How to Rise Above a Broken Healthcare System with Dr. Dimitrios Tsatiris

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:
This is White Coat Investor podcast number 431.

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QUOTE OF THE DAY

All right. Our quote of the day today comes from Dave Ramsey. Like him or hate him, here’s what he said. “Financial peace isn’t the acquisition of stuff. It’s learning to live on less than you make so you can give money back and have money to invest. You can’t win until you do this.” Good advice there.

Thanks, everybody out there, for what you’re doing. We’re going to talk about doctors today. We’re going to talk about doctors and a lot of the issues they’re having out there which are legion. There’s a real problem in medicine. It’s called burnout. There’s a lot of factors that go into it. It might be toxic work. It might be a little bit of mental illness among doctors. It might be financial stress. There’s a lot that causes this. We’re going to talk about it today and some of the things you can do to reduce it because it is a huge financial risk in your life.

You know what else is a financial risk in your life? Being an idiot about money. I do not want you to be dumb about money anymore. I want you to be brilliant with money and you’d be surprised how high yield the first few things you learn about money can be.

We’re going to do a financial crash course. This is live, August 19th, 06:00 P.M. Mountain. It’s 05:00 P.M. Pacific, 08:00 P.M. Eastern. We’re not going to spend all evening doing this. I’ve prepared a presentation for you and we’re going to stick around afterward answering questions. These questions that you’ve got out there about your finances.

Whatever the questions are, we’ll take them whether they’re basic questions or not. The presentation is going to be getting you up to speed hitting the high yield stuff. This is the crash course for your finances. This is what you ought to invite your friends and your family and that doctor in the lounge that you know needs this stuff. Invite them to this. It’s going to be perfect for them.

There’s just too many doctors out there stressed out about money, living paycheck to paycheck, not building any wealth, even with an attending physician income. You’ve just worked too hard not to be financially successful. Join me on August 19th, 06:00 P.M. Mountain time for a free financial crash course. You can sign up for that at whitecoatinvestor.com/crashcourse.

I’ve got a guest on the podcast today. Let’s get into this interview. We’re going to be talking about burnout. Big financial risk, can’t buy insurance against it. Let’s get Dimitrios Tsatiris on the line.

INTERVIEW WITH DR DIMITRIOS TSATIRIS

Our guest today on the White Coat Investor podcast is Dimitrios Tsatiris. Now, you may know Dimitrios from speaking at WCICON. If you’ve been to a number of WCICONs, you may have attended his talk. How many have you spoken at now?

Dimitrios Tsatiris:
Jim, believe it or not, it’s been four WCICONs. I’m truly grateful.

Dr. Jim Dahle:
Four WCICONs. I’ve spoken at more than that, but I don’t know that anybody else has got more than four. That’s a lot.

Dimitrios Tsatiris:
I’m giving you a run for your money, Jim.

Dr. Jim Dahle:
Yeah, you are. It’s great to have you here on the podcast. I think this is your first time on the podcast.
Dimitrios Tsatiris:
It is. I’m truly grateful and honored to come on the podcast. I thought we would talk about a timely topic, burnout, because a large portion of physicians are suffering from it.

THE BURNOUT EPIDEMIC

Yeah, it’s a real problem. You’ve become a bit of an expert in this. You’ve given talks on this at the conference. You now have a book out. Tell us the title of the book.

Dimitrios Tsatiris:
It was about time I wrote a book on the topic. It’s titled Physician Burnout. That’s what the publisher wanted me to title it. I’ve been working with physicians. About 60% of my clinical practice is caring for physicians through psychiatry, through psychotherapy, through coaching. I figured I would write about that topic.

I wanted to publish academically because I wanted a publisher to look at the evidence that I provided them on the topic and to meet their threshold. It was time to write a book on the topic.

Dr. Jim Dahle:
You say that’s what the publisher wanted. What did you want to call it?

Dimitrios Tsatiris:
I was going to pick something a little more edgy, but I’ll leave that for the next book. How’s that?

Dr. Jim Dahle:
All right. Well, burnout is apparently an epidemic among physicians. When we look at these surveys that ask, “Are you burned out?” 55%, 60%, 65% of doctors say yes. Even if you only ask something like, “Is your burnout severely affecting your life?”, you still get numbers that are way too high, sometimes in the 30% range. It does seem to be a big problem. Yet, there are burnout deniers out there. They’re like, “Well, everybody has burnout. There’s a club for that. It means Friday down at the bar. Everybody hates their job. That’s why it’s called work because they got to pay you to do it.”

What is your take on burnout? What is going on? Is it unique to doctors? Is it more than, I just don’t want to work as much as I’m working? What is burnout? Why is it such an issue these days?

Dimitrios Tsatiris:
Great question. First of all, let’s define burnout. It is a syndrome stemming primarily from work stressors. It has three symptoms. Number one is feeling emotionally exhausted. You go on vacation, you come back, and one or two days back, you’re already depleted.

Number two, it’s feeling detached, feeling detached from your patients, feeling detached from your coworkers, having a negative attitude towards them. Number three is feeling a lack of purpose and meaning, feeling as if your work lacks any sense of accomplishment.

It’s a major problem in medicine. Like you mentioned, it affects the majority of physicians. It’s multifactorial. Number one, medicine is hard from an emotional standpoint. People don’t come to us because they’re happy-go-lucky. They come to us because there’s problems. As physicians, we’re tasked to solve problem after problem, day after day, week after week, month after month. It’s only a matter of time before that takes a toll on ourselves.

