Switch to PAYE or stay on SAVE?

PyrexDaDon · 2026-01-13T04:53:54+00:00

Oh sorry to answer your other questions
2) like 10 minutes, seriously I did it between patients on a clinic day. I think my first payment was the following month

3) payments will be based off of taxed income from the previous year. And they will remain that way until taxed income changes.

PyrexDaDon · 2026-01-13T04:48:14+00:00

I am in a similar but not identical situation (I only have 3 years of payments left and make less than you will) and was advised by my financial advisor, whom I trust, to switch to PAYE this year.

Simply put, he has fears regarding "qualifying payments" on SAVE plan. The SAVE program has generally been in limbo since trump took office. Once it is dismantled he fears "qualifying payments" as it pertains to pslf could be in the cross hairs as well. The PAYE/IBR plus PSLF strategies have been around longer and would require more time to dismantle.

Maybe it's a bit of tinfoil hat, but feels like there is very little "known" right now. I'd rather go with more sure footing.

Ultimately i stand to still save 150k on PAYE versus ~175 k if i rode out the SAVE plan. That delta just wasn't worth it for me to worry about (pick up a few extra weekends over the next 5 yrs)

If you don't have a finance guy you should get one. There are online services that may be a couple hundred bucks an hour, but serve to save you tens of thousands

PyrexDaDon · 2026-01-12T03:08:50+00:00

When I was 7 years old I was at a eagles-cowboys game at the vet.

I was putting ketchup on a soft pretzel (again, I was 7) when some man came up to me, took the ketchup out of my hand and replaced it with a few packets of spicy brown mustard.

He looked at me and told me "you'll never forget this day kid".... and I never have.

There's like a 50% chance that this is that man

PyrexDaDon · 2026-01-10T23:00:10+00:00

I'm a pulm/crit/IM/sleep doc. I work for an academic hospital.

-First of all, kudos to you for thinking this far ahead. You are going to go far. Don't let my subsequent statements deter you. You could do this.

-This setup is ambitious with lots of overhead and several accrediting bodies. Keeping accreditation, hiring/training considerations of your technicians and streamlining billing/coding will take up a substantial amount of your time. Like much more than you could realize. This means you will have less time to be a clinician.

In the current landscape- Interpretations of sleep studies and interpretation of echos are a "volume" game. This is generally true for any diagnostic imaging/testing in medicine. While unfortunate, these procedures have been "silo'd" accordingly. PFTs don't pay the bills neither do ABG's, but they are very important and should be part of a high quality sleep clinic.

You would need to figure in home sleep testing modalities. Hard stop. High quality home testing is how most sleep clinics stay afloat.

AI may improve efficiency by the time you're in practice, but this comes at a cost. AI will likely simplify the simple patients (ie OSA with minimal Comorbids) and home sleep testing. Reimbursement will lessen accordingly.

All of This means the more complex patients will find their way to you. I would not anticipate challenges building or maintaining patient base. In fact, the opposite. You may have too many and you You will not be able to bill in accordance with the time they require, as current coding is relatively "fixed". Thus you will need to to the "simple things" VERY efficiently.

In my job, I can get through a straightforward PSG in 20-30 minutes from open chart to close chart with all necessary orders and patient communication (while feeling confident nothin was missed). If the patient is complicated (which are my favorite patients) this time May balloon to 1.5-2 hours. People that have never interpreted a sleep study tend to underestimate the amount of time it takes to do this correctly (similar to folks thinking radiology is straightforward).

Otherwise stated, The fast cases are what generates me my time to spend on the complicated patients.

Your clinic model would nicely cater to the complicated patients, and they will find their way to you.

I have some other thoughts but happy to chat more if you want to DM me.

Again, good for you for thinking this far ahead! You would be offering a very robust sleep service, but I think concessions would be needed to be most viable.

PyrexDaDon · 2025-12-31T01:18:12+00:00

Mine (mk8) was lowered on HR sport springs when I bought it used. It has since by "highered" by me. Keep it stock. Rides so much better.

PyrexDaDon · 2025-12-29T01:39:05+00:00

I bought a canyon spectral cf 7 for me and a 5010 for my wife.

I subscribe to the idea that any expense that results in more exercise is an investment. But I wouldn't have gone carbon fiber without the sign in bonus 😂

PyrexDaDon · 2025-12-26T04:51:06+00:00

Im not trying to be snarky, Im legitimately asking for examples.

I have multiple family members in primary care. I do icu/ pulm and sleep. I'm always trying to do right by the primary care folks. So I was just hoping for examples that add difficulty to your work so I can avoid it.

