Can you repay loans in residency?

Ha…this is pretty accurate, because it’s a fan of 1s 🙂

I’ve done my fair share of searching about this topic.  And generally, there isn’t a consensus.  I think, like most things in finance, part of it depends on your personality.  Many people say “you’re going to be a doctor…you’ll be able to pay it back someday”.  Others feel like the loan amount is so insurmountable and the training is so challenging that trying to pay off any amount (or even trying to spend less than your salary) is too much.  And depending on where you went to school, you might graduate with north of 250,000 in loans (public school average is $156,000, private school average is $183,000, but up to 27% of private med school grads have over 250k)*.  Understandable thats SO overwhelming.  I however, DO think it’s possible to repay loans.

A little background:

There are a number of ways to repay loans

1. Income Based Repayment: IBR is a method of repayment for federal loans that allows you to pay a prorated payment during training based on your income from the previous year.  This means, for your first year of payment which begins in December of your internship after the grace period ends, your calculated income would be what you earned during fourth year of medical school.  For most people, that means your calculated income would be $0!  Goose egg!  Additionally, in the first three years of training, if your calculated payment is less than the interest that would be accruing monthly, the federal government will NOT assess interest on your subsidized loans (aka, during your first year of repayment, you pay 0 towards your loans and your subsidized loans, which would start accruing that December, won’t accrue as long as you “make” your $0 payments.  During your second year, your payment may still be less than your interest on unsub and sub loans and the government will continue to forgive the interest on your unsubsidized loans). The drawback of this approach is as your income increases (gradually by 1-3k/year during residency and then a MASSIVE jump for most specialties when you become an attending doc), your payments go up.  Eventually, it’s cheaper to enter the traditional repayment plan.

2. Traditional repayment plan: In this plan, you’re on a 10 year pay off schedule and you pay a monthly payment that will lead you to total debt repayment in 10 year.  Interest accrues (for Stafford loans this is 6.8% but will be lower on new loans based on new legislation).

3. Extended repayment plan: In this plan, you pay back over an even longer term (up to 25 years) but continue to accrue interest.

And more: https://www.aamc.org/services/first/first_factsheets/112294/loan_repayment_choices.html

For those in medicine (and education), there are even better options to combine with those above

These options are even more diverse because for docs there is the option of the Public Service Loan Forgiveness Program.  In this program, if you work for a nonprofit for 10 years and make 10 years of on time payment, whatever remains at the end of your 10 years is forgiven.  The nice part for docs is that most residency training programs count as not for profits, and the payment approach you take CAN be income based repayment.  For people who are general surgery residents who often have to do 2 years of research on top of 5 years of general surgery training plus a fellowship of at least 1 year, that means almost all of your training years count and you’ll be paying at IBR, which will likely be less than your traditional repayment approach.  Once you become an attending physician and your income goes up,  you will switch into traditional repayment for a few years and then the remainder of your loans are forgiven.

So, with all of that considered, doesn’t it make sense to do IBR during residency, switch to traditional once you’re an attending, pay only what you’re required to and get loan forgiveness?

Well…yes.  For most people.  But I’m not most people.  For one, I’m not sure where I’ll be practicing.  I had previously REALLY wanted to go practice in the community I grew up in, in which case I would be practicing in a for profit center.  There goes the PSLF program.  Second, you never know when the funding for this program will dry up.  Chances are, people currently in the program may be grandfathered in, but if they aren’t, they’ve been wasting money allowing interest to compound.  But third- and I will take some heat for this because it sounds like criticism of those who do use the PSLF- I feel that I should pay back all of the loans I took out.  I knew when I started training I would be taking out this debt, and so I feel morally obligated to pay back the money I borrowed.  I do know that I’m kind of cheating the system by using the plan below since I won’t be paying some of my interest, so I’m not totally a purist. I DON’T think everyone needs to feel this way and I DON’T judge anyone for using PSLF- in fact, I think it’s a really smart idea and would love for all of my buddies going into primary care to have all of their loans forgiven.

BUT MOST IMPORTANTLY….I feel like debt is a ball and chain- I HATE IT.  It makes me so uncomfortable that when I think about it too long, it freaks me out.  So, for my own sanity and peace of mind, I’m repaying as fast as I can.    Which means I’m going into IBR and paying every penny that we (have to get used to that “we”) can on to my loans.  IBR will keep my Federal Subsidized loans at 0% and so we’re paying down the unsubsidized loans as fast as we can, since they’re accruing interest like gangbusters.  My lovely school has a wonderful 0% interest loan during medical school that gets forgiven for those in primary care, but for those of us in specialties becomes an 8% loan following internship.  It’s also not eligible for IBR.  That repayment will be my focus after internship once the interest rate jacks up.

