Rob Orman (9:10)

Tim, it is a treat to be here and finally being on the other side. Had you on my show so many times. Wow. At long last.

Jim Dahle (9:19)

Yeah, it's great to have you here. Let's. Let's talk a little bit about a little more about your bio. You went to Emory and then you trained at Denver Health, which is a little bit interesting to me because Denver is a four year program and many of you out there don't know this, but emergency medicine is one of the few specialties where you can train for three years and you can train for four years. And in fact probably the biggest thing I was looking for when I was looking for an emergency medicine training program was one in the inner Mountain West. But I decided not to apply to Denver partly because, you know, I heard some things that maybe it was really hard or a little malignant or something. Also, just because it was a four year program, I didn't apply to any four year programs. So I want to get your take on this, especially now that emergency medicine is a specialty, is talking about changing all the residencies to four years. I want your take on the three versus four year program issue in emergency medicine, sometimes called the $400,000 mist. I want your take on that extra year of training.

Rob Orman (10:30)

I'm totally biased with this, Jim. I mean I went to a four year program. Well, it was different when I went there, different than most of them are. So ours was a one plus three. So I did a transitional year at a different hospital and then I did three at Denver Health of basically pure distilled emergency medicine with all the other rotations in there. So when I applied for residency first you have this idea. It's like I want to go to the best place and at that time Denver Health and still is, I think one of the best residencies there. And I said okay, three years, four years. I actually didn't really care so much about that except that I knew that I had a lot of uncertainty when I was a student in the ed and I wanted as much training as possible and to be as good as possible getting out. And I mean this is totally self serving since I went to a four year residency. But I will say that that fourth year of residency sharpened my edge, sharpened the sword to such a high level that I felt comfortable with pretty much anything when I walked into my first attending shift. Not that I didn't make a lot of mistakes. So I am a strong believer in four years of training. That being said, I myself did not experience three years. So I don't know what that feels like to get out of a three year program. So totally biased answer now.

Jim Dahle (12:02)

Now some people say, well maybe I'll do a three year residency and then do a one year fellowship.

Rob Orman (12:07)

Sure.

Jim Dahle (12:07)

Do you think that's an equal option, a better option, an inferior option? How would you advise somebody Looking into applying to emergency medicine.

Rob Orman (12:16)

There are so many levels to that question. So let me first say that when I would work with, I'm not working clinically anymore, like full time coaching now. So when I was working clinically and a new doc would come on, and a lot of these docs came out of four year residencies, didn't matter three or four years, I would say to them, your first year here is your fellowship in clinical emergency medicine. Now this isn't the question that you asked, but that first year out you are figuring out who you are as an attending. And one thing that you get to do as a fellow is you work clinical shifts as a junior attending. So I think that there's some benefit in that. So you have a little bit of protection. You're probably working in an academic center where there's maybe a softer landing if you're not quite sure what to do. So I think that from a clinical perspective, sure, it's great. As long as you are working a good number of those clinical shifts just doing a fellowship, yes, you are going to get expertise and you very well may even have more fulfillment in your career because you've got that N+1 to balance out your clinical work. I don't know that the fellowship training itself gives you that preparation or the number of procedure reps or central lines or just seeing thousands more sick patients in that final year because you're doing a tox fellowship or an ultrasound fellowship. It is that clinical work and getting that exposure, that continued exposure. So fellowship. Awesome. Personally, I'm going to tell you, my friend, I wish I had done a fellowship. I wish I'd done a fellowship just to have that, I guess you could call it side gig, you know, outside of my clinical work and been on that track much earlier, but I don't know that a three plus one as a fellowship does the same thing as a straight four.

Jim Dahle (14:19)

Good advice. Thanks for your perspective on it. Do you think the right thing, especially is doing the right thing to. If it, if it actually goes through with this and basically, basically makes everybody get years of training, do you think that's the right thing for the specialty?

Rob Orman (14:34)

Gosh, I don't know. I, I've always thought that it was a bit of madness that this specialty had varying lengths of training. And what other specialty has that? I, I don't know of one. It, it says does it take three or does it take four to get competency? And it can be argued on both sides. If it went down to three, I guess that would be fine. If it went all to four, that's. Well, that's the decision that was made. But I think having some uniform length, amount of education and exposure to cases and what you need to know, and having that be standardized, that just makes way more sense as a legitimate specialty, which.

Jim Dahle (15:19)

Stop the madness. Yeah, exactly.

Rob Orman (15:21)

I mean, you and I, you know, we both remember when, you know, emergency medicine was barely considered a specialty and it had even been around for a long time, but, you know, when we were young doctors. So I am in favor of it being standardized, whether that was three years or four years. I don't. I'm not an expert to say personally favor. Four years.

Jim Dahle (15:42)

Yeah. So this is a financial podcast, so I gotta ask you a financial question about this. I mean, this was a decision that cost you some money, right? Whether you say it's $200,000, because that's what emergency medicine docs were making 20 years ago, or a $400,000 cost because that's what they're making today. This cost you something. Did you miss the money?

Rob Orman (16:04)

I never knew it was gone. Let me tell you, when you talk about living like a resident, I fully embraced that. My blackout blinds in my bedroom were beach towels that were duct tape up so that I could sleep after night shifts. So now, as I'm 55, I don't know any different. So. Sure. Would it have been nice to have had another year of high income earning? Yeah, absolutely. But I think on aggregate, with all of the time that I spent getting to that point to be a doctor, I mean, you know, I mean, it's a long haul that I wanted the best training that I could get, and I thought it was at that place that it was at Denver Health, and that was worth it to me. And if that training cost me 440,000, I mean, I don't know if I ever made that in a year as an emergency physician, but it cost me a couple hundred grand. Well worth it.

Jim Dahle (17:07)

Yeah. Now, your comment about, you know, a fellowship enabling you to do a side gig, I find interesting. I think it's a good segue into. Into the next topic I want to talk about, because you've maintained some sort of a side gig, you know, whether it's podcasting or speaking at conferences or running a conference, and now you do a bunch of coaching for just about your entire career. And I want you to talk about that side gig and that mentality that caused you to pursue side gigs and how that benefited you both clinically as well as financially.

