By Anonymous Hospitalist, Guest WriterRage. Shirt-rending, wall-punching, swear-inducing tears of bitter rage is what I felt as the EMR crashed for the fourth time as I tried to complete my fifth admission in the past two hours. If you have ever experienced similar soul-crushing emotions, you have first-hand knowledge of what burnout feels like. My own experience as a physician has ranged from inexpressible joy to the aforementioned tears of bitter rage. As WCI Founder Dr. Jim Dahle has commented on more than one occasion, the biggest threat to your financial well-being is not being able to continue practicing medicine.
This is a post about one such threat.
Absolute Anger with My Job
I am a traveling hospitalist for a multi-state group. Overall, I have enjoyed this position. I have worked at several hospitals in different states, and while the downsides of traveling are significant, the upsides work for my family and me overall. I have a low threshold for boredom, and traveling to different regions every 3-6 months helps mitigate this. I work a traditional seven-on-seven-off schedule, and every week when I come home, my wife and children are happy to see me. I think of it as “The Prodigal Papa” effect. Indeed, toward the end of my week home, my wife, whom I love more than the stars and the sky, starts giving me a look that clearly asks, “So, when are you flying out again?” My children (15 and 17) are old enough not to need me all the time, but when I am home, I can play chauffeur and be present in a way that helps make up for the week I am away. Additionally, it pays well above what I could make as a local hospitalist: $375,000 to travel vs. $300,000 local.
The downsides are also significant. I have missed multiple piano recitals, award ceremonies, and who knows how many opportunities for what I like to think of as “Peak Parenting:” those rare moments of genuine connection with my teenagers as opposed to the typical pushing of boundaries that are part and parcel of the teenage years. One of the biggest downsides is that new hospitals can be very challenging places. There is a reason that the hospital needs a travel hospitalist. It is often because (and I will not put too fine a line on it) they suck to work at. This leads to high turnover and the inability to recruit enough long-term docs. Those who stay are often overworked and feel trapped—either because they are on J-1 visas or they lack mobility due to family commitments.
My own recent horror story included a poor onboarding process: one hour of training on an ancient EMR, and a full panel of 18 patients on Day 1. The first words of greeting were, “Good morning! You are admitting, and there are three patients waiting in the ER.” Understaffing and byzantine workflow followed. Six weeks later, I still did not know where to find an EKG in the EMR. I didn’t feel too bad, though—none of my colleagues knew either. During my first week, I stayed several hours each day after the shift ended just to make sure my patients received a minimum standard of care.
Adding to the stress was the knowledge that I was not providing the best care. The volumes were too high (average census was in the low- to mid-20s), and incessant interruptions in the form of external transfers, ED admissions, nursing, and case manager calls made it impossible to complete a thought. A constant stream of swears that would make George Carlin blush emitted from my mouth. I couldn’t help but badmouth the hospital, the situation, and the unwillingness of the administration to provide relief in the form of an extra clinician. I found myself raging 10 times a day: I could not take care of patients safely. I would get sued, not the hospital, if anyone got hurt. It would be on my conscience if anyone died, all because the hospital did not give me the support I needed to take care of patients. I believe this is what the burnout gurus refer to as moral hazard.
More information here:
How Can I Make My Terrible Doctor Job Less Terrible?
How Suffering Through Storms, Figuratively and Literally, Has Made Me Strong as Oak
Blasting My Boss to His Face
A word of advice. When the CEO runs into you in the cafeteria and asks how it's going, it is not an invitation to actually tell him. To tell him the truth is, as they say, “A Career-Limiting Move.” Well, I made this move. What began as well-intentioned feedback became a bile-laden tirade. I told him in no uncertain terms how unsafe it was to practice at his hospital, that we needed another physician and the unwillingness to hire demonstrated the hospital's priority of profit over safety. An F-bomb may have been dropped. Twice. I became the very thing I swore never to become. I was a “Toxic Doctor.” I immediately realized I was out of line and apologized to the CEO, but it was not sufficient.
As you can imagine, this led to a heart-to-heart with my boss and my boss’s boss. Fortunately, they were both physicians and understood the dynamic to which I was responding. It is fair to say that my job was on the line. Part of me wanted to rail and scream, “I’ve quit better jobs than this,” but another part of me realized that I had lost all perspective. I had embarrassed myself and my company. Yet at the same time, I was responding to a real dynamic. I was wrong in the way that I handled it, but no doctor should regularly be put in a position where they cannot safely take care of patients.
