Medicine is like a tribal village.
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 snowstorm. It is a unique profession with both special privileges and challenges. This has led to a medical tribal culture, and we must work as village to raise the next generation into a better one.
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. Alongside our nurse colleagues, we 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. However, 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
First-year med students are like physician infants. Vulnerable, 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.
At the clerk stage, they require very close supervision.
They can practice some of their developing medical skill, but we need to watch closely so that they don’t ram their heads into the sharp coffee table corners of clinical medicine. Like toddlers. Their older-sibling-residents watch over them carefully and help them to 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 in 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.
An aspect I think we could improve further is 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. There is a nod to balancing practice with personal life and managing a career in the new Leader role description.
The Money Taboo in Medical Culture
Acknowledging that physicians need to care about money is a dicey subject in the culture of medicine. Altruism is a core value in medical culture. It is strictly enforced within the tribe. The value of altruism in medicine is so strong that it is also used for judgment 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. Financial reward is not something we openly talk about with each other 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. As they imminently face having to bill for their work to get paid, it becomes immediately relevant. With entering the fully-trained workforce, they also realize that they will need to manage that money to secure their financial futures.
Attendings often get antsy when they realize that they are now making “the big bucks”, but are still financially struggling. They may want to take their career in a new direction that fills a need, but they cannot afford to. They may be burnt out and need to make a change to be a better doctor or have a full career.
Physicians facing the end of their career by choice or unwanted circumstance may worry about whether their investments will support them when they can no longer work. Financial illiteracy is like atherosclerosis. It can silently cause problems that people don’t notice until their first heart attack. Hopefully, it is not fatal and they have time to make some lifestyle modifications and take some financial statins.
Wherever there is a vacuum, something or someone will fill it.
There is no shortage of people in the finance industry looking to fill this vacuum and help physicians manage their finances.
Physicians are a great target population because they have large incomes which means lots of money to manage and fees for doing so. Most have little time and are often happy for someone else to do it. Learning medicine consumes huge amounts of hard-drive space and is way more interesting for most docs than learning about finance. So, they don’t bother.
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.
These Factors Mean Physicians Must 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. We must build and lead our financial team.
A fellow medical tribe member is needed to help.
There are already some great physician voices out there such as the White Coat Investor, Physician on FIRE, The Physician Philosopher, and Financial Success MD 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 and some similar tax planning vehicles with different nuances. Most Canadian doctors are independent contractors or incorporated rather than employees as has become common south of the border.