"Did you get your $200 worth today?”
I often pose this question to medical students training in my primary care clinic. It’s simple math: the average annual tuition and assorted costs of the average medical education is $200 per day. Given this cost, should we be surprised if our students shift their mindsets to that of a consumer, demanding a quality product? I often pondered this when I was a medical student, notably when tasked with such vacuous work as fixing a broken printer or hand carrying a urine sample across the hospital. This is not to devalue teamwork, nor the underlying lessons to be harvested from responding to changing environments. Rather, with mountains of rising debt it is reasonable to wonder what medical students are getting in return for their investment.
A 2018 report from the U.S. Department of Education notes the average physician now graduates with $246,000 in loans. These numbers have more than doubled since 2000 with median debt at $90,000, while salaries certainly have not risen in concert. One recent graduate friend spends nearly $7,000 per month on loan repayment, while a second paid $50,000 last year toward interest without touching his principle. Much of this debt is inflated by what can be considered hidden costs outside traditional tuition: $1,000 on my first day for medical equipment, $3,355 for exam fees and unanticipated travel costs for increasingly competitive residency interviews. A close friend applying to neurosurgery programs had to take out a loan to cover the $17,000 cost to travel to dozens of interviews.
Solutions to this problem are clear: decrease total cost of tuition, decrease hidden expenses, decrease total time of medical education, decrease interest rate impact, reenact subsidized loans, or enhance or front load repayment.
These options are easy to list but are increasingly challenging to address. However, the recent announcement of free tuition for all NYU School of Medicine students (though not inclusive of living and hidden expenses) may represent a milestone for disruption and competition within our current model. While few institutions have the endowment to replicate this undertaking, it raises an opportunity for upheaval of entrenched expectations.
To offer additional transparency, I challenge medical schools to openly publish average debt at graduation alongside annual tuition costs. This publication of the debt load of the graduating class could be an ideal metric for medical school competition. The major caveat here is that indebtedness is not always a marker for lower cost, but can be a proxy for social status or parental contribution. Additionally, acknowledgment of accrued undergraduate and pre-medical school debt, as well as prevention of financial cherry picking, must be built into this paradigm. This could inspire a race to the floor, as opposed to our current steady trot upwards. A step in the direction of transparency would drive competition. Given the cost of living in New York City, I suspect that many public schools in rural areas could potentially best NYU in this regard.
That $200 daily cost is the extravagant equivalent of a magnum bottle of Dom Perignon Champagne daily. It must be curtailed. If not, our bright future physicians may toast their medical dreams goodbye and seek a path with less financial burden.
Aaron George, DO, is a family physician practicing in his hometown of Chambersburg, Penn. He was an Andlinger fellow in health policy with the Center for Public Health in Vienna, Austria, and has been awarded both the Bristol-Myers Squibb award for excellence in graduate medical education, as well as recently named one of the 40 under 40 physicians by the Pennsylvania Medical Society.