In my last post, I wrote about the college student loan issue from the perspective of the physician family.  Related to that point, I also elaborated upon my philosophy about saving for and paying college expenses with minimal debt expansion.

However, the phenomenal accumulation of debt by medical students and residents is another student loan crisis.  Unlike the college student loan crisis, medical student loans receive little attention.

I routinely interview physician candidates for my local hospital, and I have been shocked over the years by the enormous amounts of loan debt that they carry with them into practice.  $100,000 of debt used to shock me, but no more.

I frequently interview those who are $200,000 in debt.  Even worse, I know physician couples who owe a whopping debt of over half a million dollars combined!

Now, from the lay person point of view, they will say, “These doctors are going to be making lots of money, and they should be able to pay this back.”  As I see it manifested in real life, it is the unintended consequences of this debt burden that is affecting these individuals, medical care, and society in general.

Let’s take the (sadly) low end of the debt spectrum of $200,000.  Assuming a low interest rate of 5% and a term of 30 years, that is $1074/month.

So right out of the starting gate, this budding physician is paying a mortgage payment without getting the property to go with it.  The psychological burden that goes with the debt burden does not go unnoticed by the new doctors.

They are aware that they will be making more money than during residency.  Unfortunately, they will also now have to pay all this money back.

The psychological consequences include the life and professional decisions made to mitigate the debt load.   I have seen many doctors and their partners delay starting families “until we afford it.”  One young doctor in my practice delayed buying a house for his family because, again, he did not think he could afford one with his and his wife’s combined debt.

I see the professional decision-making process affected all the time.  I have seen some very dedicated and sincere family practice residents change career choice from a primary care office to a hospitalist or emergency room position because of pay levels as well as hours.

At my local hospital’s family practice residency program this year, only one of nine graduating residents will be pursuing the intended career target of the teaching program: primary care family practice in a rural setting.  The vast majority are pursuing ER, hospitalist and even specialty fellowships to improve their pay prospects.

To a person, these individuals say that if pay was at least equivalent, they would choose their original calling of family practice.  They feel forced in a sense by their economics to make this choice.

We all know that this pivotal career choice will be self-perpetuating and probably permanent.  They are unlikely to backtrack later and take a lower-paying position in primary care to assuage any remaining guilt about their choice.

In the past , I have participated on several panels and statewide advisory groups that met to discuss medical care in the state of Maine.  In one group of about fifteen, I was the only general internist, although there was one pediatrician and one family practice doctor joining me to represent primary care.

A frequent topic on these panels was the difficulty in recruiting primary care doctors, which everyone agreed should be the backbone and foundation of any healthcare system.  The disagreement usually came down to money.  Doesn’t it always?

When I forcefully suggested that the primary care crisis could be solved within 5 years if primary care doctors were paid like cardiologists, my fellow panelists reacted as if I was a bomb-throwing revolutionary.  Shock and horror and nervous laughter usually followed my comments.

“Surely, you jest, cardiologists receive so much more training, do more risky procedures, etc.”, they would say.  I would usually tell them that I did not mean to denigrate cardiologists or to imply that they did not have extended training.

To me, it was basic math and an economic question:  If you want more primary care doctors, and they are truly recognized as a vital part of the health care system (including feeders for the cardiologists), they should be paid significantly more to entice them in their career choice.  That is part of how we ended up with so many specialists, isn’t it?

Pay doesn’t have to be the only mechanism.  Loan forgiveness works too.  That is how I paid my loan/scholarship from the U.S. Public Health Service: by practicing for 3 years in a medically-underserved area.

However you slice it, dollars and debt both drive behavior for everyone, including doctors.  Depending on altruism will only get you so far.

That is about where we are right now.  For all involved, that is not a good place.

Back in the days when I was attending college and medical school, the days of disco and bad hair known as the 1970s, student loans were only a part of what was known as a financial aid package.  I was able to pay for those educational expenses through a combination of scholarship (remember those?), low interest loans and work-study jobs.

The remainder of the expenses not covered in this package could be covered by a reasonably paid summer job.  Those were the days, as they say.

