Podcasts

Social Media Part Deux: Doctoring in the Blog-o-sphere

Dr. Dana Corriel is known to some as the godmother of doctors on social media.  This all started with her personal blog, which she created for creative catharsis and to help inform patients on a larger scale than the 1:1 office visits.  She now manages a multiple facebook communities and has a presence on almost all social media platforms.  We discuss the hows and whys of being a doctor on social media with “one of the top 10 internists to follow on Twitter.” 

One of her tips: a consistent screen name.  She can be found as drcorriel on ALL PLATFORMS!  Website, Twitter, Facebook, and Instagram.   

She is the administrator and creator of 

https://doctorsonsocialmedia.com

https://www.facebook.com/groups/medicineconnect

https://www.facebook.com/groups/somedocs

 

 

How Physicians Should Buy Their Homes with Dr. Moves

Dr. Ramey had a pretty negative experience buying his first home as a med student, so he took matters into his own hands.  His wife got her real estate license, he got his, and how he helps med students, residents, and attendings around the country buy homes.  He walks us through the entire process from tip to tail, and we discuss for whom a physician loan would be appropriate, the advantages and disadvantages of such a loan, as well as the other types of loans available.

He also has an extremely comprehensive website with sources for physician loans as well as ways to earn extra income as a physician.

https://drmoves.com/

 

EPISODE TRANSCRIPT

Disclaimer: This is the transcript to the episode. This transcript was created by a talk to text application and the function of having this here is to improve the page search engine optimization. This transcript has not been proofread, so please listen to the episode and don’t read this. The information contained herein will inevitably contain inaccuracies that affect that quality of the information conveyed and the creator of this content will not be held liable for consequences of the use of the information herein.

Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians were Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have learned while we were memorizing Krebs cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.
On today’s episode, we interviewed dr. john Raimi, a fellowship trained allergist in Charleston, South Carolina, and the creator of Dr. Moves calm, that’s Dr. moves, and I know what you’re thinking, the doctor of dance moves, okay, that’s probably not what you were thinking. That’s what I was thinking. But Doctor moves helps doctors to move. He and his wife are real estate agents who own healthy real tea calm and he walks us through why you may or may not want to buy a home as a resident, how to do it, and if you don’t buy one, then how to buy one as a new attending. We discuss what doctor loans are and why you may Want to utilize them and then we walked through the entire process from finding a real estate agent to closing costs. And we really just scratched the surface and the offers much more detail on his website again, Dr. Moves calm. He also has useful information on real estate investment and other revenue streams for physicians like being a medical reviewer, expert witness medical surveys telemedicine and locums jobs. Welcome back to the physicians guide to doctoring On today’s episode we have dr. john Raimi of Dr. Moves calm he has a fantastic website that gives all sorts of information to physicians about finding a real estate agent finding a home earning extra income through either real estate or medical surveys. Becoming a medical reviewer. Really He has lots of different information is a wealth of information for for physicians, but today we’re going to focus on buying a home so if you’re a physician, who are using became a physician because you recently matched or you’ve finishing residency, you’re about to become an attending, you know, where you’re going to living for a while, and you’re thinking of buying a home. As a physician, you might have some other obstacles, like your loans that other people don’t. And there might be some more resources available to you that aren’t available to other people like a physician specific loan. And so Dr. Raimi has some particular expertise in in this area for a whole host of reasons. So first of all, Dr. Amy, thank you so much for being on the podcast today.
Thanks for having me. I’m really excited to be on with you tonight.
So I think your real estate experience first started with your experience as starting I think it was you’re starting your residency and you were looking your first home. So can you walk us through what happened there?
Yeah, I was actually getting ready to start medical school. So my For my fiance at the birth, wanting to buy a house and like most medical, he didn’t have any money we had just graduated from college. And so we went to look for houses with my law. So first suggestion I have is don’t go look for out in law that wasn’t a very good experience. So we were actually staying at a resort. And the closest real estate office was a resort real estate office. The second mistake we made was finding a realtor who was used to selling million dollar properties, which we were not looking for at the time. So took us out for the day and we were looking in the hundred thousand dollar range at that time. We actually found the house that we really liked and just after one day of looking and so the realtor takes us back to our office and she goes into a spill saying hey, listen, this is a sell seller’s market. If you don’t put an offer on this house today, you’re probably gonna lose it. You need to do some quick. And I was very nervous, you know, being my first house on the house, I, you know, I wanted to call my parents and get some advice from them. And my parents kind of called, they said, Hey, john, don’t you really want to think about this every night? I don’t think you should rush into this. And so I agree. I agreed with my wife in a big hurry to do this. So I walked back into the room with the real estate agent, my in laws, and told him I said, Listen, I want to think about this. I want to make sure this is a good decision for the realtor got really upset with me and said, you were going to lose his house tonight. This is a terrible decision and she stomped out of the room. The next person got upset with me with my mother in law, she stopped out of the room. And my fiance, Tom was crying. You know, it was just a bad real estate experience. And from that experience, my wife and I talked about it several years later, and we’re just like, man, we could done such a better job ourselves and it inspired us to get it are both of us to get our real estate license?
So you got a real estate license while you were a medical student?
No, no, it was actually after I finished up all my training, I got mine. My wife got hers during my fellowship. And so she got it for me. And so she was able actually to help us by our This was our third house by that time when we moved to our my final job as an attending your third house.
Yes. So the first house ended up happening during at the beginning of medical school.
Well, what ended up happening that house that we were going to buy, we didn’t buy and we decided to rent instead. So we ended up renting a townhouse for the first time
and said, Hey, we’d like to buy this. And
that is the end of my second year of med school and sold it two years later for a profit and then went on to residency bought a house there and ended up breaking even on that one and then during fellowship, bought another house and ended up making a good profit on that house. And that was during the time my wife got her real estate license. It was actually our fourth house that we ended up using her as the realtor.
So you’re buying and selling these houses, you’re not holding them as
rental properties. Not at that point we weren’t and, you know, that’s, you know, one piece of I said, you know, our make to residents or attendings is you know, look at, you know, the property you’re buying, it may be a good rental property long term, and that’s not something I was looking at at that point in my career.
Yeah, I actually when I was a resident, I bought a, I bought an apartment, and my parents helped me to finance it. Because the first apartment that I lived in in Washington wasn’t in the best area. So when I would leave at 530 in the morning to go to my rotations, they were still hookers outside. So my goodness, they, they helped me to put a down payment on on a place, you know, but I was a resident from 2006 to 2011. So possibly the worst time to buy to buy an apartment and then at the end, we just, we didn’t want to because I was moving back from Washington DC to New York, we didn’t want to be long distance. landlords, so we decided to just sell it and took the loss. But in retrospect, you know, might have been a better idea to, to hold on to that and use it as a rental property because that place I just had so many amazing things about it. And I think that gets to something we’re gonna end up talking about later is there are some inefficiencies in the real estate market that you can capitalize meaning like, the stock market is supposed to be completely efficient. Everybody has all the same information at all at the same time, but the real estate market, if you’re going to be living in a place for a while, you’re really going to be invested in looking at A lot of places and doing your research and doing your due diligence until you end up deciding on a place. And that research has some value to it. So if you hold on to it, you might be able to find something that is undervalued or underpriced. And then and then turn it into something.
Yeah, you’re exactly right. So, you know, we are real estate, like my wife had a real estate license around 2003. I got mine around 2005. And, like you said, the real estate market crashed around the 2006 2007 period. And, you know, we dealt with a lot of residents, especially he bought during those years, and it was really hard for them because they were like he had graduated. And they had to make a decision, you know, should they sell their house for a loss or should they keep it and hopefully hold out until the pricing had recovered. And, you know, most of them actually ended up selling for a loss because like you today, they want to they’re moving away. They didn’t want to keep moving It from a distance but no funny story, we had a resident who kept their townhouse. And he is just selling it now from that 2006 2008 top here. And these actually Finally, you know, able to make a little bit of profit after all this year, so he kept it and rented it out to help it recover back to baseline.
So there are ways that even if something like that happens, hopefully it won’t be for some extremely extended period of time to protect yourself against loss, but there is no like any investment, there’s going to be some some risk involved. So so your wife is a real estate agent, you’re a real estate agent. And your website doctor moves you. You named a doctor moves presumably because you help doctors to move
Correct. Correct. So So I saw I joined an allergy practice in Charleston, South Carolina in 2006. At that same point, my wife and I started our real estate company in Charleston, South Carolina. We called it healthy Realty. And initially, we really just focused on helping doctors relocate and did that mainly for the first few years. But as the company began to grow, we started doing a lot more online advertising and now we create a were we helping anybody houses. We did a lot of Zillow advertising over the years not really, you know, took us to another level in the real estate company. But now with all that probably worked with over 200 positions in the Charleston area over the last 10 years and few years ago, we started thinking that we’ve learned a lot through this experience how positions are different than other buyers and sellers. And you know, learned a lot about out of Lansing said, Hey, we can now teach the same thing that we’ve been teaching people in Charleston for years. You know, through a website that helps people like, relocate nationally. And so that’s kind of how Dr. Mayes came about was from just our experience in the Charleston market, and kind of went that wanted to share it with, you know, people across the US.
So let’s say you have a med student that just graduated from M USC. And he spent some time with you in the allergy office. And he comes to you for some advice, saying he’s moving to x city for residency, and he’s thinking of buying a house there. What are the steps that you’re going to take that that physician through, to make sure that they’re making the best decision for them?
Yeah, so that’s something I you know, have a lot of passion about 18 years have actually been lecturing the students at Medical University of South Carolina on that, you know, decision process and, you know, the first thing I encourage them to do is sit down and make a budget. I mean, that’s the best thing you can do before you start thinking about whether to buy or rent is sit down and make a budget, you know, figure out, what is your salary going to be after taxes, how much money is going to be left over? And then figure out, are you going to start paying on your student loans or not? And then figure out, you know, what’s your other costs gonna be and kind of figure out, you know, how much money you’re going to have left over for housing cost, whether that’s to buy or rent, one of the worst decisions, you know, I’ve seen this residence is getting in a house that they can’t afford. I mean, there’s nothing worse than having all the pressures of residency and having to worry about Can I make my house payment every month. And so the way to you know, avoid that, and again, I can go with buying or renting is just to sit down, and, you know, figure out what your budget is, and there’s a lot of great online resources to help you do that. So once you figure that out, you know, the next step I think is you know, to figure out out, do you want to buy or rent? I think there’s definitely you know, we always, you know, with the people we work with, we try to, you know, get them to make the best decision for them for each person, because each person is different, like you said, you know, you went to Washington DC now. So, a lot of times it’s harder for people in these big cities to four properties on a resident salary. So, as one of the first things to figure out, you know, can I afford a property close enough to the hospital and some cities you can and some cities you can’t? And then you know, after that, you know, that’s the next thing that ask yourself is, do I want to deal with the problems of you know, owning property, because you know, owning property is always something to deal with. And there are some people out there who like dealing with that kind of stuff and there’s some other people that don’t and so, if you’re one of these people that would not enjoy dealing with the H fac system breaking one A house that we bought on a way rotation and a pipe popped out on the second floor of a house we had water coming down from the second floor to the first topic and we had our next door neighbor call me while away rotation and say, Hey, john, you want to may want to come back. You have water flowing out of your basement and we had about $100,000 worth of damage. And we had to move out of our house for three months during the middle of residency. unfortunate thing was that we had homeowners insurance and you know, covered everything except the thousand dollar deductible. But still, you know, it was it was a big headache and having to deal with that as not been done right.
I actually had something similar happened to me. I had a link a leak. I was the fifth floor of an apartment building and there was but I was there. There was a leak coming out of the sink from under the sink right where the valve is. So I tighten the valve and then it got worse. I thought maybe I’m just an idiot. And I turned the valve the wrong way. So it turns the other way and it got worse. So every time I got worse, I got worse because the leak was between the wall and the valve. So, wow. So ultimately the place is flooded, someone ended up calling the fire department. And they came in and they just crimped the pipe. Maybe I should have known to do that. But you know, the panic was not helping and there ended up being quite a quite a bit of damage to the place.
And in New York, where I’m from,
you can’t buy a place without homeowner’s insurance. They won’t let you in Washington DC. They do. So I assumed just like in New York, it was just rolled into the mortgage. It was not I had no homeowners insurance. That was a big problem. Wow. Yeah.
Wow.
That’s one thing you gotta you know, look into when you’re buying a home. You got to make sure that you Get homeowners insurance and then now your deductible because again on a resident salary, if you have $1,000 deductible or $2,000 deductible, you need to make sure that you can afford that if you have, you know, something catastrophic happen like flooding or fire or hurricane, anything like how you just want to make sure that you can afford that if you you know, decide to buy a property.
Is there any good formula like a quick and dirty for the residents salary? What you think would be a reasonable amount to spend? I know it’s a personal decision, but certainly there’s some for like, 40% of gross or something like that.
Yeah, you know, the one that I hear a lot is somewhere between 30 to 35% of your net. Now, if you’re wanting to put money away for retirement or other things, all that those decisions enter in and it affects you and the amount you will spend per house the state. You know, I see residents Make when they’re looking for houses, there are many of them that want to buy their final home during residency and know what you’re really looking for. I think during residency, it’s not your final home. But either a home that you can sell when you move in three to five years, or you know, home, that’s going to be a good investment that it could be a good rental property. And, you know, the nicest properties out there don’t always meet that eligibility. So, again, I think those are the things you want to really listen, you want to find a good real estate agent, first of all, who can help you make a good first purchase. You know, you don’t want to buy a house probably on a major road. You don’t want to buy a house with heavy traffic. You want to buy a house that no is gonna be easy to sell. I mean, house has been on the market for a year. There’s probably some reasons why other people haven’t liked it. And so you got to ask those hard questions as he knows there’s something about this house that’s gonna make it hard to sell when I need to resell it.
So let’s say you decide that it’s the right thing for you. Do you want to buy it? Let’s talk about financing. What are the different options for either someone about to start residency? Or someone who just became an attending? Because I think a lot of the advantages of the the physician specific loans are, you know, they don’t they don’t count the debt and less of a downpayment. So if you’ve been an attending for a couple of years, the those advantages usually go away. So let’s talk about someone who needs to take advantage of a physician specific loan or an FHA loan. If that or maybe they’re a veteran, they might have those options available. What are the different options and why would you choose one over another?
Yeah, so we’ll start with Dr. Lyons. So the thing to understand about Dr. Lyons is the doctor learn, like you stated, don’t take into account educational debt if the loan debt Taken account of educational debt, many residents will not be able to buy a house because their their debt to loan value be way too high. So, one of the advantages of loans, they don’t take that into account. Another advantage of a doctor loan is that you can get 100% financing. So, most residents have not saved money to where they can put down a decent downpayment. You know, typically with most loans, you have to put down a minimum of 3% downpayment, and that’s not including your closing costs. So, again, you’d have to have a 3% saved to be able to do that. The other nice thing about the daughter’s loan is that you avoid private mortgage insurance. You hear the term PMI private mortgage insurance, and that is a fee that’s tacked on to your loan until you have 20% of the loan. Pay Also, if you’re able to put down 20% down payment, you can avoid PMI. But the nice thing about dollar sign you have no PMI starting at 100%. So typically, for most no residents that have not saved any money, you know, the dollar signs are probably the way to go. Now, if you have money saved up and you’re able to put down a down payment, then you definitely want to look at the other types of loans to to see if you can get a better rate or a better
deal. And the reason that they have this PMI is because if you’re not putting down much, then you’re considered higher risk. So the way that they mitigate this risk is by charging you more, but historically, doctors are a safe bet, and correct me if I’m wrong. The National default rate is somewhere a little over 4%. Whereas for doctors, it’s somewhere between point two and point 4%. Isn’t
that correct? I don’t know those stats. I mean, I agree with you that they’re a lower risk, but again, Like you said, the whole point of the mortgage insurance goes back to the mortgage crash back in 2007 2008. That PMI helped protect the banks when people can no longer pay their monthly mortgage payments. And you started seeing foreclosures and short sales. So as to protect the bank in the end,
so you’re paying for their insurance against the risk that they’re taking on you. Correct. Okay. Interesting. So are there any other advantages to to taking a doctor loan? Or it’s the those are the two the no downpayment, and the and the lack of PMI?
And yeah, and then like you said, you know, not taking into educational debt. I mean, those are the three main advantage. Sometimes with airlines, the rates are higher because of that so many times if you’re able to put money down, you may be able to get a better rate. So that’s why You know, you want to look at other products if you can, because you may be able to get better rates and better terms. You know, the mistake that anybody makes looking at a house, they just look at the rate, you also have to look at what the bank is charging you and points and other expenses. Because sometimes the reason you have a low rate is because they’re charging all the fees. So it’s kind of the whole package, you got to look at everything, you can’t just look at the rate and making your decision on which one to go with. So they mitigate their risks in another way. You’re saying if they because they if they have higher interest rates for you, then you might not have to pay they might be ignoring your loans, not having to pay PMI, but now they’re charging you a higher interest rate. In order to mitigate those risks, make it make it a credit or deal for them. Okay, that’s interesting, or they’ll hide that in fees. Correct. So you just have to, you know, look at that total picture. That’s what you have to do with, you know, all these lines. As I was saying, that’s really important, you know, during rush See, most people know how long they’re going to be in a town. So let’s say you’re doing an EMT residency, you know, you’re going to be in a town for five years, well, you have a choice, you get the loan, whether you’re going to do an adjustable rate mortgage, which is known as arm or a fixed rate. And, you know, I, I’m personally a big fan of the adjustable rate mortgages, you know, most likely you’re only going to be in a city for a certain amount of time. So for example, BMT You know, you’re going to be there five years, I personally would like a seven year arm, rather than like a five year arm, the five year arm, you know, something happens, you decide to stay a little bit longer, you’re, you got a chance to sit your rate go up, you know, seven year hedges, your bat bat, so a little bit gives you a little bit more time and stuff changes and now you need a little bit longer with that line for whatever reason. So I like that justify your rate mortgages because the rates usually lower than the fixed rate and again, if you know you’re only going to be in a For short term, then I think they can be a good choice.
Could you just describe what what an adjustable rate mortgage is? So the fixed rate mortgage, you have the same interest rate for the life of the loan. And that’s it. Right? And so when you take out correct most of the many, many mortgage, my mortgage on my house is we have a 30 year mortgage, it’s a fixed rate mortgage. But for the adjustable rate mortgage, how does that work?
Yeah, so So I’ll start against the fixed rate. So fixed rate mortgage is the most, the taglines that most people get is usually the 30 year fixed or 15 year fixed. So the rate of the loan is fixed over 15 years or 30 years. Typically, you know, with the with the fixed rate, the rates are a little bit higher than the adjustable rate mortgages. with adjustable rate mortgages, you have products that are three year Adjustable Rate five years, seven years, and typically the shorter the term, the lower the Right, so you’re going to get a better rate. So let’s take a five year adjustable rate mortgage, so you’re going to get the same rate for the first five years. And then after that five years, your rate is going to adjust. So if interest rates have stayed the same from when you got the loan, it’s probably not going to change much. If they’ve gone down, they, they may go down, the big risk is when they go up. So if you get into a period, when rates go up dramatically, from the beginning of when you get your loan, you could really see a big change, they typically have caps with each loan. So you want to understand what the cap is how much but again, that’s where you really can get hurt, if you No need still need that mortgage. You can always, you know, with an adjustable rate mortgage or a fixed rate you can you can refinance it, if needed, but again, you know, the cost with that may outweigh the benefit. So again, it’s a numbers game to figure all that out.
But that sounds like it makes sense for someone who’s going to have like said the anti residency is five years long, you can lock in a lower rate than a fixed rate for those five years on the adjustable rate mortgage, and then when you’re done, even if the rate goes up, either you offload, you sell the property, or at that point, you’re making an attending salary. So even if the rate goes up, it’s just, it won’t be as devastating, as if you were still making a resident salary.
Yeah. And I think, you know, I think what you want to ask yourself, you know, you want to ask yourself some hard questions when you’re deciding on the product. No one is, do you do you think you want to get rid of this house when you leave? So you say, you know, hey, I’m definitely not going to want to keep this house and if I stay in this town, I want to get a bigger better house, then Adjustable Rate probably makes sense. Another question asked yourself, like we talked about earlier, you know, do I want to start building my portfolio or passive properties and do I I want to make this into a rental property. If you want to make this into a rental property when you finish up, then you probably makes a lot more sense to get a fixed rate mortgage. So you know what your costs are going to be throughout the whole term. So if you can ask yourself those questions, it will help you a lot deciding whether you should get an adjustable or fixed rate mortgage.
And for those that are listening that thinks that that is just a crazy idea holding on to a property and, and renting it out. Since you’re listening to this podcast, you probably listen other podcasts and there are plenty out there about the benefits of real estate investment and you can find a company to manage the property for you for a fee. So like, like Dr. Amy said, it’s a great way to start building a portfolio because then you have passive income through that property. Another thing that’s discussed on on the physician specific podcasts and blogs is living like a resident. So it actually makes sense, right, when you begin And attending to not spend like an attending immediately. So if you’re in your resident, apartment or resident house, it actually makes sense to stay there for a couple of years continuing to live like a resident before you try and find that big, beautiful house. And we had the frugal physician on a couple of episodes ago, where, where she talked about what happens when you try and buy that big, beautiful house so quickly, and how stressful that can be. So, you know, this is not what, this is not how a lot of people think when they’re starting in residency, I’m going to start accumulating a portfolio of investment properties, but there are tons of benefits to having that mindset.
Yeah, you know, unfortunately, you know, I said, we see I see that a lot. There’s a lot of, you know, a delayed gratification in our field that you know, which ourselves we’ve worked so hard for all these years, you know, we deserve this nice car. We deserve this nice house and I think from you know, the best mistake Point, that’s a surefire way to not get rich or to build your wealth is to, you know, think and I, you know, I think a better way to think if you want to build your wealth, if you want to take, you know, the fire principle, which is financial independence, retire early and think more like you’re saying, you know, is this a good investment? No, it would have made more sense for me to want to buy a second house to get one that’s a lesser cost. So I can keep this rental property and start seeing some passive income accumulate.
So let’s say you’ve you found the apartment, or you found the property you want to this is where you want to live for residency, but you have so little money in the bank, just because you’re not making a down payment. Doesn’t mean there’s no upfront costs. So So talk to me about what those upfront costs are, even when you’re talking about zero downpayment.
Yeah, so a lot of people when you buy your first house, you don’t realize That, you know, there are closing costs associated with buying a house and typically as closing costs can run around 3% of the house value. Now one thing you can do with these closing costs, if you have a good realtor, you can ask the sellers to pay the closing costs. So if you don’t have cash where you can afford to pay that, you can ask the seller to pay your closing costs. Typically, let’s say that your closing costs are going to be $5,000. You ask the seller to pay the $5,000 in exchange for that seller may want to increase the price of the house for $5,000. That’s okay. It’s kind of you’re paying just you know, you’re getting them to help you pay for that, you know, a lot of residents are in that scenario, they just don’t have money to pay closing costs for downpayment. So that’s one thing to think about it you know, if you’re saying hey, I really want to buy but don’t have any money saved up. That’s one way you know, to be able to do that. That
That seems a little shady Hear that you’re you don’t have the money for closing costs, and you’re still there, because it’s getting wrapped up into your mortgage. So you’re still there still, the seller is still getting their $5,000 you’re just paying them basically, they’re loaning you that $5,000 because you’re, you’re wrapping it up into the cost of the mortgage, and then they’re paying those upfront costs. I guess, I guess that works. I guess it’s not so shady that I think about it.
Well, I mean, you know, there’s, you know, there’s two ways to look at it, you know, one way, a lot of financial advisors will say, you know, that’s a good way to do it, you know, roll that $5,000 into your loan, you’re paying four to 5% on it, you know, that’s not, you know, high interest rate, if you look at historically, and you know, one of them would say that, you know, you can invest your money and other people financial advisors would say, you don’t have that four to $5,000 you probably shouldn’t be buying a house. So you know, there’s two sides of the coin and Look at it differently. So it really depends on you know, the way you invest and you know, making that decision. And let’s say you bought your house during residency.
And now you’ve become an attending you because you’ve made it. So you’ve been living, hopefully not paycheck to paycheck but close to it. So you don’t have much in savings.
Now you’ve got this bump in salary,
and you want to buy a second property. Now that you’ve become an attending, and you still have the loans. Could you use a second physician loan? Is that possible?
It is. And if you go to our site, Dr. Moon calm, we’ve written some articles on that topic, that there are certain banks that will let you use your loans to buy the best properties and second homes. Not all the banks do that. So there are only certain ones that will allow you to do that, but it is possible and we have a list of the banks that will allow you to do that.
Okay, so you’re in Charleston. So let’s say I’m buying. I’m starting my residency in Tallahassee, how do I find a real estate agent?
So one of the things we’ve tried to do with Dr. Moves is make it easy on the doctors to find a real estate agent. Now, going back to my initial story, we made the mistake of not asking other people for references of the realtor. So you know, a minimum, you need to talk to people who live in that town and say, Hey, did you use Did you have a good experience? Even better than that, if you’re a physician, you know, talk to other physicians, because again, they’re, you know, in our town of Charleston, we have, you know, about 6000 houses on the market and we have about 4000 realtors. And so there’s about you know, almost one realtor per house. And so they’re everywhere and Not all the realtors in Charleston know anything about working with a physician. So as a physician, what you really want to do is find a realtor who has experience working with physicians because it is different. There’s many realtors out there that don’t know anything about Dr. Lyons. And, again, it’s good to have a realtor out there who understands the difference between a doctor loan and a regular line. So what we’ve done at Dr. Moves is we have made it easy on people pretty much they can send us an email, call us up, and we’ll match them with a realtor in whatever city they’re going to and what we’ve done is we’ve, we go and interview the realtors before and find out how many doctors they work with. We look at some of their reviews. And again, we try to find realtors who have a lot of real estate kinda like you want to if you’re going to have a knee replacement, you don’t want somebody that’s just done. Five knee replacement, you want somebody that’s done a lot of knee replacement. Same thing with real estate, you don’t want a realtor who has just started in the profession, you want somebody who has done a lot of transactions because the real thing about real estate is that you know, for many transactions, now, you may not need a realtor. But when you get into a bad situation, you don’t know what to do. The realtors worth their weight and gold to say, Hey, this is what we need to do to get you out this past situation. Having a realtor with experience is worth its weight gold. I’ll share story with you. We were working with a resident who had a contract to buy newly built house. It was about five days away from closing on the house to house it got hit by lightning and caused significant damage to the electrical system. So again, you’re buying your first house. What do you do if you work in with your And who’s a realtor that maybe has sales one house a year, they’re probably not going to be too much help to you, but you’re working for a realtor who does know over 100 transactions a year they probably run into something similar or at least they know people who can give you good advice on how to deal with that situation. And then
I see also have a resource in the website for finding doctor loans
based on your region, yeah, you can go and search by state
what companies do daughter loans and you know, compare rates. So, most states have multiple banks doing that and then you know, we have there also, you know, I think, you know, this program is mainly focused on doctors, but we have found banks that will do them for pharmacists and physical therapists and other medical professions out there. So, you know, General the dotted lines are for physicians that there are some out there, you know, for other medical professional
And I see you have a couple of other sources on your website that I think bear mentioning, if you want to discuss those briefly filling out medical surveys become a becoming a medical reviewer, unrelated to real estate, but certainly very helpful.
Yeah, so what we’re trying to do with that, too, is, you know, all that stuff’s common associated with the process of moving, you know, you’re looking for jobs, or looking for ways to make extra income. And I’ve been doing medical surveys now for over 15 years. And it’s related, you know, large list of companies that do this, and, you know, we’ve had a list on there and what you have to do is just go in and out. And always get the question of how do I decide which company to sign up? You know, what I did when I was in residency, I found that with most of them, and what I found is that, you know, certain companies work with certain specialties more than other so it’s good to be signed up with multiple and you know, you can earned significant, you know, spending cash doing these surveys. Over the years, I’ve earned probably 10 to $15,000 a year doing the survey. So, you know, depending on your specialty, there’s definitely a need for people doing surveys. We also have information all about doing medical reviews in telemedicine, and you know, other ways to earn extra income of expert with witnessing to something else that we have on there.
Is there anything else that you that you wanted to mention that we didn’t discuss yet today?
No, I think the main thing that, you know, I want to get back to is, you know, preparing, you know, when you decide that you want to buy a house, again, it’s a very emotional decision and many doctors get out there and they buy houses that they can’t afford or are too expensive that their time and training. And when the bank’s qualify you for a loan, they’re not always looking at your budget to see what you can afford to pay for they’re, they’re always giving you the maximum they think you can afford. And so again, that doesn’t mean that it’s going to be comfortable for you if you go with the maximum they’re recommending. So to make a good decision, you always want to sit down and think about a budget.
Yeah, they recognize that your likelihood of defaulting is extremely low. But as you’re avoiding default, that doesn’t necessarily mean that you’re not miserable because you’re stressing over the not only the mortgage payments, but all the upkeep that goes along with having a more expensive home. So as long as you’re making your payments there, they’re fine. They’re not invested in in some of the misery that’s associated with, with with living paycheck to paycheck. So I think that’s, that’s, that’s an excellent point.
And again, if you’re married, you know, you want to think you know, long term care, you know, be you and your spouse, both want to work. Now because if you Get pre qualified on both your salaries. And you know, one of the people decide to stay home, it may be very hard to maintain that payment. So again, you want to think, you know, hey, am I going to start having kids in three to five years? And what am I going to do with that in the world? Had the plan that one person was staying home, you want to try to make your initial decision on that not on both people’s salaries?
Well, Doctor me Where can people find you?
Yeah, so you can go to send me an email at info at Dr. moves, calm, happy to answer any questions. Again, we just want to be a resource. I’ve been very blessed in my career. And you know, I feel like one of the things we didn’t talk about that but very fortunate and making good real estate decisions and have, you know, investment properties that are residential, commercial, and even vacation rentals and, you know, it’s been nice to get to a point To be able to pay off a lot of those properties and re seeing them, you know, be cashflow positive. And so it’s nice to get to a point in your career where you work because you want to not because you have to. And that’s where, you know, I feel like I am at this point. And I’m only 45. And I see as a blessing. So again, the reason I was able to get there was the decisions I made when I was 32 and 33 and 34. making good decisions then will pay off in your 40s and 50s. So you just got to think about making great decisions, you know, when you’re going into being an attendee.
Well, I really appreciate appreciate you taking the time to talk on the podcast, and it has been very informative, and it’s been a pleasure.
Thanks. It was great talking to you tonight.
That was Dr. Bradley Block at the physicians guide to doctoring. Find all previous episodes on iTunes, Stitcher, Google podcasts or wherever you get your podcasts and write us Review. You can also visit us on facebook@facebook.com slash physicians guide to doctoring. If you are interested in being a guest or have a question for a prior guest, send a message or post a comment.
Transcribed by https://otter.ai

