Advice needed: MD in bad location but good $$ VS expensive MD in great city

abcdeffedcba

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Hello,
I've been lurking around pre-allo for a while. I would love any advice/suggestions SDNers have on making my school decisions.

I'm a CA resident, and hoping to return to practice in CA. My life goal is to work for the medically underserved because I came from such backgrounds. I THINK I want to do primary care (OBGYN, family, or ped) because I like the idea of working with people over long periods of time.

I will graduate undergrad with 0 debt and 50k from working and saving throughout high school and college. However, money is still a big problem for me.

I have two MD acceptances to choose from: UTHSCSA and Mt. Sinai. One is cheaper but is far from family, and the other more expensive but may be easier for me to eventually move back to CA. I don't believe in USW Rankings. But if it matters to you then UTHSCA and Sinai are similarly ranked for primary care, but Sinai is out of this world for research.

I listed the pros and cons that I can think of for both schools below. Are any of these assumptions wrong? What are your suggestions? If you had to make this choice before, how did you come to a decision?

UTHSCSA:
pros:
14k/year + low cost of living
near border of US-- very interesting underserved population to work with

cons:
no ties to SA, far from home (CA)
Difficult to get residency in CA

Mt. Sinai:
pros:
NYC
more highly-regarded school
P/F

cons:
35k/year + extremely high cost of living
 
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darkjedi

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Wouldn't Sinai be even further from home?

If you truly believe that primary care/undeserved communities is where your career path will go. Going cheaper might be better. Rankings for primary care are effectively worthless, far more so than the research ones. I wouldn't pay any mind to those.

You can also try taking to the financial aid offices to see if they might be willing to match as well.
 

abcdeffedcba

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Wouldn't Sinai be even further from home?

If you truly believe that primary care/undeserved communities is where your career path will go. Going cheaper might be better. Rankings for primary care are effectively worthless, far more so than the research ones. I wouldn't pay any mind to those.

You can also try taking to the financial aid offices to see if they might be willing to match as well.
Far from home in terms of travel time. There are many direct flights from NYC to CA, but none from SA to CA.

I have heard of asking medical schools to match other school's offer. The reason that UTHSCA only costs $14k for me is because the school awards a $1000 scholarship that allows any OOS to have in-state tuition. So technically this $1000 scholarship is worth $14k/year, but officially it's only worth $1000. So I guess my confusion is: do schools match other school's scholarship amount or other school's COA?
 
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mehc012

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Are you planning on doing rural/underserved primary care? That may end up changing the equation a bit.
 

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I would take UTHSCA. In looking at the big picture, since you want rural, underserved community, you can search for those jobs as an attending, if you don't get them in residency. You will have family ties in California and, to be blunt, they are underserved for a reason. Try to do away rotations in California during school and apply to plenty of programs in California during residency. Mt. Sinai is not only more expensive re: tuition but cost of living is more in New York.
 
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UTHSCA:
pros:
14k/year + low cost of living
near border of US-- very interesting underserved population to work with

cons:
no ties to SA, far from home (CA)
Difficult to get residency in CA

Mt. Sinai:
pros:
NYC
more highly-regarded school
P/F

cons:
35k/year + extremely high cost of living

Minor point: It's UTHSCSA, not UTHSCA. I would not normally point this out, but you made the error multiple times in your post.

Your post also reflects a rather pervasive misunderstanding of what (most) residency program directors are looking for. The fact that you are from California is the card you will play in making your case to come back to CA, not one related to the reputation of your medical school. Mount Sinai and UTHSCSA are both solid, domestic MD-granting programs that will give you a comparable educational experience. No residency program is going to offer/decline you an interview because you chose one over the other. Go look at the websites of CA residency programs and see the educational paths of their current residents. You will find a full spectrum of medical schools represented.

I am perhaps a little biased because I love Tex-Mex and Texas barbecue, but I would also never refer to San Antonio as a "bad location." If anything it's a bit like Austin was before it got discovered and overrun.
 
