As we close in on a pair of jobs, the nitty-gritty details of this complicated life-event are coming out. Today, I am focused on a line-item in our contract negotiations: the moving allowance.
This benefit has been a fixture of the recruitment package for young doctors for quite some time. I have observed many of my friends who signed contracts in previous years gleefully avoid the chore of moving their own stuff, and reassure us that we wouldn’t have to deal with the headaches, and backaches, of relocating all our stuff.
And then, in 2017, our congress passed the “Tax Cuts and Jobs Act.” This euphemistically named bill did many things, among them was to eliminate moving expenses as a deduction beginning in 2018.
In preparation for this post, I read through IRS Publication 521 , detailing the deductions allowed in past years. I thought that it was a very reasonable set of rules. Moving for a job is expensive, and these expenses aren’t things on which we would voluntarily spend our paycheck. Particularly for resident physicians completing government-subsidized training, and now looking to serve society as a major, essential, part of the healthcare industry, it would make sense that the expenses incurred in the process should be deducted from our taxable income, no?
The “Tax Cuts” architects declared that we don’t deserve a break for moving. Ok, maybe I can see their point. I could reduce the moving expenses if I were personally responsible. Should I get a bigger deduction for someone coming over and putting my cookbooks in a box, moving that box to a truck, driving that truck 800 miles, and then putting that box in my new garage, as opposed to me just doing it myself?
The other aspect to this change is that any relocation package that your employer gives to cover this mandatory and cheerless expense is now taxable income. I’ve seen a few contracts at this point, and all of them have offered a relocation package. For simplicity, let’s say that’s $1000. If I spend that $1000 to move, I have to pay taxes on that money. My box of cookbooks represents a quantifiable percentage of that budget; let’s say $1. That means that after taxes it cost $1.25 to move my box of cookbooks.
The question is not if the “Tax Cut” is justified; that’s way beyond my pay-grade. The question now is: Should I move the cookbooks?
Accepting a recruitment package with moving expenses seems rather pointless. I could just ask for a bigger salary or request the money as a sign-on bonus instead. Yes it will be taxable, but it would allow me to make some choices. I could choose not to move the cookbooks. Instead, I could choose to donate or recycle them, then take my taxable cash and either buy new ones, or not. The obvious additional benefit to this plan is that no one has to lift, handle, or haul the cookbooks 800 miles (or wherever, maybe it’s 80 miles. Not telling yet!). Seems like a win-win.
I recently had a consultation with a professional stager to prepare my house for the market. I’ve intentionally cut clutter and try to keep items in their places. I’m working through the Marie Kondo “Lessons,” and I’m particularly proud of my neat and organized closet. However, this lady destroyed me. It was brutal. I found myself struggling to keep up with her, scribbling away notes while simultaneously moving items to the ever growing “edit” pile in the floor and apologizing, “Oh, yeah, um sorry, bought that for our first apartment 12 years ago.” By the end of this appointment, the perimeter of my home looked adorable with sparse little vignettes and cozy furniture groupings, while the middle of the floor was a ransacked pile of shame.
So what should I do with this shame-pile? Should I pay taxes to move it? After this experience and in the context of the new “Tax Cuts,” I’m not only asking myself what sparks joy, but what is worth a 25% tax for the privilege of moving it. Should I pay taxes to move this 3-ring binder? That ill-fitting jacket? Our unread books–gasp?
Of course, I have to consider the cost of moving the item versus the cost of replacing it. If I have to re-purchase an item, obviously I’m going to pay taxes on the income used to purchase said item (~25%)+ sales taxes (~7%), so that would be more like 32%. So the mathematical equation becomes whether it will cost <7% of the replacement cost of the item to move it. And wow, writing it out like that makes me realize, in horror, that to buy something that costs $1, I have to make $1.32! This is why Mr. Money Mustache says, ” cutting your spending rate is much more powerful than increasing your income.” (Also see this classic MMM article).
I feel like this is a good step in the direction of paring down our stuff in case we ever want to make an international move, like the Copelands or the Duponts. It is certainly a good exercise in becoming more deliberate in how I spend my wealth (and yes, I do consider my pampered U.S. Citizen lifestyle wealthy, even on resident salaries). In the coming weeks, I will be exploring the concept of Effective Altruism, realizing that the mundane decisions regarding how we will conduct our move could have real implications on our impact for good in the world.
The bottom line is, I’m planning on letting the moving companies keep their fancy boxes and strong backs. I’ll hoard my Sunbasket boxes for a few months and only put the essentials in them. I’ll sell most of my furniture, and fit what will into another U-Haul trailer, load the dog, cat, and kids into the SUV, and haul what remains to the next home. There, I will make sure my house is a haven, and resist the urge to buy cookbooks.
How have you saved money on moving expenses? Have your contract negotiations been affected by the new tax laws? Please comment!
We welcomed our sweet baby girl into our family in late September, and the fall was a busy and challenging season. The weeks of maternity leave passed in a blur, and then it was time for my follow-up appointment with OB. I was nursing my newborn when I palpated a firm, elongated lump. As a general surgeon, I had palpated similar masses in patients undergoing lumpectomies and was concerned enough to mention it to my doctor. She examined me and to my surprise found a second mass. She referred me or workup of both areas.
At this point, Josh was in his final months of a year long neurosurgery chief service assignment. He was exhausted and burned out. He left daily at 6 and came home around 8 to 10 pm each night. I was doing morning and evening routines with the girls alone most days, and he was heartbroken from missing out on this time with the girls. I tried to shield him from domestic stress with varying degrees of success. Some days I would throw my own pity party and fuss about how much was on my plate, but mostly I really tried to get the chores done and let him enjoy quality time with the girls. Nevertheless, he was maxed-out, and I just couldn’t bring myself to burden him with the news of my appointment in the Breast Clinic.
I had completed several rotations on the Breast Surgery service in residency, and it was surreal to sit as a patient in the waiting room. When my name was called and I was ushered into a room, I saw one of my former consultants down the hall. She smiled and waved, and then a flicker of inquisitiveness crossed her face. I smiled one of those acknowledging, pursed lipped grins and ducked into my exam room. The result of that appointment was a recommendation for an ultrasound the following week.
I debated telling him about my upcoming ultrasound, but I just couldn’t. I felt like it would be selfish to tell him, but I had never kept anything from him before. Since med school, we have lived, studied, and worked in the same building. We have the same groups of friends, the same gossip. No detail is too mundane for us to discuss together. But here I was omitting something rather major. On the other hand, maybe I was just being melodramatic; this notion was compounded in my mind by thoughts that I was going to need a biopsy, maybe had cancer, maybe would need chemotherapy and surgery, maybe wouldn’t be able to keep nursing my newborn, maybe wouldn’t be there for my girls as they grew up…I had to keep reigning in my imagination from these dark ramblings.
I didn’t tell him that week. I called my sister and my mom, venting my stress to them. I called my best friend and asked whether I was doing the right thing. I got various bits of advice from each of these trusted confidants, but I didn’t know what to do. That weekend, we had to drive 3 hours to South Dakota for my weekend locums assignment. I waited for Josh to get off work, and he didn’t get out until after 9 p.m. I picked him up and tried to gauge his mood…Not good. He quickly shared with me that he had made an uncharacteristic mental error that day; no one was hurt, but he was very shaken by it.
I felt a rush of adrenaline pump through my body and inwardly panicked thinking that I had nearly made a huge mistake. This was one of those profound, “Oh Shit!” moments in life. If I had told him about my breast lump the day before, if he had to donate a thought to the scenarios floating around in my mind, if he had to spend an ounce of energy on the stress of thinking through the possibilities, I would have thought that this mistake was MY fault. If someone had actually gotten hurt, I definitely would have felt responsible. This was a new reality of having a surgeon spouse that I had never before considered.
On the drive and throughout the entire weekend, Josh oscillated between ruminating over his error and trying to enjoy the long weekend being “just a Dad.” He took the girls for fun activities while I worked, and we enjoyed some family dinner dates. I never told him about the lump or my upcoming appointment.
