The Dream Job

BPM EP66
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Rami: [00:00:00] welcome to the beyond medicine podcast. My name is Rami and I'm your host in this podcast. We bring you inspiring leaders from across the medical landscape and explore the cutting edge of science and medicine.

What's up everybody. Welcome back to the podcast. I'm here with Aleah and we're doing a followup episode to our last recording that we did, where Aaliyah interviewed me on the show. And I kind of talked about my journey through training. And since then, we've had a lot of interesting feedback. I've gotten a lot of messages from people and it's actually been really eyeopening for me to see how much people resonated with a lot of Aliyah.

And I talked about, and it's also reaffirmed to me that a lot of what I was saying or feeling. It was not just in my hat, you know, a lot of people could relate to it and a lot of people [00:01:00] felt the same way. So, um, we're going to take a little bit of a deeper dive today with Aliyah and we'll just, we'll just bounce some ideas off of each other.

So. All right. So what's up Leah,

Aleah: really excited to be here and thanks for having me back. I'm excited to be in your office, which is super cool. And. Are those ones

Rami: that you did, that's

Aleah: impressive. You could have like a whole nother career. I'm excited to be here and excited to hear about feedback that people had.

I think, I mean, the whole point of doing any of this is trying to connect with other people and reach other people and figure out, you know, how to have a good life in this field. Yeah,

Rami: which is hard. Yes. So you've been out of training now for a couple of months. Yes.

Aleah: Um, it is stressful. It is different than I expected.

And, you know, I used to, I used to hate actually, when people said this, you know, you know, when you're in medical school or in [00:02:00] residency and you hear from some attendings that like, it's like, you hear this dichotomy of either like, just wait until you're out of residency. Everything's better. You know, the golden years, like you just have to get there.

So that was what was kind of put in my head for the most part. Some people, you know, would say, you know, it's super stressful. Like it's really hard, you know, stop doing what you're doing, but you're already too far in that you just kind of ignore those voices. At least that's what I did. And so I think when I got out of training, I was kind of waiting for this promise land of like a good salary, good work hours.

You know, feeling good in my career, feeling confident. And a lot of those things have not been totally accurate. So I think there's some disappointment and frustration with that. And ultimately though, I think it has led me to now trying to figure out what do I need to do to really get myself to a place where I'm happier, because right now that's not where I'm at.

Rami: That's sad. Yeah. [00:03:00] And that there is this, you know, you're always told there's a light at the end of the tunnel, you know, you're almost there and you think that, and you believe that. And then you get out and you realize there is no light at the end of the talk. This is it's. This is a never ending tunnel.

That is dark.

Aleah: I think it's like, you know, people think that it's their own fault, which it's totally not. It's, you know, the large majority, I think, is the system. I think from years of therapy, I can totally understand how we each have some, our own control and you can respond to different situations differently or advocate for ourselves more.

But I do think we're still functioning in a pretty broken system, which makes it really difficult.

Rami: Yeah. For me, I really believe that you have to create your own light, especially in medicine. Like this career is not meant to make you happy. You know, you're getting squeezed, there's too many interests involved and there's too much money involved and it really doesn't leave a lot of room for you to [00:04:00] have the, the control over your career or the say in your career that you might have, you know, 30, 40 years ago.

I don't

Aleah: know when I know that this is a dream. I was, I was like scrolling on Facebook and I saw this advertisement from like, uh, it was like a Caribbean medical school and it's. Follow your dream of becoming a doctor. Yeah. Just like the

Rami: pause

Aleah: doctor, you know, if it wasn't sold to you like that, maybe you'd have different expectations, you know?

And I talked to my husband a lot about this cause he is an engineer and has, I guess more of a typical career. And I always try to ask him, you know, do you love your job? Is it just okay, like, do you hate it? Like what's normal. I don't even know anymore. And I think there is a subset of people like you and I, that are not happy with how things are going and not willing to settle for that.

Either. I talked to my therapist about that a lot. Actually, she. You know, some people might be okay with the current climate of healthcare and working in a clinic and seeing 20 some [00:05:00] patients per day. Some people that might work for them. And if it does work for you, like that's fine. But I think there's a subset of us that it doesn't work for us, but it's really hard to see where do we go from here?

You know, I thought that whenever I got my first job, like, it would be like, I arrived, you know, like, okay, we're here and I'm planning to do this, and this is how it's going to be. Maybe it'll change things a little. As things go, but I never imagined that, like, I would feel the way that I see.

Rami: Yeah. Yeah. And it's funny because it's almost like you don't know what a good job should feel like anymore, or you don't know what being happy in your job is supposed to be like, you can be fulfilled in.

I think some, I think a percentage of doctors are fulfilled in their jobs. It's fulfilling for them to take care of patients, but it's also wrecking their lives, burning them out.

Aleah: Well, I think in residency too, I always told myself like, Residency is very destabilizing. You switch from rotation to [00:06:00] rotation, especially for family medicine specifically, I would go from inpatient to outpatient to shadowing somebody in a different specialty, like to working in the, or it was all over the place.

And so whenever I was about to graduate, I knew my first job would help teach me like what I would want. And because I didn't even know when I was in residency. I was like, how many. Workweeks have I actually have where I work in clinic five days a week and see patients, or how many work weeks have I had where I am in control on the inpatient floor.

And I'm, you know, quote unquote the hospitalists, not that many, you know? And so I think everyone's first job in medicine probably is pretty eye-opening as to what they like. And don't like, which is pretty far along, you know, like I'm seven years deep, at least, you know, not including. So it's just a weird place to be when you're like, I just turned 30 recently and you're like, okay.

