[Editor's Note: This is a guest post from Jeff at The Happy Philosopher. He originally titled it: “Your mental health may be your most valuable financial asset” and I absolutely agree with his main point. We have no financial relationship.]
I recently wrote an article about a friend from medical school who died by suicide. The article had nothing to do with finance, but a tragedy like this does have profound financial impact. Suicide, depression and burnout have a higher incidence in physicians than the general population and anecdotally it seems to be getting worse. I’ve lost two of my medical school classmates to suicide.
Early retirement or going part-time secondary to burnout is an all too common event in medicine. It happened to me. I burned out less than 10 years into practice and a couple years later reduced my workload significantly. This was the best decision for me, and ultimately one that I don’t regret, but financially it had an enormously negative effect.
I’m not here to argue about the causes of burnout or how we can change the system. There are others more eloquent and knowledgeable than me. But I argue that what many of us fail to fully appreciate is this simple fact: Our ability and willingness to work is our biggest financial asset. This is especially true towards the beginning of our careers.
Hedging Against Burnout?
In 2015 the average salary for a specialist was $284,000 per year. Over a 30 year career this amounts to $8,520,000, not counting the time value of money. We are an enormous money generating machine, and there is no more important investment we can make than protecting that asset. This is why most knowledgeable financial advisors recommend adequate life and disability insurance. While that is a critical first step, what is often overlooked is protecting the mind and mental health of the person generating that income. Most disability insurance will pay a limited amount for ‘mental disorders’ such as depression and substance abuse. Many life insurance policies will have restrictive clauses regarding suicide [typically a 2 year exclusion-ed], or even contest the claim in murky circumstances [never very common, now even less common-ed.]
Bottom line: It is very difficult to hedge financially against burnout, depression or suicide. Prevention is the key. Sometimes I feel this is the elephant in the room. I’ve known physicians who have died by suicide, who have had their careers ended by addiction and substance abuse, and dozens that have either left medicine all together or cut back significantly on workload due to burnout.
When taking these factors into consideration it seems silly to focus only on the details and strategies of personal finance. The decision to invest in a traditional or Roth 401k, which state to fund the 529 in, whether to do an 80/20 or 76/24 stock/bond asset allocation, what to do with a small whole life insurance policy, how you restructure your student loan payments; none of this matters if you put a gun in your mouth at age 42, if you jump off the roof of the hospital in your last year of residency, or if you're too burned out by 40 to keep working full-time. These financial decisions are very minor compared to working an extra fifteen years full time instead of half time.
Two WCI employees fighting hard against burnout at work
No one thinks this can happen to them, but it does happen. It happens with a high enough frequency that we should all pay attention.
Don’t get me wrong. I love the details. I giggle like a school girl when WCI does a takedown of whole life insurance. I love pondering the differences between placing bonds in accounts with different tax treatment and figuring out how to hack the federal income tax code, but these come second to protecting ourselves and our ability to work. Without the ability to work, a lot of the details become that, just details.
Financial Effects of Burnout
The effects of burnout also have negative financial consequences even when it doesn’t end a career. When we are expending all of our energy just trying to make it through the day, our interpersonal relationships suffer and are strained. Our coping mechanisms fail. I don’t have hard data but I imagine the incidence of divorce, substance abuse and poor financial decisions are associated with an unhealthy relationship with our career. We simply have less bandwidth to make sound financial and personal decisions.
Beating Burnout
I think we can do several useful things to decrease the risk of burning out. I’m by no means an expert, but I’ve gone through it and come out the other side stronger. I did none of the things below, but I wish I had; it would have made things easier.
- Prepare for it. My advice to all medical students and residents who will listen to me: You will burn out. Probably between 40-50 years old, maybe sooner. Know the symptoms and educate yourself before it happens. Just like I believe in continuing financial education, I believe in continuing self-discovery and self-improvement. Immunize yourself against burnout. Optimize your life so you don’t burnout in the first place. Healthy eating, physical activity, good time management skills, a mindfulness or meditative practice, boundaries between work and home life; these are all good hedges against burnout and depression and they cost very little time or money to implement. Develop good habits early in your career. These suggestions will seem very hollow to you if you are in the midst of burnout and they are not perfect. If you never burnout, congratulations, you have still learned healthy habits and coping skills.
