WCI #193: Cure Physician Burnout with Dr. Dike Drummond

This is the White Coat Investor podcast where we help those who wear the white coat get a fair shake on Wall Street. We've been helping doctors and other high income professionals stop doing dumb things with their money since 2011. Here's your host, Dr. Jim Dali.

This is White Coat Investor podcast number 193, stop position burnout with Dyke Drummond. Thanks for what you do. This last year has been hard, I think, on all of us. You know, we get paid less, we do more, we have a lot extra demands at work. You know, we've been wearing PPE for months, making it difficult to enjoy our practice. I know a couple of my partners have put in for retirement this year and I'm not sure they would have without the pandemic. I think they might have worked a couple more years. It's been a hard year on all of us, so thanks for what you do. It's not easy work and, you know, you may be on your way into work, on your way home, maybe you're working out, whatever, but if nobody's told you, thanks for what you do. Let me be the first today, at some point in our financial lives, it will be time to buy a home. A physician mortgage can be a good vehicle for a young doctor who's just out of school and has a more effective place to use their money than on a big down payment. These loans allow doctors to secure a mortgage with fewer restrictions and a lower down payment than a conventional mortgage. But if you're further advanced in your career or deeper into your journey to financial freedom, buying a home with a conventional mortgage and then later on potentially refinancing that loan to a better rate with a shorter time frame could be a great move. Wherever you are in your financial journey, make sure you use the mortgage that will be most financially beneficial for you. Hop over to our recommended tab to learn more about all of your mortgage and refinancing options@whitecoatinvestor.com mortgage. You can do this and the White Coat Investor can help. All right, a quote of the day today comes from Phil DeMuth. He said people's comfort with investment volatility is dependent on their current state of mind. When the stock market is racing up, people are comfortable with volatility. Isn't that the truth?

Right?

We only like, we only dislike volatility when it's going down. All right, it's January. It's January, which means it's time to be thinking about your finances. It's time to get stuff taken care of. It's time to get Caught up to where you want to be in your financial life. We have a couple of things this month that can help you do that that we'll be announcing on the blog, one of which is a book I spent most of last year working on. It's aimed at medical and dental students. So watch the blog for more information about that. All right, we've got a special guest today. Let's get him on, then I'll introduce him. All right. My guest today is Dyke Drummond, M.D. he's a Mayo trained family practice physician and a leading coach, trainer and consultant on the prevention of burnout in individual physicians. He's the CEO and founder of the HappyMD.com, a website that gets 25,000 visits visitors a month, not visits a month, visitors a month. And hosts an online community of about 18,000 physicians from 63 countries. He's he spent over 3,000 hours doing one on one physician coaching and has trained over 40,000 doctors on behalf of 175 corporate clients to date, including me. He came and spoke to our group a few years ago as well. So welcome to the White Coat Investor podcast. Doug.

I remember that day.

Yeah, it's been a little bit different this last year and how much you can get out and do that, I imagine.

Well, yes, I remember the week of March 9th this year. I had several dozen trainings lined up over the course of the year and they all disappeared in five days.

Oh yeah, Well, I know those five days well. We were in Las Vegas running a conference during those five days.

Oh my.

So it was, it was a stressful time for sure. Oh yeah. Yeah, for sure. The NBA canceled its games in the middle of our opening reception. So it was an interesting time for sure. But let's start with a little bit about you. I want to hear about your childhood, how it affected your views on work and money. And then we'll move into your training, your medical career and kind of what you've done since your medical career as well. So let's start with childhood.

Well, so I was born and raised in Columbus, Indiana, the Athens of the prairie. My dad worked for Cummins Engine Company. Standard Midwestern upbringing, upper middle class until I was in ninth grade when my dad took a job in England and we moved to England for three and a half years. And I was an English schoolboy. We didn't go to the American school in London, we went to one of the English schools schools. And I got my O levels and learned to play rugby and drink warm beer and those movies that you see where the English schoolboys are all in their uniforms and the teacher turns their back and they're throwing spit wads and fighting and everything. The teacher turns around, they all sit back down again. It's exactly like that. And in England, they are asynchronous to the American school calendar. So when you would graduate from high school, they still have another year worth of training to get a thing called A levels before you go to college. So I do not have a high school diploma. Came back, went to Indiana University, captained the rugby team there for four years. Got a BS in biology, went up to Mayo and did my undergrad at Mayo. In my family, my great grandfather was a GP back in the depression in East St. Louis, Illinois. And my grandmother grew up remembering times when people would put a warm pie on the front banister of the porch or tie a chicken to the back porch when they couldn't pay for their treatments from my grandfather. So both my great grandfather, my grandmother and my mother went off to college wanting to be doctors, but came back as teachers. And when I was born as the first male grandchild, it was sort of predestined in my family that I was going to be a doctor. But nobody ever talked about it. Some families are very verbal about it. You're going to be a doctor, you're always going to be a doctor. Well, it was never that with me.

Or you can do whatever you want as long as it's a doctor or a lawyer.

