Transcription from Google Speech Recognition. Please excuse any errors as this has not been proofread.
Episode 32. Jason Mizell,MD Transcript
Tarang P 0:02
Hello and welcome to the doctor Money Matters podcast,
The show where we discuss important financial topics that we’ve never covered in med school. I’m your host Dr. Tarang Patel.
Welcome back to another episode of the Doctor Money Matters podcast.
I want to thank you all for continuing to listen to the podcast and continuing to make our numbers growth. And I also want to thank the many of you have recently joined the doctor Money Matters Facebook group, the group has grown by nearly 50% in the last month and the discussions have been spirited. Please continue to add your physician and medical professional colleagues so they can join in the conversation as well.
Some of our most recent popular topics have been determining your retirement number and also Dr. Meru, an orthodontist in Utah, who was recently profiled in the Wall Street Journal about having a million dollars in student loans.
In this episode, I interview Dr. Jason Mizell, a colorectal surgeon at the University of Arkansas Medical Center, he started to teach a class to residents and then fourth year medical students about finances. As I mentioned in the intro to this show, most of us were never taught these topics in medical training and it leaves us left us to figure it out for ourselves often a great expense in terms of fees and financial mistakes. Dr. Mizell, like many of us, felt lost and dealing with these topics. When he first came out of training. We’re going to talk about his experience during the show, but he realized that he he was not alone and decided to do something to help his colleagues and students.
This class has become very popular and hopefully it spreads to other schools. Perhaps we should have some of these topics addressed even before medical schools to avoid Dr. Meru type situation.
Okay, let’s get started with my interview with Dr. Jason Mizell. Okay, welcome back to another episode of the Doctor Money Matters podcast. My guest today is Dr. Jason Mizell, a surgeon and director and creator of the business of medicine course at the University of Arkansas medical school, Dr. Mizell, Welcome to the show.
Jason Mizell 2:17
Thank you very much for having me. I really appreciate it.
Tarang P 2:19
So this This podcast is about finance. And there’s a lot of blogs and other physician
financial podcasts and media out there now, but you created this course back I think earlier than most people were thinking about it. I think maybe the white coat investor was the only other person at the time who was blogging about physicians and finance at the time. So tell me a little bit about the course that you’ve developed and the the origins of the business of medicine course.
Jason Mizell 2:53
Okay, so I started here as a new faculty in 2010, I did general surgery and then did a colorectal fellowship. And then came got recruited to come here as colorectal staff. And when I started my belief is my second day here. Our billing and coding department brought me my CPT books and my ICD nine books and drop them off and said, Okay, here’s your here’s your books for CPT and for ICD nine. And I kind of laughed and said, we’re, what are these books. And so they laughed and said, that’s, that’s funny. That’s a good joke. And I was like, Well, I’m not really joking. I really don’t know what these books are for.
And so that was the, the look of horror and, and disdain on their face, for my lack of knowledge was pretty eye opening. And so what I realized is that I I knew a lot about are often you know, for, like a new fair amount about colon rectal surgery, but I didn’t know anything about everything after my training stopped as far as the billing and revenue side of it. So I really felt this desire then at that point, because I was at a teaching hospital that I did not well, my residents graduating with the same knowledge deficit that I had coming out of my residency and fellowship. So I talked to my Chairman, and we were just so happening to in the stage of where we were changing up our grand rounds, and dropping one of our monthly lectures. And so I came to him with the idea and said, I’d really like to start teaching our residents about some business aspects of medicine and finance. And so he was Welcome to give me an hour, once a month in our grand rounds. And so we actually had to faculty members here that were very savvy and business ones, a was actually a surgical oncologist who has his own business, he’s a CFP, as well. And so he would give some of the lectures on some of the investing side of it. And then we had a guy who was very prominent in the American College of Surgeons who knows a lot about the healthcare on a national platform and national level. And so I brought them in, and some other faculty and people that I knew could teach about business. And so we just created this curriculum and would give lectures during Grand Rounds that were mostly focused on business. And then once a month, we would give a lecture on personal finance that was more elective that way of residents wanted to come, they could, they could bring their spouse if they wanted, but I felt like they’re required time, which Grand Rounds that I would make that something very business specific, there’ll be more of their practice. And then if they wanted to learn the personal aspect of it, then they would come in the evenings. So we did that for for a couple years. So that’s kind of how it got started.
