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Today, we are talking with our friend, emergency physician, author, and executive coach Rob Orman. We discuss how medicine asks physicians to handle an extraordinary combination of high-stakes decisions, heavy workloads, difficult interactions, and constant pressure—often without much training in how to make the career sustainable. We get into physician burnout, better ways to navigate conflict, and why simply pushing through is not always the answer. We discuss how financial strength can give doctors more options to reshape their careers and stay in medicine in a way that works for the long term.
Medicine Is a ‘Supranormal’ Job
Medicine is not a normal job. Physicians operate in an environment that is people-facing, decisionally dense, cognitively complex, and filled with choices that can directly affect another person’s life. There is task saturation, constant interruption, difficult communication, documentation, administrative pressure, and the emotional weight of caring for people on some of the worst days of their lives. And while medical training does an excellent job teaching doctors the medicine, it does not necessarily teach them how to manage everything surrounding the medicine, including how to balance call with family life, navigate conflict with administrators, keep up when a clinic is overloaded, or handle the cumulative stress of difficult patient encounters.
Dr. Rob Orman calls this a “supranormal” career because physicians routinely function in circumstances that fall well outside what most people experience in their daily work. His newest book is called Supranormal, and it’s all about this exact topic.
Rob knows firsthand what can happen when the demands of that career become unsustainable. For the first 12 years of his emergency medicine career, he struggled with the pace and stress of the job, eventually reaching the point where he felt dread driving to work. He realized he could not simply keep grinding through it. Changing to a slower-paced emergency department helped him build a career that better fit the way he worked.
Dr. Jim Dahle then expressed that he is wrestling with a question as he continues to practice emergency medicine at roughly 0.4 FTE. He shared his concern about skill decay. They discussed whether there is a minimum amount of clinical work necessary to remain competent and whether physicians should worry about skill decay when cutting back. Interestingly, Rob believes procedural skills may be relatively durable, but what can fade first are the mental reflexes that allow an experienced physician to rapidly build a differential diagnosis and manage complicated cases almost automatically. When those processes require more conscious thought, there is less cognitive bandwidth available for higher-level decision-making.
That does not mean physicians should avoid part-time work. Working fewer shifts may actually make it easier to remain compassionate, engaged, and energized, and reducing clinical work can be an important tool for creating a sustainable career. But competence matters, too. For physicians considering cutting back, the question is not simply how little they can work, but whether their schedule allows them to remain the kind of physician they want to be. That tension between preserving yourself and preserving your skills is another example of why building a long, satisfying career in medicine requires intentionality rather than simply continuing to grind.
More information here:
- Why I Went to Half-Time as a Physician and How I Made It Work as My Family’s Sole Earner
- 7 Reasons I Practice Medicine Part-Time
Stop Pushing and Start Pulling
One of Rob’s most practical tools for physicians is surprisingly simple. When you feel challenged, stop pushing and start pulling. He learned this lesson as a brand-new resident when an experienced nurse questioned his order to give an antibiotic intravenously and suggested giving it intramuscularly instead. Rob did not actually know why she was suggesting it, but rather than admit that, he responded with, “Because I said so.” He laughs about it now, but the interaction damaged that relationship and likely his reputation with the nursing staff. Looking back, he wishes he had simply responded, “Tell me what you’re thinking.”
That phrase changes the entire interaction. Instead of immediately defending your position, you pull the other person’s perspective into the conversation. In Rob’s example, he would have learned that the nurse had a perfectly reasonable rationale. You do not necessarily need to agree with the other person or even feel what they are feeling. You are trying to understand their position well enough that you could articulate where they are coming from. As an added benefit, asking the question gives you a few seconds to collect yourself and respond rather than react.
The hard part is recognizing the moment when you need to use the tool. Rob pointed out that when most of us are supposedly listening during a disagreement, we are actually “reloading,” preparing the next argument we are going to fire back. His solution is to make the reminder as simple as possible: pull. When you feel yourself getting defensive or preparing to push back, use that feeling as the cue to pause and get curious. Ask, “Tell me what you’re thinking,” “Where are you coming from?” or, “Tell me more.” There are certainly situations in medicine when there is not time for a lengthy conversation. But during the normal conflicts of a workday, pulling instead of pushing can improve communication, teach you something you did not know, and build cohesion within the team.
More information here:
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Burnout Is Not Something You Have to White-Knuckle
Rob is not particularly fond of the way medicine talks about “self-care.” Sleep, exercise, eating well, and meditation are all valuable, but telling an overwhelmed physician to practice more self-care can make it sound like the physician’s job is simply to become better at absorbing an unreasonable workload. Meditation can help someone regulate stress and respond differently to difficult circumstances, but it cannot fix a job that routinely sends you home four hours late. Instead of simply asking whether someone is burned out, Rob likes to ask a more useful question.
He asks, “Does this feel sustainable, and how long can you keep doing it?”
That question matters because physicians are exceptionally good at enduring difficult things. The same traits that help someone survive premed, medical school, residency, fellowship, and years of demanding clinical work can become liabilities when grit is the only tool they know how to use. Some physicians may recognize that they can only continue for another six months. Others may acknowledge that they are miserable but insist they could tolerate the misery for another 20 years. Rob argues that physicians have been selected and trained to put their heads down and grind through adversity, so their instinct when a career becomes difficult is often to simply grind harder. Sometimes perseverance is exactly what is needed. Other times, it prevents physicians from addressing the actual problem.
That culture of self-sacrifice also has deep roots in medicine. Rob explained that care of the sick was historically associated with the clergy, bringing with it an ethos of service and self-sacrifice. Early medical training further reinforced the expectation that physicians should devote nearly unlimited time and energy to their work. Those traditions helped create a culture where needing rest, asking for help, or changing an unsustainable situation can feel like weakness. But physician energy and endurance are not infinite resources, and suffering through an unsustainable job should not be considered a requirement of being a good doctor.
Jim connected this directly to personal finance because burnout can become one of the greatest financial risks physicians face. A financial plan built around decades of physician income looks very different if someone burns out five, 10, or 15 years into practice and feels they have no choice but to walk away. Financial strength creates options. A physician with manageable debt, adequate savings, and a growing portfolio may be able to reduce call, work fewer shifts, change practices, accept a lower-paying job, or take time to figure out what needs to change. Rob’s own experience illustrates that the solution does not necessarily have to be leaving medicine entirely. After years of dreading his shifts, he moved to a slower-paced emergency department that fit him better, and he ultimately enjoyed the final eight years of his clinical career.
The goal is not to become better at tolerating misery. If your career feels unsustainable, identify the specific things making it unsustainable. Maybe it is documentation, workload, call, scheduling, conflict with administration, or simply a practice environment that does not fit you. Look for the lowest-hanging problem you can change and start there. If you cannot figure it out yourself, Rob recommended getting help from a mentor, group, coach, or someone else who can help you work through it. There can be an enormous return on that investment—not just financially, but in your health, relationships, and the number of years you can spend doing meaningful work.
To learn more from this episode, read the WCI podcast transcript below.
Sponsor
Locumstory.com is a free, unbiased educational resource about locum tenens—it’s not a staffing agency. It helps answer your questions about the how-to’s of locum tenens work on its website, podcast, webinars, and videos, and Locumstory even has a locums 101 crash course. Locumstory.com is where you should go to find out if locums makes sense for you and your career goals. Locumstory is unique because it’s more of a peer-to-peer platform, with real physicians sharing their experiences and stories—both the good and bad—about working locum tenens. Hence the name, “Locum-story.” See for yourself on its self-service platform with no obligation.
Milestones to Millionaire
#290 — This Fellow Reached a $600,000 Net Worth Before Finishing Training
Today, we talk with a newly minted transplant hepatology and gastroenterology physician who built a $600,000 net worth before ever receiving an attending paycheck. He shares how the GI Bill, his wife’s teaching income, frugal living, and consistent investing helped his family build wealth throughout training, including growing his kids’ 529 plans to roughly $60,000 after starting with just $50 a month. His story is a great reminder that small financial habits practiced consistently over many years can add up to a lot.
To learn more from this episode, read the Milestones to Millionaire transcript below.
Financial Boot Camp Podcast
Financial Boot Camp is our new 101 podcast. Whether you need to learn about disability insurance, the best way to negotiate a physician contract, or how to do a Backdoor Roth IRA, the Financial Boot Camp Podcast will cover all the basics. Every Tuesday, we publish an episode of this series that’s designed to get you comfortable with financial terms and concepts that you need to know as you begin your journey to financial freedom. You can also find an episode at the end of every Milestones to Millionaire podcast. This podcast will help get you up to speed and on your way in no time.
Estate Planning
Estate planning is an important part of a financial plan, and it really serves three main purposes: making sure your assets and minor children are taken care of according to your wishes, avoiding or minimizing probate, and reducing taxes when appropriate. For parents, naming a guardian for minor children may be the single most important reason to have an estate plan. You also need to decide who will manage money for your children and when and under what circumstances they should receive it. Probate can often be minimized by using beneficiary designations on retirement accounts, life insurance, and annuities, as well as joint ownership and revocable trusts. Most people won’t owe federal estate taxes because the exemption is so high, but state estate and inheritance taxes can kick in at much lower levels, making more advanced planning important for some high net worth families.
Estate planning is less about the documents themselves and more about the decisions behind them. Who should care for your children? Who gets your assets? When should your children receive an inheritance? What charities do you want to support? A typical estate plan may include a will, revocable or irrevocable trust, durable power of attorney, healthcare directive, and healthcare power of attorney. Just as important as creating those documents is talking with your family about your wishes, particularly around end-of-life care. Making those decisions known ahead of time can make an incredibly difficult situation much easier for the people you love. Beneficiary designations also deserve regular attention, particularly after major life changes such as marriage, divorce, remarriage, or the death of a spouse.
Not everyone needs a trust. Revocable trusts are primarily useful for avoiding probate, while irrevocable trusts are generally used for estate tax planning and sometimes asset protection. For most white coat investors who expect to accumulate substantial assets and eventually die as multimillionaires, spending a few thousand dollars with an experienced estate planning attorney is probably money well spent. Estate laws vary significantly by state, and advanced strategies (such as family LLCs, family limited partnerships, and domestic asset protection trusts) can become complicated, expensive, and uncertain. The goal isn’t to create the most elaborate estate plan possible. It’s to make sure your children are cared for, your money is going to the right people at the right time, probate is minimized when worthwhile, and unnecessary taxes and hassles aren’t getting in the way of passing your assets to the people and organizations you care about.
To learn more about investment glide paths, read the Financial Boot Camp transcript below.
WCI Podcast Transcript
INTRODUCTION
This is the White Coat Investor podcast where we help those who wear the white coat get a fair shake on Wall Street. We’ve been helping doctors and other high-income professionals stop doing dumb things with their money since 2011.
Dr. Jim Dahle:
Welcome to the White Coat Investor podcast.
Full disclosure, what I’m about to say is a sponsored promotion for locumstory.com. But the weird thing here is there is nothing they’re trying to sell you. Locumstory.com is simply a free, unbiased educational resource about locum tenants. It’s not an agency. They simply exist to answer your questions about the how-tos of locums on their website, podcast, webinars, videos, and even have a locums 101 crash course.