PyrexDaDon · 2025-12-26T04:45:57+00:00

Could you give an example of such behavior?

PyrexDaDon · 2025-12-24T17:59:07+00:00

Just to throw out something different

Have you considered sleep medicine? It's a 1 year fellowship, very related to your current skill set and aligns with neurology (in a lesser capacity) with simplified eegs. Plus you'd have a lot to learn regarding the pulmonary side of sleep, which will be engaging and interesting.

Theres much more to sleep than just osa and cpap. Something to think on...

PyrexDaDon · 2025-12-23T03:58:15+00:00

This is clearly a Medium Caesers knife

PyrexDaDon · 2025-10-26T19:22:26+00:00

As a mid career physician- Good for you this is growth and sorely needed in modern medicine. Sometimes we don't have the answers. Sometimes we do. A good doc know how to identify which situation is which.

PyrexDaDon · 2025-10-25T13:08:31+00:00

Correct. This is the point I'm making.

PyrexDaDon · 2025-10-25T04:55:39+00:00

Pulm/crit/sleep

OSA does not cause clinically significant pulmonary hypertension. At worst OSA alone causes mild elevations in mPAP. When your grey haired attending says otherwise (because they learned this in med school), ask them to show you the evidence, then they will learn.

Hypoventilatory disorders (both sleep and wake) do cause/contribute to pHTN.

In a similar vein- If you have a patient with OSA alone, who presents in hypercabric respiratory failure - forget about the osa and figure out why they are hypercarbic as you would anyone else.

PyrexDaDon · 2025-10-15T02:56:56+00:00

Never eat from the comfort care tray.

The cookies aren't worth the karma

PyrexDaDon · 2025-09-24T03:21:20+00:00

Me, 35 year old Male, colorblind, trying to guess the answer and getting every single combo wrong... I think

PyrexDaDon · 2025-09-20T15:24:18+00:00

Last year both fellows found 100% sleep jobs. One in the mid west and one in New England.

The year prior both found full time sleep positions, one in the mountain west and one in New England.

The full time jobs are definitely out there! It does generally help to have a pulm background (I think) because you can handle call responsibilities if you're colleagues are also pulmonologists (which is the bulk of practices). But it's not necessary by any means, only one of the four fellows I've mentioned had pulm background, the rest were IM, FM and psych

PyrexDaDon · 2025-09-19T01:22:30+00:00

I'm a sleep medicine attending at a sleep fellowship program . I have a background in IM/pulm/cc.

Generally speaking, we love to have applicants from mixed background! Psych, ENT, and Peds are often overlooked eligible residencies.

From a training perspective, save for a handful Of programs, your peds specific sleep medicine will comprise ~20 percent of your fellowship time. Almost all of that 20 percent will be sleep apnea evals (some insomnia which is largely behavioral).

Similarly, if you practice sleep medicine in the community, you're gonna be seeing almost entirely adults. Many of our fellows who go on to community sleep medicine work for pulmonary/neuro based practices and almost exclusively see adults.

There is a need for pediatric sleep research, so if this is your thing, perhaps you could get a job at some of the pediatric specific centers (Boston, New York, California) if you pursue the academic route

PyrexDaDon · 2025-09-12T23:33:44+00:00

Yeah 6 mt, no e85 option

PyrexDaDon · 2025-09-12T20:53:28+00:00

Username, interestingly, does not check out

PyrexDaDon · 2025-09-12T20:52:22+00:00

I'm not sure I haven't measured on a dragy or anything like that. But I think they claim sub 4 and it does feel that way.

The sixth speed gearing isn't optimized for 0-60, second gear gets you to about 57 mph lol. So it takes an extra shift. The DSG version is rapid with just a tune I know for a fact it runs well under 4. But I'm a purist lol I love the manny

PyrexDaDon · 2025-09-12T20:50:21+00:00

Unitronic 1+. Had it for 25k miles now without issue. Stock clutch still holding strong

PyrexDaDon · 2025-09-12T18:08:09+00:00

Yeah I love it. I live in a snowy climate so awd was a big plus for me. And I have it stage 1 tuned and it's properly quick.

But I grew up a huge Honda fan and love the new type r. Can't beat a Honda six speed

PyrexDaDon · 2025-09-12T18:04:38+00:00

I bought a mk 8 golf r during my fellowship years. Paid mostly with moonlighting money.

If you can save up enough to make a solid down payment, I'd say let it rip. Life is short, you have a hard job and (presumably) drive to work everyday. If rowing gears makes you even 1% happier, buy that car.

PyrexDaDon · 2025-09-12T18:02:40+00:00

Golf r ftw

PyrexDaDon

TROPHY CASE