This is Personal Finances and Compensation, moderator Matt McLaughlin from Children's Mercy. That's not me. My name's Greg Gorsuch. I'm one of the, I'm a PM&R doc currently at Mayo Clinic Florida. Just to get an idea of the audience, I'm not smart enough to do the polling, but how many people, and do we have any residents here? Good. Good. So mine's not hopefully too simple of a talk. Anybody out the first five years? Anybody out the first five years learned a lot of stuff about billing, coding, and collecting that they had no clue about before? Still learning. Okay. And then whatever. We have time. We have three distinct, well, two distinguished speakers today, and I'm the third. So we'll go from there. My introduction is supposed to be a lot of different jobs in my career. I've been in private practice, academic practice, ran the practice plan at University of Missouri of about 600 docs that we worked on the billing, collecting. I was also the chair of a department there. Learned probably more in private practice about some of the stuff we're going to talk about, and we have different people. Want to leave some time at the end for discussion. And why don't we go ahead and get our other speakers. So if you want to introduce yourself, Rikki. Sure. I'm Carly Reichert. I am a graduate from the University of Missouri. Attendingship. Is this on? It is on now. Is it on? It is now. Okay. There we go. Okay. I'll start over. I'm Carly Reichert. I am a graduate of University of Missouri Residency Program, and now practicing inpatient rehab and a little bit of outpatient in Neenah, Wisconsin, a small hospital-based rehab center. And I'll be talking today about retirement accounts. Hi. I'm Rikki Singh. I'm from St. Louis, Missouri, but I did not train there. I'm at Weill Cornell New York Presbyterian, where I am the director of International Spine and the vice chair. My role there is mostly focusing on strategy. I give a lot of talks to the residents and fellows, some of whom are here, about finances, how to make money, how to save money, how to spend money. My talk will be on side hustles, what are some things that you could do in academic medicine or even in private practice. I'll touch a little bit about some personal finance, what saving money looks like for your future, and then we'll open it up for questions from you guys. We are here to serve you. Thanks. All right. Why don't we go ahead and get going. So where does money come from? You know, we go into practice and it's like, I see patients and money comes from there. And then I have nothing to disclose, no financial relationships, other than Dr. McLaughlin taught me everything I knew. Hey, thank you, Matt. Disclaimer, a couple quick things here. I got a lot of numbers here. A lot of the numbers have been changed, some of them because of copyright issues from places. So that's my disclaimer. I changed a four to six or a six to a four. Couple quick questions for those that are residents or the people that find their first jobs or right now, do you have an RBU target for how much you have to work? That's a yes, someone there. Yeah, you had it on your contract. Before you signed the contract, did you know how many RBUs, what an RBU was? So some of the things is, hopefully you did before you signed it, does your department or your boss or the company or you have a designated amount of dollars per RBU or does it vary by payer? What you get paid? Anybody got a clue? Yeah. It's the same for every patient. So it's not a payer subjective. Medicaid is the best payer. No, it's the same for a Medicaid patient as the best payer. Okay. Actually, when I was in Missouri, Medicaid was my best payer, believe it or not. We got a disproportionate share. So there in and of itself is my point. Know who your payers are or how you're paid. Even if you're paid on a set amount, I still want to kind of know what my best payer pays. Am I making what I'm getting paid or not? Things that questions. What's your clinical, anybody know what a good collection rate is? What's a good collection rate? What? 80%. Anybody else got one? Anything above 30% billing. Well, you just made a point. What's the collection rate based on billing? What's that called? That's a gross collection rate versus a net. If you don't have a, we'll go over this, but if you have a net collection rate, I better have close to 100% net collection rate or I'm losing dollars somewhere. My gross collection rate is going to be based on what I bill, what my charge is, but a charge and billings that we'll go over is a lot different terminology. And what percent of your group's budget is based on clinical dollars? Anybody here work at academic centers? How much of your budget is clinical collections? 95 there, it was about 85 in Missouri. So I want to know that because everybody thinks, ah, the state pays me all the dollars. It doesn't quite work that way. It's usually your billable dollars. And we can go over some of that. But a couple of quick things. How much time do I have, Matt? Give me a warning because you know I go way over and you got smarter people. But medicine's a business. Our product is a service, right? The service industry is competitive and competition's increasing. When I came out greater than 30 years ago, if you talked about business and medicine, it was like, you know, grabbing a cactus. People just didn't do it. We had no commercials on TV about physicians or health centers. Do we have them today? All over the place. If you had a commercial back then, you were called a lawyer. That was supposed to be semi-funny, but no one's awake now. I understand it's after 3 o'clock on that today. So we got to get going. Thinking about money, let's think about the business. We're in business world. Our payers are huge. They have a lot of money. Medium is health systems. Small is a hospital. Microscopic is what you bill and collect. So you got to understand that in the system of hospitals and all. If you don't watch your money, no one else is going to watch it or know what's going on. Okay? We are peanuts. But they're my peanuts. Because if you look at health insurance companies by ranking of revenue, this was a few years ago, United Healthcare, $286 billion. If you want to make that, go into business. I mean, go into Wall Street. Okay? What are the largest health insurance companies in the U.S. by number of patients? You look at Kaiser Permanente, United Health Group. So that is big money. Okay? So also, how many people work for a hospital? I work for a hospital. So is your hospital for-profit or not-for-profit or non-profit? This is kind of supposed to help people get engaged. Anybody know? Not-for-profit. Not-for-profit. Does that mean they don't want to make a profit? No. Who said yes to that? I got a payday. I'll pay you. Who gave me that answer? No, I said it certainly doesn't mean- This guy keeps shaking his head, so I'll give you the next part. All right. So there you go. So the point is, the only difference is a tax issue. For-profit companies pay taxes and pay their dividends out to shareholders. How many here own a stock? How many here want that stock to pay me good? How many ... So if I'm working for a for-profit company, they're going to watch their dollars and cents to the T, okay? Non-for-profits, where does it go? Does it go to shareholders? No. It's supposed to be reinvested back into the system, okay? So this is just some lines. It doesn't come out. I apologize, but it makes the point. I worked and ran at the university in Missouri. The blue line was clinical dollars for budgeting. The smaller lines, as you see, were money we got from the state or from the dean's office or whatever. So you can see what was the big driver to fund education. Clinical care. So I had to rob Peter to pay Paul for education time. Anybody here a resident? I love residents because they write my notes, but ... Oh, did I say that? Okay. They cost ... We got money from the system for residents, right? If we didn't, they were what's a resident cost. It's a cost, right? Salary, wages, and benefits. But then where does the money go we collected? And we had to pay for, at a university, school of medicine, cost of operations. Who collected the money? We had our own little company that we hired people to put the bills in to collect the money. What's that called? God, no. I paid people to collect my money, whether I'm in private or academic practice. I have to pay for office space. I have to pay for things to run a practice. What's that called? Oh, thank you. Give me somebody who said that. Okay, over. There's another page. You got the right answer. So the point is, okay, it's a business. I got to run the practice, whether I'm in academics. When I was in private practice, what did we do? I had to pay for my secretary, I had to pay for my nurse, I had to pay for my office space. That was overhead. You know what I said the first day when I went to that group that I worked with? How much vacation do I get? You know what they said? As much as you want. I don't care. As long as you pay your overhead, we don't care. So guess what? It was hard to take vacation because I was trying to say, okay, how much do I make if I pay my overhead? And now, once I pay my overhead, guess what? That comes. Some of it