Debt and the Oncology Fellow 

A Conversation with Matthew Lunning, DO

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[Oncology] is a great field. You can make a difference in the lives of cancer patients daily. So the debt is worth the trip, but you need to be prepared to manage it.

—Matthew Lunning, DO

Despite today’s challenging economy, health care is one field that offers vast career opportunities. Oncology, with the impending workforce shortage, is especially eager for bright young doctors to join its ranks. But the rising costs of medical school can be a deterrent, leading the best and brightest to pursue other career paths. According to the Association of American Medical Colleges, the median annual cost for tuition is more than $32,000 at public medical schools and more than $50,000 at private institutions. Adding the costs of textbooks, equipment, room, board, and travel, it can bring the cost of a 4-year education to more than $300,000.

The ASCO Post recently spoke with Matthew Lunning, DO, a hematology-oncology fellow at Memorial Sloan-Kettering Cancer Center, about the financial stresses faced by today’s young oncologists.

Career Path

Please tell us about any early experiences that helped shape your career.

I’m from Mason City, a relatively small town in northern Iowa. During the summer break after my freshman year at college, I was introduced to oncology by doing clinical trial data collection at our local cancer center.

By pure serendipity, Dr. Gerald Marti from the National Institutes of Health (NIH) was visiting our cancer center. Prodded by one of the center’s oncologists, I approached Dr. Marti with an idea for a paper I intended to write. Impressed by my initiative and enthusiasm about oncology, he invited me to the NIH to work in his lab doing research on chronic lymphocytic leukemia (CLL).

As an undergrad I spent three summers at NIH, which not only helped my odds of getting into medical school, but also solidified my resolve to become an oncologist. Coming from a state with one allopathic and one osteopathic school, the competition is fierce. I studied at Des Moines University, an osteopathic medical school. It was a terrific experience, but since it was a private medical school, I incurred considerable debt upon graduation.

Debt at the End of the Tunnel

Was the prospect of debt something that worried you going into medicine?

It’s a thought that is always there. I came from a middle-class family. Both of my parents worked hard, but money was often an issue. They fell into the income conundrum of making enough to exclude us from government subsidies, but not enough to be able to help with the burden of medical school tuition and all the extras, which are considerable.

Medical school is so challenging that you tend to postpone worrying about what’s going to happen after you graduate until you actually do. I knew my debt would be significant at the end of the medical school tunnel, but I wanted to become an oncologist, so I just swallowed that fact and moved ahead.

But debt is a reality. More than 50% of medical students graduate looking at an excess of $150,000 in loan payments. In my case, I was lucky in that when I came out of medical school I had the ability to consolidate the majority of my federal loans at 2.85%. The current rates for some loans may be up to 6.8%. So a 30-year note for $200,000 at current interest rates—that seems like a long road, especially when you’re watching the balance grow during periods of forbearance.

Impact of Debt

As a young oncologist, what were your main concerns about how debt would affect your life and career?

First and foremost for me, it is how it may affect your ability to purchase a home straight out of training. Since I entered medical school, and on through training, the housing sector has undergone a huge change. However, the American Dream has not changed; it still begins with the opportunity to own a home to rear your family in. But debt can become an obstacle to attaining that dream.

In banking terms, your front-end and your back-end status determine your ability to secure a mortgage. In other words, when you sit down with a mortgage officer, they will look at your salary as an oncology fellow or a new attending (front-end), then look at your student debt and other financial commitments (back-end). Recently, evolving regulations after the Fanny Mae/Freddy Mac bust have led to strict lending algorithms, which may make it difficult to get a conventional loan.

Here’s an example of the change. I bought a house 7 years ago, before the crash. I simply went to the bank with a promissory letter explaining that I was going to make an intern’s salary at University of Nebraska Medical Center and got a home mortgage. Today, after nearly completing my fellowship, not accruing further sizable debt, and seeing a higher income within reach, I would be put into an algorithm that now would deny me that same mortgage loan. So I would be forced to pursue a more unconventional route.

I don’t think that this dilemma is on the radar of fellows who are about to begin their careers. Or if it is, it’s a taboo subject that no one’s willing to talk about. I have not been able to sort out which one it is. But it’s something that needs more attention and perhaps even education.

Future Plans

How does debt affect your future plans as a young oncologist?

I have a wife and three children. My wife and I met in medical school, but we decided a two-doctor family was not for us, so she left school to be at home to help raise our kids—a sacrifice I will be eternally grateful for. After my fellowship is complete at Memorial Sloan-Kettering, we’re moving back home, otherwise known as Nebraska, where I’ll be an assistant professor at the University of Nebraska Medical Center. I’ve had a great learning experience at Memorial, and I’m confident that will serve me well as I move into the next phase of my career. Needless to say, the cost-of-living is much lower in the Midwest.

I’m fortunate to have a good financial advisor who helps put things in perspective. I look at it metaphorically. An oncologist is like a cancer drug in development. A significant amount of money is required in the early stages of development, and the safety profile and effectiveness are untested. You get answers to the above questions as the drug graduates through the clinical trial pipeline and hopefully out into the market as an approved drug.

A new oncologist, like a recently approved cancer drug, has to earn enough to repay the investment (in undergraduate and medical school) and earn enough profit to make the education worthwhile. Profit in this context is not just money; it’s the productiveness of the career.

Going from being an oncology fellow at Memorial Sloan-Kettering to an assistant professor at the University of Nebraska Medical Center, I see myself in an aggressive debt reduction phase. I now realize that if you don’t put your finances into a workable equation, it could potentially frustrate your view of the future.

Closing Thoughts

Any closing thoughts on debt and oncology?

It is well vetted that we have an aging population and an impending shortage of oncologists. I wonder whether increasing amounts of debt may poison a decision to become a future oncologist. At least for now, I think oncology has immunity. It has a special allure that draws in the brightest minds that see opportunity for improvement in the ever-evolving oncologic landscape, but are humbled by the sheer impact cancer has on our population. It is a great field. You can make a difference in the lives of cancer patients daily. So the debt is worth the trip, but you need to be prepared to manage it. ■

Disclosure: Dr. Lunning reported no potential conflicts of interest.