EM, where you should live, and where you want to live

[da8s0859q]

Going into my second year as an attending. Likely moving to a more EM-friendly state. No children, not married, no obligate ties to anywhere in the country.

On one hand, there's where I feel like I should live (good salaries, good medicolegal climate and reform, +/- no state income tax, decent job market, lower cost of living -- Texas and the like).

Then there's where I want to live in the sense that I prefer more seasons in my weather, wouldn't mind some mountains in my back yard, etc. Oregon, Washington, northern CA, Colorado maybe. As I understand it, legal climate sucks in the PNW; good in CO, but money often isn't.

Reminds me of the "scheduling (or group), location, salary: pick two" sayings. But for those more seasoned than I, I'm just curious: how did you reconcile this sort of thing? I pacify myself by saying that the pay raise with relatively more time off that would come with moving to a more lucrative part of the country could easily provide for relatively frequent trips to wherever I want, but I imagine it's not the same as living there.

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[PS2020]

Really interested in this topic as well. What kind of key factors do people look at when deciding if a location for a particular specialty is a good fit? Things that I considered regardless of specialty when it comes to settling at a location are income taxes, property taxes (this is a big one), weather, proximity to culture/large cities, traffic congestion, safety and maybe schools for the future kids.

When you say medicolegal climate, are you referring to things like tort reform? What else do you look out for? Are there specific legal aspects that affect EM more than other specialties? My understanding is that the #1 job issue in EM is avoiding CMG's which are predominant on the East coast. What sources do you guys use to research locations and do you look at particular states or cities?

 

[The White Coat Investor]

Money matters less as time goes on. So early on in your career, I'd lean more toward good money. Later, I'd lean more toward desired lifestyle.

Bear in mind on a physician salary with an EM schedule it is INCREDIBLY easy to visit places you find attractive. I was in the PNW last week, for instance. My wife is in Finland now. Don't assume that just because you don't live and work in a location that you can't spend significant time there if it is a major priority.

 

[hundreddaysoff]

Going into my second year as an attending. Likely moving to a more EM-friendly state. No children, not married, no obligate ties to anywhere in the country.

On one hand, there's where I feel like I should live (good salaries, good medicolegal climate and reform, +/- no state income tax, decent job market, lower cost of living -- Texas and the like).

Then there's where I want to live in the sense that I prefer more seasons in my weather, wouldn't mind some mountains in my back yard, etc. Oregon, Washington, northern CA, Colorado maybe. As I understand it, legal climate sucks in the PNW; good in CO, but money often isn't.

Reminds me of the "scheduling (or group), location, salary: pick two" sayings. But for those more seasoned than I, I'm just curious: how did you reconcile this sort of thing? I pacify myself by saying that the pay raise with relatively more time off that would come with moving to a more lucrative part of the country could easily provide for relatively frequent trips to wherever I want, but I imagine it's not the same as living there.

I'll be in a similar situation next year and taking WCI's advice right now... make hay while the sun shines, then worry about lifestyle once I'm married and have more financial independence.

And, I was originally a bicoastal kind of guy but TX really grew on me when I was there for school. If you haven't already, you might want to vacate in some of the "less desirable" places on your list and see if they become more desirable after you've been there at least a few weeks. There is lots of geographic variation within these places. If you don't need the West Coast per se, TN seems to have most of the things on your bucket list. Most of TX does have seasons... it's just that the non-summer ones are shorter than the rest of the country. West TX does have decent-sized mountains in East Coast terms, although the lack of trees and snow turn some people off.

 

[GeneralVeers]

Salary is important right now because we are essentially at an all-time historical high for salary in EM. Are we at a peak? Possibly. If I was just starting out now, I would aim to live somewhere for 3-5 years to maximize income, even if it's undesirable. If you are making $500K for 5 years, and put enough away, you can afford to take much lower rates in a "desirable" but high cost area and be quite comfortable.

 

[The White Coat Investor]

Most importantly, take jobs that promote longevity. Even if you only make $300K vs $500K, if you can work there 10 years longer and enjoy it, that's worth A LOT. Good support, good camaraderie, fair pay structure, reasonable pph, reasonable patient mix, in a place you can be happy living etc.

If you just want to live somewhere miserable for four years and have your med school debt taken care of, you could have gotten that in the military.

 

[Dane07MD]

I'll play devils advocate. Did two years in academics, making less than the majority of you. Still saved money and lived frugal. Now I'm moving to community place in Northern CA (North Bay, no less) and the pay increases, but so does the housing and cost of living, dramatically. Figure out how important things and money are to you and if it trumps living in your own paradise. There's no right answer. For me though, I found where I wanted to live and am willing to pay more for it and make less than many of you (even still in private practice...). I just don't drive anything fancy or have too many expensive habits.

