurate. Never. You really don’t want to know the interest rate but a family medicine paycheck won’t suffice.
Regarding programs, “forcing” people to go to certain locations, I think “force” is a strong/harsh word to use. I have a friend in a similar situation BUT he is well aware of the future choices and locations. He knew the details before signing the dotted line. His debt was about 119,000 but all would be forgiven after residency and he will practice in his hometown. Alright, that was a perfect situation but really, most ppl that solicit debt forgiveness (primary care, underserved areas, research-physicians) know the details before signing anything.
HOWEVER, strangely enough (and before Graham raises his eyebrow), I was not aware of the pay attributed to my specialty of choice when I fell in love with it. I did not select it for the money. However, I might have looked at switching fields if I had fallen in love with family medicine. With retired parents and an expensive future, I’d think twice…regardless of how much programs can forgive my loans. The indebtedness does not stop when loans are forgiven: there is still much to pay for as a practicing physician (although I must say we are well compensated –maybe I just have a cheap lifestyle). I shop at Target…not Nordstroms…
…funny, I can’t even spell Nordstrom
There’s always the Army Health Professions Scholarship Program…
fakehat is right…
For those willing to commit big time, the military will pay for college (ROTC), med school, “give” you an added stipend thoughout your residency, and by the time you finish paying off all those years, you only need a couple more to get a full pension. Graham brings up obvious exceptions, but the majority of people, your life course can be completely planned (except that of course you never know WHERE the military might put you during those 10-15 years)
@ boy said: “Fortunately, myself and others in my med school have decided that medical school is not about helping people. The poor are disgusting and only depress you. Although, personally I think they exist to make you feel better about your lifestyle. Any who, my class and I have decided that medical careers should be about other things, like a good comfortable lifestyle, power, influence and respect. These make you feel good about yourself and help with picking up chicks at a bar.
That’s why, when I graduate medical school, I hope to whore myself out to an insurance company and become one of those ridiculously well-paid doctors who make extra bonuses when they deny patients access to chemotherapy.”
Are you serious? If you are, boy patients are in good hands!
MD2B:
So? Students are willing to pay for med school, and thus are charged accordingly. The federal loans help those who have even less money than you have bridge the gap and enable universities to price discriminate further. I don’t see how what you said shows that this is not the case.
This sort of debt is indeed scary, and I was very daunted when I entered med school. I was unsure of what specialty I would choose, so did not feel I could commit to the NHSC. I wound up choosing the Health Professions Scholarship Program (ie, the Army). Now, understand that I am old(er), and the nation was not at war when I made that choice.
This means that my med school was paid for by the Army, and I received a stipend to help with living expenses. I graduated without debt, but beholden to the military for several years after residency. I have not had final choice on where I would live/practice during those years, and I have deployed more than once. I am about to finish my obligation and plan to leave the military.
While I would not say that the military and I are a perfect match, overall I am pleased with my choice. I received excellent training, and financially I am debt free (except for my mortgage). Believe me, these scholarships are not particularly difficult to acquire these days (what with the war), and are worth investigating.
Don’t forget that med students also miss out on many years of income while they’re in school (including summers!), and that the salaries for residents are often quite low.
I would like to see the schools take more responsibility in lowering their prices (especially for rotations, some of which are off-campus; why should students pay high tuition for those?). I also think that many new students don’t realize how much debt they’re signing up for. We need to do a better job of educating applicants what to expect.