My stress the following week compounded. I wasn’t sure that I had cancer, but I was sure that I would need a biopsy. I had other locums assignments coming up, and I was imagining trying to reconcile my schedule. I wondered how long it would take me to recover. I wondered if I would develop a milk fistula from a needle or surgical biopsy. I imagined being exposed in front of my mentors and resident colleagues. I had tremendous guilt over the hysterical idea that I wouldn’t be there for my husband and children. I vented more to my mom, sister, and friend. My impatience for the ultrasound appointment was almost unbearable.
Then, finally, the day came. I dropped off the toddler early at daycare and then trudged through the clinic carrying my newborn in her car seat. I changed into a gown, nursed the baby so that my ducts would not be dilated, and waited for my turn. She fell asleep in her car seat. I climbed onto an exam table and stared at the ceiling while the radiologist searched for the lumps. When she had finished her exam, she gave me the excellent news that she had a very low suspicion that these were dangerous; one was just a very dilated area of normal breast tissue and the other was what she called a “lactation adenoma,” which I had never heard of, probably because those never have to be surgically removed. She recommended 6 month follow-up ultrasound and released me from the appointment. I was elated.
Josh came home from work at a reasonable hour that evening in a good mood, and I had dinner ready. I told him then about the entire situation, quickly cutting to the point that the result was reassuring. He stared at me with wide eyes and a crestfallen expression. Then he looked worried and asked again if everything was ok. He couldn’t believe that I would hide it, but I explained it to him and he didn’t give me a hard time about keeping it from him.
So here we are, a married couple deeply in love, but who have to consider the safety of one another’s patients in the news we reveal to one another. This was a new facet to our relationship, but one I can’t deny is important. We have to calculate if the stress of concealing a difficult situation outweighs the risk of burdening one another with it. As a two surgeon family, the personal and professional lines do get blurred sometimes, and I can only imagine this will become even more true working in austere environments where we don’t have stacked teams of surgical colleagues to rely on for support in the OR.
Anyone who has a spouse dealing with burnout might relate to the precarious balance of being a life-partner while protecting them from stress. I’ve also learned how it feels to be the “homemaker,” while my husband finishes an all-consuming training program. Particularly back then, while I was still on maternity leave, I experienced for the first time the stresses of being a stay-at-home parent with an over-worked spouse. I have to say, anyone fulfilling that role for an extended period of time deserves praise for the amazing amount of work and mental energy that is required. It was a humbling experience for me.
At that point in time, we were definitely operating over the line of what was healthy for our family. As physicians, ww hear about the consequences of burnout routinely, but this scenario was one I had never before considered. When I recovered from my own burnout in 2015, I realized that not even having time for a dog was my personal red-flag that I was giving up too much for work/training, and so I coined the motto, “If I’m too busy for a dog, I’m too damn busy.” Well, that was a much cuter illustration of this principle. I discovered just how much training was requiring of us, and it was tremendously more that I had previously estimated. Still, if we reach that goal of being able to truly relieve the suffering of many others, is it not worth it?
What would you have done in this situation? How can we establish healthier boundaries professionally? I would love to hear your perspective in the comments section below.
I thought this was going to be the fun part. As my friends have graduated from residency and moved on into their grown-up jobs, I’ve wistfully wondered how amazing it must feel to be wooed and recruited to a glamorous physician practice. I’ve also observed with a degree of incredulousness as my friends have each complained about the anxiety of this process. I didn’t believe them. C’mon, man, you’re at the good part–the reward for all your hard work! You’re just being humble, right? It must feel great to be at the end.
But now I get it. Josh and I have spent something like 13 years (THIRTEEN! YEARS!) hammering away at this goal. Our pre-med requirements (2 years) deserve their own chapter in the tome that is our professional training, and then med school (4 years) was tough but of course a blast, and residency (7 years) has been a mixture of great and terrible, but generally complicated and incredibly tough. So here we are, ready for launch. All we have to do is pick a destination. But it’s been very, very, very difficult. Want to know why?
For starters, there are two of us. So we must each find a suitable job for ourselves and then check to see if there is a corresponding job for the other one. Once that is established, we delve deeper and even go interview, only to realize that the job might be great for one of us but not ideal for the other one. On and on the cycle goes.
Next, there is the fact that we have children. When we ranked Mayo #1 in our residency match lists, we were confident this was 100% where we wanted to be. With no kids, th move felt like an adventure. I knew we would miss our wonderful families, but I had no complicated feelings; it felt right. Now, we DO have complicated feelings about being away from Family. Our extended families are pretty great and would undoubtedly be a wonderful part of our girls’ childhoods. But, because of the situation in the previous paragraph, we have considered several jobs far away from family and we have found good opportunities here in the midwest. Nevertheless, being close to family is a weighty factor in this equation.
Next, there is the decision to make between private practice and academics. Many residents will clearly see themselves as one or the other, but Josh and I are both firmly on the fence on this one, Josh more-so than I. He has always pictured himself in an academic job, teaching residents, publishing papers, and doing more complex cases. As I’ve seen myself more as a trauma surgeon these past few years, I’ve also assumed I would be a part of an academic trauma/critical care practice. Additionally, at Mayo we are not exposed to the private practice world and know nothing about RVUs or running a business. The interview trail has been a crash-course in different practice models, and I’ve had to do quite a bit of reading about reimbursements, opportunities for buying into practices and surgery or imaging centers, etc. Josh and I don’t really love big cities (Rochester is about right for our level of excitement and tolerance for traffic), which really makes working in academics more difficult. So to find that perfect “big hospital in a small town” again, we’ve found mostly non-academic positions available, which has required a big shift in mindset for us.
We also want to select the right pair of jobs keeping our North Star in mind, which is that one day we want to be working on major global surgery projects. Whether that means moving overseas long-term or not is unclear right now. My thinking has been majorly influenced by the book Love Does by Bob Goff, specifically for the many examples within it of the merits of having a steady, good-paying income here in the U.S. and being able to invest in amazing, high-impact projects elsewhere. Josh keeps reiterating, “I just want to help a lot of poor people. That’s what I feel like the meaning of my life is.” So while we know that it’s necessary for us to work here in the U.S. a while, the bigger goal of wanting to be financially independent so that we have the freedom to pursue this humanitarian medicine path is constantly on our minds. We are trying to select positions that get us closer to this goal, but to be honest it feels like all of our options are only taking us farther from what we ultimately want to do.
Lastly, we have dealt with some serious disappointment from a practice that really sold us on a vision for both of us, and then my half of the deal completely fell through. This practice kinda had it all–location near family, a great group for Josh, opportunities in both trauma and critical care for me–but in the end the administration just couldn’t work it out. This situation was difficult to get over, and every job we have interviewed for since then has been compared to what was this original dream scenario.
As of now, we have essentially 3 choices. One of these choices is close to family. The other two are far away but have their own merits. When we’ve signed a contract, I’ll post more specifics about the positions, locations, and our decision making process.
One day, I hope to have some wisdom from the job-hunt to share with other young physicians. In the meantime, I would welcome any advice my readers my have for selecting a job. What do you wish you had known? What helped you make a great decision? What might you have overlooked in the process? Please leave a comment below.
I haven’t written a post in a while because I left town for a locums gig and came back with a stomach bug. I’ll try to get us back on regular posting schedule with a brief one on socks, and how they relate to my overall life goals.
I embraced the low-clutter lifestyle a few years ago. Before the Kon-Marie method became so popular, I read and re-read the book It’s All Too Much by Peter Walsh and really attempted to live by the principles. In my first big purge, I donated truckloads of unnecessary belongings and threw away an embarrassing amount of junk. Through the years I’ve had spurts of renewed enthusiasm for the clutter-free lifestyle and Kon-Marie’d my closet a couple of years ago.
Since I’ve gotten into the personal finance blogs and podcasts, I’ve become more intrigued by “essentialism” or “minimalism” as they pertain to not only stuff but also time and energy. These disciplines are simply just a mindful way of spending money and living life, but ascribing to them has been quite liberating.
About a year ago, I had a rage attack while folding clothes. The inciting event was a basket full of unmatched socks that lived in the bottom of the clean laundry basket. Every few weeks I would painstakingly sort and match dozens of pairs of stupid socks. Most of them were white or gray, and had slight variations, but we had colored ones also. My husband just wore mismatched socks, but I couldn’t really stand doing that. By that time, I had been influenced by various personal lifestyle bloggers who discussed meaningful use of time, and I got fed up and just decided to quit.
