The high cost of a medical education

In the summer of 1957, Warren D. Widmann, M.D. ’61, HS ’67, earned his first year’s tuition for the School of Medicine by waiting tables at a hotel on the New Jersey shore. And he had money left over.

“I think when I started medical school, it was either $650 or $850 a year,” Widmann says. Unable to work summers after his first year, Widmann relied on his wife’s salary as a schoolteacher and some help from his parents—a high school administrator and a school secretary—and he finished medical school debt-free. “Now,” says Widmann, “hardly anybody in the middle class can afford to go to medical school without accumulating debt.”

Since Widmann’s day, medical school tuition has risen on a much steeper curve than wages and the cost of living. When “Adam” (students’ identities have been shielded in this article), the son of two schoolteachers, started medical school in 2008, Yale’s tuition was $42,350 per year. Students were advised to budget an additional $25,000 per year for books, equipment, travel to rotations, medical expenses, licensing exams, and living expenses. Adam’s parents were expected to contribute about $8,000 a year, and scholarships and loans would cover the rest.

Recent changes to financial aid policies have relieved some of the pressure on middle-class families, but students still struggle and the medical school would like to do more. “People save their whole lives to send their kids to college, but they haven’t been saving to send them to medical school. That’s a reason there’s so much debt among medical students,” says Dean Robert J. Alpern, M.D., Ensign Professor of Medicine. “The only way to address debt is to increase the scholarship endowment. I don’t see tuition going down. Our only hope is that we can get the endowment to rise faster than tuition rises.”

The basics of financial aid

Yale is not the most expensive medical school in the country. During the 2009–2010 academic year, tuition at Tufts ($50,320), for example, exceeded Yale’s $43,850. Nor is Yale’s tuition far above the national average for private medical schools—$39,233 in 2009.

How do students come up with the money? The School of Medicine has a “need-blind” admission policy and a “need-based” financial aid policy—once accepted, a student’s financial needs are fully met through loans and scholarships. But first, students must borrow what’s known as the “unit loan,” currently $22,700 per year.

Before 2008, if the parents’ total income topped $45,000, they were expected to help pay for their child’s medical school education. Parental assets apart from income are also considered in determining students’ need. (The Financial Aid Office uses a formula that considers some 142 variables.) “We determine a parent contribution,” says Laura Ment, M.D., associate dean for admissions and financial aid, and professor of pediatrics and neurology, “but parents don’t always contribute, so students borrow to cover their parents’ contribution.”

In 2008, thanks to the infusion of $1.1 million from the Yale endowment, the income threshold for parental contributions increased to $100,000. Since then, a sliding scale for parents whose incomes fall between $100,000 and $140,000 has been introduced. “These changes benefit almost 90 percent of the students who receive aid,” says Ment.

The need-based financial aid policy allows students from lower- to lower-middle-class backgrounds to graduate with debt that rivals the lowest medical school averages in the country. (In 2008, the average debt of U.S. medical school graduates ranged from $79,872 at the University of Hawaii to $194,548 at Creighton University.) In 2010 Yale medical students graduated with an average debt of about $127,000, including debt incurred prior to medical school. “By selecting students based on their merits, without regard to their financial circumstances, and by providing financial aid sufficient to enable all accepted students to attend the school without hardship, we have been able to enroll outstanding and exceptionally diverse classes year after year,” says Ment.

Making ends meet

Whatever their financial status, many medical students struggle with finances during their student days. Before medical school, “Michelle” had never had health insurance. Her father is unemployed and her mother has never worked, so she borrows only the unit loan. After tuition and any other monies owed to Yale are subtracted, what’s left goes into Michelle’s checking account each September and January. “I’ve never had accessible money before, so it almost feels like a luxury to me even though I’m budgeting,” she says.

Michelle shares a one-bedroom apartment, cooks at home, walks everywhere, and wears hand-me-downs. The money usually runs out shortly before the next disbursement is due. “I don’t know what I would do if I had to buy clothes, or if I didn’t share a bedroom, or if I had to spend any money.”

“Emma White,” who entered medical school in the same boat as Michelle, borrowing the unit loan and receiving the rest from scholarships, scrimps as well. “I never buy clothes,” White says, recalling a resident who teased her about the bleach spot on her pants. “It’s a tight budget. You don’t have a lot of extra spending money.” She grows her own vegetables and accepts gifts of tomatoes from a neighbor’s garden as well. By going to the same Cedar Street lunch cart every day, she gets her meal for half price and sometimes takes home leftovers. “You do feel like you’re a little old for this when all of your friends from college are now making six figures,” she says.

