Why A Physician Should Work Full-Time

As an evangelist of part-time work for physicians, I occasionally get an e-mail from a physician reader asking if cutting back on work is the right move for them. Often times they are early in their training, and I’m not sure how to respond. I feel conflicted. I know what is right for me, but everyone has unique life circumstances.  I’m hesitant to give people the green light because I’ve lived through the consequences, and although I like working part-time as a physician, there are definite downsides I would like to highlight. This is one of those big decisions in life, and it pays to get this one right.

When I started this blog I really had no idea what it would become. I started writing about anything that popped into my head. Over time there was a theme that evolved – freedom. As I reflect upon my writing and my life in general, I realize that freedom is my mantra. Becoming a physician can take away freedom in ways that other professions do not, yet it gives you freedom in ways that other professions cannot.  It’s complicated. It is this complex tug-of-war that makes me and others feel so conflicted at times. I did not fully appreciate this early in my professional journey.

Planes, Trains and Automobiles

Each career has a different trajectory. Let’s use an analogy. Think of various careers as modes of transportation. There are many ways to get from point A to point B, and each has certain advantages and disadvantages. Let’s look at 4 of them: a bicycle, car, airplane and rocket ship, and compare them to a variety of jobs. We will look at them in terms of energy use (upfront costs), versatility (ability to change) and maximum speed or distance (earning potential). We will ignore things like how fun or satisfying they are, because these things are more subjective. Some people love to fly, others are never more miserable than when on a plane.

Bikes

My first job was bagging groceries at a grocery store. This job was a bike. There is very little energy involved in riding a bike. Even I can power one with my skinny little legs. All I had to do to get this job was fill out a one page application and shake hands with the manager. I liked him; super nice guy. I put on my uniform and started bagging groceries the next day.

There was very little training involved (groceries come down belt, I put them in bags, and put the bags in the shopping cart and asked the customer if they would like any help to their car). Now bikes are very maneuverable and can go just about anywhere. With these newly acquired grocery bagging skills I realized I could get a job anywhere, with little to no notice or hassle. There were several grocery stores within a 10 minute drive from my house. I could even stock shelves, sweep the floors and go grab some grocery carts from the parking lot. It was great.

The problem with this job though, was that it didn’t pay anything close to a living wage. It was fine for a little extra spending money as a teenager, but I would have really struggled if I had to pay rent, buy food, etc. Most people with a career in the grocery store business eventually transitioned to higher paying positions (cashier, management, meat department, etc.). There were hard limitations to how much money I could make at this job, just as the top speed of a bike is quite limited. No matter how hard I pedal, there is no way I can get a bike up to 50 miles per hour, and there is no way the grocery store was going to pay me $40/hour to bag groceries.

Cars

My mom was a school teacher. This job was a car. A car can go faster and further than a bike, but it also requires much more energy to operate. She had to go to college and get a degree. There was certification and intermittent classes to attend. She made a lot more money than I did bagging groceries though; enough to pay for our house, food, bills, etc.  And at the same time she had a lot of freedom to change jobs, just as cars have a lot of freedom. There are roads everywhere. But they are not as free as bikes. You can’t drive a car on the sidewalk, or on a single-track dirt trail or through a park (well, not without damaging the car or getting arrested). Although the pay was much better than the grocery store, money was still tight. We had to be very frugal. There are limits to how fast and far a car can go; certainly better than a bike, but not as fast or far as an airplane.

Airplanes

A good friend of mine is an engineer. This job is an airplane. An airplane can go way faster than a car or a bike, but it requires even more energy to operate. He needed to complete more training and more certification. The math classes were not something everyone can handle (including me and my mom). He certainly has many job options, just as an airplane has many airports to land at, but there are fewer opportunities than either a teacher or grocery clerk. He has less freedom of movement, as not every community has an engineering firm. The vast majority of communities have schools and grocery stores. He is also paid quite well, earning far more than the teacher and grocery clerk combined.

Rockets

Finally, we have our friendly neighborhood neurosurgeon. This job is a rocket ship. Once a rocket gets going it moves really, really fast. It will outpace a bike, car or airplane, and it looks really cool. But it takes A LOT of energy just to get it moving just one foot off the ground. Our neurosurgeon went to college (4 years), medical school (4 years), and residency (6-8 years) and maybe even more fellowship training. She likely had to be near the top of her medical school class. Who knows how many sleepless nights she spent coiling aneurysms and draining subdural hematomas.

But once she starts working, she will likely make more in her first year in practice than I could make in two decades bagging groceries. But a rocket ship is a one way ride. You can’t just come back to the launch pad and fire in another direction without a considerable amount of new energy. Once it gets going though, it takes a much smaller amount of energy to maintain course relative to the velocity. If she decided surgery isn’t her thing and radiology is her calling, welcome to 5 more years of residency. Also, there are way fewer neurosurgical job openings than a teacher, engineer or grocery clerk. In fact, some smaller communities don’t even have enough work to support a neurosurgeon, and if there is a high degree of sub specialization there may only be a few jobs at large academic hospitals.

Cool Story Bro…

Alright, so a neurosurgeon makes more than someone at a grocery store and has to take a lot of call to get there. Brilliant analysis. So what though? What is your point philosopher?

Freedom and money have an interesting relationship. For most of us, money creates freedom, yet requires a sacrifice of freedom to make it in the first place. Freedom is the rocket fuel you sacrifice to get the rocket moving. Once you are on the journey, usually the fastest and most efficient way to recapture that freedom is to keep going. It is wonderful and terribly limiting at the same time. It is very expensive to change course or slow down. Slowing down the rocket to half speed (going part time) as I did is not a mathematically smart move. (Probably part of the reason I’m not an engineer).