Okay. And so how, how was the response.
So it was quite good. It was, it was very eye opening for them, because they had never had a faculty member that really had that interest in their education, you know, that nobody ever really shown any, any sort of drive to help make sure they knew how to deal with money. So as a little, they thought it was a little funny, I think, at first and then we had a lot of faculty that were very disinterested, you know, they would leave whenever the talks would start. But then as they realized what we were talking on slowly the crowd became a mixture of residents and then our faculty because is most of us know we don’t know anything about it either. So what what started out as resin education became Reza and faculty education, right. And I think that that’s a good point that you bring up because
Tarang P 6:27
it is a it’s not an uncommon situation that you faced, you know what, like you said, when you first got out, and you didn’t know any of this stuff, because as far as, as, I mean, my own personal training, and I would think most physicians, you know, no matter what specialty they’re in, there’s just they don’t get that there’s not enough time. I mean, some of some of them might pick it up a little bit if they’re doing some private practice type rotations or things like that. But it’s there’s very little formal training that I’m aware of, in most specialty. So I think, you know, it’s a it’s definitely a good thing that you brought up and it’s but it but it’s definitely a deficit. And like you said, a lot of your colleagues probably, you know, we’re feeling the same way when when they started, but, but it’s something that traditionally has been kind of, I don’t know, it’s, it’s not something we talked about, you know, in medicine. I mean, we’re supposed to be the the healers, and we’re well paid healers better, but we somehow don’t talk about money. So, you know, what was the response from your other colleagues? I mean, you mentioned a little bit, they initially stayed away, but how did you kind of get them to come around to it?
Jason Mizell 7:41
Yeah, so, so that’s a good question. I still get sort of this, this quizzical, confused look, whenever I mentioned to people that I’m about to go give a talk on business finance, or what have you. I mean, a still, it’s just so foreign, as you mentioned, I mean, nobody, nobody does it. And it’s this kind of taboo topic that nobody likes to talk about, even even the medicine side of it, you know, like the billing and coding and our lack of knowledge, they’re much less everybody’s personal finance, and how they’re doing with managing their own personal money. You know, so it’s, it’s just this funny topic where everybody knows it’s a huge need, but nobody wants to address it. And if you if you try, you get pushed back a little bit, I think people assume that every physician doesn’t know it. And so then when you try to begin to, to make your yourself a little bit more known for they, they doubt you, I think a little bit because they assume that there’s no way that any doctor can only think about money. So so I think I’m, I’m hopefully pass that a little bit around here. But But still, it’s it’s very common, and the other faculty members, like when I gave Grand rounds yesterday, we had a few that stayed and asked very good questions. But, but still, some feel like they’ve got it under control for whatever reason, and sort of move on, but but it’s, it’s fun, the faculty that really show an interest in it, you can get some really, really fun spirited conversations and throw some ideas. And so it gets to be very interesting. And I really like it for the residents. Because they see that it’s not just my thing, when faculty stick around for the talks. And they see that it really is something that’s important, I think, that add some weight to the, you know, the topic as a whole, and they really realized there really is something that really does matter, right.
Tarang Patel 9:32
And I mean, they and for the residents and the medical students, I mean, you know, we get so much thrown at them during training about the, you know, the academic side of surgery, or whatever field they’re in, it’s probably a nice thing in a way to actually turn on a little bit different portion of their brain too, because it’s, it’s, it’s, it’s also vitally important to learn these topics. But it is a little bit different than then obviously, the meaning stuff that they that they’re getting all day.
So right. So So you said, You started this course when you when you first arrived at Arkansas, so how, how is the chorus kind of evolved over over the years that you’ve been doing it.
Jaon Mizell 10:16
So we started off in the surgery department, and it really end up being a pilot, I did not have the intention of branching out and doing a more broad application of it. I what I noticed was that whenever I was teaching this, I can, I can very distinctly remember being in the line, one of the coffee shops here on campus and talking to one of our chief residents and asking her about the course. And she just opened up to me right there in the in the coffee line, and mentioned about how it’s been helpful for her because she was carrying about $40,000 in credit card debt. Just remember that striking the so strongly that, you know, these are these are residents that every day I’m taking an operating room and trying to teach them how to do laparoscopic surgery and cut out cancer and do all these complex things. And in the back of their mind, they’re thinking, am I gonna be able to, you know, pay my credit card bill this month?
