Bob Hildreth: Moonlighting -- or practicing medicine outside of the bounds of one’s residency program -- is common. This is just what the profession was trying to avoid when it radically decreased internship hours some years ago. But what is a young doctor to do? He has bills to pay. (The Doctr/flickr)

As we waited for an operating room before my recent knee surgery, I lay on a gurney making small talk with the five doctors and nurses who surrounded me. My anesthesia had just started to kick in when one of the doctors mentioned his eye-popping student debt. His admission prompted his colleagues to chime in with what they owed. They were all resigned to the fact that borrowing insane amounts of money was required to pursue a medical profession. As I fell into a deep sleep, I tallied their collective student loans in my head; about a half-million dollars in unpaid debt went into the operating room with me that day.

Tuition and fees at public medical schools increased by an average of 133 percent  between 1984 and 2004. At private schools, costs went up by 50 percent in the same period.

Why? Because they can. The availability of easy credit for medical students fuels tuition hikes. Schools lend government money, only to turn around and increase tuition, knowing they will receive that government money up-front. Now, tuition has risen so high that even wealthy students must borrow. Attempts by the American Medical Association Foundation to help with almost $1 million of scholarships fall woefully short.

Nothing less than reinventing the system of medical education is necessary and it will have to come someday.

More than 86 percent of doctors now graduate with debt that averages $162,000. During internships, no payment is required, but growing interest can push total debt well past $200,000.

So, why should we care?

Two recent studies have found that debt-ridden medical students and residents are seriously stressed, evidenced by psychological problems, substance abuse, depression and even suicide. The Journal of the American Medical Association has warned that the malaise could end up hurting patients.

Indeed, mistakes have reached an alarming level in hospitals. In recent years, we have seen reports of sponges left in bodies, operations on wrong limbs and incorrect medications and dosages prescribed. While there are certainly plenty of other mitigating factors, if the stress of high debt is causing doctors to make some of these errors, we should care a lot.

Moonlighting — or practicing medicine outside of the bounds of one’s residency program — is common. Even if a resident is exhausted or overwhelmed, these extra shifts — which are very lucrative — can be tempting. This is just what the profession was trying to avoid when it radically decreased internship hours some years ago. But what is a young doctor to do? He has bills to pay.

Despite the nation’s growing shortage of primary care physicians, the level of medical school debt often discourages students from pursuing careers in lower paying fields like primary care. Students with significant debt often elect more remunerative specialties like plastic surgery or obstetrics.

And what about the potential impact on bedside manner? A nationwide survey revealed that students with higher debt burdens view the promotion of humanism (altruism, integrity, respect for others and compassion) as less important than those with lower debt burden.

Of course, skyrocketing debt isn’t just a concern in the medical field. Most doctors’ student debt woes mirror those of lawyers, business graduates, engineers and, indeed, most college graduates. In the U.S., more than 36 million people owe more than $1 trillion in student debt. For the government, student debt is the goose that laid the golden egg, yielding $37 billion in profit a year.

Since most medical schools depend heavily on government-lent money to pay their bills, debt has made medical schools more vulnerable as well. If a disruption in student loans ever occurred, such as a bailout or default, the flow of money might slow or even stop. Only the schools with the richest endowments would avoid this danger, as I outlined in detail in a recent TEDx talk.

So, what can replace the student debt model before defaults and bailouts become reality?

Some see the solution as holding colleges accountable for the tuition they charge by releasing data on how their graduates fare in the labor market and whether they are able to repay their student loans (this initiative is already underway). Others focus on the student, steering doctors to geographic areas or specialties by offering debt forgiveness. The government favors tuition reductions but has hesitated to enact them because any abrupt change would put the schools at financial risk.

However well-intentioned or thoughtful these ideas, they miss the point: there is simply too much debt. To truly find relief, the burden must be reduced; painfully, this would transfer the discounted amount to us.

So doctors will keep paying as long as they can. But when they stop it will not be because their income went down, but because there was simply too much debt; their default was baked in the cake. Nothing less than reinventing the system of medical education is necessary and it will have to come someday.

Meanwhile, I’m going to postpone any future operations for as long as I can.

The views and opinions expressed in this piece are solely those of the writer and do not in any way reflect the views of WBUR management or its employees.

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  • denineann

    And not to mention the similarly overwhelming and overinflated rates paid to nurse practitioner programs…. The majority of my peers who went to school to be medical doctors at least had some pretty strong endowments backing their scholarship funds. In the same university system, nursing students (with comparatively minimal to no endowments from alumni) were taking out just as much or more in federal and private loans with an awareness that we will get a lower salary once out of school. This makes it near impossible to get ahead of loans – and the idea that we could someday give back to other struggling students as alumni is fast becoming a dream….

  • DPH

    Dental school tuition is even higher than that for Medical School. Trying to entice US dental students to practice in public health arenas or to provide a dental home to the underserved in this country is extremely difficult due to their need to repay their loans.

  • jefe68

    In my view we have reached an point in time when the cost of education has now become so absurdly expensive that one wonders how this can even be sustained moving forward. Our nation has a dysfunctional market based health care system that is failing. I’m glad dentistry was mentioned. The last time I went for a check up I paid over $300 for the visit and 30 minutes of the dentists time to do a filling.

    If I happen to have the misfortune of slipping on the sidewalk today due the weather and end up in the emergency room I will end up with a bill that could excede $15,000.

    Something has gone very wrong in this nation in terms of how we are paying for education. This kind of system cannot be sustained.

  • ecs2000

    Try “But what is a young doctor to do? She has bills to pay.” Shake up the stereotype a bit, huh?

    • Guest

      That is what you got out of this article? The person that performed the surgery was male and maybe the writer just went with that preposition for the entire article.

