By Dr. Francis Bayes, WCI Columnist
I could not ignore personal finance when I created my residency rank list last year. As I explained in my column about whether MD/PhD was a good financial decision, the opportunity cost of sacrificing clinical time—thereby earning lower income—is the biggest challenge in academic medicine. Meanwhile, my wife’s only requirement was that I match to a program in a city with good Asian food, so most of my programs were on either coast (I invest in my marriage first!). Similar to many memes, the three most important factors for my rank list were family, fit, and finance (in order of importance), but I could not have all three with most of the programs to which I applied.
I had a running rank list throughout the interview season, and the list was divided into three tiers, mostly based on fit. I would have been content to match to the top program of my second tier, whereas I would have been disappointed to match below the last program of my second tier. I started the season with a handful of programs in the first tier, but by the end, I narrowed it down to two programs that I will call Program EC and Program WC.
My most challenging decision was at the top of my rank list. I would have ranked Program EC, which is located in an East Coast high-cost-of-living area (HCOLA), as my first choice without reservations if finance was not a factor. But Program WC—where I would have liked to train even in a vacuum—is located in the West Coast HCOLA that includes my wife’s hometown and is closer to my parents in East Asia. Because family and fit are specific to individuals, I share in this column a list of generalizable financial factors that influenced the top of my rank list.
(I reveal how I weighed the factors at the end.)
#1 Future Opportunities
Based on my mentors’ advice and my impression, both programs would prepare me to become a good psychiatrist and scientist. My mentors advised that Program EC would open more doors—including at Program WC’s institution—than Program WC would. But I have heard from different residents that Program WC was more likely to continue supporting me after residency with or without external funding (e.g., flexible arrangement for clinical time).
I wrote about how I can take advantage of Economic Outpatient Care by seeking once-in-a-lifetime opportunities instead of financial comfort. Regardless of fit, Program EC’s institution is one of the few that attract ambitious physicians and scientists from everywhere, in everything, all at once. This was an opportunity for me to walk the walk.
Verdict: Program EC
More information here:
Splurge on This, Not on That
#2 Average Attending Physician Income
Medicine is one of the few professions in which physician income is higher in LCOLAs than in HCOLAs. According to the US Bureau of Labor Statistics (Table 1), neither California nor Washington state are in the top-five of best-paying states. But San Jose, San Francisco, and Seattle are in the top-five of best-paying cities for psychiatrists (Indianapolis and Kansas City round out the list).
In contrast to West Coast HCOLAs, East Coast HCOLAs such as Boston, New York City, and Washington DC have a mean wage that is 60%-70% of their West Coast counterparts. One possible reason for the difference is that Boston, NYC, and DC are in the top-five of metropolitan areas with the highest employment (i.e., number of psychiatrists). Interestingly, the correlation between the concentration of psychiatrists and the mean wage is weak (< |0.20|), in part because California, Connecticut, and New Jersey pay psychiatrists very well.
Verdict: Program WC
#3 Childcare and Travel Costs
The WCI forum thread on childcare costs was enlightening. My wife’s work is now fully remote, yet she would have to travel for work occasionally. If she switches jobs in the future, not as many jobs may be fully remote. As someone who studied the role of fathers in child development, I will do everything in my power to care for our future child(ren). But despite our best efforts and work flexibility, we would need to pay for backup childcare at some point.
Spending at least $10,000-$20,000 per year, which seems like a conservative estimate in an HCOLA, might be the “cost of doing business.” But it would hurt more if the alternative is living in the same metropolitan area as our parents and paying <$10,000 (i.e., very nice gifts for being backup childcare). Again, the less I feel stressed about “providing for the family,” the more likely that I will pursue research in my career.
Finally, we would save 20%-25% on traveling to my parents in East Asia from the West Coast in addition to saving the cost of travel from Program EC to my wife’s parents.
Verdict: Program WC
More information here:
What Happens If You Don’t Match into Residency and What to Do
#4 Salary and Moonlighting Opportunities
The difference in residency salary will not matter as much as the difference in potential attending income (e.g., $10,000 vs. $100,000, respectively). Childcare and travel costs might also offset any extra savings from greater residency salary and better moonlighting opportunities. Granted, the greater residency salary means more cold hard cash now, whereas the BLS data does not guarantee that I would earn more on the West Coast than on the East Coast after residency.
Could I increase my lifetime income by going to Program EC for residency and then moving to the West Coast? Perhaps. But such a mindset would be inconsistent with Factor #1, because if I am competitive as an applicant to match at Program EC, I should try to succeed at Program EC’s institution for as long as possible.
Verdict: Program EC
#5 Community
Are relationships related to personal finance?
The happiness literature is pretty clear that the way to maximize happiness from spending is to spend on shared experiences with people you care about.
Do more of that and less retail therapy and collecting.
— White Coat Investor (@WCInvestor) March 20, 2023
After seven years, I am leaving my friends and church community once again. Maintaining connections that I made while living in other metropolitan areas has been challenging during medical school. It would only be harder during residency.
My wife and I did not want to have to say goodbye again 4-7 years later. We wanted our next community to be where we would take root. We increased the likelihood that we would stay indefinitely in our new (yet familiar) city by living in the same metropolitan area as my wife’s parents and on the same coast as her closest friends.
Before our parents are too old, we want to maximize our vacation spending with our parents. Before we become parents, we want to maximize our dining spending with our friends. Before we grow too old, we want to maximize our outdoor spending by bringing along our family and friends to the Cascades, Sierra Nevada, and so much more. Before we die, we want to reap the fruits of giving our time and money generously to local causes over decades.
Verdict: Program WC
More information here:
From Fourth Year to the Real World: Transitioning from Med School to Residency
My Verdict: ‘Some Lessons Have to Be Experienced'
The final score for the financial factors was 3-2 in favor of Program WC, but Factor #1 played an outsized role in giving the edge to Program EC (in boxing parlance, this would be considered a controversial judges’ decision). This meant the total score was 2-1 in favor of Program EC because of Program EC’s slightly better fit.
Although I ranked Program EC and Program WC as No. 1 and No. 2, it was more like No. 1(a) and No. 1(b).
I am not being diplomatic!*** When I explained my dilemma to my mentors, half of them advised me to rank Program EC first, while the other half advised otherwise. Until I opened the Match email, I had daydreamed about Program EC only to remind myself why Program WC would be better, and vice versa.
***Residency program directors and faculty who have reviewed my application and interviewed me know that my real name is not Francis Bayes. But I will continue to write under a pseudonym during residency. Anonymity allows me to (1) write about controversial topics like crypto and (2) explain how my interest in personal finance aligns with career goals only during job interviews.
The process of creating a rank list is so personal that it might seem irrational to others even though it feels rational to the applicant. As blogger/podcaster Michael Batnick said, “Some lessons have to be experienced before they can be understood.” I expect everyone—especially those who have already ranked and matched—to disagree with something about my process or final rank list. Still, I hope this column helps readers who will be future applicants.
After all, my wife and I are ecstatic to go to Program WC, and as they say: happy wife, happy life.
What factors did you consider when making your rank list? Would you make the same ranking now? Is there anything you regret? If you're about to make your own ranking list, what factors are most important to you? Comment below!
