The Health Divide: The cost of a medical education is changing who can afford to become a doctor

Yosef Berlyand had $263,000 in medical school debt when he graduated in 2019. He has scrupulously made loan payments since then. With accumulated interest, he now owes $271,000.

The stress of bearing so much debt weighs heavily on Berlyand, an assistant professor of emergency medicine at Brown University and an attending emergency physician at Rhode Island Hospital in Providence. But that’s not why he and a college friend who’s also now a debt-saddled physician published an essay in JAMA this month, calling for reforms in the cost and financing of medical education.

“Physician incomes are certainly, by all societal standards, very high,” he told me. “I can’t possibly complain. What worries me is that the cost of becoming a physician is starting to turn people away from the profession altogether.”

Ballooning education costs are not the only challenge, write Berlyand and Vihang Nakhate, a neuro-oncologist at the Dana-Farber Cancer Institute in Boston. Young people considering a career in medicine face ever-changing federal student loan rules and years of training after medical school. Meanwhile, physician incomes are largely stagnant and the cost of living keeps going up. “The medical profession risks losing a generation of promising talent,” Berlyand and Nakhate write.

There’s growing evidence that medicine especially risks losing talent from poor and working-class families, and Black and Latino communities. That loss will hit the most vulnerable patients hardest.

The average price tag for four years of medical school plus the prerequisite college degree was about $371,000 last year, more than double the cost 20 years ago. At some private schools, the cost can approach a half million dollars. Simply applying to medical school can run up thousands of dollars in bills for all-important test preparation courses and exam fees, application fees and travel for interviews.

About 71% of medical school graduates in 2024 carried educational debt. Half of the borrowers owed more than $200,000. The federal mega-spending bill passed last year caps federal borrowing for medical students at $50,000 a year and $200,000 total. That could force a majority of aspiring physicians to take out high-interest private loans to cover the gap.

Numbers like these appear to be limiting who can become a doctor, what specialty they choose and where they might practice. That, in turn, has troubling implications for the quality of care that low-income patients, patients of color and rural patients receive — if they receive care at all.

Medical school enrollment hit an all-time high last year, with more than 100,000 students. But a growing share of applicants and students come from families earning $200,000 a year or more, while a declining share come from families earning less than $75,000, according to a 2023 study. Applicants from the lowest-income families were half as likely to be accepted to medical school as those from the most affluent ones. 

Meanwhile, in 2024-25, the first academic year after the Supreme Court banned schools from considering race in admissions, medical schools enrolled significantly fewer Black, Latino and Native American students. 

These groups are already underrepresented in the medical profession. Eroding diversity further is bad news for communities that need medical care most.

Decades of research have shown that Black and Latino doctors, and physicians who are the first generation in their families to graduate from college, are more likely to become primary care physicians and serve low-income patients, immigrants and rural communities. These communities already struggle with a higher risk of illness and death, and a shortage of health care providers.

People tend to seek more preventive care, trust their doctor more, and follow through on treatment more consistently when the doctor shares their racial or ethnic background. One study even found that having more Black primary care providers in a county was associated with longer life expectancy and lower death rates among Black patients. 

On average, doctors in front-line medicine — pediatrics, public health, or family medicine, for example — earn less than half as much as those in top-paying specialties like orthopedic surgery and radiology. The U.S. has a shortage of doctors in many specialties but it’s hardly surprising that the gap is greatest for primary care.

Berlyand and Nakhate say that when they were considering applying to medical school more than a decade ago, mentors and veteran physicians urged them not to worry about the cost. Now such advice strikes them as hollow. Monthly loan payments begin when medical school ends, though graduates spend years afterward earning modest salaries in residency programs and fellowships.

Berlyand took out three loans to pay for Harvard Medical School. Each had different interest rates, payment structures, and monthly due dates. 

Most of the money came from a federal loan with a complex plan in which monthly payments increase as income does. These plans are popular among medical students because payments remain low during residency. But those low payments don’t fully cover interest, so it piles up and increases the balance even as the borrower makes every loan payment.

That’s why Berlyand has more debt today than when he graduated. His payments now run around $3,000 a month.

Like many physicians, he has been counting on the Public Service Loan Forgiveness program to relieve his debt burden after he makes payments for 10 years. The program erases debt for people who have qualified student loans and are employed by the government or a not-for-profit or tax-exempt institution such as a hospital.

Now he sees some politicians pushing to cut back or eliminate the forgiveness program. That worries him. So do the changes the Trump administration is making to federal student loan programs, which restructure and consolidate payment plans, with harsher terms for borrowers with high incomes and a lot of debt.

Berlyand and Nakhate say health care leaders must take action on costs. More medical schools might follow the lead of the few that now waive tuition for most or all medical students. 

The Johns Hopkins University School of Medicine, for example, covers tuition for medical students whose families earn less than $300,000 and also covers living expenses and fees for families earning less than $175,000. The NYU Grossman School of Medicine covers tuition for everyone admitted to its M.D. program.

Berlyand and Nakhate also would like to see simpler, more affordable loan programs and initiatives to streamline medical education and training without sacrificing rigor. For example, universities could find ways to combine undergraduate and medical degree programs. 

I asked both men if they regret going into medicine, given the debt they shoulder.

“No, no, no,” Nakhate said. “I think it’s truly a privilege to be able to practice medicine.”

“I don't regret going into medicine,” Berlyand said. “I love what I do for a living.”

But, he added, “I don’t know what decisions I would make if I was facing the current cost landscape.”