Monday, August 23, 2010

MiM Mailbag: Is it worth it?

Hello,

I am 21 (just about 22 years old) and in the process of applying to MD schools. I have worked very hard throughout my undergrad experience and (at least according to my advisors) will likely be admitted into medical school. I have been following the blog for a really long time, and I can't think of any other place to pose this question.

Is it worth it?

I am going through this journey without the financial aid of my parents, and having done some research, I have read that malpractice insurance/taxes take about 60-70% of a physician's salary. Knowing that I am going to have over 200,000.00 in loans, it almost seems like following this path means committing myself to a life of financial agony. I have dreams of Doctors Without Borders and inner city clinics, but my dreams do not even seem feasible in light of this. I know my personal financial issues are of little relevance to any of you or the blog, but my question is this. Is it worth it to pursue this dream? Or if given the chance would you have pursued a Physician's Assistant position or something similar?

Thanks :)

Love the blog!

21 comments:

  1. I'm just a lowly premed ;) but I wanted to address part if your question. Because of what you are interested in (providing medical care to those in need) you may be able to take advantage of a loan repayment program where you sign up for a certain assignment for a period of time and your loan is repaid for you. Off the top of my head, I know there is a program like this for doctors who serve in rural areas without ready access to care, but there are a few other variations, too. Might be worth checking into if you haven't already.

    Good luck to you, whatever you decide!

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  2. As a 2nd year medical student, I'm in a similar situation as you. I have 40+ grand in undergrad loans and am now at a private medical school acquiring 50+ grand a year here, in tuition alone. I'm fortunate enough that my husband works, so I don't take out cost of living loans like my other classmates who are easily loaning out +70g a year. Oh, and add that on top of a one year post-bacc program and, well, yeah, it's a lot. Although my loans are always on my mind, I know that in the end, there is nothing else I would rather do. I can't think of any other job that would satisfy me the way being a doctor would. To me, that's worth it. It's worth it to know that when it comes to the end, I will never "wish" I had done anything else. If I went to PA or nursing school, even to the highest degree, I know that in 5, 10, 15 years I would have wished I went to medical school. I like the autonomy that comes with it, as well as the level of expertise, details, and physiology that go behind it. Everyone is different in this regard, which is why we have different levels of providers from techs to docs.

    But, like Kyla said, there are SO many programs out there that will help you if you are passionate about the nation's underserved or disadvantaged communities. If you are 100% sure of this up front, you can apply for the National Health Service Corp scholarship, which pays for your medical school as well as gives you a stipend, as long as you commit to doing a primary care specialty and will work in one of their clinics when you graduate (which are more than likely inner city or in underserved areas). If you can't commit to primary care, you can also apply to this same service when you graduate, they will pay off your loans as you work at one of their approved clinic sites. If you're not sure of your specialty of interest and have a desire to serve our country, then maybe a military scholarship is for you. You will have school paid for plus a stipend, and have to commit the same amount of years back to them when you graduate.

    I guess the point is, decide if medicine is for you, first. If you would be happy in the long run as a mid-level provider, then perhaps that's an option. If you know being a physician is the only job for you, then although the loans are VERY real and the financial burden is VERY real, there are programs to help with that. I guess sit down with yourself and do some soul searching and try to figure out what would make you the most happy in the end.

    Best of luck to you!

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  3. When I was a med student, one of our deans addressed the issue of med sch debt. She talked about how we've all heard horror stories of people paying back med sch loans decades later. Well, the fact is that physicians practicing in this country make a LOT of money (very much dependent on your specialty, of course). If you live a prudent lifestyle, you will be able to save money and repay back a substantial proportion of your loans fairly quickly. It does mean that you don't make extravagant purchases e.g. huge 1st home, then an expensive 2nd home, big yatch, luxury car, etc etc. If you are willing to spend a few years after training maybe doing private practice and earning some money to repay your loans, it will free you up to travel down the road should you decide you don't want to do the other routes suggested to you above.

    Is it worth it? At the end of the day, I'm still not 100% sure. But it's not just the money for me, it's also the fear of killing/harming someone, getting sued, how horrible residency was (although it's getting better now from what I hear), the business/profit side of medicine, bureacracy, health care inequalities.... At the very least I'm pretty good at what I do, patients generally like me, I feel like I'm helping them, and down the road if I decide to do something else (considering public health), the M.D. will be a stepping stone for me to whatever I want to do.

    Anyhow, good luck to you!

