The Outrageous Cost of Finishing Medical Training

Riya Shah was unprepared. The fourth-year medical student at Wayne State University in Detroit already spent more than $2000 on her residency application and the additional costs just kept piling up: registration fees, transcript fees, away rotation applications. 

She knew applying to residency was expensive, but no one made it clear just how much money it would take. With interviews in full swing, soon she’d have to figure out if she could afford a trip to visit at least one of the programs on her rank list. 

“I want a job,” Shah told Medscape Medical News, “but no other…job in the modern world requires you to pay…$2000 dollars up front just to apply. And you’re not even guaranteed the position.” 

Fourth-year medical students, like Shah, are halfway through the extremely expensive process of applying to a medical residency. 

They will spend thousands of dollars on exams, application fees, away rotations, and interview travel in hopes of securing a training spot in their dream specialty. In years past, students aiming for the most competitive specialties have reported as much as $10,000 in costs. They have no choice but to take out additional student loans, private loans, or even credit card debt to fund their candidacy. 

It’s an unacceptable predicament. And this year, it’s sent a ripple of reforms through the medical education community. Specialties such as ob/gyn have broken away to create their own lower-cost application. The Association of American Medical Colleges (AAMC) has restructured is application fees and added more financial aid. All eyes are on the 2024-2025 application cycle to see if they succeed at cutting costs. Early reports show application expenses are trending down — but maybe not enough. 

A Costly Dream 

Residency application costs start with the United States Medical Licensing Examination (USMLE) Step 1 and Step 2 exams. The two board exams cost $670 each, and more if you’re an international medical student. Most students take the second board in the summer before their fourth year.

Then, in the last week of September, the AAMC opens its Electronic Residency Application Service (ERAS). In years past, the first 10 applications cost $99. The next 10 were $19 each. Applications 21 through 30 were $23, and every application after 30 was $27. 

Cedric Mutebi, MD, a first-year internal medicine resident at Northwestern Medical School in Chicago, spent $1500 applying to 60 programs in 2024 — a few more than average because he was trying to couples match. And that’s for a less competitive specialty where everyone gets a spot, he emphasized. 

Meanwhile, Ashton Amos, DO, a first-year surgical resident at West Virginia University applied to well over 100 programs in 2024 and spent several thousand dollars in fees. 

“As a DO, we have to apply to more programs because not every place is as accepting of DOs,” Amos said. The highly competitive nature of surgical specialty and the fact that she also was trying to couples match significantly added to her number of applications, she said. 

Although there have always been costs to apply to residency, the amount students were spending on the application portion really started to skyrocket 8 years ago, said Gabrielle Campbell, chief services officer at the AAMC. 

Ninety-three percent of students match, but the residents applying still outnumber the available spots. Students are afraid of not matching, afraid they won’t be able to finish training and pay off impending medical debt, Campbell said. So, to cover their bases, they started applying to more programs. And year after year, each class of applicants felt the need to out-apply the class before them. 

“A lot people [ahead of you] would say this is not the time to save money. This is your future. Apply to more,” Fabian Jimenez, MD, a third-year thoracic surgery resident at the University of Florida, said. “It became an arms race of who could apply to the most places, go on the most interviews.” 

Double Rent and Mandated Travel

Although application costs are exorbitant, they certainly aren’t the end of residency expenses. 

On top of paper applications, students pursuing the most competitive specialties must pay for away rotations. Away rotations serve as a sort of residency audition. Students go to an institution where they one day hope to match and spend a month or so rotating as a sub-intern. 

You’re trying to “showcase your skills, talent, and belonging,” Michael Megafu, DO, an orthopedic surgery resident at the University of Connecticut, said. Three to four away rotations are recommended, but Megafu did six. He had to cover short-term housing and living expenses at all six placements.

“You’re paying double rent during that time, and everything costs more because you don’t have anything,” Amos, who did five away rotations, said. And sometimes the hosting institution requires additional tuition and malpractice coverage. 

Then, in October, interviews start. One silver lining is that COVID-19 normalized virtual interviews, said Alyx Porter Umphrey, MD, a neurooncologist at Mayo Clinic in Arizona and co-founder of ElevateMed, a nonprofit that provides mentorship and scholarship to fourth-year residents from underrepresented backgrounds. 

Several specialties, such as internal medicine, ob/gyn, and ophthalmology, have agreed to virtual-only interviews to promote equity. But some specialties and programs that have reverted to in-person interviews. These on-site visits often give programs and candidates a better chance to interact, but they leave students on the hook for flight costs and sometimes lodging. Depending on location and the number of interviews a candidate takes, expenses can mount quickly. 

Tack on $80 transcript fees here, a $70 match registration there, and $15 dollars for every away rotation application and extra fees for couples matching: “It feels like you get nickeled and dimed across the process,” Mutebi at Northwestern said. 

Essential Reform

The exorbitant cost of application season exacerbates existing inequities, clearly favoring students from financially privileged backgrounds who can pay for the many additional applications and travel to every offered interview.

The AAMC has come under scrutiny for allowing high costs to continue and profiting off of the sharp rise in application numbers. According to Campbell, the fees pay for a number of medical student services, such as the technology behind ERAS, information security, the Residency Explorer tool, and the Careers in Medicine Program. Still, student advocates argue that with soaring application numbers, AAMC had more than enough margin within its $120 million annual revenue to lower costs before 2024. 

This year, the American College of Obstetricians and Gynecologists took matters into its own hands and launched an ob/gyn-specific application system called ResidencyCAS. Through the platform, students interested in ob/gyn can apply to their first 18 programs for $99, then $18 for every additional application. Preliminary data showed that 100% of ob/gyn programs switched to ResidencyCAS in its inaugural year. And in early October, Emergency medicine announced it would follow suit and partner with ResidencyCAS to build its own application platform for 2025-2026. 

The AAMC also made some significant application changes for the 2024-2025 cycle. They offered new cost structure: $11 per application for the first 35 applications. Then the fee goes up to $30. The organization hopes this will be more affordable and limit the number of applications students submit. AAMC also expanded fee assistance in 2024 to 4100 people who will get 60% off up to 50 applications. 

On top of new pricing structures, students are seeing cost savings this cycle thanks to program signaling. A strategy used by both ERAS and ResidencyCAS, program signaling gives students a set number of signals they can use to let a program know it’s one of their top choices.

The number of signals varies by specialty. Dermatology gives students three gold signals and 25 silver signals. Orthopedics allows 30 signals, and radiation oncology offers four. Because data shows programs are more likely to interview candidates that signal them, signals are expected to drive down application numbers. Early data from both ERAS and ResidencyCAS show a significant decrease in applications per student for many specialties, especially those offering more signals. 

Dermatology saw one of the largest decreases, with 2024 applicants submitting 42% fewer applications on average compared with 2022 — an estimated savings of $949, according to AAMC. 

After Megafu in Connecticut saw data that only 1% of unsignaled applications yielded an interview in orthopedics, he was able to cut his number of applications by two thirds, he said. He applied to 30 programs he could signal, plus an additional 10. “Instead of 120 [programs], I was able to apply to 40,” he said. That’s an estimated cost savings of almost $2400. 

Although applications per student are trending downward compared with years past, there’s still room for progress. Students are still applying to far more programs than they can signal even though unsignaled applications have a very low rate of success. 

As for Shah, she’s pleased with the number of interviews she received and grateful they were all virtual. Because the “hidden costs” that keep popping up are exhausting, she said. She’s adamant that students shouldn’t have to take on this kind of pressure and debt just to finish their training. 

“There needs to be actionable change,” she said.