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DokterMom

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Agreeing with @Med Ed -- San Antonio is the 7th largest city in the US, so hardly a backwater. (You are talking about the main SA campus right? Not the RGV location?) It's a vibrant city with both new and old, great Tex-Mex (not the same as Cal-Mex, but really, really good) and a reputation for having the happiest med students in TX. The topography is similar to much of CA and the weather is warm to hot. Patient population is diverse, with many of the same types of health problems you will see in rural primary care. But also a large enough medical center where, if you change your mind, you will not be limited in your choice of specialty. Though not P/F, the block curriculum and testing schedule (one at a time vs. He!! Week) is very student friendly. Flying to CA would probably be via Houston (a one-hour detour), or Phoenix (en route) on Southwest Airlines, a great way to fly once you get the hang of it.

Don't know much about Mt Sinai -- just enough to caution that you should not assume you'd love NYC until you've spent a fair amount of time there and have a chance to experience both the good and the bad. In my experience, NYC is a much better place to live when you're rich versus when you're not...

Go to both second look weekends and try to spend some extra time in both cities --
 
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abcdeffedcba

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Thank you so much for your responses. I am fairly ignorant about all things Texas. I applied to all Texas MD schools mainly because my sister lives in Houston near UTH. Alas UTH didn't work out but UTHSCSA did. Your responses have greatly informed me about SA and UTHSCSA, and I will definitely do more research on the city and the school.

Would your responses be the same if my specialty-of-interest is not primary care? Does either schools leave more doors open for me if I do change my specialty interest?
 

ridethecliche

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If sinai was 35k a year, I'd say take it. Then I realized you meant room and board wasn't included...

If you go to texas, you'll likely end up being able to go to school for a total of 100-120k depending on how much you spend on 'life' stuff. You have to factor that in. It'll be more than twice as expensive to go to school in NYC. I love NYC, but I had a similar decision to make last year between a solid city and a place I didn't really want to be in with a great school. I chose the latter. I second guessed myself at first, but I really don't regret it at all now.
 

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You are truly awesome for having banked $50k while working during college and high school... that is an amazing accomplishment.

I'm a little confused. A quick internet search shows that multiple airlines fly direct from San Antonio to LAX, SFO, and at least Southwest flies direct to SAN. I'm then guessing you don't live near those metro areas but I'm surprised that the NY airports would fly direct to CA destinations outside those main hubs.

For what it's worth... I'm an out-of-stater who chose a Texas school over some top 10s, and don't have regrets thus far. I plan on making the best financial decision for my residency choice as well. IMO with the information you've given - career plans and your wisely valuing saving - UTSA is a no-brainer.

If you really want to get back to CA I strongly suggest doing at least one away rotation there because the top programs there are very competitive. (I applied to a very non-competitive field and got 1/3 CA interviews and 16/16 non-CA interviews, however I have no ties to CA and didn't do any aways). I don't think the Sinai name gives your residency application a significant enough boost to justify the extra $100k+ (like Hopkins or Harvard for instance might) though.

I don't know enough about UTSA itself but just looking at the NRMP residencies it offers - it has just about all of them - that indicates they at least have a department for every specialty.
 
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Goro

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Ditto this.



I would take UTHSCA. In looking at the big picture, since you want rural, underserved community, you can search for those jobs as an attending, if you don't get them in residency. You will have family ties in California and, to be blunt, they are underserved for a reason. Try to do away rotations in California during school and apply to plenty of programs in California during residency. Mt. Sinai is not only more expensive re: tuition but cost of living is more in New York.
 
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Would your responses be the same if my specialty-of-interest is not primary care?

Yes.

abcdeffadcba said:
Does either schools leave more doors open for me if I do change my specialty interest?

Maybe, but since life is not a controlled experiment there is no way to tell which one until it is too late to change course. You aren't exactly comparing a Porsche with a Yugo here. More like an Accord and a Camry. If you went field by field perhaps you could discern some differences between the two schools, but that says little about the experience you will have. Sinai might have a stronger radiation-oncology department, for example, but at UTHSCSA you might get linked up with a young, energetic rad-onc physician who mentors you and writes you a great LOR. There is simply no telling. And add to that the fact that you might change your mind a dozen times before deciding on a speciality.

