How to Prepare for Life After Residency

Burnout and Finance

I was recently asked to speak to a bunch of medical residents about my story of burnout and my general philosophy on finance and life. I declined for a variety of reasons, but upon reflection I realized that this was a topic I had not addressed. This is really important stuff, and if I’m not going to lecture on it, I at least need to write about it. Maybe the thoughts trapped in my brain would be helpful to physicians coming out of training.

If you are not a physician, don’t worry. You still may find this article useful. Many of these concepts will apply to other professions.It is said when the student is ready, the teacher will appear (which is why you have found yourself at exactly this moment reading this brilliant analysis). If this article is not relevant to you, I have confidence that you will open a new window in your browser and move on to the next dopamine burst of internet cocaine. If you are ready, take the red pill and brace yourself for some uncomfortable (at times) truths and my observations.

In residency I was amazed at how differently my fellow residents and I approached finance. I was always trying to figure out how to maximize our retirement accounts and maximize marginal utility of money. When I finished residency, we sold our house and made a nice little profit. We took that money and immediately put it away in anticipation of purchasing another house in about a year (after my fellowship). My good friend, on the other hand, leased a new BMW the day he passed his boards. Needless to say, we had different ideas about personal finance. I’m pretty sure if some burnt out, tired looking mid-40’s guy came and talked to us about burnout and personal finance, my buddy would have still got that BMW, and I would still have saved the money for a house.

Normalcy

From an outsider looking in, I am a strange guy. Many people can’t quite figure me out. I know this about myself. I’m a dude who burned out from my job less than five years in, contemplated quitting, then casually discarded 7 figures in future earning potential to go half time. This is after spending 14 of my most productive years, in the peak of my life, learning to do my job.

Yeah. Weird.

People just don’t do what I did, especially as a man (actually some do, they just don’t loudly blog about it like me. They quietly fade into the background). Medical students and residents don’t see people like us. They see the surgeon working Q2 call or the internist carving through clinic visits like a skilled samurai. They make life look easy, and these are the people we admire and want to emulate. When people like me are noticed, we produce cognitive dissonance because we do not fit the pattern. We don’t follow the nice little script society writes for all of us.

There is no weakness or vulnerability allowed in medical training. It is ridiculed and suppressed wherever it is noticed. There is no crying over the 10 year old kid who dies on the operating table after being flung through the windshield, or the single mother of three who is given a terminal cancer diagnosis. There is no complaining about the 36 hour shift and chronic sleep deprivation. Internalize, suppress, and move on to the next consult/surgery/conference. We are the strong and confident; the ones to lead the cavalry.  Those in training look around and only see “strength”…whatever that is.

There is subtle shaming throughout medicine, and the “weak” ones just keep their heads down. When someone burns out or becomes emotionally overwhelmed by work, the outward signs are often subtle. Docs do everything in their power to project the illusion that everything is fine. And then one day it is not.

Kind of bleak and depressing, I know. Not what you probably wanted to hear. So why am I telling you all this?

There are plenty of physicians suffering from severe burnout, depression, substance abuse and suicidal thoughts. Even amongst the ones that look strong and confident. If you experience any of these things please know that:

1. You are not alone.
2. These things are much more common than you would guess just from looking around and observing people.
3. These thought patterns are more dangerous than you might realize.

Risk

Human brains do a really shitty job of assessing risk in modern society. We are hardwired to avoid poisonous snakes and lions. We are not hardwired to avoid burnout, chronic disease and suicide; and unfortunately all of these things are increasing in prevalence, whereas very few people die from lion attacks each year*. As a result, people don’t prepare for burnout. They don’t really think it will happen to them, and by the time they do hit maximum stress in their life, they have created a situation for themselves that they cannot untangle from. Their ego and finances are completely dependent upon the very thing that is destroying them. It is a terrible feeling, believe me. I have been there.

