Making your own shifts + salary

[massagether]

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I'm a non-traditional pre-med applying for class of 2014. I'll be 33 by the time I enter med school, and 40 by the time I complete an EM residency (assuming that I still have the interest and can match into a residency first time around). I've had several of the physicians that I've shadowed tell me not to go into EM because it's a "young mans game."

I'm pretty active and healthy, workout 5-6X a week and eat clean, and have as much or more energy now as I did when I was 18. I realize that inevitably my energy will decline, but want to specialize in something that will give my the time/schedule to pursue outside interests and to keep active. Emergency medicine appeals to me because of the pace (I can't stand sitting on my ass for more than a few minutes) and bc it's shift work, which seems conducive to having an outside life. Also, it seems like the 'rawest' form of medicine in that you save lives in immediate jeopardy, as opposed to managing chronic illness or the course of a disease (I realize you also deal w a lot of drunks, addicts, and those who don't have/won't see a family doc for minor issues).

So my questions are, in your experience:

Would it be foolish to pursue a career in EM due to the age at which I'll be starting?

Do you find the level of burnout higher (and therefore sustainability lower) in your speciality vs others?

Does practicing EM seem to provide the time to live an active lifestyle?

As disparate as it may seem, my other interest lies in PM&R, as I'm a long time massage therapist who has worked in a variety of rehab settings. Every doc I've shadowed has told me to go PM&R (for lifestyle, sustainability, and stress) when I've presented the same questions, but I've yet to have the privilege of shadowing in an ER and getting it straight from the horse's mouth.

So, any thoughts, comments, answers would be appreciated from those of you "in the know"
Thanks for your input!

 

[dotcb]

{Would it be foolish to pursue a career in EM due to the age at which I'll be starting?}

No - if you love it. You'll burn out doing a lot of anything you don't enjoy. There are few fields I think I'd enjoy besides EM. How do you feel about doing 2-6 night shifts a month? If that is a huge turn off, you may have hesitations about the field. The thing is - although the jet lag feeling does affect your body rhythm, you're only working 8-12 hours of the day. Overall, given the hours worked and salary, it's pretty good gig. I find the field incredibly interesting. You've gotta find enjoyment in our bread n butter. If you can't enjoy chest pain, abdominal pain, vaginal bleeding, lacs, Cough/SOB, and abscesses, you might be unhappy. It's mostly not STEMI's and meningitis, though we love those when they happen.

{Do you find the level of burnout higher (and therefore sustainability lower) in your speciality vs others?}

Personally - no. Possibly - yes. EM is an extremely clinical field. As such, there's no hiding in your clinic, no picking and choosing your patients, a high percentage of very sick, stressful cases, and a lot of rowdy miscreants. To make it simple, there are a lot of demands placed on the EP. If you train in the field, you get used to and, hopefully, enjoy it. Get poorly trained or take a bad job, you could be very unhappy.

{Does practicing EM seem to provide the time to live an active lifestyle?}

Yes. EP's tend to have interests and pursuits outside medicine such as music, family, and a fair share of very active people who look for our own warped sense of balance in this bizarre job. There are several fields with reasonable time off - look around. The average EP works 28-36 hours per week, though you can go as low as you want.

 

[Birdstrike]

I'm a non-traditional pre-med applying for class of 2014. I'll be 33 by the time I enter med school, and 40 by the time I complete an EM residency (assuming that I still have the interest and can match into a residency first time around). I've had several of the physicians that I've shadowed tell me not to go into EM because it's a "young mans game."

I'm pretty active and healthy, workout 5-6X a week and eat clean, and have as much or more energy now as I did when I was 18. I realize that inevitably my energy will decline, but want to specialize in something that will give my the time/schedule to pursue outside interests and to keep active. Emergency medicine appeals to me because of the pace (I can't stand sitting on my ass for more than a few minutes) and bc it's shift work, which seems conducive to having an outside life. Also, it seems like the 'rawest' form of medicine in that you save lives in immediate jeopardy, as opposed to managing chronic illness or the course of a disease (I realize you also deal w a lot of drunks, addicts, and those who don't have/won't see a family doc for minor issues).

So my questions are, in your experience:

Would it be foolish to pursue a career in EM due to the age at which I'll be starting?

Do you find the level of burnout higher (and therefore sustainability lower) in your speciality vs others?

Does practicing EM seem to provide the time to live an active lifestyle?

As disparate as it may seem, my other interest lies in PM&R, as I'm a long time massage therapist who has worked in a variety of rehab settings. Every doc I've shadowed has told me to go PM&R (for lifestyle, sustainability, and stress) when I've presented the same questions, but I've yet to have the privilege of shadowing in an ER and getting it straight from the horse's mouth.

So, any thoughts, comments, answers would be appreciated from those of you "in the know"
Thanks for your input!

Read some of Greg Henry's posts on this.

http://www.epmonthly.com/columns/oh-henry/finishing-strong/

http://www.epmonthly.com/columns/oh-henry/ems-mid-life-crisis/


Burnout, wellness, longevity.....these are all valid discussions in EM. Some say it's a myth: Take such words with a grain of salt especially if the person speaking them no longer works shifts in the ED, and has moved out of clinical work, and whose job is to recruit others to work the clinical shifts they no longer work. EM is tough. It's not for wimps. That's okay, though. If you're considering it you're probably pretty tough mentally, and not likely a wimp. That being said, to say EM is no more stressful than Derm, Pathology or PMR is just disingenous. A lot of people that pick EM would be bored in those fields, though.

