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Happy doctor basics: how to care without caring too much

Posted on July 14, 2018January 30, 2021 by SmartMoneyMD

Empathy. If you don’t already have it while in medical school, it will get beaten into you through practice-based learning, role-playing, and in the brutalities of the inpatient ward. I’d expect that every single doctor has had to deliver unwanted news to her patients, and it is never an activity that one volunteers for without hesitation. That’s okay, because we should care as doctors. We heal, but we also face the frailties of life. Each uncomfortable encounter we face fortifies our will so that we can prepare better for the next stressor. In some instances, unfortunately, the doctor breaks down too. We are, after all, humans.

If you add in the privilege of working in the exceedingly imperfect healthcare complex, our mental fortitude becomes tested even further. Meaningful use. Pay cuts. Extra hours. Extra clicks. I’m all for regulation and oversight, but it’s clear that something is awry when healthcare premiums rise along with the inherent cost of healthcare expenditures. My naive view as a doctor is that if I have to significantly alter my ability to care for my patient, whether spending less time with them, spending more time checking boxes, or hearing more about why I need 12 digits in my login password but cannot use a ‘-‘ or ‘#’, I cannot perform at the level that I am capable of as a doctor.

This is one way you can get burned out as a doctor: by caring.

My colleagues will never run out of anecdotes about the inane tasks that they have to complete. It really sounds miserable. We also hear enough about the mental health of doctors. It’s clearly being taxed by the imperfect system. The problem is that there is evidence that caring doctors in general are better doctors. But caring too much burns you out.

The late-career physician has an escape plan to happiness

Late-career doctors have an easy out—they’ve put in their decades of hard work, didn’t throw too much of their earnings away with misguided investments, and can hang up their hat at any point. The trade-off, of course, is that late-career doctors are perhaps late-career in life as well. There are plenty of otherwise fully capable doctors who have practiced 30+ years in their professions who often retire before they truly wanted. Why? Retirement for them was a means to escape the whatever ails them about their job as practicing physicians. More often than not, the reason for retirement is not the dislike or inability to do their jobs.

Everyone else will need to create an escape plan

The goal of being in medicine is hopefully not to quit medicine, but it sure seems like a goal for some doctors. Some of the gals I work with seem to be counting down the years before they can throw away the white coat. What’s holding them back from handing the resignation letter in right away? Over time, I am becoming more suspicious that medicine may be the golden handcuffs for some doctors, or at least handcuffs of any sort.

Think peaceful thoughts when you start feeling that eyelid twitch…ducks in a pond!

The mental, physical, and financial investment to becoming a doctor is overwhelming. Maybe only sushi chefs who train to make tamago train longer than doctors. Doctors are invested in their careers. It would be uncommon for doctors to go through this amount of training only to switch careers. Doctors commonly have two reasons to stick out their jobs even though it may seem unpleasant at times: (1) we like taking care of people, (2) it would be difficult to find another career that has a similar pay rate. Golden handcuffs indeed.

We just have to figure out a way to escape the handcuffs.

How to care…but not too much

I recently had a discussion about this with a retired high-ranking Navy physician who now practices medicine as a civilian doctor. We discussed the common gripes about where medicine is heading, and also how different it was to practice medicine in the military. After about fifteen minutes of channeling our negativity into the system, he aptly stated:

No matter where our health system spirals down to, you’re probably not going to starve, get put into prison, or die.

An interesting take on our situation, but I could not agree more. The sky is not falling. As long as you are ethical, competent, and conscientious, you will not starve. A doctor’s skill is always marketable, and we all have to realize that we shouldn’t sweat the small stuff. You should care about your profession, but you shouldn’t need to care about the issues that are out of your control. Focus on what you can control, how you can improve, and control your finances intelligently.

Now, this is a financial website after all. The key solution to escape the golden handcuffs is not to become beholden to the gold. Again, reasons why doctors stick out their jobs include the love of the job and the need to support our lifestyle. If you eliminate the need for salary, you’d only be tied to your profession by your enjoyment of it. Find your way to financial independence, and you might actually enjoy practicing medicine even more. What are you waiting for?

You might also like: The number one reason doctors need to be financially independent

Top five methods for doctors to reclaim their time

Posted on June 16, 2018January 30, 2021 by SmartMoneyMD

As with most professionals, doctors exchange their time for money. Sure, there are clever side gigs, real estate investments, and other means for us to build our revenue stream but the fundamentally our profession compensates us for our time. Fortunately our time commands a relatively good wage, but using our trade knowledge still requires energy. Sometimes our commitment to work is satisfying. Other times it becomes more of a drain. When our expectations of work do not reflect the reality of the workplace, we can experience burnout.