Or am I going to be able to, you know, get my my loans paid this month, or, you know, should I really go buy this BMW or not, or whatever. And so, it was things like that, I was like, wow, these, this is a problem that should have been behaviorally addressed before they even started making resident money. Because, because these are, these are some fundamental issues here. So, so what I did is, I decided, rather than making the course surgeries specific and only reaching, you know, 30 or 40 residents and students that I would broaden it and expand it to be available to the whole fourth year medical school class, because I really need they were right on the cusp of a transition into where they would go from, you know, paying to work to actually getting paid or so. So I decided that doing a course in the spring of their fourth year, really, whenever they were pretty much past the interview season, and their minds had shifted away from match and all that to where they could really just settle in and learn stuff that was kind of fun, you know, at that point, and stuff that they really knew was going to really matter, right. So I usually start the course now in about mid January. And it runs through mid April. And rather than the talks being surgery specific, they’re, they’re much broader now. And so it’s a 20 hour course, 20 hours of content spread out over 10 weeks. And with some gaps in there, cuz I don’t make them come to match. We can do some other holidays and things. But, but we do it every Monday night for two hours. So their clinical duties are done. Most students come in their workout clothes, or, you know, scrubs, or whatever, and just sit and they’ll eat food and bring their spouse. Some of them, someone will bring their kids if they can’t find babysitters, or whatever. And we cover your various different topics. this past Monday night was about life and disability insurance and estate planning. And so there’s 20 hours that that we do over the course of the spring. And I really enjoy it. Because whenever I am able to teach a topic such as retirement, I’m able to say look, in two months, whenever you go to your new hospital, somebody’s going to bring a piece of paper in front of you that says pick out your retirement mutual funds and what you want to invest it in and give it back to me tomorrow. And so I’m like, this really does matter you’re about to have to make these decisions in two months. So you need to know this now, you know, because it so it it does, you know, they have a little more skin in the game, I guess, you know, because they know it’s really about to happen rather than teaching a lot of stuff whenever their first years when it doesn’t matter as much. You know,
Tarang P 14:02
you talked about curriculum a little bit, but kind of go into it a little bit more what what what are some of the what are what are what are what are your most popular topics that you’re teaching about?
Jason Mizell 14:06
the curriculum changes a little bit each year. But what I tried to do make sure that the the topics are all relevant to the students that I want to make sure that it’s one of those things where I don’t teach what I think is important. But I teach what I know is important. But then also that they are very interested in so. So what I mean by that is I i survey all of the students at the very beginning of the course each year, and I asked him really two questions on the proposed topics. So I say, all right, how interested Are you in topic x. And then I asked him, What is your knowledge level, self assessed knowledge level. And then at the end of the course, I asked the same questions. And what I have found is the topics that they’re always the most interested in his contract negotiation, because they know, they know, that’s what’s going to help get them paid. But their their knowledge pretty much every year is always the lowest in that topic.
They’re always very interested in retirement planning and investing. They know very little about it, but are very interested. And then after that, some other ones that are interesting to them, or malpractice, things that they are less interested in are things like
Medicare and Medicaid, we did that last year, they didn’t, they didn’t have any interest in that at all, which is kind of fun. You know, because I’m like, that’s how you get paid. So, so very low interest in that they have not very much interest in estate planning, you know, and doing wills and stuff and preparing for their family.
They, they like billing and coding, oddly enough, I think it’s just because this non descriptive thing that they know, they need to know. But they know zero of that but are you are the most boring topics, billing and coding, and they didn’t even have an interest in it. So that’s, that’s encouraging. But, but that’s some of the main topics. We also talk about home buying versus renting, I’ll talk to him about physician recruitment, you know, like, I’ll have a recruiter come and talk to him and say, This is what we already know about you, this is what you should know about yourself. And this is why we’re scouting you out and how we’re gonna try to make money off of you and things like that. And the topic that I think is the most engaging to them. And the one that really gives them the most aha moment is the one about budgeting and the personal personal finance side of it, when one funny thing that we do with that each year is that we divide the class up into four parts, basically. And we, you know, there, we usually have 160 students, each class, about 120 of them sign up for the course as an elective. And so we we divide them up. So it’s about roughly 20 to 30 each group, and we give one the hidden task of car buying one house buying one lifestyle, and one usually kids college and school and we tell them, which car do you want to buy, you know, the, the Nissan the, you know, mid level Toad, or the Lexus or BMW, whatever in the house, do you want the 200,000 to 500,000 or a million dollar, whatever, we sort of give them examples.
