Physicians Make Mistakes, Correct Them The Right Way

“If they will hand me the instruments when I need them, then they won’t get yelled at. This is my OR and my rules.”

“Well, I’ve always prescribed Cipro for strep throat. In my experience, it always works. No one can tell me how to practice medicine.”

We’ve all heard stuff like that before. Try to offer a correction or suggestion to a colleague and the walls go up immediately. It can be very uncomfortable, especially for non-physician staff, when a physician shuts down a conversation. Physicians often implicitly hold the most power in conversations or interactions that they have with staff and patients. If they refuse to discuss something further, then there is little recourse, but the long-lasting impact on relationships can be irreparable.

So how do we deal with this? As a supervisor, how do I hold staff accountable? As a colleague, how do you approach someone and speak up when you see a problem? It will always be uncomfortable to criticize someone, but if structured correctly, criticism can lead to growth.

If structured incorrectly, then these conversations can lead to worsening distrust within healthcare organizations. If administrators thought their job was hard now, try to lead a cadre of physicians that refuse any attempts you make at change or improvement. It can get ugly fast.

Peer To Peer Conversations

Physicians correct other physicians. That is the practice in my organization, and it is essential. Due to the extensive amount of training that the average physician undergoes, it is very difficult for non-physicians to grasp the knowledge base and unique experience that most physicians have.

This is similar to many other highly specialized fields. I wouldn’t dream of micromanaging the daily tasks of a nuclear physicist. I have no clue what he does on a daily basis. In the same way, physicians are much more apt to listen to a fellow colleague than a non-physician.

My first thought when an MBA tells me I’m not seeing enough patients? Who does this bean-counter think he is (no offense!)?

My first thought when a fellow internist tells me I’m not seeing enough patients? Holy crap, am I not pulling my weight?

Establish the Standards

If you’re going to hold someone accountable, then you need to define what the standards are. Decide the standards up front and include physicians in the decisions regarding this. As I always say, the mission is the answer, and you have to very clearly delineate what you expect your staff to accomplish when they show up at work.

These standards can get as specific or as broad as you like. I personally prefer to keep them broad so we hold each other to the spirit of the law rather than the letter of the law.

I may receive hate mail for this as well, but I think you should define what the standards are not only when it comes to behavior, but also clinical practice. Civility and respect should be a common expectation in all interactions, and most will not have a problem with this. ZdoggMD has an excellent video below demonstrating how to appropriately talk to patients:

OK, maybe not, but I think you get what I’m going for here.

There are numerous benefits to establishing clinical practice standards as well. If all physicians practice in a similar way, then it is much easier for staff to effectively do their jobs. We use published clinical practice guidelines as our starting point and have established methods for deviating from them if there is a compelling clinical reason that the physician staff can agree on.

If a situation is outside of established guidelines, then physicians need a formal venue for peer assistance. This can be through interdisciplinary rounds, tumor boards, etc. The purpose of clinical practice standards is not to cram every patient into the same box. The purpose is to practice in an evidence based manner where evidence is clear, and allow for reasonable judgement when the evidence is not clear.

Public Praise, Private Correction

Do you enjoy being called out in public? Didn’t think so. Then don’t do it to other people! Physicians are no different. Nobody responds well when called out in a meeting of their peers. A justified critique will easily be interpreted as a personal attack because of the venue.

Despite what some may think, adding the extra humiliation of public critique doesn’t “add emphasis” to what you say or “make them remember.” It just builds resentment. The average physician is a driven, hard working individual that will have no trouble remembering any criticism they receive.

In contrast, everyone wants their accolades to be publicly broadcasted. Even folks that shy away from the limelight enjoy being congratulated in front of their peers, whether they admit it or not.

Again, physicians, on average, amplify this even more. Physicians pride themselves on the quality of their work and enjoy seeing that work recognized. Remember you are talking to a group of people that earned a lot of A’s during their school years! Feed the ego a bit and let everyone know when someone performs well.

Professional Courtesy

I hear this phrase thrown around a lot in break rooms. Several physicians have told me before they should be “given the benefit of the doubt” or shown a little “professional courtesy.” Unfortunately, they don’t seem to know what that really means when they say it.

