Hi guys, it’s Medicine Mondays again and I’m going to be Talking to Med Student Me.

Basically, a lot of this web site is me reflecting back on medical school and residency. However, I wanted to take this time to reflect on some choices I made as a medical student/resident that I thought were good and would repeat, and others which I would change.

Stock Photo From: Pexels

Choosing a Specialty

As a medical student, approach every clinical rotation as if you were going to be doing that for the rest of your life. Make note of the highs and lows of the rotation. People are different, some tend to only remember the highs of a rotation, and others only remember the lows. Even a month later your memories of that rotation will be hazy. Having reminders of how the rotation felt will be good to review later so you can be honest with yourself.

I didn’t do this, but I should have.

For example, looking back on it now, I actually did like some aspects of Surgery, and I kind of wish I had explored ENT a little more. However, certain parts of my surgery rotation (while overall were good), left me not wanting to step back into the OR.

Additionally, for my wife, her first rotation was psychiatry. She thought it was “ok” when she was going through it. However, after going through medicine, surgery, and the rest of the core clinical rotations, she was distraught because she really didn’t like any of them. Even pediatrics, which was supposed to be why she went to medical school… didn’t really interest her.  However, in her mind she was never a “psychiatrist” and didn’t remember that she actually liked it when she was doing the rotation. It took a bit of soul-searching on her part, along with conversations with me to determine that yes, she did like psychiatry.

Education

Medical Student

Medicine is a career and just by the virtue of being a physician, you have committed yourself to life-long learning. Now, this does not necessarily hold true for the stuff you learned for the MCAT or Step 1, but everything after that will still relevant to your career.  Commit yourself to learning something new everyday. Just one thing, but really know it. I think it is preferable to learn one thing and really know it rather than to learn a bunch of things that you barely understand.

Resident

Residency is survival mode. Many days you are just trying to get through to the next day, or the next day (or half day) off. I understand.

However, the same as a medical student still holds true. Learn one thing every day and try to really know it.

If you can, make a note card everyday with the one thing you learned. You don’t have to review them every night, but hold on to them because you will find them useful later.

Attending

Just being a good subspecialist is not enough.

I’m a neuroradiologist, so I have way too much training. However, just being good at neuroradiology isn’t enough. My job is to be of much help as possible to all of my colleagues in medicine, with special mention of neurologists and neurosurgeons. Also, for those who have a strong Head and Neck section, being of value to your ENTs is also helpful. Just telling them what is there isn’t enough. My job is to try to anticipate what questions they are asking outside of the clinical history and do my best to answer them.

For example, a patient gets a CT Neck for staging, sent to me by an ENT. They already know the patient has cancer, they’ve likely already seen it on laryngoscopy. How do I help them? Well, first of all, you need to identify: where is the cancer, because that changes the staging. For the sake of simplicity, let’s say it’s oropharyngeal. Here is the TNM staging.

So you identify the cancer and provide your measurements. You identify the lymph nodes and provide your measurements. Is that helpful? Well yes, but you could be more helpful.

For example, comment on if:

there is epiglottic extension

the tumor is invading or not because this is what they can’t see on laryngoscopy

there is necrosis or extracapsular spread of any lymph nodes

You need to talk to your ENTs and see what they prefer to know in their reports. Perhaps there is some new research they are doing and would like you to comment specifically. Some of them would like you to provide TNM staging in the report, although, from my experience, most do not (outside of major academic centers). For me, since I do primarily teleradiology, and I read for a whole host of different sites across the nation, I try to be as clear and as relevant as possible in my reports when it comes to Neck CT for Head and Neck cancer.

This goes for all doctors. Being a good doctor means being a good doctor to patients and other doctors.

Budgeting and Roth 401k/403b

This is hard to understand, but as a medical student, you are probably amongst the poorest in the general population. You have a net income of $0 and you are continually accruing debt, which is accruing interest. It’s like you’re standing in quick sand and flailing about… but you don’t know it.

Loans are not income… don’t treat them as such.