- Be thoughtful when choosing your job. Often times we let our job choose us rather than the other way around. There is nothing more effective than the wrong job to crush your spirit. Don’t settle for something that is not sustainable. Don’t tolerate abuse. Don’t be afraid to create your own practice. There are models out there that can work; you just need to seek them out.
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- Have a mentor or coach. We all have blind spots; although in my observation physicians are more resistant to admit they have them. At times we are an incredibly delusional cohort of people. A good coach, mentor, or therapist is worth their cost many times over by helping you see your blind spots. With our earning power and busy schedules we are a little like professional athletes. How many professional athletes do you know without a coach?
- Seek help early. We are conditioned to soldier on without regards to our mental health. This is a direct result of our training, where asking for help or admitting failure was a sign of weakness. This is a mistake. Don’t let yourself get to the breaking point. I wish I could point to reliable resources for physicians with mental health issues to seek help. There are physician advocates and coaches out there; seek them out if you need their help.
Your biggest financial asset is you–your ability to trade your time for money at a very high exchange rate. Given the increasing rates of burnout in our profession, this needs to be protected. Aside from insurance, thinking through these issues when you are healthy and preparing for the possibility may be the best investment you make.
[Editor's Note: Years ago, long before most of you were reading this blog, I wrote a post entitled 14 Reasons You Shouldn't Retire Early. The bottom line is that retiring early is really, really expensive and takes a ton of preparation. Burning out is like retiring early without the portfolio or the preparation. Anything you can do to keep the earned income flowing, even part-time, is huge financially.]
What do you think? What have you done to prevent or treat burnout? How do you hedge against it? Comment below!
Great post, it’s something to really think about
Great post
Unfortunately, depression and burnout among physicians is much more common than one might think.
In terms of disability insurance, for most specialties, Berkshire (Guardian), Standard Insurance Company and MetLife provide both an “Own-Occupation” definition of total disability AND full coverage for claims related to mental/nervous and/or substance abuse disorders.
In the state of California, there is only ONE company that offers this combination – Standard Insurance Company.
For males, given the choice, if the cost difference is not significant, a policy without a limitation for three types of claims is superior to one that includes a limitation.
For females, it gets interesting – especially when a policy with a unisex rate and discount is available. At that point, it will typically come down to pricing and is one willing to pay substantially more for a policy without this type of limitation or are they willing to sacrifice the “Own-Occupation” definition of total disability in order to not have the limitation but still save money on their premiums?
There is no right answer. For this reason, it is important to understand the pros and cons of what you are purchasing and do your homework when shopping for this type of coverage.
Here is a disability insurance post that I wrote specifically about these types of claims.
https://www.whitecoatinvestor.com/disability-insurance-nervous-about-mentalnervous-benefits/
Anxiety, depression and burnout are becoming much more common among physicians. A few months ago this was the cover story in Plastic Surgery News magazine published by the American Society of Plastic Surgeons.
Thanks for this great advice. Living like a resident, paying off loans/mortgage ASAP, and saving like mad early in your career can give you options to change your practice and lifestyle to help avoid burnout. I haven’t worked an overnight, Christmas, Thanksgiving, or birthday shift in almost three years!
I wonder how much burnout has to do with the workforce pattern in general lately. People used to work for one company for 50 years, then collect a pension and a gold watch. Now, many people change careers every decade. With 4 years of med school and 3+ years of residency, that means only 3 years in practice before it’s time for a change, but we feel like we can’t change because that would ‘waste’ all that education.
I think increased burnout is due to systemic changes in medicine, not general workforce trends. It would be interesting to look at rates of suicide and burnout over time, but I doubt this data would be obtainable or reliable. Question for older docs: Has burnout dramatically increased over that past 30-40 years or are we just talking about it more? My sense is the former, but I don’t have the perspective .
Can’t say in about 35 years of practice that this problem seems worse now. Alcoholism, divorce, and, less commonly, suicide have been around the whole time. Physicians seem much more determined now about setting limits on their work hours (very few Docs work the 60-80 hr weeks that many were
doing when I started).
