“I know you joke about going back to retail if you quit medicine, but I can’t really tell if you’re serious or not and I can’t gauge your reaction over the phone.
So what are you going to do, M?”
Letting the silence linger on while I pondered my answer, I was struck by the bizarre series of events that led to this conversation. How had HD moved from handing out rambling snippets of life advice on the blog to now acting as my literal life coach while I sat in stand-still traffic on my commute home? Impatient with waiting for me to post about my progress to make a damn decision last summer about leaving my old clinic, he earned a sneak peek into the process by guiding me through contract negotiations with my new job.
The same job I was currently threatening to leave.
“I don’t even know. I’m all over the place, obviously. What would you do if you were me?”
As my unlikely mentor regaled the tale of someone who was able to work their way through burnout after doing locums work in New Zealand, I patted myself on the back for stalling.
He’s talking about this New Zealand thing like it’s an actual viable option you were going to pursue, M. How is he supposed to help you if you keep throwing out all these red herrings, designed to garner a chuckle and throw everybody off the scent of your indecision? Deflection is just another form of avoidance – you’re not doing yourself any favours.
Catching myself letting out a deep sigh, I pictured HD recoiling from the awkwardness of me breathing into his ear.
“Well, at this point I’m signed on for a 2 year contract and I still have student loans to pay. I’m finally down to under $75,000 but I still need to work. I think I’m going to try cutting back for now, otherwise I’ll have to find something else.”
“Still in medicine?”
A paralyzing wave of nausea came over me as I realized – this was the question I was avoiding.
I couldn’t help but tally up the sunk cost into this career. 12 years spent honing and improving my craft since starting med school, $250,000+ in student loans I was still paying off. Missed birthdays, holidays and wedding celebrations that I told myself was worth it because I was doing something meaningful with my life and contributing to society.
My whole self identity had been wrapped up into this story I had told myself for so long.
If I turned my back on medicine now, would it all have been worth it? And if I stayed, would I merely be giving in to confirmation bias because it was easier to remain on this path?
Realizing the length of time stretching out between HD’s question and my anticipated response, I let out another cringeworthy sigh.
“I don’t know. I’m not there yet. But I do have an upcoming meeting with my medical director in 2 weeks, so my first step is to talk about cutting back.”
The meeting
“You’ve been with us now for 3 months! Is everything going as advertised?”
Giving him a neutral smile, I wondered if all his interactions with the rest of my colleagues were this tense. Every question carried with it an ulterior motive. Did they train people in leadership to do that or does administration attract that sort of individual? Suppressing a laugh, I recalled the last conversation in which he asked thinly veiled questions about my fertility plans.
You’d think they’d at least teach them to be better at playing these games. He may think he’s being coy, but he’s as transparent as Jim Carrey’s character in Dumb and Dumber. With the same haircut too!
“Everything has gone as expected… though the schedule for March was not as 5 days on/5 off as I was initially told. As you know, I was switching back and forth from days to nights every other week, and I hadn’t anticipated how difficult it was going to be for me now that I’m older. I actually want to talk to you about cutting back and what that would look like, because that’s just not sustainable for me.”
I watched as his pleasant smile deflated into a thin flat line. This clearly wasn’t the direction he thought this was going to go.
“Yes, March was tough. Census was high and so many people had taken off for spring break. It was very atypical.”
Nodding my head, I noted the reasonable voice conflicting with the clear displeasure on his face.
“You know, I thought that too initially. But then I got to April and May and the schedule was pretty much the same.”
Exhaustion overcame me just thinking about it.
74 hours worked in a 7 day stretch, flipping from days to nights while pretending to be the epitome of health for my patients. Meetings tacked on at the end of the work day that started at 7 am, trapped in a conference room past 9 pm while administrators droned on and on about how the hospitalist department was actually losing the hospital money in order to justify the incorporation of a mandatory backup system for other outlying hospitals. Conversation after conversation with angry family members who just couldn’t understand why we couldn’t just “fix” their loved ones.
As I watched him fidget with his pen, I wondered what was going through his mind. Had he not expected me to be so direct? Was he taking my comments personally since he wrote the schedule himself?
“Well… we are aware of the staffing issues. Which is why we brought you on board and have hired 2 more docs in the fall.
Is there a specific reason why you want to cut back?”
Specific reasons
I ran through the list of acceptable reasons that would perhaps gain his support:
- Personal illness
- Family illness
- Childcare/maternity leave
- Bereavement
Likely unacceptable:
- Bait and switch situations really aren’t my thing. Like when you intentionally paint a rosy picture, knowing full well the trap you’re concealing. Seems like a good way to alienate people, you know?
