I recently unearthed all my pay stubs from residency, including the first one — all $89.14 of it.

When I received that check, I had just moved across the country after a grueling internship in Philadelphia, which left me physically and emotionally exhausted.

I was staying in a motel, which I paid for with a credit card because I used my last paycheck from internship to pay for moving across the country. My landlord in Philadelphia hadn’t yet refunded my security deposit, so I couldn’t put down a deposit on a new apartment.

I had no money and no place to live. Not because I’d done something extravagant or reckless with my money, but because that’s the way medical training is structured. Financial insecurity is part of the process.

I was a gainfully employed physician, but I was dead broke.

It wasn’t until toward the end of my first month of residency that I finally got a real paycheck. It just barely covered my first month’s rent. I know this because I also unearthed my rental agreement. As a resident, I spent 50 percent of my income on rent. Even though I rented an apartment in a University-owned complex specifically designated for residents, it wasn’t actually affordable for residents, at least according to prudent financial standards.

On top of all of that, there were my student loans. Yes, I deferred them. But I was acutely aware that each month I didn’t make a loan payment. In effect, I was borrowing more money.

Under any other circumstance, I would have gotten an extra job. I’d been working in one capacity or another since I was 14 — babysitting, filing, answering phones, stocking shelves, running inventory at a warehouse, camp counselor. I’d even spent three summers doing maintenance at my high school. I didn’t have some egotistic notion that I was too good for work since I was a doctor.

I was literally forbidden from finding additional work to support myself. And even if it had been allowed, I wouldn’t have had any time. My work was medicine, and medicine is all-encompassing. I had no choice but to peg my financial future on the medical establishment, even if I was going broke in the process, and even though it was abundantly obvious that the medical establishment didn’t actually care about my wellbeing.

Medical training is not merely an education — it’s an indoctrination. Future doctors hand over their financial future to the system. A system that first encourages us to take out mortgage-sized loans then requires us to spend a minimum of three years on the job for most of our waking hours while being dramatically under-compensated compared with the actual value of our work.

Even after finishing training, the legacy of this financial catch-22 lingers in a physician’s psyche. Ask a practicing doctor who or what has the greatest influence over his financial health, and the answer is likely to be some form of large, faceless entity — hospitals, medical groups, insurance companies — the same way that requirements set by schools, the ACGME and specialty boards controlled our wherewithal during training.

We don’t feel we have any influence over our financial state other than by working harder, faster, or “smarter” (as if doctors aren’t smart enough to start with), the same formula for “success” we were taught by osmosis during training.

For years, I worked diligently to meet the moving target of corporate-mandated productivity, ignoring the ramifications to the care I was delivering and to my own wellbeing. I dreamed of finding some other way to practice medicine but resisted making any change because I equated change with fiscal suicide.

The ugly truth is that medical school taught me financial dependence, not independence. I never developed a sense of my inherent value as a physician. Instead, I learned to accept being undervalued. Ceding the power to determine the value of my work to a faceless entity, even when I sensed there was something inequitable about the contract, was a habit ingrained in me from training. “This is how medicine works,” I told myself.

It took me more than a decade after I finished residency to recover financially — to pay off my student loans and repair my credit rating. But it took me even longer to undo the emotional backlash caused by years of financial insecurity and to gain a sense of fiscal sovereignty over my professional life. Sadly, many wonderful, skilled physicians never get to that point but instead remain, like indentured servants, working from a place of financial obligation.

We physicians must come to terms with the trauma caused by the financial insecurity built into our training and the ripple effect it has even after we finish training, both as a way to repair ourselves individually and as a way to assure that our profession survives.

The cost of medical education is high, but the cost of the financial lessons learned in the course of obtaining that education is even higher. It may be a price too high for future doctors to bear.

Elizabeth Hughes is a dermatologist.

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