By Dr. James M. Dahle, WCI Founder
Many of my readers wish they had read my book in med school or even earlier. Well, I had a recent email from a pre-med who is going into this with his eyes wide open. I thought our exchange contained some worthwhile insights.
The High Cost of Medical School Dilemma
Q.
I was just recently accepted to medical school after not getting in my first cycle. I was ecstatic to finally become accepted; I am thrilled to be entering the field of medicine which has been a dream of mine for many years! This brings me to the dilemma: the cost. It is looking more and more likely that the only school I will be accepted to has a total Cost of Attendance (COA) of, on average, $83K per year ($57K in tuition alone). This is staggering to me. And because of how tough admissions is, I have essentially no chance of attending a cheaper school. I should also mention I am very satisfied with the school I was accepted at. In addition, this school is in a low cost of living city. I have $15K in undergrad debt, which I am thankful is not higher.
I was watching some of Dave Ramsey's videos, and saw how he reacted to some of these people with massive medical school loans. He reprimanded them, and I know this will be me in a few years. Yet, I don't even have a choice on the matter. It got me thinking seriously about the finances of all of this. I am going to become a physician, this I am sure of. But what tips would you recommend to someone who is looking at this staggering cost of attendance? I feel like if I were to ask Dave Ramsey, he'd tell me either go to a cheaper school or to give up on becoming a physician because the price is so ridiculous. Both of these options are not possible for me.
I've looked into military medicine, but I have heard time and time again that to join for the financial benefits is a poor decision. I am very hesitant to join the military for purely financial reasons. Moreover, I am not sure which specialty I am interested in; I am drawn towards surgery or a surgical subspecialty but I am not ruling out primary care either. Of course, with this debt load, I believe I would pushed away from primary care, as many medical students today are. Outside of what is mentioned in your book, do you have any other suggestions on what I can do when looking at such a massive COA for attending medical school? If you were looking at the same costs, what would you be thinking? Honestly, the $200K average indebtedness for private medical graduates seems like a myth; most COA at private schools, regardless of location, appear to be $70K+ a year, at the minimum.
A.
First of all, you do have a choice. You can choose to apply again and try to get into a cheaper school. You can also choose a different career. You only have “no choice” if you operate under the assumption that you must go to medical school. I'm not saying it is a bad choice you are making, but don't pretend you have no other choice. In a very real way, you are now making your bed. At some point in the future, you WILL have to lie in it, probably for the next 1–2 decades at a minimum.
Problems with the Graduating Med Student Survey Data
Remember that $200K figure is for people who graduated last year and includes lots of people going to cheaper schools with more family support than you. That is the average for all medical students who borrowed money. That doesn't mean they all borrowed the whole cost of attendance each year. That end of med school survey generally includes quartile data as well which gives you an indication that there are many med students with much larger debts. In addition, your figure will be 5 years further down the road. That means it will include higher tuition than the currently listed tuition and interest accrued during medical school. But wait, there's more. By the time you finish training, the debt will have compounded over 3–7 more years where you won't be able to even cover the interest. To make matters worse, I suspect the data is bad for two reasons. First, it's just a survey. It doesn't require med students to actually prove how much they owe. They're just asked about it, and I suspect many don't know the exactly total and estimate low. Plus, most of them aren't even done with school yet when they take the survey. They still have a few more months to spend borrowed money and let their now huge debt compound.
Debt-Free Medical School?
I've never heard a call like this on the Dave Ramsey show where someone called before taking on med school debt. I'd be very curious to see what he would say. It simply isn't the same as undergraduate. Undergraduate can be done debt-free. The same cannot be said for med school. I do not think borrowing to pay for medical school is some huge sin and I think Dave Ramsey would be a fool to advocate that position. But you are somewhat in control of how much you borrow (by choosing the cheapest school you can get into and living on as little as possible) and very much in control of how much you earn down the road (through specialty and practice choice).
Financial Implications of Military Service
Regarding the military, if you can't figure out a way to get out of debt by 4–5 years out of residency, you'll come out ahead going into the military via HPSP (at least student loan wise) since your time debt will be paid 4 years out of residency. The more expensive your school and the more poorly paid your specialty, the better financial deal it is. That said, you may be very miserable for four years if you do not have at least some desire to be a military doctor. You especially need to understand the military match and how it differs from the civilian one before you sign up. But it's not like it is impossible to be miserable practicing outside of the military, especially if you still owe hundreds of thousands a decade out of residency and can't cut back at all due to having that debt monkey on your back.
You Don't Get a Pass on Math
As far as what to do, there is no magic here (outside of Public Service Loan Forgiveness, which may or may not be there 15–20 years from now when you will need it). The more you borrow, the more you will owe and have to pay back. You can minimize how much you borrow by trying to work as much as possible, tapping family resources, spending as little as possible, taking the loans as late in the school year as possible, etc.
How Long Will You Have to Live Like a Resident?
If your dream is to practice medicine no matter what the financial consequences, you will likely be able to achieve that. As far as practicing medicine AND building wealth, it is really just a matter of how long you will need to live like a resident after residency before you can start to grow into your income. If the average student has to do it for 2–5 years in order to be financially stable, perhaps you will have to do it for 5–8 if you rack up huge debt and choose a poorly paid specialty.
I'm not going to tell you it's okay to just borrow whatever the heck you want and that you'll be able to pay it back while living like an attending no problem because it is a problem for more and more medical school graduates each year. Is medical school still a good investment? I think so as long as you can keep your debt to attending income ratio to less than 2X. At a likely $400K–$500K in debt at the time of your residency completion, you're going to be close to that with many specialties. Tread carefully, do the best you can, and I think you can make it work.
What do you think? What would you tell this student and his classmates? Comment below!
I never considered military medicine, but at those prices it seems worthwhile. You may very well have 400K racked up by the end of med school.