      To make you feel more encouraged I guess, as an incoming M-1 I look up to many female medical students and of the five deans at one COM, two are female. The VP of Medical Affairs/Dean at UCF COM is female as well and she is amazing.There are 6000 students that apply to that school and they couldn’t be more happy to have her be in the forefront of this com.

  • Robert Bowman

    The situation is worse in veterinary medicine with costs going up and salaries going down due to a glut from overexpansion (Caribbean).

    Three dimensions of expansion (more graduates, more in non-primary care, and fewer of primary care trained graduates remaining in primary care) will result in a glut of MD, DO, NP, and PA non-primary care workforce – also bad for maintaining salaries and getting jobs and paying of increasing debt.

    Nurse practitioner graduates will face a 30% increase in the cost of training because of the requirement for a nursing doctorate for 2015 and beyond. This will result in a 10% decline in the workforce due to 2 years fewer to work for each graduate. The primary care delivery decline will be greater as nurse doctoral graduates are less active as direct care clinicians and are likely to be found in primary care at lower levels. The future NP grad loses by this design. Costs are likely to go up due to higher salaries, also found in the doctoral nurses. The nation loses with even less primary care delivery per graduate. With cost of training going up and primary care yield going down, there will be a 60% increase in the cost relative to the primary care delivery – making NP grads one of the most costly forms of training. This is the result of more graduates required for the same primary care yield.

    Family medicine is proposing an additional year of GME – a 12% increase in the cost and a 3% decrease in years in a career and likely a 10% decline in primary care yield. The debt will increase, the salary yield will be less and will be delayed – and likely fewer will choose FM. But the big loser as always will be most Americans that already have lower to lowest access to basic primary care services.

    For the purpose of primary care, the real training begins after graduation from academic training. After 5 – 7 years the relevance of academic training has been greatly reduced. What matters is thousands of learning encounters with patients – specific to career, location, population, and patient – something academic training cannot address with many additional years of traditional academic training. Longer and more costly is particularly bad for all involved – except perhaps those who get more dollars by design change.

  • docww

    You mention that medical students are not entering primary
    care because of their high student debt and the low salary of primary care
    physicians. Physicians are also leaving primary care because of an imbalanced
    payment system. I worked as a primary care physician for over 30 years and a
    few years ago I switched to working as a Hospitalist. The hours and pay are
    much better.

    Obamacare was based on the idea that everyone needs to have
    access to health insurance. It won’t do you much good if you can’t find a
    primary care physician. I agree that our healthcare system is broken and I see
    very little reason for optimism in the future.

  • almost done

    You are incorrect. The current administration changed the requirements so that residents (who make minimum wage if you actually calculate the hourly rate of their salaries vs. hours worked) now must make payments on their student loans during residency. I have a family of four and am the sole support – this administration thought I could contribute $500/month to my student loans. Each paycheck during intern year was not even $1500. As for debt, it is not uncommon for new residents to owe over $300,000. If they went to a private college, they can owe $500,000 (and climbing with interest accumulation). Something has to change.

    • Boogie

      Well maybe your wife should get a job and help contribute. Nobody told you to have a family before you finished residency, that was your choice, so deal with it like a man.

  • bossoccer

    Ok, I have a good friend who is a doc (a specialist) and we get in discussions (read: arguments) about this issue pretty frequently. I’m an attorney and twenty years out of law school, I am STILL paying off my student debt, but here’s the problem: Docs, even “lower” paid docs make significantly more money than attorneys. Docs have some chance of getting loan forgiveness. My friend works in a rural area and has had all his debt paid off and forgiven by the hospital where he works. He makesclose to 1/2 a million dollars a year, while I, twenty years out of school, don’t make six figures because I work mainly for poor and low income people. I have worked in the non-profit world and now in private practice for folks who are not wealthy for those twenty years and I never even had the option of getting my loans paid off. Docs have the option of getting loans paid off if they take certain jobs, which attorneys do not. Docs complain about resident pay, but they get paid more than I made in my first “real” paid job out of law school at a non-profit! And I had to start paying my loans during that time–I couldn’t even chose to defer like residents can. I have no sympathy for Docs, I really don’t. Their earning power over their careers–even in so-called “lower paid” areas, I mean who wouldn’t want to make six figures even if only in the 100’s and not the 500’s??–is very high. Docs have many more options that attorneys do. Whine, whine, whine . . .. I’d change places with the residents in a heart-beat. I really believe that Docs get paid WAY too much and I think that’s part of the problem with the medical system and maybe the debt should be addressed b/c if the hospitals and system are paying off the loans, that also adds to the high cost of medical care and should be addressed for that reason but Docs and residents are myopic, living in their little doc-bubble.

    • James

      You are clueless. Law school is only 3 years. If you graduated in the top of your class and went to a prestigious law school and not one of the law degree mills you can land a 6 figure job at a large firm on a partnership track immediately after graduating. Once you make partner at a large firm you are pulling in more than any doctor could ever hope to. Compare that to medical school which is 4 years, residency which is 3-5 and fellowship which is 1-2. During residency/fellowship you are working about 80-100 hours a week for about $2/hour all while your loans are compounding at 6.8%. Not to mention that the competitive high paying specialties often require students to take 1 year off from studies to do research for minimal pay in order to match. The opportunity cost to become a doctor is way higher than lawyers. A physician who started medical school immediately after college at 23 won’t be making decent money until 8-11 years post college. Not to mention that medical school is 10X harder than law school. The fact that lawyers often make more money than doctors is insane, considering that lawyers contribute absolutely no benefit to society at all. Maybe you should have gone to a better law school and graduated at the top of your class.