Right? There you go. But I was first born, so I went off to Mayo and I got. And when I went, I thought to myself, there's only one kind of doctor I would ever want to be. And that's like Dr. Schmidt, my GP growing up. So I always wanted to be a family doc. Full service country family doc. Did my residency in the UC Davis system in Reading. Year as an ER doc in a little rural emergency room. I call it a reverse mash unit because we would stabilize people and then fly them out. And then 10 years of full service primary care in Mount Vernon, Washington, where I was chairperson of the executive committee of our 40 doctor group and second busiest family doc. Delivered 500 babies. All that kind of stuff. Stuff. And for me, money programming was, if you have to talk about it, something's wrong. That's how we grew up, right? If you had to talk about it, something's wrong. So we didn't talk much about money. And we had pretty much what we wanted because my dad was a member of the leadership team of Cummins Engine Company in Columbus, Indiana. But that was my money programming, so we didn't talk a lot about it. And I went into a field where we had some of it right. So I didn't need to talk a lot about it when I was a young professional either. As a resident, we had to budget and be careful with things. But she's not my ex wife. But my wife and I got married all the way back in Wisconsin and paid for the entire wedding out of a resident salary, which was a little over 20 grand at that point in time, per year. And then 10 years into my career, at the age of 40 in 1999, I had a really unusual episode with Burnout, where over the course of several days, actually a couple of weeks in my practice, every time I went in, it felt like somebody was choking me. Like a rear naked choke is what they call it in the ufc. It's a submission move. I didn't know what it was. I thought I needed some time off. I took a sabbatical for 30 days, shaved my head, did a bunch of yoga, didn't do anything medical, and prayed that when I came back that that feeling would go away. But it did not. It returned the very first day I went back. So I didn't have a lot of coping skills at the time. So what I did was I went and signed my resignation and walked away from my medical career that day. And if there's anybody who's listening to this right now, who's thinking, yeah, I should chuck it too, just quit and leave, I would recommend you don't. And the reason is it burns too many bridges, because burnout's the number one threat to your financial well being. It's the number one threat to your practice, to your career, to your family, to your marriage. For physicians, burnout is the number one threat to all of those things. So please don't chuck your career and walk away. Give me a call and let's talk about it. Because there's all sorts of things you can do to get better without needing to throw it all away. Set me up for a bunch of struggles. About three or four years, I was working walk in clinics. I got certified as a coach immediately. And so I've been coaching Doctors for about 20 years now. But ultimately my wife became certified as a facilitator, strategic planning facilitator, and a facilitation skills trainer. And we developed a little training company called superteams. And we were actually faculty to the US Navy's Lean Six Sigma Black Belt certification program for a while. And then in 2010 that marriage and that business went away. I was burnt to the ground for the second time. And I decided to see if there was a way that I could grow a business as a coach to burned out doctors because I had realized at that point in time that that's what had taken me out. And I launched a little website in 2010 with a name that was meant to be an oxymoron, the Happy md. Happy md. What the heck is this guy talking about? There's no such thing, right? So it's meant to be a head snap, it's meant to get your attention because most people don't see doctors that way.

So we're going to get into talking about burnout and stuff. But I wanted to talk first a little bit about this transition you made. I mean, you left a relatively high paying, relatively guaranteed high income career for essentially an entrepreneurial pursuit that you really had no guarantees with whatsoever.

No, I had no idea what I was doing.

Tell us what that was like, the fear you felt, the financial struggles, if any you had at the beginning of that. Tell us a little bit about that transition.

No fear, no struggle. I had a buyout. I had bought into the group, I had a buyout and unwisely, I used that to support my life expenses for a year and did not push myself to work in the first year after I quit. I had no fear. I just knew that I could not continue. I felt like my life was physically threatened. I wasn't depressed, I wasn't down. It was a really unusual physical sensation and everybody's burnout's different. But then what I did was I went back to what I knew. And so as I was, I was learning how to create websites, right? I can remember within a year after I quit, a buddy of mine and I started a website called Check this URL out Physician Career Expansion. And we were going to try and start a coaching company for doctors right at that point in time. But I was coding things with disks on a Mac and all that kind of stuff. And I didn't have the skill set or the awareness at that point in time. So I put food on the table as a walk in clinic doc on an hourly wage. That was a lot of times it was less than the agency nurse on overtime that was manning the urgent care with me. But for me at that point in time, it felt like a piece of me was dying every time I went in and started seeing patients again. And it wasn't until my wife's ability to earn income made her the most income dense person in the family that I then stopped seeing patients for insurance payments and devoted myself to supporting her business and my coaching practice. And by the way, you said since my medical career, I don't consider myself to have retired. All my patients right now are doctors. I work with leadership teams of all sorts of organizations and individual doctors to create ecosystems where, where burnout is much less common. But I don't consider myself to have retired. And I believe that most doctors don't feel that way either. Because once you've been a doctor, your mindset and your way of seeing the world is set in a way that I notice a lot of doctors have trouble even contemplating retirement because they wouldn't know what they'd do if they weren't seeing patients.

So you view it as a continuation of your career rather than a different career.

All my patients are doctors now.

Well, let's talk a little bit more about burnout for a minute. I've spent a lot of time thinking about burnout, a little bit of time writing about burnout. It seems to me there's four big factors causing it, affecting it, and I consider them to be the first, the professional stresses of medicine. This is something that's probably not going away with medicine. It's dealing with the sick and injured. It's working evenings, nights, weekends, holidays, wearing PPE these days, maintaining your licensure and board certification, etc. So that's first stress is just being a doc. The second one's toxic jobs. These jobs where docs are under, supported, undervalued, underpaid, understaffed, they got a crummy EMR, they got ridiculous administrative demands, etc. Three personal factors, things that are going on in the doctor's life, in their personality, etc. And fourth, financial stresses, which is essentially or especially come to root in, in the last decade, decade and a half or so as the cost of becoming a doctor has become so high that some people are entering the profession already owing hundreds of thousands of dollars. What do you think about those four factors? I'm not sure what percentage of burnout I would blame on each one of them. Are there other things that you would add in there? How would you ascribe percentages to those causes of burnout?