I don’t know if any of you have stumbled across well-meaning but relatively useless articles on burnout in whatever specialty or trade journal you read. They all sound the same, like they were written by some poorly designed AI journalism bot.  Maybe a human wrote some of them, but it is apparent to me that neither the human author nor the bot have actually been through burnout. They generally start with the definition of burnout, move onto scary sounding statistics about it, and then recommend some benign and banal advice like exercise, eat more kale and meditate (which you are already doing anyway since you read my blog). They say we need to come together and solve this problem, perhaps with more group hugs and mandatory meetings with the chief wellness officer.

Unless our chief wellness officer wields a flame-thrower and is there to metaphorically burn down the medical industrial complex so we can start from scratch and design something a bit more functional, I am skeptical that this is the answer. In fact, I don’t have great answers. No one does. But this also does not mean we should throw up our hands and join some malignant Facebook group and whine about things all day long. Identify the risk, formulate a plan, and take action.

Insurance

Residency is a busy place. There seems to be endless things to learn, and not enough time to do everything that needs to get done. But residency is the place to start to think about this. No doubt someone will start to educate you about financial risk involved in medicine. You will be told to buy some life insurance (term I hope), disability insurance and malpractice insurance. These things are needed, but there is no such thing as burnout insurance. If you read your disability policy, there are very specific things that are covered, like losing both your arms to a lion attack or going blind. Mental disorders are time limited in most policies. Mine is 24 months for my entire lifetime; maybe longer if I am institutionalized. But burnout is this weird place of not quite disabled, but not quite good either. No one has your back so to speak. You have to take control and create your own policy.

Insurance companies are experts at pre-test probability . It’s called actuarial risk. They know with a great deal of certainty when you will die, how many car accidents you will be in, and generally how much you will end up costing them. Ok, not really. They can’t know what will happen to you specifically, but if they pool together 10,000 people just like you, they will be near perfect in assessing their average risk. The way to take advantage of this as individuals is to know more than the insurance company. If you know something that affects your risk that they don’t know, you can find insurance that will, on average, pay out more than the premiums you pay.

When dealing with burnout, you are both the insurance company and the customer. This means that the more likely you think you may experience burnout, the more it behooves you to create a robust and comprehensive plan. If you find yourself halfway through residency wishing you could take more call, see more patients and can’t imagine yourself doing anything else with your life, then I would say your risk of burnout is lower than a guy like me. I like medicine. I like being a doctor, but in retrospect if I’m honest with myself, I could have predicted my burnout was an above average probability. I never loved it the way some of my colleagues seem to. I’ve always really hated call. I never understood why anyone, anywhere in the world would not design their life around a good night’s sleep. I didn’t like some of the more stressful aspects of medicine, yet it was also quite tedious and repetitive at times. There are great things about my career like the cool cases, the interesting discussions with other docs, the minor procedures that break up the day, etc. That said, I never really thought I could end up so miserable.

Lesson 1: Know thyself. Assess your risk of burnout and prepare for that possibility.

Predictions

One of the problems with medicine, and life in general, is that you never really know how the next step will feel. Nobody goes into a marriage thinking they will be miserable and get divorced, yet this is exactly what happens to many people. For others, marriage is an experience that brings incalculable joy, growth and discovery. Work and career is no different. Medical school felt very different than I imagined it would as an undergraduate. Residency felt very different than I thought it would as a medical student, and my job now feels very different than I thought it would as a resident. You just don’t know how something is going to be until you actually experience it.

When I went to my last medical school reunion I talked with a woman who was now working half time. I was a bit shocked actually, because she was one of the most passionate and enthusiastic people I’ve ever known. I would never have imagined, of all the people in my class that she would be half time. The profession wore her down though. She decided that working half time and still loving her job was better than going full bore and massively burning out. Sometimes knowing thyself is not enough, because you don’t really know the person you will become in the future. The circumstances of your future are unknowable, and the longer the timeline, the more potential disruption and chaos may ensue.

