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.
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.