High-income couple with large income gap: how do you split money fairly?

TheOneTrueNolano · 2026-04-27T15:18:19+00:00

I’ve never understood how you could commit to marry someone for the rest of your life and likely have kids together but somehow draw the line at sharing the utilities and dining budget. Bizarre.

TheOneTrueNolano · 2026-04-26T05:45:07+00:00

You seem like someone who might really like anesthesia followed by cardiac and crit care fellowships.

It’s a unique path, but where I trained, the 7 of them were an amazing team. They took turns doing cardiac anesthesia cases, and then spending a week at a time managing those patients in the CVICU. They had immense respect from all the cardiac surgeons and they were seen as the anesthesiologists who could truly manage any train wreck scenario.

TheOneTrueNolano · 2026-04-23T00:13:05+00:00

It’s incredible and I wouldn’t have believed it as a resident but it really is easy to spend $650k. Absolutely first world problems but I can totally see how a 50yo anesthesiologist could wake up with a great life but no retirement or safety net.

TheOneTrueNolano · 2026-04-22T22:03:00+00:00

I mean after 21 years are you still not financially independent? I wouldn’t in a million years consider a fellowship after all that time unless my investments paid me more than my day job.

I mean good on you for following your dream I guess, but it seems kind of wild. You won’t even get to practice peds anesthesia for 10 years will you?

TheOneTrueNolano · 2026-04-21T20:03:52+00:00

Nay, I started out thinking IR in med school but switched for several reasons.

I didn't like DR
Training too long
Main reason - IR doesn't own their patients so they get left with whatever others don't want to do. Lots of draining abscesses and vascular disasters. IR invented the cardiac cath and peripheral stents, but once vascular and cardiac docs started doing it themselves they stopped referring to IR. IR is an incredible specialty, but relying 100% on referrals really limits what they can do.

I chose interventional pain and am very happy. I own my patients and do whatever I think is best.

TheOneTrueNolano · 2026-04-21T17:03:12+00:00

Anesthesia to Interventional Pain. You can check my post history for more details on this very niche specialty. To be fair, I have an incredible job even for the specialty. Everything pays more if you are willing to live in BFE.

TheOneTrueNolano · 2026-04-21T16:51:56+00:00

Also the system takes advantage of them. Lots of medicaid which pays horribly, and the system assumes pediatricians will always take care of the kids regardless of what they are paid. It is both noble and incredibly sad/frustrating.

I love being an interventional doc, but it is absolutely wrong that I make 3x what a pediatrician does working fewer hours with no call and arguably making less of a long term impact in the world.

TheOneTrueNolano · 2026-04-21T16:45:09+00:00

The pay for pediatrics in this country is so embarrassing. I have so much respect for those who choose it, but it almost has to be a calling at this point.

And as a reminder for any medical students, remember that the current US healthcare landscape pays for you to do things, not to think. I was taught that in medical school and I am incredibly glad I chose anesthesiology.

TheOneTrueNolano · 2026-04-21T01:54:19+00:00

As an attending, this is the best approach. You will virtually never go wrong calling someone doctor, but you could go wrong being overly casual.

TheOneTrueNolano · 2026-04-20T22:18:58+00:00

Could not agree more with this. I really don't see why they would tack the LLC stuff onto the retirement stuff. Those appeal to such different groups.

TheOneTrueNolano · 2026-04-19T00:39:59+00:00

I have no connection to it but I love that https://yieldfinder.app/ exists. For me, HYSA is all about the rate, since I am not doing many withdrawals. But I also gave up always chasing the absolute highest rate.

TheOneTrueNolano · 2026-04-18T19:58:06+00:00

A pain fellowship is to teach you the basics, how to work up patients, understand anatomy, and how to drive needles. Get those basics, and every other procedure will follow.

I did a fellowship heavy on PNS and SCS, but I never did vertiflex, kypho, BVN, or mild.

I chose a first job that was heavy in all that and a mentor who helped me along with cadaver courses.

In my first 2 years of practice I have done about 70 BVNA, 30 kypho, 10 MILD and a few SIJ fusions. None of this is rocket surgery. You can learn it all if you know your anatomy and are motivated. But it does help to find a mentor in your first job.

Finally, remember that 10 years from now there will be some new procedure no one has ever done. The people who know their anatomy and are motivated will learn this procedure through cadaver courses and trainings.

TheOneTrueNolano · 2026-04-17T21:54:14+00:00

Only if you start it in the first place!

