I remember sitting at my desk in January 2020 preparing to budget my costs for the upcoming medical school application cycle starting in May 2020. Speaking with other friends who went through the process, I heard that I should budget a few thousand dollars for the application, flights, and hotels for the interview cycle. During that period, I worked as a research assistant at the NIH and was making roughly minimum wage. However, for better or worse, COVID-19 restricted interviews to being held virtually. While I had more difficulty getting a sense of each medical school without visiting in person, I was thankful I could at least save on interview travel costs.
Now, 3 years later, I'm preparing to apply for residency, and I am staggered by the costs of yet another application process. It poses an immense burden on us, as medical students, and perpetuates inequities in the medical field.
To apply for residency, medical students need to complete the United States Medical Licensing Examination (USMLE) Step 1 and Step 2, which cost $670 each (and even more for international medical graduate (IMG) students), and to my knowledge, no financial assistance program currently exists. For the application process, most medical students apply through Electronic Residency Application Service (ERAS), and fees vary depending on the number of applications as well as the number of specialties. Some applicants, including myself, will dual apply if they are applying to a competitive specialty to increase their chances of matching.
Based on 2024 fees, if an internal medicine applicant wanted to apply to 35 programs -- the average number of applications submitted by U.S. MD medical students in the 2024 cycle* -- it would cost them $734 ($654 ERAS fee + $80 USMLE transcript fee). However, applicants to more competitive specialties such as orthopedic surgery submit about 66 applications, on average, which costs $1,571 ($1,1491 ERAS fee + $80 USMLE transcript fee).
I tried looking up the cost breakdown for both USMLE step tests and ERAS application fees to see how much of the cost goes towards administering the USMLE step tests and ERAS application processing versus how much goes towards the USMLE and Association of American Medical Colleges (AAMC) as organizations, but I was not able to find clear numbers. While some students may be able to take on additional loans to cover the cost of USMLE tests and the application fees, they will still be responsible for the principal and interest fees. For those who are socioeconomically disadvantaged, the costs may be a factor in dictating the number of programs they apply to, which could potentially limit their opportunities for career advancement.
As an upcoming residency applicant, I factor the number of residency programs into my cost of applying. Currently, my specialty interests include neurology and psychiatry, and I will likely apply to the number that the average applicant does in those specialties. While the cost of applying to residency programs is expensive, I want to increase my chances of matching in a town where I would enjoy living and with programs that fit my interests.
I spoke with a few other medical school students who are dual applying, and they are also willing to spend whatever they have to in the hopes of at least matching somewhere because the cost of not matching and having to reapply is greater than applying once and submitting 70+ applications. However, some students literally may not be able to afford this option.
Furthermore, some specialties have "hidden" costs since they either require or highly recommend students do an away rotation before beginning residency. Away rotations costs include the application fee for the Visiting Student Learning Opportunities, rent, and living expenses. Many students still have ongoing leases near their home institution, so they have to pay rent in two different places.
The application process to become a doctor is unfavorable towards low-income students -- and this is very clearly reflected in both the medical student and residency populations.
Many factors lead to the low percentage of low-income students in medical schools, such as limited resources for academic preparation, financial barriers to pursuing higher education, and disparities in opportunities for extracurricular activities and experiences that strengthen medical school applications. About 50% of medical students belong to the top quintile of households (≥$130,000 in 2019), and about 24% of medical students belong to the top 5% (≥$248,728 in 2019). The U.S. median household income in 2019 was $68,703. Only about 5% of medical students were in the lowest household income quintile ($25,600 or below in 2019), and these students disproportionately identify as Black or Hispanic.
Growing up with low socioeconomic status is correlated with a lower likelihood of a student getting accepted into medical school. One study found that applicants reporting a childhood household income less than $50,000 were 48% less likely to be accepted compared to those who had a childhood household income of $200,000 or greater. Residency programs benefit from a diverse cohort of students, whose unique backgrounds and perspectives enhance patient care, foster innovation, and contribute to a more equitable healthcare system.
Starting in the 2024-2025 cycle, ERAS is launching a 60% ERAS application discount for qualifying students and restructuring its fee schedule to help reduce costs. While this is helpful to offset financial barriers, it's still not enough.
The AAMC has a fee assistance program to help prospective medical students pay for the Medical College Admission Test (MCAT) and the American Medical College Application Service (AMCAS). The National Board of Medical Examiners should also have financial assistance programs to reduce the cost of taking the USMLE step exams. Some specialties use a different platform to apply for residency (e.g. ResidencyCAS for ob/gyn; SF Match for ophthalmology and plastic surgery), and I urge them to offer financial assistance programs as well.
By addressing the high costs of applying to medical residency, and promoting equity and excellence within the medical profession, we can create a more inclusive and equitable healthcare system for all.
*The average number varies for IMG or U.S. DO medical students. Additionally, U.S. DO medical students also need to pay $80 for COMPLEX USA scores for ERAS.
Andrea Zhang is a fourth-year medical student at the University of Miami Miller School of Medicine in the MD/MPH Program.