 

How Physicians Should Buy Their Homes with Dr. Moves

Dr. Ramey had a pretty negative experience buying his first home as a med student, so he took matters into his own hands.  His wife got her real estate license, he got his, and how he helps med students, residents, and attendings around the country buy homes.  He walks us through the entire process from tip to tail, and we discuss for whom a physician loan would be appropriate, the advantages and disadvantages of such a loan, as well as the other types of loans available.

He also has an extremely comprehensive website with sources for physician loans as well as ways to earn extra income as a physician.

https://drmoves.com/

The Real Estate Physician – Cherry Chen, MD

Dr. Cherry Chen, the Real Estate Physician discusses this potential source of stable, predictable, passive-income as an alternative to investing in the stock market.  We discuss how she made her foray into this field, the tax advantages of real estate investment, why she chooses multi-family commercial real estate via syndication over crowdfunding or individual units, and how picking a syndication is like picking a doctor.

http://therealestatephysician.com

https://www.facebook.com/TheRealEstatePhysician/

EPISODE TRANSCRIPT

This is the transcript to the episode. This transcript was created by a talk to text application and the function of having this here is to improve the page search engine optimization. This transcript has not been proofread, so please listen to the episode and don’t read this. The information contained herein will inevitably contain inaccuracies that affect that quality of the information conveyed and the creator of this content will not be held liable for consequences of the use of the information herein.