When most people think of their assets, they think of tangible goods, like houses, cars, stocks and money. But as a physician (and most other careers) our willingness and ability to work and generate income is almost always our largest asset, at least early in our career.

Trigger Warning: Math Ahead

Let’s look at some crazy insane salary numbers. If our neurosurgeon makes 600k/yr and has a 25 year career, that’s $15 million of lifetime earnings before taxes. Wow! Now that’s a rocket ship! Going half time, well, cuts that in half.

But it is even worse than that…

Let’s assume a third goes towards taxes. If she lives off of 150k/yr, pays 200k in taxes, she saves 250k/yr. I’m using after inflation returns to keep the numbers simple.

Investing 250k/yr at 3% return after inflation for 25 years is just over $9,000,000. She is financially independent (FI) well before retirement.

Well what if things go differently:

Scenario 1: She feels a little burned out after residency and stumbles upon some random, poorly written blog about how great part time work is, gets inspired, and takes a half time job making 300,000/yr. Let’s be generous and say her taxes fall to 20% (60k/yr). She lives off of 150k/yr, pays 60k/yr taxes and saves the rest (90k). After 25 years she has $3,300,000, which is great, but is a far cry from the 9 million she had with a full-time career.  She is technically not really FI yet trying to support a 150k/yr spending habit. Going half time out of the gates reduces her end retirement savings to 1/3 of what it would have been working full time. This is the awesome power of compounding.

Scenario 2: She instead works hard full-time for 5 years, and then cuts back to half-time (same assumptions with taxes and returns). After 5 years she will have around $1,300,000. Over the next 20 years, even with the lower contributions in scenario 1, she should have around $4,800,000. She is definitely FI using the 4% rule, which states she should be able to spend around 200k/year and not run out of assets.

You can see how putting in a few hard years of full time work early in a person’s career can make the difference between being financially independent and having to continue working. The differences are even more pronounced at some of the lower paying specialties, as there are certain fixed costs that just can’t be driven any lower.

Be Kind to the Future You

Now this is not a problem if you love your job and are able to do it, but I can tell you from both personal experience, and looking around at older docs that career satisfaction and/or ability to perform at a high level can change quickly. There is a difference between talking call at 30 vs 45 vs 65 years old. A hard week wears on me a little differently now than it did in my 30’s.

What I’m trying to say it makes sense to front load your career, when you can let compounding of investments and the greater energy and enthusiasm we have in our younger years to do the heavy lifting. Working 5-10 years full time right out of residency combined with only moderate frugality is an absolute super-power. Having a big pile of F-you money when you hit middle age is awesome, trust me on this. Be kind to the future you and give them the gift of freedom.

Another overlooked factor is one of knowledge and experience. You have to put in a certain amount of repetitions in the gym to build muscle and get stronger. You have to put in the clinic visits/surgeries/procedures to really get good at them and develop the nuanced skills it takes to really be a great physician. There are a lot of little tricks you don’t quite master in residency. I’m not saying someone can’t work part time out of the gate and be a great doctor, I’m sure many people do, but I’m glad I had a few years of full-time work under my belt before I cut back. It gave me a sense of breadth and depth that would have taken much longer to accomplish working much less.

Predictions are hard, especially about the future. There are a lot of landmines out there, and physicians are running through many mine fields. Burnout, divorce, major medical disasters are all things I have seen hit friends and colleagues. There is also the subtle lifestyle inflation that inevitably occurs after residency, which oftentimes people don’t take into account. As I have noted before, spending naturally increases from about 35-55, and it is dangerous to project the true cost of your life until spending reaches some sort of steady state. I know this kind of goes against what I preach about material things not bringing us happiness, and the beauty of decluttering and minimalism and all that, but I’m a realist. The amount you spend in residency when you have no kids, a beater car and a 1 bedroom apartment is probably not a realistic picture of your life in 5-10 years.

I love working half-time. It is near perfect for my unique situation, but it’s not the perfect solution for everyone. Instead of jumping into part-time work, see what full-time feels like for a while. Wait until you have a good idea of what you need before you slow that rocket ship down.

Here is My Generic Advice:

1. Spend a lot of time finding a full-time job that seems like it will be awesome. This is important. Give yourself a high pre-test probability of not burning out from your job. Write down what is important to you in a job and go find one that meets those criteria. Maybe it’s the call schedule, the mix of procedures, control over your schedule, administrative freedom or something else. Find or create a full-time job you think you will love.

2. Keep living like a resident until you have your student loans paid off and inflate your lifestyle slowly. The delta between spending and savings = freedom.

3. Take self-care seriously (exercise, sleep, diet, alcohol moderation, meditative/mindfulness practice). Full-time physician work requires a healthy mind and body.

4. Learn to say no. Only participate in the meetings/committees/friendships/projects that add value to the universe or bring you happiness. There are less of these than you think.

5. Stop consuming news (and television in general), and stop worrying about things not in your control (national politics, terrorism, peak oil, global warming, meteor strikes, alien invasions, etc.). You can’t control any of it, and it will just contribute to your negative mental state.

6. Learn to disconnect income from spending. Spend frugally and efficiently only on things that are necessary, or add value or happiness to your life. Understand marginal utility.

7. Rapidly build up your pile of F-you money so by 10 years of practice you have the freedom to do whatever you want (part-time, change careers, consult, etc.).

End This Already…

Good grief that was a lot of words. I will end with this: do what makes you happy. If you need to take a part-time job out of training to maintain your sanity, then do it. You must take radical responsibility for your life and deal with the consequences. As a physician you will likely be alright either way, but if you can keep that rocket ship in orbit, you will achieve freedom faster. Freedom is not the end goal of course; happiness and life satisfaction are the end game, but few people would be better off with less freedom. A wining hand is achieving both at the same time.