Friday, December 26, 2014

Before You Become a Doctor

I received a video request from a doctor through Asshole Consulting.  However, it was soon apparent he was the one doing me the favor in sharing his experiences and what EXACTLY was required when it came to becoming a doctor.  It was a much more arduous and expensive process than I originally thought, and it just makes one want to reconsider becoming a doctor (especially with Obamacare).  Anyway, thought this would be of benefit to any of my readers that are contemplating going to med school.

Economics of becoming a doctor and the situations where it's actually worth
it:

I'll start with an overview of the time and money required to become a
physician to provide context for the economics discussion.  Then I'll focus
more on the costs.

PreMed:
-4-year bachelors degree is required to APPLY to almost all medical
schools.  Medical schools don't care what that degree is in as long as the
following prerequisites are met: 1 year biology + lab, 1 year general
chemistry + lab, 1 year organic chemistry + lab, 1 year physics + lab.
Some medical schools also require 1 year of calculus, 1 semester of a
writing/literature class, and additional humanities.  This depends on the
particular medical school.  High school AP credits can substitute for
certain prerequisites, although some Medical schools will require advanced
science classes from those applicants who got AP credit for basic
sciences.  Let me reiterate that medical schools don't care what the actual
degree is as long as the prerequisites are met and up to 1/3 of medical
students have a Bachelor's in Bullshit.

-During their college years, students must take MCAT (em-cat) test which is
a standardized test.  MCAT:med school :: SAT:college.  When I took it, it
cost $300+ to register.

-GPA and test scores aren't enough.  Having significant community service
and lab research experience are also required.  Over 20% of medical
students have Master's Degrees and PhD's to supplement their application.

Applying to Med school:
Medical school classes start in August-September and the application
process begins in July the YEAR BEFORE and entails the following:
-Primary application: performed online through a national company known as
AMCAS. When I applied it cost a few hundred $$ to register and covered a
dozen applications, additional applications cost more $$ per application.
-Supplemental application: SOME (not all) medical schools will require
applicants to fill out a second application (if they like your primary
application) and I've been charged $30-$80 for secondary applications
depending on the school.
**My application process ended up costing me $1000-1500
-Interview: if schools like your application(s) then they invite you to an
interview.  It is up to the applicant to cough up the $$$ to travel out to
the school.  Since interviews start before 9AM, most applicants have to
arrive the nite before and pay for their own hotels (some schools can help
applicants get a discount at nearby hotels).  I have heard of extremely
"competitive" (affirmative action-enhanced) candidates who get flown out to
interviews and have their lodgings covered (a friend of a friend who is
Inuit, grew up in an Alaskan village, and happened to have REALLY GOOD
scores).
-Overall one can expect to shell out $5-10 for the interview process alone.

Med School:
-Another 4 years and there's no way to cut it short by taking extra
classes.  1.5-2 years of classroom learning (depending on the school) where
basically everyone has the same classes and runs on the same schedule.
This is followed by 2-2.5 years of clinical training where everyone rotates
through a certain "core" of specialties (general surgery, general medicine,
general pediatrics, psych, ob-gyn, ER, etc).  There's some slack here since
students will get 3-4 months to do extra rotations in their desired
specialty that they want to pursue post-graduation.
-When I was a med student (2006-2010) Private Med schools cost an average
35-50/year for tuition.  When adding room & board, meals, health insurance
(required), transportation (go to different hospitals for clinical
training), books & computer the total ends up being $45-60 per year.  Costs
for medical school have been increasing on a yearly basis so I don't know
the current costs.
-During this time some medical students get dual degrees: MD-PhD's,
MD-MBA's, MD-MPH (masters public health), MD-JD's.  These are required for
people who want to go into medical research, administration, get involved
in healthcare policy/law, etc.  This adds 1-2 years to time & tuition.
-During medical schools students must take their Licencing Exams which are
administered by a national organization.  A total of 3 exams are required
to obtain a medical licence.  Only 2 of those exams can be taken by medical
students.  These exams cost $500-$1000 to register for.

