8 Compromise is often key in landing that first c o u n s e i .docx

8 Compromise is often key in landing that first c o u n s e i r n f
l o r
11 Ethics Update: Protecting the confidenCiaiity of the
deceased
1^ Mindfulness-based practices bave surprising results for
students
16 Long-running column charts changes in the student
experience
18 Candidates for ACA office share their views on ihe issues
20 National specialty certifications can be r;ifeer enhancers
ACA 2007 Convention & Exposition
Detroit. Michigan March 21 • 25
REGISTER NOW- Take advantage ofthe
Sanr- " -Jfe through «' '•"' "" ^"^^
I From tiie Presiiient
o Executive Director's Messa.
12 Finding Your Way
31 Counseling Career Corner
34 Behind the Book
Private Practice in Counseling
Dignity, Development & Diversity
42 Student Focus

Washington Update
ACA Journal Spotlight
Classifieds
What I've leamed along the way
Seven ACA leaders offer words of wisdom to those embarking
on their counseling careers
COMPILED BY
ANGELA KENNEDY
Counseling Today asked
several American Counseling
Association leaders what advice
they would share with new pro-
fessicwials and graduate students.
Here's what they had to say.
Jane Goodman
ACA Foundation chair;
professor emerita of counsel-
ing at Oakland University
As a new counselor starting out,
what was the hardest lesson you
had to learn?
Like so nfiany "helpers," I
wanted to fix things and make
people feel better. Allowing
clients to struggle and suffer
was really a challenge. There
was always the desire to
reassure, suggest a solution or
comfort. I do believe that these

desires are sometimes OK, but
the trick was to recognize
whose needs I was meeting —
mine or theirs.
Whai was the best piece of
advice you received a.s a student-
or new professional?
Trust the process, trust
yourself, trust your clients.
What advice would you like to
share with students or new pro-
fessionals today?
First, the advice I received:
Trust the process, trust yourself.
trust your clients. Second, leam
as much as you can always and
as long as you live. Third, ask
for help and support when you
need it; self-sufficiency is not a
sign of strength! Fourth, take
care of yourself so you will have
the energy and strength to help
others take care of themselves.
Patricia Arredondo
Immediate past president of
ACA; dean of student affairs
and professor. Division of
Psychology in Education at
Arizona State University

As a new counselor starting out.
what was the hardest lesson you
had to leam?
Continued on page 32
Know when to say 'no' and let go
Advice on how counselors can achieve better
BY ANGELA KENNEDY and vicarious trauma can happen
to you, too!
Many recent graduates are
eager to pui school behind them
balance between their personal, professional lives
Warning all new professionals:
Compassion fatigue, burnout
PERIODICALS MAIL-NEWSPAPER HANDUNG
019
00044
and begin focusing on their
careers as professional coun-
selors. But a desire to achieve
and prove yourself can lead to
trouble if you don't take the
time to care for yourself just as
you care for your clients.
Linda Leech, president of the
Counseling Association for Hu-

manistic Education and Devel-
opment and program director of
rehabilitation counseling at the
University of South Carolina,
says counselors can have it all
— both a successful career and
a healthy lifestyle — if they
take a holistic approach to life
and wellness. "One piece of lit-
erature that has become vwy
familiar in our profession is the
Wheel of Wellness. developed
by Thomas Sweeney and
J. Melvin Witmer," she says. "It
talks about aspects of life that
are important in having a
healthy, well-balanced life-
style." Leech simplifies the
Adierian-based model into five
areas that demand the most
attention:
Spiritual health
Whether it's through religion,
faith or just going to that "happy
place," counselors need to find a
comforting center within. "It's
about going to someplace inside
yourself that allows you to
know that ifs ail going to be
OK," Leech says. "It's letting go
of things over which you have
control and embracing the fact

that there are some things you
never can control — and being
OK with that."
Continued on page 22
Balance Continued from page 1
Meaninfiful activities
Many adults define them-
selves by what they do for a liv-
ing. Finding meaning and pur-
pose in a career is important.
However, to achieve balance,
counselors should seek fulfill-
ment and achievement outside
the office as well.
"Meaningful activities can be
a lot of things, and one of those
definitions can be play," Leech
says. "It's recognizing from the
outset that your play life and
your work life are both reinforc-
ing to you."
Sam Gladding, a past presi-
dent of the American Counsel-
ing Association and a counselor
educator at Wjike Forest Uni-
versity, agrees that counselors
need to find pleasure both at
work and MI home. "All work

and no play gets you nowhere
fast," he says. "You have to take
time for yourself and do some-
thing different and something
you love besides counseling.
It's also important to plan things
with your family or your partner
that are different from work and
create memories that you can
draw from later."
Both counselors strongly ad-
vise new professionals to take
time for activities that allow
them to escape and recharge.
"Do something where you
don't have to give anything to
anybody, but the environment
and activity gives to you,"
Leech advises. "The less inten-
tional and structured that we
have to be in those times the
better it is. Art, exercise and
sports arc so beneficial to the
way we think because those
activities have different types
of structure and allow us to
make decisions in the minute.
We have to be able to find a
time, place and activities that
will allow us to step complete-
ly into a different environment.
We have to be able to have
places and activities that are
simply just for us."

Physical health
Counselors are aware that
they need to take care of their
own mental health in prepara-
tion for helping others, but
being physically fit p!ays a vital
role as well. Whether it's skip-
ping breakfast to fit in another
client or staying up late to finish
paperwork, sometimes the phys-
ical aspect of counselor well-
ness can be overlooked or
delayed.
"You have to focus on what is
going to make your body run
better," Leech says in explana-
tion. "It's having the awareness
of your body, mind and emo-
The original Wheel of Wellness model, created by John M.
Witmer, Thomas J. Sweeney and Jane
E. Myers, depicted five life tasks — spirituality, self-regulation,
work, friendship and love — in a
wheel with interrelated and interconnected spokes. Following
early research, a new model (reprint-
ed here with permission; copyright 1988) was expanded and
redefined with V components that
interact with contextual and global forces to affect holistic
well-being. Most recently, the authors

have developed a further evidence-based model, the Indivisible
Self Model of Wellness. Additional
information about both the Wheel of Wellness and Indivisible
Self Model can be found in the ACA
publication Counseling for Wellness: Theory, Research and
Practice, edited by Sweeney and Myers.
o
u
The impact of being a counselor
Like any profession, being a counselor has its pros and cons,
and the career can
botli positively and negatively affect a counselor's persona! life.
Sam Gladding, a
past president of the American Counseling Association,
suggests ways for new pro-
fessionals to accentuate the positive and overcome the not-so-
positive.
Positive factors:
• Appreciation and gratitude. "Having seen the worst, you are
grateful for your
own life that much more," Gladding says.
• Inci-cased understanding of self
• Expanded worldvicw and sense of connectedness
• Deeper understanding of your family of origin. "You realize
more deeply how

your family of origin influenced you and still impacts you," he
says.
• More sensitivity lo time, people and purpose
• Addeil attention to priorities. "You realize that there aif some
goals worth pur-
suing more than others." lie says. •"You have seen pain (and)
you w;mt to strive
more for the meaningful."
• A world of new friends and networks
Negative factors:
• Toxic emotional residue or taking home the psychologically
toxic words,
thoughts or stories from clients. "It's the negative emotions and
thoughts that
we get from clients that build up. If we don't seek some release,
they begin to
have a negative impact on us," he says.
• Resurfacing of unfinished business
• Additional stress
• Burnout
Ways to reduce the negative impact:
• Associate with healthy people
• Work with committed colleagues and oi-ganizations
• Use stress-reduction techniques
• Engage in self-monitoring
• Examine and clarify counseling roles, expectations and beliefs

• Obtain personal counseiing/supervision
• Set aside time for self
• . Maintain an attitude of detached concern when working with
clients
• Modify environmental stressors
• Retain a positive attitude
'With counseling, you have to be mindful of what you arc doing,
thinking and
saying," Gladding says. "Stiiying balanced and mentally healthy
is a job in and of
itself that requires energy, focus and cultivation. It's like
growing something —
plants, animals or yourself. You have to be mindful of what you
are doing and what
you are feeding it."
— Angela Kennedy
22
A-Burnout-Reduction-and-Wellness-Strategy--Personal-
Financ_2019_Practical-Ra.pdf
Practical Radiation Oncology (2019) 9, 231-238
www.practicalradonc.org
Critical Review
A Burnout Reduction and Wellness Strategy:
Personal Financial Health for the Medical Trainee

and Early Career Radiation Oncologist
Trevor J. Royce MD, MS, MPH a,*, Kathleen T. Davenport MD
b,
James M. Dahle MD, FACEP c,d
aDepartment of Radiation Oncology, University of North
Carolina at Chapel Hill School of Medicine, Chapel Hill, North
Carolina; bDepartment of Emergency Medicine, University of
North Carolina at Chapel Hill, School of Medicine, Chapel
Hill, North Carolina; cUtah Emergency Specialists, Salt Lake
City, Utah; and dThe White Coat Investor, LLC, Salt Lake
City, Utah
Received 14 January 2019; revised 16 February 2019; accepted
22 February 2019
Abstract
Purpose: Physician burnout is reported in more than one out of
every 2 practicing clinicians and is
just as prevalent in training physicians. Burnout severity is also
associated with increasing levels of
financial debt. Medical professionals are notable for their high
and increasing levels of debt; despite
this, financial literacy is poor among physicians, and financial
education is largely absent from
medical education. Radiation oncologists (ROs) are no different
in this regard, with 33% of res-
idents reporting high levels of burnout symptoms, 33% carrying
>$200,000 of educational debt,
and 75% reporting being unprepared to handle future financial
decisions. To fill this gap, we
reviewed the basic tenets of personal financial health for the
early career RO.
Methods and materials: The core concept of financial
independence (FI) is introduced, and we
review 4 basic tenets of personal financial health for the young
medical professional: debt,
behavior, investment, and asset protection strategies.

