Seven Things that Foster Independence in Medicine

Each July new physicians come out of residency and begin their lives as attendings. Many of them will or have already unwittingly set themselves up to lose their independence. All physicians can just as easily set themselves up for independence. 

Independence in medicine is not about being in private practice vs being an employee, although that will help. Independence in medicine is about putting yourself in a position of having options; the ability to pivot and move in a new direction when needed since you have not painted yourself into a corner. Every decision made that takes away another option is one more step away from freedom in medicine.

On this Independence Day, I would like all physicians, not just new attendings, to think about their own independence as a physician. What decisions will you be making soon, or have you already made, that cut down on your options? More options = more freedom; the freedom to do things you want to be doing. 

Always read the entire contract

It is amazing how often physicians don’t read contracts. NEVER, NEVER, NEVER sign any document you have not read and understand fully. This is not just regarding your employment contract. 

Have you ever purchased a house? Most purchasers typically arrive at the title company to sign papers without first reading the contract. Once escorted to the back for their 30-minute appointment they are handed a packet with about 30 pages of papers to sign. Since there isn’t time to read everything, they look at a few points and sign whatever is presented. 

Always require copies of all paperwork at least one week before signing. Then read all the pages. Every time I have meticulously read all the closing documents for a property, I have found errors. I have the title company correct the errors and then present corrected contracts for signing.

I just finished reading an autobiography in which the person signed a contract without reading it. A couple of years later she wanted to do something and found it was prohibited by the contract. Since she never read the contract, and didn’t even get a copy of the contract to double check, she didn’t know what she wanted to do was prohibited.  Her lawyer made a lot of money over the next few months as they worked to get out of a contract clause she had agreed to, but never read.

Remember that those contracts were drawn up by the other party, not you. Your employment contract was drawn up by the hospital’s attorney, not yours. These agreements very likely favor the other party, not you. Don’t sign anything without thoroughly reading the fine print.

Get out of debt

After years of borrowing money to be trained as a physician and not having to face the consequences of paying it back, many physicians have become numb to debt. Debt seems like no big deal. In The Doctors Guide to Eliminating Debt I called this Debtabetic Neuropathy. 

Debt reduces our options. We have chosen to have things we want now, by agreeing to make payments every month into the future until we have paid the debt in full, with interest. Later we might not have the cash flow to purchase something we want. Often our high income encourages us to rack up debt because we believe we can afford the payments.

When my wife and I were trying to buy our first home, the seller chose another bidder. During escrow, the person who got the bid purchased a car on credit. Before escrow closed, the bank who had agreed to loan her the money for the house, changed their mind. The car debt put her over her acceptable debt-to-income ratio, and she no longer qualified for the loan. The house sale fell through. The seller then offered us the house, but by then we declined.

With too much debt, we eventually find ourselves in a situation where too much of our paycheck is servicing that debt. If our payments gets too high, we paint ourselves into a corner and have fewer options. We can’t miss work, we can’t take extra time off if needed, we can’t buy the house we love, we can’t cut back to ¾ time if desired, we can’t go on that great vacation our friends want us to join them on, etc.…

I recently read about a physician who was burned out and needed to cut back on the time he spent at work to recover. He wanted to go to 0.8 FTE. His employer said no, as they only offer 1.0 FTE or 0.5 FTE. He was burned out at 1.0 FTE and could not keep up the pace any longer, but he also could not afford to drop to 0.5 FTE because he wouldn’t be able to pay the bills he had obligated himself to pay. He had painted himself into a corner by reducing his options with debt. 

Debt is not your friend.

Don’t set yourself up to be house poor

This is like the debt issue we just discussed. But since it is very rare to be able to buy your first home with cash, a mortgage is almost always part of life in our early years. Unfortunately, many of us take this opportunity to buy the most expensive home the bank will agree to. 

I’ve coached many physicians who have made themselves house poor. They had many “reasons” to buy that house. It was their dream house, it had a great neighborhood, good schools, a great yard, they thought they would get a bigger tax deduction, the kids liked it….

Then something changed in their lives, and they discovered the super high mortgage payment was limiting their options. One physician who did shift work got into a car accident. She was badly injured and should have been home recovering, but instead she was working. I asked why she was at work, and she said she couldn’t miss any more shifts or she would lose her house.

Deciding between your home and your health is a lousy position to be in. Being house poor is almost always self-imposed and severely limits your options.

Never sign a non-compete clause

There is no good reason for a non-compete clause to be in any physician’s contract. Due to recent rule changes at the Federal Trade Commission (FTC), non-compete clauses are banned. Over the next few years, we will see how that decision plays out for physicians.

According to the FTC only 35%-45% of physicians currently have a non-compete clause. That means more than half of physician contracts already do not contain the clause. Which allows you to pick a new job that doesn’t require you to sign a non-compete clause. Tell your future boss to remove the clause during your contract negotiations.