Well, I don't think it's a useful exercise because everybody's burnout is different. Here's the way I split it up. There are what I call universal causes of burnout, meaning things that all of us have to deal with that are stresses on doctors. And it's universal. You've got the same stress as I do in this particular area. And there are five universal causes of burnout. And then there's a thousand more that can be the last straw. And there's one big one that you and I will never have to deal with. And we'll talk about that in just a second. Universal causes of burnout. You chose to go into medicine. You chose to be what I call a lightworker. At some point in time, you said to yourself, should I go to medical school or should I do anything else? And that's when your stoner friends all said, anything else, and they were gone, man. And you are cut from a different cloth. You decided to be a helper and a healer. You ended up allying your professional life with the forces of light in the universe as they battle the forces of darkness. Specific forces of darkness. Illness, suffering, death, dying family members, crazed attempts to deal with those things. And in taking this fork at the lightworker's fork in the road and becoming a lightworker, you put yourself at risk for burnout, for suicide. You put yourself at high risk because in the act of helping and healing people, you can overextend yourself into burnout. So that's, number one. You chose to be a doctor, and that is a stressful choice. You'll be traumatized along the way because none of your patients are going to survive. They're all dying. You're dying, too. It's the human condition. And you've chosen to be in the front lines of very important places in people's lives when horrible things happen. You're an ER doc, right?

Yep.

Yep. So you put yourself in harm's way in an even higher level of intensity than, say, I don't know, an outpatient pediatrician. But there are things going on in emergency rooms and specifically El Paso and other places around the country right now that are traumatizing people. If they had not chosen to be doctors, they would not be in those positions right now. So being a doctor, number two, whatever is your job. And most jobs suck. Because what happens when you're taught your beautiful practice of medicine and then dropped into a corporate position? It's the classic square peg in a round hole. And when you signed the contract, you gave the boss a great big mallet to keep driving you in that hole. So there'll always be things about your job that add to the stress of the fact that you're a physician in the first place. The third universal stress is bad leadership. If you happen to have a bad or absentee leader or worse off. Worst of all is a psychopath boss. That person will drive you out of your job and will burn you out. In my experience, 30% of the people that I work with who are burned out as a coach have to change their jobs. Only 30%, 70% can recover in situ. But the 30% who have to change their jobs almost always have a conflict with their boss. Fourth life. There's any one of a thousand things that'd be going on in your life. You just had your first baby, you just had your eighth baby, right? You've got a special needs child. You got twins, twins in driver's ed. You got money problems, you got health problems, you got anything that's going on. But what ends up happening is people see somebody burning out at work and they naturally assume it's work related. That's not necessarily true. So one of the questions you have to ask early on is, how's it going at work, home? Because that may be where the problem is. And the person simply can't recharge when they get home. And that's why they appear to be burning out at work. The fifth cause is the conditioning of our medical education. Remember, at the fork in the road, you went to the side of becoming a doctor, and at some point in time, you had to acknowledge you just made a choice that was going to give you a long, difficult road to walk. And you thought to yourself, I wonder if I got what it takes. And you looked at yourself and said, yep, I think I do. And the reason you said that is because you're different than your stoner friends who ran screaming for the hills. You had some grades, you had some performance, you were driven. You had some caricature traits unique to you that you share with all doctors. Workaholic, superhero, Lone Ranger perfectionist. I'll say those again a little more slowly. Workaholic, superhero, Lone Ranger perfectionist. Give you an example. If you had ever gotten a B in high school, perfectionist would say, that's not acceptable. Workaholic would pull the all nighter and ace the test to preserve your 4o, right? So now you go into 6, 7 to 16 years worth of medical education. We're going to use those character traits every single day. We tend to become those things. Ask your kids about what it's like to be your kid, right? Because their dad is different than some of the other dads because he's a doctor, right? And then there's a couple more prime directives. You got these character traits, but there's the patient comes first. Which everybody knows, which by itself is toxic. If you have no off switch. Yeah. When you're with the patient, patient comes first, but you have to be able to turn that off to recover. And the second one that nobody talks about is never show weakness. So we follow these character traits, we follow these rules and it sets us up for burnout because we don't know how to take care of ourselves when we graduate from a residency program. Because it wasn't okay to take care of yourself in residency in the first place. It's a learned behavior. It's programming. Right. So that's the fifth one. And then of the non universal causes of burnout, the things that can be your last straw, there's a whole bunch of them. Money's one, Your own personal health or the health of your spouse or your kids is another. Another really common one is malpractice risk. You don't need to get sued or lose a case. To be overwhelmed by malpractice is your last straw. All you need is a threatening letter from a patient that says, not your favorite. And then I'm just going to put this out here because two guys like me, you and I wouldn't see this. Our society and our medical education system and our healthcare delivery system is riddled through with bias and discrimination. So I don't know if people are watching this on video, but you and I are big old white guys, big old straight American born, native English speaking white guys. And if you as the listener are different from Jim and I in any of those categories, any single one, you will have been discriminated against along the way. Heaven forbid. You're a petite, young brown, English is your second language female, because that is something that will get you rabidly discriminated against along the road that you had to come to get to being a physician here in the United States or wherever you are right now. And in a number of situations over the course of any given year, the last straw for my client has been some sort of bias and discrimination. Little cherry on the sundae right there.

Interesting that it's been so many.