Internship/Residency:
-The MD degree is actually worthless since we can't work as a physician.
Another 3-7 years of post-graduation supervised training (with progressive
responsibility).
-The interview process for residency is similar to med school.  I spent
$5K-6K on my most recent interview process (I switched specialties from
surgery to radiology).  Also in the past 5 years medical schools have
increase class sized to cope with the medical demands of an aging
population in the US however the residency programs (which are funded by
medicare) have not increased their positions accordingly and in 2011 the
number of residency applicants exceeded the number of positions available.
BTW, foreign medical grads and people who pursue a DO medical degree
(rather than MD) get lower preference for residency programs).
-After completing 1 year of residency one may register for the 3rd
licencing exam (another $500 for me) and get a full medical license which
will allow one to perform VERY BASIC medical services unsupervised.
However insurance companies won't reimburse more "advanced" services (any
kind of procedure/surgery, making "advanced" diagnoses) without completion
of residency.
Work hours range from 40/wk (psychiatry, peds, family medicine) up to 80/wk
(general surgery, neuro/brain surgery, orthopedics).  Most residency
programs 55-60 hrs per week although the particular hours depend on
seniority (1st years/interns stay in the hospital the longest) as well as
whether the resident is assigned to hospital duties vs clinic/outpatient
duties (clinic has shorter hours).  Also certain programs are more
malignant and brutal in terms of work-hours (any program in New York
city).  FYI, prior to 2003 there were no work hour restrictions and
residents could be kept in the hospital up to 120 hours (my father is also
a physician and used to work 90-100 hours/wk during residency).  BTW, any
hours worked from home (made possible by electronic medical records) are
not necessarily counted toward the work week.  Let me also add that
depending on the program and specialty, residency programs can legally
require a resident to routinely work up to 28 consecutive hours (and longer
in exceptional cases where a rare disease/procedure is taking place).
-Residency's saving grace is that residents are PAID a stipend ranging from
$42K-$65K per year, depending on the program & specialty & seniority.  Mind
you the stipend often matches the cost of living in the area where the
program is located (there are a few exceptions).  Additionally the hospital
will provide temporary sleeping quarters for the residents who are working
shifts longer than 16 hrs (we can't live there though, we do have to pay
for our own apartments).  Surgical-based residencies last longer (5-7
years) than medical-based residencies (3-4, rarely 5 years).

Fellowship:
-Residency only covers limited fields.  Many fields (intensive care,
transplant surgery, hand surgery, cardiology, many more) require a resident
to complete an additional 1-3 years of training (pay $55-70K/yr) before
they can actually start working.

Work:
-We still have a free market.  Salaries can range anywhere from $100K-$1
mil depending on whether one joins a private group vs an academic center.
It also depends on whether one takes a job and becomes an employee vs
starting one's own business.  Some practices will employ young physicians
and give them the option of working their way into becoming a business
partner.  For physicians who open their own clinic (i.e. don't join a
pre-existing group), startup costs can range from $80K to over $1 mil
depending on the scope (seeing patients, doing scans, doing minor
procedures, etc).

The minimal age to become an MD is 27 years (unless skipping grades in high
school), assuming the following: 6-year joint undergrad-Med program (RARE),
get into med school on 1st try, get ideal residency and don't switch
careers later, don't do fellowship.  In reality the most people will be
31-32 before hey become a doc (4 yr undergrad, 4 yr med school, 4 yr
residency, 1-2 yr fellowship because the market is horrible for
generalists).  For a neurosurgeon, don't expect to be out of training until
34-35 years.  THEN you can start paying off debts (which can exceed $300K
as I outline below).  This will usually take 2-3 years assuming a truly
minimalist lifestyle.
That doesn't address people with multiple degrees or who take multiple
attempts to get into med school or who have other jobs before changing
their mind and becoming doctors.

Economics:
-College: You have covered the costs of college as well as private vs state
schools extensively so I won't bore you with details.  That being said a
few medical schools who are affiliated with colleges offer joint programs
where students can perform their college prerequisites and go straight to
medical school without needing to complete the full 4-year degree or go
through the interview process (that's one thing Europe does right).  Tulane
University (where I graduated med school) started such a program.  These
schools are the exception though.

Lesson 1: Do college prerequisites at a state school.  Only go to a private
school if a joint-program is offered.

