Nobel Prize winning Mississippi-native author William Faulkner famously said, “To understand the world, you must first understand a place like Mississippi.” Such a catchy quip, this sentence is printed on t-shirts and home decor objects all over my new hometown of Oxford, MS. As a lit-major in college, I was constantly reminded of this statement, and through the years it’s often bubbled up into my stream-of-consciousness.
When I left Mississippi at the age of 27 for greener pastures in the upper Midwest, I was relieved. It was nice to be in a place that was more politically diverse, less conflicted, more even-keel. New acquaintances would chide me about preparing for the brutal winter, and I responded that at least I no longer had to fear the venomous spiders, snakes, and fire ants of the South. I was only half joking.
Time came for the next transition, for my giant leap into professional life. I stepped back into this place where I am a native and feel like a stranger. Just about every day, people ask me where I am from, and they smile from tremendous relief when I say, “Jackson.” “Oh! I did realize you were a Mississippi girl!”
My first week here, I went to the post office. I had no big expectations of this mundane errand, so I was unprepared for the level of welcoming, genuine warmth that beamed from the postal worker. I left smiling. I went out to eat lunch, and my waiter put my food down and gushed, “Watcha know Hon? Ooooh that looks GOOD!” Never in my life have I ever felt so validated in my lunch order; I rode that high for the rest of the afternoon.
I’m raising two little girls in a two-surgeon household, and I have no doubt I could ask any of a dozen acquaintances and neighbors for ANYTHING and they would drop EVERYTHING to help. There are deep abiding roots of selflessness and generosity of the individuals in this community.
I was compelled to return by this idea that Mississippi is both the hardest and most tender of places. That going anywhere else was a cop-out. That if I want to fight for humanity, I need to meet on the mat here.
I’ve come to the conclusion that Faulkner was right. He wasn’t being optimistic; quite the contrary, I think he was saying no one will understand Mississippi, much less the world. I sure don’t feel like I can understand Mississippi. But one thing I have come to understand is that change is hard. That feelings are more powerful than logic. That this community suffers from the wounds of the past and struggles to live in the present. I want the future to be brighter.
As I pondered my new life and decision to come here, and wrestled with whether I could handle it, a simpler statement came to my mind than the one Faulkner wrote. “To change the world, you first must change a place like Mississippi.”
I’m not sure I’ll ever understand a place like this. I might understand it better than an outsider would. But I am bound and determined to change it, and that, I believe, we can do. And maybe all these places in the world that are considered the hardest, most complicated, most entrenched, most hurt, will change too.
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.
My alarm beeped at 5:00 a.m., and I was instantly awake. I roused my sister, and we donned our jeans and rubber boots before heading outside in the dark. Gravel from our driveway crunched underfoot as we hurried to the barn, banged on the wall to encourage the rats to hide, and flung open the wooden door to retrieve the feed and hay for our mares. We sat on the steps waiting for them to finish their breakfast, anticipating the joys of our daily trail ride. The air was already warm and thick with humidity in the Mississippi summer, and if we didn’t get the horses on the trail with the sunrise, it would be too hot. Tack on, we mounted and sauntered down the road, taking an easy pace for the first hour through Mr. Buddy Crawford’s pastures to the beautiful old pine forrest trails. The mystical beauty of the morning and perfect harmony with my horse, Naomi, filled me with joy every day of the summer. As we emerged from the woods, a long straight stretch of unused cornfield made for the perfect runway, and my sister and I raced our horses across. Naomi responded to my voice command, “GO!” with unbridled enthusiasm, and the thrill of galloping across the flat grass course was like no other. At the end of the ride, I could tell she was just as happy as I was. This horse was my soul-mate; she came when I called, sensed my moods, and would follow me anywhere. She was easily spooked, but I knew all of her quirks. We returned to the barn and went about our day, watching the antics of our goats, dogs, and cats, and always looking for more adventure.
