MiM Mail: Finances during medical school as a mother in medicine

Hi,

I am writing with a question that I would love to see what the MiM community has to offer for advice! My question is- while going through medical school as a parent, how did you handle the financial aspects of your day to day budget? Did you find that student loans were enough to live on for a family month to month? (Spouse and one child in my case). Did your spouse work at all? How did you afford childcare if the spouse worked? Also- how did you get health coverage? My school offers it and you can include your family on the plan- but it is so expensive!! The monthly premium would take up almost all of my monthly living loans and I would get very little left over. My school does not offer more assistance for families, just one set amount. I guess private loans are an option but I’m afraid of the high interest rates on those. I have also heard that private insurance plans might be less expensive per month but I really have no experience or knowledge about that and wonder if they provide good coverage (like if we were to have another baby, labor and delivery/prenatal care, pediatrician visits, etc)? I have heard a few families say they qualified for Medicaid but I am also not familiar with that at all. Last part of this financial question- how did you afford all of the other expenses like going on interviews, paying for step, etc? Does your school provide extra loans when the time comes or do you just have to figure it out on your own?

Thanks!
Rachael

Financial Literacy Is Self Care

What exactly constitutes self care? It's different for everyone, but one thing's for certain: it's not just pedicures and massages. It's much more foundational than that.

Self care is...

• Recognizing that you must know yourself and pay attention to yourself before serving others - at work and at home. It's being attentive to YOUR particular physical, mental and emotional needs.
• Maintaining your health by keeping up appointments with a doctor, dentist or other wellness practitioner.
• Ensuring your ability to tackle challenges each day by gaining energy through nutritious food, exercise, and adequate sleep.
• Preventing defaults on your emotional bank account. And one type of withdrawal that could easily lead to a default is having problems with your real bank account.

Self-care frees you up to focus on what's most important to you

About a year and a half ago, I published this post about financial wellness. Well, I'm back on the soapbox after being motivated by a great group of financially-minded physicians in the social media sphere. We all descended on the FinCon Money and Media Expo last month, and it was an awesome display of what community can do.

I don't consider myself a financial blogger; my focus is wellness with an emphasis on how we should better know and take care of ourselves as busy women physicians. Money is a huge source of stress for many of us. Just like gaining self-knowledge, gaining financial knowledge will improve your self-care and in turn your overall health and happiness.

Figuring out how to do this in a time-efficient and effective manner is the crux. There's a TON of information out there, and it can be confusing. Here are some resources that I've found useful for learning more about finance, especially at pertains to women physicians, from some awesome ladies that I met at FinCon:

• BC Krygowski writes about downsizing and avoiding the dreaded lifestyle creep that seems inevitable as physicians transition from residents to attendings and grow their families. Ever felt like you're outsourcing everything in your life because you have no time, which in turn means you have to work more to afford the outsourcing? She and her husband (both doctors) transformed their lives over the years from New York McMansion owners to a more simple existence for their family - which translates to both of them working much less than they used to and traveling + writing much more (she also writes fantasy books).

• Eliza Minimal MD "retired" from medicine before she even turned 40 to pursue the things she's most passionate about: educating her children and traveling to far-off places. She's now back seeing dermatology patients in a clinic 1-2 days a week because she missed the mental challenge of medicine, but she exemplifies a life of minimal, intentional living. She recently published a very powerful post about stories we tell ourselves, that we're "haves" or "have-nots", and how they're completely up to us.

• Barbara Hamilton blogs at Tired Superheroine about financial wellness and navigating work-life balance as a female physician in a male-dominated field (interventional radiology). Check out her blog for practical tips about time management and simplifying life as much as possible with a young family and a leadership role in her practice.

• Bonnie Koo of Wealthy Mom MD spent years working at Morgan Stanley before attending medical school and training as a dermatologist. Her blog focuses specifically on money issues for women physicians - considerations for high income earners, blended families, couples with a significant earnings differential, etc. I've been interviewed for her "Real Women Physicians" series, and I've also guest posted on her blog to discuss parenting issues around money.

Bonnie happens to be offering a new course this fall called Money for Women Physicians*. It's an 8 week, live interactive course that marries financial education with mindset coaching only open to women physicians. A big bonus: completion of the course also awards 5 CME credits, which means you can use CME funds or pretax educational accounts for the tuition. Enrollment is only open this week (October 7 through October 14), so if this is of interest to you, please check it out!

I consider all of these ladies to be not only blogger colleagues but friends. They're examples of women employing financial empowerment as a means of self care. I hope you find as much inspiration in their stories as I have!





* The link for the MWP course is an affiliate link, which means that if you purchase the course through this link, I receive a fee. You are welcome to go through other means, but using this link in no way changes your purchase price or course experience.

