Loan Repayment Programs for PM&R

[fozzy40]

I just talked to my cousin (family medicine attending) who is doing a loan repayment program through the NHSC. It got me thinking, is there anything similar to this for PM&R? I know this is the sort of thing for primary care specialties usually but I thought I'd ask!

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[mjakec]

I recently signed up for public service loan forgiveness. This repayment plan only works if you have primarily federal loan debt (subsidized, un-subsidized, grad plus loans, etc...)
You consolidate all your federal loans and then you start making monthly payments based on your current income and number of dependents. My monthly payments are <$200. After ten years of monthly payments, the remainder of your loans are forgiven as long as you are directly employed by a non for profit agency (most hospitals in America).
As an attending, my monthly payments will go up to $2-3K per month but I'll only have to make 5 years of payments at that amount to finish off my 10 years.
Bottom line for me: I came out of medical school with $220k debt and I'll only pay back around $140k. If I deferred the loans throughout residency and then went into the 30 year repayment plan, I would pay >500k over 30 years.
Here's some links if you're interested:
http://www.ibrinfo.org/
http://loanconsolidation.ed.gov/borrower/bconsol.html

 

[101N]

"I came out of medical school with $220k debt and I'll only pay back around $140k."

I'm an attending in PM&R with subspecialty cert in pain mgt. I like my job and our patients - both rehab and PM. I'm going to go out on a limb here and say to others reading this thread: don't take on this type of debt for your medical education. With health care reform looming your sacrifices for the career will be simply TOO great.

Until ACA - or future reforms - include medical education debt reform your exposure is too great.

 

[oreosandsake]

I just talked to my cousin (family medicine attending) who is doing a loan repayment program through the NHSC. It got me thinking, is there anything similar to this for PM&R? I know this is the sort of thing for primary care specialties usually but I thought I'd ask!

the requirement for NHSC is for "primary care"

with that being said, there have been multiple instances where residents going into fields such as EM have successfully convinced them that EM is primary care.

I met the director of the NHSC during my third year of medical school and made a case for PM&R being primary care for people with disabilities. She liked my rationale and asked me to contact her to pursue it.

I never did, but I think it would be a great idea for someone else interested in NHSC.

RE loan forgiveness, you have not signed up for it yet. you might be making qualifying payments, but I don't believe there is an actual form produced yet. the first "class" that might be eligible for this will not come through until 2017. hopefully it works out

 

[RUOkie]

I just talked to my cousin (family medicine attending) who is doing a loan repayment program through the NHSC. It got me thinking, is there anything similar to this for PM&R? I know this is the sort of thing for primary care specialties usually but I thought I'd ask!

Join the military

 

[Sanchik]

I will be working for an academic hospital. I wonder if they are non profit. 503(c). Wondering if anyone else has looked into this program

 

[padresp]

I will be working for an academic hospital. I wonder if they are non profit. 503(c). Wondering if anyone else has looked into this program

I think y'all are talking about the Income-Based Repayment plan, as mjakec alluded to (http://www.ibrinfo.org/) and he was spot-on. I spoke with one of the VPs at Sallie Mae about this, and got some information. The customer service reps were, as always, useless at Sallie Mae, so I ended up working my way up the corporate ladder until I spoke with someone quite knowledgeable. She said that "it depends" on whether or not your hospital will count as being a not-for-profit organization.

The rules are that you have to work for a company that is a 501(c)(3) OR:

(1) your employer is not "a business organized for profit, a labor union, a partisan political organization, or an organization engaged in religious activities, unless the qualifying activities are unrelated to religious instruction, worship services, or any form of proselytizing;"
AND,
(2) your employer provides any of the following public services: emergency management; military service; public safety; law enforcement; public interest law services; early childhood education; public service for individuals with disabilities and the elderly; public health; public education; public library services; and school library or other school-based services.

So there is a lot of grey area. Residency can count toward this 10 year time period, and since you make almost no money, you have very small payments during these periods.

The one catch is that you have to pay 10 years into this Income Based Repayment Plan without missing a single payment or taking time off. So you can't do it for 5 years, go on a month vacation, then do another 5 years. And you can't work for 5 years for a non-profit, then work 2 for a for-profit company, and then 5 more for a non-profit.

It should also be noted that the government could conceivably cut this program when you are 9 years into it.

My advice to people entering residency is to apply to the IBR program and make monthly payments (they range from $0 to $300/month, usually, depending on your family situation and base pay). You can always pay more if you have extra left over. Worse comes to worse, when you complete your residency, you can switch to another payment plan. But if you choose to stick with IBR after residency, you'll have many years of that 10-year portion set. Just keep in mind that you can not miss a single payment for any reason during those 10 years, so keep some money set aside if possible.

 

[Tenacious DO]

On the way to work, but I thought this might help...LINK LINK 2

 

[ml2001]

This income based loan payment sounds good. However, I was wondering if someone could answer the following:

• Could you be part of this program just during the residency to keep your payments down and switch to regular payments once you are an attending if you end up in a for-profit setting like a private practice?
• Are there any disadvantages to switch out to a regular payment program after residency? (like higher interests, penalties, and so on)
• If you are part of the program only during the residency, how is it beneficial over deferments/forbearance provided that you qualify for the deferments/forbearance?
• Do you have to be with a certain loan company to do this? All my federal loans are with SallieMae.
• Since you guys are saying that the customer reps at SallieMae are not knowledgeable, is there a direct contact with someone who knows what this program is about?

Thank you
-ML

 

[The JockDoc]

Could you be part of this program just during the residency to keep your payments down and switch to regular payments once you are an attending if you end up in a for-profit setting like a private practice?

As it stands now, yes, you can.

Are there any disadvantages to switch out to a regular payment program after residency? (like higher interests, penalties, and so on)

No disadvantages like penalties per se. Your interest rates would remain the same as when you first took the loan out. You would just enter a regular loan repayment program aside from IBR as outlined by Direct Loans.

If you are part of the program only during the residency, how is it beneficial over deferments/forbearance provided that you qualify for the deferments/forbearance?