-Medical Schools:  When I was a student private schools can cost
$45K-$55K/yr when all was said and done.  Even public schools will average
$20K-40K/yr when including ALL expenses. The Carribean medical schools cost
even more (I've heard some are up to $70K/yr). Scholarships are rare during
med schools since doctors "earn so much and can pay back their loans".
The first $34K of my loans qualified for Federal Subsidies, i.e. they don't
accumulate interest until the start of residency.  Anything beyond that
amount accumulates interest from day 1, even though payments don't have to
be made until the start of residency.  I used a total of $190K of loans for
med school.  By the time I graduated the interest had grown my debt to
$210K.  My loans accumulate interest at a rate of 6.7% per year although
I've seen figures range from 5% to 9% depending on the particular lender.
I had a total of $45K scholarships and grants during med school BTW.  For
people who don't have any scholarship/grant and/or people who pursue dual
degrees can end up with medical school debts exceeding $300K, not including
undergrad costs.  Even people in public schools aren't immune (one of my
buddies who graduated from Louisiana State ended up with $150K).

Some scholarships do exist.  The National Health Service Corps provides
full scholarships to students who pursue a career in primary care (i.e.
lower reimbursements) and commit 3-4 years in a designated under-served
area (rural vs inner city vs reservation) where reimbursements will be
lower than in a well-off area.  Failure to comply results in financial
penalties (you pay your loans at a MUCH higher interest rate).  The
military is also another option where everything is paid for but a time
commitment is also required and the salary is lower than it would be in the
private sector.
The clinical rotations during the 3rd and 4th years of medical schools can
require 40-80 hrs per week in addition to reading assignments.  The
studying during the 1st and 2nd years of med schools is time consuming so a
meaningful job that can make a dent in the costs is pretty unlikely.

Lesson 2: Try to attend a state medical school.  Private med schools should
be a second choice unless one is offered significant grant/scholarship.
Foreign (i.e. Carribean) and DO schools are a last resort and in many cases
aren't even a good alternative since there is open (sometimes justified)
discrimination by residency programs.  If considering the military or
National Health Service corps to pay off loans then realize that the
reimbursement during the "pay back" phase will likely be significantly
lower than if one bites the bullet, takes the loan, and ends up in a
high-reimbursement field and working in a well-off area).

Residency pays $45K (small towns in the south) - $65K (New York) per year.
Subtract the cost of living a minimalist lifestyle and that still leaves at
most $35K per year.  Remember the interest rates of the med school loans
range from $5K/yr (assuming 5% loan and $100K debt) over $25K/yr (assuming
9% interest and $300K debt).  My interest rates were $12K-15K per year at
the outset (they're lower now because I've paid off ~$65K in debt in the 4
years I've been in residency with the help of family).  Some residents
simply choose to "live a little" and defer payments on their loans until
post-residency by citing "financial hardship".  This included people who
want to marry and start a family (because they're in their late 20's and
sometimes early 30's).  The loans still accumulate interest during this
time and those residents will have yearly interest rates exceeding $20K and
their total debt (med and undergrad combined) can exceed $400K.
BTW, most residency programs will not allow residents to take "moonlighting
jobs" (working in a nurse or physician assistant capacity in Podunk Urgent
care/ER center for extra $$) and some of the Surgery-based residency
programs won't leave enough time for residents to moonlight regardless.

Lesson 3: Don't expect to pay back loans during residency (or fellowship)
unless you had significant financial assistance/scholarships during medical
schools.  However certain residencies (family medicine, pediatrics,
psychiatry, pathology, and a few others with "easy hours") will allow
residents to take on additional jobs to significant extra $$ on the side.
I know a few who added up to $10K-15K/year working nursing/PA shifts
because their residency only required 45-55 hrs per week.  Docs who have
minimized their education costs can except to make significant dents in
their loans during residency but they are RARE exceptions.

Lesson 4: Keep an open mind initially but develop a clear picture of what
field of training to pursue and include lifestyle and reimbursement in that
decision.  I switched fields entirely from surgery to radiology (x-rays,
mri's, etc) because I started med school wanting to be a surgeon and also
didn't research the residency program where I ended up (malignant shit hole
of a hospital, might've stayed in surgery if I had taken a residency spot
at a better hospital).  Over 1/5 residents will end up switching programs
(surgery-based programs have the highest attrition rate).  The 1st year of
residency is very similar regardless of specialty, however as residency
progresses the knowledge becomes specialized.  Therefore switching fields
means that most people only get "partial credit" for their previous
residency and essentially have to repeat years and have a longer training
period.

