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. Jeannine says:

    I appreciate the points made in the original article, and have have several additions from my experience:
    -My loans went through their grace period during residency, thus after graduation from training, there was no additional time to find a job, spend with family or renew my spirits. $2500 was due only a few weeks after I was done with 3 of the most challenging years of my career.
    -My relatively modest physician income as an FP has disallowed me from taking the student loan interest deduction due to my tax bracket.
    -I delayed having a family during medical school and residency training and found that I was ready to start having children after I graduated in my early 30’s. I didn’t have any job offers with maternity leave benefits, and those that offered them to staff did not allow physician participation.

    This combined burden of high loan payments directly after graduation, absence of maternity leave benefits for physicians, and a career that starts in the mid 30’s means that most physicians will be unable to take significant leave when they are new parents.
    I think asking our physicians to put their career over their family during this key time is asking them to further sacrifice their mental health and family strength, this is on the very people that have likely already compromised these things during training. It sets us up for a generation of healers that have a diminished ability to have empathy and care for patients well, and likely leads to higher rates of burnout.

  2. I am a program director I believe that medicine is a business controlled by choice of providers of insurance from the US government to the Insurance and hospitals. Capital invest are now moving in buying hospitals and doctor practices from family practice to surgery. They are using the next cheap worker not doctors but nurse practitioners and physical assistant s. They are creating the paradigm for the new doctor. What will happen is the glut of over producing these health care workers and under producing the physician will driv e the public to accept care from them. While the industry initially adjusts things will look great then when the new Doctor(pHD) nurse practitioners and PA get their ful autonomy and are being paid the liability and malpractice will bring in the correction. more required training for them more standards. The physicians and big companies will be blamed but the physicians will be there to save the day. The shortage will be even higher and the industry will just decided to regulate the np and pa to increase education and the cycle begins. predictions of true reality

    • Stormi says:

      As a nurse and soon to be nurse practitioner who looks forward to filling the gap in primary care in rural Oklahoma, I find it offensive to hear you think you’ll be cleaning up after me. I’m not sure you understand how many errors or”clean ups” I personally have had to do to keep physicians out of trouble and avoid lawsuit. Have some consideration for the fact that I’ve spent nine years in college and 15 years in practice up to this point and don’t plan on coming into medical care with the attitude that we aren’t all on the same team trying to provide quality care to all patients at lower reimbursement rates than you will ever see.

      • ayy lmao says:

        If you really were all about providing quality care to all patients, then you wouldn’t dream of comparing your 9 years of college and 15 years of practice to a physician thats had 4 years of college, 4 years of medical school (with much harder courses than you did), 3+ years of residency and fellowship, and THEN how many years of practice actually taking care of patients from a diagnostic and a procedural standpoint. If you were “cleaning up” after physicians with considerable more training than you, how much “cleaning up” will have to be done after your considerably less trained decision making? Everyone is on the same team and have equally valuable roles to play in providing the best care for the patient, but its not the same roles.

        • Stormi says:

          I am in no way comparing my training to that of a physician or quiet honestly of a PA (which is often attempted by both NP’s & PA’s) I just know that all of us bring something to the table and to imply otherwise isn’t fair to the time, effort, and $$ we spend. I wouldn’t dream of practicing without the advise and honestly oversight of a physician because I do recognize my limitations. I just have to wonder sometimes if physicians recognize their own…

      • Stormy indeed says:

        9 years in college? Talk about dedication. Or an inability to grasp your own limitations.

        • Stormi says:

          Actually, talk about raising four kids and putting two of them through college first before I completed my own…

  3. Rob C , MD says:

    Thanks to Yousef for his interesting and insightful letter. I recently retired from a 42 year career in Primary Care , and did not have the serious debt described, but after seeing income steadily decline and costs increase, our standard of living has gone down. There is not much sympathy out there for us, but I have grave concerns about the future of first primary care, and then medicine in general. I have to believe that there are wise people out there that have solutions, and I hope the politicians will listen.

  4. Tim says:

    This article is the exact reason why I chose PA school over medical school. Much less debt, ability to begin repaying on principle right after graduation and ability to still practice medicine, albeit with indirect supervision. Mild restriction of autonomy is well worth not incurring the expense of medical school and training.

