From a young age, I knew I wanted to be a physician. There were no physicians in my family, but I had interacted frequently with doctors as a child and felt a strong desire to similarly help others as I grew older.

To this end, I focused on academics. In choosing a university, I chose the one I felt was academically best, despite being a private school in an expensive city far from home. I didn’t think about the price tag, not because I had a college fund, but because I simply didn’t think about it. My parents were immigrants who arrived in America thirteen years before I started college with nothing but two kids and two suitcases. They could not have saved enough to pay for college, much less pay for it without saving, so I needed student loans.

I completed college and medical school in seven years, during which I also worked part-time. I skipped opportunities to travel or spend a semester abroad because I knew doing so would mean sacrificing the minimal income I had, as well as taking on more debt.  Nonetheless, upon graduation, I was approximately $250,000 in debt.

At the time, I did not think much of it beyond, “I’ll be able to pay it back after residency.” This is probably a common thought among medical students graduating with student loans and, while true, represents only a shallow understanding of the situation. I could not have imagined then all of the ways in which this debt would come to affect my life.

I began realizing some of the implications of this burden when choosing a specialty. While there were fields I enjoyed, I ultimately decided against them because I felt overcoming my debt would require a greater income or fewer years spent training than some specialties offered or required. Instead, I chose a field that I enjoyed, but that also offered what I considered a good balance in terms of expected income and years of training.

During residency, my loans were in forbearance. Although I finally had an income, as a resident living in an expensive city, it was not enough to afford the required payments. After residency, I pursued a one-year fellowship, during which I moonlit to pay my loans. At the end of that year, my husband, also a resident with an equally large student debt burden, graduated and planned to start fellowship in a different state. In deciding our plans for those years, we had to choose between moving together or living apart, as I considered a second fellowship.

Ultimately, our loans decided for us. Weighing the costs and benefits of each option, it became obvious that if we lived apart and I pursued another fellowship, our debt would only grow to astronomical proportions. We chose to move together.

I wish I could say that was the only instance in which our debt influenced our decision-making, but that is not the case. Our debt made an appearance in our discussions on when to have a child, whether or not to a buy a home, and where to work after my husband’s fellowship. At times, it felt like the debt was an additional family member, one whose needs and opinions had to be taken into account. In some of these instances, we let the debt persuade us, in others, we put it’s “opinion” aside.

Now, we are both full-time physicians with a child and a home. We have made progress on our loans, but our debt still affects our daily decision-making, such as whether or not to work extra hours, how many, if any, vacation days to use per year, and how much we can afford to save for our child’s education.

In all of these instances, we made choices that were right for us; others may have made different choices. However, this is not meant to be a lament of missed opportunities; I do not regret my choices nor my career path. Rather, my intention is to show the effects student debt can have, that many, like my younger self, may not even be aware of when choosing a career in medicine.

Medical school debt is common. Currently, the average medical student graduate is approximately $180,000 in debt. Whether that debt feels burdensome or insurmountable depends on the interest rate, one’s earning potential, cost of living, and whether or not one’s spouse has debt. Regardless, most would probably agree that at the very least student debt is influential; many doctors must make personal decisions with debt in mind.

The only way to minimize this influence is to minimize the debt. For some, this comes in the way of government programs offering limited loan repayment in exchange for research, military service, or provision of primary care in underserved areas. In the last decade, the Public Service Loan Forgiveness (PSLF) program offered students the chance to have some debt forgiven after working for a non-profit institution and making monthly income-based payments for ten years. This year marks the end of the first decade of PSLF, and as students who enrolled at its outset become eligible for forgiveness, it appears uncertain whether the program will keep its promises. We have yet to see forgiveness, and in the meantime, stories of application denial are emerging.

Much like I’ve described, these students made choices based on debt. They chose lower salaries and smaller loan payments which, if forgiveness is denied, would mean they sacrificed income, while their debt grew, for nothing. While forgiveness was never guaranteed, such a scenario is nonetheless disheartening.

Significant student debt affects individual lives, but may come to affect all of medicine. The combination of increasing education cost, moderate to high student loan interest rates, limited options for repayment programs and uncertainty of forgiveness as well as decreasing physician reimbursement is an unfortunate one that may eventually deter students from choosing to be doctors. If our best students start choosing other fields, what will happen to American healthcare?

I am not hopeful that the cost of medical education will decrease, but I am hopeful that future students will continue to choose medicine. Yes, it is a long road, yes, there are a lot of sacrifices, and yes, the price tag can be hefty. While considering the long-term cost is important, following your dreams is worth more.

Kelly G. Elterman is an anesthesiologist.

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