Rob Orman (17:42)

So my side gigs. And there's A lot of different, I guess terms that you could say. I call it my N plus one, the clinical N plus one that brought me joy and fulfillment that I wasn't getting from clinical shifts alone. I like clinical medicine. There were aspects of it that I did not like at all but doing things like starting a podcast and years ago that was called Ercast which has since gone on to be under HIPPO Education. But it was one of the first fomed podcasts. I was a ultrasound director, hashtag never had an ultrasound fellowships when you could do those things back then. And so it was joy, it was fulfillment, it was stoke in my career and that was in the early stages just having something in addition to what I was doing, seeing patients to bring me joy in the, the second phase of my career, I guess you said the second phase of my side gigs, they still were aligned with what I would say is my purpose, which you know, is the lens with which you view your what, what you're doing. For me, education, teaching. But it also brought in compensation. And so at that time you mentioned mrap, I was working with MRAP or Hippo Education and working on Essentials of Emergency Medicine, this large conference that's now defunct but that brought in compensation so I could start cutting back on shifts. So in the beginning, totally purpose focused and man, I was, we were talking about this before I was podcasting with this little blue snowball first generation mic that probably started sound like I was speaking in a tin can. Very first podcast I did was on a cordless phone, man. I mean it was just, just for fun, just for joy. Then it became part of what I was compensated. So it started to have a bigger footprint in my life as and ultimately I was doing so much education I was running EM rap full time. Then I was running ER cast full time and getting paid for that and Essentials of Emergency Medicine. I had an exit strategy from emergency medicine and at that point that was 20 years in to my clinical career and I was good to go. I was good to move on to something else which was full time medical education. Now it's full time coaching. And I'll say this as I'm going through all these side gigs at the beginning of my career, 1999, fresh attending. Jim, if you would have said hey man, here's what your career is going to look like in 2025, I just would have had mouth agape. I wouldn't even have known what you were talking about because all of those side gigs, putting them all together, they kind of gave me this chance to explore and grow, in addition to seeing patients now as this kind of amalgam. I don't even see it as serial side gigs. I see it as this single, evolving side gig where one thing grew into the next. And what began as just, I mean, almost a hobby has become my career.

Jim Dahle (21:12)

You know, for those of you who aren't docs, and I know most that listen to this podcast are docs, but there's a sizable percentage of you that are not in medicine. Sometimes we have a conference that we call M and M Morbidity and Mortality, where basically we analyze mistakes that doctors make in hopes that we won't make them anymore. And if it's somebody else's mistake, that we won't make that mistake and end up in front of this conference. But let's do a little bit of M and M on your side gigs, because doctors love hearing about mistakes so they can avoid making them. What mistakes did you make along the way doing these side gigs? And what did you learn as you went along and maybe wouldn't have done the exact same way?

Rob Orman (21:53)

I want to tell you about the big mistake. There's so many little ones which could be an entire podcast. Every mistake I've made was side gig, slash business. But we'll talk about the big picture on the things that I was doing during my clinical career. And I think that the big mistake that I made was thinking that my side gigs, these things that were just aligned with purpose, filled me, fed me, that these things alone would solve the burnout I was experiencing. I thought if I could just be extra happy with teaching and podcasting and speaking, that that would outweigh any misery that I sometimes or often felt driving into work. It doesn't work that way. I thought it would. I thought that that would be kind of the cure. Eventually, I figured out that I needed to address the root cause of what was burning me out, how burnout was showing up. And once I did that, way more bandwidth for the job. The job was awesome. Way more bandwidth for the side gigs. Everything changed. But that was a big mistake that went on for many years.

Jim Dahle (23:17)

Let's hear the elevator pitch. Now. Tell us what you're doing now. You do this coaching. You help people with burnout. Give us 30 seconds explaining exactly what you do and where they can go if they want to contact you for help with that.

Rob Orman (23:30)

I help physicians recalibrate their careers, and that can be micro recalibration, which is within your current job, such as mindset, efficiency, shift structure, communication, dealing with difficult consultants. All of the things that are contained within the work you're doing right now, that can be more of a macro recalibration, which is more like a remodel. All right. I still want to stay in medicine, but the place I'm working now is not working out for me. All right, let's help you find something different, but still have that physician income. And then there is the mega recalibration. That is a reinvention or a rebuild, and I want to do something else that's not seeing patients. I don't know what that is. Financially, that's scary. Okay, we will recalibrate in that way. Whatever it is, is the docs have in some way lost that love and feeling for medicine. Or a side category. They have a behavior that is not serving them due quite a bit of behavioral coaching where they're doing something or acting in a certain way that is not concordant with the values of the hospital in which they work. And they're about to get fired or lose their license, and they need a recalibration of their behavior. And my ultimate goal is to elevate the experience of physicians in their life and work.

Jim Dahle (25:04)

Very cool. And they contact you where they can contact me at.

Rob Orman (25:10)

My website is roborman.com.

Jim Dahle (25:12)

Okay. Now, we're in this specialty where when we got in it 20 or 25 years ago, and everybody said, emergency docs, burnout. And we said, well, those were people that didn't train in emergency medicine. You remember these discussions we had?

Rob Orman (25:27)

Yeah.

Jim Dahle (25:28)

And clearly emergency medicine is one of those specialties where it's actually not that hard to work less, you know, to work fewer shifts, to do locum tenens, to, you know, go part time, et cetera. You know, this is my favorite burnout treatment. When people tell me they're burned out, the first suggestion I have for them is, why don't you cut back to full time? You know, But EM is still at the top of the specialty burnout charts every year. Why is that? Why are we still there?

