Personal Counseling Presentation

Practical Radiation Oncology (2019) 9, 231-238

www.practicalradonc.org

Critical Review

A Burnout Reduction and Wellness Strategy: Personal Financial Health for the Medical Trainee and Early Career Radiation Oncologist Trevor J. Royce MD, MS, MPH a,*, Kathleen T. Davenport MD b, James M. Dahle MD, FACEP c,d

aDepartment of Radiation Oncology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina; bDepartment of Emergency Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina; cUtah Emergency Specialists, Salt Lake City, Utah; and dThe White Coat Investor, LLC, Salt Lake City, Utah

Received 14 January 2019; revised 16 February 2019; accepted 22 February 2019

Abstract Purpose: Physician burnout is reported in more than one out of every 2 practicing clinicians and is just as prevalent in training physicians. Burnout severity is also associated with increasing levels of financial debt. Medical professionals are notable for their high and increasing levels of debt; despite this, financial literacy is poor among physicians, and financial education is largely absent from medical education. Radiation oncologists (ROs) are no different in this regard, with 33% of res- idents reporting high levels of burnout symptoms, 33% carrying >$200,000 of educational debt, and 75% reporting being unprepared to handle future financial decisions. To fill this gap, we reviewed the basic tenets of personal financial health for the early career RO. Methods and materials: The core concept of financial independence (FI) is introduced, and we review 4 basic tenets of personal financial health for the young medical professional: debt, behavior, investment, and asset protection strategies. Results: FI is achieved by saving until the desired quality of life can be maintained, independent of employment income. Debt strategy involves minimizing debt accrual, understanding student loans, and having a debt management plan. Behavioral strategy involves setting financial goals, calcu- lating worth and a savings rate, budgeting, and frugal living. The basics of investing include asset allocation, diversification, rebalancing, and minimizing expenses. Finally, asset protection includes insuring against catastrophic events with disability, life, health, liability, and property insurance. Conclusions: Healthy financial practices can lead to FI and may facilitate professional and personal freedoms with the goal of mitigating burnout-associated stressors. The tenets of strong financial health for ROs in the early stages of their career include sound debt, behavioral, investment, and asset protection strategies. Furthermore, initial and continuing financial education is an overlooked

Sources of support: This work had no specific funding. Disclosures: Dr Dahle is the founder and editor of The White Coat Investor, LLC.

* Corresponding author. Department of Radiation Oncology, University of North Carolina at Chapel Hill, 101 Manning Drive, CB 7512, Chapel Hill, NC 27599.

E-mail address: [email protected] (T.J. Royce).

https://doi.org/10.1016/j.prro.2019.02.015 1879-8500/� 2019 The Author(s). Published by Elsevier Inc. on behalf of American Society for Radiation Oncology. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

232 T.J. Royce et al Practical Radiation Oncology: July-August 2019

but important curriculum component. ROs with their financial houses in order can devote more resources to learning and practicing good medicine while living healthy, rewarding lives. � 2019 The Author(s). Published by Elsevier Inc. on behalf of American Society for Radiation Oncology. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Figure 1 Potential medical graduate educational debt load by postgraduate year during graduate medical education under a government-sponsored, income-based repayment plan. The average starting educational debt load of the graduating medical student was $200,000 in 2018 (blue line), and 12% of graduates owe >$300,000 (red line).16 This model assumes that the graduate is making the minimal payments on unsubsidized

Introduction

Symptoms of burnout (depersonalization, a diminished sense of personal accomplishment, and emotional exhaustion) have been reported in >1 of every 2 prac- ticing physicians.1 This affliction, driven by work-related stressors, is just as prevalent in training physicians2 and has become a focus of the American Medical Associa- tion.3 Burnout has been associated with substance abuse, suicidal ideation, and career dissatisfaction,4-6 and the rates of burnout are thought to be twice as high in med- icine compared with other professional fields.7 Radiation oncologists (ROs) are no different in this regard, with 33% of residents reporting high levels of burnout symp- toms.8 Indeed, a full session at the 2018 American Society for Radiation Oncology Annual Meeting was devoted to burnout in the specialty, with a focus on resident and junior ROs.

