I was talking to a young man who is starting medical school this fall. His tuition at one of South Carolina’s newer schools will be $40,000 per year. That’s admittedly on the high end. On the low end, it runs a paltry $33,000 per year.

And this is all after college, of course. He and others like him are taking out loans to the tune of $240,000 to pay for their medical educations. Another young woman I recently met is in residency and her loan payments are around $2000 per month.

Thinking back on my own medical education, it seems my tuition was around $5000 per year. But then, what with all the Saber Toothed Tigers, Neanderthals and stone surgical tools, things were simpler.. These days, I don’t know how students will do it.

The thing is, American healthcare is expensive. But so is medical education. As we embark on this century, what are the odds that physicians with $240,000 loans for medical school will be able to offer inexpensive care? What are the odds they will enter low-paying specialties? They might be interested in charity care at first, but when the first loan payments come due all the good intentions in the world won’t change the fact that lenders want their money back. Likewise, it won’t change the hard reality that it will be extremely hard for these young physicians to pay for their student loans, buy a house, have a practice (pay malpractice) and raise a family; at least without making a large amount of money in their practices. And then there’s this striking (but seldom mentioned) fact: student loans are non-bankruptable. Student loans are friends for life, or until payed off. Whichever comes first.

Of course, there are loan repayment/forgiveness programs for those who go to rural areas, or those who enter primary care. And there are scholarships for those who enter government service in either the military or Public Health Corps. That’s good. But the government only needs a fixed number of physicians on its payroll, and state and local economies can only absorb so much of that cost otherwise.

And realistically, it’s very difficult to attract young physicians to rural areas. I know because my practice has recruited them. Furthermore, not every young doctor should be in primary care. Some of them will make terrible family doctors but brilliant neurosurgeons; unhappy cardiologists but delighted obstetricians. We all have unique skills and interests, and physicians are no different.

I realize that the standard response to all of this is, typically, ’so what, they’ll be rich doctors!’ Not at this rate, they won’t be. And most of them don’t come from riches, either. They’re just kids who believe in the power of hard work, who want to help the sick and who believe that medicine will be a stable, lucrative career. Generally, they’re students who know how to press on through difficulty. But this is a difficulty they probably didn’t expect: pay lots of money for an education that may or may not pay back commensurate with its cost.

If we’re going to continue to have excellent physicians of every specialty, we’ll need to find ways to make medical education more affordable, or be willing to pay ever more money for medical care. It may be that medical education could start after two years of college, instead of four; or even after high school, as it does in some countries (though post-graduate training remains necessarily long in those situations). It may be that medical schools will need to be more lean like all educational establishments these days. Besides,, most of the practical medical education occurs in residency anyway.

Further, it may require that we trim some medical and pre-medical education to focus on what is absolutely essential. This would have been useful back in college, since many of the classes we took were simply designed to limit the pool of applicaitons by ‘weeding out’ those who couldn’t handle the academic load. Let me just say that I have very few occasions to interpret assays of organic chemicals these days; I’m too busy treating patients and figure out how to interpret Medicare billing rules.

We have a difficult task ahead. Medicine just keeps getting better, but more expensive. And the process of becoming a physician is more and more complicated and costly as well. We don’t wants less quality in healthcare. But something simply has to give or else educationally impoverished physicians will necessarily charge even higher fees in the future, just to keep ahead of their loans, falling reimbursement and the cost of having a practice.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test.

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