Unknown Speaker  0:03
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians. We’re Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have learned while we were memorizing Krebs cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.
Unknown Speaker  0:27
On the previous episode, we spoke to the frugal physician about how to save more money. On today’s episode, we talked to the real estate physician about how to invest that money. Dr. Cherry Chen is a real estate investor who has the real estate physician com website and she tries to educate physicians as to why real estate is a reasonable investment and a good alternative to the stock market. We talked about the different types of investments and why she chose commercial multifamily is her motive investment, and why she finds this to be the least risky of all the different types, as well as the different ways to invest between owning everything yourself syndication, crowdfunding, and why she chooses syndication, and then how to identify a syndication that you can trust and why it’s like finding a doctor. Welcome back to the physicians guide to doctoring. On today’s episode, we have Dr. Cherry Chen. She is a practicing physician in Texas, who now spends a lot of her time investing in real estate and connecting other fellow physicians with that method of investing. So Dr. Chen, thank you so much for for joining us today to educate our listeners.
Unknown Speaker  1:41
Yes, I read. Thank you for having me on your podcast. I’m really excited to be here and looking forward to our conversation.
Unknown Speaker  1:49
So just to get to know you, where did you do your training?
Unknown Speaker  1:54
I trained I went to medical school at Texas a&m. I’m from the Dallas area here in Texas. And then I did my internal medicine training at OHSU in Portland, Oregon. And now I’m back in Dallas, where I’m from in a practicing internal medicine hospitalist.
Unknown Speaker  2:11
So are you practicing full time?
Unknown Speaker  2:13
Yes, I’m practicing full time as a hospice. That’s correct.
Unknown Speaker  2:17
So the real estate thing has, I guess, become or at least started out as your your side gig. So you’re doing this on top of practicing full time. That’s, that’s, that’s pretty impressive.
Unknown Speaker  2:28
Yeah, that’s, I mean, that’s correct. I’m kind of lucky in that way that a hospitalist, you know, schedule kind of affords you, you know, 15 or 17 shifts a month. So there’s definitely time outside of that. And you’re right is kind of started out, as you know, definitely my own personal investment for myself and kind of just grew organically as I talked to other physicians. So that’s where I’m now.
Unknown Speaker  2:52
So how did you get there first, tell us how you got started in real estate and then where you’ve taken it from your own personal investing to expand it to offering to others?
Unknown Speaker  3:04
Sure, yeah. So I would say, you know, my story started about, you know, three to four years ago, as far as, you know, investing in real estate, that’s kind of when I, you know, finished my training and started making more money as an attending, in kind of, I think, as we’re all aware, we didn’t get any, you know, investment or financial education, through our schooling. And so, as I made more money, you know, it really was I put a concerted effort into, you know, wanting to see how my money could work for me. And in the financial world, the fancy word is you know, cash flow means just means how much money you keep in your bank account at the end of the month. Because I think when we graduate you know, we think all we make more money, we have high income as physicians, but it’s not how much you make, it’s how much you keep and that was a new concept for me. As I kind of started exploring, well, what makes a good investment? And it was through that process in that context of, you know, being more proactive about my finances now that I’m out of training. And in that context, I started exploring what other options there were for investing. And that’s how I kind of stumbled upon real estate. What do you mean, stumbled upon it? Sure. So I think, you know, for most of us, and for me, we had investments in my 401k, or stocks and bonds or your IRA account, that was kind of basically what was really kind of thought the only option, because it’s all we ever heard or heard about other people investing in and nobody talked about, oh, I invested in real estate, you know, so, for me when I looked, you know, I had certain criteria that I thought would be important, and it wasn’t like I had, you know, like my A to Z criteria, the sign from the very beginning. I kind of as I was exploring other options, you know, I realized, you know, what would make a good investment. And you think about investing in the stock market? Most people, you know, I don’t know, it’s kind of the de facto or default. So we don’t really consider it as a risky investment. But, you know, when we talk about alternative investments, which is what real estate would be considered, you know, a lot of people will say, Oh, isn’t that risky? So really depends what what you mean by risk, I would say, the differences being in Wall Street, you know, you could wake up tomorrow, and it’s, you know, the whims of the market. So it’s definitely volatile and unpredictable. And it doesn’t really, you know, put money in your pocket at the end of the month, you know, so those two two factors being the stability and predictability of what an investment I think should be and it bringing cash flow, meaning your money’s actually working hard for you, independent of your Time real estate was able to do that when I kind of explored and fit my criteria in that way. So I would say stumbled upon in terms of, I didn’t really go out seeking a knowing real estate was a good option in that way.
Unknown Speaker  6:16
So I guess more discovered the then then stumbled upon because it looks it sounds like you did a lot of research in order to arrive at this conclusion.
Unknown Speaker  6:25
Correct? Correct. I am an internist. So it’s like I have to know everything. So I, you know, Google till the ends of the earth, did all the try to educate myself as much as possible. And that’s kind of how I came to define my criteria. On what it right.
Unknown Speaker  6:42
I think the risky kind of like, when we have our patients, they’re nervous about something. And a lot of times they’re nervous about it, because they don’t understand it, or you know, they don’t know what the outcome is going to be. And so it’s the not knowing that makes you nervous. And so what you did is you mitigated that by educating yourself. When those people are saying, well, isn’t it risky? It’s a lot. Well, you know, the it’s the it’s the lack of knowledge that breeds anxiety. So, but historically is are you aware of any comparison of the market to the real estate market like the the stock market to the real estate market?
Unknown Speaker  7:19
Right, I would say I mean, real estate is really broad. And we’ll probably go into like, you know, the different categories of it later. So when I talk about my investments, and the the niche I focus on is called commercial real estate. The most basic example being like an apartment complex commercial grade, meaning it’s greater than five units. And so it’s a big apartment complex, and they’re that so that’s kind of the investment vehicle I came across that I thought met all the criteria. And so that’s kind of where I focus on
Unknown Speaker  7:55
just a historically commercial multifamily real estate tends to be fairly stable and just for the listeners, because I found this confusing commercial sounds like nobody’s going to live there. Right commercial property sounds like something where there might be real retail stores or industry, but commercial multifamily specifically refers to homes that contain greater than five units
Unknown Speaker  8:23
correct and for that’s, you know, apartments it doesn’t necessarily be homes there are things like you’ll see you know, your self storage facilities that are in your neighborhood. Some places have mobile home parks, those are all considered commercial because it’s generally greater than five units. But for most of my for most of you know, the talk will be talking about apartment complexes because I think for many people, when you think about real estate, you think, Oh, well, there’s a single family rental I wanted to go you know, buy a condo and rented out on Airbnb or something. So there’s some distinct differences when you go from A single family to a commercial grade multifamily apartment property.
Unknown Speaker  9:05
And the number there is the magic number is greater than five. So if it’s anything less than five, you know, you’re you’re dealing with maybe a duplex or an individual apartment or an individual house. And then just for completeness, because we’ve spoken about this before, you can also invest in industrials. So like a an office building, or you can invest in a retail establishment and not knowing again, I don’t have any full disclosure, I have zero Real Estate Investments right now. I would think that retail might not be the safest place to be considering how much people purchase online and the direction that that’s, that’s heading.
Unknown Speaker  9:51
Any thoughts on it?
Unknown Speaker  9:52
Yeah, you’re correct. Those are all you know, you know, real estate, commercial real estate, investment options and You know, primarily why many of the commercial real estate is focused on apartments and like you said, Because will retail so many people are buying online? Well, there’s always going to be the demand for housing. And now there’s a demographic trends where, you know, Millennials will and they want the mobility and it’s not back in the day where Oh, well, you had an employer for 30 years. And so people like the idea of being mobile and not, you know, saving up 30 years to buy their one home that they’re going to live in forever. So multifamily as far as an investment vehicle has been really popular because it’s kind of intuitive. You understand it, people need a place to live, and they pay rent and what expenses you have at the end, that’s your income for the property.
Unknown Speaker  10:49
So why do you find commercial multifamily to be the one that you’ve chosen as the the safest or most advantageous investment? Yeah, I think not to be redundant. You just mentioned why you think it’s safe because people are, are, are mobile, and they, they want to be mobile and they want to be able to move around. And also people are getting married later and having families later. And so they’re going to be what? Spend more time being mobile I’m involved had between all of our schooling tons of me. Yeah, but but financially, what has been your experience and what has driven you towards that investment?
Unknown Speaker  11:34
Right. So I think you know, so for me, my criteria is one being, I think a good investment should at least be somewhat stable, predictable, and have you know, cash flow as an investor, I want my money to work for me and give me returns. So you know, just comparing it simply to for example, if you got a single family rental, versus an apartment complex, you know, like a one door versus in 100 unit, apartment calm. Plex, the, you know, if you’re a tenant moved out tomorrow from your single family home, you would go from, you know, 100% occupancy to zero, you know, in an apartment complex if I have 100 units and two people move out, I’m still at 98% occupancy, right? So losing those two tenants, I might have a slight decline, but I would still expect a pretty stable return of my investment. As an investor who has, you know, invest into the property. If you have your single family, your tenant moves out then your cash flow is basically zero, right? And every month that you’re spending to find a tenant is is is zero income, or is the 100 unit property use it?
Unknown Speaker  12:47
Yeah, because you’re still spending money on mortgage repairs, upkeep. Yeah, all the all everything that goes into it,
Unknown Speaker  12:54
right. And so in your apartment, you still have 98 tenants paying you rent, you know? And so the basically that the main advantage of having multiple units is you have the economies of scale. And you can leverage that into into a business operation. And for I think for physicians and investors, the the the nicest thing about that is I don’t have to be the landlord, and I can pull my money together with other investors into a business. And that gives me you know, return on my investment.
Unknown Speaker  13:28
Yeah, we talked about the desire to have passive income, right? And if you own an apartment, and you are the landlord, that is not passive. That is the opposite of passive because then all the upkeep and management and finding new tenants and, and even if you outsource that labor, which actually you can do, I think it bears mentioning there. I think it’s called turnkey investments where you just get a management company and they try to flip a house and they can, they’ll manage the property and they’ll flip it and they’ll You use your money to do that. You still have that higher risk of what you’re talking about. If that goes unoccupied, then you are. It’s a losing proposition. So. So there are a bunch of different ways that you can invest in these commercial multifamily buildings. You can own it yourself, which seems unlikely on a physician income, even if you’re super successful plastic surgeon or neurosurgeon
Unknown Speaker  14:29
Yeah, I mean, even for anybody it’s Yeah,
Unknown Speaker  14:32
you’re not buying an apartment building, right?
Unknown Speaker  14:37
Then you can, there’s there’s syndications, there’s crowdfunding and you can still invest in real estate in the market. They’re called reads Rei T, but so owning yourself seems pretty straightforward. If you’re not doing just buying yourself or finding one of those turn keys, which might be a different episode altogether. There are syndications and there’s crowdfunding You talk about what both of those are.
Unknown Speaker  15:01
Yeah. So syndications is is is the way I invest in these real estate opportunities and for people who have never heard the word because I had never heard of that word, you know, but it’s just a you know, the fancy word in this real estate world where they’re pulling multiple investors or multiple investors money into a company that would purchase the apartment complex because like we said, most people do not have $10 million to go buy an apartment complex all on their own. So in a syndication, the way it works is you have these deal sponsors who who will talk to the brokers who will go look at the apartment complex, who will verify the rent roll look at all the financials and and find an apartment complex they think would be a good investment. And then they they the deal sponsors then they need to find the money in order to purchase the complex. Now in the syndication commercial world, it is still 75% leverage meaning the bank finances and is the biggest partner in the transaction. But the the deal sponsors still need to find 25% or so of the money. And that’s when they would go to, you know, for example, me of an investor who’s interested in real estate, but I don’t want to manage and I want to be able to be part of a bigger apartment complex. So then they would go to investors and to pull the money together to syndicate to complete the transaction. So that’s a syndication where one you as a passive investor are or limited partner in this in this transaction, get to reap the benefits of the investment and share in the profits and you are not at risk of you know, you’re not signing the loan, you’re not doing all the all the work of managing the property, and so you’re passing Some investor, you kind of basically collect what they call mailbox money when the apartment makes money and they distributed to the investors. So in a syndication model, you actually have direct access to the deal sponsors, you can communicate with them, you can ask them questions, you can verify things that the crowdfunding model is similar in that, you know, you still have these deals, sponsors who go out to look for deals, but they’re not coming directly to the passive investors, you’ll see, you know, crowdfunding websites, where it’s just, you know, a website with the platform of like a multitude of investment opportunities. So you’re not directly talking to the sponsorship team. You’re just kind of browsing, you know, a whole bunch of opportunities and seeing Oh, well, hey, this says there’s a 10% return. Well, that looks good to me. So it’s a more indirect way to invest, where you don’t have that direct relationship with a sponsor, so there’s no right or wrong way. Everyone’s investor, you know, trust or risk profile is different. The The only other major differences, the crowdfunding has a lot less minimum investment where you’ll see on these sites where it’s 1000 or $10,000, to invest or syndications, where at the minimum investment is usually about 50,000. So that’s also another major difference.
Unknown Speaker  18:26
So when you’re choosing syndication, because that’s typically your method of investment, how do you vet them?
Unknown Speaker  18:35
Yeah. So it’s, you have to do a syndication. You have to know the sponsors, right? That’s feeling where you would hear about the opportunity to invest. It’s not, it’s not advertised. It’s not on the crowd format site. It’s not you know, Wall Street where you just pick something. So there’s multiple ways investors can go to their local meetup local apartment. meetup where these deal sponsors will be at, and you can meet them personally personally like that, or you meet somebody else on the team and invest that way. And or that’s, that’s really the only way is to meet them, either directly or indirectly, to find out about the investment.
Unknown Speaker  19:19
So, when we first met, I asked you a question, and you had a very interesting way of answering it. And, you know, the question was, how do you know that you can trust the syndication? And you said, the same way that you can, that you know, that you trust your doctor, right, like if you’re, if you’re trusting the syndication with upwards of $50,000, right, your your, your analogy was, well, you’re trusting your physician with your life. So, you know, this is a lot of people find me by going to their town Facebook group, you know, they’ll go to the Facebook group and say, Hey, does anybody know good ENT? And sometimes my name pops up. And so they come and see me And so I guess you’d find your syndication in a similar way. Except that you could have your I guess, could you could you have your accountant look at their books and make sure that that, you know, everything that they’ve done with previous deals was all on the up and up and you know, is that type of stuff, the type of thing that they make public to you,
Unknown Speaker  20:22
right? Yeah, the physician patient analogy is something, you know, I was trying to find like a good, like a good, pertinent way to explain it. It’s like if you were the investor talking to the deal sponsor, as opposed to physician patient, right. And, and we’re managing people’s health, you know, and versus they’re managing investment, but you’re putting in significant amount of capital into the investment. How do you trust that’s like one of the biggest, I think, barriers or issues we come across when you come, you know, come across an investment opportunity. And so, the you know, it’s it’s just like how We help patients Yes, they, you know, like you said indirectly they see you on Facebook. Well, they see that you want to, you know, XYZ school you went to this residency training you are accredited at this hospital. So indirectly you have you have this, you know, track record or reputation. In the same way these deal sponsors, they have prior deals they’ve done, they have, you know, other complexes they’ve owned, and you can review all of that and you don’t even have to go through your CPA The beautiful thing about the syndication is, you ask them directly, because you are going to be a potential investor, you have the right to ask all these questions and they that you you, you ask them directly you can say Well, hey, you know and sponsor you, you projected that it’s, this will return 10% next year. Show me how you got there, you know, or show me why you think this apartment can rent for thousands dollars a month rather than maybe 800. You can ask them all those questions.
Unknown Speaker  22:07
