Year: 2021

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You Will Have A Bad Radiology Day!

radiology bad day

Almost all of us start as wide-eyed, enthusiastic residents, ready to absorb nearly anything. I know I certainly did when I first started. But, eventually, at some point, all the planets will align the wrong way. Maybe you missed a finding and then dealt with an angry surgeon. Then, that same day, you had a heated argument with an OB/GYN resident who ordered an inappropriate study. Or, the chairman chews you out for not helping out one of the referring clinicians. Regardless of the number or sequence of events, you must expect some bumps in the road. As much as I like radiology, unforeseen problems will occur. So, how do you get your head back in the game after a bad radiology day like this? Here are some tips to help you proceed when you feel the radiology world is not in your favor.

Play The Long Game

I am sick of the cliche: “Residency is a marathon, not a sprint.” But, it is true. You have four years during your residency to learn and fulfill your goal of becoming a competent radiologist. A bad day here and there is not the end of the world (although it might feel like it!) For this reason, keeping your long-term goals in mind is essential to keep you on track. You can think of a bad day as a life lesson that will make you a stronger radiologist at the end of your residency.

Learn From Your Bad Radiology Day Mistakes

You may feel that miserable lump in your throat when you’ve made your mistakes. It’s never fun to miss appendicitis or have a team of surgeons berate you. But, good residents and learners will take this opportunity to self-correct and avoid making the same mistake twice. This principle is practice-based learning in a nutshell. Those who succeed at this will eventually become excellent radiologists, even if it doesn’t feel like it right now.

Maintain A Positive Attitude

Remaining positive can be a tough nut to crack in the face of stark adversity. But enthusiasm and positive attitudes do go a long way to getting you through that bad day. If you let the negative Nancy nay-sayers get to you because you are having a bad day, how can you treat the next patient well? We have to remember our goal as physicians is to help patients. A negative outlook will not allow you to fulfill your true potential.

Take A Mental Break

Sometimes, you need to give your mind and body a break. Listen to some music. Read that book that you always wanted to peruse. Every once in a while, getting your mind out of medicine is healthy. The perfect time to do so is after a bad day. Allow your mind and body to recalibrate. Human beings should not be on task 24 hours out of every day. It is healthy to take a break (contrary to the popular belief of some program directors!)

Learning From Your Bad Radiology Day

Not every day will inevitably be in your favor. The world does not work like that. But, if you play your cards right, you will come out of this day more enriched than when you started. It’s a matter of perseverance. So, remember why you are here, learn from your mistakes, maintain positivity, and give yourself a well-needed rest until you are ready to start anew. These techniques are some of the tried and true methods that will get you back into shape to practice radiology, prepared to work another day!

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Why A PACS Crash Can Be A Disaster!

pacs crash

Many of us have become numbed by the PACS crash. Yes, it can ruin our day and prevent us from completing our work. And, it can cause us to finish up work late. As well, we joke about it as just another technical glitch that we have come to expect. However, there are real-world ramifications to the PACs crash that we don’t discuss but should take a bit more seriously. For this reason, we should have vigorous backups and supports for the systems. Here are some of the potential tragic issues that patients, physicians, and radiologists can face.

Missing Findings

I don’t know about you. But, when I am in the zone, I use all my search patterns and am thorough, going through all the anatomy that I need. But, when the PACs crashes in the middle of a case, you lose track of where you were. Well, that’s when bad things happen. You lose your train of thought. Perhaps, you forget to look at the adrenal glands or the spleen. It is now that radiologists miss critical findings that can be detrimental to their patients.

Even worse, when the PACS crashes at nighttime, the ER can bombard you with loads of phone calls and prevent you from getting a wink of sleep. When you wake up the next day, you are barely awake. It’s a setup to missing even more findings!

Incomplete Information Leading To Bad Treatments

Unable to pull up priors or histories? Well, you know what they say: Garbage In. Garbage Out! That PACS crash can cause incomplete reports that won’t even answer the question that the clinician asked. This lack of information can lead to patient disasters and poor outcomes. How is the poor radiologist to know the diagnosis of the patient when there is no history anywhere?

Significant Loss Of Revenue For The System

If you can’t dictate, you can’t get paid. PACS crashes can lead to problems with demographics and matching patients to studies. And that’s only the beginning. Depending on the severity, it’s possible to lose tens of thousands of dollars with a long-term PACS crash. A PACS crash can cut the imaging center or hospital’s bottom line!

Angry Physicians And Patients

And then there is the ill will you build with the patients and clinicians. Who wants to return to an institution with delays and constant technical malfunctions. What’s the point when they can go to the institution down the street? It is tough to build back goodwill once it is lost.

Inability To Make Emergency Diagnoses

Hemorrhagic strokes, appendicitis, and more significant disease entities can cause morbidity and mortality. We, as radiologists, find these entities all the time. And every second counts. When you lose your PACS system, you lose those valuable seconds to save a life potentially.

Potential Legal Ramifications

Even when the system comes back up, everyone is on the hook. All the misses, delays, and anger can cause lawsuits and the potential for long hours with an attorney. Not to mention all the legal fees your practice can rack up when dealing with the misdiagnoses and angry patients you could not help because of a PACS crash.

Loss Of Confidence In The System

Finally, PACS crashes can cause lost confidence in the system. These systems can be a hospital, imaging center, or clinic. Anytime you lose information, you lose trust. These patients may never come back to your department again if the PACS system does not work. It can be a permanent loss!

A PACS Crash Can Be Devastating! 

Most tend to make fun of the ineptitudes of information technology and the folks staffing them. However, there is a real-world consequence when the PACS goes down. Patients can get hurt, and we have the potential to be at fault legally. Physicians and referrers struggle. And, the radiologists can look like fools. So, the next time your hospital looks for a PACS system, make sure to get involved and find a reliable and redundant system. The last problem we need is another PACS crash!