- The 6 hours I spend charting a day to prove to the hospital’s billers that I did my job makes me fantasize about scooping my eye out with a spork because that would feel much better.
- The longer I stay here, the more I realize the futility of modern medicine – doing things to keep people “alive” because we can, not because we should. Makes me start to regret my career choices.
- It feels like I’m on a mission to convert everyone to hospice care and have started to get mad when they still cling on to hope. Point is, I’d like to make it to next year with my soul still intact, though it may be beyond repair…
Falling back on my noncommittal shrug, I eventually came up with a clearly dissatisfying response,
“It’s the right choice for my husband and I.”
Pen fidgeting evolved into pen tapping.
Was he aware of how many tells he had? Had he picked up on mine or was he too busy self-regulating his irritation at me not quietly falling in line with how this conversation was scripted in his head?
“Well, historically we don’t make any changes like that until we look at the budget. So, just so you know that doesn’t happen until January 2020. Unless you can find someone to increase their FTE as much as you go down. Also, your benefits would go down commensurately.”
6 months, M. He’s telling you they can’t find it in the budget to pay you less for 6 months. Now you know where they stand… are you going to accept this at face value or are you going to push back and declare yourself as a troublemaker?
“Interesting… thank you for telling me. I didn’t know that.”
The quick recovery of the upturned corners of his mouth lit an unexpected fury within, threatening to raze my calm facade.
Are you really going to just let this go, M? You’re going to hand over the reins to your life for the next 6 months or even longer while they play these ridiculous games because you signed a piece of paper? You kept your sign on bonus in cash and mapped out your exit strategy in case this day would come. Well, it’s frickin’ here.
Or are you going to lay down and accept this is your life now?
“So if I’m understanding correctly, the addition of 2 more full time Med Peds docs doesn’t count to make up for the 0.2 FTE I would be asking to go down. That’s what I’m hearing from you.”
There wasn’t even a slow fade of the smile this time. Just a flat line with a little bit of red under the collar.
“Well… uh… ehrm… it’s just not accounted for in the budget. I’ll have to get back to you on that.”
“Yes, please do. Until that time, I think what would work best is if I have more of a blocked schedule for my nights and swing shifts. That way it minimizes the constant flipping of days and nights.”
Penciling in this to-do item in the margin of his notepad emphatically as if to demonstrate he was “hearing” my concerns, it was clear he was done with this conversation. For a brief second, a pang of pity came and went as I realized I had pulled the bait and switch game on him as well – I was not what he signed up for either.
“I’d like to pivot now to your quality improvement project. As you know, your productivity bonus is tied into that. We have some projects that are chart review in nature, which would be great for you since you’re one of the docs with a longer commute. You can do it at home instead of having to drive in to the hospital.”
Dumbfounded, I smiled blankly at him in silence, watching him become more and more unsettled.
I literally just asked if I could cut back my hours, and now you’re talking about these “great” options to take more work home with me. Is this a bonus for volunteer extra work? Or am I being voluntold to work from home?
In a moment of clarity, I realized it would just about break his brain if I said, “No, thank you.” He and I were on very different agendas, and neither of us were interested in the other’s.
I resigned myself to playing this game for a while longer, speaking in clichés and ambiguities to say nothing and everything all at once.
“I’m still getting my bearings, looking at what’s coming through on my inbox to see what’s out there. I’ll circle back to you when I find something that interests me.”
Bullshit spewed earnestly makes it difficult to read between the lines.
The hospital system will not love you back
I’ve waded through other people’s blood, amniotic fluid, pus, mucous and tears for my career.
Held people’s hands as I broke the news of their cancer and cheered them up by looking through their Instagram feed of their kitties.
Spent the extra time sharing memories of a recently deceased wife with her still living husband, even if it made me 30 minutes late at the end of my day.
I could never leave medicine.
Taking care of people is what I do best, and to them I will give of myself freely, by choice.
The system, on the other hand, will continue to demand more and more. It will construct an obstacle course with never-ending hoops to jump through just so you can get back to doing what you love – taking care of people and practicing medicine. Ironically, eventually the course becomes so draining you start to resent the people you had set out to serve, making you question why you even began in the first place.
It will dangle rotting, flaccid carrots as bait and hold them over your head, just far enough out of reach, but close enough to make you believe if you just put a little more effort in, you can finally reach the “prize”.
Then the bar will be reset even higher.
We’ve been so enmeshed in the system for so long, we haven’t even thought to ask of ourselves,
- Do I even want their carrots?