That's how I see this laying out in terms of patterns across the thousands of folks that I've worked with. But in terms of assigning a percentage, I don't know. I don't know that it makes any sense. What I want to know is when I'm meeting somebody, what's going on? Tell me your story and what would you like it to be? What is it? What would you like it to be? And we close that gap, and they could come from any piece of the spectrum of causes. It doesn't matter. What's happened is whatever the combination of causes is, and it's always multifactorial. Right now it's driven their energy to a persistently negative level and they cannot psychologically handle it any longer.

Now there's some people out there arguing that burnout doesn't exist, that it's a myth, et cetera. I think it was Marissa Meyer, the CEO of Yahoo, said, I don't really believe believe in burnout. A lot of people work really hard for decades and decades.

She's the lean in person, right?

I think so, yeah.

All I can say is I'm going to echo what I've seen. Other people say this, but I jumped right on her case as soon as she did that. That's really great. I wonder how many nannies she's got, what her monthly house cleaning bill is. Not that you shouldn't have help for your family, but all I'm saying is to you to say categorically burnout doesn't exist because I'm a rich woman with all the help I need, that's just fundamentally flawed. Right? Fundamentally flawed. So burnout absolutely exists. And there is a couple of different kinds. Just pure physical overwhelm. And then there's the caring professions like ours who have the additional risk of helping other people. Is part of our mantra, the patient comes first, where we don't necessarily pay great attention to our own energy reserves and can put ourselves over the edge real quick. This is a universal experience for most people, right? When a doctor is exhausted and burned out, they'll say, I'm not sure how much longer I can keep going like this. That is also an almost universal phrase in all parents because the closest thing to the kind of giving light worker energy that you have for your patients as a physician is the love that you have for your children. And you will righteously overextend yourself to help your kids if the situation demands it.

How much of this do you think is doctors with this expectation of their career, that it's going to be this gratifying, rewarding experience all the time? Then they get into it and they realize, hey, this is a job too.

It's work.

They call it work because someone has to pay you to do it. And there's a support group for that they meet at the bar on Fridays. How much of this is doctors who thought that work, that this career was going to be something different than other people find in their careers?

Well, there's obviously a piece of that. Let me just go back to that lightworker's fork in the road, right? When you sent back your reply to your med school acceptance, when you sent back that letter, did you have any idea what you were getting into?

You know, I like to think I was pretty well informed going in, but I'd never practiced before. Right. I couldn't have known what it was like. Exactly.

You had never experienced any of it.

And the crazy part about it is you couldn't experience it for another eight years.

Right. And, well, that's it. You had to go through the rite of passage. So, for instance, boot camp. Boot camp in the military is six to 13 weeks, depending on what branch of the service you go in. What's boot camp for a doctor? 7 to 13 years, where if you had a vision when you said yes to being a doctor, of what it would be like to being A doctor, that's seven to 16 years into the future going through the hell of medical school and residency. Now, I'm not saying it wasn't without its rewards, but it's taxing, it's difficult, it's emotionally and physically and spiritually difficult to make it through that kind of training. And fundamentally, none of us had any, any idea what we were getting into when we went into medicine.

I think an even bigger factor is not only did you not know what it was going to be like, you didn't know what you were going to be like.

Right.

You know, 10 or 15 years later, you're not the same person. And it's not just the training, it's, you're just different.

Well, check this out. There are people in the addiction world who say when a person starts using, their emotional maturation stopped. And when they stop using, they're still the same emotional age as when they started. So if I started using drugs at 17 and I recovered at 30, I'm still a 17 year old. Like waking up at the age of 30. Medical education, medical school and residency is stressful enough that we tend to jettison friendships, jettison hobbies, and devote ourselves purely to the educational process. I believe there's a certain aspect of a halt on our emotional growth at that point that maybe opens back up again once you've graduated. So yes, you grow up, you give your twenties, you give your twenties. And I swear most doctors somewhere along the way say, man, do I want to keep pushing through. Fortunately, they don't teach the theory of opportunity cost in medical school.

Maybe we should stop on all this economic and financial training for Doctors, we're going down. We're not going to have anybody to take care of us.

Right. Don't teach them about opportunity costs, confirmation bias and opportunity costs and all that good sunk cost fallacy. There you go, all that good stuff.

Let's talk for a minute about depression. Studies have shown that the correlation between burnout and Depression is about 0.5 and slightly lower for burnout and anxiety. How can someone who feels burnt out know whether it's just depression or anxiety or whether it's true burnout?

Yeah, I have no idea. Because there's an active brush fire war between coaches and psychiatrists about who should be taking care of these people. Right. So let's just talk just a little bit. Certainly if you're thinking about taking your own life, if you're losing or gaining weight, can't get up, can't motate, maybe you've got something that requires something other than medication. But remember something like medication, just remember that cognitive behavioral therapy is as effective in depression depression as drugs are. So when I think about coaching and when I think about therapy, I think about it very simplistically and somebody's going to get on my case for this. But this is the way I think about it. Therapy wants to treat disease. You're going to be in the dsm, a diagnosis is going to be made, watch out for your license or get ready to lie when you re up. So all that stuff is all of a sudden in play. And typically when you're working with a therapist, they're looking in the rearview mirror back in time to see where this all started and how you got messed up. Like as a coach, it's not in the DSM 3. Burnout is not a psychiatric illness. It's not diagnosable, recordable. It doesn't affect your license at all. And as a coach, what I do is I help you look forward. The only reason I would look back at what's happened in the past with you is if what happened in the past is getting in the way of you moving forward. Otherwise we focus on what you want. Now here's a super important distinction too. Most of the people that I meet who are considering getting a coach are in a pretty bad situation and they want to tell you about all the stuff they don't like about their current reality, all the stuff they want to run away from. And that's interesting, right? But I have to acquaint them with the reality that you can avoid everything you don't want and you still won't get what you Want, because there's only one way to get what you want, and that's figure out what that is and go get it. So what we work on as coaches is what's your ideal job or practice or career description? Ideally, it's your ideal life description. What would you run towards? How would you like it to be in an ideal world? Let's move in that direction, regardless of what's going on right now. Does that make sense?

