Transcription – WCI – 368

INTRODUCTION

This is the White Coat Investor podcast where we help those who wear the white coat get a fair shake on Wall Street. We've been helping doctors and other high-income professionals stop doing dumb things with their money since 2011.

Dr. Jim Dahle:
This is White Coat Investor podcast number 368 – DOs versus MDs, which is the best degree?

Today's episode is brought to you by SoFi, helping medical professionals like us bank, borrow and invest to achieve financial wellness. SoFi offers up to 4.6% APY on their savings accounts, as well as an investment platform, financial planning and student loan refinancing, featuring an exclusive rate discount for med professionals and $100 a month payments for residents. Check out all that SoFi offers at whitecoatinvestor.com/sofi.

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Welcome back to the podcast. We have a fun episode today. We've got a guest on that we're going to interview. I've been on his podcast. It's Dr. Ian Storch. He's a DO. He's a GI doc. I'm going to ask him a bunch of hard DO questions. We're going to talk a little bit about getting a DO versus an MD, what that means now, what it meant 25 years ago, what it meant 100 years ago.

QUOTE OF THE DAY

I think it should be a fun episode. But before we get into it, let's get through a few preliminary things. First of all, let's do our quote of the day. Ben Graham, the mentor of Warren Buffett said, “The individual investor should act consistently as an investor and not as a speculator.” I totally agree with that.

By the way, we got something really cool coming up that people have been asking us for for a while. I can't announce it today, but it'll be on the blog within the next week. So, watch the blog this next week or listen to the podcast next week and you'll get all the information about that. But it's a pretty cool new online course or courses that people have been asking us about for a while. As usual, there'll be a special promotion that goes with it. Watch for that next week.

All right. For those of you who are residents, we got something else going next week, May 29th. It's your turn. The students had their turn a couple of months ago. It is your turn to get me to come and talk to you at your residency, except I'm not coming in person.

We're going to do it online because I can't come to all the residencies in the country. But if I could, this is the talk I would give to you. I'm recruiting my friend Andrew Paulson, one of the founders of studentloanadvice.com. The two of us are going to give you a presentation.

We're going to talk about making a smooth transition so you can hit the ground running as an attending. We're going to talk about what you need to do in those first 12 months after training. We're going to talk about what you should be doing with your student loans these days. We're talking about having the right insurance protections in place and not buying insurance you shouldn't need. We're going to talk about saving and investing your money so you can reach your goals and spend the rest on whatever you like guilt-free.

We're going to talk about all these building blocks, the basics of investing, how to build wealth. It is a presentation geared at residents. It's appropriate for fellows as well. It's totally free to you, and I don't have to get on a plane to come give it to you because it's going to be online. Sign up, whitecoatinvestor.com/resident. That will be May 29th. It's going to be live. We will take your questions live, and if it's like the student one we did, we're going to stick around for two hours afterward answering your questions. You can stay with us if you want, but a lot of times that's the best part of the presentation.

It's going to start 06:00 PM Mountain, May 29th. We'll see you there. Sign up, whitecoatinvestor.com/resident. Even if you're not sure you can make it, sign up, and we'll at least get you a recording of it.

All right, let's get into this interview with Dr. Storch. Let me get him on the line here. Ian, welcome to the podcast.

Dr. Ian Storch:
I’m happy to be here, Jim.

Dr. Jim Dahle:
All right, since I know you, but our audience doesn't, why don't you tell us a little bit about your upbringing and what it taught you about money?

Dr. Ian Storch:
Okay, that may be like a therapy session, but I'd be happy to do that. I grew up on Long Island, and my mother and father were not college graduates. They're sort of working folk. My mom was always the saver, and my dad was the spender. Growing up, the ideal was frugality from my mom. It was definitely something that she imparted on me. Again, my dad liked nice cars and probably things that he couldn't afford, so I kind of grew a distaste for those things. Unfortunate for my wife, that's kind of gone into my current life. I think more from my mother's perspective, a saver than a spender.

Dr. Jim Dahle:
All right, tell us about your education and career up until this point.

Dr. Ian Storch:
Yeah, I never thought I was going to be a doc. I grew up really being, I think my expertise was English literature and social sciences. I was an English major in college. I went to state school. I went to SUNY Binghamton. It's a New York school where I chose it because, again, my parents didn't go to college. I had a cousin who was really smart, who's now my attorney. He's still really smart, and he went to Binghamton. I said, “You know what? If he is this smart, he went to Binghamton, I'm going to go to Binghamton, too.”

And somewhere along the way, I had an interest in medicine. I actually saw a car accident. It's a cliché story maybe, but I saw an accident. My roommate was one of these EMT guys with the lights in his car and the oxygen in the backseat, and we got out to help this woman.

After we saw the car accident, I thought if I'd been by myself, I wouldn't be able to help the woman. I took an EMS class, and I fell in love with medicine. I decided I wanted to go to medical school. I really didn't know much about medical school, no doctors in my family. I started studying for the MCAT, and again, I was an English major, so I took some science classes.

I had a Barron's book, and the Barron's book, they don't have books anymore. Obviously, everything's online, but Barron's book to medicine and dentistry. And it was medical school, dental school, and the last few pages were something called osteopathic school, which I'd never heard of before.

I did some research on osteopathic school, and I thought, “This is really cool, and this is something I might want to do.” I went home, and I actually had a physical scheduled. Then I went to my primary care doctor, and I had the book. I showed him, and I said, “Dr. Horowitz, what do you think of this stuff? Is this something that's worth doing? What do you think of osteopathic medicine?” And he said, “I'm a DO”, which was shocking to me. I never even heard of it before, and I said, “Why do you have Dr. Horowitz on your jacket?” And he said, “I don't know. People just keep asking me questions over the years. It's a little annoying, so I just took it off my jacket, but it's great, and I think you should do it.”

I researched osteopathic school. I thought I was going to be a family practice doc or primary care doc, and a little bit of a long story that I'll skip, but actually, I'll give you a little bit of it. I interviewed at Kirksville. Actually, I wanted to go, if I'm going to do it, I'm going to do it right. Kirksville is the founder school. That's really where I wanted to go. I had a girlfriend at the time who was in New York, and she convinced me that I should stay. Needless to say, we dated for another few months and broke up, but that's a long, separate story.

I went to the New York College of Osteopathic Medicine for four years, and during my rotations, I fell in love with gastroenterology. Just met a gastroenterologist who I thought was spectacular, and I said, “I want to be like him.” I interviewed all over for internal medicine, Mayo Clinic, Cleveland Clinic at the time, DOs could be free agents, but I ended up staying in New York at North Shore, which is actually where I am now.

I spent three years of internal medicine at North Shore, Long Island. I did a chief resident year. I was blessed that they asked me to stay and teach the program for a year, internal medicine, that's an extra year. And again, I was blessed with a fellowship at a very prestigious program, University of Miami, which is just a spectacular GI program. I spent three years doing gastroenterology. I did full liver training. I was able to pack some biliary work, which is advanced training, into that three years.

And I had met my wife, actually. I dragged her kicking and screaming down to Miami to hang out with me during fellowship, and she said, “Ian, I really think I want to go home.” So she said, “Beautiful here. We had a great three years. Let's go home.” We came back to Long Island, and I joined a private practice. We'll talk about that a little bit later, but I joined a private practice, and that's still where I am.

Dr. Jim Dahle:
Awesome. Great summary of a great career so far. Let's get into our subject today. You're the podcast host of the cleverly named D.O. or DO NOT podcast. And today, we're going to talk about DOs and death, including the history of osteopathy and how that affected osteopathic education and practice today.

HISTORY OF OSTEOPATHY

There's a few things about the philosophy and history of osteopathy that are a little odd, and I want to hear your take on it. Before we get into those questions, though, I think it's important to point out that the history of medicine itself is not exactly a shining example of a beacon of ethics and scientific practice.

When George Washington was dying of epiglottitis, one of his three physicians wanted to try a newfangled technique called endotracheal intubation. But the other two overruled him. They went with the best treatment of the day, bloodletting. And I'm sure hemorrhagic anemia really did a lot for his epiglottitis. Doctors didn't even wash their hands until the mid-1800s, spreading peripheral fever as they went from corpses to delivering babies without any time in between.

