All right. Good morning, everyone. My name is Dr. Nick Calverma. I'll be the moderator of this session. I want to welcome everyone on Saturday morning. I'm going to just pull up the slides and go through some housekeeping and then we'll get started with the presentation. All right, so this is some housekeeping information. This session is going to be recorded. Please ask everyone to mute their webcam and mics. We have the raised hand function available for this. We're going to ask everyone to save or actually we encourage people to ask questions throughout the session. Type in the chat box and presenters that are not presenting will answer the questions accordingly. Or if they say it might be answered later in the session, then we will allow that to just kind of naturally flow. And then at the end, we're hoping to get through this presentation relatively quickly, so then we can allow everyone's question and answer session. So welcome, Financial Wellness for Students, Residents, Fellows, and Early Career Presidiatrists. I'm the moderator. In the interest of time, we want to go fairly quickly to make sure that people have the availability to ask questions at the end. With that, I'm going to allow everyone to introduce themselves as our presentation comes up. As far as we know, there's nothing disclosed. So let's just go back a couple of housekeeping we talked about. Financial Wellness for Students, Residents, Fellows, and Early Career Presidiatrists. Nothing disclosed for this lecture. So introduction, my name is Dr. Nick Ilverma. Again, some information about myself. I have private practice in Columbus, Ohio. So just to start, every one of us has a different philosophy on money. We also have a different how we value time, experience, assets, success, purchases, etc. Therefore, none of this can be taken as gospel. These are just some tips, some advice that we wish we knew when we were earlier in our careers that we want to give forward to other people to make sure that they're setting themselves up for financial success. So my first topic is I want everyone to be aware of tracking. You can't really know what you're spending on if you're not paying attention to it. So I recommend spending one to four weeks of tracking where you're spending your money. Just write it down on a piece of paper or use an Excel sheet. I wouldn't rely on the apps or automated services for this just at the beginning because it takes away from that personable feeling that you might get. So do this throughout a month and see just where you're spending your money. This isn't for judgment, just to kind of track things. The next thing, you want to be aware of your budget. The budget is just to increase your awareness of, again, where you're spending money. I'm going to give an example in a little bit. There's one recommendation that you can spend about 30% on living, like rents and bills, 20% into savings and retirement accounts, and then 10% for car, gas, payments, insurance, maintenance, and that kind of stuff. This is a good time to start using some of those automated apps or websites like Mint or youneedabudget.com, whatever you can help to keep track of your budget. These automatically will update and they can see where you're spending more money and less. Here's an example of a budget. It's an extreme example. As you can see, that 30, 20, 10% rule, $900 to rent, electricity example, you see later on $600 into saving and retirement for 20% and that 10% to car payment. But then you can kind of see various other areas where you're spending money. This is just a concept. Again, I'm giving you this as an example, a very extreme example. Ideally, you're making more than that a year. I'd include other things like gym memberships, gifts, supplements, medications, donations, and that kind of stuff. The whole point is budgeting is highly personable. It's important to get the good habits early, set an extreme budget, and then adjust accordingly. That's kind of why I used an extreme example in the last slide. For myself, I analyze and I adjust my budget about three, four times a year. It's sometimes a continuous process. The other thing is what are you willing to sacrifice money on? For example, when I lived in New York, I was willing to live in a little bit of a smaller place with multiple roommates so I could spend more money on gym memberships and dinners and that kind of stuff. But some people would rather spend more money on living in a nice place and living alone. So you just have to sacrifice somewhere with those things. Spend time to learn about these things. Your education is important in this, and your time and commitment to this will be important. I recommend about a podcast a week, read a book a quarter, and maybe a course or a lecture with question and answer a year. Here's an example of some of the top books that I recommend. This isn't a fully extensive list, just some examples that I've read that I found useful for myself that I think would be useful for people early in their careers. A podcast is well available. Here's a handful. There's so many out there, especially on the basis of money and finances and financial wellness. You need to find what works and which podcast works best for you and who you relate with the most. An example of a few blogs. I know blogs are kind of going out of style, but they still have lots and lots of useful information, and there's tons of data just compiled over the years that these people have put together. So with that, I'm going to move on to the next section. Hi, everyone. Good morning. My name is Vinny Francio. I'm a resident physician at the University of Kansas. Thank you for joining us today. As soon as the slides come up here, I'm going to go ahead and start talking about my aspect, which is more of a practical guide to medical students and residents. So next slide, please. So first things first, as Nick mentioned, you need to educate yourself on financial literacy. There are many great resources out there that have already been cited. Read books, listen to podcasts, go to webinars and conferences, and most important, I think, in my opinion, is find mentors. Ask questions. Learn, get it right, get it wrong, and pass your experience and knowledge to others. I call this get some gray hair advice. You know, find some people that you trust with gray hair that you can ask some questions because they have experience and they have been to the same difficulties and learning processes we are going right now. So make sure that you get that gray hair advice. Next slide, please. Budgeting, as previously mentioned, is still very important as a medical student resident and an important concept to carry on as an