What is 100% certain, however, is that less debt will give you greater flexibility down the road.
 
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Texas hands-down. Not only is Texas the best state in the nation by far, but it's one of the best states for physicians to practice. Chances are you won't return to California if you move here.
 
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Texas not even a question. Go buy a bag of jelly beans and have each represent 1000$. Then separate how many jelly beans it would cost to go to Texas and make another pile for mt. Sinai. Now realize that those are all 1000$ bills and make the smart choice.
 
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I would strongly lean Texas in this scenario. Other posters have brought up a lot of good points and given the career direction you are looking at and your financial situation, I think San Antonio will be a great fit.
 

imymemine

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Also I wouldn't consider preclinical P/F to be a clear pro. Yes I get that it might save some day-to-day stress during the preclinical years but the end result with this system -- your final GPA/class rank being determined solely by clinical grades -- makes those clinical grades even more important. At least at my school clinical grades have a significant subjective component to them and thus tend to lead to a lot of variance and occasionally pure BS. The subjective grade often depends moreso on who is writing your eval (ie how high their standards are) and your performance in one situation during the rotation that you have no way of knowing when it will happen than it does how hard you work and how good you are. If you are truly a good student, having purely objective grades during the preclinical years acts as a nice buffer against that sort of variance.
 
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Cookie04

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I wouldn't really consider San Antonio as being close to the border either, El Paso and Rio Grande Valley are close to the border. Also UTHSCSA and UTSA are two completely separate institutions. The only relation they have is that they are both apart of the University of Texas system. While SA and South Texas in general do have a large underserved population, SA is extremely diverse so you get all kinds of people, it's also the 2nd largest city in Texas. I'm assuming Mt. Sinai will also be far from your home, so in that case I would go with the cheaper option.

Anyway you should choose UTHSCSA so that way we can be classmates:D
 
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zaztong

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UTHSCSA hands down. I would go with it so you graduate close to debt-free with your 50k savings. I interviewed at UTHSCSA and talked to a lot of different MS1-4 to figure out the scene. Everyone gets A's or B's (20%/80%) except a rare few who don't study. I wouldn't worry about no P/F system.

NYC rent is EXPENSIVE. So is Mt. Sinai. And no, it won't significantly help your chances to get a residency in CA.

A MD is pretty equivalent independent of rankings (unless you're going into research academia with a MD/PhD or you are going to the Carribean/DO) anywhere you go and you'd be saving a lot on state income taxes when you're a resident/physician. The tax savings when you're a physician far surpass frequent plane tickets to CA. And UTHSCSA is mid-tier, not bad at all.

If you really want and insist on a residency at CA, you should do well on USMLE Step 1/2. Those matter much more than your MD school ranking.
 
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Officer Farva

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You think you might want to do primary care now, but you might be enamored by a more research-oriented specialty (Oncology, neurosurgery, etc) later on. I would choose the school with more options (Mount Sinai) in case you want valuable research connections. Plus, since you will be a recent college grad, won't you want to spend the best years of your life in one of the best cities in the country?

Just so you know. I am of course scared very easily by debt. But I also understand how important it is to make the most out of every moment in life. I think you would have more life experience in NYC.
 
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Either medical school will give you a proper foundation for a good opportunity at any residency in California.

Fort Sam Houston has long been the medical headquarters for the US Army. UTHSCSA is integrated in so many ways, especially at the residency level, but also at medical school level with the military. This adds to your educational opportunities, as you will see pathologies and life experiences from soldiers and their families that you can not find attending any another US medical school. And it cost very little to attend compared to most US medical schools. Remember, Texas universities are wealthy, and San Antonio offering you a scholarship should indicate that they want you as a student.

Now, with that said, New York is New York, unique in its own right. And you will receive an education there that is tied to Mt. Sinai's medical population.

San Antonio will not be much of a difference in terms of lifestyle than that of living in California, but New York will. There's that, and it is incredibly expensive to live in New York, and it's a dangerous place to walk around at night...