Depending on your loan, you will not be able to defer for more than 6 m i believe. According to the ibrinfo website:

If your IBR payment amount does not cover the full amount of interest that accrues on your loans
each month, the government will pay any unpaid, accrued interest on your subsidized loans for up
to three consecutive years from the date you begin repaying the loans under IBR. (You are
responsible for paying the interest that accrues on your unsubsidized loans during this 3-year
period.)

So, if you forbear, interest accrues on your SUBSIDIZED loans. With IBR, you get gov't help for 3 years for those loans.

[*]Do you have to be with a certain loan company to do this? All my federal loans are with SallieMae.

Yes, you must consolidate with the government/direct loans.

[*]Since you guys are saying that the customer reps at SallieMae are not knowledgeable, is there a direct contact with someone who knows what this program is about?

Read http://studentaid.ed.gov/students/attachments/siteresources/IBRQ&A_template_123109_FINAL.pdf and http://studentaid.ed.gov/students/attachments/siteresources/PSLF_QAs_final_02%2012%2010.pdf. You can also contact someone at directloans

Remember, there are 2 repayment programs - IBR and a subset of IBR, PSLF.

Also, regarding padresp's post about not missing payments, those documents above state that the PSLF payments do not have to be consecutive, which would mean that you can skip payments. The document states that the most important thing is to have 120 payments total in some fashion from a qualifying payment source to receive PSLF:

Q16 Must the 120 required payments be consecutive?
A16 No. You must make 120 separate on-time, full monthly payments while you are employed by an eligible public service organization, but the payments do not have to be consecutive. (February 3, 2010)

 

[padresp]

Also, regarding padresp's post about not missing payments, those documents above state that the PSLF payments do not have to be consecutive, which would mean that you can skip payments. The document states that the most important thing is to have 120 payments total in some fashion from a qualifying payment source to receive PSLF:

Thanks for the clarification. You're absolutely right - I reread my post and it was misleading. What I meant to say was that: a) you cannot be delinquent on a payment or choose not to pay for a month; and b) you can not switch to another program (i.e. standard repayment schedule), then switch back to the IBR program at a later time because it's more convenient.

 

[mjakec]

This link allows you to search your for your specific hospital to see if it is a 501c:

http://www.irs.gov/charities/article/0,,id=96136,00.html

However, many large universities are not 501c charitable organizations and would still qualify as long as they are "A federal, state, local, or Tribal government organization, agency, or entity (includes most public schools, colleges and universities)"

 

[Sanchik]

as someone who is a resident qho consilidated with sallie mae 4 years ago and deferred loans i am v interested in this bc i will be working for a hospital. but here are a couple of things im still unclear about

1. As someone who consolidated, it seems like i can reconsolidate but it might be at a higher rate bc mine was super low
2. the payments have to be for ten y so the monthly payment would be muh higher than if doing on a 30 y plan
3. there is no official program/application, you just make payments and hope that after 10 y they will forgive

i think it's a gret idea for a new resident and I wish i knew about this when i graduated but i am not sure it makes sense for a new attending.

 

[Silent Cool]

How could you graduate with less than this? Any private medical school in America will cost at least this much, more likely closer to 300k. 220k these days sounds like a public medical school.

 

[tmvguy03]

Hey everyone. Great posts! I wanted to add an additional point about IBR and the public service loan forgiveness. I just graduated and have recently consolidated my loans. There is a 6 month "grace period" when no payments are required...BUT I have formally asked them (in writing) to remove the grace period so that I can start paying immediately. I think my payments will be under $100/mo, and this way I can make these low payments for 6 months on the front end, rather than the 2000-3000/mo on the back end (after residency).

 

[Dharma]

"I came out of medical school with $220k debt and I'll only pay back around $140k."

I'm an attending in PM&R with subspecialty cert in pain mgt. I like my job and our patients - both rehab and PM. I'm going to go out on a limb here and say to others reading this thread: don't take on this type of debt for your medical education. With health care reform looming your sacrifices for the career will be simply TOO great.

Until ACA - or future reforms - include medical education debt reform your exposure is too great.

Most med students will graduate with about 200K debt. Are you advising only those with parents (or government) who are flipping the bill or those with cheap in-state tuition to follow their dreams of practicing medicine?

 

[Silent Cool]

Most med students will graduate with about 200K debt. Are you advising only those with parents (or government) who are flipping the bill or those with cheap in-state tuition to follow their dreams of practicing medicine?

Yeah, seriously, most students going to private schools will be about 300K in the hole when all is said and done. Over time, however, physician incomes will rise, just not at the rate of inflation necessarily. In other words, by the time we finish, paying this won't be as bad as you think. Also keep in mind that we are lucky to be in a profession in which you can make more simply by working more. Not a bad deal IMO.

 

[Dharma]

1. As someone who consolidated, it seems like i can reconsolidate but it might be at a higher rate bc mine was super low.

Your interest rates will be determined via weighted averages. Basically you will be paying close to the original rate for each corresponding loan; the final rate will be proportionate to size of each particular loan in relation to the consolidation total. E.g. if 50% of the consolidated loan comes from a loan that originally had a 4% interest rate, while the remaining 50% comes from a loan at 8% interest, the interest rate of the consolidated loan would be ~6%. This is assuming your loans were all federal.

There are also other factors at play. For instance, you can only consolidate during particular times. Check out the following links.

http://loanconsolidation.ed.gov/help/rate.html

http://www.finaid.org/loans/consolidation.phtml

 

[DOctorJay]

Yeah, seriously, most students going to private schools will be about 300K in the hole when all is said and done. Over time, however, physician incomes will rise, just not at the rate of inflation necessarily. In other words, by the time we finish, paying this won't be as bad as you think. Also keep in mind that we are lucky to be in a profession in which you can make more simply by working more. Not a bad deal IMO.

this is a joke right? where's the purple sarcasm font to make this clear to everyone who reads this?

 

[MaxillofacialMN]

this is a joke right? where's the purple sarcasm font to make this clear to everyone who reads this?

You didn't know that in medicine all you have to do is show up and they sign your paycheck?

At least... that's why I want to be a doctor...