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  4. I'm a veterinarian, not a physician, but I own my own practice and thus have annual discussions with my accountant re: gross earnings, deductible expenses and the status of my student loan.

    >>I have read that malpractice insurance/taxes take about 60-70% of a physician's salary.>>

    Not exactly.

    Malpractice insurance is a deductible expense. It's a cost of doing business. Compare two physicians working in the same state: according to the IRS, both earn salaries of $250K. One may pay $50K for malpractice insurance and the other only $10K, just as one may pay $24K/year for office space and another $72K/year. Both still earn salaries of $250K because business expenses like malpractice insurance and rent are deducted from GROSS earnings, not actual salary. Some specialties obviously pay higher malpractice premiums, just as some generate higher gross earnings. The disconnect comes when specialties with high malpractice premiums are not also the most highly reimbursed (compare OB/GYN to radiology, for example).

    Taxes? Well, in general, the higher one's salary, the higher one's taxes. As my accountant said one year: this is a good problem to have. He's right.

    As for student loans: it is critical to minimize undergraduate debt because graduate school is expensive. If you're projecting $200K total debt and can consolidate at a rate of 4-5%, expect to pay around $1500/month for 20 years after you finish residency. You will have to decide for yourself if you can live on your eventual salary minus the monthly loan payment.

    Given your interests, I'd advise you to check out the blog Musings of a Dinosaur, written by a longtime family practitioner.

    Only you can decide whether it's "worth it".

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  5. My mentor was consoling a friend whose husband is training in a reasonably lucrative medical specialty. She was freaked out about all their debt.

    However, in 2 years he will start practicing and probably earn in the neighborhood of 200-300K per year. That's approximately 10-15K take home income per month after taxes. It should be possible to manage to pay back $1500/month without too much problem.

    The problem arises a) with the poverty you experience while you're IN school -- what if you want to start a family, for instance. Daycare is expensive on a resident's salary. And b) suppose you go into a less lucrative specialty that pays 100K/year, or you decide you hate medicine and want to bail out for something less lucrative. That's when people start feeling the pressure of the golden handcuffs.

    There are loan repayment programs though, and you certainly could be a lot worse off than with $5000 of disposable income each month.

    Plus in the end you get to be a doctor!!

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  6. I was fortunate enough to have my father help with living expenses, so I only had to borrow for tuition. Ten years ago (when I graduated from med school), tuition at my state's medical school was only around 8-9K/year. I am lucky that after ten years I have cut back that debt by over half with small monthly payments. I think the tuition is now double what I paid.

    I have read and heard that no matter what your monthly payments are, student loan interest rates are so incredibly low that it makes more financial sense to just keep paying them off over time rather than throw your first bonus at them to get rid of them.

    As for malpractice insurance, my annual premium is only around 2% of my salary - and I get a 10 percent discount for doing a simple yearly web-based risk management seminar. Another great reason to become a pathologist - not much malpractice insurance! You would have to shop around specialties to see what individual premiums are = they vary widely. I have heard neurosurgery is pretty high, but they also are paid well. I doubt any specialty's malpractice reaches 60-70% of salary.

    I have to say for me, yes, it is worth it. And I realize I was very lucky to be trained at such a discount, especially after joining this blog and seeing the costs of private med school education (I did not look into or apply - only to my state school because I wanted to stay local).

    It is good that you are looking at this on the front end - I see a lot of doctors that think physician=mansion/luxury car/yacht/private country club and get themselves onto a financial treadmill that takes the joy out of life. I think in any job, no matter what your salary, you should look at what percentage you can stomach putting toward housing/education/transportation loans and make wise decisions on the front end so you have plenty leftover for travel and entertainment. You only live once. Good luck!

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  7. If you really want to be a doctor, money shouldn't be the deciding factor. The real question you should be asking yourself is if you are willing to devote several years of your life to difficult schooling and further training.

    Also definitely look into your state school. I am going to my state school with some grants/scholarships on the side. Coupled with a simple lifestyle and some (very modest) savings I had from working before school, my debt is not going to be bad at all.

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  8. Is it worth it? Above and beyond the money issue (which may seem the most pressing right now) try to think in the future: how will I feel about being on call nearly the rest of my life? Always attached to a pager? The grinding existence of caring for sick people all hours of the day and night? Missing friends and family for routine gatherings and important holidays or functions. You may not have kids now, but if you could ever even contemplate having them, think about how the "physician" lifestyle will affect you, them, and your relationships.
    Do I love my caring for people? Yes. Does it cause stress, worry, and sadness that I could never have forseen going into medical school? Yes. Did I really know that to be a good physician you really have to be a life long student? No. I realize these things now. Again, I love my job (in general), but honestly, I would not choose it again--there is too big of a personal toll.