comes to me, okay? If I'm sitting in my office and I do all hospital work and I don't go to the office and I'm part of the group, what's my overhead working in the hospital? My billing, my collecting, my malpractice, things like that. But my partners were in an office space, do I have to pay part of their overhead? It all depends on your contract and what it's set up. So what I'm saying is know what work you're going to do and what the costs are. All right. We'll go from there. We'll skip this one. And so when you look at billing and collecting, things that you'll learn about and you're going to start to know about is accounts receivable, billings, collections, liability insurance, expenses. How many residents have seen these terms and gone over them during their training? Anybody? Oh, well, Matt did. Yeah. Yeah. Where did you train? Yeah. No, but it's what I joke, but I'm not. But these are things you're not going to know now, but you want to start getting familiar with as a resident and ask. Ask your attendings. You know, Dr. Wong, who works at some lab, Shirley Ryan Lab, she knows and she knows to ask her attending. What patient wants to be a lab rat? I went through a lot. No, I didn't say that. I'm going to get in trouble no matter what, but what do you need to know? You need to know what's your structure. Am I a for-profit, not-for-profit? Do I work for the X, Y, or Z? What's the mission? Who makes the decision? Because who decides how much overhead gets put out or not put out? The people in charge, right? How are the decision made and who owns the money once it comes in? When I was at a university setting, the money was really owned by the university. They could make a decision left or right and it wasn't my billings and collectins, it was the university's. Now they may have let me think I owned it, right? But it's really if they needed to make a change, they could change in a heartbeat. It was just what my contract was. So what's the golden rule? Follow the money? Stupid, right. So the question I, that's my biggest thing, so we're, it's a group of residents here. What's it all about? So really it's all about what's, it's all about follow the money, stupid. So we're gonna quickly go through a few things. Basic flow of patients. I'm circled what we do. We see patients, right? But you have to have a population of patients to see. They have to be under the contract you're working with. If you don't have that, guess what? They don't come in the door. If they don't come in the door, you don't see them. If you don't see them, you can't help them or bill and collect. In the circle right there is what do I do? After I see them, I have to drop a charge. Somebody has to have a contract, contracted with Medicare, Medicaid, or a private payer. Then we have to send the bill in. Someone has to see it was, were we documented right? Did we put the right code in? Did we get it collected? And then someone does it. If it doesn't get collected, we resubmit it. All of that work that we, is not in the gold, what is that called? Overhead, thank you. So someone's got to be doing it. Someone's got to pay for that, right? And where you're at right now, I'd ask people, do you know what your overhead is? What percent of your collection? Would be kind of nice to know because once you've paid all your collections, all your dean tax, all that other, that's the money we have to then pay salary, wages, and benefits, right? All right. I'm losing the group, but okay. So I see a patient, what is the patient, what do we actually do? We do an activity, all right? I do documentation of my activity. From that activity, I have to drop a CPT code, right? Anybody know what CPT stands for? Got it. All right, come on, procedural terminology. So that CPT is going to then match a charge or an RVU value, right? So common procedural terminology code is assigned to every type of patient encounter. If you see a patient, you got to drop a charge and that matches a code. That code each has a relative value unit assigned to it, right? Which has how many components to a work RVU three? A work component, a practice expense, and a malpractice component. Each CPT code has a set RVU value. Who determines the RVU value for each CPT? It's a big thing that our Academy says, oh, we now have a memory on the resource utilization, the RUC committee run by the AMA, okay? The AMA has a copyright on CPTs and the RVU suggestions and it's usually approved then by Congress, right? So I do something, CPT. That's CPT RVU value. Is it RVU dollars? No. Medicare then has a conversion factor which they may change every year. You multiply your RVU by your conversion factor, you get a dollar amount, okay? And why do we use RVUs though? Because RVUs, we often have contracted how much work we do. They're often used for management, budgeting, resources, contracting. It's kind of a people that in the world love to say that's the double helix of physician work. Usually what you, on your contract, if you sign for RVU amounts, it'll say how many RVUs per year do you need to produce to hit it. Five minutes? Gosh, I am bad. So the RUC committee, Medicare RVU, I'm gonna be like anybody go to the keynote speaker yesterday and we're gonna do the rest of my talk kind of like that. So right now we're gonna talk about that. If you pick something up, that'll be good. If not, oh bad, I'm sorry. So basically CPTs have an RVU value. Every year those are adjusted. Well, while for PM&R, the most common codes, if you do inpatient consult work, which I do, or hospital work, our CPT value went up to more RVUs. That's good news. Bad news is the conversion factor went down. So is that a net win or net gain? Well, you have to watch that every year and I want to know that. And these can be found easily. So also then, all right, that's Medicare. Anybody see anything other than Medicare? Private payers, right? Each payer usually has a contract and they'll give a dollar amount per RVU. If I'm making decisions, which contract do I want if I'm a PM&R doc? Two pieces of candy left. Five minutes. Which one? Come on, I want B. That's a smiley face. Anybody see a smiley face? Anybody know what that means? That's happy, right? So I want B. So I want to know who's making that decision with that. And what's, if I'm a doc, if I'm working for someone, what am I, what's my production measurement? Is it cash? Not very often anymore. When you're in private, it's cash because that's what pays my bills. Is it my gross charges? That's a charge. You can have charge masters three times what you're contracted with. Is it RVUs? Is it visited? Is it other things? I've worked in a lot of different settings and no one is the right one, but I better know what it is and am I comfortable and do I feel fair with that? Don't have time to go through it because Matt kind of didn't give me the time. But is it, what's a normal amount of work? Well, there's a lot of companies that will have an average value. Might be MGMA, might be faculty practice solutions. What I want to know is, what is my system using? When I was at, in Missouri, we used faculty practice solution. When you look at that, my next question is, do pediatrics have the same measurement as interventional? Anybody know what one usually produces more RVUs? Come on. What now? No. Pediatrics like a blood, pediatrics is a blood-sucking phenomenon if you run a department on how much they produce. No. Joking aside, pediatrics are really, they're not high RVU producer, but interventional pain is. Does that make one better than the other? No, but I need to know, what is my target if I'm in that? And is my target based on general or is it based on what most pediatric physiatrists do? If you're a resident, I would ask residents to do this. One of my residents did this. Once again, why do I like residents? They write my notes and they do my work. But we looked at, hey, anybody know how many RVUs they produced last week as a resident? You think it's important if your contract is based off RVUs? But so what do you do is, hey, why don't I look at how many RVUs I produced with the notes I saw last week? If I did a hundred RVUs or if I did 20 and my contract says I need to do 5,000, is that a lot or a little? Figure this out. If you're gonna get contracted on it, I sure want to know because then I need to know how much work that is because what am I? I'm like most people, what? I'm lazy. But so I need to know how much work I need to do to produce that because what's it all about? The money's stupid. Okay, and then you can start figuring how many work RVUs do I produce if I see inpatients or outpatients? How many would that produce? How many you can do all these gains? But it gives you an idea because all I want to know is what's fair. What's fair is what I think is fair, you know, what I need to do. Can I hit that? And you can do it by physicians and you can look at how much coding I need to do. Who's watching my coding? Is somebody? Because my coding, if you look at this blue line, this is how many RVUs that we were getting as a department and the red line are number of encounters. Wow, something happened. It dropped from 1.5 RVUs to 1.18. What happened? And do I really care? I care about me. Yeah, I don't care about you. I care about me and that