One thing to think about is, if you are starting EM at 40 and have the typical amount of student loans, plan on at least, at least, 20 years of working full-time in the ED unless you are independently wealthy, or have a spouse with a six figure income . A more reasonable estimate is a 30 year career. This is the problem with medical education. You have a huge delay in payoff combined with a large debt burden. So ask yourself, if you'll want to be doing EM when you are 60, maybe even 70 (a very hard question to answer). If so, then great. If not, then it's better to have that answer now than a decade down the road. If you do decide to go into EM, have a distinct and well though out plan, for the second half of your career (in your case, age 55-70). This needs to be more than, "I'll just work less shifts." For me, EM when single or married without kids, was great. EM with a family, particularly kids school aged, was two completely different careers (you're asleep when they're awake, you're on when they're off, you're exhausted when they're rested, you're rested when they're exhauted, and so on). Take it from a guy that is much smarter, more charismatic and infinitely more distiguished than me, and allow me to quote from the above articles. This is an issue that Greg Henry has described like this:

"I propose that we start now with a frank discussion about the new demon in our midst: the maturation of the emergency medicine career" (my only disagreement being that the demon is anything but new).

That EM as you say it is "a young man's game" is enough of a vexing problem that Dr Henry's goes as far as to propose, "that the emergency medicine career needs its own grand unification theory. "

So yes, EM is a young man's game. Don't take it from me (anonymous, irrelevant and unimportant internet guy who won't tell you his real name), take it from someone much smarter, and who is a past president of ACEP. That still doesn't answer the question if it's right for you. EM may be perfect for you, or it may not be. You have to make your own decision.

 

[DreamingTheLive]

Read some of Greg Henry's posts on this.

http://www.epmonthly.com/columns/oh-henry/finishing-strong/

http://www.epmonthly.com/columns/oh-henry/ems-mid-life-crisis/


Burnout, wellness, longevity.....these are all valid discussions in EM. Some say it's a myth: Take such words with a grain of salt especially if the person speaking them no longer works shifts in the ED, and has moved out of clinical work, and whose job is to recruit others to work the clinical shifts they no longer work. EM is tough. It's not for wimps. That's okay, though. If you're considering it you're probably pretty tough mentally, and not likely a wimp. That being said, to say EM is no more stressful than Derm, Pathology or PMR is just disingenous. A lot of people that pick EM would be bored in those fields, though.

One thing to think about is, if you are starting EM at 40 and have the typical amount of student loans, plan on at least, at least, 20 years of working full-time in the ED unless you are independently wealthy, or have a spouse with a six figure income . A more reasonable estimate is a 30 year career. This is the problem with medical education. You have a huge delay in payoff combined with a large debt burden. So ask yourself, if you'll want to be doing EM when you are 60, maybe even 70 (a very hard question to answer). If so, then great. If not, then it's better to have that answer now than a decade down the road. If you do decide to go into EM, have a distinct and well though out plan, for the second half of your career (in your case, age 55-70). This needs to be more than, "I'll just work less shifts." For me, EM when single or married without kids, was great. EM with a family, particularly kids school aged, was two completely different careers (you're asleep when they're awake, you're on when they're off, you're exhausted when they're rested, you're rested when they're exhauted, and so on). Take it from a guy that is much smarter, more charismatic and infinitely more distiguished than me, and allow me to quote from the above articles. This is an issue that Greg Henry has described like this:

"I propose that we start now with a frank discussion about the new demon in our midst: the maturation of the emergency medicine career" (my only disagreement being that the demon is anything but new).

That EM as you say it is "a young man's game" is enough of a vexing problem that Dr Henry's goes as far as to propose, "that the emergency medicine career needs its own grand unification theory. "

So yes, EM is a young man's game. Don't take it from me (anonymous, irrelevant and unimportant internet guy who won't tell you his real name), take it from someone much smarter, and who is a past president of ACEP. That still doesn't answer the question if it's right for you. EM may be perfect for you, or it may not be. You have to make your own decision.

Amazing.

 

[massagether]

Thanks for the insight.

Part of the draw of EM for me IS the night shifts, excitement, and rowdy miscreants.

I spent a number of years working a side job as a barback and as security in various dive bars and clubs, and while I tend to be a pretty calm person, I got a perverse sense of satisfaction that I always had interesting stories and crazy situations in my job.
Silly as it sounds, I sometimes think that where my story left off (after stripping naked and decking someone, we put this guy down and called the police/paramedics) the ER docs story would begin (some crazy, screaming naked fellah just got carted in w a broken hand and nose).

I know I like excitement, unpredictability, flexibility (see job postings for everything from urban Level 4 trauma centers to staffing companies that will fly you out to a rural location for a week and pay you a months salary for the hassle), and plenty of free time.

I guess I asked my questions bc the older docs I spoke with all advised me that once I got a bit older my need and capacity for adrenaline would seriously decline.

Might I ask how old you are and how long you've worked in an ER?

 

[massagether]

{Would it be foolish to pursue a career in EM due to the age at which I'll be starting?}

No - if you love it. You'll burn out doing a lot of anything you don't enjoy. There are few fields I think I'd enjoy besides EM. How do you feel about doing 2-6 night shifts a month? If that is a huge turn off, you may have hesitations about the field. The thing is - although the jet lag feeling does affect your body rhythm, you're only working 8-12 hours of the day. Overall, given the hours worked and salary, it's pretty good gig. I find the field incredibly interesting. You've gotta find enjoyment in our bread n butter. If you can't enjoy chest pain, abdominal pain, vaginal bleeding, lacs, Cough/SOB, and abscesses, you might be unhappy. It's mostly not STEMI's and meningitis, though we love those when they happen.

{Do you find the level of burnout higher (and therefore sustainability lower) in your speciality vs others?}

Personally - no. Possibly - yes. EM is an extremely clinical field. As such, there's no hiding in your clinic, no picking and choosing your patients, a high percentage of very sick, stressful cases, and a lot of rowdy miscreants. To make it simple, there are a lot of demands placed on the EP. If you train in the field, you get used to and, hopefully, enjoy it. Get poorly trained or take a bad job, you could be very unhappy.

{Does practicing EM seem to provide the time to live an active lifestyle?}

Yes. EP's tend to have interests and pursuits outside medicine such as music, family, and a fair share of very active people who look for our own warped sense of balance in this bizarre job. There are several fields with reasonable time off - look around. The average EP works 28-36 hours per week, though you can go as low as you want.

Thanks for the insight.

Part of the draw of EM for me IS the night shifts, excitement, and rowdy miscreants.