Results: FI is achieved by saving until the desired quality of life
can be maintained, independent of
employment income. Debt strategy involves minimizing debt
accrual, understanding student loans,
and having a debt management plan. Behavioral strategy
involves setting financial goals, calcu-
lating worth and a savings rate, budgeting, and frugal living.
The basics of investing include
asset allocation, diversification, rebalancing, and minimizing
expenses. Finally, asset protection
includes insuring against catastrophic events with disability,
life, health, liability, and property
insurance.
Conclusions: Healthy financial practices can lead to FI and may
facilitate professional and personal
freedoms with the goal of mitigating burnout-associated
stressors. The tenets of strong financial
health for ROs in the early stages of their career include sound
debt, behavioral, investment, and
asset protection strategies. Furthermore, initial and continuing
financial education is an overlooked
Sources of support: This work had no specific funding.
Disclosures: Dr Dahle is the founder and editor of The White
Coat Investor, LLC.
* Corresponding author. Department of Radiation Oncology,
University of North Carolina at Chapel Hill, 101 Manning
Drive, CB 7512, Chapel Hill,
NC 27599.
E-mail address: [email protected] (T.J. Royce).
https://doi.org/10.1016/j.prro.2019.02.015
1879-8500/� 2019 The Author(s). Published by Elsevier Inc. on
behalf of American Society for Radiation Oncology. This is an
open access article under

the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
http://crossmark.crossref.org/dialog/?doi=10.1016/j.prro.2019.0
2.015&domain=pdf
mailto:[email protected]
http://creativecommons.org/licenses/by-nc-nd/4.0/
232 T.J. Royce et al Practical Radiation Oncology: July-August
2019
but important curriculum component. ROs with their financial
houses in order can devote more
resources to learning and practicing good medicine while living
healthy, rewarding lives.
� 2019 The Author(s). Published by Elsevier Inc. on behalf of
American Society for Radiation
Oncology. This is an open access article under the CC BY-NC-
ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Figure 1 Potential medical graduate educational debt load by
postgraduate year during graduate medical education under a
government-sponsored, income-based repayment plan. The
average starting educational debt load of the graduating medical
student was $200,000 in 2018 (blue line), and 12% of graduates
owe >$300,000 (red line).16 This model assumes that the
graduate is making the minimal payments on unsubsidized
Introduction
Symptoms of burnout (depersonalization, a diminished
sense of personal accomplishment, and emotional
exhaustion) have been reported in >1 of every 2 prac-
ticing physicians.1 This affliction, driven by work-related
stressors, is just as prevalent in training physicians2 and

has become a focus of the American Medical Associa-
tion.3 Burnout has been associated with substance abuse,
suicidal ideation, and career dissatisfaction,4-6 and the
rates of burnout are thought to be twice as high in med-
icine compared with other professional fields.7 Radiation
oncologists (ROs) are no different in this regard, with
33% of residents reporting high levels of burnout symp-
toms.8 Indeed, a full session at the 2018 American Society
for Radiation Oncology Annual Meeting was devoted to
burnout in the specialty, with a focus on resident and
junior ROs.
Burnout severity is also associated with increasing
levels of financial debt.9-13 Medical and dental pro-
fessionals are notable for their high and increasing levels of
debt, which is the highest among graduate-degree pro-
fessions.14 The median debt of medical school graduates
with loans has nearly tripled from $71,000 (in 2018 dollars)
in 1986 to $200,000 in 2018.15,16 Furthermore, 12% of
graduates now owe >$300,000 in educational debt.16 This
burden can grow substantially during residency and, at
current interest rates, may be 20% to 50% higher by
completion of training (Fig 1). Despite this, financial lit-
eracy is poor among physicians, and financial education is
largely absent from medical education.17 Again, ROs are no
different in this regard, with 33% of RO residents carrying
>$200,000 of educational debt (12% of residents report
>$300,000)8,18 and 75% reporting being unprepared to
handle future financial decisions.19
To fill this gap and in the context of the multifactorial
burnout crisis, we review the basic tenets of personal
financial health for ROs in the early stages of their career
(Table 1) and introduce the concept of financial inde-
pendence (FI), all with the goal of promoting strong
financial stewardship as a wellness strategy.

loans while enrolled in the Pay-As-You-Earn repayment plan,34
with an average loan interest rate of 6.6% in 2018,27 earning
an average resident salary of $59,300 in 2018,54 with a
family size of 1, and lives in the continental United States, with
U.S. Department of Health and Human Services poverty
guidelines.55 (A color version of this figure is available at
https://
doi.org/10.1016/j.prro.2019.02.015.)
Financial Independence
FI is the accumulation of sufficient wealth to permit
life without dependency on employment income while
maintaining the desired quality of life.20,21 This state is
essentially the personal finance endgame and is what
the retiree, who no longer works but has saved enough
to live comfortably after employment, classically strives
for. But FI need not be limited to the retiree, and the
state permits professional, personal, and financial free-
doms. With healthy financial behavior, FI is readily
attainable for U.S. physicians after 15 to 20 years, or
less, in practice. FI can alleviate work-related personal
financial stressors, allowing the physician to practice
medicine unhindered by the constraints of dependency
on income. For some physicians, the path to FI may
permit the restructuring of work hours and schedules
and provide more room for personal wellness or pro-
fessionally rewarding but less income producing activ-
ities, such as charitable work. For others, FI can be a
hedge against an uncertain future (eg, in specialty labor
markets such as in RO22,23 or times of changing
reimbursement patterns and health care reform24).
Furthermore, if individual practice patterns are driven,
consciously or unconsciously, by the personal income
benefits enabled by the relative-value-unit fee-for-

Table 1 Summary of tenets of financial health for medical
trainees and early career radiation oncologist with select
relevant and
practical resources
Tenet Details Resources
Debt strategy Debt management plan Fawcett et al, 201636
Minimize debt accrual Steiner et al, 201335
Grischkan et al, 201833
Behavior strategy Set financial goals Tyson et al, 201039
Calculate net worth Bach et al, 201640
Set a savings rate Stanley et al, 201037
Budget Zweig et al, 200841
Live like a resident (minimize spending) Clements et al, 201643
Stay the course (stick to the plan) Belsky et al, 201044
Investment strategy Pay down high-interest debt Bernstein et al,
201442
Asset allocation Larimore et al, 200749

Portfolio diversification Larimore et al, 201846
Rebalance portfolio Bernstein et al, 201047
Minimize expenses Piper et al, 201451
Minimize taxes
Asset protection strategy Insure against catastrophic events
Tyson et al, 201039
Disability Dahle, 201429
Death
Illness
Injury
Liability
Expensive property
Emergency fund
Estate planning
Personal well-being
Education Initial and continuing financial education Dahle,
201429
Practical Radiation Oncology: July-August 2019 Early career
personal financial health 233
service reimbursement model, FI could mitigate these
influences.25
FI (moving work from a necessity to a choice) can be
obtained through many routes but is classically and most
reliably done via the steadfast accumulation of wealth
such that an individual’s assets, when invested appropri-
ately, generate enough income passively to at least equal
expenses. This wealth is achieved by increasing savings

(ie, assets) relative to lifestyle costs and debts (ie, ex-
penses). Healthy personal financial practices are necessary
for FI.
Tenets of Financial Health for Medical
Trainees and Early Career Radiation
Oncologists
Debt strategy
The cost of medical education has been increasing at
twice the rate of inflation.26 For those who borrow money
to pay for this increasingly expensive education, the in-
terest rate for unsecured federal Stafford graduate student
loans from 2006 to 2018 averaged 6.38%,27 >2 points
above the average 15-year fixed-rate mortgage of
4.05%.28 Moreover, since 2012, these loans are
unsubsidized, and the federal government will no longer
cover the interest while the borrower attends school.29
Other sources of debt to consider are undergraduate ed-
ucation loans, credit card debt, mortgages, and car loans.
Finally, in the setting of an expensive U.S. health care
system,30 there is downward pressure on physician pay,
with physicians earning relatively less than ever before.31
The combination of the increasing cost of education,
relatively high interest rates on educational loans, less
favorable loan terms, and changing health care economics
make a sound debt strategy essential for physicians in the
early stages of their career.
Not to be overlooked, an important component of debt
strategy is to minimize high-interest debt accrual during
training. Techniques to curtail educational costs include
prudent school selection and using preowned or shared

books, supplies, and equipment. Frugal living choices and
cost sharing can help reduce the total debt burden.
Income during training can also reduce indebtedness.
Medical students may be able to work in a limited manner
during school, and a spouse or partner may also be able to
provide financial support. Many universities allow for
substantial tuition reductions for family members of em-
ployees. Other notable approaches include scholarships
and grants; combination degree programs (eg, MD/PhD);
the National Health Services Corps or the U.S. Armed
Table 2 Summary of available federal student loan repayment
plans under the William D. Ford Federal Direct Loan Program
Repayment plan Eligible loans Monthly payment and loan
features
Standard � Direct loans (subsidized and
unsubsidized)
� Federal Stafford loans (subsidized
and unsubsidized)
� PLUS loans
� Consolidation loans
� Fixed payments made within 10 years*
Graduated � Direct loans (subsidized and
unsubsidized)
and unsubsidized)