Burnout severity is also associated with increasing levels of financial debt.9-13 Medical and dental pro- fessionals are notable for their high and increasing levels of debt, which is the highest among graduate-degree pro- fessions.14 The median debt of medical school graduates with loans has nearly tripled from $71,000 (in 2018 dollars) in 1986 to $200,000 in 2018.15,16 Furthermore, 12% of graduates now owe >$300,000 in educational debt.16 This burden can grow substantially during residency and, at current interest rates, may be 20% to 50% higher by completion of training (Fig 1). Despite this, financial lit- eracy is poor among physicians, and financial education is largely absent from medical education.17 Again, ROs are no different in this regard, with 33% of RO residents carrying >$200,000 of educational debt (12% of residents report >$300,000)8,18 and 75% reporting being unprepared to handle future financial decisions.19

To fill this gap and in the context of the multifactorial burnout crisis, we review the basic tenets of personal financial health for ROs in the early stages of their career (Table 1) and introduce the concept of financial inde- pendence (FI), all with the goal of promoting strong financial stewardship as a wellness strategy.

loans while enrolled in the Pay-As-You-Earn repayment plan,34

with an average loan interest rate of 6.6% in 2018,27 earning an average resident salary of $59,300 in 2018,54 with a family size of 1, and lives in the continental United States, with U.S. Department of Health and Human Services poverty guidelines.55 (A color version of this figure is available at https:// doi.org/10.1016/j.prro.2019.02.015.)

Financial Independence

FI is the accumulation of sufficient wealth to permit life without dependency on employment income while

maintaining the desired quality of life.20,21 This state is essentially the personal finance endgame and is what the retiree, who no longer works but has saved enough to live comfortably after employment, classically strives for. But FI need not be limited to the retiree, and the state permits professional, personal, and financial free- doms. With healthy financial behavior, FI is readily attainable for U.S. physicians after 15 to 20 years, or less, in practice. FI can alleviate work-related personal financial stressors, allowing the physician to practice medicine unhindered by the constraints of dependency on income. For some physicians, the path to FI may permit the restructuring of work hours and schedules and provide more room for personal wellness or pro- fessionally rewarding but less income producing activ- ities, such as charitable work. For others, FI can be a hedge against an uncertain future (eg, in specialty labor markets such as in RO22,23 or times of changing reimbursement patterns and health care reform24). Furthermore, if individual practice patterns are driven, consciously or unconsciously, by the personal income benefits enabled by the relative-value-unit fee-for-

Table 1 Summary of tenets of financial health for medical trainees and early career radiation oncologist with select relevant and practical resources

Tenet Details Resources

Debt strategy Debt management plan Fawcett et al, 201636

Minimize debt accrual Steiner et al, 201335

Grischkan et al, 201833

Behavior strategy Set financial goals Tyson et al, 201039

Calculate net worth Bach et al, 201640

Set a savings rate Stanley et al, 201037

Budget Zweig et al, 200841

Live like a resident (minimize spending) Clements et al, 201643

Stay the course (stick to the plan) Belsky et al, 201044

Investment strategy Pay down high-interest debt Bernstein et al, 201442

Asset allocation Larimore et al, 200749

Portfolio diversification Larimore et al, 201846

Rebalance portfolio Bernstein et al, 201047

Minimize expenses Piper et al, 201451

Minimize taxes Asset protection strategy Insure against catastrophic events Tyson et al, 201039

Disability Dahle, 201429

Death Illness Injury Liability Expensive property

Emergency fund Estate planning Personal well-being

Education Initial and continuing financial education Dahle, 201429

Practical Radiation Oncology: July-August 2019 Early career personal financial health 233

service reimbursement model, FI could mitigate these influences.25

FI (moving work from a necessity to a choice) can be obtained through many routes but is classically and most reliably done via the steadfast accumulation of wealth such that an individual’s assets, when invested appropri- ately, generate enough income passively to at least equal expenses. This wealth is achieved by increasing savings (ie, assets) relative to lifestyle costs and debts (ie, ex- penses). Healthy personal financial practices are necessary for FI.