Lesson 2: The future is unknowable. Plan accordingly.

The Right Job

That being said, do everything you can try to set yourself up for success. I actually did a pretty good job of this when I chose my current job. We knew the kind of city we wanted to live in after having lived in a variety of places. I knew the things that were important to me in a job (plenty of time off to recharge, a fair and democratic group, good people that wanted to do good work). I picked the right job for me…yet I still burned out. However, when I sat down and really thought it through, it wasn’t really this specific job that burned me out. I think I would have burned out from any full-time radiology job. Talking to radiologists in other groups, I realized that the things that caused my burnout would really have been the same in any practice. And even though I was burned out, I was living in a place I loved, working with people I liked.

When you are unhappy with work there are really only three reasonable things you can do (in a general sense).

1. Change jobs (either find a new one or change the one you have)
2. Change careers
3. Change yourself

That’s really it. It’s not that complicated. Everything is just a variation of one of these general themes. All of these things are really hard to do, especially when you are miserable and questioning all of your life decisions. Find a job with a high pre-test probability of success and happiness, even if this means taking a bit less money. Wise upstream decisions can save many downstream headaches. Massive change is expensive and disruptive.

Lesson 3: When choosing a job out of residency, maximize for happiness and longevity.

Buying Happiness

When my friend from medical school told me she cut back to half-time, I couldn’t help but wonder about the financial impact. She was not in a high paying specialty and presumably now made much less the average physician, yet she was able to go half time. In contrast, I know high powered, two-physician households that make three times my salary (before taxes), and would have to significantly alter their lifestyle to accommodate part-time work. As far as I can tell, both are equally as happy in spite of a 5x or more spending difference (although one of them has more freedom).

I’ve beat this topic to death here on the blog, yet it bears repeating. Money and time are fungible. You trade time for money, and then give it back for stuff that makes you happy or free in the future. When you spend money, you are depleting your time bank account. Time is your most limited asset, as there is no way to create more of it.

When you practice frugality, you are actually buying future freedom. Most humans are in-the-moment hedonistic consumption machines. We try and buy happiness. Our demand for stuff is endless, but we adapt to it all.

A few examples:

• The last car I bought was absolutely amazing compared to the 15 year old one it replaced. It was incredible driving around in it those first few weeks, but now it is just a car to me. It hasn’t made me happier.

• The variety of produce in the grocery store down the street from me is probably more diverse than what was available in the entire state in the 1970’s, yet I don’t really notice. I just eat it. It doesn’t make me any happier.

• I walk around with a supercomputer in my pocket that gives me the answer to anything I need to know, and can show me how to get anywhere if I ask it a question. This is Star Trek level stuff here, but as far as I can tell, having a smartphone has probably on average brought me less happiness.

• One day, when I was a kid, my parents brought home a new television. We got 4 channels and relatively poor reception and you had to sit close because it was like 19 inches or something – and it was awesome. I figured we were rich. When I hooked up the Intellivision  gaming system my mind was blown. My friends would come over and play low-resolution, terrible video games for hours. This made me very happy. In contrast, today you can get a used high-definition 55 inch TV for almost free, and play endless games from almost any genre over the internet. The graphics are so incredible; some of these games are barely distinguishable from realty. This is all happening while simultaneously talking with people from anywhere in the world through wireless high fidelity headphones that didn’t even exist when I was a kid. But, I’m pretty sure these games don’t make me any happier.

You get the idea. Spending more money will not make you much happier than you are now, unless you are living in poverty; but not having money in the future can bring you incredible stress and misery because your choices will be limited. Use the concept of marginal utility on every financial decision you make. If you are a physician, you are making an insane about of money compared to the average person.

Lesson 4: Spend wisely because money is freedom.

