crispydoc Uncategorized 17 Comments

Alternate Title: Carolina In My Mind

This weekend was spent in North Carolina strengthening ties with people we love but see less often than we’d like. BT is one of those people.

He was not a typical emergency medicine resident

Most of us were single.

BT was married with a kid.

Most of us had family in California

BT was a southerner with a disarming drawl. On learning that fast-talking West coasters inevitably underestimated him for what they mistook as a speech impediment, he used it to great (often devastating) effect.

Most of us were wet behind the ears, and fresh out of med school.

BT had come to residency after active duty as a flight surgeon in the Air Force. I asked him why he’d enlisted, assuming the financial inducement had enticed him, but he surprised me with his answer: Where I come from, serving our country is just what you do.

All to say: I liked him immediately.

We’d not seen one another in over a decade.

On landing, we hopped in a Lyft and headed to a new Zimbabwean restaurant, Zweli’s, for Southern (African) comfort food. One taste of their chakalaka, and we were in heaven. If you pass through the Raleigh-Durham area, please consider a visit to support this one-of-a-kind dining experience.

BT and his wife had chosen the venue, and were there to greet us. I’d last seen him a few months after my wedding (which he’d attended).

A series of job and life changes had left us out of touch until I reached out through a common friend.

Within the first 15 minutes of our conversation, BT’s wife looked over at my wife and said: If you disguised the accents, I couldn’t tell if my husband or yours was doing the speaking.

Unbeknownst to us, our trajectories these past years had taken a common path.

We both came to realize that we needed greater control of our lives. BT’s journey had taken him into a remunerative community gig, followed by an academic path that resulted in a job he enjoyed requiring a commute he could barely tolerate.

When caring for aging parents began to demand more of his time, he took it as a sign that he needed to relocate back home. That move meant taking a financial hit to sell his home; he absorbed the blow and moved on.

He ultimately settled into a partnership track with a solid group of emergency physicians in his home state, but found himself unable to control his time and wearying of the physical toll that nights had taken. He was feeling burnt out, and his kids weren’t getting any younger.

He began to brainstorm how he might diversify his income streams.

He enrolled in courses on wound care and began staffing a local wound care clinic. He attended a SEAK conference and, much like Dr. Cory Fawcett has written about, it made him aware of many non-clinical pathways. He began to aggressively pursue quality reviews as a physician advisor, performing online reviews of admissions in his time outside of the ED.

He also began to learn about financial independence, teaching himself about DIY investing and stumbling across doctor blogs online whose stories inspired him.

BT: You heard of  this  fella Physician On Fire?

Me: Yeah, maybe once or twice.

BT: Ima be like him someday.

Burnout led him to pursue financial independence, which empowered him to re-prioritize his work-life balance.

Once he’d created additional income streams, he decided he didn’t want or need to work nights any more. First, he tried to change his institution from within.

He built group consensus on a night shift premium, yet when he tried to avail himself of it, his group insisted they were not staffed sufficiently to implement it.

This led him to resign his partnership status. He knew his value. He had a plan B, a plan C…

He could do this because his group needed him more than he needed them.

He walked away, and they hired him back as a per diem physician. He works 8 shifts a month now: no nights, one weekend. The loss in income has been offset by the side hustles as well as a new job his hospital offered him as a physician advisor reviewing admissions.

He accepted the hospital job, but with two explicit provisions: One, he did not want a full-time office job. Two, he wanted complete control over his work schedule. He’d get the work done, but at his convenience and on his own schedule.

Thanks to his new position of strength, he set his own terms.

I thoroughly enjoyed catching up with BT. He looked good (Why shouldn’t he? He hadn’t worked a nigh shift in two years!).

We spoke at length about the shift  in priorities that prompted us to seek a more sustainable approach to practicing medicine.

A visit with an old friend is tonic for the soul. You immediately resume jabbering in that primitive language that few others still speak.

If you are lucky, you resume those big conversations about what what feeds you; what beats you down; what keeps you waking up excited with a sense of renewed purpose.

