April 8th, 2016

The Costs of Being a Doctor

Ahmad Yousaf, MD

Ahmad Yousaf, MD, is the 2015-16 Ambulatory Chief Resident in Internal Medicine at Rutgers New Jersey Medical School.

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 $200K a year when the median household income is in the mid-$40K range.

median US income

BrendelSignature (https://en.wikipedia.org/wiki/File:Median_Incomes_US.png), CC BY-SA 3.0

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.

empty wallet

Despite that, at the end of my med 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%. To put that into perspective: My monthly interest accrual was ~$1020 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 $40K and $50K 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 $1000-$1400… a 2-bedroom ranges between $1500 and $2400. I… lived in a 1-bedroom. I cleared about $3000 a month after taxes. $1000 went to paying just the interest on my loans and never touching the principal, and $1200 went to paying rent. I was left with $800 to spend on food ($100-$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. Problem is, that after 5 years of residency, I would have owed Ms. Mae close to ~$250,000.

borrowing-repayment cycle

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 EZPass bills. I went to a public undergrad school(many people I know have debts in the $350K 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 complete/obtain/maintain to practice medicine. USMLE Step 1,2,3 tests cost about $2200. The American Board of Internal Medicine exam costs about $1200, and the American Academy of Pediatrics board exam costs a whopping $2250. Most residents spend about $1000 to $2000 on prep courses and materials for each of these exams WHILE IN residency.  And then, there is licensing: NJ state license is about $1100, 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.

government loans

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?

~Yousaf

78 Responses to “The Costs of Being a Doctor”

  1. Cesar says:

    You forgot to add the incredible expenses of processinga visa to study or to work when you are a Foreign Physician

  2. Steven says:

    Weepy and attention-seeking article about well-known facts. I, as a foreign physician, went through twice degree of hardship you’ve been, and I don’t complain, neither do my former fellow residents or fellows. Your parents should have taught you a couple of life lessons – “No pain, no gain” and “The acceptable level of misery and risk one has to bear is usually proportional to the greatness of the ultimate purpose”.

    P.S. Do the the right math – compare your level of debt today against your future projected income as a full-time attending, at least, over a decade . . . life-time.

    • Kara Conner, MSN, BS, RN says:

      While this article may coma across as “weepy and attention-seeking” there are many people, even those in the healthcare field, such as myself, who don’t realize the financial cost for becoming a doctor. Oh, I know that becoming a healthcare provider has costs beyond tuition, but I didn’t realize who expensive your licensing tests and fees were or how “little” a resident makes – per hour – when you break it down.

      Many parents, Dr. Yousaf’s too I’m sure, taught him about “no pain, no gain” but there comes a point when the pain CAN outweigh the gain. As a Master’s educated nurse I have education bills I can’t pay off; after 20 years of paying; I’m more in debt now (because of school loans) than I was before I had to declare bankruptcy (due to stolen identity). I expect to still be paying them when my toddler is ready for college. The general public out there, just sees the dollar signs doctors are making (or think they are making) and conveniently forget about all the ‘extras’ professionals have to pay for, above and beyond what everyone has to pay (utilities, car payments, etc.). I have to thank Dr. Yousaf for his article. I do hope that there is a follow-up article, by him or another doctor who has managed to pay off the education and give future doctors some hope for Gain, beyond The Pain.

      • Ahmad Yousaf, MD says:

        I appreciate both of your comments!

        @Steven, my father, a foreign medical graduate and now successful physician has most definitely taught me the value of the lofty goal of medicine. It is not a pissing contest as to who has experienced more difficulty. I reiterate my final point in the article, my concern is not with my own hardship, but what these hardships mean for the future of the field and who it attracts.

        @Kara- could not agree more with everything you have said. Thanks. I hope to write a followup in the NEAR future (I pray) to have the happy part where the loans are finally off my back!.

    • Nicky says:

      My friend: As a US medical grad, I do appreciate the different hardships that foreign medical graduates must go through. At the same time, this doesn’t mean that we have it any easier. The education system here requires us to complete an undergraduate degree (i.e. a significant financial cost and an extra 4+ years of our lives), which the vast majority of other countries do not require as far as I am aware. Also, there is a growing trend (even requirement in some sense) for pre-medical students to engage in research, volunteering, travel, and other experiences between college and medical school to enhance their resume – this only adds to the time and costs involved in becoming a physician. Furthermore, do keep in mind that every time a FMG acquires a residency spot in the US, this takes away a spot from a US medical graduate, thus adding to the competitiveness of the field and job market. In other words, even after a US medical student has gone through the 8+ years of post-high school education and acquired the correlating amount of debt, they have no guarantee of getting a residency spot. As a 1st generation immigrant who was raised in this country, I completely understand and embrace the value of recruiting FMGs to add to the diversity, skill set, and brain power of the health care field in the US. Some of my strongest mentors have been FMGs. However, it is disappointing when people who haven’t gone through a specific experience assume that they went through “twice the degree of hardship.”

