The Physician Philosopher Podcast

TPP 34: The Physician Should Come First (Not the Patient)

How many times have you heard someone say (or said it yourself), “The patient comes first”?  Yet, this is an outdated belief that doesn’t really accomplish what we want it to. It often leaves our physicians to self-sacrifice their lives to the point where they cannot help other people.

Larry Keller

Like the airline industry teaches you every time you board a flight, put on your oxygen mask before helping others with theirs.  Otherwise – when you pass out from hypoxia – you won’t be able to help anyone.

In this episode I make the case for why physicians should be put first, the current state of affairs in medicine, and how doctors can put themselves first after they realize the hospital isn’t going to do it for them. 

Today You’ll Learn

  • How to fill your cup first so that you can fill the cup of your patients.
  • Why you should be putting yourself first.
  • The brutal reality of medicine, and how we need to take self-care into our own hands.
  • Ways in which you can stop self-sacrificing your life outside the hospital.
  • And more!

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How many times have you heard someone say, "The patient comes first?" What if I told you that this is not only an outdated belief, but it is actually harming our physicians and our patients. It is time for doctors to come first, keep listening to find out why and how you can start putting yourself first right now. This is the Physician Philosopher Podcast. I'm Dr. Jimmy Turner an anesthesiologist, online entrepreneur and creator of the Alpha Coaching Experience. The Physician Philosopher Podcast teaches you how to create the life you deserve one thought at a time. Start before you're ready, start by starting, start now. Hey, hey, hey everyone. Welcome to episode number 34 of the Physician Philosopher Podcast where we take an uncurated and unapologetic look into physician life, money and mindset.

Today's thought is this. When physicians come first, our patients will receive the best care and the culture of medicine will change for the better. So back when we used to publish blog content three days per week on the Physician Philosopher, we used to have guest posts, not infrequently. And so, one of the best guest posts that we've ever had on the site was written by a doc who online goes by Vagabond MD. And Vagabond MD wrote a titled post called The Hospital Will Not Love You Back. And it talks about this strange love relationship we have with medicine as physicians, right? Too many of us go into medicine giving our every last effort into our relationship with medicine and putting our patients first. But what we experience in return is often some unrequited love, right? It's a one-way relationship where we pour everything we have and everything that we are into our jobs just to be completely ignored.

No matter how much you put into medicine, the hospital will not love you back. And is that the way it should be? Should doctors be putting medicine and our patients first only to be constantly ignored, mistreated and abused, frankly? And the answer is no, of course not. Medicine has a lot to learn from successful businesses. Because it turns out that there are businesses out there that get this right. There's this hypothetical question that often gets asked. So who should come first? And I'd encourage you to pause this after I ask this question. Think about it. If you owned a business who should come first? The customer, the employees, or the board of trustees? And many would point to businesses that say, "The customer's always right. The customer comes first," as examples that clearly customers are supposed to come first.

That's how businesses work. And they are the ones who were paying for the product, right? So wouldn't you want to make sure that they're happy? If they're not happy, then no one buys and the business doesn't grow and they go into debt and then the business has to fold because no one bought because the customers aren't happy. And others might say, "Well, if you don't make sure that the board is happy, the people that are running this place and are in charge of the decisions, then we're not going to have a job. And if we don't have a job, the employees can't work and the customers can't be happy because there's no place to have a customer. We better make sure that the higher ups, the administrators, the board of trustees that they're happy."

But I'm here to tell you that the companies who get right, companies like Costco, who have a long history of being a great place to work, they put the employee first and you know why? Because Costco understands that if the employee loves working for Costco, they're going to take care of the customers. Do you see Costco's response to the pandemic and how they handled that? I don't know if you went in there. When companies were still trying to figure it out and get it right, Costco did a really good job handling that. And they got their employees to completely buy in, then customers came in, they were happy. They felt protected. They felt safe. Had a good shopping experience. They bought more things. The bottom line got fattened and the board, or whoever runs the things at the top in Costco were probably happy because things continued to do well.

