By Sabine Fonderson MD
I have asked myself many times why some people wait till the moment before the break of dawn to have their most pressing issues resolved in the emergency department.
A 52-year-old male had come in by ambulance with difficulties breathing. The paramedic had also noted that, ‘the patient is known to have asthma and is on inhalers. All observations are fine’.
Yes, I admit there are also many times I wonder why paramedics decide to bring non-emergency cases to the emergency department for “assessment”. What more can be assessed if someone is fine?
When I ushered the patient into the cubicle I remembered how he gestured to his wife not to come in with him. But she ignored it and just walked right in.
‘What can I do for you?’ I asked the husband as he sat down on the chair.
‘I was having difficulties breathing tonight’
‘Yes, I read the ambulance triage sheet. How do you feel now?’
‘Better, I am not having breathing difficulties anymore. But doctor, can you please tell me why I am feeling this way?’

‘I do not know.’ I replied and thought to myself, if he had any sense, he would have thanked me and apologized for wasting everyone’s time and left the department.
But instead he sat there, staring at the floor as if he would find the answers to the breathing difficulties he no longer had and where they came from.
I rolled my eyes. Yes! I rolled them way up to the ceiling and back at him again because he was not even looking at me, and neither was his wife. She sat practically facing the door, ready to leap out.  I proceeded with more questions. The more I asked open ended question the longer it would take for him to give me a straight response, so I quickly reverted to questions that required a simple ‘yes’ or ‘no’ answer. It took me almost 6 minutes to get to the simple conclusion that he smoked despite his asthmatic condition. I felt the need to explain the effects of smoking.  As I proceeded to elaborate on how smoking can exacerbate an asthma attack, he felt the need to remain silent, and, to my amazement, he had fallen asleep. 
‘Why are you sleeping? Am I boring you’ I said in a raised tone. Even his wife startled and turned towards him.
‘Oh, sorry doctor. You see I have not slept in days.’
‘Yes, doctor, that is true,’ His wife confirmed. Speaking of sleep, I was so desperate to get out of the department and get some of it myself.

‘Why have you not been sleeping then?’ I was getting quite agitated at this point because that is not the main reason he was brought to the department and now he was forcing me to dig deeper into issues that, frankly, I could not care about, especially not when I had 5 minutes remaining till the end of my night shift from hell.
‘It is my wife….’ Long pause. Very long pause. ‘She is having an affair’
Well, I sure as hell did not see that coming. Daytime soap opera in the emergency department.
 
Soon a bickering match between husband and wife ensued. To my amazement, he had found his voice and started relaying all the events that led to the affair. He depicted in detail how when he was in the basement he could here her with her lover making love in the bed he brought.  Her lover was a nobody in India, and since he had lost his shop she had made it very clear how she despised him. She would not even look at him, and that is why he found himself hiding away in the basement, abandoned by his own wife. The shame he had felt was incredible. He could not talk to family and friends about this because he would be laughed at. He had already lost his shop and now his wife was having an affair with a poor boy from India.
She turned on him, repeating and confirming everything he said and looked at me as if I would take her side. 
I just sat there and listened as both husband and wife conversed with each other. I think something good did come out of this. There was some form of communication established between the two and for that second they must have felt like a married couple again. And I unintentionally became a marriage counselor

About the Author
Sabine Fonderson MD is an emergency medicine doctor in Scotland.  She is passionate about writing and is a freelance editor and content author for blogs and medical startups. Sabine is author of Unbelievable stories from the emergency department, published in May 2016.  She writes about her experiences as an ER doctor on her website www.sabinefonderson.com There you can also read how she has found creativity and flexibility in her professional life.

By Mani Saint-Victor MD
The biggest mistake physicians make in career transition is not imagining the possibilities broad, bright, and inspiring.  Whether fresh out of residency or haggard from a decade or two in industrialized medicine, when it’s time to think nonclinical it’s time to dig deep.

You’ve gotta reach inside to reawaken the inner child that you’ve been hushing in the corner as you built up discipline, practiced delay of gratification, and developed professional physician ways.  You’ve accomplished that piece. Celebrate it! Now it’s time for wide open, dreamy-eyed idealism.
This sounds ridiculously irresponsible.  It is- if you go about it without a plan.  In the age of the internet the best plan is to Google first.  Yep. Search and ye shall find.  But only if you are certain of what it is you want to find. 

