Mostly written by my brother

Everybody’s got their excuses
for why and when.
“Learn to fly and then we can talk, boy.”
Before flight comes advice,
“Move slow, take time.”
All your hang-ups, not mine

are holding me back.

If I were a smart man
I might move slow.
First you see, then you know where to be.
I’m supposed to know,

but not really to live.
Not to play, just to give
to the world.

The world hasn’t shown me shit
but my eyes were covered.
I accepted it all and never wondered
why you’d hide my eyes,
like it’s all so bad.
I was too young to see, too young to even be
alarmed by it all.

Maybe you should’ve let me look,
so I could stand tall now
and realize how I’m to make my mark.

“Advice, like youth,
probably wasted on the young…”
You forget what you’ve done
and demand me a man.
Without warning I’ll come to it
in bloodshot highway fashion
I digress in my passion. I feign maturity.

How am I to be of use
when I don’t know my heart,
can’t see the part I’m supposed to play?
This screw-all game of luck and trust,
to live you must be free of it all.
To be free you must say “no”
to what you know, else you’ll crack.
I’ll leave you and then come back
to you, a man.

How am I to be of use
to your ideals that are dying,
when my heart is screaming, crying
for the trails I have not run?
I’m as deaf to your ideals
as I am to your advice.
I’m uncertain as dice
rolls, my life.

My life to date is blank.
A space to write and fill.
A place for heart and will
to be a man?

I could just move on and pretend
and be as useless now as then,
asking “Just when will I be a man?”
A matter of hours has broken
years of thought and practice,
of life and trying to act as if
I cared about any of it.

I need to run into the night,
to practice love and sin,
fuck it up and try again
to be a man.

I can’t take your path.
When I try, you stop me.
I’m just supposed to find the spirit of a man.

The man I haven’t learned to be
mocks me, laughs and gestures,
a smile but no answer to my questions
and points at my trail.

Step aside and I’ll walk.
I’ll come back and we’ll talk
together as men.

To be a man takes practice.
You can’t smile and teach.

Your goal I can’t reach

without time and pain.

The man I haven’t learned to be
is patient, and waits for me
to do whatever it takes to come back
to you, a man.

Tentatively titled “To you, a man”

Awesome writing I found today. Check out the author’s blog to see this in its original format; reblogging it removed the paragraph breaks.

Medicine for Money Part 2: How much is $200K/year?

In Part 1 of this series, How much do doctors make?, we saw a wide variety of figures. A career in medicine neither guarantees nor limits you to an income of $200,000 per year, so we’re going to work with that figure as it’s neither excessive nor out of reach.

How much is $200K/year? The short answer is $8000 a month, for a doctor with sizable student loans.

The average debt for graduates of medical school is reported to be between $150,000 and $200,000, depending on the source. Many recent graduates cite much higher numbers, so again, this is a somewhat worthless approximation.

But, if you had education loans of $200,000 paid on a 20-year repayment plan, your monthly payment would be in the neighborhood of $1520 (…anpayments.cgi). Assuming a debt of $250K, your monthly payment would be around $1900 (…anpayments.cgi). Hilariously enough, that calculator says:

It is estimated that you will need an annual salary of at least $229,002.00 to be able to afford to repay this loan. This estimate assumes that 10% of your gross monthly income will be devoted to repaying your student loans. This corresponds to a debt-to-income ratio of 1.1. If you use 15% of your gross monthly income to repay the loan, you will need an annual salary of only $152,668.00, but you may experience some financial difficulty.

If your debt is $300K, it suggests you need a salary of $275K to comfortably make payments over 20 years. Let’s just call the monthly payment amount $1600 for a debt amount close to $200K. If you wanted to pay it off in 10 years, you would have to pay $2300 per month.

Assuming you want to save the most you can for retirement, you’ll max out your 401K by putting in $16,500 of your pretax income each year. This will lower your taxable income in this hypothetical from $200K down to $183,500. If you maxed out an IRA each year it would be another $5,000 per year. If you owned your own practice (or another business) there could be different contribution limits and tax implications; we won’t go there in this hypothetical.

Your new pre-tax income is $183,500. The marginal tax bracket for federal income tax on that amount ranges from 18% – 25% depending on whether you file independently or with a spouse ( Well call it 21% for the sake of easy calculations. Tax burden varies by state, but the average is just under 9% (…fo/09STUDY.pdf), so we’re at a total tax rate of 30%.

0.3 * 183,500 = $55,050 paid in taxes. You’d be left with $128,450, but keep in mind you’ve already put $16K away for retirement.

This comes out to $10,704 per month. If you decided to max out a Roth IRA (instead of the traditional IRA that I mentioned above, but did not include in any calculations) that would require another $417 per month, leaving you with $10,287 per month.

Take out the loan payment of $1600 discussed above, and you have $8687 per month. For the 10-year repayment plan, taking out $2300 drops you down to $7987 per month. Your mileage may vary tremendously here, depending on your regional cost of living and the lifestyle choices you make.

Just for example, if you tried to buy a million-dollar home, with a 30-year mortgage at 5.5%, your monthly payment would be around $5978, leaving you with $2009 per month to pay for cars, gas, groceries, utilities, “saving for your kids’ education,” and whatever other expenses you have. Take the same mortgage terms on a $500,000 house and your payment is about $3000 per month depending on property taxes and home insurance (…alculator.aspx). That could afford you a very comfortable house in many parts of the country, but I wouldn’t expect it to go far in NYC. Either way, you are left with about $5000 per month.

