This piece is the first in Premed Summer, a series of posts that address the most important aspects of a premedical student’s career.
Last week I watched my first open procedure. This is med-talk for when tissues and other bodily structures are exposed to air during a surgery. During the three-hour procedure, a cosmetic surgeon placed a skull cap into a patient who had sustained several head injuries following an auto collision.
My eyes widened upon seeing the grayish-pink flesh of the cerebrum beneath a milky white film. Every bit of that patient’s world was encased in the structures that now lay centimeters away from the surgeon’s knife. Any false moves could result in profound memory loss in the patient, paralysis of a limb, or worse.
Despite the obvious risks, the surgeon made quick and precise movements, first incising the scalp to reveal the damaged skull and dura that encased the brain, then fitting the premade skull cap into the exposed cavity. His every move seemed calculated. There were no signs of hesitation.
That cosmetic surgeon spent more than a decade preparing for this role. He knew exactly which bits of muscle and bone to remove, which to preserve, and could probably recite them all while singing in the shower.
Neurosurgery is one of the most sophisticated and exacting specialties within the field of medicine. The residency (the additional training that follows medical school) last seven years, followed by a fellowship that lasts an additional one to two years.
Note that workweeks for neurosurgeons at any stage of their career are almost 60 hours.
All told, they spend at least twelve years preparing for their career. (Four years of medical school, followed by residency, and the additional fellowship.) Assuming they spend 48 weeks each year during that eight- to nine-year training, they will have accrued roughly 23,000 hours of surgical experience. Take that, K. Anders Ericsson.
(48 weeks x 60 hours x 8 years = 23,040 hours)
To be sure, there is a handsome reward for that commitment. The above link from Washington University in St. Louis cites the median salary of a neurosurgeon at $580,000 in an academic setting and $710,000 in a clinical setting.
For premed students, the prospect of becoming a neurosurgeon, or any type of medical doctor, is at once thrilling and unbelievably daunting. Medical school comes with the expectation that there will be more late nights in the library fueled by caffeine, challenges that exceed any faced in undergrad, and, at last, gaining the ability to heal other human beings.
But despite that medical degree, those four years of work only begin to scratch the surface of medicine. Further commitment and delayed gratification follows to be able to specialize in any field.
Among the reasons why one should not become a physician—a disregard for the health of others is an immediate disqualifier—there are three that are the most salient for premed students:
- Medical training takes an immense amount of time.
- Medical training is extremely expensive and includes costs beyond those of tuition.
- Medical training takes a destructive toll on one’s health.
It comes as a surprise to no premed student that becoming a physician takes an inordinate amount of time. Following three or four years of undergrad, one attends medical school for another four years, and then enters a residency program, which lasts three to seven years. (Further training for subspecialties take an additional one to three years.)
Assuming an individual does not take a gap year or an extended leave of absence, the minimum amount of time spent preparing for a career in medicine is ten years. (Three years of undergrad + four for med school + three for residency.) Thus, she can start practicing medicine when she is 27 or 28 years old, at the earliest.
Many premeds have already accepted that there is a significant time commitment involved in pursuing medicine. Their passion for medicine is so strong, I am told, that the additional decade spent in school will be worth every moment.
Remember this: there are remarkably few vacations in medical school and even fewer in residency programs. Although some med schools allow for a two-month summer break between MS1 and MS2 (the first two years of medical school), most students don’t receive breaks longer than a month.
Few premeds will be discouraged by this news; forgoing break is yet another due to be paid.
Keep in mind, however, that with nearly every waking moment devoted to medicine, relationships to friends and family can wither, as can one’s health, as I touch on below. You might be able to fit in a few episodes of your favorite Netflix series, though it’s doubtful you’ll have time for much else.
In economics, the benefits of a decision can be assessed with a concept called “opportunity cost” when there are viable alternatives available. The most straight-forward example of an opportunity cost involves work and leisure:
I earn $25/hour working for a carrot farmer. On a particular Friday, I am offered the chance to go home early and forgo an extra hour of work. Depending on how much I value leisure over an additional $25, I might take the offer. In essence, I am paying an opportunity cost of $25 for that hour of leisure.
