The "hidden costs" of medical school—from Medical College Admission Test (MCAT) registration fees to travel expenses for interviews—can pose a barrier for non-white, low-income students who want to enter the profession, the New York Times reports.

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A national study from a decade ago found more than 75% of U.S. medical students came from families whose income put them in the top 40% of family income in the United States, which represents an annual income of more than $75,000. And over years, little has changed, according to the Times. The Association of American Medical Colleges last year published a new study examining medical school demographics and found more than 75% of U.S. medical students between 1988 and 2017 came from affluent households.

Why medical school is too costly for many low-income students

There are a number of reasons why a majority of medical students are from affluent and white families and very few come from low-income, non-white families, the Times reports.

For many low-income medical students, the process of applying to medical schools alone presents financial challenges. For example, medical school applicants have to pay a $315 registration fee for the MCAT, more than $200 on average for travel and attire for medical school interviews, $170 in application fees for their first medical school application, and $40 for each subsequent medical school applications, the Times reports.

David Velasquez is a third-year medical school student at Harvard Medical School who comes from a low-income community in Los Angeles. Velasquez said when he was preparing to take the MCAT, he called the Princeton Review to ask for a discount on its $1,200 preparation package.

Velasquez said he felt he would need a strong test score to compete for admissions because he came from a low-income community and had no connections.

But the company declined to offer him a discount. So, he worked overtime to save up for the package. After he bought it, he was left with $4.80 remaining in his bank account.

And even among those low-income students who can overcome the cost barriers to apply and gain admission to medical school, many are unprepared for the "hidden costs"—above and beyond the already high tuition prices—of their medical school education, the Times reports.

For instance, Shawn Johnson, who was born just outside Stockton, California, said these costs hit him as he started his classes. Johnson received an itemized list of all the equipment he had to purchase for his classes, including an ophthalmoscope and a stethoscope, which all totaled nearly $1,000.

Johnson's expenses did not end there, the Times reports. He also had to buy study aids, including a $499 subscription to UWorld, a $200 subscription to SketchyMedical's question bank, and a $40 First Aid review book. And then he had to cover the cost of test registrations, which included paying $630 for the United States Medical Licensing Exam Step 1, $1,290 for Step 2 Clinical Skills, and $630 for Step 2 Clinical Knowledge, the Times reports.

Johnson said he saw his classmates take out their credit cards to pay for the expenses as if "they were ordering something for $5 on eBay." But for him, the costs meant he had to make choices. Johnson said, "You have to decide, do you use your loans for a study aid or for a rainy-day fund in case someone at home gets sick? I haven't had dental insurance in two years. When tuna is on sale for 80 cents a can, I go buy 30 at CVS."

Other decisions he has had to make include deferring medical care for complications from a knee surgery because he could not afford to cover the hospital bill, subletting his apartment and sleeping on the medical school campus to send his parents money for a down payment on a home.

Johnson said, "There's this idea that because we'll all be doctors one day, the loans don't matter and it'll all even out. But that doesn't account for day-to-day expenses now, like if my mom texts me asking for help." Johnson said, "I have a Ph.D. in not having money. That's not easy to explain.”

Sarah Burns, a third-year student at Ohio State University College of Medicine, said she had to make similarly tough decisions. When she realized the registration fee for the Step 2 C.S. exam would be more than $1,200, she said she began to hyperventilate because she knew she would have to either ask her parents for help or she would be unable to pay her rent. On top of the registration costs, Burns said she would have to pay to travel to one of the five cities where the test is administered.

How the medical school costs limit options

Many low-income students feel the cost of medical school means they cannot to pursue lower-paying but possibly more fulfilling fields of the medicine, including family medicine, the Times reports. In many cases, once they are aware of all the attendant costs of medical school, these students begin to find higher-paying fields, such as plastic surgery, more appealing.

But many others still want to come back to their communities and serve lower-income, non-white patients.

Jose Calderon—a second-year medical student at the University of Vermont's Larner College of Medicine, who grew up without health insurance—said, "I want to show my community that it's possible to be a brown face in a white coat. That's empowering to the kid considering medicine in the slums of Houston or South Central Los Angeles" (Goldberg, New York Times, 11/26; Owens, "Vitals," Axios, 11/26; Rappleye, Becker's Hospital Review, 11/26).