Rob Orman (25:56)

I want to address what you just said there. I was speaking with a buddy of mine who's an orthopedic surgeon that we had spoken about this years ago. And I can remember when he was super stressed in his job. And we're talking about, man, because this is a strategy we do in emergency medicine. Just work less, have more time to recover, more time for your life and your love. And we were actually talking yesterday. He said, man, once I did that, my career is awesome. I could do this indefinitely. And I'LL take extra call. I don't care. I've just got bandwidth. I got time to recover. I don't think what you just said, Jim, can be oversold that doing less of it in the long run, you will make less money month to month, but your career can be extended for so long, it's almost like. Really? That actually works? Yeah, it works for so many, not for everybody. You and I have both seen that. So I would love to hear your take on this stuff with what is it about emergency medicine? And there is totally going to be a selection bias here. And I just want to tell you what I see with when docs come to me who are burnt out, what is it that's burning them out? I'd say about 80% of the docs who I talk to say that their career is not sustainable as it's currently gone. Says I want it to last a certain amount of time or they feel like I need it to last a certain amount of time. And I just don't see that happening. I think that in the big picture, emergency medicine more than any other specialty. I'm not sure another way to say this, but it's just a lot. It's just a lot. Other specialties experience some of the aspects of what EM does, little pieces here and there, but not with the same density, frequency, intensity and exposure. And I want to get into some of the unique stressors that clients come with because I coach emergency docs and critical care docs and there's definitely overlap, but just there's some stuff specific to em. What do you think about that, Jim? That EM is just a lot?

Jim Dahle (28:17)

Yeah, for sure it is. I mean, those of us who go into it, we like to think that we're the ADD docs of medicine, that we don't want to know what we're going to be doing when we go into work. You know, I can't imagine going in and having access to my schedule of what I'm going to do that day at the beginning of my shift. That sounds terrible to me, but that uncertainty and the change throughout the shift, where it goes from dead to crazy, I think gets to people after a while and especially. And this is the same in most specialties in medicine and many similar professions actually is. We have less control over our jobs. Right? I mean, I own my job. I'm in a small democratic group. It's gotten a lot bigger since I joined it 15 years ago. And yesterday at our staff meeting, our partner meeting, we found out that the bigger group is going to have some say in how we pay our APCs and how much we pay them. And we're like, great, we're losing more control, you know, and so I think that loss of control really does contribute to burnout in any specialty. And I think EM has seen a lot of that in the last decade. I think there's a lot fewer, you know, small democratic groups where you get to have significant control over who you work with and when you work and how you pay yourselves and how you staff the department. And that results oftentimes in the profit counters making those decisions. And all of a sudden, Instead of seeing 1.5 patients per hour, you're seeing 2.3 patients per hour. And a shift is dramatically less enjoyable when you're seeing 2.3 patients per hour than when you're seeing 1.5 patients per hour. It's just not fun. And I think that has contributed a lot to what we see in emergency medicine.

Rob Orman (30:08)

That with the rise of the contract manager groups or corporate management groups, you hear so much more of this, of docs working way more than they want. Or you have one doc with two apps managing this massive ED and everybody is just pinned. And yeah, that loss of autonomy, which we have seen over the years, I think has corresponded with docs feeling more burnt. But I think that even without that, just how emergency medicine is each shift you were alluding to this is so full on. It takes so much focus and energy for a single ED shift. And during a shift, there's a moment of overwhelm almost every day. You get to three or four hours in. And now patients coming in, patients need to be discharged, calls coming in. It's the juggle. It is task saturation every day. And that's a bit of stress. And some handle that better than others or differently than others. That stress accumulates, especially if you don't have time to recover. And what you were talking about before, that is connected to too many shifts. And the outside world says about emergency medicine, you work so little, why are you complaining? But in emergency medicine, a single shift has a really big footprint. So I think that's one is overwhelm and pace. And that was the one for me. That was my NIDUS for burnout. There was also some of this other one, which is fear of being named in a med mal suit. I've had many docs come to me say, I have this fear of being sued with every patient and yeah, that's why I have malpractice insurance. And you are going to see someone with A subtle or atypical presentation of a life threatening disease, they're going to go home and maybe die. That might happen. Not 100% chance you'll be sued. But for many docs the fear of being named in a med mouse suit is a specter that's always there. And those suits we see, wow, they can be totally capricious. Anyone can sue based on anything. Doesn't matter. Entitled patients and patient satisfaction surveys. This seems to be more and more of a stressor. I call it maybe more of a micro stressor. And the disproportionate impact importance placed on patient satisfaction and the way that those surveys work and they're so problematic and they only evaluate discharge patients, not the ones that you put the most time and energy into. Documentation massive stressor in albatross of many ER docs unresolved bad cases. You see this one person, you have no follow up. Something goes bad, you don't process it, it sticks with you. That happens with many other specialties. I think it's more intense and acute in emergency medicine. Also in em there's this ridiculous self imposed stuff like I don't have time to eat or drink or go to the bathroom. Don't take care of ourselves during these intense shifts. You can do that for a day or a week or a month. But over years that adds up. Administrative oversight. There is a disproportionate amount over EM docs. Every specialty has administrative oversight EM docs. From what I see, what I hear, what I felt, bigger footprint also and this is such a common one, Jim. Incivility from consultants. Not everybody gets this. Not everybody. Every hospital has this. But usually there's one or two consultants in a hospital that when you see them on oh God, it's this again today. No consultant. Nobody wants to get a call from the ed this cold call while they're busy doing all this stuff. And when a consultant is not civil or is hostile or is rude or dismissive or obstructive or obtuse, intentionally obtuse, that drains you. And this seems to be more frequent when emergency physicians call other specialties. It wears on you. I mean we, we have a, an anti burnout course and this is one of the modules that we have. It's a, you know, we spend two weeks on navigating the difficult consultant and we can keep going on night shifts. Most specialties like oh God, I gotta be on call em. Oh, you're just gonna be up all night after shift residue. You know, you're so full on for the day it is hard to reintegrate into civilian life. And I'll say that not the final one, but let me just put a bow on this. As an emergency physician, this, and I don't even remember the first time I heard this. Not my original idea, but when I heard it, it's like, yeah, that is so true. The system that you work in was not made for your well being. Some hospitals, it's way better than others. But the system is not made for your well being. It's made to work in the system. You are a piece or a part or a player in that system. Most emergency physicians don't get to design their practice. Your position fits into a system for that system to work with. Throughput and billing and all of the things that make a system functional, not for the well being of the clinician.

