Midseason Recap: What We've Learned So Far

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[00:00:00] welcome back to the Direct Well-Being Podcast. I'm your host, Dr. Anders Apgar, and today is going to be a little bit different. No guest, no interview, just you and me, because we've reached a point in this first season where I think it's worth stopping for a minute and asking, what have we actually learned?

When I started this podcast, I didn't want to make another physician burnout podcast. I didn't want to waste forty-five minutes every week talking about how tired doctors are. We know we're tired. We know the system is difficult. And I definitely didn't want to tell physicians that the solution was to become more resilient.

Most of us are pretty damn resilient already Some show feedback I've received from you listeners is that the topics we discuss can be very heavy. You don't go through medical school, residency, board exams, call, complications, difficult patients, difficult administrators, missed holidays, and years of sleep deprivation without being resilient So heavy comes along [00:01:00] with resilient The question behind this show, the impetus for its creation, was always something bigger.

How did we get here? And maybe more importantly, how do we get somewhere better? Six conversations into this experiment, I'm understanding that the answer isn't one thing. It's a series of things that seem independent but are far more connected than I realized. Our schedules, our marriages, our children, our money, our autonomy, our leadership, our health systems, our sense of purpose, and the need to recognize when something is wrong before we reach the point where we finally say, "I can't do this anymore."

So before we hit begin the second half of season one, I wanna go back through the conversations we've had, not simply to recap them, but to ask what they tell us when we put them all together Now you heard the teaser before episode one. The breaking point is the [00:02:00] beginning. The idea was simple. The breaking point usually doesn't have to look like a breakdown.

Sometimes it's incredibly ordinary. It's another night finishing charts, another weekend on call, another prior authorization, birthday you miss, dinner interrupted. Another time your kid says, "It's okay, I know you're busy."

And you realize that somehow hearing them accept it hurts worse than hearing them complain. That's what I call death by a thousand clicks. But the more important idea in that episode wasn't the breaking point. It was what comes afterwards: awareness.

Because you cannot change something you haven't acknowledged. For too long, medicine has treated physician distress like a character flaw. Visibility is vulnerability. If you're struggling, maybe you just need some more resilience, mindfulness, yoga. And I joke that implementing these solutions alone feels like putting a Band-Aid on a gunshot wound.

Don't [00:03:00] get me wrong, those things can be valuable, but they're not enough. Real well-being has to include autonomy, agency, financial security, healthy relationships, meaningful work that is clinical, meaningful work away from the exam room, boundaries, purpose, and systems that allow physicians to actually practice medicine.

So that was a hypothesis when we started. Six episodes later, I think our guests have made a great case for the formula of well-being, but we are not even close to being done My first guest was my longtime friend and college roommate, Dr. Daren Girard. And there was something incredibly appropriate about starting there because Daren's story reminds us that physician distress doesn't necessarily wait until you're fifty.

Sometimes it starts almost immediately. You finish residency, you're technically an attending, you've made it. Except your schedule still looks like [00:04:00] residency: nights, weekends, five twenty-four ER shifts in a row, young kids at home, a mortgage, and six figures of student debt. You finally have a physician paycheck, and the world thinks you're a rich doctor, but your net worth tells a very different story.

You're a negative millionaire. And you're looking around thinking, "Wasn't this supposed to get better?" Daren made an important decision early. He moved into administrative leadership, not because he hated medicine, not because he was quitting. Trust me, Daren doesn't know the word quit. He found a way to change the structure of his career so that medicine became sustainable, and that's an important distinction.

The answer doesn't have to be about leaving medicine. Sometimes the answer is changing your relationship with medicine. Daren also talked about reconnecting with your why, and that phrase can sound really cliché, but I think there's something deeper underneath it. Physicians need to remember that the work itself can still [00:05:00] be extraordinary.

Extraordinary offsets difficult. The problem is when everything surrounding the work consumes the reason we wanted to do it in the first place: the paperwork, schedules, debt, financial illiteracy, bureaucracy, exhaustion. So the first lesson of this season became you're allowed to redesign your career before your career destroys the rest of your life or redesigns it.

Maybe it doesn't destroy it, maybe it just redesigns it. But you're allowed to be the architect Then I did something much more personal. I sat down with my wife, Jackie. Two OB-GYNs, two physicians, two careers, kids, call, deliveries, emergencies, in a home that sometimes felt like medicine had moved in with us and was the third person in our marriage.