The best way to prevent burnout is not to get into a work situation that burns you out. Unfortunately we don’t always have that luxury. The second best solution is to maximize your time outside of work. Doing so may be a bridge to a more permanent solution, or it may even be a way to buy you time until you reach financial independence. How do you slow down the burn? These are five strategies for doctors to reclaim their time.

Enter a specialty that is structured around shifts

The rest of the world works on shift work. Each shift is defined by a set amount of time you spend at work. You can structure your life around how many shifts you desire to work, and clock out when you’re not there. The advantage is that you won’t likely to be called outside of your work hours, and you can have more control over your lifestyle. Tweak the schedules so that the pain of work never becomes intolerable. Beautiful.

If you are still in medical school and deciding on a specialty, there is still hope. Specialties such as emergency medicine, hospitalist (internal medicine), intensivist (many routes via internal medicine), and radiology (some employment structures) are some of the specialties that have a shift work structure. This shouldn’t be the only reason why you choose your career path, but consider the lifestyle wisely.

Delegate your tasks at work

Doctor roles have transitioned over the years with the concept of physician extenders, scribes, and midlevels. Whether we agree with the changes, they are here to stay. If you work for a hospital that has its act together financially (let’s see if any corporate folks are reading this), it should provide you with plenty of midlevel help to make you more efficient. When implemented properly, this can get you out of the office faster and bring in more money for the organization and its doctors. The fewer phone calls and prescription refills the doctor has to triage, the sooner the doctor can reclaim her life back.

Negotiate more time away from stressors

I find direct patient care to be most rewarding aspect as a doctor, but the associated tasks imposed by health insurance is a complete nightmare. Patient satisfaction surveys, meaningful use, and an inordinate amount of charting tests our ability to tolerate pain. Some doctors, after a certain number of years in clinical practice, opt to deal more with administrative work. I’m not sure whether that actually provides a more fulfilling career, but it gets us out of the stress of clinical practice. If that’s your cup of tea, go for it. We need more doctors in the C-suite too, if you’re going for the administration route, I urge you to go all the way to the top!

Alternatively, some doctors simply find jobs that allow them to leave work related business at work. No e-mails, phone calls, or meetings outside of the work place. Many startup tech companies push for this structure in order to reduce turnover. One day this will be more of a reality to doctors as well.

Become a full-time locum tenens doctor

Some specialties are more conducive to transient coverage. Doctors go on vacation, they get sick, or take time off for parental leave. Their practices need coverage while the full-time doctor is out of commission. If being a fill-in doctor suites your fancy, you can certainly carve out a career being the temp doc.

You might also like: How to become a permanent locum tenens physician

Being a full-time locum tenens doctor often requires traveling, often for weeks at a time to cover a certain practice. Doctors with younger children may find the travel difficult, but I’ve also known doctors who despise working under a single employer so much that they opt for transient work.

Job share

Job sharing is becoming more popular over the years, as millennials are looking for more flexibility in their work schedules. Many younger doctors in the workforce also have young children. They are faced with three choices:

Work full-time, committing to a career in their profession. Have full-time and overtime nanny support as job dictates.
Quit the workforce completely to care for the children.
Find a way to work part-time. Ideally, there is a working spouse to generate additional income for the family to maintain its desired standard of living.

Depending on your job situation, you might have a senior partner who doesn’t wish to retire completely from clinical practice but no longer desires to work full-time either. Perhaps you have a coworker who shares the same work-life balance sentiment. In either case, you could make a case for job sharing. It may be more of a challenge for an employer to have job sharing employees, but if that’s what it takes to retain good quality doctors then they can make it happen.

That’s it! What other strategies outside of becoming financially independent have you implemented to take back your free time?

The calculated approach to outsourcing your life

Posted on May 20, 2018January 30, 2021 by SmartMoneyMD

One of my biggest frustrations early in my career was accepting that outsourcing tasks comes at a cost. My colleagues were always able to justify house cleaners, home-pickup dry cleaners, and handymen even as residents. Their main argument was that it helps stimulate the economy. I understood that we should all help those around us, but I could never convince myself that anyone with a $40,000 annual residency salary truly needed a dry-cleaning pick-up service even if she was working 100 hours a week. If I had only outsourced my chores as a resident, perhaps I would have published more papers. I guess I’ll never know. Did doing my own laundry cost me a career as a superstar doctor?