I think our professional athlete colleagues can assist us with an example. Here is Peyton Manning and Jeff Saturday, formerly of the Indianopolis Colts, giving a wonderful example of professional courtesy (note there is some language in the video courtesy of Youtube):

See, professional courtesy means you just sweep problems under the rug, right? Ha! Professional courtesy means I do you the courtesy of coming to you, peer to peer, to ask about what happened rather than simply acting on the information I receive (or calling a press conference in Peyton’s case), under the assumption that we are both on the same page regarding our common mission and goals.

There are many vocations where someone reporting your misdeeds leads directly to termination or other bad consequences. Try working at McDonald’s and have one of your co-workers report that you stole something. Your manager will have a conversation with you, but it will be very brief and will likely end with you handing in your name tag.

Professional courtesy means if someone reports a potential problem to me about a physician, then I do not pass judgement during that initial conversation. I will promise to investigate, but I will not promise to punish or even agree. This can be frustrating for other staff at times, but to me, innocent until proven guilty is an essential part of professional courtesy.

Second, I will review the facts surrounding the case myself and come to you, physician to physician, to discuss the matter (hopefully with fewer bleeps than Peyton). I will not pass judgement before talking to you, and I am open to hearing your reasoning for your actions. This may or may not change my mind, but I will speak directly to you and not to anyone else.

As I said before, professional courtesy never means that I will ignore problems. Our standards are our standards and everyone must be accountable to them. However, I will absolutely promise to come to you, and no one else, to discuss the issue. That is professional courtesy.

Address Problems Now

If there is any final piece of advice I can give, it is to address problems immediately. Don’t ignore them. Don’t say you’ll “address it next time.” Address it now. Show your colleagues that you really think accountability and performance standards matter. Demonstrate urgency with your actions.

The single greatest problem I see amongst physicians and physician supervisors is lack of urgency when it comes to accountability. We get caught in this every man is an island mode of thinking where we simply throw up our hands and say “he’s responsible for his own actions.”

We have to acknowledge that our fates as physicians are tied together and act accordingly. It is always better for physicians to collectively improve. Always. No improvement happens without accountability.

Remember that, at the end of the day, we are going to be accountable to someone. We can either be accountable to ourselves or to someone else. We’ve tried the someone else route in medicine. Time to do something different, wouldn’t you say?

Have you ever tried to correct a colleague or bring up a problem? Did it blow up in your face and turn out well? Tell me about your experience in the comments!

Financial Independence Retire Never (FIRN)

I follow a lot of the FIRE (Financial Independence Retire Early) crowd both on their blogs and on social media. I find a lot of good advice there and many of the things I have read have positively shaped my personal finances today. 

For those motivated to do so, I take no issue with physicians working hard to achieve early retirement. In my view, you put up the money to pay for your schooling so it is your life to manage as you wish. If that means retiring at thirty-five and living in Tahiti, then God bless you and post pictures when you’re on the beach.

I suspect, however, that there are many folks like me that have a really hard time with the idea of working hard for some specified amount of time and then walking away forever. I’m willing to bet that many physicians, in general, share my uneasiness with this idea.

I will readily admit that I have a borderline pathological obsession with being active. I like to have my hand in several different pies at once and wasted time is truly my enemy. This even spills over into my vacation time. I will never be the guy that is able to sit on a beach for five straight days and watch the tide go in and out. Trust me, I would drive my wife crazy.

I am also blessed to say that I enjoy what I do on a daily basis, and despite the satisfaction I get when I stick that wedge within 3 feet, I would truly have less fun in my life if I just played golf every day. 

So with that in my mind, I would like to officially dub my version of financial independence as FIRN or Financial Independence Retire Never. I have no intention of accumulating wealth for the purpose of not working. I have every intention to attain financial independence to attain maximal flexibility to do the work I want to do.