Don’t fall for the usual trap of starting from a place of frustration.  You can tell you’re doing that when you start listing the stuff you don’t want:

1. Less hours at the hospital
2. Less tired
3. Less paperwork
4. No arguing with insurance providers
5. Less interruptions of my time with family

The list could go on.  That trap is bottomless and the relief that comes from catharsis feels good enough in the moment to pass for inspiration.
It’s not.
Instead start surfing the net for stories of inspiration.  What have other doctors done after they quit clinical medicine?  Beyond the obvious. Look for the meaningful.  Sure jumping over to a biotech firm, joining a healthcare startup, medical writing, public speaking, and even management consulting or joining venture capital firms are some frequent paths transitioning docs choose. 

But you’re a doctor, for goodness sake!  You went after one of the most challenging careers out there and you nailed it.  Bring back that indomitable spirit and imagine something wild yet aligned with your sense of purpose and go for it.
Most of us have forgotten how to freely imagine.  Cultural conditioning whispers:
“You’re too old to start that.”
“You’ve got bills to pay and that won’t make enough money to maintain your lifestyle.”
“Can you even imagine how much hard work it’s gonna take to work up from the bottom in another career?”
Again, Google to the rescue.

My single biggest lesson in my transition from clinical medicine has been to unlearn the beliefs I hold limiting my own potential. I’ve done this in three broad steps.  
First step: I looked at all of the stories about doctors who had made successful transitions that I could get my hands on. I studied their thoughts, feelings, actions, and mistakes.
Second step: I looked at at what people who made changes from other careers had done.  I looked for the same stuff but with an eye on perspectives from outside of medicine. The more mistakes I could see coming from different points of view the more confident I felt.
Third step: I got a coach. You need someone to keep you on track and to catch you shrinking your vision in moments of temporary defeat.

Read a ton of success stories. Notice the ones that set your spirit on fire. Notice which principles inspire you. Find communities who share those principles. You’ll learn fastest from like minded people.  Your curiosity and passion will drive you in pursuit of a career that matches and expresses your core identity.  
If you’d like to read a collection of revealing stories from inspiring physicians who have transitioned from clinical medicine then visit Thinking About Quitting Medicine.
 
Dr. Mani Saint-Victor, MD,  The Dropout Doctor

Physicians and medical students are often helping others and neglecting their own physical or mental health. Pamela Wible MD has done a lot of research in the area of physician despair, depression, and suicide. She also knows firsthand how being a doctor can take a toll. She knows how it feels when you hit rock bottom. Sometimes despair is related to your job, and sometimes it goes deeper than that.

If you feel overwhelmed, depressed or do not have the words to describe your needs- reach out to idealmedicalcare.org for help

By Reem Messeih
In today’s unpredictable economy, and the ever changing landscape of the healthcare industry, many medical professionals are looking for opportunities to diversify their income; and in particular, build a residual income that allows them to achieve optimal financial goals in their limited free time. While there are several ways to accomplish this plan, many are looking to the industry of direct sales. In this vast industry offering a variety of products and services, ensuring that a product/company’s mission and values compliments their own is critical in finding the right match.

Not surprisingly, many healthcare professionals are choosing to partner with the doctors and creators of Proactiv® Solution in their newest skincare endeavor, Rodan + Fields.

Many physicians, such as Dr. David Wiles, a neurosurgeon, have joined Rodan and Fields. Dr. Wiles posted this quote on his Facebook page: "I became a physician and neurosurgeon to help people. I still do that today, but the challenges to provide help to people have become exhausting. The practice and art of medicine is dying and is being replaced by the business of medicine. I am actively joining a business that allows me to help. Rodan+Fields is positive and uplifts people while offering a greater income potential than medicine offers. I will continue to fight insurance companies, CMS, hospitals, etc. for treatment for patients with neurologic diseases. And then, I will go home and relax with Rodan+Fields."

And Stephanie Moore MD, a cardiologist at Mass General, turned her Rodan and Fields business into the staring point for building her Medi-Spa, Vega Vitality, in the heart of Boston.
Female and male alike, medical professionals ranging from nurses, pharmacists, physicians or hospital administrators are all adding Rodan + Fields to their investment portfolios and resumes. So just what is attracting them to this company? In short, three things: the doctors; the products; the unprecedented opportunity. 