  5. Edwar Rodriguez says:

    In Colombia you don’t even get paid during residency.

  6. The issue of debt is continuing to increase, and it is important to edify physicians in training and those working to manage these financial issues among many others that are now an everyday aspect of medicine. As stated Medicine has been a business for some time now and have to start taking these factors into consideration and know how to efficiently manage these finances. This need is the reason behind building MedSchoolFinanicial as a site to work towards engaging more docs in the conversation and making a positive difference in these matters.

  7. Jason says:

    I hate medicine. Am considering quitting.

  8. Ed Trav says:

    I had the option of studying medicine in the US or abroad, it was simple mathematics I did before studying that discouraged me from studying in the US. I went abroad and was able to graduate totally debt free, slave to none…

  9. ahmad farwan says:

    First , thank you Dr Yousaf for your realistic artical that touch breaking difficulties to became a doctor.
    you compare the difficulties per money But I think the Big loss will be in our social relationships and old age which are pricelessness in my opinion .
    At the END, study medicine required Huge heart to be a human and huge mind to be the Best .

  10. Alvaro says:

    That’s too sad! In Brazil we are facing the same problems, but in a faster way, I believe. I’m finishing my radiology residency and there is not a nice future waiting in medicine, I predict.

  11. zeb chadwick says:

    To be honest with all of you there are programs that will help with this enormous cost. Most just choose not to. I took the route of military to pay for schooling i get all my under grad paid for and my medical school of course i have to sere in the military for a few years but no loans and no debt and they make sure my family is taken care of the whole time.

  12. Usman M. says:

    This issue needs more coverage in mainstream media and general public awareness. I am a 4th year medical student and can concur with Dr. Yousaf about the financial burden and tremendous stress that comes with it. I have always been passionate about medicine and the only thing that keeps me going is that at some point I can be of service to my fellow man (however corny this may sound).
    Notwithstanding mounting ~$1K in monthly interest, the future of medicine looks bleak at best. This is the general consensus among my peers as well.
    This issue is entirely connected with the American medical system being remarkably broken compared to other developed nations based on statistics of life expectancy (etc.) and cost of healthcare per capita.
    It is unfortunate that the general public is oblivious to the socio-economic costs of becoming a practicing physician in the US and also to where medicine is trending. Bringing in more mid-level providers (PAs, NPs) is not the answer to the medical problems…this will just promote more algorithmic healthcare delivery due to legal liability issues instead of wholesome, compassionate care that our patients deserve.
    In short, with less intervention from Big Pharma, Big Insurance, and some sensible decisions by the government under supervision of practicing physicians, we can dramatically increase our level of healthcare and begin to approach that in other leading developed nations.

  13. dontlikebeinganeng, PE says:

    Civil engineers are the lowest paid engineers however they have the most noble profession (they provide the roads, buildings, and water you use everyday).

    They require minimum 4 years of schooling, soon to be additional masters (ASCE Policy Statement 465), and like Doctors, they too require professional exams (FE/PE in Civil, Geotechnical, Structural).

    Different states require different years of experience, but on average it’s anywhere from 2-4 years depending on your education (think of it as an engineer’s residency) and specialization.

    You began your path as FE, PE, then specialized engineer (such as geotechnical or structural).

    California Fundmental Exam in CA alone is $125 + NCEES registration fee.

    California Professional Exam in Civil alone is $125 + $150 + $150 (CA BPELSG) + $265 (NCEES) + 2*58.50 (Prometric) is $807.60. They too have to buy reference manuals and take time to study for it (look up CERM)

    http://engineerboards.com/index.php?/topic/19442-ca-pe-test-fees-jump-193-284/

    Civil engineers make average $66,000 – $87,000 on average.
    https://www.glassdoor.com/Salaries/civil-engineer-salary-SRCH_KO0,14.htm
    http://www.bls.gov/oes/current/oes172051.htm

    Their debt levels may not be as much as a physician, however they are paid far less to compensate. ~$87,000 whereas your family physician is paid $192,000 (2x as much)

    http://www.bls.gov/oes/current/oes291062.htm

    In summary, I bring John Oliver’s Infrastructre Clip
    https://www.youtube.com/watch?v=Wpzvaqypav8

    “Infrastructure isn’t sexy”

    Disclaimer: I am not a civil engineer, I am a millennial petroleum engineer from two great schools (an ivy and a top public school).