But if they had, if they let’s say they put together a building, and it was doing poorly, right, right, they wouldn’t want to tell you about that. Is there a way to access that type of information
Unknown Speaker  22:18
and a way to access that? There is no you know, database where you can put in Oh, sponsor XYZ name, and, you know, all their deals would pop up. Now, most of them will have websites where they put in all their properties that they’ve, you know, acquired. So, that’s the way to go to their website to say, hey, well tell me about this property and what’s been going on, you know, and, you know, another way is, you know, invest just like patients, you know, they say, Oh, well, you know, Dr. XYZ referred to me all my friend came to you and they really, you know, loved us their physician. So that’s how I found out about you. You can talk to other other investors that have invested in them, they can say, Well, hey, even they treated me really well, or they did not treat me well. And so there’s other other investor testimonials you can do too. So, I think trust, you know, in this way, it was a question for me as well. But, you know, one that I could verify their records, the fact that the apartment is a business, they can’t make up these numbers, they look at the financial statements, they look at the income and expenses, and those are things you can ask for and verify yourself. And so that for me, and looking at things, a very objective way, you know, so that kind of helped me overcome that. The trust issue,
Unknown Speaker  23:45
can you do that with crowdfunding
Unknown Speaker  23:47
with the ground funding, I do not believe you can do that. I don’t, I’ve never invested via crowdfunding. So I don’t know this step by step process of the way that works, you know, so I don’t want to to misguide That the listeners because I’ve never done it step by step myself.
Unknown Speaker  24:05
Okay. And I think that’s that’s fair and thank you for for for admitting that that’s that’s much appreciated by by everyone for crowdfunding though I just and correct me if I’m wrong and you know you’ve never done it but I think they can advertise, we’re syndications can’t and so syndications thrive off of their reputation and these introductions right you, you find syndications that have done well you introduce them to other potential investors with crowdfunding, they have these websites and they can just advertise and you because you can find them this way. They’re not they don’t need that word of mouth reputation. It’s kind of like, I guess. Actually, I’m having trouble thinking of analogy, I guess as physicians advertising versus just just you know, before the days of advertising, there was just word of mouth. And if you had some bad outcomes, then that would get around and then you know, you’re, you’re kind of sunk it, you know if that’s true of crowdfunding.
Unknown Speaker  25:09
Yeah. So the only one exception to what you said is, you know, through syndications, you know, the sponsors there through a syndication, there’s two ways they can raise money. You know, like we said, The first way is to where they, you, you they directly know, the investors, you know, through their circle, or the other way that they can legally advertise is they they made what we call a 506. See offering in that just so is an SEC term. And that in that way, when they are only advertising to a specific investor, what they define as an accredited investor, then they don’t have to have that relationship or know you. Exactly. So there’s that one exception,
Unknown Speaker  25:59
okay. You’re making a pretty convincing argument for investing in commercial multifamily real estate through syndications. But I think there’s more of an argument to be made, right in terms of the tax advantages of these investments because, you know, high income individuals pay a lot in taxes, although our we’re not going to get political. But our current president and his son in law involved in real estate, turns out, don’t pay much in taxes. And that’s not you know, I, again, political, that’s not through tomfoolery, or trickery. Some of it may be, but it seems that it’s on the up and up because of how real estate operates. That somehow you can protect your investments from where you protect your yourself from taxes. So, so can you talk about some of the tax advantages of investing in real estate.
Unknown Speaker  27:03
Yeah, I be you know, obviously not an accountant and so I don’t know the exact ins and outs but on a very you know a basic level that I understand it as an investor myself is that because if you’re investing in real estate and real estate you know in the government’s i is something that they want to promote investors to invest in because one, you know, we talked about it provides housing and provides jobs, it provides for growth in a city in a community and they want they want investors people out there to provide housing for these people. So, government provides incentives to promote activities that they want to promote whether we believe it or you know, feel for or against it. So the the advantage of investing in real estate which people calling say, you know, you can have a Tax Free income. And that’s coming from as a real estate you get depreciation of the property of the building of the equipment. And so when the government IRS allows the accountants or you know the business to take that depreciation of these properties and buildings over time, that often will offset the income you get from your investment in. That’s how, you know, they come up with the term tax free income.
Unknown Speaker  28:34
This is how I’m understanding depreciation. And correct me if I’m wrong, you buy a building, kind of like buying a car, as soon as you drive it off the lot, right? It starts to lose value, because the building is aging. So it the building is losing value, it’s depreciating. And so it’s almost like if you lose capital losses in this in the market, you can deduct your losses. You now have capital losses because your building has depreciated. So even though you built the building a year ago, it’s a year older, and it’s depreciated and and so that capital loss can be deducted from your your taxes. Correct that would be creationist.
Unknown Speaker  29:19
Yeah like the building and and so over in commercial real estate the IRS allows you to kind of deduct that over like a, you know, the cost over 27 years or something like that. So, you know, you know, just think about how much money that is or an apartment like 100 unit apartment complex, you know, and so that depreciation is often much larger than your income that you get as an investor. So, whatever passive income you get, if that’s less than the depreciation of the building, then you don’t pay taxes even though you Have earn some income correct on your investment.
Unknown Speaker  30:03
So wait, let me see if I understand this because I, I used to live in Long Island City, which is right across the East River from Manhattan, there are some gigantic, fancy buildings there that might have 800 units. And I’m just making up a number here. Let’s say one of those buildings is worth 100 million dollars. You’re saying, in the eyes of the government, after 27 years, that building is worth zero, so it could so it has depreciated to nothing? Oh, so
Unknown Speaker  30:30
I didn’t mean it in 27. It’s like, so let’s say for instance, and these are just totally made up numbers, right. Like, for instance, this 100 unit complex building, the building itself, you know, is a million dollars. You can’t really say I’m going to take a million dollars on your, on your text form this year, you take that million you divided over a 27 year term. And that’s the amount of You know, you can legally maximally deduct on your on your tax form. That’s what I meant by the 27 years not not saying the what you were talking about. Does that make poker? Yeah,
Unknown Speaker  31:11
yeah, that definitely makes more sense.
Unknown Speaker  31:12
And so of course, I’m these are just totally made up numbers. But on a general basic level, that’s kind of what people mean when they say, Oh, well, there’s, there’s the tax advantage of investing in real estate. Because if you through through your wall street through stocks and bonds, any gain is, you know, taxes, your ordinary income, which is a lot for many of us. And so and that’s also the same if you mess and we’ll say through rates because it’s part of Wall Street. So that’s the tax advantage of investing in real estate in this way.
Unknown Speaker  31:47
But have you had any experience with your buildings being financed by the banks and in terms of non recourse loans? Have you been in that situation?
Unknown Speaker  31:57
Yes, and actually, you know, the, I would say probably I want I want to say 100%. But most of these majority of these properties are non recourse loans through the bank who finance about 75% of these transactions because that, you know, and that’s kind of another layer of, you know, if you want to say how do you vet an investment because, you know, banks are conservative and they, they’re out to make money. And for them, they see apartments or these properties as, quote unquote, safe investments. And so, they actually finance about 75% of the purchase price when you when you purchase a building like this, so, you know, they do their own underwriting, they do their own analysis, and they come up with what the what the purchase price or the value of the building is worth themselves. So they these properties are majority non recourse financed.
Unknown Speaker  32:56
So if the whole thing goes under, you don’t want this Just to clarify, this is what non recourse means. If the whole thing for whatever reason, like, let’s say, right, some of us believe that the market is a bit frothy right now and we’re at the precipice of potentially something bad. If that happens, and and the building doesn’t get built, then what happens to that 75% that the bank has lent us,
Unknown Speaker  33:25
right. So I would say so, the, you know, the, so we talked about non recourse, the other side is recourse loan, you know, so, what non recourse means, like you said, as well then we don’t have to hit you’re not liable to the bank for this loan. The only one exception in is that if for whatever reason you’re committing outright fraud, you know, or it’s called what they call the bad boy carve out if you’re not acting, you know, in quote unquote, normal behavior or committing fraud then that kind of cancels out the Non recourse, the not then you would be held liable as in that you being the deal sponsor not you as a limited partner. Because
Unknown Speaker  34:10
the loan I think if you do something to the property as well like if you something toxic or something happens on the property, something environmentally unsound happens on the property. I think that’s another reason.
Unknown Speaker  34:20
Yeah. So there’s there’s certain reasons but those are, you know, far few in between the environmental toxins is if if the bank’s found out about that, and that will be definitely before it was even an investment available to investors at the bank’s saw that and they would not lend to purchase the property to begin with. And so that’s probably what you’re talking about, okay.
Unknown Speaker  34:44
Well, if I had a friend who was investing in their 401k, and maybe they were trying to dabble in the market, try and beat the market which we know may be done. What would you say to to send and maybe just had some finances that were being managed by a financial advisor that they found? Because they they bought them lunch at when they were a resident and gave a talk that sounded good. had nice suit. Yeah. What would you say to that friend who feels that their money is as safe as it can be in the market with this educated and informed financial advisor to get this person to start investing in real estate? What’s your what’s your elevator pitch to that person?
Unknown Speaker  35:35
Um, I don’t know. So, I don’t I don’t have an elevator pitch. And I say that because one, I’m not, you know, I don’t ever want to convince somebody to invest in commercial real estate and, you know, we can talk about all the benefits and, and why I thought it was a good investment vehicle, but, you know, it’s, it’s like, you know, if your friend went to advisor it’s like, nobody really understands your financial situation, and in what your your financial needs are more than yourself, you know, nobody cares more about your money more than yourself. And so I really would say, you know, what I’ve always said to you know, other friends or families, colleagues, what, to me, the most really important is that, you know, what is your investment philosophy? Or what is your criteria, because one, you know, your friend might be right, and you know, him going to his advisor is probably the safest because maybe his or her goal is to say, I just want enough for retirement. And if I put a certain percentage of my income every year into, you know, quote, unquote, stable, safe mutual fund, I will have enough for retirement correct and he wouldn’t need to look outside of that vehicle. But, um, you know, for me, and I think for most of us, is that you, we don’t want to work forever, right? At least I don’t know forever. I Love medicine and I’ll be in it for a very long time but I want the option of you know, if I needed to for some unusual life circumstance, you know, with family or friends, my loved ones that well maybe I can work fewer clinical hours or we just want the option to have more non clinical time to spend with our family so that’s why I real estate was really attracted to me because one you know, quote unquote, predictable income in the cash flow. And you don’t get that no matter how much money you earn. If you don’t keep that in one if you’re really good at saving but to you’d have to work forever and, and that’s why I’d say you know, if real estate has the advantages and the criteria if you’re looking for passive income so that you can have the option to choose to work last should you choose to,
Unknown Speaker  37:56
so you get your investment, hopefully appreciates because, you know, the value of real estate appreciates, but then you’re also getting income through rent. So, you know, you’re, you’re in the same way that that your investment hopefully in the market appreciates your investment in the real estate appreciates, but you’re also getting that that rent. So that’s, I think important to delineate that specific.
Unknown Speaker  38:22
Yeah. And so certainly the appreciation if you look at all these for you know, is the syndication investments, it’s the good deal sponsors will not, you know, hope for that, like, you know, you they don’t anticipate that it’s like an extra bonus. So what are
Unknown Speaker  38:38
some of the resources that you consume or that you would recommend that our listeners consume? If they want to start get it like you said, you Google to the ends of the earth so that you could be more comfortable with this. Save us the time of googling to the ends of the earth. What are either the resources that you consume or the resources that either a podcast that you listen to aside from mine Of course, or, or a book or a blog or something that we can read to better educate us efficiently. Aside from I think every real estate podcast with a physician I’ve heard mentions Robert Kiyosaki was rich dad poor dad. Yeah. So we can’t end this without mentioning that. Rich Dad, Poor Dad. I’m curious how changed your philosophy on money. So aside from that, what would you recommend?
Unknown Speaker  39:37
I would say? If it depends, so one, if you think if you know your criteria, and you know what you’re looking for, even if you didn’t, so one of the nicest resources out there is probably bigger pockets. I don’t know if you’ve heard of it or familiar with that. It is a very active real estate community where people contribute all the time. Whether it be you want to do single family, multifamily, self storage, mobile, home parks, the whole gamut of real estate, there’s somebody involved in it one way or another on that site, and they contribute regularly. So I think that’s a very great starting point. And, you know, you can browse the forums and find something that fits your specific question. And to a, you know, you know, the point of going to these meetups or going to our conferences is you you build relationships with people who are who have done this or, or are doing what you want to do. So the other way is, you know, talk to other physicians who have invested before and or whatnot. And that’s kind of why I wanted to start you know, my website and company because I talked to so many physicians and one, you know, I don’t know if you identify with this because I did to in the very beginning, I didn’t want to start a company. I just Wanted to invest. But physicians, one will say, Oh, I don’t have the time to go to all those conferences. And even if I did have the time, I’m not going to, you know, you want to spend time with your family, you know, and friends and and you don’t have the time to, like you said go to the ends of the earth. And so that’s kind of one of the main reasons why I built the website to help answer these questions in one to share this kind of investment opportunity with physicians that we don’t really hear about so often.
Unknown Speaker  41:30
And where can people find you?
Unknown Speaker  41:33
The so my website is www dot the real estate physician.com. And really, it’s just a platform, like I said, that kind of grew organically out of all the conversations I had, and was a way for me to kind of systemized that and have a platform to share. So if people are interested in commercial real estate, they can just go to that site to learn a little bit more. That’s about it. And I’m always happy to answer any questions or I talked to people all the time about this, if they just want to call me or email me any questions, they don’t have to sign up on my website. And they can just email me cherry at the real estate physician calm to do that.
Unknown Speaker  42:14
Is there anything else that you’d like to mention today? We didn’t get to?
Unknown Speaker  42:17
I don’t think so. I you know, I really the one thing I would say is that I like you said, We sometimes as physicians, just leave, you know, our investments to advisors, but I really would, you know, not not to say they don’t do a good job, but really, just at least in your framework or mindset, be more proactive about your financials, whether it be well, you know, understand a little bit more about the structure in or one, you know, think about, do you need cash flow, do you not need cash flow, so just be more proactive, then you can set the criteria for what you’re looking for. And I think that’s been really helpful for me, so
Unknown Speaker  42:57
I think you’re totally right. I think it’s it’s so easy. For us to just we got on this path we got on this train, right? good scores, good grades, med school, residency, seeing patients, you know, just going through life doing what we were supposed to do. It’s, you know, we’re, we’re now being financially rewarded for it, some more than others, and to just assume that someone else to just trust someone else with that income without educating yourself, there’s so much information out there, it’s so accessible, and there are plenty of places it’s not opaque. This stuff is not that complicated. It’s really fairly easy to understand and a lot of these industries exist to try and make themselves opaque so that they seem necessary, right? A lot of these. There’s a lot of there are a lot of sales people out there and, and it’s not that hard to educate ourselves. So we really need to do it so that you know what your money He is doing you know where it’s going. And you can then not be afraid to get a little more involved in it and, and and then it also a lot more interesting than then many people think it is. So. Dr. Jerry Chen, the real estate physician, thank you so much for taking the time today. It has been a pleasure.
Unknown Speaker  44:21
No problem. Thank you so much.
Unknown Speaker  44:25
That was Dr. Bradley Block at the physicians guide to doctoring. Find all previous episodes on iTunes, Stitcher, Google podcasts. Were wherever you get your podcasts and write us a review. You can also visit us on facebook@facebook.com slash physicians guide to doctoring. If you are interested in being a guest or have a question for a prior guest send a message or post a comment.
Transcribed by https://otter.ai