 

[drusso]

"I came out of medical school with $220k debt and I'll only pay back around $140k."

I'm an attending in PM&R with subspecialty cert in pain mgt. I like my job and our patients - both rehab and PM. I'm going to go out on a limb here and say to others reading this thread: don't take on this type of debt for your medical education. With health care reform looming your sacrifices for the career will be simply TOO great.

Until ACA - or future reforms - include medical education debt reform your exposure is too great.

Too late. I already did. But I did it...but in the 1990's I believed that I would be able be compensated enough to pay it all back...

 

[PMR 4 MSK]

Yeah, seriously, most students going to private schools will be about 300K in the hole when all is said and done. Over time, however, physician incomes will rise, just not at the rate of inflation necessarily. In other words, by the time we finish, paying this won't be as bad as you think. Also keep in mind that we are lucky to be in a profession in which you can make more simply by working more. Not a bad deal IMO.

LOLOLOLOLOLOL

Lemme tell you how it really works and how things are progressing:

You see 25 pts/day, and make $200K. Not bad, you say to yourself, but I want more. Imma see 30 pts per day. No, Imma see 40, I can do it. Hours increase by 20/week, stress increases by 75%, family contact decreases by 30%, paycheck increases by.... 5%? WTF?

See, to work those extra hours and see more patients, you need more staff. And you have to pay them from your profits. You need more people to handle the rooming of pts, paperwork, and especially telephone calls and billing. And with more bills going out, more get denied. You go after the big bills, but more small bills get left in the dust. $20 not paid? Not worth it to go after. $1000 not paid? Go after it. But it takes time and money to collect. After a while, that $30K AR has risen to $200K. Most of it becomes functionally uncollectable. $200K of work you will never get paid for.

Yes that happens. It happened to me. I lived it.

At the same time, business expenses rise every year. Malpractice goes up. Rent goes up. Utilities go up. Health insurance for you and staff goes up. Staff salaries go up. Etc.

And payment for your services? Going down or remaining flat. CMS sets the standard. We are once again facing a big drop in payment. Every year, they delay it a few months, giving us a 0.5% or so increase - less than inflation, less than CoL increases. Eventually, kicking the can down the road will stop, and that 30% or more decrease will hit.

Then there is bundling. CMS loves to bundle. Last year they paid you $100 to do a procedure and $50 for the fluoro to do it. This year they bundle the two and pay you $120 total. They've done that to many of our procedures over the past few years.

Then the private insurances bring in "denial". First you do a procedure, then they deny payment saying it wasn't preauthorized. You lose out. You cannot bill the pt. So the next time you pre-authorize a procedure, do it, and they deny it saying it is not a "covered benefit." You can try to bill the pt, good luck collecting.

Then they start denying the pre-auth, saying "Not medically necessary." You write a LoMN and they still deny it. You do a "peer-to-peer" telephone call with a pediatric endocrinologist who contracts with their company to make extra money by denying you the ability to make money, and they say the pt needs 6 weeks of PT first. You do that and they still deny it.

And then, just when you think you've seen it all, Uncle Obama steps in and says "You doctors make too much money! Imma raise your taxes and lower your payments. You are not contributing your 'fair share!' Yes, I know you already pay more taxes than 95% of the population, but that's not enough. Tort Reform? Hmm? What? What's that? Sorry, I couldn't hear you over the sound of how awesome a job I'm doing!"

Not enough for you? Add in MoC. That wonderful Board Certification you'll get in a few years needs to be maintained. $600 per year to your academy, another $600 to the board. 30 CMEs per year, plus SAE's, PIPs and other acronyms. All cost money and the costs keep going up.

That $300K student loan debt you leave medical school with can easily balloon to $400K during residency and fellowship, as you will most likely not be able to afford $1600 per month payments when you are bringing home $2000 per month, so you go into deferment. Then you will pay $2500/month for 30 years, making that $300K education cost close to $900K.

Medical school is rapidly becoming a sucker bet leading to indentured servitude.

 

[Flake0006]

This all sounds so depressing. I hope (Wife willing) to live as cheaply as possible in an expensive city to try and stay ahead of my interest rates. My wife also has a significant debt from school. Job market for her sucks and if she doesn't have a job I guess military here I come...if they will take me

Not looking forward to sweating it out on IBR plan either. I can just see myself in the last year of repayment when they defund the program. Good luck to us all!

 

[Dharma]

That $300K student loan debt you leave medical school with can easily balloon to $400K during residency and fellowship, as you will most likely not be able to afford $1600 per month payments when you are bringing home $2000 per month, so you go into deferment. Then you will pay $2500/month for 30 years, making that $300K education cost close to $900K.

It is sad that most pre-meds/med students are quite ignorant of this. I don't think it will influence many to pursue a different profession though. If one wants it bad enough...

 

[drusso]

Medical school is rapidly becoming a sucker bet leading to indentured servitude.

This is what the social engineers have wanted all along. Sadly, we (doctors) only have ourselves to blame. If you ever get a chance, listen to the portion of the Nixon tapes where Kessinger and Nixon are talking to Henry Kaiser in 1970 about this new concept called "HMO's." It's very illuminating to hear how "real politics" played out and started in motion a series of events that systematically begun "de-professionalizing" medicine. Once upon a time professional organizations like the AMA had the clout to really protect our interests. No longer.

 

[Polynikes]

LOLOLOLOLOLOL

Lemme tell you how it really works and how things are progressing:

You see 25 pts/day, and make $200K. Not bad, you say to yourself, but I want more. Imma see 30 pts per day. No, Imma see 40, I can do it. Hours increase by 20/week, stress increases by 75%, family contact decreases by 30%, paycheck increases by.... 5%? WTF?

See, to work those extra hours and see more patients, you need more staff. And you have to pay them from your profits. You need more people to handle the rooming of pts, paperwork, and especially telephone calls and billing. And with more bills going out, more get denied. You go after the big bills, but more small bills get left in the dust. $20 not paid? Not worth it to go after. $1000 not paid? Go after it. But it takes time and money to collect. After a while, that $30K AR has risen to $200K. Most of it becomes functionally uncollectable. $200K of work you will never get paid for.

