Most physicians accumulate near $300,000 in debt by the time they finish residency and go to work. This debt is crushing, and it is having negative effects.

College and medical school tuition has soared in the last 20 years, keeping pace with federal loan availability. There is no clear relationship with increased quality of the educational experience or with increased knowledge of the students. Colleges are part of the problem, but, in my opinion, the medical schools are even more egregious. After all, how much does it cost to rent a lecture hall for 2 years and provide some lecturers?

I will never forget when I complained about the increasing expense of medical school to a dean once. He explained that all of the faculty’s salary is considered an expense to the medical school, and that students are only paying a fraction of the true cost.

I must object! If a professor makes a guest appearance for an afternoon or two, the medical students are expected to pay him for a year of work?

I will never forget the goofy physiology professor who gave us two afternoons of demonstrations and lectures. He hooked live frogs to electrodes and made waves on a monitor. It was interesting, but his salary is $200,000 a year. Was it worth $2,000 a student (a class of 100 medical students) to watch him make frogs twitch two afternoons? I think not.

Caribbean medical schools charge about the same as those in North America and make a large profit. Medical students have become a “profit center.” This is occurring in an age when medical students write and share much of their own educational content in an interactive environment. This cannot be sustained.

For the last 2 years of medical school, the students are turned loose on the hospital wards and become slaves. This is called running scut, and it includes running specimens to the lab, wheeling patients to x-ray, drawing blood, fetching lab results, doing much chart work (completing the chart is the most important thing), and learning a lot in spite of the grunt work. The older physicians do teach on rounds, and there is always a resident physician around.

Again, these practicing physicians (they bill for their services) would be there anyway for the residents, and if there were not residents, would have to be there for their patients. The medical students cannot possibly add much additional cost, but these attending physicians and residents salaries are included in the educational cost justification.

The debt introduces a toxic calculus to specialty selection. Residencies are chosen for their fiscal attractiveness, which is not a correct or sustaining reason in a long hard career. Also, it may become economically impossible to practice in a lower-paying specialty.

Let me tell you about Razor Rick, a college student I mentored for several years. I hire these kids in their college summers and breaks to do not much but make a little money, and in exchange they let me pontificate and smile at me. Well, Rick got through med school and then dropped out of his primary care residency, owing several hundred thousand dollars. I was stunned when his parents called me, and I insisted he come in to talk to me.

He patiently explained that his board scores were passing but not good enough to get into to a well-paying specialty. He logically explained that he would have a better life, and have a better return on his investment, if he simply went into pharma with his expensive degree.

I helped him find some interviews.

Some criticize this generation of doctors for not being engaged, for not joining organized medicine, and for avoiding the glorious heart of difficult medicine. I don’t blame them for being distracted. They have, on average, 300,000 good reasons to be more self-concerned.

Dermatology News is proud to introduce the inaugural column of Cold Iron Truth by Dr. Brett Coldiron. Dr. Coldiron is a past president of the American Academy of Dermatology. He is currently in private practice, but maintains a clinical assistant professorship at the University of Cincinnati. He cares for patients, teaches medical students and residents, and has several active clinical research projects. Dr. Coldiron is the author of over 80 scientific letters, papers, and several book chapters, and he speaks frequently on a variety of topics.