Also, number two, life is challenging. As physicians, we’re not immune from catastrophe. We may be dealing with health problems, marital conflict, ailing parents. When you combine work and life, it gets overwhelming.

On top of that, it’s worth noting that as physicians, we’re not the best equipped from an emotional standpoint to navigate challenges. We’ve dedicated our lives to master the skills, to develop the skills of practicing medicine, but we haven’t spent adequate time to develop emotional awareness and mastery.

Jim, I can’t tell you the number of doctors I’ve worked with who struggle with anxiety or burnout but cannot identify the signs and symptoms of anxiety and burnout within themselves. Or I can’t tell you the number of doctors that I work with who just can’t set basic boundaries for themselves because of emotional forces such as guilt.

And I don’t blame doctors because the culture of medicine, it does not promote emotional awareness and mastery. It promotes stoicism, perfectionism, being self-sacrificing, being a workaholic. I don’t blame doctors for not investing in that part of their lives.

And did I mention the system, the healthcare system, which is fragmented and it is designed to deprive physicians of the autonomy and authority to practice medicine. So, I see a lot of doctors in their late 30s and their 40s, they played the game a certain way, they studied medicine, they became physicians, they took out a ton of student loans, they got married, have kids, and now they’re feeling trapped because medicine did not turn out the way they had envisioned it to be and they’re dealing with an existential crisis. And that is not a good feeling. All those different factors contribute to the physician burnout pandemic.

FINANCIAL IMPACTS OF BURNOUT

Dr. Jim Dahle:
Yeah. Now, this is a financial podcast. And in a lot of ways, burnout is your biggest financial risk. If the prevalence of this is 60%, even if it’s only 30%. This is your ability to earn. It’s like getting disabled. You can buy disability insurance, but you can’t buy burnout insurance. So maybe the biggest risk to your financial plan is actually physician burnout, keeping you from being able to earn $200,000 or $300,000 or $400,000 or $600,000 a year, because you just can’t do the work anymore.

Not to mention so many of the techniques for dealing with burnout are costly or involve working less, there’s an opportunity cost there. And so, there’s a lot of financial tie-ins to burnout as well. I think people who have been to WCICON recognize this. We have half the talks about finances, half the talks about wellness and burnout and that sort of thing. And so, there’s a very close connection, I think, at the conference, but I think a lot of people don’t connect these two things in their mind. What connection do you see between dealing with burnout and finances?

Dimitrios Tsatiris:
Yeah, you nailed it. If you’re battling burnout, if you’re feeling detached from work, if you’re feeling emotionally exhausted, you’re not performing at 100%, maybe you’re performing at 60%, 70%, 80%, but you’re leaving money on the table because you’re not firing in all cylinders.

Number two, burnout comes at a risk to your overall physical and mental health. It’s associated with a host of mental and physical health conditions, depression, anxiety, insomnia, I can go on and on. And the issue is that those conditions are also a risk factor to your job performance and security.

And number three, if you’re battling burnout, if you’re emotionally exhausted, if you’re feeling detached from people and you bring that attitude home, that is not good for your marriage. That is not good for your family. And you’re putting cracks in your own marriage and your own relationship with loved ones. And any relationship can handle only so many cracks before it crumbles. And talk about that, divorce and dissolution being a major threat to somebody’s financial health. Considering the overall implications of burnout, it makes sense that it’s the number one risk factor to a physician’s financial health.

Dr. Jim Dahle:
Yeah, for sure. The first thing I tell people who are feeling burned out is why don’t you cut back to full time? Doctors are working so much that the concept of working only 40 hours a week is completely foreign to so many of them. But I find that a surprising amount of burnout goes away if you just work one job at a time. Why do we get suckered into working so many hours?

Dimitrios Tsatiris:
Well, as physicians Jim, we have certain traits. Medicine selects for and reinforces certain traits. In general, we tend to be altruistic. We tend to be idealistic. We tend to be hardworking. We tend to be perfectionists. We tend to be stoic. We tend to be obedient to fit in the culture of medicine.

These traits, medicine selects for them because I believe that they’re intended to improve patient care. You want your doctor to be hardworking and not like to make mistakes and be cool, calm and collected under pressure. So it makes sense that medicine selects for those different traits.

But these traits, when taken to the extreme as they are in medicine, they come at a cost to our mental health. For example, as physicians, we equate having a strong work ethic with self-sacrifice. Working 40 hours, it’s emotionally challenging for us because it induces feelings of inadequacy, feeling guilty, like you’re not keeping up with your peers. If your colleagues work 60 hours and you work 40 hours, you can imagine how you may be perceived by your colleagues.

Dr. Jim Dahle:
Tell me about it. I work six shifts a month. So I can relate to that for sure.

THE PROBLEM OF PERFECTIONISM

Dimitrios Tsatiris:
Yeah. I think when you’re part of a culture that idealizes perfectionism and being a workaholic and self-sacrifice, that’s the outcome that we get.

Dr. Jim Dahle:
Okay. What’s the healthier alternative to perfectionism? How do you stop being a perfectionist?

Dimitrios Tsatiris:
Well, I think, first of all, it starts by recognizing that perfectionism comes at a cost to one’s mental health. In psychiatry, we say that it’s trans-diagnostic. It is a risk factor for any mental health condition, depression, anxiety, eating disorders, suicidal ideation, you name it. It’s a huge risk factor for that.

Number two, we need to recognize that medicine is not perfect. We project perfectionism in medicine, but medicine itself is not perfect. Medicines that we prescribe don’t work 100%. They come with side effects. Many of our treatments don’t always work. We need to substitute perfection, number one, with humility to acknowledge that as human beings in medicine, we have a lot of areas for improvement, that we have our imperfections.