was impacting what I could pay out and it was a change in a coding rule and we had to meet with our coders to get it changed. If I hadn't watched that, it would have gone on for perpetuity and poor Dr. Wong would have been working like crazy and making less money. Do I care about that? Well, as long as I make the same, I don't care what she did. No. And then you can do all sorts of things. What's my break-even point? And followed things because that was, if something happens, oh crap, that was yesterday. They changed the rules and you got to follow the rules. CMS changed things. Anybody do EMGs? Boy, back in the golden years, that was fortune. EMGs was like interventional pain docs, but they found CMS said, wow, this was a misvalued code because it was way overused and changed the RVU values. Also spine clinic. Boy, we see a lot of spine. It's hard if you're not doing interventions. Hey, are the orthopods or the interventionalists you're referring to giving you some backfill money? Well, if you know the data, hey, I'm helping them make a lot of money. Well, boy, should they be redirecting in the system? Give us some money. And this is a way you can maybe make an argument. We got some extra money for people. So collection rate, we went over. I'm sorry. We don't have the time. But the net collection rate, if I charge $100 and I'm allowed $50, I better collect $50. That's my net. That $100, I can charge anything I want, but it's what's contracted for that amount. And what pays your bills? RVUs? No, cash. And that's got to be converted. And just remember, while reimbursement, I may do two EMGs, three offices, make 605, but my what's my office space and all that and my EMG equipment called? Overhead. That might drive my margin down to 255. Do 10 hospital visits, make 350, and I don't have much overhead. My margin might be a lot. So think about these things when you're contracting. In the last slide, what do I never want to do? What is assuming make out of you and me? So ask people. I'm sorry. We kind of flew through a lot, but did anybody think it was worthwhile? All right. No, but what my point is, there's a lot of information there, a lot of things you need to look at. If you're a resident, ask questions. Ask these things. Ask, and if your boss doesn't know it, ask them to find out. Because there'll be a lot of faculty members in places, they don't know this. Just ask. Learn. Am I going to change it? No, but I want to know what the rules are and am I comfortable with working in that, you know, setting. So our next speaker is going to be Carly Reichert. Carly is an outstanding clinician, even better person with number two on the way. So we want to thank her, and Carly, I'll let you do your introduction from there. Thanks. Thank you. Okay, so I'm Carly Reichert, like I said. I do inpatient rehab in Wisconsin. I just have a side interest in personal finance, and so this is mostly self-taught. I gained a lot of knowledge through podcasts and books, so it's definitely something you can do on the side and learn more about. So I'm just talking today about retirement accounts, keeping it pretty basic, geared more towards the early career and the in training folks here today. So I just wanted to start out by defining some terms. So going over pre-tax or tax advantaged and taxable accounts and kind of because we'll be using that a lot throughout the discussion. So pre-tax or tax advantaged is money you put away into an account before any taxes are taken out. This helps overall decrease your taxable income and often you are deferring paying taxes on that money until a later date. Taxable accounts or post-tax accounts is money that's put into an account after taxes have been paid out of it. And some examples could be a brokerage account or a Roth option, which we'll talk about later. So this is an alphabet soup, but the list of tax-deferred accounts are 401k, 403b, 401a, 457, solo 401k, traditional IRA, and HSA. So there's a lot of letters. We'll go over each individually here. So with the 401k and the 403b, I use these pretty much interchangeably. The biggest difference is that the 401k is for a for-profit company and the 403b is for a not-for-profit. But both of them are an employer-sponsored retirement plan. The yearly max contribution for a 403b is a 22,500 as of 2023 and that changes slightly every year. If you're over the age of 50, you also have an additional $7,500 as a catch-up amount for the over the age of 50. So with this account, you put the money in pre-tax and then it grows and then you take the money out in retirement. And at that point then you pay taxes based on your income bracket in retirement. Often employers will offer a match. The average match I think overall is about four to five percent. For example, my employer offers a 75% match up to four percent. So it's really a three percent contribution. And so when you're looking at jobs to take, make sure you're considering the amount of your match as part of your compensation and making sure you're always putting in that amount because otherwise you're leaving money on the table. Even if you can't fully fund the account to the 22,500, making sure you're always putting in the percent that your employer will match on that. Usually you set up a percent of your paycheck to get automatically contributed with each paycheck. And you also have to invest it. So you have to pick what funds to put once it's actually in the account. Usually you can do a target date fund or there's a lot of different ones you can look at. The penalty to this account is if you need the money before traditional retirement age, which is 59 and a half, you'll pay a 10% penalty and you'll also pay taxes on any money that's withdrawn. 401A, this is not going to apply to most people here, but I didn't want to leave it out. This is intended for religious institutions. And it's an employer-sponsored retirement plan, same as a 403B or 401K. However, the special provision is for clergy, so they can withdraw money in retirement tax-free if using for a housing expense. Again, not going to probably apply to most people here, but wanted to include it. The next one is a 457 or often called a deferred compensation plan. This is not all offered at all employers, but if you are offered one, make sure you try to take it. It's another tax-deferred plan, but it is different than a 403B. You contribute a percent of your paychecks to the account to a max again of $22,500 for 2023. Again, an additional amount of $7,500 per year if over the age of 50. You can fund this account in addition to the 403B, which really can help decrease your taxable income if you're funding both. What makes this account different is that if you leave your employer before retirement age, you can start taking withdrawals from this without any penalty. You still have to pay taxes on any money withdrawn, but it's available for you before the traditional retirement age. Which makes it different from a 403B. You can think of it as a backup emergency plan if you were to ever leave your employer if you needed some extra funds to get you through until you were able to find another position. Then any employer contributions do count towards the 22,500, which is different than the 403B as well. For example, my employer offered a $2,000 bonus this year towards this account, which meant I could only contribute the 20,500, whereas the 403B, the employer contribution is in addition to your contribution. It's kind of maxed out a little bit differently. Next is the 401K. This is anyone that's self-employed or a 1099 contract employee that doesn't have an employer-sponsored plan. What makes this one different is that since you are the employer and the employee, you can match up to 100%. For the employee, the max is still 22,500, but the employer can match, which is you, an additional 100% to a full 22,500. As long as your business or 1099 has generated enough income, you can contribute a total of about $45,000 yearly pre-tax just in this one account. Again, if you're over age 50, you have the extra catch-up amount, which would be almost $60,000 yearly in this one account. If you're employed and have a 403B and you work as a 1099 contract employee in a separate business, you can contribute to both accounts as long as there's no overlap between the companies. The traditional IRA, or also called an individual retirement account, is not sponsored or tied to any employer. You can open this up at any institution. Usually, you try to pick a low-fee option if it's available. Contribution limits for this type of account is much lower than the other ones we've talked about. For 2023, it is 6,500, an additional 1,000 if over the age of 50. Since it's not held within your employer, you technically transfer or contribute the money after you've paid taxes on it, but you later deduct the contributions on your taxes for the year. The contributions are considered pre-tax, but as you withdraw the money in retirement, you do pay taxes on the growth that you pull out, just like the other pre-tax accounts that we've talked about. Same penalty as the 401K or 403B, where if you withdraw before retirement age of 59.5, you do pay taxes and a 10% penalty. This is different than the Roth IRA, which is more commonly talked about. The