Absolutely.

But there's a big controversy about burnout versus depression. And the other thing I'll tell you is that they are both in any population of doctors. Example, every study that's ever been done on physicians where they measured for burnout, so even the big three sequential Mayo studies that everybody heard about, where they did it in 20, what was it? 2012, 2014, 2017, even in those studies, they checked for burnout, depression and suicidal ideation. So burnout was between 40 and 50% in the same population. Positive screen for depression was 40% solid all across those three studies. And in each one of those studies where they asked, have you thought about suicide in the last 12 months? Guess what percentage of doctors will always answer that positive. If you thought about suicide in the last 12 months, what's the percentage that will always say, yes?

I would guess around 10 to 15%?

It's 6 or 7%.

Six or seven.

Which is, if you do the math, one in about 15. And that's constant. Absolutely rock solid constant. By the way. Let me give you another little voice cue. You and your listeners, another little voice cue. The first little voice cue of the kind of exhaustion that burnout causes is, I'm not sure how much longer I can keep going. Like this little voice in your head. Here's a really dangerous one, although it masquerades as gallows humor. If you've been feeling really down and beat up and you're not recovered, you're getting ready to go to work and you think to yourself, maybe if I'm lucky, I'll get hit by a car on the way to work and I won't have to see patients. And today that may sound a little bit funny. Somebody actually, actually say it out loud and you'll get some giggles. That's a huge red flag. That's just huge. Because you know what? You ain't going to get hit by a car on the way to work. And this feeling is going to continue until you change what you're doing because you're down in a hole. At that point, I would encourage you to ask for Help if you're, if you're noticing that voice regularly right.

Now, you mentioned recovery time. And I think, you know, when people come to me and tell me they're burnt out, I tell them maybe the first thing you ought to do is cut back to full time because so many Doctors are working 60, 80 hours a week. How often do you think cutting back is the solution to people's burnout? To give them more recovery time between shifts or between patient encounters?

Well, there's obviously a dose response curve, right? So if your work environment is stressful, let's call it a hostile work environment for whatever reason, and there could be any one of a number of things, you could be short staffed, right? You could have a bad boss. It could be things going on at home. If the work environment is toxic and you do not feel that you can make it less stressful, then the only way to lower your energy expenditure would be to limit your exposure. So cutting hours is a solution. But what I found is that it's almost never the case that you cannot modify the stress in the workplace. It's almost never true that you cannot modify and lower the stress in the workplace. If you have a second pair of eyes, take all the pieces apart and look at the way you're doing things in your normal operating procedure and show you some different ways to do what you've always done. It's Einstein's insanity trap, basically, right? If you always do what you've always done, you'll always get what you always got. If you don't like your balance right now, we have to change your actions in order to change that.

And how much focus should people be putting on the workplace and its changes that it needs to make versus your adaptations to it?

Yeah, 50. 50. If you have a cooperative leadership team, right. So when you have decided to be an employee, and I think that's in the background of what you're talking about right now, is I have signed a contract to work this job description, not my ideal job description, their job description for this position in their systems with their staff and their management and their leadership and their supplies and their pay scale and their compensation formula, all of that stuff, okay? If I've accepted that bargain and I want to modify that workplace, it's going to be me adapting myself and the way I work with my personal work team underneath the radar of the leadership team to make sure we work together as a team and then hoping to influence the leadership team when I see things that need systemic change. So when we work with doctors, a couple of things we teach. How to build a more ideal practice, how to get home sooner, how to develop more life balance, how to be a better leader to share the load that you have at work. And last but not least is how to manage your boss. Because it's one of the clear missing skill sets for physicians. You were never trained to be inserted in the middle of a large bureaucracy as an employee. Never. And physicians do all the wrong things when they're trying to negotiate for some wiggle room in their job. We tend to, we tend to be too urgent, pound the table, accuse people of having manure for brains and get ourselves in trouble really quick.

That sounds like a physician. Tell us what you mean by training your boss.

Not training your boss. Manage your boss. So if you think about what an organization is, it's a hierarchy of relationships. And as physicians, we are trained to be the king or the queen of the practice, the apex of the pyramid, the alpha, the omega. Everybody waits for us to get give orders and they won't do anything until we tell them what to do. It's crazy, crazy. Top down, right? But you're trained to do that. But then when you graduate, if you decide to be an employee, they stick you right in the middle of a layer cake of a very complicated bureaucracy where you have your direct reports below you, your care team, but you also have layer after layer after layer of folks that are either beside you or above you in the organization. And for a lot of the things that are bugging you at work, you would need someone else's either permission or someone else's order to change a workflow or change the way that the patients are cared for. You would need their permission for you to develop a more ideal practice. You say, I really want this, but I can't get it without my boss saying yes. Does that make sense? And inside most organizations, I know that that ain't never going to happen. And it's because nobody has managed the relationship with their boss. Now realize, if you were my boss and I was a doctor in your emergency room. So let's say you're the director of the emergency department and you might be.