The mark of a good surgeon in the Civil War was whether or not you could take a wounded limb off in less than 10 seconds with a saw. Ether as an anesthetic wasn't discovered until 1846. Anesthesiology before that was a bottle of whiskey and a stick to bite on. Insulin wasn't discovered until 100 years ago. Before that, diabetics just died. Antibiotics are even newer.

Prior to Hippocrates, illness was attributed to evil spirits. Hippocrates actually moved us into the imbalanced humors, blood, yellow bile, black bile, and phlegm era. And it wasn't until Pasteur in the 1860s that we even had germ theory. So, there's still plenty of things we do in modern medicine that really have little if any evidence for them.

But with that introductory material out of the way, just to make it clear that we're not in a glass house throwing stones, let's talk about the origin of osteopathic medicine. In the 1870s, frontier doc Andrew T. Still was pretty dissatisfied with modern medicine. He felt the drugs were useless or even harmful. He's probably right about that.

He founded a philosophy of medicine at least nominally focused on wellness, disease prevention, and the whole body rather than just parts of the body. He wanted to treat causes rather than effects of disease. He was probably highly motivated by the fact that his wife and three of his children all died of then untreatable meningitis. So far, so good, right?

Then it got a little odd because Still believed you could treat a variety of diseases by diagnosing and treating the musculoskeletal system. Epilepsy, dysentery, asthma, period-related pelvic pain, digestive disorders, depression, colic. The idea was that there's an osteopathic lesion or a myofascial continuity causing a somatic dysfunction. And you fix the osteopathic lesion through manipulation of the musculoskeletal system, the somatic function will go away.

Now the UK's NHS says there's some evidence to suggest that osteopathy may be effective for some types of neck, shoulder, or lower limb pain, some types of headache and recovery after hip or knee operations, but there's only limited or no scientific evidence that it's an effective treatment for conditions unrelated to the bones and muscles.

And in fact, osteopathy was treated as a cult by the AMA in the first half of the 20th century. And in fact, this code of ethics forbade physicians from associating with osteopaths. That's obviously dramatically relaxed over the last century, but DO schools still teach Still's philosophy in some form and still teach every student osteopathic manipulative medicine techniques.

With all of that information out there, as a modern day DO, what are your thoughts about the history of osteopathic medicine?

Dr. Ian Storch:
Yeah, first of all, that was an amazing summary of 2,000, 3,000 years of medicine in three minutes. Bravo, great job. But I think A.T Still founded osteopathic medicine, as you pointed out. Exactly as you pointed out, we have to put everything in context. So, you can't look at a da Vinci robot when you're talking about medicine in 1870s.

As you said, we didn't even know that bugs were causing disease. Penicillin wasn't invented until the 1920s, I believe. So we're talking pre-antibiotic. We're talking pre-everything that we have now, as you said, morphine, chopping off limbs, leeches. Allopathic medicine was not what it is today. And again, A.T. Still took a different approach.

He was not an MD. He was not a medical doctor. He was a frontier doctor, again, the system, there weren't medical schools the way we have them now. When you're talking about the history of medicine in the United States, the Flexner Report, which was a person that reviewed all medical schools and actually got rid of a lot of MD, DO and other homeopathic type schools, because of the way that the education was just not what it should be and really standardized everything. None of those things had come about.

Again, he started practicing this manual medicine and a lot of allopathic doctors came and trained with him and became MD, DOs or DOs, doctors of osteopathic medicine. And the profession really evolved from there.

As a practicing DO today, it's interesting, we definitely have come a long way. And this is the 150th year, interestingly. The profession has been around for a long time and evolved over time, but we're complete physicians. DOs practice full spectrum of medical care in the United States, which again, you mentioned the UK osteopathic treatment or osteopaths in other countries are different than doctors of osteopathic medicine in the United States.

In the United States, we are complete physicians. We get a medical license in almost every state that's exactly the same as an MD would. The license is the same. There are a few states that have separate DO licensing associations, but most of them, again, same licensure. I have the same plaque on my wall that you would have as far as my ability to practice. And we can go into any specialty of medicine, from surgery to family practice, as we discussed.

The thing that makes us different is the philosophy, which you mentioned, which we have kept from Andrew Taylor Still and the manual medicine, which Andrew Taylor Still started, but has really evolved and come a long way since.

MANUAL MEDICINE

Dr. Jim Dahle:
Let's talk a little bit about that manual medicine. A lot of people look at it and they can't help but see the similarities between osteopathic manipulative medicine and chiropractic treatment. What do you see as the difference between those two?

Dr. Ian Storch:
I'm just going to preface with, this is not my area of practice. I am a gastroenterologist, as I stated, but I think, again, as the host of D.O or Do Not, I'm happy to try to tackle the answer to that question. And I'll give you a little interesting story before we start. I have an uncle who's actually my father's best friend, but we're just going to call him Uncle Freddy. Uncle Freddy is actually a chiropractor. I grew up with a chiropractor as an uncle.

Interestingly, and again, I'm not directly answering your question, but I'm going to come back. Uncle Freddy, when I went to him with that book, I said, “Uncle Freddy, what do you think of osteopathic medicine? I'm thinking about doing this.” He said, “Don't do it.” He said, “You should either become an MD, be a medical doctor or be a chiropractor. I'm not into this osteopath stuff”, which was interesting. And he's come full circle. I think he fully respects osteopathic medicine after many, many conversations with him.

But when you're talking about osteopathic manipulative therapy, which there are a few different terms, osteopathic manipulative medicine, OMM, osteopathic principles and practice is OPP and osteopathic manual therapy, which is OMT. There are some nuances to those terms, which I may or may not be able to explain to you. So I'm going to bow out, but they all kind of encompass osteopathic therapies.

First of all, DOs, I'm going to reiterate, especially in the United States are complete physicians. And again, to take a step back, I have nothing against the chiropractor. Nothing that I say is negative to a chiropractic. Uncle Freddy is a chiropractor. I love him, but a chiropractor is not a complete physician. A chiropractor only practices manual medicine and is not trained as a complete physician.

An osteopathic practitioner in the United States is a complete physician that is trained, takes all the same classes that an MD takes, and again, has a medical license that's the same as an MD.

As far as the therapies go, I'm going to talk again about strict chiropractic because some chiropractors do osteopathic therapy. Some chiropractors do physical therapy. Just talking specifically about chiropractic therapy, chiropractic therapy as a generality focuses on the spine and the nervous system coming out of the spine. Most of the techniques that people think about when they think about chiropractic therapy are high velocity thrusting techniques, which are those sort of back cracking techniques.

DOs look at multiple, and again, we're not talking about philosophy, we're just talking about therapy. DOs look at not only the nervous system, but the lymphatic flow of the body and blood flow. There's really thinking about the whole body, sort of everything that you can manually work on by manipulating the musculoskeletal system.

The osteopathic treatments range from soft tissue techniques, muscle energy techniques, to high velocity techniques. There are multiple techniques and they even go to some sort of advanced techniques, I call them, which would be things like cranium manipulation, where there are doctors that work on the cranium and the sacrum and there are different ebbs and flows that are felt to affect health.

And not all osteopaths, obviously, practice this, as we discussed at the beginning, but that's the basis. Again, some chiropractors do craniosacral techniques, but in general, they focus on the spine.

OSTEOPATHIC PHILOSOPHY

Dr. Jim Dahle:
I often tell people on this show, take what you find useful, leave the rest. What do you find useful about the osteopathic philosophy and what have you chosen to leave where you found it?

Dr. Ian Storch:
Okay, now we're going to switch gears a little bit. I'm just going to answer that a little differently. As far as manual therapy, I don't practice manual therapy. I'm a gastroenterologist. Again, I trained at University of Miami. There were no DOs. I was the only DO in my fellowship. So I practice the same gastroenterology as any other gastroenterologist, MD or DO, would.