Yes that happens. It happened to me. I lived it.

At the same time, business expenses rise every year. Malpractice goes up. Rent goes up. Utilities go up. Health insurance for you and staff goes up. Staff salaries go up. Etc.

And payment for your services? Going down or remaining flat. CMS sets the standard. We are once again facing a big drop in payment. Every year, they delay it a few months, giving us a 0.5% or so increase - less than inflation, less than CoL increases. Eventually, kicking the can down the road will stop, and that 30% or more decrease will hit.

Then there is bundling. CMS loves to bundle. Last year they paid you $100 to do a procedure and $50 for the fluoro to do it. This year they bundle the two and pay you $120 total. They've done that to many of our procedures over the past few years.

Then the private insurances bring in "denial". First you do a procedure, then they deny payment saying it wasn't preauthorized. You lose out. You cannot bill the pt. So the next time you pre-authorize a procedure, do it, and they deny it saying it is not a "covered benefit." You can try to bill the pt, good luck collecting.

Then they start denying the pre-auth, saying "Not medically necessary." You write a LoMN and they still deny it. You do a "peer-to-peer" telephone call with a pediatric endocrinologist who contracts with their company to make extra money by denying you the ability to make money, and they say the pt needs 6 weeks of PT first. You do that and they still deny it.

And then, just when you think you've seen it all, Uncle Obama steps in and says "You doctors make too much money! Imma raise your taxes and lower your payments. You are not contributing your 'fair share!' Yes, I know you already pay more taxes than 95% of the population, but that's not enough. Tort Reform? Hmm? What? What's that? Sorry, I couldn't hear you over the sound of how awesome a job I'm doing!"

Not enough for you? Add in MoC. That wonderful Board Certification you'll get in a few years needs to be maintained. $600 per year to your academy, another $600 to the board. 30 CMEs per year, plus SAE's, PIPs and other acronyms. All cost money and the costs keep going up.

That $300K student loan debt you leave medical school with can easily balloon to $400K during residency and fellowship, as you will most likely not be able to afford $1600 per month payments when you are bringing home $2000 per month, so you go into deferment. Then you will pay $2500/month for 30 years, making that $300K education cost close to $900K.

Medical school is rapidly becoming a sucker bet leading to indentured servitude.

Seriously, are you really trying to tell us that people are FORCED to pay on their loans for 30 years?

No one does that, and no one pays $900k either. That is ridiculous.

Defer your loan, and use the money you would be paying into IRB into a Roth while you're still eligible, and when you are finished with the deferment and out of residency, sign up for the 30 year plan and contribute more per month than what is required.

My God you sound jaded and miserable. I'm sorry, but you really do.

Indentured servitude? Did you ever have a job before you went to medical school?

 

[The JockDoc]

Defer your loan, and use the money you would be paying into IRB into a Roth while you're still eligible, and when you are finished with the deferment and out of residency, sign up for the 30 year plan and contribute more per month than what is required.

There is no such thing as "deferring" a loan anymore. You can forbear, but you will continue to accrue interest at 6.8% - 8.5% or more.

 

[Polynikes]

There is no such thing as "deferring" a loan anymore. You can forbear, but you will continue to accrue interest at 6.8% - 8.5% or more.

Forbearance, whatever...

The money you would be putting into the IRB plan is wasted money IMO, and better served being shoveled into a Roth IRA. After residency, you most likely will not be able to take advantage of the Roth, so now is your chance to make a deposit that is tax free upon its withdrawal.

IRB is a joke IMO, and makes absolutely no sense to do it.

You're taking a huge hit in your quality of life as a resident, with only a small amount of benefit. I honestly do not see why anyone would do it because the difference in money owed is not that great.

According to the chart from the AAMC sitting in front of me, the difference is like $20k total.


Edit: If you graduate with $170k of debt, and then go into IRB, you will pay down approximately $23k of interest, with another $21k of interest that still accrued. So, with a massive quality of life hit, you only paid down half of your interest. If you forbear, your interest is $43k, and all of that money that could have gone to the IRB could have jammed into a Roth (again, tax free when you cash it in).

IRB = You spent $23k, you have no Roth, and you're virtually on the same page as someone who went into forbearance with the difference being $21k...Big whoop...I know that my wife and two children and myself will eat that in trade for a better quality of life over 4 years.

 

[MaxillofacialMN]

Forbearance, whatever...

The money you would be putting into the IRB plan is wasted money IMO, and better served being shoveled into a Roth IRA. After residency, you most likely will not be able to take advantage of the Roth, so now is your chance to make a deposit that is tax free upon its withdrawal.

IRB is a joke IMO, and makes absolutely no sense to do it.

You're taking a huge hit in your quality of life as a resident, with only a small amount of benefit. I honestly do not see why anyone would do it because the difference in money owed is not that great.

According to the chart from the AAMC sitting in front of me, the difference is like $20k total.


Edit: If you graduate with $170k of debt, and then go into IRB, you will pay down approximately $23k of interest, with another $21k of interest that still accrued. So, with a massive quality of life hit, you only paid down half of your interest. If you forbear, your interest is $43k, and all of that money that could have gone to the IRB could have jammed into a Roth (again, tax free when you cash it in).

IRB = You spent $23k, you have no Roth, and you're virtually on the same page as someone who went into forbearance with the difference being $21k...Big whoop...I know that my wife and two children and myself will eat that in trade for a better quality of life over 4 years.

I'm really not an expert on this, but I think you aren looking big picture... The amount of interest paid is irrelevant in IBR payments because your loan disappears after 120 payments - or ten years. Regardless of your interest, you won't have to pay another penny after 10 years.... So... While you migh have started a nestegg, you'll be paying your loans for 30 years at ~2k a month, whereas others pay substantially less for 10 years, are debt free, accrue less interest in the long run and can devot more financial resources to the savings and retirement after ten years.

I might be wrong, but this is based on my limited knowledge of the subject.

 

[PMR 4 MSK]

Seriously, are you really trying to tell us that people are FORCED to pay on their loans for 30 years?