And every year so far, when the four groups come back together, and they add up what they want to spend on lifestyle, it’s always always exceeds the theoretical budget, we’ve given them of 300 grand a year. So it’s this, it’s this sort of aha moment for them where they realize, so you’re telling me, I can’t have everything I want. Whenever I become a doctor. It’s like, No, you cannot. But that’s always this, this
lecture that I don’t think they anticipate leaving with that sort of a grasp of reality. But I always like to watch this scenario play out, and the look of sadness on their face when they realize that I can’t have you know, the high end car in the high end house and the high on lifestyle and send my kids to private school. No, sorry, you can’t, you can’t.
So that’s sort of the general overview of it.
Tarang P 18:13
Okay. And, and how, over the years now, you’ve been doing this for for a while, has has the level of like, pre existing knowledge improved at all amongst the fourth year medical students? Or is it still, you know, not as not, not to where you would like it to be?
Jason Mizell 18:33
It’s still quite low. We, one of the questions I asked them is, how many of them have ever taken a finance class ever high school, college, whatever. And usually, about 20% of them have taken at least just a single finance course. So 80% have never taken finance at all. But so they come in very deficient and that’s been consistent over each year. But what I am noticing is that the, the question that I’m getting during the lectures do seem to be a little bit more solid. And you can tell their understanding is a little better. When we first started when the home buying versus renting guys are talking. One of the first questions was, what is a mortgage? Like, they didn’t, they didn’t know the word mortgage. But I don’t get quite as many, quite as many questions about that as much anymore. But, but we still do get some very basic questions. And honestly, I love those questions. Because I just helps reinforce to me how necessary the course is. Absolutely, you know,
Tarang P 19:33
it’s it, despite what’s, you know, for, for yourself, and, and people like myself, who do the podcasts and things like that. But it seems like there’s a lot of people talking about this now. Now, granted, we all have an interest in this, but you’re absolutely right. It, it’s, you know, it’s probably we talk amongst each other. And there’s a huge segment of the not just the medical student and resident population, but the practicing physician population, that’s that’s still woefully deficient in in some of these these areas. And, you know, we’re just, we’re just getting a fraction of them. But anything anything is better than, than, than none. So I totally agree.
Jason Mizell 20:15
Yeah, yeah. And what I’ve, what I’ve noticed is that as more and more blogs rollout and things like that they’re available it is, is getting a little bit to the point, when you do have a student that’s generally interested it, it’s begin to be a little bit where it’s like, wow, where do I go, there are quite a few resources now. So. So I feel like part of my job to is to filter through some of that and give them the stuff that’s is very high yield for them and say,
Look, if you if you’re going to read two books, or if you’re going to read, you know, five blog posts, here’s what you need to read, because I know that they’re tired, they’re at the end of their fourth year of medical school. Absolutely. So I, I don’t want to have a lot of homework for them or anything, but I just want to point them to the stuff like nothing else read this, this and this, and this will get you going. Right, right. So see you started, you know, you started the course of a few years back now,
Tarang P 21:08
have you seen this this type of curriculum, you know, has, has it been developed at any other school? Or have anyone contacted you about kind of doing the same thing, or teaching them how to do this at their medical school?
Jason Mizell 21:23
Yeah, so, so I get probably an email maybe maybe once a month or so from somebody that seen the paper that we published, and the on the initial part of the course. And then my piece that I wrote for the white coat investor, people kind of find me in different ways. And I’ve spoken at a couple, you know, regional meetings, and then, you know, my name would be on the program, so people will find it my Twitter page and things. But so people will email me and say, What did you do? Can you send me the schedule, can you give me an idea of what worked What didn’t, you know, store troubleshoot but process of right now of writing up our results of the four years of the curriculum, and we’re going to try to write that and get that submitted as a research paper. And so I’ve done a pretty extensive lit review, getting ready to write the paper. And there are some programs that will do bits and pieces of our course, you know, they’ll do either just the business aspect of it, or just the personal finance aspect of it, or they’ll cover both topics, but just have like, maybe one one full day, like a weekend retreat, or something like that. But, but nothing really, to the extent of this course to the the depth and the comprehensiveness of it, doing business and finance because it, it ends up being about about 60%, personal finance, about 40% business. And so the, the content is, is pretty comprehensive, and it’s spread out so that they can kind of chew on it, and process it and think through it, and then come back with questions so that they can really be able to really digest it, no, know what they’re dealing with, and what they’re learning.