And the reason for this is because they spend time making sure that their employees love working for them. They have awesome benefits. They automatically get membership into Costco. There's several things about working for them that employees love and I'm not saying it's all glitz and glamor. I'm sure there's some bad things about working for Costco, but the principal stands. When you take care of your employees first, the customer's going to be happy, they're going to buy and then the bottom line will work itself out. So instead of chasing the ends, they really try to work on the process. So why in medicine do we fail to put doctors first? That's my question. Why doesn't there seem to be any focus on the happiness of physicians? 50% of us are burned out and we're always told that it's just the way that it is. Nothing can ever change.

Why aren't we told to ever make sure that we take care of ourselves first and why aren't we provided a situation, a culture, a system, a process that actually allows that to happen? It's great. Yeah, tell me to go meditate some more. Tell me to sleep better. Tell me to do all of these things that are in my control to make this better and let's just ignore the system that clearly needs to be fixed. That makes sense, right? Think about it. We have been told the opposite our entire time in medicine. When was the first time that you heard someone say, "The patient comes first?" This is literally a mantra that 99% of us believe. It's something that we say ourselves. It's something that we've heard other people say. It might've been the first time you heard this a day where you had to stay late at the hospital to finish up work in order to put a patient first, maybe for a late procedure or a script refill, or a note.

Or taking care of that one patient who showed up right before you were supposed to leave, or fitting them into an extra patient clinic spot that you don't have at the clinic. The patient comes first. We believe this so much that we say it out loud all of the time. And the problem is that today, this not only includes our patients coming first, but it often includes the expectation that medicine and the hospital or the clinic that we work at, those things come first too. In other words, that everything else becomes before the doctor. Those who run medicine expect everything to be more important than the physician. That's just the truth of it. Our charting in the EMR, billing, pre-authorization, insurance paperwork, online modules to make sure that we know how to handle violent threats. I mean, not to include the committees meetings and all the other stuff that we have to do.

Administrators think that these things are important and that honestly, they're more important than our lives as partners and parents and physicians outside of the hospital. This doesn't even include the metrics that they ask us to chase, like length of stay and patient bounce back metrics and patient satisfaction scores. Dear God, press [inaudible 00:05:56] anyone, right? Turn over times in the operating room and all the other metrics administrators would just love to follow. Yet it doesn't make sense. They're missing. They're putting the cart ahead of the horse. When we put all of these other things first, you know what inevitably gets put last? Our doctors, physicians. And I'm here to say that this is backwards. It doesn't make sense. Physicians should come first, not last, and you can jump down my throat if you want to, I'm going to stand on this one.

I'm all about providing the best possible care we can for patients. But I don't think that happens when we focus on everybody but the person taking care of the patient and this isn't to take away from the amazing work that our nurses and our APPs do, that's not what I'm doing. But the captain of the ship in clinical care is the physician and for too long, we've ignored doctors. And I firmly believe just like many of the great companies outside of medicine understand that when they take care of their employees, the customer ends up being happy that if we started taking care of our physicians and put them first, all of the other results that we're looking for, including good patient care would follow. It would naturally happen. It's just like getting on an airplane, right? Have you ever been on an airplane? What is the thing that they tell you? If oxygen masks fall, what do they tell you to do?

They tell you to put your oxygen mask on first and then help the people around you. Why did they do that? It turns out that if you pass out from hypoxia, you can't help anybody. It's in the same way medicine should focus on what would make physicians love practicing medicine. What would help us take care of them first so that they then can take care of the people that they work with and the patients that they take care of? Then, and only then can we really expect the care that all of us want for our patients and the employees we would want to work for us if we were the ones that were running the hospital. It's not a surprise that physician turnover's bad, and it's not a surprise that it costs half a million to a million dollars to replace a physician and yet, we can't figure out how to create a system and a culture and a process that doesn't make doctors want to leave.

Because we're not putting them first. So this begs the question, how do we put our physicians first? And I think the answer is really going to be different for each doctor, right? Each institution, and each situation is different. But first we have to discuss some of the problems that many of us are all too aware of. This is just like the difference between being a good doctor and a bad doctor, right? If you treat the symptoms and you can't figure out the diagnosis, now you can't always figure out the diagnosis. I'm not saying if you can't figure out a diagnosis you're a bad doctor. But the best way to take care of somebody is to figure out what the actual problem is and then treat the problem as opposed to treating their symptoms, right? Not slapping a bandaid on it. It's just like coaching.