No one does that, and no one pays $900k either. That is ridiculous.

Defer your loan, and use the money you would be paying into IRB into a Roth while you're still eligible, and when you are finished with the deferment and out of residency, sign up for the 30 year plan and contribute more per month than what is required.

My God you sound jaded and miserable. I'm sorry, but you really do.

Indentured servitude? Did you ever have a job before you went to medical school?

When I graduated, we all had 10 year loans. When I made the mistake a couple years ago on this forum of assuming that to still be the case, I was attacked as ignorant of the fact that students now pay them off over 30 years. Now the reverse. Gotta love de internets.

Who has the money in residency to put most of the salary into a Roth? You go into forbearance because your salary does not allow you to pay the loans back, but your future potential income does. Interest still accrues during that time, of course.

Anyone can pay back their loans early, if they budget for such. But if you leave school with $300K debt, forebear it through residency, no one will be able to pay that off fast, unless they are a sports med orthopod or plastic surgeon making $1M/year. By the time they finish residency, many docs are married, with or expecting kids, buying houses and indebting themselves to banks for years to come.

I should sound jaded. I am. Many doctors are by this point in their career. Demanding, over-entitled patients combined with insurance companies and hospital admins who screw you every chance they get, while everyone expects you to take the high road takes it's tole on a doc. Having had one solo practice fold due to inability to cover even my overhead added to it.

Miserable? Not really. Aggravated that the promises sold to me pre-med by society were a bunch of BS, certainly. I make decent money, but am currently making about 60% of what I made just 5 years ago in the same practice. Doctor's salaries do not go up any more. Many are declining.

Previous jobs? Clerk in a video store. Cleaning bathrooms in a public historical park. Bailing and hauling hay. Cleaning lab equipment and animal cages. An aide for disabled students helping them with toileting, bathing, dressing, etc. Disposal of hazardous waste. Now medicine.

Medicine is the only one I've ever been locked into. Any of those other jobs I could walk away from at a moment's notice. Medicine - yeah, I could walk away. And then immediately have to come up with 3X my annual malpractice premium w/i 90 days for a tail policy. And then fulfill state requirements for closing my practice, including notifying thousands of patients of my leaving. And probably be in breach of my current employment contract and facing a lawsuit. And then wondering what to do to support my family, have health insurance, and pay my bills.

But I won't leave, because staying is currently the lessor of the evils. If I could go back and choose again, I would not choose human medicine as a career. Veterinary maybe. Or banking/finance. Maybe law. Maybe just photography.

 

[Polynikes]

I'm really not an expert on this, but I think you aren looking big picture... The amount of interest paid is irrelevant in IBR payments because your loan disappears after 120 payments - or ten years. Regardless of your interest, you won't have to pay another penny after 10 years.... So... While you migh have started a nestegg, you'll be paying your loans for 30 years at ~2k a month, whereas others pay substantially less for 10 years, are debt free, accrue less interest in the long run and can devot more financial resources to the savings and retirement after ten years.

I might be wrong, but this is based on my limited knowledge of the subject.

Understand what I'm saying here...You enroll in the 30 year repayment plan so as to get the lowest payments required per month, because this gives you the most flexibility with regards to paying back your loan. However, if you make $120k, you are essentially making $10k per month, so why would you stop at $2k per month if you can give $3k, or on some months where you are doing nothing and not spending any money you can pay $4k or $5k that month.

You pay more than the $2k requirement, and you DO NOT pay for 30 years.

Furthermore, you don't know what is going to happen to the loan forgiveness program, just as you have no idea where you will be employed after residency. You may receive a better offer from a private practice where that program is not going to be able to help you.

As a father of two with a wife who works, my IRB payment is over $700 PER MONTH.

It make much more sense for me to put $500 into a Roth, because this will be my only opportunity to invest in it due to salary restrictions, rather than pay $700 a month with a very small return on my quality of life.

The return is greater, to me at least, to spend the money that would go into IRB on a Roth.

Again, you do NOT pay for 30 years. That is completely absurd.

 

[RUOkie]

Polynikes:

Please don't judge any of the physicians on this board who try to give advice to you guys. PMR4MSK is a committed physician who cares for his patients. And everything he said was true.

I wish that med students and pre med students were allowed to lurk websites like Sermo (a physicians only forum-completely private). You would see how many of us are committed to the practice of medicine, but completely jaded. I am for sure. I've been in practice for 16 yrs. It is NOTHING like what I expected when I was in med school.

I am in solo practice, and just signed a contract to use a PA to run an Occ Med clinic of which I will be a Med Director. Why? To protect myself from the upcoming socialization of medicine.

If a nationalized single payor program goes into effect, expect physician salaries to diminsh by 50%. Then all of the docs over age 58 or so will just retire and go fishing. You kids will end up with overbloated practices doing cookie cutter medicine (since the government will decide what is necessary) and NO job satisfaction.

I just chose the lesser of two evils. I'll fill my practice with work comp malingerers and somatisizers and keep feeding my family. And I'll keep living debt free other than my mortgage.

 

[Polynikes]

When I graduated, we all had 10 year loans. When I made the mistake a couple years ago on this forum of assuming that to still be the case, I was attacked as ignorant of the fact that students now pay them off over 30 years. Now the reverse. Gotta love de internets.

Who has the money in residency to put most of the salary into a Roth? You go into forbearance because your salary does not allow you to pay the loans back, but your future potential income does. Interest still accrues during that time, of course.

Anyone can pay back their loans early, if they budget for such. But if you leave school with $300K debt, forebear it through residency, no one will be able to pay that off fast, unless they are a sports med orthopod or plastic surgeon making $1M/year. By the time they finish residency, many docs are married, with or expecting kids, buying houses and indebting themselves to banks for years to come.

I should sound jaded. I am. Many doctors are by this point in their career. Demanding, over-entitled patients combined with insurance companies and hospital admins who screw you every chance they get, while everyone expects you to take the high road takes it's tole on a doc. Having had one solo practice fold due to inability to cover even my overhead added to it.

