6) Paying for Medical School

6.1) How expensive is medical school?
6.2) How can I pay for medical school?
6.3) Can you tell me about Armed Forces scholarships?
6.4) Can you tell me about Public Health Service scholarships?
6.5) Can I really borrow more than $10K/yr in Unsubsidized
Stafford Loans?

Subject: 6. Paying for Medical School

6.1) How expensive is medical school?

Very. According to the AAMC's Medical School Admissions
Requirements, the range of tuition and student fees for 1996-1997
first-year students was:

Range Median Mean
Private, Resident: 8,152-31,925 24,925 23,835
Private, Nonresident: 16,403-31,925 25,224 25,407
Public, Resident: 2,908-20,129 9,107 9,921
Public, Nonresident: 10,680-51,669 21,129 22,153

Keep in mind that these figures represent only tuition and
fees. Other expenses include room and board, books, equipment,
transportation, insurance, and personal expenses. In all, these
additional expenses can easily be up to $15,000 per year.

6.2) How can I pay for medical school?

The first consideration is to reduce your expenses. The less
expensive schools tend to be public schools within your state. If
you don't have a medical school in your state, you may be eligible
to attend other state schools as an in-state resident through an
exchange program such as WICHE, the Western Interstate Commission
for Higher Education, which allows students from Alaska, Montana,
and Wyoming to apply to and attend any western medical school as a
state resident (with the exception of the University of Washington).
Another major expense that can be reduced, if you qualify, is the
cost of application. Be sure to apply for an AMCAS fee waiver (if
you qualify), which can save you hundreds of dollars.

Unfortunately, reducing expenses still leaves, in most cases, tens
of thousands of dollars to pay. The most common way to pay this is
via loans, particularly federal Stafford loans and private
alternative loan programs. While some Stafford loans may be
subsidized (the government will pay the interest while you are in
school), there is a limit to the amount you can borrow. Other loan
programs are often offered by the various schools.

Grant aid (aid you don't have to repay) is not common. Most schools
offer a minimal amount of merit- and/or need-based grant aid. There
are also two programs that will cover the entire cost of school plus
give you a stipend. The first, the Medical Scientist Training
Program, is a highly competitive government-subsidized program
designed to recruit students interested in earning both an M.D. and
a Ph.D. The second, the Uniformed Services University of the Health
Sciences, is the military's medical school. In return for years of
service to the military, your education is paid for in addition to
your receiving a commission in the military and the concomitant
salary and benefits.

Another possibility for covering your expenses is to obligate
yourself to later service. Two examples of this type of program are
the Armed Forces HPSP and the Public Health Service program, both of
which provide payment for medical school in return for a commitment
to serve in either the military or in underserved public health
regions, respectively.

Finally, be sure to search the Web and other sources for private
scholarship sources. You may be eligible for free money or favorable
loans due to your extracurricular activities, ethnicity, religion,
heritage, or any number of other factors. Your school's financial aid
office will be happy to suggest sources to you as well as discuss means
of payment.

6.3) Can you tell me about Armed Forces scholarships?

The Armed Forces Health Professions Scholarship Program (HPSP) is a
scholarship between two to four years in length offered to students
in schools of medicine, osteopathic medicine, dentistry, and
optometry. HPSP students receive full tuition, school-related
expenses, and a stipend as benefits. The stipend is currently (as
of 8/98) around $912/month, paid in two parts on the 1st and 15th
days on each month by direct deposit. Expenses are reimbursed by
the submission on an itemized form with receipts and a signed
approval letter from your school stating that the expenses you claim
are reasonable ones for your curriculum; typically, most texts and
equipment (i.e., stethoscopes, lab coats) are paid without any fuss.
Tuition is paid directly to your school.

Basic requirements for the HPSP are that you are a U.S. citizen and
meet the qualifications for commissioning as a military officer.
There is an application and interview process which takes place at
about the same time as med school apps. (Of course, you do have to
actually get into med school in order to receive it.) The HPSP is
offered through the Navy, Army, and Air Force (the Marine Corps is
part of the Department of the Navy and is served by Naval docs, and
the Coast Guard is staffed by docs from the Public Health Service).

In return, you owe as many years of service to the military as you
received in support. Residency does not count towards this payback
time. What you actually wind up doing, of course, varies according
to your specialty; there isn't a huge need for pediatric
neurosurgery about the average aircraft carrier, for example.

What are the advantages to this little Faustian bargain? Well, for
starters, there are the financial benefits. The more frugal
students will emerge from med school debt-free, and those who live a
little higher on the hog will owe relatively small student loans.
Salary during residency is about $10,000/yr greater in the military
(in the neighborhood of $40,000 for interns, $50,000 for more senior
residents). Even post-residency, you won't starve; average
attending salaries vary by specialty, rank, and years of service,
but most wind up in the neighborhood of $100,000/yr as junior
attendings (typically O-4 in rank: a lieutenant commander in the
Navy, a major in the other two). You are automatically commissioned
as an O-1 while a med student (ensign in the Navy, 2nd lieutenant in
the other two) and are promoted to O-3 on graduation
(lieutenant/captain). There are some pretty entertaining places to
work in the military that you might not the chance to work near in
the future: Europe, Asia, and so forth. And of course, medicine is
medicine: patients can be much the same no matter where you work,
and in any case the majority of patients in the military system are
not actually active duty troops but retirees and dependents.
Benefits can be nice as well: 30 days paid vacation each year, no
overhead, and full medical/dental coverage.