As far as philosophy, the other thing that I think really makes osteopathic medicine distinct is the philosophy. And again, just similar to talking about chiropractic, I have plenty of MD friends that say, “Look, of course we believe in that.” And I think one of the interesting things about osteopathic medicine is that it's sort of become mainstream to the point that everybody is buying into or agrees with A.T. Stills' philosophies. They're not as mind-shattering, earth-shattering as they were in the 1870s. Now people look at the philosophy and say, “Of course that's true”, MDs and DOs.

The tenets of osteopathy, I'm just going to go through, we like to chant this, but the body is a unit, mind, body, and spirit together. And they recommend the doctors look at all of these things. The body is capable of self-regulation, self-healing, and health maintenance. Structure and function are reciprocally interrelated. And that rational treatment is based on these principles.

The bottom line is, again, I don't think anybody's going to argue that when you see a patient, you have to look at the whole patient, mind, body, and spirit. And again, I'm a gastroenterologist, but when a patient comes into my office, I try to engage with the patient. I try to make a relationship with the patient. You could argue that this is just because I was chief resident in internal medicine, but I always take time to make sure they saw their primary doctor, they had their mammogram, they had the cholesterol check. I'm really always thinking about the whole patient, not just the fact that the patient's coming in with rectal bleeding. I feel that that's sort of my osteopathic background.

What do I leave from the osteopathic philosophy? Nothing. I think the osteopathic philosophy is great. Part of my pride in being a DO is the reason that I started the podcast. I think that it's really a great way of thinking about patients. And again, the manual medicine, I don't practice.

I always kid around. I've talked about it on a few interviews, but my son is 16 years old, and this is a little odd, but I'm going to share it with you anyway. My son is 16 years old. He wants to be a physician, not any push from me, but I would love for him to be a doctor. And he carries a very heavy backpack, which I'm frequently trying to convince him to stop. And then he says, “Dad, my back is killing me.” At some point he asked me, “Can you do some of that OMM stuff for my back?”

And I started doing some soft tissue techniques and occasionally a little high velocity thrusting technique. It's probably the only OMM I practice at this point, but he's addicted. He's got to leave me alone. I'm like, “No, I just did 20 colonoscopies today. I want to take a nap.” And he's like, “Come on, dad, can you just rub my back a little bit? It really makes me feel much better.” But other than that, that's not part of my practice.

CRITIQUES OF OSTEOPATHY

Dr. Jim Dahle:
There's critics out there who call osteopathy, and I think mostly they're talking about the manual medicine. They call it quackery. There's an article on Quack Watch about osteopathic medicine. What's your response to those who call it quackery?

Dr. Ian Storch:
Okay. I would just start with the term quack. If you don't mind, I'll just define where did quack come from. Quack is Dutch for quacksalber. That's where it comes from, which is an unregulated practitioner who sold cures of dubious origin without a doctor's prescription.

My first response in the United States is that osteopaths are doctors. We're complete physicians. So it's not without a doctor's prescription and it's not unregulated. We have regulating bodies, etc. When it comes down to evidence on our podcast, again, this is not my area of expertise. I can't quote papers on osteopathic medicine, but there is evidence. There is some evidence on osteopathic medicine.

There's a doctor named Jordan Keys, who's just awesome. We've interviewed her, and she's a great woman. She's at the New York Institute of Technology College of Osteopathic Medicine and she is trying to group together different practitioners to work on advancing research. A lot of DOs really are focusing now on evidence base for osteopathic manual medicine. And I think it's super interesting. They know it's needed and they're working on it.

OSTEOPATHIC EDUCATION

Dr. Jim Dahle:
When I applied to medical school 25 years ago, I applied to both MD and DO schools, got into some DO schools, interviewed, was accepted. And the main explanation I heard when I went there was that, “Yeah, we teach medicine. We also have OMM classes.” Do you think DO schools should still be teaching OMM classes?

Dr. Ian Storch:
A hundred percent DO schools have to teach OMM classes. I think that OMM is part of our culture, our history, and I think it's important to have a perspective. And sometimes people come to see me and they comment that I'm a little more, again, I am a standard gastroenterologist. I don't do anything different than an MD/GI doctor would, but there are a lot of people that do a lot of different alternative therapies or complimentary therapies.

And I think just having been exposed to manipulation in medical school, I believe gives osteopaths not only an appreciation for manual therapy, but appreciation for other complimentary therapies that may not be the standard of care in the United States, but that patients want and are seeking out.

And rather than, again, saying the practitioner that's talking about probiotics, which again, I can talk to you about GI things for a year, but microbiome is really coming to the forefront. Everyone in GI is talking about microbiome now, but if you asked someone about probiotics two or three years ago, they may have said anybody who's using probiotics is a quack. There's no data. So sometimes it just takes time for the data to come.

Again, answering your question, I think that it's integral. Manipulation is integral to our history. I think it's integral to who we are as osteopaths. And even if DOs don't practice it, I do think it's important to teach it in school.

Dr. Jim Dahle:
Now on average, based on objective data, test scores, GPAs, acceptance rates, etc, it's still a little easier to gain acceptance to a DO school than an MD school. What advice do you give to a student who's trying to decide which medical schools to apply to? Should they apply to only MD schools, only DO schools, both? What advice do you give?

Dr. Ian Storch:
All right. First of all, I'm going to circle back to our first question about your question to me about finances, and I'm going to give sort of a Jim Dahle answer, if that's okay. I don't want to be the White Coat Investor or take your spot. I already told you my son wants to go to medical school. And he asked that question. He said, “Dad, am I going to DO school or am I going to MD school?”

My thought is, first of all, look at your finances. I think medical school is so expensive. I think that's got to play a big part into where you go to medical school. But number two, I think it's similar to advice that you give someone about choosing a college. You have to do your research. You got to see if the school offers you what you want, whether it be location, whether it be outside of school, the area that the school is in. If you have a passion for a holistic philosophy, you should go to osteopathic school. If you have a passion for manipulative therapy and complementary therapies and you want to learn something more, I think you should look at osteopathic school.

As you said, people go to schools for different reasons. Some people only get into one school. If you applied to MD schools and DO schools and you only got into DO schools, I think that's great. I think it's probably something that you should consider, but I think you have to look at all of those factors when you decide where you want to go.

Dr. Jim Dahle:
Same advice once I get in. Say somebody gets accepted to a DO school and an MD school, same price, they're fine with either location, you'd tell them to make the decision based on philosophy and how they feel about it.

Dr. Ian Storch:
I agree. Yes, absolutely. I think at any school, the other thing that I would think about, and it's very difficult when you're applying to medical school, but you have to have some thought about maybe what you'd want to do. I would say what you want to do when you grow up. Most of the mission statements are to produce primary care docs. If you want to be primary care, it's a no brainer, but maybe if you wanted to be a neurosurgeon and you looked at, I would say look at the school, see how many DO schools that have interviewed DO neurosurgeons. There are plenty of DO neurosurgeons, but that's not what the average DO goes into. Maybe look at the schools, see if things that you're interested in, people have gone into those specialties. Again, I would say the same thing for an MD school.

Dr. Jim Dahle:
It's tricky too, though, because about half of us change what specialty we want to do at some point in medical school. I thought I was going to be an FP coming in. I ended up being an emergency doc. I think probably half my class changed. Some of us changed a dozen times trying to figure out what specialty we were going to do.

Dr. Ian Storch:
Absolutely. You can't see the future. It's definitely difficult. Again, I thought I was going to do primary care when I first started as well, and I ended up becoming a gastroenterologist. There's no perfect answer when you're picking a school, but I'm very proud of my education as far as going to osteopathic school.

The ends justify the means. You could only say if your choices were correct when you look at where you are at the end. Obviously, hopefully, I'm not at the end, but the ends justify the means. Looking back, again, I was very happy with my decision to go to osteopathic school at the time. Today, I'm very happy with the school that I went to, my education, and everything that I've built off of it.

Dr. Jim Dahle:
I've noticed a trend recently. There's now three medical schools in Utah. There's the University of Utah School of Medicine up in Salt Lake, where I went, and there's two new DO schools, one in Provo and one in Southern Utah. It feels to me like most of new medical schools these days are DO schools. Do you have any idea why that is? Is it some sort of regulatory thing?

