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If you are anything like me, despite working incredibly hard, not getting paid adequately for many years, and accumulating an incredible amount of debt, you could not imagine any other career.
Christopher Dittus, DO, MPH
If you are anything like me, you are sitting on the couch staring at your laptop with Disney Junior on the television and a rambunctious toddler running from his room to the couch banging on a tambourine. You know that you have an article to write, or a chapter in your ASCO-SEP to read, but you realize that these will probably have to wait until you get back to work on Monday. Unfortunately, if you are similar to me, you are also the proud owner of an ever-increasing collection of student debt. You likely have an array of different types of debt (unsubsidized, subsidized, private, consolidated), each processed by a different company, and these debts may even be transferred to other companies yearly just to complicate things. Additionally, you have probably felt a certain amount of guilt about possessing debt. However, despite the difficulties of managing and dealing with debt, there is hope.
My particularly large amount of debt has accrued through a series of events. First, I attended a private medical college. Second, I did so in the Northeast, where everything costs more, including tuition, rent, utilities, food, and other day-to-day items. With little outside financial support, and a wife in law school, I first had to take out private loans, then Grad PLUS loans, in order to have enough money for living expenses.
Once I completed medical school and started my residency, I quickly realized that living in Manhattan on an intern’s salary did not leave me a lot of income to put toward repaying my debt. To avoid making payments, I put my student loans into forbearance, meaning that I could avoid paying any interest or fees. The downside was that interest would continue to accrue and compound. Near the end of my second year, my daughter was born. This meant that we needed a nanny and a bigger apartment— and there was absolutely no way I could begin to pay off my debt.
After completing a year as chief resident, I started fellowship. Shortly thereafter, my son was born. Fellowship in Boston again meant a high cost of living (now with 2 children), with only a nominal increase in salary. I continued to put my loans into forbearance and primarily focused on providing supplemental income to pay for the rising costs associated with child rearing. Although it is still demanding, fellowship offers more elective time, particularly in the second and third years. I began moonlighting at the Boston Veterans Administration (VA) in the emergency department midway through my second year of fellowship. At this point, I had finished the majority of my inpatient rotations and had fewer weekend calls and tumor board presentations than I had during my first year of fellowship. By working two, 9-hour shifts per month at the VA, I was able to increase my income by roughly 25%. Additionally, modest honoraria provided for writing magazine articles helped fill the gaps from time to time.
As I started to look forward to my career as an oncologist, I was confronted by how I would repay my student debt, yet still provide for a comfortable lifestyle for my family. Initially, I planned to go into private practice, which was primarily a financial decision since my passion was for academic medicine. As my fellowship progressed, I realized that I did not want to hedge on my career goals. I decided that I would pursue academic malignant hematology and, if need be, make other concessions in order to achieve this endpoint.
First, I knew I would have to relocate. According to the 2016 version of the Medscape Oncologist Compensation Report,1 the Northeast has the lowest compensation rates compared with the rest of the country. Additionally, the cost of living is greater in the Northeast than in most other regions, particularly if you live near one of the larger cities. Consequently, and after a great deal of research, I accepted a position at the University of North Carolina at Chapel Hill. This allowed me to pursue my interest in academic malignant hematology while living in a lower-cost region with improved physician compensation. Importantly, if you are interested in buying a home, you should be aware that many banks offer a Physician Mortgage Loan, which has the benefit of giving physicians with extensive debt and limited funds the opportunity to obtain a mortgage with 100% financing and favorable terms. Pursuing this type of mortgage has allowed me to purchase my first home with relatively little money in my savings account. Most banks also require a very good credit score, so you should ensure that you pay your credit card bills promptly and maintain a reasonable balance throughout training.
Second, I had to address my debt directly. Since my income:debt ratio was not favorable, I looked into income-based repayment. The first, and most important, website I reviewed was the Federal Student Aid website, which is administered by the US Department of Education (www.studentloans.gov/myDirectLoan/ index.action#). They offer several repayment plans with payments that are calculated based on income; if you qualify for these plans, they can substantially decrease your monthly payments. This allows you to pay down your debt slowly and still maintain a comfortable lifestyle. The interest rate is generally favorable, so it would be prudent to pay off nongovernment debt (private loans, credit cards) more aggressively. It should also be noted that federal government loans are forgiven after 20 or 25 years of regular payments (depending on the payment plan),2 so choosing to pay down your federal student debt slowly will not necessarily mean you will pay more in the long run.
Additionally, the fact that 12 of my 13 loans can be consolidated into one monthly payment makes this a convenient option.
Finally, if you are interested in either basic or clinical research, you should be aware of the Loan Repayment Programs offered by the National Institutes of Health (NIH) (www.lrp.nih.gov/eligibilityprograms# programs). These programs are aimed at decreasing the loan burden of physicians who choose to pursue a research career.3 If you apply and are accepted, you can have up to $35,000 of your qualified educational debt paid annually by the NIH. For new physicians who are concerned that a career in academics is associated with lower compensation, this may help offset some of the financial burden of a lower- paying position.
If you are anything like me, despite working incredibly hard, not getting paid adequately for many years, and accumulating an incredible amount of debt, you could not imagine any other career. You should remember to pursue your exact medical career goals and not allow your finances and debt to dictate your level of happiness. By taking certain measures (see Sidebar), you can have a great job, spend time with your family, and live comfortably, despite having substantial student debt.