Jim Dahle (35:36)

Yeah, there's a lot that goes in there for sure. And when I became financially able to, the first thing I dropped was the night shifts. I didn't like them. I never liked them. I didn't like them even in residency. And so there was no doubt that that was dramatic improvement in how much I liked my job when I quit working the overnight shifts. You know, decreasing shifts also had a similar effect, but nothing like dropping the nights and not being there in the hospital at 3:30 in the morning when you get that achy feeling, your body's telling you you should actually be asleep right now. And meanwhile you're practicing a totally different kind of medicine at 3am than you're practicing at 9am you know, it's just a different group of patients with a different group of problems. And a lot of times maybe not as enjoyable to take care of.

Rob Orman (36:23)

You know, it's funny as I hear you say that, Jim, I loved what happened on night shifts. Just the weirdness and the kind of. There was this filter that only certain things would seem to come through on a night shift. What a night shift does to the body. I don't think there's any getting around that. So I kind of. Well, I actually, I worked nights right up to the end of my clinical career, but fewer and fewer of them. But I, I missed what happened on the night shifts because, you know, you didn't have to deal with any kind of admin nonsense or in this. It was kind of, wow, we're almost on damage control mode here. And it was, it was sort of fun.

Jim Dahle (37:02)

Yeah, it's, it's different. And depending on what you like and what you don't like. You know, almost everybody loves the people they work with on night shift. It's a different group of nurses working nights, you know, and so that aspect of it can be a lot of fun. But going to Europe once a month, you know, essentially, which is what I was doing by changing my schedule to work night shifts for three or four nights and then coming back, I mean, you basically have jet lag every month. And those of you who've never experienced jet lag, I'm sure most people probably have, that are listening to this podcast at some point or another. Imagine dealing with that. Three or four days of jet lag every month, and that's what working night shifts regularly will do for you. Now, let's get a little bit personal here. Rob, you've talked about burning out three times during your career. I want you to tell us about each of those episodes, what they had in common, how they differed from one another, and let's kind of see burnout through what a real doctor went through during a two plus decade career.

Rob Orman (38:04)

So looking at the definition or the big picture of burnout, you've got cynicism, decreased personal efficacy, and emotional exhaustion. And emotional exhaustion, that was mine. And what all of the aspects of burnout had was this sense of this is no longer sustainable. And there was also this intense dread going into work. This pit, the pit in my stomach. I remember I would, a day or two before work, the dread would start. Especially if there's a string of shifts, I'd start to feel that pit, and as I was driving in, it would kind of reach this crescendo. Interestingly, once I started seeing patients, it went away. There was a different kind of stress, but that anticipatory dread went away because now I was actually doing the thing. And all of the, I'd say burnout peaks had a similar root cause, which, you know, we talked about this a little before, but that was pace and overwhelm. And I know this now. What I'm about to say, I didn't know this then, is that I thrive in serial processing. One thing at a time. Going deep on one thing in the recess bay. Oh my gosh. Loved it, loved it. Bunch of patients all at once, don't love it. Parallel processing. I found it hard to keep up. And I was working at an incredibly busy hospital. It was the second busiest hospital in the state. And actually I saw one of my old partners yesterday. We just ran into each other and he said, oh, yeah, we still, we still talk about you, man. You know, when, when new people come to work here, he'll say, yeah, hey you, you know, you guys have heard Rob Orman talk about burnout and how this shop where he worked, it was just like so busy. He just kept burning out. Burning out. Well, guess what? That's this shop, that's this place. So yeah, it was, it was. And I was, I was working in an environment which was just not aligned with how I operated. And I was continually stressed. I was thinking, oh, do I need to do a different specialty? Do I need to just get out of medicine? And the difference between the three kind of peaks of burnout that I had was what I did to address them. So for the first one, this is probably a year or two into attending hood and you just have this sense of this is just not sustainable. And I think I probably would say that and mutter that in my breath. I can't keep doing this. I can't keep doing this. I started learning more and investing more in being an excellent emergency physician. My wife and I also, she's also an emergency doc. We were going to conferences, going to airway courses, doing lots of cme, investing in this craft or calling, doubling down. So I, at that time that probably two years in, I was getting the applications to anesthesia and ophtho, my wife said, why don't you see if you can be really good at this specialty first and keep in it. So the second peak of burnout was that was when I started getting into medical education, doing these things that I really loved. And I was talking before about the mistakes like ah, every time I got deeper into medical education it was like this pressure release valve, you know, this ah, purpose driven, purpose driven, let off a little bit of steam. But the fundamental issues were still there. They were not directly addressed or fully addressed. So the third one, this one really peaked. And I'll tell you Jim, I kind of cracked. I mean there was, there was an event where I, I was just shocked that I was, you know, basically screaming in my car as I was late for work. Just this primordial scream is like, wait, wait, wa. Wait, wait.

Jim Dahle (42:20)

This is who I am.

Rob Orman (42:21)

This is what my life is. After all of these years of trying to get to this point, yeah, this is it. And I could not keep practicing the way that I was. It was truly not sustainable at this shop. And I'll tell you, the shop where I was working, amazing, amazing group of docs, it just wasn't for me. And like, oh, okay. I kept at it, I kept at it because as a doc, you are not someone who is ever defeated. I can always overcome like, hey, you know what? I guess I was defeated by this job that was super freeing. And so at this point, 12 years in, I did a major, or you can say macro recalibration of my career, and I went to a smaller community. Ed sent. My challenge was pace. And I put all kinds of things into place. It's like, okay, I'm going to see if I can make this place work. What can I do to manage this, you know, this high pace, this high patience per hour. None of it worked. So I went to a smaller community, Ed instead of the super busy suburban place where I'd been. You know, my, my wife and I wanted to move to this community. We actually moved to a different state. I took a big pay cut. I took the job where I was working. You can imagine, suburban hospital, super busy, democratic group. I was making a lot. I took a 60% pay cut. There were just not many EDs in this place where he wanted to work. And the only game in town, or one of the only games in town, it was so worth it. It extended my career for years. And if the price that I had to pay for that was 60% of my current income still worth it.