I just graduated med school in the southeast, matched emergency medicine. I thought I’d pass along some observations about military match process (I did not join the service myself).
We had several people in my graduating class not match into their desired specialty. Many of these people were reaching to begin with, but some were surprised. Of all the people who did not match, those with military scolarships were most frustrated. One of my close friends was in the Army and wanted to do Orthopedic surgery. There were 20-30 spots for over 90 applicants. Another of my good friends in the navy matched into one of 30 Emergency medicine residency spots. There were 3 who did not get these coveted few positions. I know it’s a small sample size, but that’s 25% match rate for military EM vs more than 90% match rate for civilian EM. And these were not weak applicants.
A few other military grads going for various other specialties did not match and are now doing the military version of a transitional year. They will become general medical officers, serve for a number of years, and either A) remain in military primary care, or B) reapply for their desired specialty. For them the military match created a 3-4 year detour from the outset of specialty training. They have no debt and we’re paid during med school, but they may never Match into their desired specialty as a direct consequence of their agreement. I personally chose not to pursue a military scholarship because of the numerous constraints it can place on specialty choice, and the discrepancy between officer salary and private sector physician income. However if you’re 100% set on primary care you may indeed be better off financially going military route–and without constraints affecting specialty choice.
The match is specialty, service, and year specific. My year, EM in the AF had a 50% match rate, which was more competitive than dermatology in the civilian match.
However, I know a doc who matched into dermatology in the military who never would have in the civilian match. You get “points” for different things in the military match, and sometimes that’s to your benefit and sometimes it isn’t in comparison to the regular match.
But I agree that is perhaps the biggest downside to the HPSP scholarship.
First, Dave Ramsey is misinformed about medical school debt. America would have no new doctors if a requirement to go to medical school would be to finish school with a reasonable debt burden.
Second, please be sure that you will be able to get a residency out of medical school. If the only medical school you got into was a Caribbean school or a DO school, I would do some serious research about the match rates at graduation. The increase in medical school enrollment is outpacing the increase in residency positions, and more and more students, even US MD students, are having trouble matching. Having required an extra year to get into medical school and only getting into one medical school puts you at risk for not doing well in med school. ( I emphasize at-risk; there is a surprisingly low correlation between your premed stats and your medical school performance. Many of the highest performing medical students I know barely got in or required three tries to get in).
Work as hard as you can in medical school. You want to do as well in medical school so that you have an option to go into the most lucrative specialties. Even if you do not want to go into a high-paying specialty, getting good grades and Step 1 can get you into a better residency program, which will correlate with better job outcomes, either in location or in salary.
Finally, I have nothing to add to WCI about actually paying off your future student loans. You will need to do many years of “financial fellowship” (I.e. Live like a resident) after training. Keep on reading physician personal finance blogs, as there will likely be student loan reform between now and when you finish residency. During each step of the way in your training, be on the lookout for the most optimal way to manage your student loans.
Congratulations on getting into medical school. Being aware of the problem is the first step in fixing it. By reading physician personal finance blogs, you’ll be well ahead of the curve compared to your peers. I am confident that you will be able to manage your student loan debt appropriately and achieve your dreams of becoming a doctor.
-WSP
My guess is that Dave Ramsey would suggest to delay school a bit, work and save aggressively, and apply for a TON of scholarships.
Speaking of scholarships, this is a HUGE total bill obviously, but I wonder if there are people out there who have successfully managed to lower the cost to more reasonable levels (at least 1/2) so their post-graduation debt load is low enough to pay off quickly.
My experience is that there is precious little scholarship money available for medical school. I attended Duke for undergraduate on a full scholarship and received a check each semester for living expenses. At the time there were four medical schools in North Carolina. I was accepted at all, and applied for any and all scholarships. I think I received a total of $1000 one time for a school with a cost of attendance of $50000. Add to that the fact that I was married at the time so the school considered my parental income and my spousal income together as part of the FAFSA, and there was really no help to be had.
I did receive a partial academic scholarship to medical school based on grades and mcat scores. It was $3k per year but tuition at that time was only 6k/year. I was able to get by with 29k in loans. This illustrates how inflated med school tuition has become.
wow – 6k per year? Thats amazing. 29K total? Amazing.
Humor me. Just what are the ton of scholarships that are out there for medical students, Brad?
The only medical school scholarships I have seen (and have received so far) have been through my social fraternity and honor societies. Also this website has by far the most generous scholarship but I’m the competition will be fierce and is based solely on one essay.
…how can a normal kid compete with the financial need of someone who is married with a child and has a “wife who deserves that scholarship.” And “wants to be poor.”
I applied to med school in 2014 and I did receive scholarship offers. One school (not nationally ranked, MD, close to home) offered half tuition renewable every year if I stayed in the top half of the class. Another (highly ranked, MD, further from home) has given me about $2k per year and allowed me to switch from out of state to in-state tuition after the first year. Because this school’s tuition was extremely reasonable, 3 years in-state and one out-of-state was actually projected to be cheaper than four years of in-state tuition at a ranked state school I also considered. The school I chose also offers $10k/yr scholarships to 50-60 of the ~600 2nd-4th year students. I haven’t been lucky enough to receive one, but they do exist.
I was absolutely torn between the school that would be least expensive and the one that was “affordable” and academically great. My family ended up subsidizing the difference for me, but if they hadn’t I would have gone to the one with the bigger scholarship. I’ve also been able to subsidize myself working part time to the tune of $2-4k/year. Obviously this is harder during 3rd year, but it is absolutely doable if you’re motivated.
More anecdotal evidence: Undergrad classmate of mine (smarter than me for sure) applied in 2015 and got a 3/4 tuition scholarship to Vandy.
To say scholarships to med school don’t exist isn’t true. However, you do have to be a competitive applicant to get them.