early career physician. It is important to control your spending on large items and small purchases. You cannot have both. Some of these concepts have been mentioned by Dr. Verma. As a practical suggestion, I did use some budgeting apps along residency, which were helpful. So this has been mentioned already, so we can go to the next slide. Savings and emergency fund. In addition to your bank checking account, set up a savings account. Look for an option with high yield percentage. You can use high yield savings account as an emergency fund and save a percentage of your paycheck to deposit directly into the emergency fund. Calculate how much to save or how much to have when an emergency fund is a little bit difficult and depends and is very different person to person. I tend to save about 5% of my monthly paycheck to my emergency fund. Most people will say that you want to aim for about three months of savings and emergency fund. The reason for that is because most disability policies may take up to three months to kick in, so you want to have enough for those three months as an emergency fund. Pay off high interest debt as soon as you can, including credit cards, student loans, etc. Credit card debt is obviously not ideal and should be paid as soon as possible. Some credit cards offer great benefits to students and residents. Think of travel benefits including airfare discount, free upgrades, TSA for free, extra nights in hotel, free benefits upgrade, airport lounges, etc. There are several credit cards that you can use that will give you this benefit as a student resident that you'll be helpful during interview season or going to conferences and things like that. Own occupation disability insurance. This is essential and I cannot emphasize it enough. Think about it. If you're coming home from work and get into a car accident or you have an injury playing sports, you need this. You need own occupation disability insurance. You should choose true own occupation disability insurance, which means this would be tailored to your specific occupation as a physician, PM&R, and even a subspecialty. This is important because in case of a disability, you could still work in another occupation or medical practice. Let's just say, for instance, you are a pain medicine physician and you get this occupation disability insurance, get disability, you can still practice general PM&R. And you still receive your full disability benefits, even if you're earning the same or more income than previously. Individual policy is better. And ideally, you should get an option with future purchase riders and residual disability riders with future increased options for when your income changes from residents you're attending. Remember, the benefits are post-tax dollars. Next slide. Life insurance. This is individual. If you decide to get life insurance, get early on when you're young and when you're healthy. Look for at least a seven-figure amount as a student or resident. Several employers offer life insurance, usually a six-figure benefit. Look for a 30 to 50-year term minimum premium level. Start with about $1 million. And as you transition to early career, look for $2 to $5 million. Look for policy options that you can increase benefits without the need for additional medical workup. Life insurance is certainly more relevant if you have dependents that are depending on you. And again, this is individual. It doesn't apply to everyone. Next slide, please. Retirement accounts. Understand the difference between retirement accounts, such as Roth, IRA, and traditional account. Other options, such as HSA, triple tax privilege, FSA, those are not retirement accounts, but important that you understand. If your employment offers a Roth 401k, a Roth 403b, or a traditional 401k, 403b with an employer match, you should sign up and contribute as much as your budget allows to the maximum employer match. One practical suggestion is to go to the HR department of your employer and ask for the plan document and for retirement account benefits. See if there is a match and determine how much you must contribute to get the maximum employer's match. The reason why this is so important is because that's free money on the table for you. And if you have the opportunity to match, even if it's minimal, this is important because, again, it's free money and everybody likes free money. Next slide. If you are a student resident or early career, give preference to Roth accounts because of a lower tax bracket now compared to your tax bracket in a few years when you are attending. If your employer does not offer a Roth IRA match, see if they offer a traditional IRA match. If not, start your individual account, a Roth IRA. If you are married, consider creating one for your significant other. Even if they are not working, you can still deposit the maximum amount annually to your significant other Roth IRA. And, again, you're just maximizing all your benefits. The max amount this year is $6,000, but, again, this changes every year. Next slide, please. Investing. Diversification of your portfolio is the simple way to avoid large risk by putting your investment in just one option. So you want to diversify with stocks, bonds, real estate, mutual funds, exchange traded funds, et cetera. My practical suggestion is using a Roth IRA is the preferred method because of your lower tax bracket right now. I personally chose Vanguard. You can choose Fidelity. And then you want to consider low-cost index fund, mutual funds, ETFs with a low expense ratio. Lower the expense ratio, higher the probability for return of the investment, but lower the return rate. So it's safe investing if there is such thing. Distribution is individual. So conservative, balanced, or aggressive depending on your individual options. I chose my investing because I'm early on as aggressive as possible so I can maximize my benefits. Next slide, please. A Roth IRA may also be used as an emergency fund. These funds are a last resort in terms of assessing and likely shouldn't be touched because of tax complexity and potential costs with taking these funds out before the age of 59.5. In general, it would be best to use these assets or other sources of capital rather than cashing out retirement plans earlier. If you have an option for a health savings account, you should get it because it's a triple tax-free account for medical services and sometimes even with employer match, which is the case at my institution. So I use that. In terms of individual stock, it's a game. It's gambling. Often will require daily follow-up and no one can predict the market. If you are playing, start small and invest in companies that you truly have