And number two, I think we need to strive for maybe a healthier standard. Instead of being perfect, let’s strive for something like excellence or being outstanding, where you work hard, you do your very best, but you also recognize that, “You know what? we’re not perfect as physicians. Our tools are not perfect when we try to help our patients. So why do we idealize perfectionism when it only hurts our mental health overall?”

STOICISM AND BURNOUT

Dr. Jim Dahle:
Yeah. You mentioned that medicine promotes stoicism, too. What’s the problem with stoicism? It’s usually considered a good thing, isn’t it? I mean, what’s wrong with stoicism?

Dimitrios Tsatiris:
Sure. It comes from the ancient Greek, xenopsidium. So, of course it’s a good thing. Coming from the Greeks, myself being one. But stoicism, like any school of thought, be it a religion, be it a philosophy, there’s a lot of variation.

But at the roots of stoicism, going back to ancient Greece, what stoicism does is it puts reason above everything else. It puts it on a pedestal. And according to the early Stoics, they looked at emotions as irrational, as something that can’t be moderated. So according to the early Stoics, the ideal agent has no emotions because they’re just a hindrance to reason.

Stoicism has a lot of valuable, pragmatic teachings, for example, to focus on your sphere of control, to take a rational approach to life’s problems, and not to want for things, because according to the Stoics, when you want for something, that’s a recipe for suffering, because you either suffer because you don’t have that something, or when you have it, you’re afraid of losing it. When you want, when you desire, it’s a recipe for suffering.

But the problem with stoicism is that it fails to appreciate the value of emotional awareness and mastery. Emotions are valuable. They come with valuable data. You meet somebody, you get a gut feeling about them. It can be hard to put that into words, but your gut is telling you a lot of valuable information about a person or a situation. When we get anxious, it’s a call to action, to avoid consequences. When we get angry, it’s a sign that, “Hey, there’s been an injustice here. Somebody took advantage of you.” When we feel envy, it’s a sign that, “Hey, we want our life to move in a certain direction.”

To ignore one’s emotions is to put yourself at a disadvantage. Stoicism has other shortcomings as well, which I talked about at WCICON24. I’ll mention one more is that it overemphasizes the importance of reason. Reason comes with limitations. I’ve worked with attendings, two attendings, same case, and they’re disagreeing on how to handle a case, how to approach a case, because there’s limits to reason. And there comes times in medicine where we have to go with our gut feelings, educated guesses or intuition based off of the number of people that we’ve worked with in our past. I think stoicism idealizes reason and it fails to recognize its limitations, but also it fails to appreciate the importance of emotional awareness and mastery.

Dr. Jim Dahle:
All right. Well, I think we’ve somewhat defined the problem here. We’re picking all these type A people. We’re putting them into a hard career and we’re making them do it one and a half times as much as anybody else works. No surprise, there’s lots of burnout. And especially now that people are losing control over their workplace too. Now it’s something like 77% of docs are employees. It’s not quite that high among the dentists, but it is that high among physicians.

SOLUTIONS FOR BURNOUT

Let’s talk about solutions. The obvious one, work less. It is pretty darn effective. It’s a good solution. If you can afford to work less, it usually reduces burnout significantly. It’s often not enough, though. What are other things that people can do to reduce their burnout?

Dimitrios Tsatiris:
You nailed it. It’s not always enough. There are doctors who cut back from like 1.0 to 0.8 or 0.6 and they’re still battling burnout. I think number one is identifying the problem. There are doctors who battle burnout who don’t even know that they’re burned out.

And number two, accepting the fact that you need to get some help about it. You can’t solve this by yourself. It’s okay to seek help, to talk to a colleague, to talk to a mentor, to talk to a coach, to talk to a therapist, because when we suppress our thoughts and feelings and we try to solve something by ourselves, thought suppression leads to an exacerbation of that thought and feeling that you’re trying to avoid. And it comes with a cognitive load. It’s like the feeling and the emotion just kind of festers and grows when you try to ignore it.

There’s something very therapeutic about talking about it and releasing it and acknowledging that there’s a problem. Again, doctors, I know we’re very reluctant to seek professional help. The majority of doctors are, but boy, are there a lot of benefits to that. As somebody who’s worked with hundreds of doctors in my career, I can attest to the power and the benefit of working with a professional to help you through the webs of burnout.

But what can people do individually? I like to look at things comprehensively from a biopsychosocial model. Biologically making sure that we’re engaging in healthy coping strategies, like only 50% of doctors exercise. I’m surprised it’s only 50% when we preach that to all our patients. It should be a 90%. Cutting back on things that are unhealthy. Alcohol, a lot of doctors drink. Surveys show that. And I bet you those surveys minimize the problem.

Dr. Jim Dahle:
What do you mean? Everyone’s always honest about their alcohol use. Everyone’s had two drinks.

Dimitrios Tsatiris:
Exactly. Two with dinner, then two with supper. That’s what it is.

Dr. Jim Dahle:
And they don’t say exactly how big the drinks are. Tall drinks.

Dimitrios Tsatiris:
Yeah, yeah. From a psychological standpoint, we have to engage in mental health exercises because if you think about it from an evolutionary standpoint, the job of your brain is not to make you happy. The job of the brain is to help you survive. Think about what the environment was like for our ancestors, I don’t know, 20,000 years ago. It was a very scary place where we could fall victim to predators like lions and cheetahs and whatnot.