    P.S. – White Coat Investor has good articles, recommendation is to read it.

    • Moe says:

      It’s disingenuous to compare physicians to other professions based solely on treats of study. A resident typically works the equivalent of at least 2 fill time jobs (at least in my experience as a surgical resident I just make sure not to log hours after 80 hours) most attending physicians works more than 60 hours a week in addition to having personal liability with regard to their care. Infrastructure is important but civil engineers are not working those hours, nor can they be personally held liable every time someone injures themselves or their car on a pothole. I’ll be glad to make what a civil engineer makes, just give me a union, a 40 hour work week and true malpractice reform as well as debt forgiveness/restructuring

    • A resident internist says:

      Engineers have a 4-year degree, as you noted. It’s not easy schooling; I know, I did it. That 4-year undergrad degree was my prerequisite for medical school, which in the US is an additional 4 years (that’s 8 years of schooling beyond high school) prior to residency, which ranges from 3-7 years (more if you do fellowships!). So I’ve already been in school/training 7 years longer (or 6, if they got a masters degree) than my engineering colleagues who entered the workforce with a decent salary at age 22 and have been able to save for retirement ever since. But sure, working for $12/hour for 3-7 years while simultaneously putting your personal life on hold…especially when you can make $15/hour now working at a fast food restaurant (!!)…is definitely going to attract quality people to become physicians in the future. But don’t worry–in the near future, we won’t need doctors. Everyone knows Google is way better than all those years of training!

    • Alan Jones says:

      Not to detract from Engineers, but I paid more than some of those fees just to change the date of my MCAT. We have to pay several hundred for our application review plus $30 per school to apply ($30 for someone to check a box and email the application) and some schools charged an extra $50 to $100 just to look at my app.

  14. Dan Urbach, MD says:

    You’ve made a real contribution to the literature in your article. Now I hope that many writers will reference your article when discussing the shortage of primary care physicians. It seems to me that there is only one realistic solution to that shortage: paying well for primary care.

  15. jennifer L says:

    The info presented here is not new, but this article is very well-written and I am glad that it will be a resource for future generations. That said, even as a current medical student facing a quarter of a million dollars in tuition debt (and that’s pre-interest), I’m not sure I have a great deal of sympathy for people who feel caught off-guard, especially in the internet age when all of this info is already out there.

    It’s fairly common knowledge that residents make even less than janitors at some hospitals and if you didn’t know that going into medical school, you didn’t do enough research. Sadly, this doesn’t seem to stop at just finances; I’m appalled at the number of first-year students I’ve met who are just now learning about the match process, residency, what really happens to med students who don’t match even after scramble, etc. It’s extremely short-sighted to just do enough research to get you into medical school and opt to leave researching “the rest” for later, when just the education/training period for medicine is nearly a decade-long (longer depending on your specialty and if you decide to pursue fellowship).

    For any premeds out there reading this, I strongly advise you to do your due diligence before going into medicine. In fact, be a sponge- soak EVERYTHING in. Ask the questions you may think you already know the answer to and multiple times because even one person’s answer may surprise you. e.g. I know that the gender gap in medicine is closing, but I decided to ask a female resident about her thoughts on any particular challenges that women still face in medicine. One thing she told me that I never thought about before was that if you’re a woman who decides to go into radiology and wants to have children, you have to very carefully time pregnancy because of the higher than usual level of radiation exposure on the job.

    I’d also advise that you talk to non-doctors too. Ask nurses, PAs, PTs, allied health professionals, veterinarians, etc. why they went into their fields. It will help you decide if you just want to be involved in any aspect of patient care or if you really need to be a doctor. Plus, you’d be amazed at how many of them considered medical school themselves before deciding to go into healthcare outside of medicine. Some of my friends heard this and opted for non-medical healthcare careers and they’re very happy. Others, myself included, decided it was worth it. There’s no one right answer- everyone has to decide for themselves where their priorities lie.