- When did I start to accept that when they say, “Jump!”, I automatically respond, “How high?”
- Is this how I value my time and worth?
The hospital system doesn’t own my worth.
What it is doing is renting my value from me.
And I can take my value elsewhere.
That’s the beauty in not allowing yourself to be anchored down into the financial traps of the doctor house, car and requisite lifestyle things we’re told we must have. The beauty of being financially secure enough to throw their sign on bonus back in their face if necessary to cut the tightening noose.
Why should I compromise myself for their effing carrots?
Don’t they know I’m supposed to like avocado toast and kale anyway?
***
Photo taken by standing in the middle of the highway on the Kenai Peninsula in Alaska, watching the world set on fire by wildfire. Seemed apt to channel my inner Daenerys for this post.
***
I’m sorry that all of this is going on, M. Administrators can suck. They just don’t get it a lot of the time, or maybe they get it all the time and just don’t care. I’m not really sure sometimes.
I’ve felt similarly about being “bait and switched” at my job, though I think I can see the actual reasons behind how that happened (rapid expansion of our department led to us being short staffed). Still, the fact is that when reality looks very different than our expectations, this leads to discontentment and resentment. I’m totally with you on that.
I look forward to hearing about what you decide to do. Thanks for being honest about your journey.
Jimmy / TPP
Hey Jimmy,
Still unsure what I’m going to do, but my 5 year plan definitely does not include this! With that being said, I had seen the writing on the wall with this job before I even signed on, but I had mistakenly thought I could put up with anything for 2 years.
Now I’ve realized, yes, I can put up with anything for that length of time, but I just don’t want or care to. There were a few reasons why I chose this job, specifically to be able to be grandfathered into the peds hospitalist track without having to do a fellowship in a couple of years as well as a much higher salary plus access to a 457 plan.
I think we often forget that as much as these administrators/systems leverage our work to make them money, we have the ability to use their resources to further our goals as well. I’m going to max out my CME money to get to my next venture, and we’ll see what happens!
Even when reality is different than our expectations, we don’t have to stay stuck. Yeah, it’s painful to keep having to move on, but it’s better than resigning yourself to a miserable existence.
Wow, brilliant, as always. I hung on every word of the tense conversation between you and the Admin. I read it over and over again.
I just also commented on the @TPP’s recent post on burnout prevention. Bottom line is the Admin is focused on the bottom line – the dollars, the EM visits, the heart surgeries, the outpatient lab/x-ray visits, market share – stuff that can be quantified and measured. They have lost the ability to think about the human side of the equation, the soft stuff that you always write about, the stuff that makes one laugh or cry.
If only there were a Press-Gainey type tool that docs would fill out at the end of the workweek, one that connected the Admin and their bonuses and their livelihood.
Wouldn’t that be lovely?! I do love how the 360 degree evaluations always seem to exclude admin.
On one hand, I understand that the world runs on money, not just love like the romantics want to believe. On the other, if the focus is only about the bottom line and we end up profiteering off the suffering of others, what’s the point?
I would rather bow out of this altogether than be a part of that. Maybe that day will come, but I don’t think we’re there yet.
Great post.
Well, you’ve laid it out there for the administrator: you want to cut back.
My suspicion is that his life will be easier if he accommodates you and you stay, as opposed to not doing so and you leaving. If he’s at all competent he’ll realize this.
Another great one M showing the public what really goes on and how a doctor is treated as a small cog in a large machine.
I’m glad you had him at a loss for words when you brilliantly mentioned that the 2 new docs could not account for your slight decrease in employment time.
Too often the doctor in these meetings just sits and takes it. Likely because of fear of losing their job etc. But for someone in your position who does not have to be there, it is from a position of strength you can negotiate on.
I don’t know if it’s as much as negotiation as it is a scorched earth approach. Haha… usually I’m more… diplomatic in these types of scenarios.
Most people don’t anticipate how direct and blunt I actually am though, so when it comes out, I’ve found it makes people more uncomfortable than if those exact same comments were uttered by someone else who isn’t deceptively as “sweet” and petite. Meh, it is what it is. That’s what F-you money is for, right?
Haha.. I held back on pulling the trigger on an ultimatum, but yes, I do think at this moment in time they need me more than I need them, for various reasons.
It has been fascinating being a part of a hospital system coming from a very small private practice – the hushed whispers in the work room are mutinous, but no one seems to be willing to pull the trigger. There’s a lot of discussion about lost loyalty, having to pay for their $750,000 mortgage or their kids’ $60,000/year private school tuition, etc that are chaining my colleagues to their jobs.
