The Doctor Tribe
We hear about how privileged doctors are all the time – often due to our financial or social status. Those are valuable benefits of being a doctor, but they are not what resonates with us deep in our bones. It is not what gets you out of bed at 3 a.m. to drive to the hospital in a snow storm.
We have the privilege of having more than just a balcony seat at the concert of people’s lives. We participate in some of the most intimate events such as the birth of a child, adaptation to life altering injuries, battles with acute illness or longer campaigns against mental/physical illness. We and our nurse colleagues, are sometimes the only ones around to see the curtain fall at the end of the show.
We aren’t in the balcony. We are down front in the mosh-pit.
It is hard for those outside the mosh pit to really understand what it is like to be down there inside. I remember thinking it looked pretty cool when I was applying to medicine, but I really had no idea what it was like down in the trenches, getting jostled and elbowed, until I was actually there. It can demand everything that you have mentally, physically, and emotionally. It is also far enough outside most people’s experiences that it can be hard for those outside of the mosh-pit to truly understand.
For this reason, doctors have formed what can be described as a tribe. Medicine has its own tribal culture, and like a tribal village, we band together to raise the next generation into the tribe.
Raising The Little Ankle-Biter Doctors
Doctors mature into their careers much like kids growing into adults. I have only come to truly appreciate this now that I have moved through some of those phases and can reflect on how I felt when I moved through them.
Future doctors start off as pre-clerkship students, all wide-eyed with everything being wonderful, exciting, and new. Some may drool. These beginners grow into clinical clerks who can now toddle around and start to speak the basic language of medicine. They require very close supervision, so that they don’t ram their heads into the sharp coffee table corners of clinical medicine. Their older siblings, residents, watch over them carefully and help them find their way.
Residency is like the “teenager” doctor stage. They revel in the new found freedom, have boundless energy, and really start to act like fully grown doctors. It is exciting practicing medicine with more independence, knowing what to do, and basking in the glow of admiration from your younger siblings. It is also mostly great fun for the attendings teaching residents, but sometimes challenging to straddle the line of being the “cool big brother/sister” while sometimes having to be “the parent”.
At some point residents transition into the “young adult” phase of doctorhood and start their own practices. Even when out in practice, we continue to grow, develop, and learn from our colleagues.
I am describing this process not to be patronizing to my younger colleagues, but rather to bring out the common thread. Throughout this process, doctors of various types and stages of development are raising one another like a tribal village.
I have been fortunate to have been involved in all of these early stages both on the receiving end with multiple mentors at every stage, but also in the teaching and leadership aspect at each stage. Now, in the middle career stage, I admire my more senior mentors who are improving the tribe on an even broader scale as Residency Programme Directors, Clinical Leaders, Guideline Developers, Researchers, and National/International Educators. An attempt to emulate that contribution is actually a major driver behind why I started this site.
The Financial Training Gap in Medical Education
As a member of various residency committees for over 15 years, I have had an intimate view of the evolution of CanMEDS. CanMEDs is a framework for training doctors to be what society would view as the “complete physician” (in addition to the traditional medical expert and scholarly focii). There has been much focus and innovation for developing the professional, communicator, collaborator, and health advocate roles in training programmes. It is pretty easy to get on board with the value of developing all of these roles in doctors.
The part where I think we could improve further is on the financial management piece. This one has been a tougher sell. In fact, the “Manager” role was changed to “Leader” in the most recent framework. Even when it was called Manager, the emphasis was on healthcare resource allocation and programme management. At least there is a nod to balancing practice with personal life and budgeting/managing a career in the new Leader role description.
Acknowledging that physicians need to care about money is a bit of a dicey subject in the culture of medicine. Altruism is a core value in medical culture. It is so strong, that it is enforced both within the tribe, and in how the medical village is viewed by those outside of it. It is part of why we are such easy targets for external forces, like government, when it comes to compensation or tax issues. It is also not something we openly talk about with each other about for fear of inciting a Lord of the Flies moment.
While I have seen little practical integration of the “managing your finances” into training. There is a thirst for it. I know this because I get discreetly approached about it all the time from trainees and fellow attendings.
Residents get particularly antsy as they approach graduation and lament the gap in training as they imminently face having to bill for their work to get paid and how to manage that money to ensure their futures. Attendings get antsy when they realize that they are now making “the big bucks”, but seem to still be financially struggling.
If doctors are supposed to be altruistic, and that is highly valued, then why is there this interest in money?
Financial Health Is A Pillar In Building A Thriving Career and Practice – That’s Why!