Physicians have incredible resilience. We take care of the sickest people in society. We deliver catastrophic, life-changing news. We work long hours and treat ungrateful patients. Sometimes we do not have the resources we need to deliver the care that our patients deserve. We lament the dehumanizing healthcare industry that treats us as highly paid but ultimately interchangeable and disposable cogs. At some point, like a rubber band that is stretched to the limit, there is no more give. We can no longer absorb any more frustrations, and we snap.
More information here:
Leaving Dentistry and Finding Happiness
How to Make a Toxic Job Better for You
How can we avoid reaching the point of no return where our limbic system takes over and we find ourselves hurling verbal excrement at every little frustration and inconvenience? I don’t claim to be an expert, but here are some ideas:
Talk It Out
Address early with your clinical supervisors what you are experiencing. Your medical director may have remarkable insight into the situation. They can offer guidance, resources, and possible workarounds for the untenable aspects of the job. Even if they only offer bromides, by alerting them to the issue early you are giving them a chance to intervene and they are in a better position to work with you if things do lead to a blowup.
Build Your Resilience
Do not take extra shifts. Cut down to full-time. Make sure you are taking vacations. Identify and address the other stressors in your life. If you have money anxieties (and I suspect many white coat investors do, regardless of their income), take a cold hard look at your budget and make adjustments. You may find that you are in a better position than you realize. In my case, I had been picking up too many extra shifts due to tuition anxiety. My two teenagers will be going off to college soon, and we can expect $0 in financial aid. I did some calculations and realized that I don’t really need to pick up those extra shifts.
Get a Paid Friend
Professional counseling or coaching works for many people. The White Coat Investor has resources, but that is not the only route available to you. Therapy via your healthcare plan is another option. A third that many organizations provide is an EAP (Employee Assistance Plan) that is completely confidential (unless you are mandated by your employer because you did something egregious).
Make an Exit Strategy
Start planning your next move. Hopefully, you can resolve the situation through discussions and negotiations with your employer. But sometimes a reasonable arrangement cannot be reached. In my case, I requested that my assignment to the intolerable hospital be limited to three months (typical assignments are 3-6 months). I was told that I would be there for six months or more until they could find a replacement. I knew of at least one other doctor who was quitting as soon as his contract was up, and I realized that this was going to be an open-ended commitment. This feeling of being trapped is what pushed me over the edge into complete toxicity. Once I started looking for other travel jobs, having an exit strategy gave me a goal and dissipated much of my anxiety.
Buzzword Alert: Mindfulness
There. I said it. I am the first to be suspicious of any movement or corporate speak buzzword nonsense that tries to shift the burden of burnout to the employee rather than with the system where it firmly belongs. Having said that, I have started using a meditation app that helps me feel about 10% better. It is no panacea, but every little bit helps.
Apologize
If you screw up and lose your poop like I did, it behooves you to apologize as soon as you have the wherewithal to realize you were out of line. Apologies go a long way to repairing the damage you did. It is also the right thing to do.
Things are much better now. After the blowup, my bosses showed remarkable compassion and understanding and worked out a plan to transition me out of the toxic situation. Unfortunately for them, I had already found a similar job with much better pay and benefits. The threat of burnout and the threat to my financial well-being has been mitigated, but given the ever-changing expectations and demands on physicians, advanced practitioners, and other frontline staff, I will continue to be vigilant and look for the early signs of burnout.
What strategies do you use when you reach limbic overload? What strategies have been most helpful and which have been detrimental?
Wow! Thanks for this post. Traveling work has to exacerbate a bad situation since you don’t have the long standing connections with close at hand colleagues and family to share your frustrations and try to turn it into humor, usually dark.
At my last job I was usually able to blame the system for every ridiculous or impossible mandate- and recognized I much preferred telling myself ‘that’s the Army’ over anger/ resentment at a specific over the top supervisor or coworker. At a prior place I had quit on principle (with 3 months notice and patience) after the Boss replied to my “Please remember I am unable to work after hours now my spouse is deployed overseas” with “You work for ME, you’ll work after hours when WE tell you to!”