Jim Dahle (44:08)

You know, I run into burnout skeptics every now and then. They're like, burnout? What are you talking about? There's a support group for that. It meets every Friday night at the bar. Right. And I wonder, is burnout really a physician specific issue or do we just get more fixated on it because we expected our career to provide all this fulfillment for our life?

Rob Orman (44:31)

I don't think it's a physician specific issue. I mean, the, I guess surveys of what's happening with this would say, yeah, it's not just doc, it's many other industries. But I think it just seems more shocking and in your face because, and this is just my, my take on this, because physicians put such a massive investment into their careers. I mean, you know what it took to get to this place. Med school, residency, attending hood. Our experience even in college, Jim, like our experience was very different from people who were going to business school, right? What were their lives compared to the pre meds or law school? And medicine's also seen by so many as a calling. And then you get to this point of you have invested so much of your life and then experience this burnout. And also physicians are such an incredibly valued asset to society. You put all of those things together from the personal, the experience of the physician for how physicians are needed by society, then it's like, whoa, this seems like A crisis. And then, and you know, we have this expectation, talking about at the inside baseball as a docs that it's going to be one way, that it's going to be great or I know it's going to be hard, but it's going to be so fulfilling that we're going to be a certain way that all of this work is going to be worth it. Actually, I was talking with a client the other day. We had having a discovery session and they said, you know what? I feel duped. I feel duped. I love that word that I feel duped. I thought medicine was going to be this one thing. I worked so hard to get here. Now I'm doing the job. I would never advise my younger self to do this. There's just so much BS in it, but there's so much sunk cost. I put so much into it. I mean, I feel like I can't leave right now. So I think it just has, it's just more striking that is occurring with physicians now.

Jim Dahle (46:46)

You're obviously a big believer in coaching at this point. You work as a coach, right? How can a doctor, you know which ones are going to benefit from having a coach and how can they recognize I need a coach?

Rob Orman (46:58)

It's definitely more normalized now. You know, when you and I were starting, it was a rarity to, I mean, nobody knew what a coach did or who a coach was. And now it's much more common. Articles in the New York Times about, oh yeah, every physician, every physician should have a coach. And to some degree, yes, I want to speak from my own personal experience coaching. There's so many different types of coaching and coaches out there that from a like a 30,000 foot view, I think any physician could benefit from having a partner to optimize their experience in medicine. I work with leaders who are, they're not burnt out, they're not seeking a recalibration, says, oh, I want to work through my ideas and challenges I have in leadership. And I just want to have a partner to do that. Great. And I think there's not anybody who wouldn't have a benefit from working with a partner through their career to figure out challenges and come out with actionable steps to move forward and build momentum. And the docs that I primarily work with, not all, I'd say 85% to some degree feel stuck. They feel stuck and they want a partner to help them get unstuck. And this is going to come back to how do you know that coaching is something that might help you so And I'll see if. If where I land with this satisfies that answer. And I would totally want you to push back if it doesn't. So getting back to the stux, all right. I kind of feel stuck somehow in my career. Now, that could be I feel stuck in my current job or I want to. I want to work somewhere else. I don't really know what that looks like. I want to do an entirely new career. Got this behavioral issue. Many of the things I talked about before of I don't know how to solve this. And all of these things have different approaches, but they start from the same place. I feel stuck. I don't know how to get unstuck. So on a deeper level, or maybe it's a more superficial level, I don't know. So coaching is not cheap. So the first question is what your current challenge looks like or your current problem, what is that costing you? And if you look at what a coaching engagement costs, does that cost less than what your current problem is costing you? So from a purely financial perspective, if you're not going to be able to continue in your career and generate income for several more years, that's going to cost you a lot. That's super expensive. There's also psychological costs. You know, we've been talking about burnout, so stress residue from the shifts, just emotional exhaustion. You and I both know I've had several partners, emergency docs who died young for what could have been deemed morbidity, mortality related to stress. So the first question is, what is this problem costing me? Is it worth it to pursue this coaching? And is this something I am currently solving on my own? Am I, moving forward, solving this? If the answer is yes, if I am in the process of solving it, I'm figuring it out. I'm doing fine. And. Or it's not costing that much. Don't worry about it. I don't think coaching's the answer there. But if it does cost a lot, either physically, emotionally, or the length of your career, the longevity of your career, you're not able to solve this on your own, which is not always easy to admit as a physician, then coaching is totally worth it. Clients who get coached, and this is not just through me. I mean, I have a coaching partner, we have a bunch of coaches that we also speak with, clients who get coached. And this is the feedback from coaches are almost universally stoked that they did.

Jim Dahle (51:13)

You know, I've often said that, you know, the biggest financial risk to your career can't be insured against. Right. It's burnout. It's not being able to continue it. And that you should optimize for longevity with every career decision you make. You are far better off working for 30 years as a pediatrician than you are working for 8 years as an orthopedist. You know, it's just the way the numbers work out. You got more time for your investments to compound. You pay less in taxes overall. You have more years of Social Security contributions. It just works out better to have a longer career than a shorter career. And, you know, things like coaching, things like our physician wellness and financial literacy conference. Now, these are the closest things you can get to burnout insurance. You know, people will gladly buy disability insurance and should, don't get me wrong, they should buy it having disabled myself falling off a mountain last summer. But you can't really just buy straightforward burnout insurance. It doesn't work like that.

Rob Orman (52:15)

I love that framing of it. Yeah. And just like you fell off a mountain, you never know if you're going to need it.

