If you could go back in time, would you still choose psychiatry? If still psych, would you have done anything different about your career?

[G Sheb]

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Do you mind sharing your set up for 300+.
I’m trying to break past 250 but encountering a lot of resistance.

I pick up moonlighting shifts in a number of hospitals while building a small PP on the side.
Granted, this is more likely to work in a large metro area where there's a ton of demand and it's an unusual setup that not many are willing to go for, but it works for me.
I imagine there are even sweeter setups if you're willing to live more frugally. Or Telepsych + iiving in low COL area outside the US. There's nothing stopping you.


My point though, is I can't imagine myself complaining when I see what other people have to toil through to make a living. Especially when you add job stability through covid.
Even those who are hitting much higher numbers, my experience is that they are mostly workaholics with a lot of passion perhaps, but not much freedom. Everything's at a cost.

 

[Merovinge]

I pick up moonlighting shifts in a number of hospitals while building a small PP on the side.
Granted, this is more likely to work in a large metro area where there's a ton of demand and it's an unusual setup that not many are willing to go for, but it works for me.
I imagine there are even sweeter setups if you're willing to live more frugally. Or Telepsych + iiving in low COL area outside the US. There's nothing stopping you.


My point though, is I can't imagine myself complaining when I see what other people have to toil through to make a living. Especially when you add job stability through covid.
Even those who are hitting much higher numbers, my experience is that they are mostly workaholics with a lot of passion perhaps, but not much freedom. Everything's at a cost.

I'd actually say that's pretty typical to get into small PP. Options are either A) piggy back off another doc or group of doctors, you get the experience and some referrals, they get 20-30% of your gross. B) You figure it out on your own while working part time/locums somewhere else.

 

[Marasmus1]

I missed the social aspect of residency. It felt like college to me again. My program was chill. Maybe 40 hrs year 1 and 2, 35 hrs year 3 and sub 20 in year 4 no call. I went out thur-sat always most of that time. However, i don't miss other aspects of it including bickering and meetings due to complaints etc about various things. Having a PP near a place like that while being able to attend grand rounds would maybe be an ideal set up to have the best of both.

I am about to be an attending in 6 months. Does that bickering continue as an attending ? I am in a very small program where attendings have so much time. That leads to a lot of bickering and things getting blown out of proportion. I do enjoy the camaraderie but I feel like I have been at the bottom of the food chain in residency/fellowships. I wonder if that continues as an attending? I would hate that and very likely do Locums with side PP for the rest of my career.

 

[whopper]

I love what I do. I'd go into psychiatry again. If this is a time-travel question I'd just jump into private practice cause I'd already have the knowledge I have now. Said this before, but I recommend new graduates still focus on fostering their growth as a physician and that usually means working in academia although there are exceptions. Don't work in a bad academic place. Work in a great one where you're surrounded by the best. You'll be able to continue to grow. If you work in a bad academic setting the potential to learn is diminished.

I am about to be an attending in 6 months. Does that bickering continue as an attending ? I am in a very small program where attendings have so much time. That leads to a lot of bickering and things getting blown out of proportion.

Pretty much every hospital I've seen has bickering. Even if your department gets along well you'll have bickering with consultants coming to your floor, bickering while you're doing consults (as I said in a different thread I've never seen psych consults organized well ever out of over 20 hospitals). I remember other physicians openly saying psychiatry is bull$hit and when they needed a psych consult they'd be begging us for help. So we'd help them, they'd be happy for like an hour and then start saying psychiatry is a bull$hit field again.

It's one of the reasons why I like private practice. While I have to deal with some bickering it's nothing on the order of what I saw in the hospital.

Also, and I hate saying this, most of the hospitals I've worked in I had several problems because there were often times several bad psychiatrists and you had work alongside of them. E.g. some guy would do a lousy admission and the new patient is transferred to your unit with a 1 sentence HPI on their H&P, a pathetic MSE, and this guy does this over and over and the institution won't fire him. The only two times I worked at a place where I didn't have to deal with fellow psychiatrists doing poor work were top institutions. Expect this to happen in most places.

 

[allantois]

I don't know if I would do psych again. It's kind of weird to be one of the handful of non-EM or non-PCP specialties where patients (and/or their families) occasionally yell at me because... reasons, as well as demand specific drugs.

Unless you work in pathology or radiology I think there is a high change patients may still yell at you or demand certain things

 

[tr]

knowing what I know now, I would have studied to become a software engineer. Making $250k plus some nice bonuses or stock options, with the freedom to travel and work from wherever I am.

No way. My spouse is a computer engineer (has done both hardware and software) and those people have to stay on their toes. They are all constantly retraining and updating their skills just to keep up with the state of the art. Plus there is so much volatility among the tech companies, you have to be really good at sniffing out the bust ahead of time and fleeing for greener pastures before the hammer falls.

He has generally made more money than I have but that's because he's more focused on money than I am (I do low-paid, flexible academics), and also very good at what he does. It would be much easier and more straightforward and reliable to make any given target yearly income as a psychiatrist than as an engineer. You wouldn't even have to be a particularly good psychiatrist, whereas it seems like you do have to be a pretty good engineer to do well. I mean, I think I'm a pretty good psychiatrist but I don't get paid any more than if I were a bad one.

