Stuck midstream? Change horses - - Medical Economics

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Stuck midstream? Change horses

Jan 22, 2001
By: Deborah Grandinetti
Medical Economics

Don't strand yourself in less-than-satisfying work. Figure out what makes your heart sing—and go for it.

At age 39, Margaret A. Mahony ended her 9 1/2-year association with an ob/gyn group in San Jose, CA, to create a solo practice unencumbered by managed care. It was not a move she made lightly, since she was her family's primary breadwinner.

Just two years earlier, Mahony had questioned whether she was cut out to be a doctor. Maybe my medical degree was a mistake, she thought. But a career counselor assured her she'd chosen the right profession. The problem, he'd said, was the mismatch between the values that had drawn her to medicine and those she encountered in her practice.

It took another year of working against her grain to make the move. In 1995, she said a cordial goodbye to the group, gave herself a few months to recharge, then found a new office. A local bank lent her $25,000, only half the amount she'd requested. She dug into her savings for the rest, operating in the red for the first five months.

Some mornings she bolted awake at 4 am, her heart pounding. But within 18 months, her cash-only practice was so busy she had to close it to new patients. Now she spends as much time with patients as she feels they need. "I've never felt happier in my work," she says. Last year, Mahony published a book, Saving the Soul of Medicine (Robert D. Reed Publishers, 2000), documenting some of the abuses of managed care.

Like Mahony, you may be ready to chuck it all, even if you're not sure what's next. If you're in your 40s to early 50s, you have lots of company. There's nothing like midlife—not to mention loss of practice autonomy, downsized reimbursements, and endless bureaucratic hassles—to flush a doctor's career discontent to the surface.

Midcareer is the time when questions about meaning in life begin to take on greater urgency, says radiologist Peter S. Moskowitz, founder and director of the Center for Professional and Personal Renewal in Palo Alto, CA. But, he adds, many physicians misinterpret normal midlife angst as a flagging interest in medicine.

"Too many doctors are walking away from their practices without a plan for the future," Moskowitz says. "Financially, they can afford to do it, and they may be happy for a while. But then boredom sets in, and they feel a lack of purpose in their lives."

If you approach your midlife transition with a quick-fix mentality, disaster awaits. So before you walk away from medicine, consult the three-step checklist. It will help you clear your head so you can figure out what would give you long-term satisfaction. If you do decide to quit your current position, chances are you can find something fulfilling without leaving medicine—either in or out of a traditional practice setting. Good problem-solving skills, a willingness to be true to yourself, and equal measures of patience and fortitude can guide you to a happy landing.

Find out what you're good at

Sometimes, a simple geographic change can be therapeutic. Consider family practitioner Patricia L. Elliott, who left a bustling urban practice in Michigan at age 43 to try country life. She was newly divorced and ready for a change. Elliott ultimately found her way to rural Orange County, VA, where she now sees patients at a reasonable pace of 20 per day. She rounds out her week by milking sheep and making 'artisanal' cheese, a hot commodity these days. "I've become passionate about raising sheep and making cheese," says Elliott. "This has given me the balance I need."

But a change of location won't solve the problem if the fit is no longer right and the nature of your work clashes with your values or temperament. Bad fit is a leading cause of burnout, says former emergency physician Peter P. Farmer, director of the Center for Performance Dynamics in Rancho Santa Fe, CA. A doctor who has a low-key personality, works at a steady and deliberate pace, and is a stickler for rules and procedures may find that he's always behind the curve running a family practice group, says Farmer. His partners criticize him for not resolving problems quickly enough, and he's miserable. He'd be better off giving up the management role and undertaking practice-based clinical research, at which he'd excel.

If fit is the problem, look to "Knowing who you are and what you want" of our Jan. 8, 2001, issue. It will guide you through the process of determining the kind of job and work environment best suited to you. You should also consider what you dislike about your current situation. In assessing your job, psychiatrist Kernan T. Manion, director of Work/Life Design in Concord, MA, recommends looking separately at the tasks you perform, your work relationships, the job structure, and the practice's overall organization. Ask yourself: What's working for me in each area, and what's not? Also ask:

What saps your energy?
What are the biggest stressors on the job?
What values must you live by to be true to yourself as a physician?
What won't you stand for anymore?

Eric E. Shore, a Philadelphia-area internist, decided he wouldn't stand for managed care interference, so he's getting a law degree to add to his MBA. He'd like to become involved in "major litigation" that will redefine the role of managed care companies. One dream: to make it impossible for HMOs to dictate which prescriptions physicians write, especially when a change in the formulary means the doctor must take a patient off a drug that is currently working.