Learn about locums and get insights from real-life physicians, PAs and NPs at whitecoatinvestor.com/locumstory.
QUOTE OF THE DAY
All right, our quote of the day today is from Maya Angelou. “One must learn to care for oneself first so that one can then dare to care for someone else.”
Now, that’s going to be our topic today. We’re going to be talking about what we can do for self-care, for lack of a better term, in order to be able to reach out and help others to do better. Because what you’re doing is not easy. And I thank you for doing it because it is hard work.
I was in the emergency department yesterday and you know what? It was a hard day. It was a hard day. The medics brought somebody in that they had shocked seven times prior to getting to us. And a couple of times this patient had woken up and spoken with them. And then ended up being a difficult resuscitation in the department that didn’t go so well. And that’s not easy to face. It’s not easy to face the medics. It’s not easy to face the nurses. It’s not easy to face the family. I know you’re doing things that are just as difficult in your daily work. So, thank you for doing that.
Before we get into a pretty awesome interview we’ve got for you today, I want to make sure you know about early bird pricing for WCICON27. And we’re going to get into an interview with Rob Orman here as I get him on the line. He likes to call it WikiCon. And I always feel like we’re going to some sort of seminar for Wikipedia when he calls it that. But if you want to call it WikiCon, you can as long as you come.
But now through September 22nd, you save $300 on it. You can register at whitecoatinvestor.com/wcicon. Every year doctors tell us that the physician wellness and financial literacy conference is life changing. Now what they learned will literally add millions to their network.
We had over 240 applications submitted to speak for WCICON27. So narrowing it down to 35 was quite the job. But we did. It feels like it’s going to be one of the strongest years yet. Getting to hear your success stories, the challenges you face and answer your money questions keeps me motivated to make content for the next year.
You’re the reason WCI exists. So getting out from behind the keyboard, getting out from behind this camera and actually talking with you inspires me. We organize tons of fun things for you to do from pickleball, golf, wine tasting and dinners. You’re going to meet people you actually want to spend time with.
Take $300 off your registration through September 22nd. That’s the lowest discount you’ll get. But you can use your CME dollars if you’re self-employed. You can write this thing off. It is eligible for CME and you can take an additional 20% off your spouse’s registration if they join you. It’s fun seeing all the couples because we know financial plans are most successful when they’re made together.
So, mark your calendar for February 24th through 27th to join us at the beautiful Rosen Shingle Creek Resort in Orlando. It’s less than 15 minutes from SeaWorld, Universal Studios and Disney World. If it falls in the time for a family trip, bring the family. Let them enjoy the pools and sun while you learn. It’s a great place to take action to improve your financial life and unwind. Whether you’re flying solo or bringing the whole family, register at whitecoatinvestor.com/wcicon.
INTERVIEW WITH ROB ORMAN
Okay, great interview here. Let’s get Rob on the line.
My guest today on the White Coat Investor podcast is Rob Orman. Rob, welcome back to the podcast.
Medicine Is a ‘Supranormal’ Job
Dr. Rob Orman:
Always great to chat with you, Jim. Great to see you.
Dr. Jim Dahle:
For those who don’t know Rob or haven’t heard him on the podcast before, Rob is an emergency physician. He has been a WCICON speaker. He’s also becoming more and more famous not only within medicine but outside of medicine. He has been an executive editor at EM:RAP. He has been a consultant on The Pit. And we got to start with this question, Rob. Some are watching this on YouTube and they look at you and go, The Pit, is he the star? Is he Dr. Robbie? He looks just like Dr. Robbie. Tell me this is pure coincidence that you guys look slightly alike.
Dr. Rob Orman:
Oh, we look alike. We act alike. And when I started watching that show, I thought, wait, wait, this is kind of weird. No, not that I’m aware of the Dr. Robbie based on me, but that would be pretty cool . However, my friends do carry on that mythology that that is in fact the case.
Dr. Jim Dahle:
So, what were some of your good and bad experiences in working there as a consultant with him?
Dr. Rob Orman:
It was peripheral. I wasn’t in the studio or in the writer’s room. It was on the mass casualty episodes in season one. And what had happened was after the Las Vegas mass casualty event at the music festival, I went with a crew to Las Vegas to interview the docs and the nurses.
So, this is many of the people involved in the response to that. And it was at the single hospital, the one that got a lot of coverage in the emergency medicine news about how do you manage the ER and put all the wheelchairs out front and the stretchers. And then when you do intake and when somebody comes up in a car and they’ve been shot, you do a 10 second survey with a visual CT scan, all of these different things.
And we went and we interviewed these folks for three days straight. And we made a little documentary out of it. But we had nine hours of footage saying exactly what it was like. What did it feel like? What did it sound like? What did it smell like? What did you do? What went well? What do you wish went differently?
The producers of The Pit used that footage to inform those episodes. And I’m sure they talked with other people as well. But when I’m watching those episodes, I go, “Wow, that is exactly the thing that that person said in the interview”, or that is exactly what happened. Or when they’re pulling someone out of the car, “That’s exactly what that person said in that documentary.”
So, it was based on an actual mass casualty response. When we train mass casualty or we drill it, you learn the perfect way to do it. Here’s the tags. Here’s how you triage. But when those things actually happen, then I suspect you’ve been in a mass casualty. It is just complete chaos, which you are trying to control and keep your head and keep your patient’s heads above water.
I was a consultant on the two mass casualty episodes in season one. And that was the beginning and end of my consultancy for HBO’s The Pit.
Dr. Jim Dahle:
And it’s a different world than medicine. You’ve stretched forth beyond medicine and a lot of the work you’ve done. But Hollywood is not medicine. It is not the same thing. What shocked you the most that you can actually share on this relatively family friendly podcast about working with Hollywood?
Dr. Rob Orman:
Yeah, it was interesting. I spoke a lot with Joe Sachs, who was the doc who was involved with the ER. He is involved with The Pit. And working with a doc on that show was pretty amazing because you just have this instant connection. So that was sort of outside of the regular Hollywoodness.
I talked to some of the producers and it was funny. It was kind of, “Yeah, baby. Oh, yeah, we’ll bring you in. We’ll do this and that.” And then crickets. It’s just a lot of some of the things that that that folks say about Hollywood are true because you’re told a lot of things and then they don’t happen. But actually it was really cool because they were hungry for the realism of it. And we want to know, what is it really like? What is really happening? And watching the show, I said, well, they took everything and turned it into that show where you’re warts and all. Well, I think that show, it’s showing especially the warts. It’s not warts and all. It’s kind of here’s the cool stuff. And we’re going to give you lots of warts.
Dr. Jim Dahle:
It’s interesting. People always ask me, this is going to show my age, but back when E.R. was on, like, “Is that what your job’s like?” I’m like, “Well, all those things happen. Everything you’ve seen in an episode there has probably happened to me. It just doesn’t all happen at once in the same 40 minutes.”
Dr. Rob Orman:
That’s so funny. My wife, also in E.R. doc, we watching the watching the season, we say, “Wow, that one episode was our entire career.”
Dr. Jim Dahle:
There’s some truth to that, for sure. Okay, for people who don’t know you, give us kind of a little rundown of what you’ve been doing professionally.
Dr. Rob Orman:
I spent 20 years as a community emergency physician. And for the past six or so years, I’ve been a full time executive coach for physicians and I work with them on behavioral issues. That’s one of my main jobs. Doctors who want performance improvement plans on FPPEs, who are going to the medical executive committee or up to the state board and says, “Hey, there are behaviors that need to change or your career is going to be in jeopardy.”
So, I work with a lot of doctors on that. As well as docs who are feeling burnt or overwhelmed and their career isn’t on track. How do I get my career on track so that I have career longevity and I can actually feel joy doing it, not dread?
Dr. Jim Dahle:
Okay, now I get this question a lot and people want to know if I’m still practicing. And I think they want to hear that I do, because for some reason they feel like this message of physician literacy and discipline that we carry here at the White Coat Investor means more to them if I’m still working clinically as a physician. And now, obviously, I’ve worked clinically as a physician for a long time. I certainly understand the finances of physicians, whether I was working shifts yesterday. I was in the ER. Whether I worked that shift or not does not really have anything to do with my understanding of physicians and their financial lives.
You’re no longer working shifts now. Do you feel like that takes away at all from your message of conquering burnout? And does it cause some people to not believe you? They’re like, “Well, why should I listen to this guy? He’s out. He burned out and did something else.”
Dr. Rob Orman:
Well, I didn’t. We are happy to talk about this. I had burnout early in my career, but I didn’t leave medicine because of burnout. And I think a lot about this. And I will say that when I go and give a talk, invariably, one person says, why should I listen to some celebrity doctor who’s not practicing clinically anymore? Okay, yeah, I get that. If that is your frame, that’s totally fine.
When I left medicine, just as far as the story goes, I left clinical medicine because I had another full-time job. I was doing medical education full-time and I started getting skill decay in resuscitations. And I thought I either need to go back to full-time or maybe I’ll just pursue this other career. I’ve done 20 years of emergency medicine. I feel pretty good about it. So I went into medical education full, full, full-time. And that was my job. But then I’m doing medical education. And that particular question, I thought “I cannot do that authentically if I’m not practicing clinically. So I need to pursue something else.” And just for me, yes, could I teach it? Sure. But I did not feel right about doing that.
I thought I knew I want to work with physicians. And this is going to come across as it comes across. In medicine, who I loved working with the most were other doctors. Patients are great, but I so highly value physicians, clinicians. I thought, I want to get a master’s in counseling so that I can work with clinicians, or I want to learn to be a coach and work with clinicians. I want my 20 years of experience to inform that work.
So, yeah, I think if you ask me, hey, what is the most up-to-date management of myocarditis? I am not the guy to ask. I’m not. I am not. But if it is, “How do I navigate the stressors of medicine?” I have the experience of what it is actually like, and now, and also years of training in how to help doctors deal with that and figure that out and work through it. And thousands of hours of working with doctors on that exact stuff.
So my specialty has definitely narrowed outside of the clinical scope. When I was in my coach training, I’d work with CEOs and guys who were in tech. And the CEO said, yeah, I’m leaving my position as the CEO, but I want to help other CEOs to navigate this. I’m not doing the CEO stuff anymore, but I understand what it’s like. I understand the context and the substrate and the milieu.
I would say that the clinical experience informs how I coach. And that is actually why most people end up coming to me, is because they want to work with someone who has done the work, because oftentimes they are referred to a coach who does not have clinical experience or was not in medicine.
Dr. Jim Dahle:
Now, this is something I think about relatively frequently, because for six years, I’ve been doing six day shifts a month. I’m only 0.4 FTE. And at a certain point, you got to go, “Are you good enough to be doing this important job if you’re only doing it 0.4 FTE? How many years can you do that before a patient deserves somebody that’s doing it more frequently than you are?”
And I don’t know the right answer, but I worry about it. And in the end, that sort of a thing might be what pushes me out of medicine, because I don’t want to be doing it if I’m not doing it right, number one. And number two, I don’t really want to do it any more than I’m doing it now. And so, if that’s five years or 10 years or 15 years, or maybe you can do a whole career working 0.4 FTE and still be a competent, compassionate doc, I actually think it helps you be more compassionate at 0.4 FTEs than it does at 1.0 FTEs.
Dr. Rob Orman:
The irony of it all.