Dr. Ian Storch:
It's a great question, Jim. Honestly, I would like to know the answer also. I do not know the answer. The interview hasn't gone up yet, but there is COCA, which is the accrediting agency for osteopathic schools. We interviewed a dean that is on COCA. I don't think they actually have any input as to what schools are opened.

Obviously, you talk about this on your show. We need more docs in the US. A lot of docs go to South America or the Caribbean or other countries to train. We don't produce enough doctors in the United States, DOs and MDs, to fill all our residency spots. Again, I have nothing against Caribbean schools, but I don't see why students in the US, if we need US docs, why we're not producing them here. Whether there are more MD schools or DO schools, I don't think that matters. I think either is great.

Again, your question is, why aren't the MD schools increasing in size to fill that need? Why are the DO schools increasing? There's definitely been a dramatic increase in the number of DO schools over the past 10 years, but I don't know why that is.

Dr. Jim Dahle:
One issue with it, it seems to me that a large proportion of those DO schools, particularly the newer ones, they're not associated with their own teaching hospital. They farm out their students all over the region. They sometimes expect the students themselves to line up for rotations, like medicine and surgery, with non-academic docs at community hospitals. Do you think that's a problem? And if so, what should be done about it?

Dr. Ian Storch:
Again, I'll tell you from my experience. I went to the New York College of Osteopathic Medicine. They did have a lot of affiliate hospitals where we rotated. There wasn't one main core hospital. For me, it was actually a great experience because I could pick and choose what rotations I felt were strong. Maybe if I just had one hospital, I wouldn't be able to pick those.

As far as going into the community and not being in a big university, sometimes it does make research a little more difficult to get. I actually did a lot of research in medical school, but I had to seek that out. Again, it depends on the MD institution. I'm actually a professor now at an MD institution and a DO institution. It depends on institution to institution. I wouldn't say every MD institution allows you that research opportunity, but I do think that's something that the DO schools are working on and need to work on.

As far as rotations, again, I don't speak for the American Osteopathic Association, ACOM, or any of the schools, but I think that if you're picking a school, if I was a student and I was picking a school, and again, I have students that I mentor that go to DO schools all the time, and I recommend that they really take a good look. I think it's so important to make sure that your school has strong rotations, strong affiliates with hospitals. If they are a community, that's okay, but make sure that those rotations are great or those rotations are solid and that there's good placement for residency and fellowship after they leave. I think they just have to do their homework. As far as schools that don't have those affiliations, I think that's beyond anything I can comment on how to make that better.

Dr. Jim Dahle:
Perhaps the biggest change in MD and DO relations came just a few years ago. The MD match has essentially been open to DOs. It was kind of phased in between 2015 and 2019. I think the DO match went away completely, right?

Dr. Ian Storch:
Yeah, there's a combined match now. That's correct.

Dr. Jim Dahle:
What recommendations do you have for DO students as they approach the match process?

Dr. Ian Storch:
It's so interesting. Again, I'm going to say this like 20 times, but I'm not academic. I don't work for the NRMP, but I have a lot of students that I mentor, so I kind of try to keep my finger on the pulse. I do give them advice, and I'm happy to share that. It used to be, when I applied for internal medicine, you could go through the DO match. There was a DO match. You could go through the NRMP or the MD match or however you want to call it, or you could actually be a free agent.

I actually signed outside the match. It was really a nice thing. People said it was unfair. I was offered a spot at Mayo Clinic. I actually signed my spot at North Shore outside the match. My wife would say that I cheated. I don't know. It was a little loophole. It wasn't really cheating, but as a DO, it was kind of nice. You could sign outside the match. Again, people felt that's not fair, and they got rid of it.

There's now a combined match. DOs cannot sign outside the match. There is no DO match. It's combined. Again, is it fair to MDs that MDs can't apply to those DOs? How is that fair? That's not really fair either. Again, it is what it is. There's now a combined match.

Another question that comes up with students are boards being passed foul, and what do you do? My advice to DO students or any medical students, again, I have MD students that I mentor also, is always it depends on what you want to do. If you want to go into pediatrics and you want a rural experience that's not competitive, it doesn't matter that much, but if you want to go into pediatrics and you want to be a CHOP, you want to be in a competitive program, whether you're an MD or a DO, I think you have to do your best to try to showcase yourself at that hospital.

I think you have to try to do research, which is the coin of the realm, and you have to do well on your boards, and even more so of those things if you want to go into a very competitive subspecialty like orthopedics or dermatology.

Dr. Jim Dahle:
Or GI, frankly. A GI fellowship is pretty competitive too.

Dr. Ian Storch:
Yes, GI is interesting. I think that's an interesting fact, also. I'm very big pro-primary care. I did internal medicine obviously before I did GI. I think the internist, the family practitioner, pediatrician, those are the most important people in healthcare. I know on your show we talk sometimes about compensation for those things, and maybe they're a little less compensated than surgical subspecialties, but I think those are the most important people in healthcare. Those are the people that are seeing the patients and helping them get to where they want to be.

We talk about a lot of DOs going into primary care, but primary care like internal medicine, pediatrics, a lot of people that go into primary care end up doing a subspecialty afterwards. I think that's a little misleading.

GI, without being totally obnoxious, is the most competitive subspecialty off of internal medicine. Part of it because there are not as many spots as things like cardiology, but cardiology and GI are the most competitive. If somebody wanted to do GI, again, it's like you get into that internal medicine residency, and especially at home, which is your best shot at getting a fellowship, make sure that you're known as a hard worker, make sure you care about your patients, make sure that you do your research, and do well on your tests.

Dr. Jim Dahle:
I was fascinated by gastroenterology when I was a medical student. I thought that would be a really great career, but there was no way I was going through an internal medicine residency to get there. I just could not round for three years. There's no way I could have done it. I wouldn't have made it through.

Dr. Ian Storch:
Jim, I love rounding. I'm an internist at heart. There's nothing better than rounding. I'll tell you, it's so interesting when you think about choosing a subspecialty. I would never do emergency medicine. I just couldn't do it. I'll tell you the reason why I couldn't do ER, just like you can't do medicine because you couldn't round.

I couldn't do ER because you have to make so many decisions on a daily basis, whether to treat the patient or send them home. Some of those decisions are really tough. I think it's really tough. And it's very unforgiving. I think the system is very unforgiving. You can't admit everybody. Some people you're going to send home, and they're going to get sick and need to come back and you get judged on that.

Dr. Jim Dahle:
Well, now everybody is training basically in the same programs. After that training is done, after residency, what do you think employers and patients themselves should think about the medical degree of their doctors that they might hire, whether they have an MD or a DO? Do you think there's any advantage or disadvantage at that point that still remains, or should it just be ignored?

Dr. Ian Storch:
Once you get out of training, there's absolutely no difference. As far as patients, I've been practicing gastroenterology now for 20 years. I think the only DO comments that I get, thank God I have a very busy practice. I'm blessed that people want to come see me and have me take care of them.

The only DO comments that come up, which are kind of funny sometimes, is once a year or so, a patient will come in and say, “I really wanted to see you because you're a DO gastroenterologist, and I want a holistic approach.” Again, there's not that much holistic approach to colonoscopy for screening. It's kind of like they're getting checked and we're taking out some polyps, but I always smile, and it makes me happy. Again, as far as patients go, for most things, we're the same.

CHOOSING A JOB AFTER TRAINING

Dr. Jim Dahle:
After you finished your training, you deliberately took one of the lowest paying jobs you were offered. Tell us why and how it worked out for you.

Dr. Ian Storch:
Yeah. As you said, Jim, it's very competitive to get GI. I actually applied twice. The first time I applied, I did not get a position. They offered me chief resident, which again is a very prestigious teaching year. Then I reapplied the second year and got my fellowship at University of Miami, which again, I couldn't say enough about. It was a really difficult road to get a GI fellowship. Then after I got out, there were like 250 job offers. People were falling over themselves to give me a job.