I spent a number of years working a side job as a barback and as security in various dive bars and clubs, and while I tend to be a pretty calm person, I got a perverse sense of satisfaction that I always had interesting stories and crazy situations in my job.
Silly as it sounds, I sometimes think that where my story left off (after stripping naked and decking someone, we put this guy down and called the police/paramedics) the ER docs story would begin (some crazy, screaming naked fellah just got carted in w a broken hand and nose).

I know I like excitement, unpredictability, flexibility (see job postings for everything from urban Level 4 trauma centers to staffing companies that will fly you out to a rural location for a week and pay you a months salary for the hassle), and plenty of free time.

I guess I asked my questions bc the older docs I spoke with all advised me that once I got a bit older my need and capacity for adrenaline would seriously decline.

Might I ask how old you are and how long you've worked in an ER?[/QUOTE]

 

[massagether]

Read some of Greg Henry's posts on this.

http://www.epmonthly.com/columns/oh-henry/finishing-strong/

http://www.epmonthly.com/columns/oh-henry/ems-mid-life-crisis/


Burnout, wellness, longevity.....these are all valid discussions in EM. Some say it's a myth: Take such words with a grain of salt especially if the person speaking them no longer works shifts in the ED, and has moved out of clinical work, and whose job is to recruit others to work the clinical shifts they no longer work. EM is tough. It's not for wimps. That's okay, though. If you're considering it you're probably pretty tough mentally, and not likely a wimp. That being said, to say EM is no more stressful than Derm, Pathology or PMR is just disingenous. A lot of people that pick EM would be bored in those fields, though.

One thing to think about is, if you are starting EM at 40 and have the typical amount of student loans, plan on at least, at least, 20 years of working full-time in the ED unless you are independently wealthy, or have a spouse with a six figure income . A more reasonable estimate is a 30 year career. This is the problem with medical education. You have a huge delay in payoff combined with a large debt burden. So ask yourself, if you'll want to be doing EM when you are 60, maybe even 70 (a very hard question to answer). If so, then great. If not, then it's better to have that answer now than a decade down the road. If you do decide to go into EM, have a distinct and well though out plan, for the second half of your career (in your case, age 55-70). This needs to be more than, "I'll just work less shifts." For me, EM when single or married without kids, was great. EM with a family, particularly kids school aged, was two completely different careers (you're asleep when they're awake, you're on when they're off, you're exhausted when they're rested, you're rested when they're exhauted, and so on). Take it from a guy that is much smarter, more charismatic and infinitely more distiguished than me, and allow me to quote from the above articles. This is an issue that Greg Henry has described like this:

"I propose that we start now with a frank discussion about the new demon in our midst: the maturation of the emergency medicine career" (my only disagreement being that the demon is anything but new).

That EM as you say it is "a young man's game" is enough of a vexing problem that Dr Henry's goes as far as to propose, "that the emergency medicine career needs its own grand unification theory. "

So yes, EM is a young man's game. Don't take it from me (anonymous, irrelevant and unimportant internet guy who won't tell you his real name), take it from someone much smarter, and who is a past president of ACEP. That still doesn't answer the question if it's right for you. EM may be perfect for you, or it may not be. You have to make your own decision.

Great articles. Thank you.
Do you think in your described situation (wife, kids) that it would be possible to combine less night shifts with some urgent care staffing or even short term travel assignments to alleviate some of the tribulations of mismatched schedules? In other words, do you think this is an inevitable consequence of a career in EM when you have a family, or are there a number of creative solutions that might not fit your particular wants but are doable if one is flexible?

As to the money issue, I feel naive when talking to docs about this. Not sure if it's different standards or a lack of understanding on my part, so maybe you could shed some light as both an EM doc and a family man.
I've worked steadily for the last 14 years, and with earnings btwn 30- 45k. With a fairly minimal sacrifice (several years of multiple roommates, community college b4 university, and driving reliable but not flashy cars) I've manage to buy a duplex and put away close to 100k (which I figure to be about half the cost of med school). I love to travel, but have zero interest in 5 star hotels or restaurants, clothing, jewelry, automobiles, or toys. Not bc I'm above being materialistic, but just bc they don't do much for me. If I can afford healthy food, yoga and martial arts, and a few road trips or vacations staying in clean, simple accomodations, I'm a happy camper. All of which I've managed on under 50k.

I realize that family increases costs quite a bit, but I don't see how it would take me 20yrs to pay off app 100-140k in loans if I'm earning 150-200k a year, especially with a working spouse (with hopefully similar values). My only current debt is my mortgage, which my renters are paying for me (and then some). If I take home 100k after taxes, and peel 20k off the top to pay down my loans, I figure I can be clear within 10 yrs of working, max.
Am I wrong here?

May I ask how long you've been an EM doc and your age?

 

[Birdstrike]

Great articles. Thank you.
Do you think in your described situation (wife, kids) that it would be possible to combine less night shifts with some urgent care staffing or even short term travel assignments to alleviate some of the tribulations of mismatched schedules? In other words, do you think this is an inevitable consequence of a career in EM when you have a family, or are there a number of creative solutions that might not fit your particular wants but are doable if one is flexible?

As to the money issue, I feel naive when talking to docs about this. Not sure if it's different standards or a lack of understanding on my part, so maybe you could shed some light as both an EM doc and a family man.
I've worked steadily for the last 14 years, and with earnings btwn 30- 45k. With a fairly minimal sacrifice (several years of multiple roommates, community college b4 university, and driving reliable but not flashy cars) I've manage to buy a duplex and put away close to 100k (which I figure to be about half the cost of med school). I love to travel, but have zero interest in 5 star hotels or restaurants, clothing, jewelry, automobiles, or toys. Not bc I'm above being materialistic, but just bc they don't do much for me. If I can afford healthy food, yoga and martial arts, and a few road trips or vacations staying in clean, simple accomodations, I'm a happy camper. All of which I've managed on under 50k.