Tenets of Financial Health for Medical Trainees and Early Career Radiation Oncologists

Debt strategy

The cost of medical education has been increasing at twice the rate of inflation.26 For those who borrow money to pay for this increasingly expensive education, the in- terest rate for unsecured federal Stafford graduate student loans from 2006 to 2018 averaged 6.38%,27 >2 points above the average 15-year fixed-rate mortgage of 4.05%.28 Moreover, since 2012, these loans are

unsubsidized, and the federal government will no longer cover the interest while the borrower attends school.29

Other sources of debt to consider are undergraduate ed- ucation loans, credit card debt, mortgages, and car loans. Finally, in the setting of an expensive U.S. health care system,30 there is downward pressure on physician pay, with physicians earning relatively less than ever before.31

The combination of the increasing cost of education, relatively high interest rates on educational loans, less favorable loan terms, and changing health care economics make a sound debt strategy essential for physicians in the early stages of their career.

Not to be overlooked, an important component of debt strategy is to minimize high-interest debt accrual during training. Techniques to curtail educational costs include prudent school selection and using preowned or shared books, supplies, and equipment. Frugal living choices and cost sharing can help reduce the total debt burden.

Income during training can also reduce indebtedness. Medical students may be able to work in a limited manner during school, and a spouse or partner may also be able to provide financial support. Many universities allow for substantial tuition reductions for family members of em- ployees. Other notable approaches include scholarships and grants; combination degree programs (eg, MD/PhD); the National Health Services Corps or the U.S. Armed

Table 2 Summary of available federal student loan repayment plans under the William D. Ford Federal Direct Loan Program

Repayment plan Eligible loans Monthly payment and loan features

Standard � Direct loans (subsidized and unsubsidized)

� Federal Stafford loans (subsidized and unsubsidized)

� PLUS loans � Consolidation loans

� Fixed payments made within 10 years*

Graduated � Direct loans (subsidized and unsubsidized)

� Federal Stafford loans (subsidized and unsubsidized)

� PLUS loans � Consolidation loans

� Fixed payments increase every 2 years and loans are paid off within 10 years*

Extended � Direct loans (subsidized and unsubsidized)

� Federal Stafford loans (subsidized and unsubsidized)

� PLUS loans

� Fixed or graduated payments made within 25 years

Revised Pay-As- You-Earn

� Direct loans (subsidized and unsubsidized)

� PLUS loansy � Consolidation loansy

� Payments calculated from 10% of discretionary income � Annually recalculated using family size and income � Married couples’ total income and loan debt considered � Outstanding balance is forgiven after 20 years (undergraduate study) or 25 years (graduate or professional study)

� Forgiveness may be a taxable event Pay As You Earn � Direct loans (subsidized and

unsubsidized) � PLUS loansy � Consolidation loansy

� Payments calculated from 10% of discretionary income � Annually recalculated using family size and income � Married couples’ total income and loan debt considered if filing jointly � Outstanding balance is forgiven after 20 years � Eligibility limitations based on dates of loan and disbursement and debt- to-income ratio

� Forgiveness may be a taxable event Income-based � Direct loans (subsidized and

unsubsidized) � Federal Stafford loans (subsidized and unsubsidized)

� PLUS loansy � Consolidation loansy

� Payments calculated from 10%-15% of discretionary income � Annually recalculated using family size and income � Married couples’ total income and loan debt considered if filing jointly � Outstanding balance is forgiven after 20-25 years � Eligibility limitations based debt-to-income ratio � Forgiveness may be a taxable event

Abbreviation: PLUS Z Parent Loan for Undergraduate Student. The highlighted income-driven repayment plans (shaded) are those best suited for the Public Service Loan Forgiveness program.2

Income-contingent and income-sensitive repayment plans also exist, but these are rarely used by medical trainees. * 10-30 years for consolidation loans. y Direct loans made to students.