I did have another bad manager at the Army job, and in addition to venting to my nurses who also found him an idiot (or so they told me anyway), HIS boss; a fellow doc (who seemed to have no medical job, just roamed the oversized clinic making nice with staff); would stop by to listen to me vent about the intermediate boss’s most recent offense. Kept me working there until the next manager came through and kept my apologies needed only to the overboss for cussing etc. rather than to the source of my ire who might have responded in kind with poor outcomes for both of us.
Sadly best solution for me to the inflexibility of that last job was to retire permanently. Were we not so well placed financially thanks to following WCI practices I would have had to find other options.
This post brought back bad memories of any place I worked that was understaffed, job transitions that were made more difficult by poor EMR’s, and what I came to call “bad bosses.”
Luckily, I had more good bosses than bad, and had three positions that lasted seven to eleven years, comprising the bulk of my full time career. My side gig has also lasted from 2010 to the present despite changes in management, and the pandemic.
It was painful to read about working to provide barely adequate care and worries about how one might provide unsafe care in that grind. That was rare in my career, but was a big issue in my internship.
Most contracts me I have ever signed as an employed physician had thirty to ninety day “hold harmless” escape clauses. Anytime I felt taken advantage of, run into the proverbial ground, or was given so much work it was unsafe, I voted with my feet after securing what I used to call “job in pocket.”
One other point I would make is that $75,000 “extra” after marginal tax rates can be more like $40,000 and the work/life balance might suggest it’s barely worth it. I worked a side gig with a lot of weekends for over a decade. It was heavily taxed, but… it did allow me to max out my W2 job’s 401A, 457, HSA, and then a SEP IRA.
My weekend duties frequently ended about 2pm, but on some doubles, I worked twelve hours both days. Thankfully, it was almost always weekends, but I did work a lot of holidays too. I got out of full time work at 58, but it cost me some family time. I worked ten Thanksgivings in a row, and was home in time for the big dinner, but I still wonder if that was a good idea…
Best of luck to anyone who identifies with being a cog in a broken machine. Job in pocket might allow them to vote with their feet.
“Job in pocket might allow them to vote with their feet.” As does FI or at least ability to weather a several month sabbatical. Just beware future employers thinking you were in jail or a mental/any hospital during that time off. I always explained (even on my CV) that military moves or my maternity were the reasons for my many ‘sabbaticals’ as I called them, but I had those patriotic excuses.
That is ridiculous that the employer assumes this negativity for people who have gaps, and it is especially hurtful when the individuals who quit due to toxic work environment and couldn’t get the right references. So if it is a toxic job, get out of there ASAP before burning your bridges. The last thing you want is when you couldn’t tolerate it and you burst out (which is not wrong) and YOU have to bear the consequences for the employer’s toxicity. The employers just move on and find another replacement and don’t care less about actual patient safety and employee wellbeing. But the employee who bursts out may face other organizational retaliation that would totally drain his/her energy, time and resources. You can’t make a toxic job better but the employer can.
Dear Anonymous Writer, how we are siblings in pain! This post brings back so much in the way of blood, sweat and tears that I wish I could have a beer with you.
I’m not going to belabor anybody with my story because I suspect every one of us has one or a few.
It goes to the sad reality that despite all of us having between 23 and 27 years of education, if not more, we are subjugated by people with far lesser qualifications regularly.
An additional item is that we do not suffer equally, my friends, there is absolutely a hierarchy in private practice as well as academic medicine.
The same administrator that dumps on the ER physician, Hospitalist or Radiologist does an amazing about face and sucks up to the orthopedic surgeon that brings a lot of money to the hospital.
I don’t blame the orthopedic surgeon who made a great choice of specialty and surely has their own woes, but I do blame the system that values or devalues doctors based on what one brings to the fight, but we all fight like Warriors, day in and day out.
The sole antidote to the systemic problem, which will likely not work itself out in my career, is to find peace and harmony within oneself, whether that is time with family, vacations, an exhilarating hobby, a side gig or a combination of all of those things.
And of course, another thing that makes a tremendous difference and is the reason we are all on this site, which is to attain “screw you” levels of wealth.
Hold your head up, my brethren, and I salute you and everything you do, because undoubtedly one day you will care for me and my family. You will be the one that makes the difference, and I really don’t care about the CEO or CMO of your institution.
