One of my goals has been to figure out what to do with that new balance of time I've carved out. I want to find something that will keep me busy after the kids leave home; a fiefdom of my own that lets me settle into an empty nest rhythm; something to sustain me going forward.
It's hard to figure out what I want to be when I grow up. I've thrown a number of interests at the wall, all in the name of finding something that might stick. Turns out the wall is coated with Teflon.
Like many physician finance bloggers, I often focus on the successes that come with assuming responsibility for your finances and asserting control over your time. This is partly to inspire other docs who suffer from burnout as I once did with a message of hope that it can get better.
I thought it might prove beneficial to highlight the negative results for two reasons. First, as with the medical literature, we physician finance bloggers exhibit a bias toward publishing only positive results.
Most readers of these blogs have a notion that the White Coat Investor is making significant income from his website. Fewer readers appreciate that the vast majority of physician finance bloggers make about what our summer lawn mowing job in junior high school pulled in, minus the complimentary lemonade offered by that kind elderly neighbor. Rarely, passion projects reward us in income; mostly they reward us in non-monetary ways. If you have income taken care of, then by all means relish that fun pursuit.
The second reason is that figuring out my Act Two after medicine (a work very much in progress) has been messy, with a number of false starts and plenty of dead ends.
I've read up on topics and interviewed for positions that never quite panned out.
I've considered ideas that seemed perfect, only to find during the execution phase that they weren't particularly enjoyable (Ask any group of doctors how many fantasize about opening an ice cream shop someday; then ask someone who actually runs an ice cream shop what it takes, and you'll see what I mean).
I've dreamed big, only to wake up with slobber on my pillow.
I've overused metaphors.
Like any journey, you can't succeed until you define your destination and map out how to get there. I started out making a list of characteristics I thought my ideal second act job might possess:
- No night shifts.
- No weekends.
- Flexibility.
- Can be done remotely / will not conflict with international travel.
- Autonomy.
- Low stress.
- Intellectually stimulating, with new skills to master.
(Note that ditching medicine completely, which used to be my main goal, was no longer a requirement once I started cutting back. The less clinical medicine I engaged in, the more enjoyable it became.)
Outpatient Palliative Care
One of my mentors from medical school, a (now emeritus) professor I call monthly, impressed on me that "There's good work to be done at the end of life." My interest in bioethics, which dates back to my undergraduate years, continues to be an arena I participate in regularly and find extremely rewarding. I decided to explore and network with local docs to see how they were practicing end of life medicine.
First, I had coffee and several phone conversations with a colleague from my specialty who became director of a small hospice program after his children were grown, and who continued his hospice directorship after leaving the emergency department. He was encouraging and supportive, and even dropped off a book he'd used to study for his recent hospice boards. He implied that someone always needed to be present for hospice, so I had reservations about that specific avenue.
I also reached out via common friends to another hospice director, someone who had made a major change in his practice mid-career and attended a hospice fellowship. He encouraged me to do what he had done, uproot the family and relocate to do a fellowship. That was not feasible.
Another friend I'd come to know as a hospitalist had transitioned to running an inpatient palliative care service, and was helpful in explaining the opportunities and benefits of working within our hospital's employed physician positions. I attended a couple of meetings with his service, and quickly understood the appeal of supervising a team of clinicians.
This conversation naturally prompted me to speak with a friend who happened to also be the business director of an outpatient clinic run by the hospital. It was intended to offload some of ED volume by targeting a population with high ED utilization and terminal conditions - perhaps joining this clinic might be a way of fusing my skills and interests while fulfilling some unmet needs of the hospital administration.
I explained that what I sought was to supervise a team rather than practice clinical medicine directly. My friend outlined a position with a fixed time commitment including an element of clinical work, but which also included benefits as W-2 employee. As an ER doc I've always been an independent contractor, so the prospect of health and dental coverage for my family seemed to tip the scales toward committing to the position. I followed up with another meeting with a senior level administrator who seemed cautious but interested.
Alas, when it came time for the offer, the hourly compensation was substantially less than my emergency medicine work; the clinical commitment expected from me was greater; the position did not have a plan for transitioning to the supervisory role I envisioned; and the offer did not come with benefits. I passed and thanked them for their time.