After seeing his son’s college bill, one of my colleagues commented to me that the only way someone could pay their way through currently is if they deal drugs, run a porn website, or both.  Additionally, unless your child is a Division 1 recruitable athlete in a major sport, your kid is not getting a free ride anywhere.

If you, as a medical parent, want help with college finances, you and/or your child will need to borrow heavily to get through undergraduate years and beyond.  It is a really unfortunate fact about higher education these days, but its truth cannot be denied.

This shift in higher education finance is the reason why I have advocated to all my colleagues (who will listen) that they need to save heavily during their child’s early years to pay for the ever-increasing burden of college expenses.  This is just counting college expenses, and does not include graduate school payments, although the same rules apply.

What you cannot save during the early years, you should suck it up and pay out of pocket while they are in college.  Your children, and your future debt burdens, will eventually thank you for this move.

One of the notable stories in my family involves that day when my oldest son received news that he was admitted early decision to his first choice Ivy League (and therefore not cheap) college.  After we all danced around the kitchen and hugged with joy, I walked my wife over to the kitchen window, pointed to the cars in the driveway and said, ” Do you see those cars in the driveway?”

“Yes,” she replied, looking at me quizzically.

“Good,” I said, “because those are going to be the same cars that will be there 7 years from now when our youngest graduates from college.”  And that was the truth.

Was it painful to tighten the belt for that period of time? Of course.  But after my two sons graduated, there were no further loan money to pay back, and it felt like an enormous raise in pay.

I have read with increasing concerns about the total U.S. student loan debt of over $1.1 trillion. That is more than all of the outstanding auto loans or credit card balances of the whole country.

When I was discussing student loan debt with another colleague, he dismissed my concerns by saying, “Well, the interest is tax deductible”.  Not so fast, Dr. Einstein!

First of all, the maximum student loan interest deduction is $2500.  Secondly, and probably more importantly to physician family borrowers, in order to get the maximum tax deduction, adjusted gross income must be no more than $130,000 on a joint return, and the deduction goes away in a graduated fashion up to $160,000.

So, in other words, most physician households will not be able to deduct student debt unless they do something really stupid like take out a home equity loan.  As the old car maintenance commercial used to say, “You either pay me now, or you pay me later.”

Unfortunately, when you pay later, you are paying with interest.  Plus, this interest is most likely not tax-deductible, a fact that will eventually affect your future financial obligations like paying off your mortgage(s) and paying for your retirement.

Remember in particular this stark fact of life: No matter how much you sacrifice for your kids in their younger years through college, they will not and cannot fund your retirement.  If you don’t believe me, just wait a few years.

If you do believe me, then that’s a good start.  It’s always best to save money now so you’ll be able to pay later.  You will thank me for it later.

A recent study about doctors was published and made a big splash in the medical field and later the general media. This study, from the Mayo Clinic Department of Internal Medicine, was published in the December 2015 issue of Mayo Clinic Proceedings.  A national survey was performed 2014 across multiple specialties and practice settings and was then compared to a similar survey in 2011.

To summarize, professional burnout among American physicians had increased 10% over the 3 years of the study, reaching 55% levels.  Even though the number of hours worked by US doctors had not increased over that period, burnout and dissatisfaction with their work-life balance had increased significantly.

Compare these findings to the general population.  Working adults in all other career fields besides medicine showed only minimal changes in burnout symptoms and work-life dissatisfaction over that 3-year period, holding steady at about 28%.

Specifically, from questions within the survey, doctors showed high scores for emotional exhaustion and depersonalization.  Personal accomplishment alone, on the other hand, earned low scores.

60% of doctors felt that they did not have sufficient time for personal and family life.  There was no change in the rates of suicidal ideation, but the number still stood at a relatively alarming 6.4%.

Not surprising, burnout rates in primary care and family medicine were among the highest of all specialties at 63%.  When asked about the causes of their burnout, doctors cited practice inefficiencies, amount of administrative burden, and bureaucratic inflexibility. Unfortunately, most health care organizations from the smallest group to the largest hospital systems depend on physician resilience alone to cope with burnout.

