Et tu, Radagast?

I sort of expected some attacks when I posted yesterday yesterday about how physicians’ incomes have been steadily falling. After all, whenever Kevin, M.D. does similar posts, people with–shall we say?–issues regarding physicians often come out in droves to post nasty comments, just as they tend to do whenever he posts about how out of control the malpractice system in this country is. In fact, I was pleasantly surprised when there were so few such comments.

But et tu, Radagast?

Actually, I never really asked anyone to have a lot of sympathy for us doctors. As I’ve said many times, I make a more than comfortable income, although it took me until I was almost 38 to start making it. As I joked before, if you want to make a lot of money, don’t go into medicine. (The correllary to this is if you want to make money, definitely don’t go into academic medicine.) I don’t expect Radagast to feel a lot of pain for those of us in the upper percentiles of income, regardless if our income has been declining adjusted for inflation, but I do have one quibble with what he said:

Orac, of course, plays the “rare is the newly minted doctor who doesn’t finish with a six-figure debt” card. This article reports that in 2001 the average debt for medical school students was just around $100,000. Yes, that is indeed a large number. However, even assuming that number has risen to $125,000, that’s still less than one year’s salary for the average physician.

Radagast neglects two things here. (I won’t go into my perception that comparing incomes of everyone over 15 years of age is appropriate for these purposes. Given that few doctors actually start working “real jobs” until they are 30 or even older, I would think that a more appropriate comparison would be the population aged 30-70. But that’s a relatively minor quibble that would probably not affect the comparison all that much.) First is the effect of residency and compound interest. The interest for most student loans interest is generally only deferable for at most three years. The shortest residencies there are (internal medicine or pediatrics) take three years or usually four, and then most doctors go on to subspecialty training. Let’s look at the training of a surgical oncologist (it’s what I know well), shall we? After medical school, there’s still surgery residency. That’s a minimum of five years, although if you want to get into a good fellowship, you will probably do at least one (and usually two) additional years in the laboratory doing research. That’s seven years. Then, your typical surgical oncology fellowship is three more years. Consequently, you’re looking at 8 to 10 additional years of training after medical school before you can make anything more than starvation wages, and your interest on your student loans starts accruing around three years out of medical school. (And this interest is usually compounded.) Because residency pay doesn’t allow you to make serious payments on it, the only real choice a resident has is to let the interest start compounding until he finishes. My personal (and exceptionally masochistic) story led me to 11 additional years of training after getting out of medical school, during which time I also got a Ph.D., by which time my original medical school debt had doubled because of compound interest. The second thing Radagast neglected is that $100,000 is only the mean debt. The distribution is such that there are quite a few medical students finishing with debt loads of $200,000 or more. I’m continually amazed when talking to medical students at how much debt some of them will be carrying upon graduation.

So, no, Radagast, don’t cry for me or my colleagues, but do remember this: When faced with the prospect of taking anywhere from 4 to 12 years to finish training in a specialty so that they can actually practice, during which time they make a pittance in salary and work ridiculously long hours, even with the 80-hour work-week restrictions, more and more of the best and brightest are deciding it’s just not worth it. It’s a problem that we in general surgery have seen for years, as fewer and fewer medical students opt for surgery leading to unfilled spots in the match in good programs for the first time in decades. Things have improved somewhat since a few years ago, but it’s still enough to worry us surgeons. Alternatively, rather than going into primary care specialties, where the most new doctors are needed (and which, unfortunately, remain among the poorest-paid specialties), in order to pay off their student loans in a reasonable period of time they’re opting to become specialists.

You can speculate for yourself what all this means for the quality of American medicine when you and I are reaching the age when we start to need lots more medical care and decide if the present situation concerns you or not.