other thing that makes this account different is that if you're over age 70 and a half, you can donate any withdrawals that you take directly to a non-for-profit tax-free up to $100,000 per year. On one of the podcasts I listen to, they call this the old man giving fund. If you're interested in donating money at all in the future, having money in this account would be helpful because it does make it tax advantaged for donations. The last pre-tax account is the HSA or health savings account. You must qualify for this by having a high deductible health insurance plan, which not all employers offer. I've had an HSA in the past. My current employer only has a PPO plan, so I don't qualify for the HSA at this point. It's just something to look at when you're enrolling in health care plans. You may hear this as a triple tax advantage account. You put the money in pre-tax. It then grows pre-tax. Then you take the money out without taxes on qualified health expenses. Usually, once you have an X amount of money in the actual account, then you can qualify for the investment. For my HSA that I've had in the past, it was once you had $2,000 in the account, then you could start the investments, anything over that amount. Each HSA has a different kind of qualifying amount, so check that when you're getting yours opened. A lot of times people will say to have one to two years of your deductible for your health insurance plan not invested, just so you have money available without having to take it out of the investments. The other thing is that there's no time frame on withdrawals for this. If you are able to cash flow your health care expenses now, and you want to save those receipts, once that money is grown and worth more, then you can submit those receipts and get those reimbursements without being taxed on that withdrawal. That can be years down the road. I'm not that organized, but a lot of people are. The income limits or contribution limits for this would be if you're a single health care plan, it would be 3,850, and a family account is 7,750. Then moving to post-tax or after-tax accounts, there's really three main divisions within this. There's a Roth option within the 401k, the Roth IRA, and then a taxable or brokerage account. With the Roth option, this is within your 401k or 403b. Not all employers will offer this, but it is considered a Roth option, and it's a contribution within your total, the 22,500. This means that you contribute the money to the investment account after you pay taxes on it, but it's still within your employer-sponsored retirement accounts. With that, that means that it goes in post-tax, it then grows tax-free, and then you can withdraw the money tax-free in retirement. Your entire 401k or 403b has to equal 22,500 or less, and this can be divided between pre-tax or post-tax, with the post-tax being considered a Roth contribution. If you have that option. The other one, and this is kind of a hot-button topic in personal finance, is the Roth IRA. You'll hear this talked about a lot. It's similar to the traditional IRA or individual retirement account when it comes to contribution limits, which is 6,500 per person or 7,500 over the age of 50. You put the money in post-tax, it then grows tax-free, and then you withdraw it without any taxes since you paid the taxes on it before you contributed. The hot-button topic on this is that there are income limits for being able to contribute to this regularly. If you are a single tax filer, if you make over 153,000, or as a married file jointly, 228,000. As a high-income professional, a lot of us will be hitting those income limits, but luckily there is a way to contribute, and it's called the backdoor Roth IRA. It's totally legal. It sounds like it's not, but it is. It's actually a pretty simple thing to do. All you have to do is open a traditional IRA account and make sure the balance is zero. If you have rolled over any other retirement accounts into a different IRA, then this gets a little bit more tricky. If you open a new IRA and the balance is zero, then you can contribute the desired amount up to $6,500 to the account, and then usually we convert it within a couple days. You don't want it to sit in the regular IRA because any earnings that it accrues is then taxable, and you don't want it to pay taxes on anything before it's converted. You can repeat this yearly. The reason that if the balance is not zero and money is in there that was pre-tax, you end up with a pro-rata rule of having to pay taxes on a portion of it, and that just doesn't make it clean and simple. Just to repeat, open an IRA, balance is zero, contribute the amount, convert it, repeat it yearly. The last kind of overarching taxable account or post-tax account is just a typical investment account, brokerage account. They all kind of go by the same name. It's a group of investment accounts in which you can invest money post-tax, and then it grows, and then you take the withdrawals and have to pay taxes on any growth. There's no tax advantages to this type of account. You can open these accounts yourself or use a financial advisor, whatever is in your best interest at that point. No contribution limits, no withdrawal penalties, but like I said, no tax advantages to that. Now, this is kind of a busy slide, but I wanted to go over kind of a real-life example and why all of this matters. As you move into an attending job, or as I said, like my first big kid paycheck, I want everyone to try to automatically set up your retirement accounts to max out everything that you can before you get used to having that paycheck coming into your account, and then also setting up auto deposit into savings accounts and investment accounts. For example, you have a base salary of $270,000, and you get paid every two weeks, which is about a $10,384 paycheck. If you set up the maxing out of your 403B and your 457, that's $803 per paycheck per account, and then you pay taxes after that money is taken out, so you end up paying about $2,000 of taxes. Then your take-home is about $6,000 per paycheck. From there, you can automatically set aside money for your Roth investment and any after-tax investable accounts, for this example, about $250 per paycheck. So that still leaves $5,500 per paycheck, which is about $11,000 per month that you have left over for paying student loans, paying your mortgage, going on vacation, and, you know, using as you would like. At the end of that first full year, if you continue that for all your paychecks, you'll have accumulated $22,500 for your retirement account, another $22,500 for your 457. For your Roth, you would have had $6,500 and $7,000 additional in an investment account. So this would increase your net worth by about $60,000 without even realizing you're missing the money, while still having plenty of leftover to live your life as you'd like. And why this matters is it will grow over your entire career. So if you start, let's say, after residency around 32 years old, starting with $0 in investments, and you plan to work till around 62, I did 30 years just to keep it an even number, and you contribute or invest the $60,000 per year, and you're averaging a 77% return, accounting for inflation, you'll end up having $6 million by retirement around age 62. If you want to retire earlier than that, the compounding gets less dramatic, but you'll still have $4 million by age 57, or $2.6 million by age 52. And that is what I've got. All right, I will try to... That's my slide? Okay. All right, so my talk is on side hustles. I will be relatively brief so we can open up for questions. So of the attendings in here, if you want to, I'm going to give you a little bit of time. I'm going to give you a little bit of time to think about what you're going to be doing. So of the attendings in here, if you want to raise your hand or not, who has a side hustle that they do outside of work? All right, good. So why do people have side hustles? I mean, I think it's pretty obvious, first and foremost, is to make money. Second is, you know, hedge against medicine. You know, insurance is paying less for the services that we provide. Dollars per hour you are going down. Medicare wants to cut our salary every year. We try to fight it through our various PACs. But having a side hustle kind of protects you against that. So it diversifies your own income when it comes to portfolio. It also might be something you enjoy. If you have a passion outside of medicine and you get paid for it, why not do it? So multiple reasons as to why someone should have a side hustle. The most important thing is to figure out your own why and then do it. If you're doing something outside of work that you don't enjoy, you're just going to burn out faster. I mean, the end of the day, you just don't wanna make money for the sake of making money. Some people do and that's fine, but I think for most of us in this room, you know, we're physiatrists, we get into this specialty for a particular reason because we have a certain personality. So do something you enjoy. So some non-clinical opportunities. So I broke this down into clinical and non-clinical. There's consulting opportunities. I would suggest joining some of these services, GLG, GuidePoint, Alpha Insights. I mean, these