I drove to Costco, bought myself two packs of black no-show socks (figured they’d last longer than white), and I threw away all of my socks. I offered to do the same for Josh, but he declined so I just threw his unmatched socks into his sock drawer for him to deal with.
Since doing this for myself, I have seen sock problems everywhere. You can’t shop for a pack of socks without getting six different styles of socks. Even most “white” socks will have a little thread in the toe or at the top that is pink, yellow, blue, green, teal, purple…WHY??? I don’t really know for a fact, but my conjecture is that the sock companies know most people want matched socks. Not everyone can be as wisely dismissive as my dear husband. So when we can’t find a sock’s mate, we consider that sock “out of commission.” We drop it in the bottom of some laundry basket and there it sits, in-prisoned until its match is found. But we never find all the matches, so then we are short pairs of socks. So we buy more socks. And on it goes. The more socks you have, the harder it is to find the other mate, as they are swept further apart in a sea of ever-so-slightly-different foot-mittens.
People aren’t shy when it comes to complaining about their consumable goods. Yet, in all my 34 years I have never heard anyone criticize their athletic socks, lamenting that if only there were a fuchsia thread near the toe they would be so much more exciting. Now, I’m all about the exciting sock trend with ironic, funny, sarcastic, and rebellious scenes and phrases; that is different. In fact, I would gladly still wear my “Kick this day in it’s sunshiny ass” sock if I could just find the other one. But most of these special socks are sold as single items, so if one design really spoke to you, you could purchase 7 pairs and just be done matching them forever. Or if you just have one of those days, you can wear your obscene socks and snicker to yourself all day. This is a legitimate coping strategy.
My toddler is legitimately low on socks, so I decided maybe I would buy her some nice socks from Pacts Apparel or Bombas for Christmas. Here are the some options:
Not a SINGLE option to buy a pack of all matching socks or to buy them individually. Amazon was even more dramatic. I sifted through about 30 options for packs of “variety” socks until I found the one containing all white and matching pairs. I bought that one.
I might make fun of my husband wearing the one green and one blue sock, but he’ll smile because he knows he’s above caring. But if I send my kid to daycare like that I’m a terrible mother (or at least struggling pathetically).
Ok so this is clearly an outrage and a conspiracy to make everyone buy more socks. Fine. But from a perspective that is more relevant to my life, hopefully yours, this is just one of those marketing tools that I was completely naive to for like THREE DECADES. How is it that I didn’t realize sooner all the hours and money I was wasting by letting the sock companies dictate that my purchase would be six pairs of slightly different socks? And how many more of these money and time wasting strategies am I falling for? Well the answer to that last question is, “Lots. Guaranteed.” and I’m hoping to do better by hunting them out and doing away with them ASAP.
No doubt we are wasting our precious time on other useless tasks. As medical professionals, much of the day spent on redundant documentation and butt-covering tasks will feel like matching a basket full of stupid socks. Over the arc of our careers, we might waste years of time on tasks that don’t contribute to our big goals. The potential is more than theoretical, it is the normal and expected narrative that ensnares the majority of us. I’ve heard countless times from late-career physicians, “I wish I had taken mission trips sooner,” “It was always what I wanted to do but I just didn’t do it for whatever reason.” Life is so busy, so cluttered, that our “urgent task” list never gets done, and so the big, optional goals never get prioritized.
My practical advice is: Be boring when it comes to socks. Get a dozen identical pairs and throw them haphazardly into your sock drawer. Never match them, and yet always have matching socks. Or be like Josh and never match them and always have non-matching socks. It’s kind of his thing.
Don’t let pesky little tasks steal your time and joy. Stand up and shake off these menial little traps, and don’t delay what’s important. If you want to do missions, make it happen. If you want to give more charitably, just do it. Find what’s holding you back and eliminate it.
I’m speaking to myself more than anyone else here. This year holds big decisions and little decisions that could alter our trajectory for decades down the road. I’m hoping that making a bunch of little improvements in how I spend my energy and money that make me 1% better now will result in a life that is 1000% more fulfilling.
What have you found to be holding you back, wasting your time, or stealing your joy? Comment below!
We are in the thick of the job hunt, and it seems like every time I feel like we are inching closer to having a couple of jobs locked down, some new variable comes up. We’ve interviewed at small private practice groups, large private practice groups, academic and “priva-demic” groups located in the southeast and midwest. The more I learn about these different job configurations, the more I realize I don’t know. However, along the way we have discovered a few morsels of information, and I’ve been struck by some aspects of the evolving healthcare climate that I wanted to share.
First, there is a noticeable migration of surgical practices toward hospital-employed rather than private practice. In my limited sampling on the interview trail, the practices have either just become hospital-employed, or are doggedly fighting to resist the gravitational pull of becoming hospital employed (and discussing this situation openly). Coming from my academic institution, at first this did not strike me as noteworthy, and I felt like the physician-employed model was essentially more convenient and equitable.
I was pretty close-minded regarded going into private practice, and definitely didn’t consider full-time locums as a viable option until I started listening to Nii Darko’s podcast Docs Outside the Box. I’m sure it was somewhere in the dozen episodes I’ve listened to where I first heard the phrase, “No one will pay you more than you will pay yourself.” Such a simple statement, but it got me thinking about this situation with physicians voluntarily giving up control of their practices, and to a large extent, their paychecks. My experience matches the published statistics on the AMA website that as of 2016, less then half of physicians own their own practices, and the statistics are more dramatic for younger physicians, with 59% of physicians under 40-years being employed.
The second issue that has come up more and more frequently is that of the federal program for Public Service Loan Forgiveness. I first heard of this program in med school, roughly ten years ago, and at the time it was described as a program that may or may not ever come to fruition but has the potential to wipe out your loans after ten years. I was quite skeptical at the description, and honestly I assumed that it would never work out. I kept my loans on the standard repayment plan, even though it was a bit difficult at times to keep paying them on that schedule through residency. Then I refinanced near the end of residency (I should have done this sooner) with SoFi. However, I have many friends and colleagues who bought into the program, made the minimum payments to stay eligible (opting for the income-driven repayment plan), and consequently ran up piles of interest, graduating with larger balances than they entered residency with. THEN, they are limited in choice of employer to these “not for profit” entities, and now are facing the frightening possibility that they still won’t ever see the loans forgiven. (Note: I don’t mean to incite panic or add to any melodrama. The White Coat Investor has some good advice for anyone worried about this issue). Whether or not this program was written with the intention of limiting physicians’ practice options in order to encourage the employed model is questionable, but it has certainly had this effect. (Here’s link to .gov site for direct info).
Taking into account the principle that “No one will pay you more than you will pay yourself,” these physicians have: #1. Taken out massive amounts of loans, #2. Had interest payments balloon through residency thanks to income-driven repayment plans that don’t touch the principle, #3 signed up for jobs that will likely pay less and prevent them from taking control over their practices. This situation seems like an ideal formula to take a tremendous amount of power and earning potential away from physicians and transfer it to administrators.
Now, I’m personally not against taking an employed position. As a trauma + critical care surgeon, I think this is probably a much more common scenario for my field considering many tasks we are responsible for are non-RVU based and located in larger hospital trauma centers. Nevertheless, I’ve been amazed at how many neurosurgery practices have been bought by hospital systems, and the main reason cited is complexities of billing.
At the risk of sounding glib, I’d like to point out that this same evolution happened in the record industry, did it not? We ended up with a bunch of simple, formulaic, boring bands and cheesy music genres. Same thing happened with beer; remember before craft brewing was a thing and all that was on the shelves was weak, smelly water with clever ad campaigns? Fortunately, these two industries, among many others, have benefited from an awakening of independent artists and craftsman, and there is now a flourishing variety of creative music and micro-brews for us to enjoy. Maybe the same thing can happen with healthcare, but that there are much stronger influencers including lobbyists, politicians, and that infamous army-of-middle-men standing in the way. However, if it’s best for patients and best for physicians, we can keep the indie spirit alive in healthcare as well. The Frugal Physician has just written an excellent post about this very idea, expanding on the idea that in order to take back control of medical practices we have to control the finances, starting with our personal finances (i.e. student loans).