 

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What To Do If You Have A Blemish On Your Radiology Application!

blemish

Some of you are applying for radiology this year with a blemish. Maybe, it’s a course or two in medical school that you initially failed but later retook it and did fine. Or maybe, you had a tough time in one of your clinical rotations because of an errant resident or attending. Regardless, now is the time you need to deal with these issues. Why? Because radiology has become more competitive, many program directors toss aside many applications with a blemish since there are many without them. This problem can also be the case, even though you would be an excellent candidate for radiology. So, what can you do?

Own The Blemish

First of all, don’t disregard the facts. Own your blemish. Yes, you may get fewer interviews than others. But, if you play your cards right, you can increase your chances of acceptance at sites where you interview.

By owning the blemish, you need to have insight into what caused it in the first place and use it to make you stronger. Yes, it will affect you. But, you need to address the issue. The program director will ask you about it. So, explain in your personal statement. Show what you learned from your blemish and why it can be a strength rather than a weakness. No radiologist is perfect,  Don’t go hiding it or sweeping it under the rug. Most programs will know or find out!

Complete Radiology Research

Radiology research is the grand equalizer. It shows that you are interested in radiology even while busy with an internship or senior-level courses. And, it allows you to succeed even though other parts of your application are subpar. It is not a cure-all, but it can compensate for some faults elsewhere. Heck, a paper of yours that gets into the New England Journal of Medicine will undoubtedly elevate your application to a much higher level!

Ace Your Internship/ Senior Level Courses

This statement goes without saying. However, many applicants concentrate so much on the blemish that they don’t get the grades in their most recent courses or internship that will give them that needed boost. Don’t forget that your current courses can count just as much as the blemish. If you don’t perform well on your current rotations, all may be lost!

Do Well On Your Remaining USMLE Exams

All is not lost if you did not ace Step I or even II. Yes, it will make it a bit harder since many programs screen those exams. But, whether it is step II or III USMLE that you need to take, they can still matter a lot if you do very well, especially while you are busy with other endeavors. It shows you can handle stress well and have the potential to pass the radiology core exam.

 And remember, for those of you who have not yet graduated, USMLE step I is no longer going to be scored in the future. So, the Step I exam will become less of an issue (unless you fail, of course!)

Get To A Know A Radiology Residency Program

Finally, try to get to know the faculty in a radiology residency near you. Maybe, you are in medical school and have access to the folks in a residency program. Or you are amid an internship. In any case, attempt to get to know the staff in the local residency program. Ask to meet with the faculty or participate in projects. These connections can help get them to know you as a person and not just as an application with a blemish!

Applications With A Blemish: All Is Not Lost!

I cannot give you a money-back guarantee that you will find a spot in a residency with an application blemish, especially as radiology has become a bit more competitive. However, in most cases, all is not lost. If you own the blemish, complete research projects, do well at your current level, ace the following USMLE exams, and get familiar with a radiology residency faculty, you can surely up your chances of getting accepted!

 

 

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New Tax Laws Cancelling The Backdoor Roth IRA- A Major Loss For Radiology Residents!

backdoor roth IRA

Debt, burnout, declining reimbursements are some of the issues new radiologists need to face. But, yes, the hits keep on coming. Now, new radiologists also have to contend with a potential loss of the Backdoor Roth IRA. Again your future has just become murkier.

Right now, in Congress, Senators and representatives are duking it out over taxes and how to raise money for a multi-trillion-dollar spending bill. One of the line items on the agenda is the cancellation of the Backdoor Roth IRA, as the public perceives it as a tool for the rich to save on taxes. So, what exactly is a Backdoor Roth IRA, and how will this affect you? And, most importantly, what you can do to help to stop it.

What Is A Backdoor Roth IRA?

Let’s first start with what a Roth IRA is. A Roth IRA, which many of you know, is a post-tax account that accumulates tax-free for the rest of your life. Most residents should put as much into this account right now while they have a low salary and are underneath the income limits. The Roth account allows any future earning on this money to grow tax-free in perpetuity, even when your income climbs as an attending.

A Backdoor Roth IRA is also a Roth IRA. But most radiologists cannot put money into a Roth IRA directly because there are income limitations (you need to make below 140,000 as a single filer and 208,000 as a married filer in 2021). 

However, there has been a loophole. Any high-income earner can first put money into a Traditional nondeductible IRA and immediately convert it to a Roth IRA. Now, you essentially have the same Roth IRA as any earner below the limits has. 

Why Is/Was It Such A Great Option For Radiologists?

I have been using this savings vehicle since we were allowed to start in 2010. It has allowed for outsized tax-free earnings on money that I have put in the account. Not having this account would have significantly negatively impacted my savings. It is truly one of the last tax breaks for high-earning professionals like radiologists.

Because of the power of compounding, the younger you are, the more beneficial the account is. So, any resident should be concerned about Congress eliminating this Backdoor Roth IRA because it impacts you more than someone like me who has already been depositing into this account for years.

Moreover, you never had to pay another dime of taxes on the money you put inside the account. Granted, at present, it is only 6000 dollars per individual or 12,000 dollars for a couple. But, that number rapidly increases over time with the tax-free earnings and rising yearly contributions pegged to inflation. Over the long run, it was an excellent tool for avoiding tax drag on your accounts.

Finally, some radiologists may be in a high tax bracket when they retire because they may have most of their savings in 401k type accounts. It allowed for some money not to be taxed and hedged your bet about future taxes and earnings on your withdrawals.

What Can You Do Prevent Congress From Cancelling The Backdoor Roth IRA?

Every radiology resident should be writing to their congressman and asking them to refrain from canceling the bill. You have so much debt. You don’t start earning real money until late in life. And, you have been taking on the burden of Covid. I see this as a stab in the back for all future high-earning physicians. Of course, radiology residents are not a large bloc of citizens. But, every person counts. So, consider writing to your congressman to add to the lobbying in your congressional districts!