are companies that will send you opportunities to consult for companies. There might be a new STEM company that needs your advice and they'll pay you for your time, they'll pay you for a survey. There might be a new NSAID that they wanna talk to you about and see what you think based on the research. So join them, they come through your email and you can say yes or no or whatever and they pay pretty well. Set your rate, $300 an hour, $500 an hour, something like that. And a couple of cases here and there, it's vacation money or it's dinner somewhere, something like that. So think of it that way. Telemedicine, there's a couple of companies, SecondMD, Grand Rounds, Best in Care. These are places where employers sometimes send their employees to these telemedicine portals to get a second opinion. So that can come to your desk, you review the records, you review imaging. It's not a patient, it's a client, will contact with you and you can go over their case, you can tell them what to expect after surgery, you can give them your opinion and get paid for that. The most important thing, Greg mentioned, is check with your employer. Are you allowed to do it? And if you are allowed to do it, who gets that money? Does it go to the university or your boss and then they pay you from it? Or do they say no, you're allowed to collect on your own, set up an LLC and things like that. But make sure you review your contract and stay compliant with that. Expert witness, chart utilization and IMEs, I'll talk about those in a second. Medical surveys, like I mentioned, there's so many companies out there that will send you surveys to ask for your opinion and they'll pay you for it. Might be a couple of bucks, might be 25, $50. They take five, 10 minutes. Not infrequently, I get an email saying, complete the survey, it'll take 15 minutes, we'll pay you $120. You can do that on the plane sometimes. I mean, there's a lot of opportunities to make some income while you're not seeing patients. We all have degrees for a reason, so let's use those degrees, we are experts. We have a lot of knowledge, so we should leverage that. Education, I mean, if you want, you can write a book, you can be a tutor, you can write a blog, you can be a TikTok all-star. Sometimes if you have enough followers, you'll get paid for it. So if you're interested in that, it takes a lot of work. I don't know who has an Instagram or TikTok in this room, but if you're a content creator, it's a full-time job. I mean, you really want to commit to it, especially if you want to get paid by advertisers, by products. I dabble a little Instagram, I think it's fun. We make some fun videos and things like that. Sometimes advertisers will approach us for a product to sponsor or to talk about, so it's an option if you want to do it. You can be creative, invent something. This happens, the more you see patients, you start thinking about, man, this could be easier. I could be more efficient with this certain procedure, or I wish I had an AI scribe, or we talked about some AI stuff today. Come up with an idea. I mean, you're seeing patients 24-7. You probably have a better way to do things than you're currently doing them, so leverage that opportunity and create something. Again, check with your employer. Is there a technology transfer office? Who owns the patent to the university? At Cornell, it's a third, third, third. The university will own a third, the department will own a third, and you will own a third. So at Cornell, we invented a needle because when we were doing radiofrequency ablation, a lot of the anesthetic was going ventrally into the foramen and patients were getting weakness afterwards, and they still had pain during the ablation. So me and one of our other residents, Eitan Rand, we kind of said, what if the medicine went around the needle and not out? So we created a stupid needle, and we told the university, they're like, we're not interested, this is not big enough for us, so they gave the whole invention back to us. So we have a patent, marketing it and selling it and licensing it and things like that. Utilization review. This is pretty common, especially for physiatrists. A lot of people in our department have done this. I no longer do it, but it was pretty lucrative. Basically, with these medical chart reviews or utilization reviews, doctors who are practicing in the community will go to insurance, say, I want to do an epidural, I want to do an EMG on a patient. Insurance might say, it's denied because you haven't met certain criteria. That goes to a third-party appeal process, which could be you as a utilization reviewer. You look at the records, you look at the guidelines, and you say, is it appropriate, is it not appropriate? What's nice about it for me was, A, I got to see other physicians' documentation. Did that help me be a better documenter when I myself am applying for authorization for these procedures? And the answer to that was yes. It really made me look at the guidelines, made me look at the LCD coverage to make sure I'm doing all the SI joint provocative maneuvers. Have they failed therapy, have they failed medications so that I can apply for authorization for an injection? It's easy work. It's sometimes boring, it's sometimes a little mind-numbing, but you review records, you look at the guidelines, and you get paid. And again, this is, you can make as much or as little as you want, depending on the companies. There are some companies in the exhibit hall, so if you get a chance, go down there and meet them. One of them is GenX. You get paid $50 to $100 per review. You can do a lot of reviews in a given month. So do it on the weekends, do it on a flight. Again, just another way to educate yourself because you're learning about the coverage guidelines and also documentation, but also make some income. Big Pharma, you know, obviously, we all have a stigma associated with speaking with medical device, speaking with pharmaceutical companies. But I think if you're ethical about it and you're really passionate about it, you can do it the right way. And there's different ways to get into medical device and industry. The first is a consultant. If you're using a product, if you're prescribing a medication, they might ask you questions like, hey, do you mind being a consultant for us? Give us feedback on what we already offer to your patients. And you might set up an hourly rate, and you get paid for speaking to them about their own product. Speakers Bureau. We don't do a lot of this at Weill Cornell. They don't love it. If you do Speakers Bureau, the policy at our institution is you have to create the slides yourself. If you use the industry slides, you have to modify them, take out all branding. So it's agnostic to the brand. It's only specific to the treatment or the therapy. That's nice. I mean, you can go to dinner, educate your colleagues on a new device or new therapy that you're seeing good results in your own practice and get paid for it. That's an ethical way to do it. Advisory Board and Key Opinion Leader. I think that's kind of the pinnacle when it comes to being involved in industry that really suggests to your colleagues that you're an expert in this. You're a KOL. You're a Key Opinion Leader. I've done a lot of treatments with a lot of different companies. It doesn't matter whom. And now when industry wants to come up with an idea, they contact you. And they say, we're thinking about coming up with a new neuromodulation or a new long-acting triamcinolone or whatever. And you're a KOL. There you're well-known in the community. There's many people, especially in the neuromodulation space, who are those people. So anytime a new device comes out, they get contacted for their feedback and their input. So a lot of different ways to make money, to get involved with industry. Medical legal expert witness. There are gonna be times when you're in your own daily practice. You might get called by an attorney to give a medical narrative on your own patient. So that's already medical legal. Basically, they want you to give a summary of all the treatment you've done. What's the outlook of the patient? Is this permanent? Sometimes they wanna talk about causality. Was this related to an injury? If you do some personal injury or workers' comp work. But that's kind of the intro to med legal work. Then you can decide, hey, I want to be an expert. I like getting queried from attorneys about a case that's not mine. You can do an independent medical evaluation. It's not the most fun work. I mean, getting deposed. I don't know if anyone's been deposed in this room or gone to trial. It's not fun. You kind of feel dirty. You get paid, but it's not something that I love when it happens. But again, it's a way to make ancillary income. So utilization reviewers, the pros are it's flexible. You can do it when you want. It is kind of boring. You kind of, you do it for five, 10 years. And if you're like me, you kind of get sick of it and you stop doing it. Pharma, you can set your rate. Usually it's whatever fair market value is. So make sure you check your geographic location to get a fair market rate for yourself. I know when I got to Wauquanel, I came from Denver. So the rate that I had set was low for New York standards. My