Dr. Jim Dahle:
Competence is important as well. But I think it’s a legitimate worry that some of us have. I have not seen a patient after midnight in six or seven or eight years. Is that even real emergency medicine after a while? Because the population is different that comes in after midnight. It’s not the same patients people are seeing.
Dr. Rob Orman:
It’s maybe the best population, and then the night shift is the worst physiologically for the doc. Yet when what you speak of is skill decay, and you feel it, you know it. And it’s that I’m working up a chest pain patient, and okay, I need to really work to extract the entire differential diagnosis versus boom, boom, boom, boom, boom. It’s reflexive.
And that’s one of the first things that you notice. It’s not the procedural skills. I will bet that you could do a procedure that you haven’t done in years, maybe not masterfully, but.
Dr. Jim Dahle:
But safely and competently.
Dr. Rob Orman:
Enough, well enough to save the patient. But it is those mental skills of having the reflexive memory that, yeah, this all comes real. And then what also is that is that when you have that repeated exposure, you then have more bandwidth for the higher level thinking, the higher level cogitation versus if you’re not working a lot, much more of your brain is used. “Okay, what is the differential diagnosis for this weird thing?” You can look it up now, but you’re still thinking a lot harder.
I don’t know if I told this story on the last one, but the time that I noticed it was, I was working two full-time jobs outside of medicine. I had, I don’t know, an N+2 outside of medicine. And I had a resuscitation of a patient who had had an MI in their front yard the day before, and they’ve laid out in the sun for 24 hours. And this was an LAD lesion. Laid out in the sun with this big MI, came in every arrhythmia going on and hypotensive and altered. And I think pH was 6.7.
Dr. Jim Dahle:
Geez.
Dr. Rob Orman:
It was quadruple pressers and this anti-arrhythmic and I think they weighed maybe 400 pounds. It was very complicated. However, as an emergency physician, managing that patient, that’s the core of your job, all of that complicated stuff. And I was having to work so hard to extract the information of, “Oh, I’m on my third presser. What am I supposed to do here?”
Now, granted, that’s going to be hard for anybody, but as you’re talking about, you can feel it. You can feel when that skill is starting to decay. And I had clearly reached the point of the number of shifts that it’s not enough.
And for me, it was six, seven shifts a month was kind of the inflection point. And below that, I would start to, I would start to feel it. And that’s when I thought, “Well, I need to really increase my shift number.” You know what? I’ve gotten all I have to get. I’ve given all I have to give and I’m okay calling it a day.
Dr. Jim Dahle:
It’s interesting. I feel occasionally my shifts get blocked and I have three days in a row. I work six a month, but for some reason I’m working three days in a row. I’m better on the third day.
Dr. Rob Orman:
Yes.
Dr. Jim Dahle:
I don’t care as much about the patient on the third day, but I’m better at the job beyond that point of being compassionate. I’m more compassionate on day one, but it’s interesting, there’s a little ramp up. It’s almost like compression only CPR. There’s a little ramp up to fill the cardiac output that takes a few compressions to fill it up.
It’s interesting there. I think it’s something to be thinking about for those of you out there who are thinking about part-time and debating how much of your career can you do part-time and do you want to do part-time? It’s a legitimate concern and something to be thinking about.
But today I want to think about something different. I want to think about Supranormal. For those of you watching on YouTube, I’m holding up a book here with Supranormal and Rob Orman MD on the front of it. What’s this book about? Why is the title Supranormal?
Dr. Rob Orman:
As we were talking about a few minutes ago, I work with physicians as my full-time job and I get to not only see what was my experience in medicine, but hundreds of other doctors, what’s their life like across specialties. And over the years, I was saying, “Wow, this job, the experience of being a physician is at least a standard deviation outside of what most people experience.”
The initial image, the title is as a doctor walking a slack line, but the initial image was of a bell curve and a tiny little triangle on the right side, lay a little R in the triangle and almost like the asymptotic part of a curve. And I said, yeah, if you just live in that little outlier space, that is not what most people experience in their lives. And it’s people facing, it is decisionally dense. It is decisionally complex. And you make these decisions every day, all the time. There’s task saturation and the decisions you make directly impact people’s lives.
There are very few jobs that incorporate all of that. And in addition, just the practice of being a physician is so much, it feels nearly impossible at times, yet people do it. I thought this is not normal. This is not normal. This is super abnormal. And then I think it was on a bike ride and that word popped into my head. I said, “Wait, is that even a word? It’s Supranormal a word?” I look, I said, “Yes, it is a word.” And that became the book’s title, Supranormal. The subtitle is A Field Guide for the Impossible Job. And the job feels impossible, yet people do it. Yet people also struggle with the job. They struggle with mindset. They struggle with workflow. They struggle with communication. They struggle with just keeping their head above water. And that’s what this book is. It’s a field guide for that job.
Dr. Jim Dahle:
It’s interesting to be thinking about it as a job. Something I’ve been doing for so long. And my son just started school. We’re recording this at the beginning of September. He just started school. He’s a senior in high school. And one of the things he’s doing down at the community, whatever they call it, technical institute or whatever, is he’s taking an EMT class. So yesterday was CPR. I don’t know whether they were trying to do conditioning or what. He did CPR on like 20 dummies.
But it’s been interesting because for the last week or week and a half, he’s been asking all these very thoughtful questions about my career and about emergency medicine and about EMS and all these great questions that he never seemed to care about before. And I guess he’s not terribly shocked that I know all the answers to the questions. But it’s been very interesting to have discussion with him about my career that I have not had with any of my other family members before. Just because he’s getting some insight into it.
We’re talking about CPR and resuscitations and what medics do and what they don’t do. And those sorts of things. It’s been a really fascinating look kind of from the outside into this Supranormal job that I’ve been doing both full-time for many years, as well as part-time for the last few years. But it’s not just emergency medicine though. There are plenty of people in other specialties who are also in Supranormal situations on a daily basis.
Dr. Rob Orman:
Oh, that’s for sure. When I was at… Can I call it WikiCon?
Dr. Jim Dahle:
You’ll be the only one who calls it that. We generally call it WCICON.
Dr. Rob Orman:
Well, when I was there last year, there was a revolution where I was calling it. I think I was fomenting dissent calling it WikiCon.
Dr. Jim Dahle:
If anybody calls it WikiCon this year, I will give you credit for it.
Dr. Rob Orman:
You realize that this is going on the air. This is how revolutions start.
Dr. Jim Dahle:
People are going to show up thinking we’re like Wikipedia or something.
Dr. Rob Orman:
When I was at WikiCon, I spoke with so many docs of different specialties. I did a workshop there, a half-day workshop. And there was no one specialty I think that was more represented than others. And there were questions from ophthalmologists, from colorectal surgeons, from primary care, from urologists, from dermatologists, from emergency medicine.
The questions are all the same. Because every job has its unique flavor of stress, of seemingly impossibility. But you could say it’s all within that bubble of this is a lot. And I was actually not trained how to navigate this stuff. I know the medical stuff really well. But how do I be on call and have a family? How do I deal with documentation when I’m quadruple booked in my clinic? How do I deal with this communication with administration when we’re having conflict? How do I deal with stress when a patient is getting really agitated or angry?
We were never trained for those things. And that’s why when you have that community, we all went to med school, we all got the same training. That’s why when you’ve got that group of docs together, it’s, “Oh my gosh, we are all facing the same stuff. We are all in the same boat.” So yes, to your point, I have yet to find a physician in any specialty who does not feel this.
Stop Pushing and Start Pulling
Dr. Jim Dahle:
Okay, let’s throw people a pearl here. There’s this book, Supernormal. And hopefully, somebody’s going to listen to this and go read this book because it’s awesome. But toss them a pearl. Share something specific, actionable, a tool from the guide that a doc could implement tomorrow. Give them a sample of something they could take from this book and implement tomorrow, make their lives better.
Dr. Rob Orman:
Let me share a story with you. When I was a new resident at Denver General Hospital, this is day one, I’m in the trauma zone, trauma/sick medical zone, and had a patient with cellulitis. It wasn’t that bad. So I ordered a gram of IV Ancef. Can I say Ancef on the show? Do I need to use the generic?
Dr. Jim Dahle:
I think that’s fine. I guess it’s a medical podcast, but it’s not that kind of medical podcast. So you can say Ancef, you can say cefalexin or whatever you want.
Dr. Rob Orman:
Cefazolin, cefazolin, but yeah. Yeah, I’m not the guy. I’m not the guy to ask that. So nurse said to me, “Hey, can we give this IM? – Well, I ordered it IV. – Well, yeah. – Well, can’t we just give it IM?” I said, “No, I ordered it IV. – Well, I think we should give it IM.” And actually in my mind…
Dr. Jim Dahle:
It’s an experienced nurse, I’m assuming.
Dr. Rob Orman:
Yes, very experienced nurse.
Dr. Jim Dahle:
Yeah, because the new ones would have stopped after the first or second.
Dr. Rob Orman:
Yes, exactly. And then I had only ever in medical school, where I was fresh from, written for this or ordered this or even seen this given intermediately. I’d actually never seen it given intermuscularly for this indication. I didn’t know that was an option. She said, “Why can’t I give it IM?” And I said, “Because I said so, because I said so.”
So, what one thing that we do in life is when we are challenged, we push, we push back. And what would have happened in that moment if I had said, “Tell me what you’re thinking?” Just that, tell me what you’re thinking. Instead of pushing, that is pulling. That is pulling in their thoughts. Where are they coming from?
So really, you are trying to create cognitive empathy. There’s two types of empathy, affective empathy, where you feel what they feel and cognitive empathy, where you fully understand and can articulate where they’re coming from.
So pulling, when you feel challenged, pull in with curiosity, that “Tell me what you’re thinking.” Just use that one phrase. And I use this a lot with clients who are on performance improvement plans, who are used to pushing back and getting advice. They are used to that. And we work on a lot of different things.
This is one of the small things of when you feel challenged, pause and pull. “Tell me what you’re thinking. Where are you coming from? Tell me more.” And that does a couple of things. Number one, the other person feels validated. They feel heard. You’re also probably going to learn something. At least you’re going to learn their perspective. And maybe they’re seeing something that you’re not. Maybe they know something you don’t know.
Also, you feel a little bit frustrated when you’re challenged as a doctor. It also gives you a moment to collect yourself so that you can respond instead of react. Pull instead of push when you are challenged.
Dr. Jim Dahle:
This isn’t just work advice. This is marital advice. This is raising kids advice.
Dr. Rob Orman:
This is all for life.
Dr. Jim Dahle:
This is get along with the neighbor advice.
Dr. Rob Orman:
Yes, you’ll see something like this across pretty much any communication framework, but this is just how I phrase it and frame it. But what would have happened in that situation with this nurse? And I will say this, it took at least a year to repair the relationship with that nurse.
Dr. Jim Dahle:
I’m shocked if it’s only a year.
Dr. Rob Orman:
I think she actually held the grudge for all four years of my residency.
Dr. Jim Dahle:
How long did it take to fix your reputation among the rest of the nurses is what I’m curious about.
Dr. Rob Orman:
I don’t know. Does that sigh? Boy to your point, Jim, word really traveled fast. But what would have happened in that moment? If I would have said even if. It’s funny when I’ve put this out there, people said, hey, you know what MD stands for? It stands for My Decision, or an ACLS – At the very end when there’s nothing else to do. And it says, seek expert consultation. Well, that’s me.