San Antonio is a nice city in a beautiful area of Texas, it isn't El Paso. And Austin is just 90 miles up the road... :)

Good luck, and congrats.
 
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Honestly, in the big picture the difference in cost will be negligible 10-20 years down the road. Yes UTHSCSA is cheaper, but at the end of the day you should go with whichever location and school you really jived with! If that's Mount Sinai, then maybe you spend an extra 80-100k to go there, realizing that's about half a year's salary. Also Sinai, will probably be (slightly) advantageous if you decide to get competitive with your future residency programs or specialty.

Med school will be a long 4 years at a school that isn't right for you. My advice is to go with the school that you can see yourself happiest at!
 
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Honestly, in the big picture the difference in cost will be negligible 10-20 years down the road. Yes UTHSCSA is cheaper, but at the end of the day you should go with whichever location and school you really jived with! If that's Mount Sinai, then maybe you spend an extra 80-100k to go there, realizing that's about half a year's salary. Also Sinai, will probably be (slightly) advantageous if you decide to get competitive with your future residency programs or specialty.

Med school will be a long 4 years at a school that isn't right for you. My advice is to go with the school that you can see yourself happiest at!

I'll put my 30 years of debt repayment against your "long 4 years" of medical school any day.

This "go where you will be happiest!" tripe is a lie peddled by the ignorant. The OP's happiness thermostat will normalize in either location. The main difference is the financial hangover.
 
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abcdeffedcba

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Thank you so much for your sincere answers. I was going to rescind my acceptance from UTHSCSA before I decided to ask for your opinions. Now I will definitely wait until second look for both schools!
 
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MD2025

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I'll put my 30 years of debt repayment against your "long 4 years" of medical school any day.

This "go where you will be happiest!" tripe is a lie peddled by the ignorant. The OP's happiness thermostat will normalize in either location. The main difference is the financial hangover.

I'm not saying finances aren't important. If it was something like 67 at South Dakota vs 14k for San Antonio it would be a no brainer. However a 20k (+cost of living) delta to attend a school like Sinai isn't necessarily the end of the world if it's really where someone wants to go. Honestly, I'd probably go with San Antonio if it was my choice, but for someone who really preferred one location to the other, I think the difference shouldn't be THE deciding factor.

Also with proper budgeting, there's no reason a debt of $140,000 - $50,000 + interest + living expenses can't be paid off in well under 5 years of practice.
 

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I'm not saying finances aren't important. If it was something like 67 at South Dakota vs 14k for San Antonio it would be a no brainer. However a 20k (+cost of living) delta to attend a school like Sinai isn't necessarily the end of the world if it's really where someone wants to go. Honestly, I'd probably go with San Antonio if it was my choice, but for someone who really preferred one location to the other, I think the difference shouldn't be THE deciding factor.

Also with proper budgeting, there's no reason a debt of $140,000 - $50,000 + interest + living expenses can't be paid off in well under 5 years of practice.

According to estimates on expenses for Mt. Sinai per year:
tuition = $35,000 (actually I believe it is 48k a year if you check out the website: http://icahn.mssm.edu/education/financial-aid/tuition but I'll go with your number in case I'm wrong.)
room and board = $24,000
books = $2,000
mandatory health insurance = $3,353
loans after 4 years, not including interest = $257,412
misc expenses = $??? (aka plane tickets back home every year, a car to get around, gas and parking, trying different foods, social life, possibly dating...$15000 at least over 4 years?)
Including interest, if left unchecked, his loans after 2 years would be $293,610 + misc - that's around 300k! (assuming if 48k/year is right it would be around 370k if you include misc!)

I'd say it's far from just 140k. Assuming a salary of 140k as PCP, after taxes & living expenses in CA would be around 60k, about 5 times his annual salary! And you definitely cannot write off your student loan interest on taxes. He may be able to pay it off within 5 years considering he has 50k right now, but it's going to be pretty harsh and you'd be making some significant sacrifices. Most Americans can't even save 20% or even 10% and he'd have to send almost the whole paycheck to student loans every month.