At this phase of life, around age 8-10 years old, I simply knew who I was, what I wanted, and what I liked. Shortly thereafter, around middle-school, my self-consciousness soared while I became thoroughly confused about what I liked and wanted. Unfortunately, that “phase” of life continued through high school and in some form through college, and young adult life. I made decent decisions for majors, friends, career, life-partner (ok an astonishingly fantastic decision on that one!), but I didn’t have that effortlessly pure, distilled sense of who I was. I also didn’t realize that this was the case, until I faced my own big monstrous burn-out during residency. This topic deserves it’s own post, which I will eventually write, but for now suffice it to say that it took months for me to work through the challenges associated with it, and when I was finally emerging from those doldrums I had a burning question constantly on my mind: What would my 10-year old self think of me now?
It was hardly a rhetorical question, and I had lots of answers. First of all, I would have been appalled at the lack of book-reading happening. As a child, I devoured stacks of fiction-book series. I read in my room, in the car, in the yard, in trees, at night, first thing in the morning, on the bus…I was a bookaholic. If I recall correctly, I was into several equestrian stories, maybe had just finished all the Boxcar Children, Baby-sitters Club, Chronicles of Narnia, and Saddle Club books. Anyway, at the point of my burn-out recovery in residency, i hadn’t read a novel since 4th year of medical school, when I read one chapter each night of War and Peace to help me fall asleep; it took me about a year to finish (short chapters) but I loved the ritual.
I also would have been perplexed as to why I didn’t write more. I always enjoyed journaling and writing stories, and even through high-school and college I nurtured the interest and skill in writing. I took AP English and was an English major in college; I wrote all the time. Even as a math (double) major, I wrote an honors thesis (on Non-Euclidean Geometry), which is just to say, I worked in writing at every opportunity. As a med student and resident, I never wrote anything except daily notes and H&Ps.
The next one was even more painful to admit to that little girl of my past…I had grown up into a woman who was too busy for a dog. This was a profoundly sad realization, and was decidedly the catalyst for springing me free of the burnout and depression because I made his resolution: “If I’m too busy for a dog, I’m just too damn busy and something has to give.” I decided then that this would be one of the barometers of my life to keep things in balance. And I adopted, and got adopted by, my soul-mate dog Ramble. (If you want some insight into how low I felt at this point in life, listen to the song, “Too weak to Ramble,” by Dr. Dog, which inspired his name.)
Maybe one last big one would have been participating in humanitarian work and travel, essentially being connected to current events. I had picked cardiac surgery as a specialty and was pretty determined to not fall back on what I felt was a commitment to that field, but increasingly I felt that trauma surgery was so much more intricately connected to the community and current affairs, which I was very interested in. I did go on a trip with a cardiac surgery group (Novick Cardiac Alliance, which is a fantastic organization I will write more about in future posts) to Ukraine, and learned a lot there about delivering superb quality, highly advanced surgical care in a developing country, but I was much more interested in what was going on with the folks being bombed at the border than with the cardiac stuff. I hadn’t really made being an activitist in global health topics a priority with my time and efforts to that point; I was just trying to “get through” training.
Ramble and I went for hikes every weekend that I was free from work that spring, summer, and fall. His influence on my life was profound, and taught me to be open to sharing my time and energy with the right people (and creatures). I also wrote a couple of articles for a local independent journalism group. I picked up some good books to read. I started the first Global Surgery Journal Club at Mayo Clinic in Rochester, and networked with some awesome surgeons and residents who had similar interests. I’ve never had a recurrence of burnout or depression.
So many people go through similar growing pains in their early 30s, it’s almost a cliché. But the transformation was real, and was about taking back my life in small ways, and stopping that utter neglect of all the things that made me “Me.” But where am I going with this long, long post? What’s it got to do with Indie Docs, or Global Medicine?
Learning about myself, what I genuinely like, how I truly want to spend my time, has been a challenge and has developed some skills of insight. It almost feels like a muscle that started out pretty weak those few years ago. It can be quite stressful to trust myself to step off the prescribed path of daily routine or academic medicine, and even more-so for choosing a really unusual career narrative.
Josh and I have discussed the subject, “What do we want our lives to look like in 5 years,” countless times, and we are still discovering the answer.
