Student Loans: Modern Indentured Servitude

When it comes to my finances, everything else besides paying off my student loans seems trivial. I mean, I am attending physician. We have no shortage of money to survive on.

Nonetheless, 6 years out from my medical school graduation, almost half of my after tax income goes to servicing my student loans. Indeed, I might have quite medicine altogether after my daughter died if not for my student loans

Given that our finances provide more than enough for a comfortable life, all other financial decisions take a back seat to my student debt. Pretty much anything I forego financially is because of student loans.

My student loans are financial and emotional albatross that weigh on me constantly, even when I am not consciously thinking about them. Currently, I am an indentured servant to the medical profession. The debt changes the relationship physicians have with their chosen calling.

Debt is a trap, especially student debt, which is enormous, far larger than credit card debt. It’s a trap for the rest of your life because the laws are designed so that you can’t get out of it. If a business, say, gets in too much debt, it can declare bankruptcy, but individuals can almost never be relieved of student debt through bankruptcy.
-Noam Chomsky

The Long Road to Freedom

I prioritize paying off my debt above all other significant expenses. This has led to some significant improvement in my student loan balance. This has tracked about like this:

Graduate from medical school: ~$285,000 principal + interest.

6 months later, interest capitalized: $330,000 principal.

Finished residency: $330,000 principal+$65,000 interest=$395,000.

Currently, almost 3 years out from residency graduation: $188,000 principal+$30,000 interest= $218,000.

So, progress is being made. On the other hand, it comes at a cost. I have avoided contributing to the economy in significant ways because of my debt.

Some are basic consumer activities which I am more than happy to forestall. These include buying newer cars, new furniture, etc. These thing bring me little to no happiness, so foregoing them is not a sacrifice. The economy might miss those purchases some, but relatively little.

These, on the other hand, are significant:

  1. Saving for retirement: Back when I was employed (W-2), I took advantage of my employer’s match and maxed out my 403b. However, now with SEP-IRA which has no match, I still contribute, but at a much lower rate than maxing out (partially because the max is so high relative to my income (>50,000). The 6.5% guaranteed return on my debt is hard to dismiss.
  2. Home ownership: we tried this, got lightly burned. We will probably rent for a total of 3-4 more years before we try and buy another house. Another significant investment in the economy delayed.
  3. Pursuing activities other than working and finances. I have to focus a great deal of time and energy on paying down debt. So much so, it sometimes feels like I am in debt residency. I read about finances, scheme on ways to increase my debt payments, etc. Sometimes, it leads to neglecting other parts of my life.

Who Cares?

A reasonable response to my hand wringing over my debt is, indeed, “Who Cares?” I am in no way living in destitution. I will, in the next 2-3 years be able to pay off my debt entirely without any real deprivation (we live on about $90k/year for a family of 3 – very comfortable).

Additionally, one could point out I went to medical school knowing what it would cost and was not forced to accept loans in exchange for education. This is also true.

Moreover, what will likely end up being a total $500,000 investment will have moved me from a childhood of living on about $50-70,000/year in today’s dollars with a family of 5 to 4-5x times that income/year. I was never going to be an investment banker, tech entrepreneur, or engineer, so it is unlikely I would have made that jump in income any other way.

If you feel these things, that is totally legitimate. I do not need anyone’s pity for my financial situation, but you might want to stop reading now.

On the other hand, if this affects a privileged actor in the economy such as I, imagine how it holds the lives of less privileged students hostage.

Paying to Play in the Modern Economy

This plays out in the broader economy. We have placed increasingly expensive layers of education in between poverty and opportunity.

This is key.

The increasing cost of education and student loans, in particular, have made opportunity only available to the wealthy and those willing to live a good portion of their lives in indentured servitude.

I want to emphasize this point: for a huge number of students the price for the access to opportunity can only be paid with student loans. They do not represent an investment with a guaranteed return, but the only the opportunity to collect.

On top of this, unlike almost any other business debt, educational debt is non-cancellable. For example, I know someone who started medical school. Her mother got cancer when she was in medical school. She was able to finish, but with great difficulty and still has not been able to start residency. But her debt keeps accumulating interest….

In any other business situation, if you took out a loan to invest in a business and something terrible happened, you could declare bankruptcy and at least get back to zero. Educational debt just sits there, continuing to accrue interest despite your inability to collect on the investment….for the rest of your life.