I would second and third the search for any and all scholarships. There are some med schools that offer scholarships directly (make sure to talk to your Dean’s office and Office of Fiancial Aid). There are also some state scholarships that are separately administered. My state (Oregon) has a state scholarship commission that includes administering scholarships for grad students (including medical school) https://app.oregonstudentaid.gov/ . Make sure to search if your state has the same. And finally talk to your local medical societies. If you grew up in small town or county there may be some surprising (and amazing opportunities).
For reference, I graduated from my med school in 2015. My parents read an article in the local paper about a scholarship fund administered by the local medical society for students who attended primary/secondary school in my county (one of those articles your parents send you that you are actually really grateful they clipped and mailed to you). I applied and got the scholarship for 3 years for $10-20k/year (increasing amounts each year). I also won two other scholarships (from the state scholarship commission that amounted to about $5k/year). My med school tuition was 40-50k/year (increased each year).
Needless to say, my debt is currently about $200k in residency instead of $250k because I took about 4-8hrs/year to find and apply to scholarships. Also, I’d say I was pretty much middle-of-the-road for performance in my med school class (not for lack of effort). These scholarships were certainly not awarded for being top of class.
Only one thing is certain, if you don’t search for and apply to acholarships, you won’t get any.
Just commenting to agree. I also went to medical school in Oregon (graduated in 2012) and benefited from applying to the state scholarship commission. The medical school also gave me 3-4 scholarships directly, despite my average grades, and I found a few more small external scholarships from a local union and diversity group. (I saw those ads for the county scholarships, but I never saw one for my county. Well done, OregonERDoc!)
I think that so few medical students bother to look into/apply for scholarships that your chance of actually getting one of the few out there is rather high–IF you spend the time to apply. The ROI is pretty darn good, at least $500/hour for even the smaller scholarships.
With over $30k in scholarships and also earning perhaps $5 total from what work I could do during medical school, then paying off all accruing interest during residency, I was able to lower the debt burden substantially. What you don’t borrow, you never have to pay interest on, which also keeps the total cost down. Combined with living frugally (bike to med school, vegetarian, low rent, etc.) and borrowing much less to live on, I was able to rid myself of med school debt within 2 years after residency even though I’m in family practice.
TL;DR: Apply for scholarships! You CAN make it work, you just need to stay focused.
Two years, nice work.
Back in 2011, the New York Times published an op-ed by Karen S. Sibert, MD, an anesthesiologist in California. In this piece, Dr. Sibert discussed the increasing prevalence of doctors — particularly women doctors — choosing to work part-time or leave the profession altogether at relatively early ages. She noted that, historically, medical school tuition did not cover the full cost of modern medical training, and that public support had long been essential to creating new doctors. This is particularly true for residency slots where trainees receive a salary (instead of paying tuition), with the lion’s share of the costs essentially subsidized by Medicare. But given contemporary trends, society is losing out on its investment in medical training due to physicians downshifting or quitting at an early age.
In the years since reading that article, and having kept an eye on medical school tuition growth, I speculate that astronomical tuition and debt burdens are a natural consequence of these trends. If more and more doctors are explicitly willing to take the money and run — declare themselves financially independent and quit medicine, or go part-time for substantial portions of their careers on a “mommy” or “daddy” track (but let’s be honest with ourselves — per Sibert, this usually means a “mommy” track, not a “daddy” track) — then something has to give. We can no longer rely on doctors working full time for 30 years simply because that’s what a respectable paterfamilias does, or because those Jaguar payments don’t grow on trees. Those incentives no longer bind.
If doctors prefer to work less over the course of their careers relative to prior generations of doctors, society needs some combination of additional trained-up doctors relative to past levels and/or stronger countervailing incentives than used to exist to induce trained-up doctors not to leave the profession or go part time too early. Higher medical school tuition and higher student debt burdens are a way to achieve this. More tuition money means the schools can get bigger and train more (but question how this helps solve the residency bottleneck, given that those slots are not traditionally supported with tuition dollars), and higher student loan debt burdens means that young post-residency doctors are trapped in debt slavery for longer periods. More debt slavery creates a greater sense of compulsion for the next generation of doctors to continue in full-time practice than they otherwise would. A win-win!
Interesting hypothesis. Kind of doubt it’s true though. I don’t think there is an underlying conspiracy to raise tuition to keep more docs in the work force. I think they’re just charging what the market will bear.
Correct. When they start having unfilled slots in the first year class, we will be at Peak Tuition.
I am no longer in academics, but my theory is that, just like community practice, schools are trying to maximize every dollar to pay for the bureaucrat class while dealing with a climate of decreasing reimbursement on top of diminished funding (such as from the state).
We must allow student debt to be discharged in bankruptcy and put schools on the hook for this loss. Our children are not a limitless cash crop to be harvested by the universities.
For the original pre-med student’s question, it might be worth breaking down the monthly loan payments and comparing to various incomes. If you’re making 150k, paying 20k in taxes, 25-50k in rent/mortgage/electricity/gas/beater car/insurance…50k in loan payments doesn’t leave much to live on, let alone saving for retirement/kids.
Plenty of women docs work a full career!
Plenty, but is that most? And comparable to a male physician? Probably still too early to tell.
Craigy I do not have any stats on how long female physicians work. I decided to go part time at 56 (meaning I quit OB) because financially I could. I think I did my time running into the hospital at night and on holidays for long enough. I am one of 2% of female physicians with a net worth > 5 million according to medscape. Above a certain number the medicolwegal risk makes no sense.
Hatton1, you might not have stats on how long female physicians work, but rest assured they are easily accessible in the online literature.
The NYTImes article I originally cited provides some statistics and figures showing that women doctors systematically work less and take more extended leaves than male doctors. Furthermore, back in July 2012, the Atlantic published a piece by Keith Chen and Judith Chevalier which also noted that women doctors tend to work less over the course of their careers than male doctors do, and provided some quantification of this. In fact, those authors concluded that the average woman primary care physician would have been better off financially had she foregone medical school entirely and became a physician’s assistant instead! They did not reach this conclusion for male PCPs, and they attribute the difference in large part due to the “hours gap” between men and women doctors.