In the moment when you pull, if I pull with that nurse and say, okay, I feel challenged. I’d said, “Hey, tell me, tell me what you’re thinking with this. That’s not my normal approach. – Oh, giving it IM it’s going to be just as effective as giving it IV. We’re not going to have to put in the IV. That’s going to be painful. It’s going to be expensive. It’s going to be slow. And then we can just discharge the patient.” Oh, wow. All right. I just learned something new. And I built unit cohesion. I built small unit cohesion. I built team cohesion caveat to this.
In the resus bay, when you need to make a decision in a second, you’re doing a crike or you’re a crack in the chest, that’s not always the time for just long cognitive empathy conversations. You do want to have clear communication. And if somebody sees something that you are missing, you want to be able to receive it. So there’s different ways to communicate it in that venue. But I’m talking about just in the regular run of day conversations. And yes, this does apply to your neighbor, your friends, your kids, and the rest of your life. If you just do this one thing, your life will be fundamentally different and there’ll be a lot less friction.
Dr. Jim Dahle:
Yeah. It’s hard to do though. It’s hard to do for two reasons. One, maybe we aren’t confident enough in ourselves to do it, which is clearly an issue for most interns. And two, it takes a fair amount of humility to do that. And those two attributes, hopefully we’re all working on them, but none of us are perfect at them.
And so, I think the natural thing to do is react. And it’s really hard. The pause, just the pause is hard. And then to respond with curiosity, many of us go to therapy for years to learn how to do this. It’s not easy.
Dr Rob Orman:
That is why I want to make it as simple as possible. When you feel that, you feel that because really, usually when we’re listening, we’re not listening. We’re reloading. We’re reloading our response. So like fighter pilots or pilots, they have all these instructions for what to do in an emergency, but there’s the bold face. It’s just the thing that will flash into their mind in the emergency. They’re not going to remember the pages and pages, but what’s the bold face? The bold face is pull. One word, pull. When you feel that urge to “Let me push back and let me tell you, let me tell you how it is.”
Burnout Is Not Something You Have to White-Knuckle
Dr. Jim Dahle:
Okay. So you’ve given us a piece of good advice to help us deal with hard situations, burnout at work. What’s a piece of standard burnout advice out there that you think is crummy? It’s useless, or maybe even counterproductive.
Dr. Rob Orman:
I want you to start practicing some more self-care. I want you to be better at self-care. Let’s really focus on that, baby. So, this term self-care is in and of itself is great because what does it mean? Sleep, exercise, eat well, do the things that actually help you physiologically, mentally, cognitively.
But the packaging of that is problematic because how it comes across is do these things for yourself so that you can more effectively absorb the load so that you can be a better cog in the machine. I don’t know, that might sound a little cynical, but it is the packaging of this term that people either rankle at it or it feels kind of hollow or it feels soft. What is the one thing that you do not want to be called when you are in medical training? Doctoriness is weak.
Dr. Jim Dahle:
Right. You don’t want to be weak. You don’t want to be soft. You don’t want to be the person who needed a day off.
Dr. Rob Orman:
Yeah. Nah, you want to be strong. You want to be strong. So it’s the packaging of this term self-care and it doesn’t really get to the core of the issue. And if we’re talking about feeling burnt, feeling burnt out, and even that term burnout, even that term is problematic because what does it even mean? There’s the burnout inventories that look at cynicism and lack of personal efficacy and emotional exhaustion. What does that even mean? Well, there’s all sorts of questions about it. The question I’ll ask is, “Does this feel sustainable? How long does it feel sustainable?”
And here’s where this whole self-care thing becomes problematic is you may be white knuckling your career. And I think a lot of doctors are white knuckling their careers. And they say, “How long do you think that you can keep this up?” And well, some of them will say six months. I got six months. Okay. Well, we got some work to do, but some will say 20 years. I can suck up misery for 20 years and I can do it.
And one of the things is as physicians, we were selected for this attribute. We were selected to be able to persevere, selected to grind it out, to grid it out. That is actually one of our core strengths. But we end up using it as our only tool whenever things get stressful. It says, “I will put my head down and I will just grind it out and grid it out further.”
And so this whole self-care, the term doesn’t work. It’s also not specific. How do you operationalize that without getting granular and apply that to each individual situation?
Dr. Jim Dahle:
So true. Self-care, just go meditate and you’ll be fine. There’s a lot more to burnout than that.
Dr. Rob Orman:
Yes. And so, let’s build on that. Meditation’s great. Meditate every day. And meditation has been studied as a tool for burnout for doctors. Now, if you put it along with a whole bunch of other stuff, it’s going to be an incredible adjunct. But actually by itself has not been shown to reduce burnout symptoms.
And part of that is because it’s not getting to the core issue. It says, “Well, I’m able to accept my situation better.” That’s meditation will give you that. I’m able to down-regulate. That’s great. But still, hey, what is the thing that is really stressing you? Well, just only meditation in isolation. This is kind of a part of the self-care problem. Only meditation in isolation is not going to address you getting home from work four hours late every shift. So yeah, I love that you brought that up. I’m a huge proponent. We teach meditation in our courses, but it’s not the only module.
Dr. Jim Dahle:
Let’s get personal for a minute. You work with a lot of docs experience burnout, but you experienced it yourself to the point where you’re screaming in your car on the way to work. Now, I don’t know that I’ve ever done that, but I have felt that in actually my White Coat Investor work.
This year I’m giving four presentations at the ASEP scientific assembly in a month or two. One of the things I like the least about White Coat Investor is putting the presentations together. I call it making slides. It’s not just making the slides. It’s figuring out what I’m going to say and making the slides and all that. But I don’t like it that much. I love being there. I don’t mind doing the presenting. I love talking to people afterward about their challenges and their triumphs and that sort of thing.
But that’s the sort of thing I would scream in my car on the way to work. If I was going to work and putting together PowerPoint presentations to present at ASEP, I would be screaming in my car on the way to work doing that. But tell us this story about when you were most burned out in your career.
Dr. Rob Orman:
This is, I think one of the early chapters in a book, the day I cried on NPR, screaming in my car. So for the first 12 years of my career, this is 12 out of 20. The last eight were awesome. The first 12, man, did I struggle. I struggled so much. I found it difficult to keep up with an incredibly busy pace. You’re seeing 25 patients a shift and a busy ED. That was really hard for me.
Naturally, I took a job at the busiest hospital in the city. And so I was feeling the stress all the time. And I felt this pit of dread in my stomach every day when I’m driving to work.
When you get there and you start doing the work, that pit sort of goes away because then you’re in the action. But the anticipatory dread just got worse over you. It didn’t get better. It didn’t get better because I actually didn’t do things to address it. It didn’t get better. It didn’t get better.
And it would always happen at the same point in my drive, this pit, and I would feel the acid in the pit and it would just start building and building. And one day I’m driving to work and there is grid lock traffic and there is no way around. And I’m going to be late. I’m going to be late for my shift. And Jim, you and I know that you are never late for a shift. That is such a cardinal sin. It’s soft. It’s weak.
Dr. Jim Dahle:
You really couldn’t beat traffic today?
Dr. Rob Orman:
So, here I am, I’m in gridlock traffic and I’m going to be late for my shift. And I just start sweating. And I’m already kind of at maximal stress driving in. And it’s like, “Well, I’m going to be late. And this is this. And I don’t really even want to be there anyway.” That’s funny. Telling the story, I can even feel the stress. “I’m just going to be late.” And then from deep within the depths comes this primordial scream of, “Ah!”. And I’m gripping the steering wheel.
And then I felt this pop in my vocal cord. And I don’t know what actually happened there, but I felt this pop. And it just kind of snapped me back into the moment. I thought, “Whoa, whoa, whoa, whoa, whoa. What is going on here? This is not normal. This is not normal behavior.”
And I just paused there and I’m stuck in gridlock traffic. And it felt like this washing away of stress at that moment, because I said to myself, “You know what? I have been battling this job for years.” Admittedly, I didn’t approach it in a strategic way of “How do I actually survive or thrive or flourish at this job?” I was just trying to keep my head above water. I’ve been battling this job that did not suit me for 12 years.
And you know what? I lost. I lost the battle. I just lost. I realized, I just realized I lost. And in that moment, I thought I need to make a change. And I’m going to tell you, Jim, saying that, saying those two things to myself, I lost because I don’t lose, I don’t lose battles. No. And I need a change. Wait a second. Is that admitting failure? Is that admitting defeat?
That was the equivalent of climbing the highest possible peak of saying that I need a change. Because that was just not in my DNA. And I think that’s not a lot of doctors’ DNA.
And it’s funny. I was being interviewed on the show, The Pulse on NPR. We’re talking about burnout. And the host asked me a similar question. I’m just sharing this story. And I didn’t expect to share this story. And she said, “How did you feel in that moment? How did you feel when you said to yourself, I need a change? I have lost this battle.”
And I’m going to tell you, man, well, actually, I can feel it well enough right now. I’m there. And actually, it had been a dream to be on NPR. I can’t tell you how excited I was. I started sobbing. I started sobbing in this interview because it was such an emotional release. And I actually hadn’t talked about the story really much over time and just kind of bringing that up. And I said, darn. And in that moment, I felt free. I finally felt free of the constraints that I had put on myself of my own BS that “You must, you have to stay in this. It is weakness to leave. And you are not a weak person.”
I’m finally free. I’m finally free. And I can make a change. I did make a change. And I went to an ED that was much slower pace, had sick patients, had a cath lab, had a better mix and just better suited me. And actually there, then I could start building frameworks on how to keep up with documentation and all the things that had been problematic before.
Dr. Jim Dahle:
Yeah. Pretty remarkable story and not an uncommon one.
Dr. Rob Orman:
Yeah.
Dr. Jim Dahle:
I look at surveys these days and you’ll see figures like 50% of doctors say burnout is having a strong or significant impact on their lives. It’s not a tiny percentage of people. It’s most of us. We spend so much time on finance at the White Coat Investor. And I’ve told people, this is the biggest risk financially speaking. It’s your biggest financial risk is burning out after five or 10 or 15 years of your career, because the financial plan you’ve drafted up when you borrowed $400,000 to pay for school requires you to kind of stick with it for a while in some form or another. It doesn’t work out very well.
And so, it’s a challenge. And it’s not just a lifestyle challenge. It’s not just an emotional challenge. It is also a financial challenge because going to a slower paced job or cutting back on call or whatever, there are financial ramifications to all those moves. I don’t know, 75% of the things you can do about burnout require some financial strength. And so, if I can just get to docs at the beginning of their careers and help them to build that financial strength so when they get to mid-career and burnout rears its ugly head as it so often does, they’ve got capacity that they can actually do something about it.
Dr. Rob Orman:
Oh, I love that. I think at the beginning of your career or when you are considering what specialty you’re going to go into, even in medical school, is “How am I going to approach this with intentionality, knowing that it can be an impossible job?”
What we’re talking about is all of these different things coming at you. It’s so cool to be in medical school and get to just do all the fun stuff. That’s all you do. It’s stressful, but you do the fun stuff. The reality of what the job is like is the fun stuff plus everything else around it.
