Tag: medicine

Psychological impact of leaving medicine

Psychological impact of leaving medicine

We talk about money on this website, and how to make sure that you have enough of it.  In fact, that’s pretty much the entire strategy for the growing crowd of people in the world who are gunning to retire at an age that most neurosurgeons start their careers.

Those of us in the medical field who also have similar ambitions to work our finances intelligently are likely to have similar end-game strategies in our profession, albeit less extreme.  Sure, it’d be great to give your boss the finger, sell your house, and move the entire family down to St. Kitts. What’s not to like?

The reality is that even if pipe dreams like that may not be palatable even if we have the means to do so; family, kids, friends, and our contacts will have to be on board if we expect to continue interactions with them. You know how that will likely end—not well.  The interesting aspect, however, of being a physician is that the public expects you to have money.  Even if you are only rocking a paltry $120,000 a year in a low-paying specialty, you are still a high-earning doctor to your non-medical friends (even if they earn more than you and not realize it).

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In this scenario, walking away completely from medicine may actually be more socially acceptable.  Dr. X, who drives a fleet of Tesla X’s, probably doesn’t even need to cut back on his expenses to afford a third home in Puerto Vallarta.  No one will bat an eye if you hung up your doctor hat.  What you need to be aware of is how attached you are to your profession.

Your self-image will be impacted after your leave medicine

What might be more critical is how you will accept changing your professional identity if you decided to change what you do.  I work with plenty of hospital administrators who have a medical degree, but no longer practice medicine.  These are typically internists, family practictitioners, and emergency room physicians.  These doctors have all rationalized to me that they saw a new calling outside of clinical practice. Many of them found administration to be more interesting than what they did previously and found that they could impact the medical paradigm more meaningfully through other means. Fair enough. They still are contributing to the healthcare system through other means.

Let’s say that you decided to leave your job as an ear, nose, and throat specialist at the age of 45 to work on your woodworking hobbies.  You’ve made your $4 million safe withdrawal fund, sell your wood-turned teak corner tables at the local artisanal market, and maybe earn enough to pay the utilities every month. Can it be fathomable that you had just become a newly minted attending slightly over ten years ago, yet you are now contemplating letting your board certification lapse?

Give up your career in medicine too early and you will have to put your pup to work!

Most of your classmates will still be ramping up their careers, building their practices, and working long hours. They will be working on research projects to present at the next annual society meetings. Would you be ready to transition to a non-practicing status on your board certification? What do you intend to tell your classmates at your ten-year medical school reunion what you ended up doing with your life?  Furthermore what would it feel like to exit a career that you toiled for decades to gain admission into? Can you still call yourself a doctor if you’re no longer practicing medicine or considered a viable practitioner by your specialty?

Prepare for the end goal while you’re working towards it

Several of my mentors are practicing medicine well into their 70’s, only because they cannot see themselves doing anything else outside of their profession. On the other end of the spectrum, millennials and younger doctors have other intentions in mind.  Avocado toast, luxurious honeymoons in Hawaii, baby moons in Bali, and enjoyment of four-day workweeks are all part of the plan.  Whether you are part of this younger doctor generation or cringe every time your potential hires tell you they need to have Tuesday and Thursday afternoons off to pick up their kids from grandma, the principle is to simply find a means to set your priorities and stick with it.  

If you intend to crank through a decade of sleepless nights in your profession to maximize your income, reach fatFIRE, and call it quits, that’s okay. Be sure that you will be okay with what you intend to do hit your goal. Would working 0.5 FTE be adequate to maintain your skills and foot in the door? Is that even possible with your specialty? Would you be completely miserable leaving medicine completely?

Case in point: I had a colleague who retired at least 5 times before finally officially retiring. Even now, he’s anxiously itching to find ways to continue medical work without being officially employed. He’s in his mid seventies.

Whatever you decide to do, do it with a purpose. Remember, no regrets!

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Physician pawns in the healthcare system

Physician pawns in the healthcare system

Doctors and other caretakers are the pawns of the healthcare system. We provide the services that allow hospitals and medical groups to bring in big revenue.  Unless we are contracting directly with insurers, doctors will never realize the true financial firepower that we have. As the healthcare environment evolves, we are seeing fewer individual physician-owned groups and more conglomerates.  The larger the system that we belong in, the greater number of layers of complexity we face.