vice chairman was like, no, no, you have to up the rate, but it made me very uncomfortable. So it took me like 10 years to slowly increase that rate because I also didn't want to not get any business. But look at your fair market value. Set a rate that you think is appropriate. It doesn't have to be unethical. Just do it the right way. Look at yourself in the mirror. If it passes that test, then get involved with pharma and medical device. Expert witnessing medical legal, again, higher than normal clinical work in terms of collection. Again, it could make you feel a little bit dirty, but just cap how much you're doing. You don't want to be a trial expert. Maybe when you're trying to retire at the end of your career, fine. But when I'm opposing another expert and I'm still 70, 80% clinical, that gives me a lot of credibility because I'm still seeing patients. I'm on the front line. I know what the treatments are versus someone who just does cases all day. And attorneys love going after those people and saying, you know, you haven't seen a patient in 20 years. Why should you be an expert in this certain area? So physician life care planning, and just a little two slides on this. This is something I started four years ago. It is in the medical forensics domain. You are essentially creating a life care plan for an evaluee or for the attorney's client. What I liked about this was, is what we do. In physiatry, we know how to do this. This is like perfect for our specialty. Patient or a client gets hurt at work. They're in a car accident. They get rear-ended. They have an attorney. They start getting treatments. And as a life care planner, all you have to do is say, what is this person's current situation? What is their diagnosis? Will it last forever? And if so, what do the future medical requirements to make this person have an optimized quality of life, diminish pain, decrease complications? And I think it's great. I mean, I'm not really speaking to causality. There's usually an expert that already has said, this accident caused this disc herniation, which required this fusion surgery. Sometimes we get asked that, but really our job is not that. Our job as a life care planner is to say, this is the diagnosis. Here's the future medical requirements. And you outline them by goods. So it looks like this. Physician services, they need to see an orthopedic surgeon once a year. They need to see a physiatrist a couple times a year. They might need an MRI every five years. And it's a really nice way to get involved with the life care of a client or an evaluee without quote being that medical expert or having that physician doctor relationship. So there's a booth down there also at the exhibit hall if you're interested in physician life care planning. It's fun work. It's fun work. You get to go do home visits. I took one of my residents to a home visit a few months ago. It was a patient who had cervical myelopathy following a fall and needed accommodations at home. They didn't have a ramp. They were stuck in their house in a motorized wheelchair. So we went in and said, you need widened hallways. You need a ramp. It costs this much. You need a shower chair, a tub chair. You need lower countertop. No one thinks about this stuff. Insurance doesn't want to pay for it. So our job was to go and say, what does this person need to optimize their quality of life? So kind of fun work. Clinical opportunities. You can moonlight. You can do locums work. You can see patients in a subacute if your department allows that, take extra call. All these ways to make extra money on top of your clinical income. What about investing? Carly talked a lot about investing and doing that early. We cannot stress that enough. The eighth wonder of the world. Anybody know what that is? Time, yeah, compound interest, right? It's get involved early. Start maxing out your pre-tax retirement accounts if you can, because if you do it early enough, yeah, I mean, your initial quality of life might suffer because you're maxing out, but you're going to reap the benefits at the end. So angel investing, again, join these companies. Join AngelList. You'll see new innovations coming across. They're looking for private equity money that you can contribute. You can contribute $1,000 or $5,000 and some of them hit, some of them don't hit, but if it's in a domain that you're interested in, it's a good way for you to get exposure to some of these venture capitals, some of this new technology. It's kind of exciting. Aura Ring, when it came out, came through AngelList and they were looking for individual investors like us to give five, 10, $20,000, whatever you can afford. Stocks, we talked about, and I'm going to spend a few minutes just on real estate. So I got involved in real estate. I live in New York and I have a couple of colleagues here and we look at our patients. We're like, who are these patients? What do they do? I said, yes, there's the finance folks, the hedge fund guys and the investment bankers, but then there's everybody else who has a ton of money in New York who could have been a teacher, who could have been a police officer. I was like, what did you do? They all did real estate. So I'm like, there must be something to real estate, especially in New York. So I started learning about it, podcasts, books, just getting myself educated on what are some investing opportunities because investing in real estate seems scary. I was like, I'm a needle jockey. I don't know what else to do besides put needles into spines and I don't have the time to go look at an apartment complex or look at what's the market trends. So there are different ways to get involved with real estate. The easiest ones are what I listed here, crowdfunding. Basically, you don't have to do the work. There are experts, there are sponsors. They go out there, they find a multifamily home in Texas or Oklahoma or Georgia. These are just some of the markets where we've invested and they say, we're gonna buy this multifamily home, we're gonna rehab it and then we're gonna start generating cashflow or flip it. Do you wanna contribute $5, $5,000, $25,000, whatever you want. So you don't have to do the work. You just have to educate yourself on the deal terms. What percentage are they taking? Is it a good market? And you can get involved with real estate. So that's crowdfunding. Crowdstreet, equity, multiple fund rise, all easy ways to just throw in a couple thousand dollars and see if that grows. Syndications, that's where I spend most of my time at syndications. Basically, that is a sponsor finding a deal. The bank is only gonna give you so much money so they have to raise the other money through private investors and that could be us. So they create a syndication and again, you can contribute some money there. The entry for syndication is a little bit higher. Sometimes those deals are 20,000 or 50 or even $100,000. So I would say start with this crowdfunding. Just get your feet wet, learn about real estate. So you can, again, diversify your portfolio. You don't wanna be fully correlated with the market. Markets crash sometimes, every 10 years. So if you have some other income that's doing something else while the market goes down, you're just protecting yourself. In terms of active versus passive investing, the most passive is mutual funds, real estate investment trusts, it's called REITs. These syndications are relatively passive. You don't have to do the work. You put your money in, hopefully you get some cash flow and hopefully it sells on the exit and you get a big lump sum back. Excuse me, or it could be active where you're the landlord. You bought a property in New York, you moved out and now you have a renter. You are a landlord. Some people are into that, some people are not. It's a lot of work. I have one condo in New York, we have a renter. Toilet breaks, they text me. The light goes off, they text me. I mean, it's terrible. I don't wanna do it. The problem is you outsource that to a management company, now there's no delta. Management takes 10% and so we're trying to figure out is this the business we wanna be in? I don't think it is. So that's the most active way to be involved in real estate. So I mentioned this, real estate funds, REITs. REITs generate a good return. Some of them are eight or 12% a year. So you can just throw some money in and get, again, dividends on an annual or even quarterly basis. So at the end, side gigs, are they worth it? Maybe. It's all about personal, finance is personal. Decide where you are in your life. If you're a busy resident or a fellow and you're moonlighting, you might not have time to have a side hustle and that's okay. Learn your craft, that's probably the most important thing. If you're an expert in what you do, people are gonna come to you and answer your opinions. So really get good at what you do and then decide to branch out in these other things. Why do we all do what we do anyway? Why do we save for money? Save money for retirement. It's time. We all make money to give ourselves more time to do things, to spend time with our families, to go on vacation, to be present. So decide that. Don't work here and then work more somewhere else and in the end have no time for yourself and for your