Shore, who is in his 50s, maintains a solo practice while keeping "an almost full-time schedule" in law school. His children tell him he's crazy for pursuing another degree, but he says, "if you aren't part of the solution, you're part of the problem." Shore also hopes to make medicine's future brighter for his son, who's about to enter medical school.

Before pediatrician Paula L. Stillman made the transition from medical school dean to senior medical director of a hospital network in Pennsylvania, she did a lot of introspection. At 51, Stillman realized she needed a fresh challenge. Her self-analysis, supplemented with frank appraisals from her husband and close friends, led her to conclude that she was especially skilled at "bringing diverse groups of people together and figuring out the strategies that will benefit most of them."

Those are exactly the skills that attracted the attention of the Lehigh Valley Hospital and Health Network, which initially hired Stillman to reorganize its home health care department just as she was completing her MBA. "This is the best job I've ever had," she says. "It's a fabulous place to work."

As part of your self-assessment, look closely at your proudest accomplishments, and list the skills you need to achieve them. For instance, if you've successfully organized a pre-hospice program for your practice, that means you have proven abilities in team-building, coordinating community resources, and bringing an idea from concept to fruition. Be certain to focus on the skills you love using, and de-emphasize the tasks you don't enjoy.

Manage your time—and your money

A career change can require significant chunks of time for retraining, or creating a new job from scratch. This is where a lot of doctors get stuck. Where's the extra time in a day already packed to the max? Can you really afford to sleep less? Financial obligations may argue against taking a leave or scaling back on work.

Before you assume you can't go forward, examine your priorities for the next phase of your career. They may necessitate a change in how you manage your time and finances. A good source of help is Julie Morgenstern's book, Time Management From the Inside Out (Henry Holt, 2000).

Cutting down on spending may be stickier. This may challenge the very assumptions your marriage was based on—"that a doctor could provide a good lifestyle," Moskowitz says. That's why you and your partner should probably seek assistance from a financial planner, marital counselor, or both, if you're attempting to scale back financially, Moskowitz adds. On the other hand, financial downsizing can revitalize your marriage and family life. When Moskowitz scaled back his practice to build his coaching business, his wife returned to work—in a new career as an Internet marketing consultant—to cover extras, like the family vacation. The changes were personally and professionally satisfying for both of them, says Moskowitz, and those positive feelings spilled over into the marriage. While you may be loath to deny your children any of the luxuries that your current earnings now provide, Moskowitz says, "children are often only too happy to contribute to the family's financial downsizing. They consider it an adventure."

Moskowitz recommends the following books for help in dealing with your finances: Money and the Meaning of Life by Jacob Needleman (Currency/Doubleday, 1994), The Energy of Money: A Spiritual Guide to Financial and Personal Fulfillment by Maria Nemeth (Ballantine Wellspring, 2000), and Inner Simplicity by Elaine St. James (Hyperion, 1995).

Tough it out

Once you've settled on your objective, you need to define the interim steps and set dates for completing them. For instance, mini-goal No. 1 could be to recast your resume, and No. 2 might be to investigate opportunities for retraining. Once you've determined the goals and deadlines, ask a trusted colleague or friend to check with you periodically to make sure you're following through. Don't get discouraged if you encounter obstacles you never envisioned. Making the transition from group member to soloist stretched Margaret Mahony in many ways. Until she began earning a profit, anxiety was a constant companion. She learned to deal with it by breathing deeply, and then taking a constructive step to market her practice, such as sending out another mailing.

Joel V. Brill, a Camarillo, CA, internist/gastroenterologist, left behind a "very healthy income" and a position as chief medical officer for a large multidisciplinary medical group to found Software Pharmacy. His company makes a system designed to help managed care organizations integrate pharmacy and laboratory data. Brill got the inspiration in the mid-1990s, while working as a medical director for Blue Shield. He and his business partners worked nights and weekends to make it come together, finally opening for business in 1999.

"It's been a long, arduous struggle," Brill says, but his passion for the new venture has carried him through. His wife's support has also been invaluable, he says, particularly since the start-up put the family at risk for bankruptcy. (To retain control of his new venture, Brill and his partners financed the company with "the Bank of Credit Card, Personal Loan, and Second Mortgage.") Brill has also sacrificed time with family. He's on the road so much now he jokes that his home is United Airlines. Yet he can't imagine doing anything else. "I'm working with medical groups and health plans around the country on a process that just might allow us to say that we're doing a better job of improving care," says Brill. "That's very fulfilling."

