is 60 hours a week worth it if got you near a 7 fig salary?

Discussion in 'Psychiatry' started by finalpsychyear, Jan 5, 2019.

  1. finalpsychyear

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    Psychiatrists in my area are doing a combination of inpt, outpatient work and approaching this is what i am hearing. I asked one who claims to be hitting nearly 7 figures without a midlevel and this is what his schedule was:

    1. 630am starts Inpatient rounding on 16-18 pts taking anywhere from 5-6 hours Mon-Fri
    2. Outpatient Private practice (private insurance based only) 1230pm-6pm Mon-Fri
    3. No weekends or nights.

    Is this guy lying or is approaching this type of income with this kind of set up actually realistic without burnout?
     
  2. Bartelby

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    I would burn out. It doesn't sound pleasant to me. You also have to make sure you don't rush through substandard care for the inpatients (especially given the need to make it to clinic whether acute issues come up or not). I imagine this setup would go over 500k and could conceivably push towards 7 figures.
     
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  3. PathoTurnUp1865

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    I’ve heard 700k around my area 7-5 m-f
     
  4. Piebaldi

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    I'm not in Psych, but with anything, *anything* or just about *anything* is technically possible. There are outliers out there for all sorts of things. However you should really look at what's *realistc* and also good medical care. Sure you can work yourself to death, but is it really worth it. I'm sure if you can charge 200-300bucks per hour for therapy and have every slot filled you can make some good money. You can also work 80 hours and make even more. But a big part of life is having time to spend all that money you will be making. If you are making a bunch of money but have no time and no one to spend it with, what 's the point?
     
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    finalpsychyear

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    To retire early meaning 45-50 would be the only real benefit given you started doing something like this at 34-35 years old for maybe 10-15 years. Also 6 hours for 16-18 inpt is on the slow side. I used to see 7-8 as a resident on weekend call in 90 min granted they were all follow ups.
     
  6. Piebaldi

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    what on earth would you do by retiritng at 45-50?
     
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  7. OP
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    finalpsychyear

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    retire from full time work and just do part time so you can travel the world, video games, take classes in some other subject. The point is if you can amass and invest early on with that type of income you can probably be getting returns like 250-300k indefinitely and even more in maybe 10 years time.

    I think you need 5-6million to be getting a 250-300k yearly return assuming a 5% rate. Not sure I can ever get there but i am in my early 30s and will probably have to work for 20 years minimum assuming earning the medium psych salary and maybe not even then.
     
  8. nexus73

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    This only works on weekend coverage with no emergencies or discharges. And you’re providing garbage care. You can’t do this M-F because you won’t really know what’s going on with your patients and you’ll end up discharging people who aren’t ready.
     
  9. Piebaldi

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    Yep. 5-6hours for that many patients is unrealistic, especially if you have to do admissions, discharges, etc. it's important to actually provide care to patients.
     
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    finalpsychyear

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    6 hours of rounding is too little on a census of 16-18 if it would be at a hospital where avg length of stay 7-9 days? I could see the first day of the week like monday taking longer but def not the rest of the week once you know the majority of the patients?
     
  11. TexasPhysician

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    That sounds absolutely miserable, and the care would not be good. Hard pass.
     
  12. Merely

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    Everyone is different bro, I can tell you I’ve def seen attending work that fast and even faster..just depends on how efficient you are..whether it’s worth it or not is completely subjective and a personal preference and I’d say for most the answer is no because it’s not about money man money isn’t everything
     
  13. nexus73

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    Efficient is one way to describe it.
     
  14. Trismegistus4

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    With a census of 16-18, you're probably getting 4 admissions per day, which also means 4 discharges. So in 6 hours, you've got to conduct four complete initial psychiatric interviews on four patients who are brand new to you, dictate/type up all four H&P's, see the four discharges, dictate/type up four discharge summaries, see 8-10 follow ups, and dictate/type up 8-10 follow up notes, all of which also includes contemplating each patient's case, making decisions about any changes in treatment, and putting in orders for all 16-18 patients. All that is more than a full-time job as far as I'm concerned, let alone going and seeing an entire afternoon clinic full of patients with how mentally taxing it must have been to do all of the above in six hours. I know there are people who do it, but I honestly have no idea how, and they must be providing what I would consider substandard care.
     