 

[The White Coat Investor]

The ideal, of course, is to find somewhere you love living, with a great job, that costs significantly less than the Bay Area or Manhattan. Doesn't even have to be average or less as far as COL. Just not crazy high.

I can think of lots of places like that for me. There's a lot more between California and New York than Kansas.

 

[deleted109597]

Nuh uh

 

[bravotwozero]

Lol at the representation of jersey and Chicago on the map. That's great


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[sum dude]

If you are looking for money but want to live in PNW, should consider doing locums. Wyoming/Idaho/Montana also pay well compared to pacific coast. Most friendly state to physicians is Texas. If you want decent salary and mountains, consider NC/TN.

With that said, differences of <80k prob. won't matter much, and if you focus on making money over finding a good, enjoyable group, you will be miserable and asking where to move to in 3-4 years.

Simply put, if you can't make ends meet or be content making 300k/yr, you won't make ends meet or be content making 500k a year.

 

[n2b8me]

The ideal, of course, is to find somewhere you love living, with a great job, that costs significantly less than the Bay Area or Manhattan. Doesn't even have to be average or less as far as COL. Just not crazy high.

I can think of lots of places like that for me. There's a lot more between California and New York than Kansas.

wait, what's a Kansas?

 

[Apollyon]

wait, what's a Kansas?

Oh, ska-ka-rah-hoo you! For every "flatlander" or "flyover state" person, I tell you to "stick it"!!

 

[Mbekweni]

Also consider the effects of partnership. If you want to slave away at a high paying location for 4 years and then relocate you will likely be moving to a new partnership structure and losing out on 40-80k per year for a few years which makes the calculations even closer.

 

[Groove]

I live in the SE for the money and proximity to family and friends. Personally, I'd rather be living in CO, Hawaii, Lake Tahoe, Asheville, etc.. However, that's not economically feasible for me right now. My philosophy is that you can live damn near anywhere as long as you have good proximity to a major airport. Until you have your loans paid off and 1 mill in retirement, I'd suggest taking the job with higher pay in an area that you don't mind living. Just take a lot of vacations. Once you have the loans paid off and a reasonable start to your retirement, then I think the world opens up a bit more and you can do a bit more hunting for that dream location.

 

[GeneralVeers]

I live in the SE for the money and proximity to family and friends. Personally, I'd rather be living in CO, Hawaii, Lake Tahoe, Asheville, etc.. However, that's not economically feasible for me right now. My philosophy is that you can live damn near anywhere as long as you have good proximity to a major airport. Until you have your loans paid off and 1 mill in retirement, I'd suggest taking the job with higher pay in an area that you don't mind living. Just take a lot of vacations. Once you have the loans paid off and a reasonable start to your retirement, then I think the world opens up a bit more and you can do a bit more hunting for that dream location.

Exactly! If you can be at the airport within 30 minutes, then fly anywhere in the country it doesn't matter. On my work days, I don't have time go to the beach, hiking, or do much else. I'd rather group my days off and take a proper vacation. If you are working somewhere that reimburses well, you can pretty much take a vacation anywhere you like: NY, San Diego, Europe or even Australia. Much harder to do if you are living in a high cost/low reimbursement location. I'm taking 3 weeks off starting tomorrow to do a transatlantic cruise after a stopover on the East Coast. Good luck doing that as a full-timer with any group.

 

[bravotwozero]

Given what the above posters have said it might not be a bad idea to live in a place like Atlanta or DFW. You can easily get affordable non stop flights to pretty much anywhere from either of those two airports, and the pay for ER docs there is better than most cities in the country.


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[deleted109597]

Also consider the effects of partnership. If you want to slave away at a high paying location for 4 years and then relocate you will likely be moving to a new partnership structure and losing out on 40-80k per year for a few years which makes the calculations even closer.

This makes absolutely zero sense. It doesn't matter when you start trying to make partner. If it's year 1 or year 5, you're still working that sweat equity time.
None of the high paying places are partnerships. You aren't pulling any sweat there.

 

[dchristismi]

Second (or third?) the comment about nearby international airports. I live (and mostly work) in a smallish town. But I have 2 international airports 50 min and 1:10 away from home. Cost of living isn't bad, and I have a lovely lakefront home and a nice safe, community. I can hop on a plane and be in NYC in a couple hours.

Which reminds me, I need to book my rail tickets for this year's European 3 week extravaganza. Because in EM, you not only CAN take vacations, you should.