To survive that kind of an environment, two things have to happen. Number one, you need to have anxiety. You need to look at worst case scenario. You need to have a lot of what ifs, like what if there’s a lion behind that bush, what if there’s a crocodile lurking under the water.

But number two, you need to be dissatisfied because if you’re dissatisfied, you’re more likely to go hunting for more because satisfaction does not promote action whereas dissatisfaction does.

Because of that, we have to be engaging in exercises to override our evolutionary tendencies. So, what I do every morning is I practice gratitude. I take one minute before I leave my house and I take a moment to feel grateful for something that I have in my life. It might be my kids, my wife, my health, whatever, and all the things that I’ve been spared. Just one minute a day, and it sounds really cheesy and hokey, but it makes a difference.

There’s different types of meditation. There’s mindfulness. There’s transit. There’s so many different types, but it’s important for doctors to be working on their psychology, on how to look at the world around them. And then finally, socially, connection. As doctors, we tend to isolate. When we have a problem, we say that we’re fine and we isolate, and this only exacerbates the problem. To connect, to talk about your problems with somebody else, to spend time with loved ones, that is an antidote to burnout. Again, I like to look at things biopsychosocially, and those are some interventions along that spectrum.

Dr. Jim Dahle:
Let’s go through the list here. We talked about working less. We talked about exercising, and I’m a big fan of exercising. When I’m feeling depressed, I go for a run, and most of the time, it helps. We talked about spending some time, gratitude, meditation, prayer, whatever. We talked about getting social connections, being connected. Those are certainly some great burnout techniques.

What else is there? A fair amount of burnout is probably related to the workplace. You put a bunch of docs into a toxic workplace, and they all get burned out. It’s not necessarily an issue with the individual doc, it’s a toxic workplace. What can we do to help our workplace be better and promote more wellness?

Dimitrios Tsatiris:
Yeah, you’re nailing it. The system is the primary driver to physician burnout. There are countless systemic factors that contribute to the burnout, and the reality is that if we’re hoping for the system to change, boy, are we going to be waiting forever, because there’s no evidence, in my opinion, that the system is going to become more compassionate, more humane, and more physician-friendly.

But what can we do? Support each other. Check in on each other. Have camaraderie. Collaborate instead of compete against one another. As doctors, we’re not the best at supporting one another because we’ve competed against one another during our medical training to get into the residency of our choice or to get the job of our choice.

The other thing is promoting psychological safety. As human beings we need to feel safe to express ourselves, our thoughts, and our feelings, and medicine does not promote psychological safety. We suppress, we repress emotions, and we isolate ourselves. I think to check in with your colleagues, that’s important, to be vulnerable, to be honest, and to give them the time and the space to express themselves. I think it’s also important that we support each other work-wise.

The majority of doctors take less than three weeks of vacation, and they even work during vacation. And I think it’s important that as doctors, we support one another by doing concrete things like, “Hey, let me cover for you when you go on vacation. And then, you know what? When I go on vacation, you cover for me.”

So, when we’re on vacation, we’re actually on vacation and not doing refills or solving patient problems on vacation because you might be spending 15 minutes a day solving a patient problem, but actually you’re spending two hours stressing about that patient and worrying about it and thinking if you did the right thing, which takes you away from the vacation. Doing concrete things to support and take care of one another.

And then one more thing that we can do, let me add this too, finding meaning and purpose in our lives. There’s a study that shows that the lack of meaning and purpose at work is a greater risk factor for burnout than the hours of work that somebody does. Because you can work 20 hours a week, but if it doesn’t have meaning and purpose, you’re still going to be burned out.

You can work 60 hours a week, but if the work is meaningful and purposeful and it’s a calling for you, you’re not going to burn out. Burnout is more than just hours of work. Burnout is also about the lack of meaning, the lack of purpose, the lack of fulfillment, the lack of autonomy. And we need to find ways to reclaim that as physicians, both within medicine, but also in our daily lives.

ARE PEOPLE WHO PROFIT FROM BURNOUT PART OF THE PROBLEM?

Dr. Jim Dahle:
All right. Now is the part of the podcast when I push back on you a little bit. It feels like there’s this burnout industrial complex out there. These people who profit from burnout, they sell burnout courses, they sell burnout books, they do burnout coaching. And they’re constantly reminding us, “Hey, most docs are burned out, aren’t you burned out too?” What role is there for this burnout coaching, burnout specialists in it? Is there a problem? There’s so many physicians out there being burnout coaches.

Dimitrios Tsatiris:
Yeah. Yeah. Let me talk about myself personally and I’ll answer your question. I’ve been a psychiatrist for a dozen years, an attending, and I provide care to physicians, psychiatric care, psychotherapy care. And the practice just grew to the point that I’ve been seeing more and more physicians because it’s meaningful to me. It adds meaning and purpose to my life, treating physicians, because I get it. And I see the blind spots in physicians as far as the difficulties with setting boundaries, difficulties with identifying feelings, difficulties with expressing feelings, and the toll that it takes on one’s mental health.

If you’re going to work with somebody, they better have experience and expertise because anybody can call themselves a coach. You want to work with somebody who knows what they’re doing. At the very least have some kind of certification, some kind of experience having worked with doctors. Because if you work with the wrong person, you’ll get no benefit and actually harm can happen.

The other thing that I want to add is that I believe there’s a huge mental health stigma. And as physicians, we are reluctant to see a psychotherapist because of the stigma against mental health. Mental health is seen as a weakness. We’re afraid that there might be repercussions to our career. But coaching seems like more in. It’s like a back door to mental health. It’s like, I’m not depressed. I’m not anxious. I got a little burnout from work.