234 T.J. Royce et al Practical Radiation Oncology: July-August 2019

Forces with their Health Professions Scholarship Pro- gram; the Uniformed Services University of the Health Sciences (Bethesda, MD); or financial assistance programs.32

However, for many with heavy student debt loads at the end of training, 2 primary strategies exist: consoli- dating loans and pursuing forgiveness, or refinancing and eliminating the high-interest debt as soon as possible. There are several service-based loan repayment or forgiveness programs. For example, for those working in underserved areas or conducting research there are the National Health Services Corps and the National In- stitutes of Health Loan Repayment Program, respectively. For those pursuing work in academics and nonprofits (ie,

organizations with a 501(c)3 tax designation), the most widely adapted forgiveness path is the U.S. government’s 2007 Public Service Loan Forgiveness (PSLF) program, in which more than one third of graduates with debt are participate despite increasing scrutiny of the program.33

Under the PSLF program, borrowers who are enrolled in qualifying repayment plans and employed directly by a 501(c)3 or government organization may be eligible to have all educational debt (principal and interest) spon- sored by the federal government forgiven, tax-free and without a cap, after 10 years of payments (120 qualifying, monthly, on-time payments). There are several qualifying repayment plans (Table 2), which are largely income- driven repayment plans (ie, the monthly payment owed

Practical Radiation Oncology: July-August 2019 Early career personal financial health 235

is dependent on income, such as the Pay As Your Earn, Revised Pay As You Earn Repayment Plan, and Income- Based Repayment plans).34 Because most residents and fellows are employed by 501(c)3 organizations, the years of training can count toward the 10 years of service needed for forgiveness. This is particularly appealing with the income-driven repayment plans and results in a lower monthly payment while the borrower earns a lower salary as a trainee.

For academics and others who plan to be directly employed by a 501(c)3 nonprofit or government organi- zation after training, this program can be an appealing approach. Of note, placing student loans into deferment or forbearance during training can be a costly mistake because the borrower would not be accumulating pay- ments toward the PSLF. The PSLF exists at the whims of Congress33; therefore, financially savvy borrowers hedge against possible changes in the program and their career path by saving an amount equivalent to their loans on the side in an investing account. These funds can be applied against the debt in the event of career or program changes.

Another recommended strategy for those with high- interest debt is to eliminate the debt as quickly as possible by refinancing with a private lender, living frugally, and directing every available dollar to the debt. Since 2013, private lenders have been refinancing medical student loans at lower interest rates than those offered by the federal government. Being free of student loan debt in 2 to 5 years after residency is an attainable goal for most29

but requires the behavioral discipline described in the next section. As illustrated by the numerous repayment plans outlined, student loans are complex, and the optimal debt strategy for any individual depends in part on personal goals and preferences. Fortunately, there are many excellent resources available to help with this process.35,36

Behavioral strategy

A goal-oriented approach to personal financial health keeps the individual on track to success. A common unit in financial goals is net worth, which is essentially net assets minus net liabilities (ie, debts). The surest path to increasing net worth is a high savings rate, or the pro- portion of income not spent and placed into savings (eg, investments). In other words, this is achieved by living well below your means. Wealth is what you accumulate and can be achieved by increasing net worth through savings; it should not be confused with income.37

This behavioral strategy, that of a “prodigious accu- mulator of wealth,”37 is particularly important for physi- cians, with their delayed entry into the workforce as a result of prolonged education and training and high debt burden. Physicians are typically in their early thirties by the time they complete training. Although there are social

and societal pressures for physicians to increase con- sumption (eg, buy a house) upon completion of training with the accompanying increase in income, our preferred approach is to delay gratification and live like a resident for several years after training. This approach requires physicians to maintain a resident’s standard of living as an attending physician, despite the higher income.

The difference between attending-level income and trainee-level standard of living can permit the rapid accumulation of wealth by paying down debt, increasing the savings rate, and getting one’s financial house in order. Converting income into wealth involves consciously avoiding the hedonic treadmill38 and growing into higher income slowly. Creating a monthly budget is the traditional technique to track spending, saving, and progress toward financial goals, and many excellent re- sources are available to help with this process.39 An even simpler way is to “pay yourself first” with automated deductions for bills and savings accounts.40

Finally, when saving and investing, setting financial goals and working toward them by staying the course despite market volatility is critical. Changing goals and strategies during a turbulent market can lead to selling low and buying high, which decreases investment returns and slows the process. Common behavioral investing traps are paralysis by analysis, recency bias, herd behavior, loss aversion, mental accounting, and changing long-term plans in response to short-term events.41 A competent, low-cost financial advisor can assist with developing, implementing, and maintaining an appro- priate investment strategy. However, all else being equal, the cost of an advisor reduces investment returns. Many physicians, who have already demonstrated the character traits of hard work, planning, self-discipline, and perse- verance intrinsic to the profession, are capable of man- aging their own finances with great success. Of course, this requires interest, the accumulation of a new body of knowledge, and sufficient discipline to maintain a simple, low-cost investment strategy.42 Many excellent resources are available detailing the nuances of financially healthy behavioral strategies.41,43,44