� PLUS loans
� Fixed payments increase every 2 years and loans are paid off
within
10 years*
Extended � Direct loans (subsidized and
unsubsidized)
and unsubsidized)
� PLUS loans
� Fixed or graduated payments made within 25 years
Revised Pay-As-
You-Earn
� Direct loans (subsidized and
unsubsidized)
� PLUS loansy
� Consolidation loansy
� Payments calculated from 10% of discretionary income
� Annually recalculated using family size and income
� Married couples’ total income and loan debt considered
� Outstanding balance is forgiven after 20 years (undergraduate
study) or
25 years (graduate or professional study)
� Forgiveness may be a taxable event
Pay As You Earn � Direct loans (subsidized and

unsubsidized)
� PLUS loansy
� Married couples’ total income and loan debt considered if
filing jointly
� Outstanding balance is forgiven after 20 years
� Eligibility limitations based on dates of loan and
disbursement and debt-
to-income ratio
Income-based � Direct loans (subsidized and
unsubsidized)
and unsubsidized)
� PLUS loansy
� Payments calculated from 10%-15% of discretionary income
filing jointly
� Outstanding balance is forgiven after 20-25 years
� Eligibility limitations based debt-to-income ratio
Abbreviation: PLUS Z Parent Loan for Undergraduate Student.
The highlighted income-driven repayment plans (shaded) are
those best suited for the Public Service Loan Forgiveness
program.2

Income-contingent and income-sensitive repayment plans also
exist, but these are rarely used by medical trainees.
* 10-30 years for consolidation loans.
y Direct loans made to students.
2019
Forces with their Health Professions Scholarship Pro-
gram; the Uniformed Services University of the Health
Sciences (Bethesda, MD); or financial assistance
programs.32
However, for many with heavy student debt loads at
the end of training, 2 primary strategies exist: consoli-
dating loans and pursuing forgiveness, or refinancing and
eliminating the high-interest debt as soon as possible.
There are several service-based loan repayment or
forgiveness programs. For example, for those working in
underserved areas or conducting research there are the
National Health Services Corps and the National In-
stitutes of Health Loan Repayment Program, respectively.
For those pursuing work in academics and nonprofits (ie,
organizations with a 501(c)3 tax designation), the most
widely adapted forgiveness path is the U.S. government’s
2007 Public Service Loan Forgiveness (PSLF) program,
in which more than one third of graduates with debt are
participate despite increasing scrutiny of the program.33
Under the PSLF program, borrowers who are enrolled
in qualifying repayment plans and employed directly by a
501(c)3 or government organization may be eligible to
have all educational debt (principal and interest) spon-
sored by the federal government forgiven, tax-free and
without a cap, after 10 years of payments (120 qualifying,
monthly, on-time payments). There are several qualifying

repayment plans (Table 2), which are largely income-
driven repayment plans (ie, the monthly payment owed
is dependent on income, such as the Pay As Your Earn,
Revised Pay As You Earn Repayment Plan, and Income-
Based Repayment plans).34 Because most residents and
fellows are employed by 501(c)3 organizations, the years
of training can count toward the 10 years of service
needed for forgiveness. This is particularly appealing with
the income-driven repayment plans and results in a lower
monthly payment while the borrower earns a lower salary
as a trainee.
For academics and others who plan to be directly
employed by a 501(c)3 nonprofit or government organi-
zation after training, this program can be an appealing
approach. Of note, placing student loans into deferment or
forbearance during training can be a costly mistake
because the borrower would not be accumulating pay-
ments toward the PSLF. The PSLF exists at the whims of
Congress33; therefore, financially savvy borrowers hedge
against possible changes in the program and their career
path by saving an amount equivalent to their loans on the
side in an investing account. These funds can be applied
against the debt in the event of career or program changes.
Another recommended strategy for those with high-
interest debt is to eliminate the debt as quickly as possible
by refinancing with a private lender, living frugally, and
directing every available dollar to the debt. Since 2013,
private lenders have been refinancing medical student
loans at lower interest rates than those offered by the

federal government. Being free of student loan debt in 2
to 5 years after residency is an attainable goal for most29
but requires the behavioral discipline described in the next
section. As illustrated by the numerous repayment plans
outlined, student loans are complex, and the optimal debt
strategy for any individual depends in part on personal
goals and preferences. Fortunately, there are many
excellent resources available to help with this
process.35,36
Behavioral strategy
A goal-oriented approach to personal financial health
keeps the individual on track to success. A common unit
in financial goals is net worth, which is essentially net
assets minus net liabilities (ie, debts). The surest path to
increasing net worth is a high savings rate, or the pro-
portion of income not spent and placed into savings (eg,
investments). In other words, this is achieved by living
well below your means. Wealth is what you accumulate
and can be achieved by increasing net worth through
savings; it should not be confused with income.37
This behavioral strategy, that of a “prodigious accu-
mulator of wealth,”37 is particularly important for physi-
cians, with their delayed entry into the workforce as a
result of prolonged education and training and high debt
burden. Physicians are typically in their early thirties by
the time they complete training. Although there are social
and societal pressures for physicians to increase con-
sumption (eg, buy a house) upon completion of training
with the accompanying increase in income, our preferred
approach is to delay gratification and live like a resident
for several years after training. This approach requires
physicians to maintain a resident’s standard of living as an
attending physician, despite the higher income.

The difference between attending-level income and
trainee-level standard of living can permit the rapid
accumulation of wealth by paying down debt, increasing
the savings rate, and getting one’s financial house in
order. Converting income into wealth involves
consciously avoiding the hedonic treadmill38 and growing
into higher income slowly. Creating a monthly budget is
the traditional technique to track spending, saving, and
progress toward financial goals, and many excellent re-
sources are available to help with this process.39 An even
simpler way is to “pay yourself first” with automated
deductions for bills and savings accounts.40
Finally, when saving and investing, setting financial
goals and working toward them by staying the course
despite market volatility is critical. Changing goals and
strategies during a turbulent market can lead to selling
low and buying high, which decreases investment returns
and slows the process. Common behavioral investing
traps are paralysis by analysis, recency bias, herd
behavior, loss aversion, mental accounting, and changing
long-term plans in response to short-term events.41 A
competent, low-cost financial advisor can assist with
developing, implementing, and maintaining an appro-
priate investment strategy. However, all else being equal,
the cost of an advisor reduces investment returns. Many
physicians, who have already demonstrated the character
traits of hard work, planning, self-discipline, and perse-
verance intrinsic to the profession, are capable of man-
aging their own finances with great success. Of course,
this requires interest, the accumulation of a new body of
knowledge, and sufficient discipline to maintain a simple,
low-cost investment strategy.42 Many excellent resources
are available detailing the nuances of financially healthy
behavioral strategies.41,43,44

Investment strategy
Historically, approximately 4% of the initial portfolio
value, adjusted upward annually for inflation, can be spent
each year throughout retirement with little risk of complete
portfolio depletion. Thus, FI, or the amount needed to
feasibly retire, can be defined as a sum of money that is 25
times annual retirement spending. For example, if
$100,000 is needed from the portfolio each year, then
$2,500,000 is needed in savings. This is known as the 4%
rule45 and is defined by assumptions based on the historical
performance of investments (ie, equities and bonds). A 3%
withdrawal rate would be even more conservative.45 The
Figure 2 Lifecycle funds. This schematic shows how lifecycle
(target retirement) funds adjust their risk profile as the target
retirement date (Year 0) approaches. As the years to retirement
approach 0, the fund’s asset allocation get progressively less
risky, shifting the balance from stocks (higher risk) to bonds
(lower risk).
2019
nuances of an appropriate long-term investment strategy to
reach FI are beyond the scope of this article (eg, invest-
ment portfolio design involves many personal decisions),
but we cover some fundamental principles. It is critical to
recognize that fruitful investing need not be overly com-
plex; some successful investors use a portfolio with only 3
types of assets.46
The future value of savings is primarily driven by 4
factors: income, savings rate (ie, percentage of income
saved and invested), the rate of return on those in-

vestments, and the amount of time over which the money
compounds. The amount of control the individual investor
has over these factors varies but is greatest for the savings
rate, as discussed previously. The expected rate of return
depends on the risk profile of the investment portfolio,
which is primarily reflected in its asset allocation (ie, the
mix of different types of investments in the portfolio, such
as stocks, bonds, and real estate). The appropriate port-
folio balance of riskier investments (stocks, real estate)
and less risky investments (bonds, cash) is determined by
the investor’s need, ability, and desire to take risk to meet
financial goals.
Essential to portfolio design is to minimize uncom-
pensated risk. Ideally, an investor who takes on more risk
should receive a higher long-term return as compensation.
Uncompensated risk (ie, risk that can be eliminated
completely through diversification) should be minimized
whenever possible.47 This can be done by holding mutual
funds, which are essentially a pool of many different as-
sets (ie, many different stocks, bonds, or real estate
holdings lumped into a single fund) as opposed to
choosing a few individual securities.48 This approach
provides broad exposure to the market and minimizes
having “all your eggs in one basket.” Active mutual fund
managers attempt to outperform the market by choosing
securities that will do well in the future and avoiding
those that will perform poorly. Passive (index) mutual
fund managers give up the potential to outperform the
market in exchange for eliminating the risk of under-
performing the market. Primarily because of their
dramatically lower costs, the investment literature has
consistently shown that over the long term, passively
managed index funds outperform the majority of actively
managed funds, especially on an after-tax basis.47-50