What's so interesting is I thought getting a fellowship was hard. Again, we're talking about getting into medical school is hard and maybe only have one choice. That always seems terrible, but it was actually so much harder to pick a job, and I just didn't know what to do.

Ultimately, I was offered, and I never looked at money when I thought about it. Maybe it was naivety, but I just did what I loved. I love GI, and that's what I did. When I got offered salaries, I was like, “Really? They're going to pay me that much to do what I love? That's great.”

But a lot of the jobs that I looked at had restrictive covenants, and had turnover, had doctors that had turned over. I interviewed with a doctor who was a fellow. When I was an internal medicine resident, he was a fellow. He went off into practice with another doctor, and they had actually had a little bad divorce. He was on his own.

I spoke to him. I actually came in for an interview as an attending physician working for the hospital. I ran into him walking out, and he said, “Storch, listen, I really got to hire somebody. I'm so busy.” I had sent him a letter, I think, or called him. He's like, “Would you be interested in a job?” I'm like, “Yeah, I would love to talk to you.” I sat and talked to him, and he said, “Listen, let me think about it, and I'm going to make you an offer.”

His offer was, he sent me a contract or sent me a proposal. It was basically, “This is what I'm going to offer you. I don't really have a practice to offer you, so you're not going to have any patients. I'm going to pay you about half of what everybody else is offering you. I'm not going to make you sign a restrictive covenant. If I mistreat you in any way, you can hang a shingle next door. I'm going to give you occurrence insurance, and you can build your own practice.”

I really saw it as a great opportunity, and I’m really blessed with my wife. My wife's just a very, very supportive woman. It was tough. Miami was great, but we were not living the good life in Miami. My salary, when I graduated, and again, this is going back a number of years, but I think it was $24,000 or something like that.

In fellowships, sometimes the more prestigious the fellowship you get, the less they pay you because they know you're going to come. I told her, “Look, I think I can build my own practice as opposed to taking this big salary and a restriction and taking someone else's patients and having them grow my business. I think I could do this on my own, and I think I could grow my own practice. I think this is the way to go. I think I got to bet on myself.”

My wife was supportive of the decision. It was a very difficult decision, but I took the job and still have my own practice, still in the same practice. Again, looking back, I could not have been happier or done better with any of the other 249 jobs I was offered.

Dr. Jim Dahle:
Financially, how'd you do? Did you feel like you came out ahead despite starting at a relatively low rate?

Dr. Ian Storch:
A thousand percent. There is absolutely no question that I would not be financially in the position that I'm in if I had taken any other job. Again, obviously, I can't go down those other paths, but I can imagine I would be in as good a position as I am now. I believe, and this was my philosophy when I was looking at a job, was have a five-year plan.

Sometimes students come to me and they ask me for advice, docs coming out of residency, students that I've mentored in the past, or they find my name on the bathroom wall and they're like, “Storch, what do you think of this job?” I always tell them, and again, this was my own thought process, which I really feel is true. Don't look at that initial salary, because when you start off as a doc, that's not your top end. Your top end is going to be five, seven, it depends on what you're doing, but it's going to be a few years down the road.

And as you said, even with changing your mind to med school, you may not be with the same job, but you want to take a job that you really think you're going to be with, because you want to maximize your chances of getting to that five-year or whatever year that is, where you're going to have your wings fully stretched, and that's where you're going to do the best, if you get to that point. If you're bouncing job to job, you're never going to get there and your earning potential is going to be much less.

Again, I was fortunate that I built my own practice. I didn't owe someone, I didn't have to buy into my practice, I didn't have to give someone, my partner. That was the other piece, there was no buy-in, it was sweat equity, so he made some money off of me for a few years, and then whatever I had was mine. Again, if I wanted to leave, if we had a disagreement, I didn't have to give up that five years or whatever years of reputation that I had built, I could keep it and stay. It worked out great.

Dr. Jim Dahle:
A lot of people I think don't realize there's value to a non-compete. Now, it sounds like they're probably all going to be outlawed soon anyway, but there's value. You got to get paid more if you're signing a non-compete because you're losing something when you do that. They should pay you more if you're having to sign non-competes, absolutely.

Dr. Ian Storch:
I think advice that I would give to or that I regularly give, you have to know yourself. This may sound negative, but you have to know, are you the person that just needs to be employed, you just want to come in, you want to check in, you want to do your thing and go home? Or are you the person that you're going to hustle, you're going to stay late, you're going to put in 110%?

Because again, there's nothing wrong with being an employed doc. I have my own practice. There's a lot of business pieces that I have to do. Those things take a lot of time. I love it. I wouldn't trade it in for anything, but you have to decide, do you want to bet on yourself? If you really believe in yourself and you really know that you're awesome, always bet on yourself.

PEARLS FROM A PRIVATE PRACTICE DOC

Dr. Jim Dahle:
Do you have any other pearls? As a private practice doc, there's not that many of us left. As a private practice doc, what pearls do you have about contracts, partnership, working with insurance, et cetera, that you've applied in your practice over the years?

Dr. Ian Storch:
Yes. I would say coming into practice, you just mentioned the restrictive covenant. We'll see what happens with that. As you said, that may or may not go out the window, but that would definitely be great for people coming out if it does. But as you said, for me, not having a non-compete was great.

When you become a partner, part of the problem is, and it's interesting, when you're looking at a job, there was a practice that actually offered me a letter of intent. Practices don't tell you, or they're not going to legally tell you, you'll be partner year five, and this is what it'll look like because maybe things won't work out.

But there was a practice that offered me a letter of intent of this is what partnership will look like. My attorney told me that had no value, but in retrospect, I thought it was real nice. I think it's a nice thing to writing what partnership's going to look like.

Private practice, as you said, there's not that many of us around. Most docs, majority of docs at this point are employed. I think there's great value in private practice. Again, it's an effort, it's extra work, it's not easy, but I think that there's something extra that you can offer to your patients as a private practice doc.

Don't get me wrong, I have plenty of colleagues and friends that are employed and practice like a private practice doctor. But private practice doctors in general, because it's theirs, if it's five o'clock, six o'clock, and today I had office hours, a referring doctor called up and said, “Storch, I have somebody in my office. I know you probably have an interview with Jim Dahle later today, but they're having an issue. I would love if you could see him.” Send him over. Again, you may not have that ability if you're employed. Maybe the office closes at 02:30 because we have an interview with Jim Dahle. Sorry, you can't see that extra patient.

Waiting times for procedures. Again, my practice is very blessed. We're busy, but we can always, if somebody comes in, and I got a phone call today, a patient is having a kidney transplant, they really need to get their colonoscopy before the transplant. No one else will do their colonoscopy. Everybody else is booked out for two months. Of course, we're going to take care of that patient and make sure that they get what they need.

People talk about private practice going away and there not being private practice anymore. I guess that's possible, but in my opinion, I think there'll always be that niche of the extra value add that private practice can give.

As far as insurances, the negative to being in private practice, I think most private practice docs, most docs in general with an IPA or a physician organization that helps them get better contracts, obviously those things are always helpful and you can do that and still be independent. Definitely hospital systems can negotiate higher rates. Many times, organizations that want to acquire my practice will point that out.

The question for those situations, for big groups that hire docs, is are those monies actually going to the docs? Even if they're making more money on the procedure, is the doc actually seeing that money? That's question number one.

The other question that I always think about is patients have high deductible plans. They have responsibilities. I think it's important, or at least in my practice it's important to provide great care at the lowest cost possible. That's for the healthcare system at large, for the insurance company. They look favorably on people that are lower cost providers. Again, if you could do it for less, don't do it in the hospital. If you do outpatient procedures instead of doing them in the hospital, it saves money, again, when clinically appropriate.

For the patient, again, patients have high deductible plans for a lot of things. It's unfortunate that patients are consumers, but they are. I think you can help more patients have access to care and get the care that they need if you provide lower cost.

Dr. Jim Dahle:
One of the best things I like about private practice is just control. As you move through your career, the control matters. You get less burned out when you have control over your work environment and how much you're working. I think that's the best part about being in private practice, that new grads don't realize how important that's going to be to them in a few years.