And I think many physician couples understand exactly what that means. Medicine really doesn't care if it's your anniversary, and labor doesn't care if it's [00:06:00] Christmas morning, if you celebrate. A patient doesn't care that your kid is a soccer game, nor should they. That's the responsibility we accepted.

But somebody eventually pays for that responsibility. Sometimes it's us, sometimes it's our spouse, sometimes that's our relationship, but sometimes it's our children. Jackie and I talked about the mental load, about childcare, about the reality that female physicians often carry professional expectations at work while still carrying disproportionate expectations at home.

We talked about what happened when I stepped away from full-time clinical medicine while she continued practicing. And we talked about something that I think really deserves more attention. What does medicine look like through the eyes of our children? We tend to tell ourselves we're working hard for them, but sometimes the question we need to ask is, what did they actually experience?

And if I can get those little monsters to sit down for twenty-five to thirty minutes, I would be able to express that to you or at least show it to you through [00:07:00] their eyes. I think that's gonna be a really great episode if I can get them to sit down. It's gonna take some brand label coffee cards or something like that to, get them to do it, but I'll get them out there.

Some-something neither of us had time to consider when we were working to become doctors about what they actually experienced. But that conversation with Jackie reinforced that with me. A medical career doesn't exist in isolation. Physician well-being is family well-being. And marriage and medicine probably isn't fifty-fifty, certainly not always.

Sometimes it's a hundred a hundred. Sometimes one person has a very small percent to give, and the other one carries the rest. And then the roles reverse. The goals shouldn't be about perfection. It's staying on the same team Then we talked about something physicians are remarkably uncomfortable discussing, myself most of all: money.

Brian BK Case joined me to talk about financial stress in physicians, and this conversation is fundamental what Direct Wellbeing is all [00:08:00] about because financial literacy isn't separate from physician wellness, it is physician wellness. Think about your typical path: college, med school, residency, maybe a fellowship, years of delayed income, years of losing the time factor of money, student loans accumulating, And then suddenly you're earning what looks to everyone else like an enormous salary, so you're supposed to be wealthy.

Except maybe you're thirty-five with hundreds of thousands of dollars in debt, no meaningful retirement savings, ten years lost, a new mortgage, childcare expenses, and ten years of financial catching up to do. And because you're a doctor, you're embarrassed to admit that you don't understand money. We can explain renal physiology.

Well, at least some of us can. I have no idea what that thing does. We can manage a crashing patient, and we can operate. But ask many physicians to explain disability insurance, asset allocation, [00:09:00] tax strategy, or a retirement plan, and suddenly we're uncomfortable. The danger isn't simply financial.

Financial stress changes behavior, and it changes decisions in and around medicine. It changes decisions when you're in front of patients. Maybe you take another shift. Maybe you tolerate a toxic job because you need a paycheck. Maybe you just stay in a dead-end situation you desperately want to leave.

That's where the golden handcuffs tighten. The physician salary that was supposed to create freedom can actually become the thing that takes freedom away. Brian's message wasn't complicated. Start, learn, ask questions, get help from people you trust, demand accountability from yourself, then from your advisors.

Demand trust. It's rarely too late because financial independence isn't about becoming rich. It's about creating options, and options create autonomy, and [00:10:00] autonomy is one of the most important ingredients of wellbeing. Autonomy is the ability to continue in medicine because you want to

Dr. Ridgley Salter helped us widen the lens. Ridgley had experienced burnout himself. He talked about reaching a point where he actually told his son not to go into primary care. Think about that. A physician who dedicated his life to medicine telling his own child, "Don't do this." And yet that experience eventually helped lead him into physician well-being leadership and his son into primary care.

One of the most important ideas from that conversation was the shift from creating resilient physicians to creating resilient organizations. Because if you take an extraordinary resilient physician and put them into a dysfunctional system long enough, the system eventually wins, and patients lose. We talked about moral injury, second victim experiences, peer support, psychological first aid,

And job crafting, [00:11:00] the idea that even having a meaningful twenty percent portion of your professional life dedicated to work outside of direct patient care, work that you genuinely value, how that can dramatically change your experience and your longevity.