None of these study results are at all surprising to me.  I have experienced many of them myself off and on over the years.

The real question is: How did I handle it?  Before I answer that, I want to put forward the observation that people who do not have control over their environment and feel helpless to control their life are more likely to be depressed, anxious and burned-out.

Personally, I feel that the ability to control your practice setting and your finances gives you, as a physician, the emotional power to handle the rigors of medical practice.  Being a doctor has always been a high stress job and not for the faint of heart.

Why are doctors feeling more burnout now? My answer is that they have less control.  Also, despite the fact that doctors certainly make more money in yearly income on average than the general population, they feel that they need to stay on the treadmill of practice to pay the higher bills of their lifestyle.

When I was able to control my income through the practices I developed, a degree of personal and professional freedom pervaded my life.  As one of my old medical mentors counseled me, I managed my professional life such that “they” needed me more than I needed them.

I knew that I could survive on my own if I had to.  I knew that I could pick up and leave my group, my hospital or even my geographic area if I wanted to and still do fine professionally and financially.  That mindset and approach to practice continues to drive me forward.

I think that we as professionals cannot wait for larger health care organizations to make our lives easier or less emotionally exhausting.  That is not their priority.

You need to be the priority for you and your family.  You need to grab the reins.  If you can’t do it in terms of your practice setting, do it in terms of your personal finances and their management.

The title of this article, “The Riches Are In Niches”, is from a phrase I heard while listening to CNBC in the background one day in my office.  The on-air discussion at the time was in reference to the stock value of companies.  Specifically, the companies that did one thing very, very well were worth more to investors than companies that did a lot of generic things that could be commoditized.

Unfortunately, for primary care doctors, we have become marginalized as “providers” and frequently referred by insurance companies and hospitals alike as PCPs.  Even if you do your job very well and do an excellent job for your individual patients, you are not worth anything more to your hospital employer and group.

In fact, many primary care doctors are discovering this sad truth for themselves as they are retiring.  Despite the fact that there are fewer doctors going into primary care, these doctors are are being replaced by nurse practitioners or physician assistants, a.k.a. “mid-levels”.

From an economic point of view, the marketplace is saying that your generic medical services are not worth as much as you thought, and that it can be replaced by a lower level provider.  I say this not to demean or insult mid-level providers.

I have met and worked with many mid-level professionals over the years who are very smart and learn by experience.  However, there is a reason that they are mid-level: they have not had the extensiveness of training or the ultimate accountability of the board-certified and credentialed doctor.

Be that as it may, if you take this signal from the marketplace and want to accumulate more income, you must become more valuable.  The medical system reimburses the doctor better who becomes more specialized in his field, or does something specific that few others do.

This trend happens everywhere in medicine.  For example, the cardiologist that does cardiac catheters is paid better than the office-consulting cardiologist.

How did I implement this philosophy in my internal medicine practice?  I always enjoyed doing procedures during my medical school years, residency, and early practice days.

When my group was growing up to 6 office providers at one point, I noticed that many of my colleagues were referring out procedures that I was performing on my individual panel of patients.  So, I went to each provider and offered to see their patients for the small procedures that they did not do.

It would keep the patient in-house, and I would guarantee that I could get them in my schedule faster than any outside specialist.  As a result, I became the “lumps and bumps” doctor in my group.

My RVUs went through the roof!  Already the most efficient doctor in my office, I was seeing more patients with higher value reimbursements.

Since our income was based on productivity, my income continued to increase while those providers who just kept doing the same old primary care thing stagnated.  There definitely were more riches in that niche.

The most interesting aspect of being in a niche is that once you are in one, you can see other possibilities to niche down further.  While dealing with a large number of patients for skin procedures in the early 2000’s, I fielded lots of questions about other new procedures in which they were interested, including Botox, fillers and lasers.

While attending continuing medical education on skin procedures, I met other doctors who were essentially doing the same thing.  Over meals and breaks, I brainstormed and found kindred spirits who stimulated my medical entrepreneur side to help me explore these areas further.