So, what I do in my personal life is I meet people where they’re at. I can see the problem from a mile away because I’ve done this a dozen years. But if they want to say that they’re burned out, okay, we’ll stay in the shallow waters with burnout. And then when they’re ready to go into deeper waters with me, physicians, then I go to deeper waters with them. I meet people where they’re at.

But yeah, I think that’s what’s happening. It’s that because physicians are reluctant to seek care for their mental health, and there’s that stigma, they seek coaching as kind of a back door to mental health treatment.

Dr. Jim Dahle:
Now, the correlation between depression and burnout is elevated. It’s not insignificant. Is burnout just depression? Is it separate from depression? Or is this just another one of those depressive symptoms that people get?

Dimitrios Tsatiris:
No, they are different. Burnout tends to be more occupational. That’s the context, more occupational related. Typically, with burnout, when you leave work, you feel better, like when you’re on vacation. But when you return to work from vacation, bam, the symptoms are right back. Whereas depression tends to be more pervasive. If you’re depressed, you go on vacation, you’re still feeling depressed. Or if you’re at home, you’re feeling depressed at home, or you’re feeling down on the weekends.

But again, burnout is the number one risk factor for depression amongst physicians. And that makes sense because we’ve dedicated a major portion of our lives to this calling. And when the calling doesn’t pan out the way that you think it was going to, and you took out a quarter of a million dollars for this call, you can appreciate how that leads to an existential crisis.

But I think doctors feel safer saying that they’re battling burnout versus saying that, “You know what? I’m actually depressed.” Because depression is seen as weakness. Depression is seen as a personal flaw. And it has a negative connotation, does depression, the same thing with anxiety. Whereas burnout implies that I’m working so hard at work, and there’s a problem at work. And there are many problems at work. But it’s more like work related, and it makes it less stigmatizing to acknowledge.

Dr. Jim Dahle:
All right. Dimitrios Tsatiris, author of Physician Burnout: How to Rise Above a Broken Healthcare System as a Practicing Clinician. Thanks for what you’re doing in your work at WCICON, in your work with doctors, and in your daily work with non-doctors. It sounds like docs are becoming a bigger part of your practice though, every year.

Dimitrios Tsatiris:
Yeah, they have found me and they’re coming to me. And again, it’s an honor and a privilege to be working with people in our profession. And again, Jim, thank you for everything that you do for physicians out there to help them with their financial health, because that is essential to a physician’s overall well-being.

Dr. Jim Dahle:
Awesome. Well, thank you for being on the podcast.

All right. I hope you enjoyed that interview. I love that guy. He’s doing great work, helping docs out. Recognize if you’re feeling burnout, whether you got a little depression with it or not, there is help out there. And addressing it now, figuring out how to deal with it now, whether it involves job changes or not, is worthwhile.

Why suffer? It’s like I tell patients all the time in the emergency department. You don’t heal faster because you’re in pain. Let’s get you out of pain. And there’s a lot of psychological pain involved with burnout. And you don’t need it in your life, let’s get it out of your life, that can be done.

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Keep your head up, your shoulders back. You’ve got this. We’re here to help. We’ll see you next time on the White Coat Investor podcast.

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The hosts of the White Coat Investor are not licensed accountants, attorneys, or financial advisors. This podcast is for your entertainment and information only. It should not be considered professional or personalized financial advice. You should consult the appropriate professional for specific advice relating to your situation.

INTRODUCTION

This is the White Coat Investor podcast Milestones to Millionaire – Celebrating stories of success along the journey to financial freedom.

Dr. Jim Dahle:
This is Milestones to Millionaire podcast number 234 – Psychiatrist opens a private practice but still manages to pay off student loans in less than three years.

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 to get this critical insurance in place, contact Bob at www.whitecoatinvestor.com/protuity today. You can also email [email protected] or you can just pick up your phone and call (973) 771-9100.

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We have a great interview today. I think you guys are going to really like this one. I enjoyed doing it. Stick around afterward. We’re going to talk about how to invest at all-time highs.

INTERVIEW

Our guest today on the Milestones to Millionaire podcast is Danielle. Danielle, welcome to the podcast.

Danielle:
Thank you for having me, Jim.

Dr. Jim Dahle:
It’s so awesome to have long-term White Coat investors on the podcast. You mentioned before we started that not only had you listened to a few of these milestones, you think you’ve probably listened to all of them. It is not that unusual for our guests, actually, but this is your chance. We’re celebrating you today, so it’s pretty awesome to have you here.

Danielle:
Yeah, I’m thrilled to be here. I think this has been a huge part of my journey is listening to your podcast and feeling inspired to accomplish these goals, so I’m excited to share mine.

Dr. Jim Dahle:
Cool. Well, let’s introduce you a little bit to the audience. Tell us how far you are out of training, what you do for a living, and what part of the country you’re in.

Danielle:
Yeah. I’m a child adolescent and adult psychiatrist. I graduated from my child adolescent fellowship in June of 2022, and I practice in southeast Florida.

Dr. Jim Dahle:
Okay. And what have you accomplished recently that we’re going to celebrate with you?

Danielle:
Yeah, two goals. One is paying off my student loans in less than three years, and then opening a private practice.

Dr. Jim Dahle:
Cool. Well, the first one we celebrate on here all the time. The second one, not that often, and it feels like less and less and less often among doctors these days. So. let’s do the student loans first. Tell us about where you’re at when you graduated from med school. How much did you owe when you came out? Do you remember?

