The Economics of Being a Medical Student
By Justin Salman, OMS-III
By most objective measures, medical school education has become more competitive, more expensive, and more mentally taxing than ever. Compared to even twenty years ago, medical students and residents find themselves more debt-ridden and “burned out.” Nevertheless, we seem to casually accept these conditions as inherent to the medical school experience, going so far as to glorify them as rites of passage and necessary to becoming a good doctor. For most of us, getting into medical school was met with such relief and deference that anything that followed was just a corollary to being inducted into such a small and prestigious group. Every medical student is grateful for the opportunity to realize his or her dream of becoming a physician and helping others, but the narrative that accompanies what it means to be a medical student must be recalibrated to better reflect the real-world conditions.
Let’s begin with cost. In 1989, the cost of attending a public and private medical school was roughly $6,600 and $18,300 per year, respectively. Today, according to the Association of American Medical Colleges (AAMC), the average cost at those same schools is $36,755 and over $60,000 annually. That’s an increase of over 550 percent for public schools and 327 percent for private schools over a span of thirty years. For reference, the inflation rate over that same time period was 107 percent. Moreover, the median student debt for students in 1989 was around $50,000 and $28,000 for public and private schools, respectively.1 In 2018, the average medical school debt across all institutions rose to $196,520.2 Highlight the point further, the average debt incurred by the 2018 graduating class at Rocky Mountain Vista College of Osteopathic Medicine was $364,000! Despite these substantial increases in tuition costs and overall cost of living expenses over time, resident physician salaries have remained stagnant for the last forty years.1 By any metric standard it is clear that medical students today are starting behind the curve financially compared to a generation ago.
In addition to the increased financial burdens, medical students face an increasingly rigorous and competitive residency application process that emphasizes elite performance on standardized exams. The United States Medical Licensing Examination (USMLE) Step 1 is the first standardized exam medical students take in their second year and is considered the single most important academic benchmark when applying for residency. In fact, it is cited by the AAMC as the most important scoring criterion when considering applicants by program directors across all specialties. Unsurprisingly, the USMLE Step 1 average has increased dramatically in direct response to the emphasis placed on it by program directors. In 1993, the minimum score to pass was 176; that number increased to 194 in 2017. The mean score in 1992 was 200; today the mean score is 231, and at the current trend the average will be 250 in 2030.3 The term “Step 1 Mania” has gained traction among medical academic communities due to the noticeable and dramatic psychosocial effect that Step 1 performance has on students. These effects include increased risk of burnout, depression, and suicide, all despite the fact that little correlation has been established between Step 1 scores and physician competency.4 That is not to mention the massive revenue streams generated by the National Board of Medical Examiners (NBME) in administering the exam and selling practice exams to students. In fact, this year represents the first year that the NBME generated more revenue selling practice exams than they did on Step 1 exam fees.5 The over-emphasis on Step 1 scores along with the continually increasing averages translates to a hyper-competitive residency application process and reflects the current trend of students going into higher paying specialties in place of primary care fields to pay off their increasing debt.
As future physicians, we are trained to gather as much data from the patient as possible in order to make an accurate diagnosis and treatment plan. Likewise, in order to fix the current system, it’s important we start gathering accurate data. This article is not meant to be prescriptive. It is meant to provide insight into the trends and patterns that govern the current environment of medical and post-graduate education. We can continue down the path of treating the symptoms of the current system with an endless stream of wellness lectures, or we can try to implement systemic changes that address the underlying pathology. Whether it’s mitigating the cost of school tuition, increasing resident physician wages, or re-evaluating the residency application process to put less emphasis on a single exam score, we need to start confronting the foundational issues of our medical education system for the well-being of its constituents.
1. U.S. Department of Education, National Center for Education Statistics, 1988-89 through 2009-10 Integrated Postsecondary Education Data System, “Fall Enrollment Survey” (IPEDS-EF:88-99); “Completions Survey” (IPEDS-C:89-99); “Institutional Characteristics Survey” (IPEDS-IC:88-99); Fall 2000 through Fall 2009; and Spring 2001 through Spring 2010. (This table was prepared October 2010.)
2. Medical Student Education: Debt, Cost, and Loan Repayment Fact Card. (2018). Medical Student Education: Debt, Cost, and Loan Repayment Fact Card. Retrieved from https://store.aamc.org/downloadable/download/sample/sample_id/240/
3. Carmody, J. B., Sarkany, D., & Heitkamp, D. E. (2019). The USMLE Step 1 Pass/Fail Reporting Proposal: Another View. Academic Radiology, 26(10), 1403–1406. doi: 10.1016/j.acra.2019.06.002
4. Carmody, B. (2019, January 20). Raising the bar: encouraging trends in USMLE Step 1 performance, 1997-2017. Retrieved from https://thesheriffofsodium.com/2019/01/17/raising-the-bar-encouraging-trends-in-usmle-step-1-performance-1997-2017/.
5. Carmody, B. (2019, January 20). Raising the bar: encouraging trends in USMLE Step 1 performance, 1997-2017. Retrieved from https://thesheriffofsodium.com/2019/01/17/raising-the-bar-encouraging-trends-in-usmle-step-1-performance-1997-2017/.
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