Investment strategy

Historically, approximately 4% of the initial portfolio value, adjusted upward annually for inflation, can be spent each year throughout retirement with little risk of complete portfolio depletion. Thus, FI, or the amount needed to feasibly retire, can be defined as a sum of money that is 25 times annual retirement spending. For example, if $100,000 is needed from the portfolio each year, then $2,500,000 is needed in savings. This is known as the 4% rule45 and is defined by assumptions based on the historical performance of investments (ie, equities and bonds). A 3% withdrawal rate would be even more conservative.45 The

Figure 2 Lifecycle funds. This schematic shows how lifecycle (target retirement) funds adjust their risk profile as the target retirement date (Year 0) approaches. As the years to retirement approach 0, the fund’s asset allocation get progressively less risky, shifting the balance from stocks (higher risk) to bonds (lower risk).

236 T.J. Royce et al Practical Radiation Oncology: July-August 2019

nuances of an appropriate long-term investment strategy to reach FI are beyond the scope of this article (eg, invest- ment portfolio design involves many personal decisions), but we cover some fundamental principles. It is critical to recognize that fruitful investing need not be overly com- plex; some successful investors use a portfolio with only 3 types of assets.46

The future value of savings is primarily driven by 4 factors: income, savings rate (ie, percentage of income saved and invested), the rate of return on those in- vestments, and the amount of time over which the money compounds. The amount of control the individual investor has over these factors varies but is greatest for the savings rate, as discussed previously. The expected rate of return depends on the risk profile of the investment portfolio, which is primarily reflected in its asset allocation (ie, the mix of different types of investments in the portfolio, such as stocks, bonds, and real estate). The appropriate port- folio balance of riskier investments (stocks, real estate) and less risky investments (bonds, cash) is determined by the investor’s need, ability, and desire to take risk to meet financial goals.

Essential to portfolio design is to minimize uncom- pensated risk. Ideally, an investor who takes on more risk should receive a higher long-term return as compensation. Uncompensated risk (ie, risk that can be eliminated completely through diversification) should be minimized whenever possible.47 This can be done by holding mutual funds, which are essentially a pool of many different as- sets (ie, many different stocks, bonds, or real estate holdings lumped into a single fund) as opposed to choosing a few individual securities.48 This approach provides broad exposure to the market and minimizes having “all your eggs in one basket.” Active mutual fund managers attempt to outperform the market by choosing securities that will do well in the future and avoiding those that will perform poorly. Passive (index) mutual fund managers give up the potential to outperform the market in exchange for eliminating the risk of under- performing the market. Primarily because of their

dramatically lower costs, the investment literature has consistently shown that over the long term, passively managed index funds outperform the majority of actively managed funds, especially on an after-tax basis.47-50

When investing for the future, minimizing expenses is a fundamental principle of increasing returns.

Similar to minimizing fees, minimizing the tax liability of investments is essential to optimize long-term returns. More broadly, understanding the tax implications of financial activities is a fundamental principle of good financial health.51 The best way to optimize investment- related taxes is through the prudent use of tax-protected accounts, such as 401(k)s, 403(b)s, 457(b)s, health sav- ings accounts, 529 college savings accounts, and indi- vidual retirement accounts. The most common distinction is Roth versus traditional (tax-deferred) individual retire- ment accounts. Both accounts reduce the drag on returns from taxes during growth, but Roth account contributions and withdrawals are made after-tax and traditional ac- count contributions and withdrawals are pre-tax. Because trainees are generally in lower tax brackets than attending physicians, the usual strategy is to make Roth contribu- tions during training and then tax-deferred contributions during peak earnings years. When investing in a non- qualified account after maxing out retirement accounts, special care should be paid to using tax-efficient investments.

