Tuesday, May 31, 2016

The cost of becoming a doctor

I start this article with a disclaimer: I am not here to comment on the decreasing salaries of physicians or the knowledge that I will never get paid the way the prior generation of doctors got paid. It is hard for me (and the American public) to feel bad for anybody making more than $200,000 a year when the median household income is in the mid-$40,000 range.

What this article is about is the absurd costs of becoming a doctor (both in medical school and residency). Let me tell you my story to put things in perspective.

I went to a state undergraduate university and, thankfully, left that school with no debt. I then entered a public medical school, with no way of paying the tuition on my own. I faced the decision of taking out loans or dropping medicine and doing something else. I stuck with it — like many of my colleagues — because I could not imagine not being a doctor; and honestly, I was naive about the financial hardships I would undergo.  I lived at home for 2 of the 4 years of med school, was single for 3 of those 4 years, had no kids, and had amazing parents that subsidized my living arrangement with home cooked meals and car insurance payments. 

Despite that, at the end of my medical school education, I had acquired $180,000 in loans (close to the national average), almost all of them with an interest rate of 6.8 percent.

To put that into perspective: My monthly interest accrual was ~$1,020 a month, and good old Aunty Sallie would capitalize the interest into the principal at the end of every year.

Then came residency. Finally a salary of my own, or so I thought. The average resident’s salary starts between $40,000 and $50,000 a year. At 70 to 80 hours a week of work, that comes out to $9.50 to $12 an hour. Most residencies prohibit moonlighting (for reasons beyond my comprehension), so the money you get from your institution is the only money you get.

I live in northern Jersey, where monthly rent for a 1-bedroom apartment is around $1,000 to $1,400; a 2-bedroom ranges between $1,500 and $2,400. I lived in a 1-bedroom. I cleared about $3,000 a month after taxes. $1,000 went to paying just the interest on my loans and never touching the principal, and $1,200 went to paying rent.

I was left with $800 to spend on food ($100 to $300, thank God for a mother and mother-in-law who have phenomenal cooking skills), gas ($160), car payments ($200) because you cannot move between three hospitals on public transportation, insurance payments ($200), cell phones ($80) with no landline, internet ($50), and, well … there is no money left.

So, I guess I could have just paid the minimum on my loans and have had money for heat and electricity. The problem is, that after five years of residency, I would have owed Ms. Mae close to ~$250,000.

This is the thing: I was better off than many residents. I had parents who gave me money when I was short and paid my E-ZPass bills. I went to a public undergrad school (many people I know have debts in the $350,000 range when starting residency). I never had any large unexpected costs during my training (e.g., medical bills, big car bills/accidents). For much of my training, I was not yet a parent. Residency sucks, and not just because of the intensity of the training and the stress of trying your best to become a decent physician.

This article is not over yet. The real impetus for me to write this has to do with the loads of money I recently dumped to fulfill the next step of my training. What many people outside of medicine might not know about are the enormous costs of tests/licensing that doctors are required to practice medicine. USMLE Step 1, 2, 3 tests cost about $2,200. The American Board of Internal Medicine exam costs about $1,200, and the American Academy of Pediatrics exam costs a whopping $2,250. Most residents spend about $1,000 to $2,000 on prep courses and materials for each of these exams while in residency.

And then, there is licensing: NJ state license is about $1,100, the DEA/CDS licenses cost another $760, and there are others, depending on your practice. All of this occurs before you make “doctor money,” all while your student loans continue to grow.

My concern is not for my own misery; that time has passed. My concern has to do with the next generation of physicians who have already started pre-med tracks in their undergrad colleges.  What type of candidates will medicine attract when the associated costs of becoming a doctor are no longer the extreme intellectual rigor and high academic expectations of the training … but instead, financial suffering?  To put it in plain English: Who in their right mind would do this when you know you are putting yourself, and potentially your family, in great financial peril?

My inner optimist tells me that there will always be a group of highly motivated people who will bear the difficulties, because the goal is lofty and righteous enough to keep their eyes on the prize. But what are we saying as a society when we make an education in healing so difficult to attain?

Ahmad Yousaf is an internal medicine physician who blogs at Insights on Residency Training, a part of NEJM Journal Watch.
Courtesy of Doximity

1 comment:

  1. Despite a shrinking gender gap in compensation, medical residents in the United States are battling debt and depression and a fair number aren't satisfied with their salary, according to results of the 2016 Medscape Residents Salary & Debt Report.

    The report, released today, is based on an online survey of 1888 medical residents across 25 specialty residency programs. The margin of error for the survey was +/- 2.31% at a 95% confidence level.

    In 2016, the average resident salary is $56,500, which is up slightly over that reported in Medscape's 2015 Residents Salary & Debt Report ($55,400). Male residents earn an average $56,700 and female residents earn $56,100 — averages comparable to those in 2015 ($56,000 for men, $55,000 for women).

    Most male and female residents believe they are fairly compensated (52% and 55%, respectively), but these rates are lower than in the 2015 report (60% and 65%, respectively).

    Reasons for their discontent include higher pay earned by nonphysician healthcare professionals (nurse practitioners and physician assistants [PAs]) and nonmedical professionals with comparable education and experience.

    Saddled with a significant amount of medical school debt, 56% of residents say future compensation will influence what specialty they pick (and 36% said it is the leading factor in specialty choice). More than two thirds (68%) owe $50,000 or more and 40% report debt of $200,000 or greater, according to the report...

    Residents' relationships with attending physicians were slightly less positive this year than last. In Medscape's 2015 survey, 96% of respondents rated their relationships with attending physicians as good, very good, or excellent. In this year's survey, 88% of participating residents felt the same.

    Nearly one quarter of respondents said they have suffered bullying from physicians often or occasionally...

    Eighty-seven percent of residents were satisfied with the degree of supervision by attending physicians, and 76% felt satisfied with the quality of their learning experiences. Still, more than half of residents (55%) said that they only occasionally have sufficient time with patients, and nearly one in five (19%) said they have doubts about their ability to be a good physician.

    Depression is a problem for some residents, with 10% saying they feel depressed always or most of the time — a figure higher than the 6.7% seen in the general population (National Institute of Mental Health, 2014). And 9% of respondents said they have considered suicide, compared with 3.9% of the general population aged 26 to 49 years (Substance Abuse and Mental Health Services Administration, 2013).