I realize that family increases costs quite a bit, but I don't see how it would take me 20yrs to pay off app 100-140k in loans if I'm earning 150-200k a year, especially with a working spouse (with hopefully similar values). My only current debt is my mortgage, which my renters are paying for me (and then some). If I take home 100k after taxes, and peel 20k off the top to pay down my loans, I figure I can be clear within 10 yrs of working, max.
Am I wrong here?

Remember this, when you jump all those brackets you are going to go from being a guy who pays very little taxes at all, to paying the majority, yes, the majority of your money,

gone
.
.
.
.
gone
.
.
.
gone
.
.
.
to taxes.


Roughly estimating (off the top of my head) up to 39% federal income tax, 0-13% state income tax, 1.4% Medicare tax, 6% SS tax, property taxes, sales tax, plus hidden Obamacare taxes and fees, gets you well over 50% in taxes depending on the state (California, NY, Hawaii the worst).

Start by giving over half of your check to Obama, your Governor and mayor, treating yourself a little with a decent house and car (which you rightly deserve) after busting your tail for over a decade before you collect your first "doctor check," throw in a sizable student loan payment anywhere from a few hundred to a few thousand a month for a decade or longer....

See how it goes? Pretty soon you become a whiny "rich guy" doctor, you start finding your hand uncontrollably going toward the "republican lever" in the voting booth (then libertarian) and then start complaining in packs with other whiny, greedy "rich guy" doctors about your rich guy "one-percenter" problems like paying too much taxes, and the rising costs of country club memberships.



Just kidding.


But really, if you are happy living on <$50,000 living frugally, doing what you are doing, why go to medical school and take on $250,000 in debt before you even get your first paycheck? It sounds like you are happy and doing well, doing what you are doing right now.

 

[Birdstrike]

Amazing.

What's so amazing?

 

[DreamingTheLive]

What's so amazing?

Lol. Feel more comfortable putting that vs. "I heart Birdstrike"

 

[winkleweizen]

Remember this, when you jump all those brackets you are going to go from being a guy who pays very little taxes at all, to paying the majority, yes, the majority of your money,

gone
.
.
.
.
gone
.
.
.
gone
.
.
.
to taxes.


Roughly estimating (off the top of my head) up to 39% federal income tax, 0-13% state income tax, 1.4% Medicare tax, 6% SS tax, property taxes, sales tax, plus hidden Obamacare taxes and fees, gets you well over 50% in taxes depending on the state (California, NY, Hawaii the worst).

Start by giving over half of your check to Obama, your Governor and mayor, treating yourself a little with a decent house and car (which you rightly deserve) after busting your tail for over a decade before you collect your first "doctor check," throw in a sizable student loan payment anywhere from a few hundred to a few thousand a month for a decade or longer....

See how it goes? Pretty soon you become a whiny "rich guy" doctor, you start finding your hand uncontrollably going toward the "republican lever" in the voting booth (then libertarian) and then start complaining in packs with other whiny, greedy "rich guy" doctors about your rich guy "one-percenter" problems like paying too much taxes, and the rising costs of country club memberships.



Just kidding.


But really, if you are happy living on <$50,000 living frugally, doing what you are doing, why go to medical school and take on $250,000 in debt before you even get your first paycheck? It sounds like you are happy and doing well, doing what you are doing right now.

No One pays over 50% of their salary in taxes. Doctors arent even close.

Check it http://whitecoatinvestor.com/doctors-dont-pay-50-of-their-income-in-taxes/

 

[Birdstrike]

No One pays over 50% of their salary in taxes. Doctors arent even close.

Check it http://whitecoatinvestor.com/doctors-dont-pay-50-of-their-income-in-taxes/

Nice try, but taxes have gone up since that post, due to Obama. Plus it depends on the person, state, deductions, etc. Regardless, the realities of a progressive income tax are the same.

Your exception only proves my rule: that I've become a whiny rich-guy doctor that complains about my taxes, to other whiny rich-guy doctors.

🙂

(I realize no one feels sorry for me/us)

 

[winkleweizen]

Nice try, but taxes have gone up since that post, due to Obama. Plus it depends on the person, state, deductions, etc. Regardless, the realities of a progressive income tax are the same.

Your exception only proves my rule: that I've become a whiny rich-guy doctor that complains about my taxes, to other whiny rich-guy doctors.

🙂

Im whiney too, but even with the changes it doesnt knock it over 50%....but who cares...**** the government.

 

[Akail]

Nice try, but taxes have gone up since that post, due to Obama. Plus it depends on the person, state, deductions, etc. Regardless, the realities of a progressive income tax are the same.

Your exception only proves my rule: that I've become a whiny rich-guy doctor that complains about my taxes, to other whiny rich-guy doctors.

🙂

That damned Obamer!!!! UGH!

 

[Birdstrike]

Double post

 

[Birdstrike]

Im whiney too, but even with the changes it doesnt knock it over 50%....but who cares...**** the government.

Atta boy!

 

[Birdstrike]

Lol. Feel more comfortable putting that vs. "I heart Birdstrike"

Nothing special here. Regardless, thanks, dude/dudette.

 

[strongboy2005]

Roughly estimating (off the top of my head) up to 39% federal income tax, 0-13% state income tax, 1.4% Medicare tax, 6% SS tax, property taxes, sales tax, plus hidden Obamacare taxes and fees, gets you well over 50% in taxes depending on the state (California, NY, Hawaii the worst).

Very few people (my guess would be no one) pays 39% in federal income tax. The top marginal rate is 39.6% on anything over $400,000, so you would have to make a ton of money (by my calculations, $10 million a year) to even approach 39% on the federal income tax. All of that $10 million would have to be in earned income (not capital gains) and that person would have to have no deductions at all. In other words, people with this kind of money have accountants that make sure they are not paying 39% in federal income tax, so probably close to no one actually pays that rate.

Assuming an emergency physician makes $300,000 a year and takes the standard deduction with married filing jointly tax status and no exemptions, they would pay 22.97% federal income tax rate, 7.77% in California income tax, 2.27% to social security, and 1.45% to medicare.