The WSJ recently published an article discussing contracts that large hospital systems have with insurance companies that theoretically reduces competition and obfuscates costs.  Basically there are two conclusions of the article:

  • Hospitals can make agreements with insurance companies that prevent the insurance company from offering contracts to competitors without including them.
  • As a patient, it is common not to know the cost of a medical treatment until you get the bill.  Many families with high deductible plans suffer since they cannot shop around for the best price.

These are interesting and valid points but it is impossible to understand the complexities of the healthcare system in one’s entire career, yet alone one article.

Neither the hospitals nor the insurance companies are victims

The WSJ article paints a negative view of mega hospitals as aggressors who prevent competition by restricting insurance companies from negotiating with lower cost providers.  There is indeed something awry with restrictive language in contracts, but we have to realize that this is simply a business.  Of course McDonald’s wants everyone to eat their burgers.  If the insurance company is willing to make an agreement, you’d also bet that they are benefitting too.  The insurance company always wins.  It doesn’t matter what they sell, whether it’s life policies, health policies, whole life policies…the math always works out in favor of the insurer.  The patients and healthcare workers on the field are actually the ones that suffer.

Think about it…if Hospital A is willing to accept less pay than Hospital B for the same services, clearly Hospital A has figured out how to lower costs: (1) Hospital A is able to operate more efficiently and (2) Hospital A pays its workers less.  Don’t forget that you, the doctor, is the worker getting less pay for the same work.  Your work is paying for the management to make the rules.  If you don’t like what they are doing, then you have the choice to leave.  The hospital will always be able to find someone else to replace you.

Pawns, after all, are dispensable but needed to win the game.

There’s nothing wrong with being a pawn in a big company

Doctors get the short end of the stick

Those of us involved with direct patient care have all encountered situations where patients leave our practice due to changes in their health insurance.  It’s an interesting phenomenon like a reluctant break-up: the patient claims that their doctor is great but due to a change in their health insurance, they have go elsewhere to an unknown entity.  It doesn’t matter if the doctor has taken care of them for decades either.  Money talks louder than one’s health, but that is the unfortunate truth of healthcare.

I’ve certainly had colleagues who have had patients tell them that their prices are “too high”. Ironically these price differentials may be a difference between a $50 copay and a $35 copay office visit, all dictated by an insurance contract beyond the control of the individual physician.  Sometimes plans that require the lower copay actually generate bigger bills on the backend and pay the doctor less, which isn’t obvious to the patient.  If I were only paid the copay to evaluate whether someone needed to get a carotid endarterectomy, I would have quit my job long ago and become an organic farmer.  This situation reflects the confusion in an opaque healthcare system.  If my patients are coming to me for their knee surgeries because they think that I am the most economical option, there is something wrong with the system.  Healthcare shouldn’t be a race to the lowest bidder.

The case to untie yourself from the system

In American chess, there is a rule whereby pawns can become promoted to whatever piece the player chooses once the pawn reaches the end of the board. This is called, “pawn promotion”.  It’s about time that doctors find a way to get that pawn promotion.

You might also like: Why do young doctors hate medicine so much?

We each have to define what our pawn promotion means to us.  Does it mean financial independence? Does it mean putting yourself in a position to effect healthcare change? Is it a way to lift our fellow physicians from the shackles of our profession?  I certainly don’t want to spend the rest of my career clicking through radio boxes and drop-down menus so that someone else can tell me how meaningful my quality of care is. It’s time for doctors to wake up and figure out the best way we can use our skills to benefit our patients without shortchanging ourselves.

The key to physician success: it’s okay to be missing out

The key to physician success: it’s okay to be missing out

It’s human nature to be social.  The collective sensation of being in a group or organization helps us belong. We see this in school, where kids band together for activities. We see this in the doctor’s lounge, where the anesthesia guys chat about the latest hospital gossip. Occasionally we see the loners who shed the collective mentality and shine through their own path. If these novel beliefs are compelling enough for the masses to adopt, then the long wolfs become mainstream.

