Medical School Debt And The Potential Impact On Patient Care

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.