This totals 34.47% ($103,410). This is no where near 50%, which requires an income of $5.8 million to reach (living in California).

Many people making that much money are able to take even more than the standard deduction (e.g., mortgage interest deductions), further driving down the overall rate.

In other words, if you pay 50% of your income to taxes, you are doing something VERY wrong. Fire your accountant ASAP.

 

[strongboy2005]

Also, to address the sales tax issue, you would have to pay $46,590 in sales tax to hit a 50% overall tax rate (using my above figures for income taxes)

That would be $517,666 worth of taxable goods purchased during the year to hit that mark (assuming 9% sales tax).

 

[Arcan57]

Thanks for the insight.

Part of the draw of EM for me IS the night shifts, excitement, and rowdy miscreants.

I spent a number of years working a side job as a barback and as security in various dive bars and clubs, and while I tend to be a pretty calm person, I got a perverse sense of satisfaction that I always had interesting stories and crazy situations in my job.
Silly as it sounds, I sometimes think that where my story left off (after stripping naked and decking someone, we put this guy down and called the police/paramedics) the ER docs story would begin (some crazy, screaming naked fellah just got carted in w a broken hand and nose).

I know I like excitement, unpredictability, flexibility (see job postings for everything from urban Level 4 trauma centers to staffing companies that will fly you out to a rural location for a week and pay you a months salary for the hassle), and plenty of free time.

I guess I asked my questions bc the older docs I spoke with all advised me that once I got a bit older my need and capacity for adrenaline would seriously decline.

The issue with adrenaline is the same problem that plagued the early punk bands. When you don't know what the hell you're doing, everything is new and fun and exciting. But if you do something long enough you start getting competent at it and it no longer creates the energy it used to. When you can see the end game reliably, the bumps along the road become annoyances rather than challenges. The poly-trauma victim that lit up your night as an R2 becomes 2 large bore IVs, pan-scan, and skirmishes with your consultants about whether the patient needs to be transferred or can be cared for in house. The septic shock is line, lab, CVL for pressors if needed, 20 minutes on phone calling hospitalist, intensivist, and a dealer's choice of consultants for the patient's pre-existing dysfunctional organs: cards, renal, neuro, etc. I'd much rather be good at my job then excited by it, but YMMV.

 

[Birdstrike]

Very few people (my guess would be no one) pays 39% in federal income tax. The top marginal rate is 39.6% on anything over $400,000, so you would have to make a ton of money (by my calculations, $10 million a year) to even approach 39% on the federal income tax. All of that $10 million would have to be in earned income (not capital gains) and that person would have to have no deductions at all. In other words, people with this kind of money have accountants that make sure they are not paying 39% in federal income tax, so probably close to no one actually pays that rate.

Assuming an emergency physician makes $300,000 a year and takes the standard deduction with married filing jointly tax status and no exemptions, they would pay 22.97% federal income tax rate, 7.77% in California income tax, 2.27% to social security, and 1.45% to medicare.

This totals 34.47% ($103,410). This is no where near 50%, which requires an income of $5.8 million to reach (living in California).

Many people making that much money are able to take even more than the standard deduction (e.g., mortgage interest deductions), further driving down the overall rate.

In other words, if you pay 50% of your income to taxes, you are doing something VERY wrong. Fire your accountant ASAP.

I have no idea what my effective tax rate is after deductions. The point was, that it's much higher than when I made much less. This is part of the answer to the question, "Where could all that money go?" when you are an attending. The point is, a much greater chunk goes to taxes, than when you are a pre-med.

 

[EM_Rebuilder]

I have no idea what my effective tax rate is after deductions. The point was, that it's much higher than when I made much less. This is part of the answer to the question, "Where could all that money go?" when you are an attending. The point is, a much greater chunk goes to taxes, than when you are a pre-med.

Yeah, who cares what the actual percentage is..

All that I know, I worked many days, weekends, nights, Christmas, our anniversary, etc. I made some good money, took some nice trips, have a nice house.. BUT.. I effectively gave the government a brand new Porsche 911 Turbo Convertible in taxes...

I dont care if that was 2% or 80%. It causes me ulcers at times and I sit up at night thinking about it. I worked hard for my family to be where we are; I am happy to lend a helping hand; we do the soup kitchen thing, volunteer, etc. I will even give a hand out time to time. I donate my time to medical students, I do a fair amount of proffesional travel to try to serve EM... But when a government is misaligned with my values and I feel my earned money is being spent poorly.. it worries me...

 

[deleted109597]

My favorite is writing that quarterly check that could go towards either: a new car every 3 months; an entire remake of my kitchen; flying a family of 6 to new zealand;...

 

[massagether]

Remember this, when you jump all those brackets you are going to go from being a guy who pays very little taxes at all, to paying the majority, yes, the majority of your money,

gone
.
.
.
.
gone
.
.
.
gone
.
.
.
to taxes.


Roughly estimating (off the top of my head) up to 39% federal income tax, 0-13% state income tax, 1.4% Medicare tax, 6% SS tax, property taxes, sales tax, plus hidden Obamacare taxes and fees, gets you well over 50% in taxes depending on the state (California, NY, Hawaii the worst).

Start by giving over half of your check to Obama, your Governor and mayor, treating yourself a little with a decent house and car (which you rightly deserve) after busting your tail for over a decade before you collect your first "doctor check," throw in a sizable student loan payment anywhere from a few hundred to a few thousand a month for a decade or longer....

See how it goes? Pretty soon you become a whiny "rich guy" doctor, you start finding your hand uncontrollably going toward the "republican lever" in the voting booth (then libertarian) and then start complaining in packs with other whiny, greedy "rich guy" doctors about your rich guy "one-percenter" problems like paying too much taxes, and the rising costs of country club memberships.



Just kidding.


But really, if you are happy living on <$50,000 living frugally, doing what you are doing, why go to medical school and take on $250,000 in debt before you even get your first paycheck? It sounds like you are happy and doing well, doing what you are doing right now.