Good coaching involves figuring out what you're thinking, because that's the cause of everything else in your life. And once we do that, then we can make some adjustments. We can make some decisions about what we need to do. Otherwise, if you show up to a lot of coaches and say, "Hey, just do this. This thing will make you happy." [inaudible 00:08:29] works. If you don't know what's making you unhappy, you can't figure out what's going to make you happy. So figuring out the diagnosis, right? So this is how we treat the problem. But I think we can still point to some of the things that are causing physicians to feel trapped in medicine. And why do doctors feel unappreciated, undervalued, unheard? I think a large part of this is the top down edicts that come in medicine from insurance companies, administration, and ever increasing tuition rates that lead to unsustainable student loan debt, burdens, things that place us in these invisible shackles that make us feel trapped basically.

Things like insurance companies telling us how to practice medicine when we have a procedure that we know that they need, and we can't get it authorized for the patient to have it done, to be taken care of, so they don't get saddled with a multi $1,000 bill or writing a script for something to find out the insurance company didn't approve it because they think that they need to do X, Y, and Z first, even though you know it's the right thing for the patient. Hey, here's one. Non-competes and contracts. That's cool. So instead of fixing a system and making the people love working for you, if people love working for you, they're not going to leave. Instead, we're like, "Nah, that'd be too hard. Let's give them non-competes in our contracts so that they can't leave and if they do, we can take lots of money from the doctor that's already $400,000 in student loans." Because that's okay.

Or what about in academics? The publisher, parish mentality. Fortunately, I don't have this where I am, but I know lots of other doctors that do, if I get one more online module about how to deal with a myocardial infarction or a stroke, I've literally diagnosed locked-in syndrome post-operatively in the PACU on a patient that had a procedure when they literally weren't doing anything, they're locked in. All they can do is blink. I knew what the diagnosis was before I sent them for a scan. If I can diagnose that stroke, I'm pretty sure that facial drooping and dysarthria are not something that I'm going to miss. Can we please stop making our physicians do modules online to check a box that are completely unnecessary. Same thing with maintenance of certification requirements, right? That's been all the rage for the last five years. People getting up in arms about that.

Or electronic medical records, they're glorified cash registers. They're meant for billing, they're not meant for patient care. And yet, they add hours to doctor's days. When are we going to be like, "Nah, that's not okay." Or hold backs for performance. We actually call them hold backs. Who came up with that name? So if this metric that I often have nothing to do with doesn't happen, you're going to hold back part of the money that would be flowing to me? Even if you're going to do something like that, by the way, why not call it an incentive and say, "Hey, if you reach this metric, we're going to give you a bonus." Just that positive framing in and of itself would improve that situation. The fact is the focus is clearly not on the people being affected by these decisions. And in medicine, it's always a stick and never a carrot. It drives me insane.

Yet the biggest thing that probably encompasses all of them is this idea that there's just a status quo in medicine and that there's nothing that you can do about it. And so, when we get to this point, that is when doctors feel lonely. That is when they feel trapped. That is when they feel like they have no options. And that there's nothing that they can do. And that is when I love working with you. That's when I love working with people because the problem is this. The system is how the system is. And until we have enough doctors who feel free from medicine to stand up and to say something and to try to make a change and to say, "No, I'm not doing that. That's ridiculous. I'm a doctor and that's not what's best for me. It's time consuming and it doesn't help my patients either. I'm not doing it." But the problem, of course, is that we need free doctors to do that.

We need doctors who feel like they have true freedom in order to do that. So you can often feel like a trapped physician, which is the doc that feels unappreciated, undervalued, unheard that's made suggestions and been told, "That's just the way that it is." You feel overburdened, you're burned out maybe. She's a doctor that's worked hard to get to where she is and she isn't happy. She feels stuck, trapped. Doesn't know what to do. That can be powerless and very lonely. And this is where most physicians stop and if you've made it this far, fantastic for you. I'm glad that you've listened to me for 10 or 15 minutes on this podcast because this is where most people throw up their arms and they say, "He just confirmed everything that I've experienced." It's exactly how it is. I can't do anything about this. It's just the way that it is and there's nothing that I can do.