 

[Angry Birds]

Which reminds me, I need to book my rail tickets for this year's European 3 week extravaganza. Because in EM, you not only CAN take vacations, you should.

When you take vacations, how long do you go for, and what does the rest of your month end up looking like due to that? (A question for everybodies...)

 

[dchristismi]

So before, when I was employed (and mandated to work 120 hours a month or more), what I usually did was bunch my shifts up so that I'd have a week or more off at the end of the month, and a week or more off at the beginning of the next. The months would often suck, but that's how the cookie crumbles. I also happened to be the scheduler for several years, so that helped. Shorter vacations (a week or less) were even easier to arrange.

Now that I'm an independent contractor, I can just tell them that I can only work so many shifts and won't be available for the days I'll be gone. Now, I have also paid off my loans and have cut back to enjoy life more, so I'm not working near as much as I did as a new attending. I also don't have a terribly expensive life... I splurge on travel and the memories.

 

[Dannyboy676]

So before, when I was employed (and mandated to work 120 hours a month or more), what I usually did was bunch my shifts up so that I'd have a week or more off at the end of the month, and a week or more off at the beginning of the next. The months would often suck, but that's how the cookie crumbles. I also happened to be the scheduler for several years, so that helped. Shorter vacations (a week or less) were even easier to arrange.

Now that I'm an independent contractor, I can just tell them that I can only work so many shifts and won't be available for the days I'll be gone. Now, I have also paid off my loans and have cut back to enjoy life more, so I'm not working near as much as I did as a new attending. I also don't have a terribly expensive life... I splurge on travel and the memories.

No better way to do it.


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[BAM!]

Exactly! If you can be at the airport within 30 minutes, then fly anywhere in the country it doesn't matter. On my work days, I don't have time go to the beach, hiking, or do much else. I'd rather group my days off and take a proper vacation. If you are working somewhere that reimburses well, you can pretty much take a vacation anywhere you like: NY, San Diego, Europe or even Australia. Much harder to do if you are living in a high cost/low reimbursement location. I'm taking 3 weeks off starting tomorrow to do a transatlantic cruise after a stopover on the East Coast. Good luck doing that as a full-timer with any group.

Sure, if you have no kids then definitely live in high-paying BFE and take vacations solo or with your flexible spouse. But it's not realistic for Dad to take off for a 2 week surf trip to Bali every month.

 

[bravotwozero]

...all the more reason to live in bfe! Going out with toddlers is a mission and a half, and you won't be traveling much with them anyways. Might as well rake in the money in a low col and high pay area


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[GeneralVeers]

...all the more reason to live in bfe! Going out with toddlers is a mission and a half, and you won't be traveling much with them anyways. Might as well rake in the money in a low col and high pay area


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Exactly. What's the point on living in a beautiful place near the ocean with great weather, if you spend all the time working, or looking after young children? Live in the crappy area that pays more until the kids are old enough to be somewhat independent, then move to the more desirable area.

 

[da8s0859q]

Appreciate the input, all. I'm kidless and wifeless, and I'm still planning on moving to a higher-compensating part of the country that, while I probably wouldn't absolutely hate living, I'd still probably rather live somewhere else (better climate for me, etc). Don't think I can have my cake and eat it, too. Seems more prudent to have the extra money, be rid of remaining student loans faster, all that.

 

[BAM!]

...all the more reason to live in bfe! Going out with toddlers is a mission and a half, and you won't be traveling much with them anyways. Might as well rake in the money in a low col and high pay area


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Can't disagree more. Part of childhood is playing outside. being cooped up indoors because it's too hot for 9 months out of the year is not a quality childhood in my book. plus the schools can be lacking in BFE too. Nice climate areas are usually HCOL areas. Life's always give and take. I think if you're single and aren't tied down, then go for it -- live in an undesirable part of the country, be a work-a-holic, get a high paying job, make a ton of money for 5-10 years. If you have a few ball and chains around your legs, then better to find a job that's enjoyable which promotes longevity in a nice part of the country and take the pay cut.

 

[bravotwozero]

There are plenty of affordable cities that pay well where you can take the kids out to play year round - Houston and Atlanta (I live in the former) to name a few. Granted, they're not exactly BFE, but not the left coast or northeast either where you'll get takes over the coals.


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[deleted109597]

Part of childhood is playing outside. being cooped up indoors because it's too hot for 9 months out of the year is not a quality childhood in my book.

Literally none of those exist in the United States. Sure, maybe people shouldn't do it in Death Valley. But since the overwhelming majority of people in the parts of the world warmer than here also have way less income, they're not running the A/C in their wallless shed.
Kids can play outside when it's 100 degrees out. They've been doing it for over 1000 years.