I finally feel like. You know where I'm supposed to be, but then you [00:07:00] kind of have this eye opening moment of like, actually, I don't even know where I'm supposed to be. Cause right now it doesn't feel like it's the right.

Rami: Yeah. You're still figuring it out. You're just good. And we talked about this earlier.

It's like, you're still stabilizing yourself after all of the de-stabilizing that happened in residency where you're on a different rotation each month, you're on a different call schedule. You're not sleeping. Right. And all things are that are like proof, like scientifically proven. Very harmful to our health.

Aleah: When you say I'm going to need like 10 years of therapy to dig myself out of like what residents

Rami: a hundred percent it's taken me off. I'm not kidding. It's taken me a full year to regain my health. And after the accumulation. Those we'll call it de-stabilizing of medical school and residency. And you forget, it's like the temperature's always being raised in medical training.

You're getting exposed to more and more, and you're getting desensitized more and more to where you think like horrible practices are actually just normal. Like you think it's [00:08:00] just normal to not sleep for a week. It's just normal to walk around depressed all day. It's just normal to tolerate bullshit and bite your tongue.

You know, in every scenario that you could possibly be in, like that's not normal. Having boundaries is normal, the patient steps out of line and having boundaries that's normal. If your higher ups are treating you on fairly, you speaking up or drawing a line, that's normal, but we're taught in residency that that's not normal.

We're taught that, you know, you gotta be a little runt and there's, there's so much on the line. And there's so much at stake that we can't risk any of that. And so you come out on the other side of all of this, and I talked about. With Kyle from resolved in the last episode of this, be in puppy mentality where you come out on the other side, not knowing how to be a normal human being again, all

Aleah: fear-based.

I mean, it's so much fear. And I constantly recognize that in myself, even now from residency, you know, in residency is the fear of like you speak up and you'll get fired. You'll speak up [00:09:00] against your program and your program will get shut down and then you'll still be in a bad situation. I think it's like constant conditioning of like, sit down, be quiet, get your head down and get through it.

And then on the other side, You'll be okay. Attending life's. Okay. And I think for a lot of people that's proven to not be true. And I, I honestly, I hate saying it because I remember hearing these words and blocking them out. Cause I was like, I'm already $278,000 in debt. I can't afford to think that there is no promised land.

Like I just couldn't do it. I knew I couldn't make it through residency without having this. Something's going to be better on the other side, you need

Rami: hope. Yes. And there is, there is hope. We'll talk about the hopeful parts of this, because I think there is a lot of hope for,

Aleah: right. Yeah. I don't want people to think.

We're just like, you know, really touting

Rami: things. We're going to try to fix things. Nobody talks about that's the thing you feel then

Aleah: you feel [00:10:00] alone. I mean, a lot of the times, I think in residency, when some of my colleagues, like wouldn't say anything about bad things going on or, you know, whatever I felt alone, like I was going a little bit crazy, like, oh, I'm crazy to think that this is.

Like abnormal or mistreatment or whatever. And I think the less people that are talking about it, you know, the, the more alone we're all gonna feel, which is not good. We need to feel, I think you've talked about this before. We need to feel empowered. We need to feel like more togetherness and that's just not happening right now.

And I think of course COVID has like totally. Annihilated a whole bunch of other things too, but my reckoning is coming. Maybe this is like good for the reckoning.

Rami: Yeah, winter's coming. But for real, I really think a reckoning of unprecedented magnitude is approaching us. And I think that we're going to face a massive resignation of clinicians, which we are already experiencing.

There's already, you know, we've known about the doctor and clinician shortage for a [00:11:00] long time. COVID is exacerbating that, you know, it's an almost impossible to staff, an ER, with nurses at this point, conditions have gotten really bad for a lot of healthcare workers. And the pay hasn't improved the tree hasn't improved.

Right. And you know, there's going to be a reckoning. People are going to have to pay for this, and it's going to end up being the patients and clinicians too, because, you know, I just feel that there's going to be so many people that, that are just done and leave and go do all their things. And there's going to be other options for them.

There's new markets that are emerging right now after, after

Aleah: COVID and everything getting smarter. And I, you know, even though sometimes I think I hate. Sometimes, you know, I do see that it provides a lot of connection and that's, you know, every year I make some new connection that leads me somewhere different.

And I think people are utilizing social, obviously to connect with other people and figure out what are these other things that doctors and other healthcare providers can do that. [00:12:00] Clinical-based work. It's scary though, because I'm like, you know, individually. Yeah. If I can find something that's nonclinical and do that part-time and do some clinical part-time maybe that would be a better fit for me.

I don't know. But on a more mass scale, it's kind of scary. Cause I know there's already a shortage of primary care providers. There's already a short. Good primary care providers. And I mean, I'm a person too. I need a primary care provider, you know, and if all these people leave, like what are we going to do?

I really don't know.

Rami: Yeah. And that's the, that's the dilemma here? Like what do you do? I refuse to advocate for any doctor to stay in a career. If it's. If it's harming them or hurting their families. And I don't think that we should just put up with it and I'd rather watch the system burn than watch every, all my colleagues.

Aleah: I think all of, you know, our generation especially is very in tune with our mental health and values it way more than I [00:13:00] think maybe other generations do or are more vocal or maybe were more vocal about it. I don't know. I see that a lot in people, our age, which is we're not willing to go down, you know, without, you know, something different.

Yeah. Without a fight. Yeah. So anyways, what kind of feedback did we get about our episode? I don't know. We

Rami: just want, well, I hear, I've gotten a lot of submissions on the website and then we also got, so I just got personal messages and surprisingly, I got some messages from students. Yeah, I got one from a student here.

