Why medical education needs to be more affordable

I was talking to a young man who is starting medical school this fall. His tuition at one of South Carolina’s newer schools will be $40,000 per year. That’s admittedly on the high end. On the low end, it runs a paltry $33,000 per year.

And this is all after college, of course. He and others like him are taking out loans to the tune of $240,000 to pay for their medical educations. Another young woman I recently met is in residency and her loan payments are around $2000 per month.

Thinking back on my own medical education, it seems my tuition was around $5000 per year. But then, what with all the Saber Toothed Tigers, Neanderthals and stone surgical tools, things were simpler.. These days, I don’t know how students will do it.

The thing is, American healthcare is expensive. But so is medical education. As we embark on this century, what are the odds that physicians with $240,000 loans for medical school will be able to offer inexpensive care? What are the odds they will enter low-paying specialties? They might be interested in charity care at first, but when the first loan payments come due all the good intentions in the world won’t change the fact that lenders want their money back. Likewise, it won’t change the hard reality that it will be extremely hard for these young physicians to pay for their student loans, buy a house, have a practice (pay malpractice) and raise a family; at least without making a large amount of money in their practices. And then there’s this striking (but seldom mentioned) fact: student loans are non-bankruptable. Student loans are friends for life, or until payed off. Whichever comes first.

Of course, there are loan repayment/forgiveness programs for those who go to rural areas, or those who enter primary care. And there are scholarships for those who enter government service in either the military or Public Health Corps. That’s good. But the government only needs a fixed number of physicians on its payroll, and state and local economies can only absorb so much of that cost otherwise.

And realistically, it’s very difficult to attract young physicians to rural areas. I know because my practice has recruited them. Furthermore, not every young doctor should be in primary care. Some of them will make terrible family doctors but brilliant neurosurgeons; unhappy cardiologists but delighted obstetricians. We all have unique skills and interests, and physicians are no different.

I realize that the standard response to all of this is, typically, ’so what, they’ll be rich doctors!’ Not at this rate, they won’t be. And most of them don’t come from riches, either. They’re just kids who believe in the power of hard work, who want to help the sick and who believe that medicine will be a stable, lucrative career. Generally, they’re students who know how to press on through difficulty. But this is a difficulty they probably didn’t expect: pay lots of money for an education that may or may not pay back commensurate with its cost.

If we’re going to continue to have excellent physicians of every specialty, we’ll need to find ways to make medical education more affordable, or be willing to pay ever more money for medical care. It may be that medical education could start after two years of college, instead of four; or even after high school, as it does in some countries (though post-graduate training remains necessarily long in those situations). It may be that medical schools will need to be more lean like all educational establishments these days. Besides,, most of the practical medical education occurs in residency anyway.

Further, it may require that we trim some medical and pre-medical education to focus on what is absolutely essential. This would have been useful back in college, since many of the classes we took were simply designed to limit the pool of applicaitons by ‘weeding out’ those who couldn’t handle the academic load. Let me just say that I have very few occasions to interpret assays of organic chemicals these days; I’m too busy treating patients and figure out how to interpret Medicare billing rules.

We have a difficult task ahead. Medicine just keeps getting better, but more expensive. And the process of becoming a physician is more and more complicated and costly as well. We don’t wants less quality in healthcare. But something simply has to give or else educationally impoverished physicians will necessarily charge even higher fees in the future, just to keep ahead of their loans, falling reimbursement and the cost of having a practice.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

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  • http://hokiemd.blogspot.com Christopher Bayne

    When I was considering residency specialties a year ago, I’d be lying if I said I didn’t think about my 200k loans as part of the overall equation. In the end, I don’t think it played a part in my decision, much like like doctors don’t think the name of the drug on their pen influences their prescription patterns. People will call me all sorts of things for this, but I’m being honest, at least.

  • soloFP

    When I was at a public med school around 15 years ago, tuition was around $16,000 a year. Private school would have been around $25,000 a year or more. Nowadays I have heard $20,000 or more for public and $35,000 for private school. That said, a 6-9 month medical assistant program at a private school in town is $24,000. Medical education is very expensive, as job security is pretty good. People do not stop getting sick, and a 40 year or longer medical career should more than payback the expensive medical education.