Join A Med-Tech Startup
As an extension of a passion project, I connected with several purveyors who license software intended to provide complex case management tools for docs at the point of care through an information exchange database. One product stood out in particular. I had coffee with the CEO as he traveled through our area, and I continued to advocate that our hospital purchase their product. After several years of persistence, the hospital opted to purchase the software license.
I was able to cobble together a multidisciplinary team and visit a sister institution that already employed the software. We started strong and gained momentum, inviting stakeholders to join our committee and obtaining buy-in from our administration. We developed plans to care for challenging patients, implemented these plans across the hospital, and our successes pleased the administration and provided additional proof of concept for the software maker.
Based on our utilization of the software, I was one of twenty physician-leaders invited to participate in an ad hoc advisory retreat out of state. While there, I had the chance to pick the brain of their Chief Medical Officer, to get a flavor for what his job entailed and how he had gained entry into this nonclinical world.
He shared that he'd taught himself to code in college, then joined some startups as a programmer in the late 90s. He'd worked clinically in medicine, eventually using his IT background to become Chief Medical Informatics Officer for his health system. Most recently, his background in Silicon Valley entrepreneurship combined with his medical degree had helped him become the CMO of this company as he could credibly claim to bridge the technical side of IT with the needs of the clinician at the point of care.
As for the current job, he traveled extensively, averaging two weeks away every month. Furthermore, he'd had to relocate his family to another state for his CMO job opportunity. He said his family (wife, 2 school-aged kids slightly older than my own) had adapted, reluctantly, to the hours and travel associated with the job. Despite these trade-offs, he loved the work and believed in the mission of the company.
He suggested that for someone like me without a tech background to try to enter the med-tech space, it would involve reaching out and spending many hours offering free consulting services to one or more early stage companies that could eventually be leveraged into a job offer as the company grew.
I thanked him and assessed what Id' learned from him. Pursuing a med-tech job would require a large, up-front investment of uncompensated time with no guarantee of income to follow. At best, that would lead to an offer potentially requiring significant travel time away from home.
Much as this CMO loved his work and it rated highly on the intellectual stimulation front, it did not fit with the remaining objectives of my Act Two job, so I crossed it off my list of possibilities.
If you are also mulling over your exit strategy from medicine or just enjoyed this post, please check out Part 2!
Comments 17
Thanks for writing this. I’ve also tried some non-clinical pathways without much success. I found that remote utilization management wasn’t a fit. Lower pay than clinical work, feels like a game of denying care after a while, and unpleasant peer-to-peer calls. I imagine that working in-office for a regional health plan may be somewhat better, but the review and deny part of the work would remain the same. I’ve also gotten involved with clinical documentation improvement, which is also low paid and tedious, but feels more ethical. I have avoided trying tech and EHR vendor work since I don’t want the constant travel. If I lived near pharma, I would consider trying to get involved. For now, I’m sticking with clinical work and waiting to see what else comes along. I look forward to reading part 2.
Author
ED,
It’s interesting to hear about your experiences. A couple of friends have taken the utilization management pathway, one with great success as an exit strategy from clinical emergency medicine, and I’ve always wondered what that would be like. I suspect I’d share your reaction and impression (review and deny doesn’t sound appealing).
Extensive travel might have been great when I was young and unattached, but it won’t cut it as a father and husband.
Improving documentation sounds ethically less ambiguous and more supportive of your fellow physicians, so I can see the appeal despite the drudgery.
What would you see as your ideal role in pharma? Clinical studies?
Hope to hear more from you,
CD
This was really interesting. First, it confirmed my belief that looking for a job IS a job😁 Secondly, I appreciate that you were so candid about your options and how you went about filtering through them. Lastly, as a low-wage earner, it was fun to read your list of desirable job characteristics, as my personal list has some similarities!
Author
Mrs. T,
Appreciate the kind words and feedback. I suspect that as we age, our ideal job characteristics start to converge irrespective of income:
-Respect
-Autonomy
-Flexibility
-Sense of making a difference or having an impact
-Only boss we care to answer to is ourself
My sister just finished taking a year off of work (crap timing with COVID), and her conclusion was that she’s happier working, it just needs to be the right kind of job. There’s a deep truth in her discovery that pure leisure isn’t all it’s cracked up to be.