I think it was like an, uh, a medical

Aleah: that's cool. That medical students are listening to your podcast. I wish I would have been more just like open-minded or I don't know, woke. Is that the right word about stuff? When I was in med school, then maybe. You know, change things

Rami: or whatever. So I found this is actually really interesting.

I'm going to try and keep this person anonymous and try not to divulge any information that could give [00:14:00] away the identity, but I just discovered your podcasts. Thank you for sharing the content and the work of innovators and medicine. I'm reaching a point where I still like medicine, but I'm not excited about the time demands.

That I can expect in the next few years, I'll listen to your story about why you left presidency and didn't know that it was possible to practice medicine without completing residency. How do you do this? Is this an option for me? I'm also looking at careers in biotech because I don't picture myself in full-time clinical medicine.

I just haven't seen someone in your position and I'm not sure who to talk to about it. And about I burning. I thought that was an interesting submission. I mean,

Aleah: there is no, there is no transparency in medical school that you can do other things. I totally believed that you had to work, you know, 40 hour work week in clinic or in, you know, in the hospital, whatever.

And that was that, and it is much more flexible than that. I will say that about our career is that it is more flexible. You [00:15:00] know, hospitalists oftentimes work like one week on one week off clinicians in my field, you know, can work anywhere from like two days a week to five days, a week or more if they wanted, I guess.

Um, so it is very flexible in that way. Um, but in many other ways it is also inflexible

Rami: and you, you said a good thing and that was, there's no transparency. And I really don't think there is like, why don't we know that. You can get a medical license after a year

Aleah: of residence. Why would people tell us that though in medical school, the people that are running these medical schools, a lot of the times aren't actually doctors, you know, I think some medical schools, yes.

There are some doctors that do like, you know, lectures and stuff like that. And some may have higher ups that are clinicians, but most of them actually left clinical work to do what they're doing, running the medical schools. But I don't think a lot of that. You know, I mean, a lot of these schools too, they want to churn out.

Some of them have a focus for primary care or underserved care or whatever [00:16:00] it is. People don't value in med school. Like a lot of this innovative thinking, to be honest, at least I never saw that. So I think some of it's just lack of understanding or lack of awareness in some of the people that run these medical schools.

There's already so much stuff. That's like jam packed into curriculum. And a lot of it, like doesn't even

Rami: matter. It's not just the medical schools, even it's the whole ACG and me and the structuring of removal from he's going hard because no, this is true. And the entire structuring of our curriculum is not made for you to be an independent.

Anyhow. You're meant to be a worker. You're meant to be a family medicine or internist or surgeon. And that's it. There's no other path outlined and we need to do a better job now with curriculum that that's not the only path. There is a path for business and medicine look like the fact that you can spend, like this blows my mind still the fact that you can spend $300,000 on a medical degree, [00:17:00] graduate medical.

And they're still like to this day, there's more medical students graduating than there are residencies available. You can finish medical school with a useless medical degree that you can't use to see any patients, despite you having done all of the work and you know, all the four years and graduated your degrees useless.

And on top of that, w what I discovered after that process was that if you actually finish your medical degree, And then don't do residency. You actually can't even volunteer to help people. That's that's hilarious. You can't even, because it's then considered malpractice, you're practicing, you're practicing medicine without a license.

So you can't even go volunteer and attend or do like blood draws or anything like that because that's considered practicing medicine. Which is hilarious.

Aleah: Wow. Yeah. I mean, there's no transparency in these kinds of things. There's no transparency. If, if you want to leave [00:18:00] in medical school, like what's the best route to do that.

When should you do that versus not do that? You know, how do you get into these other career paths? You know, it's all like a black box. And I mean, the only way I have seen, and I guess for this person that gave the feedback, the only way that I've seen. This kind of information be shared is talking to other people that have done it.

You know, recently I talked to somebody that works at Google health to just talk to her and say like, I don't know what I'm doing with my life. And I know you went to residency. Uh, this person had gone to like a pediatric residency and completed it, but never actually practiced like clinical work because this person knew that it wasn't the right thing for them.

And then now is working in AI at Google health. And I just wanted to know more of like, how did you get from point a to point B? What were the steps? What do you need to do? And, you know, we're not really taught to do a lot of exploration once we're out of med school, you know, cause you have to pick [00:19:00] your specialty, you've got to nail it down and then you're married to it is what they make you think.

Even though it's very untrue. I know tons of people that switched, you know, residency programs and specialties,

Rami: even musically, this is like another interesting question. Why are other provider groups like nurse practitioners and physician assistants. Okay. So they go through less training than doctors.

They, uh, are allowed to switch specialties whenever they want. There are a lot to go and get different experiences. They can go and start working right after two years of PA school, but a doctor who does four years of medical school and a year of residency. Can't practice medicine, unless he goes and start, like, if you get your license, there's still barriers.

Like, I can't go work in a hospital. I can't go. Like, not that I'd ever want to, but there's still limitations. I'm not board certified. So I can't go and like work for a hospital. I can't go join. Uh, most practices. I can join a private practice and still do [00:20:00] some work with some insurance networks, but not all of them.

And like, that's still a barrier, but why. Mid-level provider who has less experienced than me able to go and work wherever they want, for whatever practice they want, even switch specialties. Like these are the things our medical boards are ACG and me. They need to start addressing these things because they're flat out bullshit.

They try to justify this. Like I've heard the counter-arguments these sort of

Aleah: things. So let me give you a scenario. So, I mean, I'm definitely for. And I guess I want to be clear that I think nurse practitioners and PAs do add value to our system. And I'm glad that they are allowed to have lateral movement because I think it is a wonderful thing for people.