This idea of finances being the key to engineering the practices, and lives, that we want has been coming up again and again lately. Personally, we have little choice but to pay off our debts and achieve some measure of financial independence if we really want to pursue careers in humanitarian medicine. But for those outside of this field, ignoring finances has the analogous consequence of limiting the type of practice, and ultimately life, that one can have. It’s likely no coincidence that these changes are correlating with the burnout epidemic. I’m not the expert, and I don’t have the answers. I’m merely the naive young doctor observing and asking the question: Is it too late for physicians to take their practices back? Who is really benefiting by keeping us out of practice ownership?
I am pleased to share this post detailing a day in Dr. Jessica Schnur’s life. She is a general surgeon with a subspecialty in minimally invasive surgery at Stony Brook University Hospital. Despite her humor and talent for writing, I’m sure it will be quite apparent that her job and career require astounding commitment and sacrifice. While I have heard it said that the average person underestimates his/her free time, this statement couldn’t be further from the truth for dedicated physicians like Dr. Schnur. We are all searching for the balance that will allow us to do the jobs we love and use our talents to help our patients while loving our families the best way we can.
The last 6 weeks for me has been complete madness, between work and family I feel I have barely been able to stay afloat. I wrote this as a compilation of the combination of things that happen simultaneously every day. The amount of emotional and intellectual energy one must dedicate to taking care of your patients, your family and your friends is at times exhausting. We all became physicians because we want to help people, but the risk of burnout is real and while I have read many articles advocating for remedies to it I have yet to see anything significant be done about it. Dr. Jessica Schnur
My alarm goes off, it’s 4:40am. I flail around trying to turn it off so I don’t wake up my husband. Find it! I close my eyes for a second and pass out instantly, open my eyes to find that 15 precious minutes have passed. I debate whether I have enough time to exercise and still leave for work on time. I have an hour and 15 minutes. I can do it. It’s never happened before, but today it’s going to. I go downstairs, take my coffee and sit on the couch in the dark to enjoy my few minutes of peace for the day. My mind wanders until my phone goes off. Ping ping! I look over, my junior colleague was on call last night, he is letting me know there are a few new patients for today, two gallbladders. Maybe three. Also a patient with a decubitus ulcer. He is leaving town now for a “conference,” would I mind taking care of all that? Of course, I write, my freakin pleasure. I start to feel some unrest in my bowels, a combination of the rocket-fuel grade coffee I made and rage against my lazy co-worker. It’s been ten minutes and I need to get ready to work out. I go back into the kitchen to wash the dishes from dinner last night. I didn’t cook, so I do the dishes. Can I do this in 30 seconds? 100% More unrest from my bowels, I abandon my dishwashing and run to the bathroom. I finally get my workout in, inhale breakfast and jump in the shower. When I get out I see I have 11 minutes before I have to leave the house. Plenty of time. I look in the mirror at the pale bloated face looking back at me, pimples and wrinkles that need covering, significantly greying hair that needs to be blow-dried so I don’t look like Albert Einstein. Various creams, concealers, highlighters, blush… check the clock again. One minute left. Mascara flies on, blow dry my hair for 60 seconds, good enough. Compression stockings, scrubs, find a sweatshirt that doesn’t have too much dog drool and marker on it. Ready to go! Should have left the house 15 minutes ago but what else is new.
I arrive at work, tires squealing in the parking lot like I’m running from the cops. My phone rings, it’s my chief resident. We have an intraoperative consult from GYN, they have run into some difficult adhesions and are requesting help, can I meet her there? Ummmm, I’m not even in the building yet but sure. Run up to my office and try to find somewhere to throw my stuff. It looks like a tornado hit, papers everywhere, dirty scrubs in piles on the chairs, multiple empty water bottles. I sort through the madness and am about to head down to the Operating Room when I realize I am wearing slippers. This is disappointing, but there is nothing to be done.
About an hour later we are finishing up the first case and my phone starts going off again. Ping Ping! Ping! Ping Ping Ping! It’s my husband, my little one peed all over her bed. He’s annoyed. The text message is multiple screens long and involves some talk about how we are going to sleep train her. After a few paragraphs, “Where are you?” I write back a frowny face. I have to round, still have four cases to do. I come out of the OR and find my intern and PA to start rounding. My intern is pale, sweating, looks like he might be in heart failure. I try to console him, it’s ok buddy, we will get through this day. He actually might not, but we must move on.
We go see a patient I operated on a few days ago, “Hello, sir! How are you feeling?” He’s a very nice elderly man, looks like he’s doing well. “I want to eat!” Fantastic! “That’s great! You can eat!” He looks thrilled, asks me if I can tell his doctor he can eat. I debate whether to point out to him that I am his doctor, decide to go for it. This may have been a mistake, he stares at me wide eyed, speechless. Was it the slippers? It is best to leave at this point. “See you later!” I say cheerily.
I battle my way through the rest of rounds, some more consults and admissions, a few cases. I get my phone to dictate my last case and there are multiple missed text messages and a missed call from my daughter’s school. I panic momentarily about the school phone call but it is just a robot announcement. We have told the school as well as any other place our children or dog goes to call my husband with issues because he stays at home but they still call me. Every. Single. Time. The texts are from two of my friends and my husband again. One friend wants to know if we can get together for a playdate tomorrow afternoon at 3, which is Friday. I say I will ask my husband if he can bring the kids over and then lose the motivation to relay this information to him. The next is from another friend who is seeing the latest greatest nutritionist among the other moms who magically helps you become thin and fit and full of energy. He had sent off a panel of blood work and told her she may have a gallbladder issue. She sends me three pages of lab results and asks me what I think. I think I really can’t look at this right now. Finally my husband. He is unhappy with the light fixture in our younger daughter’s room, it is apparently flickering, which may or may not be true. He is debating on how to rewire the fixture and switch to fix this. He is not an electrician and refuses to call one. I only ask that he not burn the house down while the kids are home.
At some point I realize I’m starving. It’s 5pm and I forgot to eat lunch. Or drink water. I don’t think I’ve peed since I left the house this morning. I go to the recovery room to get some water and graham crackers, but there are no cups. Or crackers. I ask one of the staff for a cup, he points out the cups really are supposed to be for the patients, reluctantly shows me where they are hidden. I apologize profusely for being a human being and take my water.
One more consult to see. Ping Ping! Husband again, apparently my younger daughter is “very angry” at me because she misses me and wants to know when I’m coming home. I’m on till 6, but things are looking good. Just one more patient to see, I tell him. We go to the ED to see a middle aged man that was suspected of having a bowel obstruction. He is there with his wife and mother, all look extremely concerned. He has been constipated for a week, very bloated. I listen intently to the tale of his failed attempts to poop this week. We look at his labs, imaging, he has no bowel obstruction, he is simply constipated. We recommend some laxatives and stool softeners, fiber, etc but his family catches us as we are leaving and wants to talk more about constipation. It is now well after 6. I have received a video from my husband of my four year old angrily telling me I have to come home and she is very mad. I extract myself from the ED and head back to my office to gather my things to leave.
I get home around 7:30, dinner has been had, my husband tells me he gave the kids a bath, but they washed themselves. He is proud of them. I’m concerned about their hygiene but too tired to look into it. He tells me to eat dinner quickly before we put the kids to bed but at this point my priority is the glass of wine that I am going to pound before story time. Teeth get brushed, stories read, I lie down next to my 4 year old to rub her head while she goes to sleep and pass out before she does. I wake up because she is kicking me in the face. I get up and look at my watch, 12:30 am. I crawl into my own bed and prepare for another day of complete insanity.
One of the biggest “Aha!” moments for me came from finding Jillian from Montana Money Adventures, initially while listening to her podcast on ChooseFI and then reading her article “Big Family Minimalism,” on Cait Flander’s website. I signed up for her email list in order to gain access to her awesome Resource Library, which contains mentoring questions and “Let’s Chat Worksheets.” These are pages of guided discussion and questions that can really challenge us to address what our true goals and passions are, instead of simply following the path of least resistance and hoping we end up somewhere decent.