So what’s all the fuss?  I wanted those out there who are budding premed students, or who are finishing medical school and don’t know what to do about repayment, or those who wonder why I work my butt off to save money to know what the options are for repaying loans in residency.  Also, I’ll be posting on it periodically, so a grounds for the discussion was important.

*The AAMC compiles these facts: https://www.aamc.org/download/152968/data/debtfactcard.pdf

A little wisdom from the trenches

Just some insight that I had tried to overlook before this year: Internship is really, really hard. 

 

First, it’s the time commitment. On wards months, you’re working 11 to 12 hour days, 6 days a week.  I function well with a schedule, so I started my wards months getting up at 5am, running with Max and then walking with Piper or taking them both for a longer walk together.  I’d get back, make lunch (sometimes I would do this the night before so Dan had lunch too), try and straighten up the house or edit someone’s personal statement for my part time job, run around getting my breakfast ready and the dogs fed, and then be off to the hospital.  The days always go by in a blur- rounding in the morning, calling consults, answering pages, going to noon conference, writing notes, discharging patients, and admitting new faces.  At 6 pm, the night person comes in (that’s a whole different story on nights- trust me) and you can sign out your patients.  I would rush to get done for around 6pm so I could sign out my pager.  Some interns choose to stay at the hospital after theyv’e signed out so all their work is done before going home.  Usually those guys were leaving later.  But for me, I was working 11 hour days and then going home to work on notes.  I was adament that I wasn’t going to sit in the hospital for one minute more than absolutely vital.  Instead, I would get home, greet my beautiful dogs and husband and plop down on the couch and start notes.  Sometimes notes only took me 45 minutes to wrap up, othertimes I was working until 9 pm.  Either way, the days felt REALLY long. 

 

Then, it’s the fear.  It’s a crazy thing realizing your mistakes could kill someone.  Hospitals do a wonderful job of not letting interns get too sleep deprived (I can’t imagine life before duty hour restrictions!) and there are multiple checks in the system (pharmacy double checking orders, nurses questioning what you write, residents peeking over your shoulder) to ensure costly mistakes don’t get made, but they still happen.  And that realization has woken me up from sleep a few times, panicking I didn’t order someone for a vital antibiotic or that I didn’t order them for a needed stress test.  I haven’t been afraid of my attending doctors yet <knock on wood>, but the fear of hurting a patient is real and it’s powerful.

 

Then it’s the patients.  Patients can drive you absolutely nuts.  They can be needy, complaining, whiny aggrevations who seem like they’re just trying to make your day longer.  They can complain about every little thing you do, but be in the hospital for conditions that they could have controlled.  They can become delirious, really disoriented, and combative.  They can suddenly stop breathing or their blood pressure can bottom out.  They can ask you to explain their condition over and over and then make you call each of their children to explain.  Or worse, they can lie to their spouses and ask you to lie to their spouses as well.  They can keep you late, overwork you, and drive you to your wits end. 

 

Or, you can see that they’re human.  That they’re scared and alone, and just want someone to recognize that they’re a real person with a family and hobbies and a deep desire to be happy.  They can make you realize the little old lady with anemia was actually a beloved former educator, or that the crotchety old man with liver disease is a veteran who put in time serving our country.  Worse still, you can realize the patient with a new diagnosis of terminal cancer is about your father’s age.  Or that the suddenly critically ill patient has eyes that look an awful lot like your grandmother’s.

 

And then that fear returns, only this time it’s different.  Because it’s not a nameless patient, it’s your friend in bed 314A who wants to go home and make sure their cat is okay.  I will never forget the first time I saw a patient truly understand they were dying.  I stood at the foot of the bed of this patient I had cared for for two weeks, listening to the attending dispassionately but slowly explain that the patient had untreatable cancer.  We had warned the patient and the family about the possible diagnosis, but when the “C” word came out as a definite there was a palpable change in the room.  I watched the patient’s spouse’s body sag.  The patient looked bewildered until the spouse blurted out “You have cancner, and they can’t do anything about it”.  At that point, the patient began to tremble and immediately teared up.  I felt so wrong being there- not because I was uncomfortable with the emotion, but because I was in a white coat and was part of the unemotional, detached team delivering the bad news.  Inside, I felt emotionally battered by the “is it cancer” “is it not cancer” dance I had been doing for the past two weeks.  I had been rooting for a good outcome and had been praying for this patient (a topic that gets some in medicine heated) each night.  I had to leave twice during the conversation, pretending to answer pages, because I knew I would emotionally lose it in the room.  And as much as I wanted the patient to know I was upset for him, this wasn’t my pain…I didn’t want my grief to muddle the intense emotion the patient and the family were feeling.  So  I waited.  After the attending physician left, I quietly told them just how much I wished there had been a different outcome, and that I would be outside the room, working on his paperwork since he was electing to go home.  Before they left, I hugged the patient’s family and the patient, making eye contact and wishing them the very best.  Still and all…it was a crummy day.