      As the author of this article nicely describes, this is essentially the problem. These actually are not “well-known facts”. No one in my family (or even extended family several levels out) is in health care; having spoken to these people and others, it is apparent that people do not know what is involved in the journey to medicine. I applaud the author of this article in shedding some light on this, simply to raise awareness and pose some important questions. It is not a cry for attention because truly most people have NO idea of what it takes. The average person outside of medicine does not even know how long medical school is or what residency means. The immediate assumption of outsiders is based on the final product: You are a doctor; therefore you are rich and vain/arrogant. I know physicians who are 10 years into their practice and still paying off their undergraduate student loans. They don’t like to continue having these financial responsibilities – nonetheless, they are so happy to have the privilege of taking care of patients every day that it makes it all worth it. I agree that no pain means no gain; no one in the medical field needs to be taught this. As physicians, we are also not claiming to be martyrs or that no one else has suffered like us. Everyone suffers in life in different ways. However, I think as a medical community we do have a unique experience/path to reach our destination, which many others do not know about.

      The real concern is that there are many young high school/college students out there who are intellectually and emotionally very capable of becoming great physicians – however, due to significant financial restraints, lack of family support, or other responsibilities outside of their control, they are unable to pursue their dream of medicine. The path to medicine is complex and permits less flexibility than some other fields. One can become a lawyer by enrolling in a night program or part-time program; this accommodates other “life”/”work” commitments. On the other hand, medicine is more rigid and requires putting many other things “on hold”. As a society that creates all these hoops and barriers in order to select only the “fittest” for medicine, are we actually losing out on some of the best?

  3. pgy2 says:

    …to add to the bummer… many of the patients and our co-workers still hold the perception that I we are the “rich doctors”… The idea that we play a lot of golf, drive nice cars, and hang out on yachts etc… All the while I struggle to make payments on my used honda, I live in a sketchy neighborhood and survive on a beans-and-rice diet.

    This “rich doctor” perception lends to the idea that we (docs), are the bad guys. When patients look at their outrageous hospital bill, they tend to believe their money its going to us. They think we are the ones that are screwing them. On top of that, we are the providers that spend 15 seconds with them (because we are spread so thin). Its no wonder patients are dissatisfied with doctors.

    I’ve been a patient. As a patient I was dissatisfied with my care. I go to work daily as a doctor. As a doctor, I am dissatisfied with the care I am capable of delivering. I am also regular person with a life, a family and job. As a person, I am unhappy. I am unhappy because I have a modest lifestyle and a wildly demanding job that has left me entirely unstable financially.

  4. Rebecca says:

    Thank you for laying out the financial path residents take to becoming practicing physicians. I’m a family physician, Harvard Medical School graduate, and was in a very similar position to you after residency. I tried different ways to balance practice, family time and financial responsibilities but most were unworkable, especially when children came into the equation.

    Though it isn’t a solution for everyone, what ultimately worked for me was adding procedures to my practice. They were fun, patients were appreciative of the convenience and I could decrease the number of people I saw per day without compromising revenue. Decreasing my patient volume really decompressed my days and got me out of the office on time. I started with the whole gamut: IUDs, joint injections, skin cancer excisions etc. Overtime I incorporated cosmetic procedures such as Botox, dermal fillers and chemical peels, all of which are not covered by insurance. Now I primarily do office-based cosmetic procedures and I teach the UCSF residents and how to perform them. Again, it may not work for or be of interest to all, but for some, adding adjunctive procedures in practice may help with the work-life-finance balance.
    Rebecca Small, MD

  5. Carly says:

    True perhaps if they served the military then it will be a free ride and quite frankly some would have more respect for your colleagues returning from the war!

  6. Faylinn says:

    My son really looks up to our family doctor and has recently decided that is what he wants to go to school for. However, I had no idea that a medical school could mean acquiring $180,000 in loans at such a high interest rate plus other expenses. But are there any options for students to make that cost go down so that they do not have to be in so much debt?