Dr. Ian Storch:
Yeah, 100%. Recently, one of my endoscopy technicians said, “You know what? It would be great if we had another pediatric colonoscope. What do you think?” I said I think that's a great idea. I think we should, yes, we should have an extra pediatric colonoscope. I called up my scope rep and I told them, look, can you send us another scope? We cut him a check and we got a scope. There's no red tape. That was a great idea. We got a new scope.

On the other side, I have a good friend who was in private practice. He's with a hospital system now. I remember when he first joined, his son had a hockey game two weeks from the day that he found about it on a Friday. He went to his office manager and said, “Listen, my son's in the hockey championship. Two weeks from now on Friday, I need to take the day off.” She said no. He said, “What do you mean no? It's two weeks from now. I really want to be there for my son and spend time and go to his hockey game.” She said, “There's a policy in the office. You need to give a month notice for elective. You already have patients booked and you can't take that day off.” I don't know that people realize that when they sign up.

Dr. Jim Dahle:
Yeah, those sorts of situations are very burnout inducing. What else has helped a lot of people with burnout, though, is having some sort of a side gig. I know you've done some. What do you see as the role and the benefits of side gigs in a career for a doctor?

Dr. Ian Storch:
Burnout is so interesting to me. I would say, first of all, we all know burnout is a huge problem. I think the best way, and again, I'm not answering any of your questions directly, but I'm going to come back. The best way to avoid burnout is to do what you love. I think you got to pick something that you love. It's always interesting when I speak to students and they're like, “What do you think I should do?” Maybe they're going on a Medscape search and seeing what docs are making the most money or have the least hours. I think those are bad ways to make a decision. I think you got to try everything on.

As you said, you may change your mind 15 times, but pick what you love. I love coming to work. I love gastroenterology. God bless, I've been doing this for 20 years. I work a lot of hours and I don't think I'm getting burnt out. But I definitely think having outside interests and doing other things is amazing. I definitely think it's true that it avoids burnout.

The term side gig is always interesting to me. I don't know that I have side gigs. Side gigs would be like if I worked at McDonald's on top of my GI practice. Most of the things that I do outside of my clinical practice, and again, we can call them side gigs, but they're affiliated ventures. The great thing about GI, and I know you said you didn't want around to do GI, but the thing that's so appealing about GI is I have my practice, I see my patients, I have relationships with people, but then on the side, I get to do cool procedures. That's just fun.

Part of that is the tech of GI. I've always tried to stay involved with companies that are developing tech. Little interests of mine are like capsule endoscopy, which I've been very involved with since it was FDA approved in 2021. The idea that you can swallow a little movie camera that takes pictures of the small intestine as it goes through and give you diagnostic information is super cool to me. I have had some ability to work with some companies to develop different technologies specifically for capsule endoscopy, which has been great.

Early in my career, another thing that I was able to get involved in was defending doctors for malpractice. That's such a hard time for any of us. That's the dark times for a doc. Whether we like it or not, we're all going to end up, most of us, in some sort of malpractice suit. Whether you do something wrong, which happens sometimes. Like I said, I couldn't be an ER doc because at some point, you're going to send somebody home that if you look back, maybe it looks like you shouldn't have even though at the time it was the right decision. You didn't do anything wrong, and you're just getting sued.

I was very interested in medical malpractice. I did a lot of work defending doctors, again early on in my career. And ultimately I've been fortunate to be brought onto the board of directors of a malpractice company that insures doctors for malpractice. And it is just been such an interesting thing to be involved in the business aspect of a company.

All these things are time. I'm blessed that from a financial perspective, my wife hasn't divorced me and taken half my money. That's always a good thing. She's actually sometimes a little less happy when I actually am home. She's like, “Don't you have something else to do? We have our own thing going on.” We're kind of yin and yang and work out, but again, I agree burnout, for me is definitely less because I stay interested in a lot of different things.

Dr. Jim Dahle:
We've been talking with Dr. Ian Storch, the podcast host of the D.O. or DO NOT podcast. It's been great to have you here. Obviously people can look up that podcast, they want to hear more from you. Do you have any last words of advice for people before we let you go and get to your scopes this afternoon?

Dr. Ian Storch:
I'm going to give one little anecdote, if that's okay. One little story. People ask me if I think I'm successful or what doctors are successful, and again, I think it's very difficult to rate success. This is from New York College of Osteopathic Medicine, my osteopathic school. When you're in school, the biggest bond that you have I think for many students is in your anatomy pod, Jim. I don't know if you remember your anatomy pod, but it’s like five guys or gals put together and you spend a ton of time digging and finding nerves and arteries and it's very difficult, but you really form a tight bond. And those many times I think are your besties. Do you have those?

Dr. Jim Dahle:
Yeah, absolutely. Although I'm not sure it took precedence over the friends at the foosball table.

Dr. Ian Storch:
Right, the foosball table is a set. I only have time for one story. So, my anatomy group, which I always think is so interesting. My anatomy group, we really bonded. And of course, you get older and everybody has their career and their family. You don't see each other as much as you like.

But I always have this little story that I tell people and the question, the framework is “Who's the most successful?” I'll just tell you, I just think it's so interesting. I think about this a lot. So, you got me, you got Ian. Again, you heard my story NYCOM, internal medicine at North Shore, University of Miami, GI private practice. Great.

And then my buddy, Joe. Joe went to NYU, Long Island for medicine. He did cardiology there, and he ended up going to Mass General. He went to Harvard for electrophysiology, and he's now an employed EP doc. That's top of the line cardiology, dare to dream, that's what you do.

My friend Pat, who's actually my roommate, he hated rounding, Jim. He agreed with you. He ended up doing ER at Lenox Hill. He went out into practice on Eastern Long Island, and he decided he wanted to do administration. So, he went into administrative position. He is now president and CEO of a large healthcare system on Long Island. Pretty impressive, right?

Then the other two. Bob did family practice at a community hospital. His grades were spectacular. That's what he wanted to do. He spent three years in family practice, and one day he went to get a hair transplant on Park Avenue. This is a true story. You can't make this stuff up. And the guy was thinking about retiring and he told him he was a doctor. He said, “Do you know what you want to do when you finish?” And he said, “No, I don't have a job yet.” And he said, “Maybe I'll teach you a hair transplant.” So he learned hair transplant, and he took over the guy's practice. He's now doing hair transplant on Park Avenue. That's pretty cool.

And then the last doc that I had in my anatomy pod was Adam. Adam did internal medicine. He went into primary care. He has a beautiful practice. He is still a very close friend of mine. And when we go out to dinner at a restaurant, he's got beautiful house. He's got a beautiful wife, he's got a beautiful kid, and we go out for dinner sometimes. And every time we go out to a restaurant, a patient comes up to him and says “Doc, you saved my mom's life.” He is like a celebrity. Everyone loves him. And I am so blessed that I'm even sitting at the table with him, and I'm always impressed with these people, and he's so humble. Amazing.

I think you have to decide, I think it's such a cool story because there's no right answer to what makes you the most successful. I always think about who the most successful person in our anatomy pod is, and I don't have an answer.

Dr. Jim Dahle:
Awesome. Great anecdote. Thanks so much for your time and for being on the podcast today.

Dr. Ian Storch:
Thanks for having me, Jim. I appreciate it.

Dr. Jim Dahle:
Okay. I hope you enjoyed that interview as much as I did. Dr. Storch is great. We kind of made the title of this podcast a little bit click baity. As we've seen over the last a hundred years, the MD and DO streams of doctors have really merged more and more and more and more. And it'll be interesting to see over the next 20 or 30 or 50 years any other changes that may come with the merging of those two branches of medicine.

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Transcription – MtoM – 171

INTRODUCTION

This is the White Coat Investor podcast Milestones to Millionaire – Celebrating stories of success along the journey to financial freedom.

Dr. Jim Dahle:
This is Milestones to Millionaire podcast number 171 – Medical student creates a budget.

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All right, we went over in our company meeting earlier today, the results of last year's White Coat Investor survey where we surveyed the whole audience and try to find the ways we can serve you better. A recurring theme was that people want more basic information. We're doing all kinds of things to try to get that out there, including adding to this podcast episode short snippets of basic information about the basics of personal finance and investing, trying to increase your financial literacy.