An example of simple, low-cost (ie, fees and taxes), passively managed, broadly diversified, index mutual fund portfolios is the lifecycle (target retirement) funds offered by many investment companies and available in most employer-sponsored retirement plans. These funds are automatically rebalanced and adjust their risk profile as the target retirement date approaches (Fig 2). Investing savings in these funds requires little-to-no maintenance and provides a simple approach that is preferred by many investors. As previously indicated, there are many excellent resources available that detail the nuances of simple yet sophisticated and financially healthy investing strategies.42,46,49

Asset protection strategy

Protecting oneself against catastrophic financial events through insurance is another fundamental principle of personal financial health.39 Examples of financial catas- trophes include disability, death, illness or injury, liabil- ity, and loss of expensive personal property. In general, we favor insuring well against these risks and self- insuring against noncatastrophic risks to save money. Using high deductibles also reduces the cost of insurance.

Disability insurance premiums are relatively expensive but essential because the ability to practice medicine is a typical physician’s primary asset. Individual, specialty- specific policies are generally more costly and difficult to

Practical Radiation Oncology: July-August 2019 Early career personal financial health 237

qualify for than group policies, but are portable and may provide superior definitions of disability. We recommend working with an experienced, independent agent to ensure appropriate coverage at the lowest possible price.

Term life insurance, with the binary outcome of life or death, is much less complex and expensive but no less essential for those with dependents. Simple 20- to 30-year term, level premium life insurance can readily be found online through comparative aggregators and purchased from an independent agent.52 Buying disability and life insurance while young and healthy is easier and less expensive. Whole life insurance, which combines a death benefit with an investment vehicle, can be much more costly and complex than simple term insurance. Optional at best for any physician, it is generally inappropriate for young, indebted physicians. We caution against combining insurance and investing in this manner.

For unexpected life events or expenses, an emergency fund of 3 to 6 months’ worth of living expenses in a safe, accessible location is useful. This can be a buffer for life’s inevitable curve balls, including short-term disability.

Estate planning should also be part of any financial plan. Estate planning dictates where children and assets go in the event of an individual’s death and minimizes the hassles and cost of this transition. Consisting at a mini- mum of a last will and testament, many physicians also opt to have a power of attorney, living will, and various trusts in place.

Finally, and not to be overlooked, the most valuable asset we have is our mental and physical health, and devoting the necessary resources (eg, time, energy, and money) to caring for ourselves and our personal re- lationships (eg, marriage) should be prioritized above all else. Each of these aforementioned asset protection stra- tegies have their own complexities, but many helpful educational resources are available.29,39

A Way Forward

The increasingly well-described burnout crisis among ROs and medical professionals is likely a multifactorial process, but personal financial factors, including debt loads, have been implicated as a contributing force. Increasing income is of diminishing returns for increasing happiness,53 but robust financial health can lead to FI and may facilitate professional and personal freedoms, with the ultimate goal of mitigating burnout-associated stressors. The essential tenets of strong financial health for ROs in the early stages of their career include sound debt management and behavioral, investment, and asset protection strategies (Table 1). Initial and continuing financial education is an overlooked but important cur- riculum component for medical professionals, and many resources cited in this review can help in that regard.

The ultimate hope is that those with their financial houses in order can devote more resources to learning and practicing good medicine while living healthy, rewarding lives.

References

1. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general U.S. working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600-1613.

2. Dyrbye LN, Burke SE, Hardeman RR, et al. Association of clinical specialty with symptoms of burnout and career choice regret among US resident physicians. JAMA. 2018;320:1114-1130.

3. American Medical Association. Preventing physician burnout. Available at: https://www.stepsforward.org/modules/physician- burnout. Accessed November 1, 2018.

4. Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149: 334-341.

5. Oreskovich MR, Kaups KL, Balch CM, et al. Prevalence of alcohol use disorders among American surgeons. Arch Surg. 2012;147:168- 174.

6. McMahon G. Managing the most precious resource in medicine. N Engl J Med. 2018;378:1552-1554.

7. Dyrbye LN, West CP, Satele D, et al. Burnout among U.S. medical students, residents, and early career physicians relative to the general U.S. population. Acad Med. 2014;89:443-451.