I have an acute interest in the human body, medical science, and a passion for helping others. I feel that medical school will give me the most in depth training in my interests and the ability to directly help others by using that knowledge and training. Why did you go to medical school?

I work as an independent contractor, so I pay a little more than most employees making the same in salary. Regardless, it seems that no matter how progressive the tax rate, there is never an instance in which someone earning a higher gross income will net less than someone making a lower gross income. Assuming the source is classified the same (earned income vs earned income, investment vs investment, etc.) the person who earns more will always take home more.

I think I would have a difficult time raising a family, enjoying life, and saving for retirement w my current earning power. But I'm not pursuing a career in medicine as the fastest means to riches. It just seems like a very rewarding career that can also provide a nice living.

Thank you for taking the time to share your opinion and some of your frustrations with me, though.
I can certainly understand how you feel after having sacrificed many years and dollars to get where you are and then having to relinquish a large portion of your income to a poorly managed government.

 

[JShephard]

Very few people (my guess would be no one) pays 39% in federal income tax. The top marginal rate is 39.6% on anything over $400,000, so you would have to make a ton of money (by my calculations, $10 million a year) to even approach 39% on the federal income tax. All of that $10 million would have to be in earned income (not capital gains) and that person would have to have no deductions at all. In other words, people with this kind of money have accountants that make sure they are not paying 39% in federal income tax, so probably close to no one actually pays that rate.

Assuming an emergency physician makes $300,000 a year and takes the standard deduction with married filing jointly tax status and no exemptions, they would pay 22.97% federal income tax rate, 7.77% in California income tax, 2.27% to social security, and 1.45% to medicare.

This totals 34.47% ($103,410). This is no where near 50%, which requires an income of $5.8 million to reach (living in California).

Many people making that much money are able to take even more than the standard deduction (e.g., mortgage interest deductions), further driving down the overall rate.

In other words, if you pay 50% of your income to taxes, you are doing something VERY wrong. Fire your accountant ASAP.

Also, to address the sales tax issue, you would have to pay $46,590 in sales tax to hit a 50% overall tax rate (using my above figures for income taxes)

That would be $517,666 worth of taxable goods purchased during the year to hit that mark (assuming 9% sales tax).

Don't forget to add the taxes listed below to your calculations... it appears that you're already over 40% after sales tax (assuming spending all the money). You also cut the social security and medicare taxes in half (since they technically are double - due to the employer paying half of them) that's 44% right there. You could find another 5% in here between all the taxes, property tax alone could be 1 or 2% - depending on the home (reaching 45-46%).

Don't forget about the medicare tax hike for Obama care from: 1.45% to 2.35%... that's an extra percent to add to the total also (2% if you count the employer match). So that moves us to ~48% without any of the taxes listed below.

Personal/Consumer Taxes & Fees

Federal income tax
State income tax
Local income tax
Employee social security tax (your employer pays the other half)
Employee Medicare tax (your employer pays the other half)
Property taxes
Road toll charges
State sales tax
Driver's license renewal fee
TV Cable/Satellite fees & taxes
Federal telephone surtax, excise tax, and universal surcharge
State telephone excise tax and surcharge
Telephone minimum usage and recurring/nonrecurring charges tax
Gas/electric bill fees & taxes
Water/sewer fees & taxes
Cigarette tax
Alcohol tax
Federal gasoline tax
State gasoline tax
Local gasoline tax
Federal inheritance tax
State inheritance tax
Gift tax
Bridge toll charges
Marriage license
Hunting license
Fishing license
Bike license fee
Dog permit/license
State park permit
Watercraft registration & licensing fees
Sports stadium tax
Bike/nature trail permit
Court case filing fee
Retirement account early withdrawal penalty
Individual health insurance mandate tax
Hotel stay tax
Plastic surgery surcharge
Soda/fatty-food tax
Air transportation tax
Electronic transmission of tax return fees
Passport application/renewal fee
Luxury & gas-guzzler car taxes
New car surcharge
License plate and car ownership transfer taxes
Yacht and luxury boat taxes
Jewelry taxes & surcharges
State/local school tax
Recreational vehicle tax
Special assessments for road repairs or construction
Gun ownership permit
Kiddie tax (IRS form 8615)
Fuel gross receipts tax
Waste Management tax
Oil and gas assessment tax
Use taxes (on out-of-state purchase)
IRA rollover tax/withdrawal penalties
Tax on non-qualified health saving account distributions
Individual and small business surtax (page 336 of Obamacare)
Estimated income tax underpayment penalty
Alternative Minimum Tax on income
Business Taxes & Fees

 

[massagether]

The issue with adrenaline is the same problem that plagued the early punk bands. When you don't know what the hell you're doing, everything is new and fun and exciting. But if you do something long enough you start getting competent at it and it no longer creates the energy it used to. When you can see the end game reliably, the bumps along the road become annoyances rather than challenges. The poly-trauma victim that lit up your night as an R2 becomes 2 large bore IVs, pan-scan, and skirmishes with your consultants about whether the patient needs to be transferred or can be cared for in house. The septic shock is line, lab, CVL for pressors if needed, 20 minutes on phone calling hospitalist, intensivist, and a dealer's choice of consultants for the patient's pre-existing dysfunctional organs: cards, renal, neuro, etc. I'd much rather be good at my job then excited by it, but YMMV.

Wow! Excellent point. Never thought about it like that. Thank you for your perspective.
What do you like the most about your field? The least?

 

[Birdstrike]

. Why did you go to medical school?

The same reasons as you, but none of those things you mentioned will pay off a student loan. I think most of us want to help others that haven't gotten where we are yet, go into thing with eyes wide open. When I applied to medical school SDN didn't exist.

There are great things about being a doctor, but most people use forums like this to vent about the negatives. The positives have been sold to you already. The reality is somewhere in the middle.

Here's a grain of salt.



(Edit: I fully support your decision to become a doctor. More importantly, I fully support you doing it wisely, and by repeating as few of the mistakes of those before you, as possible.)