The Real Estate Physician – Cherry Chen, MD

Dr. Cherry Chen, the Real Estate Physician discusses this potential source of stable, predictable, passive-income as an alternative to investing in the stock market.  We discuss how she made her foray into this field, the tax advantages of real estate investment, why she chooses multi-family commercial real estate via syndication over crowdfunding or individual units, and how picking a syndication is like picking a doctor.

http://therealestatephysician.com

https://www.facebook.com/TheRealEstatePhysician/

 

The Frugal Physician: A Primary Care Physician’s Journey to Financial Independence

In residency, we have to live with less.  Less money.  Less time.  Less dignity.  And after finishing, we are rewarded for our herculean efforts with higher income.  Sometimes the time and dignity come back, too.  In today’s episode, the Frugal Physician and I discuss the pitfalls that can come with that increased income and how falling into the materialistic abyss brings with it more financial stress and often less happiness. We discuss her journey to frugality and lessons learned along the way.

Home Page

http://www.facebook.com/TheFrugalPhysician

 

EPISODE TRANSCRIPT

This is the transcript to the episode. This transcript was created by a talk to text application and the function of having this here is to improve the page search engine optimization. This transcript has not been proofread, so please listen to the episode and don’t read this. The information contained herein will inevitably contain inaccuracies that affect that quality of the information conveyed and the creator of this content will not be held liable for consequences of the use of the information herein.