This idea of intentionally designing the life I want started during my 3rd year of training when I realized that I wasn’t doing ANY of the stuff I enjoyed and was suffering from severe burnout as a result. After a few years of pondering these topics on my own, I was ecstatic to find Jillian’s excellent guidance. Answering these questions is HARD! Josh and I have been working through them together, and we can only do a few questions at a time before we are a little worn out mentally, and it takes us a few days to complete a worksheet. Nevertheless, going through the worksheets together has been a wonderful exercise for our relationship; it has gotten us communicating about these ambitious big goals and deeper motivations, and it has definitely helped us understand one another better. We will often be mulling over the same question and, lo and behold, come up with the same answers. It’s also amazing to hear him come up with a totally different answer than mine, as I then have something entirely new to consider. I definitely recommend these resources to any individual or couple who is interested in mindfully constructing their lives and purposely cultivating relationships, careers, possessions, time-management skills, etc.
I contacted Jillian by email to ask her permission to post the worksheets completed with our answers, and she graciously agreed. If you find value in these posts, please head over to her website and sign up for her email list, so that you can have access to her entire resource library. She never sends emails that aren’t very insightful and beneficial.
We decided to start our mentoring questions with the worksheet titled, “Highlight Reel.” The following is our completed worksheet…
What were the most significant moments from the last year?
Joy graduating general surgery residency.
Esmé being born.
Starting our website and podcast.
Starting research year.
Joy taking time to spend with the girls, having a real maternity leave with this one.
Finding FI information
Interviewing for jobs together.
What are our best memories from the last 10 years?
Eddy being born.
Esme being born.
Trip to Big Sur.
Matching at Mayo.
Music festivals together.
10 year anniversary
Choosing our sub-specialties—being liberated from pressure of doing cardiac/peds neurosurgery
Family vacation to smoky mountains
Family get-togethers in Nashville
Watching Archer on maternity leave with Eddy (seriously one of the most fun memories I have. We watched two episodes every night and laughed our heads off).
Joy-trip to Ukraine and Guatemala
Joy-trip to ACS 2017 meeting global surgery sessions
What do we wish we would have done in the last 10 years?
Travel more for global health projects
Gotten an MPH or MBA during residency
Been more active in global surgery world instead of putting it on hold for training
Gone on more family vacations
Decided to do trauma earlier, let cardiac go earlier, not let myself become burned out
More date nights
What are our most significant achievements? What are we most proud of?
Beautiful girls. Toddler who is very sweet, affectionate, and confident.
Breastfeeding for 2.5 years.
Strong marriage through all of education and training challenges and parenting. Staying best friends and supporting one another.
Couples matching at Mayo.
Both of us succeeding through specialty training.
Living below our means during training despite needing SO MUCH childcare.
What would be amazing to see happen in the NEXT five or ten years?
Significant involvement in high-impact global surgery projects focused on alleviating suffering.
Network of folks working toward the same goal.
Girls traveling with us frequently and understanding our mission.
Spending down time near our extended families (hopefully moving closer to home)
Financial independence with funds for early mini-retirement.
Indie Docs having regular post and reaching anyone who might find it helpful (easily visible).
What are a few money goals we would love to hit? In five years? Ten years? Twenty years?
5-years: Debts paid, Financial independence with enough $$ for mini-retirement, couple of investment properties to maintain income while overseas, kids college funds fully-funded.
10-years: Enough money to give away generously to projects we believe in, passive income to sustain personal finances and giving and Indie Docs ventures.
20-years: Solidly funded full-retirement accounts, high-impact projects that are self-sustaining and more projects that we are investing in.
Do we have a net-worth goal?
Sorta. Arbitrary “fat-FIRE goal” of $3-3.5 million. Highly subject to change.
Passive income goal?
$3000/month or enough to just tread water when we are out of the country or not working (don’t really know about this number specifically )
Is our goal to pay off our home?
Certain amount or percentage donated or in a donor-advised fun?
Would like to eventually be able to donate all income.
Certain size inheritance to pass on?
Enough to fund kids retirement so they are able to pursue whatever career they are most passionate about.
Any health/physical highlights that seem exciting to you?
Staying healthy and energetic, being able to do certain body weight exercises like pull-ups and pistol squats, and increasing flexibility to stay injury-free (for Joy).
General fitness, daily exercise would be a win (for Josh).
Any relationship highlights you want to add?
We want to be more intentional about doing fun and exciting things together, being more affectionate, having deeper conversations.
Get to work together on passion projects.
Definitely want to be traveling regularly to sites of our global surgery projects.
Also would like some fun adventure travel to unplug and recharge.
Work highlights you would love to hit? Certain position/rank/awards/contribution?
Become confident and experienced surgeons.
Don’t care about rank or position.
Would like our practices to be impactful for local community.
If I’m running a private practice, would like to be maximizing impact and using smart financial strategies and tax strategies to run the business successfully.
It would be a huge bonus to be able to get back into academic medicine within the sphere of global health so we can be 100% into global neurosurgery and global trauma surgery AND teach residents AND publish high-impact projects that lead to real progress in these areas.
What would a highlight in your schedule be? In 10 years, about what would you like to be able to look back and say, “We always made time for…”
Time for family and each other. Want to have time to indulge in play activities in the evenings, take our time with meals and housework without feeling like we are rushing through the daily routine. Time to travel. Time for birthdays and special occasions with cousins.
Are there any highlights you want to create from your hobbies?
Start white-water kayaking and more “glamping” adventures in the mountains, time outdoors.
What kind of impact do we want to leave in the world?
Alleviate suffering for a lot of people permanently, sustainably.
Create some new trauma systems where there aren’t any currently.
Improve the resilience of current trauma systems in settings of disasters.
Happy and generous, empathetic kids and grandkids
Create some training programs for neurosurgery, trauma and general surgery.
How would we finish these sentences?
The world is better because I…
Used my training to impact communities.
Paid attention to what people need.
Used my income to help people.
Told the stories of hard-working humanitarians.
Tried to help.
People around me are better because I …
Worked on my weaknesses.
Tried to become kinder, more thoughtful, and generous.
Don’t allow myself to become over-extended and grouchy, not exist in “survival mode” which makes us just try to make it through the day and through interactions with others. Make sure each interaction is dealt with thoughtfully and mindfully paying attention to that person. Treat people as people and not a task on the list.
When my time on this earth is done, how do I want each of these people to describe my contribution: Spouse, kids, extended family, coworkers, community members, customers, friends?
This section is pretty personal and unique for each individual, so I just left this set of questions here for you to ponder on your own.
What’s your “most important” and what is “the rest”?
(Joy) My most important is having a happy marriage, making sure Josh feels loved and cherished, loving my two girls and keeping them safe and healthy, and having a career that feels like a calling. For me, “the rest” is academic prestige, stuff like cars and a fancy house, yuppy vacations.
(Josh) Most important: Caring for the poor. If I get to the end of my life and haven’t done that, I’ll think I haven’t done the thing that was really important.
What kinds of things do you want on your highlight reel?
Joyful and hard work that made a lot of people’s lives better. Generous giving of our time, money, and energy.
By creating more financial freedom, what would that make possible?
The main thing that having financial freedom would make possible would be control over our schedule so that we can travel and work overseas. We would also be able to choose any job or assignment that was a good fit for us, and we would be able to give generously to causes that we were passionate about.
It’s odd the places you find concepts that bring your life and goals into focus. I never thought the founder of Sam Adams —Jim Koch—a guy whose name I didn’t even know, would say something that changed my perception of what’s at stake in choosing a career path (full disclosure: I am biased against Sam Adams because I don’t like their beer much, and if there’s one thing I have impeccable taste in, it’s beer). I came across the story as told by Jim Koch in the podcast, How I Built This with Guy Raz.
Jim tells the story of how he finished business and law school and got a great job at a firm called Boston Consulting Group (BCG). The pay was high and he flew first class to important meetings with important people, but he came to the realization that he did not want to do the job the rest of his life, and if he didn’t want to do it the rest of his life, then why do it tomorrow? So he quit that job and decided to…brew beer?!
His reason for leaving that great job is fascinating, he says:
I left it because staying there was very risky. Leaving it was not risky. And it’s the difference in life between things that are scary and things that are dangerous. And there are plenty of things that are scary but aren’t dangerous, and there are things that are dangerous, but not scary. And those are the things that get you.
He goes on to give an analogy in climbing. Rappelling down a rock wall is scary because you are jumping down a huge cliff, but it’s not dangerous because you are held by strong ropes and a harness. On the other hand, walking down the side of a mountain on a sunny day with blue skies around you is dangerous, but not scary. It’s prime weather for an avalanche that could easily kill you, but the beauty of the day lulls you into a sense of security. He elucidates further about his great job:
Staying at BCG, was dangerous but not scary, and the danger there, the risk of it, was continuing to do something that didn’t make me happy, and getting to, you know, 65 and looking back and going, “Oh my God, I wasted my life.” That is risk. That is danger.