To make a long story short, I developed a separate practice on the side and in my spare practice time to do aesthetic procedures, as most of these techniques are not reimbursable by insurance companies.  At first, I was nervous about leaving the insurance world.  Later, I found out that this move was in fact liberating.

By going into a cash-only niche,  I didn’t have to fight with insurance companies about medical necessity or delay in reimbursements.  If someone wanted a procedure such as Botox, I would tell them how much that procedure would cost, and that person would simply choose to pay the price or not.

By niching down, I became more valuable to the marketplace.  By eventually shedding the health insurance handcuffs,  I was able to be reimbursed for more of what I was doing, and not be obligated to pay for overhead to get the money I am owed.

I am living proof that the riches are in the niches.  As a result, I can control my own destiny, and it is one of the best professional steps I have ever taken!

I just came back from a weekend “retreat” sponsored by my local medical center for board of directors, physician leadership and patient advocates.  This gathering was to discuss the coming changes in medical compensation both at the doctor and hospital levels.  Several national speakers talked at length about how Medicare and private insurance companies plan to expand plans to transition from traditional fee-for-service medicine to quality-based or accountable care compensation.

I have been involved with my physician-hospital organization (PHO) for over 20 years and running my own practices for over 30 years.  From that perspective, I knew that this day was coming.

The shocking aspect for me was how many members of the audience were not aware of these changes being afoot.  Whenever I brought up this possibility to doctors in meetings, many did not feel that this change was going to affect them.

However, unless retirement is imminent and by that I mean in the next year, the medical care system is going to go through significant change.  Ultimately, hospitals will only be compensated for the right care at the right time, and at the price determined by the government entities that control the purse strings.

Now, I am not going all “Tea Party” on you here as I am the furthest from that viewpoint politically and socially.  However, I see it as a relatively simple math problem.

Our society is getting older partially because of our efforts to prolong life, and that’s a good thing.  The bad part of the equation is that the older are getting sicker and more expensive due to chronic diseases that we cannot cure but can only manage.

Because the older and poorer citizens are covered by government-based insurance (mostly due to the fact that private marketplace either won’t or can’t cover them), government in the form of Center for Medicare Services (CMS) will make the rules on reimbursement.  Frankly, there is a limited number of dollars that our society can expend on health care, and the fee-for-service pie cannot keep on growing without bankrupting all of us.

What I tried to express to the doctors in attendance at the retreat is that this new compensation model will affect them in their pocketbook eventually.  If you are an employed physician, eventually the hospital or group employer is going to demand that you be more efficient and cost effective, or face pay reduction or even dismissal from employment.  If you are in private practice, you will have to be nimble and accountable to prove to the payers that you are able to deliver quality care by whatever metrics they determine.

Obviously, one other approach is to drop out of the system altogether by not accepting insurance reimbursement and going fee-based or concierge model.  The bottom line is going to be your bottom line.  If you do not save or invest enough on the front end, you will not have enough freedom to choose on the back end.

By adhering my high savings and low debt model, which included practice options that did not depend on insurance reimbursement, I was able to make choices in the past several years that led my current practice.  Very little of my cashflow now depends on insurance payers.  I can make decisions on what I want to do or how I want to practice without feeling like I am being painted into a corner.

As Bob Dylan sings, the times they are a changing.  They will continue to change mostly because the current system, even the advocates of stopping Obamacare have to agree, is unsustainable.

If we as physicians don’t want to be run over by this train coming down the tracks, we must be prepared to change with the times or jump off the tracks.  In either case, you need to know what is coming, have a plan to deal with it, and gather the resources to implement that plan.

During the course of my multiple decades of medical practice, I have met some amazing people, particularly those in the business arena.  I have had several patients who have run relatively (or seemingly) mundane businesses such as roofing and janitorial companies.  They dress daily in jeans and T-shirts, yet are worth millions of dollars.

One roofing contractor I know pointed out to me that he barely had a high school education, but was worth more than most of the doctors in our town.  He claims that fact is because most of the local doctors he knows “were stupid about money”.