But there's a whole bunch of other stuff we do as well. For example, we have a WCI 101. This is the basics email series, totally free to you. You sign up at whitecoatinvestor.com/basics, and basically we email you a couple of times a week for a few months. These short, little emails that teach you a basic principle about personal finance. You can totally just sign up for that. You can stop anytime, you can unsubscribe, whatever. It's totally under your control. It's totally free, whitecoatinvestor.com/basics.

We also have our “Start Here” page on the website. It's the upper left. If you go there, you will find information grouped by topic that can help you find exactly what you're looking for. Also, on that front page of White Coat Investor is a search function. I just found out what we're paying for that search function every year, and I'm debating not using it as much myself, but the truth is, it works really well now. I'm glad to pay for that.

But I encourage you to use that search function. Any question you have about personal finance or investing, chances are good I've blogged about it at some point in the last 13 years. So, use that search function to find what you're looking for.

We also have a Frequently Asked Questions page. If you go to whitecoatinvestor.com/faq, guess what? Most doctors all have the same 50 questions or so about personal finance and investing. You can read all the answers right there. It's not even that complicated.

You can learn this stuff. It is really very doable. And if you can become financially literate and develop some financial discipline and you combine that with a physician or other high income professional income, it's pretty powerful. This stuff is worth millions to you over the course of your life, but you do have to learn it. So make sure you do that.

On this podcast, we interview people who have accomplished some sort of milestone and it's quite a lot of variation what those milestones are. For example, one I recorded earlier this week with somebody who had an $8 million net worth, and today we're talking to a first year medical student.

So, it's exciting to run the gamut of what people encounter during their careers, but I think it's also instructive and shows that one by one we all take off the same milestones. If you'd like to come on and inspire others to do what you've done, you can apply at whitecoatinvestor.com/milestones. We'd love to have you. Stick around after this interview. We're going to talk for a few minutes about donor advised funds.

INTERVIEW

My guest today on the Milestones to Millionaire podcast is Garrett. Garrett, welcome to the podcast.

Garrett:
Hey, Dr. Dahle, thanks for having me.

Dr. Jim Dahle:
Tell us where you're at in your career.

Garrett:
I'm a first year medical student at the Texas College of Osteopathic Medicine, otherwise known as TCOM in Fort Worth, Texas at the University of North Texas Health Science Center. And I went to Texas A&M for undergrad.

Dr. Jim Dahle:
Very cool. I think this is the first time we've had a med student on here. It's certainly the first time we've had an MS-1 on here. A lot of people are now wondering what milestone are we celebrating today. What milestone could an MS-1 possibly have hit? So, tell us what you've done.

Garrett:
My milestone is just creating a budget. It sounds very elementary, but I argue it's arguably one of the best milestones to conquer.

Dr. Jim Dahle:
Yeah, I think it's awesome and I'll tell you why. We just did our annual WCI survey and it turns out that about half of White Coat Investors, these are people who are hardcore enough about WCI to actually answer our survey, don't have a written financial plan. So, the fact that you have got at least the start of a complete written financial plan done as an MS-1 puts you way ahead of tons of people. Congratulations to you on that.

Let's talk about your budget, though. Are you single, married, kids? Where are you at in life?

Garrett:
I'm single.

Dr. Jim Dahle:
Okay. Tell us about your budget. How much do you plan to spend every month and what's the money going to go to?

Garrett:
Creating the budget, I split it up in wants and needs and ultimately I have to spend money for rent. I have to spend money on gas and groceries, and I have a whole column just for those needs. And then I have separate columns for Amazon purchases and a lot of the wants. I like going out with friends, you got to have some balance in med school. Roughly, give or take, around $2,000 per month for the rent and all those wants combined, give or take.

Dr. Jim Dahle:
$2,000 total. That's what you plan to spend every month during med school,

Garrett:
Roughly. The tuition is separate from that but for the wants and needs, give or take, it's around there.

Dr. Jim Dahle:
Okay. So, what's rent going to be? What do you expect it to be?

Garrett:
Oh, rent is around $1,000. And then I have water and pest control and a lot of those extra fees that come with owning an apartment. So, it's around like $1,100.

Dr. Jim Dahle:
Okay. Is that all by yourself? Is that with a roommate? How did you make that decision whether to get a place on your own or try to find someone to split that with?

Garrett:
I did want to have a roommate going into med school. I know that it's just going to cost a little bit less having a roommate. And it's nice to have someone to vent with, with classes. He goes to medical school as well with me. I did want to have a roommate and I do have a roommate now, and I felt like that's been a strong financial decision. I know people who live alone spend a lot more and I felt like this has been a good fit for me.

Dr. Jim Dahle:
So, that $1,100, that's just your share of the rent, right?

Garrett:
That's my share, correct.

Dr. Jim Dahle:
Okay. So how much do you plan to spend on food?

Garrett:
Food, roughly $350, $400. If I can do around $100 per week for groceries. $400 or $500, I don't want to spend more than that per month on groceries. But you got to eat right and if you want to spend some nicer deli meat and eat healthy, you're going to have a little bit more cost for your lunches and whatnot. But I feel like around $400 is solid.

Dr. Jim Dahle:
Very nice. What's the most interesting category in your budget?

Garrett:
I do have a separate category just for Amazon because there's so much stuff that you can spend on Amazon and a lot of those purchases are needed for med school. I had to buy all the different auto scopes and the different medical supplies you needed to get started out with med school. But it's kind of surprising how much you can spend on Amazon. It's right there and it's so easy to use and you can find yourself overspending easily on Amazon.

Dr. Jim Dahle:
For sure. It's so convenient. One click ordering and it shows up 24 hours later on your front porch. It's pretty awesome. All right, is there any income in this budget or are you living completely on borrowed money?

Garrett:
Completely on borrowed money.

Dr. Jim Dahle:
So how much do you think you're going to owe when you come out of medical school?

Garrett:
At least $200,000 for sure. Probably $200,000 to $250,000.

Dr. Jim Dahle:
Okay. And what do you think about that? How does that feel here sitting at the beginning knowing that a few years from now you're going to owe more than $200,000 in debt and you're not even going to start paying that back for a few years after that?

Garrett:
When I first started making the budget, I was very worried about that. You hear stories of physicians who still have a lot of debt and they're paying it off into their 50s and 60s, and I didn't want to live that sort of lifestyle.

One of the pieces of advice that I got was for my dad starting out with taking these loans, and he had a great piece of advice, which was think of these loans as an investment on your business. Think of it as like a small business. You have to take loans to invest in this business, and this is a necessary sacrifice you have to make in order to one day become a physician and make a lot of money one day and pay off those loans pretty quickly. I think by creating the budget and being consistent with it has decreased a lot of the stress. And I realize this is the necessary evil that you just have to deal with.

Dr. Jim Dahle:
Any idea what specialties you might be interested in?

Garrett:
Right now, I'm really interested in anesthesia and I know that things can change. I'm still a first year medical student, so during my rotations in third and fourth year, that can always change. But right now, I'm really interested in anesthesia.

Dr. Jim Dahle:
Well, pretty cool. You shouldn't have any trouble paying off $200,000 or $250,000 debt as an anesthesiologist. Certainly, no doubt about that. Have you thought about that? Do you expect you'll be paying your loans back, or do you think you'll be chasing after public service loan forgiveness or something similar?

Garrett:
I think I'll be paying my loans back straightforward, traditional way. I don't anticipate doing another route.

Dr. Jim Dahle:
Did you give any consideration to paying for school with a contract like, MD–PhD or a HPSP contract with the military or something like that? What was your thoughts behind deciding you were going to borrow the money to pay for school?

Garrett:
I didn't want to do any of those other routes. I've had some friends do the military route for, and then they're in dental school actually. And I've heard pros and cons weighing those out. I figured the most straightforward route is just to take on the loans and one day paying them off pretty quickly.