Medical Schools Hold Abnormal Bargaining Power

Medical schools have disproportionate power when negotiating with potential clients (students). They are the gate keepers to a prestigious and historically wealthy profession.

What bargaining power do individual students have?

The average age of beginning medical students is 23 years old. Many of them have spent close to a decade striving towards medical school admission. Every physician they know has taken on loans to become a physician, so who is going to say no?

Are the risks of being unable to repay your loans explained to first year medical students before they sign on the dotted line?

I think not, because medical schools don’t care.

As long as medical students graduate, they don’t care about their debt. They just want all four years of loan payments.

It is inaccurate to say medical students really understand what they are getting into when they accept loans. For instance, I think few understand the cost of the interest compounding while they are in residency.

Moreover, no first year medical student knows how long they will be in residency. So, it is literally impossible to know what the cost will end up being when beginning medical school.

However, no student agreeing to take on loans can understand how the yoke of student loan payments will make them feel. The way it might weigh on their lives for 10-20 years. That can only be experienced and doesn’t have a cost measured in dollars.

Still, most physicians with discipline, and some luck, can pay off the loans relatively quickly.

Student Debt will have Long Term Effects

Beyond the specifics of my or any physician’s experience is the reality of student debt becoming a giant drag on the overall economy.

As a society, we are trading a large prolonged stimulus to the higher education sector in exchange for a significant drags on future productivity and consumption.

Moreover, we have provided the education sector with a way to be almost completely cost insensitive. In the days when state and federal dollars made of the bulk of their budgets, public universities had to be cost sensitive. Now, they just increase income from students, almost overwhelmingly from student debt.

We expect the most financially vulnerable of our population (young students) to enter into lifetime binding contracts with these institutions.

Meanwhile, where are they getting most of their financial advice?

From these institutions themselves, whose main goal is to keep up their class sizes. They certainly don’t have the long term financial health of their students as their primary concern.

We have yoked an entire generation with the personal responsibility for our penchant for deficit spending.

Back to My Indentured Servitude

A colleague of mine who paid off his student loans with hard work and sacrifice told me, “I am so glad I did, it has completely changed my feeling about practicing medicine.”

He gave voice to what a lot of young physicians know: their ability to get creative, tack risks in business, and try and improve the healthcare system is hamstrung by the need to get out of massive debt.

The Hospital-Pharmaceutical Complex has been very adept at exploiting this as a way to keep a churning stream of physicians willing trade their profession for escape from financial bondage.

As for myself, we are yet to see if it turns out to be worthwhile investment. I could have been earning income and saving for retirement since my mid-late 20s instead of accruing debt. It largely depends on how long I work as a physician.

Luckily, I have found a practice arrangement that I can imagine working in for quite a while. The freedom to take a couple of months off from a particular working environment has greatly extended my working life.

2 years ago I was thinking about trying to FIRE like so many physicians and possibly switch to a non-clinical job in the process. Now, as long as I get my debt paid off soon, I can imagine a reasonably lengthy time career as a physician.

However, not all physicians are so lucky, and most non-physicians don’t have anywhere near the options physicians.

In Praise of Collegiality

Working in small emergency departments without any local back up often demands “phoning a friend,” so to speak. I encounter patients who present with findings and disease processes with which I am unfamiliar.

One warm Fall day, I got called in for a kid injured at football practice. Tom was a 16 year old who was hit head on (axially) in a football game. On exam, he had complete numbness and significant weakness in all four extremities.

Strangely, this was only from about 3 inches above the knees and elbows down (not a well recognized anatomic distribution).

Moreover, his CTs were totally normal. I had no surgeons on site, and the MRI is only available 1-2x/week. My next move was in no way obvious.

My questions almost always stem from the vagaries of practicing medicine in the real world and in resource-limited settings. Those limitations often mean the algorithms only get me so far.

On the other hand, I can only imagine how difficult it would be to practice Critical Access Medicine without uptodate and other electronic resources. Thank God for the internet.

So, I phoned a friend.

With Tom, I called the closest Children’s Hospital, I talked to Neurology first who felt he needed an emergent MRI. The neurologist was thorough and business-like. Then, I was routed to the Peds ED Doc, who was similarly helpful and gave me recommendations of immobilization and transfer.

