Educating a doctor is expensive. Per our state’s public budget, it costs around $90-120K/year per student to get a med student to graduation. It’s not just classroom and instructors they need to pay for, but specialized libraries and facilities, support staff, support services for students, overhead costs like health insurance & utilities, compensation for doctors who preceptor med students (because a med student is a huge drag on a doctor’s productivity), payments to clinical sites for accepting student on rotation, insurance cost (each med student has to have $1M in malpractice insurance) and research programs (mandated by accreditation committees).
And working for a qualifying 501(c) organization–that’s becoming a job that harder and harder to find. Public hospitals–yes they qualify, but doctors often work for self-owned physician groups or venture capital-owned corporate management groups (CMGs) who contract with hospitals to provides physician services. (Pretty much standard for EM, also for anesthesia, pathology and expanding to more specialities every day.)
Physicians choosing to work in public hospitals take big pay cut for the privilege. In one my daughter’s case the difference between working for the university hospital and her private practice group started out at $80K/year and has widened as she has developed her practice.
As for the low reimbursement for residents-- hospitals are free to pay their residents more than the Medicare stipend if they want. They don’t want to. Residents are the “free” labor force that keep a lot of hospitals afloat.
(A university program lost its neurosurgery residency for year-after-year egregious hours violations. After It was decertified, the hospital had to hire 10 new staffers–2 full time physicians and 8 midlevels to replace 4 residents.)
This is sobering. Thank you for the reality check.
Until someone has a hospitalization and gets the bingo card of bills from entities they’ve never heard of, it’s hard to fathom that the professionals working so hard in the hospital while you’re there are not actually employees of the hospital. The labs- yes, outsourced even though they’re on premises. But even with a relatively minor surgical procedure, you’re going to see 15 or so professionals by the time you’re done, and very few of them will be getting paychecks from the hospital.
Yes but taking a pay cut for 3, 4 or 5 or so years to qualify to get your debt paid by PSLF seems like a fair trade off. We are talking about hundreds of thousands of dollars.
After 3 years or maybe a bit more and finishing your first contract, you are free to pursue offers that do offer more compensation. Or work part time while raising children. Or even change professions. Because now you are unburden by debt. You have lots of options. And the rest of your working life.
As a resident and a fellow you are not paid a lot. Income based repayment isn’t going to be much. It could be a small amount of time but may be close to those magical 10 years of repayments.
Taxpayers pay for elaborate sports stadiums which benefit wealthy players and team owners. Taxpayers pay farmers not to grow or harvest, depending on which agricultural product is in an oversupply situation. Taxpayers pay for men who are on Medicare to have Viagara. Taxpayers pay for someone whose beach house was destroyed by a hurricane to collect enough insurance to rebuild that same house on the same vulnerable spot. Taxpayers pay to evacuate people who are told “you will not survive this hurricane so please get out now” when they decide it’s more important to stay in their homes since the local shelters won’t take their five dogs and three rabbits.
I think I can live with us subsidizing medical education for the small fraction of doctors who are able to take advantage of this narrowly defined program! We all pay for a lot of stuff which has zero societal benefit (90 year old men need us subsidizing their sex lives?) so I’m good with PSLF.
I don’t agree with the other ways our taxpayer dollars are spent either. Lots and lots of waste out there.
I do wonder what the future is, will lobbyists advocate for the future of PSLF? Like the insurance industry does for beach homes that keep being built. Although many of the people who I know that are buying houses in Florida are self insuring. Because insurance costs have skyrocketed.
I do have a child who has a master’s degree. Self pay, that they paid back themselves. They have a job that pays the bills and they buckled down and paid for the degree they got.
I know someone who’s in a 7 year residency program. 2 of those years are research, which is a 40 hour a week job, they’ve done quite a bit of traveling on their years of research. They no longer want to be in academia but will probably find a job where they supervise residents. After a fellowship. At which point, their 10 years of repayment will be over. Do I agree staying a resident or fellow for 10 years is a good use of time? Not really. That’s their choice.
10% of your income when you can barely afford housing is a lot for a resident to pay–esp if they live in high COL areas and most university-based residencies are in high COL areas. (Remember med students do not get to choose where they do residency. The NRMP computer algorithm does that for them.)
I also think you’re overstating how easy it is for a doctor to just “switch” employers. Most employment contracts for doctors have non-compete clauses that prohibit working within 100-150 miles of the original job site for 3- 5 years after leaving a position. Also doctors typically have to give a 3-6 month notice they are leaving a job. (because it often takes that long to fill a position.) Getting a medical license in a new state is hugely long and cumbersome process. It can take 6 months or more.
And if a young physicians leaves a position in the first 3 years, they often have to pay back their signing bonus–which can be thousands of dollars.
If there are changes going forward to restrict PSLF, I hope that the changes (1) grandfather those already in the program, (2) are part of a larger scheme of reforms of how higher education is financed, and (3) are driven by data, not anecdotal stories of someone who seems undeserving. I’m actually relatively optimistic that PSLF will survive because there are so many critical public service professions that depend upon it. Hope I’m not wrong!
Let me mention that this individual likely has no retirement savings, probably no investments, no house and a limited amount personal savings.
After 10 years of residency & fellowship, they are in their late 30s and are way behind the curve financially.
I did this too. But that doesn’t mean that I don’t see the value in taxpayers subsidizing some pathways if it means that more people are able to work in a field that benefits the public.
Do you want a medical system where there are only two types of doctors- the ones who are gung ho on making as much money as they can, as quickly as they can, and the kids from wealthy families who can subsidize their education for years and years?
I don’t. There’s value in having doctors from a variety of backgrounds and personal circumstances, and there’s value in having physicians who are able to retire their debt (mind you- it’s not like they are sitting watching TV for a decade- they are actually working as physicians with sick people) and not be shackled into their 50’s.
The total cost of the program seems like a pittance compared to other “special interest” payments. We are actually keeping obsolete missile silos and military bases open long past their useful date because some congressperson figured out how to tack those billions of dollars onto a nutrition bill or an urban renewal bill.
So yeah, I’ll happily pay to keep PSLF for the physicians who are able to use the program.
There are federal programs with asset tests. There are those without. As long as someone is following the rules, they can do anything they want with the money they have.
Must everyone be indigent if they want to practice medicine? Do you want someone in residency sleeping under a bridge?
Perhaps the correct answer is to raise those (state/community) salaries. If the state/community does not see the value in PD’s, why should taxpayers in other states bail them out by forgiving their loans?
fwiw: I think PD’s do yeoman’s work and are a key component in our criminal justice system. And they should be compensated fairly for their efforts by their employers.
We subsidize both our daughters extensively so they just dont quit and take up a well paying job in the industry. This is happening more and more. They have no loans but discuss most of their co residents/fellows carrying huge burdens. One of them recently got called on a private loan and suddenly being asked to pay 5k a month while getting paid 80k. They are suddenly figuring out it is better for them to just continue after their fellowship at their current non-profit rather than moving to a lucrative private practice.
To me PSLF is the least of the problems taxpayers have if budding doctors stop practicing or do other things after all that education. Medical education should be free to start with.
My kid took out loans. That kid fully expects to pay back all of their loans. They even continued to pay down all the interest during the pause period. So, I guess it doesn’t matter what loan repayment program they are in as they intend to pay the remainder off within the next three years.