Yeah. And especially what if your life changes? What if now all of a sudden you have three kids and you want something different. I think you should be allowed to do that, but a scenario. Okay. So I did my family medicine training for three years. In addition to my medical school. So yes, I have more training than, you know, a PA or an NP coming out of school [00:21:00] without residency training.

Why I see a variety of conditions all the time. Why am I not allowed to say, say I wanted to do. Dermatology. Why can I not practice under a dermatologist? Get training on the job, just like a PA or an NP does for, you know, time and use or, you know, utilize another clinician who has done the dermatology training to bounce ideas off, get more information, learn, et cetera.

Why can't I do that too?

Rami: I'll tell you. I don't really get it. Maybe says clashing interests. That is the answer like from our own colleagues, even from our own colleagues. And I will say this, like, if you're a dermatologist and you done the four years of training, you're entitled to want to be the board, your board.

So why would you open up your market to other practitioners that can most likely do the 99% of your job? Probably not. Let's not assume, let's say 95% because there's the 5% of zebras [00:22:00] that, you know, all that experience comes into play for. But unexperienced doctor could come in and learn from you and do a almost informal residency and learn everything from you.

But why would you do that?

Aleah: I think it comes down to money too. I mean, NPS and PAs are notoriously paid less than. Doctors to do the same thing in a lot of scenarios. I mean, when you have a dermatology practice, I'm just using dermatology, just because not because of any specific reason, but you know, they see a lot of patients, they hire a couple of PAs to see more patients and they pay those PAs.

I don't know, one third of what they pay a dermatologist, maybe less. I'm not sure. Why would they want to pay me my normal salary, which is probably more than a maybe, maybe not even more. I don't know, but why would they want to do that? I think it comes from , but at least that would give us more flexibility for if you ended up not loving what you did.

I don't know, but everything's just too set in stone for us. We need to have more

Rami: options. Let's do, let's do an example here. Let's say you start [00:23:00] taking an interest to be tender crime. You start taking an interest in black box for me, but let's say hypothetically, you started taking an interest, your board certified family medicine, doctor, you start taking an interest to endocrinology and you already are seeing tons of diabetic patients.

You have tons of experience in treating diabetes. What's to stop you from going and exploring, just, you know, working with diabetic patients

Aleah: because the system would tell me that I need to go back to residency and there's no route for that. You know, for endocrinology comes out of an internal medicine residency, not family.

So why would I want to repeat the worst ears?

Rami: Yeah, it'd be stupid to do that. That'd be absolutely terrible idea. But why wouldn't you, let's say you one of your best friends as an endocrinologist, and you're going to go and learn from their clinic two days a week. Well,

Aleah: there is some people that I think do.

Some of this niche work, especially this happens actually out of family medicine. I see this a lot of people moving to functional functional medicine, right. Where [00:24:00] they, you know, they're trying to get this extra training and then they open their own practice and they do only these things where they focus on, for example, PCO S thyroid disorder and weight management or something.

And they only do those things. They don't offer these other things. I'm not in place of your primary care provider. Like I don't treat UTIs and give Z packs. I don't do any of that stuff. I only do these kind of couple of chronic conditions. I think that's a bigger issue with we're really bad at dealing with chronic conditions.

We don't know enough and we're not very good at it. So patients don't like us because we're not curing. Their diseases or helping them in a lot of, you know, especially like PCOS is a great example where I think a lot of patients feel totally alienated. They feel like they're not getting any better. Yeah.

And so then they go seek out these other people that have kind of quote unquote alternative medicine, but they also have an MD or Dio degree. So they feel, you know,

Rami: Yeah, I think that's, I think like it's funny because this let's say functional medicine became a [00:25:00] fellowship and you had to become

Aleah: a pseudo fellowship when you think medicine is a

Rami: pseudo.

Yeah. But right now most docs can just go and do a course and get functionally medicine certified, which I think is great, I think is actually really good. But like sometimes what I think happens in medicine, like let's say we went and made this official, like it's a resident. And you go get a functional medicine, you know, saw a piece of paper, makes it

Aleah: obesity, medicine.

Rami: Yeah. But then it explodes. It becomes exclusive. And so you, then you get imposter syndrome as a fully qualified doctor that, oh, it must be something you have to go through residency for in a full formal training. So I must not be good enough or I must not be smart enough to actually practice because I don't have formal training in it.

This whole idea of everything has to be formal. Is that I think bullshit. I think doctors are incredibly smart people. I think they are the cream of the crop when it comes to any like academic professional and they can go and learn [00:26:00] things onsite on the job we don't need. So

Aleah: this came up actually in, um, I had a conversation with this person from Google.

And essentially what my question to this person was, you know, is how did you get from point a to point B, which was ending residency and then working at these startups basically. And I also asked, you know, if I was interested in that kind of a thing, Should I go to business school? Should I go back and learn engineering?

Like, you know, cause I can do those things. I definitely can do that, but should I do that? And you know, I told her this person that I just felt, yeah, like what qualification or skill do I have to like work with? Or, you know, weigh in on some new health product. I don't know. And this person broke it down pretty nicely for me.

You know, all the things that I knew that no engineer or coding person knows, you know, do they know how somebody goes through? You know, enters the emergency room. [00:27:00] What happens when they're like there? What does it mean to be boarded in the ER, what happens when you get moved to the general floor? What about if you go to a step-down unit, when you get discharged?

What's what happens? Like you have a discharge appointment with your primary care provider, then what happens. And, you know, this person was telling me there's products and different things that are being developed for every step of just a simple thing to, to me, that's simple, this process it's like patient comes in, does this, this and this.

