Holly Nath, M.D., who recently completed her ob/gyn residency at U-M, wrote the following personal account of the aftermath of the September 11 attack on the World Trade Center to Timothy R. B. Johnson, M.D. (Residency 1979), chair of the Department of Obstetrics and Gynecology. Holly's husband, Pravene, is a 1999 graduate of the U-M Medical School finishing his emergency medicine residency at Bellevue Hospital in New York City. The Naths graciously gave Medicine at Michigan permission to reprint the account here.

Dear TJ,

I've been thinking of you all and miss everyone at U-M. Pravene and I are safe and healthy. I wanted to give you an update and share with you what's been going on here these past few days. We are in the thick of things and are still pretty raw and overwhelmed.

It all started for us Tuesday morning when Pravene heard on National Public Radio that there was an explosion in the north tower of the World Trade Center. He saw smoke billowing from a huge gash in the tower as he looked out on the Center from our balcony. Like all ER docs from Bellevue anytime there's a major event or accident in the city, he put on his scrubs and headed to the ER. Before leaving the apartment, he stepped onto the balcony again to have one last look and while looking south, he saw the second plane hit and then the huge bright orange and red flames. He couldn't believe his eyes — it was too unbelievable, so bright and brilliant and clear, like a cartoon. It was then he realized it was not an accident. En route to the ER he called me at work and told me there was an explosion. I was in the midst of giving MTX to one of my patients with an ectopic. I looked out the window of my office on 32nd Street, which has a beautiful unobstructed view of the World Trade Center, and saw the smoke from both buildings.

This is Pravene's account of Tuesday's events in the ER:

"As I walked to work, smoke billowed from the southwest side of the city over to the East River. Everyone knew something was wrong, but many had not yet seen or heard the details. People were still trying to carry out their business.

"I spent the morning in the Bellevue Emergency Department along with hundreds of other health care providers. The entire emergency room was cleared of all patients. Our disaster plan was implemented, and we had a surprisingly well-organized group. Eight full trauma teams headed by chief residents and attending surgeons were assembled and standing in triage. Twelve emergency medicine attendings were on duty, along with at least fifteen residents from our department and scores of other house staff and medical students. Miraculously, supplies were mobilized and placed in the emergency department. I have no idea from where they came. Endo-tracheal tubes, saline bottles, suture kits and everything in-between were stacked in boxes.

"The NYPD had set up its command post in Bellevue, standard emergency procedure for even small incidents in the city. Our morning conference room became the command station, filled with administrators, detectives, police and fire commanders, telephones, computers and lots of other high-tech equipment Bellevue doesn't normally have. Police surrounded the building. All clinics were closed. The emergency room was closed to walk-in patients. No one without hospital or police identification could enter the hospital. People seemed to understand.

"We waited. Slowly they trickled in. A few traumas, lots of walking wounded. One fireman who could not be resuscitated. But only a trickle.

"I was sent home in the early afternoon, to remain fresh and return for the 'second wave' that evening. I bought food in a crowded grocery store and waited in a long line to get cash from an ATM. A sheet of paper hung in the window of the Chase Manhattan Bank branch on 40th Street and 3rd Avenue that read 'Emergency Closing!'

"There was no panic. Thousands of people were walking north on each avenue, quietly. Some were covered in soot. Cell phones were not working. People waited in line for pay phones, most of which I had never seen used before.

"I tried to sleep in the afternoon, expecting a long night ahead. I couldn't, so I listened sometimes to the news, sometimes to the sirens. Holly returned from work early, and we spent some time together. Shortly after 5:00 p.m., we both headed for the Bellevue Emergency Department.

Candlelight vigil, U-M Diag, September 11, 2001
Photo: Martin Vloet

"Unfortunately, the scene was the same as it had been earlier. I was assigned with two interns and an attending to 'side three,' essentially one-third of the acute emergency department which includes the suture room. Plenty of staff, not enough patients. Holly walked around, ready to help. One patient, a fatigued rescue worker, arrived during the first two hours. I discharged a 56-year-old woman who had been cared for earlier. She worked on the 72nd floor of the north tower and walked down the stairs to safety after the building was hit. Her triage blood pressure was 192/112. We treated a fireman for conjunctival irritation, the most common problem related to the dust exposure. He had been off that day and reported to the scene later where he found that his company had been one of the first to respond. All of his coworkers were trapped inside during the building collapse.

"We cried when a medical student brought in a photo-graph given to her by a woman outside the hospital. The woman was looking for her husband who worked on the 104th floor of one of the towers. We didn't know what to do with the photograph, so we posted it on the wall. This was our first exposure to what has now become a common sight.

"A few hours later, we were once again sent home. There was little to do, and the place was overstaffed. I was to return to NYU Hospital Emergency Department the following morning at 8:00 a.m.

"The streets were closed. Police were guarding every intersection. Sirens echoed everywhere. We watched the news and tried to sleep. It was hard. We felt useless at work and guilty at home."

On Wednesday, I went to work to cover L&D. It was hard to get into the hospital because of the tight security, also there were lines of hundreds of New Yorkers waiting to donate blood. The medical examiner's office is on the premises of our hospital, and so First Avenue was closed because refrigerated trucks with bodies were lined up outside of the medical examiner's office. Unlike the crowded medical examiner's building, the ER and ambulance bay at Bellevue and NYU were deserted. Pravene was called in and went with a medical team down to 'ground zero.' He spent the afternoon down there. When he came home Wednesday night he was covered with soot and really had no words, just tears. He could not describe the scene. He's still having a tough time. The devastation is horrific — body parts, dust, papers, concrete and steel, body bags. No patients to treat. No survivors. We all feel so helpless, as there is no one to treat or take care of.