Fast forward to today. I’m no longer working 100 hours a week, but 50 hours a week is still taxing. Life evolves as we age. We get arthritis. Kids need to be shuffled to their activities. Elderly parents need medical care. Suddenly there are too many events and obligations to meet in a given day. How do we find more time?

Outsource your life.

Welcome to the world of personal assistants. TaskRabbit. You name it, you’ve got it. You pay a negotiated amount for someone else to take care of your unfinished business. Buying furniture. Putting together your furniture that they bought for you. Cleaning your house. There is almost always a price to be named for a chore that you don’t want to complete yourself. If you have an unlimited budget, you could outsource every aspect of your life.

These feline friends know how to take life easy

As reality dictates, most of us do not have unlimited budgets. How do you put a price on time? I generally follow these two principles:

Put a rate on the job.

What is the going rate for a chore that you’d like to outsource? How easy is it to get the job outsourced? It may actually be more difficult to outsource a job than you’d otherwise think.

For instance, two years ago my air conditioning unit stopped working. One of the capacitors broke in the unit, and the unit was mounted on the roof of my two-story house. The cost of the job was clearly over my normal pay scale as a physician, but it was not prudent to for me to risk breaking my neck from a fall on the roof. Unfortunately it was high season for the air conditioners, so the wait-time for a routine repair was 2 weeks! An emergency call would’ve cost 2.5x!

An analysis table was useful in this situation:

Advantage of outsourcing

Avoid fall and shock risk
Avoid other potential injury to unit.
Exchange money easily to no worry about details
Instant resolution of a problem

Disadvantage of outsourcing

Relatively expensive post-tax cost—would need to perform a roux en y surgery to cover the after-tax cost of the air conditioning repair
The paid help may not do a good job on the work.

I ended up paying up for the emergency repair, and all was well for one day. Another part of the air conditioner ended up breaking (supposedly), and I ended up having the call the repairmen back. They had to charge me another fee, stating that the second malfunctioning part was not related to the original repair! Go figure.

Another $400 later, I was back enjoying cold air in the hot summer. Thank goodness for having a decent paying job. The biggest sting when you have to cough up for a big ticket item is that mathematically it delays getting to financial independence. Sometimes that is the only option that you have.

Prioritize according to what gives you pleasure.

In contrast, you can cherry pick what you want to do with your time. One of my friend’s husband, a gastroenterologist managing a relatively large practice, enjoys washing his car. He takes call every three weeks, has limited time for the family yet he spends a few hours every month washing and waxing his car. Is that time well spent?

In a purely time per cost model, he should be outsourcing his car washes. In fact as a highly paid physician, he should actually outsource essentially every task that costs less than what he could generate from his profession if money were the only goal. There are two problems with this logic:

In order to make a direct financial comparison, he would need the ability to generate income from his profession while his car is getting washed elsewhere. Good luck finding a way to match that up. At best, he could generate income through taking more call or working more during the workweek. However, that still doesn’t confer a perfect 1:1 exchange of time for money.
Your day job may actually be mentally taxing, even if it confers a great pay rate. How much mental and physical energy does take to do the day job instead of washing a car? What if every additional weekend you work confers a week of shorter lifespan? What is the price you can place on your health?

Clearly this gastroenterologist has decided that washing his own car provides enough enjoyment that he chooses not to outsource the task. There is nothing wrong with that.

How do you decide to outsource your life?

Rookie mistake – letting children thwart your retirement plans

Posted on April 22, 2018January 30, 2021 by SmartMoneyMD

Our future lies in the success of our progeny. They are the ones who will advance our society, healthcare, and keep us safe. Unfortunately our successors aren’t born with the tools to run the world–they still need the support of those with more experience. At age one, I was definitely crying most of the time. At age six, I still cried at pretty much every chance I got. At age 10, I was probably helpful around the house but I was definitely not solving world problems.

Don’t worry, your car seat has an expiration date so it won’t sit in the garage forever!

In fact, I was pretty much useless in my line of work until my late 20’s. Up until then, I probably consumed quite a few financial and mental resources from my parents and society.

Children have even more opportunity today to burn through your doctor-sized income.

Serious money can be spent raising a kid, long before they reach schooling age. Bassinets, pack ‘n’ plays, rocking chairs, diapers, formulas, strollers, “travel systems”, and all of the early life activities.