8. Ramey SJ, Ahmed AA, Takita C, Wilson LD, Thomas CR, Yechieli R. Burnout evaluation of radiation residents nationwide : Results of a survey of United States residents. Radiat Oncol Biol. 2017;99:530-538.

9. West CP, Shanafelt TD, Kolars JC. Quality of life, burnout, educational debt, internal medicine residents. JAMA. 2015;306:952- 960.

10. Dimou FM, Eckelbarger D, Riall TS. Surgeon burnout: A systematic review. J Am Coll Surg. 2016;222:1230-1239.

11. Xu G, Veloski JJ. Debt and primary care physicians’ career satis- faction. Acad Med. 1998;73:119.

12. Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Stress and coping among orthopaedic surgery residents and faculty. J Bone Joint Surg Am. 2004;86-A:1579-1586.

13. Kibbe MR, Troppmann C, Barnett CC, et al. Effect of educational debt on career and quality of life among academic surgeons. Ann Surg. 2009;249:342-348.

14. Woods D. Medicine, law, business: Which grad students borrow the most? Available at: https://www.npr.org/sections/money/2015/07/ 15/422590257/medicine-law-business-which-grad-students-borrow- the-most. Accessed October 24, 2018.

15. Grischkan J, George BP, Chaiyachati K, Friedman AB, Dorsey ER, Asch DA. Distribution of medical education debt by specialty, 2010-2016. JAMA Intern Med. 2017;177:1532-1535.

16. Association of American Medical Colleges. Medical school gradu- ation questionnaire 2018 all schools summary report. Available at: https://www.aamc.org/download/490454/data/2018gqallschools summaryreport.pdf. Accessed October 24, 2018.

17. Bar-Or Y. Empowering physicians with financial literacy. J Med Pract Manag. 2015;31:49.

18. Royce TJ, Doke K, Wall TJ. The employment experience of recent graduates from U.S. radiation oncology training programs: The practice entry survey results from 2012 to 2017 [e-pub ahead of print] J Am Coll Radiol. 2019. https://doi.org/10.1016/j.jacr.2 018.11.021. Accessed October 24, 2018.

238 T.J. Royce et al Practical Radiation Oncology: July-August 2019

19. Witek M, Siglin J, Malatesta T, et al. Is financial literacy necessary for radiation oncology residents ? Radiat Oncol Biol. 2014;90:986-987.

20. Pfau W, Kitces M. Reducing retirement risk with a rising equity glide path. J Financ Plan. 2013;27:38-45.

21. Robin V, Dominguez J, Mustache MM. Your Money or Your Life: 9 Steps to Transforming Your Relationship With Money and Achieving Financial Independence. Revised. London, United Kingdom: Pen- guin Books; 2008.

22. Burt LM, Trifiletti DM, Nabavizadeh N, Katz LM, Morris ZS, Royce TJ. Supply and demand for radiation oncology in the United States: A resident perspective. Int J Radiat Oncol. 2017;97:225-227.

23. Fung C, Chen E, Vapiwala N, et al. The American Society for Radiation Oncology 2017 Radiation Oncologist Workforce Study. Int J Radiat Oncol Biol Phys. 2019;103:547-556.

24. Song Z, Goodson JD. The CMS proposal to reform office-visit payments. N Engl J Med. 2018;379:1102-1104.

25. Mitchell A, Rotter J, Patel E, et al. Association between reim- bursement incentives and physician practice in oncology A sys- tematic review [e-pub ahead of print] JAMA Oncol. 2019.

26. Adashi EY, Gruppuso PA. Commentary: The unsustainable cost of undergraduate medical education: An overlooked element of U.S. health care reform. Acad Med. 2010;85:763-765.

27. U.S. Department of Education. Interest rates and fees. Available at: https://studentaid.ed.gov/sa/types/loans/interest-rates#rates. Accessed October 27, 2018.

28. FreddieMac. 15-year fixed-rate mortgages since 1991. Available at: http://www.freddiemac.com/pmms/pmms15.html. Accessed November 1, 2018.

29. Dahle J. The big squeeze. In: The White Coat Investor A Doctor’s Guide to Personal Finance and Investing. The White Coat Investor, LLC; 2014:15.

30. Emanuel EJ. The real cost of the U.S. health care system. JAMA. 2018;319:983.

31. Seabury SA, Jena AB, Chandra A. Trends in the earnings of health care professionals in the United States, 1987-2010. JAMA. 2012; 308:2083.