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Working From Home: A Difficult Dilemma For Radiology Practices

from home

Since Covid began, almost all practices have established a teleradiology presence from home. But, it is a work in progress. Some radiologists still need to man the forts, especially in hospital and imaging center-based practices. Contrast issues, treatments, complex studies such as cardiac CTAs, and on-site ultrasounds still involve a radiologist on-site. And many practices have been struggling to figure out the right mix. This dilemma leads to problems with structuring rotations, compensation, and making the staff happy. Therefore, I will discuss the most significant issues practices face and potential solutions to the most critical problems. I will divide these into rotations, compensation, and personal staff issues,

Rotation Problems Caused By Working From Home

Setting rotations to staff the practice from home versus in-house adequately can be daunting. Some radiologists typically have expertise in areas more conducive to work at home. Others need to be in the department more often. These lead to inherent problems of inequity and jealousy. So, setting up appropriate rotations to equalize home rotations can be very difficult. In addition, technologists and nurses need to be in contact for occasional events like contrast reactions and when to do so. If you create new rules, you must ensure the staff understands who to get and when.

To create equity, you have to recognize the following facts. First, only some people can work from home all the time in a non-teleradiology practice. And then, some specialties allow radiologists more freedom to work at home. Once we recognize these inherent problems with total equity and fairness, we can create rotations to equalize some of these issues. For instance, the practice can make some of the in-house rotations “easier” to compensate for inequities within the practice partially. Or, you can make some rotations on-call rotations. These are just simple ways to relieve some of the problems of unfairness among the staff.

Compensation 

Should employees and partners receive the same compensation if they can do more at home? Is there an upcharge or premium for having to come in more often? These potential inequities in the fairness of compensation also lead to other problems. Some procedures you can read at home pay more per unit worked (MRI) than others involving in-house work (IR). How do you account for that when you compensate your radiologists for their work?

Well, there are a few simple models. First, you can make all work equal with the philosophy that all work is valuable to the practice regardless of the reimbursement. It would help if you had the low RVU fluoroscopers as much as the high revenue MRI readers because they all provide a helpful service. This philosophy works much better in a partnership. In addition, you can provide more revenue and moonlighting opportunities to increase income for radiologists who are more interested in making some extra money. These opportunities help out a bit.

You can also decrease pay for radiologists who only work by teleradiology since they do not provide the same on-site services, such as management of contrast reactions, consults, and procedures. A practice can adjust the rate depending on the time worked outside the office compared to an “average” practice radiologist.

Either way, these models provide some equity for the practice.

Personal Staff Issues

Finally, you have issues such as radiologists who have extenuating circumstances. You may have new mothers or radiologists who temporarily need to move far from the practice, and so on. Sometimes, you need to make accommodations for individual radiologists so they can continue to work. Again, compensation needs to reflect the amount of time that these radiologists work outside the office and the need for the radiologist once they return. 

Working From Home: Not All A Bed Of Roses

On an individual basis, working from home can be a godsend. What’s better than being present at home with kids, dogs, spouses, contractors, and more? On the other hand, from a practice perspective, working from home introduces many additional problems. Fairness/equity of rotations, compensation issues, and individual staff issues are just some of the problems that group leaders need to contend with. Practices can work out most of these kinks. But getting the right mix takes a bit of effort and creativity. Having all radiologists working from home is more complex than it seems!

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9-11: Now And Then: A Radiologist’s Perspective

9-11

9-11 is one of a few days frozen in time for my generation. For the Baby Boomers, it was also the assassination of JFK and the landing on the moon. But for us, it was this day. Most of us remember exactly where we were and what we were doing at the time on this twentieth anniversary. So, like many, I have been reflecting on my experience, the meaning of 9-11, and how the world has changed. For radiology, in particular, the technologies since that time have significantly evolved. The attitude/culture of physicians and patients have transformed. And, the general sense of security and well-being is no longer the same.

It turns out that on 9/11, I was amid my radiology residency as a 3rd-year resident. And, so I will share my own experiences of what happened while I was working as a radiology resident on that fateful day. And, then I will shift gears toward the seismic changes that we have experienced over the past 20 years in radiology since that day.

My 9-11 Experience

Ironically, that morning, I donned a gown and was helping out with thyroid biopsies on my ultrasound rotation at Rhode Island Hospital. As the procedure ensued, at some point, a medical student walked int0 the room and exclaimed, “An airplane hit one of the world trade centers!” My first thoughts were about how that made no sense. Maybe he had gotten something wrong. So, within a few more minutes, we completed the biopsy, and I walked toward the patient TV area to see for myself. There was a jumble of confusing voices on the TV screen with the pictures of the first world trade center alight with billowing dark smoke. They said that a plane had hit the tower, but no one was certain if it was a terrorist attack or an accident.

Affixed to the TV screen, watching the first trade tower live, all of a sudden, the cameras shifted to the second tower, which was now also on fire. At this initial time, the cameras did not catch the second plane hitting the building. It took some time to figure out that another plane crashed the second world trade center. And, then the secretary called me into the following procedure as I was concerned about friends that I knew that worked near the area in Manhattan. It was a harrowing experience completing the ultrasound procedure, not knowing what was happening in Manhattan at the time.

Eventually, I found out that everyone I knew that might have been in or near the towers was alright. One friend who was a resident physician in medicine had tried to help out downtown, but the officials turned him away. After the incident, some other friends I knew had started their long trek to leave Manhattan from their jobs. And a family member was on the road at the time, nestled in traffic and watching the billowing smoke from the trade centers from afar. Fortunately, that was the closest that I had come to the 9/11 incident.

Nevertheless, the nonstop drumbeat of media reports issuing terrorist threats would continue over the next several weeks and months. And, you could not watch TV the constant replay of the videos of the trade centers. There was a perpetual reminder of the incident for a long time.