To that end, I thought I would summarize some of the lessons I have learned from these unlikely millionaire mentors in my community in the next several blog posts.  These lessons are relatively universal and can apply to many professions and lines of work.

Becoming a self-made millionaire is no simple task.  For those who accomplished this goal, they all had a process or a set of guidelines that they followed on that path.

Lesson #1- Make It A Game.  One elderly patient I know who owns multiple single family homes and apartment building rentals has accumulated his real estate empire slowly over many years.  When I asked him about his philosophy, he basically always looked at his business as a game to be won.

When the money to buy a large apartment building or office building got big and he was nervous, he thought about it as “Monopoly money”.  As long as he could clear enough to pay the mortgage and expenses, he knew he would be OK and the rest was gravy, or would go into the next acquisition.

Lesson #2- Never Get Comfortable.  This is a problem too many doctors have in their careers and their financial lives.  Many business people have told me that stopping on the journey to the top to say ” I’ve worked hard enough. I can slack off now,” is the kiss of death.

When you meet your goal whatever that is, you need to set another goal further out.  Sitting on your laurels is a dangerous thing.  Either the rapidly changing world will pass you by or the financial eggs you have accumulated in your basket will shrink a la the Great Recession.

Lesson #3- Continue To Study and Work Harder Than Anyone Else.  Even those in fields like roofing and hardware tell me that they need to continually read in their fields, go to trade shows and keep up on the latest innovations.  There is always someone somewhere who is trying to get an edge in the marketplace.

Doctors unfortunately seem to feel insulated in their niches, but if they don’t keep up, it is bad for their careers and worse for their patients.  No matter how talented you are or how advanced you may feel you are in your field currently, you will never reach your full potential or a mastery level if you don’t continually “sharpen the saw” more than others.

Lesson #4–Learn From Your Mistakes.  Everyone fails and makes mistakes. It is human nature.  For liability and ego reasons, us doctors do not like to admit that, but it is true.

Sara Blakely of Spanx fame has told the story that her father used to always ask her what mistakes she had made or failures suffered during the day when they sat down for dinner each night.  He was always disappointed if she didn’t at least have one, because to him that meant that she was not trying enough things outside of her comfort zone.

The failure or mistake is not the problem.  The problem comes if you do not learn from the mistake and grow from it.

I have made many mistakes in my medical career, especially in this business side of running a practice.  However, I always examined what happened, took it as a learning experience, brushed off my ego and moved forward.

Lesson #5- Read Every Day.  While I discussed studying and working hard in Lesson #3,  reading in general is incredibly important.  Since an early age, I was a voracious reader.

My mother always used to say you can go anywhere if you know how to read.  Try to read a wide variety of books, including novels, self-help, biographies, history, and anything else under the sun.

You can always learn something and frequently apply that to some aspect of your life and business, even if it is simply inspiration.  I have had business mentors tell me that they found lessons that they used in their offices from reading Doris Kearns Goodwin’s great biography of Lincoln, Team Of Rivals.

I have several more lessons that I will continue to impart on you in next week’s blog post.  Suffice it to say that medical professionals and doctors have lots of lessons to learn from those in other industries and lines of work.

If we can learn and integrate these lessons, then our lives, our patient’s lives, and our profession will be greatly rewarded on multiple levels.

A big campaign in medicine nowadays is to get more patients aware of each of their important health parameters. Billed as “know your numbers”, patients are urged to know their individual blood pressure, blood sugar and cholesterol levels in addition to their weight. Knowledge of these numbers allows a patient to assess her health risk in the longer term.

I think that as important as your physical health is, your financial health is also vital to your longevity. One’s finances are a common source of stress for individuals and families that can and does affect mental health, physical health, and the stability of marriages and relationships.

In terms of numbers, doctors, especially in employed settings, concentrate on annual salary. While certainly a factor in your fiscal health, salary is not everything. Whether you make $100k, 200k or more a year means nothing if you spend more than that in a year.

Knowing your net worth is critically important. Net worth requires you to know a significant list of other numbers, especially as your financial life expands.  Simply put, net worth is assets minus liabilities.