Exceptions of course exist: My late father was an ophthalmologist, but he only worked into his 40s — he was forced to retire on disability during his prime years due to crippling injuries sustained in a car wreck. By contrast, my mother, who is also an ophthalmologist, worked until about age 60, when she was forced to retire on disability due to the side effects of cancer treatments (she has since made a good recovery, thankfully).
With five more years of tuition inflation behind us, I do wonder whether it is worthwhile for anyone but the staunchest of workaholics to get an MD just to go into primary care — and I’m not the only one!
OK Ben I read the Dr Sibert article. The atlantic one is inaccessible to me. Are you familiar with FIRE? Most of the proponents of this are male. Why don’t you check out Physician on Fire or The Happy Philosopher. There has been a recent forum thread about do we as physicians owe society a long career. The answer seems to be no. All docs male and female should be able to retire early or work part time as they please.
Well women have children, that’s the obvious reason. And even if we have working male partners, women still bear the brunt of rearing children. You can’t have women docs stop having kids.
And agree with Hatton1 – pretty much all the FIRE MDS are male.
Yes, until the family leave policies and cultural expectations change in this country along with better access to quality child care I’m sure female physicians will continue to take work less than their male peers. Also I suspect many more female docs are married to a working partner and thus there is less financial pressure to work full time. Ultimately though, who cares? I feel like being on the”mommy track” was meant to be a bad thing in that article (although I didn’t read it) but from my vantage point I’m quite happy to be out here and thankful to not be forced to work more than I want.
I agree with Miss Bonnie and wideopenspaces. I think the stress of balancing a family with a medical practice demands would lead more female MDs to completely quit if part time work was not available. You only have one life so everyone has to figure it out.
No one should feel shamed for choosing to raise children. That’s just ridiculous. If men were the child-bearers I’m sure we’d have amazing paternal leave with crazy benefits.
My advice to the student would be to do a PA program.
Having done academics my guess is that a student who only gets into one medical school after several cycles is unlikely to crush their classes, rotations, Step etc. Everyone thinks they are the unicorn but in reality almost no one is. If there is any pattern of being a little bit below average the chance of having a great deal of freedom in terms of specialty choice is severely reduced. $400-500k is doable as a hand surgeon, potentially crippling as an FP.
These conversations are also informed by the fact that basically every premed thinks that “just being a doctor” will be enough no matter the sacrifice. Again, this is only true for unicorns. I probably personally know 1 physician well who just genuinely doesn’t care about money (practices in rural Guatemala for pennies on the dollar). Most of us get into residency and for better or worse start feeling like we “deserve” certain things. Whether that’s a Mercedes or that’s WCI’s canyon trips, you want to do stuff besides patient care.
This person is taking a significant risk of being unhappy and feeling trapped. I would say I’m about a standard deviation above the mean in terms of genuinely enjoying my medical practice (not 2 std dev, just 1). But if here at 38 I was cranking away trying to make headway against what was still a massive debt that would take the fun out of things quite a bit.
As far as what would Dave say about med school more generally? I would say that going $200k into debt to land an incredibly secure $300k/year job is even better than putting your money in 4 classes of mysterious “good growth mutual funds” with a 12% return.
I love that a Mercedes and canyoneering go into the same category. I just got back from a one week trip. It ran us about $200 a person, including food and gas. I think I’ve spent another $200 on gear this year.
That’s a couple of months’ Mercedes payments. Plus the week of opportunity cost might cost the rest of the year’s payments. 😉
used mercedes i guess, heavily used
A PA program costs about the same in terms of their earning potential, just able to start earning a little bit quicker. In 20 years OP may have serious regrets if the dream is to be a physician. I am in a similar situation starting school in August and I would personally hate having to have my notes signed by a physician who is younger than me/ may be dumber than me.
Opposite is also quite likely, maybe more so to be true. Do not discount earning much quicker, its not at all insignificant. Time value of money.
PAs may get some kind of autonomous primary role soon, seems inevitable, also they are free from a lot of the responsibility and pressure of md’s, and largely overlooked in med mal but that is likely due to the primary care focus.
This may seem like something you dont/wont care about at all, but once you’re done this kind of thing will be some of the more important and or stressful parts of your life.
Going back and doing the PA route would have been a phenomenal move as far as investment of time, money, ultimate worth and life enjoyment. During residency you may see them participating in all the fun stuff during the day, punching out at 5 and handing the pager to you. Wont seem like such a big deal then.
I got confused for a male nurse the other day and I wanted to die. I don’t mean to offend anyone, it’s my own biases. I know male nurses are great, and nurses in general are a vital part to the care team. I personally could not live my life with assistant in my job title, I just couldn’t. I promise I wouldn’t be happy as a PA or NP even if it were a better a financial choice.
Welcome to what female MDs face all the time. I hope you’ll do your part in always addressing female MD/DOs as “Doctor” and not by first name.
Thats an egotistical way of going about your life that will land you in situations that are not what you wished they were. Not a personal bad judgement of you, believe me, we have all been there. I mean I dont think I ended up in plastic surgery because I didnt like the idea of getting into the hardest residency, etc…etc…Sometimes you cant do much about being young and headstrong, ambitious, but if there is a truism its that those feelings fade and much different issues become your dominant reality. Im sure no one could have talked any sense into me at your age, so good luck to you.
While you think you may not be happy as those things because youre just enamored with the idea of being a doctor and some sort of prestige of it and such, while that can be slightly true, it fades and you get over it (hopefully).
You will see the great upside of the overlooked and hardly bothered rn/pa enjoying their life while you spend enough time in the hospital to figure out the exact number of hours in a week. You never get time back.