Unknown Speaker  0:03
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians. We’re Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have learned while we were memorizing Krebs cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers.
Unknown Speaker  0:27
On today’s episode, we speak to the frugal physician. She’s an internal medicine physician that gave up the life of luxury, resolve that stuff was actually making her life worse. The stress of paying bills not paying down debt. Let her to downsize. Matt Damon sense life actually got better. We talked about why physicians tend to live up to the expectations of others in terms of material goods. Getting the house a physician should own the car a physician should drive rather than living up to their own expectations. And one of the most effective ways to be more frugal. How do you Get on the same page with your partner. And after all this talk of giving up material goods, why you should buy the Insta pot. Welcome back to the physicians guide to doctoring. On today’s podcast, we have the frugal physician and internal medicine physician in upstate New York. The key to how she became the frugal physician is in her origin story. So if you would please introduce yourself and tell us how you became the frugal physician.
Unknown Speaker  1:32
Hey, thanks for having me on here. I really appreciate it. So yeah, I was a just a regular old primary care doc. Actually internal medicine hospitalist Initially, I did the usual thing, went to med school and took out a bunch of loans and then went to residency and initially I planned on doing public service loan forgiveness but like many people that actually got into that plan. I didn’t, I don’t I don’t think I did the paperwork, right. So anyway, by the end of residency, I had decided not to pursue that anymore. And decided to take a job as an attending in a private company and found myself stuck with my huge amount of student loan and a house loan, actually to house loans. And then I became a mom and had to take maternity leave. And all of that kind of added up to me finding myself in a situation that I didn’t want to be in anymore. And we decided to make some major changes and ended up making a huge life changes. We actually ended up paying $100,000 in student loans, and about six months after we made some of these changes, so I really felt like we kind of found something important to for medical students and residents, so kind of wanted to share that. And so that’s why I started blogging at the frugal position.
Unknown Speaker  3:09
And I appreciate that so much because with some of my friends and colleagues, I find that that the even with significant incomes, some of them live paycheck to paycheck and there there are a lot of resources out there for us positions. Passive Income MD, that white coat investor that talks about the importance of investing wisely, but you can’t even get to that step if you’re spending all your money and not doing any savings. So I think before you even get to exploring those, you need to visit the frugal physician com
Unknown Speaker  3:52
Thank you. Yeah, I mean people get that’s that’s kind of where we were we upgraded our lifestyle. You know, I was so Ready to have it all once we got once we got done with residency rather once I got done with residency, my husband was in the army initially, but he decided to get out and we decided to move to the beach and have it all and bought a big house and and, you know and had bought a new car actually around that time too. And we found ourselves three fourths of a million dollars in debt, if you can believe that. I don’t know how that happened. Well, I do know how that happened. I had $237,000 in student loans, even after making payments in residency, and I had about 335 and house loan 40,000 and car loans and 130,000 per rental property that we had. So three, three fourths of a million dollars in debt.
Unknown Speaker  4:57
And you had mentioned that before. You said you had two houses. So you just finished residency and had already accumulated two houses. How does that right? I know
Unknown Speaker  5:12
so well in residency, I bought a house I did what Jim Dolly says don’t do.
Unknown Speaker  5:18
And we actually but we were kind of responsible in that we only use my husband’s income for the financing of it. He was the one that took out a VA loan, because he’s not army. So we did buy a small house that actually that makes a good rental now. It didn’t make sense to sell it because it was bringing in good rental income. Or at that point, we wanted to make it a rental. So so that’s why we kept that.
Unknown Speaker  5:47
In some ways. I think that makes sense. Some might argue that in buying a house for residency, or an apartment, you know, whatever the case may be You you do a significant amount of research before you buy it. Right. Right. And so, you know, there are inefficiencies in the real estate market. And so you might have been able to capitalize on and find what you thought at the time was the best deal around, right? Otherwise you wouldn’t have bought that. And that is, if you’re buying an investment property later on, you’re probably not doing as much research for an investment property as you would have for the home that you’re going to be living in throughout your residency. So I think there are some advantages to if you have the means to buying a home during residency and then keeping it as an investment property.
Unknown Speaker  6:41
Yeah, it turned out to be a good goodbye because it’s, it has almost tripled in value in the last four years, four or five years. Yeah, yeah. We just we bought in a gentrifying neighborhood. It wasn’t a place where, but it but it’s a fabulous place. And I love it so much and, and it’s getting the attention it deserves now and everybody wants to move there. So it’s a it’s a good place and we plan to keep it around for a long time. But moving away from all these decisions I made to get us in debt or we made to get us in debt. I found that, you know, everybody told us we were doing great, we paid everything on time. We didn’t have any credit card debt, but we were spending almost exactly what we were bringing in every month, we were really walking a very fine line and bringing in a significant attending income, we were still living paycheck to paycheck, and that was an eye opening thing. I mean, even as a primary care physician or a hospitalist, you know, people whine about how much how little money we make, but we make A lot of money. I mean, the average average, what’s the average us salary like in the 50? Thousands, right? I mean, the average of primary care physician makes you know, hundred and 80 to $200,000. That’s not that’s not a little amount of money, we should be able to be perfectly happy with that. But I think we set us set each other up, or set ourselves up in our mind to live this expectation of you know, that we have to be this high rolling, Lexus driving, you know, doctor, and if we’re not, then we’re not worth our salt. You know, and this is, and that’s what, that’s what society sells to us. And that’s what, that’s what everybody tells us we should be. But it doesn’t have to be that way. We don’t have to. That’s what I discovered what when we when we went through this journey when we were so stretched, we were so unhappy because we have Everything we had the big house, we had the cars. But we were financially insecure we had no investments are, our net worth was very negative as well like negative $170,000. And that didn’t feel good. And so we said, you know, we got to do something, we’ve got to make a change, especially when I got pregnant and had to take unpaid maternity leave. And then I wrote a post about how how that really messes up your finances, especially when you work in a private on a private company. That that was kind of the turning point. I decided, I remember I was sewing a cover for my couch because I didn’t want to buy one. And I was listening to Jim Dolly’s book, and on audio book and I said, this has to change and we have to do something and I said, I went to my husband. I was like, how about we started dead and you know, try to try it. change our situation somehow. So we both sat down and started off with just kind of listing what we were spending. And that’s actually really hard to do to go through your account and be like, Okay, this is what we spent on food. And this is what we spent on, you know, gas. And thankfully, there are a lot of good resources out there now to help you with that. There are several apps like every dollar or why NAB but and actually the the bank that we use USA actually does break down the kind of in a budget format, all you’re spending. So that’s what we do. And we just transfer that to a spreadsheet. And we just started to go through our big line items of where money was going. And that was in you know, that’s that unsexy word that I don’t want to say, but we came up with a budget and, and really all that is is you’re just taking an account of what’s happening with your money. That’s All and we decided to put a certain amount towards our snowball. So initially we started paying off one car, this our smallest loan. Once that was paid off, we paid off the second car. And there’s a little bit of a drama there because we got in a car wreck and we had to replace the car, but any case, and then once we got things will happen,
Unknown Speaker  11:25
and if you’re living from paycheck to paycheck, then that puts a lot of stress on you and the marriage and the family and and it leads to a lot of unhappy. Exactly, yeah, or that you bought was going to make you happy. And in fact, it does.
Unknown Speaker  11:43
Yeah, it just doesn’t. It’s not there. I know. It’s like it’s the everybody talks about that. All the older people that you talk to otherwise people will tell you know, happiness is not in stuff. Yet somehow. We all keep seeking that And I don’t understand why. It’s the expectations, I think that we’re trying to live up to. But
Unknown Speaker  12:06
you mentioned that before, and I just want to want to explore that a little more. That it’s the the external expectation, you know, we talked about, we have free will, right? We make our own decisions to do what we want to do. But at the same time, these external pressures are influencing your decision making. So it’s really not as free as you think it is yet. We have all these external pressures that that caused us to make these decisions. I did the same thing I finished residency. I spoke to my friends about that know about cars about what kind of car I should get. I ended up getting I was single at the time, so I didn’t need anyone to. There’s no need for car seats or anything like that. I got an Infiniti coupe. Right. But I also lived I lived in Manhattan at the time, but I worked on Long Island and I surf. Oh, so I wanted to be able to serve and I didn’t think you know what, it might be a little more reasonable to get a sedan and I could put a surf rag they don’t make surf tracks for but, but like, this was the sports car that these knucklehead friends of mine told me that I should get because that’s a doctor’s call. Right? Right, which I’ve gotten, you know, I don’t know maybe the Volkswagen mini bus bus or something. But right it was those external influences that ended up making me less happy so I had these you know, significant car payments for a car that didn’t even like because I wasn’t able to do the stuff that I wanted to do. I can someone else told me
Unknown Speaker  13:39
and yeah, and don’t let me get my on my horse. There’s nothing wrong with the coop, you know, there’s nothing wrong with a nice car. And some for some people, it makes them really happy. But the problem is, when you when you finance out your entire lifestyle, and you pay for that as you go, you have no room left to pay yourself. And that’s the problem when you don’t have any room in your budget is to make savings. That’s when stuff becomes a problem. There is and you know, and once once you were financially secure and had a significant amount of savings Sure, Cooper, perfectly fine idea, right? I mean this by other than not being able to put a certain code on it.
Unknown Speaker  14:28
But to that same token, I think, like what you said earlier about stuff doesn’t make us happier and in a car is a big ticket item. So, you know, how much is this car, really like this fancy car versus a reasonably priced car really making you happy? Right? Where does it just become you after a while, your new normal and it actually just doesn’t make you any more happy. It’s still cost you the same amount of money, but it’s not making you as happy when you get used to it as it did when you first got
Unknown Speaker  14:59
and you know, that’s the Key, it’s the what you get used to, is exactly what I found was the biggest driver in savings actually. So the biggest things that make it make a difference in our savings rate is not the stuff that we do occasionally. It’s the stuff that we get used to, like a nice car. After a while it loses its luster. It’s just something you drive to work well, with, what if that’s something that you drove to work wasn’t an you know, the top of the line car, but it got you from point A to point B, you don’t notice it, but you’re saving money every single day because that becomes a habit, or that’s that’s your new normal. And same thing with cooking for example, I heard a post on batch cooking and how that saved us a lot of money. Because in the one change that we had, we decided to make was let’s not buy stuff at work. You know, let’s Not good work and buy lunch and then buy snacks and then buy coffee. How about we take that average $10 a day and just save that. And in order to make that happen, I cook a bunch of food on Sunday, and I save it in our fridge. And we just grab a container and head out to work and take a few snacks with us. And that $10 a day, five days a week, 52 weeks in a year saves us 20 $600 a year, which doesn’t feel like that big of a deal anymore. You know, that’s just our new normal, but that 20 $600 a year invested over a 30 year working career
Unknown Speaker  16:42
with compounded interest yields $260,000 in savings in addition to all of the CO pays and medications fees that you’re going to avoid, because you’ve now cooked for yourself. Evidently what you’re going to cook is healthier. you’re avoiding getting the metabolic soup.
Unknown Speaker  17:02
And that’s right. Yeah, I’m putting myself out of business. It’s okay.
Unknown Speaker  17:08
Yeah, absolutely. That’s, yeah, you make yourself healthier. I usually eat while I’m working while I’m charging so that I don’t really get super hungry, which is great. And then I can use my lunch break to actually go outside or workout. It just makes my life so much better. That small change that became a habit became this huge driving force and saving money and being happier. And it doesn’t feel like a burden. And that was really kind of my limiting thought. You know, initially, when I was a resident, I didn’t have much of an income but I spent all this money on eating lunch and going out and stuff still and didn’t realize where that money was going. But now that I cook, and I don’t spend Money it just it makes me happier it’s insane that it makes me happier but it does you know
Unknown Speaker  18:07
Well it sounds like it’s just it’s fulfilling yes it is right yeah it’s not it’s me you know like you said you get used to driving the car, the car whether it’s the nicer car or the not so nice car or the last night but it you know, making those payments on your loans or, you know, filling your 401k or buying your first rental property. I don’t think that satisfaction ever gets old.
Unknown Speaker  18:35
Right? Whatever. That satisfaction of seeing the number take down is insane. Like it’s so fun. We I made this this jar of macaroni cheese to visually depict our little my loan. And and I i know i was like how because when you’re making payments on these two loans, it feels like this doesn’t go anywhere like the principal does not come down right? I mean it just seems to be there and like forever so I wanted to kind of visually see some change. I didn’t think you’d be that huge. Over a small amount of time. But just have we have this jar of macaroni is on top of this cabinet that’s very visible in my living room. And I see it every day. And
Unknown Speaker  19:24
what macaroni represent
Unknown Speaker  19:26
one macaroni is $1,000 of loan. And so I put it put in there enough macaroni to cover the loan principal and also the expected amount of interest that I was I was going to pay on this loan if I took the seven years so I refinanced in January with sofa and I refinance $208,000 and so I put in that plus the expected amount of interest I was supposed to pay and so we every month we take out the macaroni cheese that we paid and Miley Mr. loves doing it. In fact, he begged me yesterday, even though it’s not loan payment day yet, he begged me to take out the macaroni cheese for this month’s payment. So
Unknown Speaker  20:12
it’s a valuable lesson for him. It’s satisfying to him that you’re reaping
Unknown Speaker  20:17
it is yeah, we make it a big deal. we cheer and stuff, you know. And it’s funny because like he’s three years old, by the way, and and we were like running the other day, and he sees a house and he goes, Mommy, I like that house. Like, yeah, you know, that’s a nice house. He goes, how about we buy that house once our macaroni are done?
Unknown Speaker  20:36
You just say that.
Unknown Speaker  20:39
I love it.
Unknown Speaker  20:40
Yeah, gets it.
Unknown Speaker  20:41
Yeah, he gets it. So anyway, we started off in January at $208,000. And this month in October, we’re going to be at 85 only that, yeah, we we made 100 and what 35 right. doing that. Yeah, thousand dollars of payment this year already. It’s insane. I don’t know how that I mean, I know that’s happening, but it’s insane to see it move that much. And all it took was just making it a priority. And well, then we made some huge changes.
Unknown Speaker  21:19
Let’s talk about that. Right. Yeah, let’s talk about we talked about the car, we talked about the food. But there was one big change that ended up making a huge difference in your life in your, in your repayment. Right, right.
Unknown Speaker  21:32
And this was like the biggest thing. So you know how everybody tells you live like a resident, or at least Jim Dolly tells you live like a resident for another couple of years after after you graduate, and then you can pay off your debt really fast. Well, you know, I read this, I read this book. Two years after I’d already been attending and inflator a lifestyle, and my husband and I talked about It and we went through some big decisions. And he said, Okay, so first of all, we wanted to move because of several different reasons. But he wanted to go back to his hometown and upstate New York. And so we said, okay, we’re going to move and what are we going to do when we get there? And thankfully, I post this question to this really smart group of females on Facebook, physician women, finance and everybody there and there’s I’m so grateful for them because they I’ve actually run most of this these decisions decisions by them and they’ve guided me correctly. That you know, there is Lisa rent when you get there and and and figure out where you want to live. And so that’s what we did. We rented and we rented a small house. So we basically ended up deflating our lifestyle from the attending, attending lifestyle to a resident lifestyle, which, initially when we thought about it, when we’re looking at houses, it was a little depressing to look at these small houses when we were used to living in big one. But, but that was the most painful part, honestly. Because once we got there, we moved into this smaller house unpacked, the house was right next to the hospital, I could walk there, there was a backyard and a basement like we had everything we needed. And honestly, not a huge difference, not a huge difference in our life at all. My In fact, my happiness was a lot higher. I blessed a clean, less to maintain, and it was a rental so that we don’t have we didn’t have a bunch of unexpected expenses, which when we had when we own the house, down south, which is where we moved from that house, you know, had hurricane damage every year. So it actually turned out to be really good for us. So we deflated our lifestyle. And that was the big thing. You know, mortgage or rent is such a huge ticket item. If you can cut that down, you’ve really can make huge, huge, huge progress. And what I really wanted to get out there was it’s never too late, you know, if you’re willing to make a change, and take that little bit of a, I don’t know, ego head and, and deflate just for a little bit. You can get these loans paid off really, really fast. And in that makes such a huge difference. I think a lot of physician burnout is feeling like they’re stuck, you know, feeling like they’re stuck with this huge mortgage and a huge loan payment, and there’s no other job we can do that can really make us let us afford all of that. Would you agree badly?
Unknown Speaker  24:55
Well, I think one issue thankfully your house didn’t depreciate. Right, chill. So if your house had depreciated, if you had bought it in 2005 Mm hmm. Trying to sell it in 2009 Yeah, I think would have been your kind of stuck. Right. I think there are situations in which it would be much more challenging to to get yourself out of that situation. Absolutely. Yeah. Thankfully you were able to, to leave that situation without such a major financial it know, certainly there are things like closing costs and that you just have to just have to eat it. Right. But right, in your situation, it sounds like your biggest barrier was was mental and once you were able to get past that idea of having to give away this lifestyle that you thought you were giving up, right, that actually moving in, you’re fine. It wasn’t as painful as uncomfortable in any means. That you thought it was going to be. It was just the idea in your head, right?
Unknown Speaker  26:05
That was the limiting thing. Exactly. Yeah, it’s once we deflated. Honestly, we actually had a small rental next to the hospital and then I changed the primary care. We actually ended up not inflating, not buying, we’re like we’re making such great progress on the loans. We wanted to just keep renting so that we didn’t have unexpected costs, and we found actually a cheaper house, but uh, and we moved there. So that’s where we are now and seriously, like, as far as, as far as happiness goes, we’re pretty pretty, you know, at peak right now. Historically speaking, for me, you know, it’s, it’s the big ticket items, the house and the cars and then the daily habits, the spending habits That you do thoughtlessly throughout your throughout the day that don’t actually add anything to your life or your, the quality of your living. Those are the things that make the biggest difference when you when you want to save money. So you
Unknown Speaker  27:12
mentioned creating that, that budget, right? Yeah. And I think my wife and I put together a budget A while ago, and it was fairly simple just because we use credit cards for everything. Uh huh. Credit cards for everything. You have a paper trail, right? You can just go through the last few months of spending. Yeah. And find out where you’re where you’re spending that money. So do you remember where those other issues were that you were able to adjust without significant change in quality of life?
Unknown Speaker  27:44
Yeah, so yeah, food was a big one. Um, groceries. You know, groceries, I love cooking, and I love good ingredients. And I would spend way too much money, groceries shopping. And that was a hard thing to cut for me. But it actually, again, just finding the more efficient ways of doing things rather than cutting down on quality instead of shopping at Whole Foods, now I shop at Walmart. But it’s actually really good for me because Walmart has a pickup service and I have two toddlers. So I can just order my food online and go park in a spot and somebody brings the groceries out to me and I don’t have to take the kids out of the car seat. And so they just load up my car and off I go and it’s like 10 minutes. Yeah, and it really it cut my weekly grocery budget down from 200 or 300 to 80 $200 you know, every week which is insane, but We still like invest in good produce, I’ll still go to farmers markets and we have a lot of farms around where we live. So we buy a lot of our fresh produce from there. And there’s actually also a milk delivery service which is so awesome i love it. But it’s you know, so we get we get good dairy as well.
Unknown Speaker  29:19
That sounds so rural.
Unknown Speaker  29:24
You have a milkman
Unknown Speaker  29:26
man
Unknown Speaker  29:29
it’s pretty awesome.
Unknown Speaker  29:32
So I mean, your your, your blog isn’t a cooking blog, but no sin that is such a big ticket item and so important for really for health as well. For those who aren’t so maybe not interested or they don’t see themselves as so good at cooking. Do you have any quick tips for four people?
Unknown Speaker  29:56
Yeah. Ok. So the instant pot is a necessity
Unknown Speaker  30:03
is that so we use a crock pot we use a slow cooker is that different?
Unknown Speaker  30:08
Yeah, it’s so the crock pot. It’s kind of it’s a similar size and shape then some pot is but the crock pot only has one function, it’s slow cooks. The instant pot can slow cook, but it can also fast cook it can pressure cook. And so it really cuts down on the cooking time. It also has a salty function so you can kind of brown whatever you need to brown and then put the liquids in and let it pressurize and cook in that. And it has a microprocessor I think so that it actually adjust the cooking time to what you put in it and it has like so you say you’re cooking chicken, you just throw chicken in there with whatever spices or some salsa or whatever, and close it and just hit poultry. And it’ll come to pressure to what exactly what it needs. It’ll time it and then it’ll count down and I It’ll be done. It’ll be Batu and if you’re not quite ready for it yet, it’ll keep it warm until you open the pot so you could just put something in there you know do whatever you need to do and come back to it and understand it’s pretty amazing.
Unknown Speaker  31:15
I love it now I want to go out and buy it which is complete anathema to what we’re talking about here which is not buying more.
Unknown Speaker  31:23
I know. Yeah, that really it took me a little while it took me several months stuff like thinking and like do I really need this and but I gotta say that was definitely a value add in my life. In the end in the end it’s a it was a good Yeah, you know, actually a really good way to track the price of something. And I picked this up on choose FI podcast, it’s camel, camel, camel.com ca MEL, camel, camel, camel calm and you can, you can just plug in into the pot and you can see where the price has been historically and where Compared to that to say it’s like median right now versus like at the lowest it’s ever been you probably should buy it now you know,
Unknown Speaker  32:06
another money saving tip from the frugal physician. Yes
Unknown Speaker  32:09
sir. I use it all the time for stuff like this where I’m like, I don’t know I’m going to kind of think on this. So you can actually create an alert to so you can just put that in and I’ll email you when it reaches like a point where it’s you know, good time to buy.
Unknown Speaker  32:25
camel, camel, camel, camel, camel camel, that’s it. We should be getting reimbursed for these plugs. Really? I know. He’s gotten a bunch of plugs today. camel camel calm was getting some plugs.
Unknown Speaker  32:36
I know I mean it. These are things that have made you know made a difference in my life. So I don’t feel bad sharing them.
Unknown Speaker  32:43
Then you feel less you feel less guilty about the purchase. Right? There you go. You’ve gotten the best deal. So you’re married two kids, right? How did you get on the same page as your spouse because I think that is all So a barrier to some people, right? Because what you might have is one spouse spends a lot more than the other. And so if you’re the one who wants to be frugal, but the other person is spending, you might think, oh, screw it. They’re spending, I’m just going to spend or you don’t spend, and then it starts building some resentment. So first, did you guys start off on the same page? And if you didn’t, how did you arrive there?
Unknown Speaker  33:29
Yeah, that’s a very good question. Um, initially, when I started working, I was the primary earner the sole owner, my husband decided to stay home and take care of our newborn, which was such a huge thing for us, I mean, for our firstborn, but it was really difficult on our marriage because I was doing all learning and then I was doing all the money management, and I’ve kind of felt alone in that and so on. What it really took was us sitting down and dreaming together, talking about what do we want? You know, like, what do we what are our goals with our money? Like, where do we want to end up? Because when we, when I found myself in this place where I was really unhappy, we kind of sat down, we talked about it and, and you know, and I said, you know, but five year plan 10 year plan, like, you know, I want to be when I have made it, I want to be, I want to own a vineyard on a beach.
Unknown Speaker  34:36
And I want to have a jazz club in it.
Unknown Speaker  34:39
And I want to have a restaurant.
Unknown Speaker  34:43
And, and that’s my why, you know, that’s what that’s where I want to end up and for him. It’s his Why is a little different. But, um, but we had to come up with this, like, what are we going to do? He wants a brewery in the vineyard.
Unknown Speaker  35:00
Talking about,
Unknown Speaker  35:00
but, uh, but so we kind of came up with, okay, where do we want to be? What’s our goal?
Unknown Speaker  35:07
And then from that, you know, we we went to Okay, how do we make that happen? Well certainly we can’t make it happen if we carry a lot of this debt and just live paycheck to paycheck that’s not going to happen. So So then we started the debt payoff thing the debt snowball. And and it was actually the snowball was actually his idea. And he had heard about it. So then we sat down with the spreadsheet. And really, the spreadsheet is kind of key, because every month we sit down at the end of every month and sometimes he drags his feet will definitely say that, but we’ll sit down and we’ll go through our budget together. And we’ll go through our expected expenses. And you know, a lot of times you catch things like what did they charge you For that, or what did that payment go up? You know, and we’ll find things that we need to fix or make phone calls about and then cut that out. And, and, you know, and we, at the end of every month kind of re center on that dream, you know, we center on look at how much progress we’re making. And this is amazing and we’re so proud of us, you know, and, and it brings us together.
Unknown Speaker  36:24
It’s really important to have monthly meetings.
Unknown Speaker  36:27
Yeah, column budget dates. He loves that.
Unknown Speaker  36:32
Yeah, so every month, on the 30th 31st of every month, we sit down with a glass of wine and, and you know, and just and go through the nitty gritty of the numbers, and a beer. Oh, yeah. He actually know is more of a bourbon guy.
Unknown Speaker  36:49
There actually is a physician owned, or at least he started a brewery on Long Island. No, geologists. Yep. It’s called the Great South Bay brewery. Okay. Favorite Long Island brewery. So, the dream the dream is possible
Unknown Speaker  37:03
haha awesome
Unknown Speaker  37:06
jazz club in it. But
Unknown Speaker  37:09
that is a very real dream. So is there anything else that you would like to share with our listeners advice for becoming more frugal getting past those misconceptions about what it takes to be more frugal?
Unknown Speaker  37:27
Anything else that you think we didn’t discuss today that we should?
Unknown Speaker  37:30
Yeah, the biggest thing I just wanted to share with my colleagues and people listening. So it’s just it’s just never it’s never too late. You can if you make it a priority, get out of debt. It’s completely possible. There are a lot of people out there talking about it. There’s a huge community of people talking about getting out of debt and becoming financially independent and Really all what you have to do is kind of come up with your priorities, what’s important to you. For me, my priority was my family, my time, and most And finally, my freedom, my the freedom to be able to do what I want. Because once I was able to, once I’m able to get out of debt, I feel like I can finally more freely advocate for my patients do what I think is right without having the fear of someone telling me I might lose my job, you know, I want to be in that place where that’s not an issue anymore, that I can be a better doctor because I am not in debt, and I don’t need my paycheck. You know, and I can do without it. That’s that’s kind of my goal. And I think that can free a lot of people from the unhappiness that medicine can sometimes bring. It really doesn’t take all that Much you don’t have to work a ton of shifts, or lose time with your family. If you’re willing to make just a few changes in your lifestyle, in your everyday habits, you can make some significant
Unknown Speaker  39:14
progress and do your best to shed yourself over the expectations of others. And just figure out what’s important to you think that irrespective of those people and try and meet those goals, rather than those external pressures, which I think was a huge, huge point that you made earlier.
Unknown Speaker  39:33
Yeah, yeah, absolutely. You gotta find what makes you happy.
Unknown Speaker  39:39
So, where can people find you if they want to learn more about batch cooking and camel, camel camel, latest blog posts, how you can find the most delicious yet frugally chosen wines.
Unknown Speaker  39:53
Yeah, that’s at WWW dot the frugal position.com or You can follow me at Twitter at frugal physician or on Facebook at football physician,
Unknown Speaker  40:05
well, frugal physician, I have to say very informative. And thank you for coming on today. It has been a pleasure.
Unknown Speaker  40:12
Thank you so much for having me.
Unknown Speaker  40:16
That was Dr. Bradley Block at the physicians guide to doctoring. Find all previous episodes on iTunes, Stitcher, Google podcasts, or wherever you get your podcasts and write us a review. You can also visit us on facebook@facebook.com slash physicians guide to doctoring. If you are interested in being a guest or have a question for a prior guest send a message or post a comment.
Transcribed by https://otter.ai