The only exception is that the sky's the limit for a tech person who starts or gets in early on a successful company. But that's an extremely small fraction of the population and not something you could guarantee.

And the remote work thing is now 100% possible for psychiatry, if that's your bag.

 

[Desired Member]

Or Telepsych + iiving in low COL area outside the US. There's nothing stopping you.

I thought we couldn't see patients in the US when we are outside the US?

 

[TexasPhysician]

I thought we couldn't see patients in the US when we are outside the US?

Medicare and Medicaid are typically against this. I haven’t seen this affect other patients.

 

[MacDonaldTriad]

No regrets. It's objectively the most interesting field. Lifestyle is good. All the sacrifices you make are for medical education in general, not psych specifically.

Amen TheRightMedication. The right medication may seem like our mantra, but it isn't. We offer a lot and are and are not appreciated for what we do at times. We belong in the trust that includes doctorates of medicine. All those that see this differently can go F&$#m themselves quite frankly. At least this is the way I see this.

TexasPhysician, I agree with the mission of Medicare and Medicaid you mention, but "affecting other patients" vs. effecting human lives is are different things.

 

[whopper]

What are the exceptions?

Extremely low pay, the place is not a good academic place, there are no specific attendings willing to further mentor you, a lack of collegiality among your peers.

 

[tr]

I thought we couldn't see patients in the US when we are outside the US?

My understanding of this is that you can be located anywhere, but you must be licensed in the state where the patient is located at the time of the visit.

 

[vanfanal]

No way. My spouse is a computer engineer (has done both hardware and software) and those people have to stay on their toes. They are all constantly retraining and updating their skills just to keep up with the state of the art. Plus there is so much volatility among the tech companies, you have to be really good at sniffing out the bust ahead of time and fleeing for greener pastures before the hammer falls.

He has generally made more money than I have but that's because he's more focused on money than I am (I do low-paid, flexible academics), and also very good at what he does. It would be much easier and more straightforward and reliable to make any given target yearly income as a psychiatrist than as an engineer. You wouldn't even have to be a particularly good psychiatrist, whereas it seems like you do have to be a pretty good engineer to do well. I mean, I think I'm a pretty good psychiatrist but I don't get paid any more than if I were a bad one.

The only exception is that the sky's the limit for a tech person who starts or gets in early on a successful company. But that's an extremely small fraction of the population and not something you could guarantee.

And the remote work thing is now 100% possible for psychiatry, if that's your bag.

Interesting. Thanks for the perspective. Helps clear up the whole grass is greener thing.

 

[Merovinge]

No way. My spouse is a computer engineer (has done both hardware and software) and those people have to stay on their toes. They are all constantly retraining and updating their skills just to keep up with the state of the art. Plus there is so much volatility among the tech companies, you have to be really good at sniffing out the bust ahead of time and fleeing for greener pastures before the hammer falls.

He has generally made more money than I have but that's because he's more focused on money than I am (I do low-paid, flexible academics), and also very good at what he does. It would be much easier and more straightforward and reliable to make any given target yearly income as a psychiatrist than as an engineer. You wouldn't even have to be a particularly good psychiatrist, whereas it seems like you do have to be a pretty good engineer to do well. I mean, I think I'm a pretty good psychiatrist but I don't get paid any more than if I were a bad one.

The only exception is that the sky's the limit for a tech person who starts or gets in early on a successful company. But that's an extremely small fraction of the population and not something you could guarantee.

And the remote work thing is now 100% possible for psychiatry, if that's your bag.

Absolutely true that people need to be aware of the standard deviation of lifestyle and income and not just stories of FAANG upper level tech jobs. Medicine is so incredibly resilient of a career, particularly in psychiatry where I can closes my eyes, throw a dart at the map of the US and make 300k in that city. My SO is in a much smaller specialty than psychiatry and while there is still significant demand for their work, it was significantly more arduous to find an ideal job.

As an aside your post is making me think you are not a 65 year old man smoking a cigar when responding which is really ruining my experience reading your other posts 🤣.

 

[hallowmann]

My understanding of this is that you can be located anywhere, but you must be licensed in the state where the patient is located at the time of the visit.

This is true regarding billing private insurance in most states (some require licensure in both where you are and where the patient is). Medicare/Medicaid often requires being in the US. The bigger issue is finding a malpractice provider that will cover you physically being in other countries, while seeing patients in the US. These are usually harder to come by.

 

[clausewitz2]

He has generally made more money than I have but that's because he's more focused on money than I am (I do low-paid, flexible academics), and also very good at what he does. It would be much easier and more straightforward and reliable to make any given target yearly income as a psychiatrist than as an engineer. You wouldn't even have to be a particularly good psychiatrist, whereas it seems like you do have to be a pretty good engineer to do well. I mean, I think I'm a pretty good psychiatrist but I don't get paid any more than if I were a bad one.