 

[RustedFox]

License plate and car ownership transfer taxes. <----


Dear lawd, THIS. it cost about 1200 for the titles/plates for two cars for me.

Makes limited sense.

 

[SeekerOfTheTree]

License plate and car ownership transfer taxes. <----


Dear lawd, THIS. it cost about 1200 for the titles/plates for two cars for me.

Makes limited sense.

Dang what are you driving? A Delorean?

 

[SeekerOfTheTree]

The same reasons as you, but none of those things you mentioned will pay off a student loan. I think most of us want to help others that haven't gotten where we are yet, go into thing with eyes wide open. When I applied to medical school SDN didn't exist.

There are great things about being a doctor, but most people use forums like this to vent about the negatives. The positives have been sold to you already. The reality is somewhere in the middle.

Here's a grain of salt.



(Edit: I fully support your decision to become a doctor. More importantly, I fully support you doing it wisely, and by repeating as few of the mistakes of those before you, as possible.)

I agree with this. It is not much different on this side. Take it from a guy that's mowed both lawns, the grass is the same.

 

[RustedFox]

Dang what are you driving? A Delorean?

I wish; that'd be awesome.

Nope; its just Florida for you. No state income tax... but they get you in every other way that they can.

 

[docB]

When you can see the end game reliably, the bumps along the road become annoyances rather than challenges.

I think you've articulated something here that I've felt for years but could never put into words.

Dang what are you driving? A Delorean?

Ditto Nevada. I pay about $1100 a year in car taxes. Now this is deductible which muddies the waters but still.

 

[Arcan57]

Wow! Excellent point. Never thought about it like that. Thank you for your perspective.
What do you like the most about your field? The least?

Most, uncommon - bringing someone back from the dead who walks out of the hospital neurologically normal
Most, common - fixing something that provides immediate relief (nursemaid's elbow, abscess, shocking a.fib, etc)

Least, uncommon - dead kids
Least, common - seeing patients who I have no ability to help (addicts, non-commitable psych stuff especially anxiety, parents who are losing their $%$# on day 2 of their kid's viral URI)

 

[NOsaintsfan]

Not to beat a horse about taxes but keep in mind that many people in lower tax brackets have their taxes taken out of their check each pay period. So not only do you pay a lower percentage in taxes but since you never really had the money (b/c it was automatically deducted from your check) its easy to "forget" or not realize how much you pay.

This is in contrast to many people who make 6+ figure incomes who often pay their taxes quarterly or in one lump sum at the end of the year. When you do it that way you are VERY aware of how much you pay. I don't care if you do make 250K+ or whatever when you write out 5 figure checks to the government you really start to scrutinize what you see the govnmt spending YOUR money on.

 

[massagether]

The same reasons as you, but none of those things you mentioned will pay off a student loan. I think most of us want to help others that haven't gotten where we are yet, go into thing with eyes wide open. When I applied to medical school SDN didn't exist.

There are great things about being a doctor, but most people use forums like this to vent about the negatives. The positives have been sold to you already. The reality is somewhere in the middle.

Here's a grain of salt.



(Edit: I fully support your decision to become a doctor. More importantly, I fully support you doing it wisely, and by repeating as few of the mistakes of those before you, as possible.)

Thanks for that. Have a lot of trepidation due to my age, but also some relief in that I know how to work hard and have socked away half the cost of med school on relatively small income over the past decade

Hopefully it will be a good (and not TOO disillusioning) investment

 

[JShephard]

I'm a non-traditional pre-med applying for class of 2014. I'll be 33 by the time I enter med school, and 40 by the time I complete an EM residency (assuming that I still have the interest and can match into a residency first time around). I've had several of the physicians that I've shadowed tell me not to go into EM because it's a "young mans game."

I'm pretty active and healthy, workout 5-6X a week and eat clean, and have as much or more energy now as I did when I was 18. I realize that inevitably my energy will decline, but want to specialize in something that will give my the time/schedule to pursue outside interests and to keep active. Emergency medicine appeals to me because of the pace (I can't stand sitting on my ass for more than a few minutes) and bc it's shift work, which seems conducive to having an outside life. Also, it seems like the 'rawest' form of medicine in that you save lives in immediate jeopardy, as opposed to managing chronic illness or the course of a disease (I realize you also deal w a lot of drunks, addicts, and those who don't have/won't see a family doc for minor issues).

So my questions are, in your experience:

Would it be foolish to pursue a career in EM due to the age at which I'll be starting?

Do you find the level of burnout higher (and therefore sustainability lower) in your speciality vs others?

Does practicing EM seem to provide the time to live an active lifestyle?

As disparate as it may seem, my other interest lies in PM&R, as I'm a long time massage therapist who has worked in a variety of rehab settings. Every doc I've shadowed has told me to go PM&R (for lifestyle, sustainability, and stress) when I've presented the same questions, but I've yet to have the privilege of shadowing in an ER and getting it straight from the horse's mouth.

So, any thoughts, comments, answers would be appreciated from those of you "in the know"
Thanks for your input!

Honestly, I wouldn't do it if you had to borrow 300k or something like that. PA route is a lot faster/cheaper also. I'm not in EM though, just a med student. You lose a lot of freedom (and income) going from having a job to being a med student + resident for 7 or 8 years.

 

[SeekerOfTheTree]

Honestly, I wouldn't do it if you had to borrow 300k or something like that. PA route is a lot faster/cheaper also. I'm not in EM though, just a med student. You lose a lot of freedom (and income) going from having a job to being a med student + resident for 7 or 8 years.

Agreed. The biggest thing I regret is that dude. It cost a million to go to medical school in lost income and debt for me.

 

[ptarmigan]

The issue with adrenaline is the same problem that plagued the early punk bands. When you don't know what the hell you're doing, everything is new and fun and exciting. But if you do something long enough you start getting competent at it and it no longer creates the energy it used to. When you can see the end game reliably, the bumps along the road become annoyances rather than challenges. The poly-trauma victim that lit up your night as an R2 becomes 2 large bore IVs, pan-scan, and skirmishes with your consultants about whether the patient needs to be transferred or can be cared for in house. The septic shock is line, lab, CVL for pressors if needed, 20 minutes on phone calling hospitalist, intensivist, and a dealer's choice of consultants for the patient's pre-existing dysfunctional organs: cards, renal, neuro, etc. I'd much rather be good at my job then excited by it, but YMMV.