This concept can also be applied to less concrete situations. Let’s say it’s still Friday night and I’ve returned from the carrot farm. I was planning on studying for the MCAR (the exam to enter carrot farming school), but a few friends offer to take me out for carrot cake instead. Here, the opportunity cost of me gorging my face with others is perhaps a lower score on the MCAR, which might limit my ability to go to a top-tier farming school.
The fickle nature of calculating opportunity costs in these amorphous situations is that one can only speculate as to the costs and benefits of the decision. I could have a great insight about irrigation while reviewing MCAR material, or I could feel serious FOMO and not be able to focus.
Ultimately, I cannot know this ahead of time and can only guess at what my experience studying or being with friends will be like.
We can also apply this concept to the field of medicine. During that decade, many medical students put their lives on hold, choosing to postpone getting married or having children, and loosening bonds to old friends in the process. The benefit, of course, is becoming a physician, and for some that might well outweigh the costs.
For the sake of this post’s focus, we will ignore any debt a medical student might accrue in their undergraduate career.
The amount a medical student pays for their education hinges on two main factors,
- Where they attend medical school, and
- Their family’s income
Let’s look at annual tuition at a top private medical school (Harvard) and a top public medical school (University of Michigan).
University of Michigan: $32,428 (in-state), $50,854 (out-of-state)
(The data come from US News & World Report.)
Multiply each of those values by four and you’re looking at spending over $120,000 to attend UMich (in-state) and an additional $90,000 to attend Harvard. Not a small sum of money to say the least and we’re not done yet.
Factoring in the costs of living, a year at Harvard Medical School (HMS) sums to $87,175 while a year in Ann Arbor costs $57,276 for in-state attendees and $76,452 for out-of-state students.
There is a large caveat, however. 79% of students at HMS and 83% at UMich receive financial aid. The average debt load upon graduation from HMS is $111,000; it’s $124,000 at Michigan. (Data from the AAMC’s MSAR.)
While Harvard and UMich are indeed top schools, the majority of medical students graduate with far more debt. According to the AAMC, the class of 2015 graduated with a median indebtedness of $183,000. And it gets worse.
The current interest rate for direct unsubsidized graduate loans is 5.84%. According to the same piece by the AAMC, interest on $183,000 in loans ranges from $407,000 to $108,000.
To be sure, there are several loan forgiveness programs.
Harvard, with its coffers continually overflowing, offers a forgiveness program for graduates who take positions with a salary that is less than average, presumably in a field of medicine that is underserved.
To my knowledge, Harvard is the only medical school with such a program. I recently asked Dean Paul White, who serves on the admissions committee at the Johns Hopkins School of Medicine, whether they have a similar program.
He squinted and replied, “Hopkins doesn’t have that kind of money.”
He might have laughed too.
The US government famously offers the Health Professions Scholarship Program (HPSP), which pays for tuition costs in exchange for military service, and various forgiveness programs through the US Public Health Service. The Indian Health Service (IHS), the Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH) all pay off student loans for service in their respective organizations.
The debt that comes from medical school notwithstanding, there is an additional opportunity cost to medical training.
The website Best Medical Degrees provides an expert analysis of the implicit monetary costs of becoming physician. I’ve summarized the main points of that piece below,
- Medical students lose out on earning about $30/hour by attending medical school.
- Assuming one works as much as they do in medical school (80 hours/week), one loses ~$460,000 during those initial four years. (4 years x 48 weeks x 80 hours = 15,350 hours; $30/hour x 15,350 hours = $460,000)
- Adjusting for salary during the three years of a residency program, a medical doctor loses about $675,000 before their career formally starts.
Note that these estimates assume the $30/hour wage is static for seven years (unlikely) and do not take into account the debt load from medical school, the median of which is, again, about $183,000.
In sum, a doctor just starting her career is $850,000 in the hole.