And then this is the end result. Why would an engineer know that? Why would a coding person know that? And so it really empowered me to be like, I do actually have skills that are not clinically based, you know? Cause some clinically based things. Yeah, it takes a lot of experience. Other things are guided.

You know, who can read a guideline,

Rami: anybody? Well, most guidelines will be replaced by AI. At some point in the future, like guideline directed work or clinical work. That's a good point. That's a good point that you have experience and you have insight. You have industry experience, like in a [00:28:00] very in-depth way that you can get doing any other kind of work, but

Aleah: none of us know how to market ourselves or find the right people.

'cause, you know, we've been brainwashed that it's just like, you are a clinician. That is what you

Rami: are. Yeah. And, uh, so the company I'm joining now, I'm disrupted. So my thesis and what I'm most excited about with joining this company is this whole emerging industry of new expert work. That's going to become a big part of, I think physician careers and clinical.

So the gig economy has been around with like things like Upwork and Fiverr. And, you know, you can do these freelance jobs and consulting jobs. Like this has been a growing trend for quite a while. I think in the future with the development of new technologies, with the growing emerging markets and AI and digital health and things of that sort.

I think clinicians are going to have a lot of opportunities to do more of the, these quote unquote gig jobs, [00:29:00] where they can be an health expert where before there really wasn't need for health. But now with when, when companies are building products for medicine, for health, they need doctors to help in evaluating these products and reviewing these products and making these products better and helping the business and development team market.

These products create the right messaging for these products. There's a whole new market that's emerging right now. And I think clinicians are going to have a huge opportunity here. And this is gonna, you know, continue to grow through like the next five to 10 years. It's not going to be. I don't think you're just going to go and have one job anymore in the future.

I think, I think you're going to have multiple jobs. I don't think you're going to go and sign up with a hospital and that's going to be your only job. I really don't. I think you're going to take a telemedicine job two or three days a week, probably going to do some consulting on the side. You might join a health tech company as a fractional.

And that's the sort of direction that I think we're going for a lot of

Aleah: clinical careers. Well, I think too, though, people are going to need help [00:30:00] breaking out of like the chains. You know, we've talked about this before, you know, you're in residency, you have a ton of debt, insurmountable debt for a lot of people, you know, myself included and you know, you're, you're getting to the finish line.

And you sign your contract. It has a big dollar sign on it. And you're like, okay, finally, you know, I'm going to be able to pay my things. I'm going to have stability. I'm going to know what's happening next. And it's hard to break away from that because you know, all of us do need some financial stability to be okay.

You know, a lot of people by the time they're 30, which is like one of the youngest ages to exit residency. Have a family, you know, may have a house or whatever, you know, we have obligations and things like that. So I think people are going to have trouble, some trouble breaking out of that system and feeling.

Steady enough to do that and go to this more gig work, which I think is definitely important to have more than one thing going on. But you know, this goes back to like, we should be [00:31:00] teaching more people about like finance, you know, most doctors don't know anything.

Rami: Yeah. And you brought up a good point because a lot of people, and I get this actually a lot from people as they want to start their own practice, but they don't feel like they have the time to go and do that.

And you shouldn't just leave your job. And go start a new business. Like that's not the smart way to do it. Like you should have a plan. Yeah. So the smart way to do it is, you know, you start to scale back appropriately. So if you have a full-time job or if, you know, like, let's say you're new, we'll do a couple of scenarios here and let's see your new graduate.

And you know, you don't want to take a full-time job. You know, you don't want to work for the hospital. You want to start your own business. Well, you want to start making some money and paying off some bills and you've been in residency for a long time. Now you've got a family. Like, I don't want to be like, not making any money for their first year of starting this business.

So there's several ways to structure this. You, you either you take a part-time locum job where you work [00:32:00] in a clinic for three days a week or four days a week. There's tons of them out

Aleah: there not talked about

Rami: often. Yeah. Yeah. And it's not, I think everybody coming out of residency should probably start with a local.

Because it will give you more insights into the kinds of things you can do. And it'll give you more flexibility to explore other things like you don't want to take risks when you're 50, you want to take risks when you're

Aleah: 30, can you explain what, like just basics. Some people might not even know what a locums job,

Rami: so it's just like, you know, like you can do a local urgent care job.

If you're a family medicine doctor, you can do a local. Uh, endocrinology dot job. There's local, straight, everything. It's just like you fill in all your doctors.

Aleah: It's almost like travel nurses.

Rami: It's contracted work. Yeah. It's 10 99 pay. You get paid 10 99 and you can, for me, you can open up your own escort, your own business account.

You can use some of that money for tax deductions and things like that, but you start off small and you start off doing a locums and then you've you let's [00:33:00] say you have, your passion is being an obesity medicine doc, and just doing obesity medicine, you start leaning, you start like a. You know, maybe you rent out an office for one day a week from friend, say, Hey, just once a week, I need to borrow your office and see a couple of patients start off with two or three, then four or five, then 20, then 30.

Then you start growing slowly. And as that's growing, you scale back from like your locums job or from your other job. And then if your obesity medicine practice is taking off, then you can start going in on that deeper. And if it's not, and it's not doing well, maybe you got to try something else or figure out something else that's working that might be more.

But it mitigates the

Aleah: risk, right? Yeah. And I think that's definitely good to do because I agree. I don't think you should just drop everything and, you know, go off. But the other thing too, is I think for a lot of new graduates what's happening is, you know, in the third year of residency or fourth or fifth, whatever specialty you're in, you're still really busy.