Some Of The Changes For Radiologists Since 9-11

Travel– (To And From Conferences)

Most notably for radiologists, the way we travel and getting back and forth to conferences has become a little more involved. 9/11 spurred the development of the TSA. Shampoos and drinks all had to be small in size to get on the plane. Lines have become longer, and we now have to leave much sooner to the airport to get there on time. And, air travelers are a little bit more irritable than ever before, both from the long lines and from thoughts about the terrorist attacks on 9-11.

Technology:

A lot has changed over the past 20 years, yet much has stayed the same. The bare bones of the hardware, including ultrasound, CT, MRI, and PET scans, were available at the time. But, the applications have since multiplied. PET-CT was more of a research tool at the time. It came into its own a few years later. But, FDG was used.

Applications of Technology

MRI and CT

Body MRI and MSK MRI is much more common today than it was back then. Now we order MRIs on all the joints routinely. Back then, it was a bit more sparingly used. Larger institutions were introducing CT applications such as Chest CTA for pulmonary embolism due to the faster speed of the scanners. . Having a sixteen multidetector or more CT scanner was a big deal back then. And only specific experienced radiologists could read them.

PET/ PET-CT

Pet scanner applications were much more limited by medicare/insurance reimbursement. Medicare and insurance companies would only pay for lung cancers, solitary pulmonary nodules, and several other indicators. You had to pay for others out of pocket if you wanted it done. And, as mentioned above, PET-CT and its applications mainly were a research tool with a lot of debate whether it was better than PET!

Ultrasound

We used breast ultrasound primarily for diagnostic purposes at that time. Most institutions would perform breast ultrasounds only sparingly for screening. For better or for worse, screening ultrasounds have become much more part of our culture.

PACs

PACs machines were not yet ubiquitous. Fifty percent of institutions had them back them. And, they were much slower than they are today, with more crashes and less flexibility. (Although not all these issues are resolved!)

General Attitude of Physicians, Patients

Now, this part might be a bit controversial. Some of you might think that what I will describe happened before 9/11. And others might feel a bit differently. But, I believe this event contributed, at least in part, to the tribalistic nature of our society today. Everyone had differing strong feelings about what happened and who was responsible. And everyone retreated to their tribe. Republicans and Democrats became more fixed in their thoughts, unwilling to compromise or hear the other side. And, this event along with social media, was one of the foundations for this shift in attitude and politics. 

Changes After 9-11: A Mixed Bag

Of course, 9-11 and the ensuing days were a rough time. But, some good has happened since. The adaption of new technologies has increased radiology’s footprint in medicine over the past twenty years, probably for the better. Yet, the decreased ease of travel and the new tribalistic attitude of patients and physicians has partially counteracted some positives.

The base notion about 9-11 is that it is one of those days that have shifted everyone’s lives in one way or another. The world and radiology will never be the same!

 

 

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Are All Radiologists Destined To Have Chronic Back Pain?

back pain

After walking my dog a while back and pulling a back muscle (thankfully, I recovered), I started to think about the risk of lower back pain and radiology. Am I more prone than others to having back issues? What are the chances that I can permanently have back pain from my day-to-day work? And, are the risks related to what kind of radiology you practice?

According to the literature, if you are a radiologist who sits and reads lots of films from a PACS workstation or an interventionist who always wears lead shielding and does procedures, your back may not thank you. Based on reality in the field, the human body was not meant to sit for many hours or stand in one place with heavy weights. So, let’s drift into the nitty-gritty data on radiologists and back pain. Then, we can discuss some standard solutions to remediate our woes.

The Hard Data About Radiologists And Back Pain

Here is some of the information to support these radiology-specific related back issues. In one study in the JVIR, the mean prevalence of the general population was around 31 percent for everyone. Then, when you look at the radiology community more specifically, you even get more stark statistics. Within the interventional radiologist population alone, 20.1 to 24 percent have back and neck pain limiting work. Additionally, the same study reported a prevalence of lower back pain in the general radiology population of 52 percent and back and neck pain in interventional radiologists at 60.7 percent. If you believe this study, the prevalence of back pain in radiology is nearly double the general population. This number is not small. It is the majority of us!

Another JVIR article states that the prevalence of back pain gets worse with age, especially among those who complete interventional procedures. (We all have something to look forward to!) That makes sense because of the extra weight that interventionists need to bear. The only saving grace is that radiologists have less back pain than nurses and techs. But that does not change the fact that we have a very high prevalence of back pain as radiologists.

The Only Solution: Prevention!

The last thing that radiologists want to do is get into a situation where you need back surgery. We all know that is the last resort. Heck, many of us read many spine X-rays and MRI horror shows. Some of the solutions espoused in the JVIR papers are reasonably simple. Taking a break is the best plan of action. If you notice that your back is beginning to hurt, you must take a break. Repetitive motions can exacerbate back pain. Exercises involving strengthening the back muscles may prevent significant injuries.

Others are more immediate and easy to do, including lifting slowly, sleeping on your side, and avoiding rapid bending movements. Stretching can also potentially prevent some forms of back injury (I’m a big proponent of this one!)

Finally, ergonomics helps with the situation. That means appropriately positioning equipment and monitors, back supporting seats, clearing the floors of obstructions, and custom-fitted garments for the interventionists among us.

Let’s Face It: Chronic Back Pain Is The Radiologist Bugaboo!

For surgeons, needle stick injuries are a big concern. For psychiatrists, their most significant issue is mental wear and tear. But we, as radiologists, face chronic back pain as our most prevalent job hazard. Furthermore, based on my recent back issue and this short survey of the literature, we need to take the prevention issues seriously. As the old Benjamin Franklin quote goes, an ounce of prevention is worth a pound of cure. Don’t let your imaging centers and hospitals convince you otherwise!

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How Much Headstart To Retirement Do Radiology Residents Without Student Loans Get?

headstart

Due to my fascination with this topic and the bewildering debt of new residents, I wondered how much headstart you would get to accumulate five million dollars if you had no student loans vs. substantial student loans. So, I have decided to use the following numbers for student loan debt- 0 dollars (paid for by a rich Mom and Dad) or 500,000 (private schools, no help, or excessive spending). 