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  15. Piebaldi

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    Agreed!
    I recently saw 20 inpatients (not in Psych but in inpt in my specialty), and then I saw 5 outpatients (luckily one cancelled!) I had discharges and admissions, among the follow ups. I was typing up inpt notes until 8pm!! I was fried. Occasionally sure but daily? no way. There's also no way you can attend to any emergency, or something that might come up. I spent I remember one whole freaking hour! counseling a patient on pain medication and ajusting his regimen, I spent another hour transferring a septic patient to the medical floor, etc, I spent another hour getting supplies and doing 2 procedures on the floor. No way you can see 16-18 inpts and a full outpatient clinic daily.
     
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  16. J ROD

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    The only way I see this possible with some sort of decent care is to do some of the notes at home. Plus, someone has to be on the inpatient unit or at least available during the afternoon. Also, another thing to consider is if you have a NP that could help. That would make it possible.
     
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  17. Piebaldi

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    True. But then you are spending monies on an NP/PA. Also part of the problem of us as a group - physicians that is - is that many of us have been inculcated to have nothing outside of medicine and to work work work. and the only reward in that is money, outside of the gratification obviously of helping people. but it's important to have a life outside of marriage. i speak from experience. i was a gunner in med school, matched into a competitive high paying specialty which was a horrible fit and transferred out. i was much happier with my choice. i also learned to enjoy life - i traveled to like 9 or 10 countries during residency, tried restaurants, went to shows, etc. there is life outside of medicine. even if your boss says otherwise! haha.
     
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  18. J ROD

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    The hospital would be spending the money on the NP/PA. Just saying that would make the scenario much more plausible.
     
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  19. Trismegistus4

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    :bored:

    :D
     
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  20. Georgit

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    From personal experience, I think that working part-time is the best setting, it's better than do not work at all.
    To have a work add meaning to life, with a part-time you have still all the free time you need, so it is perfect.
     
  21. futuredo32

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    My shrink works outpatient 55 hours a week and makes low 6 figures. If you like psych I would do it for a few years. Can I ask what area of the USA the job is in? Either Michigan doesn't pay well or I am not working at the right jobs. I'm happy (money wise) with 150 an hour at my clinic job and thrilled with my 1500 dollar a day once a month weekend job.
     
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  22. futuredo32

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    Where is this?
     
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  23. NickNaylor

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    That volume of inpatient work for the amount of time set aside seems completely untenable, unless you're doing a garbage level of clinical care.
     
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  24. sluox

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    It's possible. But with a 7 fig salary you are looking at an effective income of 600k even with a DBP of 225k. This seems tax inefficient. I (seriously) suggest if you really want to retire in your early 40s you do mostly 1099 income start an LLC and purchase commercial real estate on leverage. It's not too difficult to amass a commercial real estate portfolio of 3-4M by generating overall a net loss on your business. Alternatively, you can try to hire people to build a larger business -- though this would in the end be somewhat less passive (i.e. would require a medical director in your 40s to run the business).

    The government doesn't want you to work this hard on labor. It strongly wants you to re-invest labor dividends into creating jobs and as such the tax code is written in this arguably weird way where capital gain (esp. long term) is taxed at a much lower rate..
     
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  25. UTUT

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    It is true capital gains tax rate is much lower than income tax rate, but is it really better idea to own businesses through 1099 or LLC rather than through working?
    I suppose you can write off some taxes with loss from your business.

    However, consider that in businesses the risk of losing money is much higher, and making a 60% profit off your revenue is considered an excellent feat. In physician income, your are technically making 60% profit (take-home pay) off your revenue base that is your gross income. You can make 60% profit by physician salary consistently, whereas with businesses, it's hard to make 60% profit consistently and you can actually lose money.
    I don't own business personally, but I have watched many Shark Tank episodes and a 40% margin is considered wise, and a 20% profit from revenue is considered quite good.

    I think most people who went into medicine are the risk-averse, play-it-safe kind who want to make decent money with low risk of losing money. In businesses the risk of losing money is high.
    Perhaps residential real estate or the stock market are better income sources over the long term than commercial real estate or business ventures.
     
  26. OP
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    finalpsychyear

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    hmm.. .ok but to be fair if i and my future partner each had a 401k in the business i think that is an extra 110k at least right there prior to paying any tax on the rest plus 7k hsa deduction and i also think if you become an S-corp you can save some medicare tax so that is nearly an additional 130k plus the defined benefit.

    I don't think that type of lifestyle would really be sustainable for more than a few years and i think to do a DBP you need to commit 5 years or something minimum.
     
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  27. calvnandhobbs68

    calvnandhobbs68 I KNOW NOTHING
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    I didn't go to medical school but I did stay at a Holiday Inn Express last night.
     
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  28. sluox

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    This is correct.