Ridge also gave us something wonderfully simple: vitamin G, gratitude. Three good things, family rituals, one crappy, two happy. Small practices that remind us that life can be more than what went wrong today. But here's the distinction that matters: individual strategies and systemic reform aren't competitors.

We need both. I can work on myself, and my organization still has a responsibility to integrate wellness into every decision, to bake wellness into the work Then I sat down with Dr. Neil Roy and we moved to the other side of the hospital door. What are physicians executives actually thinking about? What keeps [00:12:00] them awake?

There's an easy story in medicine. Doctors care about patients. Administrators care about spreadsheets. But Neil challenged that. Healthcare leaders aren't villains. Resist that thought temptation. Most of them are physicians themselves.

They're dealing with physician shortages, patient safety, staffing issues, finances, regulations, and an increasingly complicated healthcare system. But there is often a huge communication gap between leadership and the clinicians doing the work, and into that gap rushes distrust.

Neil brought us back to the autonomy and financial literacy as fundamental to wellness. Not the first time we've discussed that on the Direct Wellbeing podcast. He talked about delayed gratification, one of the topics that I have the most distaste for, but it's hard. Delayed gratification is hard, but it's one of the best ways to success.

He talked about investing. He talked about passive [00:13:00] income. He talked about prioritization. He talked about getting through a finish line. This is a paradigm I prefer much better than the one Brian gave me, which was on the X-axis is your life. On the Y-axis is your amount of money. You need to make sure that the Y-axis hits zero when the X-axis is far enough out and you're dead.

We laugh a lot about that paradigm now and that graph. Not a fan when the, line hits the X-axis, just to tell you. Neil and I,

We talked about the ability to eventually reach a point where you practice medicine because you choose to, not because financially you have absolutely no alternative. That doesn't mean everybody needs to retire early. It means we need to stop confusing dependence with dedication.

A physician with options can still choose medicine for the right reasons. In fact, that physician may enjoy medicine more because the decision to stay becomes voluntary. And then last week's episode, we had a conversation that brought many of [00:14:00] these ideas together. John McMahon from the Wellbeing Index joined me to talk about something deceptively simple: measurement.

The Wellbeing Index grew out of work at Mayo Clinic because burnout alone doesn't capture the entire experience of clinician distress. Sure, there's fatigue, work-life balance, meaning in work, risk of medical errors, and turnover, and other dimensions that can tell us something important long before a clinician reaches crisis.

And that led to one of the most important concepts of the first half of this season. Burnout is a symptom. It's not a diagnosis. If you have a fever, you don't diagnose someone with fever and stop thinking. You ask what's causing it. Physician burnout deserves the same curiosity.

Is it workload? Is it financial stress? Is it loss of autonomy? A toxic work environment? Moral injury? Broken equipment? Terrible workflow? An EHR that turns a [00:15:00] ten-minute task into thirty minutes and four billion clicks? Leadership that isn't listening? Problems at home? Acute events in life? Or simply years of cumulative stress that nobody, including the physician, noticed building?

John also talked about the low-hanging fruit organizations can address, and some of it isn't glamorous. Fix the equipment, stop unnecessary work, reduce friction, improve communication. Listen to the people actually doing the job. Physician wellbeing doesn't have to require a multi-million dollar initiative.

Sometimes somebody just needs to fix the damn printer

So what have we learned? Six conversations, different people, different perspective, different lenses, different approaches. But I hear the same themes over and over, and I keep coming back to five things. The first one is awareness. You have to recognize what's happening. [00:16:00] Whether that's a personal breaking point or an organizational measurement tool, change begins when we stop pretending everything is fine.

The second one's autonomy. Physicians deserve to demand some control over their lives, their schedules, their careers, their money, their professional identity. When every meaningful decision is controlled by somebody else, well-being becomes almost impossible. But physicians should not expect this to come from somebody else.

Physicians, caregivers need to design the life that they want. Imagine it, then make it come true. The third is financial literacy, and that's gonna be one of the main components moving forward. It's just about the literacy so that you know where to go. We're not here to sell you anything. Maybe not yet.

Maybe we'll sell you a whole bunch of things later. But money isn't everything, and financial insecurity can make everything harder. Understanding money gives physicians choices, and choices create freedom. The fourth is [00:17:00] connection. Connection to our spouses, our children, our families, our colleagues, our patients, and our communities, and to the reason we went into medicine in the first place.