As I look for a job after residency, I think a lot about this idea, that there are things that are perilous, but do not raise alarm. The job choice all residents face out of residency is private vs academic. I won’t go into the differences, as I’m sure most of you reading this know, but I’ve always leaned academic.
I have been fortunate to train at a great neurosurgery program with wonderful mentors who have excelled in academia and are master surgeons. The thing about mentors is they make you want to follow in their footsteps, to do what they did because they are inspiring people. I like the academic side of medicine. But it’s a regimented path that requires discipline, dedication, and persistence to be successful. It doesn’t leave a lot of room for other pursuits.
I don’t have any illusions that if I decided to pursue academic neurosurgery I would eventually be the chair of a renowned department or the president of one of the neurosurgical societies. Heck, right now, I’ve applied to more than a couple of academic positions and I can’t even get an interview. But academic neurosurgery is a clear path to pursue with well-defined goals and milestones. It doesn’t seem scary at all to me.
Pursuing a career in global health, on the other hand, seems quite the opposite. I worry about how Joy and I will raise our daughters in a different country (how will they be educated? what risks will they be exposed to?), how will our finances work out (where will our funding come from? our retirement?), what if we fail (what will job prospects look like then?), and many, many other things from dying from some strange virus to not having access to good beer (it’s the little things after all).
But when I sit in the quiet moments, late at night when I am honest with myself, it’s taking the defined path, the one that doesn’t FEEL risky, that I am terrified of looking back on and saying “Oh my God, I wasted my life.”
Trying to think about my life from the perspective of my 65 year old self is an insightful exercise. I imagine myself at the end of a career at a major academic neurosurgery program, I’ve mentored a lot of young surgeons, done interesting cases, I spend my day mostly doing the surgeries I like, and writing the papers I want to write, etc. When I think about that, I still find this nagging part of me that feels, well, unfulfilled. I don’t mean to disparage people who do this; I have benefitted immensely from people who found this was the right path for them. I also acknowledge that there are inspiring people in academics who have successfully pursued global neurosurgery projects (Dr. Haglund at Duke comes first to mind), but something in me just seems to say it’s not the right path for me. I also worry I could be diverted or distracted or not be able to devote enough time to my main goal.
When I think about dedicating my career to trying to improve neurosurgical care and education, as well as learning how people are already providing this care around the globe in resource-strapped settings, I get excited with the kind of feeling you get when you are clicking up the first hill of a roll-a-coaster held down by a harness. It feels scary, but people are there doing it with you and others have done it before you. When my 65-year-old-self thinks about looking back on that life, he has a deep satisfaction and peace.
I can’t say completely why dedicating a career to improving care in resource-limited settings has become my version of a life well-lived. I think it’s partly because I was raised in a Christian home, and the aspect of that upbringing that rang truest to me was that a life well-lived is one in which you gave up some comfort of your own to provide comfort for others less fortunate than you. That principle has stuck with me when a lot of other parts have faded. And I’ve come to realize I’m not really choosing a career between private practice and academics; I’m choosing between the defined and undefined, the well-trodden path versus my own unique one.
When it comes down to it, the things I worry about in working in global health are mainly logistical, not dangerous. Lots of missionaries have raised and educated kids across the globe. There are ways around the financial concerns. Strange viruses could pop up anywhere. And I can always home-brew. But the chance to pursue a career that you feel lines up with a truth you intrinsically and inexplicably hold regarding what gives your life purpose and meaning, you only have one lifetime to make that happen. The more I think about that, passing on it, or pursuing it only half-way, is the real danger.
We are overdue for a “state-of-the-union” post. Part of the reason is because I started this blog in a big state-of-transition; I was at the end of residency and then at the end of pregnancy, so any post about where we are would have been instantly obsolete.
I can do a brief recap of the past 6 months or so (a more full audio version of a lot of this is in ourfirst podcast episode). I had just decided to take a research position here in Rochester so that I could take maternity leave and care for the girls during Josh’s chief year (sans au pair), and Josh and I were starting to interview for real jobs. This job-hunt prompted the serious discussions about how we still wanted to do global surgery, and so I started researching the topic obsessively, and getting overwhelmed by all the information and options regarding huge, life-altering decisions. So I started the website and blog, wrote a few posts, graduated, started the podcast, and had a baby.
As we will emphasize time and again, we started this project because we needed a way to organize the information we were finding and because we wanted to tell the stories of inspiring humanitarian health providers. We are not the stars of this show; we are the naive amateurs trying to join the bigger leagues.
Despite that awareness about ourselves and vision for Indie Docs, I had a conversation last night with Josh that made me a little sad. He expressed regret for not “doing more” in residency. Back in 2005, his motivation for taking his very first college-level science class (Basic Chem 101) was to become a doctor and do global health work (after reading Mountains Beyond Mountains). That goal wove it’s way into countless conversations regarding specialty choice and long-term plans beyond residency. Josh spent a month in Uganda as a 4th year elective in med school (while I was on another away-rotation) with the Cure hospital, and he had a fantastic experience. Mayo has generous funding for short humanitarian surgery electives but no formal program for long engagements during residency; I enjoyed two such trips, one to Ukraine and another to to Guatemala, but Josh hasn’t travelled for a medical trip since Uganda.
My response to Josh was to list all the reasons for us not traveling more. In 2012 we became a two-resident household, both in surgical specialties, and I was proud of us for just keeping it together through training and the birth of our first child. We needed lots of help, from our au pair and day care and one another, and I honestly didn’t feel like galavanting around the globe was a huge priority. I didn’t have any doubts about humanitarian work as a long-term goal that felt like a road-test was needed. Honestly, before I became a chief resident I wasn’t super useful on medical trips, which is a bad feeling after taking all the effort to go. This is the same sentiment I had back in college and I was teaching math and English in Nairobi when I decided to become a doctor; I wanted to do something concrete and unequivocally helpful (education IS definitely important, but there were plenty of local educators who needed the work, and it didn’t quite feel like my purpose in life). In another sense, I felt like Josh and I took somewhat of a mental break from the subject of global surgery, and if we were really meant to do it I thought we would return to that goal. And we did. So in short, I supposed I felt like we were biding our time, doing the necessary hard work of getting excellent training, and enjoying some aspects of life in the meantime (namely starting our family).
Despite these points, I don’t want to dismiss Josh’s feelings. It is entirely possible that the above paragraph is nothing but a pile of excuses and we absolutely should have done more. We could have gone for MPH degrees during training, adopted a passion project overseas, made a serious effort to travel together, been more generous with our money, volunteered more here in town, etc. Like Dr. Dupont discussed in his podcast episode, we could have foregone buying a house, gotten more serious about slashing our debts, and maybe set ourselves up to travel sooner. I will absolutely admit there is more that we could have done.
So why didn’t we? Like I alluded to earlier, being so busy and stretched so thin probably had a lot to do with it. There is a buzzy word that I think applies here: that of the “scarcity mindset.” We never had enough time to spend together. Our money was relatively tight and I’m a big saver; it’s hard for me to spend money on travel. With the birth of our first daughter, I was worried about having enough in the budget to cover 80 hours per week of childcare (we definitely dipped into our savings those two years). Additionally, I simply didn’t have the bandwidth to pay much attention to this idea.
In a way, Josh’s regrets represent the real and present danger we are in professionally. If we slacked off and made excuses during residency, how much more likely will those mistakes be as we acquire more responsibility. Josh often refers to a statement by Sam Adams founder Jim Koch that some things are scary but not dangerous and others are dangerous but not scary (paraphrasing, he will have a full-post about this up soon); I think this situation falls under that latter category. It doesn’t feel scary to grind out an over-loaded daily life, but we might look around a decade later and realize we haven’t accomplished our goals and haven’t found our greater purpose (or get majorly burned out).