a genuine interest to see it grow and you understand. Lots and lots of reading every day, Niels Stocks app, watching the news, of course, Reddit. Next slide. So in a nutshell, here are the bullet points. You're not going to become rich by what you do as a resident or by what you learn here today. Don't do too much, but focus on living like a resident. If you are disciplined enough to study for USMLE for one, two or three months, well, then you are certainly disciplined enough to live on a resident salary of less than $50,000 a year. Again, leave frugal as a resident. Try to have 20 to 30% savings rate into your savings account. Get disability insurance. Get life insurance. This is individual. If you have dependents, highly recommend it. Pay high interest credit card debt and all other kind of high interest debt first. Maximize your contributions to your retirement account, hopefully with an employer match. Again, another concept that is very individualized, but the rule of thumb is rent. Don't buy a house. Have a small emergency fund, about three months savings. Write a 12-month financial plan for your first year as an attending right after residency, even during medical school, even during residency. It's important to write a financial plan. What are you going to do with your paychecks? That's important. The most important financial year of your life is the year that you transition from residency to become an attending. Make sure that you are being smart and make sure that you continue to leave like a resident. This will pay later on. Next slide. Thank you very much. Now I'm going to go ahead and introduce. I'm going to let Dr. Nadia Zaman introduce herself. All right. Good morning, everyone. My name is Nadia Zaman. I'm an assistant professor of PM&R at Tufts Medical Center. Today I'm going to be talking about financial advising. Thank you for moving on to the next slide. Financial advising is not just for wealthy folks. The decisions you make right now, as Dr. Francio mentioned, as Dr. Verma mentioned, are going to help and affect how comfortable you are in your retirement. Financial advisors are essentially financial planners. They don't just provide investment planning, but they can also cover things like debt repayment, insurance products, suggestions regarding what to get, what not to get, depending on your situation, estate planning, as well as tax planning, among many other things. It's actually been found that if you aren't knowledgeable in your personal finances and if you're not looking into how to basically save as much money as you can and invest as much money as you can, the average individual actually loses almost $1,200 a year. Next slide. How do you know if you need a financial advisor? It really depends on your situation in your life right now. Things to look at. Are you married? Do you have a partner? Do you have children? Do you have a lot of debt, such as credit card debt, private loans, loans, mortgages, even student loans? How much money do you have right now to start putting in towards investments and planning for the future? What other assets do you have? What other things do you own? Do you have other stocks and bonds from other sources? And what do you need help with? So the biggest thing you can identify really is whether or not you're just looking for investment advice versus are you looking for ways to pay off your student loans faster? Are you planning to buy a house in five years? All of that is essentially going to go into which kind of advisor you need and what exactly you need to look into. It's a lot more straightforward, obviously, when you're single, you don't have children. You have very low debt versus someone who may have a partner, may have children to plan their futures for as well, and then also have a lot of debt. Next slide. So who is a financial advisor? So unfortunately, there's really no laws in place that regulate who can call themselves a financial advisor. If you do a quick Google search just with the words financial advisor, you'll run into anything from big companies like some of the ones that some of my colleagues here have mentioned, down to like, you know, John Smith LLC, who's providing financial advising to individuals as well. So it can be small firms, it can be individuals, or it can be big companies like the vanguards, the Merrill Lynch's, the Ameritrades. However, there are laws that regulate something called fiduciary duty. And there's actually essentially two parts to what fiduciary duty means. One is the duty of care, and the other is duty of loyalty. Duty of care means that whoever is essentially a financial advisor under the fiduciary duty is required to review all information with a quote, unquote, comprehensive eye. And that may mean that they analyze all of the documents in front of them, as well as talk to other financial advisors to make sure that they're making the best decisions for you. And then duty of loyalty is that they are essentially bound to disclose any information regarding any economic or personal conflict of interest that they have for providing you financial advice, and that they also have to disclose how they are monetarily making money themselves off of your portfolios. But this applies to only some financial advisors. So other financial advisors may only be under something called the suitability standard, which means that they may have to disclose some things to you, but they don't necessarily have to disclose all things to you. And then how a financial advisor is compensated, there's essentially three major ways that that can occur. They can be commissions based, they can be fees based or fees only, or they can be assets under management. That essentially means that only what they're managing for you is what they're allowed to charge you on. And then the type of financial advisor that's available to you may depend on the value of your assets. So some will have actual minimal limits of money that you have to have under their care in order to be able to use them. A lot of times it's the bigger companies that tend to be a little bit like that. More recently, there's been a lot of smaller companies and a lot more app-based companies where there may be no minimal limit, and it's a lot easier to get involved when you have less money, such as when you're a trainee or an early career physician. Next slide. So this is just an example of what some of the costs may be. Obviously, this is not the end-all be-all. This can be very different based on every situation, but just so you can kind of see, someone who has an assets under management type of plan, it's usually a percentage of the total assets that are being managed. So on average, it