Isolation makes distress worse. Connection kills distress. And the fifth and last thing is that systems matter. We cannot keep asking physicians to personally adapt to every broken part of healthcare. Workarounds great word. At some point, the broken parts need to be fixed and the workarounds need to stop.

And that requires leadership, not slogans, not crappy pizza, not another mandatory wellness module. Leadership, listening, accountability, and action When we started this show, the question was: how did we get here? Six episodes later, I think the question has changed a bit. Now I'm asking: what are we willing to change?

Because awareness without action [00:18:00] eventually becomes another form of frustration. If you know your schedule is destroying your family life, what are you willing to change? If you know financial stress is keeping you trapped, what are you willing to learn? If you're a leader and your physicians keep telling you the same process is broken, what are you willing to fix?

If you've lost your sense of purpose, what part of your work can you redesign? And if you're approaching your own breaking point, what would happen if you treated that very moment not as failure, but as information? Maybe the breaking point really is the beginning So that's where we're going in the second half of season one.

We're going to keep asking uncomfortable questions. We're gonna keep talking about money. We're gonna talk about mental and emotional health. We're gonna talk about what our careers do to our families. We're gonna talk to physicians, to leaders, to career mentors. I've got a whole list of folks coming up, really great people who have volunteered their [00:19:00] time.

We're gonna talk to people trying to change the systems in which we work, and we're going to keep looking for things you can actually do Because I don't want you to finish an episode of Direct Well-Being simply thinking, "Wow, that's exactly how I feel."

That's important. That's great. I hope it resonates, but that's not enough. I want the next thought to be, "Okay, what can I do about it? What did this podcast teach me?" Maybe it's one conversation with your spouse. Maybe it's opening your retirement statement or your student loan shoebox.

Maybe it's finally meeting with a financial planner. Maybe it's saying no to another committee or yes to the right one. Maybe it's saying yes to a leadership opportunity. Maybe it's asking to change your schedule, finding the twenty percent of your job that gives you meaning, walking into your department chair's office and saying, "This isn't working.

Here's how I think we could make it better." Or maybe it's simply admitting, "I'm not okay with [00:20:00] living like this anymore." That statement's not weakness. That's awareness, and awareness gives us somewhere to start So as we come to the conclusion of another episode, I would like to invite you to connect with us.

Here is your episode ending action item. go to directwellbeingpodcast.com, where you'll find stuff like our show notes, links to information, support, and ways to communicate directly with us. I'd really appreciate your feedback, your questions, your comments.

If it sounds like crap, I wanna know now. I've enlisted the help of some really incredible guests for the second half, and they'll continue to share insights and expertise about wellbeing and the journey to realize it. Bruce Lee once said, "You don't find peace. You choose it by what you ignore." And finally, I wanna thank every person who has joined me for the first half of this season.

Dr. Daren Girard, my wife, Dr. Jackie Apgar, Brian Case, Dr. Ridgley Salter, Dr. Neil Roy, and John [00:21:00] McMahon. Thank you all very much for spending time with me, and don't hesitate to call, and I would very much expect to hear from you again. I'd love to hear your perspectives as the show progresses. Each one of these folks brought a completely different perspective, but collectively, I think they helped us begin answering the questions we started with: how did we land here?

We landed here because of our commitment, the Hippocratic Oath, because medicine asks a lot from us, because we willingly give a lot of ourselves, because sometimes we don't understand the financial consequences. Sometimes we don't protect our families enough. Sometimes our organizations fail us. Our symptoms fail us.

Sometimes we simply don't know there was another way. Often we fail to protect ourselves. But here's the part I want you to remember. We are not done writing this story. We have only just begun. You don't have to hate medicine to want medicine to change. You don't have to leave medicine to reclaim your life.[00:22:00]

And your value as a physician is not measured by your RVUs, the size of your inbox, see, size doesn't matter, the number of shifts you worked, or how much suffering you managed to tolerate without complaining. Fatigue will never be a currency. You worked incredibly hard to build this career. You should be able to build a life alongside it.

That's what Direct Wellbeing is about, Finding that intersection between your career and your peace. Thank you for spending the first half of this season with me. We asked how we got here. In the second half, let's start figuring out where we're going.

I'm Dr. Anders Apgar, and this is the Direct Wellbeing Podcast. I'll see you next week

Transcripts are lightly edited for readability and may contain minor errors.