There has been a push over the last year in the online physician community to venture into seemingly radical pursuits, like trying to retire early.  Other more tempered pursuits seem to revolve around doctors finding self-sustaining means to escape medicine itself. Multilevel marketing, real estate, side hustles, and other income-producing hobbies are the rage. I am always amazed at how motivated my peers are.  The irony is that sometimes it seems like more effort is put towards pursuing something outside of medicine.  Nearly all of the side hustles that I’ve encountered don’t require having gone through the pain, time, and intelligence of medical training.

I had a classmate in medical school who finished his medical degree and a year of internship before joining a huge medical consulting firm.  I never really knew why he did that, since medical school isn’t exactly a walk in the park for most people.  Unless he ends up in the C-suite of a major hospital or healthcare behemoth, it is difficult to justify the financial advantages of the career route that he chose. Fast forward to today. He’s not exactly in the C-suite, but he has a similar income trajectory as most doctors his age and a much greater potential to impact healthcare that most of us will never even dream of doing. Go big or go home, as one might say.

Dare to be normal

Most people would prefer to live according to their own terms, and blend into the crowd. This applies to doctors as well.  Some of us are workaholics; some of us want to do the minimum amount possible.  But average is still somewhere in the middle.  I only know a handful of doctors who actually love booking elective surgical cases the Friday after Thanksgiving or rounding on patients every weekend.  Everyone else just wants to be able to play a round of golf on their off-days, and take their families out on a road trip in a nice U.S.-made German-branded SUV.

Not missing out on this would mean more inches to your belt.

Not every doctor wishes to own a dozen homes, a private jet, or a Maybach.  On the other end of the spectrum, most doctors aren’t going to want to pack up their medical practice, travel the world for weeks at a time, and homeschool their children.  It’s okay to teach your kids about World War I by renting an AirBNB in Sarajevo, but a textbook will probably do just fine.

It’s important for practicing doctors to focus on what is important to their family and careers. There is a lot of noise in the online community with anecdotes of doctors who are able to build an escape route out of envious medical careers that most people would only dream of being in.  There is nothing wrong with being a doctor working 55 hours a week, taking call every fourth weekend, and earning a comfortable living.

There is nothing wrong with being out of the loop

Fear of missing out, or FOMO, can be self defeating.  It doesn’t matter what your colleague down the hall is doing with the latest real estate craze.  You might be missing out on the biggest financial opportunity of the day, but you could also be missing out on the biggest flop.  Just because your roommate quit her stable job as a gastroenterologist to join a startup doesn’t mean that you need to find some radical way to prove yourself.  The key to success is to keep your head in the game.  You are already a physician. You have a better income and lifestyle than many other professionals.  Don’t sabotage it.  Hone your plan for a successful career and follow it.

Debt-free medical school a financial blunder for doctors?

Debt-free medical school a financial blunder for doctors?

Education can be expensive. Higher education can be even more expensive.  Even partial scholarships can be deceptive as one might opt for a more expensive school for the sake of redeeming “free money”.  As a student, I had no financial understanding of return of investment when I was considering higher education.  All in, I plowed through more than a quarter million dollars in my college and medical school after substantial scholarships and grants.  And that was a long time ago.  If you are finishing medical school today funded solely on loans, you’ll likely owe slightly south of $200,000—if you attend a private school expect to add in another $100,000 to the tab.

You might also like: Is a degree from a prestigious medical school advantageous for doctors?

Fast forward to today.  My medical school alma mater recently announced that it will become completely tuition/debt-free for all students. That’s right. Zilch. You don’t have to be surviving on subsistence living either.  No need to strategize on Public Service Forgiveness Loans either.  If you are admitted, your education will be free.

The cynical side of me says that the medical school did well for itself: enough of its alumni have become hotshots so that its scholarship fund is big enough to fund its future graduates.  That’s a nice pot of money, especially since tuition today is over $65,000 a year.  Getting into medical school itself is challenging enough; going through it without paying a dime is like winning the lottery.  The rarity of this windfall is akin to that of Qatar discovering oil and natural gas…big.