Living Like a Resident

You have probably heard the concept of “live like a resident” the first few years of practice. Unless you are a master of stoicism like Mr. Money Mustache, this just is not going to happen. No one really does this, and the good news is you don’t have to. You will be making enough to live a little more richly. When the big doctor paychecks come rolling in, no one maintains their spending level at what they did in residency, but this doesn’t mean go crazy either. Here is my modification:

Live like a resident and a half.

This means you can buy a new car. You don’t have to live in a crappy 1 bedroom apartment anymore. But also don’t run out and lease two brand new BMWs and buy a 2 million dollar house.

If you believe survey data:

• The average resident makes around 60k/yr. This is around the average household income in America.
• The average primary care doc makes around 225k/yr.
• The average specialist makes around 325k/yr.
• 15-25% of this will go to federal and state taxes.

If you spend 90k/yr you will have plenty left over to massively save and service your debt.

Keep spending in the 5 figure range until all of your student loans are paid off and you have a few years of spending saved.

Lesson 5: Live frugally.

Student Loans

Speaking of student loans, I was chatting with a medical student a few years ago about the cost of medical school. She was paying over 60k/yr in tuition and fees alone, which was entirely financed with student loans. She also had a pretty nice car, went out to eat occasionally, and didn’t live a life of deprivation. She estimated between undergraduate and medical school loans, and taking into account the accrued interest, she would have 500,000 dollars of debt when she graduated. After my heart palpitations and blurry vision went away I inquired what her plan of attack was. She threw her head back a bit and laughed.

“I’ll just make the minimum payments for 10 years and the federal government will forgive them. No big deal”

I was speechless. When I went home that night I researched student loan repayment and she was right. The federal government indeed did have a program like this. It’s called PSLF (Public Student Loan Forgiveness), and it’s absolutely bananas that a program like this even exists. My tax dollars were being used to fund a private, for profit medical school and the ability for a medical student to live a relatively luxurious life. My spending in medical school outside of tuition was probable below the poverty line. I had roommates, a car of questionable reliability and I ate Top Raman way too often.  I was outraged (this was back in the day where I was a bit more triggered by these things).

Well, as it turns out she may not want to open the champagne and start running that victory lap. It seems the federal government outsourced the administration of these programs to companies who have no financial interest in actually allowing anyone to have their loans forgiven. It has become a bureaucratic dystopian nightmare for most borrowers who are discovering they are not eligible for forgiveness in spite of trying to follow the rules. Only time will tell how this story ends. My guess is a class action lawsuit and congressional action, but my crystal ball is a bit cloudy.

There is one thing I do know though, and that is that student loans are a terrible form of debt. If student loans were an STD they would be herpes. There is no way to get rid of them. Lose your job? Become temporarily or partially disabled? Go bankrupt? Tough shit, pay your loans buddy. The only sure way to get rid of them (and herpes) is to die. That’s right; short of actually paying them off you have to die to get rid of them. This should be a red flag to you. Please pay off your student loans within 5 years, because student loans are modern day government sponsored slavery.

Straight from the US Department of Education:

“You must repay your loans even if you don’t complete your education, can’t find a job related to your program of study, or are unhappy with the education you paid for with your loan. You also can’t claim that you have no responsibility for repaying your loan because you were a minor (under the age of 18) when you signed your promissory note or received the loan.”

Translation: We don’t care about you in the least. Pay us back or we will use the full force of the federal government to repatriate our funds and destroy your life.

Lesson 6: Student loans are evil and should be quickly eliminated.

The System

I read a lot of stuff about burnout, and one thing I’ve noticed is that the system is universally blamed. “If only we could change the_______ then I would not be burned out.”

Insert whatever problem into the blank you want: Electronic medical record, medical malpractice, meaningless paperwork, clueless administrators, grumpy patients, insurance company requirements, crappy reimbursement, toxic patriarchy, etc.

