Tuesday, January 15, 2013

The "D" Word

I have a vividly clear memory of a conversation with my sister-in-law that happened years ago.  At the time, I don't think she was even my sister-in-law yet; I think she and my brother were dating or maybe engaged.  They must have been in their senior year of college or just graduated, and she was somewhere in the midst of the very long academic-requirement-and-standardized-test-filled process of getting into medical school.  Someone asked her where she thought she might want to go, and she told them she was hoping to get into UAB, in her home state of Alabama.  She was a resident there, she explained, and going to a public school with in-state tuition would be far less costly than other options.  As a happy bonus, it also happens to be quite a good school, but, as she told her inquisitor, keeping her student debt load as low as possible was a priority, because she did not want to feel its pressure someday exert influence on her choice of medical specialty.

At the time, I was still working random jobs to prolong my gallivanting the globe as long as possible.  I had no idea what I wanted to do with my life, but I had zero intentions of going into medicine.  I remember overhearing this conversation, and privately thinking to myself, "Well, now, that is just absurd."  After all, I thought, doctors are not poor.  They may not be investment bankers, but they do just fine.  Even the lowest-paid specialties in medicine earn significantly more than most other jobs.    And plenty of people go into plenty of debt for graduate school, but it works out - in a field like medicine, you will be able to repay your loans eventually.  How short-sighted to limit your options for something like money.  (I must confess that the other thing I thought during this conversation was, "Alabama??  Really???"  And not just because of some inherent prejudice I had against the south, although that was certainly part of it.  I totally adore my sister-in-law and my brother, and I was maybe just a teensy bit pissed off that she would not consider moving to Colorado, or some other, more desirable part of the country, closer to the rest of the family.)

I should stop here to note that I could probably tell dozens, if not hundreds, of personal stories and sprinkle them liberally with giant asterisks that would direct you to postscripts about the overwhelming force that irony seems to have in my life.  Seriously, if I have ever thought that something would definitely not happen to me, that thing will most definitely happen.  If I ever say that I will never do something, I might as well just start planning for the day that I will do it. *  

I am posting an article tonight about student debt that originally appeared about a month ago in the New York Times.  It is a subject that hits painfully close to home, and it's a rather interesting (in addition to distressing) factor for me to ponder as I near the point in medical school where I will need to get serious about one medical specialty and decide to devote my career to it.  Our schedule at Emory being set up as it is, I am approaching the end of the third-year curriculum, and have now rotated through many of the major specialties and spent a very small amount of time on just a few of the minor ones.

I, like my sister-in-law, came to medical school enthusiastically committed to the idea of primary care - its importance to health, the critical need in this country for more physicians in this specialty, my own career heading in this direction - and at this point, my theoretical commitment to it has not wavered.  On a personal level, however, I am not at all sure that this is the specialty I want to pursue.  Multiple factors obviously play into this: my experiences on my third-year rotations, my greater understanding of what different specialties entail, my clearer vision of myself, my talents, my interests and my future goals.  It would be naive of me, though, to assume that debt burden and future potential salary were not at least subconsciously casting their votes as I try to process this decision.  

*Of course, the multiple ironies in this story, starting with my going to medical school, include my moving away from family, to the south, where I am currently very much aware of the burden of student debt and its potential influences on choice of specialty.

Tackling the Problem of Medical Student Debt
By Pauline Chen, M.D.
December 13, 2012

Thursday's announcement from the University of California, Los Angeles, of a $100 million medical student scholarship fund should inspire all of us to question the fact that medical education in the United States is paid for largely by student debt.

The new merit-based scholarships, established by entertainment executive David Geffen, will cover all educational, living and even some travel expenses for a fifth of next year's entering medical school class, some 33 students. Mr. Geffen and school officials hope that eventually the school will be able to pay for all medical students and free them from the obligation to take out student loans.

"The cost of a world-class medical education should not deter our future innovators, doctors and scientists from the path they hope to pursue," Mr. Geffen said in a statement. "I hope in doing this that others will be inspired to do the same."

The cost Mr. Geffen refers to has skyrocketed over the last 25 years. The median annual tuition, or yearly cost for attending classes, is now more than $32,000 at public medical schools, and more than $50,000 at private institutions. And medical students must also pay for textbooks, equipment, room, board and travel expenses, adding $20,000 to $30,000 to each year's expenses and pushing the total four-year cost of attending medical school to more than $200,000 at public institutions and close to $300,000 at private schools.

Some medical students commit to military service or to practice in a medically underserved area to reduce costs. But the vast majority end up borrowing money from federal or private loan programs, or from family if they are fortunate enough. The median debt for medical students upon graduation is more than $160,000, with almost a third of students owing more than $200,000. And those figures do not include interest costs over payback periods of 25 to 30 years.

There are several reasons for the runaway costs. One is that the academic medical centers that house medical schools have become increasingly complex and expensive to run, and administrators have relied on tuition hikes to support research and clinical resources that may have only an indirect impact on medical student education.

An equally important contributor to the problem has been our society's placid acceptance of educational debt as the norm, a prerequisite to becoming a doctor. Obtaining a medical education is like purchasing a house, a car or any other big-ticket item, the thinking goes; going into debt and then paying over time with interest is just the way the world works. And, say many observers, newly minted doctors will earn big salaries, allowing them easily to reimburse their loans.

While it is true that most doctors can pay off their debt over time, those insouciant observers fail to consider how loan burdens can weigh heavily on a young person's idealism and career decisions.

For example, financial considerations have been shown to be a major deterrent for undergraduate students considering a career in medicine, particularly for students from diverse backgrounds. And even the most committed students who do make it to med school may eschew research or specialties like geriatrics, family medicine and pediatrics in favor of a more lucrative career in dermatology or ophthalmology.

These choices have enormous social repercussions. Despite the well-studied benefits of a diverse physician workforce, more than half of all medical students currently come from families with household incomes in the top quintile of the nation. Even more worrisome, student concerns about debt are exacerbating the nation's physician shortage. By the end of this decade, we will be short nearly 50,000 primary care physicians and an additional 50,000 doctors of any kind.

Educators and groups like the Association of American Medical Colleges have been trying to address the problem of medical student debt for more than a decade. Some have suggested simply freezing costs or prorating debt according to the earning potential of a student's chosen area of specialty.

But the most durable solutions thus far seem to be scholarships made possible by philanthropic donations like Mr. Geffen's. The University of Central Florida's new medical school, for example, was able to offer its charter class in 2009, consisting of 40 students, a four-year scholarship that covered tuition and living expenses thanks to several gifts. And the Cleveland Clinic Lerner College of Medicine, established with a $100 million gift from philanthropists Al and Norma Lerner, has been able to educate a small cadre of future physician-scientists while granting all of them scholarships to cover tuition costs.

Mr. Geffen's fund represents the first sustained scholarship to cover all expenses, not just tuition, for a sizable portion of students at a single medical school. Combined with his unrestricted gift of $200 million that led to naming the medical school in his honor a decade ago, Mr. Geffen's contributions represent the University of California system's largest donation ever from a single individual.

But the real importance of Mr. Geffen's donation for the rest of us lies in not its historic largesse, nor its hopeful vision. Rather, it is in the dramatic impact one individual can make when he makes medical education a priority, and the inevitable question such a gesture raises: Why has our society been so slow to do the same?

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