I have concluded that it is only FINANCIALLY (I don't address "personal
satisfaction" worth being a physician if the following criteria are met:
1. Do undergrad at a public school or MAYBE at a private school that offers
joint enrollment.
2. Get into med school on 1st try.
3. Don't get master's degree or PhD unless you plan to start out in another
job and you only pursued medicine because you had "calling" to be a doctor
later on.  One of my colleagues worked as an engineer but became inspired
to be a doctor after he was hospitalized following a car-wreck, so these
things do happen.
4. Don't go to a private med school unless you plan for military career or
do primary care in an underserved area, have other significant
scholarships, have rich family helping with school costs, or have saved
money from a previous careerr.
4. Don't pursue an MD-JD, MD-MPH, MD-PhD, MD-MBA.
5. Don't pursue a Surgery-based specialty unless you've met the above
criteria and have minimized your undergrad/med school costs.
6. Don't pursue any specialty unless you do you damn homework so you don't
have to switch residencies (I addressed the shortage of residencies
earlier) or unless you've met the above criteria to minimize education
costs.
7. Forget about starting a family before the age of 30 unless you meet the
above criteria (which is incompatible with peak biological years for
reproduction).
8. If you enjoy a truly minimalist lifestyle (Aaron, you're ability to take
vacations is too extravagant for the degree of minimalism I refer to) then
the above information is irrelevant.

17 comments:

Anonymous said...

As a second yr medical student at a private institution (also getting an MPH in Biostatistics and Informatics that is mostly covered by a scholarship), I can agree with just about everything that is said. As someone looking to go the Infectious Disease route (maybe CDC) and/or get into health information field, an MPH (in something real like Biostatistics or Epidemiology) is helpful. However, I have added up the costs and know that minimalism will be the name of the game for sometime post-graduation. It is a choice we all have to make at some point if there is something we really want to pursue. Fortunately, men can play the "mating & dating" game a little longer than women due to basic biology (although this may not be as extensive as some in the 'Sphere would suggest). So, there is less pressure on a male physician to start a family sooner than female physicians. As a guy, most of the women I have met in medicine are cordial and decent; however, they are too career focused in many cases to be marriage material. Anyways, great & spot-on post! Lieutenant out!

TroperA said...

Under those circumstances it would be impossible for anyone to have a child AND spend any significant time with them. Your spouse would have to be the primary caregiver or you would have to ship them off to strangers to be raised.

In other words, the Cosby Show took place in a world run by magic and unicorn farts.

Jeff said...

Wow. As someone considering a career shift - with medicine as a possibility - this is truly eye-opening. Over the long haul this training system seems insupportable in terms of both financial and time cost.

I have heard that becoming a PA is a decent alternative -- much less schooling at a cost of lower pay and responsibility.

wesley mouch said...

Aaron I am a physician and can only say that you would have to be crazy to enter Medicine. The effort vs payout is a very poor return unless you hit the right residency (specialty) at the right time. For fields like family practice and pediatrics you are better off being a plumber or teacher. Lawrence Kotlikoff has done the analysis and total employment earnings are higher in teaching and plumbing vs family medicine. Some fields like gynecologic oncology can pay quite well ($1 million plus year) but the window of those earnings is quite small and all specialties are vulnerable to getting whacked by cuts from Medicare. Thus you can enter a high payout specialty only to find it decimated by government rules changes. My own field of pathology has suffered through several of these in my 22 year career. By luck I managed to avoid these but if my timing had been poor I could have ended up unemployed for long periods of time. Of course Obamacare makes Medicine an even bigger crap shoot.

By the way I am a resident of Minnesota and am retiring this March. I have had it with the weather, the Socialism and the high taxes. I am moving South and retiring. Most of my colleagues would like to join me but are wage slaves due to their high spending and trophy wives and some even own horse farms.

Best of luck I enjoy reading your columns.

wesley mouch said...