Like you're still working like 80 hours a week and it's not [00:34:00] easy to just like go interview for jobs. I remember when I was in residence. You know, we weren't really like allotted a lot of extra time to say, oh, I want to go do this interview. And so to put some of those things together, I think can be difficult.

And I think that's kind of a common trap is at the end of residency, you're like scrambling to find a job and. You know, you, you sign whatever you need the money. Cause you're running out.

Rami: It's like almost they create this. I think the employers, the employers create this pressure. I think they're, they're creating this pressure

Aleah: purposefully a lot of extra money.

I mean, that's at least was true for me, you know? You get out of med school, like you're making no money in med school. Most people cannot hold a job. So then you go to residency, you make a very small amount of money in comparison to like what you're doing, the hours you're putting in. And then a lot of these places you're still living in an area of high cost.

So the extra money that you have. You're trying to stay sane and do a couple of nice things for [00:35:00] yourself instead of like building an emergency fund or building funds for you to take a couple months off after residency. I don't think people are thinking ahead like that. Cause it's not brought up. Nobody ever told me.

Yeah. Maybe after residency, you're going to want to take a couple months off and you should save the money to do that. Okay.

Rami: Well, yeah. And think about this. Let's just another thought experiment here you work. Let's say the sixties a week in residency, right? One of those days. You could go and work moonlighting doing the eggs.

You can Moonlight for your own residency.

Aleah: That's also not talks about often.

Rami: Yeah, but it's bullshit because it's all it's about the money you could do that make $120 an hour moonlighting for your own residency, doing the same work you already would have been doing and making some extra, real money.

That's going to be able to help you. You know, but why isn't that allowed? Why isn't that a thing? They may, oh, you're in residency to train bullshit. You're in [00:36:00] residency, don't work. You're in residency to work. You're getting trained. If it's really about the training, we then work so many

Aleah: hours, but it wouldn't be like such high volume.

The focus

Rami: would be on education. If it's really about the training, then why can't you after your first. Go and work with another doctor. Yeah. There's so many things that are contradictory to what we say is the reason we're doing something, right. Like I get really heated up about some of these things, because for whatever reason, like I tested really high and based on things I get emotionally reactive to, and one of them is injustices.

Like for whatever reason, like I probably should have been a lawyer, but. I get really heated up about when people are being wronged. Yeah.

Aleah: But it doesn't feel good. I mean, yeah. I know. I, whenever I was in residency, I had a rotate with general surgery for part of it. And like, I literally was like holding the laparoscopic camera for hours in the, or when I [00:37:00] was like, I'm not learning anything, if anything, I'm like, you know, my wrist is in pain and I didn't learn really anything.

And why did I need to do that? Because the surgeons didn't have a first assist from a surgery program. I mean, there's like literally, I mean, I wasn't planning to do surgery. Why couldn't I say that this isn't, I'd rather spend this time learning about obesity medicine or I'd rather spend this time learning about finances.

Why can't, why can't some of the, residency's be more like tailored to what you actually want to do. Like, what is the reason? And the reason goes back to, we already know this, the hospital systems make a lot of money off of residents and the care that they provide. I mean, it's, it's being highlighted more, you know, I saw some post recently about how, you know, residents again, are being asked to work more hours than they're supposed to be working and they're not being compensated because of COVID, you know, and it's preying on the whole, like, you know, we're good people.

We want to help people. Of course.

Rami: And then what's the justification. The [00:38:00] justification is all they're in training. They're learning, they're learning so we can pay them less. Yeah.

Aleah: It's sad. It's what other comments did you get? She helps with another one. That one took us out of 10.

Rami: Well, another, another common one was people who, who have either gone through remediation residency or.

Gone or experienced something in residency that they are probably a little bit too ashamed to ever admit to anybody else. For some reason they felt like now they could admit that to me. And so I've had a lot of people reach out and say, you know, like, I mean, I know what you're talking about. I experienced that in residency.

It was terrible. It was such bullshit. It was this, it was. And they, nobody wants to sound. I think what I've realized. And sometimes it's funny because a lot of people are open up to me now, like randomly, like if they, you know, either got kicked out of their residency or maybe I'd left residency unexpectedly, or maybe took a leave of absence or something like that, they'll reach [00:39:00] out to me because for whatever reason, Do you think I might be able to offer some guidance, which I try to, but I can hear through people's words.

Like I can read between the lines of what they're saying, because I've been there, you know, and it makes me like, it's interesting because I remember seeing similar lines because I felt too ashamed. Talk about my story, you know, so I could, I'd be, yeah. So I'd be reading between the lines and obviously, you know, like I I'm, I'm just listening, I'm just hearing them all.

And I'm like, you know, no, man, I get it. I get it. Like, it's bullshit. And there's a lot of things that it doesn't mean your any less of a great doctor or any less of whatever. It just means people are people like there's some, like someone might have. And you just get, you just get screwed over like that.

And that's just,

Aleah: well, our culture obviously definitely values like perfection. And we don't like to talk about things that are shameful, obviously, but it doesn't help [00:40:00] anybody. It makes you just, like I said before, feel more alone, you know, in a, in a time that I think people already feel very lonely in residency and in medical school, I remember in medical school, I failed my general surgery shelf by like one.

And I had been up, uh, you know, I had to take my test basically after a night shift, which I mean, there's tons of research to show that that's just not, not good. And I remember I was like, so embarrassed by that and I actually posted it on social media eventually. I think it was after I had, I think actually it was before I remediated and redid the test.

And within like a week I like barely even restudied and I took the test after sleeping and I had scored substantially higher. But I remember so many people messaged me after that. Just being like, thank you. You know, I, I failed this too. And because it's, our culture thinks like failure is failure.