Software engineers talk about the difference between a regular engineer and a "10x engineer". Not only do you have to be pretty good to get paid well, other people can tell if you are doing a good job or not. In psychiatry, sure, other mental health folks might be able to tell if you are phoning it in, but there are very few measurable metrics someone can use to demonstrate you are, in fact, bottom quartile. So you can get paid just as much for just as long being a cr**py psychiatrist.

Also, I have a couple of patients who in the process of trying to get start-ups off the ground. Hard pass, the lifestyle sounds absolutely hellacious.

 

[TheRightMedication]

I agree with the above, it's important to remember that the alternative to being a physician is just another job.

Or an entrepreneur, but it's been hard enough for me to build a business where the product is a service I provide directly, with minimal infrastructure, a relatively simple regulatory environment, and guild protection. I don't see myself developing the next killer app or product.

 

[FlowRate]

It's hard to know if I would do something differently if I only got one "do-over." There are a lot of variables involved. If I got a free retry and could revert back to my current life if I was unhappy then 100% I would have pursued software development/gotten in on the ground floor of the machine learning boom. This is something I am interested in and actually know that I'm reasonably good at/able to self teach to a good standard (published on applied ML during med school, always very facile with data/math/programming/engineering.) It also helps that I actually really enjoy data/programming quite a bit. Why don't I do it now? Opportunity cost, risk aversion, and I enjoy my current day to day well enough to not be convinced that the alternative would be that much better.

 

[emergentmd]

I find this fascinating and I am EM. Almost everyone here said they Love Psych and would do it again. If you pose the same question on the EM board, you would get about 10% that are happy with their choice. Maybe this is just due to SDN bias as the becker review shows only a 13% satisfaction edge to Psych.

29 specialities with the highest, lowest job satisfaction - Becker’s ASC

Dermatologists have the highest job satisfaction among 29 medical specialties, while internal medicine physicians have the lowest, according to a 2022 speciality report from Medscape.

www.beckersasc.com

 

[emergentmd]

Take a physician that could contribute $150k+ toward investments/retirement. While contributing a fair amount to low risk mutual funds, some of that $ could go toward real estate, starting a business, franchise, or other possibilities. While there is higher risk, physicians have the time and earnings to take some risks for larger rewards.

I agree with this. If a doc puts away 20% of their income yearly for 20 yrs, they will have more than enough to retire. If this is all you care about and want passivity, then this is it.

My goal is to create passive income where when I stop working and get out of medicine completely, I will have 3-500K in passive income without selling anything.

To do this, you must get into something you own be it a business, real estate, syndication, oil wells, etc... As a physician, you have enough extra cash to take more risks and with it come greater rewards.

 

[forchinet121]

I agree with this. If a doc puts away 20% of their income yearly for 20 yrs, they will have more than enough to retire. If this is all you care about and want passivity, then this is it.

My goal is to create passive income where when I stop working and get out of medicine completely, I will have 3-500K in passive income without selling anything.

To do this, you must get into something you own be it a business, real estate, syndication, oil wells, etc... As a physician, you have enough extra cash to take more risks and with it come greater rewards.

You have that already though don’t you? If I recall you make 1M+ from owning an emergency department passively?

 

[Merovinge]

I agree with this. If a doc puts away 20% of their income yearly for 20 yrs, they will have more than enough to retire. If this is all you care about and want passivity, then this is it.

My goal is to create passive income where when I stop working and get out of medicine completely, I will have 3-500K in passive income without selling anything.

To do this, you must get into something you own be it a business, real estate, syndication, oil wells, etc... As a physician, you have enough extra cash to take more risks and with it come greater rewards.

You absolutely do not need to doing any of those things to have passive income. You can withdraw money from an investment portfolio at a lower percentage indefinitely or near indefinitely. Now if you really want 300-500k to spend/year in today's dollars that would be hard to achieve, but a 4% drawn down on 5 million invested is 200k/year which is certainly attainable for a number of doctors.

Our higher earning potential makes taking risk less necessary to reach financial goals, it's the opposite of what is being espoused here. Unless you view money as a race to a high score and/or do not believe in the concept of enough, most doctors who are happy working full time for 20 or more years should absolutely be avoiding risk and just socking away as much as they can in broad market index funds.

 

[Iamnew2]

This reminds me of that scene in Boston Legal where a quirky associate is suing the firm for not making partner and at one the defense lawyer asks 'How much would X be expected to make over the next year?' and the named partner replies 'About $300 000". The defense lawyer ironically replies 'Wow, a real coalmine over at Crane, Poole and Schmidt'. Any job where meeting the basic qualifications guarantees an income that is that high is a better career part than what 99% of people will ever be able to pursue. I am sure excellent electricians can do better but to suggest that medicine is somehow a toxic profession is to shift the Overton window in the extreme.

Haha! I remember that episode, that was the slightly odd-ball attorney who wanted to make partner but couldn't! I at times remember that episode and wish I had gone into law. Seems less BS, lawyers make up their bills charging you several times a day with no qualm and then giving you some BS about how their charges are appropriate, charging like 300 bucks an hour.