So this was longer than I thought it would be, but I think it’s cathartic.  I think its good for others to hear what the ups and downs of internship can be, and how it’s possible to still keep your soul but sometimes it’s damn hard.  It’s nice being on elective, as now I have a chance to reflect like this 🙂

Table update

Continuing to sand! We started with a 50grit sandpaper to remove the stain and finish and to even out the pine surface which had been dinged up from years of Horan family use. Some of the surfaces have had a 50grit AND 120grit sanding but today I worked on the table base with 50grit. So much sanding!!

What happens when you have to make the bed with two dogs…

I’ve REALLY tried to become a neater person and I think it’s working a little…part of it is being married to someone who is organized but for me part of it was having to train my brain to notice messes. Now when I’ve noticed something I can’t ignore it. I’m still working on a cleaning schedule so things stay tidy while I’m on wards, but while I’m on elective I’m doing as much laundry as I can! We have an awesome clothes line so yesterday I stripped the bed, washed the sheets and hung them out to dry. Of course, when I later went to go make the bed I found our furry pals snuggled in…

Afternoons off are rare…

So I took full advantage! I swept, mopped, did a load of laundry, sanded part of a furniture project I’m working on and mulched some of the yard. I’m so grateful to the old home owner because she essentially made it so our yard is constantly flowering and we don’t have to do much for it!

Do I dare?

Medical internship is not a good time to start blogging.  The demands of long work days- mostly around 12 hours, 6 days a week- compounded by the demands of a physically fit black lab, an attention-seeking golden retriever, a new home, a part time job advising premed students, and a wonderful husband who wants to spend time with his new wife all mean I don’t have tons of time.  In fact, sometimes it feels like I have no time.  So why restart blogging?

 

I miss it!  I love the forced reflection blogging brings, and the inspiration I get from looking at what some of the blogs I follow post.  As a blogger, I liked posting my own projects, proud moments, and other significant things in my life.  It helped me focus on the positive parts of my life, and that’s why I think in this particularly difficult season of life, I’m going to start back up.  

 

At least for now.  Right now, I’m on an elective which means I work NORMAL hours…I get in at 7, leave around 5, and don’t work weekends.  I’ve got 5 more weeks of that, and then I’m back on wards…which means 7-7ish 6 days per week.  And I work that schedule through the new year.  We’ll see what happens to blogging then, but it feels good to be back!

Seattle series: getting outside

This is my third post in a series about Seattle.  You can read my first post that I wrote in Seattle here and about Pike Place Market here.

I’m somewhat ashamed of how little I did outdoors in Seattle as it’s an incredible city for active people.  Here are a few of the things I did manage to do :

The Burke Gilman trail is a well maintained, popular bike and running trail that curls along the waterfront and the University of Washington area of Seattle. One point of access was 3 blocks from my apartment, so it was nice to be able to head out there to walk or run.

The Coal Creek trails are in Seattle rigth next to a busy road and you’d never know they were there. The hike was beautiful- everything was super verdant and sheltered from the sun (which naturally, I loved). Picture from seattlebackpackersmagazine.com.

Our trip at Coal Creek was cut short when Dan and I turned a corner and ran into THIS! Okay, not quite…we ran into one adolescent bear on the trail, but that was enough. We scared the poor thing and he ran up off the trail but we turned and hightailed it…because we all know, where there’s a cub, there’s a mama. (Picture from acapella.harmony-central.com because I was NOT dumb enough to take out a camera. I was getting the heck out!)

We also went hiking on Whidbey Island, but that’s for another post.

And a few things I didn’t get to do that I wish I had:

– I wish I had rented a bicycle.  The city is covered in bike trails and it’s a hugely popular activity.  It would have been fun to do.

– I wish I had rented a kayak at Agua Verde Canoe and Paddle Club.  Dan and I went to the restaurant (Agua Verde) where he had possibly the worst service ever but pretty good food.  We saw the kayak rentals, but they were a little to expensive and we got there too late.  Still, it would have been neat to cruise around on the water and see the houseboats.

What would you do with 6k?

$6,000 dollars can buy you a lot.  My car, for example, was $4500 when I bought it 5 years ago.  It could pay almost a year of my rent or about a third of tuition and fees for a year of med school.  $6,000 is enough to buy 6 “cheeses of the world” packages on Heifer International (meaning it pays for 6 heifers, 6 water buffalo, 6 goats and 6 sheep all of which produce…wait for it…cheese)  How on earth, could someone pay that much for a dog’s hip?  Especially someone who lives on loans?

Trust me, I struggled with the decision to do surgery.  Even though it was clear that Piper was uncomfortable and unable to function at a normal 3 year old dog level, it was hard.  Before medical school, I had gone on a service trip to Jamaica and had seen real need in the orphanages there.  The memory of seeing how few toys and books there were for the 20 plus kids that lived there has stayed with me.  How on earth could I spend that amount of money on an animal and not another human being?

