The Real Cost of Medical School

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There is no doubt that medical school is expensive. Many newly-minted resident physicians face a mountain of student debt upwards of $200,000.1 Although tuition and cost of living is a significant portion of that debt, the real cost of medical school also includes board exam preparation and applying to residency. Without a doubt, these real costs are likely felt most among those of us pursuing a career in neurosurgery, one of the most competitive specialties.

USMLE board scores are considered to be one of the most important elements of a residency application. It comes as no surprise that medical students spend on average over $4,000 on additional study resources in the hopes of achieving a competitive score.2 In addition, it costs $3,475 in 2020 to take all required USMLE exams.3 Even as Step 1 becomes pass/fail, Step 2 CK and clerkship shelf exams will increase in importance, causing students to continue paying for additional study resources.4 This could create an avalanche of costs in the third year that many students might be unprepared to pay for.

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In 2019, neurosurgery applicants spent on average $11,676 during the residency application process.5 Why is this number so high? In part, applicants typically attend three or four away rotations in their fourth year of medical school and apply to a high number of residency programs due to the competitiveness of the neurosurgery match. The cost of applying to residency was highlighted in the 2021 application cycle, where programs are receiving a higher-than-usual number of applications because of the uncertainty surrounding COVID-19.6 All of these costs might make pursuing a career in neurosurgery financially difficult, if not impossible, for some students.7-9

Typically, most residents defer loan repayment until after the completion of residency. However, neurosurgery has the longest residency with seven years and many surgeons pursue additional fellowships. The long duration of training worsens the impact of student loan interest and limits early-age contributions to retirement funds.

Ballooning undergraduate and graduate debt, combined with falling reimbursement rates,10 might create a perfect storm of financial instability. In the age of COVID-19, the traditionally high neurosurgery salary is likely to decrease further. All of these costs will be felt more among neurosurgery applicants who are parents or family caretakers, first-generation college students or from lower-income families.

The real cost of medical school and training for neurosurgery prospects includes personal sacrifices. These non-financial costs are shared among all students pursuing any medical specialty, but are amplified for  those pursuing a neurosurgical career.

Although we must all take care of ourselves and each other, the aforementioned real costs of pursuing a career in neurosurgery are worth the price of admission to be responsible for the care of neurosurgical patients. To take a phrase from the AANS 2018 Annual Scientific Meeting, this is The Privilege of Service. I’m optimistic that we will continue towards making these “real costs” as equitable and affordable as possible for all neurosurgery prospects in the near future.

 

References

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1. Youngclaus J & Fresne J. (2020). Physician Education Debt and the Cost to Attend Medical School: 2020 Update. Association of American Medical Colleges. https://store.aamc.org/physician-education-debt-and-the-cost-to-attend-medical-school-2020-update.html

2. Bhatnagar V, Diaz SR, Bucur PA. The Cost of Board Examination and Preparation: An Overlooked Factor in Medical Student Debt. Cureus. 2019;11(3):e4168. Published 2019 Mar 1. doi:10.7759/cureus.4168. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6497509/

3. https://www.nbme.org/examinees/united-states-medical-licensing-exam-usmle

4. Huq S, Khalafallah AM, Botros D, Jimenez AE, Lam S, Huang J, Mukherjee D. Perceived impact of USMLE Step 1 pass/fail scoring change on neurosurgery: program director survey. J Neurosurg. 2020 Jun 19:1-8. doi: 10.3171/2020.4.JNS20748. https://thejns.org/view/journals/j-neurosurg/133/3/article-p928.xml

5. Texas STAR (Seeking Transparency in Application to Residency) Database. https://www.utsouthwestern.edu/education/medical-school/about-the-school/student-affairs/texas-star.html.

6. https://www.aamc.org/media/6231/download

7. Agarwal N, Choi PA, Okonkwo DO, Barrow DL, Friedlander RM. Financial burden associated with the residency match in neurological surgery. J Neurosurg. 2017 Jan;126(1):184-190. doi: 10.3171/2015.12.JNS15488. https://pubmed.ncbi.nlm.nih.gov/27058197/

8. Chang PS, Rezkalla J, Beard M. An Analysis of the Financial Burden Associated with the Residency Match at the University of South Dakota Sanford School of Medicine. S D Med. 2018 Feb;71(2):66-69. https://pubmed.ncbi.nlm.nih.gov/29990414/

9. Fogel HA, Liskutin TE, Wu K, Nystrom L, Martin B, Schiff A. The Economic Burden of Residency Interviews on Applicants. Iowa Orthop J. 2018;38:9-15. PMID: 30104919. https://pubmed.ncbi.nlm.nih.gov/30104919/

10. https://www.aans.org/en/DC-E-News/2020/8-25-E-news/CMS-Issues-Proposed-2021-Medicare-Physician-Fee-Schedule-Rule

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