 

[Candidate2017]

Unless you work in pathology or radiology I think there is a high change patients may still yell at you or demand certain things

Inpatient psychiatrists get yelled at almost daily. Outpatient, maybe once or twice a week, in addition to the onslaught of demands for controlled substances. This is way more than most IM subspecialties (cards, onc, ID, pulm, etc) and surgical specialties (ENT, ophtho), as well as gas.

Psych, EM, FM/IM, pain, OB, sometimes peds... these are the specialties that get randomly yelled at. No new eval ever shows up to a cardiologist asking to be diagnosed with CHF and demanding scripts for "mah hydrochlorothiazide for mah HFpEF" because "that's the only thing that works, I know I have HFpEF because I tried my friend's HCTZ and felt great!"

 

[ObsequiousAplomb]

Inpatient psychiatrists get yelled at almost daily. Outpatient, maybe once or twice a week, in addition to the onslaught of demands for controlled substances. This is way more than most IM subspecialties (cards, onc, ID, pulm, etc) and surgical specialties (ENT, ophtho), as well as gas.

Psych, EM, FM/IM, pain, OB, sometimes peds... these are the specialties that get randomly yelled at. No new eval ever shows up to a cardiologist asking to be diagnosed with CHF and demanding scripts for "mah hydrochlorothiazide for mah HFpEF" because "that's the only thing that works, I know I have HFpEF because I tried my friend's HCTZ and felt great!"

Wait why are your outpatients yelling at you or your staff? Why are you tolerating that?

I let patients yell TO me all the time. If they ever yell AT me then I enforce the boundary and nobody's ever done it twice without being fired.

If patients are yelling at you then you either accept inappropriate referrals, haven't trained the staff adequately, are (most likely inadvertently) reinforcing them yelling at you, or telling them "no" in a way that's too emotionally charged. I tell people "no" for inappropriate things all the time and they never yell at me for it. The only time patients repeatedly have yelled at me has been hospitalized patients who were yelling at someone before I was called to talk to them. I don't think that I'm especially talented, this shouldn't be too hard to obtain.

Sure, the patients might be unhappy. They might have some waterworks. They might sound exasperated or desperate. They sure as hell don't yell at me.

 

[FlowRate]

My goal is to create passive income where when I stop working and get out of medicine completely, I will have 3-500K in passive income without selling anything.

To do this, you must get into something you own be it a business, real estate, syndication, oil wells, etc... As a physician, you have enough extra cash to take more risks and with it come greater rewards.

These things often aren't really "passive" income--they're another job/business you own. Maybe some people get certain business ventures to a point where they require a low personal time commitment, but true passivity is probably more akin to skimming off of your investment returns.

 

[allantois]

Thankfully I’ve never gotten yelled at (maybe being a tall male helps). Demanded controlled substances? Sure, all the time

 

[Meyer-Overton]

These things often aren't really "passive" income--they're another job/business you own. Maybe some people get certain business ventures to a point where they require a low personal time commitment, but true passivity is probably more akin to skimming off of your investment returns.

Yeah I mean most good things require at least some work or effort, at least on the front end to get the ball rolling. Personally I find researching and analyzing real estate deals moderately enjoyable

 

[emergentmd]

You absolutely do not need to doing any of those things to have passive income. You can withdraw money from an investment portfolio at a lower percentage indefinitely or near indefinitely. Now if you really want 300-500k to spend/year in today's dollars that would be hard to achieve, but a 4% drawn down on 5 million invested is 200k/year which is certainly attainable for a number of doctors.

Our higher earning potential makes taking risk less necessary to reach financial goals, it's the opposite of what is being espoused here. Unless you view money as a race to a high score and/or do not believe in the concept of enough, most doctors who are happy working full time for 20 or more years should absolutely be avoiding risk and just socking away as much as they can in broad market index funds.

I use the term somewhat loosely but passive income is a vehicle that keeps producing income without selling any of the assets.

You could do stocks too if you have dividend producing stocks. I include business ownership where you do little work and take profit. Apt syndications with dividends. Rental properties with cash flow. I like for my assets to keep appreciating but never selling it.

Everyone's goal is different. Some just want enough to have a comfortable life til they die, some want an affluent life til they die. I want to give my kids a large inheritance when I pass away so hopefully my assets will produce 500k-1M when I pass away and have my kids continue the legacy.

 

[psychmd03]

Thankfully I’ve never gotten yelled at (maybe being a tall male helps). Demanded controlled substances? Sure, all the time

Dang I wish. That is impressive supposedly I am a fairly large and tall male on IP they seemingly dont hesitate to threaten me or yell luckily no one has committed to a swing yet. Benzos and stimulants are a hard no for me always. It makes it much easily I never have to think I just say too bad, you will not be discharging with those.

 

[allantois]

Dang I wish. That is impressive supposedly I am a fairly large and tall male on IP they seemingly dont hesitate to threaten me or yell luckily no one has committed to a swing yet. Benzos and stimulants are a hard no for me always. It makes it much easily I never have to think I just say too bad, you will not be discharging with those.