They admitted him to their Neurotrauma ICU, and he made a full recovery without intervention. Diagnosis: Transient quadriplegia, or aka cervical cord neurapraxia. This was a first for me.

This was a neutral phone consult. I get the information I need to help the patient and we expedite his care. Generally, the physician’s at the Children’s Hospital are more civil than most.

In fact, a Peds ED consultant is to date the only accepting physician to tell me I did a good job. The patient was a pediatric DKA. By the time I called, I had fluid resuscitated the patient, the insulin drip was going, and a bag of D10 with 40 mEq of KCL was y-ed in to allow for titration on the 2 hour transfer ride based on POCT glucose testing.

This was the first time since residency a fellow physician had told me I did a good job with the clinical care of a patient. I am not particularly dependent on praise (honestly probably much less so than the average millennial). Nonetheless, it felt damn good.

I was surprised how good I felt being told I had handle a complicated case well. It made me realize how rarely we get positive feedback from our colleagues. And, if I am honest, how rarely we give it.

How much more pleasant would our days be if we battled a dysfunctional and inhumane system with our colleagues rather than in spite or even because of them?

The Normal Experience

Ruminating on my surprise reaction to a little bit of positive feedback, I started to think about my usual experience. After a time, I realized the marker I now use for knowing I did good a job with a transfer is the absence of snark.

If all I get from a hospitalist after I give the report of a patient is a begrudging, “Ok,” I know I have done a good job in setting up a patient for transport.

John’s Story

For instance, John, a 65 year old man with diabetes who had been struggling with recurrent infections of a diabetic wound on an old amputation site came into my emergency department the other day.

Three days prior he stopped his latest round of oral antibiotics. The wound had increased purulent discharge, pain, and surrounding redness. I looked into the putrid hole at the end of his leg, clearly infected.

Moreover, His blood pressures are soft, he was mildly tachycardic and febrile.

“Likely early sepsis,” I thought to myself, a lactate of 2.9 quickly confirms my suspicions. I order a wound culture and blood cultures, fluids, and antibiotics.

After examining the surrounding area, I took a sterile probe and inserted into deep into the wound. It slid past the slimily infected tissue and felt the sure, soft thud of bone at the end of the probe.

“Shit,” I think, “No way infection isn’t in his bone”

“John,” I start, “I think we need to get an X-ray (MRI is of course not available today) to look for infection in the bone.”

The techs wheel him off to X-ray.

Sitting in the reading room, I (the humble ED doc) can clearly see the lytic lesions at the of the bone indicating infection, and the likely need for surgery. My nurse starts the antibiotics and I call a hospitalist at a referral hospital.

I get the hospitalist on the phone. I run through his story ticking off all the important information: Vitals, lactate, white count all point to early sepsis with a clinically infected wound. X-ray showing acute osteomyelitis – he will need a surgeon and long term IV antibiotics.

I detail the care I have already given the patient. I feel he is stable for transfer. Moreover, John and his family requested transfer to the this specific hospital (multiple hospitals are effectively equidistant for transfer).

On the other end, I hear a long pause. Then, the quiet, begrudging, “Ok, we’ll take him.” Those are the last words he speaks to me, switching to addressing the operator to arrange bed placement.

I apparently don’t even merit a good-bye.

The sad thing is, I now interpret this kind of interaction as evidence that I have done a good job. No snarky comments, no prolonged questions and second guessing, no arguments as to why going to some other facility or service would be better.

And I felt good about it. I had won in the battle to deny him any reason to do any of the above.

That is how low my general expectations for civility have sunk when talking to another physician. Moreover, this is a physician with whom I am technically collaborating on the care of shared patient.

Civility is the Grease of Teamwork

Now, the art of the long distance phone consult is a delicate one. I don’t always nail it perfectly. Walking the line of giving someone all the information he/she needs while still making a coherent narrative of why you need his/her help is often difficult.

To boot, my phone call is almost always interrupting some other work the consultant is attempting to accomplish.

Furthermore, as physicians, we all work in high stress environments where it can be difficult to find a moment to focus on the problem at hand. We all have bad days, I get it.