Renewed and nourishing friendships have been the most immediately tangible benefits of reallocating my time according to my priorities.

What gifts have you received as a byproduct of shifting your priorities?

Comments 17

  1. That is exactly what financial independence allows and BT is living proof. Great that when something comes up in life he was able to address it without much concern for the financial hit.

    Getting paid per diem seems like a great compromise between income and lifestyle. Most people can’t do it because they are too dependent on the $. Hopefully I can continue my trend of decreasing clinical workload. I almost feel like I can work indefinitely if could cut it down to 3 days/wk (not quite there yet).

    1. Post


      That’s precisely the beauty of hitting your career stride and eliminating the rate-limiting aggravations: suddenly you feel like you can glide indefinitely because your job has a lot of wonderful stitched into the fabric of every day.

      Figure out a timeline until you can make three days of clinical work your new steady state, and start now adjusting the internal workings of your group to enable them to embrace 3 days as an option that helps everyone age with grace. Find natural allies more charismatic than you (that is setting the bar high!) and recruit them to your cause.

      Wishing you luck in taking work from good to great,


    2. Post

      That’s the beauty of hitting that sweet spot – the terminal time allocation in your career glide path becomes infinitely sustainable (until mind or body decide otherwise).

      Can’t wait to hear when you hit 3 days a week!

  2. This morning while laying in bed watching the sun rise on a new day. I was thinking about what it took to run a practice. I ran one for many years and even reinvented it and went into competition with my old practice when I left. My practices took me where I wanted to go. The hidden cost of a practice is the overhead, the “turnkey” cost. The reason you can’t easily work a couple shifts a month is the turnkey cost. Every week you work the first day and a half covering the turnkey, and only then do you become profitable. You have to pay for vaca, ten kinds of insurance, office help, billing, compliance, licensing, legal, accounting, management, and all that cost is virtually fixed whether full or part time, and the reason practices aren’t “flexible” or amenable to the politics of internal derangement. Practices are like a the loaded spring in a clock. Wind it up too tight and it sprongs like in a bugs bunny cartoon of old. If you go 1099 your “turnkey cost” to the practice is drastically reduced. They pay you in cash, you cover your own turnkey out of that.

    Like your friend, you can get what you want, if you can figure out the economics (including the turnkey in the analysis). An excess of ER docs (like Anesthesiologists) are not just sitting around on couches waiting to be beckoned, and that makes them quite valuable. This story is what I love about living in this country. You can grab your ass with your own two hands and elevate yourself to anywhere you want to go. You just have to understand the cost of doing business and your true goals. You don’t get it for free but you sure as hell can get it.

    1. Post


      Amusing image of playing grabass with myself as a more delightful metaphor for bootstrapping notwithstanding, your economics lesson resonates on a number of levels:

      1) No one will ever value your time, labor (and money) like you do.
      2) Valuing time over money will prompt you to augment income, reduce spending, or both.
      3) The downstream consequence of #2 is you will no longer need to submit to another’s terms and conditions.
      4) #3 will render you a more powerful agent in your life than your peers considered possible.

      When you don’t need the money, you don’t mind incurring a higher cost as long as you can use your employer as much as your employer uses you. I imagine my friend’s colleagues whispering how foolish it must be for him to sacrifice a perfectly good partnership position for a more desirable schedule with lower pay. Meanwhile they accept worse health for more money. That’s a commodity you can’t buy back once it’s been traded away.

      Comes a time when you’re driftin’
      Comes a time when you settle down
      Comes a light, feelin’s liftin’
      Lift that baby right up off the ground

      Whoa, this old world keeps spinnin’ round
      It’s a wonder tall trees ain’t layin’ down
      There comes a time

      With affection,


    2. Overhead…the eternal damnation of a fixed place of business.

      In anesthesia, the opportunity to do locum tenens is wonderful. Minimal overhead, and a high degree of schedule control.