Dr. Jim Dahle:
It’s like when I was in the military. You had to do all this. You got to go salute, and you got to go put your gas mask on, and you got to go to physical training, and there’s all this stuff that comes with the job.
Dr. Rob Orman:
Wait, wait. You were in the military?
Dr. Jim Dahle:
I was. I spent four years in the Air Force, at least on active duty. Technically, I was in for 11 years, but really four years of active duty.
Dr. Rob Orman:
As a physician?
Dr. Jim Dahle:
Yes.
Dr. Rob Orman:
Have you talked about that on this show?
Dr. Jim Dahle:
Every now and then. Mostly, I’m talking to military docs who have military-specific financial questions, but I don’t know that I spend a lot of time going through that experience. It was definitely an experience. This was back in 2006 to 2010 when everybody was being deployed like crazy.
Dr. Rob Orman:
Yeah. To that point, both of my kids are going into medicine, and the book is dedicated to them. It is, these are the tools to at least start to be intentional about how you approach it. It’s not the only way. Different things stress different people. We go into this job like we’ve gone into everything else.
When you’re in medicine, college, med school, residency, maybe fellowship, attending hood, everything is laid out before you. You really don’t have to think about it. It’s all just set up. But once you get out into attending hood, it is a whole different world.
Thinking about before you even get there, “What do I want my life to be like? How do I use that as a rough heuristic to make decisions about my career?” In the beginning of your career, you’re going to be saying yes to a whole bunch of things. You’re probably going to have a semi-full plate. That’s in the very beginning.
Ultimately, the job you get is not made for you. The job you get is made to fit into a system. It’s not that the job is malevolent or the system is malevolent. It’s just a system. You are meant to fit into it. The job is not necessarily suited to how you want to operate. You’ve got to craft that job so that it more aligns with how does my mind work? What are my stress points?
Dr. Jim Dahle:
It feels like manage your manager. Manage your job.
Dr. Rob Orman:
Yeah, right. Manage up. Manage up for your career.
Dr. Jim Dahle:
Let me turn the page for a minute. I’m a little bit of a history buff. I like history. In the book, you describe self-sacrifice as something medicine inherited, not something doctors invented. Where does that concept of self-sacrifice come from?
Dr. Rob Orman:
We think it’s just kind of, “Of course. Of course, being a physician has to be like this”, but most jobs are not like that. Engineers in general, not like that. Attorneys, well, most that I know, not like that, but maybe some are.
Medicine has these really unusual roots. Care of the sick was previously done by the clergy. And what’s the ethos of the clergy? It is complete self-sacrifice. It’s often celibacy. And that clergy-like ethos transitioned or transferred into medicine when it became professionalized.
And physicians, especially in training, were in the hospital most days of the year. In some programs, they were not allowed to marry in their intern year. And that self-sacrifice was just seen as normal in medicine.
And then you get into modern medical training. And Johns Hopkins, which was one of the early training institutions in the United States, and that’s where William Halstead was. He was this revolutionary surgeon. And he was also very involved in the origins of Western civilization’s medical education and how it went. And he was experimenting with cocaine so that he could really drive himself and work seemingly nonstop and have boundless energy. And he expected his trainees to have that same level of focus, dedication, energy.
Dr. Jim Dahle:
It’s interesting because people think of the Blitzkrieg. In World War II, there’s Germans overrunning Europe in just a few days with their planes and their tanks. But a large part of that was meth. So, it’s an interesting connection there with stimulants.
Dr. Rob Orman:
Yeah. So, well, I guess we’ll pull it away from the meth and the Blitzkrieg. Is that our energy and our endurance somehow in the culture became seen as this infinite resource. So, there is this self-sacrifice built in. And there is that, “Hey, you know what? Doctors have infinite energy. And we ourselves think we should have infinite energy.”
So you’ve got the clergy history. You’ve got the whole Stedian model of medical education. Cocaine is not part and parcel of, I’d say, most medical practices these days. I can’t say all, but still that mindset persists, at least to some degree.
Dr. Jim Dahle:
Interesting. Interesting history there. All right. Our time is getting short, but there is one more phrase in the book that I want to talk about because I think it’s a really clever way you phrased it. There’s a chapter in the book called The Drama Triangle.
Dr. Rob Orman:
Yeah.
Dr. Jim Dahle:
What is that? How do you actually stay out of it when someone’s yelling at you in mid crisis?
Dr. Rob Orman:
The drama triangle, this was described previously by a social psychologist to describe human relationships. And so, what I’m going to describe is not pathological. It’s normal. We just fall into these roles whenever there is, let’s say, conflict. And the triangle consists of the roles of the hero. “I’m going to save the day.” And a lot of us in medicine, we’re the heroes. And you think, “Wow, hero, why not? That’s a great role. Of course, I want to be the hero.”
But the hero cannot exist without the other two roles in the triangle, the villain and the victim. And the villain, “Oh, you’re not doing it right. You’re not doing it right.” And the victim of “Why me? Poor me”, and just cowering in the corner. And in any dynamic or say conflict dynamic, we can oscillate between these roles.
And so, if we are in the hero role, then invariably there is also a villain or victim. And if we are the villain, then there’s going to be a victim and so on. I think, well, maybe I should just shoot to be the hero. Well, the actual move is to not be any of them and to step outside of the triangle, because it is the drama, because it is the drama triangle.
And when you are involved in the drama, you are sucked in. And you are not acting from a place of discernment. You are acting from a place of judgment. And whenever judgment is involved one way or another in any of these roles, well, you’re probably not going to have the ideal outcome. And you are probably not going to be at your best.
The greatest example I ever saw of this was with a gynecologist. And she had recently left the military. And I had a patient with a ruptured hemorrhagic ovarian cyst. And you see those all the time in the ED. But this was really atypical. And she had a belly full of blood and was in shock and hypotensive and we were doing aggressive transfusion. It was a massive transfusion. And she needed to go to the OR yesterday.
So I called the gynecologist down. And I’m outside the room getting things ready for the patient to go up to the OR and get admitted and writing the orders. And the gynecologist enters the room. And I hear her introduce herself. And the patient’s husband says, “Who are you to tell me what’s best for my wife? Who are you?” And he just lays into her this 30-second screed. And I’m thinking, “What is going on here? Your wife is on the fast track to dying. And here you are arguing with the doctor.”
And she could have taken on any of these roles. The hero. “I will save the day. Kiss my ring.” She could have been the villain. “Who are you to talk to me that way? She could have been the victim of, “Oh, why is this person yelling at me such?” There was a pause. And she said, “Sir, I am not the author of your story. Nor am I the source of your distress. Your wife lays here dying. How would you like to proceed?” Seconds later, the entire crew is on their way up to the OR.
And I asked her later, I said, “What happened? What did you do?” And she said, “Hey, I wasn’t going to get sucked into the drama.” You get sucked in. You got to decline the invitation. You feel that. It’s almost like that push-pull. You feel it. I wasn’t going to get sucked in. And that guy was scared. Anger and fear. Kissing cousins in the brain. “That guy was scared and I needed to help him get out of his own way. So I just needed to throw a figurative bucket of ice water on this whole situation and reflect back to him how preposterous it was that he was speaking in such a way.”
And so, she had stepped out of the triangle. And she was completely discerning. And she saw the story for what it was. And she was able to approach it calmly and have an effective result.
Dr. Jim Dahle:
Very cool. That’s good advice. Stay out of the drama triangle. Our time is gone. But you have the year of 25,000 or 30,000 White Coat Investors, most of them doctors. What have we not talked about today that they ought to know?
Dr. Rob Orman:
If you feel like your work is not sustainable or it is too much or you feel dread, that is not a requirement of being a physician. Although sometimes it can feel like it is when you look at the surveys. If you feel that, there is a path out of it. Yes, there’s this book. There is coaching.
There is also, you can DIY this where you say, “What are the things that are stressing me out?” We think that we can just muscle our way through or because we’re smart, we can survive. But identify what are my stress points? If there is something that is low-hanging fruit that you can address on your own, find the small first step in how you make a change there.
If you feel like you can’t do it on your own, then get help. Get help with a coach, with a group, with a mentor, or someone who can help guide you through that because the return on investment for that, even if you pay for it, is going to be hundreds or thousands full for not only your income, but your health and the longevity of your career.
Dr. Jim Dahle:
Thank you. We have been talking with Rob Orman, emergency physician, WikiCon speaker.
Dr. Rob Orman:
Wikicon!
Dr. Jim Dahle:
And the Pitt consultant, executive coach and author of Supranormal. You can pick it up today. This is on Amazon or where do we buy this thing?
Dr. Rob Orman:
It’s on all the places.
Dr. Jim Dahle:
All the places, okay.
Dr. Rob Orman:
It’s on Amazon, there’s the audible version, there’s the e-version, the paper version. It’s interesting. I’m not sure if this is the case for your books. I thought that the e-version would be the one that most people would buy. It’s probably 30 to one, the paper version of the book.
Dr. Jim Dahle:
Our ratio is not 30 to one, but we definitely sell more paper than Kindle or whatever.
Dr. Rob Orman:
Yeah. Interesting.
Dr. Jim Dahle:
Very cool. Well, thank you, Rob, for being on the podcast again. Thank you for what you’re doing in your life. We appreciate the help you’re rendering to doctors, not only by doing things like this today, but through your daily work. So thank you for your time.
Dr. Rob Orman:
Jim, thank you. It’s always a treat to chat.
Dr. Jim Dahle:
Okay, I hope you enjoyed talking with Rob as much as I do. He’s always eloquent and always has some great insight about what it’s like not only to be a doc, but to be a doc dealing with burnout.
And while I don’t know that I have had clinical burnout from my clinical work, I have certainly had burnout from WCI. I can remember back in 2019, I was basically still working, for the most part, two full-time jobs. We were trying to hold WCI together with four part-timers. And you just get sick and tired of being sick and tired. And Katie and I stared at each other and said, “We don’t even need this. We’re already financially independent. What are we doing?”
And we had some long conversations and a lot of thought about whether we wanted White Coat Investor to get bigger and hire a lot more people, or make it smaller and do a whole lot less. And thankfully, we were able to make it bigger. We have a wonderful team here. We are thrilled with having them, and it makes a huge difference in our lives.
But the most important part is we know there are a ton of you that weren’t White Coat Investors in 2019, and we would have never been able to help you if we hadn’t been able to get through that burnout episode.
Well, it’s the same way with your patient care. If we can’t get you through this burnout episode, think of all those people and their families whose lives you are not going to be able to impact.
So, we want to get you through it. And whether you get through it by coming to WCICON and learning from people like Rob, he was a speaker there just last year, whether you get through it by reading his book, by hiring a coach, whatever it takes, get through it.
Not just because burnout is the biggest risk to your financial life, but because we need you in medicine in some way, in a way that works long-term, in a way that works for your career longevity. We need you in medicine. So let’s see what we can do to get you the help you need so that you’re able to stay with it.
SPONSOR
All right, full disclosure. What I’m about to say is a sponsored promotion for locumstory.com. But the weird thing here is there’s nothing they’re trying to sell you. Locumstory.com is simply a free, unbiased educational resource about locum tenants. It’s not an agency. They simply exist to answer your questions about the how-tos of locums on their website, podcasts, webinars, videos, and they even have a locums 101 crash course.