I talk to all sorts of consultants – board certified ED docs in a large trauma center, Peds ED docs, surgeons, OB/GYNs, cardiologists, stroke neurologists, or hospitalists and intensivists for transfers.

I need all kinds of help out here on the High Lonesome.

In particular, hospitalists at large referral centers are slammed with work which is often effectively clerical. I.E., admitting a pre-op hip fracture patient so that Ortho can focus on more important (ahem, profitable) endeavors.

I know civility is rarely at the top of our lists. Nonetheless, I think we as a profession are forgetting or have already forgotten the importance of civility and collegiality.

Afterall, we are all in the game of trying to help sick people, together.

If I am uncivil to a nurse who is caring for a patient of mine, he/she will avoid calling me. If that patient crumps when we could have avoided the situation, I need to take some responsibility for that outcome. 

Civility and collegiality are the social tools we have to reframe our interactions from oppositional to collaborative. Without them, our profession splinters and we are all little Lone Rangers fighting our own pitched battles day in and day out.

So, I for one am going to try and put a little more civility back into my interactions. It costs me nothing, and I have found more often than not, it pays dividends over the course of the conversation.

And, most importantly, my patients get better care when their physicians collaborate with, instead of battle against, each other.

Back to Work

I haven’t posted in a while. Not surprisingly, I have been somewhat occupied. Our new baby requires plenty of work, time, and love. Blogging hasn’t seemed all the important in comparison.

However, I am back on the High Lonesome, which brings with it periods of down time. This time is ripe for blogging.

Being back in the doctor’s role is an interesting transition from new father. Especially, after all the struggle over the last year and a half.

A Baby Brings Perspective

In some ways, I have a newfound acceptance of the failings of medical culture. All the pettiness, greed, and self-importance of many of the actors in a hospital are easier to tolerate, because the reason I show up is so much more important now.

Sometimes the work is its own reward. The times when I actually connect with a patient can sustain me – for a time. The rare critically ill patient who my team triages, treats, and transfers effectively can boost morale and help add meaning to the work.

Nonetheless, the reality is, most of any profession or job is mundane. Having a reason to go to work outside of paying off of my loans and funding my own diversions adds meaning to the mundane – especially when you are paid by the hour.

Knowing that my daughter is home and depends on me adds a certain nobility to the simple paycheck. It helps put a little shine back on the tarnished image medicine has for me.

Yet, on the first day of returning to work at one of my frequent work locations, I end up in my first meeting in over a year. Somehow, we are now having meetings….as locums.

I was scheduled to work and the ED wasn’t busy, so it didn’t turn out to be a big deal.

Of course, the main action item of this meeting was how to improve our billing and reimbursement. After only 3 years in practice, I am almost positive no other kind of meeting exists in healthcare.

This one specifically focused on improving critical care and procedure billing.

Good to be Back!

Other than this inauspicious start, the first day of the shift went fairly well. Going back to a familiar site was a good call for a first shift back. Weirdly, I seemed to actually enjoy being in the hospital.

The hospital had changed the way the local docs rounded in the hospital. This had actually improved communication and the nurses were asking me less questions about patients whom I didn’t know.

Finally, a change whose goal was improving patient care that delivered some results.

The first two patient’s were turfs from clinic for a DVT rule out and a CHF exacerbation. I quickly and efficiently ruled out the DVT. The CHF patient was known to me so the work up and admission to the hospital ended up being fairly straightforward.

Having wrapped up this work, I noticed a lull had set in. I went to the doctor’s quarters in a nearby house to rest and put some space between me and the hospital (it always seems to make the shifts go quicker). I felt good.

Watching some Netflix and making dinner, I waited to be called in. Around 11 pm, I got a call. An ambulance was out for someone who was found down and unresponsive.

An Actual Emergency

I find this chief complaint to be one of the most varied in actual cause. Benzodiazepine overdose, DKA, patient already deceased, sepsis, vasovagal episode, seizure – it could be practically anything.

In small low acuity EDs it tends towards the more mundane. Nonetheless, I headed back the ED and arrived right as the patient was being wheeled into the ED bay.

I recognize her immediately. She is a chronic respiratory disaster.

At 57, She already has end-stage COPD with multiple intubations in the last 12 months. This is, of course, coupled with right-sided heart failure. Shockingly, her kidneys are okay.