can be 1%, but it can be as low as a quarter percent to a half percent if you're using more of a robo-advisor. Hourly fees, depending on how often you're meeting, can cost on average $250. Per plan can be more in the thousands. And then if you have a retainer where someone's kind of doing a lot of this work for you, it can be closer to $5,000 to $10,000 essentially. And this is more of a per annum basis. Next slide. So who is a financial advisor can depend. So high-cost options are often tailored to be more person-to-person consultations. These are people that you're going to have one-on-one conversations with, either virtually or at their offices. You're going to be a little bit more hands-off in terms of your management. You essentially tell them what your goals are, and they do a lot of the management for you. The meetings you have are more so to kind of go over whether or not your portfolio is meeting your goals, whether you want to make any changes. Versus lower-cost options, which tend to be kind of more for it essentially needs you to be more involved. But this can be a great option for someone who is a trainee and maybe can't pay $5,000 a year to put in for a retainer. This is also for someone who maybe has more straightforward financial needs and then has a really good knowledge already as a foundation for understanding finances. So you may only need someone once a year to just take a look at the portfolios, or maybe you're only doing tax planning and at the beginning of every year you're already going over what you need to do, so you don't need a lot more kind of hands-on knowledge from them. And then the other option oftentimes, and it's a great low-cost option, is these robo-advisors. There's a lot of them out there now online. Even a lot of the bigger companies have options for robo-advisors as opposed to person-to-person advising. And those are great because a lot of times it's more kind of like pop-ups where they'll ask you like, what do you need help with? And then based on what you choose, it'll give you a lot of information. You can ask in the chat boxes and they give you a lot of information that way as well. But again, a better option for someone who has a lot more financial literacy to start with. Next slide. So how do you pick a financial advisor? Knowing all of that, right? So research, research, research. There's, like I said, tons of stuff online, but not everything online should always be trusted, right? So some of the best places to go are more of these global organizations for financial advisors. So just like we have AAPM&R to find a great podiatrist in your local area, there's something called the NAPFA, which is the National Association of Personal Financial Advisors. You essentially can go to their website, type in where you're from, how many miles within where you're from you want to look, as well as oftentimes what kind of things you want help with, and a number of names will pop up. And these are all individuals who are certified to be providing advice to you. And a lot of times it'll even say if they're a fiduciary or not. Another way to find them is through the Certified Financial Planning Board. This tends to be kind of more within the financial planner industry, something that they use, but this is also another way for you to sort of see if the same names that pop up in the NAPFA also pop up on the CFPB. You can also ask family members, friends, colleagues for their experiences. Obviously, lean on your senior colleagues who have been through this before. As Dr. Francio mentioned, I think it's a great way to put it, lean on the gray hair advice of those that come before you. Consider robo-advisors, as I said before, especially when you're a medical student, resident, or a fellow, where the cost is low and you can still learn a lot. You can kind of, you know, add to the financial knowledge you have already. And then whatever way you end up looking, whether it be your friend has a great financial advisor or you found a great one online, speak to many of them and ask lots of questions before you essentially choose one. And oftentimes when you're speaking to them, the first consultation will oftentimes be free, and that allows you to see what kind of questions they ask you, because that way you can prepare to almost know, you know, these are the important things that I need to focus on as I'm making a plan for my financial future. And then utilize those free consultations to really kind of figure out where you'd want to go from there, because after that, the next meeting on is likely going to cost you some money. And then next slide. So these are just some sample questions on what you may want to ask during that first meeting that you have with the financial advisor. So things to think about. So asking them, are you a fiduciary? If you didn't see that on the website, or if you want to just confirm whether that's still the case, how are they going to be making money based on what they do for you? What is their approach to financial planning? What planning services do they offer of the many things that are available? Investments versus taxes versus estate planning, etc. What is the account minimum if they have one? What information do they need to look at in order to be able to develop your financial plan so that you know coming into the next meeting what you need to bring with you? How often are you going to be meeting? Is it going to be annually? Is it quarterly? Is it once a month? And what kind of things are you going to be meeting about so you can always be prepared for each meeting that comes up? And is there anyone else that's involved in managing the account? In bigger firms, you may have more than one financial advisor who takes care of your account. In smaller firms, it may just be the one individual. They may also have accountants that are a part of the firm that are also helping manage some of your money as well. And then next slide. So remember that financial advisors are not always right for everyone, but financial wellness is always right for everyone. And so you always want to make sure that you're planning ahead because you never know when you're going to need to access some of those funds. So if you're a medical student or an early years resident, early in your career, do your research. Start learning some of the the terms that Dr. Verma and Dr. Prenzio mentioned before. Start saving money so you can start building up your assets as you get later into your residency or you're a fellow or you're about to start your career as a physician. That's when you want to start identifying what you do know and what you don't know and then what you essentially need help on. And