    Bottom line, you have to hear all of it and NOW– the good, the bad, and the truly terrifying– because if you thought trying to get through medical training was a financial struggle, trying to walk away after having started the process becomes truly financially impossible. (I’ve met students/residents who regret going into medicine but they’re just too much in debt to walk away.)

  16. Wayne says:

    Great article. My wife is a doctor currently and I am a second year Med student. If 120k is a lot of debt, I have a tumultuous road ahead. I had a combined $300k from undergraduate/graduate school (of which is largely interest) and have added an additional $150k for medical school so far and that includes upwards of 100k I’ve recieved in scholarship monies. My wife’s debt is roughly ~400k total and her residency will be done come December. Ridiculously our tution has risen every year by 5-7% and that’s pedaled as good news.

    I’ve essentially been on my own since my teen years and I effectively abided by money is not an issue when pursuing your goals, thus living on student loans for my entire 20’s.

    Our first child is on the way and I’ve contemplated cutting my losses to not finish school and to return to the job market, however as many students may know, leaving medical school is stigmatized. Medicine was once appealing to me based on a variety of reasons and I largely ignored the financial repurcussions until my own family came to be. Now I feel disgruntled, and unhappy as little is being done to change things. Furthermore, the distain expressed by colleagues in residency and beyond is somewhat unsettling.

    After reaching out to colleagues these are the responses I have gotten: “finish because the degree matters.” “Residency isn’t that bad – it’s all down hill after second year.” “The debt isn’t that bad.” “You have to finish to pay your debt off.” (In summary a lot of have to’s and not many want to’s).

    The question I now pose to those have gone before me, is it worth continuing forward and adding an additional 300k + to our debts Or is it worth entertaining cutting my losses to begin working/paying debts today with the graduate degree I’ve already obtained? It’s a shame I was so blinded by ambition and a belief of what medcIne could be, that I disregarded educating myself on the actual “cost” of an education. Weirdly all of this reminds me of a Kanye West song (all these paper degrees and no money).

    Decisions, decisions.

    Great post.

  17. Jennifer says:

    Yousef thank you for telling your story, and that of many in a similar position as yourself. Most people accept that they need to pay for higher education, however what you have shared is quite frankly disgraceful. There are people out their in ‘bank land’ that are making obscene amounts of money, taking advantage and essentially stealing from hardworking community orientated people. I agree that this will have very damaging affects on the future of medicine, but unfortunately listening is not something that happens early. But this does take many people like yourself to speak out and keep doing it, to wake the many who are asleep and haven’t noticed anything, until they themselves need a doctor.

  18. Ryan Casey MSN, FNP-C says:

    Joseph, your comments re: NP and PAs are less than educated. It’s apparent you see no fit for our presence in medicine. Shame on you. Times change, MDs will always be the superiors however our place is to aid in bridging gaps. Sad you and many others can’t and won’t get past egos.

    • jennifer L says:

      @Joseph Dougherty: There are a lot of amazing PAs and NPs out there and it’s sad that you dismiss all of them, when there are just as many horrific doctors out there. Plus, bear in mind that the scope of practice for PAs and NPs can be drastically affected by geography. e.g. I’m natively from a major city, where PAs and NPs just take histories. I had to move to a rural area for medical school and suffered an accident during my first year, where I received far superior care from PAs and NPs than from the doctor who spent just 5 minutes with me.

  19. Stove says:

    It’s just as bad, if not worse, for the dental profession. Dental schools cost quite a bit more on average and the fighting with insurance companies is bad for dental work too. I know I’m on the low end coming out with ~400k in debt.

  20. Vikranta Sharma says:

    why it becomes a conversation about physicians versus APN or PA is beyond me…should we replace RNs with LPNs and LPNs with CNAs and CNAs with CHHAs because their education and trainig is less costly and shorter…. its absurd.
    The agencies that charge money for licensure after the MD/DO degree is for making money for themselves and not to ensure better workplace/conditions for the workforce or better care for patients.

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