Instead of thinking, failure is a way, you know, quote unquote failure is a way to learn more things and have some kind of lesson, [00:41:00] you

Rami: know, owning it is the most counterintuitive thing. It's so funny because I feel better. Yeah, it does. It makes you feel better. It makes you feel lighter. Yeah. Actually you think with a thought process processes, you think people are going to respect you less?

Or are they going to think less of you? And most of the time, what you'll notice is like people are incredibly grateful and respect you more for being honest and owning, owning your story, which is what I've learned. Like I, I try to always remind myself that if I am, like, if I just own this, people are going to respect the fact that I'm owning this.

They're not going to not respect me because I didn't finish residency. You are the worst thing, like the worst thing. And it's unfortunate that people feel they have to do this. When you lie about your experience? Like there, there are a lot of doctors. I didn't finish residency. Some of them just hide it.

All right. Hide it. Like they just avoid it, calculate their words. So it never comes up, like avoid the entire [00:42:00] conversation just on it, like fucking own it. What do you tip to add respect you so much more if you just own

Aleah: that? Well, because people think though, you know, they assume, oh, if you didn't finish residency, it's on you.

Like you did something wrong. Almost, you know, it doesn't really seem like that's the case. In most scenarios. It seems a system failure. I mean, this happened to me in residency actually. I was going through like really a lot of stress. Like I, what is happening right now is like not working for me. This is during, you know, kind of the COVID explosion every day.

It was like a new email saying like, you're going to be doing this. You're being pulled to this thing. You, you thought you were out of, you were done for inpatient for a while. No. You got to come back. You're jeopardize. So many constant changes and I was really struggling with that, which was normal actually.

And I remember kind of the response to me, asking for help and kind of some changes, maybe decreasing some of my clinical hours if possible, or just doing something, anything to help me. The response [00:43:00] was basically like, maybe you need to take a leave of absence and you know, to me, I was like, thank goodness.

I had like enough personal insight to. Like, this is not a problem with me. This is actually a problem with the system I'm doing quite, quite well for the circumstances. I went to a

Rami: top medical school when it was top of her class or a top residency, like, come on, like it's like formulated to make you feel like the person that there's something wrong.

I remember

Aleah: being in shock actually. And just being like, there's nothing wrong with me. Like actually, you know, I'm quite resilient, you know? But, you know, in residency is just like, the stakes are so high, everything's so high, you know, and you're in a system where you have to believe that it's your fault instead of other people just trying to like help you get through times that are tough for everyone.

So.

Rami: It rewards the wrong things. It rewards you for being a people pleaser, which is not a good thing. It's not healthy to be [00:44:00] that or a perfectionist or you for trying to be a perfectionist that rewards you for trying to take on more than you can handle a rewards. You a lot for self sacrifice.

Aleah: So the more you can say using resident, if you, if you volunteer to do like extra shifts, all these things.

Of course, everyone would think, wow, what a team player. I hate that when people say like, oh, you know, one of the things that happened recently, I had a friend

Rami: who, um, this podcast, so not PG, but I'm going to bite my tongue, keep it PG. Well, so

Aleah: I had a friend who, you know, in the current climate of, of healthcare was asked to do some hospitalists work.

Um, even though, you know, they're a primary care person and generally do outpatients. Asked to volunteer for that, um, to help with the COVID crisis or whatever. And so this person was like, okay, you know, I think I could do that, but I would like to know, you know, my compensation and if I'm going to be working nights or weekends, I would like extra compensation for those things.

And then [00:45:00] I'd be willing to do it perfectly reasonable things to us. And the response was basically, um, you know, we can't do that right now, but thanks for being such a team player, those words. Exactly. And, you know, and it's just these things that happened to us. All of us in healthcare are like, you know, nice people.

Like we, we do want to help people. That's our primary motivation. And so of course, you know, a lot of people just fold and we are the team players, but to our own sacrifice, you know, we're, you know, being mentally unwell, physically unwell,

Rami: all these things.

Where I felt like, I don't know. I just felt like, I felt like there was something wrong with me. And the more I reflected on this, the more I've thought about everything. I realize, look, I had definitely screwed up in some areas like in training, but like, yeah, you're right. But I also, I think my personality like is as one of those personalities, that really just didn't fare well with being a [00:46:00] resident.

Like, and it goes back to that thing that I mentioned earlier, like injustice just rubs me the wrong way. And it really like, like, I felt so much resentment and it just ate me up all the time because residency. It just made me resentful. It just made me feel like I was being wronged. It made me feel like my colleagues were being wrong and like, I always want, I want it to be the one that would speak up for us to my own Dutch, Maggie in trouble.

Like, you know, and so, but we need

Aleah: to shift from that kind of a culture of, if you speak up and say something that your deemed like the problem child. I don't really think it should be that way. You know, I think if anything, it just tells me or shows me that you have new ideas, you have things that you want to say that could potentially improve the situation for everybody.

But our culture just like, doesn't, it doesn't align with that,

Rami: sadly. Yeah. Yeah. And it just certain environments that value [00:47:00] everybody's drinking the Kool-Aid everyone's drinking the Kool-Aid and when you're not drinking the Kool-Aid you look like, you look like an.

Aleah: Well, and I actually think though, talking to more and more people, I think a lot of people realize there's problems understand, but again, you're in a system where you are the lowest rung on the ladder.

You can't do a lot. What you have to lose is really high. And so it's easier sometimes to just put your

Rami: head down, but it's sad. You want to talk about. The times I felt the most burnout in my life are those times that I wanted to speak up or the times that I was just like, this is so fucked. This is so wrong.

