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.