I don't know, not right now I'm not.

And I'm one of your worker bee doctors, right? Ideally, we have a relationship. What's a relationship? Well, we talk to each other every once in a while. And I'm going to be very specific, we talk to each other every once in a while outside of a crisis. Like when I'm not in trouble, right? Because we can't really have a relationship if the only time I see my boss is when I'm in trouble. And there's a very easy way to figure this out, I call it the lookup trust test. If I say to you, it's like, hey, Jim, if your boss. Do you know who your boss is? Do you have a boss?

I do.

Okay, cool. If your boss showed up unannounced during one of your shifts, is that a good thing? Sure.

Maybe he's coming in early to take over for me.

So you would look him in the eye and say, hey, boss, what's going on? To what do we owe this unexpected pleasure? Right.

Yeah, probably.

Yep. That means the two of you have a relationship and it has some trust in it. When I'm in front of rooms full of doctors and I ask that question, if your receptionist came to you between patients and said your boss in the waiting room wants to talk to you when you get a break, is that a good thing? The answer is almost never no. And I say, why are they there? Because I'm in. And they all say trouble. Big trouble. Echoes through the room. Right. You can't have a relationship with your boss and you can't manage that relationship if the only time you see them is when you're in trouble. So you have to have regular meetings with your boss outside times of crisis. They don't have to be long. And in order to get on their schedule, you tell them you want to have a regular meeting to stay on the same page. That's the phrase that works. But you want to develop some sort of a relationship, right, where their presence is not a bad thing. And once you've developed that relationship, and There's a ratio 5 to 1 that you use to figure out how long this is going to take. Once you've developed that relationship, you understand what their boss is asking of them, you understand their personality and what's important to them. It's relatively straightforward to craft a question, to craft a request, to craft an innovation project that will get a yes rather than getting slapped down with a no because you didn't know how to manage your boss.

Good tip. I appreciate that.

It's actually a whole. It can be checklisted, just like a pre op checklist. I have a seven part checklist for the process. Right.

So a lot of doctors, you know, they see these surveys that 40% of doctors are burned out or whatever and they wonder, well, am I burned out? What's the best way to know if you're burned out?

That's an interesting Question, because what you're talking about is scales on a survey versus your own personal experience. So let me, let me give you an example. One of the main surveys, it actually was a gold standard for burnout measurement for years, is a survey called the Maslach Burnout Inventory by Christina Maslach. She started doing this test, a 22 question test, back in the 1970s. And it measures the three symptoms of burnout. The three symptoms are exhaustion. I'm not sure how much longer I can keep going like this. Cynical, sarcastic, it's also known as computer compassion fatigue, where you start to have to vent about the patients that you're serving. And the last one is, what's the use? My work's really not serving a purpose here. Exhausted, cynical, sarcastic, what's the use? And so these 22 questions in her survey measure those three scales. And the researchers have these cutoffs for the number that you score on each of those three scales. And they'll say that the person who is above that point score on that cutoff is suffering from that symptom of burnout. It's an arbitrary score. I'm not sure that we can tell the difference between burned out and not burned out on a single score in our own physical experience. But if you look at the way that they diagnose burnout in these surveys, it says suffering from at least one symptom of burnout. And the most common symptom that doctors suffer from is which one do you think it has?

I'd guess exhaustion.

Exhaustion, because everybody's had their little voice say, I'm not sure how much longer I can keep going like this. Right? And if you look at the studies that connect burnout with low patient satisfaction, low quality, low safety, error rates, turnover, and all the negative consequences, all it takes is that suffering from one symptom. But if you talk to Christina Maslach, she'll tell you, you people in healthcare use my test all wrong. First of all, I would never have a solid cutoff where somebody was burned out if they were above it and not if they were below it. And if I did, it would be across all three scales. I would want you to be missing all three. Exhausted and cynical and sarcastic, and what's the use? Because in my experience, she'll tell you that's when a person's burned out. So what you'll find is that. And again, doctors, their self awareness of their own energy levels and their self awareness of their own personal needs has been wiped out by the trial of residency education. But if you are Looking at a group of doctors and you're asking if they think they're burned out, I would think that far fewer of them would say they're burned out than would score as burned out by the standard way it's measured.

So maybe it's over calling it. The surveys are over. Calling it.

No, it's not over calling it, because that measurement is what's associated with the low patient satisfaction, low quality, higher error rates. All the negative effects are matched with the way it's diagnosed. I'm just telling you that subjectively. Would you call yourself burned out at that level? The answer is probably no. You'd have to be farther down in the hole. But it just shows you if you are stressed. And again, remember, you've been trained to ignore that. Never show weakness. Right. If you are stressed, there is a pretty dramatic effect on your ability to be present with a patient and do a really good job. That comes on pretty darn early, as soon as you start to drop down in your energy levels.

Maybe before you'd even recognize it.

Maybe before you'd even recognize it. Just like most disease, like, how much pulmonary function do you have to lose from COPD before you're actually Dyspnec? It's like 80%, right? We all know these curves that only become symptomatic in their extreme pathologic states.

Speaking of extreme times, let's talk about this. Last year, COVID 19 pandemic has put a lot of additional stress on workplaces, on doctors, et cetera. What's been your take over the last year on physician burnout? Is it worse? Is it better? Is it about the same as it's always been? What's your take?

