Build A Profitable & Fulfilling Practice- Go Where You Are Needed

Go Where You Are Needed

In the first part of Loonie Doctor Wolverine origin story, you found out how I slid along the scale of altruism and greed to find that symbiosis is key to a healthy medical career. While I was fighting off ninjas and planning my ultimate attending job, I received the advice to “go where you are needed”. Unknowingly, that one sentence of advice was already interwoven into my stumbling journey up to that point. Once explicitly articulated, it became an anchor as I developed my career moving forward.

Why does this matter?

Well, in addition to the really cool pictures of me that involved no photoshopping or body doubles whatsoever, this story can hopefully help you to build your own kickass career. By that, I mean one that is personally fulfilling and financially rewarding. Medicine is a helping profession, but you need both for symbiosis.

Let’s pick up where we left off. I had just finished residency. I killed the Royal College Exams and was ready to start my first job as an attending physician.

licensing exams

My First Attending Job

As mentioned in the preceding post, the pendulum had serendipitously swung and my interests in clinical medicine, education, and leadership were in demand by the time I finished residency. I had chosen medical specialties (respirology and ICU) based largely on my interests. These fields have good income potential – if you can get a job. Both are at the mercy of fixed space within hospital-based groups or pulmonary function lab licenses. The demand for my non-clinical skills was great, but there was not a full-time job opening within any one of my medical sub-specialties.

My first job consisted of doing some general internal medicine (GIM), some respirology, and a smattering of intensive care (ICU). I was very grateful for this because jobs in an academic ICU  were scarce. Plus, working multiple jobs appealed to my short attention span.

Within that first job, I went where needed.

Much of the “need” for coverage tended to fall during the summer, long weekends, and holidays. Another part of how I landed a job in a teaching hospital was because there was also a major gap in covering the in-house nights. That had caused some clinicians to vacate and created another void for me to fill.

On the upside, those “less desirable” hours also came with pay premiums to entice workers. My wife and I were in our physical prime, enabling me to “make hay while the sun is shining“. There was also a need for someone to coordinate and revitalize the educational curriculum in respirology and ICU at our site. Because of the need, I was even able to negotiate a stipend for doing so.

Going where needed was a symbiotic relationship. My colleagues were grateful that they didn’t have to fill the needs, and the work was both interesting and lucrative.

“Going where needed” changes over time. Reflect on your practice to guide its growth in the direction you want it to go.

Each year, I reflected on how my practice had done. Which aspects of practice had I enjoyed the most or least? How much time had I spent in those pursuits? What income had that generated? What incremental costs did they incur? That’s right. I used a business plan to help build a great practice. I could use that information in conjunction with where I could see need an opportunity for growth.

Dominant companies in the business world don’t occur by accident.

Someone sees a need and builds or grows a company to fill it. They also see where things are heading and adapt to be the first into new areas. Apple is a good example of this. Medical careers are no different and doctors are well equipped to do this.

grow medical practice

Where I was needed shifted after a few years into practice.

After a couple of years of acclimatizing, a number of areas of need struck me. The biggest one was that how we provided critical care within our hospital needed a total overhaul. This first became apparent to me because of looking at what I enjoyed the least about my job.

We had a number of different units that provided critical care – all functioning as silos. Not having beds or resources to look after patients in the right location was a constant battle. A scarcity mentality amongst the different units caused them all to dig in further. I was spending inordinate amounts of time and effort trying to overcome these issues in a reactive fashion.

These frustrations had contributed to how I got my job in the first place. Morale was low amongst our nurses and physicians. I could accept it – until eventually burning out or moving on. Or I could “go where needed” and fix my job by leading change.

My Career Growth Explosion

The initial foray into a breach is difficult and not without risk.

starting practiceFor some, that may be a financial risk from the lost income of a stable job. There could even be regulatory or legal risks in other cases. Building a new service could mean risking capital on equipment and infrastructure.

In my case, it involved a large investment of time and effort without pay to get the various players together, identify issues, and articulate a common vision. The required changes involved shifts in power/control/income for various stakeholders. That meant real emotions and potential for conflict. Particularly with those who had the most to lose.