This time around, we will make the following assumptions: Either you will live in a relatively low-cost-of-living area and have a decent attending lifestyle or live in a relatively high-cost-of-living location with a proper attending lifestyle. I chose these assumptions because they are within reason for many residents. Of course, you can live with more or fewer expenses, but this will have a significant impact on the outcomes.

Also, we will have you save for college for two kids (twins), starting as an attending on day one. We are using the magical five million dollar amount because it is the amount that studies like Medscape’s annual net worth survey use for a reasonable retirement amount. We will calculate everything for inflation using that 3 percent inflation rate. Again, based on the survey, this will be a one-income family with an average radiologist salary of 413,000 dollars. Go directly to the end of the blog to check out the final numbers and conclusion!

Low Cost Of Living Area With Student Loans Of Five Hundred Thousand Dollars

Low cost of living areas with significant student debt

Additional numbers for this assumption:

  1. The house will cost 500,000 with a down payment of 100,000, saved over your first five years of working. (20,000 dollars saved per year)
  2. You will pay off student debt over ten years at an interest rate of 4 percent (5062 dollars per month*12 months)= 60744 per year.
  3. Practice puts away 30,000 dollars, including a match, into your 401k starting 1st year.
  4. Investment rate of return 8%
  5. Federal Income Taxes after deduction will be 76182 dollars per year based on an internet calculator.
  6. State Income Taxes are 0 dollars.
  7. You have twins beginning at the of your attending work and are putting away 556 dollars per month per kid to get to 250,000 dollars at age 18. (13,344 dollars per year)
  8. Rental of a three-bedroom house for five years at 2500 dollars per month

First five years

Total Salary 413000

Expenses

401k: 30,000 (383000 left)

Taxes: 76182 (Federal) + 0 (State) (306818 left)

Loan payments and house savings and children 529 plan: 60744 (student loans) + 20,000 (house down payment) + 13,344 (529 plan) (212730 left)

Rental/heating/electricity  30000  (182730 left)

Subtracting food for family 10000 (172730 left)

Transportation expenses for two cars/insurance 10000 (162370 left)

Vacations 10,000 dollars (152370 left)

Computers/Cellphones/Electronics/Cable Bill 3600  (148770 left)

Preschool/Day Care Expenses for two kids 24,000 (124770 left)

Clothes 5ooo dollars (119770 left)

Life and Disability Insurance  9600 (110170 left)

Dues and License and CME 5000 (105170 left)

Miscellaneous Entertainment  10,000 (95170 left)

Saved

Remaining available to save around 95170 per year (not including 401k)

30,000 dollars in 401k

Assuming an 8% rate of return on 125170 over five years- 734334 dollars in savings

Following five years (Own house)

Expenses

401k: 30,000 (383000 left)

Taxes: 76182 (Federal) + 0 (State) (306818 left)

Loan payments and house savings and children 529 plan: 60744 (student loans)  + 13,344 (529 plan) (232730 left)

Salary after mortgage payments and taxes (400,000 mortgage -30 year fixed at 3.5 percent 1796*12 (211178 left)

Salary after property taxes and insurance 12000 (199178 left)

Home maintenance= 5000 (194178 left)

Subtracting food for family 10000 (184178 left)

Transportation expenses two cars/insurance 10000 (174178 left)

Vacations 10,000 dollars (164178 left)

Computers/Cellphones/Electronics/Cable Bill 3600 (160578 left)

Education and Expenses for two kids 12,000 x2 (136578 left)

Clothes 5000 dollars  (131578 left)

Life and Disability Insurance 9600 dollars (121978 left)

Dues and License and CME 5000 dollars  (116978 left)

Miscellaneous Entertainment  10000 (106978 left)

Saved

Remaining available to save around 106978 per year (not including 401k)

30,000 dollars in 401k

Assuming an 8% rate of return on 136978  over five years +734334 in savings= 1882500 dollars

Following eight years (Student Loans Paid Off)

Savings After Expenses

Savings now 106978+60744 +30000 (401k)=197722 dollars per year

Assuming an 8% rate of return on 197722 over eight years +1882500 in savings= 5587000 dollars or 3428000 in today’s dollars

Next 5 Years (No More 529 plans)

Savings now 197722+13344= 211066 per year.

Assuming an 8% rate of return on 211066 over five years +5587000 in savings= 9447000 dollars or 4786000 in today’s dollars with 3 percent inflation

Following ten years (No More Kid Expenses)- if you were to go past 5,000,000 dollars

Saving now: 211066 +24000= 235066 dollars per year

Assuming an 8% rate of return on 235066 over ten years +9447000 in savings= 23802000 dollars or approximately 9.0 million in today’s dollars with 3 percent inflation

 

Changed Assumption: No Student Loans In Low Cost Of Living Area: How Much Headstart?

First five years:

Savings: 125170+60744 (headstart without loan)= 185914 per year

Assuming an 8% rate of return on 185914 over five years- 1090000 dollars in savings

Following five years (Own Home)

Savings: 136978+60744=197722

Assuming an 8% rate of return on 197722  over five years +1090000 in savings= 2762000 dollars

Next eight years

Savings= 197722

Assuming an 8% rate of return on 197722  over five years +1090000 in savings= 7215000 dollars or approximately 4.23 million in today’s dollars with 3 percent inflation

Next 5 Years (No More 529 plans)

Savings now 197722+13344= 211066 per year.