This is on the outpatient side.. No one should be getting yelled on the outpatient side.. I guess unless they work at the VA or somewhere they can't discharge patients for inappropriate conduct

 

[emergentmd]

These things often aren't really "passive" income--they're another job/business you own. Maybe some people get certain business ventures to a point where they require a low personal time commitment, but true passivity is probably more akin to skimming off of your investment returns.

You are correct. But most businesses, you can eventually cut down on active management but still reap some rewards.

My medical business is quite active right now b/c I still enjoy medicine but I could completely stop working tomorrow, never go to any meetings, never answer an email/call, essentially go off grid and will make 50% of my current income.

I have 9 rental properties and quasi active. I probably spend 10 hrs/month visiting the homes, doing small odd jobs, setting new properties up, answering emails as 7/9 have property managers. I could drop this down to 5 hrs/month if I get all my properties under management but then I take a further hair cut.

I am very fortunate that I could quite medicine tomorrow and my passive income would still be more than most docs make but I still enjoy medicine, real estate management, and still want to grow my portfolio. Plus I just turned 50 and still want to wake up with something to challenge me. My current project/hobby is overseeing a major renovation with architecture plans/roof reframing/adding 1000sqft.

 

[emergentmd]

You have that already though don’t you? If I recall you make 1M+ from owning an emergency department passively?

I fortunately do and very blessed to have things go my way. The Medical ownership is capped for me as I do not want to venture into any more ownership. I have shifted my cash flow into syndications and real estate.

 

[ArdorAyurveda]

I agree with this. If a doc puts away 20% of their income yearly for 20 yrs, they will have more than enough to retire. If this is all you care about and want passivity, then this is it.

My goal is to create passive income where when I stop working and get out of medicine completely, I will have 3-500K in passive income without selling anything.

To do this, you must get into something you own be it a business, real estate, syndication, oil wells, etc... As a physician, you have enough extra cash to take more risks and with it come greater rewards.

My plan is to start my own private practice, get into commercial real estate (REITs perhaps? not sure what the difference is), and dividends off my portfolio...I still have a lot to learn but having multiple income streams is a must

 

[TheRightMedication]

I admire your industry but I don't think "multiple income streams is a must." You can live a very happy life as a physician on your one income. I think thats relevant to the OP - you can make a good living doing psychiatry. Yet also, you can free up the time to pursue more wealth if thats something you value, which is another good thing about psychiatry.

 

[Meyer-Overton]

There are those of us who want to make a good living and there are those of us who want to be rich. If you want the latter you need income streams outside of clinical work.

 

[Merovinge]

There are those of us who want to make a good living and there are those of us who want to be rich. If you want the latter you need income streams outside of clinical work.

If you want to be proper Rich with a capital R, choosing to go into medicine was a grave mistake and psychiatry even graver. Outside of hitting the jackpot on sale of a RTC/PHP/IOP (which we are already probably out of the window for following the sale of Newport or multiple sales of Eating Recovery Center) I do not see why you would choose psychiatry. Maximizing income in medicine almost always comes at the cost of harm to other people along the way. I have known two doctors who ran incredible scams with fraudulent billing, both are currently in prison, however even in their hayday they barely made more than one of my friends who is as up-and-up of a neurosurgeon as you can be. I think these folks were apt to scam/cheat in whatever industry they ended up in and unfortunately they ended up in medicine.

Separately, I think you will be hard pressed to explain to doctors that make low 7 figures a year in clinical practice why they need multiple income streams. Outside of the significant outliers, most work an MD does pays less per hour than clinical work, it's one of the curses we have as one of the highest reimbursement/hour jobs on Earth. Picking up extra shifts or changing jobs to a higher paying one is usually the right move if finances were the only consideration.

I use the term somewhat loosely but passive income is a vehicle that keeps producing income without selling any of the assets.

You could do stocks too if you have dividend producing stocks. I include business ownership where you do little work and take profit. Apt syndications with dividends. Rental properties with cash flow. I like for my assets to keep appreciating but never selling it.

Everyone's goal is different. Some just want enough to have a comfortable life til they die, some want an affluent life til they die. I want to give my kids a large inheritance when I pass away so hopefully my assets will produce 500k-1M when I pass away and have my kids continue the legacy.

This is a common misconception from a lot of people, dividend stocks simply force you to sell off a percentage of themselves every time they kick out dividends. There is no difference between selling 2% of your shares annually vs receiving a dividend in the same amount other than that automation of the process (and frankly the process takes a few minutes these days). Dividends have pros/cons as far as corporate governance/strategy, but at the individual investor level they do not differ.

If you are trying to kick an 8 figure inheritance to your kids (which would be needed to produce 500-1000k annually) then I agree that taking more risk is needed to meet that goal. I would be very interested to hear your thought process on why you want to do this. Most folks of affluence I know are aware of the data on what inheriting that type of money does to a person and are looking for ways to teach their kids how to make a go of it themselves rather than trust fund their way through life. Personal finance will always be personal, but as any good empiricist and parent, I would look to see what will actually maximize the outcomes you want for your children.

