Docs Who Cut Back #11: BT

BT is an emergency physician residing in the south. He's married to an internist and a father to three daughters (the oldest just started university). His career saw him working at a community hospital, which he left to become an academic faculty member and researcher, which he left to return to community practice once again. He picked up and grew a side hustle after relocating to a low cost of living area, and the combination has propelled him toward Financial Independence as it has enabled him to escape night shifts.

BT is thoughtful, open to changing his mind, and an absolute delight to spar with verbally. You'll get a flavor for his renaissance interests in the unconventional trajectory his career has taken.

1. What is your specialty, and how many years of residency/fellowship did you complete?

I am an Emergency Physician, among other things. I graduated medical school in 1996 and went into the US armed forces as a doc. I was lucky to have a scholarship to pay for medical school, and that required payback time in service. After that, I completed an Emergency Medicine Residency. Including internship, the total training time was 4 years.

I worked in a lively community ED for one year, during which the realities of the ER Doc lifestyle began to weigh heavily. That led to a cross country move and switch to an academic track, including a fellowship in clinical research/resuscitation and a public health/clinical research degree.

After 4 years of the academic treadmill, we made another cross country move, where I took another academic job at a gritty, fun ER residency program. Alas, a combination of family exigencies and the ongoing realities of the ER Doc lifestyle led to a third cross country move, this time to a surprisingly busy ED in the rural south, near my family’s ancestral home. Regrettably, no manor houses or estates were involved.

By about the 5^th year in this ED setting, I knew a change was in order. I began agitating for change within the group, but there is only so much change that can be tolerated by a group providing 120-130 physician hours of coverage per day. So, I sought out other opportunities to replace income, and began to consider ways to reduce expenses. Finally, after 7 years of full-time practice with this new group, I was able to reduce my ER hours.

The reduction was substantial, from an average of around 1600-1700 per year, down to about 500 hours in 2018. The icing on the cake is that I no longer work night shifts. That alone is almost priceless. I cut back in late summer of 2016 at age 46. That was 20 years after graduating medical school and 13 years after graduating residency. However, I replaced those hours with nonclinical administrative work. It is far less stressful, with an accommodating schedule and reasonably interesting

2. What did your parents do for their livelihood?

Pa was a railroad man through and through. He ate nails and shat fire. Gentle, kind, stern and scary all at once. Ma was a chemist. A ‘southern woman’ true to her roots and upbringing. Both were fantastically hard workers, and children of the depression from the rural south. That is, they worked throughout their lives, saved prodigiously, and really demonstrated the value of living below one’s means. They created a financially secure environment and showed me the dangers of debt.

3. What motivated you to cut back?

Family? Social time? Boredom? Short attention span? Fatigue? Broad interests? Some combination?

In the end, I got tired of others dictating my schedule. I got tired of shifts weighted towards evenings, nights and weekends. I got tired of working when most of the world is off work. I got tired of not feeling able to pursue other passions and ideas because of the limitations of a shift work schedule. I got tired of unpredictable work flow. I got tired of having to stay late. I got tired of being the one-stop-shop for the disenfranchised and the unloved. I got tired of great men proclaiming how great is the US healthcare system. Sounds like burnout.

4. What were the financial implications of cutting back?

Uhh… none? But I still work, just in a kinder, gentler role.

I firmly believe that if an ER doc does not have enough money, then she has a spending problem, not an income problem. The median income in my state is around 50K. So, we ought to all be able to get by on some positive integer multiple of that.

That is not meant to be flippant. It is just that we all must decide what we value. For example, there is no automobile that I value enough to justify 30 shifts in the ED.

On a broader note, I have one profound advantage that many others lack: I married a doc. She works part time but is blessed to get benefits including health coverage. That lessens the impact of any decision I make, and it certainly softens any blow to the bank account.

One GIGANTIC advantage of being an ER doc is that our skills are in high demand, and it is usually quite easy to upscale work if needed. In a sense, our skills give us an unusual amount of “work liquidity.” That is, within a relatively short time, we can upscale our income to meet new demands on our bank account.

This is a dangerous luxury though, as ER docs tend to think of extravagant purchases not in terms of money, but rather in terms of shifts. “How many shifts will that trip to Bermuda cost?” “How many shifts will that Tesla cost?” “How many shifts per month will I have to add to buy that house at the lake?” It is easy to borrow against your future work life like it is a loan and burn yourself out. You could get crispy, doc.

5. How did colleagues react to your decision?

When I finally announced that I was really going to cut back by handing in a resignation letter at a group meeting, there were some words said that led me to get up and walk out of the meeting. It was a difficult situation. The comments were from a friend and meant to be in jest. Still, it was a tough moment for me, on the front end of possibly throwing over my and my family’s financial future by resigning a lucrative partnership at the only game in town, so that I could… what, exactly? Sleep more? Travel a little? Go to more parties?