Assuming an 8% rate of return on 2110666  over five years +7215000 in savings= 11840000 dollars or approximately 5.99 million in today’s dollars with 3 percent inflation

Following ten years (No More Kid Expenses)- if you were to go past 5,000,000 dollars

Saving now: 211066 +24000= 235066 dollars per year

Assuming an 8% rate of return on 235066 over ten years +11840000 in savings= 28960000 dollars or approximately 11.9 million in today’s dollars with 3 percent inflation

 

High Cost Of Living Area With Student Debt Of Five Hundred Thousand Dollars

High cost of living areas with significant student debt (500,000)

Additional numbers for this assumption:

  1. The house will cost 1,000,000 with a down payment of 200,000, saved over your first five years of working. (40,000 dollars saved per year)
  2. Student debt will be paid off over ten years (4049 dollars per month* 12 months), or 48,588 per year.
  3. Practice puts away 30,000 dollars, including match, into your 401k starting 1st year.
  4. Investment rate of return 8%
  5. Federal Income Taxes after deduction will be 76182 dollars per year based on an internet calculator.
  6. State Income Taxes will be around 6 percent or (413,000*0.06)=24,780 dollars.
  7. You have twins beginning at the of your attending work and are putting away 556 dollars per month per kid to get to 250,000 dollars at age 18. (13,344 dollars per year)
  8. Rental of a three-bedroom house for five years at 4000 dollars per month

 

First five years

Total Salary 413000

Expenses

401k: 30,000 (383000 left)

Taxes: 76182 (Federal) + 20290 (State) (286528 left)

Loan payments and house savings and children 529 plan: 60744 (student loans) + 40,000 (house down payment) + 13,344 (529 plan) (172440 left)

Rental/heating/electricity  48,000  (124440 left)

Subtracting food for family 10000 (114440 left)

Transportation expenses for two cars/insurance 10000 (104440 left)

Vacations 10,000 dollars (94440 left)

Computers/Cellphones/Electronics/Cable Bill 3600  (90840 left)

Preschool/Day Care Expenses for two kids 24,000 (66840 left)

Clothes 5ooo dollars (61840 left)

Life and Disability Insurance  9600 (52240 left)

Dues and License and CME 5000 (47240 left)

Miscellaneous Entertainment  10,000 (37240 left)

Saved

Remaining available to save around 37240 per year (not including 401k)

30,000 dollars in 401k

Assuming an 8% rate of return on 67240 over five years- 394446 dollars in savings

Following five years (Own house)

Expenses

401k: 30,000 (383000 left)

Taxes: 76182 (Federal) + 20290 (State) (286528 left)

Loan payments and house savings and children 529 plan: 60744 (student loans)  + 13,344 (529 plan) (212440left)

Salary after mortgage payments and taxes (800,000 mortgage -30 year fixed at 3.5 percent 3592*12 (169336 left)

Salary after property taxes and insurance 14,400 (154936 left)

Home maintenance= 10000 (144936 left)

Subtracting food for family 10000 (134936 left)

Transportation expenses for two cars/insurance 10000 (124936 left)

Vacations 10,000 dollars (114936 left)

Computers/Cellphones/Electronics/Cable Bill 3600 (111336 left)

Education and Expenses for two kids 12,000 x2 (87336 left)

Clothes 5000 dollars  (82336 left)

Life and Disability Insurance 9600 dollars (72376 left)

Dues and License and CME (5000 dollars per year)= 67376 left

Miscellaneous Entertainment (10000 dollars per year)=57376 dollars

Saved

Remaining available to save around 57376 per year (not including 401k)

30,000 dollars in 401k

Assuming an 8% rate of return on 87376  over five years +394446 in savings= 1092000 dollars

Following eight years (Student Loans Paid Off)

Savings After Expenses

Savings now 57376+60744 +30000 (401k)=148120 per year

Assuming an 8% rate of return on 108480 over eight years +109200 in savings= 3596000 dollars

Next 5 Years (No More 529 plans)

Savings now 148120+13344= 159454 per year.

Assuming an 8% rate of return on 121824 over five years +3596000 in savings= 6220000 dollars or 3155000 in today’s dollars with 3 percent inflation

Following ten years (No More Kid Expenses)

Saving now: 159454+24000= 183454 dollars per year

Assuming an 8% rate of return on 145824 over ten years +5428000 in savings= 16080000 dollars or approximately 6.06 million in today’s dollars with 3 percent inflation

 

Changed Assumption: No Student Loans In High Cost Of Living Are: How Much Headstart?

First five years:

Savings: 67240+60744 (headstart without loans)= 127984 per year

Assuming an 8% rate of return on 127984 over five years- 751000 dollars in savings

Following five years (Own Home)

Savings: 87376+60744=148120

Assuming an 8% rate of return on 148120  over five years +751000 in savings= 1971000 dollars

Next eight years

Savings= 148120

Assuming an 8% rate of return on 148120  over eight years +1971000 in savings= 5223000 dollars or approximately 3.07 million in today’s dollars with 3 percent inflation

Next 5 Years (No More 529 plans)

Savings now 148120+13344= 161464 per year.

Assuming an 8% rate of return on 161464  over five years +5.223 million in savings= 8.622 million dollars or approximately 4.37 million in today’s dollars with 3 percent inflation

Following ten years (No More Kid Expenses)- if you were to go past 5,000,000 dollars

Saving now: 161464 +24000= 185464 dollars per year

Assuming an 8% rate of return on 235066 over ten years +8.622 million dollars in savings= 21.3 million dollars or approximately 8.03 million in today’s dollars with 3 percent inflation

The Final Numbers (How Much Headstart Will You Get?):

Low Cost of Living Area and High Student Loans: After 23 years, you have saved 4.78 million dollars in today’s dollars. After 33 years: 9 million dollars in today’s dollars

Low Cost of Living Area and No Student Loans (Headstart): After 23 years, 5.99 million saved in today’s dollars. After 33 years: 11.9 million dollars in today’s dollars

High Cost of Living Area and Student Loans: After 23 years, you have saved 3.15 million dollars in today’s dollars. After 33 years: 5.42 million dollars in today’s dollars

High Cost of Living Area and No Student Loans (Headstart): After 23 years, you have saved 4.37 million in today’s dollars. After 33 years: 8.03 million dollars in today’s dollars

Does Student Debt Prevent A Reasonable Retirement?