Thanks for stopping by and pointing out the overlapping Venn diagrams of our lives,
CD
I think the real question for many FIRE folks is would they rather work at a job without the above characteristics or not work; most people would be happy working at the Perfect Job, but finding one can be a tough call.
I’d be interested to know if your sister found her ideal job, and if so, what it is.
Author
Snowball,
Good to hear from you!
The Perfect Job is kind of like the Perfect Partner – it’s a list of traits where you never realistically expect to get everything on it, but the more boxes you can check the happier you feel. The devil is in the details – if you have 5 boxes and take a job that checks only 2 of them, is that sufficient? What if those are the two you weight the most heavily? Like in most of medicine, the answer is “it depends.”
As for my sister, she ended up deciding among 3 offers:
A) Biggest salary, biggest title, huge time commitment, location indepedent, tepid about the product, liked the CEO
B) Great salary, big title, more defined time commitment, location indepedent, excited about the product, loved the CEO
C) Least but still great salary, defined time commitment, location indepedent, meh about the product, unsure about the CEO
She chose B. She decided that she wanted to prioritize work-life balance which had been poor in her prior job, and wanted to live abroad. She also decided that loving her administrative leaders was important, so she went where she felt she’d be supported and not micromanaged.
Is it ideal? That depends, said the zen master.
Thanks for always keeping me honest, Snowball.
CD
I appreciated the article and your candor in laying out the options. You are not alone! Like you, I have decided to cut back to part-time Hospitalist, and it is that more enjoyable!I I enjoy international travel and my ideal “next job” would be something that would allow me to work from anywhere. Telemedicine?? I am curious to what your sister’s choice was, and how can one go about finding something like that out there. I am too looking forward to reading Part 2! Good luck!
Author
RC,
I feel like part-time medicine is this little buried treasure of a secret that too few burnt out docs know about. Congrats on discovering it!
An old friend in EM recently wrote me to share the story of his final departure from medicine. Before he left, he was doing exactly what you are – part-time work interspersed with international travel.
As for telemedicine, one of the great pioneers in remote location telemedicine services is Dr. Mo, who until recently was writing at digitalnomadphysician.com (he’s fine, just on hiatus). He purchased a minimalist apartment in Spain, and had practiced telemedicine while living there with success. Sadly, his site is offline for now.
My sister is nonmedical, just going through parallel career midlife crisis issues; I’m sorry if that was not clear from the outset.
Thanks for reading, and please keep me posted as to what fork you decide to take.
Fondly,
CD
Really cool insight CD. I sometimes daydream what my purpose will be when I leave radiology for good.
Blogging is fun but, as you mentioned, if you are not in the big 3 or 4 in this space it is more of a hobby than a profession.
Writing a book and teaching probably are sectors I am gravitating towards. Hopefully can continue blogging as well.
Look forward to part 2
Author
Xray,
Given your impending FIRE readiness, I’d think you’d already be moving from daydreams to book outlines and teaching gig listings! I’d love to see you keep blogging, but also hear about the other cool stuff you plan to do. How else will I get more ideas?
Fondly,
CD
I think that this article is totally relevant. I backed out of clinical ED medicine for the most part in the Spring, when the risk of insufficient PPE and knowledge combined with family underlying health conditions and COVID risk made it seem too much. I spent six months contemplating other options and less risky scenarios. Ultimately, after interviewing for a number of different jobs I found similar issues..lower pay and higher work requirements than ED medicine doing primary care (although more ability to control my work environment) and very low pay and endless heartache as a public health officer.
I have signed onto a part-time role as medical director now of an addiction medicine clinic. It won’t require travel, or weekends, or nights, and it allows me the sense of altruism that EM gives: serving the under-served. The pay is lower, and the adrenaline rush is not there, but it gives me all of the other things I want and need.
Author
Juliet,
I genuinely appreciate hearing your story and how it’s unfolded. I’ve come to the conclusion that adrenaline is a young physician’s drug. Those aspects of EM I found sexy and exciting as a newbie (trauma, invasive procedures) I now find algorithmic and inconvenient (stuck again an hour after my shift running a resuscitation).
