Docs Who Cut Back #19: By Well Design

The physician who blogs at ByWellDesign is an example of a specialist who cut back despite having a strong procedure-based component to her work. She was a decade into a typical nose-to-grindstone medical career until a cancer diagnosis forced her to reconsider her path.

With wonderful clarity, her writing conveys how a cancer diagnosis immediately undermines assumptions about the future; how stress-inducing and risky it feels to be the first to ask your department chair to cut back; and the trade-offs in reputation that often accompany a reduced presence at work.

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

I am an anesthesiologist. I did one year of internship in internal medicine followed by 3 years of anesthesiology residency training. I was anxious to start working when I graduated in 2005 and skipped doing a fellowship.

I cut back when I was 41, after working 10 years at my current and only job after residency. At that time, I was diagnosed with invasive breast cancer and stopped working completely for almost 10 months to undergo chemotherapy and surgeries.

When I returned to work, I asked to come back part time and I became the first person in my very large department to be granted part time status. I think this is largely due to the culture of anesthesiology because there are many other departments at my institution that support part time work for partners, including pediatrics, ob/gyn, family medicine and IM. I am extremely thankful to my chief at the time for being so supportive.

2. What did your parents do for their livelihood?

My father was the primary bread winner and was an aerospace engineer for a large military contractor. My mother stayed at home to raise my brother and me. She went back to college when I was in high school and pursued a BA in Fine Art and went on to have a small amount of success as an artist.

I would describe my family as staunch middle class. We never worried about money or went without basic needs. We enjoyed a lot of travel and I was lucky to do all the activities I ever wanted. But we never had anything “fancy”. We didn’t have luxury cars, we didn’t eat out at nice restaurants, etc. I think this explains my love and weakness for a fine, well served meal even though I work part time now!

My father retired young at 55 (he is now 85). He was a pioneer of the FIRE movement without even knowing it. You can read all about his financial decisions (both good and bad) at my blog (shameless plug here). My parents were very smart and conservative with their money. They lived a modest lifestyle well below their means, invested heavily, and carried little to no debt, ever. I think it’s because I adopted many of their behaviors toward money that I was able to cut back on working without worrying about finances.

3. What motivated you to cut back?

First and foremost was my battle with cancer in 2015-16. It changed everything in my life.

My son was only 3 and a half when I received my diagnosis and I was terrified by the thought that it was possible I might miss out on seeing him grow up. I thought about all of those hours I worked when he was a baby and how I was not home enough. I knew that if I returned to working the way I was, and god forbid my cancer recurred, I would never forgive myself for not spending every possible second I could with my husband and son.

Requesting to work part-time was scary and one of the hardest things I have ever done, but I am so glad I did it. The other answer is definitely related to burn out. This was not quite the buzz word in 2015 as it is now but I remember reflecting on the irony that I was, in some ways, more relaxed during my time off receiving treatment for my cancer than I was when working full-time. I intuitively felt that stress, and not having the time to deal with it proactively, had a role in my illness.

4. What were the financial implications of cutting back?

I had a trial period for what our finances would be like for almost one year when I was on disability during my treatments. My disability benefit was about 60% of my normal income and we did not even notice the cut.

We had purchased a small and modest home when we lost money in the stock market in 2008. We had plans to sell it and upgrade at some point, so our mortgage was significantly below our income to begin with. Our spending on things like cars, shopping, etc. were easy to cut back since these things seemed so frivolous after my diagnosis.

Months before I got my diagnosis, we began looking for a bigger home in an expensive area in Los Angeles and I think it was very auspicious that we didn’t find anything to buy, or I would probably be working full-time now. We choose to stay put in our cute, small home so I could work less, and I have zero regret over this decision. We are also very lucky to live in an area with phenomenal public schools.

As for savings/retirement, I still maximize contributions to my two work provided retirement accounts (a Keogh and 401K). As for when I retire, this may be pushed back somewhat since I am investing less in my private taxable accounts; but I would still be able to retire on the younger side if I wanted to.

I just don’t have the desire to stop working all together anymore because I actually enjoy what I do now that I am doing it less.

5. How did colleagues react to your decision?

Most people at my work were very supportive. I did get some interesting comments about how it is a waste of resources to train a physician that only ends up working part time. I attributed this partly to jealousy and it didn’t bother me at the time since I have new priorities. I think this mentality is what got physicians into this cycle of burn out in the first place.

I am part of a generation of doctors (gen Xers) who were on the cusp of this shift in attitude toward the work we do. We grew up in medicine when it was prioritized, even glorified, to make maximum personal sacrifice to become a doctor, but I believe we are the first generation that began looking at the practice of medicine as more of a job than a lifestyle.

The physicians in the subsequent generation have made even more strides because they appreciate the value of a personal life. It is hard to ask a doctor now to sacrifice everything to a career that, other than the intellectual stimulation, the personal interactions and providing care to people in need (the things I love about our work), does not have as much to give back anymore.

I personally think this transition and the internal conflict it induces, is partly contributing to the “burn out” epidemic in medicine.

5b. Was your family supportive or critical?

All of my family and friends were extremely supportive. They were all impacted by my illness and they believe I am healthier working part time. They also knew how stressed I was before, and how much it bothered me to miss out on so much of their lives because I was working too much.

I also think it’s partly because I am a lot nicer to be around when I am not working full time!

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

The biggest benefit is the extra time I get to spend with my husband and son.

I am around for the majority of my son’s activities, I volunteer in his classroom (he’s now in first grade), and we spend a lot of quality time together on the weekends. When I’m not able to be there because of work, it’s OK because it happens less often. Before cutting back to part time, I was constantly filled with guilt for missing out on so much.