 

[forchinet121]

If you want to be proper Rich with a capital R, choosing to go into medicine was a grave mistake and psychiatry even graver. Outside of hitting the jackpot on sale of a RTC/PHP/IOP (which we are already probably out of the window for following the sale of Newport or multiple sales of Eating Recovery Center) I do not see why you would choose psychiatry. Maximizing income in medicine almost always comes at the cost of harm to other people along the way. I have known two doctors who ran incredible scams with fraudulent billing, both are currently in prison, however even in their hayday they barely made more than one of my friends who is as up-and-up of a neurosurgeon as you can be. I think these folks were apt to scam/cheat in whatever industry they ended up in and unfortunately they ended up in medicine.

Separately, I think you will be hard pressed to explain to doctors that make low 7 figures a year in clinical practice why they need multiple income streams. Outside of the significant outliers, most work an MD does pays less per hour than clinical work, it's one of the curses we have as one of the highest reimbursement/hour jobs on Earth. Picking up extra shifts or changing jobs to a higher paying one is usually the right move if finances were the only consideration.


This is a common misconception from a lot of people, dividend stocks simply force you to sell off a percentage of themselves every time they kick out dividends. There is no difference between selling 2% of your shares annually vs receiving a dividend in the same amount other than that automation of the process (and frankly the process takes a few minutes these days). Dividends have pros/cons as far as corporate governance/strategy, but at the individual investor level they do not differ.

If you are trying to kick an 8 figure inheritance to your kids (which would be needed to produce 500-1000k annually) then I agree that taking more risk is needed to meet that goal. I would be very interested to hear your thought process on why you want to do this. Most folks of affluence I know are aware of the data on what inheriting that type of money does to a person and are looking for ways to teach their kids how to make a go of it themselves rather than trust fund their way through life. Personal finance will always be personal, but as any good empiricist and parent, I would look to see what will actually maximize the outcomes you want for your children.

I would venture to say the vast majority of people commenting have not considered the topic in as much depth as you and simply want to “be very rich” whatever that means so enough is never enough

 

[Meyer-Overton]

Separately, I think you will be hard pressed to explain to doctors that make low 7 figures a year in clinical practice why they need multiple income streams. Outside of the significant outliers, most work an MD does pays less per hour than clinical work, it's one of the curses we have as one of the highest reimbursement/hour jobs on Earth. Picking up extra shifts or changing jobs to a higher paying one is usually the right move if finances were the only consideration.

My point is that it would be dumb and cowardly not to take some risks when you have that level of income at your disposal given the potential upside. Let's assume the high earning physician above has 400k to invest per year after he pays for all the things he +/- his family need and want for the year. Should he dump it all into index funds? That would be okay, but I think there is a lot of missed opportunity by not allocating a certain percentage (which would depend on individual risk tolerance) of that capital to investments with higher potential returns.

And regarding choosing medicine or psychiatry specifically as a path to becoming rich, I agree. Sometimes we don't make the best decisions throughout the course of our life or the decisions that align best with our goals, but we can still choose to make the most of whatever situation we happen to be in.

I agree with Emergent. If he wants to build an empire that his kids can eventually expand on and also reap the benefits I don't see an issue with that.

 

[ArdorAyurveda]

What's wrong with pushing myself to make as much money (in an ethically palatable) as possible?

What if I don't simply want "a good living"? What if I want a living that is quantifiably superior?

An empiricist would tell me that all I "need" to have a good life is 80k/yr salary, a healthy partner, weekly attendance at religion, 2.5 hours of exercise per week, and having a high degree of social connectedness.

I'm a combination of an Epicurean, a nihilist, and Type A overachiver.

I personally want to see what I am capable of. I don't want to make only 250k/yr, and just be satisfied with that.

I want the challenge of starting my own business, I want the excitement of at least attempting to shoot through the stratosphere, even if that means that I don't succeed, even if it means that I "fail" by other people's standards.

For me it's more about the journey than it is about the end result. I'm not doing this so that my kids live comfortably, I'm doing it because I can, and I deem it a worthy pursuit based on my own vision for my life, not what some scientific, case-controlled clinical trial tells me is good for myself.

 

[finalpsychyear]

My point is that it would be dumb and cowardly not to take some risks when you have that level of income at your disposal given the potential upside. Let's assume the high earning physician above has 400k to invest per year after he pays for all the things he +/- his family need and want for the year. Should he dump it all into index funds? That would be okay, but I think there is a lot of missed opportunity by not allocating a certain percentage (which would depend on individual risk tolerance) of that capital to investments with higher potential returns.

And regarding choosing medicine or psychiatry specifically as a path to becoming rich, I agree. Sometimes we don't make the best decisions throughout the course of our life or the decisions that align best with our goals, but we can still choose to make the most of whatever situation we happen to be in.

I agree with Emergent. If he wants to build an empire that his kids can eventually expand on and also reap the benefits I don't see an issue with that.

