Money Minutes for Doctors #12 - The 529 Plan

Welcome to spring in New England…typically a time when many high school seniors, and their parents, will be well on their way to planning the final summer before heading off to college and the next (challenging) chapter of parenting. Part of the challenge is developing a “plan” to approach the financing of what will prove to be some of the most memorable and definitive years of their children’s lives. One option that has received a tremendous amount of attention in recent years is the “529 Plan”. Simply stated, a 529 Plan is a state-sponsored investment plan that enables people to save money for a beneficiary to use toward higher educational expenses. Of course, the nuances of the 529 go much deeper…and to help us navigate those waters, it is our pleasure to welcome back Ms. Katherine Vessenes, JD, CFP®, RFC, Founder and President of MD Financial Advisors.

Katherine blog pic.jpeg

About Ms. Vessenes:

Ms. Vessenes works with over 300 physicians and dentists from Hawaii to Cape Cod. Her firm uses a team of experts to provide comprehensive financial planning to help doctors build their wealth and protect their wealth while reducing taxes now and in the future. Katherine is a longtime advocate for ethics in the financial services industry; and has written three books on the subject of investment strategies. She has received many honors and awards including: numerous tributes from Medical Economics as a top advisor for doctors, multiple 5-Star Advisor Awards, honored as a Top Woman in Finance, in addition to being selected to be on the CFP® Board of Ethics. Katherine can be reached at: Katherine@mdfinancialadvisors.com or 952-388-6317. Her website: www.mdfinancialadvisors.com.

Quick Summary:

What is a 529 Plan?

  • A designated plan, each state has one, that allows anyone (parents, grandparents etc) to contribute after tax money to save for college and then the money can be pulled out tax free in the future

  • Allows you to avoid capital gains tax on the earnings as long as used on an approved college/university

  • Does cover vocational schools, a few international schools are also included

  • Various plans offer more or less benefit and fees are variable

  • If total value of fund not used on child #1 then can be passed on to subsequent children and even to grandchildren

  • Can use any state plan, do not need to live in that state, and can be spent at any college, not limited by the fund location

  • Tax savings best if you are in a high earning speciality (i.e orthopedic surgery/plastic surgery) AND started saving when child young (just a few months of age)

Downsides:

  • If student applying for financial aid all of the 529 goes to the college, compared to a brokerage account where calculations differ and only portion of account goes to college

  • Investment options within the plan vary significantly from state to state 

  • Various states have different funds and costs so need to be savvy and choose best plan

  • Significant tax penaities if money taken out and not used for college expenses, a non-liquid investment strategy

  • 529 funds likely to get less robust returns than brokerage accounts.

Saving for college can be a collective approach with combination of accounts… 

How much to contribute?

  • Perform a College funding analysis.  

  • Goal to save for 50% of college.  Very few doctors can afford private primary and secondary school along w college and still be able to retire.  Plan for 50% and the reminder comes from cash flow, loans, etc. 

  •  Determination of the amount is based on local state universities (or if parents have specific educational goals) as inflation of college tuition is over 7.5% per year, much more than average inflation rate. 

  • Think of college as an investment, a great education that can be used to support themselves and then ask “Is it worth that?”


Ultrasound Case of the Month

Video by Victoria Fox; Text by Nichole Michaeli

The Case

51 year old male who presents post-op day 4 after an abdominal surgery with vomiting and abdominal pain and distention. Patient does not endorse fevers or chills, and denies bowel movements or flatus in past day.

Vital signs: BP 144/81 HR 83 Temp 98.2 RR 16 O2 95%

Pertinent physical exam findings:

Alert and oriented x3. Comfortable, no pallor.

Abdomen is distended, tympanic, tender to palpation. Surgical wounds in the LLQ and superior to the umbilicus are intact. Wound to the R abdomen is open with clear drainage.

Catheter in place with clear urine.

A bedside abdominal ultrasound is performed.


What is the diagnosis?

Small bowel obstruction

In the United States, post-operative adhesions from prior abdominal surgery are the most common risk factor for mechanical bowel obstruction. One systematic review found a 9% incidence of small bowel obstruction by any cause after abdominal surgery. Other risk factors include pelvic surgery, abdominal wall or groin hernia, intestinal inflammation, history of neoplasm, prior irradiation and history of foreign body ingestion.

Small bowel obstruction leads to bowel dilation proximal to the obstruction. As dilation increases, there is a decrease in perfusion with can cause bowel edema, necrosis or even perforation.

Small bowel obstruction will often present with nausea, vomiting, intermittent cramping abdominal pain, and an inability to pass flatus or stool. Initial diagnosis can be made by abdominal ultrasound, but it is less useful for determine the location or cause of the obstruction. Abdominal CT can aid with identifying the specific site and severity of the obstruction, the cause, and potential complications.

Ultrasound Findings

Using a curvilinear transducer, scan the patient’s abdomen with the marker towards the patient’s right. Move your probe up and down interrogating all 4 quadrants of the abdomen. SBO can be identified by looking for the following signs:

  • “Keyboard Sign”: Identify the pilcae circulares, which span the entire width of the bowel wall. These will appear like black and white piano keys- the keyboard sign  

  • Dilated Fluid Filled Loops: Measure the width of the bowel. Dilation >2.5cm is suggestive of obstruction  

  • To-and-Fro: In the fluid filled bowel, you may be able to see the liquid moving backwards and forwards again and again as the bowel peristalsis, but there is a distal obstruction. 

  • Tanga Sign: Look for free fluid outside the bowel wall


Case Conclusion

The patient had a CT abdomen/pelvis which showed high-grade small bowel obstruction with transition in the distal ileum. A nasogastric tube was placed and the patient was admitted to surgery for management of the small bowel obstruction.   

Image 1: Keyboard Sign

Image 1: Keyboard Sign

Dilated Bowel Loops >2.5cm

Dilated Bowel Loops >2.5cm

Tanga Sign

Tanga Sign

Another example of small bowel obstruction

Faculty Reviewer: Dr. Kristin Dwyer

References

  1. Bordeianou L, Dante D. UpToDate: Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in adults.

  2. ten Broek RP, Issa Y, van Santbrink EJ, et al. Burden of adhesions in abdominal and pelvic surgery: systematic review and met-analysis. BMJ. 2013 Oct; 347:f5588.

  3. Frasure SE, Hildreth AF, Seethala R, Kimberly HH. Accuracy of abdominal ultrasound for the diagnosis of small bowel obstruction in the emergency department. World J Emerg Med. 2018;9(4):267-271.

  4. Unlüer EE, Yavaşi O, Eroğlu O, et al. Ultrasonography by emergency medicine and radiology residents for the diagnosis of small bowel obstruction. Eur J Emerg Med. 2010 Oct;17(5):260-4.

Brown EM Whit-ticisms: Ultra-Secure IV

Picture this: You just gained access on your critical patient who is a particularly hard stick. The patient is diaphoretic and constantly moving around. How can you ensure that your IV access, that you worked so hard for, doesn’t just fall out? Watch our latest Whit-ticism video by faculty member Dr. Whit Fisher to learn how you can safely secure an IV.