I am also a lot healthier and happier. I exercise more and spend time by myself which I find very restorative. As a result of all these changes, I am more grounded and feel fulfilled. I honestly can’t say enough about how lucky I am to be doing what I do. I absolutely love working part time.

7. Main drawbacks?

I am tempted to say there are none, but I figured that’s not a very constructive answer. So, if I reach deep down for something to say, I would say the obvious drawback of working less is making less. That being said, I am known for chirping “I make half as much, but I am twice as happy!!!” to anyone who wants to listen.

The other vague drawback is one of reputation and familiarity. I do think that I lack some of the esteem I held when I was contributing more to the workload in my department. This is something that I find hard to quantify since less of my identity is tied to medicine after my illness. I still care a lot about my patients, my colleagues, and I still want to contribute something valuable to my team.

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

Yes, this was a concern for me since a lot of what I do is procedure based. I didn’t practice at all for almost one year and, when I returned, I had some residual mild neuropathy from my chemotherapy. I had some anxiety about if I would be able to practice the way I had before.

What I found though was after a few days, things fell back into place and the technical skills I had acquired before leaving were still intact and it wasn’t an issue. I figured this is because I had practiced intensely for 10 years and had done these procedures countless times before going out on sick leave.

I do struggle a little with keeping up with the fast pace of changes in my practice, our new electronic record being the number one issue. I also took complicated pediatrics out of my practice since I didn’t feel I was doing the volume I needed to remain proficient.

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

Before cutting back, some of my identity was tied to my work, but I would say probably less than the average physician. I have diverse interests and have always had a very active social life outside of medicine. No one in my family is in medicine, nor are the vast majority of friends I socialize with regularly.

Now that I work less, even less of my identity is tied to my work. Some of the moms from my son’s school were surprised to learn recently that I was a physician which was eye opening for me. I think I see myself now as many things - a wife, mother, daughter, sister, a doctor and a patient.

I enjoy being able to wear (and at times take off) all of these hats depending on the circumstances. It has expanded my ability to empathize and I feel this has made me a better person and a better doctor.

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

I have always loved design. I actually earned a certificate in interior design from an on-line program while I was out of work on sick leave. I am about to put these “skills” to the test on an upcoming remodel/addition we are doing to our home this summer.

I also worked in bench laboratory research in molecular biology while in college and then for both a large biotech company and an academic laboratory before going to medical school. I was initially planning on pursuing a PhD in Neuroscience until I made a last-minute change to go to medical school my senior year at UCLA. I sometimes wonder what my lifestyle would be like if I hadn’t changed my mind.

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

I volunteer in my son’s class at least once a week, take him to almost all of his activities and have regular play dates. I read, write, hike, work out, cook, do lunch with friends, see family, and practice yoga weekly.

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

I don’t think I’m approaching retirement anytime soon. I think I will probably retire in another 10 years or so. I will continue to do what I am doing since these activities keep me busy and I am content with the balance in my life.

When my son is out of school and that frees up more time, I may try to do more with my writing. Perhaps a deep dive into something research based which I think would be fun, or maybe I might try to write a book of essays. I have started a blog recently so I will probably put more energy into that as well. I would also love to travel more abroad which is a little harder to do with a small child in school.

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

I front-loaded my work and savings for the first 10 years and think that was what enabled me to switch to part-time. I don’t think I would have done it any differently since I wouldn’t have the resources I have now if I had cut back sooner.

As far as what I would do differently, I wish I had a better understanding of personal finance and had made smarter money decisions right out of residency. Physicians don’t learn much, if anything, about finance when we are in training. I think the people who start thinking and planning for these things right away will be at a huge advantage financially and this will give them the power and flexibility to work in a way that they want to.

ByWellDesign's interview covers a lot of important ground, so let's dig right in on the take-home points:

• It's fascinating to me how scary it feels to ask to cut back (I felt similarly when I made this ask of my group). There is the element of feeling as if you are requesting special treatment or creating inequity among physicians. There is a sense of a tremendous imbalance of power if you are told "no," and the dreaded prospect of having to find other employment and potentially uproot your life to do so - which explains why many of us simply stay in jobs that range from unpleasant to exploitative.
• Bread and butter procedures seemed to present less of a challenge after a year off, while a low volume of complex pediatric cases led her to remove these from her caseload entirely. This is one of the first interviewess to report that cutting back limited their scope of practice in some way.
• "I intuitively felt that stress, and not having the time to deal with it proactively, had a role in my illness." The practice of medicine is often chided for fixing health problems after they occur instead of preventing them. Sadly, the typical physician lifestyle does not provide the time or bandwidth to practice what we preach in terms of allotting ourselves adequate time to maintain our own health and wellness. Cutting back allowed this physician to allot time to make fitness a priority.
• "I am a lot nicer to be around when I am not working full time!" We treat those we love poorly when we are grumpy, undernourished, depleted. When we take time for self-care, the benefits can transform us and get paid forward to these same folks.
• "Some of the moms from my son’s school were surprised to learn recently that I was a physician..." I love and relate to the idea of being a stealth physician.
• "I front-loaded my work and savings for the first 10 years and think that was what enabled me to switch to part-time." This is an important point that I fear blogs like mine can risk overlooking - making that first decade out of residency into your workhorse decade for saving, paying off debt and investing can make a world of difference over the remainder of your career. The Happy Philosopher recently wrote a post explaining why physicians should work full-time out of the gate. This may not work for every doc, especially those whose mental health is at great risk in their current positions, but the advice is sound and the benefits are real. Find a happy 40-something physician who has cut back. Odds are that they worked and saved like fiends their first ten years of practice - something to consider.

You can find ByWellDesign at her blog. Her writing is delightful.