(With a hat-tip to Hybrid Vigor for the idea-PB)

Dear Medical School Hopeful,

I wouldn’t presume to imply that you haven’t given your decision to apply to medical school a lot of thought. Of course you have. The application process alone will weed out anybody who is not completely serious. Still, you may have some lingering doubts and if you do, it is better to hash them out now than when it is too late and you are so deeply into it that to withdraw will mean an unacceptable loss of your considerable investment in time and money.

The first thing you need to do is to cool your jets. Medicine is a good career but it’s just a job. I’m sure you will meet some zealots who seemingly breathe, eat, and live medicine but for the most part, by the time you get into residency you will find that most of your colleagues want pretty much what other working people want, namely a useful job with good pay and decent hours. In this regard, maybe the years of working long hours for little of no pay like you’re going to do in medical school and residency beats the idealism out of people but I prefer to think it teaches them the difference between professionalism and fanaticism. Naturally you have to pretend to be driven to get into medical school as showing passion is a de facto requirement. Your real reasons for wanting to be a physician, while perfectly legitmate, would sound trite and self-serving if you even dared breathe them aloud. Just between me and you I didn’t want to save the world either and just applied to medical school because I thought being a doctor would be kind of cool.

And it is kind of cool, at least when you’re not at the hospital making a career out of not knowing things (which is going to be your modus operandi for most of your training). Still, people who don’t know what goes on during medical training are likely to be impressed. Your mother is going to be proud, your friends will be amazed, and your annoying brother-in-law will have a hard time one-upping you on this one.

It’s a decent career but the fanaticism is not warranted. It isn’t that good. Nothing is. That’s why fanatics are so creepy. They see and hear things that normal people do not.

So, as you are about to commit to a huge undertaking in terms of both time and money and one which will set the course for your entire life, you have to ask yourself if it’s worth it.

From an economic perspective, it may or may not be worth it in the end. Doctors do make a pretty decent salary but what seems like a lot of money to a young, single college student might not seem like so much after four years of medical school and a minimum of three years of low-payed residency training. You can, for example, bust your hump for seven years to become a pediatrician (the lowest-paying specialty, on average) and make under the talismanic “six figures” which is the mantra of salary expectations. $90,000 a year seems like a lot now but it’s the medical equivalent of minimum wage.

I understand that the majority of people in the country live on half of this and are not considered poor but most other careers don’t quite involve the same level of sacrifice. It’s a cliche, but never-the-less true, that while your friends in college who decided on engineering, business, or law are building their careers and starting to enjoy the fruits of their labors you will be working brutal hours for very low wages, losing sleep on a regular basis (in fact, sleep deprivation is both expected and built into the training), and suffering the kinds of indignities that you probably can’t imagine at this point in your adventure.

Just keep in mind that all doctors, after residency, start at salaries much higher than is typical for any other profession. Maybe some lawyers can leave law school and go straight into well-paying jobs but most just sort of scrape along. The same with business and engineering. Still, if you put as much effort into your engineering career, let’s say, as you are about to put into a medical career you will probably do better than most. I don’t buy into the theory that people who are smart enough for medical school will automatically do well at other careers but if you have any other other legitimate talents you might want to mull this over.

The bottom line here is that you are going to sacrifice a decade of your life and arrive at the start of your career with almost nothing to show for it but gray hair and a mountain of debt. The debt is inevitable because medical school is an expensive undertaking, the exact cost of which depends on many factors. Some state medical schools, as they are subsidized by the taxpayers, are a relative bargain while others, like super-premium ice cream, are much more expensive. A year’s tution and fees at Harvard Medical School which is a typical pricey confection will set you back close to $40,000 per year. Compare this to my air-injected, vanilla-flavored alma mater, LSU Shreveport, which charges only $13,000 for in-state residents.

These fees do not take into account living expenses which, while minimal for a single, young medical student are not trivial. Fortunately as most pre-meds are used to eating ramen noodles and living in crappy apartments the standard of living in medical school will not be too much of a shock. You’re going to be pretty busy for four years anyways and a futon on the floor of some ratty place with thirty-year-old shag carpets and furniture that makes it look like the set of a pornographic movie will probably be enough and all you’ll really need.

But you do have to live and, as it is almost impossible for most medical students to work while in medical school, things are going to be tight. What do you need to live? Again, it depends where you live. I imagine that housing is a little more expensive in New York City that it is in Bossier City, one of the suburbs of Shreveport. Crossing the Red River to get to Shreveport as it involves a barely noticable interstate bridge is also a good deal easier than crossing the Hudson River to get to New York.

You need to think about these things when you select a medical school. I wouldn’t insult the aspirations and dreams of thousands of pre-meds and their prestige-hungry parents by stating that price is the most important factor but it is top three. However, at the risk of drawing their ire, if you know perfectly well that you despise research and academic medicine and are almost completely sure that your goal is private practice, it probably makes no difference where you go to medical school as you can match into any specialty from any medical school provided you have the grades and the board scores. Not to mention that a Radiologist who went to medical school in Sistercouple, Arkansas and trained in Trailer City, Oklahoma probably makes the same as one who trained at Dartmouth.