32. U.S. Air Force. Financial assistance program. Available at: https:// www.airforce.com/careers/specialty-careers/healthcare/training-and- education. Accessed November 1, 2018.

33. Grischkan JA, George BP, Dorsey ER, Asch DA. Medical education and the public service loan forgiveness program: Unnecessary un- certainties. Ann Intern Med. 2018;169:566.

34. Federal Student Aid. Choose the federal student loan repayment plan that’s best for you. Available at: https://studentaid.ed.gov/sa/ repay-loans/understand/plans. Accessed November 1, 2018.

35. Steiner J. The Physician’s Guide to Personal Finance: The Review Book for the Class You Never Had in Medical School. 1st ed. South Dublin, Ireland: Two Pugs Publishing; 2013.

36. Fawcett C. The Doctors Guide to Eliminating Debt. 1st ed. Eagle, ID: Aloha Publishing; 2016.

37. Stanley TJ, Danko WD. The Millionaire Next Door: The Surprising Secrets of America’s Wealthy. Lanham, MD: Taylor Trade Pub- lishing; 2010.

38. Diener E, Lucas RE, Scollon CN. Beyond the hedonic treadmill: Revising the adaptation theory of well-being. Am Psychol. 2006;61: 305-314.

39. Tyson E. Assessing your fitness and setting goals. In: Personal Finance for Dummies. Hoboken, NJ: Wiley Publishing; 2010:1-76.

40. Bach D. The Automatic Millionaire, Expanded and Updated: A Powerful One-Step Plan to Live and Finish Rich. Manhattan, NY: Random House; 2016.

41. Zweig J. Your Money and Your Brain: How the New Science of Neuroeconomics Can Help Make You Rich. Reprint ed. New York, NY: Simon & Schuster; 2008.

42. Bernstein WJ. If You Can: How Millennials Can Get Rich Slowly. Portland, OR: Efficient Frontier Publications; 2014.

43. Clements J. How to Think About Money. 1st ed. Seattle, WA: CreateSpace Independent Publishing (Amazon); 2016.

44. Belsky G, Gilovich T. Why Smart People Make Big Money Mistakes and How to Correct Them: Lessons from the New Science of Behavioral Economics. New York, NY: Simon & Schuster; 2010.

45. Cooley P, Hubbard C, Walz D. Retirement savings: Choosing a withdrawal rate that is sustainable. AAII J. 1998;10:16-21.

46. Larimore T, Bogle JC. The Bogleheads’ Guide to the Three-Fund Portfolio: How a Simple Portfolio of Three Total Market Index Funds Outperforms Most Investors With Less Risk. 1st ed. Hoboken, NJ: Wiley Publishing; 2018.

47. Bernstein WJ. The Four Pillars of Investing: Lessons for Building a Winning Portfolio. 1st ed. New York, NY: McGraw-Hill Education; 2010.

48. Bogle J. Common Sense on Mutual Funds. 10th ed. Hoboken, NJ: Wiley Publishing; 2009.

49. Larimore T, Lindauer M, LeBoeuf M. The Bogleheads’ Guide to Investing. 1st ed. Hoboken, NJ: Wiley Publishing; 2007.

50. Malkiel BG. A Random Walk down Wall Street: The Time-Tested Strategy for Successful Investing. 12th ed. New York, NY: W. W. Norton & Company; 2019.

51. Piper M. Taxes made simple. Simple Subjects, LLC; 2014. 52. Term4Sale. Available at: https://www.term4sale.com/. Accessed

November 1, 2018. 53. Kahneman D, Deaton A. High income improves evaluation of life

but not emotional well-being. Proc Natl Acad Sci. 2010;107:16489- 16493.

54. Levy S. Medscape residents salary & debt report 2018. Available at: https://www.medscape.com/slideshow/2018-residents-salary-debt- report-6010044#2. Accessed November 28, 2018.

55. U.S. Department of Health & Human Services. U.S. Federal poverty guidelines used to determine financial eligibility for certain federal programs. Available at: https://aspe.hhs.gov/poverty-guidelines. Accessed November 28, 2018.

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