that's essentially what's going to help you decide whether or not you have knowledge gaps where a financial expert can be helpful. And so now I'm going to pass it over to our last presenter to talk about the rest of the financial wellness. Good morning, everyone. My name is Maria Vanyushkina. I'm an attending physiatrist at UC Health in Colorado Springs. I practice interventional spine and musculoskeletal medicine. Next slide, please. The goal of today's talk is to serve as an overview of some information that I think you'll find helpful and important during a very exciting but at times stressful part of your life, which is that very first job out of training and how to choose it and what to do about it. We're going to start with student loan repayment. So next slide, please. The best advice I have for any large debt you have, and of course, for many of us, student loans definitely fall into this category, is to refinance it, usually refinance it early. A lot of the times your rates are pretty high, especially if you have federal loans. And pay it down as quickly as you can, starting in residency. That usually does take a lot of self-discipline and budgeting, but it is usually worth it. You will save yourself a lot of money, thousands of dollars over the years. I would say anything that's like 6, 8, 9% like federal loans are, I would consider that a high interest. I would consider something along the lines of 1, 2, 3% low interest for this type of big debt. Good question. So get that stuff done. Do projections to help you stay motivated and on track to show yourself how much money you can be saving. Next slide. For folks that have, Dr. Berman, next slide, please. For folks, back one more. For folks that have federal student loans, thank you. Public service loan forgiveness could be a very tempting, yeah, yes. One second, guys. We will definitely get through that. For those with federal student loans, public service loan forgiveness is definitely a very tempting option. For those of you who are not familiar with the program, you have to have direct student loans. President Biden in October did announce that he's planning to make some changes to this program, which all do appear to be for the better. It includes things like FFEL loans, and it expands some of the repayment plans that are eligible for this program. But before that goes into effect, the current program essentially requires you make 120 payments. You have to be on a qualifying income-based repayment plan, and you have to be working for a qualifying institution, which is usually a government institution or a non-for-profit 501c3 tax code organization. You also have to be employed at said organization at the time you apply for your forgiveness and during the entire time that that application is being processed. Otherwise, you will not qualify for this forgiveness step. As a general rule of thumb, I would suggest that for folks that have a relatively high student debt burden, especially relative to your potential income as an attending, it makes a lot of sense to consider this as a repayment plan for yourself. The time you spend in training, including your residency and fellowship, for the most part, except for maybe some private practice-based, usually spine or pain fellowships, will count towards this repayment period. So usually you'll be four, maybe five years done with your repayment by the time you start working as an attending. Of course, all of this is based on your income. So as a resident with a pretty low income, your payments may be very low for several years, which is very nice when you're trying to live on a resident budget, but obviously comes with certain risks. Usually, if you're making low payments, you're not really touching the principle of the loan. You're barely covering your interest. So during your time in training, your principle will grow, which is a little bit risky. This program is definitely not for everybody. So what I would recommend you do and try to help yourself make your decision about whether or not this is something that you are willing to do and risk is do some projections. So if the strategies we discussed on our prior slide, which is essentially refinance ASAP and pay it down ASAP, works well for you, both lifestyle-wise and budget-wise, and you think that you'd be able to pay down your debt faster than the five to six years that this program would give you, I would suggest you just refinance it and pay it down as quickly as possible. But for those of us, again, that either went to private medical schools or have other debts, a lot of the times a program like this can save you sometimes perhaps literally hundreds of thousands of dollars on your interest payments, essentially. This is a political topic, of course, right? This program is subject to change by our administration. So there's some inherent risk that is involved with trying to choose something like this. And it does require discipline, I would say. When this first set of candidates qualified for forgiveness in 2017, the initial approval rates for this were really, truly abysmal, something in the one percent line. But again, this was largely because the servicer wasn't keeping track of the documentation. People weren't keeping track of their own documentation, their payments, and their employment. They weren't certifying on a regular basis. So what I would recommend is, again, if you're a candidate, and if you think that this makes financial sense for you, or you stand to gain or save a lot of money, definitely do it, but stay on top of your stuff. Make sure you're certifying your employment, make sure you're keeping paper records of that stuff, and make sure that you understand what you need to do in order to actually qualify for the forgiveness. Of course, this program does limit some of your options. So during the job hunt, if you are thinking about PSLF, you are going to be looking at organizations that would fit in within those requirements. Next slide, please. So on those notes, as far as a job hunt goes, my best advice for you is to start budgeting early and start planning early, about a year before what I would consider your ideal start date, which is, of course, a variable from individual to individual. Some people want to take some time off, get married, go travel, whatever, in this unprecedented amount of time that we usually have in between our training and our first job. When you're first looking, I would recommend you start by narrowing down your location and going from there. Obviously, the broader you look, the more states you look at, the more options you have, and perhaps the more competitive options you have, but the more places you look, the