The motivation for a debt-free medical school

The elimination of educational debt confers significant advantages for medical students. Remember the Hippocratic oath? It mentions nothing about prepayment, prior authorizations, Bugatti’s, or care contingent upon reimbursement.  We chose to become doctors in order to care for others.  That is how medical education was intended. The reality, however, is that we also have to make decisions based on practicality.  Imagine going through medical school supporting a family with 1.5 kids and studying nearly every waking moment of your day?  Your spouse wants to go back to work, but you contribute nothing to the cost of day care.  Many medical students contact me simply to ask about the compensation and lifestyle of a particular specialty. Many of those students are drowning in debt. You’d better believe that if you’re half a million dollars in the hole, you probably aren’t going to be tooting the virtues of pediatrics, no matter how much you love children.

If you wipe out educational debt from the picture, you might be more inclined to choose a potentially less lucrative but more enjoyable career path for the long haul.  Perhaps you’d end up realizing your calling as a geriatrician and do great work for the elderly.

Debt-free medical school lifts a psychological burden as well.  As a medical student, I was always torn between budgeting my time and saving money.  Do I study an extra hour and buy take-out for dinner, or do I need to sacrifice precious study time in order to cook dinner?  Do I spend my Sunday mornings buying budget groceries for the week or enjoying my limited free time?  Without the big price tag attached to medical education, we might even have happier students.

You might also like: Are you turning away millions of dollars as an academic doctor?

A happier person makes a happier doctor.  Do happier doctors make healthier patients?  If you love what you do, you’ll likely be a better doctor.  When educational debt is eliminated from the picture, society benefits from having a better doctor.

Debt-free medical education is bad

How can free ever be detrimental?

Because free implies the absence of cost.  Free is easy.  Easy doesn’t fire the synapses in our brains.  And we all know that our brains need to fire in order to learn.  Remember the college chemistry exam that you didn’t study for because you thought the class was too easy?  You’d bet your tail that you remembered to study for the rest of that semester.  No matter how conscientious we try to be, human nature dictates that we are less alert if we are in a comfortable situation.

Free medical education will make you complacent.

Being in debt allowed me to understand the importance of finance and how much doctors are worth.  Society does not value doctors adequately.  It is appalling to compare my medical school experience with one of my friend’s business school experience.  My research job the summer after my first year of medical school granted a $3000 stipend for three months of living expenses.  My business school friend secured a two-month internship with a salary of $10,000 and free meals!  Neither of us were truly viable in our respective professions as students, yet society was able to value a business trainee much higher than a healer in training.  Would I have cared if medical school didn’t come with a big bill? Maybe not.  If weren’t already financially invested in medical school, I might have jumped ship straight to a business degree.

Paying for medical school teaches you how much you are worth

As service professionals, doctors exchange their skills and time for money.  Fundamentally that is the only way that we are compensated (side hustles and real estate aside).  Our earning power is limited by time.  And healthcare is constantly devaluing our time.  You don’t earn more by spending an extra two hours of your day charting.  Quality metrics are great in principle, but the goal of our profession is to provide emphatic expert care.

Having been in debt makes you hungry to succeed in life.

I don’t think that I would have such a profound opinion of the value of our medical skills if medical school did not come with a price tag. Knowing that I invested a significant portion of my youth and finances towards medical knowledge has allowed me to negotiate a fair salary for my time and experience.

The cost of medical school teaches frugality 

After digging myself in a hole of student loan debt, I knew not to crank up my luxurious expenditures when I started making good money as an attending.  I wanted no chance of reliving those days.  Would I have become as conscientious about money if medical school were free? No way.

Obviously medical school debt isn’t the only way to learn frugality, but medical students frankly don’t have many opportunities to learn it. Most doctors never hold a real job before becoming a high-income doctor.  Our training is arduous and takes many years.  Sometimes the only thing that gets me through my long days of surgery is the thought of buying an overpriced outfit or car. What often reels me back to reality is remembering that medical school came with a big price tag that took a lot of effort and sacrifice to repay.

Do you agree on the principles of a free medical education?

Why do young doctors hate medicine so much?

Why do young doctors hate medicine so much?