Her family has been told multiple times she may never come off the ventilator and she always has – so they now think she always will.

I know her to be angrily, vehemently, and obstinately FULL CODE, despite her terrible chronic disease and inability to care for herself at home.

She has had repeated blood transfusions for anemia which is of unknown source because her respiratory status is too tenuous for endoscopy. Not surprisingly – she also has terrible veins and recently finished a prolonged course of IV antibiotics through a PICC line (which I noticed sadly had already been removed).

“Oh, Shit,” I think to myself.

I look at her on the gurney. She is on a nonrebreathing oxygen mask. Oxygen is actually reading in the high 90s – remarkably good for her. But you can hear her audibly wheezing. Her chest heaves almost off the bed as she breathes in, and then her breath just slowly leaks out.

Her GCS is 3. Yelling, sternal rubs, nail bed pressure – nothing.

Getting to Work

We all get to work. An intraosseus line is placed in one leg – she gives no indication of being aware of a needle being drilled into her tibia. The nurses draw blood and send it to lab.

We give her narcan – she is on a large number of narcotic pain medications. Again no change.

I have the team set up for her intubation as her oxygen levels are starting to drop. Positioning myself at the head of the bed the intubation kit lays ready. I tell the nurse to push the anesthetic, then the anxiolytic, and finally the paralytic. She stops breathing.

Opening her mouth, I slide the laryngoscope into her mouth, visualize the cords, and slide a number eight endotracheal tube into her trachea.

We secure the tube, verify correct position, and begin to breath for her. All in all, it goes pretty well. The chest X-ray shows pulmonary edema, possible infiltrate, ET tube in good position.

Her labs come back, possible sepsis, blood gas shows a PCO2 of 124 prior to intubation. Methamphetamines in her urine. We start sepsis and influenza anti-infectives, give steroids, and get her ready to transport to ICU.

All in all, from arrival to transfer, we do this all in less than 3 hours. Not bad for a family doc in a two-bed emergency department 100 miles from the closest trauma center. Also, it is snowing, so the helicopters won’t fly – she has to go by ground, of course.

The Thrill of Being Present

As she leaves in the ambulance. I am feeling pretty good, alive. We just saved a life – for now. I just spent three hours completely engrossed in something pretty amazing – working as a team with people who gave a shit on something important. It can be intoxicating in small doses.

I like critical care. I like obstetrics (though I don’t deliver babies non-emergently anymore). What I love is the focus on the task at hand. The power of a small group of people fully engrossed in what is happening in that very instant can be amazing.

Both critical care and obstetrics demand this kind of focus. We should all strive for that kind of focus in all aspects of our practice. Sadly, this is difficult given the seemingly coordinated effort to destroy it going on around us.

The High Fades

After a rest and a drink a water, I walk back to get some sleep – it is 2:30 AM after-all. On the walk, I can’t help but feel a tension between the excitement of caring for a critical patient and the ethics of how we spend healthcare dollars in this country.

How many intubations is too many for one person? Is it ethical to repeatedly intubate and, God forbid, actually code someone who lives on death’s doorstep every day?

Does one person have a right to unlimited medical expenditures to prolong their life? How many childhood vaccinations could that cover? How many addiction treatments, or early parenthood interventions could we pay for?

The methamphetamine in her urine and her 3 different narcotic prescriptions are evidence of a life of great suffering. That suffering predated her current illness. Indeed, the smoking and drug use which caused it were likely attempts to numb that suffering for decades.

Is it ethical because these are the patient’s stated wishes? Or are we just hiding behind a weak patient autonomy argument so we don’t have to wrestle the suffering we witness – and prolong.

The things we do to save a life, needles drilled through bone, tubes into bladders and lungs. It would be torture in any other situation.

I feel guilty about how excited I was afterwards – even though I saved her life. I also kind of feel guilty about that…

When is it too much? When is continuing to torture someone to keep them alive, and suffering, unethical – even if they demand you do it?

Are these even questions we can ask in American Healthcare?

Recognition

A week later I get an email from our new ED medical director:

“Doctor HP,

Great job with the care of patient #1234567 in the ED last week. Your documentation of the intubation and critical care time was excellent!

Sincerely,

Your Medical Director”

I sit back and sigh, good to back working again….