I think there is some truth to what you are saying, that things get less exciting as you get used to them. But just to add some diversity to your opinion: I never get tired of treating sick patients. Central lines, chet tubes, trauma patients, septic shock, the crashing kid, etc. That is always what I enjoyed most about the specialty as a medical student/resident and even now as an attending I don't look at the critical care patients as a series of "bumps in the road." YMV, but I want people who read this thread to know that there are people who enjoy this stuff just as there are people who feel it has lost its luster. Maybe its the adrenaline that got me going at first. Now its more the complex physiology that I love. Don't get me wrong, its a job, and there are crappy parts of it, but the sick patients are what I look forward too (even when I'm single coverage and there are patients to be seen).

As you progress in your career, there are different things that excite you or the same things that excite you for different reasons. One of the docs I work with is in his 60s or 70s. He is always excited to talk about a case, and always pointing out xray findings or telling me about a cool case. Those people are around in every group. There is a lot on this board about the negative aspects of medicine in general or EM, but realize that there are also people who are perpetually fascinated by their work. Despite pressures from insurance companies, hospital administration, Press Ganey, and decreased reimbursement there are still docs managing to have long, successful, and satisfying careers.

 

[namethatsmell]

I think there is some truth to what you are saying, that things get less exciting as you get used to them. But just to add some diversity to your opinion: I never get tired of treating sick patients. Central lines, chet tubes, trauma patients, septic shock, the crashing kid, etc. That is always what I enjoyed most about the specialty as a medical student/resident and even now as an attending I don't look at the critical care patients as a series of "bumps in the road." YMV, but I want people who read this thread to know that there are people who enjoy this stuff just as there are people who feel it has lost its luster. Maybe its the adrenaline that got me going at first. Now its more the complex physiology that I love. Don't get me wrong, its a job, and there are crappy parts of it, but the sick patients are what I look forward too (even when I'm single coverage and there are patients to be seen).

As you progress in your career, there are different things that excite you or the same things that excite you for different reasons. One of the docs I work with is in his 60s or 70s. He is always excited to talk about a case, and always pointing out xray findings or telling me about a cool case. Those people are around in every group. There is a lot on this board about the negative aspects of medicine in general or EM, but realize that there are also people who are perpetually fascinated by their work. Despite pressures from insurance companies, hospital administration, Press Ganey, and decreased reimbursement there are still docs managing to have long, successful, and satisfying careers.

Thanks so much for this post. Aside from being imbued with curiosity and resilience, do you have any suggestions for maintaining a "long, successful, and satisfying career?" The most common tips on here seems to be "work less shifts" and "if you don't like your gig, vote with your feet"...any other words of wisdom to add?

Thanks again.

 

[la gringa]

remember that you don't know everything and always seek to learn more - you won't last long in medicine if you don't enjoy learning

remember that you are there for the patients who really need you and try not to let the other stuff get you down - hopefully that's why you went into medicine/EM in the first place. if it's not, you will get worn down faster too.

 

[JShephard]

Thanks so much for this post. Aside from being imbued with curiosity and resilience, do you have any suggestions for maintaining a "long, successful, and satisfying career?" The most common tips on here seems to be "work less shifts" and "if you don't like your gig, vote with your feet"...any other words of wisdom to add?

Thanks again.

I read this in a blog and it correlated with the what the other poster mentioned:

http://onsurg.com/voice/blog-news/choosing-your-specialty

There may be a few people who have a lightening bolt hit them and know instantly what specialty they should go into, but they are few and far between. Most people gravitate in a direction without a clear destination i.e. more medical than surgical, more procedural than not, more or less direct patient care, children vs. adults. At some point they pick a specialty that is in their "zone" of interest&#8230;. and then they worry that they haven't seen enough specialties or they may be making a bad choice.

"The more I studied the issue, the more I noticed that the passion hypothesis convinces people that somewhere there's a magic "right" job waiting for them, and that if they find it, they'll immediately recognize that this is the work they were meant to do. The problem, of course, is when they fail to find this certainty, bad things follow, such as chronic job-hopping and crippling self-doubt." &#8211; Cal Newport

Here's where it gets interesting.

What Cal Newport explains in his book parallels what I have seen in the happiest physicians I know, regardless of their specialty. We have all seen the chief resident or seasoned attending light up when they learn something new at 2am, or when the complex diagnosis becomes clear with steady, deliberate investigation. Cal Newport calls this the "craftsman mindset". It's the process of devoting yourself to deliberate practice in order to master your field. When you adopt the "craftsman mindset", the passion follows. Or, as Cal Newport summarizes it "working right trumps finding the right work."

If you want to love what you do, abandon the passion mindset ("what can the world offer me?") and instead adopt the craftsman mindset ("what can I offer the world?") &#8211; Cal Newport


As I've thought more about it, I have also begun to wonder if picking a specialty isn't somehow similar to how we choose the important relationships in our lives. You may fall head over heels in love with another person or slowly realize you have met the person you want to spend you life with &#8211; but either way, the real relationship comes with time and "practice".

One other thought, if you are currently struggling with your specialty choice.

There are no bad choices.

All the specialties in medicine are noble and important. It's a privilege to serve others&#8230; and we need all the specialties to be able to do it well. Take the plunge. Make the best choice you can and then devote yourself to being a craftsman in that field.

"We are here to add what we can to life, not to get what we can from life." &#8211; William Osler

 

[Birdstrike]

remember that you are there for the patients who really need you and try not to let the other stuff get you down

👍

 

[Old_Mil]

200,000 isn't the whole story. Most EM positions are structured as independent contract jobs so all your benefits come out of your paycheck... And go to paycheck city and use their tax calculator to figure out how much (or little) you get to keep.

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