Now look at UTHSCSA:
tuition = $14,000
room and board = $14,302
books = $2,000
mandatory health insurance = $3,353
loans after 4 years, not including interest = $134620

That's like a little more than 1/2 of Mt. Sinai. Seriously it's a no-brainer, numbers-wise. Plus, no state income tax leaves you to pay off more of your student loans. You can buy a house in the vibrant, diverse city of SA with the amount you save from not going to Mt. Sinai and able to start a family soon once you come out of SA easily if that's your thing.

Now that we've talked pure numbers, let's talk how that translates to utility/happiness. You should be ready to make significant financial sacrifices in food, social, living, future dating and/or family during & after medical school. Otherwise, your loans are going to take quite some time to repay if you are going to "enjoy" NYC to the fullest. Doesn't sound too fun to me in the long run after you move to CA and rake up a ton of debt that's over 5 times your income, doubling at a rate of every 10 years. You should only do it if you absolutely must go to Mt. Sinai and nothing else will bring you pleasure and joy. Just ask yourself - is this worth 150-200k to you over a mid-tier medical school in SA? If so, then take Mt. Sinai. Most MD programs are equivalent if you are going to practice. Think it through and run your numbers for a better, more accurate estimate, depending on your misc expenses.
 
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I'm not saying finances aren't important. If it was something like 67 at South Dakota vs 14k for San Antonio it would be a no brainer. However a 20k (+cost of living) delta to attend a school like Sinai isn't necessarily the end of the world if it's really where someone wants to go. Honestly, I'd probably go with San Antonio if it was my choice, but for someone who really preferred one location to the other, I think the difference shouldn't be THE deciding factor.

Also with proper budgeting, there's no reason a debt of $140,000 - $50,000 + interest + living expenses can't be paid off in well under 5 years of practice.

Totally agree, except for that last sentence. I lived between several big cities on both coasts my whole life, and I am providing the point of view of a coddled city boy. There is no place like Manhattan in your 20s, which I consider to be a good trade for financial burden, which is crazy considering how anti-debt I normally am. Other parts of the country away from the coasts pays a lot more money to MDs than the coasts yet are faced with less physicians for a particular reason, and that is lifestyle over their earning potential.
 
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Also with proper budgeting, there's no reason a debt of $140,000 - $50,000 + interest + living expenses can't be paid off in well under 5 years of practice.

Totally agree, except for that last sentence. I lived between several big cities on both coasts my whole life, and I am providing the point of view of a coddled city boy. There is no place like Manhattan in your 20s, which I consider to be a good trade for financial burden, which is crazy considering how anti-debt I normally am.

Suffice to say there is a very strong consensus among those who have already walked the path to give COA primacy in choosing a medical school. "Proper budgeting" can fly out the window pretty quickly if you hit the ground post-fellowship with a spouse, house, kids, 529's, and zilch in the 401k.

If you do some research on "the pain of paying" it may become clear why so many people in their 20's run up their credit cards and/or go into deep educational debt, only to spend years digging themselves back out. It is an emotional trap that leads people to behave like they are dealing with Monopoly money. It also explains many of my interactions with tequila.
 
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If you truly hated your time in San Antonio or at UTHSCSA, then that's one thing. But if you're basing your decision largely on the imagined glamour of NYC -- well, that could be a very expensive mistake.
 

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San Antonio is a pretty neat city IMO and I'm from CA as well. I'd be happy to take your seat in San Antonio and pay 14k tuition if you don't want to :p

In other words: GO TO SAN ANTONIO!
 

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Also I wouldn't consider preclinical P/F to be a clear pro. Yes I get that it might save some day-to-day stress during the preclinical years but the end result with this system -- your final GPA/class rank being determined solely by clinical grades -- makes those clinical grades even more important. At least at my school clinical grades have a significant subjective component to them and thus tend to lead to a lot of variance and occasionally pure BS. The subjective grade often depends moreso on who is writing your eval (ie how high their standards are) and your performance in one situation during the rotation that you have no way of knowing when it will happen than it does how hard you work and how good you are. If you are truly a good student, having purely objective grades during the preclinical years acts as a nice buffer against that sort of variance.