 

[Old Grunt]

Kids can play outside when it's 100 degrees out. They've been doing it for over 1000 years.

Seriously. It's good for them.

 

[e30ftw]

Can't disagree more. Part of childhood is playing outside. being cooped up indoors because it's too hot for 9 months out of the year is not a quality childhood in my book. plus the schools can be lacking in BFE too. Nice climate areas are usually HCOL areas.

I would say the majority of low COL areas have more opportunities for playing outside than high COL areas. jmo.. urban vs rural. An urban idea of playing outside is going to the park/beach on a 70 degree day with a bunch of other kids. A rural idea is spending the entire day exploring miles of undeveloped secluded wilderness.

I lived in SoCal 4 years and prefer the climate in East TN/Appalachians.. more weather, actual seasons, very comfortable the vast majority of year and it actually rains enough to support natural life here. Not to mention more lakes/rivers/valleys/mountains/forest in my backyard than I know what to do with as well as total seclusion a few steps away..

 

[Old_Mil]

Going into my second year as an attending. Likely moving to a more EM-friendly state. No children, not married, no obligate ties to anywhere in the country.

On one hand, there's where I feel like I should live (good salaries, good medicolegal climate and reform, +/- no state income tax, decent job market, lower cost of living -- Texas and the like).

Then there's where I want to live in the sense that I prefer more seasons in my weather, wouldn't mind some mountains in my back yard, etc. Oregon, Washington, northern CA, Colorado maybe. As I understand it, legal climate sucks in the PNW; good in CO, but money often isn't.

Reminds me of the "scheduling (or group), location, salary: pick two" sayings. But for those more seasoned than I, I'm just curious: how did you reconcile this sort of thing? I pacify myself by saying that the pay raise with relatively more time off that would come with moving to a more lucrative part of the country could easily provide for relatively frequent trips to wherever I want, but I imagine it's not the same as living there.

Well, I'll tell you how I resolved it - the wrong way.

I was offered an outstanding job coming out of residency. Great pay, student loan repayment, good medicolegal climate, no state tax, low cost of living.

No matter what, I couldn't convince the wife to go there. So I turned it down and took a much worse job for geographic reasons that I ended up quitting in 6 months.

To this day, I never found anything close to what that first job out of residency had offered me...and honestly I believe it was that good because in the intervening years I've never seen it come open again.

Screw geography.

You can buy an unlimited number of airline tickets and you'll have the time off to use them.

Take it from someone who screwed that decision up.

 

[hundreddaysoff]

Well, I'll tell you how I resolved it - the wrong way.

I was offered an outstanding job coming out of residency. Great pay, student loan repayment, good medicolegal climate, no state tax, low cost of living.

No matter what, I couldn't convince the wife to go there. So I turned it down and took a much worse job for geographic reasons that I ended up quitting in 6 months.

To this day, I never found anything close to what that first job out of residency had offered me...and honestly I believe it was that good because in the intervening years I've never seen it come open again.

Screw geography.

You can buy an unlimited number of airline tickets and you'll have the time off to use them.

Take it from someone who screwed that decision up.

... but on the upside at least you're still married? ... I hope?

 

[engineeredout]

I have my sights set on a particular, basically Midwestern medium sized city. Cost of living isn't too bad, although from what I've seen while keeping an eye on things there, it is increasing as the city itself becomes more popular. Salaries there seem to be moderate (250-300k), certainly won't be making the 500K type salary with reasonable hours.

Could absolutely go elsewhere to make more money. Wife does the same thing I do. No children (except a dog). We both have a pile of loans to pay off. We've thrown the idea of going somewhere a little less interesting so we can bear down and knock those loans off faster, but after four years of med school, five years of residency, living in places that don't make us fully happy, we want to live somewhere where we are happy.

I think recently we've been seeing more and more sick and dying patients who are close to our age. Some of them did it to themselves (drugs) but others haven't. **** can happen to anyone at any time. We want to start living our lives.

 

[DocEspana]

Nuh uh

I see you took that photo from my apartment.

 

[namethatsmell]

@ engineeredout...

So between you both you'll make 5-600k/yr in a place that's not crazy expensive to live in (ie NYC, LA, DC, CHI, etc). That's plenty of purchasing power. While plenty of people on here talk about ways to make $500k/yr by living in Nowhereseville, the reality is that if you lead a reasonable lifestyle that allows you pay off your loans while saving a solid chunk of your salary each year you can live and work almost anywhere and still be in great shape for retirement. As long as you don't buy too many porsches and boats it sounds like your choice of city is a great one for you, congrats.