Well, first of all, there haven't been a lot of burnout surveys since COVID hit, but we know that it was the prevalence of that measurement that I just told you about was 40 to 50% prior to Covid. We also know that not all physician practices were hit the same by Covid, and we know that the best from the first wave. So if you looked at a large hospital system with a whole bunch of inpatient and outpatient doctors, a comprehensive delivery system back in the spring, one third of the physicians and staff were overwhelmed by that first wave. Two thirds were almost completely laid off for a short period of time. What ended up happening was, unless you were on capitation at that point in time, huge losses, huge financial losses for those companies, and a lot of layoffs and. And wage cuts and other things for the doctors in most companies around the US of A. So I can tell you, though, that what's more stressful, being super busy in the ER or being laid off? I mean, you tell me. So there's various different kinds of stress for the different doctors, but what it did is the whirlwind of your practice that swallows you as you walk in every day. I say doctors. It's like being in a whirlwind. That whirlwind has been sped up by Covid. The other thing is, Covid now is putting stress on you at home. You can't go out to eat, you might get sick at the grocery store. Your kids, are they at school or not? So what's happened is your ability to recharge when you go home has been compromised by Covid effects there. And secondly, wouldn't we have liked Covid to have been a standard natural disaster? A one shot hurricane, tornado, right? Terrorist attack, 911. Just give us that one shot hit. Give it to us one day and let us recover from it. From that point forward, it's been a slow, rolling, repetitive tidal wave, and we're still in the middle of it right now. So it is a chronic disaster. It can hurt you at work and at home. It can speed you up, slow you down. It can kill your grandma. And we're just talking about COVID We haven't talked about the elections. We haven't talked about politics in America. Right. We haven't talked. It's still going on. It shouldn't be, but it's still going on. And then somebody's gonna have to govern in January, and we're still gonna be in the middle of a pandemic. I mean, let me ask you this, Jim. If the COVID 19 pandemic was a baseball game, what inning are we in? In your mind?

I think we're in the seventh inning.

Really? Okay, excellent.

Well, I mean, I got. I got a vaccine scheduled in three days, so I'm seeing some light at the end of the tunnel.

You're going to go all, you know, I got mine. Screw the rest of you. Is that where we're going here?

I just think the other. Well, I'm getting mine in the seventh inning. Everybody else gets theirs in the ninth inning, and then it's over. So, yeah, I think we're. I think we're. I think we're certainly past halfway, without a doubt.

Okay, so I don't know if you're an optimist or not, but most people I'm asking that question to are not giving me anything near seven.

Maybe I am an optimist, then I'm not sure.

But what I can say is that if we can get herd immunity sufficient enough to be able to go to outdoor sporting events by Labor Day, I'll be happy. Anything earlier than that is a bonus in my book.

Well, I think you're probably in for a bonus would be my best guess, but I guess we'll see how it plays out, right? All right, well, let's. This is supposed to be a financial podcast, so we got to talk at least about a little bit of financial stuff. You've had a pretty interesting transition in career. Lots of docs get to be about the age you were at the time of that transition, you know, 10 years, 70,000 patient encounters, et cetera. And they start looking at, you know, non clinical, less clinical, something else careers. What wisdom have you learned over the last decade that you can pass on to them?

Well, I had 35,000 patient visits by the time I was 10 years in. As a family doc, it's always a good exercise to multiply it out and see what you think your total is. I think that there's a lot more smoke than there is actual fire when it comes to people saying, I'm going to quit earlier, I'm going to get a side gig, or I'm going to move to a new career. There's a lot of talk about it, a lot of Facebook posturing about it, but I don't think there's a lot of people actually leaving medicine personally because of the money. Burnout is the biggest risk to your finances because your fastest path to cash as a board certified doctor is to continue to practice medicine, at least here in the United States of America. And I talked to a couple people a month who say, yeah, I want to open a pizza joint. It's like, well, what kind of financial expectations do you have? I think the 300 grand I'm getting as a doctor will work just fine. It's like, well, good luck with that. All I can say is this, and I think it's Ben Franklin, right? No matter what you do, put a little aside. No matter what you do, put a little aside, always make more that you spend. And I personally don't know how you get to 3 or $400,000 worth of student loan debts. I don't know how you do that, but it's obviously something that can be done. But I also know there are all sorts of loan forgiveness programs out there that can get that trimmed in very short order. If you find that debt is your big issue but right now, your fastest path to cash, for most of the people that are listening to this, is to continue to practice as a doctor. No matter what your business model is for your practice, it's your physician skills in the United States that will continue to drive superior financial performance for you.

How would you try to treat burnout differently in somebody that's already financially independent versus somebody who really does need that income?

Yeah, that's the challenge. This point of financial freedom is a super important one for Doctors. So I'm 63. Well, I'll be 63 next year. There's a generation of boomer gunners like me who don't need to be working. They're way past financially free and they can't stop because it's all they've ever known. And at least in part because they came through non work hour restricted residency programs, which at point some submerse them in the burnout culture of medicine. And when we're gone, there's going to be a lot less of that kind of activity in healthcare. But I think there's a whole bunch of people for whom that point of financial freedom is more confusing than anything else. I mean, when I meet somebody and I say, what's your net worth? And they say, what's that? I say, you need a financial planner. Come back and see me in a week. But if I say, what's your net worth? They say, $6 million. And I say, okay, how much does it cost for you to pay your bills every month? And they say, $8,000. All I do is get out my calculator and say, why are you working? What do you mean? Well, look, you could take that amount of money out of your net worth every month for 65 years. Why are you working? You're past the point of financial freedom. And they're unfamiliar with the concept. And I say, look, anything you do vocationally in the future, when you decide what it is you want to do and how many hours a week you want to do it and who you want to do it with. You don't have to worry about making money. You can take money completely out of your decision process. And I guarantee you you'll never not be a doctor. And I also guarantee you there are literally thousands of people who would take you on as a volunteer to do your clinical thing any day of the week. You can be as busy doctoring as you want to. You just don't have to make your decisions and based upon money. And for most doctors that I talk to, that is an absolutely revolutionary concept.