Your opinion is not supported by studies. They have been consistently showing that preclinical grades are ranked LAST (or close to last) to be considered by the residency directors. Your clinical grades and Step 1 are important regardless what schools you go to: your preclinical grades won't buffer those.
 

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So in other words, your perspective on what life would be like for the OP is completely useless.

Take it easy, just providing an opinion and not completely perfect advice the OP must follow.
 

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Current Sinai student here. Decisions that involve substantial amounts of money are always challenging and given your career goals you may very well be better off at your cheaper option. Just for informational purposes, we have a substantial amount of students matching to Cali programs. Over the past couple of years, there's been neurosurgery at Stanford, urology at UCLA/Kaiser, tons of peds at Stanford/UCSF/Oakland, IM at UCSF/UCLA and other specialties. I don't think any CA doors will be closed if you go to Sinai (provided you do well). Good luck with your decision!
 
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Your opinion is not supported by studies. They have been consistently showing that preclinical grades are ranked LAST (or close to last) to be considered by the residency directors. Your clinical grades and Step 1 are important regardless what schools you go to: your preclinical grades won't buffer those.

Relax bro. I wasn't belittling the importance of clinical grades, and I didn't mention step 1 at all. My point is that good preclinical grades can buffer class rank, which is usually a factor for AOA selection. Class rank and AOA matter, no?
 
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Officer Farva

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OP, spending your 20s in NYC :) + Mount Sinai is an amazing school
 

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OP, I think very good arguments have been made for both schools. I would strongly urge you to make your decision entirely on fit and comfort. In the end, you're looking at a difference of 150k, which is substantial but not a deal breaker, in my opinion. I know a lot about Mt Sinai and NY, and nothing about San Antonio. To my ignorant ears, San Antonio sounds like a fine school in a good location. If you came here saying that San Antonio was home, and tuition the same, but you preferred Texas, I would say fine, go there. However, Mt Sinai is a top school with a better reputation, and you will have the opportunity to live in the absolutely best location in all of NYC for 4 years. The hospital is located right on Central Park, and you are a 10 minute walk down 5th avenue from the Metropolitan Museum of Art and 10 or so other museums. You won't have a lot of free time or money, but you'll have enough, and this will be your only opportunity to live in NYC, so I would strongly urge you to do so. I have the sense that they treat their students well and support them, and you'll get to live in NY for 4 years. Think of it this way: your tuition includes several free trips to NY each year. Instead of going to a movie on the weekend, you can go to a Broadway show. Instead of going to the mall, you can go to a museum. NY can be stressful and noisy and crowded, however, so it's not for everyone. But don't let the money stop you if it's a location you will prefer.

Mt Sinai's reputation might help a little in getting back to California, but I wouldn't necessarily factor that into my calculations.

Do the second looks and see which one feels better. Talk to Mt Sinai students. And see if Mt Sinai can give you some money.
 
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p0gono

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The points about tuition differences should be taken seriously. BUT I think it's worth noting that Mt Sinai is special among the New York schools and actually among all of the various schools I have visited. Their housing is very nice (esp for NYC) and so heavily subsidized that they pay less rent + utilities than any other students that I have talked to at any other schools so far, east coast / west coast / Midwest / urban / suburban, yup it's the cheapest. The 4 bed 2 bath is something like $580 per person.
 

bc65

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Considering the 4-year COA for Icahn is >$300,000, I hope that's one hell of a show.

Clever reply, but let's be serious.

First of all, it's a difference of 150k, not 300k. For that money, you're going to see more of NY than you would on 5 trips there, and save the cost of going to NY later, So you have the benefit of saving perhaps 40k or more in travel, plus the intangibles actually living in NY, which is a very worthwhile experience, and an intangible but probably valuable increase in school reputation. I think that's worth more than 150k. Not everyone will agree.
 

christmasindr

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There's no clear right or wrong answer in this case. Both are good schools, and you can do well either way and able to come back to CA if you wish. Do revisits and wait for the actual financial package. Those should help your decision making.
 
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