I was talking with colleague recently and noticed that she had a very intricate travel system for her young twins. For those of you not in the “know”, a travel system for young kids involves a mobility carrier to ease movement between car seats, strollers, and even airline travel. It looked fancy and appeared to take effort to put together. Several weeks later, I had a coworker who complained about the cost of the very same travel system. It turned out to be $800!

That’s right. This is an $800 investment that ought to ease the burden of parenthood, keep your kids safe, and last up until age 2. Afterward, you’ll likely need to upgrade to a better system for older children. If you’d like to have the state-of-the-art jogging stroller for your children, you’ll have to lay down another $1,000 purchase. If you’d like to find a portable stroller that you wouldn’t have to gate-check when flying, be prepared to drop another $200.

We have to be mindful of our own limitations

One of our goals as parents is to instill best practices to our youth. We hope to give them the opportunities that we didn’t have ourselves. This can get us into a lot of trouble. Just because mom and dad can afford the nice childhood luxuries, nannies, au pairs, and early educational toys doesn’t mean that Jr. needs it in order to become a productive member of society.

I blame peer pressure on our shortcomings. It is easy to compare ourselves to our colleagues, friends, and acquaintances. Society expects a certain standard of living based on our profession. We expect a certain standard of living for ourselves based on our professions. When our coworkers have the latest gadgets for their children, it is tempting to follow suit. After all, it’s for our kids right?

In order to reach our financial goals, we create a financial plan based on our in’s and outs. It’s easy to increase our expenditures especially if we rationalize that we’re helping our children succeed. But that is the wrong move. You’ve made it thus far in your career to build a stable financial footing for your family despite the challenges. Your children should be up for the challenge too. It will only make them stronger.

What big ticket expenses for your children could you have foregone?

How to survive (and thrive) with a doctor (in-training) spouse

Posted on March 25, 2018January 30, 2021 by SmartMoneyMD

Okay guys and gals, this entry is written tongue-in-cheek, but those of you who are in this sort of situation know that there is a great amount of truth in what I’m about to say. Take it in jest, and know that everyone is in good company. Once the dust settles after their training is over, life does get a whole lot better…at least certain aspects of it. Those spouses who just matched into residency last week (#Match2018), well get ready for a bumpy but rewarding journey for the next few years…or decade!

Time

Time is always in short supply. Sure, there are regulation work hours, but it’s uncommon that the work ends when medical residents leave the hospital or clinic. There are exams to study for, grand rounds to present, papers to review, and articles to author. There is a call schedule, where both of you (plus the children and pets) are woken up at potentially ungodly hours. Depending on the specialty, rigor of the training program, and motivation of your spouse, time will always be in short supply.

There really isn’t too much leeway on this borrowed time, especially if you expect your significant other to successfully finish her training, graduate, and start earning the big bucks.

The key to time management is to set protected time, whether it is only a few hours a day and a handful more on the weekends. This is the 21st century, and not the 1980’s where the doctor spouse essentially lives a parallel life from his (more male doctors then) family. The family gets a say in how time is allocated. By simply having a time management schedule, everyone in the household actually becomes more productive. Once both of your schedules open up with more free time, then you will be superstars.

Organization

If your doctor spouse is highly organized and contributes to arranging the family schedules, then consider yourself lucky. Given the hectic training schedules, it is unlikely that any medical resident would have much more executive function that staying alive. If you have more time on your schedule, then it is up to you to plan family schedules and have your spouse follow them. This includes kids’ events, family outings, and whatever other events that your spouse ought to be present in. It is unlikely that you will have any opposition if you lay out everything. Pack her lunch, make sure you have a good system to keep track of important events, and delegate away.

Leftover donuts from grand rounds might be all you’ll get if you rely on your doctor spouse for dinner.

Finance

Finance is an interesting arrangement in a doctor household. If you, the non-physician spouse, have a full-time job, it’s likely that you are the breadwinner. This probably also means that you are calling the shots on home purchases, big ticket items, and the general business structure of the home.

Some spouses have career situations where they will always remain the breadwinner even after the doctor spouse finishes training. It’s actually becoming more common as insurance reimbursements dwindle and some doctors opt to work part-time. It’s even more important for you to be attuned to the financial health of the household if your doctor spouse has no interest in money (that is still okay).

If you are lucky / unlucky to have a doctor spouse to trolls Bogleheads or understands all of the latest nuances in tax codes, just hand over the money matters to him (yes, it is almost always a guy). As long as he can delegate time and organization matters to you, then you have the foundation for an efficient household.