Jim Dahle (52:22)

Yeah, for sure. You have said in some of your writing, some of your speaking, to embrace the positive. Right. Instead of the negative, which, you know, my wife tells me this sort of stuff all the time. You know, think about the positives, not the negatives. It feels wishy washy. Obviously, that's a smart thing to do. You're going to be happier if you embrace the positive. It sounds easy. I'm not sure it's actually easy. How do you teach people to embrace the positive?

Rob Orman (52:50)

Oh my God. Did I have I really said that?

Jim Dahle (52:52)

Jim, I think I've read somewhere that you. That you wrote embracing the positive is important.

Rob Orman (52:58)

Oh, geez Louise. Okay. All right, let's get it. Let's get into it. So I'd say 50% of the work I do with physicians is mindset. And that could be mindset on this thing that I have a negative view of or mindset of this limiting belief of something I think I can't do. Let me address that first, mindset. Does mindset make a difference? And you know, we have this inherent sense that it does, that how we approach something or think about it will impact the outcome. And like the. The evidence on this is so revealing. Have you ever heard of this study? It was done in the, I think in the late 70s called the counterclockwise study. So this was one of the first true studies done on mindset. And what the researchers did, they took a group of men in their 70s and they built this. The study authors built this retreat center, this house that was isolated from the rest of society in the woods. And they set it up so that it would look like it was 20 years earlier. The TV only played shows from 20 years ago. There were magazines and newspapers. The clothes that these men Wore were from 20 years ago. And they were told to speak about events from 20 years ago as if they were the present tense and act as if they were in their 50s. So it's just, I want you to think and act as if you're in your 50s, even though you're in your 70s. What's going to happen with this? They did this for a week, just one week, and shifted their mindset. And at the end of the week, their mental acuity had improved, their physical flexibility had improved. This shocks me. Their eyesight and hearing had improved. Yeah. And when others. So they had, you know, independent observers looked at before and after pictures. Oh, which is before. What's after the after pictures? Like, oh, well, this is them at a younger age. This was just mindset. What a difference that makes. So back to your question. Embracing the positive. I want to give what you said some credence here, is that there is a trap in just embrace the positive. Was it Stuart Smalley on Saturday Night Live? I'm good enough, I'm smart enough, and by gosh, people like me. So there's a trap in just say, oh, think positive. That thought replacement, replacing a negative thought with a positive one rarely works or doesn't work. And what usually happens with that is that the negative thought often gets stronger. So it's very hard to just put a thought out of your mind. I mean, come on, come on, Jim. Don't think about an elephant. Don't think about it. Don't get it out of your mind. Get that elephant out of there. That's just not the way the mind works. What does work are things like reframing, which is the story that you are telling yourself about what's happening. We see this all the time. You probably have this in your group. You got one person who's just whining, whining, whining. They hate their job. Another person loves it. They can't. They can't believe they're so lucky getting to do this job. One reason is the narrative that they are applying to this same situation. So if you want to know how to tactically do this, I know you love to get into the kind of the granular details. The first thing, it seems almost like a paradox is to get familiar with the negative inner voice, the one that is saying, oh, this sucks. And you know what? You over there, you suck. And you know what? I kind of suck. I suck, you suck. This sucks. This inner critic criticizes all these three things. And that voice, that inner critical voice touches on so much. There's a lot of exercises to work through it. And we have a three day conference just looking on this and how do we work around it is to not to fight it, but to face it head on and actually welcome it. That voice, that inner voice, that negative inner voice telling you, oh God, this is horrible. It's actually trying to help you, trying to protect you. It's like a friend who wants to give you advice, but maybe it's like the friend's a little bit drunk and it's often not good advice. Certainly doesn't bring joy, but it is trying to help. Once we are able to identify that and stop struggling against that inner voice, that inner critic, inner critical voice, we can then reframe the situation or recalibrate and decide, how do I want to show up here? How do I want to show up in this situation? This can be months of work with a single physician. But if we're going to say, here's a tiny tool that you can do next, next shift, or when you're done listening to this podcast, we get stuck in what if? And why did loops. Oh my gosh, what if this happens? What if I get fired? What's. There's an outcome. What if, what if, what if, what if? Or why did, why did they say that? Why is this happening? Oh, why is this happening to me? Why does the administration do this? That is a negative ruminative cycle. So there is the question that you're answering in your mind. If we're going to get into the neuroscience that lives in the default mode network, I mean, not exactly, but if we're speaking in generalities, the part of your brain that has that ruminative, non focused thought to switch from that is not so much of saying the answer of, ah, okay, this is good, this is good. It is switching from what if, what if, what if? To asking the question what's next? Action oriented action is an antidote for negative rumination. Rumination is generally negative thinking action which lives in a network of the brain, the task positive network. And these things are like a toggle on, off. When you turn action on, you start turning rumination off. So you're putting in a test tube and it goes awry. It's kind of, oh my gosh, this is horrible. What if, what if, what if? It's kind. All right, let's come back. Let's put this into sequence. What's next? What's next? Re prep. Make a new hole. Here's what I'm going to do differently. Action. Antidote for negative rumination. It's not a panacea. That's just one example of shifting out of that negative thinking and reframing it into how do I move forward?

Jim Dahle (60:09)

Love it. Super helpful. I love that shift from rumination to action. Now, Rob, this is a financial podcast, and we've been talking about things that you know a great deal about, which is, you know, emergency medicine, as well as burnout and coaching and so forth. But because of our focus on finances on this podcast, I'm also going to ask you to tell us about your financial journey as a physician. You know, starting as a pre med until now and maybe looking forward to, you know, whatever final retirement looks like. You've had, obviously, a switch out of clinical medicine more recently in as much detail as you feel like sharing in a way that would be informative for our audience as they struggle through their own individual financial journey as a physician.

Rob Orman (60:54)

Oh, Jim, I don't know if I've ever told you this story when we've done other shows together, but some of this is not going to be pretty.

Jim Dahle (61:05)

It would be unusual if it all were pretty, to be honest with you. Yeah.