To get free yoga classes during her first two years of medical school, “Lynn” would show up at 5:30 a.m., take a 90-minute class, wait for the others to leave, then clean the bathrooms and the studio. She also subsists on a backyard garden and supplements her harvest with weekly deliveries from a farm share program.

One student, whose father is a hospitalist and whose mother doesn’t work, said that he can’t expect much help because he has six siblings. “My parents have had to help them all,” says the student, who asked to be identified as “Mike.” “I’m not going to receive any money from them.” He borrowed $50,000 for his undergraduate education and will add $240,000 to those loans by the time he finishes medical school. At $290,000, his debt will be more than double the average debt of a recent graduate of the School of Medicine.

Disbursements arrive in January and September, and budgeting can be a challenge. “Right now I’m living on my credit card,” says Mike, who admits that he could budget better. “A number of us all run out by the middle of June. As soon as September comes, I’m going to pay off all my credit card bills. And the cycle will start all over again.”

Ment and Gerber advise students on ways to live within their means. “We show students where they need to cut corners—whether it’s finding a roommate, eating at home, or going to Costco and buying in bulk,” Ment says. “I think the vast majority of our students understand these strategies.”

Living with debt

Despite significant student debt, loan forgiveness programs like those of the National Institutes of Health (NIH) and the National Health Service Corps (NHSC) attract relatively few students. These programs offer full or partial loan repayment to physicians who conduct research for nonprofit organizations or practice primary care in underserved areas. Although the United States has produced roughly 20,000 doctors per year for the past 10 years, in 2009 only 3,391 physicians who had earned their M.D.s in the previous decade applied to the NIH’s loan forgiveness program. For NHSC, the number of annual applicants dropped from 963 in 2003 to 355 in 2008.

Michelle, who came to medical school to be a psychiatrist, says she would go into a loan forgiveness program only if its stipulations fit her career plans. Nor is Mike, who plans to pursue an ear, nose, and throat specialty, willing to alter his career plans over his nearly $300,000 of debt. As Adam pointed out, “Not many students will go into primary care just to have their debts forgiven; they go into primary care because they love the field and having their debt repaid is a bonus on top of that.”

Many students—those with debt levels ranging from relatively low to quite high—take their indebtedness in stride. “Jonathan” is leaning toward pediatrics or medicine but does not intend to apply to a loan forgiveness program. He feels that many of his peers are not interested in the programs because they “are not that fearful of their debt.”

Some students, however, feel profoundly burdened by their debt and the emotional toll does not necessarily correlate with the number of dollars borrowed. “It gives me a knot in my stomach every day,” says White, who borrowed only the unit loan for her first two years. “You don’t know what lies down the road and if you’ll be able to pay it off.”

Debt and career choices

Although it would seem that debt would drive young doctors into high-reward specialties, studies on the issue have only confounded researchers. A December 2008 report by the Association of American Medical Colleges found that both debt and students’ plans to pursue primary care or practice in underserved areas rose in parallel. Many Yale students feel debt has little to do with career choices and describe a host of other intricate factors—not the least of which are personal goals and dreams.

When Nancy R. Angoff, M.P.H. ’81, M.D. ’90, HS ’93, associate dean for student affairs and associate professor of internal medicine, polled students several years ago, she found that for many, debt was a significant factor in their choice of specialty. But Angoff and other faculty believe that debt is not the greatest motivator in students’ career decisions. Nevertheless, all acknowledge the desire to ease the financial burden of becoming a physician or even to remove money from the equation completely. “I personally feel we’d be a lot better off as a country if there was no tuition for medical school,” says Robert H. Gifford, M.D., HS ’67, the school’s first deputy dean for education, who retired in 2000.

Lowering student debt is a continuous priority for Alpern. Like Gifford, he would like to see the medical school eventually go tuition-free but admits it would be a challenge. The medical school, Alpern notes, was able to institute more generous financial aid policies in 2008 and then again in 2009 and 2010 because the Yale endowment was steadily growing. “And we had plans to do more until the endowment dropped, so if the endowment recovers, we’ll be able to get back into the business of doing more to lower debt.” YM