Dr. Jim Dahle:
Very cool. So, what are you going to do if you're having trouble staying within your budget? You get going at it, you look at it and you're like, “Wow, I'm not spending $2,000 a month. I'm spending $2,700 a month.” How will you adjust?

Garrett:
When I first made the budget, it was less than $2,000 per month and it was too strict. It wasn't necessarily due to unnecessary spending, but you have to anticipate maybe an emergency fund or something that just comes up that you have to spend for. And I dialed it back a little bit to the $2,000, or maybe a little bit more than $2,000, but I don't necessarily anticipate a whole lot of ripples in the budget.

I've been doing this now for a few months and I've gotten into my rhythm of things. I check it every Sunday and add up all my expenses and add it all together. But if there was something that comes up, I guess I just have to ask my parents for help and see if they can help out with that. But as of right now, things are going relatively smoothly, which is nice.

Dr. Jim Dahle:
When did you get interested in finance and start thinking about things like the White Coat Investor and forming a budget? Because this is pretty unique among your classmates, I'm sure.

Garrett:
Well, there are a lot of classmates that are much more versed in finances than me. I'm just getting in the start of things with creating a budget. That's the one thing that you learn going to med school is that a lot of my classmates are married and some of them have kids and they have different priorities in life than me right now. Their budget probably has buying diapers for their kids per month. I don't have to worry about that,

But I first got interested in the White Coat Investor right before starting med school, the summer before med school, just doing some Googling on how to take care of your finances and you were one of the first people who came up. I bought your book, read your book, and got the audio book too. And by reading that and doing a little bit googling online, you can use ChatGPT too and learn more about finances. It's pretty empowering and it helps de stress during med school and I can focus more on my grades and ultimately work to become a great physician one day.

Dr. Jim Dahle:
Yeah. Do you have any financial goals that you can share with us?

Garrett:
First goal is to pay off loans as soon as I can. Whether or not that's four or five years after residency, I'm not entirely sure. Kind of depends. If I'm married where I'm living, cost of living. I guess I'll cross that bridge when I get closer to fourth year.

One of the things that I'll also have to take care of closer residency is figuring out how to balance saving my money and paying off the debt while trying to learn how to invest in a 401(k) or trying to invest in the company and try to make money on my money, but still pay off the debt pretty aggressively, which is something that is difficult to manage and I still have much to learn about that.

And one of my other goals is to become more financially knowledgeable. I think at this stage of the game, it's important just to read a finance book every year. I'm going to read that Millionaire Next Door book probably soon and try to go from there.

Dr. Jim Dahle:
Very cool. Do you have a WCI champion in your class? Has somebody passed out a copy of the White Coat Investors Guide for Students to everybody in your class yet?

Garrett:
It's funny you say that. We've had at least two different lunches with some excellent faculty who have talked about the White Coat Investor and have given free copies to a lot of students. I'm not sure if there was a White Coat Investor student who's gotten that yet, but we've had some great faculty who really want to emphasize creating a budget and try to start to take control of your financial life.

And a lot of the students are aware of the book and a lot of them have read the book and a lot of them are way more in depth with their financial knowledge. And they can speak more about finances than me, but I'm not sure if someone has actually done the actual White Coat Investor Champion yet.

Dr. Jim Dahle:
Awesome. Well, we'll double check. Otherwise, we're going to elect you champion and send you a couple of boxes of books to pass out.

Garrett:
Awesome.

Dr. Jim Dahle:
Pretty awesome to be thinking about this stuff right from the beginning because the beautiful thing about it as you mentioned is it allows you to then focus on what matters most. You can quit worrying about all that debt because you've got a plan to take care of it and you know “Hey, yeah, it's a quarter million dollars, it's a lot of money, but with my plan, I'm going to be able to knock it out and it's going to work out fine.”

Awesome job for putting a budget in place and making sure you don't borrow more than you have to for medical school. I want to congratulate you and thank you for coming on the Milestones to Millionaire podcast to inspire other students to do the same.

Garrett:
Thank you for having me. It's been a pleasure.

Dr. Jim Dahle:
Okay. I hope you enjoyed that interview. It's fun to get people early in their careers. This might be the earliest we've had somebody do a milestone. I'm not sure we've ever had a medical student at all, but it's awesome. Be knocking stuff out early in your career.

A budget is absolutely critical. In some ways it's training wheels, it's training wheels to teach you to spend within your income, but when you don't have much income or in this case don't have any income and are actually living on borrowed money, it is so important to make sure that your spending is aligned with your values. Most attending physicians can buy anything they want, but even they cannot buy everything they want, at least not all right now. You've got to prioritize. All a budget is, is your priorities in written form. I encourage you to do that.

FINANCE 101: DONOR ADVISED FUNDS

I promised you at the top of the podcast that we were going to talk about donor advised funds. These are pretty cool. People sometimes ask, “What's one thing you've changed your opinion about over the years?” And this is my usual answer, donor advised funds.

When they first came out or I first learned about them or whatever, I didn't like the fact that people could get the tax break for contributing to a donor advised fund, even if the charity never gets the money. I've learned to get over that somewhat. I do think some people with big donor advised funds ought to give a little more to charity each year, aka, the jerk move, but they're so convenient that it's hard for me not to use them for my charitable giving.

The beautiful thing about it is it's even easier to donate shares of appreciated stocks and mutual funds that sort of a thing to a donor-advised fund than it is to donate them directly to charities because the donor-advised fund expects them. Now you can basically have your donor advised fund at the same company as your brokerage account, and it makes it really easy to donate appreciated shares.

Remember, when you do that, not only does the charity not have to pay capital gains taxes, but you don't either. And you get the entire value of what you're donating as long as you've owned it for at least a year ad as long as it's a publicly traded company or mutual fund, you get the entire thing as a charitable deduction.

They're really convenient that way. Plus you might only have to make that transfer once a year. Instead of keeping track of every little receipt, every time you give something to charity, you only have to keep track of one thing and that makes it way easier. You've got this great record when it comes time to do your taxes.

But my favorite benefit of a donor advised fund is it has eliminated charity porn from my mailbox. And if you don't know what a charity porn is, you ought to give a little more money to charity. But let's say you give some money to Doctors Without Borders, for instance. Well, what you'll find is that two weeks later you'll get a 20 page glossy, full size magazine essentially in your mailbox, and you'll continue to get one every few months for the rest of your life because they use about 10% of the money they raise to try to raise more money.

And most charities are like that. In fact, many charities actually raise more money by selling your name and mailing address to other charities. So, if you decide you donate to 10 charities directly one year, you'll have something from a charity every day in your mailbox for the rest of the year. And I call that charity porn. It's obviously not pornography. A lot of it's actually really kind of inspiring. That's the whole point of it, is to inspire you to give more. But it seems like a waste. I want my money to go to whatever the charity's actually trying to accomplish. I don't want it to be used to market to me to raise more money.

So, the benefit of the donor advised fund is when you make a donation from it, you can check, “I want to be anonymous”, and then you are. They don't have your address. They can't send you charity porn, they can't hassle you, they can't call you, they can't do anything, and you still get your charitable deduction and all of your money gets to go toward helping the charity.

I love that aspect of a donor-advised fund. I totally encourage you to use one if you donate any significant amount to charity. Vanguard has one. The downside of the Vanguard one is they have a $25,000 minimum to start it. I think additional contributions have a minimum that's like $5,000 and your actual donations from the fund have a minimum of $500.

So, if those numbers don't work for you, you probably want to use something different. Fidelity has one that's pretty well thought of, has much lower minimums. Daffy is one that I've been impressed with lately. We had their CEO on the podcast not that long ago. But they have some pretty darn low fees and, hopefully will become more and more popular as time goes on. But you might want to look into those if the Vanguard numbers are just a little too high for what you want to do with your donor-advised fund.

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All right, keep your head up, shoulders back. We'll see you next time on the Milestones to Millionaire podcast.

DISCLAIMER

The hosts of the White Coat Investor are not licensed accountants, attorneys, or financial advisors. This podcast is for your entertainment and information only. It should not be considered professional or personalized financial advice. You should consult the appropriate professional for specific advice relating to your situation.