What other strategies have you implemented to keep your doctor spouse in line?

Focus on your savings rate when short on investment time

Posted on February 23, 2018January 30, 2021 by SmartMoneyMD

It’s human nature to want to tweak our investment strategies. Tax-loss harvesting, optimizing your asset allocations, delving into real estate or even multi-level marketing are some of the strategies that we all try to use to give that additional alpha to grow our net worth. The basics of these principles are not rocket science, but implementing them does take time. Even with appropriate strategy, returns are never guaranteed.

Many doctors simply still don’t have enough time or energy to tweak our investments. One of the reasons why I haven’t delved into real estate investments is simply due to the lack of time, motivation, and the interest. Likewise, it’s okay to realize that you can’t win everything. There is no set formula to reaching our financial goals. The great news is that you can still win in the end without micromanaging your investment options.

I like to focus on mini-victories in my daily life. Whether it’s simply getting the laundry basket emptied, keeping the house clean, or even getting through a rough workday, these are all wins. On the investment front, I focus on simplicity when I do not have the time to tweak my investments.

Drinking additional beer will cut into your savings rate

Remember that the majority of our net worth comes from our savings, especially early in our investment careers. We can’t control the bull or bear markets, but the longer we are in the investment market, the more time we have to ride out any dips. This means that we ought to front load our investments to maximize our ability to win.

When you are too busy in your daily life to go for advanced tax and investment strategies, focus on your savings rate. The more you save, the more you can place into the market to grow (and ride out losses). Last year (2017) showed tremendous growth in the stock market, and even with very basic total stock market index fund investments, my pot grew by over 18%! Being able to invest heavily prior to these up markets can offset most losses outside of the worst recessions. This is all due to controlling your savings rate, nothing else!

The next time you find yourself struggling to find time to optimize your investment strategies, just remember on your savings rate.

Employment or partnership? A physician’s dilemma – Part 1

Posted on February 18, 2018January 30, 2021 by SmartMoneyMD

Some people want to run as far away from employment as possible.

The business of how physicians practice medicine has undoubtedly evolved over time. Proponents of healthcare reform argue that many of the changes allow better care for our patients. Some doctors aren’t too convinced. Whether or not we’re on the mainstream bandwagon, we still have to play the game if we practice medicine.

The healthcare system in America has largely operated on a fee-for-service basis. This means that the health insurance (or patient) pays the doctors a pre-arranged amount for services. There was a time in the 1980’s where this compensation almost went away, but due to reasons I can fully understand fee-for-service has stayed alive.

The employed physician

The prominence of the employed physician has grown over time regardless of the underlying compensation structure. This is partly due to growth of certain physician specialties and economic demands of physicians.

Hospitalists, intensivists, and emergency medicine doctors constitute a growing number of the physician workforce. These specialists often work shifts for hospital systems, either as contracted groups or as straight employees. This means that they are compensated for a set amount of work. If they provide more services, they will likely earn more.

You don’t have to belong to those specialties above in order to be employed. Doctors who opt for straight employment contracts with a medical group can also work as an employee. Additionally, you could join a managed care group such as Kaiser Permanente to live a career as an employee.

The benefits of being an employee are exactly the same disadvantages of employment. As an employee, you provide a set amount of services for payment. Life is pretty clear-cut. You receive benefits from your employer, but you also have to work under the rules of the employer. As long as you finish your work, your job is done. Bad coworkers? Tough luck getting rid of them. If you’re the bad coworker, then you could probably feed off of the system while getting paid! In fact, an employed physician exchanges professional time for money. This is an important aspect—whether or not you are actually practicing medicine during this time you are still paid on the clock.

The owner/partner physician

Many years ago, doctors literally started a business to care for patients. They contracted with insurers, bought or rented an office, equipment, hired staff, and worked the business. With any business, the owner is responsible for everything. Deadbeat payors? Deadbeat employees? Your problem. That’s perfectly fine for some of us, but some of us aren’t equipped to run a business in addition to practicing medicine. Some of us simply prefer not to deal with running a business—we became doctors presumably to practice medicine, not to handle the front desk employees.

Presumably the hassle of running your own medical practice or being an owner of a medical practice ought to come with some reward, whether it be freedom to call the shots or monetary compensation that you wouldn’t otherwise enjoy with being a corporate slave or peon.

The take-home? Do you want the freedom to practice medicine for your career in exchange for others managing the business, or does the reward from being your own boss outweigh the additional work?

We’ll look at some financial analyses in a later post. Stay tuned…