I am sure you are right but I am sure there are just as many NP and PAs who wish they were physicians. I know 2 mid levels so far and one is my aunt. She has said multiple times she wishes she became a physician.
The other one is my brothers girlfriend and a recent quote was “these surgeons make so much more than me and I’m in on all their cases, I deserve a raise!”
It is easy to not care about prestige when you have it. The same can be said for money/ lots of free time. Just the nature of the world.
Yes, well…theres the rub. Cant really do anything about that.
I think med school is so competitive that they turn down plenty of perfectly good candidates. So I don’t think OP is lesser because of this. And PA school is also very competitive. I would not assume you can just easily get in there if you didn’t get in to med school. However I do think PA school is a great choice for people and if I’d known more about it I may have gone that route. So might be something for OP to consider if they are that worried about the COA of med school.
I’m a 16 year Navy Emergency Physician, so I’m biased, but you should strongly consider the military. My wife and I both did the HPSP scholarship and as a result avoided $500K in debt. If you want to discuss the military with someone who has been around the block, particpated in 4 military GME matches in a row, and is in a similar place financially to WCI, go to my website (MCCareer.org) and use the “Contact Me” tab. We can talk about it.
Joel, great blog ! Congratulations . One other benefit of military route is the opportunity for leadership and other educational opportunities such as an MBA as you have also done.
For my husband (we were both US Army docs) the other ‘educational’ opportunities included flying multiple US and British military aircraft and visiting multiple countries- experiences I’m sure glad we didn’t have to pay for. All I did interesting was also travel a bit more extensively and jump out of a perfectly good airplane a few times. Oh and indulged my oldest child take charge urges by commanding medical clinics soon after residency.
Biggest drawback I saw in primary care was having to apply for military residencies if you wanted a civilian one. No problem for me- I felt the Army’s FP programs were better than the ones I knew best in my town. And actually, if you want O/O/O and have the time, most military docs (used to?) get the chance to get a coveted residency after putting in their time- the reason harder to get a residency right off, it is a reward for time and patience not just excellence. So a mediocre doc had a better chance I believe at O/O/O in the military than civilian side. However the military now wants less folks practicing after a transitional year so they might push one to take a less coveted residency if not accepted in one’s hoped for specialties. Not sure about current military medicine.
I think this is the notorious Dave Ramsey video this premed is referring to: https://youtu.be/F3qjug9N5BQ
There’s a bunch of his clips like this. Anything in the six figure range seems to give him a panic attack.
There is a choice; it’s just a scary one. The choice is to decline enrollment and apply next year to try and get into a cheaper med school. The question that needs answered is “why didn’t that happen already?” If you are a native of a state like California where the public meds schools are swamped with qualified applicants, seriously research residency requirements for other state med schools. I had half a dozen friends in med school who were California natives but established residency in my home state to have a better shot at acceptance to a public med school. If you live in a smaller state and didn’t get in to your state school (twice), why is that? Poor MCAT? Poor GPA? Anything fixable, or is this the resume you have to apply with?
The second part of the equation is how likely is it that attending the med school you got accepted to will allow you to reach your career goals. There are plenty of private medical schools with well established reputations, and doing well there will make you a competitive candidate for whatever residency you pursue. There are others…not so much, and if you go there, a serious possibility of sinking $400k in debt and going unmatched exists. That is financial catastrophe and must be avoided at all costs. It is better to not be a doctor than to be a doctor who can’t practice as a doctor with a huge debt burden.
It is not a crazy idea (yet) to go $400k into debt to become a physician, as long as you are willing to live like a resident while you climb out of debt. However, it is definately worth asking tough questions before making the plunge.
I agree that deferring a year and reapplying is probably not a great idea. Sure, it’s a plausible idea, but because you’d be the outlier your answer might be suspect to your interviewing committee. Additionally, one deferred year is another year of lost wages. You could theoretically make the high debt a little more manageable if you had an extra working year in your career.
I gotta tell you the people that I work with who have gone through multiple application cycles don’t tend to do much better the longer they try it.
That’s my sense as well. I would be very hesitant to go for the birds in the bush if I had one in the hand, especially with the lost year of earnings. Apply correctly the first time and take the best you get.
“I’ve looked into military medicine, but I have heard time and time again that to join for the financial benefits is a poor decision.”
You are going to be making plenty of decisions in your future because of finances with the debt load you are taking on. Please do not be so naive as to listen to what you have heard on the military. You need to research this option and consider it very seriously. Could it even help you get into the area of medicine you want if you are not a strong applicant from med school? My husband and I were not military but did consider it. I was lucky to get a full tuition scholarship to med school which make the decision mute for us. Most of these scholarships are not applied for. You are automatically considered upon admission. Fair or not, the committees seem to heavily favor applicants with undergraduate research. So, for premeds reading this, do research in college.
I wouldn’t bank on the military – particularly the Navy that still does GMO tours – making it easier to get into the specialty of your choice. When I was an intern they accepted 5 ortho interns every year for 3 spots. Rarely did someone go straight through. The rest cycled out into operational tours (think opportunity cost), joining the pool of others lying in wait, or just gave up. They weren’t alone as a specialty. If you’re considering the military I recommend talking to as many people as you possibly can who have gone through the process. Pros and cons, just like anything else in life. Just has to jive with your needs.
Hi,
The above comments are very thoughtful and insightful and I agree with them. First of all, congratulations for getting into med school. Your grit and committment is displayed by you applying for multiple cycles and facing the daunting news of the financial costs head on. That will be your biggest tool in determining your success.
The only thing I have to add is that you need to pay very close attention to the income and earning potential of your specialty choice. Look at ancillaries income, geographic distribution, insurance/reimbursement trends, population trends, and the average age of practitioners in a field of interest. Gone are the days where you can blithely “do what you love” and not have any financial stress.