As financial security increases and debt decreases, the emphasis shifts to controlling your own time and destiny. I hope your new position offers that opportunity.
Sincerely,
CD
Narrative is just narrative. Because a million FIRE bloggers write every day about living a happy go lucky life where the dough rolls in by the car load while they sit around in their jammies, in general the narrative is somewhere between total BS and partial BS. There isn’t any skillset most physicians possess beside medicine that pays nearly as well as medicine. Your best bet is locums in terms of bang for the buck and flexibility.
I left a 34 year solo IM practice and joined a big group due to all the HIPAA, OSHA and EMR that I could not keep up with on my own. Hated everything about the big group and lasted only 3 months. Had a house call job then spent 16 months as a jail doctor- did fine with the prisoners and staff but could not take it any longer as the sheriff and administration and I were not on the same page regarding patient care- like not even close. I walked into a psychiatry hospital and got a job doing medical care on the psychiatric patients and that was ok but kind of dangerous as no security- I actually felt a lot safer in the jail. They had an MAT clinic and I took the waiver course and started seeing outpatients with substance use disorders. I did this for four years and had over 120 patients and I found this to be very rewarding. The patients certainly had their issues and some slip ups but generally they were all regular people trying to get their lives back together again. Many of them developed an opioid problem due to medical issues. I got to know them very well just like when I did primary care and I would recommend this work to anyone. I called patients when they did not show up, helped them with PAs and when they were treated terribly by pharmacies or pharmacists, I went to bat for them. Unfortunately the clinic was run poorly and after praising my work one month, the next month they told me I would have to cram 1 1/2 days of patients into 1 day-I would not do that so I had to leave. I would like to continue this work but with the virus and me being 74, I don’t think it is safe and I don’t feel comfortable doing this work remotely with patients I do not know.
Author
Bob,
That’s a powerful story and a fascinating journey – thanks for sharing it! It’s helpful to hear about success stories of folks with substance use disorders getting their lives back on track through MAT, especially since in the ED we often see them at their worst.
In pre-COVID times, I once had a former patient throw an arm over my shoulder and thank me for confronting him about his opiate use – he proudly told me he’d been clean for six months at that point. I offered praise and encouragement over some free samples of cabbage salad. A friend from residency pioneered a program in northern California initiating MAT from the ED with explicit next day follow up in a clinic. I have tremendous respect for folks who undertake that difficult and important work.
It sounds wise to take yourself out of the viral crossfire of in-person medical appointments for the time being, but it gives me to hope to hear how you found a niche within medicine that offered the long-term relationships you valued.
Here’s to finding another opportunity that feeds you going forward,
CD
Great article, Crispy Doc! After a decade as an IM trained doc, first as a hospitalist and then later in the SNF world, I am considering a change in career.
I think about Pharma (Have a lot of options where I live) but have had some trouble breaking in. Have also thought about transition to an IT position focused on healthcare, but don’t have programming experience. Am I too old to learn Python? Do I even WANT to learn Python? 😬
Your article is timely! Good to consider other possible circumstances. I also agree that your list of ideal job characteristics probably converge over time with what most people want. It’s certainly a list that matches mine after a decade of employed attending life in a large health system!
Author
Anony,
Hospitalist and SNFist are two difficult jobs in medicine – thanks for serving in those positions for so long. A friend and colleague began serving in IT related capacities as a volunteer at first, which made her a known, liked and valued quantity to the decision-makers in the IT department at our hospital (for good reason; she’s a gem). This led to a trial period as Chief Medical informatics Officer, an online master’s degree in medical informatics she pursued while practicing clinical medicine, and recently a formal position as CMIO.
She played the long game and developed her network from within because she loved being the liaison between docs and machines, and she was great at it. It also turned out be a something that took a ton of work and personal investment to achieve. By all means learn python if it appeals to you, but if it does not beware that it may turn out to be more of a serpent around your neck.
Dr. Sylvie Stacy and Dr. Cory Fawcett have both written resources that may prove helpful in figuring out your next step. The former specifically describes what life in Pharma might be like to ensure its the right fit for you.
Here’s to your finding an escape from that cog in the wheel feeling,
CD