      1. Post

        Clever physicians are finding workarounds in traditionally overhead-requiring specialties as well, planedoc. The internist at DiverseFI created a concierge housecall practice where he drove out to see patients in their homes. It was a risk, but the minimal overhead (he bought a Tesla to make the constant commute more fun) and premium he charged created a huge financial win for him.

  3. Many of us do not have jobs but are self employed physicians in Canada. My husband, before he trained as a surgeon would just take years off to hang out with our newborn.

    After he trained as a surgeon, he decided to take a month off each summer from the start and gave his call away to anyone who would take them. I think he just did it without fanfare and as it turned out no one cared. As long as he covered or got his call covered, that was all that mattered to the group.

    Trying to change your colleagues was never something we cared about. We made sure to avoid careers with large groups. I started in a mainly hospital based specialty but quickly realized I prefer to work by myself instead. Especially as two physicians, very challenging to juggled two sets of work obligations. Thus I chose private practice. It was strategic.

    I believe my husband’s ability to continue taking a lot of time off had prolonged his career. He is the slackest and happiest surgeon I know. And his practice continues to grow.

    We say nothing when our friends look at him sadly and think he works so much. (I won’t tell on him…the guy is off A LOT)

  4. In the depths of burnout a few years ago, by happenstance, I reconnected with an old buddy from residency, who lives a few states away, and our families traveled a bit together and got to know each other again. As an aside, it was great watching our kids become friends, and my son and his daughter maintain an independent relationship over time and distance. I secretly hope that they marry some day.

    On one of these family get togethers, at his ski condo in Colorado, while the wives and kids were all skiing, he and I went for a six hour hike on snow pack. We had a loooonnngg conversation on our jobs, our groups, and our frustrations, and it turns out we were both at about the same point in our careers, largely fed up and needing a change. For me, I felt somewhat validated that this old friend, whom I respected and admired on multiple levels, appeared to be suffering in a similar fashion. “I am not alone,” I thought to myself.

    The next time we all met up was again in Colorado, maybe a year or more later, this time at RMNP. On a 16 mile morning hike, we discovered that we had largely come to the same solution (drop IR, give up leadership, go part time). Once again, I felt validation and support for making changes for which I shouldered some shame. In retrospect, I am not sure that I could have come out my burnout so well without his sharing essentially the same story.

  5. Oh, man, so sad I missed you, CD. Next time you’re going to be in the Tar Heel State, let me know. Mrs. Groovy and I would love to meet you for dinner, drinks, coffee–whatever. And thanks for the review on Sweli’s. Mrs. Groovy and I have been looking for something different, and that restaurant looks like it would be a lot of fun. Great post, my friend. Cheers.

    1. Post

      Mr. Groovy,

      I would have loved to meet up with you and the Mrs., but we were over-committed for having only 3 nights in town.
      I always prefer to under-promise and over-perform than risk not doing what I say I’ll do.
      Please know that you are on my radar, my friend – there simply was not enough time to go around on this visit.



  6. Vagabond,

    I see you are a runner. You are likely disciplined. Many of the respected doctors such as yourself have a more difficult time allowing themselves to be and do less. It is probably a habit to keep grinding.

    Maybe that is what a midlife crisis is for many people. The ability to just be unpredictable and not follow an expected path.

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  7. MB, yes that is a very appropriate insight. Competitive running is 50% talent/practice and 50% willpower, willing your body to keep going when it wants to quit. Medicine is similar.

  8. I have a few friends from my residency I see once every year or two at conferences. It’s always great to reconnect. Our conversations pickup where we were years ago, but now with other topics like kids and aging parents. We talk and laugh until late. It’s difficult to maintain these friendships due to geography, lack of time, etc, but these relationships are what life is about. I need to make more effort. Thanks for the reminder CD.

    1. Post


      There’s a rhythm to friendships, a natural ebb and flow, and a good friend understands and navigates those currents the best that they can. Those maturing topics (parents, kids), even if not as often as we’d like, deepen already good friendships.

      Thanks for your kind words,


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