Miserable? Not really. Aggravated that the promises sold to me pre-med by society were a bunch of BS, certainly. I make decent money, but am currently making about 60% of what I made just 5 years ago in the same practice. Doctor's salaries do not go up any more. Many are declining.

Previous jobs? Clerk in a video store. Cleaning bathrooms in a public historical park. Bailing and hauling hay. Cleaning lab equipment and animal cages. An aide for disabled students helping them with toileting, bathing, dressing, etc. Disposal of hazardous waste. Now medicine.

Medicine is the only one I've ever been locked into. Any of those other jobs I could walk away from at a moment's notice. Medicine - yeah, I could walk away. And then immediately have to come up with 3X my annual malpractice premium w/i 90 days for a tail policy. And then fulfill state requirements for closing my practice, including notifying thousands of patients of my leaving. And probably be in breach of my current employment contract and facing a lawsuit. And then wondering what to do to support my family, have health insurance, and pay my bills.

But I won't leave, because staying is currently the lessor of the evils. If I could go back and choose again, I would not choose human medicine as a career. Veterinary maybe. Or banking/finance. Maybe law. Maybe just photography.

I completely understand your frustration, and if I'm in your shoes I am probably pissed off as well.

However, you haven't ever had another job. Sure, you had part time stuff here and there likely while in college or high school, but you have NEVER had a full time job as an adult, at least not one that you consider to be how you're going to survive long term. That is a huge difference, and trust me when I tell you that 95% of people who work regular jobs full time would switch places with you in a heart beat, even if they were aware of the BS that surrounds a physician's life.

About the Roth...You're not understanding what I'm saying...The money that would be going into IRB would instead be funneled into the Roth. If you are going to pay a chunk of money each month and have your QoL suffer, it makes more sense to me that the chunk of money should be considered long term money with nontaxable withdrawal.

Sure, loans are long term money, but they are NOT 30 year type long term money.

And where do you get this thing about $1M per year being what would be required to pay off a loan early? That is a completely ridiculous statement to make, and you're embellishing by saying it.

If you make, after taxes, $180k per year, and your loan is $300k at the end of residency, you can pay that off in several years without suffering too terribly. That salary is the same as getting $15k per month, of which you could easily put $7k per month on your loan while still sitting on $8k per month to live off of (a ton of money)...

At $7k per month, you are paying off $84k per year, and that is while simultaneously sitting on $8k per month after your loan payments.

You could even do $9k per month, and pay $108k per year, while still living off of $6k per month.

If your spouse works, that's further income supplementation.

Give me a break about 30 years and $900k. Don't spread that BS around here and add to the neurosis that is common amongst med students and residents.

This conversation highlights the fact that people who go into medicine know nothing about economics, which is why so many doctors get into trouble financially.

 

[RUOkie]

You will NOT be making 180K after taxes. THAT IS FUNNY!

 

[Polynikes]

Polynikes:

Please don't judge any of the physicians on this board who try to give advice to you guys. PMR4MSK is a committed physician who cares for his patients. And everything he said was true.

I wish that med students and pre med students were allowed to lurk websites like Sermo (a physicians only forum-completely private). You would see how many of us are committed to the practice of medicine, but completely jaded. I am for sure. I've been in practice for 16 yrs. It is NOTHING like what I expected when I was in med school.

I am in solo practice, and just signed a contract to use a PA to run an Occ Med clinic of which I will be a Med Director. Why? To protect myself from the upcoming socialization of medicine.

If a nationalized single payor program goes into effect, expect physician salaries to diminsh by 50%. Then all of the docs over age 58 or so will just retire and go fishing. You kids will end up with overbloated practices doing cookie cutter medicine (since the government will decide what is necessary) and NO job satisfaction.

I just chose the lesser of two evils. I'll fill my practice with work comp malingerers and somatisizers and keep feeding my family. And I'll keep living debt free other than my mortgage.

I'm not judging anyone, rather I am merely stating facts. PMR4MSK is clearly jaded, and as it is readily apparent and he/she makes no bones to hide it, than no one should gripe if I point it out.

As far as giving advice: What good is the advice if it is (1) incorrect, and (2) coming from someone who hates his/her job and wishes they didn't do it?

Most physicians are individuals who went from high school to college to med school to residency to the physician work force, and never had to support themselves in the regular work force.

Key word in my previous statement: MOST

I know there are some who worked their butts off to feed themselves, but to sit here and gripe about your job while never having had to support a wife and kids living paycheck to paycheck is mildly annoying.

The vast majority of people in America would switch places with you if they could.

 

[Polynikes]

You will NOT be making 180K after taxes. THAT IS FUNNY!

If you change $180k to $120k my point still stands.

 

[RUOkie]

keep going down and you might get close. The starting wage for a PM&R doc is 120-180K/yr BEFORE TAXES.

 

[Polynikes]

keep going down and you might get close. The starting wage for a PM&R doc is 120-180K/yr BEFORE TAXES.

Right, and it will increase shortly thereafter, especially if you become a partner in a group, or after your patient base grows if you're a solo guy.

Bottom line, you're not going to require 30 years of $2k per month for a grand total of $900k. No matter what arguments you make, or how low the life of the PMR doctor, the argument is fundamentally incorrect.

Furthermore, I do not see how anyone benefits for doctors who wish they had chosen a different specialty to go onto an internet forum and trash medicine in the faces of those who recently entered it. If you want to vent, why not go to website you mentioned earlier?

Would this conversation even be taking place if this was the radiology forum? Ortho?

I'm currently writing a book, so I'm done discussing this. Later guys. I hope everything works out for you.


Edit: From the AAMC: Salary information ... Median compensation for assistant professors is $180,000, and for associate and full professors the median is $210,000.

That is academic professorship, which routinely pays less than privately practicing physicians, or those within a large group.

I respect you guys that have been in practice, and I do understand your frustrations. Just thought I'd point that out. See you later guys, I have a book to finish.

 

[Eilat87]

You will NOT be making 180K after taxes. THAT IS FUNNY!

Just curious. What area of the US are we talking about.. with a salary of 120?