And I didn't see. I would end up in a depression. I sorta, I would end up like, that would burn me out. It wasn't like there wasn't the work. It wasn't like, I I'm, I'm a hard worker. I worked like a hundred hours a week. Like when I was [00:48:00] starting my business or what I'm doing, what I'm doing now, like I work hard.

Like I like, especially when I'm doing something I enjoy, I burned out from those things. Yeah. I agree. And that's, it's just, I think a lot of doctors would say or would agree. It's, there's some things that you can't quite put your finger on, but a combination of lack of autonomy. Lack of respect, lack of individuality or ownership of your time and lifestyle combination of those sorts of things are really the major contributors.

Aleah: And, you know, in medicine, I think there's almost no boundaries. I don't know, you know, a lot of practices, they give access patients access to doctors, 24 7 with the EMR. You know, you go home, but oh wait, you have a message. Oh, wait. You know, this person has a new clinical question and you need to provide answers free of charge on your off hours.

I mean, you [00:49:00] know, we've got nurse triage lines at night. We've got somebody on call on Christmas. There's no boundaries in medicine and you, and I both know, like from therapy probably that, you know, boundaries are good. Boundaries are good, but we can't put up boundaries with patients it's not healthy. So I'm like, you know, then doctors are getting calls in the middle of the night for a refill on L.

When this person could have called tomorrow, you know, I mean, it's just, if we just made more boundaries, doctors would probably be happier. A lot of people would probably be happier and actually boundaries tend to benefit both parties. Maybe not initially, but in the long run they do.

Rami: Yeah. There's a app.

Some examples that we could definitely talk about here, but I think you definitely have to have boundaries with patients, especially in the way health insurance. Patients are taught to use the medical system, which is not really tiny patients fault. It's just the way we're [00:50:00] conditioned in American healthcare to perceive our

Aleah: medical care.

Right. I think if patients knew more, what was going on behind the scenes? They probably wouldn't want to bother their doctor in the middle of the night for something that was not urgent. I think most people would respect that if they understood, but it's advertised as like, uh, come to our health system because you have access to your doctors all the time and just

Rami: Teitelman aspect to it, which is wrong.

And I think I've had this conversation before about the idea of. You know, people being entitled to healthcare or entitled to medical services. I think everybody is entitled to access. They're not entitled to great care because you can't forcibly. If someone was someone else's service like you can't like, I can't force you to give someone great care.

If you don't feel like the patients receptive to you, why are you obligated to exhaust yourself for this person that may not be [00:51:00] receptive to anything you do or.

Aleah: Oh, yeah. It's like these things that are, I'll give you an example, like, you know, on my EMR, I need to have people do their preventative care and I order it.

And if they do not want to get it done or do not do it, then we get dinged and we make less money for that, which is like, I mean, I did all the counseling. I told them why it was important, but they chose not to do it, which patients should have a choice if they want to make an informed decision. They don't need HIV screening.

They feel they're low risk. And I agree with that, but if they don't do it. You know, alert, doesn't go away on my EMR. Then now I'm compensated less.

Rami: The goal is not to create a codependency between us and patients. Patients are to be informed by their doctors to be guided in the right direction. No, one's like, if you're not going to, I'm telling you how to get healthier.

I'm going to be compassionate, especially if I really like you, like, I'm going to go the extra mile for you. I'm going to listen. I'm going to really try to help you, especially if I see [00:52:00] that commitment. That's going to engage me even more and I'm going to be more invested in you. And I'm going to tell you, and I'm going to spend time.

And if you show me, you're willing to work on this, I'm going to invest in you further. And we're going to really try to make things work. But if you're coming to me for a quick pill or a quick solution, and you don't want to do any of the work, if you're being rude, if you're acting entitled, if you're saying, well, why is my Avon C not lower?

It was lower three months ago. Why was it higher? Well, I walked you in the right direction. I guided you like there's, some people just don't want to do the work or don't want to do not only the work, but don't want to take responsibility for their own health. And it's not the doctor or the provider. Role to take on that responsibility.

You have to give people their own choice and do your job in terms of guiding them in the right

Aleah: direction. Yeah. And I think in some scenarios that is definitely true that some patients don't want to participate. I do also think though that our system is [00:53:00] so convoluted, that it makes it very difficult for patients to even do the right things.

I mean, I have tons of patients that they, you know, they have multiple jobs. They can't really commit to certain things. Their medications are too expensive. Wait they've the EMR is aren't connected. So actually they can't remember if they got, you know, X, Y, or Z done. And none of this stuff's taught to you in school.

It's like being a patient is a full-time job. You know, I've had a couple of, you know, health issues recently and it's like, I have some trouble navigating things and I'm a doctor. You know, I mean, it's crazy. And I, I try to like empower patients to, you know, keep their own records, know what's going on, understand what's going on, but I can see how, you know, it's bigger than just the.

You

Rami: have to, you have empathy and accountability. You have to always go hand in hand. Like you have to have empathy for people's situations. You have to empathize with people. You have to be able to put yourselves in people's [00:54:00] spots and it, and that actually relieves it relieves resentment. It relieves negative feelings.

Like when you're able to empathize with someone it's not about, they had their living their own experience. At the same time, you have to hold people. You have, there has to be a. And you can be responsible for what other people are accountable for. And you got to keep those two things together. I think let's wrap it up.

I think we've had a pretty good conversation.

let us know what you guys think. If you enjoyed this podcast, uh, head one of us up webby.deal or medicine in Michigan, tag us on social listening that you liked. Send me a DM. I'm really curious about the feedback I enjoy. The people, because it guides us in the right direction and lets us know what people are resonating with and where we should talk.

So please send us that feedback. All right. Peace out guys.