When investing for the future, minimizing expenses is a
fundamental principle of increasing returns.
Similar to minimizing fees, minimizing the tax liability
of investments is essential to optimize long-term returns.
More broadly, understanding the tax implications of
financial activities is a fundamental principle of good
financial health.51 The best way to optimize investment-
related taxes is through the prudent use of tax-protected
accounts, such as 401(k)s, 403(b)s, 457(b)s, health sav-
ings accounts, 529 college savings accounts, and indi-
vidual retirement accounts. The most common distinction
is Roth versus traditional (tax-deferred) individual retire-
ment accounts. Both accounts reduce the drag on returns
from taxes during growth, but Roth account contributions
and withdrawals are made after-tax and traditional ac-
count contributions and withdrawals are pre-tax. Because
trainees are generally in lower tax brackets than attending
physicians, the usual strategy is to make Roth contribu-
tions during training and then tax-deferred contributions
during peak earnings years. When investing in a non-
qualified account after maxing out retirement accounts,
special care should be paid to using tax-efficient
investments.
An example of simple, low-cost (ie, fees and taxes),
passively managed, broadly diversified, index mutual
fund portfolios is the lifecycle (target retirement) funds
offered by many investment companies and available in
most employer-sponsored retirement plans. These funds
are automatically rebalanced and adjust their risk profile
as the target retirement date approaches (Fig 2). Investing
savings in these funds requires little-to-no maintenance
and provides a simple approach that is preferred by many
investors. As previously indicated, there are many
excellent resources available that detail the nuances of

simple yet sophisticated and financially healthy investing
strategies.42,46,49
Asset protection strategy
Protecting oneself against catastrophic financial events
through insurance is another fundamental principle of
personal financial health.39 Examples of financial catas-
trophes include disability, death, illness or injury, liabil-
ity, and loss of expensive personal property. In general,
we favor insuring well against these risks and self-
insuring against noncatastrophic risks to save money.
Using high deductibles also reduces the cost of insurance.
Disability insurance premiums are relatively expensive
but essential because the ability to practice medicine is a
typical physician’s primary asset. Individual, specialty-
specific policies are generally more costly and difficult to
qualify for than group policies, but are portable and may
provide superior definitions of disability. We recommend
working with an experienced, independent agent to ensure
appropriate coverage at the lowest possible price.
Term life insurance, with the binary outcome of life or
death, is much less complex and expensive but no less
essential for those with dependents. Simple 20- to 30-year
term, level premium life insurance can readily be found
online through comparative aggregators and purchased
from an independent agent.52 Buying disability and life
insurance while young and healthy is easier and less
expensive. Whole life insurance, which combines a death
benefit with an investment vehicle, can be much more

costly and complex than simple term insurance. Optional
at best for any physician, it is generally inappropriate for
young, indebted physicians. We caution against
combining insurance and investing in this manner.
For unexpected life events or expenses, an emergency
fund of 3 to 6 months’ worth of living expenses in a safe,
accessible location is useful. This can be a buffer for life’s
inevitable curve balls, including short-term disability.
Estate planning should also be part of any financial
plan. Estate planning dictates where children and assets
go in the event of an individual’s death and minimizes the
hassles and cost of this transition. Consisting at a mini-
mum of a last will and testament, many physicians also
opt to have a power of attorney, living will, and various
trusts in place.
Finally, and not to be overlooked, the most valuable
asset we have is our mental and physical health, and
devoting the necessary resources (eg, time, energy, and
money) to caring for ourselves and our personal re-
lationships (eg, marriage) should be prioritized above all
else. Each of these aforementioned asset protection stra-
tegies have their own complexities, but many helpful
educational resources are available.29,39
A Way Forward
The increasingly well-described burnout crisis among
ROs and medical professionals is likely a multifactorial
process, but personal financial factors, including debt
loads, have been implicated as a contributing force.
Increasing income is of diminishing returns for increasing
happiness,53 but robust financial health can lead to FI and
may facilitate professional and personal freedoms, with
the ultimate goal of mitigating burnout-associated

stressors. The essential tenets of strong financial health
for ROs in the early stages of their career include sound
debt management and behavioral, investment, and asset
protection strategies (Table 1). Initial and continuing
financial education is an overlooked but important cur-
riculum component for medical professionals, and many
resources cited in this review can help in that regard.
The ultimate hope is that those with their financial houses
in order can devote more resources to learning and
practicing good medicine while living healthy, rewarding
lives.
References
1. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout
and
satisfaction with work-life balance in physicians and the general
U.S. working population between 2011 and 2014. Mayo Clin
Proc.
2015;90:1600-1613.
2. Dyrbye LN, Burke SE, Hardeman RR, et al. Association of
clinical
specialty with symptoms of burnout and career choice regret
among
US resident physicians. JAMA. 2018;320:1114-1130.
3. American Medical Association. Preventing physician
burnout.
Available at: https://www.stepsforward.org/modules/physician-
burnout. Accessed November 1, 2018.
4. Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and
suicidal
ideation among U.S. medical students. Ann Intern Med.
2008;149:
334-341.

5. Oreskovich MR, Kaups KL, Balch CM, et al. Prevalence of
alcohol
use disorders among American surgeons. Arch Surg.
2012;147:168-
174.
6. McMahon G. Managing the most precious resource in
medicine. N
Engl J Med. 2018;378:1552-1554.
7. Dyrbye LN, West CP, Satele D, et al. Burnout among U.S.
medical
students, residents, and early career physicians relative to the
general
U.S. population. Acad Med. 2014;89:443-451.
8. Ramey SJ, Ahmed AA, Takita C, Wilson LD, Thomas CR,
Yechieli R. Burnout evaluation of radiation residents
nationwide :
Results of a survey of United States residents. Radiat Oncol
Biol.
2017;99:530-538.
9. West CP, Shanafelt TD, Kolars JC. Quality of life, burnout,
educational debt, internal medicine residents. JAMA.
2015;306:952-
960.
10. Dimou FM, Eckelbarger D, Riall TS. Surgeon burnout: A
systematic
review. J Am Coll Surg. 2016;222:1230-1239.
11. Xu G, Veloski JJ. Debt and primary care physicians’ career
satis-
faction. Acad Med. 1998;73:119.

12. Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL.
Stress
and coping among orthopaedic surgery residents and faculty. J
Bone
Joint Surg Am. 2004;86-A:1579-1586.
13. Kibbe MR, Troppmann C, Barnett CC, et al. Effect of
educational
debt on career and quality of life among academic surgeons.
Ann
Surg. 2009;249:342-348.
14. Woods D. Medicine, law, business: Which grad students
borrow the
most? Available at:
https://www.npr.org/sections/money/2015/07/
15/422590257/medicine-law-business-which-grad-students-
borrow-
the-most. Accessed October 24, 2018.
15. Grischkan J, George BP, Chaiyachati K, Friedman AB,
Dorsey ER,
Asch DA. Distribution of medical education debt by specialty,
2010-2016. JAMA Intern Med. 2017;177:1532-1535.
16. Association of American Medical Colleges. Medical school
gradu-
ation questionnaire 2018 all schools summary report. Available
at:
https://www.aamc.org/download/490454/data/2018gqallschools
summaryreport.pdf. Accessed October 24, 2018.
17. Bar-Or Y. Empowering physicians with financial literacy. J
Med
Pract Manag. 2015;31:49.

18. Royce TJ, Doke K, Wall TJ. The employment experience of
recent
graduates from U.S. radiation oncology training programs: The
practice entry survey results from 2012 to 2017 [e-pub ahead of
print] J Am Coll Radiol. 2019. https://doi.org/10.1016/j.jacr.2
018.11.021. Accessed October 24, 2018.
http://refhub.elsevier.com/S1879-8500(19)30069-4/sref1
https://www.stepsforward.org/modules/physician-burnout
https://www.stepsforward.org/modules/physician-burnout

https://www.npr.org/sections/money/2015/07/15/422590257/me
dicine-law-business-which-grad-students-borrow-the-most
https://www.aamc.org/download/490454/data/2018gqallschoolss
ummaryreport.pdf
https://www.aamc.org/download/490454/data/2018gqallschoolss
ummaryreport.pdf
https://doi.org/10.1016/j.jacr.2018.11.021
https://doi.org/10.1016/j.jacr.2018.11.021
2019
19. Witek M, Siglin J, Malatesta T, et al. Is financial literacy
necessary for
radiation oncology residents ? Radiat Oncol Biol. 2014;90:986-
987.
20. Pfau W, Kitces M. Reducing retirement risk with a rising

equity
glide path. J Financ Plan. 2013;27:38-45.
21. Robin V, Dominguez J, Mustache MM. Your Money or Your
Life: 9
Steps to Transforming Your Relationship With Money and
Achieving
Financial Independence. Revised. London, United Kingdom:
Pen-
guin Books; 2008.
22. Burt LM, Trifiletti DM, Nabavizadeh N, Katz LM, Morris
ZS,
Royce TJ. Supply and demand for radiation oncology in the
United
States: A resident perspective. Int J Radiat Oncol. 2017;97:225-
227.
23. Fung C, Chen E, Vapiwala N, et al. The American Society
for
Radiation Oncology 2017 Radiation Oncologist Workforce
Study.
Int J Radiat Oncol Biol Phys. 2019;103:547-556.
24. Song Z, Goodson JD. The CMS proposal to reform office-
visit
payments. N Engl J Med. 2018;379:1102-1104.
25. Mitchell A, Rotter J, Patel E, et al. Association between
reim-
bursement incentives and physician practice in oncology A sys-
tematic review [e-pub ahead of print] JAMA Oncol. 2019.
26. Adashi EY, Gruppuso PA. Commentary: The unsustainable
cost of
undergraduate medical education: An overlooked element of

U.S.
health care reform. Acad Med. 2010;85:763-765.
27. U.S. Department of Education. Interest rates and fees.
Available at:
https://studentaid.ed.gov/sa/types/loans/interest-rates#rates.
Accessed
October 27, 2018.
28. FreddieMac. 15-year fixed-rate mortgages since 1991.
Available
at: http://www.freddiemac.com/pmms/pmms15.html. Accessed
November 1, 2018.
29. Dahle J. The big squeeze. In: The White Coat Investor A
Doctor’s
Guide to Personal Finance and Investing. The White Coat
Investor,
LLC; 2014:15.
30. Emanuel EJ. The real cost of the U.S. health care system.
JAMA.
2018;319:983.
31. Seabury SA, Jena AB, Chandra A. Trends in the earnings of
health
care professionals in the United States, 1987-2010. JAMA.
2012;
308:2083.
32. U.S. Air Force. Financial assistance program. Available at:
https://
www.airforce.com/careers/specialty-careers/healthcare/training-
and-
education. Accessed November 1, 2018.