So many of us at this point have learned that medicine's not going to change, right? So I want to go back to that Vagabond MD post. The hospital's not going to love you back. So you know what you have to do in this situation? You have to take matters into your own hands. And the answer in my mind has always been to empower doctors to create the freedom that they need to practice medicine however they want. This means mastering your mindset, mastering your money, mastering your ideal life like we talked about in episode 30 and 31. So what does this look like in real life when physicians like the clients that we have come through the program, they experience freedom? How does that work? Some of the mindset stuff is getting clear on exactly who you are, exactly what you're about and exactly what you're willing to put up with. So for anyone's whose followed me for any period of time that I have something called a hell yes policy.

And this requires you to have some deep reflection to figure out what actually matters to you, answer some tough questions, really dive into your mindset, the thoughts that you have about what matters most and most doctors who feel trapped feel like they don't have a choice. And the first step in this is really realizing that everything is a choice. You staying in medicine is a choice, you going to the hospital is a choice. You surrounding yourself with a bunch of people that tell you, "You can't do anything about this," is a choice. You do have the ability to say no and recognize that every time that you say yes to something, you're probably saying no to something else that matters to you. So if you can get clear on what matters most to you and put your time and energy into those things and start saying no to things that don't matter to you, you're going to find some freedom and that's just purely mindset stuff.

You haven't changed anything about your situation, you're just starting to say no to things that you refuse to do. And this comes from a place of knowing your value. You are valuable, you're worthy. You are enough. And whether the hospital makes you feel that way, getting to the point where you really believe that and your intrinsic value, that is when you can stand in your truth. That is when you can have a hell yes policy and that is when you can feel unapologetic about doing so. But some people still feel trapped, right? Part of this goes back to my roots, the financial freedom that you need to have the leverage that's required to feel like you can stand up. Now, I think you can do that even without the financial freedom and I hope that we get to a place where we can change the culture of medicine from the inside.

I certainly don't want a bunch of doctors leaving medicine, I want doctors who feel empowered to stay and to change this thing because that's what we all need. That's what this country needs. It's what our system needs, it's what our doctors need. The people that are coming behind us need. And I remember when I first started talking with one of my leaders in my department about going part-time and I'm now in my mid 30s, I'm 35 years old when I record this. And this leader is actually someone that I have tons of conversations with, love him dearly. He's a rare bird who actually cares about what people think and he listens. And he expressed some concern that if I went part-time or I start focusing more on my subspecialty that I might lose some of my skillset because I'm pretty young and what if I needed to change jobs.

And he didn't want me to be in a bad financial situation. And while this is really well meaning, he really meant this out of a place of concern. I explained to him that I had all the financial freedom that I needed through the financial decisions that I've made early. Getting away from that monthly mindset of monthly payments, the only monthly payment we really have that's mandatory right now is our mortgage and even that, technically, if it got bad, I could sell my house. And right now, actually, if I sold my house I'd make a killing because the market's crazy. But lowering our monthly expenses and then on top of that generating non-clinical income through my online business, that provides all the financial freedom I need. So if it didn't work out in medicine, it really would be okay. And I know that I have the ability to fail forward now, like we talked about in the last episode.

Through entrepreneurship, I've learned that skillset. I'm not worried about the future. And so, when you stop taking on that monthly payment mindset and you drive down your required monthly expenses, you have more freedom. That's just the way that it works. That's why I'm a big proponent of paying off your debt. I have so many people who are like, "Oh, well, the math doesn't make sense. You can leverage your debt and make so much more money in the market by investing it in your Roth IRA or your 401k or your 457." Nah, you should fill up your 401k, that's a bad example. But by putting it in a taxable brokerage account, should I pay off my debt or invest? I think this is a psychological question because I know that my freedom for right now came when I paid off my debt.

So even if it didn't mathematically make sense, I know too many doctors who feel trapped and then they put money into the stock market investing it while they still have loads of debt and tons of monthly payments. And I often ask them, "I'm not going to tell you what to do, but have you thought about this? Have you thought about what it would feel like if you didn't have those monthly payments anymore?" And all of a sudden people were like, "Oh, well, when you say it like that, I guess I do want to pay off my debt," because I never tell people what to do. I just tell them, "Hey, this is the situation. You can leverage it mathematically, and mathematically that is right." I'm not going to argue with anybody that is mathematically the right thing to do. And if we were all stuck in a vacuum where humans were rational and we didn't have any psychological principles that dictated what we think and what we do and how we make decisions, it would be right 100% of the time.