It’s really eye opening to see the golden handcuffs at work in real time.
I’d hope so! But my suspicion is that my other colleagues don’t really put up much of a fight, and I may be the first one to rock the boat and leave before the contract is done.
For right now I’m going to stay put and see where everything falls once January come. Thanks for reading and commenting!
Sadly, the only thing I’ve found that works is a combination of “no”, and “vote with your feet”. As you well stated, keeping your lifestyle where you can actually do either/both of those things is important.
Contracts can be hell. Never, ever, sign anything you can’t live with. I recently was working part-time at a very pleasant clinic. All was well….until the wife of the doc who owned the practice marched in with a contract that bore no resemblance to our verbal agreement. I refused to sign, no longer work there….which is too bad…the doc was good, the clinic was great…but I’ve learned…the hard way….never, ever sign anything you can’t live with….
M, I hope you can find your way through this. We need docs who care. We need docs who will say “no”, and walk away from the profit-hungry admins…(who aren’t working at 0200).
Your experience is just downright awful. Fortunately I can live with the current work scenario (I haven’t quit just yet!), but I am also able to walk away if need be.
I hope I’ll be able to find my way through this as well. And if I can’t find something that suits my needs, maybe I’ll get fed up with searching and start my own clinic! I have no idea where I’d start but I think I could figure something out…
Freedom’s just another word for nothing left to loose and nothin ain’t worth nothin but it’s free. All time travel is forward moving. Sometimes the present is a step into the future. When I went to med school I had the money saved. It was 1981 and suddenly inflation was 13% and student loans were 19%. My tuition went up 50% between the day I accepted the offer and the day I matriculated. It doubled the next year and doubled every year after. I ran out of money the second year and had nothing left to loose, and I wasn’t going to sign any 19% loan. I went down to Glenview NAS raised my right hand and swore to defend the constitution and peeps of the US. It cost me 2 years of my life, but it turned out OK. I hated the Navy but I taught myself how to do pain management beyond what I learned in residency. Me and Dr Raj’s handbook. Practiced that as a side gig for 30 years and found it quite rewarding. I had nothing left to loose but a career to obtain. I hated those 2 year but in the scheme, it mattered.
You aren’t stuck, just on a stepping stone. 2 years is a countable number of days. I know, I counted it. You don’t like carrots? Don’t eat any. That’s the definition of freedom. Sometime there is great joy in missing out. By choosing what is essential, you necessarily are forced to ignore what is trivial or toxic.
Initially 2 years felt like forever but now that I’m 6 months into this, I’m more willing to ride this out. Quite honestly, I’m more curious to find out what will happen in Dec/Jan to see what my medical director ends up doing, or not doing, for that matter. Since the time of me writing this post back in June (not published til now), I’ve been able to adjust my schedule to something more palatable, and I just gave away several shifts in the next coming months. I’m definitely not passively waiting out my 2 year stint while they play with my schedule.
There is a great joy in “missing out”. Except I wouldn’t call what I’m doing missing out by any stretch of the imagination – more time spent with my husband, friends and family is never a waste.
“…Rambling snippets of life advice…”
Really? Really?! There is nothing rambling about my advice; every word that comes out of my mouth is gold. 😉
I will say that you do inscrutable very well, so I feel the tiniest bit sorry (not really) for your supervisor. He’s definitely getting more than he bargained for with you.
This is another fantastic post, with some valuable takeaways for others struggling with similar situations. In particular, don’t let Admin force you to answer their questions. If they’re asking you to do something unreasonable, make it clear that you reject the premise of the question. I remember one particularly uncomfortable meeting between me and two docs high up on the chain. The issue was how I was going to add hours and get my colleagues to do the same. I flat out rejected the premise, encouraging them to figure out other ways to make up an organizational budget shortfall.
That turned into a staring contest, which leads me to important takeaway #2 from your post: let silence do the work. Nothing makes Admin more uncomfortable than silence. It takes practice to maintain an outwardly calm facade during these silences, but it’s a great skill to nurture. When they asked, “how do you plan to make up the shortfall,” I made it clear that answering that question was above my pay grade, and was more their job than mine.
By the way, I knew you were throwing out a stall tactic with your “what would you do if you were me” comment, but I decided to play along. Now I realize I should’ve just called you out. 😉
Haha.. I never said there wasn’t any value in your ramblings. It was just too easy to lead you into a monologue. Much like it was too easy to bait you by calling your advice rambling snippets 😉
Thanks for making it seem like I had a strategy of some sort going into that meeting. It was not my intention as I like to see how things play out in the moment, and as you and I both know, the only real strategy I had was to deploy my scorched earth approach. I suppose I should thank you for talking me off that ledge, but then you’d really believe you have that Midas touch 🙂 Just looking out for you, friend!