There are no bad LCME accredited American medical schools. They are all good and you will get a quality education at any of them which, no matter where you go, also depends on how much effort you put into it. So you have to ask yourself whether the potential for a quarter-million in debt (on top of your undergraduate debt) for nothing but prestige and name recognition among a very small subset of people is is better than $80,000 dollars of debt at your state medical school.

Having a familiy will magnify the difficulties of selecting a medical school (assuming you have the luxury of more than one acceptance) especially if you are giving up a well-paying career. The bills will not go away and the cost of living needs to be considered carefully.

Practically, unless you go to an inexpensive medical school, can live without a salary for four years, and can pay for tuition and fees out-of-pocket, you are going to have to borrow money and lots of it. Fortunately (or unfortunately because the availibility of financial aid is one of the most important factors driving up the cost of education) the financial aid office at your medical school can arrange a combination of federal loans and the occasional scholarship or grant to almost exactly cover your cost of attendance.

Funny how that works out.

In a nutshell, your medical school’s finanacial aid office will calculate you cost of attendence which includes tuition, fees, and estimated living expenses and tailor an aid package, primarily of loans, to cover as much of it as they can. Almost nobody actually writes a check to their medical school and it’s easy to think of these loans as funny money. This would be a mistake because you will have to pay them back. They can, however, be deferred while you are a resident and you can consolidate them at a lower interest rate. There are some drawbacks to consolidation as you may lose your rights to deferment and forebearance but if you run the numbers, it will be a lot less expensive to service and pay your debt if you can consolidate at a low rate.

So that’s the choice you have to make, namely, whether a decade of your life, huge debt, and the opportunity cost of medical training are going to be offset by what you can make as a doctor. People are pretty good at gauging their willingness to incur debt but are unfamilar with the simple concept of opportunity cost. Opportunity cost is the price you pay for not doing something. Suppose you have a $60,000 per year job (or the potential to have one) which you give up to attend medical school. The real cost of your education is four years of lost income plus the money you pay for tuition and fees plus the difference between the salary you gave up and your pay as a resident.

Suppose you need to borrow $40,000 per year. Thats $160,000 in debt added to the $240,000 opportunity cost of medical school plus the $60,000 dollar opportunity cost of a three-year residency where you will make about forty thousand a year. That’s almost half a million bucks, not even considering the time value of money which is not working in your favor. if you match into pediatrics and make $90,000 per year, your net benefit from all of those long years will be $30,000 a year which, again ignoring the time value of money, puts your break-even point sometime in 2031. This explains perfectly why American medical school graduates eschew the lower-paying primary care specialties. They are fairly intelligent and can do the math.

Many pre-meds have degrees that, while rigourous, are not worth much except as a requirement for medical school and some people don’t incur nearly as much debt as others so your mileage is going to vary considerably. But as opportunity cost is a measure of what you could have done, not what you did, I think you can see how you still have to consider it.

Another thing to consider is that you can match into specialties that currently pay very well and, even if they require a few more years training, will obviously pull your break-even point closer. Working against you, however, is the disturbing trend of the electorate to insist on paying nothing for health care. While there is no such thing as a free lunch, the vast amounts of money needed to pay for free health care is not necessarily going to be paid to you. You need to know that in some Western democracies with socialized medicine, physicians make less than a typical American electrician. In Germany, for example, surgeons are pulling in the equivalent of sixty to seventy thousand dollars a year, on top of which they live in a high tax society which pays for cradle to grave socialism by punishing the productive sector of which they are a part. Now, it’s true that they didn’t incur the debt that you will and their opportunity cost was less but suppose you muddle through only to have the rules change on you five or ten years from now when the electorate, driven by the trailer-park and ghetto vote as it sometimes is, finally takes leave of its senses and leaves you holding the bag?

That’s going to smart a little, no doubt.

And then their is the question of malpractice. I’m not one to be an alarmist but in this case, medical malpractice is a very real crisis and is sucking the life out of medicine. Under the onslaught of completely unethical plaintiff’s attorny’s it is possible to be successfully sued even if you did nothing wrong. Remember, the case is not decided by a jury of your peers unless your peers are people who can take two weeks off from their job and look at living at the the local Motel Six and eating off of meal vouchers for that time as a little slice of hog heaven. The days are also coming to a close when your malpractice carrier, win or lose, would protect you. Even they are forced to stipulate caps to their liability and the lawyer is now going to come looking for your assets. Because medicine is a high risk profession that deals primarily with an unhealthy and irresponsible public, the simple act of plying your trade will routinely place your home, your livelihood, and your savings in jeapordy. Think about how you’ll feel having your wages garnished to pay the widow of a crack dealer on whose discharge instructions you forgot to write, “Follow up in the Emergency Department if your chest pain returns.”

Just a few things to consider.


Panda Bear

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