The Frugal Physician: A Primary Care Physician’s Journey to Financial Independence

In residency, we have to live with less.  Less money.  Less time.  Less dignity.  And after finishing, we are rewarded for our herculean efforts with higher income.  Sometimes the time and dignity come back, too.  In today’s episode, the Frugal Physician and I discuss the pitfalls that can come with that increased income and how falling into the materialistic abyss brings with it more financial stress and often less happiness. We discuss her journey to frugality and lessons learned along the way. 

https://www.thefrugalphysician.com/

http://www.facebook.com/TheFrugalPhysician

Acute Flaccid Myelitis

Acute Flaccid Myelitis is a polio-like illness that tends to start with symptoms of an upper respiratory tract illness and leads to flaccid paralysis.  There are more questions than there are answers, but Dr. Uzma Hasan, pediatric infectious disease specialist, walks us through what we do know so we can all be better prepared if we encounter this illness.

EPISODE TRANSCRIPT

This is the transcript to the episode. This transcript was created by a talk to text application and the function of having this here is to improve the page search engine optimization. This transcript has not been proofread, so please listen to the episode and don’t read this. The information contained herein will inevitably contain inaccuracies that affect that quality of the information conveyed and the creator of this content will not be held liable for consequences of the use of the information herein.

Unknown Speaker  0:03
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians where Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have learned while we were memorizing the Krebs cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers. This podcast is intended for medical professionals. The information is to be used in the context of your own clinical judgment. And those on this podcast accept no liability for the outcomes of medical decisions based on this information, as the radiologist like to say clinical correlation is required. This is not medical advice. And even though the magic of podcasting may make it seem like we’re speaking directly in your ears, this does not constitute a physician patient relationship. If you have a medical problem, seek medical attention
Unknown Speaker  1:00
On today’s episode we discussed the cute placid, my lightest, the polio like illness that has been in the news lately with infectious disease specialist, Dr. Umar Hassan to talk about what the cause may be, how it presents some of the workup management strategies, and current research with hope for the future.
Unknown Speaker  1:19
Welcome back to the physicians guide to doctoring. On today’s episode, we have Dr. Uzma Hassan. She’s a double boarded physician board in pediatrics and pediatric infectious disease and is currently the division head for pediatric infectious disease at St. Barnabas Hospital in New Jersey. Dr. son was willing to do this on short notice given the recent increase in episodes of acute flaccid, my lightest, so that’s what we’re going to talk about today. One of the functions of this podcast is to educate physicians about current events. And given the recent spike in cases. I think it’s important for physicians who see this and don’t see this necessarily To be familiar with it, because, as an outlier geologist, I’m not likely to see this, but that doesn’t mean that I won’t get questions from family, friends and possibly patients. So Dr. Khan was educated in medical school at the Agha Khan University, went on to residency at the Cleveland Clinic and completed her infectious disease fellowship at Northwestern and is currently like I said the division head of infectious disease at St. Barnabas Hospital in Jersey. So, Dr. Hassan, thank you so much for taking the time to speak with us today.
Unknown Speaker  2:31
Thank you so much for having me. So,
Unknown Speaker  2:34
as an old alarm geologist, it’s not likely that I’m going to see this but as a doctor, people might be asking asking me about it. So can you just give us some basics about what is acute flaccid mellitus?
Unknown Speaker  2:48
Yes, sure. So to placid my light is is actually a very rare illness or reported about one 1 million young adults and children and it is characterized by rapid onset of weakness or paralysis of one or more limbs. And usually these children or adults a wind up having some abnormality in their gray matter when we do imaging with MRI. Some of these children can present with grouping of their eyelids having some difficulty speaking, they can present with the facial group. And most of these patients will have an acute wireless illness with you know, running those upper respiratory infections symptom, sometimes gastrointestinal symptoms about a week prior to the onset of this paralysis.
Unknown Speaker  3:43
So it can affect a cranial nerve or a peripheral nerve. That’s correct. Does it usually affect a singular nerve or can it can it affect a number of nerves
Unknown Speaker  3:55
typically, the involvement is is mostly seen and in spinal cord is fixed multiple segments of the spinal cord at the same time. In the cases that be seen for some reason, the cervical part of the spinal cord seems to be involved more often, which means that some of these patients might end up with respiratory issues. That’s exactly right.
Unknown Speaker  4:17
Oh, so I thought as a little oncologist, I wouldn’t be seeing it. But if it’s a respiratory issue, sometimes they’ll call us for things like that, especially if someone is has been on a ventilator for a while and needs a tracheostomy. So so if you are let’s say, you’re someone who’s who’s more likely to see this initially like a pediatrician, a neurologist, infectious disease intensive lyst emergency medicine physician, how does this what what are some signs that will that should make this part of my differential?
Unknown Speaker  4:54
Very good question. So you know, most of the children who present with this illness will Have a proceeding illness or an upper respiratory infection, and then they will come in with a sudden onset of weakness of an arm or leg. They complain of a feeling of heaviness or being unable to move that extremity. And I think the key thing is that too, not to dismiss those symptoms, but to take them very seriously. Yeah, a lot of times, you know, children this age group will be labeled as feigning illness. And and I think the key thing to recognize is that this is a real entity. If we start seeing the child who is not wanting to move and extremity that, and especially in the context of a recent viral syndrome, we have to take that very seriously.
Unknown Speaker  5:45
So what in particular Am I looking for on it on exam? Right, are there any particular parts before we get into diagnostic tests?
Unknown Speaker  5:53
Yes, I think there’s a couple of things that you will see in the extremity is significant muscle weakness. The children that we have seen will not be able to move there will be involved arm or leg at all You will see absence of reflexes in that extremity. And typically you know you do not see any sensory symptoms. So they will not typically complain of tingling, or of your temptation and their extremity. Typically they have internet sensation, but the ability to move that extremity is what gets compromised. Is there anything that we might confuse this for? Yes, there’s a bunch of things that can can mimic acute facet my latest. Some of these children get evaluated for things like Jamboree, or Crohn’s or smile lighters. They can be evaluated for peripheral neuropathy or so. So there’s a bunch of things that can mimic q classic, my latest I think the key distinction distinguishing feature is what we find on imaging, as well as some of the CSR findings. To help us sort of weigh in on the diagnosis So, the CDC had has now classified attracted by lightest, the the group the cases as probable cases versus confirmed cases. The probable cases are labeled based on their spinal fluid finding in in the context of a child who has an exam that’s abnormal or paralysis of an extremity. If you see spinal fluid parasitosis, which means a white cell count of more than five on the spinal fluid. We label that as a probable case, and a confirmed case is when they have truly have abnormality of their gray matter on an MRI, and they are presenting with involvement of, you know, a vocal paralysis of a limb or so so that’s a confirmed case. What do we think is causing this? So you know, there’s been several viruses that have been previously implicated with to trusted my light is enterovirus. The 68 was implicated in the outbreak in 2014. And usually it’s the non polio, enteroviruses that sort of take the lead amongst other viruses that have been implicated in cases of the future acid. My light is there is the non polio enteroviruses, like I mentioned. Then there has been some cases described with Admiral virus. Some some cases described the herpes zoster with rabies, or so so, so but most commonly, it’s the non polio ankle viruses that have been implicated in cases of a to class of my lightest.
Unknown Speaker  8:38
Wow, that’s interesting because that’s something that’s been implicated in vestibular neuritis. Yes. Yeah. So, so, there there are some parallels are interesting. And what can we do for this what what is the house of medicine have for these patients?
Unknown Speaker  8:58
So, so amongst a limited number of cases that we have seen over the years or so, there’s been a bunch of modalities of treatment that have been tried patients have been given IBM, you know, globulin. They have been plasma for research has been tried in some cases or so, and, and variable outcomes. Pretty much treatment is done on a case by case basis and there’s really no data to back up one treatment versus another. The CDC and advisors use a use of steroids with caution in cases of a non political or non fully enterovirus related to class in my life. So, so steroids youth has been pretty much reserved as the cases that are really severe who have who have been a front acknowledge or recipe involvement, which is where we have used steroids but again advised caution with the use of steroids in this case scenario. Is it communicable
Unknown Speaker  10:02
because if it’s a virus, right, you shouldn’t you shouldn’t be seeing it in in clusters. But I don’t think of vestibular neuritis or Labyrinth itis as something that’s communicable right? You never see that spread through a household where every family member comes in at the same time with vertigo. It’s like it’s an isolated incident. So, very good question. Typically this disease is sort of confined to the host in which it is happening in. So you do not see clusters happening in the household or multiple memory family members of a household getting infected.
Unknown Speaker  10:35
So presumably though the virus was contagious, so you might have seen a bunch of family members get a cold at the same time but only one one person ends up with AFM. That’s it. That’s exactly right. The that you may see a symptomatic infection or you may see a milder form of infection and the other members in the household and you may have another household member wind up with a FM
Unknown Speaker  11:00
You have that’s been described where you’ll have more than one family member household member with with this?
Unknown Speaker  11:08
No, actually not. Typically, you will see a symptomatic illness and other household members. But you you will, you will it is typically just one member of the household who’s been who’s been symptomatic with AFM. There’s not been a cluster of AFM cases described in one one household
Unknown Speaker  11:26
focus. Okay, I misunderstood and so what what do we tell parents family members? If they’re if they’re concerned that you know, oh, my my child was exposed there was a kid in their class. Now you know, he’s my, my son has a runny nose. I’m worried that he’s going to develop AFM how what what can we say to those parents?
Unknown Speaker  11:53
I think the key message to get across is this is exceedingly rare and and you know, like Like the CDC discusses less than one in a million cases or so the and probably fewer related issues are much more common, or flu related deaths are much more common than you would see and a child having enterovirus related AFM. So I think it’s a constant reminder that that even though this is Block media attention, I think that there are other things that are that are bigger troublemakers than AFM is.
Unknown Speaker  12:30
That’s a great point actually, that this is an excellent teaching opportunity. So you have an anxious parent that comes in with a child with a with what seems like a cold and making sure that that child and the parent has both of both had their flu shot because that is is more likely to be problematic for them for something that’s that’s exceedingly rare like like FM. Are you familiar with any research That, that’s being done right now that might give us some, some hope for some more effective management strategies.
Unknown Speaker  13:07
Yeah, so a couple of things that are in the works. One is the CDC has has come up with has sort of following these patients long term. So so all the patients and from each state that gets a group ordered out there collecting specimens, identifying, you know, commonalities in between these patients, and then these children will get cracked long term to see how they recover. Interestingly, there has been some great research out of Children’s Hospital LA, were there the good looked at North comfort in the kids with AFM, who had persistent weakness. So depending on where they had involvement, they were offered surgery if they had Dr. paralysis, they were offered surgery actually of the five to six month mark. If they had one focal lemon movement, for example, a shoulder or elbow they would due north conference with them at the six to nine month mark and then if they had isolated one muscle involvement they did they did it around a year out from their initial presentation and their initial results are actually very promising. The has had some children who had significant than moment wars is now starting to still show some recovery and in muscle function and the children who’ve had these North conference done so I think that this is extremely promising. I also know that the Children’s Hospital of Philadelphia is taking this up. And and I think in the children who have extreme compromised and and lack of improvement, or lack of significant improvement, this is a very, very promising
Unknown Speaker  14:49
opportunity or promising
Unknown Speaker  14:53
method of treatment that’s out there and and something to do look for in the future business. How the Quran fair in the long run.
Unknown Speaker  15:04
That’s interesting that you that you brought this up that this is being done at Children’s Hospital in LA, because one of the guys doing this was a resident with me at Georgetown. I didn’t have residency at Georgetown and he was a plastic surgery resident. And I think he’s been actually featured on the news and he’s been posting on his Facebook page about this. Mitchell Surya SERUYA. So I’ll find out from him if we can post post a link to his department, so Children’s Hospital. So if you have a patient or you know somebody that has a compromised limb from AFM, it sounds like get them in touch with I guess it would be the plastic surgery department at CHOP or at Children’s Hospital la because there’s some there’s some promising work being done on on nerve transfers. Wow.
Unknown Speaker  16:01
That’s that’s, that’s amazing. That’s amazing that they’re doing these things.
Unknown Speaker  16:06
Are there any other questions that you’re getting from family member from from families or from other physicians that you think we haven’t covered yet?
Unknown Speaker  16:16
Yeah, I think the one other thing that they people ask is about the 60 of the flu vaccine in the context of these viral illnesses or so. You know, I always say that that flu is entirely if the children were vaccinated against flu, even if they were to have you in that season, they get a much more attenuated for both the illness so absolutely must be vaccinated. I think that’s the only doctor going to provide them with the additional level of protection. And and, and that’s the question that we get asked regarding regarding the FM patients. So far BB amongst the Colorado cluster, We had in 2014, you know, from my understanding from the CDC folks is that all of those children were vaccinated against the flu and they did. Absolutely fine. So though the CDC actually even advocates for vaccination in this population, and and that’s just something to put out there.
Unknown Speaker  17:19
Oh, yeah. I can’t imagine if if one of them had respiratory compromised, and then were to develop influenza that that would be horrible.
Unknown Speaker  17:27
Exactly. Wow.
Unknown Speaker  17:29
Well, this this has been extremely informative. I really appreciate you taking the time out of your, your busy day, which was so busy that you actually had a meeting this morning about this illness and and about your patients. Because this is such a such a relevant, relevant illness. Um, one more thing actually, that comes to mind. You mentioned that Colorado cluster in 2014. And part of my research for this podcast I listen to another podcast. where that was recorded in 2016. So there seems to be
Unknown Speaker  18:04
a pattern there. That’s exactly right. Would they have noticed is that we have a biannual peak to this illness. It looks like that. In 2014, there were about 120 confirmed cases in 3034 states. Between the timeframe from August to December, the following year 2015, there were just 22 confirmed cases in 17 states 2016, we saw rise again 149 confirmed cases in 39 states. And in 2017, we had a drop down to 33 cases in 16 states and 2018. Again, we’re back up so there are 62 confirmed cases in 22 states 155 case reports which are sort of pending confirmation from the CDC. So you’re absolutely right, we see a sort of a biennial pattern to the subtler
Unknown Speaker  19:00
Interesting, but but as you were saying, the likelihood of getting it one in a million
Unknown Speaker  19:07
influenza much higher. So when you do have parents that are bringing their children in, and you know, parents, we’re talking we’re just talking about children. What was the age group that’s affected by this?
Unknown Speaker  19:17
Very good question. The average age group for this year’s cluster has been around for years. We have seen a ages up to 17 years being reported out.
Unknown Speaker  19:30
or so but the it’s usually the younger age group that gets affected. Interesting. It’s almost it’s almost as if the illness knows what our cutoff is for what’s considered an adult. It’s gone up to 70. No reported, no reported 18 year olds. Well, exactly right. Dr. Hassan again, I really appreciate you taking the time out, making the excellent point that this is a good segue when a patient brings this up or a parent bring this up to make sure that they’re vaccinated for influenza. And giving us some some great clinical details on what we should keep in mind to look out for this and to educate our peers. So, thank you so much for taking the time. been very informative.
Unknown Speaker  20:11
pleasure. Thank you so much for having me.
Unknown Speaker  20:15
That was Dr. Bradley Block at the physicians guide to doctoring. Find all previous episodes on iTunes, Stitcher, Google podcasts, or wherever you get your podcasts and write us a review. You can also visit us on facebook@facebook.com slash physicians guide to doctoring. If you are interested in being a guest or have a question for a prior guest send a message or post a comment.
Transcribed by https://otter.ai

Acute Flaccid Myelitis

Acute Flaccid Myelitis is a polio-like illness that tends to start with symptoms of an upper respiratory tract illness and leads to flaccid paralysis.  There are more questions than there are answers, but Dr. Uzma Hasan, pediatric infectious disease specialist, walks us through what we do know so we can all be better prepared if we encounter this illness.  

My Neck, My Back, My… Goodness

Seth Grossman, MD, a fellowship-trained orthopedic spine surgeon, discusses his most common consults; how to differentiate emergent spine injuries from less emergent issues, and why both patients and practitioners alike should be doing yoga, Pilates, and trying to fly like Superman.

TRANSCRIPT

This is the transcript to the episode. This transcript was created by a talk to text application and the function of having this here is to improve the page search engine optimization. This transcript has not been proofread, so please listen to the episode and don’t read this. The information contained herein will inevitably contain inaccuracies that affect that quality of the information conveyed and the creator of this content will not be held liable for consequences of the use of the information herein.