So whatever the reasons, legitimate or not, that we’ve had for inaction in the past, the time is here for transformation. We are beginning to plan for our first humanitarian trip together as a family; I will write about our destination, financial strategy, and timing in upcoming posts. I was recently challenged by Episode 1 of the So Money Podcast (hosted by Farnoosh Torabi) with Tony Robbins, in which he says that being generous helps us to avoid the scarcity mindset by convincing our subconscious that we have enough to give, and if we don’t give when we have a little money, we certainly won’t give when we have a lot of money (paraphrasing again). So we will also establish some causes to support on a regular basis rather than just the helter-skelter giving we’ve been doing until this point. And of course, we will continue to make a big effort to post useful content on this website and tell the stories of inspiring humanitarians making the difference with their hard work.
One thing I must address briefly at this point is the reason that we won’t be moving to a medical mission immediately out of training. I will do a complete post on this topic soon, but suffice it to say that it doesn’t make sense from a financial or professional standpoint. We have debts, namely student loans, and very little savings. At the same time, we have the potential to make what is frankly a huge income between the two of us, and I feel like there’s no way I could justify asking for charitable donations when we could essentially be self-funded in a few short years. We’ve determined that achieving financial independence is really the only pathway that makes a lot of sense for us. And, although we both were raised in Christian homes and are heavily influenced by many Christian ideals, we wouldn’t meet the standards to qualify for the same funding programs as our evangelical friends. Additionally, Josh needs to take neurosurgery boards in a couple of years, and we would both like to get some good experience as full-fledged surgeons before jumping out on our own in a low-resource setting.
The project of creating Indie Docs has jolted us with motivation, and accountability, to push ourselves to learn more and do more. Establishing our plan of action with clear intentions and wisdom is requiring intense effort, but one that I hope will pay off not only for us, but also for other physicians struggling to find the best way to make this life-goal a sustainable reality.
Trigger warning: This post contains references to burnout, depression, and a brief and non-specific account of my friend’s suicide.
I was reluctant to write this post, but I can’t get past it to write others until this one is out there. I’ve been mentally ruminating on what I should say for weeks. I’m convinced this topic, although widely discussed and written about by physicians, is still in the stage where sharing our personal experiences might be what helps someone else fend off their own struggle with burnout and depression, as there are few institutionalized solutions or strategies for dealing with it. And perhaps for myself, sharing without shame is a form of therapy.
2010, residency interview trail. In my smart gray suit and burgundy blouse, I focused on maintaining eye contact and a slight smile as I introduced myself to my interviewer, a heavy-set man with a bushy mustache and friendly face, somewhere in the Southeast. First question, “So I’ve looked through your CV, and I have to ask you…what are you doing here? You and I both know you’re not going to rank this program.” Well, actually I’m couples matching with a neurosurgery candidate, so I’ll be ranking all programs and your program has a good cardiac surgery department and research capabilities, so…awkward. Ok next question. “You are like the medical version of a gym-rat. You like never leave the hospital. Don’t you know you’re going to burn out?”
I was adamant that I was doing what I liked. Of course I was not going to burn out, thank you very much.
2014, 3rd year of general surgery training. I was edging ever closer to entering the integrated cardiac surgery track I had committed to during my 4th-year med school away-rotation. The advice from my wonderfully supportive mentor, Dr. S, back home echoed in my mind, “If you go up there to do this, you have to follow through. Don’t punk out. Don’t be one of those women who gets washed out.” The problem was, I was conflicted about cardiac vs. trauma in med school, and I remained so those first few years in residency. I reasoned that in the worst-case scenario, I could just do the integrated cardiac training and then be a trauma surgeon; it’s just an extra year of training, that’s doable, right? In any case, I was not going to quit.
I have had a few other instances in life of not knowing when to quit. In the first grade, my teacher gave explicit and strict instructions to not interrupt her lesson for any reason; I’m pretty sure she gave the example of not even for the bathroom. And then I had to go really bad. But I said nothing, and her lesson seemed like it yawned toward eternity, and of course, I ended up sitting in a HUGE puddle of urine as my neighbor silently laughed his head off. I was quite confused when my mother and my teacher both admonished me to simply raise my hand and ask to leave next time I had to go that bad.
To get a discount on my prom dress, I posed as a “human mannequin” in the mall. I could go hours without moving a muscle. Teenage boys would try to get me to move or smile, and I was so determined that I would have tears rolling down my face from dry eyes before I gave in. I was also undefeated in staring contests; I still do not know my upper limit of standing still.
3rd year of med school, Dr. S informed me that there were no residents on his service that week, so if I showed up I could scrub all day every day and be 1st assistant. Needless to say I was PUMPED. By the end of the week, I was taking 600 mg of ibuprofen before every case to deal with the neck pain, but having a blast. We had a case that was going great, and so true to routine he ordered for the room to be warmed up in preparation to come off pump, but then we weren’t actually able to come off pump for quite a while. The surgeon ran through various maneuvers and waited patiently for the right constellation of labs and monitor feedback. Minutes stretched into hours, and I could feel beads of perspiration dripping down my shirt and legs. The room was over 80 degrees. I started to feel faint, and so I held a valsalva maneuver to get my blood pressure up; that helped. I tightened my leg muscles, shifted back and forth, flexed my calves, and kept myself from passing out at the table. This went on for another couple of hours. If I relaxed, I got light-headed and the room would start going dark, so I’d tighten everything back up. Finally, at a point where I was starting to hear that high-pitched screech that comes right before you really pass out, the surgeon told me to go scrub out and take a little break, since it was obvious it would be another 30 minutes. I went to the locker room, collapsed on a bench and ripped off my dripping wet scrubs. I looked down at my legs and saw that they were covered in petechia up to my thighs. I put on fresh scrubs, guzzled a glass of water, and went back in to finish the case.
There are other examples, but I’ll wrap up this digression by saying that I might be one of those few people that Angela Duckworth references in Grit who really doesn’t know when to quit.
So back to 3rd year, I was flying high after coming off of one of the hardest but most enjoyable rotations in residency, where I was the senior resident with one of our most respected and demanding surgeons in the program. I had also just returned from my trip to Ukraine with Novick Cardiac Alliance, where I learned how much potential there is for advanced-level surgery care in lower-resource settings.
Having wanted a career exactly like Dr. Bill Novick’s since med school (He founded cardiac programs in low-resource countries all over the world), I should have been sure of my direction, but small doubts were persistent as to whether cardiac was the right field for me. I was more interested in the bombings on the Ukrainian border a short drive away from our site than in our pediatric cardiac cases. I couldn’t deny that I was a little bored with cardiac, which was a very troubling concept, but one that I shoved aside. I couldn’t quit.
I felt great going into my thoracic surgery rotation, which was a big test for whether the integrated cardio-thoracic spot would officially be mine. Only a couple of days into the rotation, I felt myself faltering. After a couple of weeks, I was drowning. Nothing I did was right, nothing I said was right, I was never where I was supposed to be when I was supposed to be there, and I felt like my brain was 10 steps behind me at all times. I confided in trusted mentors that I didn’t know why I was failing so miserably. I didn’t get it and I was frustrated and terrified of failure.
One of the fellows, T, knew Dr. S from back home. He gave me compliments every day, telling me how highly Dr. S thought of me and all the nice things he would still tell people about me. T was a meticulous clinician, and shared with me his routine for rounding, which was truly exceptional. I tried to emulate him. He was probably the nicest person I’ve ever met, especially within the hospital, and his encouragement kept me going.
At our program, we have chief conferences for every rotation, where we go to the fancy auditorium, get onstage in our suits, present our cases from the rotation, and field questions from the staff. It’s a nerve-wracking event for all the senior residents, and we spend hours and hours preparing. I met with multiple staff to go over my case list. I studied for 15 hours one Saturday that I wasn’t working because I needed to make up for my poor performance on the rotation. I kept trying to meet with one particular staff member who would be leading the questioning for my conference, and who always met with residents regarding the conference in the past. She rescheduled with me no less than 10 times, even rescheduling a phone-call with me, and always at the last minute. Finally, the day of the conference she sat down with me, looked at my list, said it looked good with a finality in her voice that did not invite further discussion. I left that meeting knowing that I was about to get massacred; it was just obvious. Sure enough, despite my preparation, I fielded a rapid-fire of questions on controversial topics, and my brain was stuck in red-alarm mode. I could see the paper sitting in my bag discussing how there was no professional consensus on a certain topic, but my mouth just couldn’t say the words that demonstrated what I knew.