Financial Wellness?

Do you know how social security works? Are you maximizing contributions to your retirement accounts? Have you ever heard of a 529 account, or a backdoor Roth IRA?

I combed the archives of this blog, and while there are a smattering of posts on money and costs of being in the field of medicine, I didn't see much about money management and financial planning. It's not a topic people commonly like to discuss, and yet it's so important to our overall well being. Physicians are notoriously horrible at managing money, and yet many in our profession shoulder a huge debt burden, one that can amount to hundreds of thousands of dollars by the time all the training is over. And at that point, the last thing most people want to do is continue "living like a resident", so they commence with lifestyle inflation and remedies for their delayed gratification.

                             

Last weekend I had the pleasure and opportunity to attend the first Physician Wellness and Financial Literacy Conference, aka the White Coat Investor Conference. It took place in beautiful Park City, UT with two days of CME talks, broken up by mid-day skiing time. The conference featured valuable information presented by physician experts in the areas of finance, financial independence, and burnout, along with some financial professionals (who did not have an interest in charging huge fees to physicians for their services, an issue common to many physician-targeted financial advisors). There was even a talk by one of the only female physician financial bloggers, Miss Bonnie MD, who also happens to run the very active informational goldmine Women Physicians Personal Finance Facebook group.

On day two of the conference, I represented both PracticeBalance.com and Mothers in Medicine on a panel of six bloggers for a Q&A session. Despite being the only blogger there who does not primarily blog about finance, it was a lively discussion with lots of inquisitive attendees. It left me with inspiration to blog more, and blog more about financial issues that I deal with!

Over the course of the weekend, I met so many inspiring people - especially women - who are taking control of their finances so as to not become an "underwater doctor" statistic. We often say in my household that debt = slavery, and that sense of lost control is what often leads to burnout for many professionals. While debt is for most people unavoidable on some level during medical training, we physicians have the power to manage it and at the same time plan sensibly for the future. I felt so much more empowered after attending this conference, and I highly recommend that you all check it out the next time it comes around. At the very least, take a look at the blogs (linked above) by the White Coat Investor, Physician on Fire, and Miss Bonnie MD. They are a great starting point on the path to proactively managing your money.

Money and mothers in medical training

Children are expensive. So is medical school. Children take up a lot of time. So does medical school. Unfortunately time and money are two things in considerable shortage during medical training. Mixing children and medical school can be an unhappy combination. We had our baby halfway through medical school (me) and residency (the Mister). There has been lots of discussion regarding the timing of procreation in medicine (eg here and here and on this blog). My general takeaway can best be summarized with this license plate.

I have found some serious life wisdom on vehicle license plates.

My general takeaway 1.1 regarding the subject of timing babies in medical training is that there is no perfect time. Each time is good in some respect and not so great in others. Having spent my 20s in pursuits of other advanced degrees, I didn't want to wait until I had a "real doctor job". But that meant that financially it was not such a great decision. Residents stipend is not enough for supporting a family, especially when one member of said family is incurring expenses of medical school. More than a third of our income goes to childcare expenses, and that's not even including food, diapers, and a multitude of other child related expenses. We are always worried if we'll be able to pay all our bills at the end of each month. I am in debt up to my eyeballs. Financial worries are always lurking in the background of my thoughts, and money has been on my mind even more as I am looking into taking out more loans for upcoming residency interviews.

A friend offered me wisdom from her interview experiences, telling me about some common interview questions, one of them being "Tell me about a difficult experience you had in medical school". I said (almost half jokingly), urrmm pretty much the entirety of medical school since having a baby has been one incredibly difficult experience. It is difficult to separate the experience of being a parent from that of being a medical student, and money has been one of the connecting threads between the two.

Daycare was the only affordable childcare option for us, and we are lucky to have hospital subsidized daycare. It was amusing (not really) when one of my classmates thought that "hospital subsidized" meant that all costs were covered by the hospital and it was free of charge. No, it just means there is a small discount. Though it is a "hospital affiliated daycare", but like most other daycares, it is not a 24/7 facility. Having both spouses in medical training means that both of us have very little control over our schedules. There are plenty of times that we are both working outside of daycare hours. And trainees may have an 80 hour a week work limit, but a child requires care 168 hours a week.

This same classmate who thought that daycare was free, was also surprised to learn that I hired baby sitters to study for medical school exams. "Wait, so every time you have to study, you have to pay someone to watch your kid? Can't you just put him in a playpen and do your studying?" Before I had a baby, I envisioned this picture of getting home from the hospital and spending daily finite hours of "quality time" with the little one and then he would, I don't know, put himself to bed or maybe I'd read him a little bedtime story at the end of which he'd dutifully doze off and sleep through the night, and I'd get more hours of "quality time" studying. Or just like my classmate I assumed that I would be studying while the baby/toddler would be happily playing by himself on the side with his toys, of course, without interrupting me. Those fantasies/assumptions disappeared pretty fast when a real baby (who is now a toddler) showed up.