33. Grischkan JA, George BP, Dorsey ER, Asch DA. Medical
education
and the public service loan forgiveness program: Unnecessary
un-
certainties. Ann Intern Med. 2018;169:566.
34. Federal Student Aid. Choose the federal student loan
repayment
plan that’s best for you. Available at:
https://studentaid.ed.gov/sa/
repay-loans/understand/plans. Accessed November 1, 2018.
35. Steiner J. The Physician’s Guide to Personal Finance: The
Review
Book for the Class You Never Had in Medical School. 1st ed.
South
Dublin, Ireland: Two Pugs Publishing; 2013.
36. Fawcett C. The Doctors Guide to Eliminating Debt. 1st ed.
Eagle,
ID: Aloha Publishing; 2016.
37. Stanley TJ, Danko WD. The Millionaire Next Door: The
Surprising
Secrets of America’s Wealthy. Lanham, MD: Taylor Trade Pub-
lishing; 2010.
38. Diener E, Lucas RE, Scollon CN. Beyond the hedonic
treadmill:
Revising the adaptation theory of well-being. Am Psychol.
2006;61:
305-314.
39. Tyson E. Assessing your fitness and setting goals. In:
Personal
Finance for Dummies. Hoboken, NJ: Wiley Publishing; 2010:1-
76.

40. Bach D. The Automatic Millionaire, Expanded and Updated:
A
Powerful One-Step Plan to Live and Finish Rich. Manhattan,
NY:
Random House; 2016.
41. Zweig J. Your Money and Your Brain: How the New
Science of
Neuroeconomics Can Help Make You Rich. Reprint ed. New
York,
NY: Simon & Schuster; 2008.
42. Bernstein WJ. If You Can: How Millennials Can Get Rich
Slowly.
Portland, OR: Efficient Frontier Publications; 2014.
43. Clements J. How to Think About Money. 1st ed. Seattle,
WA:
CreateSpace Independent Publishing (Amazon); 2016.
44. Belsky G, Gilovich T. Why Smart People Make Big Money
Mistakes
and How to Correct Them: Lessons from the New Science of
Behavioral Economics. New York, NY: Simon & Schuster;
2010.
45. Cooley P, Hubbard C, Walz D. Retirement savings:
Choosing a
withdrawal rate that is sustainable. AAII J. 1998;10:16-21.
46. Larimore T, Bogle JC. The Bogleheads’ Guide to the Three-
Fund
Portfolio: How a Simple Portfolio of Three Total Market Index
Funds Outperforms Most Investors With Less Risk. 1st ed.
Hoboken,

NJ: Wiley Publishing; 2018.
47. Bernstein WJ. The Four Pillars of Investing: Lessons for
Building a
Winning Portfolio. 1st ed. New York, NY: McGraw-Hill
Education;
2010.
48. Bogle J. Common Sense on Mutual Funds. 10th ed.
Hoboken, NJ:
Wiley Publishing; 2009.
49. Larimore T, Lindauer M, LeBoeuf M. The Bogleheads’
Guide to
Investing. 1st ed. Hoboken, NJ: Wiley Publishing; 2007.
50. Malkiel BG. A Random Walk down Wall Street: The Time-
Tested
Strategy for Successful Investing. 12th ed. New York, NY: W.
W.
Norton & Company; 2019.
51. Piper M. Taxes made simple. Simple Subjects, LLC; 2014.
52. Term4Sale. Available at: https://www.term4sale.com/.
Accessed
November 1, 2018.
53. Kahneman D, Deaton A. High income improves evaluation
of life
but not emotional well-being. Proc Natl Acad Sci.
2010;107:16489-
16493.
54. Levy S. Medscape residents salary & debt report 2018.
Available at:

https://www.medscape.com/slideshow/2018-residents-salary-
debt-
report-6010044#2. Accessed November 28, 2018.
55. U.S. Department of Health & Human Services. U.S. Federal
poverty
guidelines used to determine financial eligibility for certain
federal
programs. Available at: https://aspe.hhs.gov/poverty-guidelines.
Accessed November 28, 2018.
https://studentaid.ed.gov/sa/types/loans/interest-rates#rates
http://www.freddiemac.com/pmms/pmms15.html

https://www.airforce.com/careers/specialty-
careers/healthcare/training-and-education
https://studentaid.ed.gov/sa/repay-loans/understand/plans
https://studentaid.ed.gov/sa/repay-loans/understand/plans

https://www.term4sale.com/
debt-report-6010044#2
debt-report-6010044#2
https://aspe.hhs.gov/poverty-guidelinesA Burnout Reduction
and Wellness Strategy: Personal Financial Health for the
Medical Trainee and Early Career Radiation Onc

...IntroductionFinancial IndependenceTenets of Financial Health
for Medical Trainees and Early Career Radiation
OncologistsDebt strategyBehavioral strategyInvestment
strategyAsset protection strategyA Way ForwardReferences
Work-Life-Balance--Burnout--and-the-Electronic_2018_The-
American-Journal-of-.pdf
Work–Life Balance, Burnout, and the Electronic
Health Record
United States physicians were studied by Shanafelt et al in
2011, and again in 2014, regarding burnout and satisfaction
with work–life balance.1 Physician burnout increased sig-
nificantly, from 45.5% to 54.4%. Parallel studies of all US
workers during the same period showed no changes.
There are several possible explanations for this. New phy-
sician members were added to the cohort between 2011 and
2014. It is conceivable new expectations could have changed
the outcome. Since the internet-enabled smart-phone users
born after 1982 had barely begun to graduate residency in
2014, however, it seems more than a stretch to blame yet
another malady on ″Millennials″.
The rates of physician suicide and depression remained
stable from 2011 to 2014, whereas the “healthy work–life
balance” portion of the Shanafelt study dropped from 48.5%
to 40.9%. The definition of work–life balance has been vari-
ously misused, but in the most general sense it focuses on
satisfaction with work and the ability to have a happy life away
from work. The Maslach Burnout Inventory was used to mea-
sures personal accomplishment, emotional exhaustion, and
depersonalization.2 Doctors are not depressed or less content
at home, they are less happy at work.

Physician burnout is characterized by 1) a feeling of a lack
of accomplishment; 2) feelings of cynicism; and 3) a loss of
zeal, zest, and enthusiasm for work. Apart from the effects
burnout has on individual physicians, there is evidence that
relationships with patients and family also suffer. Although
increased burnout has been found to be notably worse in
primary care and emergency room physicians, it has also wors-
ened in 18 of the 20 categories of specialist physicians
sampled. When compared with the absence of worsening in
the general US working population, and noting the spec-
trum of advancing earnings among the general US workforce
compared with doctors in primary care, or higher earning
Emergency Medicine doctors, or still higher earning
subspecialists, we can conclude that higher physician earn-
ings are neither a cure nor a cause of burnout. Something else
is happening to our beloved profession.
LACK OF ACCOMPLISHMENT
The doctor–patient relationship has sustained the happiness
of both doctors and patients for generations. This centuries-
old relationship has only recently been threatened by a de facto
insurer–employer–provider relationship. Medical boards and
malpractice courts may cite the law of doctor–patient primacy,
but urgent care centers, on-call hospitalists, on-call sur-
geons, and even on-call obstetric laborists have made continuity
of care a romantic notion of a noble profession. More than
90% of graduating residents now choose to be employees
rather than enter the old world of private practice. The new
world penalizes patients who go outside of existing employer–
insurer–provider contracts to see a noncontracted physician;
and it makes no sense to blame new doctors for becoming
group employees. They might otherwise wait up to 6 months
to be accepted as new participating “providers” in Medi-
care or other insurance programs. Few recent residency

graduates can afford food, rent, and the interest payments on
a quarter million dollars of medical school loans while they
wait for the contractual right to start a new practice. It is un-
derstandable that new physicians would feel an immediate
“lack of accomplishment” were they to attempt to enter private
practice as did their predecessors. It seems reasonable there-
fore that almost all new graduates would enter an existing
practice or a hospital-owned healthcare system. Avoiding rural
or independent practice is a rational means of dodging the
first symptom of burnout: lack of accomplishment.
CYNICISM (DEPERSONALIZATION)
The second of the symptoms, cynicism (depersonalization),
is more difficult to avoid. Although practicing doctors have
and still find solace in the comfort of their doctor–patient re-
lationships, the preservation of these person-to-person
relationships can be beyond the control of the physician. Con-
tinuity of care historically provided the necessary bonds that
Funding: None.
Conflicts of Interest: None.
Authorship: Both authors had a role in writing the manuscript.
Requests for reprints should be addressed to Andrew George
Alexan-
der, MD, University of California, Riverside School of
Medicine, Clinical
Medical Education, 900 University Avenue, School of Medicine
Education
Building, Riverside, CA 92521.
E-mail address: [email protected]
COMMENTARY
0002-9343/$ - see front matter © 2018 Elsevier Inc. All rights
reserved.

https://doi.org/10.1016/j.amjmed.2018.02.033
http://crossmark.crossref.org/dialog/?doi=10.1016/j.amjmed.201
8.02.033&domain=pdf
regenerated the early career feelings of scientifically based
benevolence that attracted most doctors into the healing arts.
Physician burnout measures highest in Emergency Medi-
cine, Family Medicine, Internal Medicine, and Pediatrics. We
expect this in Emergency Medicine, which by definition lacks
continuity of care. Primary care specialties, however, have
only recently become arenas of episodic care. Patients now
routinely change doctors, employers change insurers, and in-
surers change physician panels during yearly health insurance
renegotiations with employers. Community health centers offer
appointments of their clients (patients) to the “first avail-
able” provider. Continuity of care is no longer an expectation
by the health plan member (patient). Perhaps physician hap-
piness requires reframing of the future role of the physician
along with expectation management. Mindfulness therapy also
helps, but it is not magic.
LACK OF ENTHUSIASM
The last symptom of burnout is the lack of enthusiasm for
work. Doctors love their profession, even as they lament what
has happened to it. Every pre-med student jumps at the in-
vitation to enroll in medical school. Every third-year clerkship
student starts out each rotation with enviable enthusiasm. Even
the long hours of residency do not keep interns and resi-
dents from donning their stethoscopes with pride. What events
could extinguish the enthusiasm of helping others through sci-
entific problem solving? Something has changed, and it has
worsened over the past few years.