There is a perpetual mentality that generations after our own seem more entitled than we ever were ourselves.  Since when did a second grader ever need the latest cellphone?  Avocado toast, month-long honeymoons, extended vacations after residency, and baby moons are just some of the luxuries that prior generations were unlikely to have experienced.  Maybe society is simply more advanced, or maybe I’m just getting old.

In the medical world, more doctors are asking for more time off, shorter workweeks, less call, and more pay. No way would younger doctors willingly sign onto a job with a call schedule of every other day. Is quality of life that much more important to us even though many recent graduates have upwards of a quarter million dollars of educational debt? I once had a senior partner who opted to take more hospital call when he was in his thirties so that he’d earn more to support his family.  What happened to good work ethic?

You might also like: Getting out of debt is easy. Getting rich is not.

I see this trend in doctors not only in generations after my own, but also in a few years my junior. They seem to be working less, wanting more, but all seem to hate medicine. Some of these gals are doing amazing things, like resuscitating dead people, putting in new heart valves, and curing cancer. What is there not to like?

What gives?

Medicine offers a lot to be disgruntled about.

If you remove the aspects of patient care, healing, and all of the reasons why we became doctors, there really isn’t much left over to praise. Prior authorizations, meaningful[less] use, patient satisfaction scores, inordinate amounts of charting, useless meetings, and reimbursement cuts are just some of the recent inventions in medicine that erode the enjoyment out of medicine.  Autonomy frequently gets replaced by mandates. How sad.

You might also like: The number one reason doctors need to be financially independent

The irony about these unfavorable healthcare mandates is that most of our administrators tell us that with a little more hard work, we can accomplish all of the expected tasks. Most doctors are not opposed to working hard—we did go through a decade of servitude in order to master our specialties—but the problem with the ancillary tasks associated with medicine is that there is little perceived return in our effort.

The intention of these time consuming tasks associated with medicine is primarily to improve safety and cut costs in the healthcare system. There are so many layers in the bureaucracy that it is essentially impossible to determine whether working doctors harder is going to pare down the cost of healthcare.

Follow the Benjamins and you will realize why doctors are unhappy 

Capitalism.  I love it. If it works well, there is a direct correlation between hard work and return.  Unfortunately, capitalism doesn’t always work if you’re an employed physician.  The reward for completing more charts and seeing more patients doesn’t always translate into direct financial gain.  In fact, if you save the healthcare system more money you might actually benefit the guy in the C-suite or the company’s stockholders first.

Young Padawan with $300k in debt has a lot to learn from the elders

Several weeks ago, I was in a meeting where one of the administrators in my organization (who holds a pseudo-degree from an online for-profit institution) alluded that one of the trauma surgeons ought to be working harder given that the group was paying him $X. That amount was about a third of what a normal trauma surgeon ought to be earning.  I was blown away that this trauma surgeon was even willing to work for a fraction of what he is worth.  I was even more shocked to hear that the administrator thought that the surgeon was overpaid.

These instances reflect that people holding the power in healthcare still believe that doctor salaries play a role in cutting down the cost of healthcare.  One hospital that employed 60 doctors reported a deficit of $87 million.  There is a problem when you think that cutting your neurosurgeon’s salary is going to solve that problem.

Do doctors who aren’t considered young have the same sentiment?

In general, we all do. The difference is that doctors who have been working twenty or thirty years are in a different point their careers.  Most of their children who are out of the house and even self-sufficient.  Some of them even practiced medicine in the heyday and hopefully invested their earning appropriately. Maybe some of them are financially independent.  They are no longer in the earning phase in their careers, so many of the burdens that we endure do not necessarily impact their long term career plans. If the hospital mandates too many EHR clicks or an excessive number of patients per day, they can just hang up their hats and ride off into the sunset.

What can younger doctors do in this situation? You already know the answer if you’ve read this far. Make it so that you, too, can ride off into the sunset if you have to.

Five reasons why doctors leave their first job

Five reasons why doctors leave their first job

One of the biggest fears that doctors have in taking our first jobs is that the opportunity might not work out. For many professions, moving to a new position is expected. The administration at one of the local hospitals has turnover every few months. I think that the CFO position there has been occupied by five different people in five years!