Learn about locums and get insights from real life physicians, PAs, and NPs at whitecoatinvestor.com/locumstory.
Don’t forget about that early bird pricing at WCCON. Now through September 22nd, you save $300. Register at whitecoatinvestor.com/wcicon, or WikiCon. Don’t spell it like WikiCon or you won’t go to the right place. Spell it WCI Con.
Please leave us a five-star review and tell your friends about the podcast. It really does help spread the word. A recent one came in saying, “Life-changing. So grateful for Dr. Dahle and WCI. I went through most of residency, making the wrong choices, but luckily discovered his book and then podcast. Now my wife and I are student loan free and have a written financial plan. I recommend WCI to anyone that will listen.” Five stars. Thanks. That’s a very kind review, and we’re grateful we were able to help you.
Okay, keep your head up, your shoulders back. You’ve got this. The entire White Coat Investor community is standing behind wanting to help. We’ll see you next time on the podcast.
DISCLAIMER
The White Coat Investor podcast is for your entertainment and information only and should not be considered financial, legal, tax, or investment advice. Investing involves risk, including the possible loss of principal. You should consult the appropriate professional for specific advice relating to your situation.
Milestones to Millionaire Transcript
INTRODUCTION
This is the White Coat Investor podcast Milestones to Millionaire – Celebrating stories of success along the journey to financial freedom.
Dr. Jim Dahle:
Welcome to the Milestones to Millionaire podcast.
This podcast is sponsored by Bob Bhayani of Protuity. He is an independent provider of disability insurance and planning solutions to the medical community in every state and a long-time White Coat Investor sponsor. He specializes in working with residents and fellows early in their careers to set up sound financial and insurance strategies.
If you need to review your disability insurance coverage or get this critical insurance in place, contact Bob at whitecoatinvestor.com/protuity. You can also email info@protuity.com or call (973) 771-9100.
All right, you may not be aware of this. We have recommended pages. We get asked for resources and referrals and recommendations all the time. And so we put those together on the White Coat Investor website. If you go to whitecoatinvestor.com, you’ll see at the top a recommended tab. And one of those you may not know about if you scroll down under experts there, you’ll see a link for practice management.
And on that page, we have all kinds of resources. We have people asking all the time for help with practice management and consultants and things like that. And so as we find those partners, this is the page we put them on. There’s companies there like Wisdom Dental Billing and Argus Medical Management and Medical Revenue Recovery Group and Thrive Dental Coach. And as we find other great resources for you, we will add them to that page as well. We also include all kinds of information about practice management software and all kinds of other revenue growth strategies and things you can do about your practice management.
Now, I know that only like 50% of dentists and a quarter of physicians actually own their practices these days. But if you’re one of those, check out the resources we have there and the information we have there. I think it’d be very helpful. You can go directly there just by going to whitecoatinvestor.com/practice-management, or you can just go into the recommended tab on the main website.
INTERVIEW
All right. We have a great interview today. Let’s get them on the line. I think you’re going to like this one.
Our guest today on the Milestones to Millionaire podcast is Matthew. Matthew, welcome to the podcast.
Matthew:
Hi, Jim. Thanks for having me. Appreciate your time.
Dr. Jim Dahle:
Introduce yourself a little bit to the audience. Tell us what you do for a living, where you’re at in the training pipeline, and what part of the country you’re in.
Matthew:
Absolutely. I just finished a fellowship after a long, many years process. I currently practice in the Midwest. Just started my attending role for about a month now. And it was a long process getting through internal medicine. And then I did a fellowship in gastroenterology. In my last year, I did a combined fellowship in transplant hepatology. I currently serve as a transplant hepatologist, but also in a GI role as well at an academic institution.
Dr. Jim Dahle:
Yeah, super specialized. Congratulations on finishing. That is no short path.
Matthew:
It’s a long one.
Dr. Jim Dahle:
Okay. Tell us what milestone we’re celebrating. You hit a pretty impressive net worth before you were done with your training. Tell us what that is and then some details, how you did it.
Matthew:
Absolutely. I have probably about a month left of fellowship. I have an app that keeps track of everything in terms of net worth. And my wife and I, we actually crossed the $600,000 net worth, all assets and debts combined.
Dr. Jim Dahle:
$600,000 before we even got out of training. I think my net worth coming out. Keep in mind, the military paid for my school, so I didn’t have student loans. I had a $5,000 student loan. But I think my net worth was like $20,000. That’s what I came out with. That’s been a little while. But even adjusted for inflation, it was nowhere near $600,000. $600,000 is off the charts. So tell us about your assets and your liabilities. What is that made up of?
Matthew:
Absolutely. We have currently, I would say, we own a home. My wife, we have two boys together. She was a teacher for many years, kind of throughout my entire medical training after I got out of the military. And so that was a huge financial support along the way. But we had a little luck with COVID and buying our initial house and residency, selling that for a profit, and then eventually bought our current home. I think we have a net value of that house of plus about $150,000 or so.
In that time frame, really just focusing on a lot of investing over the last three years, focusing on our Roth IRAs and kind of building those up, as well as a very decent emergency fund. The combination between all of that, as well as the kids’ 529s, I think it’s about $300,000 plus or minus. And the remainder is mainly cash assets or car values. So, combined total is about $600,000. As of this recording, it’s about the same. And the only debt that we have is our mortgage currently. So that’s a huge benefit.
Dr. Jim Dahle:
I know about what teachers make. And I know about what residents and fellows make. This is not a super high income. If I look back over a six- or seven-year training period, $600,000 is pretty close to all of it, at least after taxes. You basically got everything you ever made. What was your net worth going into med school? Did you have a whole bunch of money before then?
Matthew:
I remember our savings account was probably less than $10,000. And we lived in an apartment, as every med student does. And honestly, I got the GI Bill for my service in the military. So that basically covered the rent aspect of things and the tuition. And then it was honestly living off a teacher’s salary for pretty much everything else. We paid off our cars as aggressively as we could.
Dr. Jim Dahle:
She was teaching during med school?
Matthew:
Yes. Yes. She was the main source of income during that.
Dr. Jim Dahle:
She’s been earning for 10 years, even if you’ve only been earning for seven.
Matthew:
That’s right.
Dr. Jim Dahle:
So that helps quite a bit. Okay, tell us about your investments. What kind of accounts do you have?
Matthew:
We both have Roth IRAs right now. That’s probably the bulk of our investments. My wife, through teaching, has a pension plan, which she’s contributed to as a teacher for honestly well over 12 years. It’s probably closer to 15 years at this point. So that makes up her vested amount is about $60,000 and that alone. Obviously, pensions are calculated a little differently in terms of how they’re distributed.
But outside of that, my current employer has a lot of opportunities for pre-tax contributions. And so we’re taking advantage of that now. But it currently makes up a small portion of our portfolio.
Dr. Jim Dahle:
Because you just got out of fellowship.
Matthew:
Yeah, that’s correct.
Dr. Jim Dahle:
Okay, but now I was interested when I saw your list of accounts that you’ve already got some money in 529s.
Matthew:
Yes.
Dr. Jim Dahle:
How come you decided to start 529s relatively early in your career? Certainly before the big money started rolling in.
Matthew:
Before I rolled those over to Fidelity, I think the broker that we were utilizing, they required like a $50 minimum a month contribution without any fees. So I kind of like set it and forget it. And honestly, during the time of residency in medical school, I would put $50 a month for each of our kids in there. But I wasn’t even saving for my own retirement. It was very backwards. And in retrospect, not the right way to do things.
But in my mind, I was always like, “Well, I’m going to become a gastroenterologist or hepatologist. The income will come, I’ll save for retirement later.” And so that $50 minimum just kind of forced me to contribute to that. And that’s kind of where those essentially came from. And then my parents and my wife’s parents, the kids’ grandparents, essentially, they contributed about $1,000 a year to support them as well.
Dr. Jim Dahle:
But that’s grown to about $60,000 already, which is pretty awesome. How old are the kids?
Matthew:
My oldest is 11. He was born before I went to medical school. And my youngest is seven. So he was born my third year of medical school, I believe.
Dr. Jim Dahle:
So they’ve still got some time there. But what a great start. I mean, I had nothing saved for kids college. I had pretty close to nothing when I got out of four years of being an attending physician in the military. It really wasn’t that much at all.
So pretty cool. You guys are obviously crushing it. Most people do come out of residency or fellowship with a negative net worth. Their student loans are more than any money they were able to invest by far. Obviously, it helps you have the GI Bill from your prior service that helped avoid the student loan part. But even if you just ignore that, this is pretty awesome what you guys have accomplished. And her income has helped. Obviously, she’s been working along the way. It’s not like you don’t make anything as a resident or a fellow, and you obviously save some of that.
But tell us about how you guys manage money. You sound like you’re pretty close to being on the same page. So give us a sense of how you guys have budgeted and managed money over the years.
Matthew:
Well, historically, I think even in medical school, I had a spreadsheet, and I knew how much our fixed costs were, and about how much our credit card bill comes to every month. So the goal was those two really should be zero. Zeroed out, so we were living on less than we make. And that was the back of the napkin math of doing things for the longest time.
And honestly, fast forward to only about the last three years or so is when I really started budgeting more seriously in terms of how much are we spending on food, how much are we spending on gas, etc. Just to have an idea of where all of our money is going rather than this lump sum credit card bill.
And so that’s been more stringent, but it’s allowed us to have an idea of where our money is going, but also save more aggressively into either investments or our savings account. So that’s helped with planning and being more knowledgeable about it. But historically, we honestly lived off of less than we made. That was probably the biggest factor, not having credit card debt.
And then also, my wife and I weren’t shy to hit up the garage sales or other things, or her parents getting rid of their kitchen table that they’ve had for years. It’s still currently our kitchen table at our home. Those types of things have gone a long way in terms of helping us keep financially afloat during the last 10 years.
Dr. Jim Dahle:
Yeah, it turns out frugality matters.
Matthew:
That’s what it does.
Dr. Jim Dahle:
Is one of you more of a spender than the other? What’s the biggest fight you guys had about money?
Matthew:
Oh, she’s the traveler. The biggest predicament now is I’m very much like, “Hey, save and invest. Let’s really hit the ground running with this.” And she’s along the lines of, I want to go on four trips and build a chicken coop in the backyard, those types of things. And so we all want to do these things, but the order of things is a little bit more of a discussion. But we’re both very frugal where she doesn’t need all the bells and whistles. I tend to do it if it’s something I don’t want to hang on to long term. But overall, it’s very balanced. Communication is still ongoing, despite being married for almost 17 years at this point. But it’s been great.
Dr. Jim Dahle:
I imagine you can build quite a chicken coop for the cost of a nice trip.
Matthew:
Don’t tell her that.
Dr. Jim Dahle:
All right. Very cool. Very cool. I’m impressed with what you guys have accomplished. It’s pretty awesome. Looking back on your military service, were you already planning to go to medical school? Was this a strategy or was this sheer dumb luck that you actually ended up getting paid twice as much as you thought you were in the military because you got so much value out of that GI Bill?
Matthew:
Initially, way back when I joined the Marine Corps and went into the infantry. So not many Marine Corps infantrymen become physicians. So that in itself is its own story. I know of one and that’s about it. But outside of that, that was the plan was to enlist, serve, deploy overseas, and then eventually go back in as an officer and kind of serve in that same role. That was the plan out of high school was to pursue that path.