Tarang P 23:02
Right. And, you know, I was looking at an article from from University of Arkansas, his own you, you ain’t, you know, I don’t know, it’s just a flyer, or a weekly, monthly journal that they put out, but they they mentioned your course specifically. And, you know, it says it’s, the word is spreading amongst the students. And approximately Well, it says up in spring of 2017, 100% of the students rated the course as helpful. And 90% said, the course should be mandatory in medical school. So obviously, it’s something that is necessary and, and wanted by the students. So I One can only hope that, you know, this type of curriculum does make its way to the other medical schools, dental schools, any of these graduate programs, because we are that we get so much stuff that we have to teach, and I, you know, but, but some of the most precious tactical things seem to slip by the cracks. And I’m glad that people like yourself, or are kind of remedying that. Let me ask you this. So you’ve you’ve been doing this for a while. And like you said, when you first got out, you, you you didn’t know anything about the professional side of it, that ICD nine codes and stuff how has this course as it has it had any impact on your own personal finance?
Jason Mizell 24:25
Yeah, so you got this is like our fourth iteration of the course I’ve heard the talk on taxes for different times now, and estate planning for different times, and, you know, the budgeting and cash flow. And every time I sit through these topics, and a lot of our speakers are the same, because we have a pretty solid lineup now that we’ve gotten, I learned stuff every time and always tinker with mo and finances and, and whether it’s a talk on malpractice, just how to protect yourself and or whatever it is, you know, it’s, it’s been very helpful for me. And now as I have going around to some of our residency programs. As I give talks on this, I’m constantly learning because I want to be prepared for questions that may come from the audience and the students. They’re smart people, you know, these are some very smart medical students and they catch on quickly, and they have some in depth questions. And I often feel like who, I’m I’m glad you asked that to the the tax guy and not me, cuz I’m not sure I could answer that question. So I really like having the experts be able to give the lectures and then I can get all this education essentially for free while I sit there. And so I do, I learned stuff all the time, and tinker with my own finances, and, you know, try to make sure that I’m on the right trajectory for good out, you know, successful financial outcomes, too.
Tarang P 25:44 So, and that’s a, you know, honestly, that was one of my goals with with this podcast is similar to be able to speak to people and, and, you know, just kind of get the right information from the experts. So, you know, I think you as kind of the person who kind of filters out some of this information, and then guides the students, in a way is invaluable. Let me ask you this. One more question about the course if you could, you know, so, at the University of Arkansas, the students are lucky to have this course. But if you’re a medical student, let’s say, you know, across the country, and you’re interested in this topic, what would the one takeaway one point that you would like to make to, you know, fourth year medical students? If there’s one idea that you could put in their head?
What would that be about? Finance?