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  9. if you cant imagine doing anything else, it is worth it. if it is your dream to be a doctor, you wont feel satisfied unless you pursue it, or you may regret or resent your decision later.
    i love my life. i love my job. it was hard getting here, and i do still have loans to repay, but i couldnt imagine doing anything else...so, yes, for me, it is worth it.

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  10. Echoing previous commenters about loan repayment program which can be a great option while you are doing service for the underserved.

    Depending on what you do in medicine, you don't have to choose to have a "physician's lifestyle" as noted by anonymous above. You don't have to be attached to a pager or be on call 24/7 (except for your kids and family!). You could choose any number of routes in medicine to have more work/life balance.

    I agree that it comes down to what makes you satisfied in life and if caring for others as a physician does that--then this path will be immensely gratifying and completely worth it.

    Like Marni, I can't imagine doing anything else. My job is amazingly rewarding. Amazingly. I've always loved it - loved it through residency pre-80 hour work weeks, continue to love it. So yes, I would do it again. Of course. In a heartbeat.

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  11. I'm a second year resident. Went the MD/PhD route, but between my husband and me, we still have cost of living debt. To answer your question--I often find myself jealous of high school classmates who went the PA route. Oddly, they seem to have more control of their lives than I do..

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  12. My opinion, it will NEVER be worth it. Practicing as a physician is a sacrifice that I am beginning to believe no rational person would ever make. Just like it is not rational to work 40 hours straight. It is not rational to go all day without peeing (or eating) because you do not have time. It is not rational to spend weekends in the hospital, nights answering pages, etc.

    I graduated over $100,000 in debt. I trained for 8 years after med school. Now I bring home over $10,000 a month. There are no curtains on the windows of my beautiful waterfront home because I do not have time to shop for them.

    It is ridiculous but the reason why I do this is because I believe it is my divine mission to do so. When I feel discouraged or angry it seems like I am shown, again and again, by patients, grateful family members or students that I have a special gift. Perhaps I am psychotic. Perhaps I am brainwashed.

    We consider medical training to be delayed gratification. For those who are smart and choose lifestyle specialties that is probably true. For those of us who a gluttons for punishment, it is a sacrifice of time, money and spirit. No guarantee that you will register a benefit over cost ratio.

    It is either worth it every day- while you give more than you get- or you will never be happy as a physician.

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  13. Asking if it's worth it is kind of like asking if it's better to be a boy or a girl. Some people are suited to a career in medicine and some people made huge mistakes going into medicine. It really depends on YOU. You need to investigate other careers and find out if you'd be happier going those routes. I'm sure you already realize that medical training is a huge sacrifice of both time and money, and it will become your life. It's not a decision to make lightly, but it's one that you need to make based on your own personality and desires. Nobody can tell you if it's going to be worth it for YOU.

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  14. >>I would not choose it again--there is too big of a personal toll.>>

    A recent survey of rural veterinarians found that a significant proportion leave practice in less than five years, citing salary, benefits and on-call/lack of time off... even though these were NOT significant factors when those veterinarians first chose rural practice.

    IOW, people change over time. It may be okay to work long hours and take call for a few years, but many veterinarians and physicians, male and female, eventually decide other priorities (family, children, personal interests) take precedence over giving oneself selflessly to one's career.

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  15. Although we can sometimes forget it, most physicians make quite a bit more than your average working person, even after malpractice, paying off loans etc. That said, in light of the current situation in health care, I don't think it's safe to assume that you will necessarily be able to get rich from a career in medicine over the next 40 years. So, I would say not to let the financial aspect make the decision for you in either direction- if being a doctor is your dream job, don't let loans/malpractice etc dissuade you, but if it's not your dream job, don't do it just for the money.

    In my case, I realize in retrospect that I would have been just as happy (or happier) as a PA or NP, but too late now... As many above have mentioned, the personal toll of residency and being a physician is pretty huge, and in my opinion, that's what should be a bigger factor in your decision than the financial aspect.