    You want to get your future partner to also get 55k in solo 401k this requires a business income of > 200k. Approximately 0.9% of US women can achieve that level of salary according to Census data.

    Political Calculations: What Is Your Income Percentile Ranking?

    Good luck to you finding someone like that if you are single. Sounds like you are a man, and best bet is finding a female physician--but this is difficult once you are out of residency, and very very difficult if you are not living in a major city. Just a warning though: the way you think does not compute with many women. Few people find an idling retiree in their 40s sexually attractive or a good candidate as a father figure... it's admittedly a cultural bias, but don't shoot the messenger. This level of income is more easily achieved if you are a childless gay male couple in a major city, and indeed is one reason why this lifestyle is more common in that particular demographic.

    Frankly I find it curious that you are going into psychiatry to do this. Psychiatry is really the best specialty to do the OPPOSITE of this. There are plenty of excellent psychiatrists practicing well into their 70s and beyond. If you are not in a rush the work ITSELF is really fun to do, and the per hour renumeration is excellent. I find it completely defeating the purpose if you are rushing through 30 people just so you can make a million dollars and get taxed 50% after the fact. The whole point of this specialty is to slow down and get interesting stories and, in turn, manipulate people's brain chemistry (meds) and circuits (therapy) for their benefit.
     
    #28 sluox, Jan 10, 2019
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    finalpsychyear

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    Actually the solo 401k is a bit different. Even if my sig other is not a physician and lets say makes an office manager salary of 50k in my clinic for example, you can contribute close to 40k just from that salary. Sep is the one that has the 25% rule and you need an income of over 200k to hit those numbers.

    I am trying to get on the higher end of pay as a goal for two reasons.
    1) I don't know how long physician salaries or our specialty will be doing so well but even under a doomsday scenerio it is unlikely any changes will occur in the next 5-10 years at which point i'd love to be in a position where I "could" retire or work part time not that i would actually retire but just knowing that would give me an amazing amount of satisitfaction.

    2) i used to date exclusively doctors, lawyers and now probably may not end up with someone making >100k salary so I for some reason want the same lifestyle I theoretically could if i had another 100-150k working partners.
     
  30. sluox

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    Something is weird. I (seriously) suggest you talk to a therapist about this. What you are saying does not even compute in my brain, even though I can certainly appreciate your impulse and also have a high savings rate with the intent to achieve financial independence. It seems like the way you examine and appraise risk is distorted.
     
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  31. OP
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    finalpsychyear

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    The way i assess risk drives me to work harder.
    Well that is arguable. I don't think you realize that medicine is on the brink of being radically changed in just over the next decade as amazon, walmart all take it over piece by piece. The time to work and make your money is now as i promise you things are headed in a model where compensation will be largely reduced.
     
  32. AD04

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    If said retiree idles at the gym, has a luscious mane and tanned complexion, and wears a flowing white linen shirt with the top 3 buttons unbuttoned while walking barefoot along the beach after idling at the gym -- and on top of that is a secret multimillionaire ... I would be to differ.
     
    #32 AD04, Jan 10, 2019
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  33. Armadillos

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    Yeah I was thinking more another word ending in -ent that gets the lawyers drooling
     
  34. JSizzles

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    Many psychiatrists do similar models in my geographic area. 25 patients a day 5 days a week should get you safely above 500k in the midwest. Tons of ways to get that number inpatient/outpatient/php/nursing home. PHP is pretty easy way to make money especially if you already knew them from inpatient. Nursing home work is very easy once you get them stable. 25 patients a day is very doable if you keep the inpatient total to around 10. The lower the inpatient number the better for your own mental health. A typical day I would do 8-10 inpatient 8-10 php mix with up with some clinic or nursing home work depending on the day. Make all your clinic appts 30 mins and bill a majority of 99214 (if you can meet criteria) with 90833. Even a 99213 with a 90833 is a nice chunk of change.

    All the hospital employed psychiatrists make 250 full bennies, chill all day then cry when they take 1/16 weekend call. The independent docs have no lives, hustle hard, and sometimes you have to do a double take to make sure that they aren't a patient that eloped (I am independent). The hospital docs that try to beat the system with RVU bonus are somewhere in between. Obviously vague generalizations, but mostly true in my hospital.
     
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    finalpsychyear

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    Would you do even less inpatient work or none if you could simply have 25 outpatient med check+90833 codings in a PPs Mon-Fri?
     
  36. sluox

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    LOL, maybe. I guess we are all just BSing on the internet. If finalpsychyear wants to see 25 patients a morning to make 1M a year for 10 years, then stop working at 45, that's his choice in life. I don't know if it's doable in general, but I know it's not doable for me.
     
