One of the pieces of advice that I casually dropped in the post about how to start and build your medical business was to “Go where you are needed“. This one short sentence is central to building a financially successful and fulfilling career. This is good advice not only when starting independent practice. It should be considered way before then and throughout the stages of your career. It is vital to get this career thing right because, as professionals, our career forms part of our identity, whether we admit that or not. You have to find symbiosis. Learn how I have worked through this in my career.
The Symbiotic Balance
Throughout our careers and lives, there is an exchange when we provide something and receive compensation in return. Sometimes, that balance has been grossly in my favor (selfish). At others, it has been an even exchange (symbiotic). Altruism requires a sacrifice with really little or no benefit in return. That has rarely been my experience. When we give, we almost always receive an intrinsic reward in return. I will share how I have slid around on this spectrum while “going where needed”.
This isn’t warm & fuzzy (like me). It is about money.
You’ll also get a piece of the Loonie Doctor Origin Story. Wolverine would be a good X-men parallel for me. He has Canadian origins, is pretty badass, has sideburns, and has lots of body hair that sometimes obscures the six-pack beneath. In Wolverine’s style, this is also not a mushy post about the warm and fuzzies.
The fact is, my net worth is pretty healthy. Not because I have been a great investor or a 100% diligent-tax-optimizing-whiz. I try, but I am neither of those things. Making good financial choices as an early attending definitely helped. Luck played a role in building our financial foundation. However, it is also because I decided to make more money by going where I was needed.
How I Came to Medicine
Before medical school, I was on track to become a career high school science teacher. I found that I enjoyed teaching OAC (Grade 13) biology. Teaching grade 9 and 10 science – not so much. A big attraction for pursuing medicine was the opportunity to teach high-level medical science as a faculty member. Of course, I was extrapolating my experience of high school teaching to university faculty. I figured that they must get paid better and still have summers off. Plus sabbaticals. Selfish reasons. I really had no clue!
Most medical students talk about how they want to serve and save the world during their medical school interviews. I can say that, having also been on both sides of the interviewing equation. I did enter medicine because I wanted to have a career where I was helping people. However, that was only one aspect of the decision. My real passion was for teaching patients and doctors, as part of that process.
The Medical Student Years
Unfortunately, once in medical school, I found out that clinical teaching was not seen as particularly “academic”. Thankfully, that has changed since those days. I was called to meetings with University leaders where they told me that they had heard that I had great potential but that I needed to up my game.
I was told, “Anyone can be a decent clinician. Anyone can teach… Only the elite special squad of physician ninjas can do research. To work here, you must join the researcher clan.” Ok, I took artistic liberty with the ninja part. Still, my visions of being a nutty medical professor evaporated because I had no interest in pursuing a clinician-scientist career track.
In fairness, I agree that the clinician-scientist track is probably the toughest path to pursue in academic medicine. However, all of the cogs in the academic medicine gears are vital for the machine to function well.
As you can imagine, that climate translated into a paucity of people gunning to be clinician educators. In fact, the clinical teachers had left in droves. That left a big gap and a few staff carrying a huge load. It was also an opportunity for me to “go where needed”. Even though it wasn’t valued yet, this aligned with my interests. So, I continued on this course during my residency. I was willing to altruistically sacrifice myself to fill the gap.
Symbiosis as a Resident
While in residency, there was a major need for people to teach medical students. This need aligned well with my goals. So, I spent considerable time teaching clinical skills and organizing other teaching sessions. Not only did this make for great experiences for the medical students. I also honed my own clinical skills through teaching them. The reality was that this was a symbiotic relationship. At the same time, there were changes afoot within the University.
The teaching crisis had reached a point by the final years of my residency that there was a new emphasis being placed on developing clinical educational leadership. I was poised to take advantage of that in getting the plum job that I coveted. Not only had I developed strong clinical abilities, but a reputation as an engaging and skilled teacher.
This was when I first received the “Go where you are needed” advice.
To set the backdrop. At this time, resident physician work-hour restrictions were just starting and lifestyle balance had suddenly become all the rage. In my PGY-1 year there were suddenly rules about not doing more than 1 in 4 on-call. By PGY-2 the rules were being somewhat followed and in my PGY-3 year, we were even going home post-call by noon sometimes.
There was a major counter-cultural push by my resident peers at the time. Those who didn’t follow all of the rules were frowned upon and the derogatory term “macho-doctor” was applied. Our resident union even had posters in the lounge to shame dissenters.
Against that backdrop, I was chatting with one of my faculty mentor/champions about where I saw my career going. We discussed what I wanted in terms of lifestyle. Which types of clinical practice I found the most interesting. How I wanted to teach because I enjoyed that. My focus was really on what I wanted out of my career and this line of discussion was a well-worn road from discussions amongst my contemporaries. I was largely on the selfish end of the spectrum in my perspective.
He then blew up my smoothly-paved-thought-road by simply saying, “You know. You haven’t mentioned the one thing that we all talked about while at your stage… Where am I needed?” I was left speechless. A rarity. That shook me up because I had slipped from my altruistic-medical-student thinking into a self-centered mode. Neither extreme was optimal. This caused me to recalibrate.
Altruism & Selfishness Are Both Sub-Optimal
In medicine, a purely altruistic approach of filling needs with little return can be sustained for short periods. However, the needs are usually infinite. The gratitude of our patients goes a long way as a reward. However, a given person may not value our efforts. Or the broader system may not. Those negative experiences often carry more emotional weight. Unchecked, an altruistic imbalance becomes medical martyrdom and contributes to burnout.
A self-centered approach is also ultimately detrimental. You need empathy and compassion to practice medicine well. Further, one of the greatest rewards for practicing medicine is the feeling of self-worth generated by making meaningful contributions. Those who practice medicine for money without empathy or regard for the rewards to their karma don’t last long. Most leave. Exceptionally bad ones are forced out.
What is optimal is a balanced symbiotic relationship. Ideally, “Going where needed” means that you fill a need and have your needs met by doing so.
Symbiosis: Required By Us & “The System”
Finding symbiosis takes work. But is rewarding.
A healthy sustainable medical career involves finding symbiosis. To do that, you must not only “go where you are needed” but you must also be rewarded for doing so. We make many choices with consequences that influence our chances of success. Often, we won’t get them all perfect. That is ok. I waffled and oscillated, but eventually found balance too. That does take reflection. Both self-reflection and from others. Listening to the perspective of your mentors can also supplement that and cause you to consider your blind spots. That helped me and that is why I felt compelled to share this part of my origin story.
We require symbiosis. So do the systems we work in.
When I started on my path as a medical educator, there was a symbiotic balance as a resident helping medical students. However, as I became an attending, the sacrifice-reward balance shifted greatly towards altruism from a financial standpoint. A sacrifice-reward imbalance can be tolerated for periods of time. However, too much altruism leads to a burnt-out doctor. Selfishness simply makes for a bad one and is the other direction things can go. Avoiding the poorly paid, but still important tasks.
Fortunately, market pressures eventually attenuate imbalances. We require a symbiotic relationship with the system that employs us for our career to be fulfilling, long-lasting, and have the most impact. However, the systems that we work within also require that to benefit from our work. Whether that is directly serving the population or through training and mentoring the next generation who will do that.
In the next chapter of the Loonie Doctor Wolverine origin story, the rubber hits the road as I move from resident to attending physician. That one piece of advice from my mentor, “Go where you are needed”, has guided me since. That concept of finding a need and filling helped me to not only build a rewarding career, but also a profitable one.