If doctors cycled through jobs like this, then there would be no hope for us. Many medical specialties require long term care of our patients in order to establish a repoire and to build a successful practice. Unfortunately we do sometimes find ourselves in a job hunting scenario even though we did our best to pick the right job.

Here are five reasons that I’ve seen attributed to physician turnover:

Work schedule not compatible with the doctor.

Everyone can claim to be willing to work hard. If we made it through medical school, we probably have worked hard at some points by in our lives. But we also know that slackers exist everywhere, even in medical school. We all know that one person who seemed to do the minimum to get by—maybe you are that person.

Nonetheless, the work-life demand in any job situation truly implies nothing about the character of a doctor, but rather that the arrangement may not be suitable for both parties. Most employers will hopefully delineate the job expectations a priori, but the employee may not know what she wants for herself.  Life goals simply change over time.

I knew an emergency room physician who complained bitterly about working overnight shifts. She made all attempts to switch out those shifts with her coworkers. Eventually she left the area and hopefully moved on to a work arrangement that better suited her needs.

Compensation not what was expected

Compensation is always a sticky subject, since doctors aren’t trained to be be greedy (unlike those of you all in finance!). Physician compensation depends on the region and the specialty, but most doctors I’ve met don’t really understand how they’re paid. This includes doctors who have been working for decades!

The dynamics of medical compensation depends on insurers, the employer-employee arrangement, and the terms of the contracts. Sometimes the employee may feel that she isn’t getting a fair share of the revenue. Sometimes the employer feels that the employee isn’t pulling her weight enough. I’ve known doctors who weren’t offered partnership, and the junior associate opts to find greener pastures elsewhere.

Sometimes the compensation structure isn’t amenable for either party, and the junior associate starts looking for a new job.

Lack of growth potential

Medicine, like most other professions, becomes a routine for many of us. After so many years of medical practice, the common diseases that present are relatively easy to diagnose.  While boredom isn’t necessarily what most doctors complain of in their first jobs, sometimes routine can indeed be tedious.  Perhaps the work situation doesn’t utilize one’s level of training fully.  Perhaps the cost of providing that higher level of care prohibits that doctor from offering her services.

I’ve known several doctors who ended up returning to academia after working in the private sector, citing that they wanted more of a challenge in their medical practice. Cases like these show that money is not always the sole motivator to justify a work arrangement.

Position is no longer available

One of the most devastating situations for anyone to hear is that their services are no longer needed.  Sometimes the driver is financial demand.  Let’s say your group contracts with the local hospital. The hospital ends up in financial distress and closes it doors. All of its employees and contractors are out of luck. This happened several years ago at St. Vincent’s Hospital in New York City—the hospital simply closed it doors.

Alternatively, you may be working in a specialty group as a new hire, but the senior partners decide to sell the group to private equity.  The new owners of your medical practice may decide to downsize and eliminate the new hires—suddenly the younger doctors end up losing their jobs.

Chronic malcontent

This is a touchy topic. It’s human nature to gripe. School, homework, jobs, other people, you name it and there is a way to complain about it. The dynamics of healthcare give us all the reasons in the world to be unhappy.

If you are too picky about your job prospects, you might starve!

I’ve interviewed dozens of M.D. applicants in my profession, and over a hundred support staff thus far in my career. Many of these doctors and medical professionals have cycled through a surprisingly high number of jobs in what would otherwise seem like a limited working career. I always hope that their turnover rate is caused by bad employers, but that is unfortunately not always the case.  There are also people who have chronically unhappy about their situation.  The reasons for malcontent may actually be trivial, but they become magnified and used almost as excuses to find another job.

While there are legitimate reasons why some jobs don’t work out, chronic malcontent is essentially a personality conflict. These are the most difficult to resolve, since the inherent problem is with the doctor herself.

What other reasons do you attribute to doctor attrition?