Rob Orman (61:09)

You know, it's so funny that we have this massive expertise in one area or maybe a couple of areas. And as young doctors, hopefully, you know, now that you're putting out your stuff and people are getting more financially savvy, we don't think that we have domain transfer of that expertise into everything like finance, but I certainly did. So let's just take the time machine back a little bit. And when I was the first year attending, I had $15,000 in the. I just had $15,000 of basically savings. And I was somewhere, I don't remember where it was, but I was somewhere that I heard these people talking about an amazing company called Lucent Technologies. And it was so undervalued. And it wasn't like I was, oh, I'm eavesdropping, getting inside information. I joined the conversation. So they said, yeah, this is so undervalued. And they were going to pour a ton of cash into Lucent because this stock was going to go crazy. Jim, my friend, I did not know anything about finance. I had not read the Motley fool or any of these things back then. I just thought, you know, I'd seen Wall street and Gordon Gekko. And you can take a hundred dollars and come away with a million. I thought that's how this stuff worked. So I thought, oh, my gosh, this Lucent Technology sounds like a major win. I'm gonna. I'm gonna get a 10x return. I'm gonna put. I'm. Put 15 grand in this, come out with 150k, which was gonna. Which was my salary, my first year of attending hood. I put all of my money into that single stock. Oh, Jim. I was getting ready to wear a top hat in a monocle. I was. I couldn't believe it. And Lucent went from $70 a share. I think I. I bought it. I mean, here we go. Here we go. It went to $1 a share very quickly. Now, 15 grand, I mean, it's a lot of money. It's not a massive amount of money to what I would make later in life, but that was everything. That was everything that I had. Oh, my God. I'm like, I'm shaking telling this story right now. That was a hard lesson to learn, Jim. And your listeners might be listening, thinking, I mean, there's pretty savvy, like, what an idiot. What an idiot. And let's just fast. Oh, my God. I'm feeling flushed. Anyone watching the video, you probably see the sweat on my forehead. Okay, so my wife and I get married, and she's also an emergency physician. And, I mean, if you want any. This is an open book. If you want any more detail on this, I'm happy to provide it, but we'll just skim the service here. So we had about 80 grand between us. Well, we had exactly 80 grand between us. And we did two things that set us up for success. And in between this, I had read books, and I was really into the Motley fool at that time, and it was just, put your money in index funds and reap the rewards. And great. So I started doing that.

Jim Dahle (64:28)

I'm so happy. That's the message you took away from the Motley Fool. Because there's a lot of messaging coming out of the Motley fool, and it's not all invest in index funds.

Rob Orman (64:36)

Okay? This. This was when the Motley fool had just one, like, one book. I don't. I don't know what the Motley fool is now, but back then, that was it. It's this. Hey, here's what happens with the stock market over time in our lifetime, it's going to rise, it's going to fall, but over time, it's going to rise. And if you invest in Index funds. You're going to be fine. So most of what we had was our retirement account because we were both working in groups where we had 401ks and did we have. I can't remember if we had matching or not, but I was running our Vanguard account and trying to figure stuff out there. I'll tell you, I didn't love it. I did not love doing that. And that'll come up in a moment here. But we read a couple of books. Probably the most important book we read, I don't know if it's still in print. I think it was called the Road to Wealth by Susie Orman. And I mean, there's so many great books, you know, rich dad, Poor dad, the Mindset of Money, or Money mindset. There's so many great books on this, and I think any of them are going to put you in the mindset of what is my mindset about money. And so this Suze Orman book really helped us with mindset, and it had the basics of how do you buy a house? Should you buy a house? What is mortgage insurance? Okay, Jim, if we're getting inside baseball here. When I bought my first house, I was a resident, and this house cost $153,000, which at that time, I think I was making 30,000 as a resident, it could have cost 10 million. And when I bought that house, I got mortgage insurance. And I thought, wow, this is awesome. My mortgage is insured. This is great. I didn't realize that this wasn't something that I wanted, but how would I know that? Nobody told me. And so we read this book, like, oh, wow, mortgage insurance. You probably don't want to be paying that. And here's. Here's how you manage your finances. It gave so much clarity. And the other thing we did with our $80,000, and this was one of the best decisions we ever, ever made, was hire a financial advisor. Actually a team. And I love it. You know, we looking on your website, you know, all these courses, fire for your financial advisor. Fire financial advisor. Now, I know that that's, you know, a little bit hyperbolic, but back to this. This was a financial advisor team who worked with a lot of the physicians in our area. And we knew that we were going to be paying a percentage of our assets to them, which was, I think, 1% at that time. But we both felt, my wife and I both felt that attending to the finer points of our finances was not something we wanted to do. I. I would just get so stressed looking at the vanguard options and is this how I want to be doing? I don't know what to do with my money. And we're going to be making a lot more. And I want to have general strategy. I want to talk risk level, and then I want to have them run the show based on that. Could I have done that with Vanguard or another one of these things, like, here's the risk. Okay, here's where you invest. But I wanted to talk big picture and then set it and forget it and not be choosing all of those menu items. And with the financial advisor, it's not like getting feedback. You're talking to them frequently. And I would periodically say, all right, I can do what they do and I'll get invested in finances. And I would open this separate Vanguard account. I disliked it massively. We tried passive income with rental properties. Hated it. Invested in REITs. Love those. So we started off with our financial advisors, and we're paying about 1% and is a lot. That is a lot of money, especially when you start having a lot of assets. And that's where most folks start. And key as your assets grow, money ideally grows. That percentage needs to go down. It cannot stay 1% in perpetuity. And the way that I think about all of this now and we can get into retirement and all that stuff is the chances are you are not going to beat the stock market. You think you're going to hire this financial advisor. You beat the stock market, beat the Dow, beat the S and P or whatever, the nasdaq, whatever it is that you want to. You want to be good luck. The odds are against it. You're almost certainly not going to beat it. So when I was starting out with my Lucent investment. You remember the logo for Lucent? I don't know if you ever see this.

Jim Dahle (69:20)

I don't remember the logo. What does the logo look like?