THE CHANGING FACE OF MEDICINE
There were at least 5 major transformational medical prac-
tice events that occurred between 2011 and 2014. These include
pervasive hospital purchases of medical groups, rising drug
prices, the Affordable Care Act, pay for performance, and man-
dated electronic health records (EHRs). We hypothesize that
1 or a number of the above 5 events deserve to be investi-
gated as being contributing to the problem of physician
burnout.
Because doctors voluntarily sell their practices to hospi-
tals or large groups to escape chaos, we doubt the move from
physician practice ownership to hospital or corporate own-
ership is a major factor in increasing physician burnout.
Likewise, rising drug prices—although deleterious to those
without insurance, businesses, individuals, and government
agencies who must buy costly medications—do not keep
doctors from using cheaper generic drugs. We believe we can
forego escalating drug prices as a factor. The Affordable Care
Act (Obamacare), although politically problematic, has in fact
brought more people with a means of paying for their care
to the doctor than ever. This is unlikely to be a factor. Pay
for performance, the incentive/disincentive program cur-
rently being phased in by Medicare, has yet to deliver any
significant payment boost or change any performance, and
it cannot convince significant numbers of practicing physi-
cians that it ever will. It is not a probable suspect. This leaves
us to consider the EHR.
A recent study from the University of California, San Fran-
cisco on their use of EHRs showed that medical students, house
staff, and faculty cloned approximately 80% of their pa-
tients’ daily progress notes.3 Concurrent studies show that
doctors spend more face time on their EHRs than with their
patients.4 The hours spent cloning notes in a mandated doctor–

computer relationship leaves the physician unable to experience
the best part of being a doctor. No humanistic physician gets
up with zeal in the morning, hopeful for a chance to have a
meaningful relationship with Epic or MEDITECH. Ratio-
nal people should feel cynical if the institutional
accomplishment for the day is to produce 20 cloned medical
records with enough federally mandated bullet-point entries
to obtain fair reimbursement and survive a billing audit. Thus,
in 1 paragraph about EHRs, we have defined lack of enthu-
siasm, lack of accomplishment, and cynicism: not one but all
3 of the attributes of physician burnout.
Burnout is not voluntary, and a fertile environment for its
attributes has been placed before us. There are always non-
medical causes of interpersonal and professional strife, so it
behooves us to guard our families, loved ones, pets, and
hobbies against this menace. Meanwhile we must keep a sharp
eye on novel medical entities, like EHRs, so we can avoid
the potential effects that might distance us from our pa-
tients. Epic notes written by US doctors are vastly longer than
Epic notes from Europe. Type less and spend less time staring
at a screen. Prepare your notes in the presence of your pa-
tients. Leave the examination room without a monkey on your
back. Use a scribe (if you have the money). Make your notes
meaningful, and never make your EHR more important than
your patient. Demand more productive voice recognition–
linked diagnostic EHRs in the future. Lobby to rid medicine
of bullet-point-based reimbursement. For the sake of our pro-
fession, get out of the current EHR rut, and enjoy the balance
of the rest of your life as a doctor.
Andrew George Alexander, MD
Kenneth Alan Ballou, MD
Clinical Medical Education
University of California, Riverside School of Medicine

References
1. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction
with work-
life balance among US physicians relative to the general US
population.
Arch Intern Med. 2012;172(18):1377-1385.
2. Maslach C, Jackson SE. The measurement of experienced
burnout. J Organ
Behav. 1981;2:99-113.
3. Wang MD, Khanna R, Najafi N. Characterizing the source of
text in elec-
tronic health record progress notes. JAMA Intern Med.
2017;177(8):1212-
1213.
4. Arndt BG, Beasley JW, Watkinson MD, et al. Tethered to the
EHR: primary
care physician workload assessment using EHR event log data
and time-
motion observations. Ann Fam Med. 2017;15(5):402-404.
858 The American Journal of Medicine, Vol 131, No 8, August
2018
http://refhub.elsevier.com/S0002-9343(18)30286-9/sr0010

Work-Life-Balance--Is-it-Possible-to-Achi_2017_The-Journal-
of-Emergency-Medi.pdf
The Journal of Emergency Medicine, Vol. 53, No. 6, pp. 924–
925, 2017
� 2017 Elsevier Inc. All rights reserved.
0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2017.08.031
Reprints are no
RECEIVED: 11 Ju
ACCEPTED: 11 A
Humanities
and Medicine
WORK–LIFE BALANCE: IS IT POSSIBLE TO ACHIEVE?
Benjamin Honigman, MD
Department of Emergency Medicine, University of Colorado
School of Medicine, Aurora, Colorado
Corresponding Address: Benjamin Honigman, MD, Department
of Emergency Medicine, University of Colorado School of
Medicine,
Mail Stop C-301, 12631 E 17th Ave, Aurora, CO 80045
I love my profession; I have been an academic emergency
physician for 40 years. One of the best parts of my work
life is my interactions with physicians in training. It is
rewarding because these young doctors are smart, ener-

getic, and curious. One thing that I have noticed more
with this generation is that they are concerned with
work–life balance. And as a concept, who isn’t? But as
I have thought about what this means, I have reservations.
It seems to me that what is meant by work–life balance
is that a separation exists between the demands of one’s
career and the other aspects of their life that bring them
joy. To me, that is a false dichotomy. I do not believe
that such a balance is possible. Do not misunderstand
my position; for the past 6 decades I have been a husband,
a father, and a devoted friend. I love to travel; I love a
great meal with friends; I work out and enjoy the outdoors
but I have never assumed that separating these activities
from being a physician is the only way to have a fulfilling
career. Has the concern about finding balance lessened
the value of commitment to our profession?
A colleague of mine recently used the term ‘‘impecca-
ble commitment’’ to describe the continuum between
professional and personal life. This concept has more ap-
peal to me. Success at each requires sliding back and forth
between the two poles.
This point was crystalized for me recently as I was
meeting with a group of community internists, who were
critical of today’s resident graduates—‘‘millenials’’—
t available from the authors.
ly 2017;
ugust 2017
924
who want to work limited hours, get out on time, and yet
earn high salaries and have terrific benefits. They also
wished that I as a medical school and resident educator

would teach students and residents the value of patient
care and hard work. I was troubled by this conversation
because of the perception that young physicians are not
hard-working and do not love medicine and patient care.
It is true that many parts of our medical school educa-
tion promote the idea of work–life balance. In our medi-
cal school, we have a course entitled ‘‘hidden
curriculum,’’ which is a small group session where stu-
dents have the chance to reflect on their education, their
teachers, their patients, and their lives. We ask about
this balance, and I must say that I have on many occasions
endorsed the need for students to take time away from
medicine and enjoy their families—go to the gym, go
for a hike, etc. Had I not endorsed the wonders of patient
care and service to people enough? Had I reinforced the
idea that these students’ lives would only be rewarding
if they got ‘‘away’’ from medicine? Where was the dis-
cussion that being a physician required an obligation to
our patients, their families, and to our profession? Upon
graduation, new interns are immediately told they cannot
work more than a specific number of hours per day or
days per week or they will be in violation of duty hours.
Were these community internists right? Are we as educa-
tors creating a platform that supports this separation of
physicianship and ‘‘the rest of your life’’? I think so!
Millennials are often profiled as striving to achieve a
work–life balance. Perhaps this is a reaction to the
Delta:1_given name
http://crossmark.crossref.org/dialog/?doi=10.1016/j.jemermed.2
017.08.031&domain=pdf
http://dx.doi.org/10.1016/j.jemermed.2017.08.031

Work–Life Balance 925
examples of parents and grandparents who emphasized
work and careers above all else. In my own family, my fa-
ther worked 14 hours a day as an owner of a small grocery
store to make enough money to support his family and
send me and my 2 siblings to college. There are hundreds
of other examples of overworked individuals who have no
time for family or self. But medicine is a profession that
perhaps requires more of that than other professions—
not out of necessity, but because of professionalism and
dedication to healing and caring. It is a profession that
often requires a commitment beyond a set time schedule.
It requires a commitment to a career. The ability to gain an
intimate view into people’s lives, emotions, and fears is
certainly a privilege. The wonder of exploring someone’s
problems and examining them to develop a diagnosis as
well as attempting to improve their lives is inspiring on
so many levels. How can one remove oneself at a predeter-
mined time, drop everything, and go do something else?
Work does not happen that way, and neither does life.
In emergency medicine, we do not have the same is-
sues of never-ending office hours or being on call as
our practicing colleagues. We have set hours and
shifts—yet we too are faced with times when our commit-
ment to our profession holds sway: instances where we
need to stay later than our schedules to care for patients
and their families. We also have commitments to our
medical community, organizations, medical committees,
institutions, and many others.
I wondered whether our emergency medicine resident
applicants spoke to this work–life balance issue in their
personal statements—so I reviewed several of the essays
of our recent resident graduates and found such wonder-
ful statements as:

� Medicine encompasses many of my life’s greatest
ambitions and core values.
� I have the unwavering drive to be an excellent physi-
cian and a profound dedication to my future patients
and colleagues; remembering always that although
health care may be a right providing it is a privilege.
� I have an unfulfilled need and desire to do more.
� From an early age, the values of hard work, respon-
sibility, and diligence were instilled in me.
� I believe in emergency medicine because there is no
other field in which the nature of the work is as
exhilarating and the responsibility of the work is
as demanding, fulfilling, and necessary.
� I intend to serve all and constantly seek better out-
comes through learning and experience.
Thesewere not written by individuals who did not want
to work hard. The words and thoughts emphasized the
value and love of medicine as a career and a profession.
They did not emphasize a work–life balance. Perhaps
they had not yet confronted the important challenge and
tension that exists early in one’s career. Establishing a
successful medical career requires significant time and
effort, as does committing to and caring for a young fam-
ily. Unfortunately, these often occur simultaneously.
I recall in my life many instances where I chose to be
with my patients and their families or chose to attend an
important meeting to try to improve our health care sys-
tem—sometimes at the expense of family or personal

time. I reflect on these choices and realize that I did not
make them to avoid my family but because I love my pro-
fession and the privileges that go along with being a doc-
tor. We can work toward a ‘‘best practice’’ of impeccable
commitment, which means different things at different
times. There will be times when as physicians we need
to have an impeccable commitment to our patients and
their families. This decision will be good for patient
care; good for one’s own education and fulfillment; and
important as an advocate for your profession. There
will be other times when that impeccable commitment
is to our own families or our own personal health and ac-
tivities—never losing sight of the other.
A recent article by Arthur Brooks in the New York
Times referenced the Buddha saying on his death bed
that one should ‘‘work consciously’’ and that our labor
should be an agreeable path to spiritual enlightenment
(1). The same article referenced the Talmud: ‘‘for a
man not to teach his son a trade or profession is equivalent
to teaching him to steal’’ (1).
Although these 2 writings promote work, perhaps an
equally important theme is how we also need to look
for opportunities to blend the two. Taking your child to
work, having discussions about your work day over din-
ner, exploring the good along with the difficult, and using
medical stories to teach life lessons. I recall one such
instance when I had for the second time failed to achieve
departmental status for emergency medicine at our med-
ical school. My wife, who saw how upset and disap-
pointed I was, thought that it would be a valuable
lesson for our children—to hear of this failure. I dis-
agreed, but finally relented and the ensuing discussion
was enlightening for several reasons. My children saw
what it was like to fail and then how an adult deals with

that constructively—and ultimately how that failure can
be a life lesson. It also elevated them into roles of impor-
tant family members. For me, it provided an opportunity
to blend that impeccable commitment to both career and
family and not to enforce an arbitrary separation.
So as we welcome new graduates into our medical
community, my charge is to continually look for ways
to create that impeccable commitment, or the blending
of both a wonderful profession and a healthy personal life.
REFERENCE
1. Brooks AC. The father’s example. New York Times
2014;A25.
http://refhub.elsevier.com/S0736-4679(17)30737-0/sref1Work-
Life Balance: Is it Possible to Achieve?Reference
A-Burnout-Reduction-and-Wellness-Strategy--Personal-
Financ_2019_Practical-Ra.pdf
Practical Radiation Oncology (2019) 9, 231-238
Critical Review
A Burnout Reduction and Wellness Strategy:
Personal Financial Health for the Medical Trainee
and Early Career Radiation Oncologist
Trevor J. Royce MD, MS, MPH a,*, Kathleen T. Davenport MD
b,
James M. Dahle MD, FACEP c,d
aDepartment of Radiation Oncology, University of North
Carolina at Chapel Hill School of Medicine, Chapel Hill, North
Carolina; bDepartment of Emergency Medicine, University of

North Carolina at Chapel Hill, School of Medicine, Chapel
Hill, North Carolina; cUtah Emergency Specialists, Salt Lake
City, Utah; and dThe White Coat Investor, LLC, Salt Lake
City, Utah
Received 14 January 2019; revised 16 February 2019; accepted
22 February 2019
Abstract
Purpose: Physician burnout is reported in more than one out of
every 2 practicing clinicians and is
just as prevalent in training physicians. Burnout severity is also
associated with increasing levels of
financial debt. Medical professionals are notable for their high
and increasing levels of debt; despite
this, financial literacy is poor among physicians, and financial
education is largely absent from
medical education. Radiation oncologists (ROs) are no different
in this regard, with 33% of res-
idents reporting high levels of burnout symptoms, 33% carrying
>$200,000 of educational debt,
and 75% reporting being unprepared to handle future financial
decisions. To fill this gap, we
reviewed the basic tenets of personal financial health for the
early career RO.
Methods and materials: The core concept of financial
independence (FI) is introduced, and we
review 4 basic tenets of personal financial health for the young
medical professional: debt,
behavior, investment, and asset protection strategies.
Results: FI is achieved by saving until the desired quality of life
can be maintained, independent of
employment income. Debt strategy involves minimizing debt
accrual, understanding student loans,
and having a debt management plan. Behavioral strategy
involves setting financial goals, calcu-
lating worth and a savings rate, budgeting, and frugal living.

The basics of investing include
asset allocation, diversification, rebalancing, and minimizing
expenses. Finally, asset protection
includes insuring against catastrophic events with disability,
life, health, liability, and property
insurance.
Conclusions: Healthy financial practices can lead to FI and may
facilitate professional and personal
freedoms with the goal of mitigating burnout-associated
stressors. The tenets of strong financial
health for ROs in the early stages of their career include sound
debt, behavioral, investment, and
asset protection strategies. Furthermore, initial and continuing
financial education is an overlooked
Sources of support: This work had no specific funding.
Disclosures: Dr Dahle is the founder and editor of The White
Coat Investor, LLC.
* Corresponding author. Department of Radiation Oncology,
University of North Carolina at Chapel Hill, 101 Manning
Drive, CB 7512, Chapel Hill,
NC 27599.
E-mail address: [email protected] (T.J. Royce).
1879-8500/� 2019 The Author(s). Published by Elsevier Inc. on
behalf of American Society for Radiation Oncology. This is an
open access article under
the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
http://crossmark.crossref.org/dialog/?doi=10.1016/j.prro.2019.0
2.015&domain=pdf

2019
but important curriculum component. ROs with their financial
houses in order can devote more
resources to learning and practicing good medicine while living
healthy, rewarding lives.
� 2019 The Author(s). Published by Elsevier Inc. on behalf of
American Society for Radiation
Oncology. This is an open access article under the CC BY-NC-
ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
Figure 1 Potential medical graduate educational debt load by
postgraduate year during graduate medical education under a
government-sponsored, income-based repayment plan. The
average starting educational debt load of the graduating medical
student was $200,000 in 2018 (blue line), and 12% of graduates
owe >$300,000 (red line).16 This model assumes that the
graduate is making the minimal payments on unsubsidized
Introduction
Symptoms of burnout (depersonalization, a diminished
sense of personal accomplishment, and emotional
exhaustion) have been reported in >1 of every 2 prac-
ticing physicians.1 This affliction, driven by work-related
stressors, is just as prevalent in training physicians2 and
has become a focus of the American Medical Associa-
tion.3 Burnout has been associated with substance abuse,
suicidal ideation, and career dissatisfaction,4-6 and the
rates of burnout are thought to be twice as high in med-
icine compared with other professional fields.7 Radiation
oncologists (ROs) are no different in this regard, with
33% of residents reporting high levels of burnout symp-

toms.8 Indeed, a full session at the 2018 American Society
for Radiation Oncology Annual Meeting was devoted to
burnout in the specialty, with a focus on resident and
junior ROs.
Burnout severity is also associated with increasing
levels of financial debt.9-13 Medical and dental pro-
fessionals are notable for their high and increasing levels of
debt, which is the highest among graduate-degree pro-
fessions.14 The median debt of medical school graduates
with loans has nearly tripled from $71,000 (in 2018 dollars)
in 1986 to $200,000 in 2018.15,16 Furthermore, 12% of
graduates now owe >$300,000 in educational debt.16 This
burden can grow substantially during residency and, at
current interest rates, may be 20% to 50% higher by
completion of training (Fig 1). Despite this, financial lit-
eracy is poor among physicians, and financial education is
largely absent from medical education.17 Again, ROs are no
different in this regard, with 33% of RO residents carrying
>$200,000 of educational debt (12% of residents report
>$300,000)8,18 and 75% reporting being unprepared to
handle future financial decisions.19
To fill this gap and in the context of the multifactorial
burnout crisis, we review the basic tenets of personal
financial health for ROs in the early stages of their career
(Table 1) and introduce the concept of financial inde-
pendence (FI), all with the goal of promoting strong
financial stewardship as a wellness strategy.
loans while enrolled in the Pay-As-You-Earn repayment plan,34
with an average loan interest rate of 6.6% in 2018,27 earning
an average resident salary of $59,300 in 2018,54 with a
family size of 1, and lives in the continental United States, with
U.S. Department of Health and Human Services poverty
guidelines.55 (A color version of this figure is available at

https://
doi.org/10.1016/j.prro.2019.02.015.)
Financial Independence
FI is the accumulation of sufficient wealth to permit
life without dependency on employment income while
maintaining the desired quality of life.20,21 This state is
essentially the personal finance endgame and is what
the retiree, who no longer works but has saved enough
to live comfortably after employment, classically strives
for. But FI need not be limited to the retiree, and the
state permits professional, personal, and financial free-
doms. With healthy financial behavior, FI is readily
attainable for U.S. physicians after 15 to 20 years, or
less, in practice. FI can alleviate work-related personal
financial stressors, allowing the physician to practice
medicine unhindered by the constraints of dependency
on income. For some physicians, the path to FI may
permit the restructuring of work hours and schedules
and provide more room for personal wellness or pro-
fessionally rewarding but less income producing activ-
ities, such as charitable work. For others, FI can be a
hedge against an uncertain future (eg, in specialty labor
markets such as in RO22,23 or times of changing
reimbursement patterns and health care reform24).
Furthermore, if individual practice patterns are driven,
consciously or unconsciously, by the personal income
benefits enabled by the relative-value-unit fee-for-
Table 1 Summary of tenets of financial health for medical

trainees and early career radiation oncologist with select
relevant and
practical resources
Tenet Details Resources
Debt strategy Debt management plan Fawcett et al, 201636
Minimize debt accrual Steiner et al, 201335
Grischkan et al, 201833
Behavior strategy Set financial goals Tyson et al, 201039
Calculate net worth Bach et al, 201640
Set a savings rate Stanley et al, 201037
Budget Zweig et al, 200841
Live like a resident (minimize spending) Clements et al, 201643
Stay the course (stick to the plan) Belsky et al, 201044
Investment strategy Pay down high-interest debt Bernstein et al,
201442
Asset allocation Larimore et al, 200749
Portfolio diversification Larimore et al, 201846
Rebalance portfolio Bernstein et al, 201047
Minimize expenses Piper et al, 201451
Minimize taxes