But we are human and we do have human brains and we are irrational and we do have things that we worry about. So this isn't just a mathematical conversation, right? So that financial freedom piece is hugely important. And if your monthly expenses are high, this is one of the things that can make you feel trapped, so don't do that. Pay off the debt and generate non-clinical income so that you're not completely dependent on your monthly paycheck in medicine. That's the goal. And when you're not dependent on the monthly paycheck in medicine, you have all of the freedom that you could ever need to do exactly what you want and practice medicine however you want and to step into that third pillar and start creating your ideal life. That's how it works. Each little step in the right direction provides you a little more financial freedom you need to live the life you want.

It is this financial freedom that provides all the leverage you need to do all sorts of things that most doctors won't, which leads me to my next tool. Boundaries. Please, dear God, put up some boundaries in your life. Know your value, know who you are. Stop saying yes to everything and stop being constantly available. That's not best for you. If you put yourself first, the patient will get taken care of, I promise. If you can just create some white space in your life to actually enjoy a day or two without having to be connected, super helpful. So for example, I used to be constantly available outside of work. I had my email on my phone and I'm sure it is for many of you and I felt like I needed to respond the second that I got it, the second the notification went off and now not only do I not push emails to my phone, not only do I not have email on my phone, I rarely check my work email unless I'm actually at the hospital.

So there's a boundary there to protect my family's time. And another boundary I've set is that I no longer attend committees and meetings that don't fit into my hell yes policy that I've talked about above or before, I should say. So my major passions consist of my family and friends, my business, the physicians in training I interact with, my clients and the patients that I take care of clinically. And if it doesn't fall into one of those realms, these days, I'm probably going to say no. And the last thing I'll tell you, one other way to put yourself first is to join a community please. There's a reason that they say, "You are the average of the five people that you spend the most time with."

And it's because whether you want to talk about mirror neurons and psychology and how we become who we hang around with, it's the reason that two people when they get married they become more and more like each other or that your kids say the same exact things that you say and you notice that they have the annoying tendencies that you have. And when you catch them [inaudible 00:18:52] like, "Why did you ... Oh, I do that. That's why you did that." You can't help but become like the people that you hang around with the most. And so, surround yourself by people in a community that is full of doctors who are no longer willing to accept the status quo. Share this podcast. Join communities. I don't care if it's the Alpha Coaching Experience or a community like it. I really don't. I just want you to get the help that you need and to join a community of people that are going to support you.

And that is what is important because if we are the average of the five people we spend the most time with, we should choose to surround ourselves very carefully by people who refuse to be put in a box. By people who refuse to accept the status quo, who challenge it, who are all about helping physicians who feel trapped in medicine find the freedom they need to practice medicine how they want. Those are the people that I want to surround myself with. So it's time that we put our physicians first. And when we do that, hopefully some of the tools I just mentioned will help you start that process even today. The rest is going to take care of itself. Our patients are going to have better care. They're going to want to come back to our hospital. The bottom line is going to get bigger.

You administrators, you're going to be happy. If you made it this far into the podcast, you're going to be happy. I hope there's some administrators out there listening to this. Our physicians will be happy. The physician burnout and suicide epidemics that exist right now might be put to bay. God forbid that got better, right? Our patients will receive the best care and even the bottom line, it's going to improve. But we have to realize that the hospital's not going to love you back and this is something you have to take into your own hands and to find empowerment to become who you need to be with your mindset, your money and your life in order to buck against the gourds, to challenge the status quo.

And it is on us to find the financial freedom we need to practice medicine how we want to work so that we can work how we want to work. And on our mindset to create the boundaries and tools we need to live that life, right? So today's thought is this. When physicians come first, our patients will receive the best care and the culture of medicine will change for the better. So until next time my friends, start before you're ready, start by starting, start now. I'll see you next week.

My dad, Dr. Jimmy Turner is a physician first, personal [inaudible 00:20:48], blogger and a life coach for doctors. However, he is not your physician or your life coach. He also isn't a financial advisor, financial planner or accountant. Anything discussed in this podcast is for general education and entertainment purposes only. Life coaching is not a substitute for therapy, medicine, or medical treatment. However, if you're a doctor looking for a life coach, you can reach out to my dad at [email protected]




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