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  16. Medicine requires still that it should be an avocation-something you wake up every morning knowing you want to do. Otherwise the stresses of the training, the length of delayed gratification and the future financial uncertainty can make you miserable. I knew when I turned 8 that this is what I wanted to do. Luckily, thanks to kind parents, scholarships and a high earning husband, I can do what makes me happy. I count my blessings.

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  17. The things that were important to me when I was 21/22 are not the same now that I am going on 30, married, and have an almost 2 year-old daughter. I'm in my last year of anesthesiology residency (supposedly one of the "lifestyle" specialties). If not for the 6-figure debt that I have accumulated and the nearly 12 years of education that I have put into this, I would quit in an instant. Most days I sincerely wish I had chosen something else besides for medicine.

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  18. Wow. Maybe the happy people are not writing. I LOVE my job. Yes I have frustrations but when my daughter asks me about what I do all day, I am happy to talk about it. Yes, there are days when I wonder about the nanny having more face time than me, but today I felt like I really made a difference. If you do not feel that way about what you are doing get out of the profession. The money is not enough to justify the unhappiness. Good luck!

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  19. I really wish I had explored other options. Don't get me wrong, I like what I do (pulm/cc), but I just wish it didnt take up so #&$! much of my time. It is hard to know when you are in your 20s what kind of lifestyle you may want in your 30s and 40s. I would recommend taking some time (work a bit, pay off some of those loans!)--if you still can't imagine doing anything else, then go for it.

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  20. I had the same question at certain points in my training once I had children. Prior to that time, I loved what I was doing so much that I honestly couldn't imagine wanting to be anywhere but the hospital during the (excessively long) hrs I was there. I, too, was a product of the pre-resident-work-hr-restrictions training. I think my training was awesome and wouldn't change it for the world. After having kids (I have 3), I began to resent the imposition on my family life of my career--I am in a very demanding profession, oncology--and had a lot of guilt about going to work while my kids begged me to stay home. I contemplated in some vague way leaving medicine, but felt that I had too much time and money invested to walk away. The real reason I stayed, though, is that I love being a doctor, sometimes can't imagine that you can do something so challenging, fun, and rewarding and get paid for it. In short, I am still the person I was before kids, but unquestionably changed in some ways since having them. So, 4 yrs ago, when my oldest was 2.5 yrs old and my now middle child was 1 yr old, I crafted a part-time arrangement for myself in my specialty (see my previous post under label Tempeh on how). I now work 24 hrs per week, love my job, enjoy my family, and have as close to zero "working mommy" guilt as a mother could ever have. I didn't miss a single field trip or school activity for my kindergartener last year, volunteered in his classroom, and have had 4 out of 7 days off per week (truly off, no pager, nothing with very few exceptions) every week since 2006. Money should not be the deciding factor in whether you become a doctor, in either direction. Yes, most people walk out of med school with some debt, and for some people, it's a big figure. Yes, malpractice and taxes take a bite out of your salary (though malpractice is generally paid by your employer, so it doesn't "come out" of your salary per se). Yes, with changes in health care and the realities of the US economy, physicians will probably be less wealthy in coming decades than they have been historically. But the bottom line is that there is a lot of job security in general for doctors, and that will only become more true with the aging of the baby boomers. Most doctors enjoy a level of comfort and financial security that far exceeds the general US population. And if money is really a huge issue for you because you will graduate with a large debt, there are a number of loan repayment programs. One you have already heard about (NHSC, if you are sure you want to work in an underserved area). Another is the NIH loan repayment program, which pays off about $60K of loans on top of your regular salary in exchange for including research in an academic job. Still another is the federal govt where you can get currently $10K per yr in loan repayment on top of your salary for up to 6 yrs, one yr of repayment for each yr of work as a federal employee in any one of a number of institutions, including the VA. If you really want to serve underserved populations but the financial realities of your situation seem to preclude it, you can always have a regular "doctor job" in a high-paying and lifestyle-friendly specialty such as dermatology and volunteer in a homeless clinic or other similar place. I can assure you that those folks don't get annual skin cancer screening or any dermatologic care, so you would be providing an unmet need. Just some thoughts on how to address your issues. Lots more that could be said, but I've gone on too long already.

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  21. The mid level practitioners in my area are making more htan 2x as much as the physicians (180 on a 99213 compared to my measly 60) from medicare/medicaid because of their "rural designation". BTW this designation is not open to physicians. So if you want to serve an underserved population and get payed for it, I say go to PA school then move to the country. You'll save your self a lot of money and time and make a lot more money.

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