Talking to other people in our situation (two medical trainees with no family close by) most options I heard of were not financially viable alternatives for us. I have heard people say to not worry about money and keep taking out loans because when I have a "real doctor job", I'll be able to pay it all off. Maybe there is truth to that. But when I look at the enormous amount of debt that I have already accumulated, and when I think about the uncertainty with future physician compensations, I don't feel comfortable taking out loans to whatever amount.

Things haven't always worked out great with this whole arrangement. I have less than perfect grades in medical school. I feel like if it was just the hours in the hospital and then I could come home and eat, pray, love or something, it would be fine. But because work just gets started after getting back home from work, is what makes it so hard. After a particularly rough rotation that had lots of nights and weekend shifts (read: "when daycare is not open" shifts) and an end of rotation exam, I bombed the exam. The course master told me that he was really surprised about my exam performance because the clinical portion of my grade was stellar and there was such a discrepancy between the clinical grade and the exam grade. I didn't know how to explain that for me studying for exams cost money. Whatever little savings we had, had recently disappeared after a family emergency, and as interview expenses had drawn closer, I had scrimped on getting sitters to study for tests.

As a minority it is sometimes difficult to explain or convince people even in the face of overwhelming evidence that social factors control how you experience your life and the color of your skin can change the opportunities and travails you encounter. At some point it is tiring to keep going through the explanations over and over and knowing that unless someone has actually been there, they really won't know what you are talking about. I feel that way about the experience of being a mother in medicine too. I could go blue in the face with my explanations but it is exhausting.

Surprise! Female physicians are paid less.

I am sure many of you have seen this recently published article about physician wage gender disparity in the New York Times. The original research article was published in JAMA Internal Medicine, and received a lot of popular press with mentions in the New York Times, Time magazine, Boston globe, Marie Claire and many others. I am always a little wary of science/research reporting. I sometimes try to read the primary research paper behind the news item, especially if the topic interests me. Pay equity for physicians is certainly a topic of interest for me.

This article put a specific number on the gender pay disparity: female physicians make roughly $20,000 per year less than male physicians. This is after adjusting for age, experience, faculty rank, specialty, scientific authorship, NIH funding, clinical trial participation, and Medicare reimbursements. This news came up in a non-work context with a male resident physician. He told me that the problem with these types of studies was that they don't account for the amount of work put in. According to him, "female physicians work less than male physicians". Well how do you mean sir? Do you mean more female physicians work part time? He said, "In my experience, women complain more and work less, period. They always have to go pick up their kids or some other excuse and they dump their work on me". Ugh! Alright then Dr. Curmudgeon.

The paper is well written and the research is pretty well done, I highly recommend reading. Sad statement, but female physicians being paid less won't come as a big surprise to anyone. Safe to say, I was being ironic in the blog post title. Gender based pay disparity occurs in the rest of the US workforce. The dicey question, which Dr. Curmudgeon raised, is the pay disparity unfair? It maybe unfair from a social standpoint. Women ending up with more childcare or household responsibility and not being able to match male productivity. But is it unfair from an economic standpoint? Are they truly being paid unequal amount for equal work? Is there is an inherent bias towards them? This paper suggests that there maybe a component of both social and economic unfairness.

Comparing unadjusted salaries, i.e. without taking into account specialty, faculty rank etc., the difference is even larger, $51,000 per year. It may be true that more women than men make choices that lead to being paid less, such as working in certain specialties or working part time. But women don't choose to be overtly discriminated against. The authors adjusted for a lot of factors that could explain the pay disparity and still found a gap of roughly $20,000. The authors lacked some information, most importantly, full time vs part time status. They did two things to counteract that. One, they used Medicare reimbursement in their multivariate analysis to adjust for clinical volume. Two, they eliminated bottom 25th percentile of income data, with the assumption that it would eliminate part-time workers from analysis. They are imperfect measures, but the best that could be done with the lack of available information.

I am pretty early in my training, and from my own limited experience, I do believe that there is at least some inherent bias. Dr. Curmudgeon is not an exception, there are more people like him inhabiting the medicine world. They may be outspoken about their biases, or maybe not, or maybe only in certain contexts. They may be aware of their biases, or maybe not. I suspect, a lot of Dr. Curmudgeons are even in positions where they can influence factors, like promotions and pays. If you have encountered one of these Dr. Curmudgeons, I'd be interested in hearing your stories in comments.