The next morning, my typically formal, reserved and always gentle attending greeted me with the words, “I was so PISSED last night! That was BEYOND inappropriate.” I had cried my eyes out after the conference, but I felt responsible for it all. I should have been able to do better. I should have done lots of things better. I took the blame despite more admonishing that it wasn’t fair to me. What’s fair got to do with it?
The remainder of that year was a downward spiral mentally. I had never outright failed professionally before. I continued to force myself to fight for something I didn’t really want. I relived all the moments of shame and humiliation over and over again, all day every day. I became irritable and would pick fights with my husband. During a car ride, I even heard myself say, “I am yelling at you because you’re the only person I can yell at that will listen.” Things had gotten very dark for me.
I was at my workstation getting vital signs one morning when I got a page. Our friend T was missing; he hadn’t shown up for work. So uncharacteristic and worrisome. I paged my other friend on a rotation with T to find out what was going on. I got another page, returned it, was told to sit down. Two days after supper club and movie night where we had a great time, laughed and joked, where I consciously perceived that his presence was like a port in the storm for me, T took his own life. I wailed in the workroom, felt sick, then felt numb. I rounded. Cried, felt numb. Scrubbed into my first case, cried at the sink, went numb. Did the case. My attending asked what was up. I told him, cried, went numb again. Did another case, actually thankful for the distraction. My group of friends stayed in close contact all that week, tried to get together as much as possible. We were all scared, although we could say exactly why or what we thought would happen to us at this point. I couldn’t understand how such a kind and gentle person could…it’s still too painful to write.
I slipped further into a dark, heavy, and bleak state. I functioned at work, had rebounded to some level of good performance, but every day I felt like I couldn’t keep up with all the tasks on my to-do list. My mind frantically begged for a pause button. Weekends off weren’t enough to recharge; vacation time didn’t help either. Every day started with a panic over how much needed to get done and seemed to end almost instantly, with nothing but shame on my part for not getting to this or that. My life felt like it was careening forward at breakneck speed, and I couldn’t slow it down, keep up, or catch up.
I had no emotional reserve. I received feedback that I seemed miserable from my intern, but I felt like I was doing all I could to simply function at work. My marriage suffered.
Then, my elderly, cancer-ridden, sweet greyhound, Pfeiffer, died. We knew it was coming for months. But this tipped me over from what was probably severe burnout to full-blown depression.
One of my trauma mentors, Dr. M., had talked to me a few times over the years about a particularly hard rotation he had in residency, and he described his emotional state during that time as “suicidal-enough.” He didn’t have a plan, but said if his car happened to run off the road or something like that, he wouldn’t have been disappointed. That’s also how I started feeling. But I also became convinced that my husband would be better off without me, my friends were only friends because they felt sorry for me and were nice people, and although my parents loved me they would actually be better off without me too. I had intrusive thoughts about my car running off the road every time I drove. I thought, maybe with some measure of hope (if that’s what we can call it), that perhaps I would develop a terminal illness.
I also felt trapped. My fate as a cardiac surgeon was still unclear, or at least for the integrated spot. I wasn’t ready to quit because I didn’t want to be a quitter. I agreed to go back to thoracic for another audition rotation. I did fine but not stellar. Whatever, I didn’t care.
I recognized my symptoms of depression and was acutely aware of the danger I was in, especially after my friend, who was much kinder and gentler than me, had recently succumbed to it’s pain. I took an online questionnaire that pegged me as “severely depressed,” and instructed me to seek medical attention. I shared this information with my mother and told her I needed advice but I didn’t want to go to the doctor. Could we just talk it through? I thought her wisdom and love could pull me out of it. I didn’t want “depression” in my medical record, and I didn’t want to tick that box on professional forms in the future.
I researched strategies to combat depression. I exercised regularly, tried to get outside on every sunny day, eat healthy, connect with friends, talk about it with my mom, Josh, and my best girl-friend.
I longed for some canine companionship and so decided to volunteer to walk dogs with the local greyhound rescue group. I met up with them and instantly connected with a big yellow staghound. I picked him up on the first 50-degree Saturday of the year, and we went to a hiking trail.
There was still a nice covering of snow on the ground that sparkled in the warm sunshine. It was a glorious day. I smiled and my face literally hurt because I couldn’t stop smiling and laughing as we clumsily jogged up and down the rutted out, snowy trails.
We stopped at a bridge and just sat together, and the dog literally hugged me, draping his giant neck over my head and just resting there long enough for me to snap a selfie.
Ramble had a gift for making everyone feel important. Indeed, he convinced everyone that they were important with his confident affection. I thought about many things sitting on that bridge, including what my options were in life. I could do so many things still… I could learn a foreign language, write creatively, read some books, adopt this dog! I could be a trauma surgeon if I wanted. Suddenly, there were a dozen sunny paths before me instead of the claustrophobic walls of a dark dungeon.
Of course I got the dog, and named him Ramble. I created the life-motto of, “If I’m too busy for a dog, I’m too busy.” I decided I would never cross that line again; it was too dangerous. I made room for all the things mentioned above. I apologized to my husband and started doing fun things with him, like seeing as many indie-rock shows as humanly possible. It was a blast.
I sat through the meeting where I was told I did not get the integrated cardiac spot. One loud thought started flashing across my brain…I’m going to start a family! So we did. And I went all-in on trauma/critical care, and that felt so, so good. Trauma is just more fun, and I loved every day of my fellowship year. And thus, What-is-More-Fun finally became a guiding light.
What actually changed for me that day with Ramble? Only one thing: Perspective. All of those possibilities in life were always there, but I couldn’t see any of them. I went from trapped to in-charge. It was a sudden revolution, but one that I’ll never forget.
I made some mistakes on this journey. I got lucky that I made it through; but not seeking medical help was a huge risk that is not worth taking. I know of residents with the most stellar reputations, who have won the biggest campus-wide leadership and teaching awards possible, who are open about being on anti-depressants. Anyone with symptoms of depression should seek professional help. One other excuse that I made was that my symptoms hadn’t been going on that long, so I couldn’t really be depressed, it was all situational, blah blah blah. Again, I urge anyone who recognizes these symptoms in themselves or a friend or relative, seek and encourage others to seek professional help. It’s just too important, you are too important, to settle for less.
I hope that I am able to spot the symptoms of burnout among my future residents. With my performance level dropping, seeming tired and overwhelmed by the schedule, even after asking for help and understanding from my staff, the signs were fairly apparent. Yet, I had only one single attending ask me during the course of the year whether I might be depressed after I confided that I felt overwhelmed with my to-do list every day (and at that point I summarily denied it). It seems that this is a common experience during 3rd year of general surgery, but it can happen at any time. I hope that by sharing openly about this issue, that someone feels less alone, and less trapped. The biggest lesson to overcome burnout for me was that I was in charge of my life. No one else could be expected to carry me to my desired destination, but I absolutely had the freedom, and responsibility, to make it happen. I learned the importance of knowing oneself and being honest about what I really want rather than what is expected of me.
Another concept from Dr. Angela Duckworth’s Grit is that having an overarching purpose in life helps one have grit, because even if you fail at something specific along the way, you will just find another way to continue the long arc of achieving your greater purpose. I’ve always wanted to do humanitarian medical missions. Indie Docs is about intentionally, methodically, making it happen. Several studies and sources have published that humanitarian medicine can combat burnout among physicians, and the reasons are fairly obvious. By helping those with less resources, we get that “givers high” and feel like we have an awesome purpose, and I truly believe there is nothing better in life than that.
There are many other great posts and discussions on burnout, but the one that really got my attention several months ago was the ChooseFI podcast with guest The Happy Philosopher, where he talked about his burnout and recovery; this got me reading his blog, and there are numerous fantastic posts about purpose, meaning, and his own story about burnout. This is a great resource to start with if you are struggling with it. I hope that my little contribution to the subject might connect with someone and help you know that you’re not alone, you’re not weird for feeling this way (over half of physicians have symptoms of burnout!), you’re human, you’re the boss, and you can make your life into a fantastic story that you’ll be happy and proud to live out.
Feel free to email me at joy@indiedocs if you’re struggling or just want to share your experience, or share your own story in comments below. If you have thoughts of self-harm, please call the Suicide Prevention Lifeline at 1-800-273-8255 or seek help at your local emergency department.