 

[RUOkie]

Just curious. What area of the US are we talking about.. with a salary of 120?

academics

anywhere.

and to rebut the above numbers that Polynikes posted. AAMC inflates things. I have been there. Current academic positions have to support their bloated support staffs. Academic programs are imploding throughout the nation because of finances.

 

[donkeykong1]

Polynikes:

Please don't judge any of the physicians on this board who try to give advice to you guys. PMR4MSK is a committed physician who cares for his patients. And everything he said was true.

I wish that med students and pre med students were allowed to lurk websites like Sermo (a physicians only forum-completely private). You would see how many of us are committed to the practice of medicine, but completely jaded. I am for sure. I've been in practice for 16 yrs. It is NOTHING like what I expected when I was in med school.

I am in solo practice, and just signed a contract to use a PA to run an Occ Med clinic of which I will be a Med Director. Why? To protect myself from the upcoming socialization of medicine.

If a nationalized single payor program goes into effect, expect physician salaries to diminsh by 50%. Then all of the docs over age 58 or so will just retire and go fishing. You kids will end up with overbloated practices doing cookie cutter medicine (since the government will decide what is necessary) and NO job satisfaction.

I just chose the lesser of two evils. I'll fill my practice with work comp malingerers and somatisizers and keep feeding my family. And I'll keep living debt free other than my mortgage.

ehhh that's a bit exaggerated no?

 

[PMR2008]

academics

anywhere.

and to rebut the above numbers that Polynikes posted. AAMC inflates things. I have been there. Current academic positions have to support their bloated support staffs. Academic programs are imploding throughout the nation because of finances.

I don't believe that you will get paid 120 anywhere(except Academic programs or if you work part time). I have asked residents from my current class, alumni who graduated during the past 2 years and my attendings who started 2-3 years back and none of them are making less than 200. Friends who are living in smaller town are making 250+ and some people who are in academic centers in a city like Chicago are making 180+. I am interviewing for positions and there are tons of opportunities to make 250+. Not saying I will take those opportunities but they exist. I have 200,000 in loans and I will continue to forebear them until after my fellowship. I plan on living like a resident for the next 5 years and paying off most if not all the loans. It is doable and anyone who disagrees is probably a big spender or would rather work in an academic institution and make less than most CRNAs.

 

[Polynikes]

academics

anywhere.

and to rebut the above numbers that Polynikes posted. AAMC inflates things. I have been there. Current academic positions have to support their bloated support staffs. Academic programs are imploding throughout the nation because of finances.

I'm sorry, but you are being completely dishonest here, and I find it mildly disturbing. Of particular importance is your statement that reimbursement will decrease by 50%, which is completely and utterly false, and is driven by doom and gloom conspiracy theory.

No one is going to take a job for $120k out of residency, as there are many opportunities that provide much greater reimbursement. I am sure there are places offering those types of salaries, but I find it hard to believe that anyone would accept such a position, to the point that I consider that offer an outlier if this was to be considered a statistical analysis.

Would you like to rebut the fact that academic medicine routinely pays less than solo or group practice in the private setting? If you can not, than you are conceding that reimbursement is higher than what you posted on average.

To say that you are going to make $120k - $180 out of residency is not exactly entirely forthcoming as it pertains to earning power as a PMR physician, because you are neglecting to disclose the rate at which that salary increases over time, which is important if you look at becoming a partner.

If you join a group and your offer is $175k, with a partnership in 3 years, you should disclose that information because as soon as you become a partner, it is expected that your income will rise dramatically.

So, in the context of this discussion, you say that it is impossible to pay off loans with an income of $175k, but you're leaving out the fact that 3 years later, the amount you can put to your loan per month is greatly increased.

That is dishonesty at worst, and halftruth at best.

 

[RUOkie]

At no point did I suggest that private practice jobs pay the same as academic positions. The 120K number was for academics, which some people WANT to do. Many people go into academics right out of residency.

You seem to have this idea that partnership is a guarantee for all people. It is not. I was offered partnership in a previous job and then chose to leave that practice because I did not agree with the practice structure.

I also paid off my debts very quickly. But in reality, I am the outlier. Most physicians don't.

What I am trying to impart is this: THERE IS NO GUARANTEE AS TO WHAT PHYSICIANS WILL BE PAID IN THE NEXT 10 YRS!

Every physican was at risk for a 28% decrease in reimbursement THIS YEAR! It was held over for another year. IF congress does not do something, we will be cut by 34+% in 2013. That does not only apply to Medicare/Medicaid since most fee schedules are based on RBRVS.

 

[Polynikes]

At no point did I suggest that private practice jobs pay the same as academic positions. The 120K number was for academics, which some people WANT to do. Many people go into academics right out of residency.

You seem to have this idea that partnership is a guarantee for all people. It is not. I was offered partnership in a previous job and then chose to leave that practice because I did not agree with the practice structure.

I also paid off my debts very quickly. But in reality, I am the outlier. Most physicians don't.

What I am trying to impart is this: THERE IS NO GUARANTEE AS TO WHAT PHYSICIANS WILL BE PAID IN THE NEXT 10 YRS!

Every physican was at risk for a 28% decrease in reimbursement THIS YEAR! It was held over for another year. IF congress does not do something, we will be cut by 34+% in 2013. That does not only apply to Medicare/Medicaid since most fee schedules are based on RBRVS.

Did you not state the following:

"keep going down and you might get close. The starting wage for a PM&R doc is 120-180K/yr BEFORE TAXES"

You stated those figures, which are most likely academic rather than private practice, as an attempt to attack my statements about loan repayments, knowing that the ability to earn more was readily available if one went outside of academics.

And I never said that partnership was a guarantee for anyone, I merely stated it as an option for some people, which it is. Given that it is not an automatic thing, I ALSO stated that reimbursement increases as a physician in solo practice expands his patient base, which is true. So, right there I gave two way in which salary can increase.

For academics, the salary would increase as one ascends to full professorship.

You don't know what will happen to reimbursement in 10 years, and in keeping with that idea, you don't know what will happen to the loan forgiveness program in 10 years, so I do not consider that to be something worth gambling over, especially with the deficit and the fact that the federal government loses billions on lost loan money due to that program.