Danielle:
Yeah, I owed about $200,000, I went in-state for medical school. Unfortunately, the tuition costs were on the lower end, and then during residency, I was in an income-driven repayment program, probably accumulated another $10,000 to $12,000 in interest, and then COVID hit, and it actually worked to my advantage because my payments were put on pause for a good chunk of my training, which actually served me well in the long run.

Dr. Jim Dahle:
All right, you owed $210,000, $215,000, $220,000, whatever it was, which is pretty close to average. If you survey medical students, they’re coming out of an MD school, it’s like $200,000, $205,000 is what they have coming out. So, you had basically an average burden, and you came out of residency, and for some crazy reason, maybe because you’ve been listening to a bunch of these podcasts, I don’t know, you decided, “I’m going to take this in the corner and drop an anvil on it.” So, tell us what you did for income the last few years.

Danielle:
In training, my income was probably average for most residents, around $55,000, $60,000. A little bit more in fellowship, I did Moonlight and could earn up to $70,000, $75,000. When I graduated in June of 2022, that first year out of practice, my total income was only about $55,000. I had just opened my practice a few months out of training, I was trying to accumulate patients. So, a good portion of that was actually just from my fellowship income.

And then the following years, the income grew as the practice grew. I think my second year of being open, I made about $315,000 gross, and then last year, I made $377,000 gross.

Dr. Jim Dahle:
Really, you paid off the student loans in two years, because that’s when you were making money.

Danielle:
Technically, yes, if you want to say that, yeah.

Dr. Jim Dahle:
Very cool. Well, this is going to be a fun story to talk about opening the practice, but bottom line, you didn’t make that much money and you decided to dedicate a couple hundred thousand dollars of it to these student loans. Why was that an important goal for you?

Danielle:
I think I hate having debt. You talk a lot about the psychological burden of debt, and I think everybody has a different threshold of tolerance, and mine is pretty low. I knew that I wanted to pay it off as soon as possible so I could really work on saving and reaching financial independence quickly.

I think I got some advice that as I was paying down the loans and my interest was lowering down to maybe like 5.5% that it made more sense to invest it, and I just really didn’t like that idea. It felt like a huge shackle on me, tying me to med school, and I wanted to get rid of it. I was just very focused on dropping as much money on it as possible, and when the COVID pause lifted in October, I think I put like $60,000 towards it, just a lump sum, and then from there it was another $5,000 to $12,000, sometimes $15,000 a month, whatever I could funnel there.

Dr. Jim Dahle:
Yeah, you send them big checks. Those debts go away quickly, don’t they?

Danielle:
They do. It’s sad not seeing your actual bank account number rise. That staying steady is a little discouraging, but seeing the number come down on the loans was really, really motivating.

Dr. Jim Dahle:
Yeah. And both of those affect your net worth in the same way, which is really that if you want to keep a score, and it’s a single-player game, of course, but if you want to keep score, that’s the score to keep, not necessarily just the bank account balance. Very cool. Well, congratulations on that. Did it end up being easier or harder than you thought it was going to be to pound out those student loans in less than three years?

Danielle:
Yeah, I think easier in the grand scheme of things. I think I’ve modified my lifestyle to some degree. I went on a couple really big trips. My sister got married in Italy, and I was able to do that. I took another international trip with a friend. I didn’t feel like I was wanting for anything.

I think my initial goal was to pay them off in two and a half years, but taxes were a lot more than I expected in private practice, so I had to delay it a few months, but in the grand scheme of things, those extra few months don’t mean much.

Dr. Jim Dahle:
Yeah, that’s a common shock that new attending physicians have when they realize they’re paying more in tax than they made during their training. Pretty awesome, though. Very cool. So, you kind of live like a resident. You inflated your lifestyle a little bit, took a couple of trips, but it sounds like you kept things under control pretty well and really prioritized wiping out that debt.

Okay, let’s talk now about starting a private practice. Something like three-quarters of docs now are employees, and the majority of the rest of them are joining partnerships. There’s already somebody that’s kind of sorted out the business, and they’re kind of joining it and learning as they go along. Very few people are going into practice on their own, and I would say a pretty good chunk of them are psychiatrists, probably because maybe the equipment and overhead, I don’t know, is a little more straightforward. It’s a little easier to do some cash pay kind of stuff. But tell us about your journey of starting a private practice, why you wanted to do that, and maybe some of the surprises along the way.

Danielle:
Oh yes, lots of surprises and mistakes, but I think I always knew I wanted to open a private practice. I like being my own boss, but more so, I like being able to provide people with care that I think they deserve. And in training, I felt like the time that I could give to people was so diminished based on regulations by insurance companies, and I just didn’t like that model of care.

In my fellowship, I connected with a mentor who had a private practice and tried to absorb as much information from her as possible on the business side of medicine, which you don’t get any education on in medical school, and she gave me a lot of knowledge. I connected with some groups that I got some additional info with, and then I just went for it. I think a lot of it was learning as I went.

You’re right in that psychiatrists don’t have a lot of overhead. I really don’t even need an office. I have an office, but I need a computer. I could use paper charts if I wanted, an EMR system, and a couch to talk to people.

Dr. Jim Dahle:
The classic Freudian couch, huh?

Danielle:
Exactly. I think the area I set up my practice in is fairly well resourced, so I don’t have to deal with insurance companies. It’s a cash-based practice. I still do prior authorizations, of course, but that has allowed me to build something that I can feel really fulfilled with, and it’s just steadily grown by word of mouth. I was really lucky to connect with a therapy group for a source of referrals. I hired an assistant to manage the phones and the billing and scheduling, and it just kind of keeps growing to the point where I’m thinking at some point, I might want to hire some therapists or maybe another psychiatrist just to be able to provide people access because it seems like there’s a need.