Assuming you’re willing to put $1000 per month toward a car or cars for you and your family (leaving you with $4000/month), you could afford $56,000 worth of vehicle (…nt=120&pmt=290). This could be one fairly nice car, 2 x $23,000 cars, or any other combination. If you’re willing to put $2000/month toward cars (leaving you with $3000/month for everything else), you could afford $108K worth of car. You could also put that extra money into a larger mortgage, so this is well past the point where the breakdown becomes highly individualized.

Basically, making $200K per year with a debt burden of about $200K, after maxing your retirement contributions and making the minimum monthly payment on your loans, you would be left with around $8,000 per month for mortgage/rent and living expenses, investment, or to otherwise allocate as you please. As has already been mentioned, you can live comfortably but this won’t afford you a lavish lifestyle of vacation homes and Lamborghinis.

My dad could most assuredly beat up your dad

When I say he was tall I mean that he was 5’10 and I was 6’1 and nobody knew I was taller. He was barrel-chested—not fat but not in good shape but confusingly strong. In a moment of frustration he could slam his fist down on the table so hard you wondered why it didn’t go crashing through the floor into the basement.

He was not handsome. He had a thick auburn beard which he sometimes trimmed to just a moustache—one that would have looked ridiculous on somebody else, but somehow made him more of an icon and less of a mortal. When he lost his moustache to chemo was when I knew he was going to die. The gravity of the situation before that point was lost on me. The missing moustache got me to pull my head out of the sand.

Medicine for Money Part 1: how much do doctors make?

It depends whom you ask. It also depends on choice of specialty, practice modality (private practice vs. academic vs. other options and combinations), and whether you practice in a rural or an urban area. We’ll start with some data from an MGMA survey…I would link it but the link I had a year ago is now expired. The sample size was over 60,000 but I don’t remember anything else about the survey. This bit just compares median incomes for each specialty in “academic” practices vs. “other” practices.

All Primary Care:————$158,218———$191,401
Family Practice—————$164,469———$183,999
Internal Medicine————$161,916———$197,080
All Specialists——————$235,587———$325,916
Cardiology: Invasive———-$295,050———$481,878
Cardiology: Noninvasive——$240,781———$421,377
Emergency Medicine———-$223,385———$262,475
Endocrinology—————–$157,000———not reported
Infectious Disease———–$159,502——-not reported
Maternal/Fetal Medicine—–$296,933——-not reported
Neonatal Medicine————-$208,762——-not reported
Nephrology———————-$183,093——-not reported
Orthopedic Surgery————$400,335———$496,264
Pathology: Anatomic———–$214,557——-not reported
Pulmonary Medicine———–$183,475———$288,279
Radiology: Diagnostic———$350,000———$478,824
Rheumatology—————–$166,767——-not reported
Surgery: General—————–$280,121———$336,084
Urology—————————-not reported———$390,678

All Nonphysician Providers————————-$94,441
Nurse Practitioner————————————$85,706
Physician’s Assistant (Surgical)—————–$101,000
Physician’s Assistant (Primary Care)————$89,021

All of the pretty graphs below are from a physician income survey done by Medscape. You can still go directly to their site to check out the methodology, etc. All of this should serve to get the point across that physicians have a tremendous range of incomes, and that there is still overlap between physician income brackets and other health professions.

Pretty Graphs From Medscape

I had heard that physicians in smaller towns earn more. The explanation I got from a family medicine resident was that, at least for salaried physicians, the pay had to be better in more rural areas as an incentive to go somewhere you wouldn’t want to live elsewhere. Regardless of the reason:

Regrading hours worked per week, and breakdown between patient care and other activities:

There’s a lot more info in the study about other compensation factors. You’ll need a Medscape account to view it, and if you don’t already have one I highly suggest you check it out ASAP. It is a great resource.

Premed FAQ: Is it ok to become a doctor for the money?

You want to choose medicine for the money. And you want my permission. Well, go ahead.

There are 2 problems I’ve recognized every single time this question comes up.

  1. The person who asks it (assuming they’re asking in earnest and not just trying to get a rise out of someone) doesn’t know they’re not supposed to ask it. In other words, they’re kind of dumb.
  2. The (dumb) person doesn’t listen to the responses. They’ve already decided that it’s ok to become a doctor for the money, and they were simply asking as a courtesy, without the slightest intention of considering other peoples’ thoughts on the issue.

Well, in my new-found blogging spirit of “who the hell cares if people are listening to me?” I’m going to address the issue anyway, once and for all. It’s going to take a while, so I’ll do it in a series titled “Medicine for Money.” That way my non-existent readers don’t get too bored.

Because this is such a frequently asked question, I have plenty of fodder for discussion. I’d like to start by ridiculing some of the fruitless analyses other people have done on this. Don’t worry, they won’t be offended. They’ll be glad that I’ve linked people to their crappy content.

Here’s one:

And here’s the other:

While I admire the effort (and I don’t begin to disagree with the point they’re attempting to make), the numbers aren’t that hard and fast. There are zillions of different possible scenarios with different debt figures, different choices of medical specialty, different investment outcomes, and myriad other things that would affect the final figures for net worth or how many years it takes for a physician to catch up to a UPS driver.  It’s easy to ignore these spreadsheets because they are so hypothetical; I could spend the rest of my life creating equally plausible, yet contradictory spreadsheets where the physician comes out vastly ahead and maybe even becomes POTUS. I might pay attention if they posted 30 years of tax returns for a real UPS driver and a real physician, but the fake projections are sadly unconvincing.

This series will not rely on math to prove any points. It will not rely on hypothetical or anecdotal “evidence.” It will not make appeals to your emotions. It will just explore the reality of choosing a career in medicine for the money, and the implications of making such a choice in the high school and college years.

I hope you enjoy, and comment along the way.

Things Girls Say

My wife says, and does, everything in both of these videos.