Any day now they'll get their dirty fingers into that as well.

Edit: I currently do not believe that physicians will receive a 34% cut in reimbursement this year, or anytime soon. Think about how much of a cut that is for one second, and then tell me if you believe it will happen, because I personally do not. Over time I can see it occurring as a series of small steps, but one drastic cut is not going to happen.

There is no wisdom on this planet that could defend that sort of cut.

 

[PMR 4 MSK]

If you take home $10K after taxes, and have the discipline and planning to put 60-70% of that toward loan repayment, you are a financial god and will reap incredible rewards in life. Delayed gratification is one of the keys to wealth. We should all strive for this.

Most people don't have that kind of fortitude. When going from resident's salary to attending, that is a windfall for most, which results in a spending spree. Pay off the credit cards, and pay for or pay off the wedding expenses. Buy a new house. Fill the house with furniture and electronics/ Buy new cars. New clothes. New toys. Most people feel they've delayed financial gratification long enough, and indulge.

Problem is, that becomes your new spending level, and you never get out of it. For most people, whatever their salary is is what they spend.

If people would do as Polynikes suggests, they will pay off those loans in a few years instead of decades, but will likely need to continue living like a resident - apartment or small rented house, old car, Kmart clothes instead of whatever high-end store you like. 36" TV instead of 60", etc. That is hard for many to do, but is the best thing you can do for yourself and your finances. we don't really need all that crap anyway.

If, however, they just pay the minimum monthly payment on their loans, it will take them 30 years, and they will pay 2-3X it's original value. I'm sure many people do.

 

[PMR2008]

If you take home $10K after taxes, and have the discipline and planning to put 60-70% of that toward loan repayment, you are a financial god and will reap incredible rewards in life. Delayed gratification is one of the keys to wealth. We should all strive for this.

Most people don't have that kind of fortitude. When going from resident's salary to attending, that is a windfall for most, which results in a spending spree. Pay off the credit cards, and pay for or pay off the wedding expenses. Buy a new house. Fill the house with furniture and electronics/ Buy new cars. New clothes. New toys. Most people feel they've delayed financial gratification long enough, and indulge.

Problem is, that becomes your new spending level, and you never get out of it. For most people, whatever their salary is is what they spend.

If people would do as Polynikes suggests, they will pay off those loans in a few years instead of decades, but will likely need to continue living like a resident - apartment or small rented house, old car, Kmart clothes instead of whatever high-end store you like. 36" TV instead of 60", etc. That is hard for many to do, but is the best thing you can do for yourself and your finances. we don't really need all that crap anyway.

If, however, they just pay the minimum monthly payment on their loans, it will take them 30 years, and they will pay 2-3X it's original value. I'm sure many people do.

I am glad I talk to a lot of the alumni from my program and they are guiding me through the process. We should all have mentors who we can trust. Almost everyone has told me NOT to buy a house right away and wait atleast 2 years until I am certain I like the job/area and see myself living there for many years. Also continue to use your old car, if getting a new car get a low monthly lease with no money down. I am only going to get a new car(hopefully a GTR ) once I have paid of all my debt. I have been told that once you are an attending the peer pressure can be strong, specially when your fellow partners/friends are buying nice things and taking expense vacations. I hope not to fall in that trap.

You are right that it is difficult not to indulge after the delayed financial gratification but paying off all the debt is the best investment possible.

 

[Polynikes]

If you take home $10K after taxes, and have the discipline and planning to put 60-70% of that toward loan repayment, you are a financial god and will reap incredible rewards in life. Delayed gratification is one of the keys to wealth. We should all strive for this.

Most people don't have that kind of fortitude. When going from resident's salary to attending, that is a windfall for most, which results in a spending spree. Pay off the credit cards, and pay for or pay off the wedding expenses. Buy a new house. Fill the house with furniture and electronics/ Buy new cars. New clothes. New toys. Most people feel they've delayed financial gratification long enough, and indulge.

Problem is, that becomes your new spending level, and you never get out of it. For most people, whatever their salary is is what they spend.

If people would do as Polynikes suggests, they will pay off those loans in a few years instead of decades, but will likely need to continue living like a resident - apartment or small rented house, old car, Kmart clothes instead of whatever high-end store you like. 36" TV instead of 60", etc. That is hard for many to do, but is the best thing you can do for yourself and your finances. we don't really need all that crap anyway.

If, however, they just pay the minimum monthly payment on their loans, it will take them 30 years, and they will pay 2-3X it's original value. I'm sure many people do.

Maybe I just have an impossible time coming to grips with what you just said, although I know it's true. I have no ability to understand the lack of discipline that you just highlighted. None whatsoever.

If you have a student loan, while simultaneously having credit card debt, a car payment, insurance (health / car) and expensive tastes in clothes, you are a fool, and I hope that you spend the rest of your bailing water on a sinking ship.

I think that people who go into medicine have no common sense when it comes to money, and it is no small wonder that a significant portion of doctors who invest in small businesses, real estate, or the stock market lose their tails, and then sue over the lost funds.

What residents don't understand, because most have no concept of money and how to make money work for them, is that if you clear $10k per month after taxes, you are earning several times what you made as a resident.

Total income increases by a factor of roughly 4, if you consider a starting salary before taxes to be approximately $180k to $200k), and a resident salary to be $45k to $52k.

So, if your quality of life as a resident is supported by a financial factor of 1, and you then find yourself sitting at a factor of 4, the difference is 3.

By doubling your QoL from 1 to 2, you are still able to put a factor of 2 on your loan, which is a significant loan repayment and would result in your paying it off early.

If you have a working spouse, you can either (1) put even more money on your loan each month and pay it off sooner, or (2) take advantage of your "windfall" and live high.

Just because someone finishes medical school and residency doesn't just automatically rate them an expensive new car and a big house. I don't get that mentality at all.

 

[RUOkie]

you are in the minority.

 

[Polynikes]

you are in the minority.

That's because today's young adults are soft and weak. Thank God for the Marine Corps.