You should know the value of all your existing monetary assets quickly.  All you have to do to obtain that number is add up your savings accounts, retirement funds, and equity on properties owned.

Some strict accounting folks add value on property such as cars and furniture, but I discourage that practice. It’s a lot of work, doesn’t amount to a lot of money, and all those assets depreciate over time anyway.

Liabilities are obviously all money owed, including student loans, mortgages, car loans and business lending.  If you followed my advice from previous blog posts, you should not have a car loan, as borrowing money to fund a deprecating asset is doubly wrong.

Once you calculate your net worth, which is the big kahuna number, at least you know where you are now or where you are starting from financially.  The next number everyone should have is a goal number.

The goal number can mean different things to different doctors. For most, the goal number may be the amount of money needed to retire.  For others, it may the amount of money needed to buy multiple priority items such as your kids’ college, a second home, or rental properties.

Just like your net worth will change over time (hopefully always to the upside), your goal number will change also as life goal posts are passed and your goals get more adventurous.  As I have said before, some just want financial security, and some want eventual financial freedom (my choice).  Security and freedom in the fiscal arena will only happen if you KNOW YOUR NUMBERS.

I recently met with a new bank manager at one of my local banks to fix a screw-up in one of the bank charges on my checking account.  In a nutshell, they had previously convinced me to change to a different type of checking account with no fees, free checks, and other benefits that would be fitting given the size of my account, business holdings and other assets of mine.

Lo and behold, a $50 per month fee starts showing up in my checking account statements!  As this young lady was calling up my information on her computer, she quickly found the error and corrected it.

She said the usual bank mantra of “let me take a look at your financial info and see if we can save you any more money.”  No, I didn’t need or want a car loan.  No, I didn’t want or need a home equity loan or a bank credit card.

Then, after a lot of screens and looking back and forth, she assured me that the problem was corrected and that I was well cared for with my current banking relationship.  Her last comment as I got up to leave and shook her hand was, “But you don’t look like a millionaire.”

I almost stopped to ask what a millionaire is supposed to look like, but I realized that she, at her age, was probably envisioning lots of sparkling jewelry, flashy clothes, and perhaps at least one fancy car.  I smiled as I got into my (fully paid for) 2014 Chevy Equinox and drove off.

In my studies, most of the individual doctors I know who are millionaires don’t live like millionaires.  They don’t spend their money the way most people think millionaires do.

They are generally fiscally conservative except for an occasional splurge.  They don’t have the fanciest house on the block.  In fact, many of the doctors I have known who did have the fanciest houses on the block with the over-the-top renovations ended up losing money when they went to sell, or even eventually filed for bankruptcy.

Most physician millionaires know the true value of their money.  They tend to save and, most importantly, invest their money.  The docs in private practice who are in this fiscal category can usually tell you how much their equipment cost and how quickly the money spent returned its investment or ROI.

So, rather than be offended, I was proud to not look like a millionaire to this branch manager.  If I ever splurge on a car in the future, I will pay in cash and not need a loan any way.  That Tesla Model X SUV is a long way off.

I was at the movies the other day and saw a doctor who I had not seen in a number of years.  We talked briefly before and after the movie and agreed to catch up at length later for coffee.

But the one question he asked me before we went our own ways was interesting.  He asked me, “How did you do it, man?”

I must have looked puzzled by the question because he followed that previous question up with, “You know, how did you get to stop practicing so early?”

I could have said many things that are commonly said in polite conversation such as “Just lucky I guess”.  Instead, I told him “I just followed The Plan”.

We exchanged cell phone numbers and as he peeled away, he said, “I need to hear about this plan.”

What is The Plan?

I think that the first step for doctors in particular is to realize that they have to have a plan for their financial future.  Many are lulled into a state of denial due to their above-average incomes.

They frequently justify purchases of luxuries by saying, “I’m making good money.  I work hard. I deserve it.”  Unfortunately, I know many doctors who, as a result, live paycheck to paycheck.

The first part of The Plan is to make one.  No one is going to come and bail out old Doc So-And-So when he falls on hard financial times due to old age, illness and poor planning.