Unknown Speaker  0:03
Welcome to the physicians guide to doctoring A Practical Guide for practicing physicians where Dr. Bradley Block interviews experts in and out of medicine to find out everything we should have learned while we were memorizing the Krebs cycle. The ideas expressed on this podcast are those of the interviewer and interviewee and do not represent those of their respective employers. This podcast is intended for medical professionals. The information is to be used in the context of your own clinical judgment. And those on this podcast accept no liability for the outcomes of medical decisions based on this information, as the radiologist like to say clinical correlation is required. This is not medical advice. And even though the magic of podcasting may make it seem like we’re speaking directly in your ears, this does not constitute a physician patient relationship. If you have a medical problems, seek medical attention.
Unknown Speaker  0:57
On today’s episode, we speak to orthopedic spine surgeon, Dr. Seth Grossman about neck and back injuries, when to worry when not to worry, and why we should all be doing yoga polities. And once a day, get on our bellies and try to fly like Superman.
Unknown Speaker  1:13
Welcome back to the physicians guide to doctoring. On today’s episode, we have Dr. Seth Grossman, a spine surgeon in New York and New Jersey. Seth, thanks a lot for speaking with us today and helping to as you put it, demystify the spy.
Unknown Speaker  1:28
Sure. Thank you so much for having me.
Unknown Speaker  1:31
Could you just give us a little background on your training?
Unknown Speaker  1:34
Sure. So I went to medical school down in Philadelphia at Jefferson Medical College, which is now Sidney Kimmel, Medical College. After that, actually, before that I did I did some some graduate work in, in Computer Engineering, then maybe a little change in my career. So I went to medical school down at Jefferson and then I did my training at Albert Einstein Medical College monitor Medical Center. in the Bronx, and then I did a fellowship training in spine surgery at university California in San Diego. And since then I’m and again, I’m in private practice now I’m in a group. We have offices in Bergen County in North Jersey and then also in the city. few a few locations in the city. New York City, New York City. Yeah.
Unknown Speaker  2:20
This This podcast is international. So Oh, okay. Our audiences is broad. So, so Seth, you are going to talk to us about demystifying the spine. And so what are some of the things that you think all doctors, whether they treat related conditions, whether they’re referring physicians, like primary care physicians or er doctors, or treat things that are completely unrelated? What should all doctors know about the spine and I’ll give you an example. Let’s say you’re because in New York, New Jersey here we can get a lot of snow, your neighbor your neighbor is shoveling his driveway or her driveway and throws out his back, you know, whatever that means to me and otolaryngologist probably means something very different to you. And he he says, Hey, Doc, Hey Doc, because you know, everybody calls us Doc, if they can’t remember her name. Hey, Doc, just I just hurt my back. What do I do? So what do I asked him to make sure that it’s not a medical emergency? And should it not be? What do I tell him?
Unknown Speaker  3:28
Right? So it’s good question. So back pain in general is extremely common. It’s one of the most common reasons for loss of work in the United States. It’s one of the most common disabilities people have to miss work. And pretty much everybody at one point or another is going to figure out their their neck or their back. So something I see a lot in my office, something about, you know, a year, you know, people, my neighbors and such. So, it’s a very common occurrence and most of the time, vast majority of the time, you know, patients are going to be fine. The time is reassurance to your back you got arrested, you know, ice, you know, basically just kind of take it easy for a few days, maybe taking some incentives and that’s, you know 90% of the time patients will get better and within a period of time so red flags that you want to always you know look for is any kind of weakness or numbness So, just in general, the spine as an orthopedist, really any any specialties is a joint you know the series of joints in your back just like you know, your neck, your back just like just like a New York shoulder. So you can pull it you can strain it there are muscles and ligaments and tendons that can get injured and they heal much like any other joints. You know, the rest ice wrapping it that kind of thing babying it. The added complexity in terms of the spine is out there there are major nerves that run through that joint. So if something were to dislodge or press on a nerve, you know that can be dangerous and that you can damage that nerve and nerves. You know depending on how badly that they’re damaged or how much pressure is on the nerve not may not necessarily heal so you can end up God forbid with with neurologic dysfunction which can be permanent so that’s where I think everyone you know people get a little bit concerned a little bit over cautious with the spine so anyone who’s complaining of a neurologic type of a symptom that in my mind and you know in any doctor spine should be a red flag so doc I pulled out my back it’s killing me it’s throbbing my pain is 10 of the 10 I can barely walk that’s not uncommon complaint and that I see every day in my office and again I would say up in you know, 90% of those patients are are fine within a week. But you know, Doc, I pulled out my back shoveling my snow shoveling snow and now like, you know, my my foot is dragging and I can’t feel my toes, you know, is another sort of another added layer to that and that that may be something that is a little bit more serious.
Unknown Speaker  5:57
Okay, so numbness tingling, we can Does that warrant an immediate ER visit? Or should they follow up with you in the in the office?
Unknown Speaker  6:08
Yeah, it’s a good question. Certainly someone that should be seen soon. Whether or not it’s an emergency, I guess would depend on that the met you know, how bad the the neurologic dysfunction is?
Unknown Speaker  6:21
Nothing but loss of function probably is the is it? Would you say that that’s like a hard red line?
Unknown Speaker  6:27
Yeah, I mean, you know, you can lift your toes, that’s really an emergency, you have a little bit of tingling in your toes, that, you know, may not necessarily be something that has to be, you know, evaluated in the emergency room, especially during a snowstorm.
Unknown Speaker  6:42
So sounds like the differences sensory versus motor function. If it’s a motor function, it’s an emergency. If it’s sensory, then you can you know, wait for an office visit.
Unknown Speaker  6:54
Yeah, I would, I would say generally, obviously, that’s that’s a generalization but but clearly defined On the degree if it’s a little bit of numbness, a little bit of tingling, if you can’t feel your, any of your toes or you know something, but clearly, again, as the radiologist like to say, clinical correlation is required correlation Exactly. And then again, I’m sure everyone has heard the term called Aquinas syndrome which is which is a very rare but obviously, saddle anesthesia you know, bowel and bladder incontinence, anything like that, that happens soon after. an injury is also that’s that’s an immediate no trip to the emergency room. I will sort of preface that in that you know, patient versus back also has a little bit of prosthetic you know, prostate issues and has urinary retention that’s been ongoing for you know, 10 years and he takes medication for it doesn’t isn’t necessarily a quote Aquinas syndrome, and I think that we were very quick to, to jump to that. So loss of bowel and bladder basically where you can’t can’t feel or control your, your bowel and bladder movements. That’s an emergency and Having chronic issues constipation, you know, urinary retention is not there’s not a court appointed.
Unknown Speaker  8:07
If these things far preceded the injury then they’re probably unrelated to the injury.
Unknown Speaker  8:12
They’re probably unrelated. It’s probably not an emergency
Unknown Speaker  8:15
emergency or any of his his related. It’s not the fact that long history speaks to the lack of urgency. Okay, so let’s actually get back let’s get away from the urgent ones because those are the ones that that are going to be managed by you. What about the ones that aren’t urgent? So you you said Well, a few days of rest baby it for a little some end Said’s? What are you? Are you more specific than that? With your patients? You know, do you do you tell them more specific instructions? Three days, five days a week, wait until it feels better? Or is the data not just out there? And so, you know, I sometimes have trouble with this in my practice, like some people are sometimes looking For a specific answer, like a week, right? If I don’t feel better for my sinus infection in a week is it is it’s you know, doesn’t mean that the antibiotics aren’t working or three days, like they’re looking for something hard and fast. And the fact of the matter is, if you’re going to be giving someone a hard and fast number, you’re going to be kind of making it up, or are their recommendations.
Unknown Speaker  9:22
Right? By there’s a very good question. So I mean, there are recommendations in terms of the radiological societies are the biggest sites have ever released guidelines in terms of when you should say order an MRI, get, you know, get x rays, you know, do advanced testing and, and to be honest with you in today’s day and age, especially where we are in the New York, New Jersey area, I feel like patients, you know, pretty much demanding an MRI, you know, minute one when they when they walk into your office. So, you know, in terms of managing it again, even if it is, you know, I tell patients that You know, you pulled you back out, it’s probably a muscle sprain. But even if it is a herniated disc, which can be more serious, even that is going to get better with time and not necessarily need any kind of intervention. So, I generally try to, you know, I give patients either a course of events, heads or even, or even steroids for a week, and I haven’t time to come back and you know, rest, you know, if they’re, if they’re working, I give them a work note, especially if they do some manual labor. And I say within a week, if they’re not much better than we can go ahead and start ordering up tests and doing interventions, that kind of thing. So, roughly, you know, I basically say a week I don’t know that that’s an evidence based recommendation, but you got to give it a few days, everybody’s a little different. But typically, you know, most of the spasms and sprains will at least be 50% better, if not more in a week.
Unknown Speaker  10:50
And so does it improve outcomes to rest? It’s hurting or should they actually start to push their like will they recover from faster if they actually put limits like where’s where what I’m asking is where is that inflection point? Not necessarily time wise but time or symptomatic Lee or, like, you know, they shouldn’t lay on the couch until it feels 100% better. Right? So right.
Unknown Speaker  11:18
Where do you believe that and what point right sure so i mean i think if we extrapolate this out to a year right I think all patients are going to pretty much be better at that point whether they rested for two weeks or four weeks or I personally I definitely push you know, physical stretches. Walking you know, physical therapy definitely I think has a certainly in the short term definitely has a great effect that can really can really help but in the really immediate, you know, Doc, I just do my back out shoveling snow year is a time where I tell patients really just just rest. You don’t need to be lying in bed 24 hours a day to the point where you’re going to get a blood clot or something. like that but you know really just stay off your feet try to read you know I said minimize your your any kind of bending lifting and twisting for at least a few days and again after that then you can you know, you start to go do some stretches or see a therapist have a massage or something along those lines to try to get the muscle get the get the blood flowing to the muscles a little bit try to move a little bit for you know, stiffness and such.
Unknown Speaker  12:25
And is it is it any different for a neck injury or you’re saying this is not just lower back this is the entire spine? Yeah, I would say I would say you know, my advice is pretty much the same for the entire spine.
Unknown Speaker  12:41
You know, the neck
Unknown Speaker  12:43
can be a little more acute, you know, the spinal cord to get technical, you know, runs down your, your cervical thoracic spine, it ends around the top of your lumbar spine. So, most of the time you have a discrimination even a pinched nerve or ridiculous but the it’s a nerve root which is a little bit more tolerant of pressure and perturbation and then then the spinal cord itself. So if you have an injury where this you have pressure on the spinal cord that that also can, that can be a little bit more acute but in general, you know, just shoveling snow or sleeping wrong or you know minor trauma, you’re, you’re unlikely to have a major,
Unknown Speaker  13:23
you know, event where you’re having, you know, acute compression of your spinal cord.
Unknown Speaker  13:27
Now, have you just a little aside? There’s this text neck phenomenon. Have you seen this at all?
Unknown Speaker  13:36
Sure. I think that’s just, you know, this text neck is is just in the greater scope of 21st century living. So, we spend our days on the computer we’re on our phones in between, we’re basically always looking down and also as we age, our distance generate so your whole, you basically you’re focusing your whole, your whole body is is being pulled forward. And, yes, definitely a problem. And, you know, I, I talked to my patients about doing strengthening poses, specifically their posterior chain, so their extensive muscles, you know, working on flexibility but specifically with extension type activities because we tend to lose that naturally with age but even more so now in today’s society where all you know, our whole life is spent kind of crush over something.
Unknown Speaker  14:24
Can you give some examples of that? That sounds like something that is, is really great advice for human beings in general. And again, kind of the idea behind this podcast right, what what are the things that every doctor should know? That sounds like something every doctor should know. So what are some good exercises that we should
Unknown Speaker  14:46
maybe I can help? Yeah, so so anything where one thing that I tell a lot of patients is to do like a Superman, or basically if you you know, if you get a mad you put it on the ground, you lie in your stomach, and you put your arms out like you’re flying like this. Superman and then you basically you want to work on extending and lifting you know reaching your arms and your legs out and up as high as you can. And holding that for five seconds 10 seconds or you know doing or doing you know, doing set to that where you’re basically working on it on strengthening your extensors. That’s a really good one to do at home. If you have access to a gym I mean they have these these machines his boot him developer machines where you can go and you can you can also work on extension of your back of your neck that kind of thing. So the Superman is a good one you can also do it you know if you’re if you if you have a exercise ball, you can work on kind of, if you lean over the exercise ball with exercise ball in your stomach and you’re working on extending your your arms and your legs, you know, that kind of thing. I think it’s can be beneficial.
Unknown Speaker  15:47
So as a spine specialist when you are meeting with your patients and working on your electronic medical record, are you sitting on one of those balls?
Unknown Speaker  15:57
I wish no tonight unfortunately The Google ization of has not happened in medicine or no foosball tables or beer dispensers in the office, unfortunately. But I do tell patients so another thing to expand upon on top of just the Superman activities is yoga and polities. I tell everybody, I do it myself, I try and I tell all my patients to you don’t need to go too expensive. You don’t spend a lot of money you can go on YouTube, and just type in yoga exercises for your back. Just basic, the basic yoga poses like downward dog, Cobra, you know, cat cow, I don’t know how many Yogi’s are out there, but those are great exercises for your back and they all work on no flexibility, spine flexibility extensions.
Unknown Speaker  16:43
So I think it’s a it’s very beneficial.
Unknown Speaker  16:46
I think the classes also in terms of
Unknown Speaker  16:52
habit formation, right. I think I think going to those classes gives you a sense of accountability because you meet the other people there. Wait, where were you last week? So it gets you to keep going and then there’s a sense of community as well it’s Oh definitely definitely you can if you can incorporate that as part of your life and go a couple days a week I think dramatic improvement especially in patients chronic pain, you know, chronic
Unknown Speaker  17:19
you know, issues keratosis have their back and that gets certainly can be huge. But even if they can’t, you know, some patients don’t have the time or the means even putting on a video for half an hour, once or twice a week. But But definitely, if you can join a group and go to a class on a regular basis, I think patients will see dramatic improvements. So it’s rare to see to be honest with you. I say patients, you know, I tell them but, you know, it’s, it’s hard in today’s life, just to make time.
Unknown Speaker  17:45
Yeah, I hope to incorporate that into the podcast at some point and get some of these experts on habit development in here. So that when we do give advice to our patients, it can be in a way that is realistic. Stick where we can expect them, you know, it is a realistic expectation that they will take the advice because we want them to do all of these things, but how can we get them to do it is the challenge, right? We all want them to eat better and exercise more and sleep more and have less stress. And so but right but how do we actually get them to do it? You know, there’s this pervading idea that that we are not
Unknown Speaker  18:26
holistic,
Unknown Speaker  18:27
right? Like, right we have a sick care system where the health care so exactly, exactly, well,
Unknown Speaker  18:33
well put. And so it sounds to me if you’re recommending these things, for your patients that you are a holistic doctor to me because you are considering the whole patient and not just the one injury that you happen to be seen them for. So
Unknown Speaker  18:49
yeah, no, definitely. You know, it’s hard as a physician as well, when you’re, you know, push to see more patients and you have X amount of time with these patients and you know, it’s enough just to get the spine exam down. But I do try you know, I see a lot of patients, you know, with with metabolic syndrome that are obese you know, and, and that’s a lot of extra weight you know, if you’re if you’re every pound of weight over your ideal body weight in the daily biomechanics of going through your life can be up to four pounds extra on your spine. So don’t patients if you’re 10 pounds overweight, it’s like carrying a 40 pound backpack around. Imagine doing that all day your back would hurt. And these patients you know, you can do the math on patients are, you know, pretty, pretty heavy. So I asked them, you know, what do you what do you maybe you can, you know, try to cut out sugary drinks or try not eating after a certain time, small things, you know, it’s hard to go on a radical crash diet and they have a high failure rate but just being a little aware of how they can at least make some changes. And actually, in an upcoming episode, I’m going to be interviewing someone who specializes in obesity research, who will be talking to us about how we should be addressing that specific population, there was just a Huffington Post article going around around the my physician friends on Facebook about how bad doctors are about talking about obesity. And, you know, I think with regards that article is probably just a few standout callous individuals, I think most of us are saying things like you’re saying, right, like, trying to give them some advice that is reasonable and not discouraging, right. Like, you know, maybe not eating after nine o’clock at night. That’s a reasonable recommendation that that is easier for them to stick to as opposed to like, don’t eat carbs ever again, right? Like that’s really easy to lose 50 pounds I mean, it’s it’s a lot easier said than done. And I’ll say again, if you say in the wrong way, you can certainly get some poor online reviews for as a result, but is that it but I think if you say it in earnest, and you’re somewhat sensitive about a patient, understand, I may know piecemeal pitches, no one there, you know that they put it together. You know, being being obese being out of shape is, you know, one of the root causes of their back pain because it just makes sense.
Unknown Speaker  21:07
So, so let’s get back. So that’s for a later episode. I’m really looking forward to that, that, but I’m also really enjoying this interview. So Seth, let’s talk some more about some of the common concepts that you see. What would you say is the most common thing that you see something one of the most that you think would be useful to discuss?
Unknown Speaker  21:27
Well, I mean, again, I see obviously, all day long, I’m seeing neck and back pain again, just especially in this area is the usual it’s, you know, patient has neck or back pain and, and maybe they get to men’s ends or maybe, you know, and then they get an MRI and, and the MRI sounds terrible and they you know, and then they show up in my, my office, is there degenerative disc disease on an MRI, like, just if you
Unknown Speaker  21:53
just give me some statistic that you know, of,
Unknown Speaker  21:57
yeah, extremely, extremely common. I use the Patients age as the percentage. So if you’re 50 years old, you know, I took 100, healthy 50 year olds with no back pain at all and did them rise and then probably 50% would have significant degenerative this disease, if you’re at that number is 80%. You know, so So that’s sort of a rough thing. There’s some, there’s some studies to show but as a rough generalization, it’s your age is the percentage of patients your age, so they would have, you know, findings on an MRI.
Unknown Speaker  22:28
So those findings could be used to explain pain that’s there, but it’s not predictive of pain.
Unknown Speaker  22:34
Yeah, it’s a very good point. Very good question. And I’ll say, you know, makes makes the job tough sometimes, because, you know, it’s very common to see herniated discs. It’s very common to see degenerative disc bulging discs. And it’s, it’s not so easy. You know, in some cases, those are patients are in severe, you know, pain to the point where they need surgery for it. And in some cases, it’s an incidental finding where, you know, it was there already. And it’s just a muscle spasm. So it can be a challenge to, and some people for some reason, you know, feel it. pain receptors are different or whatever. But some patients are more sensitive to those to those changes, and some people are not. I think this was a very productive conversation and really appreciate you taking the time. Is there anything else that you wanted to discuss today that you think we might have missed? Yeah, I mean, just in general. So just to expound a little bit more on that visit. So you know, in general, if you’re a you know, 53 year old man and you pulled you back out, you know, shoveling snow and you ended up with an MRI, or likely not to a layperson even to another doctor. It’s going to sound terrible, that’s, you know, radiologists, you know, like to be thorough, and they like to describe everything and it’s going to see things like spondylitis is this creation, impingement. But really, you know, to tease out, you know, all that really the thing I when I went I, you know, obviously I try to read all my films, I look at all the reports examined the patient, I try to make it the most educated, you know, decision as possible. But at a glance when I look quickly at an MRI, what I’m looking for is things like stenosis and more central stenosis, like if there’s pressure on the canal on the on the in the middle of the canal where this where the spine runs down, if that if that’s being compressed, that can really be an issue if there’s any kind of obviously a fracture or a tumor that’s that’s a red flag for everyone but stenosis or significant you know, Mal alignment of his mind to spinal this thesis was whether we’re bones are slipping on each other. You know, I look for conditions where the nerve is compressed, because all that other stuff is is very common, and usually not not really a problem. Certainly not in the in the short term.
Unknown Speaker  24:50
Great. I really appreciate you taking the time to talk to me and talk to the audience. I think clearly polities in yoga now. We’ll have to find their way into my regimen somehow it’s not just going to be clean and jerk. And
Unknown Speaker  25:08
especially if you’re going to do create clean and jerk you gotta do some yoga employees in there as you get older. Well, you know, I can’t touch my toes. That’s a problem.
Unknown Speaker  25:18
It’s going to start catching up with me and clearly the Superman’s needs to find their way into my routine because myself and, you know, I’m sure almost all doctors would with the EMR even, you know, without the MRI dictate a lot of my notes, still hunched over my phone hunched over my computer, and you know what, we’re surgeons, hunched over our patients in the office and in the operating room.
Unknown Speaker  25:42
Yeah, your whole your whole life is spent in an inflection of your spine. So you definitely want to focus on the extension and try to try to keep that strength and mobility, very important.
Unknown Speaker  25:52
So all of us need to start doing the Superman before we go to bed. Maybe next,
Unknown Speaker  25:57
I want to see worldwide. I want to people doing Superman all those would be my wish tonight. All physicians in
Unknown Speaker  26:03
every everybody Superman minutes, right every night before bed.
Unknown Speaker  26:10
Yeah, that’d be that’d be I’d be out of a job where the light was busy.
Unknown Speaker  26:15
Maybe I don’t want people to do that. I think
Unknown Speaker  26:17
there’s a little conflict there.
Unknown Speaker  26:18
Okay. Well, thanks again. I appreciate you taking the time. It’s been a pleasure.
Unknown Speaker  26:24
Thank you so much. Thanks for having me.
Unknown Speaker  26:27
That was Dr. Bradley Block at the physicians guide to doctoring. Find all previous episodes on iTunes, Stitcher, Google podcasts, or wherever you get your podcasts and write us a review. You can also visit us on facebook@facebook.com slash physicians guide to doctoring. If you are interested in being a guest or have a question for a prior guest send a message or post a comment.
Transcribed by https://otter.ai