Military residencies, by the way, are generally quite good. When
considering your training site come application time, you do want to
think about issues like patient volume, didactics, and so forth,
just as in any residency, but board pass rates for military
residency grads have been uniformly excellent, and people have
gotten into fine fellowships with minimal difficulty.
(Incidentally, if you do a civilian fellowship as an active duty
officer, the military will still pay you as an attending. Which is
pretty sweet.)

Now for the downside. You are sacrificing a few years of your life,
in a sense. Although a flexible mindset and a willingness to
compromise will help you get a good posting, not everyone in the
Navy gets to go to Italy or San Diego. Internship and residency are
relatively separate entities and require separate applications, not
only for fields like anesthesia but even for fields with categorical
internships like internal medicine or general surgery. Not only
that, there is a risk that you will have to spend a couple of years
away from training between your R-1 and R-2 years as a general
medical officer, or GMO. This risk is greatest in the Navy overall
but present in the Army and Air Force; it is also greater if you
plan on pursuing a more specialized field like neurosurgery or
anesthesia. Medicine, peds, and family med residents are more
likely to complete their training uninterrupted. GMO tours vary
between one to three years in length.

(A brief proviso on the whole GMO thing. An anesthesiology
attending at the National Naval Medical Center in Bethesda spent
three years as the medical officer aboard the USS Belknap in the
Mediterranean, and he loved it. After finishing his tour, he went
on to his residency at Mass General. So it's not the kiss of death.
Also, GMOs are a dying breed. The DoD is currently working out a
plan to abolish GMOs and staff those positions with
residency-trained docs. So stay tuned.)

The military is a startlingly bureaucratic organization which has
little ways of reminding you that it is, in fact, a branch of the
federal government. For physicians, though, military medicine is
actually not really different than working for a good HMO. Research
in military medicine is quite impressive, incidentally, although its
work is often very practical in orientation. There are good
research ties with the NIH and CDC, and most residencies are very
supportive of research (and may in fact require it of residents).

There are a certain number of people each year in the HPSP who defer
their commitment in order to do civilian residencies. The exact
number varies depending on the year, the specialty, and the needs of
the service. If you want to defer, it helps to have a good reason
(i.e., spouse's job) and to not be rude (e.g., "I want to defer
because military residencies are inferior").

If you want to postpone the decision about military service, there
is a financial assistance program (FAP) available to residents in
most specialties, wherein you get about $30,000/yr on top of your
civilian salary to repay loans (or buy a new car, possibly) in
exchange for an equivalent number of years of service.

6.4) Can you tell me about Public Health Service scholarships?

The Public Health Service offers a scholarship (The National Health
Service Corps,  http://bphc.hrsa.gov/nhsc/ http://bphc.hrsa.gov/nhsc/ ) paying full tuition,
books, and supplies, and a monthly stipend, with the following
requirements:

1) You must enter a primary care-type of residency (medicine,
family med, peds) or at least something that's close (OB/GYN,
psych), or a residency combining two of the above fields. A main
limitation is that the residency not take more than 3 or 4 years.
After serving your commitment you can undergo further medical
training (i.e., fellowships).

2) You must serve one year in a federally-designated underserved
area of your choice for each year the NHSC paid your tuition
(minimum two years), be it an inner city (30% of sites) or a rural
cow town (70% of sites).

3) As of December 1998, the IRS has deemed ALL parts of the NHSC
scholarship as taxable, including tuition. So, if you go to a
school that costs $28,000 per year, taxes will leave you with about
$350 from your monthly $950 stipend. The NHSC has been trying to
get Congress to reverse the IRS's reading of the law, but to no
avail as of yet.

There are similar programs available through various state
governments and the Indian Health Service, some funded by the NHSC.

Physicians who have completed training in a primary care field are
eligible for Public Health Service positions, with opportunities for
loan repayment. Some feel that this may be a better choice, as you
are not locked into a primary care field without first going through
your medical school rotations. See the NHSC web site for more
information.

6.5) Can I really borrow more than $10K/yr in Unsubsidized
Stafford Loans?

With the phaseout of the HEAL program at all schools, the Department
of Education has now authorized increased unsubsidized Stafford loan
limits for Health Professions Students. This limit is now $30K/yr.

The Student Financial Aid Handbook section detailing these limits
may be found at:
 http://ifap.ed.gov/sfahandbooks/attachments/0102Vol8Ch3loanperiodamts.pdf http://ifap.ed.gov/sfahandbooks/attachments/0102Vol8Ch3loanperiodamts.pdf .