Soon, I think people came to accept it with no hard feelings. I still am privileged to work shifts with the same ER group, at the same hospitals, with my same (former) partners and friends. There has not been a rush to follow in my footsteps, though. Perhaps I am a malcontent. Perhaps others are more tolerant of the ER lifestyle than I. Perhaps everyone is broke. I don’t know.

5b. Was your family supportive or critical?

Universally supportive.

6. What have been the main benefits of your decision to cut back?

I have near complete schedule flexibility. So, I can generally do what I want, when I want. I am home for dinner with my family most days. I sleep at night. One exciting and unanticipated side effect is that I enjoy doing ER shifts these days. It is a good job.

7. Main drawbacks?

One must take care to maintain the skill set required to be an effective ER doc. It is remarkably difficult, and if you don’t practice it, the skill and speed fade. I think you must keep your hand in the game enough to be competent.

If you need an income (as I in fact do) then you must find other income streams to replace at least some of what you have given up. There are many alternative income streams available to physicians, but they take some time to identify, pursue and develop.

8. Did you fear your procedural or clinical skills might decline?

Not at first, but the farther I get from full time clinical practice, the more I worry about this. I consider a 3-fold approach to maintaining skills: 1) continued practice in the ED – titrate to effect; 2) CME; and 3) consciously identify problem areas and be mindful of them (speed, a particular procedural skill, EMR literacy, etc.)

9. If you are honest, how much of your identity resides in being a physician?

I am at the hospital more now than before I cut back (because I have taken on a nonclinical administrative role). Probably more people in the institution know me as a doc now than did before. In the community, because I still work in the ER and at the hospital, it really has not changed. Even part time clinical work maintains the doctor identity. Having said that, I hope that my most important identity is not ‘doctor.’ Doctor is part of my identity, but not all. If I were to give it up completely, I have no idea how much of me would be gone. Honestly.

10. If you had not gone into medicine, what alternate career might you have pursued?

Through high school, I always envisioned myself as working outdoors, perhaps in forestry or as a park ranger. Through college I thought I might end up as a professor of literature. In college, I majored in English and biology. I even applied for an MD/PhD program.

There is an obvious overlap between medicine, literature, philosophy, ethics and the human condition. For a couple of years after fellowship, I had the pleasure of starting and teaching a course for undergrads at a large university. It was a seminar type course called “Fundamentals of Clinical Research.” We talked about research history, IRBs, human rights, study design, etc. For a while, I got to play professor to young minds. It was a pleasure, but I probably had impostor syndrome. That happens a lot if you surround yourself with people smarter, harder working, and more successful than you.

The whole doctor thing just kind of happened. The ER doc thing also just kind of happened. I found no part of medicine unusually interesting. Maybe I’m too lazy.

11. What activities have begun to fill your time since you cut back?

I still work, probably more hours than before, but MUCH less intense hours. I study finance a bit, hoping to figure out how to have passive income going forward. I am learning music (old time banjo and fiddle).

12. If approaching retirement, what activities have you begun to prioritize outside of medicine so that you retire to something?

Yeah...     About that…

13. Did you front-load your working and savings, or did you adopt a reduced clinical load early in your career?

We frontloaded. We saved aggressively early, but we were foolish. Little knowledge, mediocre investments, and bad timing. The housing crash did violence to our bank account. Luckily, we are reasonably frugal, and we live in a low-cost area. It was advantageous to make mistakes while young enough to correct them. You can make up for a lot of mistakes on a doctor’s income.

Absolutely unequivocally I would live below my means. I would seek inexpensive housing and transportation. I would begin to develop passive income streams within one year of graduation. I would set up a schedule of passive income and try to meet it. I would be very clear with my partner about teamwork, about what it means to be equal partners in a relationship – equal but divided work and responsibility.

I would invest time in relationships. I would prioritize friends and family. It is hard to make close friends in middle age.

Allow me be the first to suggest that BT reserve the domain name FIREshitter.com and adopt that pseudonym as his blogging alias. Barring a salsa manufacturer using the legendary ghost pepper as an ingredient, I suspect the domain is available.

• "I am an Emergency Physician, among other things." Diversification of identity for the win!
• Being home for dinner and sleeping through the night are the holy grails of medicine. BT walked away from a lucrative partnership to obtain these prizes. Enjoying privileges other physicians do not usually involves sacrificing significant income others will not.
• Medicine provides a spectrum of opportunities. BT experienced the military, community practice, academics, and most recently a non-clinical administrative role. If you are struggling with burnout, consider alternative ways you might use your medical degree to reinvigorate your career.
• Development of passive income streams early in a medical career is advice several interviewees have endorsed.
• Cutting back helped BT once again enjoy shifts in the ED, something that resonates deeply with my own experience.