family. No one's winning in that situation. So really try to balance work-life. We stress that a lot in New York when I speak with the fellows and the residents. Try to create your ideal life. I talk a lot about this in, I have a podcast called The Backstory. We talk about arrival fallacy. You know, we all are trying to get to this destination. We have no idea what it is. Maybe the destination is, oh, I just wanna graduate, fellowship, I wanna make $100,000. You get there. Now what? Now I'm at the next destination. And you just keep chasing where you're trying to go and you forget about this whole journey that you're on the entire time. So I was guilty of that for many years as a junior attending. I just, I gotta make more money. I gotta make more money. I gotta be more patient. And then you get there and you're like, what was the point of all this? So really my thoughts on that is enjoy the journey. It's just be present wherever you are. Money will come, everyone in this room is smart, everyone's passionate. Do the right things, be ethical about it, and you'll be just fine. Let me spend two minutes to talk about money. Cash Money Millionaires, that was a big group when I was growing up. I don't know if any of you junior residents really know about it. Tips for financial success, especially for residents. So never grow into your income. Live like a resident. I really think it's cliche, but the first couple years out of training, live like a resident. Two, three years. It will pay off. I mean, I lived like a resident for my first three years of attending at New York City. We saved enough money to buy a condo, and we lived like a resident, it was fine. Everything was savings. We just lived on what I made as a PGY-5. Create a plan, insure yourself against catastrophe, get disability insurance if you're a resident, get that earlier, it's cheaper now. Once you become attending, it's gonna be more expensive. 20% of your income. Carly talked about this. Super important in building wealth. Front load your wealth building. Pay yourself first. If you haven't read Rich Dad, Poor Dad, read it. He says, pay yourself first. Build up your asset column. Slowly decrease your liabilities. Different generations view debt differently. You know, my parents' generation, Greg's generation, they don't like debt. In our generation, we love debt. Leverage your life. Take a mortgage. I mean, rates are not great now, but two summers ago, if you were lucky enough to buy something at 2.5%, great. I mean, lock that in. Don't pay that off. Don't pay off that mortgage. Take your time doing that. I mean, this might not be advice for everyone, but that's my personal advice. Some books to read, Psychology of Money, Millionaire Next Door, read them. Do it before you graduate. Great books, really give you perspective on, don't keep up with the Joneses. You're gonna be disappointed. I always tell this story about New York. I have a patient who works at Goldman Sachs, and we were good friends, and he started when I started, and we talked about money, and he was going up through the ranks of Goldman Sachs. He made 200,000, 300,000, 400,000, moved out of the city, moved to Long Island, came back with three kids to Manhattan. I was like, dude, you're back in New York. What happened? He's like, oh, I became partner. I was like, what does that mean? He's like, you know, my salary went up to 650,000. I was like, yeah, but that's not really enough to live in Fifth Avenue with three kids. He's like, no, I got a bonus. I was like, how much was your bonus? He's like, $19 million. So my head was like, oh, you're done, right? You've achieved this arrival fallacy. You're done. He's like, the problem, Ricky, is like, now my peers at Goldman Sachs are billionaires. And I was like, this sucks. Give me a reality check. I'm like, what are we doing? This hamster wheel is not worth it, so really live and be present. Don't compare yourself to your colleagues. 20% savings. She gave a great example. If you make 250K, you can save $2,700 a month. $2,700 a month on 250K. This is what it'll look like. You'd only save $275, you'll have 900,000, or sorry, a million. If you save 2,700, you'll have $10 million. This is 35 years. I used 35 years, but same example. Save that money. This is all you need for retirement. I mean, in theory. This is plenty of money, so just save early. Don't time the market. Some numbers that Fidelity throws out at us on how much you should save by certain age points. This is for all people, not people in medicine, so we get a late start to life, right? We don't get our first job until we're 32 or 33, so I think by 45, if you can catch up, or 55, you're in good shape. 35's a hard number to really reach because you've only had salary for a couple years. My experiences, I'll list that here, but otherwise, sorry I rushed. Thank you. All right, we have time for questions. Three quick things I gotta do is, one, any sarcasm I used that offended anybody? Well, good, but no, off the record, I apologize. Second, we're gonna do it the old-fashioned way. No questions have come in through the iPad, so if people have questions, feel free. Third is, great talks. Time, Carly, is the key. Both you and Ricky mentioned that on investing. I think the big thing that came across is, we don't know, nobody sitting in this room knows everything about all the stuff we talked about. Just get educated. You gotta make good choices, like finding a job, get educated. Ricky made some great points. What's my contract say? Carly made great points. Does my contract include a retirement plan, a matching plan? You know what, those are considered part of your salary and compensation. So whenever someone says, oh, I am making this much, look at the whole picture. What is everything that's involved with it? Not things we usually talk about in residency, but if you can find a mentor like Ricky or somebody, or Carly, latch onto them, learn. Okay, Ricky, you mentioned, I get the first question. Life care planning, I know quite a few docs that do that. Do you just do it? Do you get a degree in it, or what? Yeah, that's a great question. I think as physiatrists, we have the training anyway to become life care planners. That's inherent in our residency training. There is a special certification called CLCP, Certification for Life Care Planning. Then there's another certification, specifically physician life care planning, so CPLCP. Most of the life care planners that are out there in the community are usually physical therapists, chiropractors, vocational rehab specialists, very few physicians. So now that physician life care planning is kind of getting popular, a lot of attorneys and firms look to us because we can diagnose when we see an evaluee on our own, and we can prescribe, not directly, but in our life care plan for that condition that we treat, unlike other vocational specialists. So yeah, there's a certification. You need to do 120 hours of online modules, and then take a written test. Yeah, thanks. I have a, here was a question that came from the audience. Who are the important financial advisors to have in order to maintain a portfolio? Go ahead, Carly. So you can definitely do it yourself. If you're interested in that, you can also get a financial advisor. There's kind of two main ways to do that. There is one that gets paid by assets under management. Usually it's a percent-based. This can cost you a lot of money in the long run. Then there's also a fee-based financial advisor, which is you pay X amount, and you meet with them once or twice a year, but you're gonna just pay the one amount, and then you're gonna continue doing it on your own, but they're giving you the advising. I think in general, in the personal finance field, the fee-based, if you're gonna use a financial advisor, the fee-based is the way to go instead of the asset under management. Yeah, I agree with that. My college roommate ended up being someone who works at Morgan Stanley as a financial advisor, so I use him, but it is fee-based. He does have an AUM fee. Luckily for me, he doesn't charge me that. A what fee? Asset under management fee, but yeah, get someone that's fiduciary, which means they don't make money on the products that they sell you. They're just paid by you to give advice. I think it's a good idea. You should check in. This is your health and wealth we're talking about, so it's a good idea to get an outside opinion every once in a while. Just another comment. Yeah. I used to work in finance, and the finance industry actually really targets positions as kind of sitting down to go and learn anything about finance so be really, really careful when you're finding a financial advisor. Make sure they know what they're doing and they're not selling you a product that they don't even know. You have to be very, very cautious about who you're testing, just because the background of the positions can be very real at times. Yeah. A general rule is if they're trying to sell you a product, they may not be having your best interest at heart. They should be giving you advice, not trying to sell you something. Yeah. I have a brother who worked for a big finance, as an advisor, and I use him, so that's probably the worst person. Oh, I'm sorry. No. There was a hand up