Aaron I am a physician and can only say that you would have to be crazy to enter Medicine. The effort vs payout is a very poor return unless you hit the right residency (specialty) at the right time. For fields like family practice and pediatrics you are better off being a plumber or teacher. Lawrence Kotlikoff has done the analysis and total employment earnings are higher in teaching and plumbing vs family medicine. Some fields like gynecologic oncology can pay quite well ($1 million plus year) but the window of those earnings is quite small and all specialties are vulnerable to getting whacked by cuts from Medicare. Thus you can enter a high payout specialty only to find it decimated by government rules changes. My own field of pathology has suffered through several of these in my 22 year career. By luck I managed to avoid these but if my timing had been poor I could have ended up unemployed for long periods of time. Of course Obamacare makes Medicine an even bigger crap shoot.

By the way I am a resident of Minnesota and am retiring this March. I have had it with the weather, the Socialism and the high taxes. I am moving South and retiring. Most of my colleagues would like to join me but are wage slaves due to their high spending and trophy wives and some even own horse farms.

Best of luck I enjoy reading your columns.

Dan said...

Great post. I think it would be helpful to know why medical school costs so much each year. Is it personnel, equipment, medical supplies? What can be done to reduce it (increase class size etc.)?

Why do medical residents need subsidized slots, as opposed to being paid from hospital revenue or allowing the residents to work at a discount?

I know undergrad degrees can be completed in two years or less with appropriate AP credits, but is it possible to speed up the pace at which medical information is conveyed or limit it to what is actual used (i.e. Psychiatrists probably don't deliver babies often)? How can it best be reformed?

thenoisyrogue said...

The truly worrying thing about this valuable information is not the dubious financial and sacrificial barriers to entry for the medical profession. It is that a person who comes through this obstacle course will have spent their entire adult life focusing on just this one aspect.

And yet, the best doctors possess that most valuable of human conditions, empathy. The best doctors know how to effectively listen to a patient. I fail to see how these two extremely important characteristics can be developed in a person who must spend a good part of their adult life completely self-absorbed in the pursuit of their own career.

Anonymous said...

Wow, great article. One point, there's a goof in this line:

-Overall one can expect to shell out $5-10 for the interview process alone.

Is that 5k to 10k?

Anonymous said...

Wow, great article. One point, there's a goof in this line:

-Overall one can expect to shell out $5-10 for the interview process alone.

Is that 5k to 10k?

Anonymous said...

My doctor just retired early - he got fed up with all the constraints that the new ACA applies to care-giving and all the additional bureaucracy.

Replacement is in his mid-50's - wonder how long he'll stay.



Dan said...

Nearly 4 decades in the medical field....not an MD but as a specialist in radiology technology. Have known a LOT of doctors over the years. Many...perhaps most have in addition to the costs of schooling to deal with made the mistake of getting married to someone who was enamored with being married to a doctor. These types of marriages are DOOMED as the negatives of the career quickly outshine the status and money (and not all doctors make tons of money) and want out. Then the doc not only has professional costs to deal with but the added burden of the divorce costs PLUS frequently child support. And judges don't care about anything but your gross income.....THAT is what they use to decide how much the ex gets. I know plenty of MD's who live in a condo because they can't afford a house.

Eric Mueller said...

From what I've heard, part of this is restricted supply. The AMA approves existence of all medical schools; not the free market. They also create the hoops you have to jump through. I've heard it's been decades since a new medical school opened in 'murca.

And from my experience, the majority of doctors out there are useless. I'm sure like cops and young single girls, there are a mythical few good ones out there. I haven't come across them yet.

They can't keep appointment times or follow up. My wife waited 48 hours for her crap-bag doctor to call in the right prescription for her pain. That's after he was late for the appointment (I've only known one doctor who could keep an appointment time within 10 minutes) and spent about 2 minutes with her.

This myth about "ask your doctor" is bullshit. What the hell can a doctor know about you while only spending 30 seconds to 2 minutes in the room with you? Doctors might as well use Skype except in cases where they actually HAVE to examine some physical ailment.

Anonymous said...

The prescription racket, run by the American Medical Association and the Food and Drug Administration, deprives us from our medical rights.

We are no longer allowed to self-medicate nor request certain tests. It always requires a doctor's approval.

This looks pretty much like parasitic make-work to me. It's about control, extortion and prestige, not about genuine health care.