The satisfaction that taking care of patients is part of the currency by which we doctors are paid. Understand that you do not have to be a pediatric transplant cardiologist to get the immense pleasure of engaging a distressed individual and providing a solution by using your skills, knowledge and compassion. It all depends on how engaged you are with the problem at hand. I’ve seen child psychiatrists completely detached and interventional radiologists that I’ve caught on rounds late at night. I guess what I’m trying to say is don’t stop looking at the money and don’t buy into the notion that you should place financial consideration regarding speciality choice high on your list. I went into medical school inspired to become an ER doc and came out a urologist. I love my job, my patients and my income.
I hope you study hard, earn money in a job in your first 2 years of classes and do not waste the summer between 1st and 2nd years “enjoying the last summer vacation I’ll ever have.”
-ZD
If the sender of the email prompting this post is reading — DON’T DO IT!
Taking on something that will likely end up being north of $400k in student loans to go to what is likely a marginal medical school as a below average student is a dumb choice, plain and simple. Few people will tell you something like that so directly because they don’t want to ‘crush your dream’, however, making that choice you would be destined for a nightmare. Historically, there was a term for the decision you’re considering, indentured servitude.
a bit dramatic, but i don’t disagree.
“I’ve looked into military medicine, but I have heard time and time again that to join for the financial benefits is a poor decision.”
I must disagree on this point. Joining the military for the financial benefits is the main reason for doing so, and if you attend an expensive school, you will definitely come out of the military financially ahead of your peers who borrow money. If you go the military route, your choice of specialty will matter less in terms of finances, and you can choose what really interests you most.
Also, in the military, residency training in competitive specialties, such a surgical subs, dermatology, etc, is often easier to come by for those who aren’t coming out of a high-powered med school than it would be in the civilian world. There is definitely less discrimination in the military against DO’s and those from off-shore schools, etc.
The advice not to join the military for financial reasons only is often given as to prevent disappointment with the decision when residency is over and payback time comes and the recipient of the support has to deploy abroad to somewhere unpleasant. I would rephrase the advice to say that it is OK to choose the military for financial reasons as long as you can tolerate military service with respect to your family situation, personal beliefs, etc.
I attended an expensive private school on an HPSP scholarship, and this route placed me in a great financial position as a junior attending.
Agree for the most part. Going military is primarily motivated by financial factors. Your rephrase of the advice is on point. Regarding choice of specialty, I disagree. You don’t end up ahead financially if you are in a high paying specialty. The military wins on that one. The chasm that exists between the private and military salaries (even taking into account non-taxable income) is wide, and the debt burden can be paid off in a few years, all the while building a practice. Now for primary care or low-paying specialties, if you can deal with the downsides of military service, going the HPSP route and staying in 20 years is – without question – a superior decision to going the civilian route. The problem is, many people have to commit to HPSP before they really know what they want to go into, so judgement of prior decisions is very biased depending on the specialty of the physician you talk to. Why does this matter? For students out there it matters who you get your advice from. Get it from a wide variety of doctors (young and old) in multiple different specialties.
I agree with many of the comments above, including the fact you are going into this with your eyes wide open. You also need to be very self aware and realize that you need to do everything right to get to where you want to go. Doing well in school and getting through Step 1 will help ensure that you will have reasonable choices and increase your chances of matching in a residency that fits with your long term plans.
I went to a foreign medical school but I tried to make sure I did everything right to remain competitive. I matched with an ER program and everything worked out. That being said, I had 300k+ in debt when I finished residency in 2008. After fumbling around a few years I started reading WCI and since that time my finances have turned a 180. Although I had to buckle down a bit at times, I never felt like I was deprived of anything and I’ve been able to fully enjoy myself while fixing my financial situation.
I think as long as you are true to yourself and know your strengths and weaknesses you will get to where you want to go. You don’t have to be the unicorn described above, but you do have to have a good plan and do well. I know several individuals that did well from foreign schools and a few made 1 or 2 mistakes along the way. Things still worked out because they worked hard and used common sense. I also watched a few fall by the wayside and if they had my kind of debt they would be looking at an uphill battle for years to come.
Concerning the military route, I agree with the previous comments, only consider this if you have a desire to be in the military. I spent several years in the National Guard and it’s not for everyone, however if have an itch to see what it is about- it can be a great experience.
Continue to do your homework and things will work out. Ignore the nay-sayers that think you will never make it but use common sense and get all of the good advice you can find.
Glad to hear it worked well for you but the data are not on your side: http://www.nrmp.org/wp-content/uploads/2016/09/Charting-Outcomes-IMGs-2016.pdf
Most IMGs who apply to EM don’t match. It’s not “nay-saying” to point that out especially when this can turn into a $400k+ project.
Remember that there are both new allopathic schools and new osteopathic schools opening in the USA. The group that is going to feel this squeeze the most is FMG.
Here’s the reality: if this person had such a difficult time getting accepted into medical school, what are the odds that he can suddenly flip a switch and end up with the top notch grades and board scores required to match in a competitive, high paying specialty? The only way I would take out such a large amount in loans is if I honestly felt that I had both the brains and work ethic needed to get into one of the more lucrative fields of medicine.
If I were uncertain about this, or my heart was set on primary care, then I would apply for PA school and get nearly all the benefits of being an MD at a fraction of the time and money.
Yours and many other comments on this post make the assumption that med school application strength and number of acceptances determine performance in medical school. Unfortunately (or fortunately for this applicant) that is not the case for US MD schools. At our program where I recently graduated, internal data suggested that the classic factors of MCAT score and gpa among others, did not correlate with rank or step score. In fact, an biology score of <9 on the old MCAT scale was the only objective data point that correlated with poor step scores. Anecdotally, many of the top quartile in our class took more than 1 try at getting into med school.
That being said, the financial points above are something to think about. However, only this applicant has the ability to decide their suitability and ability to succeed in med school and obtain a position in their chosen specialty.