"Be patient with the process," adds Cleveland critical care specialist Bruce W. Sherman. "Don't rush into the first job that comes along." After years of taking call 12 nights out of every 14 as a pulmonary critical care specialist at an urban teaching hospital, Sherman decided it was time for a change. He left his hospital job, took a couple of months off, then started looking for a new position. The doctor found happiness—and time for a personal life—as medical director of clinical quality services for a company that brings physicians and nurse practitioners on site at large corporations and federal agencies. Sherman started with the company part time, and the position grew. He loves having nights and weekends free, especially now that he's married.

His advice to others? "As a physician, you have tremendous skill and talent," says Sherman. "There will be a job for you. Follow your heart."

Making good use of a sabbatical

By Jefferson C. Brand, MD
Orthopedic Surgeon/Alexandria, MN

Seven years into private practice as an orthopedist, I felt stuck. My group had a good reputation, and so did I, but I wasn't satisfied with my level of skills. Conservative by nature, I was hesitant to try new treatment options. Shoulder arthroscopy, for instance, had evolved since my residency days; the myriad and subtle forms of shoulder instability confused me. Many of the local high school and college athletes—by my choice or theirs—sought surgical treatment elsewhere.

It occurred to me that a sports medicine fellowship would bring me up to date. It would also make me more competitive, because I'd be the only fellowship-trained sports medicine orthopedist in central Minnesota.

But the decision presented certain challenges. I'd have to uproot our family from Minnesota to Kentucky for one year. Fortunately, the timing was good: My 11-year-old daughter was still two years shy of junior high school, and our other two children were young enough not to protest. Furthermore, our longtime babysitter was leaving for college.

My wife, though, had to be dragged kicking and screaming. She was teaching parent education classes at the early childhood and family education program in our community, and was quite active with volunteer work. But ultimately, she relented, as a 40th birthday present to me.

The biggest challenge was financial. As a fellow, my salary would be less than a fifth of what I was earning in private practice. Fortunately, my wife came from a farm background and had seen firsthand how a successful tomorrow can be determined by "how you get by without" today. We chose to place all bonuses in our savings account the year prior to the fellowship. We also made double payments that year on a bank obligation so the bank would allow us to suspend payments for the fellowship year. My group generously agreed to cover my disability insurance. Just as generous was my in-laws' help with our move.

On top of that, we got help from the Bush Medical Fellows Program (www.bushfoundation.org/programs/MedicalFellowsProg.htm), which provides financial assistance for physicians in the Dakotas, Minnesota, and western Michigan who want to make a midcareer change. The program's goal is to invest directly in the physician and indirectly in the community. It seeks doctors who will not only bring new skills to their communities, but train others or motivate them to acquire complementary skills.

My goal—to polish my arthroscopy skills and get paid to keep people active—was not exactly altruistic. But the Bush committee liked the fact that my goals were focused and attainable.

The fellowship year helped me develop confidence not only in my new skills, but also in my ability to handle change. It made me more willing to attempt new or different procedures, including those that were peripheral to my fellowship. Procedures I learned or perfected during the fellowship now dominate my elective operating schedule.

I also gained enough self-confidence and skill to apply for a position as the physician to a professional team. Although I did not get the job, I never would have dreamed of applying prior to the fellowship. Even more satisfying was the research experience I gained; the findings were presented at six different state and national meetings.

Some good things came out of the fellowship for my family, too. My daughter has memories of horseback lessons and front-row seats with her friends at professional hockey games. And my wife and I enjoy the additional spare time and income we sacrificed during the fellowship year. I even learned from my fellow physicians about how to create more distance between myself and my work, so that when I come home I'm not carrying it with me.

Back to college, at 49

By Michael S. Smith, MD
Neurologist/Tucson

You a student?"

I was waiting in line to get a parking sticker on my first day on campus in New Mexico State University.

"Yes, I am."

"Gee. How old are you?"

"Forty-nine."

"Wow. What did you do before?"

"I'm a physician."

"Really! That's amazing. What are you studying?"

"Experimental statistics."

"Oh."

End of conversation. But for me, the beginning of a brand new way of life.

As a medical director in charge of quality for a health network, I had developed a keen—some would say evangelical—interest in defining, measuring, and improving the quality of care. As I became more involved in measuring, however, my lack of formal statistical training really began to bother me.

