A High Income Is Not an Exit

There’s a moment physicians spend more than a decade waiting for. Medical school, then residency, maybe a fellowship, and suddenly the paycheck changes. You finally made it, so you buy the house, maybe the car — I did — take a vacation, upgrade your life.

Then something strange happens quietly, over a few years. Your income goes up, and so does the amount of money you need every month just to keep your life running. One day you notice something uncomfortable: you make more money than you ever imagined, and you can’t afford to stop working.

My guest this week has spent thirty years on both sides of that problem. Dr. Jerry Schreibstein is an otolaryngologist who has led a private single-specialty group in Western Massachusetts for three decades, and whose interest in what money does to physicians eventually sent him back for formal wealth management education and licensure. He founded MD Wealthcare LLC. We sat down to record one episode and got two.

The lecture in the first week

Jerry grew up in what he calls a blue-collar family in Brooklyn, in a rent-controlled apartment. Neither parent finished college. There were clothes and food and the occasional vacation, and there was no conversation about money at all.

He got into Stuyvesant, then into Boston University’s six-year medical program, and early on he walked into the dean’s office to ask for an extra year to study abroad. He remembers the answer exactly: “You’re on financial aid. You’re not going abroad.” He was, he says, shell-shocked. Forty years later he still hasn’t taken that year.

Then came the first week of medical school and what he calls the lecture that changed everything. The school brought in a Princeton economist to explain student debt in an era when health-profession loans carried 17, 18, sometimes 20 percent interest. His point was arithmetic: “if the loan is 18%, the principal doubles every four years.” Defer through medical school, defer through residency, and a hundred thousand dollars becomes two hundred, then close to three.

And here is the part worth sitting with. “If you’re an investor and you’re a saver, that compounding interest works for you. But if you’re a debtor… it doesn’t.” Same force, opposite direction, and which side of it you land on is decided years before anyone explains it to you.

So I asked him the question I keep coming back to: why do we teach acid-base physiology and the Krebs cycle, and almost nothing about compound interest? His answer was blunt. “We don’t teach them anything about finance, not even compound interest. We don’t even teach them about how to read a balance sheet, how to understand what it means to be in debt.”

That is not a character flaw in the people who go into medicine. It is a gap in the training, and it produces graduates who are extraordinarily capable in one domain and unequipped in another.

Income is not wealth

Somewhere in medical school Jerry picked up The Millionaire Next Door, and it rearranged something for him. “Just because you have income and you can buy things and consume things does not really make you wealthy.” What makes you wealthy is what you keep.

He puts it in numbers a physician can feel: a teacher earning $80,000 with a million dollars accumulated between retirement accounts and savings may be, relatively speaking, wealthier than an orthopedic surgeon earning $800,000 with $300,000 in the bank.

What makes this hard for us specifically is the deferred life path. Four years of college, four years of medical school, three to six years of residency — you emerge in your early thirties while the college roommate who went into sales has a 401(k), a house and a car that runs. Wanting to reward yourself after that is not vanity, it’s human. The problem is that the reward arrives at the exact moment we are least prepared to size it.

And the money is right there. “It’s very easy to loan money to physicians,” he says — auto loans, home loans, practice loans, because the cash flow is good. “But that doesn’t necessarily mean you can afford it.”

One more year as a resident

His practical answer is unglamorous, well known, and almost nobody does it: live like a resident for an extra year or two. Long enough to get your house in order, understand the debt, take stock of where you want to be in three, five and ten years, and let the lifestyle grow into the income instead of sprinting ahead of it.

He also offered a filter I have not stopped thinking about, one he got from his own advisor: try to avoid buying things that depreciate. “Family experiences don’t depreciate. You get a dividend for that memory forever.” He is not arguing for austerity. He is arguing that the same dollar buys either a shiny object you stop noticing in a year or something that keeps paying out.

The plan is dynamic

The line I most want people to take from this episode is Jerry’s, and it is four words long. The plan is dynamic.

Finishing residency is not an end point, any more than a wedding is. Children arrive, parents need care, health changes, and a plan that can’t absorb that was never a plan. He reached for a surgical analogy: you need five ways to find the facial nerve in a parotid case, because a tumor may be sitting on two of them. You go in with a roadmap and you navigate the curveballs. We all studied Netter. The patients didn’t.

I made the same argument in a different key last week, with a homework assignment attached: you cannot predict which future you’ll want, so preserve the ability to change your mind. Jerry’s version is the financial half of that. Know your baseline, revisit it, and everything else is gravy.

What call actually costs

We ended part one on call, where the money conversation and the well-being conversation stop being separable. Call is unpaid overtime. You don’t get paid extra for doing it — and reducing it, changing it, or getting off nights costs you money. How is that fair?

Jerry has been on both sides of that ledger. He came off call in his own practice and pays a percentage of his salary for it — the hospital releases physicians after twenty-five years of service, but his private group has no such rule, so it had to be negotiated and paid for. He thought the income was worth giving up. He also, for years, started office early on Wednesdays and left early for his kids’ games, seeing fewer patients that day than on a Monday. He could do that because he knew he was on target. “The patients will be there in the next season.”

That is what the money is actually for. Not a bigger house. Optionality — the ability to go to 0.9, to drop a half-day, to decline the call schedule, to be in the stands. Jerry doesn’t love the retire-early framing; he prefers a financial independence day. The day the number stops making the decisions for you.

Part two is next week: knowing your number, what financial security does to your relationship with medicine, and the hardest questions we ask on this show.

Listen to Episode 13