here. Yeah. Jerome. I have a buddy of mine who's a dentist. The reason why it's nice is that there's this wave of professionals that are going to not have a 401k to have more of their income now and being able to do some of these investments. Oh, sorry. I can repeat the question. Can you guys hear me okay? So, I was recently educated about the fact that there's an alternative way for your retirement to avoid the 401k, intentionally to be able to invest earlier. The mindset is, you don't know that you're gonna live to 62, and so have a better quality of life now, but also have a higher rate on your investments so that if you do live to where you're 62, you actually have more in your nest egg. So, what your thoughts are on that? I was interested in that. I'll start out with that. I would say make sure you're at least getting your percent match from your employer because otherwise that's money that you're not gonna have either way. And if you're gonna not contribute to the pre-tax retirement accounts, making sure you're putting the same amount in a different investment account. So, it doesn't have to be a retirement account, but if you're just gonna spend it, that's one thing. If you're gonna put it into another investment, I think that's something that you should consider, but always at least get your employer match. Know what this person's getting paid that has this fund that's supposed to be gonna beat your 401k, give you a higher return. Know what they're getting paid because, I mean, just hearing it flat out, that kind of sounds a little bit like a scam. I don't know what this account is or whatever, and our experts could comment too, but someone says they can get you a higher return with better, with less, and it's, I'd question that. I know, breaking. Yeah, that is a new kind of school of thought in terms of retirement accounts. But what Carly said, the most important thing is don't leave money on the table. If you have a match, that's your first bucket. Employer match, put your money in, get that match, and then if you don't wanna do a 403B or 457 or a Roth, fine, if you're more interested in other alternative investments like real estate or land or those things. It has to suit your personal finance goals. There's a book called Die With Zero. Great book to read. It basically says this. A lot of people who are 70s and 80s are gonna die with millions of dollars in their bank. Go ahead, Matt. And should that be someone, could you have spent that money in your 40s with a better quality of life? It is a school of thought. I think the biggest point in all of that is know in what you're invested. Regardless of what you choose to invest in, please make sure that you're educated enough that you understand what it is that you're actually invested in. Don't just blindly trust in a lot of different ways. When you know what you're invested in, that gives you at least the opportunity to make a decision. Is this risky? Is this too risky? And is the return I'm getting a reasonable return for what my risk is? So we had a question here, sorry. Be educated, that's all. All this is education. I was just curious what you feel like for a financial planner, fee for service. What are some maybe ballpark estimates of something that sounds a reasonable, meeting twice, three times a year with a financial planner versus things that sound outlandish in terms of total cost out of your pocket that you're paying these individuals? So I have not used a fee-only financial advisor, so I can't speak to that personally. But I think some of the numbers I've heard from others is like a couple thousand dollars for a session or a couple hours of their time. But in the, which may sound like a lot to get started, but if you're doing assets under management over the long run, there's gonna be a huge pay difference. Usually the fee with the assets under management, if you're less than something, $5 million, it's a one and a half percent. That's a lot of money, especially when you look at the stats on managed money versus an ETF, managers don't do any better. So just put it in an ETF, open a Vanguard account for free. And if you wanna meet with someone, pay them a couple thousand bucks, go over your life goals, they might say put it in a target fund, which is totally reasonable, or pick some of these ETFs. But yeah, I would not recommend doing the AUM model, unless you're eventually gonna be an ultra high net worth individual. A quick question about the solo 401k that you mentioned. I know a lot about regular 401k, but I'm fortunate enough to be in a private practice where we get to buy in after a year or two. So you were saying that if we use that option, we can basically contribute double that normal $22,000 limit. Like if we have a LLC that our collections goes into, you basically contribute twice, just to kind of clarify how that works. So I think if you're a 1099 employee, you can do that. And then the employer, which is also you can contribute that. If you're eventually gonna be like on a salary or a W-2 with an employer sponsored, then you can't contribute to the solo 401k. If someone knows more about it, because I don't have personal experience on that. Yes, if you have a W-2, you can't contribute. That's right. I was just gonna mention on the 401k, when I first started with my company, they gave us a couple of options, low growth, high growth. And I asked, there are some other positions in the group that bought their own stocks through that. So that's when I learned you can do self-directed 401k. It's just another option that's not usually presented at first. And so I pick them all my own stocks and I've been much better. And it was a good way for me to learn about stocks at first because like, oh, the company matches. So I was like kind of free money. So I was like, okay, that's like free money. I can kind of lose on some stocks if I mess up, but I kind of learned about the whole process of buying and selling stocks. And I know about some industries and stuff, but it's also made it a little bit more fun for me. But, and I've done much better with the self-directed thing that a lot of people don't seem to know about. So you. It depends on your company. I was just gonna say that self-directed account is dependent upon whether or not your 401k or 403b allows that. And so some, the difference is because it's employer sponsored, some companies choose to give you access to 10 or 15 funds and that's it. Others allow you to have within that account a self-directed account, which allows you to essentially open up all investments. So that's a very big difference between a lot of employers only allow 10 to 15, believing that they're operating in your best interest to only not confuse you by giving you more than 10 or 15 funds. And there are specific retirement advising programmers that they go in and give you these, give companies there's 10 or 15 funds. So anyway, sorry to jump in on that. I think Ricky made it the best point to be a happy person physician. My wife is my mentor and she says, we all spend our money differently and we all invest differently. Find out what's good for you and make a plan. There's some basics I will say. Time is a factor, even though you have student debt, you're paying that off. Make some room for investments because time is that compounding that Ricky mentioned because we got a lot of young people in here, start early. That way when you're old like me, you're not up here still talking. No, I'm kidding. No, then you choose whether or not you work when you're old like me. One thing that Greg mentioned was about RVUs. So for the residents in here, I would suggest when you go back to your programs and you're working with faculty, ask them to teach you about RVUs. You know, when you rotate with me at Weill Cornell and we have a busy clinic day, I asked the resident, like how many RVUs do you think we did today? And I want you to tell me by tomorrow, here's all the CPT codes. And it really gives them an idea because when they go for that job and says the target's 3,800 RVUs or 5,000, is that doable? You know, in one day, if I do 20 RVUs, what does that extrapolate to over monthly? So I would suggest to the residents and fellows, go back to your own institutions and really ask your attendings, teach me about RVUs. Yeah, because more and more contracts are RVU-based productivity, population-based rather than cash-based. When I started, we had a, you know, when I was in private, it was all cash. You know, what did we produce at the end of the, not, what did we collect and all that. So, because if you don't know, how can you, it's like doing investments. If you're not educated, you can't make good decisions. So, Matt, I want to thank you. I don't know if, I think we're wrapping up for the day. Yeah, exactly. This is the end of the session, so thank you very much to our speakers. Wonderful advice and thank you guys. Thanks. I think this is like the sixth or seventh year that we've had some kind of personal finance lecture at the academy meeting, and it's always a goal of ours to ensure that we find some way to educate our physicians, especially physiatrists, so that we use what we've got in an appropriate way, so thank you all.

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