Maybe these things are all true, and if so I think we can all agree they could be reformed and made better. The problem with blaming “the system” though, is now you are the victim, and your oppressor is a faceless bureaucracy or system you have no control over. People spend their whole careers trying to reform these systems, and most of them accomplish only slight nudges of incremental change, and when they are changed it usually doesn’t benefit you, the physician. I’m not saying these things should not be done. If you want to get on the “Make EMRs Great Again™” committee in your free time then have at it, but don’t expect this to be the magic bullet to cure or prevent your burnout.

If you are going to work within the system then you have to play by the system’s rules. This is society 101. You could work largely outside of the system. Some physicians manage to do this. There are docs who are independent of a hospital system, practicing some form of concierge medicine that works for them, and I think this is fantastic. But let’s be honest with ourselves for a minute. Not everyone has the skills, knowledge and desire to open up an independent practice. In some specialties this is almost impossible. Telling people that aren’t really entrepreneurs to go open their own practice is like telling the 50 year old laid off truck driver to just learn to code. Most of you will probably end up working for some sort of system whether it is a hospital, multispecialty group or independent group (like me). And when that happens, you are now part of a system with rules and flaws just like every other system out there.

Prioritize the things that you can control. Minimize the impact of the things that you cannot. Change from an external to an internal locus of control. Figure out the system and where your pain points are. Only spend your energy working on things that can be changed and will have a meaningful impact.

Lesson 7: Don’t waste energy on things you can’t control.

Resiliency

When I burned out from my job, I decided I would work for 5 more years then quit medicine altogether.  After doing some back of the napkin calculations I figured this was all it would take. After congratulating myself for coming up with such an awesome plan, I quickly realized that I still had to go to work the next day. I don’t know how many days there are in 5 years…but there are a lot. I had a choice to make. I could be unhappy and miserable, or I could make the best of it. I could have spent all of my energy complaining about things and trying to reform the system, and I probably would have burned myself out even more. Instead, I decided to change myself.

I needed to become the person who could be happy working 5 more years. I started experimenting with mindfulness and meditation. I read voraciously and consumed podcasts, listening to people who were smarter and happier than me. I got outside more. I started practicing gratitude. I started saying no to obligations and requests that didn’t make sense, and I got rid of the clutter in my life.

It helped. By the time I went part time a couple years later, I noticed that I had become a calmer, happier person. The job was no less tedious or stressful, yet somehow I had changed myself to be more resilient. There are many people that believe by focusing on wellness and resiliency, we are enabling the system and blaming the victim. I think this is a 100% wrong and deranged thought process. Becoming a stronger person and developing strategies to deal with a dysfunctional system does not make us a victim. It empowers us. Blaming the system and doing nothing makes us a victim. We must become the strongest, best version of ourselves to work in this chaotic, broken system. Take control of your life and optimize everything.

Lesson 8: Become the strongest, most resilient version of yourself.

Preparing for the Storm

Last year I went to a radiology business conference. I don’t know how the job market is right now in your particular specialty, but in 2019, radiology is spectacular. There are job postings as far as the eye can see, and not enough radiologists to fill them. A few years ago it was completely opposite. With our last couple of hires we have noticed the pool of applicants getting smaller than ever. I’ve also noticed that my job is a heck of a lot busier than it was 5 years ago. It seems as if the demand for radiology is nearly endless, and I suspect it is like this in many other specialties.

One of the biggest challenges with a radiology practice is that there is limited control over the volume of work. If my hospital becomes 10% busier, guess what? My workday just got 10% busier. The work just has to get done. One of the major factors in burnout is the sheer volume of work. At some point, your brain becomes saturated and you can’t really take any more. You need time off and the ability to recharge. When the 9 hour day with leisurely lunch routinely becomes an 11 hour day with no breaks, there is a point at which most normal people start to spiral.