If we all say no to non-compete clauses, hospitals will have to get rid of them to get physicians on their payroll. We have the power. Don’t limit your options by signing one.

Don’t supervise non-physicians unless it was your idea

Many physicians are complaining about being forced to supervise nurse practitioners and physician’s assistants. If you hired a non-physician to help you, then you made the choice to supervise them. But if your employer hires them and demands you supervise them, that is not acceptable.

If your employer makes demands of you, outside of seeing patients, that hasn’t previously been agreed to in your contract, and you let them, then they will keep pushing your boundaries until you break. Don’t give up your freedom to choose what you will do outside of seeing patients.

Live within your means

If you spend all your money on your lifestyle, you will paint yourself into a corner and lose options. When money becomes tight, you are likely to give in to your employers’ wishes so you don’t risk losing your job.

If money is tight, and you need time off, you might not be able to take the time off. Look back at the physicians I discussed who were injured and burned out. Always be in a position where you have a financial cushion so you can pivot if needed. Living on the edge of your income is a good way to fall off the cliff and get into financial trouble.

I remember being asked by my attending during residency (I was teaching finance back then too) how long I could last if I lost my job as a resident. I told him indefinitely. He didn’t believe me as he earned a lot more than me, yet he would struggle with a job loss. 

My wife and I both earned the same income, yet we only lived on one income. The second income went into the bank. Thus, if one of us lost our jobs, we would simply live off the other income and stop saving money for a while. We made an agreement to live on only half of our income when we got married during my first year or residency. It was that agreement, which we used for the rest of our earning years, that led to our early financial independence. It was not how much I made, but the agreement to only spend half of it, that did the trick.

Never set yourself up with a long commute

Often physicians choose a house a long way from their work. They always have a special reason as to why they needed that house in that location: More space out in the country, better price, lower taxes…

The bottom line is the longer your commute, the fewer options you have. The daily commute eats up much of your precious time. I remember feeling bad for one person who told me her daughter wanted to move into the city because all her friends were too far away. This same parent complained that she spent all day taking her kids to their activities and running errands because their house was so far out of town. Running errands was a full time job!

When you live out in the country, everything that you and your children want or need to do requires a drive, which takes extra time: School events, friends, church activities, theater, gym…. Too much of your life gets lived in the car.

One complaint most physicians have is they don’t have enough family time because of their long hours at work. Don’t compound the time you are away from your family by choosing to have a long commute. Buy or rent a home less than 15 minutes from work. The extra time you have will be so much more valuable than a big yard.

If you adhere to these seven suggestions, you will have more freedom as a physician. Having options will create a happier life. If you want more ideas on ways to have a better life in medicine, pick up a copy of The Doctors Guide to Starting Your Practice/Career Right. It is full of ideas to make your job better and keep your options open.

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1 thought on “Seven Things that Foster Independence in Medicine”

  1. I think there’s a lot of wisdom here, mostly the fact that as we enter our medical careers we have lots of choices to make and those choices can limit our opportunities later on. Some of what the author says is only true on the surface, at first glance, and is much more nuanced upon deeper thought than he appears to realize. In the northeast USA, a physician can not really raise a family “near” the physician’s mega-city large hospital center. You would not want to live or send your children to the city public schools in Philly, NYC, Boston, D.C., etc. You are going to have to live with a commute. Some less-populous areas are probably different. Danville, PA with Geisinger Medical Center has great neighborhoods and excellent public schools, a bike ride away from the hospital. St. Christopher’s Hospital for Children in Philly, uh definitely NOT. I did work at St. Chris at one point, and there’s no way around it that you are just going to have a 40-60 minute commute morning and again in evening every day; no way around that. Aside from that, most families have two parents and there are reasons to consider the physician’s spouse’s work issues, preferences, other family issues, etc when deciding on locations. The family life is not all about what the doctor-spouse wants.

    I realize now that when I was in medical school and residency I made choices about my career path, and I made those choices for “good” reasons but they were probably not the best choices, and were not made for the “best” reasons. I wound up, after 6 years of low paid training in a pediatric subspecialty that, 25 years later, is not really very satisfying work and I am either required to work for a mega-max hospital system or try to go out on my own and be on-call by myself every minute of every day of every month of every year. Two guys I did training with are doing exactly that in areas of the country I don’t want to work — I don’t want to join them and they would not want to move to join me. The point is that I made choices and lived my life and spent my career with the results of those choices. I never realized early enough that I’d have had more career options (jobs) and more flexibility and a better salary for all these years if I had gone into IM instead of pediatrics. When choosing the field for a career, anyone only talked about what kinds of medical issues any given career involved. No one talked to me about, for example, when you are 51 years old, and it’s a rainy Monday morning, and the alarm clock goes off, are you ‘really’ going to want to jump out of bed to go do ‘this’ career job, or would the variety and flexibility of options for ‘that’ career be a better fit for you?” No one gave me that kind of guidance or advice.


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