Asset protection strategy Insure against catastrophic events
Tyson et al, 201039
Disability Dahle, 201429
Death
Illness
Injury
Liability
Expensive property
Emergency fund
Estate planning
Personal well-being
Education Initial and continuing financial education Dahle,
201429
service reimbursement model, FI could mitigate these
influences.25
FI (moving work from a necessity to a choice) can be
obtained through many routes but is classically and most
reliably done via the steadfast accumulation of wealth
such that an individual’s assets, when invested appropri-
ately, generate enough income passively to at least equal
expenses. This wealth is achieved by increasing savings
(ie, assets) relative to lifestyle costs and debts (ie, ex-
penses). Healthy personal financial practices are necessary
for FI.
Tenets of Financial Health for Medical
Trainees and Early Career Radiation
Oncologists

Debt strategy
The cost of medical education has been increasing at
twice the rate of inflation.26 For those who borrow money
to pay for this increasingly expensive education, the in-
terest rate for unsecured federal Stafford graduate student
loans from 2006 to 2018 averaged 6.38%,27 >2 points
above the average 15-year fixed-rate mortgage of
4.05%.28 Moreover, since 2012, these loans are
unsubsidized, and the federal government will no longer
cover the interest while the borrower attends school.29
Other sources of debt to consider are undergraduate ed-
ucation loans, credit card debt, mortgages, and car loans.
Finally, in the setting of an expensive U.S. health care
system,30 there is downward pressure on physician pay,
with physicians earning relatively less than ever before.31
The combination of the increasing cost of education,
relatively high interest rates on educational loans, less
favorable loan terms, and changing health care economics
make a sound debt strategy essential for physicians in the
early stages of their career.
Not to be overlooked, an important component of debt
strategy is to minimize high-interest debt accrual during
training. Techniques to curtail educational costs include
prudent school selection and using preowned or shared
books, supplies, and equipment. Frugal living choices and
cost sharing can help reduce the total debt burden.
Income during training can also reduce indebtedness.
Medical students may be able to work in a limited manner
during school, and a spouse or partner may also be able to
provide financial support. Many universities allow for

substantial tuition reductions for family members of em-
ployees. Other notable approaches include scholarships
and grants; combination degree programs (eg, MD/PhD);
the National Health Services Corps or the U.S. Armed
Table 2 Summary of available federal student loan repayment
plans under the William D. Ford Federal Direct Loan Program
Repayment plan Eligible loans Monthly payment and loan
features
Standard � Direct loans (subsidized and
unsubsidized)
and unsubsidized)
� PLUS loans
� Fixed payments made within 10 years*
Graduated � Direct loans (subsidized and
unsubsidized)
and unsubsidized)
� PLUS loans
� Fixed payments increase every 2 years and loans are paid off
within
10 years*

Extended � Direct loans (subsidized and
unsubsidized)
and unsubsidized)
� PLUS loans
� Fixed or graduated payments made within 25 years
Revised Pay-As-
You-Earn
� Direct loans (subsidized and
unsubsidized)
� PLUS loansy
� Married couples’ total income and loan debt considered
� Outstanding balance is forgiven after 20 years (undergraduate
study) or
25 years (graduate or professional study)
Pay As You Earn � Direct loans (subsidized and
unsubsidized)
� PLUS loansy

filing jointly
� Outstanding balance is forgiven after 20 years
� Eligibility limitations based on dates of loan and
disbursement and debt-
to-income ratio
Income-based � Direct loans (subsidized and
unsubsidized)
and unsubsidized)
� PLUS loansy
� Payments calculated from 10%-15% of discretionary income
filing jointly
� Outstanding balance is forgiven after 20-25 years
� Eligibility limitations based debt-to-income ratio
Abbreviation: PLUS Z Parent Loan for Undergraduate Student.
The highlighted income-driven repayment plans (shaded) are
those best suited for the Public Service Loan Forgiveness
program.2
Income-contingent and income-sensitive repayment plans also
exist, but these are rarely used by medical trainees.
* 10-30 years for consolidation loans.
y Direct loans made to students.

2019
Forces with their Health Professions Scholarship Pro-
gram; the Uniformed Services University of the Health
Sciences (Bethesda, MD); or financial assistance
programs.32
However, for many with heavy student debt loads at
the end of training, 2 primary strategies exist: consoli-
dating loans and pursuing forgiveness, or refinancing and
eliminating the high-interest debt as soon as possible.
There are several service-based loan repayment or
forgiveness programs. For example, for those working in
underserved areas or conducting research there are the
National Health Services Corps and the National In-
stitutes of Health Loan Repayment Program, respectively.
For those pursuing work in academics and nonprofits (ie,
organizations with a 501(c)3 tax designation), the most
widely adapted forgiveness path is the U.S. government’s
2007 Public Service Loan Forgiveness (PSLF) program,
in which more than one third of graduates with debt are
participate despite increasing scrutiny of the program.33
Under the PSLF program, borrowers who are enrolled
in qualifying repayment plans and employed directly by a
501(c)3 or government organization may be eligible to
have all educational debt (principal and interest) spon-
sored by the federal government forgiven, tax-free and
without a cap, after 10 years of payments (120 qualifying,
monthly, on-time payments). There are several qualifying
repayment plans (Table 2), which are largely income-
driven repayment plans (ie, the monthly payment owed

is dependent on income, such as the Pay As Your Earn,
Revised Pay As You Earn Repayment Plan, and Income-
Based Repayment plans).34 Because most residents and
fellows are employed by 501(c)3 organizations, the years
of training can count toward the 10 years of service
needed for forgiveness. This is particularly appealing with
the income-driven repayment plans and results in a lower
monthly payment while the borrower earns a lower salary
as a trainee.
For academics and others who plan to be directly
employed by a 501(c)3 nonprofit or government organi-
zation after training, this program can be an appealing
approach. Of note, placing student loans into deferment or
forbearance during training can be a costly mistake
because the borrower would not be accumulating pay-
ments toward the PSLF. The PSLF exists at the whims of
Congress33; therefore, financially savvy borrowers hedge
against possible changes in the program and their career
path by saving an amount equivalent to their loans on the
side in an investing account. These funds can be applied
against the debt in the event of career or program changes.
Another recommended strategy for those with high-
interest debt is to eliminate the debt as quickly as possible
by refinancing with a private lender, living frugally, and
directing every available dollar to the debt. Since 2013,
private lenders have been refinancing medical student
loans at lower interest rates than those offered by the
federal government. Being free of student loan debt in 2
to 5 years after residency is an attainable goal for most29
but requires the behavioral discipline described in the next
section. As illustrated by the numerous repayment plans
outlined, student loans are complex, and the optimal debt
strategy for any individual depends in part on personal

goals and preferences. Fortunately, there are many
excellent resources available to help with this
process.35,36
Behavioral strategy
A goal-oriented approach to personal financial health
keeps the individual on track to success. A common unit
in financial goals is net worth, which is essentially net
assets minus net liabilities (ie, debts). The surest path to
increasing net worth is a high savings rate, or the pro-
portion of income not spent and placed into savings (eg,
investments). In other words, this is achieved by living
well below your means. Wealth is what you accumulate
and can be achieved by increasing net worth through
savings; it should not be confused with income.37
This behavioral strategy, that of a “prodigious accu-
mulator of wealth,”37 is particularly important for physi-
cians, with their delayed entry into the workforce as a
result of prolonged education and training and high debt
burden. Physicians are typically in their early thirties by
the time they complete training. Although there are social
and societal pressures for physicians to increase con-
sumption (eg, buy a house) upon completion of training
with the accompanying increase in income, our preferred
approach is to delay gratification and live like a resident
for several years after training. This approach requires
physicians to maintain a resident’s standard of living as an
attending physician, despite the higher income.
The difference between attending-level income and
trainee-level standard of living can permit the rapid
accumulation of wealth by paying down debt, increasing
the savings rate, and getting one’s financial house in
order. Converting income into wealth involves
consciously avoiding the hedonic treadmill38 and growing

8 Compromise is often key in landing that first c o u n s e i .docx

8 Compromise is often key in landing that first c o u n s e i .docx

Recommended

Recommended

More Related Content

Similar to 8 Compromise is often key in landing that first c o u n s e i .docx

Similar to 8 Compromise is often key in landing that first c o u n s e i .docx (17)

More from blondellchancy

More from blondellchancy (20)

Recently uploaded

Recently uploaded (20)

8 Compromise is often key in landing that first c o u n s e i .docx