What exactly is rich defined at in this convo? if its 5-10m during a career 150k-200k through 401k, hsa, and after tax money isn't that crazy esp if you have a working spouse. Over 20 years at 7 percent you hit that range just in index funds i think? And 20 years takes most to early 50s.

 

[Merovinge]

What's wrong with pushing myself to make as much money (in an ethically palatable) as possible?

What if I don't simply want "a good living"? What if I want a living that is quantifiably superior?

An empiricist would tell me that all I "need" to have a good life is 80k/yr salary, a healthy partner, weekly attendance at religion, 2.5 hours of exercise per week, and having a high degree of social connectedness.

I'm a combination of an Epicurean, a nihilist, and Type A overachiver.

I personally want to see what I am capable of. I don't want to make only 250k/yr, and just be satisfied with that.

I want the challenge of starting my own business, I want the excitement of at least attempting to shoot through the stratosphere, even if that means that I don't succeed, even if it means that I "fail" by other people's standards.

For me it's more about the journey than it is about the end result. I'm not doing this so that my kids live comfortably, I'm doing it because I can, and I deem it a worthy pursuit based on my own vision for my life, not what some scientific, case-controlled clinical trial tells me is good for myself.

There is absolutely nothing "wrong" with starting your own business. Shoot for the moon and do your thing, as long as it's not coming at the cost of human lives it's likely a net positive for the world. That's very different than stating that other people should do this or are making a mistake by not doing so in medicine.

 

[clausewitz2]

What if I want a living that is quantifiably superior?

I'm a . . . nihilist. . .

These things do not go together.

 

[Merovinge]

My point is that it would be dumb and cowardly not to take some risks when you have that level of income at your disposal given the potential upside. Let's assume the high earning physician above has 400k to invest per year after he pays for all the things he +/- his family need and want for the year. Should he dump it all into index funds? That would be okay, but I think there is a lot of missed opportunity by not allocating a certain percentage (which would depend on individual risk tolerance) of that capital to investments with higher potential returns.

And regarding choosing medicine or psychiatry specifically as a path to becoming rich, I agree. Sometimes we don't make the best decisions throughout the course of our life or the decisions that align best with our goals, but we can still choose to make the most of whatever situation we happen to be in.

I agree with Emergent. If he wants to build an empire that his kids can eventually expand on and also reap the benefits I don't see an issue with that.

In your scenario, let's say this very successful doc somehow has 400k after expenses/tax to allocate over a 20 year career, 8 million dollars.

Option A is you take a very stable approximately 7% rate of return on that money and come out with a very comfortable 8 figure amount without spending any time (your most valuable resource) on alternative high risk investments. You could fully automate to a whole world or whole us index with each paycheck and spend 5 minutes/year on your investing.

Option B is you take a much wider standard deviation of outcomes in which you can lose all of the alternative investments and have whatever you have left in safer investments OR a huge hit and say you have now double option B.

The expected value of A, even separately from the time spent necessary to choose option B is much better. You both add risk that you don't need to take and face the stone cold truth that marginal value keeps dropping with every dollar gained. I am really not sure what you get with 30 million that you don't with 15.

Now if you want to swing for the fences because you like to swing for fences, then do it. But to think that you are somehow missing out by simply investing in the markets is just absolutely and fundamentally not the case.

 

[SmallBird]

My point is that it would be dumb and cowardly not to take some risks when you have that level of income at your disposal given the potential upside. Let's assume the high earning physician above has 400k to invest per year after he pays for all the things he +/- his family need and want for the year. Should he dump it all into index funds? That would be okay, but I think there is a lot of missed opportunity by not allocating a certain percentage (which would depend on individual risk tolerance) of that capital to investments with higher potential returns.

And regarding choosing medicine or psychiatry specifically as a path to becoming rich, I agree. Sometimes we don't make the best decisions throughout the course of our life or the decisions that align best with our goals, but we can still choose to make the most of whatever situation we happen to be in.

I agree with Emergent. If he wants to build an empire that his kids can eventually expand on and also reap the benefits I don't see an issue with that.

Your question is an empirical one and actually the evidence is that index funds are on average going to generate the biggest return. There are other investment strategies that could have greater returns but increased risk of major loss - yes, some people make a fortune in real estate but the average is brought down by people who make nothing and lose everything. There is no investment strategy that on average is a better option that suddenly becomes available when one is a high earner. The consequences of an investment going badly is smaller if you have more money but I find that to be a very poor argument to pursue high risk investing.

 

[calvnandhobbs68]

I'm a combination of an Epicurean, a nihilist, and Type A overachiver.

Did you type this sipping your handcrafted tea in the middle of the student union with your laptop dramatically placed on top of a thick philosophy text while also making sure everyone can see your open First Aid for Step 1 book with a zillion tiny notes furiously scribbled in the margins?

 

[Meyer-Overton]

Alright. I think some of us just have different desires and different worldviews so this is going to be my last argument. I am going to give a simplified scenario as food for thought.

Lets take 2 people who each have 150k to invest per year over a 25 year long career. Person A takes what I will call the "safe route" and invests alll 150k into index funds. Lets assume a reasonable yearly return of 7% over that horizon. This person, assuming they started with nothing and don't receive a large windfall, will end up with ~9.5 million at year 25.