Fortunately, through her interview on the ChooseFI podcast, I discovered Jillian from Montana Money Adventures. I started working through her mentoring worksheets, and I was blown away by the insight they provided me. I asked her permission to use the worksheets as topics for discussion here, to which she has graciously agreed. So in upcoming posts and maybe on some podcast episodes, Josh and I will use her mentoring worksheets to answer the questions of how we are purposely designing our lives, engineering our time and finances, and thinking about the future in order to be true to our most quintessential goals (doing humanitarian medicine!)
I gave birth to a beautiful baby girl this past week. I’ve designed my year so that I get lots of time at home by taking a research position rather than an attending job. I’ll be doing some locums assignments as well to keep my skills sharp and gain experience, but doing this “off-year” was one decision I made that may have been different than what most surgeons would think is the right way to spend my first year out of training. With our unique circumstances, and how much fun I am having with my girls AND with stretching my skills as a researcher, and I’m secure in knowing that I made the best decision for us.
The ability to answer these simple questions of what we really want in life will be central to making sure we make the right decisions about what jobs to take this year, particularly in order to facilitate our bigger goals of making humanitarian medicine a major part of our lives. The decision could enable us to have the freedom to pursue many global surgery projects, or strap us to confining responsibilities.
There are trade-offs to every scenario, pros and cons to weigh, futures to consider (the girls’ in addition to ours), and plain old money questions. But all of those specifics take a back-seat to the simply being able to know and do what will make us happiest and give us the deepest sense of purpose.
With the help of some great mentors this year (stay tuned for that!), I am certain that we will find the right path.
Many physicians reading this are familiar with Doximity, a professional social media site that publishes articles ranging from scientific papers to editorials. Most of us are also keenly aware that finding funding for humanitarian medical travel can be very difficult and time consuming.
I’m very happy to share that Doximity is now sponsoring travel scholarships for humanitarian projects. The process is a simple application, and currently 80% of projects are approved! To check out their website and apply, follow the link.
Despite having a huge campus, state of the art healthcare, and an amazingly diverse group of employees, my hospital did not have a Global Surgery “group.” There were surgeons, nurses, scrub technicians, and even pharmacist going on medical and surgery missions projects and lots of individual efforts going on. We have a fund available to us as residents for competitive scholarships to various locations for humanitarian health endeavors. But no one was getting together to have discussions and provide wisdom and support to the group. No one was addressing the enthusiasm of our medical students for this field. And no one was promoting education of the larger group of employees regarding all the potential benefits of participating in humanitarian projects. I could imagine an amazing Global Surgery department at our hospital, much like what I explored via the internet sites from Harvard and Stanford.
I tried to think of the most basic first step. What was the move that would be completely without controversy, free, and easy for this one person to pull off? The answer: Organize a journal club. Journal clubs are ubiquitous, 100% educational and therefore in line with the mission of my program, and flexible. I could design it to meet when and where was convenient for me (I hosted the first few), and also drum up enthusiasm and support from others that might want to participate.
So that’s what I did, and we just decided to see what might happen next…
We had a small group of highly enthusiastic participants, including medical students. We met at the homes of group members and enjoyed very wonderful home made food. I was thrilled that some of our attending physicians agreed to host!
I was committed to meeting monthly with the exception of December and selected articles that tried to set the groundwork for understand the current state of the Global Surgery arena. We started with the Lancet publications (see http://www.lancetglobalsurgery.org/) and ended up talking through various publications from this series for the first 3 meetings. We branched out to publications featured on the Lifebox website (see http://www.lifebox.org/professional/publications/).
Group members started to undertake fantastic research projects and promotion of humanitarian missions. As a group, we brainstormed about how to establish a Global Surgery center, which is our current active goal.
Perhaps most importantly, we became a close-knit and defined group of Global Surgery enthusiasts, and there is tremendous motivation in having this support from peers and mentors.
Starting a Global Surgery, or medicine, or pharmacy, or simply global health, journal club, is a quick and easy first step for starting the fire at your institution. With consistency, you can build an alliance of folks looking for camaraderie and practical advice. There are no downsides!
Let me know if you’ve had a successful strategy for starting a humanitarian medicine group of any subspecialty at your institution in the comments below. It would be great to share strategies for success!