According to US News and World Report, physicians had a median salary of $187,199 in 2014. So, in theory, a doctor could recoup all implicit and real costs in four and a half years, assuming there were no taxes, no consumption, and no interest payments for loans.
That is, of course, impossible. One will be taxed, one will consume, and one will inevitably have to pay the interest and the principal on all of their student loans.
I’ve heard horror stories from friends’ parents, who have only finished paying off their loans as their children were graduating from high school.
Again, one might declare the benefits of becoming a doctor, particularly one that makes a lucrative salary, to be well worth the debt burden and implicit monetary costs that stem from medical training.
Whereas the time and money necessary to complete medical training is easily quantifiable, the toll that that decade takes on one’s health is much harder to measure.
In 2009, Academic Medicine reported that 12% of fourth-year medical students (4MS) and internists (the first year of a residency program) surveyed had probable major depression. 6% reported suicidal ideations, with the highest rate among African American respondents.
Nearly 90% of physicians cope with stress on a daily basis, according to American Medical News. 14% of those in the study left their job because of the stress. (Note that a “struggling economy” was the most prevalent stressor at the time of the study.)
Greek researcher Anthony Montgomery published a scathing rebuke of Western medical schools in 2014, stating,
Burnout is the inevitable consequence of the way that medical education is organised and the subsequent maladaptive behaviours that are reinforced in healthcare organisations via the hidden curriculum.
The hidden curriculum, as first theorized by F.W. Hafferty in 1998, is the learning that occurs outside of formal and informal classroom instruction. Montgomery argues that the hidden curriculum present at most medical schools emphasizes performance and competition over compassion and care for patients.
Most recently, Dr. Pamela Wible gave a poignant TED talk entitled, “Why doctors kill themselves“. In the talk, Wible cites an earlier study that found 400 doctors kill themselves annually, resulting in the highest risk of death by suicide of all occupations and professions in the United States.
That finding bears repeating:
Physicians have the highest risk of death by suicide of all occupations and professions in the United States.
Even worse, medical schools and residency programs are showing few signs of change in light of this news.
The American Medical Association (AMA) recently launched a new initiative to create the “medical school of the future” by awarding grants to 32 medical colleges.
Each participating school is tasked with revamping their curriculum to improve patient outcomes, implement advanced technology, and increase diversity in the physician workforce. Bettering physician outcomes, implementing efforts to lower stress and abate depression, and decreasing the rate of suicide is not mentioned anywhere on the website.
What is perhaps even more troubling than the rate of stress, depression, and suicide among physicians is that their fundamental role is to do no harm to their patients. When a doctor sees hundreds of patients a day, works 60-80 hours a week, and sleeps 6.5 hours a night, how can they possibly maintain their Hippocratic oath?
The stress and sleep deprivation wear away at their decision-making capabilities, leading to less effective patient outcomes and inevitably more harm.
If you are a premed student and you are currently thinking, “I have great stress-management techniques. I won’t end up like those others.”
If you scrolled past the TED talk above, I implore you to watch it.
Jeez, I really paint a bleak picture of the medical profession in this piece. And I call myself premed?!
Despite what I’ve written in this post, I want to emphasize that being a physician can be one of the most rewarding and meaningful positions in our society. There are few roles that eclipse a doctor’s ability to save lives and make an impact in communities.
For now, those pursuing a career in medicine should take several considerations into account before investing a great deal of time, money, and health into a career.
- Are you after a large paycheck? There are plenty of other careers that involve less stress and time commitment, and pay just as well.
- Do you want job security? Again, there are several careers that can give you that.
- Want the respected position in society? Run for political office and actually do a good job. People will respect the hell out of you. Become a teacher and, in the words of Henry Adams, you’ll “affect eternity.”
- Do you have a desire to help others? Once more, there is no shortage of careers that can provide you with an opportunity to better the lives of others.
Perhaps this piece has only strengthened your resolve to attend medical school and become a doctor. If so, I am delighted.
On the other hand, maybe you’re now leery about the premed track, given the significant drawbacks of becoming a doctor. Again, I am happy that you are thinking critically about the trajectory of your career.