Dr. Jim Dahle:
Pretty awesome.

Danielle:
Yeah.

Dr. Jim Dahle:
I don’t want to say it’s like an overnight success. It’s not. You had at least one pretty hard year, it sounds like.

Danielle:
Yeah.

Dr. Jim Dahle:
This is relatively quick for business success. White Coat Investor, its second year made $5,000. I was working pretty darn close to full-time at it. So, you’ve been very successful in this business. What was the biggest surprise, you think, other than taxes? It sounds like the tax bill, especially when you’re paying both halves of the payroll taxes, was a surprise, but what else surprised you?

Danielle:
Honestly, it was a bit of an adjustment to be my own boss. I still had a resident fellowship mentality of, “I have to work as hard as possible.” And granted, I had a goal of paying off my loan, so that drove some of that, but if I have a really heavy week and I’m feeling burnt out just by the aspects of work and I want to take a day off, I can do it. I can block my schedule and I can have my assistant help call people. And for the longest time, I wouldn’t do that because there was a lot of sense of guilt and just this mentality that you have to go, go, go, go, go, always. Adjusting to having control of my life and my schedule and being able to maintain balance, I think, was more challenging than I thought and a little bit of a surprise for me.

Dr. Jim Dahle:
Now, I imagine the first two or three months, you had all your overhead, all the expenses you have to run in this business, and you didn’t have that many patient encounters. Tell me about the doubts that seeped into your mind in those first few months.

Danielle:
Yeah, it was scary for a while. I would say the first year, year and a half, there was a lot of anxiety about it. I would have one or two patients a week, and fortunately, with it being out-of-pocket type of service, I could get reimbursed a little bit better, but I took a personal loan from my dad for $10,000 just to be able to pay my bills and make it through, and then once I started getting enough patients to have a day in the office, one full day, it started to even out fairly quickly. My overhead is pretty low. It’s maybe 18% to 20% of my total gross income, so it leveled out faster than I expected, which I didn’t feel very lucky about.

Dr. Jim Dahle:
Yeah, very cool. Is there anybody else dependent on your income? Is it just you, or do you have a partner? Do you have kids? Anybody else dependent on you?

Danielle:
Nope, just me right now. I am engaged, I’m going to be getting married next year, and I’ve had a lot of talks with my partner about finances from the beginning.

Dr. Jim Dahle:
I bet you have.

Danielle:
Yeah, he’s been so supportive, and I think we both felt really excited when they were finally paid off. We had a celebratory dinner.

Dr. Jim Dahle:
Yeah, good for you. One thing I do regret is not celebrating milestones better than we did. We blew through a lot of milestones, some of them we blew through very quickly, and I wish we’d celebrated them better than we did. So, we try to make a big deal out of milestones these days.

Okay, all right. What else should people know? There’s somebody else out there. They’re coming out of residency, and they’re like, “Man, it seems like nobody’s opening their own practices anymore.” What would you tell that person that would like to but is scared to do it?

Danielle:
Just do it. Learn as much as you can. I think you advocate for learning when it comes to finances. All of this information is out there, and there are people who have done it. Find them and learn from them. I reached out to people. I made a lot of mistakes along the way, and I try to help people learn from my mistakes if they’re interested in opening a practice. But we spend and devote so much time and energy learning this field of medicine, and then oftentimes ending up in a job that we feel depleted by.

I think if there’s an opportunity to take control of your job and find something that fits better, whether it is a private practice or whether it’s connecting with a smaller group and having a little bit more say in how it’s run, I think it’s important to look for those opportunities.

But I think the knowledge that a lot of us possess and the ability to learn can be focused very easily on business. I think there are a lot of business owners that just picked up a book and learned it, and I think we’re really good at picking up books and learning, and we have a lot of resources out there. So, put the fears aside and try it.

Dr. Jim Dahle:
Amen to that. What you’re saying is personal finance and investing in business is way easier to learn than psychiatry?

Danielle:
Yeah, I get confused every day with psychiatry. The more I do it, the less I feel like I know, to be honest.

Dr. Jim Dahle:
Yeah, yeah, I can relate to that for sure. Very cool. Well, congratulations, Danielle. You’ve been very successful. You have accomplished two milestones, either one of which you should be very proud of, and we’re excited to celebrate them with you and hope it inspires other people to do the same.

Danielle:
Yeah, thank you so much, Dr. Dahle. You are fantastic and provide hope for all of us. So, keep doing what you’re doing. We appreciate it.

Dr. Jim Dahle:
Thank you.

All right, that was a fun interview. How many docs are opening up their own businesses right out of residency these days, opening their own practices and going at it. It’s scary. No patients come in that first day, and you’re like, “Oh, is this going to work?” And you’ve got to go home and explain to your spouse or your parents or your kids that this is worth the risk, this is going to work out eventually.

It’s scary to open your own practice. Danielle has not only done it, but has gotten her income up very rapidly and been able to use it to meet her financial goals like crushing her student loans.

You can do this stuff. It is not that hard. Other doctors before you have done it, you can learn it. You’re an expert at learning. You can learn new stuff, and you can learn this finance stuff for sure.

FINANCE 101: HOW TO INVEST AT ALL-TIME HIGH

All right, I promised you at the top of the hour that we were going to talk a little bit about all-time highs. We see questions about this all the time on blog comments, by email, on the forums, et cetera.