Stephen Covey spent his career studying what made successful leaders and organizations. His The 7 Habits of Highly Effective People was written almost 30 years ago and is still one of the “go to” books on leadership. The reason for that is because it isn’t gimmicky, it is real. I read this book last summer after having formally studied and focused on developing as a leader for over 25 years and was blown away. This guy articulated pretty much every lesson that I had learned either through training or the hard way through reflective practice. He also gave me yet more areas to work on.
To be an effective person, you need to be a “whole person”. That means that you need to look after 4 key facets: the physical needs of your body to live, have meaningful relationships to nourish your heart, growth and development to keep your mind sharp, and a sense of making a contribution to feed your spirit. With any one of the parts missing or weakened, people flounder. You need to be an effective person as a foundation to function at the high level of a physician and fulfill all of those other CanMEDS roles.
When I look at the times where I have failed as a collaborator or communicator, it was when one of those four aspects of being a whole person was compromised. If you think that you are immune, then think about how nice and empathetic you were to the confrontational patient or family member when you were tired, hungry, stressed, or felt that it was pointless. If you are batting 100%, then you are a better person than me.
A medical practice or career has needs, just like a person, to be healthy and effective. Finances are the physical need, like “the body”, of that practice. If your financial house is not in order, then your practice is like a person trying to function without enough food or sleep.
It is very hard to provide the best care when your practice cannot afford the necessary equipment and personnel. Similarly, if you are not at your mental and emotional best because you are stressed out about your finances, then you may not be as empathetic or even-keel as you need to be. This is particularly exacerbated by higher stress clinical situations, which seem to be in no short supply regardless of specialty.
Ignoring the financial needs of our lives and practices to pretend that they don’t matter does not work. You can put off sleep and food to a certain degree, but eventually you will need to make it up and may suffer more along the way for it. Ignoring financial health allows problems to compound in the background and become bigger until there is a blow-out or burn-out.
Wherever there is a vacuum, something will want to fill it.
There is no shortage of people in the finance industry looking to fill the vacuum and help physicians manage their finances. Physicians are a great target population because they have large incomes (lots of money to manage), have little time (are often happy for someone else to do it), and many have little financial knowledge (learning medicine consumes huge amounts of hard-drive space and is way more interesting for most docs).
Besides the physical impossibilities and Physician College objections, I would not want to operate on myself or my family. I would want a qualified surgeon, both for their higher skill level and their increased objectivity. Having financial professionals involved in your financial planning has analogous considerations. However, the difference is that a surgeon has ethical obligations to provide the best care without the expectation of further business gain by taking alternative paths. There is much more variability in the financial industry.
Similar to a medical problem, where there are often many different viable approaches to treatment, there are often many ways to approach a financial plan. Just like in dealing with your health, where it is important to be an informed patient to get the best possible care for your individual needs, it is important to be an informed client when dealing with financial experts to get the best possible plan for your situation.
Much of personal finance is not something that someone can just do for you. Like many diseases, there are lifestyle considerations that contribute to a financial plan that only the person living it can choose. That means both choosing the lifestyle that best suits them and executing any recommendations for improvement.
Put together, these factors are why I think it is important for physicians to teach physicians about money.
- Medicine is more than “a job” and physicians face unique issues that “outsiders” may not totally understand.
- This has led to our tribal culture and the need for physicians to raise their own into the tribe.
- We do well at teaching many of the aspects to develop complete physicians.
- Teaching the financial health piece has been a gap.
- Financial health is like “the physical body” for a balanced and successful career and can’t be neglected without consequence.
- We need to be informed “patients” and active participants in the care of our financial bodies.
Some doctors will take the time and effort to learn to manage their finances on their own. However, in many or most cases, outside expert help is also needed. Like patients seeing a physician for health advice, doctors can be vulnerable if they do not come to the table with some basic financial knowledge. This could mean exploring how to find the right advisors, deciding which parts to do yourself and what to contract out, understanding the pros and cons of the various financial tools available to you, or even identifying strategies that your advisor may not have considered or may have passed over that could be of use to you. A fellow member of the medical tribe is best positioned to provide guidance with that.
There are already some great physician voices out there such as the White Coat Investor, Physician on FIRE, and The Wall Street Physician in the United States taking up the cause. Much of the financial advice on those sites is generalizable, but Canadian doctors face a different environment in many respects. We have grossly different tax systems, some similar tax planning vehicles with different nuances, most Canadian doctors are independent contractors or incorporated rather than employees, and we have a single payer public healthcare system that brings its own benefits and challenges.
For this reason, we need Canadian Doctors teaching Canadian Doctors about money.
Enter The Loonie Doctor.