We should replace doctors with technology and basic medical knowledge should be taught in school so that people become medically self-sufficient and consult doctors only when it's truly necessary.

Could it be that the doctor's insistence on controlling everything and using the coercive power of the state to do so is what's driving health care costs through the roof ?

Could it be if people had more medical freedoms and medical knowledge that health care costs would be significantly lower ?

Finally, this looks like a profitable business opportunity for those who know electronics and programming.

There is already many phone aps and peripherals that are used to diagnose health conditions and manage your health. Doctors in the future will face technological competition and general patient rebellion.

Atham Aldecua said...

Holy molly!

I will stick to ChemE.

chris said...

Um.... to all you talking about medical rackets.... Nope.

Son one is doing Pharmacy and reckons he dodged the bullet as I have reminded him that I did not get my fellowship until I was in my late 30s and then took a pay drop to become a consultant in my field.

And that is in NZ: in the commonwealth all medical schools are state run, you need an A+ average in first year to get into second year, and after six years you will have an MB, and face two intern years (house surgeon in the commonwealth) and then a minimum of five years specailty training.

If you pass the exams first time: these exams have a 40 -- 70 % failure rate. And you cannot practice independently without passing them.

But you get a reasonable wage for the 60 odd hours you will be working (and yes, that includes psychiatry).

Consider medicine like the ministyr. Only do it as a calling. You would, financially, do far better setting up aa business.

Usagi Yojimbo said...

Residents are subsidized because most private hospitals won't pay for them. It's cheaper to hire a midlevel they can bully to save money than someone who actually thinks critically. It also is a money grab by the hospitals.

Medicare pays $100-150k/year per resident a hospital trains. $10k of that is given to administration of the program, probably another $10k for the benefits (health insurance, etc,) for the resident. Average pre-tax salary of a resident is $45k/yr. The hospital pockets the rest.

The payoff for the hospital is they have to be qualified to take Medicare payment, which is mostly a paperwork chase. For that, they get people they can push around for 3-8 years, dependent on specialty, up to 80 hours or more (off the books) a week to push more patients through their system, and gives them more people who have to pay for services.

Working out the pay per hour, it is less than minimum wage a resident earns. The payoff depends on the specialty you choose. The primary care specialties have a poor ROI of them all.

It's a different mindset to go into medicine. Empathy, along with a bit of masochistic streak to put of the rewards that come, and then only if you chose the right specialty.

I got lucky with opportunities I optimized. I did some military time that paid for a lot of my medical education through various ways and the VA. While my colleagues are $300-400k in the hole for their combined education, I ended up just under $90k in debt. I just got accepted to where that debt will go away in a year or so. Most of them are buying McMansions they will not pay off for 30 years, putting them more in debt.

I plan to rent for a year or so to see if I like the area, then think of buying a modest house outright or find a place elsewhere if I don't like the place. Thanks to what I have done, I would be eligible to retire early (like just over a decade,) and do what I want. Since it's just me, I have nothing more to do than save money or put the money into tangible assets as I need to. I would rather have my resources at the ready and portable enough to go anywhere if needed if something happens.

The way I plan to live my life in front of these old feminists is to be somewhat akin to the promised land to Moses: Forever seeing it as a paradise, but never allowing them to enter it. Your story on the 30/40 something you turned down in a bar was something I look forward to happing to me, just to burn them down to the ground. I already do it, and the meltdown into gibberish is something sweet to behold after being blown off in my earlier education.

MS-1 said...

First year medical student.

Everything that guy posted about getting into med school is 100% correct. It was a SERIOUS pain in the ass.

And for anyone thinking of primary care- DONT DO IT
Just the other day the law that had increased primary care physician income expired, and the "czar" or whatever basically said "Fuck you" to all primary care physicians, the reimbursement is not going back up- EVER

No wonder all these docs aren't taking Medicare/Medicaid et al...they don't like getting fucked in the ass after years of hard work.

Sometimes I get soft and think how nice it would be to be a Marcus Welby type generalist, but the reality of getting into an Allopathic (M.D. program) school in the USA is that you are a fool if you don't flee to high paying subspecialties where you aren't screwed over financially because you like caring for your fellow man.