What would you all rate the activity of someone as he reaches age 60? 65? 70? I ask because we see all of these articles about retirement, taking distributions, considering conversions, etc. But I wonder how much any of us doctors or anyone else utilizes this money for his supposed “retirement”? Does it matter if you are 50%ile in health, or 90%ile?
What if you have children, and/or grandchildren at that point, does that also make it less likely you’ll do very much beyond going to somewhere like Florida for a while for the winter?
Having worked at multiple academic and private practice hospitals over the past 35 years, I can say that burnout and rage don’t define you, they define the job. It’s not your burnout, it’s the job that is burning you out.
Save and move on. Making a toxic job better is like putting frosting on a pile of poop, it still stinks with the most delicious frosting you could find. No amount of wealth is worth it if your physical and mental health takes a hit and it would take much longer to recover than you think. I know burnout physicians who could quit early due to early saving and investing, but even several years after the retirement, the mental suffering from toxic work still lingers and makes them wonder if it is worth it. It is ideal to achieve FIRE but it could be achieved in a more sustainable way. In this case, yearly addition of $75k as the travel physician is not worth it in my opinion. For that amount of suffering, $1 Million more could barely help. And also why the heck you need to apologize ? The CEOs need to apologize and take a big pay cut or be fired for creating toxic and unsafe environment for the frontline workers!
Same thoughts here. At a prior job as an employed physician, I had more than one occasion where I let administrators know what I thought of their poor decisions in blunt terms and never felt the need to apologize. I think it was kind of cathartic but I left that behind and am more satisfied in my current position.
If all you say is true, you shouldn’t have apologized. Should be the other way around.
Don’t write off pharmacological therapy, such as citalopram.
Can you name the group so others can avoid or would that open you up to libel charges? Seems like there are many bad hospitalist jobs out there.
Never mind, realized you shouldn’t as you don’t want to lose your anonymity. There’s the national practitioner databank for doctor concerns too bad there isn’t a similar resource for bad jobs.
Greg actually the WCI forum is a safe place to voice personal qualms regarding jobs that have been toxic. also the student doctor network has candid and raw opinions on jobs without fear of reprecussions if you bad mouth a job.
Greg that is an awesome idea! Why can only medical “providers” be flagged?!
Did you swear at the CEO? Dropping an F bomb shouldn’t get you fired. It shows you’re passionate. Unless there’s a bunch of patient family members in the cafeteria too. What exactly did you say?
First, I want to thank the author for sharing his story. Even anonymously, it is hard to relive the moments when we fall short (and we all do). Reading this post, all I could think about was, “This is exactly why every physician should pursue financial independence.” I also want to rage, shout, and curse, not at the CEO but at my fellow physicians, to Wake Up!
Look at some of the problems the author faced:
1. Traveling in order to make 25% more income ($375k vs $300k).
2. Working for a “multi-state group.” Are they owned by a private equity firm, perhaps?
3. A group that takes contracts at hospitals that “suck to work at.”
4. A Hospital with a poor onboarding policy, a terrible EMR (ok, that’s every hospital), and insufficient staffing.
5. A Boss and a Boss’s Boss (both physicians) who had your back when you screwed up, yet who (apparently) haven’t advocated enough for better working conditions.
My takeaway from the article was not that the author was wrong for cursing out the CEO (he was) but that all these problems can be addressed by an educated and united physician workforce – educated in business and personal finance.
If the author were FI, or even approaching FI, would he still work a travel job for 25% more income? Perhaps he would work closer to home in a less toxic work environment for the lower amount. Maybe he would choose to travel yet work 20% less and still make $300,000.
If all physicians were FI, would anyone choose to work for a private equity firm? We could stand up to their cost-cutting, dangerous practices by simply choosing not to work for them, especially at hospitals that “suck to work at.” We could also refuse to work at a hospital or for a company with poor policies and insufficient staffing. We’d still probably have to suffer through bad EMRs, though.
Before things became this bad, the bosses would have been able to stand up to their non-physician counterparts. While the author shouldn’t have yelled and cursed at the CEO, he most definitely should have been able to voice his concerns to all involved parties and leave if the dangerous conditions were not resolved.
