Build A Profitable & Fulfilling Career

In the first part of Loonie Doctor Wolverine origin story, I shared how I slid along the scale of altruism and greed. How I found 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. Learn how “going where I was needed” helped me to build a profitable and fulfilling career.

Well, in addition to the 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 both personally fulfilling and financially rewarding. Medicine is a helping profession, but you need a balance between effort and reward 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

As mentioned in the preceding post, the pendulum of supply and demand had serendipitously swung in my favor. My interests in clinical medicine, education, and leadership were in demand by the time I finished my residency. I had chosen medical specialties (Respirology and ICU) based largely on my interests. These fields have good income potential. But only 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 the premises 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 both Respirology and ICU at our site. Because of the need, I was even able to negotiate a stipend for doing so. Almost unheard of at the time, and a lesson that negotiation is important. Even though many doctors find it hard to do.

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.

To move your career to fill areas of need, you must reflect and adjust course. Those voids change and so do your interests and needs. 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 unmet needs in our hospital. Those were opportunities for growth and expansion. That is also part of building a successful business.

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 to market in 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

Things that annoy you may be a clue.

Where my skills and efforts were most needed shifted after a few years into practice. After a couple of years of acclimatizing, several gaps within our hospital struck me. The biggest one was how we provided critical care. It was fragmented and needed a total overhaul into an integrated system. This first became apparent to me because of looking at what I enjoyed the least about my job.

We had several 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 rather than collaborate. I was spending inordinate amounts of time and effort trying to overcome these issues reactively. One patient at a time. Daily, but especially nightly and on weekends. When it is the most annoying to be stuck at the hospital.

These frustrations had contributed to how I got my job in the first place. Morale was low amongst our nurses and physicians. When I came into the mix, I was faced with two choices. I could either accept it (until eventually burning out or moving on), or I could “go where needed” and fix my job by leading the necessary changes.

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

starting practice

For some, that may be a financial risk. To spend the time and effort to develop something new often requires lost income from a stable job. Or time taken away from your life outside of work. 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 several years, we built or reorganized several 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. Initially, it was hard to attract people to fill the rosters of a new service. The income was usually low to start, the work required to establish a niche was high, and the risk of it not working out was significant.

I closed doors to open new ones.

Most doctors work to full capacity. I was no different. 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. It wasn’t until I found karate, that I found that work-life balance again.

Just like investing using financial instruments (like stocks or bonds), greater risk also gives the potential for greater rewards in your career too. Fortunately, the risks that I took paid off.

Eventually, the critical care system 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, our quality of work-life, and our incomes all went up. Our system also helped us to mount a very robust response to the Covid-19 pandemic. Not only for our hospital but the whole region. I stepped down as Chief of our Department after twelve years this past week. However, that will all stick with me. In contrast, the financial and power perks have a shelf-life.

Some Advantages 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 underserved niche can then attract others to do the same. That may cure the “under-serviced” problem. Similarly, others will see an excellent clinical 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.

Growing More Roots vs Pruning

career success

When it gets crowded & competitive, people start fighting over the slices of the pie rather than growing it. That could be a sign that the need is not ongoing and the pie is shrinking or fixed in size. Some may want to continue with the same practice despite that. Maybe they have reached as far as they want to go in their career and are happy with that. It is comfortable.

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 that also typifies this continuous process. “Where you are needed” may have changed and you need to re-plot your course to go where you are needed next.

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. As I move into higher levels of 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.

physician parenting

As my kids get older, I am increasingly needed at home to mentor and guide them. Even though they are now teenagers and think I don’t know anything. I originally wrote this article when the biggest conflict in their lives revolved around sharing the washroom. The washroom is still a battle zone. Just, with more “products”. However, I need to be available for those other big problems that come up with teenagers. They seem to happen sporadically and usually later at night.

At some point, when that need has changed, I will again re-evaluate where to go next. 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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