  37. Merely

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    Does your idea above still hold if you purchase millions in residential rather than commercial real estate? Like single family homes for ex. Why do you suggest commercial?
     
  38. PSYDR

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    Personal anecdote:

    Without giving too much away, I'm friends with a psychiatrist who did this volume of work for a long time. It has taken a severe toll on his life. No friends, wife divorced him for never being around, kids don't really have a relationship with him, his wardrobe is almost exclusively work stuff, his car is more geared towards ease of maintenance than what he likes, he has lost most of his friends because he was never around, etc. So now that he wants to slow down, there's not a lot of things to go home to.

    Edit: I'm not trying to insult the guy. We're friends for a reason...
     
  39. clausewitz2

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    Yeah I feel like if you go too far down the workaholic pathway you're kind of locked in and hope you die of a massive MI or stroke in the middle of your work day at like 60 because retirement is going to be pretty desolate.
     
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  40. sluox

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    Buying residential real estate is not a deductible business expense. But of course, consult your accountant.
     
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  41. PSYDR

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    I know many surgeons that either refuse to retire because of this, or have engaged in ridiculously self destructive behaviors after retiring.
     
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  42. Trismegistus4

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    Have people never heard of video games?
     
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  43. MedMan80

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    Personally looking to get a switch for during no shows and clinic downtime
     
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  44. VA Hopeful Dr

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  45. JSizzles

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    90833 is a 30 min code. You can use it if you spend at least 16 mins of a 30 min session engaging in psychotherapy. The key part to that is 30 mins so you can't see 25 if you use the add on. You should never see that many in the clinic There will always be patients in the hospital, but the clinic is your business. Spend the right amount of time with patients and provide excellent care- thats how you grow the practice and reputation in the community. The ideal aspect of inpatient and nursing home is that if your census is 15 you will see 15. In the clinic there will always be no shows. I never plan a lunch knowing (sometimes hoping) someone will not show up and I will take it in that half hour slot.
     
  46. splik

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    incorrect. 90833 can be used if you spend 16-38 minutes doing "psychotherapy" which is distinguishable from the E&M component of the visit. There is no total duration of the visit set. So if you can justify having spent 5 mins E&M and 16 mins of supportive psychotherapy = 21 minutes, that would still count for a 90833 add on (typically with a 99213 or 99214).
     
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    finalpsychyear

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    I know i over-save but i made an agreement to live like a resident for the first 5 years as an attending. Also, you made a great point about real estate and using higher income if and when earned to leverage that to minimize taxes. I think inpatient doesn't make sense for my situation. Fully expanding into a 4 day PP does and in the next year or two if i can really get it going then to get into real estate and various investments to help offset paying more taxes and then i can retire (part time) in 10-15 years and move to australia.
     
    #47 finalpsychyear, Jan 19, 2019
    Last edited: Jan 19, 2019
  48. OP
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    finalpsychyear

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    I don't get that 60 hours can be considered "overworking". I came from a residency where we pushed 80 hours with a combo of night, call and wknds. Most weeks I currently avg 32 clinical hours and feel under worked as i never do nights, wknds or call.

    I am sure if i was doing this "hypothetical" 60 hours (54 is the most i would do) I would always have friday end at Noon or 1pm and essentially always have weekends where I traveled with my sig fig. Most of the specialties getting in the higher income range are working above 40 hrs that is for sure.

    I also don't think it is a bad idea to start on the higher end once you graduate as you will gain a lot of experience and knowledge in those few 2-3 years that you work like that. I am not saying this is a 5 or 10 year type of schedule but if someone did this for the first 2-3 years out of residency they would gain great experience, clinical knowledge, pay off nearly all their loans and have a great future fund in place for investing. After this of course you would cut back a bit.
     
    #48 finalpsychyear, Jan 19, 2019
    Last edited: Jan 19, 2019
  49. PSYDR

    PSYDR Psychologist
    10+ Year Member

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    Personal experience: it quickly gets very, very, very difficult to scale back once you get like this. There are a host of issues that I never predicted, both personal and financial.

    Feel free to PM me.
     
    Jules A likes this.
  50. nexus73

    2+ Year Member

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    60 hours is 12 hours a day x 5 days. So get up a 6am, get to work by 7am, then work straight through to 7pm with no break. Then go home tired, get home at 7:30..in bed by 10 so I'm not sleep deprived. See my family for 2.5 hours a day if I don't ever go the gym during the week. That schedule sucks.
     
    Trismegistus4 likes this.

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