FIRN

It’s really hard to find a FIRN image

The Four Principles of FIRN

Practically, many of the principles employed by the FIRE crowd are the exact same ones I employ, mostly because the basic principles of FIRE or FIRN are time honored tenets of wealth creation.  Here are my four basic principles:

Minimize expenses-I am not part of the extreme frugality crowd, but if you can do this then more power to you. The basic math dictates that the less you spend, the more you keep. This is especially important for physicians that find themselves in the upper tax brackets. Working to earn more money at a 35% federal tax rate can be downright demoralizing at times. Cutting out your $1000/month shopping budget is a tax free way to give yourself a big raise without having to pony up to Uncle Sam.

Eliminate Debt-I shouldn’t have to tell any physicians about the weight of student loan debt. Carrying six figure student loan debt definitely decreases your financial and professional flexibility and locks you in to having to pursue jobs that pay large salaries, regardless of whether you enjoy it or not. Unloading that burden can really improve your FIRN opportunities.

Use Compound Interest-There is no greater magic than watching money compound year over year. If you are earning an average physician wage, then your retirement accounts should be maxed out (401k, 403b, IRA, whatever it is). You should also take advantage of any other compound interest opportunities you may have. I will discuss more of these opportunities in future posts and link you to some great resources for getting the compound interest ball rolling.

Diversify Your Income-You might earn a fantastic wage as a physician, but your nest egg is at risk if that is your only source of income. Hospitals and physician practices are not immune to closure. You should work to diversify your income streams so that losing one will never be the end of you. Some do this by additional medical work on the side like expert witness work, chart reviews, locus work, or telemedicine. Others do things totally outside of medicine that they are passionate about. Take stock of whatever skills you have and see if you can apply them to set up an additional income stream.


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The Freedom of FIRN

In my mind, a key principle of physician FIRN is that you always intend to do something, not necessarily medicine. Personally, I very well may decide to move on from clinical medicine one day. I have no idea what my professional future holds in this regard. I might even decide to cut back my work schedule one day. However, I can fairly confidently say that I will always be doing something that likely brings in a paycheck of some kind as long as I am physically and mentally able. 

What this really comes down to at the end of the day is what you enjoy. To some people, work of any kind is simply a means to an end. For others, work is part of what makes life enjoyable. It’s all about what makes you tick and what your passion is. For me, a life solely based in leisure would be unfulfilling. As my About Me page says, I am the guy that would probably train to join the Senior PGA tour if I ever devoted my life solely to my hobbies.

Ironically, I think a lot of the FIRE crowd actually falls into FIRN if we are being strict about the definition. Most of the blogs I read and people I come across are still very much working and bringing in paychecks (sometimes really big ones), even though that have “retired” from their day job. Maybe they will prove me wrong one day and totally pull the plug on working, but many of them look like they have the same itch to keep moving that I do.

FIRN Investing

The choice of FIRN vs FIRE has real implications when it comes to applying the art of compound interest. For investors of all stripes, there is often distinction made between returns that come in the form of value you receive now versus value you receive later. For real estate, this is cash flow versus appreciation. For stocks, this is dividends versus equity.

For the individual pursuing true FIRE status, investment activities would most logically be geared towards the immediate income side of the equation. The FIRN investor, on the other hand, can gear activities more towards total return. Assuming that a FIRN investor has already undergone some basic income diversification, then he can afford to engage in activities that may pay out nothing now but will be the most profitable in the long run.

A practical example would be Berkshire Hathaway stock. Berkshire Hathaway has paid out a dividend exactly one time in its entire history. This stock is much less valuable to an individual pursuing FIRE, but could be much more attractive to an individual pursuing FIRN. No dividends are no problem for the FIRN person. They can afford to play the long game and just watch the equity grow as the company’s value goes up. In reality, most physicians probably should have their money in index funds and not be buying individual stocks, but we’ll leave that for another day

At the end of the day, I’m not making value judgements about either philosophy. Everyone needs to decide what their goals are and then act accordingly. If you really do want to live life from your beach hut, then I wish no tropical storms on your paradise.

Both philosophies will eventually lead to financial independence, which is really the core goal you should be striving for. If a person that has achieved FIRE sits down to dinner with a person that has achieved FIRN, then I’m pretty sure they’ll both be happy with their lot in life and have a lot more in common than different. The FIRE person may have to wait for the FIRN person to get off work, but hey, retirement is just a big waiting game for life’s last big event anyway, right?