  7. Sam says:

    I appreciate the financial hardship as I also paid every penny for my undergrad degree at a state supported institution, PA school and then medical school. I was in my 30’s and started a solo family medicine practice at age 41, which was also expensive to start up. I paid off my medical school debt at age 61. I had a family to raise at the same time. Maybe I would not do family medicine again but taking care of families was the reason I went to medical school in the first place. It is almost mandatory to becoming an employed physician or seek some form of subsidized practice today. Unfortunately health issues forced me to retire early. Alas, the time to add to my retirement fund has been derailed. In the end it was never about the money. It was about the profession. I wish you luck.

  8. Varun Wagle says:

    Well written.

  9. MM,MD says:

    Despite all the obstacle and hardships, I am of the opinion,after 51 years of treating patients and teaching medicine, that most young people aspire to become physicians to cure and care for the sick, and alleviate suffering. It is still the best job there is.
    While I am in full agreement and sympathy with the problem of extraordinary costs of medical education and training in our country, we as physicians must understand that this crisis is not a result of inevitable expense of preparation for a medical career or the costs of technological advancement in medical science,. Instead, it is a direct consequence of the emergence of a ruling plutocracy of unchecked corporatism and private financial conglomerates, which has emerged in the past 60 years, to manipulate and distort the public’s perception of what we have come to accept as normal. Alone in the developed democratic countries, our government is ruled by political parties, both corrupted by billionaire donors, special interest pacs and and lobbyist money supplied by those same profiteers. Once elected these politicians prioritize these irrational predatory business practices despite public opinion and even essential human needs.
    America’s distorted priorities, as we are now witnessing in both medical education and practice, is indeed a bizarre aberration, and is unsustainable, nonproductive, and which in no way can be reconciled with basic tenets of a democratic society.

    Aside from signing on with the military, for a “free” education (in Orwellian terminology) as some as suggested in latter commentary, there are many societies which are more evolved in recognizing humans needs of their own people I.e., every country in Western Europe,Canada, Japan, Israel, etc.
    There is even one which goes further: The Latin American Medical School, in Cuba (ELAM), with 10,000 students from poorest, communities in Asia, Africa and the Americas, including the USA. Established as “a school to graduate the doctors for all the world,” and based on the belief that access to medical care is a right of all people. Admission priorities are given to candidates who are poor, female, or from an indigenous population, from most underserved communities in the world, And, despite being a poor country, every single one of those students is on full scholarship and are supplied room, board, books and a small stipend by the Cuban government. In return, students make a non-binding pledge to practice medicine in their home communities.
    http://www.pbs.org/newshour/rundown/cuba-offers-poor-med-students-a-free-ride/
    Instruction is from the start focused on preventive medicine, and treatment is more hands on. “The results are stellar: Cuba was the first country in the world to eliminate polio and measles. According to a 2006 journal of epidemiology, it has the lowest rate of AIDS in the Americas. Cuba has a lower infant mortality rate than Canada and the United States. The average lifespan, at 78, is just three years lower than Canada’s.” ….In parts of Detroit, a black males’s life expectancy is 64.
    https://www.thestar.com/news/world/2012/06/02/cubatrained_doctors_making_difference_around_the_world.html.
    Rather than a government student loan forgiveness program (Hillary), yet another give away for the big banks, we might dial back the clock to a time when America addressed the needs of the poor and working class, respected, employed and educated the poor, protected the elderly and disabled,(Bernie Sanders).
    In the 50’s, balanced by labor unions, a free press antitrust laws, and banking restraints, we taxed the rich and prevented them for the most part, from extracting the all society’s wealth. Now with monopolies fattened by government largesse, a debased mass communication, powerful, unelected unaccountable institutions and corporate goals fueling endless illegal foreign wars, while the wealthy strut and congradulate themselves without shame. It all can and will evaporate in a flash when people come to understand that they are the real source of all power.

    “Power concedes nothing without demand. It never did and it never will.”
    Frederick Douglass;

  10. MM,MD says:

    OK, it’s 41 years. And sometimes I’m lucky to remember to match my socks in the morning.

  11. Recently I was reading an article about suicide rates in physicians and I was quite alarmed by the high rates in our profession. I think, that the financial burden a medical student faces before becoming a well earning doctor does contribute to this burden.
    I always wanted to come to USA to practise medicine (the grass is greener) but have been deterred by the cost of doing USMLEs.

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