The modern doctor needs to think long-term about his or her finances.  Building wealth is a long process that requires vision of the future, discipline, and sacrifice.

We are not talking about stupid people here.  Doctors all go through a gauntlet of rigorous testing and courses that was intent on weeding out the weakest academically in math and the sciences.

The doctors who have what it takes to formulate The Plan must be willing to change themselves and their lifestyle to alter the course of where they are going.

You need to know where every dollar goes. As some financial gurus say, every dollar has to have a name and a place.

You need to know what all of your assets are doing and how to manage them.  You can certainly get professional help from lawyers and accountants, but you should not just give your money away to them to manage.

By the way, the movie I saw this weekend was The Martian*, which is the story of an astronaut (played by Matt Damon) who is left stranded on Mars.  Several lines from the movie returned to me as I was writing about financial plans in this blog.

When talking to himself about one of the technical problems he faced in his survival, Matt Damon’s character said to himself, “It’s just a math problem. Figure it out.”  In reality, that is all that long range financial planning is. It is math, and it isn’t even that complicated.

Like NASA and astronauts, we have to plan for every known eventuality.  We also have to leave enough redundancy to be able to “science the s*** out of it,” as Matt Damon in The Martian would say.

*I highly recommend this movie.  It was awesome especially for an admitted science nerd, but funny and exciting at the same time.

I was in Starbucks this morning after running a number of errands in my local area.  This relatively common event for a lot of folks was something I could not have done in the middle of a “working day” for about three decades.  However, since I walked away from my primary care practice several years ago and left call schedules and administrative headaches of running a modern office behind, I can do the work I want to do at the speed and intensity of my choosing.

How can I can do this? Because I am financially free.  But you don’t get to be financially free just by venture of making lots of money by itself.

I know many physicians my age (just turning 60) and older who are not even close to being financially free and may never be.  To accomplish this feat, you must have a plan and a buy-in from all in the family.

Both my wife and I came from large families and knew at an early age that we alone would be responsible for whatever financial success we would have.  Our plan early on was to limit debt and if debt was absolutely necessary, it would be paid off as soon as possible.

We followed that general plan for our student loans (college, medical and nursing schools), our initial vehicles and our primary residence.  In a variation of Dave Ramsey’s snowball method, as we paid off each loan, we rolled that money into paying off the next loan.  Paying off these loans early saved large amounts of interest.

After our initial vehicle bought on a loan when we needed 2 vehicles for our growing family, we paid cash for all cars over the past 25 years. When my wife went back to college to finish her bachelor’s degree, she worked at the college infirmary as a nurse and was able to pay her tuition and fees.

When my wife wanted to further her education by going to law school, we paid cash and she graduated without loans hanging over her head, unlike a lot of her classmates.  When our two sons went to college, other than a small loan they each took out to establish a credit rating for themselves, my wife and I paid cash for two tuition, room and board packages at private northeast colleges in the 2000s.

All the cash payout mentioned was not easy, but we had a plan and we knew it had to be done to keep to the plan.  Currently, we have other friends in the medical community who either cannot even consider retirement, or will retire unable to do what they really want, because of financial restrictions imposed by debt and lack of savings.

As far as I am concerned, the work we did over the past three decades was not really a sacrifice.  We made a plan and had a goal in mind.

I never wanted to be one of those doctors who made significantly more than the average person, but who still poor-mouthed about how little money she has.  I saw many older doctors early on who kept working and literally worked themselves to death because they could not afford to retire.

As I said in the headline above, you are not free truly unless you are financially free.  But the achievement of that freedom status does not come easily or quickly.

You have to be diligent but you can still enjoy the ride.  Over the years, my family and I certainly took a number of nice vacations and even bought a second home on a lake here in Maine, but they were planned for financially and were part of the overall lifetime plan.

As Benjamin Franklin once said, if you fail to plan, you are planning to fail.  In addition, a popular American idiom used with reference to the American military is appropriate here as well: “Freedom isn’t free.”

If there is anybody in this country who should be to afford a comfortable lifestyle and retirement, it should be physicians. If not, shame on us!