And then, honestly, as time evolved and I was going to college and was planning on starting a family, it was more of like, “Well, I know military life and I know high school. I don’t know anything beyond that.” And so rather than committing to that plan that I may or may not have enjoyed, ultimately just decided to go to college and see where that took us.
And ultimately, through college and the background of more of the science classes, got interested in medicine and kind of took off from there. So it was an interesting car ride. Our parents live about five hours away from us. And so the long travel home, all of a sudden, I brought up one time like, “Yeah, I think I’m going to apply for medical school.” And so that makes for a very interesting, very long five hour car ride.
Dr. Jim Dahle:
I went over like a ton of bricks.
Matthew:
Yeah, that sounds about right. So the plan was like, “Hey, if I do all this and you get through all this and you can choose whether or not you want to work after this is all said and done.” And so that was the deal on the table 10 plus years ago at this point.
Dr. Jim Dahle:
Yeah. And what do you think? Have you gotten your first attending paycheck yet?
Matthew:
It hit already. And honestly, most of it went towards the investment accounts and things for now. But she’s no longer working full time, taking time off to just kind of figure out what’s the best next step for her. She will still be substitute teaching. She really enjoys teaching. But there’s no real pressure to do that full time at this point. And so it’s more for fun than anything and being with the kids.
Dr. Jim Dahle:
Yeah. Financially speaking, she’s done her part for the family.
Matthew:
That’s correct. She reminds me of that constantly.
Dr. Jim Dahle:
Very cool. What years were you deployed? And where were you sent?
Matthew:
I was deployed to Iraq in 2007. We lived in the farmland area outside of Fallujah. I did that deployment for seven months and then came back and then deployed again. In 2009, we were on a marine expeditionary unit. So with a naval group that was off the horn of Africa with the pirates and Captain Phillips type stuff that was going on at that time. We were there for that as a sea service deployment.
Dr. Jim Dahle:
Well, thank you for your service. We may have laid eyes on each other at some point if you went through Qatar on the way into country.
Matthew:
It’s possible.
Dr. Jim Dahle:
I was there in 2007. So thank you. All right. Well, there’s somebody out there like you thinking about maybe a career change, maybe somebody that would like to start a little bit later in life and needs to be building wealth even during residency and fellowship. What advice do you have for those people?
Matthew:
I think everybody’s story is a little different. And so, I’m very fortunate enough to be in the position that I’m in, not having any med school debt and consumer debt. But I think a lot of that comes down to really just being proactive and knowing where your dollars are going. And most people, they may not need to budget every single dollar as it comes in. But having a general idea of what your fixed costs are and where this money is going. And ultimately, with that goal of living on less than you make, I think student loan debt aside, I think can go a long ways in terms of being able to recover from that.
Dr. Jim Dahle:
All right. Well, Matthew, thank you so much, not only for your service, but being willing to come on the podcast and serve some more, helping White Coat Investors to be inspired to be financially successful. Congratulations to you. I know you have a great career ahead of you, both helping a whole lot of people, as well as becoming very financially successful. And I wish you best of luck moving forward with your investments and your career.
Matthew:
Thanks, Jim. I appreciate your time.
Dr. Jim Dahle:
I hope you enjoyed that. It’s always good to talk to a fellow veteran, especially somebody who’s over in the Middle East, same time I was. It’s interesting. Everybody does have a different path, and we all find success in our own way. It might be that you started a little bit later than somebody else, but you had the GI Bill to help. Or maybe you had a little bit of help from your parents, then another doctor didn’t help. Or maybe you ended up in a higher paid specialty or a lower cost of living area.
You have advantages in your life. You might think that you have no advantages whatsoever. You’re always looking at we tend to compare and we tend to compare up usually. But the truth is you have advantages that other doctors don’t have. Financial advantages. Maybe your spouse works. Maybe they’re only a teacher. Maybe they’re another physician. You never know. But whatever your advantages are, take advantage of those. Be grateful for them, but take advantage of them.
And you also have some weaknesses. Maybe you have $450,000 in student loans. Maybe you’re in an academic PM&R job that maybe doesn’t pay that much. So your income is a little bit lower.
There are strengths and weaknesses in all of our financial pictures. What I want to encourage you to do is take the strengths and use them to make up for the weaknesses. Don’t dwell on the fact that something’s not perfect in your financial life. Something isn’t perfect in your financial life. You might be like I was. You came out of residency and you’re only making $120,000. That was a significant weakness in my financial life.
But you know what strength I had? I didn’t have any student loans. So low income, yes. No student loans. They kind of canceled each other out. Four years later we didn’t have any debt and we’d started building some wealth and then I was able to get a higher income.
We’ve all got our own financial strengths and weaknesses, but if you pay attention to your finances, they will improve. They will, instead of being a stress in your life, will be a strength in your life and you will be able to move forward toward your reasonable financial goals.
Remember, this is all a one player game. You don’t have to have more money than the other person on the White Coat Investor Forum. You don’t have to have more money than your colleagues that you work with in your department. The point is to meet your goals. Hopefully taking as little risk as possible, but to meet your goals. It’s a single player game. We can all win it. It’s you against your goals.
FINANCIAL BOOT CAMP: HOW TO CHOOSE A FINANCIAL ADVISOR
Let’s talk about how to choose a financial advisor. The truth is the vast majority of doctors, I estimate something like 80%, Bill Bernstein would tell you 99% of doctors need a good financial advisor. When I say good financial advisor, I’m talking about somebody who gives good advice at a fair price. That’s what you’re looking for, good advice at a fair price.
And the vast majority of people who call themselves financial advisors really aren’t what I consider true financial advisors. They are product salespeople and they might be selling insurance products. They might be selling mutual funds. They might be selling some other type of investment. That’s not a financial advisor. That is a salesperson masquerading as a financial advisor. And the reason they’re able to do that is because there is no legal meaning of the term financial advisor.
In general, when you’re looking for a financial advisor, you’re looking for two services. One is financial planning and the other is investment management. And they’re often bundled together, but do not have to be. But either way, if that’s what you’re looking for, you don’t want to be paying somebody to sell you products because you’re not looking to buy products. You’re looking for a plan. You’re looking for somebody to manage your assets. You’re not just looking for someone to sell you something.
The first thing to look into is how they get paid. And you can just ask them that. Or you can look it up on their required disclosure documents. The best financial advisors tend to put their fees right on their website and you can look it up very easily and know exactly what you’re going to pay and how you’re going to pay them.
But you’re looking for fee only advice. Fee only means you pay them like you pay your attorney, like you pay your doctor, like you pay your accountant. They do a service, you pay them a fee. Now imagine you’re going to see your doctor and they didn’t actually get paid for giving you advice. They only got paid a commission, a percentage of whatever medication they prescribed for you. So they prescribed you Zoloft and it cost 30 bucks a month. Well, then they get paid $5 a month. Indefinitely while you’re on the Zoloft.
Well, the problem with that sort of a model, as you can imagine, is the conflicts of interest. Maybe if they put you on Selexa, they’d get a $10 a month commission instead of a $5 a month commission on Zoloft. So now you can see the problem with getting that biased advice that comes from not being fee only.
And they might be completely commission based. That’s the way a lot of insurance agents work. They just get paid a commission when they sell you a policy. Or they might be what’s called fee based, which means they get paid fees and commissions. Just recognize that fee only is not the same thing as fee based.
You also want an advisor that is a fiduciary. Fiduciary is a word that means basically Hippocratic. It’s somebody that is going to do the right thing for you, even if it’s not necessarily the right thing for their pocketbook. Basically, they’re putting your needs first. You want an advisor that intends to act as a fiduciary, is legally required to act as a fiduciary, and actually does act as a fiduciary because the vast majority of advisors are going to tell you they’re going to be your fiduciary. But you want somebody that you see ongoing evidence that they are actually doing so.
You want them to believe in a reasonable investing philosophy. There are all kinds of people out there that invest in all kinds of different ways. The academic literature is pretty clear about the best way to invest, at least as far as investing in publicly traded stocks and bonds. The way to do that is to keep your costs low, be broadly diversified, and don’t be jumping in and out of the market all the time.
So what does that mean? That usually means investing in low cost, broadly diversified index funds. If that is not a huge chunk of the portfolio that this advisor is going to put your money into, you probably need to move on to a different advisor. People who are picking stocks, people who are chasing performance, people who are trying to time the market are probably best avoided when you’re looking for someone to help you with your investment management.
You can also ask for help. When you ask for what you need, figuring out what services you actually need, and then asking if they provide those services can be very helpful. You don’t necessarily just want somebody to manage investments for you. You might want some advice planning your taxes or making projections for retirement or analyzing your insurance or doing estate planning or helping you with your cash flow, which might be the most important aspect of what a good financial planner can help you with.
Understand what services an advisor offers and see if that actually aligns with the services you need. If you have no idea what services you need, that makes it very difficult. But if you can at least write down a handful of what you really need done, that will help you find that person that can offer those.
Ask them what their typical client relationship looks like, how often they’re going to be meeting with you, what happens between the meetings, and find out who exactly you’re going to be working with. If it’s not the owner of the firm, maybe you ought to talk to the planner that you’ll be working with before committing to hiring them.
Some advisory companies tend to specialize whether it’s in business owners or tech workers or physicians in the case of a lot of the financial advisory companies we work with. Now, the truth is 95% of it is the same for everybody, but it’s nice to have someone that has a few clients like you so they understand the issues that are unique to you.
You wouldn’t believe how many accountants out there don’t seem to know anything about a backdoor Roth IRA process, which seems so common among the White Coat Investor community, but actually isn’t very common once you get away from physicians and other high income earners. So you want someone who has clients that are somewhat like you.
You may want to ask them how they approach taxes. Do they coordinate with a CPA or other type of accountant or enrolled agent? Ask about if you’re going to have a taxable account that they’ll be managing, ask about things like tax loss harvesting and Roth conversion strategies and how they plan to withdraw from the portfolio and make sure they’re doing that in a way that is tax savvy.
It can help to ask them to walk you through a sample financial plan. If they’re a financial planner and they make financial plans for other people all the time, they should be able to bring you up one that’s anonymized and help you see what you would be getting. You want to actually see the deliverable. What is this written financial plan they’re helping you to make actually look like when they’re done with it? Talk to them about how they measure success for their clients.
And if they start talking about beating the market and things like that, that’s kind of a turnoff. You want to see somebody who’s actually talking about your goals and is focused on your goals and achieving those goals while taking the least amount of risk possible.
Ask them what they do in a bad market. Will they be contacting you more often? How are they going to communicate with you when stocks are dropping like crazy? Because it’s going to happen. There’s a bear market on average every three years. And what should you expect as far as support from them when the next bear market hits? Ask them about what changes, if anything, they will make during the bear market so you understand and so you can see what their temperament and discipline is like.
Ask them about their conflicts of interest. Ask them if there’s any revenue sharing agreements or proprietary products or insurance commissions. If they say they have no conflicts whatsoever, either don’t understand the question or aren’t being honest, even a fee-only, hourly-charging financial planner has some financial conflicts of interest. He’s incentivized to take longer to do your work than it might otherwise take because he gets paid by the hour. So everybody that’s getting paid has some sort of conflict of interest and ought to be comfortable discussing it with you very openly.