The Doctors:
Rodan + Fields products are not created by chemists or sole entrepreneurs.  These products are developed by two of the most esteemed dermatologists, with years of clinical experience, patents and accolades in the industry. Innovators in the dermatology industry, Stanford trained dermatologists, Drs. Katie Rodan and Kathy Fields had phenomenal global success with Proactiv® Solution. The doctors wanted to further their vision of bringing dermatology based skincare to the masses. A skincare solution developed for retail, originally, Rodan + Fields was sold in high end department stores and was among the top selling retail clinical skincare brands. However, the doctors recognized that given inevitable demise of the retail environment: their vision would never fully be realized behind the department store counter. Seeking to take advantage of the rise of social commerce in 2008, Rodan + Fields became the first premium skincare line to exit retail, and enter the world of direct sales, putting their own spin on the industry: no parties, no paperwork, no inventory.

Allowing their loyal consumer base to partner with them, open their own virtual franchises and share R+F’s clinically proven products with their networks has allowed the company to far exceed its retail sales volume and experience unprecedented growth. In 6 years, they became the “Fastest Growing Premium Skincare Brand”, and the “2nd Largest Premium Skincare Brand in America” (according to Euromonitor independent studies). 
They are among the Top 10 Female Entrepreneurs of the Decade. Still practicing physicians and educators, these women have a true passion for dermatology, and it shows in their practice and their products.
The Products:
Regardless of age, gender or skin concern, Rodan + Fields products appeal to a broad spectrum of consumers. That expansive potential market-share is quite appealing, as their target demographic is everyone that has SKIN. Rodan+Fields products are clinically proven and results driven.

The Opportunity:
Partnering with Rodan + Fields allows consultants to diversify their income potential and share in the growing multi-billion dollar anti-aging industry. Because these products are effective and consumable, not only are R+F clients loyal, but they also recognize the incredible opportunity in sharing these products and building their own businesses. While in the medical industry, a practitioner’s reach is limited by proximity to the patient, this business model allows consultants to reach beyond their location: consultants can share products with their networks nationwide, in Canada, and soon, in Australia. As a consultant builds a team, he/she can earn income on not only his/her own sales, but on the sales of team members as well. This residual income allows consultants to more quickly meet their financial goals without having to sacrifice time, while knowing that consumers across the country are getting the best products and achieving their best skin. 

Additionally, compared to the time and financial investment it takes to earn a medical/advanced degree in the industry, the investment and fixed overhead in Rodan+Fields is minimal, and virtually risk free.
The desire to impact people’s lives and help others is a common core value for medical professionals.  Rodan + Fields helps foster that impact, not only in terms of giving people the gift of great skin and confidence, but in building entrepreneurs that can then change their own financial future and the lives of others.  The markets’ embrace of social commerce, combined with the power of these doctors reputation and legacy, clinically proven products and their refreshing approach to entrepreneurship makes the opportunity to partner with Rodan+Fields unique.

Student Loan Management: Refinance Student Loans or Public Service Loan Forgiveness with Income Driven Repayment Plans by Amanda Liu DO
Not only has average educational debt grown drastically more cumbersome over the past decade, but decisions on how to manage one’s student loans have also become much more complex.
For the 2016 class of graduating medical students, there are 4 federal income driven repyament (IDR) plans: ICR (Income Contingent Repayment), IBR (Income Based Repayment), PAYE (Pay as You Earn) and REPAYE (Reviwed Pay as You Earn), in addition to standard, graduated, extended repayment plans.
Adding further complexity, for the first time in early 2015, residents and fellows are given the opportunity to refinance their federal and private student loans with 2 private banks: LinkCapital (currently out of funds to lend) and DRB. Upon becoming an attending, many more banks are willing to refinance doctors with large debt as well as high income.
Here’s a flow chart which summarizes the most beneficial repayment options for a typical post-graduate trainee with high debt-to-income ratio (50-70k income; 200k student debt). These options include IBR, PAYE, REPAYE, & refinancing student loans.