Over the course of several years, we had built or reorganized a number of services into a cohesive critical care system within our hospital. This provided win-win solutions for many problems. Whenever we created a new service, it was typically with a few core people. It was hard to attract people because the income was usually not much initially, the work required to establish a niche was high, and the risk of it not working out significant.


Most doctors work at full capacity.

So, to take on a new service commitment usually means giving up another established, well-paying one. You can sometimes realize efficiencies with compatible jobs, but you need to be careful not to over-extend yourself. Those who helped us to grow our services had to prune their practice in other areas to do so.

career balance

During this period, I had to close my outpatient practice, give up my pulmonary function test reading gravy, and prune some other areas of practice that I enjoyed. This was a risk both in terms of lost income, but also from closing the door on my backup plan. Respirology would have been a good slower-paced practice for me when my body could no longer handle the adrenaline or stamina required for ICU practice.

I also spent many weekends and evenings away from my family. My diet and exercise regime slipped.

There was a personal, financial, and cardiovascular risk.

Just like investing, greater risk also gives the potential for greater rewards.

Eventually, what we had built became well established. The services thrived, grew, and became financially quite lucrative. Further, with the annoyances that had prompted our efforts resolved, it became a really enjoyable work environment. We had revitalized and grown a fantastic multi-disciplinary team of doctors, administrators, and allied health. Eventually, we even became an official “Department” and I received both influence and an income for leading it.

Most importantly, I look back on this aspect of my career as the most personally rewarding thing that I have done. I feel like I went where I was needed and I made a difference. The care we provide, our academic productivity, quality of work-life, and our incomes all went up. That will stick with me. Conversely, the financial and power-perks have a shelf-life.

The benefits of going where you are needed can eventually fade.

This may not be the case if the need is ongoing and unmet. However, like in any business, the supply, demand, or environment can change. If you develop a successful product, eventually the patent will be up.

In medicine, building a great practice to fill an under-serviced niche can then attract others to do the same. That may cure the “under-serviced” problem. Similarly, others will see an excellent clinic model and emulate it. They may even improve it – sometimes as a competitor.

Those who are “first to market” in a medical practice do have an advantage.

They have an established referral base or otherwise occupy positions of influence due to being a leader from the outset.  That can eventually fade as the physicians who lived through the changes start to scale back and those who enter the system to replace them don’t have that institutional memory. The older crowd will remember the sacrifice required to establish the practice and the newer crowd may simply wonder why they don’t have an equal piece of the pie.

career success

That could be a sign that the need is not ongoing. Some may want to continue with the same practice despite that. Maybe they have reached their career fulfillment and are happy with that. Alternatively, it may be time to reflect, prune again, and take action to grow in a new direction. The story of how Doc G from Diverse FI grew his practice to generate a huge income in a primary care practice is another also typifies this continuous process.

“Where you are needed” may have changed and you need to re-plot your course to go there.

Where am I needed next?

I have decided to gradually shift again to “go where I am needed”. My clinical time is slowly scaling back as our team group grows and some need a bigger piece of the clinical pie to fuel their academic careers. The closer I am to financial independence, the less that money factors into my decisions on how to spend my time wisely. Of course, money isn’t the only reason why I work clinically. I will still want to maintain a robust clinical practice as part of what I do. For the joy of medicine.

However, working less clinically allows me to focus on some of the other areas where I am needed. Some of that is mentoring other physician-leaders trying to build clinical or academic services. Or mentoring family, friends, and colleagues to take control of their investing.

Starting this blog to fill the need for physician financial education is another attempt to fill that educational need on a broader scale. There are a number of other physician finance bloggers also doing this from different perspectives. I hope that mine will complement their work.

As my kids get older, I am increasingly needed at home to mentor and guide them. We have our own breakdown of unicorns and rainbows. There is a time-limited window for me to have maximal influence while my kids are old enough to mould, yet small enough to let me do so. At some point, when that need has changed, I will again re-evaluate where to go next.

physician parenting

Whatever career or life stage you may be at…

How can you “go where you are needed”?





  1. Hey LD!

    I love the Hugh Jackman pics! It will be interesting to see where we all head in our careers/ or non careers.

    This writing has been helping all of us think and re-think things. Very healthy indeed. Plus it will be fun to look back at “what were we thinking?” when we look back at older posts. I am already coming to that stage myself.