Rob Orman (69:22)

Well, you know, this is a medical crowd. It looks like a giant red anus, and it's like this red paintbrush circle. When I invested in that, certainly what.

Jim Dahle (69:34)

It looked like after it went from $70 to a dollar a share. I'll bet that's exactly what it looked like to you.

Rob Orman (69:39)

Exactly. So I thought I could beat the stock market. Changing that mindset was probably one of the main things that saved me, saved us. Hey, don't need to beat it. Just don't have great losses. Balance things out so that you don't have great losses. And when we invested in the. Was it early 2000, maybe year 2000. Eight months later, stock market tanked. We lost almost everything we stayed in. And we were also heavily invested in the next crash in the late 2000s. And we know what that feels like. That has definitely impacted our mindset that we first play not to lose and we are okay with slower gains. And that's how we have our investment set up is protected from massive crashes. We don't need to beat the market. If we meet the market after our advisor fees, I am totally fine with that. I just don't want to be the one pulling the levers. I don't want to have to select the menu items. I want to set a general strategy and let them run the show.

Jim Dahle (70:56)

So in the financial services industry, somebody like you is referred to as a delegator. Yes, there's delegators, there's validators who just want to check in with somebody every now and then, make sure their plan's okay, but are okay running the plan. And then there's the hardcore do it yourselfer. You know, the person who's going to take an online course called fire your financial advisor, but you are clearly a delegator. And so it sounds like the one of the best things you ever did relatively early on was find a good advisor and pay the fees. It's way better to pay 1% a year than to watch what you're buying go from $70 to a dollar.

Rob Orman (71:34)

Loose it. Yes, that's right. Yeah. When I went down from 12 shifts a month to 10 shifts a month in the ED, I felt like a weight was taken off of my shoulders and I had room to breathe. When I went from being a do it yourselfer to a delegator, it was that same weight of. And I didn't even know that it was stress that I was carrying. You know, I think you have something on your website about the waterfall of what you do with your finances. I mean, listeners go to that blog post. If you are a, you know, a student, a resident and attending, it is brilliant. And I honestly, I wish that I had seen that when I was a resident of. What should you pay for first? What should you pay off first? Please put that in the show notes of, of this pod gym. It's awesome.

Jim Dahle (72:31)

Great. Very much appreciate it. And obviously we refer people to financial advisors as well. If you, if you like Rob, are a delegator, you are far better off paying some fair fees, getting good advice and making sure this is done properly. You know, everybody is not a do it yourselfer. I think it's important to recognize that there's lots of people listening to this Podcast that are not do it yourselfers.

Rob Orman (72:52)

So you said some. I don't remember. I think it was probably four years ago. We were recording a pod and we were talking about real estate investing and relayed what I just said to you. I was like, oh, my gosh, Jim. I know that real estate investing is a great thing or can be a great thing. We've tried to have rental properties, and I just. I don't. I don't love it. Which I think goes along with that same DIY with the finance. I did not want that on my plate. And you said, yeah, just invest in REITs. I said, we're heavily invested in REITs. And he said, then you're invested in real estate. Oh, my gosh. I felt like such a champion that I was doing the right thing. So thank you for that, Jim.

Jim Dahle (73:34)

You're very welcome, and congratulations to you and all of your success. You know, I run into docs every now and then, in their 50s, in their 60s, sometimes later, that haven't learned these important lessons that, you know, matching the market's okay, that it's okay to pay for advice, but you just want to make sure you're paying a fair price and getting good advice. You know, you got to put some money in the retirement accounts if you want the retirement accounts to be big. The most important thing is how much money you put in there. You know, people just don't learn these lessons until oftentimes it's too late or nearly too late. And so I appreciate that and congratulate you on your success there. Well, our time has gotten short. I don't know how much longer we can make a podcast and still have people listen to it. I'd love to talk to you all day, but I appreciate what you're doing, both in your career, the education you've done. I've been the beneficiary of much of the content you've produced over the years, as well as what you're doing now and coaching and keeping people in the game. Because both enjoyment in our lives as well as financial success often depends on staying in the game for a decade, two decades, three decades, whatever. So thank you so much for what you're doing, Rob, and we appreciate you coming on the White Coat Investor podcast.

Rob Orman (74:52)

Thanks for having me, Jim. It has been a treat.

Jim Dahle (74:57)

I hope you enjoyed that interview as much as I did. You know, the fun thing about this is I'm recording this interview today. I'm on his podcast tomorrow. So the day after I recorded ours, I'm on his podcast. So if you want to talk more finance, I think we're going to actually talk more finance on his podcast than we are on our podcast. But you can check that out as well on Rob's podcast. Great doc, great person. Always love chatting with him. As I mentioned at the beginning of the podcast, SoFi could help medical residents like you save thousands of dollars with exclusive rates and flexible terms for refinancing your student loans. Visit sofi.comwhitecodeinvestor to see all the promotions and offers they've got waiting for you. One more time, that's sofi.com whitecoatinvestor SoFi student loans are originated by SOFI bank and a member FDIC. Additional terms and conditions apply. NMLS 696891 don't forget about submitting somebody for the Financial Educator of the year award. Whitecoatinvestor.com educator is where you do that, where you can win a free online course and they can get a thousand bucks and some serious recognition. That's also where you download the slides that I put together that you can use to put together your own presentations. Thanks to those of you out there leaving us five star reviews. Those really do help us spread the word about the White Coat Investor message. A recent one comes in from Lerner from LA who said, Incredible podcast. This podcast has been incredibly helpful in improving my financial literacy. I wish I had discovered it sooner. I would have made fewer mistakes which could have translated into millions. I learned something new from every episode and even tried to go back and catch up on earlier ones. Thank you for everything you do. Five stars. Appreciate that kind review. All right, it's been a long episode. You probably don't have a commute long enough to listen to this all at one whack. So if you had to listen to it on the way home too, I'm sorry. But now you can get back to the music. We're done, so keep your head up and shoulders back. We'll see you next time on the White Coat Investor Podcast.

Rob Orman (76:49)

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