While the author’s ideas on how to Make a Toxic Job Better for you were well thought out and valid, the bigger issue is why physicians should settle for a toxic job in the first place.
Some don’t have a choice, as the author mentioned (J-1 Visa holders), but for the rest of us, we can vote with our feet. IF we can afford it. Follow the advice of WCI and others. Spend less than you earn and invest the difference. Don’t buy into the “rich doctor” mindset. And spread the word to all young physicians that they don’t have to be a hamster on a private equity-owned wheel. There are other options.
First, I want to thank the author for sharing his story. Even anonymously, it is hard to relive the moments when we fall short (and we all do). Reading this post, all I could think about was, “This is exactly why every physician should pursue financial independence.” I also want to rage, shout, and curse, not at the CEO but at my fellow physicians, to Wake Up!
Look at some of the problems the author faced:
1. Traveling in order to make 25% more income ($375k vs $300k).
2. Working for a “multi-state group.” Are they owned by a private equity firm, perhaps?
3. A group that takes contracts at hospitals that “suck to work at.”
4. A Hospital with a poor onboarding policy, a terrible EMR (ok, that’s every hospital), and insufficient staffing.
5. A Boss and a Boss’s Boss (both physicians) that seemed to have your back when you screwed up, yet who (apparently) haven’t advocated enough for better working conditions.
My takeaway from the article was not that the author was wrong for cursing out the CEO (he was) but that all these problems can be addressed by an educated and united physician workforce – educated in business and personal finance.
If the author were FI, or even approaching FI, would he still work a travel job for 25% more income? Perhaps he would work closer to home in a less toxic work environment for the lower amount. Maybe he would choose to travel yet work 20% less and still make $300,000.
If all physicians were FI, would anyone choose to work for a private equity firm? We could stand up to their cost-cutting, dangerous practices by simply choosing not to work for them, especially at hospitals that “suck to work at.” We could also refuse to work at a hospital or for a company with poor policies and insufficient staffing. We’d still probably have to suffer through bad EMRs, though.
Before things became this bad, the bosses would have been able to stand up to their non-physician counterparts. While the author shouldn’t have yelled and cursed at the CEO, he most definitely should have been able to voice his concerns to all involved parties and leave if the dangerous conditions were not resolved.
While the author’s ideas on how to Make a Toxic Job Better for you were well thought out and valid, the bigger issue is why physicians should settle for a toxic job in the first place. Some don’t have a choice, as the author mentioned (J-1 Visa holders), but for the rest of us, we can vote with our feet. IF we can afford it. Follow the advice of WCI and others. Spend less than you earn and invest the difference. Don’t buy into the “rich doctor” mindset. And spread the word to all young physicians that they don’t have to be a hamster on a private equity-owned wheel. There are other options.
“My takeaway from the article was not that the author was wrong for cursing out the CEO (he was) but that all these problems can be addressed by an educated and united physician workforce – educated in business and personal finance.”
Come on! There is no credible organizing mechanism in the physician workforce to accomplish the end stated. In fact the opposite. Further, such an “idea” doesn’t change the individuals’ lives who are caught in the meat grinder called “medical practice”. No professional societies have any inclination to actually speak the truth and act in physicians’ interests. The full on corporatization of medicine has reached such proportion and is so deleterious to the workers therein, that only unionization will move the needle. Yes, everyone should become financially educated and try to extract themselves (see my post )-but stating such oft stated platitudes as a mechanism to solve the problems of the profession is absurd. The corporations and hospital administrations are infinitely more powerful than an informed physician or group of captured physicians, absent legal workplace organization to address working conditions and pay.
I agree! It is high time us physicians took control away from the organizations and systems that only exploit us. Professional organizations have their own interests in mind, as you stated. We have to stand up for ourselves!
Which is what I do in my coaching practice working with frustrated and depleted physicians: getting back not only control over our lives and livelihoods but our profession as well!
David,
I wasn’t using “such oft-cited platitudes” as a way to “solve the problems of the profession”. I was thinking more of the interested minority (those physicians reading this blog). I agree with you that “there is no credible organizing mechanism in the physician workforce to accomplish the end stated.” My comment was not out of naivete, but cynicism. I have written posts titled “An Emergency Physician’s Guide to Working for the Devil”, “The Corporate Practice of Medicine Takeover”, and “Contract Management Groups: Get to Know Your Private Equity Owned Overlord”. I understand the problems we face as physicians and use whatever platform I have to speak out about them.
