When I started this blog, I was all over the FIRE bandwagon. I felt trapped by medicine, and was looking to load up, cash out and exit as quickly as was financially feasible.
Something happened along the way to the early retirement component. Cutting back on my clinical time transformed medicine from a vindictive and jealous ex-mistress whose only objective was my misery into an old friend with a shared history who offered me a remunerative and interesting hobby with a community service angle.
Perhaps we could extend our friendship, or at a minimum slow its demise.
Buoyed by a record bull market, I hit my number, and then decided to stick around. I liked my colleagues, and I enjoyed our shared sense of mission. My reduced clinical role meant I could now prioritize family and self-care more than I had during the first decade and a half of my practice of medicine, so it was no longer an either / or decision between medicine and happiness.
Financial independence removed the yoke from my neck, and as a result I could practice a different kind of medicine on my own terms. That made all the difference.
What About My Debt To Society?
Let me go on the record as saying that the community's claims to control physician destiny are flimsy to nonexistent. If a physician wants to retire early, so be it.
For the nearly half of physicians who report symptoms of burnout, there is high inter-rater reliability in the assessment that full-time medicine is a crap job.
If society truly values physicians sufficiently to want to keep them from leaving the field, society can make it a career in medicine a better, more sustainable job and let the free market provide the incentives in place of maudlin appeals to a moral code no one else is expected to abide by.
- Restore physician autonomy in patient care.
- Enable physicians to own and operate their businesses by favoring physician-owners over physician employees through regulatory incentives and via the tax code.
- Reward personalized care designed to meet human needs over economies of scale with replaceable, disposable human widgets designed to be burned through and discarded as afterthoughts.
- Implement flexiblity in scheduling so that "the patient comes first" doesn't always equate to "the patient comes first at my family's expense."
Others, notably Physician on Fire, have addressed in greater depth whether physicians owe a longer period of practice to society.
If It's Not An Obligation, Why Am I Taking The Risk?
Lean in close, big secret here: I like caring for patients. Most docs do.
What I don't like is bureaucracy, hassle and red tape: Computerized Order Entry, the Electronic Health Record, quantification and metrics, onerous documentation. Eliminate these and it's a job I enjoy.
The aggravations deplete me less since I started working fewer shifts.
Sometimes, in advocating for a patient or completing a workup, I end up staying late after a shift. This used to cause tension at home. It matters less now that I have lunch most days with my wife, since I am cashing in chips from a much larger pot of goodwill.
Looking beyond those reasons, life is not a zero risk activity (as Warren Zevon put it, Life'll kill ya).
People are getting sick. I am able and willing to help. I feel lucky to have the skills that allow me to do so. I'm not so burnt out that I can't take it any more.
Most docs feel similarly.
No one on a moral high horse is going to guilt trip someone who is done with the practice of medicine into coming off the bench.
But most docs entered the field because they enjoyed being the kindergarten teacher's helper; because they liked helping a friend work through calculus problem sets during college; they accepted that to learn a certain skill set they would sacrifice income and social opportunities during the prime of their lives.
I like helping people. It's the absolute worst kiss-of-death cliche in any med school applicant's essay. It's also a defining characteristic of most docs I am proud to work alongside.
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You have certainly demonstrated that the FI in FIRE is the most important part. You can salvage a career and last much longer if you can design a practice more in line with what you want rather than it be driven by finances.
Author
Xray,
Salvage is precisely the term I’d use – the sense of rescue from imminent loss is spot on. I’d hope others find the unexpected up side in renewing their practice by eliminating or reducing aggravations, but not every doc has either the flexibility in practice nor the bandwidth to want to go part-time. Being able to say no because you don’t need the money as badly as they need you – that’s negotiating from a position of strength, and a superpower I wish more physicians availed themselves of.
Fondly,
CD
I likely would have taken a part time gig but unfortunately, zero employers local to me were interested in part time surgeons. I know some suggest locums, but this would involve more time away from family, which didn’t make sense to me either.
Kudos for being able to practice medicine on your own terms!
Author
Hey TSMD,
Appreciate the kind words. It’s bizarre to me that employers in need can’t be more flexible in accommodating specialists they would love to recruit on a part-time basis. Cory Fawcett had arrangements where he took ER call for general surgery at low volume hospitals where he slept through the night. Perhaps you could be the call guy from 7a-7p so other surgeons can see clinic patients as scheduled (although I imagine in a post-COVID world fewer of them will be willing to give up any patients due to reduced volume across the board). Perhaps per diem at Kaiser?
It’s a shame your medical talent doesn’t have an easy outlet, although your day trading talent seems to fill to keep you off the street and out of gangs pretty successfully.
Thanks for stopping by,
CD
You should interview yourself for Docs Who Cut Back! You’ve answered most of the questions already but that would collect the responses in one place. I’m happy for you, it sounds like you’re in a good place.
Author
Thanks, GasFIRE, I feel like (pandemic nothwithstanding) there’s a decent balance to life.
Not sure that a self-interview would be that interesting compared to the far more fascinating folks I’ve interviewed thus far, but I’ll think it over.
Appreciate your stopping by,
CD
It’s hard to find contentment in medicine. In general, happiness is a side effect of spending time in that sweet spot where the needs of our social group and our own personal needs are being met by the same activity. Only looking our for ourselves is sociopathic. Giving ourselves over to the insatiable appetite of societal need is self-destruction (or martyrdom, if you want a positive spin).