One thing not mentioned is taking periodic sabbaticals (especially in a non academic setting); I think taking 2-3 months off, especially when kids are less than 15 years, every 4-5 years, is very healthy and creates family bonds that persist long after your children have left home. Also a good way to rejuvenate in the latter part of your career. I recommend this strongly to my new associates with young families.
Thank you, very well written. To effect greater change, there need to be changes made in the system rather than just us and how we practice. Most often, how we practice is a result of the system around us, and making changes is easier said than done. Of course, your point is well taken, until such time that system improvements occur, it is our personal and social responsibility to take care of ourselves so we do not burnout. I am just trying to get the conversation started on how to effect some meaningful system changes.
Agreed. System changes help the greatest number of people, but relying on systemic change is not a reliable strategy. There are plenty of people who focus on policy and system change – my focus is on the individual. We need to be healthy individuals, and the best versions of ourselves to be effective in changing the system. And even if nothing changes we have become more resilient in the process. Tiny acts of subversion by thousands are more powerful than big systemic changes in my opinion 🙂
Not a physician but having seen the hospital/private practice situation nowadays I cannot fathom how you guys manage physchollogically with the rules and regs, phone calls and referrals, insurance and approvals
to me the best of the worst is single payor and everything standardized
These changes need to happen at the government level since all of it starts with CMS. Unfortunately our associations that we pay dues into have done very little to protect the medical practice since the AMA and our other organizations appear to be in bed with CMS. The only way to make change happen is by working less and creating a real physician shortage. As long as we are willing to comply with the BS, more BS will be thrown our way. I just learned the other day that in 2019 physicians will be reimbursed based on PQRS data. Low performers will be paid less, high performers will be paid more. More BS is heading our way.
Physicians need to get their financial home in order and just cut back on the hours. Eventually CMS will be forced to respond and give us a reason to go back to work.
Physicians also need to move out of the northeast and west coast. They are propagating a system that takes advantage of their doctors through high cost of living and lower reimbursement. They become enslaved to their job and burnout is a guaranteed result for many.
Spot on.
Or they may replace us all with midlevels
The way I manage burnout:
1) Make sure my wife and I have regular date nights. We prefer at minimum once every 2 weeks.
2) Make sure I have plenty of time off between work
3) I schedule “no electronic days.” No phone, no email, no texting, no facebook or other social media.
4) I make sure I am on a clear path to early financial security.
5) Eat healthy and exercise.
6) I am starting to think even paying off all debt quickly even low interest rate loans may be an important aspect to preventing burnout. When you are debt free, in your mind you know you can always sell your home, downsize and either retire or work part time. Having that in the back of your mind makes the drudgeries of work much more tolerable..
I totally agree
I tried at 52 from practice. I think some burnout, especially from focus on measuring financial outcomes that seemed to become the ‘product’; and that physicians are specialized to the point that you either do the same thing forever, or stop.
Most of the people I know in business or other careers have major changes in their jobs every 5-10 years.
I lived on about 50% of my after tax income., tithed, and saved the rest. With no kids left at home, college already saved for, and no debt we can maintain your lifestyle without habits to have income.
The biggest issue is not accelerating lifestyle as kerfuffle covered in this blog.
This is why I chose academic medicine. I work 70% clinical and get paid roughly 70% of that which I could make in private practice*. The asterisk is that the private practice jobs paying this wouldn’t be in an attractive big city a la my academic job, so I effectively get paid more for the work.
This is counting the academic side of things, the research and the writing, as free, but to me it more or less is. Publishing is not hard but just another game, and it’s a game that I can see myself playing for a few decades, especially as a senior author/group leader rather than in the trenches.
Add to this the 8-5 lifestyle of radiology and I think I’ll hit financial independence before I burn out, although the race may turn out to be closer than anticipated.
Research was what made me give up academics. After doing clinical, I just wanted to go home and be with family instead of sitting and reading or writing an article.
What a great article.
Why have all this money if you cant enjoy.
I’m a radiologist in a private practice group and I’m afraid the “8-5” lifestyle for radiologists is long gone for us. We are a busy practice 24/7. Maybe in academics with residents thats a reality for some, but its a false narative that I wish would go away.