Five Reasons Why Doctors Fail At Getting Rich

Five Reasons Why Doctors Fail At Getting Rich

One would think that doctors should have no trouble getting rich, given that our profession as a whole has higher earning power than most other professions.  The path doesn’t take much more than above average intelligence, an incredible amount of hard work, and many years of education. The problem is that there is frequently a problem with converting a high income to high wealth.  There are times in my career where I’ve thought that getting rich from being a doctor ought to be a slam dunk, but we are all human.  Why can’t smokers quit smoking? Why do I love sugar so much?  In reality, we all have to realize that no one is perfect. These are some of the reasons why doctors can’t be perfect about money:

Poor and inadequate investment choices.

I first contributed to a tax-deferred account in fellowship, which was a 403b. Mind you, I was already in my 30’s, and even had bought individual stocks in a taxable account years before investing in any tax-advantaged accounts.  I didn’t max out my 403b account either, since I spent the rest of my money on living expenses and [fortunately] repaying some of my student loans.  I was actually one of the more financially conscientious of my peers too, so I really felt good about myself then.  Most of my coworkers eventually contributed a maximum to their 401k’s as attending physicians, and really felt proud that they were making great financial moves.

Some of them work at Kaiser Permanente, which does have a decent pension plan at retirement so perhaps everything will work out in the end for them.  Everyone else without a pension will realize that their 401k’s won’t have enough to pay much of anything when they decide to call it quits.

Choosing a low-paying job in a high cost of living city. 

I love geographical arbitrage as much as any online financial enthusiast, but sometimes it’s hard to justify moving to Minneapolis if your entire extended family lives in Philadelphia.  Add in the fact that you consider the best Jewish deli in Minneapolis to be inferior to the any of the dozen pastrami vendors in Philly, you’re in trouble.  Guess what? There’s also a dermatologist every few miles in the greater Philadelphia area, and there are also dozens of other dermatologists wanting to move to Philadelphia waiting to take the low-paying job offer that you’re reconsidering.

You get the point.

We all have to make choices that suit our lifestyles.  If that means living in a higher cost of living area, then you will have to prioritize your expenses more astutely (or be like @PassiveIncomeMD and hustle in a crazy number of revenue streams).

Poor family choices (aka divorce)

I don’t recall ever reading any statistics that doctors have higher divorce rates than the average population, but I recall reading a study that surgeons and psychiatrists have the highest divorce rates among doctors.  Obviously the doctors I’ve known who’ve had divorces (sometimes more than one) are the ones that stick to my mind as being on shaky financial ground.  I don’t know any of these divorcees well enough to inquire about their financial situations, but I can’t imagine that paying alimony for three kids would be cheap.  Sometimes the biggest blow in divorces that I’ve seen are disputes on the house or illiquid finances like retirement accounts. This can set your retirement dreams back by decades.

Believing that they are rich (when they are not).

I had classmates who “borrowed” from their future selves.  Fancy international vacations during medical school. Nice car purchases to go along with a nice home during residency. New designer dresses every month.  I’ve wondered for years whether I had been wrong to judge their financial decisions, but not everyone has a family who owns a diamond mining business.

Leverage works quite well in real estate, but not in selling your professional skills.  At some point in your career you might not want to be operating ten hours a day or seeing fifty patients a day. If you leverage your skillset too much into the future, your bank account values may never catch up.

Lifestyle inflation that exceeds earning capability

Another group of my medical school classmates were incredibly cost-conscious during school. They ate ramen, supermarket spaghetti, moonlighted in the ER, and bought used clothing. They let loose the financial reins slightly during residency, but transformed into new people in their first job.

I love waiting in line so that I can spend more on a handbag

Mega mansion, three new Audis, designer clothing, and top-quality organic hired home chefs, all within the first year of her first job.  Suddenly that old Crate & Barrel dining table is no longer adequate for breakfast. It’s not clear to me how a granite-topped dining table is any better than a wooden or glass one, unless you’re comparing yourself to Napoleon (who also ate from a granite-topped table).

This is an extreme case, but it doesn’t truly take much lifestyle inflation to exceed your earning capability.  Just because you have a six-figure salary doesn’t mean that you can sustain six-figure expenses indefinitely.  It takes quite a bit of financial reserve in order to generate out a six-figure annual bill when you stop practicing medicine.

Have you been guilty of any of these financial follies?