COVID and Med Ed Cost: Are Future Docs Paying More for Less?

Emily Sohn

October 30, 2020

Like most medical students, Kaitlyn Thomas's education was abruptly interrupted by the pandemic. Her school, an osteopathic medicine institution in the Midwest, followed guidelines issued by the American Association of Medical Colleges (AAMC) in March, shifting lectures online and suspending activities in which students interacted with patients. But even as Thomas's learning opportunities dwindled for the sake of safety, the costs kept piling up.

Instead of going home to live with her family, she stayed in her apartment near school — and kept paying rent — so she could be nearby for the two licensing exams she was scheduled to take 3 months later. Both tests were canceled 9 days before she was scheduled to take them, one without any notification. This meant she had to travel to two different testing sites in two different states. All told, she says, the whole thing cost her around $2000.

Thomas's experience isn't rare. Across the country, medical students find themselves paying substantial costs for a medical education now greatly altered by the pandemic. Despite restrictions on time spent in hospitals, hands-on learning, social events, and access to libraries, gyms, study spaces, and instructors, the price of tuition hasn't dropped but has remained the same or has even risen.

In response, students have become vocal about the return on their pricey investment. "Am I just going to end up doing most of my year online, and what does that look like for my future patients?" Thomas asks. "It really doesn't feel like a time to be limiting education."

Medical schools and administrators are scrambling to find creative solutions for safely educating students. No matter what those solutions may be, experts say, the pandemic has drawn fresh attention to enduring questions about how the cost of medical education compares to its value. Although many are frustrated, some see the potential for COVID to open new opportunities for lasting innovation. At the very least, the pandemic has sparked conversations about what matters most in terms of producing qualified physicians.

"While this is a challenging time, we will get through it, and we will continue to educate doctors, and we will get them through to practice," says Robert Cain, president and CEO of the American Association of Colleges of Osteopathic Medicine (AACOM). Many in the midst of training still have one lingering question: Is the price future doctors are now paying still worth it?

COVID's "Hidden Costs" for Students

Tom is a third-year student at an allopathic medicine institution in the Carribean. He asked not to be fully identified here, owing to concern about possible backlash. In March, Tom was doing clinical rotations in New York City when his training was put on hold. He returned home to Connecticut and resumed working 60 to 80 hours a week as a paramedic. As much as 75% of that income went to pay for the New York City apartment he was no longer living in — an apartment that cost more than $2000 a month — and for student loans that suddenly came due when his enrollment status changed.

Tom has been able to take some online courses through his school. But he still doesn't know whether state licensing boards will accept them, how residency programs will view them, or whether he will eventually have to retake those online classes in person. At the end of September, he was allowed to return to the hospital but was relocated to Chicago and was forced to move on short notice.

Like many students, Tom has worried that the pandemic may prevent him from acquiring crucial elements for his residency applications, things like letters of recommendation or key experiences. That could delay his next stage of training, which would mean lost future income, increasing student loan interest, and lost work experience. "This could also mean the difference between getting a residency and being able to practice medicine and not being able to practice my intended specialty," he says. "This is the real hidden cost we may have to deal with."

International medical students hoping to practice in the United States face additional costs. Michelle Warncke earned her bachelor's degree in America but went to the United Kingdom for her master's and her medical degree, which she completed in 2019. She then moved to North Carolina with her husband and saved money to take the exams she needed for residency in the states. But her scheduled Step 2 CS exam was canceled because of the pandemic. Now, like hundreds or even thousands of other students, she says she is unable to apply for residency, even as her student loans collect interest. An active Facebook group of international medical graduates includes about 1500 people with comparable dilemmas, she says.

The path to becoming a physician carries a well-known price tag, one that is already quite high. Now, for many, that price is substantially increasing. "The only way I can actually keep my medical credentials up to date and passable, to be able to ever get a shot at a residency in the following years," she says, "is to move to another country and work for less pay, pay for a visa, pay for my exams, pay for my language test, and wait and hope that I might be able to as an older graduate then be able to apply for residency."

Scaling Back the Price of Med School?

Questions about the economics of medical education aren't new, says David Asch, MD, MBA, an internal medicine physician and executive director of the Center for Health Care Innovation at the University of Pennsylvania in Philadelphia. But the changes forced by COVID could lead to innovations that may finally better balance the financial scales.

Such innovations are necessary, many say, given how medical education costs have skyrocketed over the past half century. In the 1960s, 4 years of medical school cost about $40,000 in today's dollars, Asch and colleagues wrote in a 2020 analysis, which they conducted before the pandemic began. By 2018, the price of a medical education in the United States had ballooned to about $300,000. About 75% of students were taking out loans. Upon graduating, the average debt was $200,000.