Student Loan Management for 4th Year Medical School Students & Post Graduate Trainees (Residents and Fellows)

Once you’ve decided to refinance your student loans, rather than going for income-driven-repayment & Public Service Loan Forgiveness, it is critical but challenging to shop for the best interest rate and term. One way to start shopping around includes asking friends for recommendations and applying to multiple banks simultaneously. When you apply to multiple banks within a short period of time, these inquiries will only count as one ding to your credit score. It is understood that you are simply shopping around for a big-ticket item such as student loan refinancing and or home mortgage.

I have been paying very close attention to the interest rates and terms that banks are offering for student loan refinancing and this is what my research has shown me. A friend of mine from Touro University in California who is now a practicing pharmacist refinanced her student loans with to a 15-year fixed 3.5% interest rate loan (she refinanced before the feds adjusted the prime rate up by 0.25%; the current 15 year fixed is 3.75%.) She is happy that not only is her  interest rate ½ of what she was paying before refinancing her federal student loans, but also the long 15 year term allows her to reserve more cash flow (than a shorter term loan) for retirement savings and down payment for buying a home in California.
I am happy to see that there’s finally a break for the medical professionals, especially those living in high cost of living areas such as many cities in California.
So I reached out to First Republic Bank, and after several weeks, I heard back from Kerry Berchtold, Relationship Manager at FRB.
FRB Rates (March 2016):

• 5 Year Fixed: 1.95%
• 7 Year Fixed: 2.65%
• 10 Year Fixed: 2.95%
• 15 Year Fixed: 3.75%

This is a 5 year fixed rate that is 1.55% lower* than competitors lowest rates in their published interest rate ranges. By paying 0.25% more with FRB, you get much better cash flow on a 15 year term rather vs. the 5 year term offered by most competitors.
*The lowest 5 year fixed rate with CommonBond, DRB, Creidble, or Sofi right now is 3.5%. If you qualify to refinance your student loans with FRB, you get the ONE published rate and term, not an interest rate somewhere in the range of rates offered by most other refinancing banks. For example, my friend with 800+ FICO score refinanced with DRB and got 5.65% interest rate (which initially surprised me as it was at the high end of the advertised range of interest rates for 10 year fixed loan). DRB explained that he didn’t get the low end of the range because his debt/income ratio was high, which is true of most typical PGY's with 200k+ debt and 50-75k in While DRB was the best option for him as a PGY4 (he would not have qualified with FRB due to geographic requirement and debt-to-income ratio requirements by FRB), I definitely encourage him to refinance again, when he becomes an attending.

To qualify:
#1:
It all hinges on debt-to-income ratio, which differs by individual circumstances. In general, attending physicians can qualify; tougher for PGY’s to qualify but never hurts to find out.
#2:
You have to live or work in locations FRB have banking branches, which include:
California, specifically San Francisco, Palo Alto, Newport Beach, Palm Desert, Los Angeles, San Diego, and Santa Barbara
New York, NY
Boston, MA
Portland, OR
Palm Beach, FL
Greenwich, CT
#3:
You Forego Potential Forgiveness such as PSLF like refinancing with other private banks.
This loan is a personal, unsecured loan with all that entails. It doesn’t go away if you die (and will be assessed against your estate.) It goes away in bankruptcy. There are no provisions made for unemployment, underemployment, death, or disability. So be sure you have enough life and disability insurance to cover the amount borrowed.
#4:
 $60k-$300k Range: FRB won’t refinance loan amounts lower or higher than this range. If you have 300k+ in student loans, refinance 300k with them to get the lowest rate/best term, and then refinance the excess portion with another bank. If you have less than 60k in student loans, you are in pretty good shape. You can still refinance with other banks like DRB, common bond, Linkcapital, Earnest, etc.
Dr. Wise Money (DWM) is a 1st year resident (PGY2) in the Department of Medical Imaging at Banner University Medical Center. As DWM achieves her financial goals of purchasing a home (MS4), paying off student loans (PGY1), & maxing out retirement savings (starting PGY2), she begins writing and giving talks on personal finances for doctors to help her colleagues also achieve financial success. DWM firmly believes that financial freedom makes better and happier doctors. DMW is featured websites including White Coat Investor and nonclinicaldoctors.com. You can follow DWM at drwisemoney.com. Email me at drwisemoney@gmail.com for more information.