To remedy the situation, I took a dozen management courses from the American College of Physician Executives and completed a nine-day program at Tulane University, earning a certificate in Medical Management. But it wasn't until I took Intermountain Health Care's Advanced Training Program in Clinical Quality Improvement that I realized I could earn an advanced degree in statistics.

A year later, I became serious about exploring graduate programs. The one at New Mexico State appealed to me because it was small, took only two years, and emphasized consulting and practical use of statistics. It also allowed me to go home on weekends, even though that meant an eight-hour round trip.

My biggest concern was flunking out. I took courses in sampling, statistical theory, statistics programming, and statistics consulting. I also had a new job—paying $1,000 a month—as a teaching assistant in a beginning statistics course. I had no idea whether I'd be able to handle all that; if I couldn't, I would have given up a great deal, including a six-figure income. Fortunately, I did well and finished the semester with a 4.0.

Other adjustments were harder. For the first month, I truly missed being a "somebody." I had no secretary, no fax, no voice mail. My office was a cramped, windowless 10 x 10 box. I did my own typing, made my own phone calls, went to the laundromat. That's normal for most people, but I had been a "somebody" for 25 years. The statistics faculty knew my background, but generally forgot about it. Only a few people called me Doc.

As time went on, I began to feel more comfortable on campus. And that spring brought me the opportunity to give a talk on quality improvement at the local hospital. I spoke to 20 people for 40 minutes, and was warmly received. It felt great to be back in a medical environment, speaking from my expertise.

In my second year, the folks at the hospital offered me part-time work as a paid consultant. I still recall one meeting in which a group of administrators talked about how to apportion my limited consulting time so they could all benefit from it. For the first time in 15 months, I actually felt wanted. I helped the finance people set up control charts on a few important indicators, led a team dealing with medication errors, and provided the hospital with a simple, meaningful way to measure patient satisfaction.

In May, I got my degree—proof, I suppose, that an old dog can learn new tricks. I am building a consulting practice slowly. It is teaching me how to be more assertive. With my new knowledge, I am able to help people ask the right questions, and design surveys and audits to get good data. I believe there is a huge need for this in health care, and a real future in this field.

Before you chuck it all, try this

Ready to throw in the stethoscope and open that nightclub in Tahiti? Give yourself time to think things through. Maybe your impulse to quit medicine is on target. More likely than not, however, you're simply exhausted and confusing short-term relief with long-term gratification. Here are three bits of advice:

1. Analyze your current situation to see what's draining your energy. (See "Can you find happiness where you are?" of our Jan. 8, 2001, issue). Weed out the time-wasters in your practice, so you can give yourself more personal time. Ask a colleague who is not in your specialty to help you problem-solve, suggests Robin Ryan, a Seattle career coach. Someone in another specialty won't share your assumptions about how things must be done, and may see alternatives that would never occur to you.

2. Next, consider issues of life balance. Are you allowing enough time for the relationships and personal pursuits—intellectual, cultural, and leisure—that could revitalize you? Are you attending to your emotions and the call of your spirit? Physicians who address these issues "often find that their enjoyment of practice returns," says radiologist Peter S. Moskowitz, director of the Center for Professional and Personal Renewal in Palo Alto, CA. "That's when they change their mind about wanting to leave."

3. Take a vacation. Get away for at least seven days, says Ryan, and completely disconnect from your practice: no e-mail, no phone calls. Give yourself a few days to unwind and clear your head before you begin to contemplate the future.

Another way to give yourself a breather is to do something really different for an extended period. After critical care specialist Bruce W. Sherman left his post at a Cleveland teaching hospital, where he was on call 12 nights of every 14, he spent a challenging but gratifying six weeks volunteering at a squatters' camp in Zimbabwe. The experience was so "emotionally rich" that he took another month off before looking for his next paying job. It was in that more relaxed frame of mind that he found a part-time job that has since blossomed into a full-time—and fulfilling—position as a medical director of clinical quality services.

"The surest way to know whether medicine is still the right profession for you is to ask, 'What do I have to accomplish to feel that I'm doing something worthwhile with my life and remaining true to my highest calling?'" says pediatrician Todd D. Pearson, director of the Center for Physician Renewal in Bellevue, WA. "If you are willing to follow the answer where it leads, you may return to medicine transformed."

Stuck midstream? Change horses. Medical Economics 2001;2:72.