I’d have to agree with you. Even my neighbor the radiologist doesn’t come home until 6. Just kidding.
Seriously though, someone is reading my films all night, every night. I wouldn’t have guessed anyone thought radiologists worked 8-5.
Nice work on this post. I’d love to see more on this topic from WCI in the future.
Probably the most important column on this site. Thank you.
It’s amazing to me how little physician satisfaction matters to hospital administration, CMS, and apparently the public. Physician burnout has been called no less than a public health crisis by Medscape. We are expensive to train, hard to replace, there aren’t enough of us, and many of us provide a critical service to the public. In any other field this would follow the law of supply and demand and we would be able to write our own tickets!
The only response in my speciality has been to raise salaries. But at my shop they are also aggressively discouraging part-time work, denying vacation, and cutting administrative hours, and it’s not unique to my place of work. Eventually people burn out even if they are being paid top dollar.
With all the other options out there, from the self-scheduling of locums to international work to public health to informatics, is it any wonder physicians are voting with our feet? Yet nothing is done to protect the public from a physician shortage. The nights continue. The drug seekers are not turned away. EMTALA remains. The EMRs do not improve.
It’s insane. Give docs a decent life and treat them with respect and they will remain. It would cost so little and be of such benefit to society. It’s senseless.
Thank you. It is unfortunate you are in a practice that is so inflexible. I think a happy doc does a better job and in the long run is much more productive. We need administrative support and enough time off to recharge and stay healthy.
I am a big fan of part-time work even in spite of it’s massively negative economic effect. Half time was the most expensive short-term decision I have made, but long-term I think the results will be neutral. I think I would have retired by now if I didn’t have the option of cutting back.
The best option is
I would add to avoid toxic people in your work environment. Unreasonable people, especially those above you in the hierarchy can drive you to feel very burned out, even with small exposures.
I agree. I managed to burn out on military medicine within a few months once I realized that the people above prioritized many things above my welfare and happiness and that of my patients. You know, like killing people and blowing up stuff (and promotion and metrics and “readiness.”)
And not just people above you. As odd as it sounds I have seen one place where the secretaries were (in my opinion) destroying the practice. They made some of the younger doctors miserable (and probably the cause of the high turnover rate), sucked up to the older doctors, were very rude to the patients, and generally didn’t do a whole lot (if possible they would pass there work on to the other doctors, which sounds bizarre but it happened). But hey, they were Union, so what did they care.
Perish union ancillary staff- it really unfairly stacks the deck against unionized (but powerless) physicians.
“Don’t settle for something that is not sustainable. Don’t tolerate abuse. Don’t be afraid to create your own practice.”
For those of us in hospital-based practices (emergency medicine, anesthesiology, hospitalists, and radiologists), any ideas, suggestions, or recommendations from the author or WCI community about creating your own practice? My contention is that it is more difficult for hospital-based physicians to start your own clinical practice (more overhead, funding, etc.) whereas physicians in office-based practices can turn to concierge medicine to hedge against many of the factors that lead to burnout. But maybe I’m wrong and not thinking outside the box.
I should preface that with the fact that I’m currently with a contract management group, not a democratic group, and it is likely contributing to my hopelessness about creating my own clinical practice and having ownership/autonomy.
Any conversation would be appreciated.
You definitely need to stick your head out of the box.
EM = Free standing EDs or urgent cares
Anesthesia = A concierge pain clinic
Radiology = Free standing imaging center
It is tougher to create your own practice when you are employed by a hospital or in a large group, but it is not totally hopeless. Often the mistake is in job selection right out of residency or fellowship. We don’t really know what is important in a job and we don’t even know the right questions to ask. We take a job based on money or location, but not necessarily to maximize happiness which should be our focus.
You are correct in it is hard to make your own practice when you are part of a 50 person radiology or anesthesia group, but there are other options. For example, how about doing Locums for a year and test driving various jobs? You may be best served by finding a model of employment that works for you rather than creating your own practice.
I don’t have all the answers, but I do know that when you are already feeling hopeless and burned out it is a difficult place to try and fix things from. Step one is to maximize your physical and mental health. Once you are the best version of yourself you are in a much better position to make rational career decisions.
