Think about medical school tuition debt before becoming a doctor

Recently, I received a call from the son of some old friends. This 30-year-old man has been an elementary schoolteacher for the past few years and recently decided that he would like to go to medical school and eventually become a surgeon. He wanted to know what I thought of the idea.

Suppressing the urge to tell him not to even consider becoming a doctor, I tried to help him think it through. He is looking at about 10 years of hard work including taking a year of post-graduate pre-med science courses, four years of medical school and five years of surgical residency training before his dream becomes reality. Here are the issues.

He is still paying off his college tuition loans. He will have to pay tuition for his post-grad year. Medical school tuition alone will cost at least $40,000 per year [private] or $20,000/$40,000 per year [public, resident/non-resident]. Fees, health insurance, books, housing, food etc are not included. According to the AMA, the average debt facing graduating medical students in 2009 was $156,000. Here is a Wall Street Journal story about the worst case scenario for medical school tuition debt, a whopping $550,000 tab run up by a family practitioner.

He will not be able to earn much money during his five years of residency training. The average salary for a surgical resident is about $56,000 per year, which will force him to defer paying the principal on his loans while the interest keeps on accruing. By the time my young friend is ready to start his residency [2015], I fully expect the current allowable work hours to be significantly lower than the current 80 hours per week. This may lead to a lengthening of the duration of surgical training to six or seven years.

At best he will be 40 years old when he is ready to start practice. No doubt Medicare reimbursement for physicians will be reduced as this was barely averted for 2011 by a last-minute compromise band-aid bill passed by Congress. The insurance companies will surely follow with decreases of their own.

God only knows what will happen to malpractice insurance premiums, the cost of running an office and other practice expenses. One thing for sure is that decreases are unlikely. “Private practice” may not even exist by 2020. Every doctor may be salaried as regulated by the government.

So do you want to invest ten years of your life to become the 21st century’s version of an indentured servant who runs up a debt so big that it can never be repaid for the privilege of working 60-80 hours per week for the rest of your life? If that sounds like a good deal to you, then go for it.

Skeptical Scalpel is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • http://www.john-goodman-blog.com Devon Herrick, National Center for Policy Analysis

    I had an uncle that retired from teaching in his early 50s and attended a private medical school to become a DO. He was already relatively wealthy and had a pension when he went back to school. If I’m not mistaken, he only practiced for about a decade before he died.

    I cannot see how it could be worth it for a 30-year old with student debt starting out today. It would take far less time to become a nurse practitioner and provide primary care.

  • http://www.healthgrades.com/neurology-directory Sarah Hill

    I asked my doctor about this. He told me the best doctors never second guessed going to medical school. They knew they wanted to help others and their passion only grew over time. I am grateful for those types of doctors, otherwise we probably wouldn’t have many around if everyone worried about debt. Just like we wouldn’t have any teachers if everyone was concerned with salaries…

    • Jack

      Perhaps several decades ago one can think that altruistically. Unfortunately reality hits. You put anyone under a debt load of $300K starting out that person’s vision will change. It’s just reality.

      Bills will come in and needs to be paid. MD or not, banks don’t drop their interest rates just because you help people.

    • Melissa

      Sarah,

      You may want to discuss this matter with a few more physicians. Fiscal responsibility or irresponsibility, i.e. not worrying about debt, is a huge issue in the minds of most of the medical students I work with. I am thankful for the scientific Ghandi types of the medical world. TRULY THANKFUL. They do exist. But, in my 18 years of working in the medical field I have met few.

      Fortunately, most every physician I have encountered commonly provides services to people who can not pay for their care. Most are willing to make extensive sacrifices to their lifestyle and endure severe emotional strain to maximize the health of their patients. They possess countless other values that regularly trump maximizing profit. But, I rarely have met anyone who completely does not feel responsible to take in to consideration their financial future as it usually affects not only them, but their spouse and children as well.

  • Matt

    If all the assumptions in the post were to come to fruition, the analysis above is true. But based on average incomes for every type of physician but family practitioner, a medical degree gives you a heck of a return on your investment.

    • pj

      Not true. Pediatricians make even less than FP’s, ostensibly because of all the preventive care they do. This nation does not value preventive medicine.

  • DVM

    >>The average salary for a surgical resident is about $56,000 per year, which will force him to defer paying the principal on his loans while the interest keeps on accruing.>>

    Gee, that’s about the average starting salary for a new graduate veterinarian. The new grads I know manage to start paying their loans (the average is roughly equal to average medical school loans) without too much hardship.