Sure, we are needed, but unless medicine is something physicians actually enjoy doing, there will be more and more of us who opt out, either physically or worse, emotionally.
I’m genuinely happy for you if you’ve found your sweet spot, CD. Since I have returned to medicine after our year off, I have been somewhat less successful at finding contentment in this work.
Author
It’s cyclical, Matt, so I apologize if I had misrepresented it as sunbeams and unicorns shooting out of all orifices. The mean is average, the median is a net positive, and the occasional awful days are not regular enough to thwart my desire to return for that next shift.
Most shifts are meaningful: at times for the patient interaction, at other times for the interaction with the staff, sometimes for a sense of service and advocacy where it was sorely needed, rarely for moments of flow.
Some shifts are intellectually stimulating – I’ll follow up and find someone I saw had an outcome I’d not expected, positive or negative, and I learn.
Some shifts are commiseration leading to understanding – sometimes it’s the patient who is miserable, sometimes it’s an unhappy person that tries to make miserable. I have a lower tolerance for the latter than I once did, but they happen and I try to insulate myself. I think it was a guest on the WCI podcast who referred to a consultant that came down to see a patient with a hostile family member that immediately laid into her when she entered the room. Her response: “I’m not the author of this chapter in your life, but I’m here to help.” Grace I am able to conjure under infrequent, non-excessive pressure is still grace, so I appreciate testing myself (even if the value occurs mostly in retrospect as lessons learned).
I like your definition of absolute self-absorption as sociopathy. I’ve yet to find anything positive about martyrdom, but perhaps that’s because the variant I’ve been exposed to is others asking me to bear crosses of their choosing on their terms. I handle service on my own terms just fine.
It’s a sweet spot not because it’s always terrific, but because at this point I’d miss it if it were gone, and because it balances out the other (more sociopathic / self-focused) activities I pursue.
My net sweet spot is like my net worth – a volatile path, hard to get a sense of at a single point in time, but the overall trajectory remains positive and the risk tolerance is about right. Hope that clarifies where I’m at.
Appreciate your friendship,
CD
Love this post – especially the part about society. I always enjoy reading your writing because you’re such a dang good writer! Thanks for saying what so many of us are feeling.
Author
You are too kind, my friend.
What is your sweet spot for number of ED shifts/hours? How did you figure it out?
I have gradually decreased from 140/month to around 115/month with mild improvement in my burnout and frustration with the system. In terms of figuring out a long term plan, I’m just curious how low you had to go to appreciate a significant change. And how do you compensate for concerns in knowledge and skills retention with fewer hours?
I enjoy your blog and appreciate learning from those who have navigated a workable solution.
Thanks
Author
Hey EMDoc,
Great question. The answer changed over time.
Initially I worked less in order to limit my pain. We’d been short-staffed for a couple of years, and we’d all worked more than we’d wanted to because our group doled out all excess shifts equally. I proposed 2 tracks for our group, a full and partial profit-sharing track. Those in the full track worked above a certain # of shifts per month. Those in the partial track worked within a lower range of shifts and received half the profit-sharing of the full group, but were promised that in times of short-staffing, each full track member would add 2 shifts for every 1 additional shift added to the schedule of each partial track member. I chose to be at the top of the range of the partial track because it capped my pain, and I did not want to work excessively if we ended up short-staffed as we’d been in the preceding few years.
What led me to cut back further was a combination of several factors: we reached certain financial goals we’d set for ourselves, and felt more at liberty to reduce our income, with the thought that if we simply left our nest egg untouched and earned enough to cover our expenses we’d be okay; our kids reached ages where we planned to travel aggressively in the summers, and reducing my shifts significantly was needed to create the requisite flexibility in my schedule to allow such travel; finally, my wife’s side business grew reliable enough to become a dependable source of supplemental income.
My present shift load of 6 per month has allowed us to take major family trips over the past couple of summers to Greece, Mexico and Spain, as well as numerous trips to visit family during the year. We were all set to go to Turkey this summer until COVID hit. The motivation for taking such a drastic cut was prioritizing independent family travel during this window of time in our kids’ lives.
As for the concerns about knowledge – I read more EM literature than I ever did, because I have greater energy and engagement with the specialty than I did when I was chronically tired. The skills are a concern – I intubate sufficient cases to feel comfortable, but I certainly place fewer chest tubes and central lines than I did formerly. That said, being 17 years out of residency, I feel more comfortable with the experience under my belt than if I were trying to cut back 5 years out of residency.
I’m also fortunate to be in a collegial group where we help one another out when sick patients arrive. For example, a few years ago a toddler with a cleft palate repair one day earlier presented in severe respiratory distress with stridor and was assigned to one of our newer docs. Three docs immediately entered the room: One colleague set about ordering the intubation meds and explaining what would be happening to the parents, our newbie double-checked vent settings in advance with the RT and then hit the phone to initiate transfer to a local PICU, and I intubated the kid. Point being that I work at a place where seeking help from your friends is encouraged and a part of our culture.
Hope this answers your questions. Best advice I have for you is to create your road map, decide what you would do with the balance of time if you cut back further, and determine what life or financial milestones you’d use to trigger the next stage of cutting back.
Wishing you success in finding the right balance,
CD