Thank you both for your responses. Good things to think about!
One potential option would be to do what The Happy Philosopher did. Share a full-time job with another physician and work the same job, but half as often.
I’m in anesthesia, and have zero interest in treating chronic pain, but my friends that went into the field make their own schedule, which includes no call and no weekends, and more money than I will ever earn.
I would like to reiterate the being healthy part. You need to go out of your way to be happy with your own life. Cut down to not working extra shifts. Take time off for yourself and your family, exercise and eat healthy. Once you have yourself taken care of, it is much easier to move on. If you are in a toxic environment, you may need to switch jobs. This is why early financial security is so important in a medical career. it gives you many more options on how to shape your own practice.
Seems to me private practice will be obsolete shortly in medicine
dentists in urban areas will fare better
Managed care came about because doctors fees were unsustainable to maintain health insurance premiums at a reasonable rate
There is gross over treatment and over utilization
Just read Medicare has limits yearly on physical therapy
When I went for PT they try to have you go for the max no matter your progress
Earlier you claimed that you were not a physician when you touted single payer system.
Now you claim to understand the dynamics, and downfall of private practice. Also with, supposed, detailed knowledge on the managed care system. Seems to me that you have an incredible understanding of medicine from the outside… Or you are a troll.
My take: as long as people value their health, there will be those willing to pay for care (i.e. Private practice). Not everyone will be willing to wait months for care- as they do in the VA system (which is single payer, btw)
My first post, but Ken needed to be called out
Ken is a dentist. He is retired and a multi-millionaire.
Don’t really care how much someone is worth.
As a physician you take the hippocratic oath to do what’s best for the patient. When you are employed by a hospital, you have a new ‘boss’ to please. And that is not always in line with what is best for the patient.
Physicians have been very compliment in this shift. A simple dialogue about decreasing cost of care is a great example. Honest assessment of that thought process demonstrates that we have allowed ourselves to be derailed from ‘what is best for the patient’.
Happy to see The Happy Philosopher weigh in here. I’ve been following his blog more or less from inception.
The issues he brings up (burnout, our inability to admit infallibility, physician suicide) are big reasons I preach financial independence. You may enter medicine because you love science and caring for people, and you may be happy early in your career, but times, circumstances, and we as people change as time goes on.
I say live like a resident, work like a resident, invest sensibly, and you can have options if and when burnout takes hold. Financial independence allows you to work part time, in a lower paying job, or not at all. When you spend the vast majority of what you earn, there is no opportunity to jump off the treadmill, or even slow it down.
Right on my brother.
But seriously, I fully agree that early financial security is the best way to hedge burnout. Money doesn’t buy happiness, but it does buy you options. I could only imagine the stress of a toxic job as you are living paycheck to paycheck and forced to work more hours due to some regulatory burden without increased pay. I think just about anyone would snap.
Like you stated, the key is prevention. One of the greatest books I’ve ever read was “Feeling Good” by David Burns. I was a high achieving perfectionist that often led to self inflicted stress. This book was instrumental in extending my enjoyment of clinical practice and gave me the tools to deal with hostile co-workers and patients, criticism from others, etc. This book should be required reading at the high school level.
From what I have read almost70% of docs are salaried employees in hospitals and corporate settings and rising.
Yes, single payor for all is the best of the lot
Financial independence is wonderful and gives one the oppty to work as they please, but what % of docs ever reach that point before 65??
3% of dentists might reach it, MIGHT
Professionals are notoriously poor managers of $$$$
I think lots of docs are afraid in this day and time to set up a new practice independent of a hospital or corporation. The demise of the small practice has been predicted since I began practicing in 1987. There are many headaches to owning a small business but many rewards as well. I have read that self employed docs are happier than those who work for the “man”. Patients seem to like a more personal format so it is possible to leave a big group and do your own thing. I did this in 1993 and have done just fine.
Very good and thought provoking post. For me, meditation and just taking a few minutes of silence everyday has worked wonders. Most docs are gung ho the first few years out of the gate, but burnout happens to everyone, even professional athletes!