more expensive that is going to be for you, both time-wise and finances-wise. There are a series of steps that need to happen before you can actually see patients, bill insurance, and then get paid for it. So once you've got the location piece figured out, what I would recommend you do is pretty immediately start applying for your state license. Some fellowships actually require that you do that, and also applying for your DEA. Please look up how much those cost. It is literally hundreds of dollars, so make sure you budget for that appropriately. And again, this is fairly time-sensitive in the sense that a lot of employers do require that you be licensed in their state before they consider your job application seriously and consider it to be complete. There are a series of expenses that go along with the interviewing process, both from flights to attire to food, and of course there's relocation expenses if you're moving somewhere outside of the area of where you were doing your training. Those are harder to budget for because sometimes employers will cover an aspect of that expense. For example, it's not unusual for a prospective employer to pay for your trip out to them to interview for your hotel and perhaps for even a rental car, but some of the other expenses you will need to cover on your own. Same with relocation. Employers do sometimes offer that as an incentive or a benefit for competitive candidates. That amount is variable, and what is important for you to know about that is that it is not tax deductible. It used to be, but that has recently, or I guess several years ago, changed. What happens is if they say pay $10,000, $20,000 for you to move all your stuff across the country, that is going to count as a part of your annual income for that year, and you'll be taxed on that accordingly. Usually those taxes can be taken out of your paycheck at any time, but the most common time to see that is usually in the first few paychecks or at the end of a fiscal quarter or a year. That can sometimes come as a nasty shock because what you'll find is that they'll write that these are relocation expenses. You'll be taxed on a very big amount of money, so your paycheck is going to look very small compared to what you're used to. Very disconcerting. Plan for that, and also, of course, budget for the time off. Obviously, when we finish training, there's a period of time where we're going to be income-free, unfortunately, and that's variable from person to person how long that period is, but again, budget for that, you'll still have living expenses, you'll still have bills. So make sure that you plan that accordingly and also plan for any important big trips or financial expenses you may want to have during that time period. It usually takes about one or two weeks depending on your billing cycle to get your paycheck after you actually start working. So those down payments and rent and all of that stuff will not go away. Next slide please. Once you've got that location piece narrowed, the next step is to ask yourself some questions about what type of practice setting you may want to work on. And there's a lot of options that exist out there and most of us as trainees are only really familiar with the employed or academic physician model. I would echo everybody's advice to ask your mentors about their prior experiences and do some reading to make sure you understand the pros and cons of different practice settings. Ask yourself, do you need to be at a government or not-for-profit job because of your student loan plans? Do you want to be a business owner? Do you want to take on the responsibilities of business ownerships? Do you like being your own boss? Do you need to be part of a group to kind of keep your sanity or to maybe share some of the expenses a practice may incur? Do you care about exclusivity? Do you care about things like having the opportunity to have a side hustle like maybe doing a little bit of locum's work at a sniff if you're doing something else otherwise? Do you care about your payer mix? Are you wanting to just work with workers comp and personal injury people or do you want to make sure that you have Medicaid and Medicare and all the different insurers in there? And overall just what is your general tolerance to risk? Go ahead and move on to the next slide please. What I'm going to start with is sharing just some basic information about the practice model most of us have the least exposure to, which is what I call the lone wolf physiatrist. This route can be a little bit intimidating and there's a variety of different actual day-to-day work life things that will fall into that. As I mentioned you can be a locum's provider, work at a sniff, work in your own independent private practice, do some non-clinical consulting or some research. Because there is more than one way to do this some people choose to be what's called a sole proprietor. That's the lowest startup costs which are pretty much zero there. You get taxed at your own personal income levels and it's a pretty easy way to start doing business. But what most people do end up doing is getting what's called a limited liability corporation or whatever their state's equivalent of that is. What that allows you to do is separate your personal finances from your business finances. So if you were to get sued whether for something like malpractice or you just got in a car accident and somebody wants to go after your business it gives you that separation and protection of your assets which is usually worth that slight hassle of having to incorporate and advertise in a newspaper and a bunch of other hassles that go along with starting your own business. Obviously keep in mind that when you are a business owner you can build equity which is very nice that's not available in all practice settings but you also have a large amount of business burden that falls on your shoulders. You have to make sure that you understand billing, coding, that you have your own scheduler. You are responsible for all your overhead costs in fact which are very variable and can range from 30 to upwards of 60 percent of what your potential income would be. Going this route does put you at a little bit of risk in the sense that you can definitely be in the negative especially when you're first starting out and if you're having a hard time getting patients to your practice. So keep that in mind this is not a pathway for everybody but does have the opportunity to have a great amount of rewards for the right type of person. Next slide please. For those that do like the idea of being in prior practice being their own boss but don't want to go at it alone joining a PAC or a group is