In a high-cost-of-living area and with lots of student loans, you will need a long career, over 30-something years, to accumulate that mythical number of 5 million dollars. But, if you have no student loans and live the same way, you will have a headstart of less than ten years of working if you desire to retire earlier. On the other hand, those with high student loans and who live in a low-cost-of-living area can reach that mythical number of 5 million dollars around the twenty-something-year mark.

You may want to work for an entire thirty-something-year career. And, of course, you may not want to live to save money. Also, there are lots of factors that should go into where you should live. But, for those of you with lots of debt, the debt will significantly impact the number of years you will need to work to accumulate your desired nest egg. Without that student debt, you may have a headstart and more flexibility in your decisions. Just something to consider!

 

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Will I Be Able To Save Five Million Dollars As A Radiologist With Large Student Loans?

five million

There is something mythical about the number five million dollars. Medscape’s annual net worth survey for physicians uses that barrier as one of the leading wealth accumulation goalposts for their survey and has been doing so for years. The media has created a monicker that they love to use as well called pentamillionaire. And, it is a number that makes sense for those of you that eventually want to retire in today’s dollars.

Imagine. You can reasonably safely withdraw 4 percent of five million dollars per year and have an income of about two hundred thousand dollars while still allowing for capital appreciation. It may not be a king’s ransom in some parts of the country. (California, New York) But, it is undoubtedly a decent nest egg that can allow most folks the ability to live out their years comfortably. This five million dollar number most likely seems very large to those of you in residency that live frugally off of much smaller dollar amounts. But, believe it or not, it will all seem like a lot less when you live like an attending. 

Additionally, inflation will most likely eat into the principal of this dollar amount so that we will account for inflation on that five million dollars in today’s dollars. We will assume an inflation rate of 3 percent to be conservative.

Is It Even Possible To Achieve Five Million Dollars With High Debt Loads On One Radiologist Income?

So, I ask: Is it even possible to save this much with all the student debt you have accumulated and salaries that may not keep up with inflation? Let’s do the calculations for two sorts of residents: Those of you who decide to live in high cost of living areas with significant student debt; those who choose to live in low cost of living areas with considerable student debt. You can skip to the bottom if you want to see the final results. Or, you can peruse all the nitty-gritty details if you are so inclined.

Assumptions For Accumulating Five Million Dollars

We will assume in all cases that you have higher than average debt (400,000 dollars) when you finish residency, that you have a family of four, with a spouse that is taking care of the kids and is not working. We will assume that you want to buy a decent size four-bedroom house in a nice area. Let’s also start with the assumption that you will male the mean income for a radiologist based on the 2021 Medscape compensation survey (413,000). Of course, you can make more or less depending on the practice. But, for simplicity’s sake, we will use this number.

Then we will assume that on average inflation rate is around 3 percent, with a worst-case scenario of radiology salaries that are relatively stagnant due to declining reimbursements. And, we will assume an interest rate on student loans of 4 percent. Finally, we will take that you will put aside a nice chunk of change for each of your kids to go to college (250,000 dollars). Of course, I want to make these circumstances as if you live like an attending instead of a resident. And, then we will go through how long it may take you to accumulate this amount of wealth given your circumstances as a radiologist.

High cost of living areas with significant student debt

Additional numbers for this assumption:

  1. House will cost 1,000,000 dollars with a down payment of 200,000 dollars, saved over your first 5 years of working. (40,000 dollars saved per year)
  2. Student debt will be paid off over 10 years (4049 dollars per month*12 months)= 48,588 per year
  3. Practice puts away 30,000 dollars including match into your 401k starting 1st year
  4. Investment rate of return 8%
  5. Federal Income Taxes after deduction will be 76182 dollars per year based on a calculator
  6. State Income Taxes will be around 6 percent or (413,000*0.06)=24,780 dollars
  7. You have twins beginning at the of your attending work and are putting away 556 dollars per month per kid to get to 250,000 dollars at age 18. (13,344 dollars per year)
  8. Rental of a 3 bedroom house for 5 years at 4000 dollars per month

First 5 years

Total Salary 413000

Expenses

401k: 30,000 (383000 left)

Taxes : 76182 (Federal) + 20290 (State) (286528 left)

Loan payments and house savings and children 529 plan: 48,588 (student loans) + 40,000 (house down payment) + 13,344 (529 plan) (184596 left)

Rental/heating/electricity  48,000  (136596 left)

Subtracting food for family 10000 (126596 left)

Transportation expenses 2 cars/insurance 10000 (116596 left)

Vacations 10,000 dollars (106596 left)

Computers/Cellphones/Electronics/Cable Bill 3600  (102996 left)

Preschool/Day Care Expenses for two kids 24,000 (78996 left)

Clothes 5ooo dollars (73996 left)

Life and Disability Insurance  9600 (64396 left)

Dues and License and CME 5000 (59396 left)

Miscellaneous Entertainment  10,000 (49396 or around 50000)

Saved

Remaining available to save around 50000 per year (not including 401k)

30,000 dollars in 401k

Assuming 8% rate of return on 80,000 over 5 years- 469000 dollars in savings

Next 5 years (Own house)

Expenses

401k: 30,000 (383000 left)

Taxes : 76182 (Federal) + 20290 (State) (286528 left)

Loan payments and house savings and children 529 plan: 48,588 (student loans) + 40,000 (house down payment) + 13,344 (529 plan) (184596 left)

Salary after mortgage payments and taxes (800,000 mortgage -30 year fixed at 3.5 percent 3592*12 (141492 left)

Salary after property taxes and insurance 14,400 (127092 left)

Home maintenance= 10000 (117092 left)

Subtracting food for family 10000 (107092 left)