Now person B. This person takes what I will call the "courageous route" and allocates 2/3 of his funds in index funds at 7% and 1/3 into well researched yet riskier investments (real estate, business ventures, whatever). Scenario 1 is this person's 100k invested into index funds returns 7% and their 50k invested per year is an absolute failure. They lose every cent of it every year. At year 25 this person will have ~6.3 million. I would argue that there is not a significant difference in qol in retirement on 6.3 M vs 9.5 M that person A achieved. However, lets say person B was successful and achieved an average 20% return on his riskier investments, which is actually doable with research and due diligence. Person B will have roughly 29.8 million at year 25 or at least cash flows from investements that would extrapolate to that amount (ie the net present value would be equal). Or they could potentially stop investing earlier and retire/cut back on clinical work early if they choose.

I would personally rather swing harder and go for a home run knowing that even if I strike out i am not financially ruined rather than playing it safe and ensuring a life of mediocrity.

Sometimes we have to give up on good to get to great.

 

[sloh]

which is actually doable with research and due

Risks aside, people underestimate how much additional time this takes. We are constantly exchanging both money AND time at the best exchange rates possible

 

[sloh]

If you are trying to kick an 8 figure inheritance to your kids (which would be needed to produce 500-1000k annually) then I agree that taking more risk is needed to meet that goal. I would be very interested to hear your thought process on why you want to do this. Most folks of affluence I know are aware of the data on what inheriting that type of money does to a person and are looking for ways to teach their kids how to make a go of it themselves rather than trust fund their way through life. Personal finance will always be personal, but as any good empiricist and parent, I would look to see what will actually maximize the outcomes you want for your children.

And a staggering 70 percent of wealthy families lose their wealth by the next generation, with 90 percent losing it the generation after that.

 

[Merovinge]

And staggering 70 percent of wealthy families lose their wealth by the next generation, with 90 percent losing it the generation after that.

Which is why I would argue that for wealthy individuals trying to maximize a trust fund is one of the worst uses of time. Certainly any amount of time or effort to teach your children the value of hard work, altruism, personal finance, and how 99% of the world lives will lead to a much more successful lineage if that's the sort of thing you are after.

I'll be honest and say that I come from no money, my inheritance will be essentially nothing, which is completely fine as I make plenty to support myself and my family. My wife comes from a moderately affluent family and I go out of my way to encourage her parents to spend their money in retirement. We don't need their money, they worked very hard to earn it, and they should spend it. It will not materially impact our lives as neither of us would stop seeing patient's just because we had more money in the bank. As I've seen both sides of things, the lessons my mother taught me are worth more than a 7 figure inheritance. I will likely end up giving my progeny a low 7 figure sum but I sure recognize that time spent together and teaching what really matters is much more important than a trust fund getting transferred on death.

 

[Merovinge]

Alright. I think some of us just have different desires and different worldviews so this is going to be my last argument. I am going to give a simplified scenario as food for thought.

Lets take 2 people who each have 150k to invest per year over a 25 year long career. Person A takes what I will call the "safe route" and invests alll 150k into index funds. Lets assume a reasonable yearly return of 7% over that horizon. This person, assuming they started with nothing and don't receive a large windfall, will end up with ~9.5 million at year 25.

Now person B. This person takes what I will call the "courageous route" and allocates 2/3 of his funds in index funds at 7% and 1/3 into well researched yet riskier investments (real estate, business ventures, whatever). Scenario 1 is this person's 100k invested into index funds returns 7% and their 50k invested per year is an absolute failure. They lose every cent of it every year. At year 25 this person will have ~6.3 million. I would argue that there is not a significant difference in qol in retirement on 6.3 M vs 9.5 M that person A achieved. However, lets say person B was successful and achieved an average 20% return on his riskier investments, which is actually doable with research and due diligence. Person B will have roughly 29.8 million at year 25 or at least cash flows from investements that would extrapolate to that amount (ie the net present value would be equal). Or they could potentially stop investing earlier and retire/cut back on clinical work early if they choose.

I would personally rather swing harder and go for a home run knowing that even if I strike out i am not financially ruined rather than playing it safe and ensuring a life of mediocrity.

Sometimes we have to give up on good to get to great.

I appreciate your motivational speaker writing and there is certainly a logic behind what you are saying. Ultimately if you break it down, you are still stating that you want to add risk and spend time for it to reach a financial state that will be minimally meaningfully different. If your bank account reading 20 million is materially different to you then it reading 10 million, that it helps you achieve your life goals and actualizes you as a person, then I can definitely understand wanting to reach for that.

I suspect you will find that sustaining 20% returns annually is much more difficult than you anticipate, certainly over a multiple decade time horizon. If you do pull that off, you'll have been one of the most successful investors of all time, so I guess to that extent if you want to make the history books it does make some sense. Best of luck to you, I hope to read about this doctor who made 20% returns averaged over 25 years as I get ready to retire on a podcast and think "oh yeah, I remember that guy from SDN".