This one came on the White Coat Investor Forum. It said, “I have absolutely no clue why the S&P 500 is within a half percent of new all-time highs. Geopolitical US politics, government policies, micro and macroeconomic theories, and the pundits or prognosticators do not seem to provide any reasonable explanation. The market seems to its own way simply because that is what markets do. Feel free to answer why.”

Well, here’s the deal. What you got to recognize about all-time highs. When people try to scare you with the phrase “all-time highs”, what they’re really saying is the market’s going to go down. And how do they know that? They don’t, because their crystal ball is just as cloudy as yours is, just as cloudy as mine is, just as cloudy as all the financial advisors’ crystal balls are, and certainly just as cloudy as the crystal balls of the talking heads on CNBC are.

Nobody really knows very well what’s going to happen in the future. You can guess a little bit, but the truth is you really shouldn’t have an investment plan that requires you to know what is going to happen in the future.

As far as all-time highs, look at a stock market chart. Go ahead and look at it. What does it look like? What percentage of the time is the market at an all-time high? A very high percentage of the time it’s at an all-time high. And in fact, if you pick any given point on those stock market charts, you realize that all-time high also often means a low never to be seen again. You may never, ever, ever be able to invest again at this all-time high.

The markets typically go up in the long run, not only for inflation, but also because guess what? People are getting better at generating profits. They’re working hard. They’re going to work all day long and working for the most successful corporations in the history of mankind.

Yeah, no surprise that just because it’s at an all-time high doesn’t mean it has to go down. It can go up from all-time high. Now, maybe it’s a little more likely to go up if you’re 20% below an all-time high. That’s not necessarily the case. Sometimes it can go down from there too. Sometimes it goes to 40% below the last all-time high. That happens every few years in the markets.

So, don’t assume that looking at a chart, you can divine what’s going to happen in the future. There’s a whole school of thought of people who try to predict the future by doing nothing but looking at stock charts and they look for patterns and all kinds of stuff. Most of it’s voodoo, let’s be honest. They have no idea what’s going to happen in the future. If they did, they’d be making a killing. They’d be gazillionaires.

Because if you could predict the future in any sort of accurate way, there’s no way you should only be managing your own money. You should be managing billions and billions and charging a high percentage of that additional value that you can provide and keeping that. The likelihood of somebody else knowing that, if they’re not a gazillionaire or rapidly on their way to doing so, seems pretty low.

Okay. So don’t be afraid of all-time highs. Don’t let it keep you from continuing to follow your investing plan, which if you’re like most of us, means investing some money every month when you make it. Sometimes you’re buying at lows, sometimes you’re buying at highs. Over the long term, the effect of this periodic investing, sometimes actually mistakenly referred to as dollar cost averaging, allows you to pick up more shares at lower prices and fewer shares at higher prices. So, in the long run, it works out very well for you as an investor. I assure you, I’ve invested a lot of money at all-time highs in the past and I’m very glad that I did so.

Okay. Now let’s talk about what causes the market to move. There is an entire industry called the financial media, whose job is to write about or talk about why the market moves every day. They have to go on the screen and they have to come up with a reason and they have to tell you that’s the reason why it moved. Or they have to write something every day, whether that’s a blog, whether that’s an article, whether it’s something on social media, this is their job to come up with a reason.

Nobody goes back and tries to figure out if they were right. Nobody goes back and says, “Oh, that’s not why it moved and moved for this other reason.” The truth is markets are really complex. A market is the opinion of literally millions, tens of millions, hundreds of millions of people about what something is worth at any given time. That’s what a market is.

In general, the market as a whole is smarter than any of the rest of us as individuals. There’s a lot of factors that go into it, whether it’s politics, whether it’s economics, it’s time for something to be different, interest rates, whatever. There are lots of things that cause markets to move and the market, meaning everybody as a whole, feels differently about things at a time.

Sometimes the market goes stark, mad, crazy. Some political event happens and everybody goes, “Oh, this is going to be terrible.” And all of a sudden you can buy things at a pretty serious discount. Sometimes they are totally wrong. They’re not always right about what something’s going to be worth long-term. Sometimes things are bid up way more than they really probably should be. And sometimes things are discounted dramatically more than they should be.

But the market’s right more often than any of us are as individuals. So, don’t take too much confidence that just because the market went down that it’s going to go up or that just because it went up, it’s going to go down. There’s a lot more to it. And if you think it’s a very simple that you can explain it with one thing on the nightly news, you are probably mistaken. You’re probably a novice. You don’t recognize there’s far more nuance in how markets move than a lot of people give credit for, particularly in the beginning of their investing journey.

SPONSOR

This podcast was sponsored by Bob Bhayani at Protuity. One listener sent us this review. “Bob has always been absolutely terrific to work with. Bob has 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 underwriting process in a clear and professional manner.”

Contact Bob at www.whitecoatinvestor.com/protuity today. You can also email [email protected], or you can just call him at (973) 771-9100. If you need disability insurance and you don’t have disability insurance, or you’re worried your disability insurance is not very good, get it taken care of now. Don’t wait until you’ve developed another medical problem or heaven forbid, become disabled.

All right, we’re at the end of a podcast. These milestone podcasts only happen with your participation. So, if you’d like to apply to come on, we’ll celebrate your financial milestone with you if you apply at whitecoatinvestor.com/milestone. We can use it to inspire somebody else to do the same, I’m sure. See you next time on the podcast. Thanks for being here.

DISCLAIMER

The hosts of the White Coat Investor are not licensed accountants, attorneys, or financial advisors. This podcast is for your entertainment and information only. It should not be considered professional or personalized financial advice. You should consult the appropriate professional for specific advice relating to your situation.