Medical school is expensive for many tangible reasons, Asch says. Schools must pay for curriculum, faculty, technology, textbooks, lab materials, facilities, administrators, and more. But policy changes could decrease those costs.

He says one idea would be for medical schools to join forces and give students access to the same basic lectures in the early years, delivered online by top-notch instructors. Students could then participate in on-campus programs that might only require 3 years to complete instead of 4. By demonstrating what can be done via online platforms, he says, the pandemic might pave the way to permanent changes that could reduce costs.

"I'm not trying to pick on biochemistry professors and medical schools, but how many do we need in the country?" Asch asks. "We're all watching the same episode of Seinfeld. Why can't we all watch the same episode of the Krebs cycle?" If all 190 or so medical schools in the United States shared such preclinical courses, he says, each would require a fraction of the current cost to produce. "We could save 99.5% of the cost. So why don't we do that?"

Pandemic as Opportunity

Although the price of medical education has yet to decrease, schools are working to leverage the pandemic to provide increased educational value.

This generation of physicians will not only have to cope with the fallout of this pandemic, they will be the ones responsible for confronting the next pandemic as well, says Donald Brady, MD, senior associate dean for health sciences education at Vanderbilt University School of Medicine in Nashville, Tennessee. "They will be the leaders in the future who will better be able to know how to handle it [a pandemic] because they were able to watch it and be part of it safely in the current circumstance."

As much as possible, Vanderbilt is using the pandemic as an opportunity. As soon as it became clear that students couldn't be involved in certain hands-on training, instructors developed a course about pandemics that included lectures on ethics, global health, systemic racism, and other topics. It also included experiential components of pandemic management, such as opportunities to work with patients through telehealth.

Students say they feel that they are getting less for their money and that they are paying for experiences that are no longer available, such as hands-on patient contact and community events. However, Brady says, schools have had to account for new expenses, including various now-required technologies and transitioning to courses online.

Some challenges can't be solved with money alone. Medical schools across the country are working together to ensure that they are still adequately preparing students. Vanderbilt participates in an AAMC group that meets regularly and is also one of 37 institutions involved in an American Medical Association Consortium (AACOM). These groups discuss challenges, strategies, and opportunities for optimizing medical education during the pandemic.

Some institutions have come up with creative solutions. Ohio University's Heritage College of Osteopathic Medicine, in Athens, Ohio, in collaboration with the Ohio Department of Health, launched a 4-week rotation for third-year students that focuses on public health. Harvard Medical School, in Boston, Massachusetts, was one of several schools that allowed students to graduate early in the spring. "We're constantly talking to our colleagues and friends," Brady says. "We learn from each other. There's a lot of sharing going on."

Other organizations are also working to make sure students ultimately get what they are paying for: a high-quality education. As soon as the pandemic began, the AACOM organized four working groups to address how schools could better use technology to deliver curricula and how students could participate in public health efforts, among other topics. "For the students, the part they don't see and can't really be aware of is all the things that happen behind the scenes," Cain says. "People were working really hard to make sure that their education was still delivered, and delivered in a way that was going to assure a good product at the end."

Ultimately, that product will be held to a rigid standard, says Geoffrey Young, the AAMC's senior director for student affairs and programs. Medical schools must still meet standards of competency set by the liaison committee on medical education. Young says that even now, those standards remain rigorous enough to ensure that medical students are learning what they need to know. "The core elements for competency may be slightly altered to address the realities that we're experiencing because of COVID, but the core tenants of competencies will not change," he says.

Even as conversations continue about what a medical education is worth, the pandemic is drawing new attention to the profession. No signs suggest that the value of tuition or a shift to more virtual offerings are scaring students away. Applications for medical schools were up 17% for the fall of 2021.

Brady expects the surge in interest to continue. "The increased focus and emphasis on public health, the increased focus and emphasis on health equity, the increased focus on the need for a more diverse physician workforce, the interest in basic science research around viruses, the interest in COVID itself ― there are a lot of different elements that are setting us up for a potential boom in applications to medical school," he says.

Beyond increasing interest, the pandemic may also finally force a reckoning on the disconnection between how schools think about costs and how students think about value, the University of Pennyslvania's Asch says. "When students say, 'I'm not getting as much from this,' they're saying, 'You should price this according to its lower value.' And when the medical schools are saying, 'Oh, but it's costing us so much more,' they're talking about pricing according to the cost. It's like one group is speaking Latin and the other group is speaking Greek." Perhaps, he says, COVID-related changes will finally get them speaking the same language.

Do you think your medical education was worth the cost? Tell us what you think in the comments.

Emily Sohn is a freelance journalist in Minneapolis. Her stories have appeared in the New York Times, the Washington Post, Nature, National Geographic, and many other publications. She can be reached on Twitter @tidepoolsinc. For more news, follow Medscape on Facebook, Twitter, Instagram, and YouTube.

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