There are some demographic trends that will shape the practice of medicine, both economically and practically. I’m sure you all have heard of this cohort of people affectionately called the “baby boomers”. Well, they are all old now, 55-75 to be exact. And older people use more health care than younger people. Love them or hate them, they have arrived full force into the health care system. They are a sicker population with more hypertension, diabetes and cancer. They require more office visits, ER trips, gall bladder surgeries and CT scans…and they are just getting started. The slope of the aging of our population is just starting to accelerate, and the number of physicians is not increasing fast enough to keep up. We are in the second or third inning of this ball game and our starting pitcher is looking pretty tired. Charts like this one make me scratch my head and wonder how all the work will get done.

With the policies in place today, there is no chance we will not be facing massive physician shortages over the next 10+ years. Physicians are not like fast food workers or Uber drivers; you can’t just throw an ad on Craigslist and have people working a few weeks later. There is a massive lead time that goes into preparing physicians for the workforce with a minimum of 8 years of application process, medical school and residency before the first newly minted doc comes off the assembly line. It’s longer if you actually want fellowship trained specialists.

Additionally, the current physician workforce is aging alongside the general population. The average doc is around 51, and this will likely increase over the next few years. As the workload increases, medicine will become both more lucrative AND accelerate burnout simultaneously. I predict the average physician age will drift higher, while at the same time the average physician retirement age will drift lower. As these physicians retire, there will be more stress placed upon those left in the system. Those remaining will start to burnout at higher rates. Many of the younger millennial docs and gen Z will say ‘fuck this’ and start demanding things like part time work and a reasonable schedule, which they sort of wanted all along but were too timid initially to start asking for it. The difference is that now they will have leverage.

As everyone is standing around pointing fingers at one another, doctors will start noticing that although they are working really, really hard, they aren’t making all that much more money. This is because more of their patients are Medicare now, which reimburses at a lower rate than private insurance. Those that don’t prepare will be trapped in a system that becomes busier, more stressful and less lucrative. It will start to eat away at the souls of those who are least resilient. Remember, the system does not care about your well-being. They only want you to show up to work and do your job. As soon as that ability or willingness ends, you will be cast aside.

There is a ray of hope though. Looking at data from the National Residency Matching Program it does seem there was a sudden upswing in the number of PGY-1 positions beginning around 2014. It is unclear to me that this will be enough though. Only time will tell.

What really worries me though is that the job I burned out from a decade ago was actually a much easier job than I have now, and everyone I talk to in medicine echoes this sentiment. I’m not one for alarmism and moral panic, but I am concerned for our newly minted physicians being thrown into the system. Society really needs good, competent and compassionate doctors, yet I worry that they will be devoured by the medical industrial complex as we try and figure out as a society how to care for our rapidly aging population.

Lesson 9: The forces that lead to burnout will only get stronger in medicine, so put yourself in a position of financial strength and resiliency.

Summary

Being a physician can be a wonderfully rewarding career, but it can also kill you. It can be fascinating and tedious and boring multiple times in the same hour. You will see people at their most vulnerable moments; and often on the worst days of their lives. Sometimes you will help them live. Other times you will help them accept death. It’s a messy and often beautiful experience.

Recap

• Lesson 1: Know thyself. Assess your risk of burnout and prepare for that possibility.

• Lesson 2: The future is unknowable. Plan accordingly.

• Lesson 3: When choosing a job out of residency, maximize for happiness and longevity.

• Lesson 4: Spend wisely because money is freedom.

• Lesson 5: Live frugally.

• Lesson 6: Student loans are evil and should be quickly eliminated.

• Lesson 7: Don’t waste energy on things you can’t control.

• Lesson 8: Become the strongest, most resilient version of yourself.

• Lesson 9: The forces that lead to burnout will only get stronger in medicine, so put yourself in a position of financial strength and resiliency.

If you distill these lessons into their essence it is this:

Make decisions that maximize your freedom and happiness. 

Every decision you make should go through this heuristic. If it is not making you either happier or increasing freedom, it is usually the wrong choice. Not always of course, but it is a good starting point. Hopefully you find this guide useful.

Namaste.

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*about 250 people are killed by lions each year. Comparatively about 800,000 people die by suicide annually.