If I had it to do over again, I would have tried to save more money. Now, don’t get me wrong, I didn’t spend a lot of money overall. However, I think I would have tried to split living expenses with a roommate rather than staying in a one bedroom apartment by myself. For all other things, I was pretty frugal overall.

Internship

For my year of internship in Staten Island, I did pretty good overall. I lived pretty close to the hospital and didn’t spend much. I even saved some money that year on my resident’s salary. However, looking back on it, I should have put whatever money I had extra every month into a Roth 401k/403b. After finishing fellowship, it is unlikely I will ever make less than $50k a year… and in retirement, by income will likely be more than $50k a year. Combine those two items with 30+ years of compound interest and well, I missed out on a lot of retirement money.

Residency

I then moved to Albany for my 4 years of radiology and lived in a reasonable 1 bedroom apartment. However, I probably should have had a roommate. One of my other co-residents was renting a house and I could have stayed with him and split his rent. This would saved me money. Money that I could have, once again put into a Roth 403b at Albany.

However, no one told me and I was just getting by as it is. How could I know that putting away some more money would lead to a lot more later?

I only realized wayyyy later during residency and started putting money into a 403b at the end of residency. However, it was just a 403b, not a Roth 403b because once again, no one told me. So I will have to pay taxes on that money later when I pull it out in retirement.

Fellowship

I then moved to Baltimore for my neuroradiology fellowship, and this was the first time my wife and I would be living together. With dual fellow income, we could afford a slightly nicer place so we rented an apartment in Harbor East. This was a great year overall. We had easy access to the Harbor East and Little Italy and it was close to our hospitals.

However, that came at a pretty heft premium with regards to how much our rent was. Nonetheless, we were still able to save money which I wanted to keep toward a down payment on an eventual house. Of course, once again, this was probably not the best idea, as we could have put the extra money toward Roth 401k/403bs at our hospitals… but didn’t.

If you combine this with the fact I don’t recommend buying a house until you’ve lived somewhere for at least 3 years, then you know that saving that little extra money didn’t do anything for our down payment.

Young Attending

Remember my post The Biggest Mistake of Your Life? It’s because I made it, kind of.

As an associate at my private practice, I didn’t have access to the company 401k that first half year July-January. So I just banked that money that first year… saying that I was going to save for a down payment on a house. My wife took a little time off before starting her job in September and while she had access to a 403b, I decided to not try to maximize it in the 4 months left… once again, with the rationale that we were saving for a down payment on a house.

THAT WAS A BIG MISTAKE.

What should I have done?

We should have maximized my wife’s 403b in the 4 months, it shouldn’t have been difficult.

I should have paid down more of our loans with the money that I wasn’t able to contribute to a 401k. Alternatively, I could have used that money for a Traditional IRA, but I think the tax benefits would not have been available to us with our two incomes.

But…. you saved a bunch of money for a down payment on a house… right?

Yes, we save money… but was it really “a bunch”? However, in the grand scheme of things, it wouldn’t have changed my plans since we didn’t buy a house until January 2016, 3 years later. Additionally, I didn’t plan to buy house until probably January 2018 or so because I changed….

Once we moved to Hawaii, I realized my ENORMOUS mistake. As such, I maximized my TSP from April-December to try to get as much a match as possible. My wife worked August-December and we maximized both her 403b AND 457 in that short time period. Now we were back on track, and essentially living off just my salary, even though our cost of living went up considerably when you compare Rhode Island to Hawaii.

Learn from my mistakes.

TL;DR

Learn one thing new everyday… but really know it.

Keep an open mind.

A good doctor is a good doctor to patients and other doctors.

Be frugal as a medical student and resident. Loans are not income.

If you’re ok with it, get a roommate and put the extra money toward a:

Roth 401k as a resident/fellow. That is the optimum time for their use.

Don’t make The Biggest Mistake of Your Life. Learn from my mistakes. Help me help you.

I think I may dedicate a whole post to utilizing Roth 401ks/403bs in residency so you can see the dollar values.

-Sensei

Agree? Disagree? Questions, Comments and Suggestions are welcome.

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