Thank you for posting this! I have had many similar interactions and experiences over the 16 years since I graduated from medical school when I didn’t feel like a human being and like I was losing myself. I considered several options, but for many of us, part time or a different working environment either isn’t an option or doesn’t solve the inherent problem.
I decided to leave medicine a year ago. I adhered strictly to a FIRE lifestyle and paid off my loans and put away everything I could. Unfortunately, I started this practice only after finishing residency, fellowship, and several postdoctoral research positions so I’m not at full FIRE, but I pulled some difficult levers to minimize my ongoing expenses, and I have a long runway to reignite my passions in life.
I initially told everyone I was taking a break from medicine, but now I have transitioned to saying I am retired from medicine. This is still an experiment for me with an unknown outcome, but despite my feelings of failure, inadequacy, and laziness when leaving medicine, I am an intelligent, competent, resourceful, and hardworking person, and I have confidence this will work out! I hope you find your exit strategy! Maybe just having an out from medicine will be enough, if you find a slightly more receptive administration!
That is impressive! Congratulations on finding your path.
I’m sure you’ve encountered the belief that everything you went through was a “waste”, but everything you’ve done has brought you to this point. You’ve learned skills and had experiences that will help guide you forward, and just because you may be taking an untraditional path doesn’t mean you can’t forge your own.
I have several friends who feel trapped by their student loans/mortgage/etc that they don’t feel there’s any way out – thus, they just try to keep their heads down and keep chugging along. The physician FIRE community I’ve find since blogging has been immensely helpful in seeing there’s another alternative, and I’m glad you’ve found FIRE as well! I’m still bouncing around trying to make this work, but that doesn’t mean I can’t work toward FI at the same time.
Thanks for the comment and for the well wishes!
M
Nice chess, Kasparov! These moments of watching you think several steps ahead are a delight for the insight into your mind.
Parry, deflect, lunge – there’s almost a choreography present in the lines.
There’s a follow-up I’m not alone in awaiting: “Unfortunately, that’s not going to work for me, but I’d be willing to stay on at a reduced capacity if these reasonable needs can be met starting the next scheduling cycle…”
It seems the metrics that matter most are the least prone to be measured, beginning with, “What can we do to keep you happy and make you stay?”
I was reading somewhere it takes $30,000-$50,000 to recruit a new physician. You would think they’d ask the question you posed above, but either they DON’T care to ask or they’re waiting for me to up the ante until they’re forced to ask it. Which seems like a horrible way to maintain employee retention, and at that point I’d be highly unlikely to play ball.
I’m curious to see what will happen come Dec/Jan time as I responded to Gasem’s comment. I may have to use your perfectly worded response, so thanks in advance 🙂
Wow M. You are incredible at articulating emotion into words! I read your blog regularly, and sometimes feel as though you are speaking from my heart better than I can. I actually had a similar meeting recently with admin. I spent hours beforehand thinking of the ways to both improve my job while still benefiting them, coming up with solutions to likely questions.
Lets just say that it didn’t go down like I expected at all. At one point after 30 minutes of their circular, non-sensical, and borderline adversarial logic, I interrupted their diatribe with “Look…these are the simple changes that will make me happy here”. I was initially proud to speak up for myself in that manner, and briefly hoped that they would finally understand, but my proud feelings melted as I received the same forced emotionally-muted look that you describe, followed by a peak at his watch, and a similar change of subject. I also now firmly know where they stand. Please keep up the great work here, and know that you are speaking to and a voice for so many of us! Thank you!
JH,
Thank you for your kind words! I’m so sorry you’re also feeling like you’re banging your head against the wall with admin. I’m finding drawing my lines in the sand gets easier the more I do it – now the difficulty I’m running into is not providing solutions for the people who choose not to respect my boundaries. It is so ingrained in us to always come up with solutions, but quite honestly, admin’s inabilities/decisions to staff appropriately, retain people, etc ARE NOT your problem. You aren’t getting paid to be an administrator – that’s their job. Don’t take on the responsibility of managing their circus. The longer we continue to take on other people’s responsibilities, the more complacent they become to finding solutions that work for everyone.
People are interesting – the more you push back, the more it encourages almost like an extinction burst response where they challenge your stance. So I would encourage you to stay firm, and if not, vote with your feet and leave. We don’t have to live like this.
Thanks for commenting!
M