    I agree with Matt: one heck of a return on investment.

    • Patricia

      Be a vet. The patients are nicer and you are more apt to get paid.

  • soloFP

    About 1/3 of my med school class was non traditional, with studens in their 30s and 40s. Most of the “older” students chose specialties to quickly repay their loans, knowing that they would work 10-20 years less than in primary care to retire.

  • guest

    Your analysis is slightly flawed. He will have living expenses regardless if he continues teaching or goes to medical school. He CAN pay off the loan debt if he gets creative and does things like rent an apartment instead of having a mortgage. If he is married with kids of course, this may not be possible/desirable. You can definitely lower your variable expenses to the tune of half that of the school’s estimates if you are creative.

    The return on investment is still pretty solid for medicine, even when considering the tuition and, more importantly, the opportunity cost. His opportunity cost, if he is an average teacher, is not that bad.

    Also, he may very well be paying off his old college loans since the interest rate pales in comparison to what he can make in investments. Please don’t look at one point in time (2008) and say that the stock market is a bad idea to increase one’s net worth. Invest for the long haul and you will almost assuredly have a very solid return.

    • joe

      Really?
      It is such a “good investment” that only recently has it again reached 2000 levels (the NASDAQ is still only 50% those levels). Let me guess, you sell mutual funds?

    • Vox Rusticus

      Some things in life are not necessarily possible with family obligations. In the past, people deferred and declined college educations due to family obligations. Anymore, those are considered harsh choices, but the reality is that medical education cannot always accommodate having a family with young children, unless you have a spouse with a substantial income or a family able to provide financial support.

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

    “You can definitely lower your variable expenses to the tune of half that of the school’s estimates if you are creative.”

    Depends on location and living status. Maybe you can do this if you’re single and have a roommate, but no way if you’re married. Try cutting living expenses by 1/2 in a large, metro areas, where 700 sq feet costs $2k, the gas is $0.20-0.30 more expensive, and the occasional coffee or quick lunch on the go is double what it would be in the more rural Midwest.

  • http://skepticalscalpel.blogspot.com/ Skeptical Scalpel

    Thanks for the comments. A few thoughts.

    @Guest I’m not looking at a single point in time. I tried to project what I think might happen in 10 years. And he is married with a child.

    @DVM That’s $56K/year for the whole 5 years. Do all graduating vets stay at $56K for 5 years?

  • Resident

    56k is a little high from my experience. My hospital pays 45k and gives 1000 more each year. I do get money on a food card though to of 700 dollars

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    I would tell him to follow his heart and ignore doomsday scenarios. It can’t be all about the balance sheet.

  • Meg

    Are you advising that it is not worth it for anyone looking to apply to medical school unless they start planning for it in highschool?

    What if your partner has a stable job and about $40k ready to use on your education, and you start off medical school with no debt? Is it worth it then?

    Please understand that I am not trying to be controversial. I am just trying to understand if becoming an MD is worth it. I am WAY past highschool. I actually have my MBA and work on the corporate side of medicine, but I am not happy with what I am doing and want to move to the clinical side.

    • alex

      The money aspect is really the least of it. Compared to other professional education, it’s a decent return on the investment although it has gotten significantly worse and god only knows how much worse it will get.

      What people don’t understand AT ALL is the lifestyle and cost it exerts on your health and relationships. Not just the hours, but the ever-present pager and the lack of flexibility that is unparalleled in any other field. How many other fields are there where the concept of a “sick day” is nonexistent? It’s absurd.

      Ironically, the only ones who start to understand are the patients in the hospital who are there for a week or so and realize they’ve seen you at pretty much every hour of every day. They invariably become horrified on our behalf, which is equal parts nice of them and depressing for us.

      • Melissa

        I think many times, if an individual had the foresight, what might be off-putting to someone considering the field is the emotional investment that is large and ongoing. Statistically high rates of depression, burnout and even suicide are commonly documented among physicians. Lying awake in bed at 2:30 in the morning, rehearsing your clinical decisions in your mind, and worrying about a patient’s outcome can be extremely consuming. Facing the federal government’s bullying attempts with documentation burdens that if not abided by could result in CRIMINAL charges can be a extremely fatiguing over the years. Fighting with insurance companies and hospital administrators that ultimately are advocating cost issues as a primary agenda is an ongoing frustration. Facing the threat of being sued for negligence even with competent, best effort care being provided to a patient that still has a bad outcome. -Realizing that ultimately you commonly do not have full control of the outcome of the disease processes in a patient, but intensely wanting to secure their wellbeing. Having to advise a young mother of 3 that she has metastatic cancer. The psychological expenditures are so often unforeseen to the yet uninitiated.