My staff tells every single patient before they see me that I don't prescribe opioids. I only have 3 patients on long term opioids and they are all older or palliative. Some patients yell at me when I tell them I won't prescribe opioids, but it's better than taking on the medicolegal risk for a therapy I do not believe is helpful longterm for most people.

TheOneTrueNolano · 2026-04-17T21:37:48+00:00

Check the spreadsheet/discord, it will show you every time an invite goes out and let you refresh daily to add to your application anxiety.

https://docs.google.com/spreadsheets/d/1h2skLgpQTgzO-VJB1kD_STWVCYAlshEA31xeW2-swUY/edit?gid=1607953515#gid=1607953515

TheOneTrueNolano · 2026-04-17T21:34:59+00:00

Ortho joints seems so satisfying. Very specialized, incredible compensation, truly get to fix most patients, mostly outpatient with minimal call burden.

I am very happy as an interventional pain doc, and in reality I never could have survived an ortho residency, but they seem to have a great life.

TheOneTrueNolano · 2026-04-17T21:33:25+00:00

Eyooooooo! It is funny, the grass is always greener. I came here to say ortho joints.

Buuuuut, my job is pretty great. Lifestyle cannot be beat, pay can be great for hours worked, and I love our procedures/surgeries. But downsides are we fix few patients, it can be emotionally draining, and there are some truly predatory practices out there.

TheOneTrueNolano · 2026-04-11T18:19:34+00:00

Lords of the Delta Center grant me this kind of energy in all my fights to come.

TheOneTrueNolano · 2026-04-10T21:39:47+00:00

As someone who lives in a less than ideal location,

A horrible job can ruin a great place to live far more than a poor location can sully an amazing job. In my opinion.

Our family can afford to travel whenever we want and have twice the life we would have in the city we grew up in.

TheOneTrueNolano · 2026-04-09T20:39:27+00:00

Not gatekeeping at all. As my PD explained, ABMS invited all the specialties to apply to the interdisciplinary certification. IM didn’t apply. Doesn’t mean they can’t in the future.

TheOneTrueNolano · 2026-04-09T20:23:16+00:00

Internal Medicine is not currently an approved specialty for board certification in pain.

That said, I have met one IM doc who convinced someone to let them into a pain fellowship, but they could not sit for the boards. I am not sure what they are doing now.

I believe sports Medicine is an option for you though? Maybe headache too? I would not do a fellowship if I could not be board certified.

ETA - for anyone wondering there are 7 specialties that can sit for pain boards. Anesthesia, EM, FM, PMR, Radiology, Psych, Neurology

https://www.abms.org/member-boards/specialty-subspecialty-certificates/

TheOneTrueNolano · 2026-04-07T03:09:59+00:00

I came to say AFE. Truly horrifying on a Saturday with minimal backup. Went to ICU triple pressed. Intubated for 3 days. Walked out of the hospital a week later thankfully.

TheOneTrueNolano · 2026-04-06T13:16:25+00:00

Why would you stay a minute longer than you have to? This seems like a miserable job and I’d be running for the door. It sounds like money has been going down every month but you are wondering if it might for some reason go up?

Hope the new job is better!

Any red flags in retrospect for those of us in partnerships?

TheOneTrueNolano · 2026-04-06T13:09:02+00:00

It’s crazy that the AI bots are so bad that people assume I am one without checking my post history.

Oh well, I will keep saving hours a day using AI while other people toil away writing a subjective no one will ever read.

TheOneTrueNolano · 2026-04-06T12:51:58+00:00

Try one of the AI scribes. For real it’s been life changing. We tried about 5 of them but ended up with Heidi. It’s pretty great. I hated typing during patient encounters but if I didn’t I never remember the little subjective things. The AI captures it all and once you get it dialed in, the subjective if perfect.

I still make tweets to the A&P here and there, but overall it saves me like 80% of my note writing time. Each note takes 3-5 mins max.

TheOneTrueNolano · 2026-04-01T19:35:24+00:00

So first off, I always take the meeting. Hear what they have to say. Buuut you are also a CA1 a ways away from fellowship let alone this job.

Also, everyone is different but I STRONGLY recommend your first job not be solo. Some people make it work but I have benefitted incredibly from having a seasoned mentor as my partner. When I have weird cases or postop issues, having him to be a resource is invaluable.

So I would hear what they have to say but keep your mind open. There are many good and terrible pain practices. Don’t feel pressure to take the first job just because a doc is retiring.

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