  • http://www.edwinleap.com/blog Edwin Leap

    A forty year career should pay it off; and yet, one term in the senate gives a politician a lifetime pension and benefits. A forty year career should pay it off, and yet 20 years in a good public school system, or as a union firefighter in a large city, and one can retire with an awesome pension and benefits. A forty year career should pay it off, but 20 years in the military or post office, and one can retire, turn around and be hired again in a similar job with similar benefits; starting as early as 38! At some point, young, aspiring physicians may do the math. Especially when, for that forty year career, they are vilified as ‘rich doctors.’

    • Patrick Mac

      I agree with your comments and recommend this analysis of the deceptive income of physicians, by Dr. Ben Brown. He compares the earning potential of a primary care physician to that of teachers.
      http://benbrownmd.wordpress.com/

  • Edward Stevenson

    My schools tuition tipped $50,000 for this coming year. tuition goes up 5% each year at a time of supposed economic deflation. my cousin at a private school on the other side of the country tuition is $60,000. The dental program’s tuition at my school is around $65,000 but at least they are set to make decent money at graduation unlike doctors who get to fester in their own interest accumulation for 4-5-6 years. least I forget that is merely the tuition on top of that is housing, books, board registration, flights and hotels to interviews, travel to away and rural rotation, housing, food, gas, car payments. I know several student that are easily topping $100,000/year in debt accumulation while in school.
    as a premed everyone says yeah its expensive but you make good money and everyone pays it off. little do they realize the resident they are talking with probably paid 1/5-1/2 less tuition than they will. tuition and living go up and reimbursement keeps going down. at a point it medical education will be unsustainable if we aren’t already there yet

  • http://fertilityfile.com IVF-MD

    It’s well known that monopolies (or oligopolies) lead to high prices. Why? Suppose someone wanted to work hard to come up with a better, more efficient way to teach medicine at a faster pace, with better retention of information and that would produce better doctors at a lower tuition cost? That person or group would find it extremely difficult to jump through the red tape hoops and they’d be effectively barred from existence. Why do costs come down in other fields where there is competition (ie cell phones, computers, refractive surgery, cosmetic surgery)? Prices have come down despite the inflated dollar, meaning the true cost reduction is even greater! Monopolies or restrictive oligopolies are only good for those in the monopolies. Competition is good for the consumer or end user. By the way, this applies to the costs of healthcare as well.

  • http://www.picumd.com PICU MD

    I think the key is to compare the income of PRIMARY CARE physicians with those of other fields. I think if you take the human, “I want to help people” element out of medicine and look at it as a “business” decision, primary care medicine does not make any sense compared to law, business, or dentistry. However, with subspeciality practice doing a fellowship doubles your salary and actually makes the extra effort worth while. (Granted some subspecialities, esp those in pediatrics doing the extra 3 years of fellowship does not get you any additional salary and only delays you getting your attending salary. Hence the vacuum in those subspecialities).

    I think we need to have a frank discussion about what type of income (either by the hour or by patient etc) is what MDs should be making given the loans and hours making sub minimum wage as residents, work backwards from there, and adjust billing codes accordingly.

  • PAULMD

    It is still a sellers market. Tuition will continue to rise.

    • http://fertilityfile.com IVF-MD

      Lowering the barriers to entry for healthy competition to enter the game would be one way to help solve the problem of costly medical education. Although med schools are warming up to the power of the internet and computing, there is still a lot of untapped potential for incorporating powerful technology into the teaching process. There are smart innovative people who would love to have a shot at it.

  • Dr Chris

    It took me over 15 years to pay mine off-(about 100,000 , med school 20 years ago). That was only because my husband had a good job, and we could pay it off earlier. I have no idea how two doctors married in medical school could make it. We called me the second mortgage. Paying for my daughter for an ivy school was another hit. It worked best to be employed by someone else until I got out from under the above until I could pull it together to open my own practice.
    My other advice-make sure you have disability insurance to cover all of the above (bitter experience-ACP has a great plan) , and overhead insurance if you have your own practice,
    One of my friends had dual citizenship and went to medical school in Germany-$300.00 a semester.

  • rv

    And to think that _____ tuition is $71,000 a year. All this makes me want to give up on Ivy and go to state. Is the extra $200,000 in debt worth it?

  • doctor-in-training

    I wholeheartedly agree with your comments about medical education. If there is such a shortage of physicians, something needs to happen to make medical education more affordable. Narrowing and focusing the premed curriculum to what is actualyl needed in the medical field would be a good place to start.

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