You can ask about their credentials. The most common credential for a financial planner is a Certified Financial Planner, a CFP. There are a few other high-level designations like a CFA, or a CHFC, or a CPA, but the vast majority of letters after the names of a financial advisor represent the equivalent of weekend courses. So just because they have 20 letters after their name doesn’t mean all that much unless some of those letters represent a significant commitment to the profession.
While credentials matter, their behavior actually matters more and it’s entirely possible for somebody with fewer credentials to actually be a better financial advisor. But I like to see some of the basics done showing that they’re going to be committed to the profession long enough to be providing you advice and service for many years.
You can ask questions like “What would make this a bad fit for me?” Not every client is right for every advisor and there ought to be some clients that your advisor is just not the right fit for and they can talk to you about that.
You should also talk about the end. Any financial advisory relationship does not last forever and you should know how it’s going to break up from the beginning. Are there any contracts or lockups or exit fees? And who holds custody of the assets? You want flexibility and you want control and you want to be able to move on to another advisor if this isn’t working out very well.
You don’t want somebody that makes it hard to leave. You want somebody that feels complimented. When you go to them and say, I think I know enough now to do this myself, they should be feel like that’s a compliment and help you to take over on your own rather than fighting you every step of the way to keep you as a client so you keep paying them fees.
Choosing a financial advisor can be tricky. Getting referrals from people you trust, such as going to the White Coat Investors financial advisor recommended list is a great place to start your due diligence process.
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This podcast was sponsored by Bob Bhayani at Protuity. One listener sent us this review. “Bob has been absolutely terrific to work with and has always quickly and clearly communicated with me by both email and or telephone with responses to my inquiries usually coming the same day. I have somewhat of a unique situation and Bob has been able to help explain the implications and the underwriting process in a clear and professional manner.”
Contact Bob at whitecoatinvestor.com/protuity today. You can email info@protuity.com or you can call (973) 771-9100 and get your disability insurance in place today.
This is the Milestones to Millionaire podcast where we feature you and your successes and use them to inspire others to do the same. You can apply to come on the podcast at whitecoatinvestors.com/milestones.
But I’ll be honest. It’s getting more and more competitive to come on. And if your goal coming on here is to promote your business or something like that, don’t bother applying. We’re just trying to feature regular White Coat Investor listeners and the successes they have had.
We’re not going to bring you on if your goal is to find investors for your real estate business or bring people into your VC fund or something like that. It’s not necessarily a place to toot your horn, but we’re going to do some horn tooting with your successes because we want people to understand that doctors, it’s okay to focus on finances with a certain amount of your time and a certain amount of your life.
And if you do that, it will help you to be a better doctor, better partner, a better parent, a better physician, et cetera, because you’re not going to be worried about money and you can really focus on what matters the most.
Until next time, keep your head up, shoulders back. You’ve got this. We’ll see you on the podcast next week.
DISCLAIMER
The White Coat Investor podcast is for your entertainment and information only. It should not be considered financial, legal, tax, or investment advice. Investing involves risk, including the possible loss of principal. You should consult the appropriate professional for specific advice relating to your situation.
Financial Boot Camp Podcast
Estate planning is a critical part of your financial plan. There are three main purposes to estate planning. The first one is to make sure your stuff, and especially your minor children, go where you want them to in case something happens to you. So it directs where your assets go and, most importantly, designates somebody to be the caregiver, to be the guardian for your child.
You may want somebody separate managing the money on behalf of your child. Some people like to have some checks and balances in the system, but it’s certainly convenient for that guardian to also have access to the money they need to help take care of your child. Frankly, that’s the most important aspect of estate planning and lasts until your youngest child turns 18. That is generally done with a will.
The second purpose of estate planning is to avoid or minimize the painful, expensive, hassle, public process of probate. Probate is basically when a court looks at a will and figures out where everything’s supposed to go. By not having things that are in the will because they’re transferred by some other mechanism, you can minimize the expense and the time and the hassle and the publicness of probate.
You might do that with beneficiary designations for your life insurance policies, or for your annuities, or for your retirement accounts, and then they pass completely outside of probate. Likewise, anything you own in common with somebody else just becomes theirs when you die and thus passes outside of probate. Be careful; you might lose what’s called the step-up in basis at death and give them higher income taxes by doing that, but it does keep it outside the probate process.
Another common way that people keep assets outside of probate is to use a revocable trust. This is a trust that you can put stuff in and take out at any time while you’re alive. But when you’re dead, anything that’s inside that trust is passed outside of probate.
The third purpose of estate planning is just to minimize the taxes associated with your death. Those can be federal estate taxes, they can be state estate taxes, they can be state inheritance taxes, they can also be income taxes.
Now, the vast majority of Americans don’t have any taxes due as a result of their death, thanks to living in a state without an estate tax or inheritance tax, or being below the minimum exempted amount from those taxes. The federal exemption is also quite large. It’s $15 million, $30 million if you’re married, and indexed to inflation, and so it goes up in future years from that amount. And so most people just aren’t wealthy enough that they owe any estate taxes. They owe no death taxes whatsoever.
They should still pay attention to some of the income taxes associated with that last year of life and those sorts of things. But for the most part, everything you own directly gets a step-up in basis at death. It’s as though your heirs bought them on the day you died at that price, and so if they sell them immediately, they don’t owe any income taxes on them anyway.
And so most people don’t need to worry that much about death taxes. But if you are wealthy enough to have an estate tax problem, I congratulate you. You know, $30 million-plus for a married couple is no small amount of assets that you acquire during your life. You should be congratulated on that.
Recognize that amount is much smaller in some states. For example, in Oregon, it’s only $1 million, and then you’ve got to start paying estate taxes above that. And in some states, the estate tax can be pretty onerous. In Washington, the top estate tax bracket, it doesn’t start at $1 million; it starts at about $9 million, is 35%. But you add that on to the federal estate tax of 40%, and 75% of everything a very wealthy person owns in Washington State is going to the taxman rather than going to the people or the organizations they would rather see them go to.
So obviously, in that sort of situation, doing some estate planning, preferably earlier in life when you can make a bigger difference, is very worthwhile to prevent that from happening. In general, people think of estate planning; they think of documents.
Now, really, what estate planning is is the decisions behind the documents, right? Who’s going to care for your children? Where do you want your assets to go? If you’re leaving money to your kids, when do you want them to get it, and under what circumstances? And how much? If you’re leaving money to charity, which charities, and when do you want to give it, and in what form? You know, these sorts of decisions are the hard part.
But generally, you do walk away with some documents as well. Typically, a will, maybe a revocable trust, maybe an irrevocable trust or two. Often, some documents like a durable power of attorney, and this can be useful both in the event of your death as well as in the event of your disability for somebody to manage your financial affairs.
People also often throw in some healthcare documents. You know, these are under the broad umbrella term of a healthcare directive, and maybe it’s a living will that actually says what you would want done in the event that you’re incapacitated. Do you want to be on a ventilator? For how long and for what conditions? Do you want CPR done on you? Those sorts of things. You might also designate a healthcare power of attorney, somebody to make decisions for you in the event that you’re incapacitated.
Those of us who work in healthcare know that it doesn’t usually come down to requesting the documents and poring over the documents when making medical decisions. For the most part, we talk. If we can’t talk to you, we talk to the people that seem to care about you the most, whether that’s a spouse or your children or somebody else, and ask them what you would want.
So make sure when you create these sorts of documents and make the decisions about what you would want done in your later years of life that you share those decisions with those you care about. That’s probably even more important than creating the document. I’ve seen family members be pretty uncomfortable making those decisions because they don’t know what you want. When you’ve actually told them what you want, the decision-making is much easier for them at a very hard moment in their lives. So please do share those with others.
So a lot of people ask, “Do you need a trust or is a will enough?” Well, there are two types of trusts. There’s revocable trusts and irrevocable trusts. Irrevocable trusts, for the most part, are about avoiding estate taxes and maybe some asset protection benefits. Revocable trusts are mostly about avoiding probate.
If you don’t have any of those issues, you don’t need a trust at all. And in some states, probate just isn’t that painful or expensive. And so maybe it’s no big deal to run your estate through the probate process. Maybe it’s not worth spending the money and the time to create a trust up front.
In other situations, it’s clearly well worth creating a trust and passing as much through the trust as you can, rather than via a will and the probate process. But it’s a discussion that’s well worth having with an estate planning attorney in your state.
For most white coat investors that are going to acquire substantial assets during their life and probably die as a multimillionaire, it’s worth spending a few thousand dollars talking to a specialist in this, an estate planning attorney in your state, because these laws are all state-specific, and really coming up with a plan that you are comfortable with.
More and more these days, you can get a will and even some basic trusts online. Maybe an attorney looks over it at some point, but I don’t think it’s the same as sitting down across the table from somebody who really does this day in and day out and feeling like you have somebody in your corner that’s really made sure you’ve dotted all the I’s and crossed all the T’s in this process.
I mentioned earlier beneficiary designations. Very important. It’s a good way to pass assets outside of probate, and for the most part, you don’t want assets like life insurance policies, the proceeds of them, or retirement accounts coming to your estate at death. You want them going to your beneficiaries, but you want them to be the right beneficiaries. Maybe the beneficiary is a trust, maybe it’s your spouse.
But if something happens in your life, your spouse dies, you get divorced, you get remarried, you get married for the first time, you probably want to look at all your beneficiary designations, make sure your money is still going where you want it to go.
Okay, there are a fair number of advanced estate planning techniques out there. Most of them are sold at least partially for asset protection reasons, and the truth is that most good asset protection plans were put together for another reason, usually a business reason or an estate planning reason, not just to avoid paying your creditors in the event you get a judgment against you. But it’s worth considering all those considerations as you go along.
But we’re talking about things like family limited liability companies, family limited partnerships, a lot of types of irrevocable trusts, particularly domestic asset protection trusts, and so you start mixing your asset protection plan and your estate plan together.
Is that worthwhile? It probably is for some people, especially when you have a lot of assets that aren’t protected by some other mechanism in your state. Typically, your retirement accounts are all protected, and that tends to be the lion’s share of assets for most wealthy physicians. But if you’ve got a lot of money that’s outside of retirement accounts that isn’t protected by some other law in your state, it’s probably worth thinking about some of these techniques.
Just recognize that there is a fair amount of uncertainty as to whether they will work for the asset protection reasons, and that it’s all governed by state law, so it varies by state as well. And very little of it is free. Sometimes the cost is really kind of exorbitant for the amount of benefit you’re likely to get from it, since most people never get into an above-policy-limits judgment situation.
Estate planning is well worth doing. The most important aspect, of course, is making sure your minor children are taken care of and making sure your money is going in the right way, at the right time, to those that you care about most. But there’s a little more nuance to it in avoiding probate and reducing your taxes along the way.
The White Coat Investor Podcast is for your entertainment and information only and should not be considered financial, legal, tax, or investment advice. Investing involves risk, including the possible loss of principal. You should consult the appropriate professional for specific advice relating to your situation.
The post How to Build a Medical Career Worth Keeping with Rob Orman appeared first on The White Coat Investor – Investing & Personal Finance for Doctors.
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