Well, I hope a lot of them, when they do that calculation, realize they are already financially free. I run into a lot who would love to make changes, would love to cut back, would love to do something different. And they run the numbers and they're not quite there. So it makes for a lot more difficult decisions.

Well, and that's the tail. So there's a couple of crests of burnout these days. First of all, there's an early crest of burnout in the folks that are coming out of work hour restricted residency programs and are starting to work with people like me. Right. Boomer Gunners, right. They've never worked as hard as their first few months in their practice because they didn't have to work that hard in residency. Whereas in my generation we came out and in practice it wasn't necessarily as busy as you were as a resident because they beat the crap out of us in residency. Right. So there's that early bump, right, for primary care doctors who pride themselves on, wow, I've never seen anything like that before. We think that's cool. Specialists don't necessarily think that's so cool when you can't diagnose something. So about 10 years in, when you are starting to see less and less of the new things that you've never seen before, it starts to lose its shine. And what you're talking about is that third bump where I'm in my 50s, I've been doing this a long time, and I'm just not quite there with my financial people. Right. I just not got enough money yet. That's difficult to gut that out sometimes.

All right, well, we better wrap up here soon. But you've got the year of 30 or 40,000 docs and similar high income professionals by the time this podcast is run and listened. What have we not covered today that you think they ought to know?

Well, the first thing I would say is that those of us who are in the giving professions, those of us who are helpers, healers, or care about your clients, whatever it is that you do. One of the things we almost never do is look in the mirror and ask ourselves, how do we think we're doing? So the first thing I would say is grab a piece of paper, take a big breath and think back over the last couple of weeks in your practice, your job, your career, your life, and just give yourself a satisfaction score from 0 to 10. 0 meaning your satisfaction couldn't be any lower. 10 meaning your satisfaction couldn't be any higher, and give yourself a score. Write that number down on that piece of paper and put today's date next to it for me right now it's the 15th of December. Now close your eyes, take another breath and open your eyes and look at that number. How do you feel about that number? How do you feel about that being your satisfaction with your life, your career, your practice, your job? Are you okay with that number or would you like to be just a little bit higher? By the way, if Your number is 2, 3, 4, you need to do something about that. You need to change your actions to raise that up or you're in a world of hurt pretty quick. If your number is 6, 7, 8, you're doing great. You have a fundamental overlap with your ideal job or career and I wouldn't change too much of what you're doing except fine tuning. But if any of you listening want to do something different to get more satisfaction out of your career, your life, you're going to need to change your actions. It starts by writing down the things that stress you out, encircling one and taking a baby step in a new direction towards a more ideal job or a more ideal practice. And recovering from burnout and preventing burnout and building a wonderful life is just a series of baby steps, but it takes new actions to get new results. If you don't like the number you're looking at, you would have to change your actions to make that go away. No amount of whining is going to save you and it's always later than you think. Always awesome.

Thank you for sharing that. Dr. Dyke Drummond, author, coach, burnout expert. You can learn more about him@thehappymd.com thank you for your time with us today on the podcast.

You bet. Make sure you put the word the on the front of Happy MD. Otherwise you're going to a porn site.

Thehappymd.com we'll make sure we get that right in the show notes. Hope you enjoyed that interview. Be sure to watch the blog for the new stuff we got coming out this month. New book, all kinds of cool stuff for the new Year. At some point in our financial lives, it will be time to buy a home. A physician mortgage can be a good vehicle for a young doctor who's just out of school and has a more effective place to use their money than on a big down payment. These loans allow doctors to secure a mortgage with fewer restrictions and a lower down payment than a conventional mortgage. But if you're further advanced in your career or deeper into your journey to financial freedom, buying a home with a conventional mortgage and then later on, potentially refinancing that loan to a better rate with a shorter timeframe could be a great move. Wherever you are in your financial journey, make sure you use the mortgage that will be most financially beneficial for you. Hop over to our recommended tab to learn more about all of your mortgage and refinancing options@whitecoatinvestor.com mortgage. You can do this and the White Coat Investor can help all right, thanks. For those of you who've left us a five star review, we appreciate that it helps spread the word about the podcast. Thanks. For those who are spreading spreading the word with your trainees, with your attendings, with your students, residents, interns, whatever. We appreciate you doing that as well. Our most recent review came in from Scott, or actually this was a few months ago. He said don't miss this. If you are a six figure earner or will be after school, you should listen to this. Jim very clearly and succinctly helps you become financially literate so you can decide what you want to spend, save or give away and achieve your life goals. This is no simplified cut up all your credit cards advice and it won't help you get rich quick, but if you follow even some of the advice, you will become financially independent. The more advice you follow, the sooner you hit fi. Great work. Thanks. Five stars. Thank you for that. Appreciate that kind review. Scott. For the rest of you, keep your head up, your shoulders back. You've got this and we can help. We'll see you next time on the White Coat Investor Podcast.

My dad, your host, Dr. Dahl, is a practicing emergency physician, blogger, author and podcaster. He is not a licensed accountant, attorney or financial advisor. So this podcast is for your entertainment and information only and should not be considered official personalized financial advice.