Our apartment is in the midst of craziness — we're four blocks from the United Nations building and four blocks from Grand Central Station, both of which have had bomb threats and evacuations during the last few days. The UN has a one-block perimeter around it with police, military vehicles, and bomb-sniffing dogs. Our street is closed and filled with police. Five blocks south all of First Avenue is still closed because they need to be able to bring the big freezer trucks carrying bodies to the morgue which is part of NYU. There's always a long line of weeping families in front of the NYU morgue looking for information about their missing loved ones. Lots of pictures hanging on the hospital from family members looking for loved ones. It's really tough around here still. The sirens are non-stop. It is not clear when we will be able to reclaim our city or some normalcy.

That's all for now. Please let people know that we are safe and well. I'd like to give a big hug to everyone in this tough time.

Love,

Holly

The Case for Scholarship Support

Initially, upon reading Dean Lichter's comments about the debt load of recent medical grads (Spring 2001), I was shocked, but after reflection I realized that the main change in the 43 years since my graduation has been in the value of the dollar, which has decreased by a factor of about 10.

I was able to survive as a student on about $2,000 per year, or about $8,000 for the four years. Tuition, as I remember it, was about $900 per year. The most expensive textbook that I bought was Pilsbury's Dermatology, for the huge cost of $16.

As an intern I was paid the princely salary of $300 per month. On entering small-town general practice with an established doctor, I was paid about $10,000 per year, more by quite a bit than I really earned. He celebrated the coming of a new associate (me) by raising the fee for the routine office visit from $3 to $4. My wife and I were able to rent a nice new house for $90 per month. That first year saw our fifth wedding anniversary, and we dined at Lansing's finest restaurant — steak and all the trimmings and tip for under $5. A new car, had we been able to afford it, might have cost $2,000.

Now, if each of those figures is multiplied by 10 for inflation, we are not far from the averages quoted by Dr. Lichter. That new grad will have $100,000 debt, will be paid in excess of $100,000, and, if in family practice will charge $40 for the routine call. The new car will cost $20,000. When will it stop? Probably never. In another 40 years, the new grad will owe $1,000,000.

Thomas F. Higby
(M.D. 1958)
Fowlerville, Michigan

Dean Lichter replies:

Inflation, unfortunately, does not account for the enormous debt that must be assumed by many of today's graduating medical students. I asked University of Michigan economist Saul Hymans, one of the nation's best-known economic forecasters, to explain why. Here is his answer:

"If it really were the case that inflation alone explained the higher costs of attending medical school, that might mean that the average family of today could afford the current tuition to the same degree that the average family of 40 years ago could afford the tuition of $550 at that time. From 1960 to 2000, after-tax income per person in the U.S. has gone up from $2,026 to $25,400, a factor of 12.5. If Medical School tuition now were $6,875 ($550 x 12.5), the average person today could afford to pay the tuition out of current income to the same degree as the average person of 1960. But tuition today is not $6,875; it's $18,760! (Current in-state tuition is $18,760; non-resident tuition is $28,814.)

"Here's another way to look at it. The average price level for all consumer goods and services (the CPI) was 172.2 in 2000; the 1960 CPI was 29.6. So the average price level has gone up by a factor of 5.8, which amounts to an average inflation rate of 4.5 percent from 1960 to 2000. If Medical School tuition had risen at this average rate of inflation, it would have gone from $550 to just about $3,200. But going from $550 to $18,760 implies a tuition inflation rate of 9.2 percent per year, not 4.5 percent.

"The better way to look at it is the income way, not the price way. Basically, people used to pay about a quarter of their after-tax income for tuition; today they pay three-quarters of their after-tax income for tuition!"

Thus one has to interpret the change in tuition as a huge increase, far beyond what inflation could ever account for. It explains why tuition that was affordable for the average family in 1960 is not affordable today. It explains why students must assume enormous debt in pursuit of their dreams.

Key points regarding a student's ability to repay a loan include, of course, the loan interest rate and the student's salary. Many students, too, one has to remember, are entering medical school with substantial debt accumulated during their undergraduate years.

Currently, under the federal Stafford loan program, students are charged six percent interest annually. The cap is 8.5 percent. (Under the Stafford program, students can borrow $8,500 per year interest-free until graduation. They can borrow up to $36,667 per year under the Stafford program, but the loan amount above $8,500 begins accruing interest immediately.)

Assuming no undergraduate debt, how fast can the student who graduates from medical school with $100,000 of debt, the average at Michigan currently, repay his or her debt?

Residents currently earn about $34,000 per year with slight increases over the course of their residency, which amounts to an after-tax income of about $25,000 during those years. The interest alone on their debts will be about $6,000 the first year. So, beginning to repay the debt during the three to seven years of residency while maintaining a household is very difficult if not impossible.

Graduating from medical school with a huge debt burden creates financial pressures that make it difficult for physicians to choose rural over urban practice, to choose family practice over higher-paying specialties. It makes it difficult for certain highly talented individuals with limited resources to even consider medicine as a profession.

We alumni who benefited so greatly from attending a tax-supported public university can help ease the burden on these young people who have chosen to follow us into one of the most rewarding and demanding of all professions.

President Lee Bollinger, at the spring honors convocation earlier this year, summarized beautifully the sense of obligation we all, as graduates of a public university, must assume: "Each of you has achieved something quite special, and you, accordingly, deserve our congratulations and admiration. But it would be a mistake to think either that you did it alone, on your own, without the contributions of others, or that the system, the institution within which you have achieved these successes is without meaning for you. You have been provided with the opportunity to do well, and now you must think about how, over a lifetime, you can return the favor, and help others to do well, too."