obviously a good idea for a lot of you. When you're first out of training likely you are going to be what's called a junior associate at a practice that you join. A junior associate usually is a salaried employee by the practice. Your partners will help you build your practice which is the advantage of this model. They will help you with things like referrals, establishing relationship with referral sources, getting you in on their rates with the payers, helping you with the overhead, helping you with call. So all of that stuff is definitely worth it but as an exchange oftentimes your salary is less than what you would expect for your the market median especially when you're first starting out the first couple years. The reason for that is that you're not always profitable when you're first starting out and the partners do take a risk in bringing you on. They do obviously have the potential for great rewards so obviously if you're salaried and you're making them great money the partners are going to do well financially while you're on your salary. Eventually the goal is of course to become a partner yourself. You usually do that by taking out a business loan against the practice and then buying into said practice. Just like with any independent practice you then begin to build equity which means that the business is part yours and you can sell it or sell your share of it if you choose to move on. It also opens up the door for you for a certain what I would call passive income opportunities so a lot of private practices also have things that they own for example the business or the actual physical building or the equipment which has a lot of tax advantages to do that. So definitely do some research on this stuff and decide if this is the right fit for you. Just like with any business ownership again you're the boss. You do have business responsibilities like paying taxes, choosing employer, hiring and sometimes firing employees and trying to negotiate things with your partners. You share the overhead expenses but obviously if not all partners in the practice do the same thing as you that your share of the overhead expenses may be lesser or higher than theirs. So trying to come up with an agreement on how to divide that fairly is something that would be worth a discussion with your team. Next slide. If all that stuff sounds way too complicated and the business side of medicine is not something that appeals to you which is true for many of us you can be a employed physician and again this is the model that most of us are very familiar with. Obviously academic physicians or school of medicine faculty fall into this category but you could also be a community provider like myself or you can even work for a for-profit practice like Kaiser and still be an employee. This has a lot of benefits in the sense that you usually come with a built-in referral source which is very nice when you're first starting out because you'll be busy quickly and your employer assumes the contractual obligations for filling your schedule, providing you with staff, providing you with space, all that stuff. You do have less control over the business side of things and you also have a little bit less control over what services you are able to offer. In a private practice you can have a half day or full day of cosmetic Botox if you really want to assuming you've had the appropriate training. When you're an employee they may tell you what you can and cannot offer to your patients especially in places like Kaiser where they may not even want you to do certain things like knee injections because they have primary care injection superstars that are cheaper for the plan itself. So there's compromises that you make when you're choosing some of these options but overall the employed model seems to be a little bit more secure and less hassle for certain personality types. So next slide please. Let's talk about money. How are physicians paid and honestly the answer is it's super variable between the three attendings on this panel. All of us have a different contract and reimbursement model. You can be paid on something called collections. That is the most common strategy for when you're in either private practice or even in certain other settings. What that essentially means is that you take the money that the insurance companies pay you, subtract your overhead costs and that is your take home. Of course this can be variable from month to month so it's possible that your salary may fluctuate. That could be a challenge for budgeting and things like that but again also has some great rewards to it. If you have a particularly productive month you could be making decent money. So if you're planning for vacation or whatever you can sometimes adjust that accordingly. You can be completely salaried. That's usually my personal preference but everyone again is an individual. The way that your salary is determined is usually based on market medians for your specialty specifically. So again you can either be PNR, pain, sports and also for your region. Usually there are survey companies, the big one being MGMA, that have essentially huge excel worksheets of medians for each specialty. So usually your mentors or your training program will be able to give you access to that data so that you can use that for your contract negotiations. The other option is to be paid on what's called productivity. Similar to collections in the sense that it's kind of kill or eat what you're killed but the productivity model tends to take the payer mix out of the equation. So instead of having variability with different payers in terms of what you get paid for each service that you offer, when you're on a production model they use an external form of metric to keep track of how busy you are essentially and then pay you based on that. The most common of those metrics is something called the RVU. So let's go on to our next slide. RVU stands for relative value unit. It's essentially how insurance companies determine what each service you offer is worth to them and it's usually made up of three different components. So it's important for you to familiarize yourself with this stuff. The part that you really want to look at of course when you're on a production model is something called the work RVU component or the physician portion of the services. Next slide. Who sets all this stuff and who determines what each service is worth and what your conversion rate will be? The honest answer to that is that this is a political topic and it is heavily regulated by government entities. You have something called the relative base relative value system which assigns a numerical value to the difficulty and liability