Jason Mizell 26:28
Yeah, that’s a, that’s a great question. You know, I, I feel like, despite really not having any knowledge at all coming out, I felt like while I was a resident, there was so little time to try to self educate. Like, I, I know that I was with my attendings for a limited time, so I needed to learn as much surgery as I possibly could in that amount of time. And that was, honestly that was all I had time for, right. And I knew that whenever I graduated fellowship, that was it, there wasn’t anybody over my shoulder anymore. And fortunately, like you guys and byte code, and like, all these different people have done such a good job of making resources available, you don’t really need to have a mentor, per se, to educate and some of the finance stuff and to have a basic plan. And so I would say there is a little bit more more hype about the finance which I think is amazing and very good. But I want to make sure that while they are in training to be physicians to devote themselves to being amazing it that gleam gleam, what you can offer your mentors. And if you are super bored with your studying under product syndrome, or whatever it is that here you study, and you want to pick up something that I would say pick up the white good investor book on your leisure time, your vacation, or something like that. And, and just you’ll get your basics in order. But don’t feel too pressure to be able to know how the, you know, the finer points of active versus passive investing or all that are because that that can come. But it’s some basic behavioral principles that you’d want to do, you know, contributing to retirement and not, you know, overextending yourself that you can get, I think, by some fairly straightforward simple reading from from you guys podcast, or from like, White Coat investor books, or whatever. And as long as you’ve got that, then you’re, you’re good, don’t don’t do things. Learn what you need to be learning and then you get out, then you can really fine tune in and know some of the deeper points
Tarang P 28:22
Absolutely, I think that’s, that’s it, I think one of the key things is that you, you made it through medical school, or you’re, you’re going through residency, that is the primary reason you’re there and doing a good job at what you’re training for. That’s the best financial decision you’re ever going to make. So make sure like you said, you do great at that. But the other thing that I would add to that is that the rest of this stuff is really not that complicated. As long as you’re doing some simple things. Yes, you get very esoteric into some of the terminology and things but even if you understand those points, it’s it’s only going to be marginally, you know, you might be marginally better. But, but the key thing is, like you said, being the best physician you can be, and, and just not making any heinous financial mistakes. And, and those are the big ones that you can learn about within a very short time. So totally agree. Yeah, absolutely. I think that’s good. Well, I wanna thank you, Dr. myself for for appearing on this podcast. Is there is there any resource obviously, we mentioned, like code investor, but any resources that you might recommend to our listeners about finding out more about your, your own, you know, your curriculum, your course, or just resources that you would recommend?
Jason Mizell 29:41
so I from from my course, I always on Twitter, anytime I try to mention something finance wise, whether it’s our speakers, or when I go to other conferences, always hashtag it with business of medicine. And there’s not many people use that hashtag. So you should be able to find interesting little little points and articles that I’ll try to pluck out and retweet so that’s easy to follow. And then the as far as books, yeah, there’s, I get that question quite a bit. As far as, you know, do you have a syllabus or whatever, I don’t really, I’m actually in the process of trying to accumulate a decent list of articles for different topics. But I think one book but obviously the white coat investor book helped me quite a bit. And but one book of recent that really helped me a lot was how to think about money, the Jonathan Clements book. And that was interesting, because I, as you mentioned earlier, you know, we’re, we are taught to be healers. And that’s what that’s what we’re here for. And we put a lot of hours into making sure we do a good job of that. I think sometimes we can get so lost in our purpose of what we’re supposed to do, we almost forget what we like. And that that book was very interesting for me, because this was sort of things like if you had all the money that you you needed or wanted, what would you do with it? And, and I had almost forgotten what that was like, for me, you know, because you become such a server. And so I think keeping that mindset of of, as much as we don’t like to talk about money, it is very real in our profession, and to not lose yourself so much in the profession. You forget what you really do enjoy and why you’re working this hard. Oh, absolutely. Yeah, I think that book is a is a good refocus or of of, you know, if because it does no good to earn a bunch of money but then not really realize how you can use it, you know, further your, your plans and purposes and happiness and so that that book was particularly helpful for me So, oh, good, good. I’ll have to I haven’t read that one off to check that out. It’s good. Yeah. Alright, as far as the the actual courses itself I what I’m hoping is that once we get this last course completed next week, then I’ll actually write it up and then I’ll try to put it out there as far as once the paper gets written just to find out some more details and some of the ways we researched it and I’ll include our surveys and stuff so that people want to try to roll this out of the their own place how they can get started with you know surveys and things to try to make an academic because that’s that’s been a huge benefit to me is in my academic setting it has allowed me to proceed up through the assistant Associate Professor ranks and things and that’s all you know important academics so it’s been it’s been helpful from that standpoint as well.
Tarang P 32:21
I want to thank Dr. Jason Mizell for coming on this show and for starting this conversation and this course for for the medical students at the University of Arkansas it’s great to see someone taking initiative to help educate our younger colleagues doing it in the structured way that he does really brings value to these students maybe some of you are already helping out your students or residents by bringing the these topics up informally if you do please let me know how you’re doing so by you can tweet me or email to me at email@example.com
Sometimes when you start learning about these financial topics the basics such as interest, inflation, compounding seem pretty simple but an article I read recently talked about how the majority of people around the world and they surveyed people in many countries developed and undeveloped and most people could not get even two of these questions right to it to two out of three questions correct. If you don’t understand these fundamental concepts are going to have a hard time getting ahead financially.
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