I still don’t know a satisfactory answer for that question.  I decided to do the surgery because I couldn’t stand seeing an animal I love in discomfort every day.  It’s not totally satisfying, but I know I put my money where my mouth is and took care of something/someone I love.  And I try and remind myself that often times there isn’t a right answer to what is the most noble or “right” thing to do- that it’s a personal choice and as long as you can be at peace with your decision then it’s the right one for you.

And Piper goes to the vet AGAIN…

Anyone who knows me knows that I value my dog Piper over and above any of my possessions.  She’s just awesome- she is so excited to see me whenever I come home, she’s great company, before this whole thing she used to motivate me to get outside, and she reminds me to live more in the present- that’s what she does all the time.

Yet another time Piper got herself in some medical trouble. She rolled in something she was clearly allergic to. This time we just treated her at home with Benadryl for a couple days.

 

And as I love her and value her so much, I’m willing to spend crazy amounts of money on her.  I am willing to be super cheap when it comes to stuff for myself, but not for her.  And anyone who doesn’t have a dog of their own doesn’t get it.  It’s cool- I don’t mind.  I thought people who bought their dogs titanium hips were crazy at one point too.

Right around the time of this picture I was hooked…and the rest is history

Yes, that’s right folks.  In addition to being treated for hypothyroidism, Piper has congenital hip dysplasia, a condition where her hip sockets didn’t form right and as a result she developed osteoarthritis really early in life.  She’s always “bunny hopped” when she ran, which is a sign of CHD, but this past January, Piper stopped putting weight on her back left leg.  She’d have a few days where she’d be fine and then she’d have trouble climbing the stairs or would occasionally hold her back left foot in the air.

Piper running free on the beach before all the exercise restriction

Not good for a 3 year old dog.  I knew it was going to maybe require surgery, so I called my wonderful vet at Anchor Animal Hospital to ask for recommendations for a surgeon.  We ended up choosing Tufts Vet in Grafton, MA because it’s a great hospital and it’s close to Worcester.  At the visit they gave us 3 choices:

1. Medically manage with NSAIDs, swimming and low activity.  Not a great option, as we had tried restricting activity, doing swimming AND two types of NSAIDs.

2. Femoral head osteotomy, a surgery where they lop off the head of the femur (upper leg bone) so that there isn’t a hip joint anymore and the top of the femur sits in the muscles instead of in a joint.  Not a great option as it doesn’t work well on big dogs and dogs don’t recover full function.

3. Total hip replacement.  BINGO!  With this procedure, they would lop off the femoral head and the part of the pelvis to replace them both with a metal implant.  The new hip joint has a VERY high success rate and most dogs recover 100% functionality.  Sounds great?

6 k later…the jury is still out.  Piper had surgery 1 week ago and right now is on strict cage rest.  She’s putting a little weight on the leg, which is normal at this point but time will tell how well she’ll respond to the replacement.  Stay tuned.

Seattle series: Pike’s Market

I had started my blogging of Seattle while I was there with essentially one post about what we did the first few days.  Here are some more details about our time there.

Anyone who goes to Seattle MUST go to Pike Place Market.  Originally started as a fish market, they’re still famous for their seafood but there is so much more to see (and buy).  The floral vendors were probably my favorite, but there were hand made leather bags and belts, jewelry, cosmetics, art, and many more things for sale there.  Scattered throughout the market are a bunch of performers- some really good, some comical.  There are great restaurants around. too.  Check it out:

A look down into the opening of the marketplace space.  From pikeplacemarket.org

Some of the gorgeous arrangements they have that are so cheap! When I was there, posies were in season and they were selling them for around $1 a bloom, or cheaper if you bought a dozen.

The famous fish toss done regularly by the staff at the fish counters. Picture from riceowls.com as it was too good to use my own.

Cheap, delicious produce. Photo from sixthavenueinn.com

The infamous Johnny Hahn- who sits and plays the piano all day at the Market. He’s such a familiar face that a lot of the artists renditions of Pike Place Market have him in it!

Just across from the Market is the original Starbucks…a total tourist trap. It’s the only store where you can buy Starbucks gear with the original logo and people come in droves to buy mugs and get their Seattle coffee fix.  And there are ALWAYS performers outside.  It’s got to be prime real estate.

Le Panier is a famous French bakery across from the original market. I had a croissant and Dan got pain au chocolat and both were perfectly baked.

And last but not least, to me the best part of Pike Place Market is when you walk just past it there’s an open park space where you can see THIS:

MT RAINIER!!! Often Most days Seattle has a bit of cloud cover, but on days when they clear away and you can see this peak it’s absolutely stunning.