However, I guess I’m taking my cynicism one step further in that I don’t see physicians organizing and unionizing. How many hospital committees have you sat on? You can’t get 7 physicians to agree on the color of excrement. Some new passionate physician leader may come along and prove me wrong, but in the meantime, it won’t hurt for more physicians to become financially independent. FI is the reason I can use my real name in these comments, write about topics that matter to me, lecture on these issues at my hospital, and speak out without fear of retribution.
Unfortunately, I’m not the charismatic, passionate leader that such a movement would require. If you are, I’m happy to support you. If you have a plan on how to make things better, I’m all ears. Otherwise, its all just talk. I am trying to do something – educate, encourage, and support young physicians to treat their career as a business, become financially independent, and navigate our broken system as best as possible. We’re all on the same team here.
Thank you so much for sharing your story and normalizing what so many of us go through.
The drivers of the system are so broken and many things need to change in order for medicine to value its most important resource..it’s physicians.
The biggest mistake I see people make is drown in anger and resentment ..which doesn’t change the system it just takes an internal toll on them.
If we want to fight for change we have to be calm strategic rested and empowered. And there ARE things we can do to help ourselves. Coaching is an evidence based intervention that has been shown to reduce and prevent burnout. I run a program for women physicians that has helped over 300 women do exactly this. And it works.
Thanks again.🌻
Am I the only one that thinks he was right on the money to tell the CEO what was up?
This doesn’t sounds like a gray situation – he was well overworked, not able to provide appropriate care and felt it was dangerous for patients. All so the hospital didn’t have to pay another few thousand dollars per day for another clinician?
THAT my friends is the absolute BS.
The fact that we have to restrain ourselves and bow at the feet of some craptastic CEO and not tell him what we legitimately feel is the larger source of the problem here.
You had a spine when you did that, OP. Seems like you lost it.
The fact that you spoke your mind and spoke of your barriers to the care you were providing to the patients in front of the CEO is fantastic . There is nothing to apologize to anyone for . You did nothing wrong ! The hospital that hired you should have apologized to you for the lack of support you were being provided !
This post struck a cord with me because I experienced similar. I did not speak up and just took the punches. I eventually quit and now do nursing homes which has it’s own set of problems. I recommend you get out. Being stretched thin in the hospital is not worth it. These companies should not get away with abusing us, just like they are doing with nurses.
I was interested in the comment that White Coat Investor had some “coaching resources”. Where can I learn more about that?
Under the recommended tab on any page of the website:
https://www.whitecoatinvestor.com/physician-burnout-coaching/
Once upon a time, physicians were self-employed and could structure their practice however they chose. Today, physicians have lost control over their lives and livelihoods, and many are depleted and looking for relief. It is high time to Rebirthinate the physician of yore to regain autonomy and control not just over our own lives, but over our profession and healthcare as a whole.
Successful entrepreneurs have known the secret to making this happen for a long time: coaches.
I work with physicians and healthcare executives in charge of physicians who are dealing with utter depletion from and frustration about the current healthcare system that no longer supports the well-being of either doctors or their patients.
With my new program, Rebirthinating Medical Lives – Starting with Yours, I help my clients embody and ground a new mindset with powerful skills and approaches that shows them how to avoid burn-out and find relief from the depletion that is draining them professionally and personally.
If that’s you or anyone else you know, I would love to connect.
No one needs to be making $375k if it’s in a sanity-jeopardizing job. I happily cut back to a few shifts a month, and as hard as it may be to believe, it’s possible to live a very nice life as well as provide for a family and save for the future. All on a sad little salary of “only” $120k…which is still way above median income. Being a martyr in order to avoid confronting the meaning of “Enough” seems a short-sighted way to live. (Just general statements–I don’t know anything about the author’s specifics, but I DO know about our materialistic culture and the stunning keeping-up-with-the-Jones’ mindset of a lot of docs.)
Or you could suffer a ski accident with a trimalleolar fx dislocation and a tibial plateau fx. Off for 12 weeks non wt bearing. My acupuncturist stated ” why would you go back for 3 days of school before summer break”? I was discussing my possible return to the grind of primary office IM, my current contract is up 8/1.