Data for that?
I know that the MCAT does not predict Step scores very well but why would we expect it to? The MCAT is at least partially an aptitude test whereas USMLE is all knowledge based.
The calculation here is not “is there a chance that my dreams can come true?” it’s “I am accepted to a very expensive school and it took me a few tries, what evidence do I have that I am going to be able to secure a spot in the residency of my choice?”
If you’re a likable person and the expensive school is a Top 20, that answer my be “pretty good, I’m going to go for it.”
Anesthesiology is probably the highest paying specialty that average medical students can get into. If you are then willing to work in a small midwest city, you can pay off your loans.
Highly consider the military option. In addition to financial benefits, there is honor in serving your country.
Every choice has requirements that may be distasteful. But you rarely get everything out of a life decision that you want.
Average board scores for anesthesia have been moving substantially up over the past decade or so. Med students are catching onto how nice a gig it is, or perhaps being forced to consider it with all the loans they have.
According to SDN the sky is falling in anesthesia and they are all about to lose their jobs to CRNA and salaries are going to plummet. They all seem to think private practice physician owned groups are going to be a thing of the past. Can’t always trust SDN but their complaints certainly have turned me off from the field.
Are they wrong?
Yes.
Except maybe that physician owned groups are on the way out, but that’s true for everyone (especially EM).
The legit US MD schools with these ridiculously high tuitions are not intended for people paying (borrowing) their own way, even though they do it. They’re for the slightly lazy children of the existing doctors who can afford to pay their kids way through school. These schools are happy to take the money from wherever it comes, and they know the borrowed money is there and they’re willing to spend it for you, but these schools understand that they have to take a lower quality applicant as a result of the added cost.
And yeah I would love to know which school this is. If it’s a DO school, Caribbean etc., it may be a terrible decision unless you can really bust ass to make great scores, interview well, etc. And even then it’ll be an uphill battle. Even with a US MD it’ll be tough, but at least you’d stand a decent chance of matching to a decent residency.
As others said above, it’s a rare person who struggles getting accepted who then is very successful let alone shining brightly among his or her peers in medschool. Keep in mind, MCAT scores directly correlate to USMLE scores, and USMLE is what decides your choices for residency.
In hindsight, I was a little crazy and only applied to 3 schools (they were also all top/great schools). How foolish! Could have easily not received any spots at all. That has less to do with my scholastic ability and more to do with not thinking probabilistically enough about applications.
I dont think the MCAT correlates that well to step scores, as mentioned above only a low to mild overall correlation. Part of that problem is parity and that for the most part only those that do well on the mcat and school gets to take the USMLE.
Agree if a Caribbean, etc…school this may be a bad idea.
Having served in the Air Force following HPSP I agree military medicine can be a good route to go financially with certain caveats, depending on your specialty. However I would strongly caution not to do it just for the money–you really need to have an actual interest in serving in the military and be willing to re-locate to wherever they need you following Residency, which could be anywhere, and you might get deployed to a garden spot like Afghanistan. I had a good experience overall, and had my own small department at a hospital in Japan for 2 years, which was a great professional and life experience. But I knew quite a few people who were very miserable and looking for angles to “get out” of their service commitment–invariably they joined “to get my med school paid for” and had no other motivation or interest in the military. If you’re interested I think it’s critical to talk to people who are currently military docs and get their perspective on the pros/cons, then go into it with eyes open.
Great comments here.
Deferring med school is a scary thought, but a decision none the less. If you actually don’t end up enjoying medicine you are going to regret the debt or military commitment. There is a chance you will not enjoy it. If you love medicine, then you will likely be okay anyway, but come out with a large debt burden. This debt will be hanging over your head (particularly since you are informed enough to be reading sites like WCI) and you will want to live like a resident to get rid of it.
Anyone have any advice for me? I am in a similar boat except I got a little luckier than OP.
I got accepted to my local state school where I will be able to live at home and not take out loans for living expenses. The issue is my tuition is still 39k/ yr (so far). I also have about 25k in undergrad debt because I realized I wanted to be a physician during my 3rd year as a psychology major and had to add 2 years onto my undergraduate education taking the pre reqs (terrible financially, but still better than graduating with a psych degree) I applied to several scholarships and so far received 3000$.
So I’m basically looking at 160k for med school the day I graduate because I am fortunate enough to have parents who can afford to pay off the interest each year and they are not charging me for food or rent. I will also have the 25k from undergrad so about 185k total.
My question is how terrible is it having to pay that back? Is there anything else I can do besides rob a bank?
Also military already denied me because I had a juvenile cataract surgery :/
Since you do not have to borrow for living expenses you are ahead of the game. I think you should be ok.
Agree with Hatton. You will be fine. That debt load is manageable on really any physician income. Keep reading this site. Learn from the mistakes of others so you limit yours as much as possible.
Finishing med school with about $200 is very different than finishing with $400.
Go read Jim’s post on student debt/income ratios. It’s trivial as a doc to crack $200k/year except in the very lowest paid specialties. You can do that in anesthesia working 1/2 time if you are willing to live in a less desirable area.
Thank you for the advice , I have read the article and feel a bit better. My only question is does the “1x” “2x” rule include the total interest paid on the lifetime of the loan or is that just the principal at any given time?
It’s just a rule of thumb. I guess when I envision it, I consider it the amount of debt you have when you walk out of med school. Certainly not the total cost of the loan over a decade.
Thanks for the clarification Dr. Dahle.
Wise move to go to the state school and stay with mom and dad for living expenses. You’re on track to have a debt burden low enough that you can work in pretty much any specialty, including psych, family practice, and peds.
Recommend moving to a location with low cost of living, low taxes, and higher than average reimbursement than is typical for whatever specialty you get in the match. Consider moonlighting or taking locum tenens work during your first few years out of residency to kill off the debt and jump start your savings. Overall you’re very well positioned financially. Study hard and work hard to get a residency that meets your intellectual, financial, and quality of life goals. Work hard during school, work hard after residency, and then set yourself up for the freedom to dial it back if you want to.