    You sound like you enjoy leading people. I am the exact opposite. Interesting. If not for this blog, we would never have crossed paths in Medicine.

    Have a good weekend my blog buddy!!

    1. Hey Dr. MB! The process of leading people is a bit of a mixed bag, but the results are gratifying. Regarding the unadulterated candid photos of me – who’s “Hugh Jackman” ;)?

  2. I love how you took risks and got rewarded for it.

    It is very hard to come in and turn around a system that has been in place for years. People get indoctrinated in the old inefficient system and can often resist change.

    I was not as brave as you. When I moved to my current location I had the choice of 5 places to practice (every place I interviewed offered me a spot). One practice I spoke with the ceo and he admitted the radiology department was in disarray and they had to let go of the former radiology group. He tried to sugarcoat this by saying that it meant that I could come in and design the department from the ground up to whatever I liked.

    Huge reward but big risk. Plus I would be the first radiologist hired with no guarantee of others joining.

    I ended up not choosing this opportunity (ie did not go where I was desperately needed) and instead chose a job I’ve been at for 12 yrs now (I chose lifestyle with no call and no weekend pretty much 830-5 Mon through Fri initially (now I only do 4 days a week).

    Glad there are people like you that can take on such a daunting task and truly make a difference

    1. Hi Xrayvsn! I think we all take on daunting tasks in different realms. Sometimes at work, like I did early on, sometimes at home, or sometimes in the larger community. You are taking on one with the blog you are building from the ground up now. It depends on the opportunity, skill set, priorities, interests, timing, etc.

      Sometimes with opportunities like I had, you are just lucky that all those line up together. Others, you make your own luck. Usually, it is a bit of both.

  3. Hi LD,

    Avid reader, first-time poster. Great blog post – thanks for articulating the factors you considered to ‘go where you were needed’. I am struck by the theme near the end of the post, “the benefits of where you are needed can eventually fade.” I thought this was a prime opportunity to quote Christopher Nolan’s, The Dark Knight. “Batman: “You either die a hero, or you live long enough to see yourself become the villain.” I guess this isn’t a DC-Marvel crossover?! Ha! In all seriousness, best wishes as you go where you are needed next.

  4. LD,

    Your ability to take initiative and build your department back in the late Cretaceous when doctors were warring over turf is admirable, and it explains your battle-hardened exterior impervious to both Sticks and Stones.

    That pendulum swings over time. My role has been leading the internal battle. For better or worse, I had a Michael Landon in Highway to Heaven type mission: Bring people back in touch with what they once were, who they once were to one another, and what medicine was supposed to mean to them. It’s an admittedly soft power, behind the scenes role, but I feel it’s been my calling (perhaps even more than medicine).

    I advocated for options where group members could work less and retain equity status, increasing the proportion of people who sought balanced lives that had the opportunity to vote and enact change.

    Once quorum was reached, I remained a bit of an enigma to those I worked with. I’d brought about reforms that made their home lives better, so they never dismissed my latest crazy ideas outright, but viewed them as test cases for lives they might wish to lead someday.

    The long digression is all to add a corollary to your wonderful axiom of going where you are needed, which might be summarized: Go where you are misunderstood, and use your powers of persuasion to become the mouthpiece for common sense. Then again, it might just be another way of saying the same thing.

    Enjoy your wise reflections as always, my friend.


    P.S. Your art has become such a wonderful signature complement to your writing! Thanks for taking such care in rendering it.

    1. Thanks Crispy Doc.

      I like that thought. The best changes are those where you are breaking up what has become “the norm”, but has strayed from normal. The best changes for us have also been the ones where those outside our physician group think we are nuts. I must say that the docs that I have worked with to make changes within our hospital always end up doing “the right thing”. It may take some challenging to cause us to pause and examine where things are and where they should be. Once that is agreed upon, it is a compass to guide decisions and there is very little resistance.

      I think that the voice of reason for enabling physicians to practice in different ways that enable each to find their own balance is gaining strength. It can be hard for those not “in it” to understand. Hopefully, the proportion of those within the circle of reason will grow with time and via folks like you pushing at the edges.

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