and risk associated with different services. That's the RVU. There's a conversion rate that is set by the centers of Medicaid and Medicaid service, Medicare and Medicaid services that is variable from year to year and essentially you multiply your RVUs by the conversion rate and that's how you're paid. Private insurers typically pay you in multiples of that. It is reviewed on an annual basis by the RVS Utilization Committee and AAP MNR now has a permanent advocate on that which is wonderful so they can advocate for retaining the values of the services we provide. And of course there's E&M codes and CBT codes and bundling and it's very important for you to invest time especially if you don't get it during your training in learning what that is so that you save yourself money or actually get all the money that you actually deserve for a service. So as we are low on time I am going to stop here and open things up to questions. Thank you. All right just want to unmute myself there. We'll access the raise your hand session to allow people to ask questions. I'm going to leave this slide up as well so people can look into getting ahold of us by encouraging them to download the slides at the end and see if they can if they have further questions they can message us directly. All right so let me share. So I'm going to and I just messaged it in the chart. I'm going to quickly answer one of the questions which is does refinancing affect your ability to qualify for student loans or public service forgiveness? Yes it does. You have to keep your loans through the federal government which again usually carries a higher interest rate. You do want to consolidate them but if you refinance them through a private payer you will no longer qualify for that program. And yes to Christopher who commented on something. Right now what President Biden is proposing is that any of the federal plans including the standard plan the standard 10-year plan would qualify for this process. So you don't necessarily have to be on an income-based repayment plan if what he is proposing goes through. But at the moment it is specifically direct federal loans and specifically income-based repayment plans. Okay. Let's see. Yeah okay good question from Jess too. My general strategy for for PSLF because this is something that I am pursuing is what you suggest right. You want to minimize what's called your modify adjusted gross income especially when you're a trainee. The easiest way to do that is to contribute to accounts that affect your above the line income. So that's your traditional retirement accounts like the IRA, the HSA. The way that your payment is calculated is based off your salary minus your state poverty line times I think 115 percent and then that's the amount you actually pay on. So the strategy of course is make the lease payment so you get the largest forgiveness but again that is not without risk if something changes with the program or if you have a change in your employment situation throughout your career it may you may end up having a pretty large principal amount. Okay I think that's everybody's questions from my end. Were there any other questions during the presentation that might not have been answered or anything else that anyone wants to go over or just here maybe I'll give a couple seconds and then we can just do some final wrap up from everyone on the panel. Okay Benny I'm starting with you. You just want to give a one or two liner just final advice and then we'll go through the list and then we'll wrap it up. Yeah absolutely. As a as the resident here on the panel and maybe a lot of residents out there that are listening to us you know you're not going to be rich by the suggestions that we made today. This is going to be long term but you know make sure that you continue to leave like a resident for the first year after your residency training and just be smart. You know just be smart about savings and investing your retirement in retirement accounts and just ask for advice gray hair advice. That's my words of wisdom and thanks everyone for joining us. Great Nadia want to go ahead? Sure really echoing the same sentiments as Benny did with the addition kind of go back to what I said is it's okay to not know all the information but it's not okay to just sit with the knowledge gaps. So when you don't know something definitely reach out for help to to anyone that comes before you. You know people that are actually have expertise in financial wellness and and whatnot but ultimately you don't you don't want to just stay in the dark because that will affect you you know not right now but maybe 20 to 30 years down the line. Maria? Honestly I agree with all the other presenters you gotta put in the time now to do your research to improve your financial literacy and if it is something that you know is just not your area of interest make sure that you do make the right steps and get somebody that is an expert on board that can help you so that you don't end up paying unnecessary money on debt on interest or anything like that. Great Morgan just to answer your question if you download the slides there's a handful of other literature I quoted or cited in there and we kind of all agreed on those ones and secondarily if you have any questions feel free to reach out to us again all of our information is at the final slide. Just want to echo what Vinny kind of said is you know living like a resident I just finished my fellowship last December and trying to get my practice started so living lean is too full for me not only that to be lean on practice but to lean in my life because I'm not making a lot of revenue right now. Thankfully I have all these other systems in place to make sure I'm successful for the future but honestly I'm living on $5,000 a month which may sound like a lot to some people but after you break it down it's really not that much money and if you look at my example my extreme example I gave earlier that was $3,000 a month so it's just some food for thought it's just kind of what you have to do for a few years just to make yourself beneficial for the future. So again I want to thank everyone for their time and joining us on this Saturday morning AAPM&R is always known to throw some great conferences I always have a good time doing this and I was excited to be a part of it this year and hopefully the years forward we'll continue to do something like this. All right thank you all. Thank you everyone. Have a good Saturday. Thank you. The rest of the meeting.

financial wellness

students

budgeting

student loan repayment

physicians

financial literacy

learning resources

public service loan forgiveness

qualifying strategies