Transportation expenses 2 cars/insurance 10000 (97092 left)

Vacations 10,000 dollars (87092 left)

Computers/Cellphones/Electronics/Cable Bill 3600 (83492 left)

Education and Expenses for two kids 12,000 x2 (59492 left)

Clothes 5000 dollars  (54492 left)

Life and Disability Insurance 9600 dollars 44892

Dues and License and CME (5000 dollars per year)= 39892

Miscellaneous Entertainment (10000 dollars per year)=29892 dollars

Saved

Remaining available to save around 29892 per year (not including 401k)

30,000 dollars in 401k

Assuming 8% rate of return on 59892  over 5 years +469000 in savings= 1040000 dollars

Next 8 years (Student Loans Paid Off)

Savings After Expenses

Savings now 29892+48588 +30000 (401k)=108480 per year

Assuming 8% rate of return on 108480 over 8 years +1040000 in savings= 3080000 dollars

Next 5 Years (No More 529 plans)

Savings now 113480+13344= 121824 per year

Assuming 8% rate of return on 121824 over 5 years +3080000 in savings= 5240000 dollars or 2655000 in today’s dollars with 3 percent inflation

Next 10 years (No More Kid Expenses)

Saving now: 121824+24000= 145824 dollars per year

Assuming 8% rate of return on 145824 over 10 years +5428000 in savings= 13240000 dollars or approximately 5 million in today’s dollars with 3 percent inflation

 

Low cost of living areas with significant student debt

Additional numbers for this assumption:

  1. House will cost 500,000 dollars with a down payment of 100,000 dollars, saved over your first 5 years of working. (20,000 dollars saved per year)
  2. Student debt will be paid off over 10 years (4049 dollars per month*12 months)= 48,588 per year
  3. Practice puts away 30,000 dollars including match into your 401k starting 1st year
  4. Investment rate of return 8%
  5. Federal Income Taxes after deduction will be 76182 dollars per year based on a calculator
  6. State Income Taxes are 0 dollars
  7. You have twins beginning at the of your attending work and are putting away 556 dollars per month per kid to get to 250,000 dollars at age 18. (13,344 dollars per year)
  8. Rental of a 3 bedroom house for 5 years at 2500 dollars per month

First 5 years

Total Salary 413000

Expenses

401k: 30,000 (383000 left)

Taxes : 76182 (Federal) + 0 (State) (306818 left)

Loan payments and house savings and children 529 plan: 48,588 (student loans) + 20,000 (house down payment) + 13,344 (529 plan) (224886 left)

Rental/heating/electricity  30000  (194886 left)

Subtracting food for family 10000 (184886 left)

Transportation expenses 2 cars/insurance 10000 (174886 left)

Vacations 10,000 dollars (164886 left)

Computers/Cellphones/Electronics/Cable Bill 3600  (161286 left)

Preschool/Day Care Expenses for two kids 24,000 (137286 left)

Clothes 5ooo dollars (132286 left)

Life and Disability Insurance  9600 (122686 left)

Dues and License and CME 5000 (117686 left)

Miscellaneous Entertainment  10,000 (107686 left)

Saved

Remaining available to save around 107686 per year (not including 401k)

30,000 dollars in 401k

Assuming 8% rate of return on 137686 over 5 years- 807690 dollars in savings

Next 5 years (Own house)

Expenses

401k: 30,000 (383000 left)

Taxes : 76182 (Federal) + 0 (State) (306818 left)

Loan payments and house savings and children 529 plan: 48,588 (student loans)  + 13,344 (529 plan) (244886 left)

Salary after mortgage payments and taxes (400,000 mortgage -30 year fixed at 3.5 percent 1796*12 (223334 left)

Salary after property taxes and insurance 12000 (211334 left)

Home maintenance= 5000 (206334 left)

Subtracting food for family 10000 (196334 left)

Transportation expenses 2 cars/insurance 10000 (186334 left)

Vacations 10,000 dollars (176334 left)

Computers/Cellphones/Electronics/Cable Bill 3600 (172734 left)

Education and Expenses for two kids 12,000 x2 (148734 left)

Clothes 5000 dollars  (143734 left)

Life and Disability Insurance 9600 dollars (134134 left)

Dues and License and CME 5000 dollars  (129134 left)

Miscellaneous Entertainment  10000 (119134 left)

Saved

Remaining available to save around 119134 per year (not including 401k)

30,000 dollars in 401k

Assuming 8% rate of return on 149134  over 5 years +807690 in savings= 2061000 dollars

Next 8 years (Student Loans Paid Off)

Savings After Expenses

Savings now 119134+48588 +30000 (401k)=197722 dollars per year

Assuming 8% rate of return on 197722 over 8 years +2061000 in savings= 5918000 dollars or 3476201 in today’s dollars

Next 5 Years (No More 529 plans)

Savings now 197722+13344= 211066 per year

Assuming 8% rate of return on 211066 over 5 years +5918000 in savings= 9934000 dollars or 5033000 in today’s dollars with 3 percent inflation

Next 10 years (No More Kid Expenses)- if you were to go past 5,000,000 dollars

Saving now: 211066 +24000= 235066 dollars per year

Assuming 8% rate of return on 235066 over 10 years +9934000 in savings= 24854000 dollars or approximately 9.4 million in today’s dollars with 3 percent inflation

 

Can You Accumulate Five Million Dollars In A High or Low-Cost Area?

The results are stark. Yes, you can accumulate 5 million dollars in a high cost of living area in today’s dollars with high student loan debt if you are willing to wait 33 years based on these numbers. On the other hand, if you decide to live in a low cost of living area, you can expect to accumulate 5 million dollars 10 years earlier. Now, money may not be everything. But, if you decide you want to change your lifestyle earlier than you expect, there will be many more doors accessible to you in your career if you choose to live in a lower-cost area. And, if you wanted to work a whole 33-year career, you would accumulate a large nest egg for your heirs. Something to think about!