Thank you for this advice and anxiety reducing thoughts.
Unfortunately, I am from New Jersey which is basically a terrible state for taxes and COL, although it’s not quite manhattan or San Fran.
My life plan has always been to move out west where I can enjoy my outdoor hobbies more but it is looking like I will have a wife by the time I finish school and i am starting to realize it is far easier to say you are going to move away from all your family and friends than to actually do it. Let alone convince someone else to do the same for you. An unhappy wife is far more costly than living in NJ. One thing about My area is that it seems to pay about 10-20% higher than most other areas id want to live on average.
Ultimately who knows what the future will hold.
That seems very reasonable to me. That’s less than 1X for most specialties, very doable.
As WCI says, it’s math. I view education (all kinds med school, b school, etc etc) as an investment in yourself. Can you “recoup” the cost of your investment.
400k to have a an income north of 300K for the rest of your life (assuming you’re in a field you enjoy) is a good deal. 400k to be a low paid generalist in a big city at 120k is not.
Which fields of medicine essentially guarentee a a salary of over 300k/yr?
Any over Over 400k/ yr?
Which physician surveys are actually accurate in terms of salary?
I would say most fields can offer income of 300-400k if you find a job in private practice and are willing to work in a non-coastal location. My wife and I are in specialties with overall average salaries according to most surveys, but live nowhere near a coast, and each now earn around 400k/year in private practice.
I think the better question is in which specialties can you not earn 300k even in a non coastal busy private practice. My guess would maybe only be pedals, FP, psych…
Some residents have gotten offers for peds (esp hospitalist positions) in the low 200s (which is starting for PICU, NICU, Peds EM on the east coast). So that begs the question: PA school at what, $120k salary or peds at 200k in the mid west.
I agree that getting to 300k is tough in peds. PICU/NICU/P-EM in non-academic non-coastal areas can hit that. To do those fields requires an additional 3 years beyond peds residency.
Peds would be more of a challenge, otherwise FP and psych can both hit 300k if you work hard and depending on area and practice type obviously. In terms of “guarranteed” that’s another story for most specialties.
I should clear over 700k my first year out as a psychiatrist in a major metro area. Psych is not a low income specialty.
That’s awesome! Cash only practice?
lot of med management and not a lot of therapy is my guess?
Inpatient. Lots of inpatients. Definitely not a lot of therapy.
Gotta get the loans paid and the investments at 7 figures before I focus on therapy.
Let’s face it: your psychiatrist should not be your therapist! We charge too much and have way less training than a PhD. Plus in most areas there are tons of therapists but few psychiatrists. The wait time here is 3-6 months. I personally feel I do the most good doing med management. However I still get 30 minutes with patients which is enough time to do some therapy and figure out what is going on in people’s lives.
Wow, how many hours are you working for that? I’m pretty sure if you posted that on a certain med/premed forum you’d be immediately called a liar while everyone echo-chambered the same sub-300 numbers everyone here guessed. Psychiatrists have always struck me as a group who values a “work life balance” and I’ve wondered whether their average salaries on the surveys were skewed by working fewer hours than most specialties.
I think you can pretty easily make 300k in psychiatry, even at a non profit (I’m a psychiatrist). You just need to do inpatient work. However, you’re going to be graduating residency in 7 years. Not sure what things will look like then. . .
There are no guarantees in life, but anything other than primary care should get you to $300K+. $400K+ usually means a surgeon, anesthesia or even EM. But there is so much intraspecialty variation that the interspecialty variation pales in comparison.
Most surveys are reasonably accurate, but MGMA are probably the most accurate. Also the most expensive data to buy.
Military is a big question for you and your spouse (if married then) with the relocation- in retrospect I wish I had considered it. A good cause (I think) and great life experience.
400K is going to be a lot- it will be worth it if you are passionate about medicine in general but more so if you know exactly what you want to do after- you can start planning and training yourself for the job you want afterwards- whether that’s clinical, pharmaceutical, consulting, health policy, administration, etc.
I had 250K at a mix of 2.9% and 4.5%. Took me 5 years to get to 120. Would take another 4 years to finish the job with what I want to prepay. I was a little sidetracked by a move and part time work for 6 months, but you get the idea. And my wife was working for much of the time.
Ways to lower the cost while you go through-
1. Read Dr Wise Money (debt free doctor on WCI)- on advice on deferring your loan withdrawals till later. Will likely save you a ton in interest and capitalization with your high cost. Note that her credit card solutions are only for the organized!
2. Get a job in medical school to minimize borrowing. Any little bit helps.
3. Consider being upfront with your school about expense and getting a job for a year to save up for years 1-2 (and live cheaper than a resident while doing it).
4. Commit to moonlighting in residency. Good for your training and your debt. Make sure that malpractice won’t cut too much into your take-home.
5. Refinance at graduation. Your rates will be higher than mine. Use WCI links.
6. Be ok w living in a low-COLA long-term- probably the biggest factor in being FI.
Good luck!
man, if i could do it over i would have done #2.
as busy as med school was, there was tons of time esp during M1 and M4.
i bought into the idea that “my down time is important and needs to be protected.”
i would strongly advise current med students to get a job, even for 10 hours a week.
My main concern would be that this is not a caribbean school (you may not match), and that the applicant is not particularly weak or amotivated academically. The students who “flunked” med school in my time were either very poor students or very lazy. Otherwise the loan debt should be repayable with most specialties, with the caveat that you may not want to take the academic subspecialty Pediatrics position in NYC..
what is the tuition breaking point
private dental schools in big cities are hitting 500k
when does the insanity end
Waiting one year and reapplying does not make a lot of sense. You would also be losing one year of attending income.