Over the last two weeks, I have been engaged in an email discussion with a young woman who is trying to decide where to attend medical school. I shall call her Ms. X. Ms. X has been accepted to numerous schools and has narrowed her options to two: School 1 is a private school in Boston (not Harvard), and school 2 is a public school in suburban New York City in her home state of New York. While the private school in Boston is ranked slightly more highly than the public school in suburban New York City according to US News and World Report (not a terribly reliable source, but anyways…), the public school in suburban New York City ranks within about 20 slots in both the primary care and research categories. What is the not-so-surprising kicker? The annual tuition and fees at the private school in Boston is approximately $22k more than the public school in suburban New York City.
Choosing the private school in Boston over the public school in suburban New York city would cost Ms. X approximately $88k additional in tuition and fees alone over the 4 years of medical school, all other things being equal, which, of course, they are not because the cost of living in Boston is higher than in suburban New York City. For the sake of this discussion, let’s assume that the cost of living would be $3k more per year in Boston than in suburban New York City for a total of an even $100k difference over the 4 years of medical school. Ms. X has expressed one factor that is pulling her towards the public school in suburban New York City: cost. She has expressed two factors that are pulling her towards the private school in Boston: 1) ranking and 2) she really liked this school better. I gave Ms. X the same advice that I give every pre-med whom I meet: If you are paying for medical school yourself, then go to the least expensive school at which you get accepted. With Ms. X, though, I gave the advice more emphatically as Ms. X has stated time and again that she wants to go into primary care.
Why do I tell pre-meds to go to the least expensive school possible (i.e., if there is a large difference in cost between the schools from which they are choosing)? In my circuitous and protracted path from medical school graduation to family medicine residency completion, I have (admittedly anecdotally) observed that how one performs in medical school (and on USMLE exams) is much more important in landing a competitive residency than where one attended medical school (if anyone has empiric data or knows of published studies on this topic, then please let me know… a quick PubMed search didn’t turn up anything useful). Granted, a bottom-of-the-class student at Harvard will likely have more opportunities than a bottom-of-the-class student at a low-reputation (public or private) medical school, but the top students at nearly any school will likely have similar access to the most competitive residencies. It seems to be much more important HOW one does in medical school than WHERE one does it. And Ms. X is not the kind of person who will do poorly in medical school. This is why I don’t pay much heed to the differences in the US News rankings between Ms. X’s two options, aside from the fact that these two schools’ rankings are actually quite similar relatively speaking anyhow.
Regarding Ms. X’s liking the private school in Boston better than the public school in suburban New York City, only she can place a monetary value on that, but $100k is a lot of money, which brings me to my next point. If Ms. X is being honest with me, and I think that she is, then her dream is to be a primary care physician. We all know that primary care physicians don’t make the big bucks, and many of us have heard or read stories of would-be primary care physicians who ended up pursuing more highly-paying specialties largely because of their perceived inability to manage their medical school debt burden on a primary care salary.
Ms. X has been getting a lot of advice from orthopedic surgery residents whom she knows. Their consensus opinion is to go to the BEST medical school that she got into and that the money will take care of itself. While I’m not convinced that performing equally well at a slightly lesser-ranked medical school would close any doors, even for a would-be orthopedic surgeon, their vantage point is completely different from that of a would-be primary care physician. If your dream is to be an orthopedic surgeon where the competition for residency slots is fierce and where you will likely be making a lot of money when you are in practice, then maybe it’s worth $100k to go to a slightly more highly-ranked medical school to give you that tiny edge in achieving your dream. But if your dream is to be a primary care physician, then it seems to me that an additional $100k in debt would actually be a significant deterrent to achieving your dream.
Ms. X is an intelligent, thoughtful, and very motivated young woman. I have little doubt that she will make the decision that is best for her and achieve whatever she sets out to achieve. But medical school can be very expensive, and I believe that for anyone considering becoming a physician, it is important to consider one’s goal and how the cost of medical school might impact one reaching that goal before choosing a medical school.