  • guest

    Joe: You are pretty much saying that you can time the market if you think you know when the market will go up or down? I’m saying that if you keep your stocks for a long period of time (20+years, for example. Ideally, you never trade until you die) you will almost assuredly have a very high yield or roughly 10%.

    He won’t be able to halve his variable expenses if he has a wife and child and wants to have a mortgage. But he can pick the used car, buy everything on sale, etc.

    Look at the chinese savings rate: the chinese are saving roughly 20% of their post-tax income while the american savings rate is like 1%. You just have to be creative.

    • elmo

      No guest I am saying no such thing about market timing. Nor am I a proponent of it. I invest in total stock market index funds with low costs (vanguard/fidelity) and totally leave out the “financial planner” whom in the vast majority of cases is little more than a salesman for whatever captive (active and usually poorer returning) investments they sell.
      I am simply responding to your statement of:
      “Also, he may very well be paying off his old college loans since the interest rate pales in comparison to what he can make in investments”
      is incorrect given resent history and I certainly would not be a proponent of investing in the stock market at the expense of paying off your loans. Over the last decade one would have been better served paying off ones loans off then investing a lump sum in the stock market in 2000 (yes I know that is not DCA). Did you know how long it took the stock market to recover from the great depression?….25 years. It has now taken 10 years for the stock market to recover from 2000. The NASDAQ probably will not be back at pre2000 levels in my investing lifetime. These are not isolated events. The stock market crash of the early 70′s did not return until 1982. The reality is that stock market investing is little more than roulette. But it is a roulette table in which we have all hitched our wagons to thanks to 401K’s, 403b’s, 457′s, IRA’s, etc, etc. Frankly I would take a guraranteed pension over the present system in a heartbeat. Private employers long ago realized that pension plans were not sustainable. The only people left in these plans are public employees simply because politicians allow these plans to continue in order to not rock the boat. In reality they are not sustainable either and in the coming decades the taxpayer will be asked to pay more and more contributions to these frankly unreasonable promises made to public employees.
      In conclusion…..pay off your debt.

  • PAULMD

    SkepScalp prognostications feel about right to me.

    IF he nails his premed requirements and IF he is accepted to med school and IF he gets into a state school and IF he is near the top of his class so that he can have a better chance of acceptance into a more lucrative area of medicine….it may work out. Specialty practice may not be his dream and gen surg is a TOUGH slog that does not get much better after you finish your training.

    If his only option is a high priced private school it is not a good dollars and cents decision. Ultimately, it’s his decision.

    Remember, it’s only a dream when you can wake yourself up and it all goes away. He may be pursuing a lifelong nightmare of slavery to debt. Lots to think about.

  • anon

    if he will get a pension if he continues teaching, the opportunity cost is huge. if he gets medical benefits + pension, the opportunity cost is beyond huge. the lost income and retirement savings will never be made up (11 years worth during the training plus loss of years for interest to accrue)

    medical incomes are projected to slide. i do not know how to figure that into dollars and cents calculations. i do not know how to figure the lifestyle of a general surgeon with all night call at 65 into the calculations versus retirement with a pension. it might be worth it to him, but financially it is still probably a significant risk. lots of people love to do things at 30. after 20 years of doing them, most still do not have the same passion. once you accumulate the loans, though, you cannot just drop it easily. hopefully if he chooses to pursue it though, his family fully supports him. if his wife makes good money, they might not need to take out so much in loans. long lonely nights for the family though, compared to what i envision teachers have.

  • mc

    I remember looking into rural recruitment programs in underserved areas that pay all your educational debts IF you agree to stay with them for many years. Kind of like another form of indentured servitude, only in Appalachia. If you’re crazy dedicated…

  • http://demandeuphoria.blogspot.com Vickie

    @PAULMD, I love this line: “Remember, it’s only a dream when you can wake yourself up and it all goes away.”

    Did you make it up? Because I LOVE it.

  • PAULMD

    Yup, Just made it up. I’m funny that way.

  • ninguem

    There was a study about 1994 as I recall NEJM, came to about that same conclusion. Making the assumption that someone with the ability to get into medical school should be able to get into the better 1/2 of business or law schools, as there are no night medical schools or other part-time routes.

    Best return on investment was a MBA, followed by a tie between law and specialty medicine, family medicine is dead last.