Dear Director,
I’ve been a chair/medical director for 7 years and am done. It was a good run, but I can’t do it anymore. I’m thinking about going back to being a pit doc. Does anyone ever do that? What do you think the pros and cons of going down the ladder look like?
The average life expectancy of an emergency medicine medical director at a specific site is somewhere in the 5–7-year range. Some will move on to other sites or other administrative roles. Due to our skill set, there is a sub-set of medical directors who without even looking for a “promotion,” get drafted to become their hospital’s chief medical offices.
Others, actively seek out that job. On the other hand, sometime performance issues will lead a hospital CEO to remove a medical director. And some, like you, are considering, will decide to step down and go back to being a full-time clinician.
I’ve seen plenty of chairs make the decision to give up the admin job to go back to 100% patient care. At my current hospital, most departments have a new chair every 5 years and without fault, pretty much every time I talk to a non-EM chair after their term is up, they are very happy to be back to being a full-time clinician. Kudos to you for recognizing your own wants, desires, and limitations so you can focus on you and know that you are not alone.
Emergency medicine may have more people looking for an admin role early in their career than any other specialty. Many of us were encouraged to find a niche outside of the clinical area to reduce burnout, supplement income, and control our schedule a bit. Particularly if you were a chief resident, you may have started down the admin career path very early in your career.
Why Go Into Administration
While we may get into hospital leadership as a break from the clinical world, there are likely other reasons. As I doc, I enjoyed taking care of one patient at a time. But by doing admin work, I realized I could have a broader impact than just one patient at a time. I started doing admin projects because our boarding was awful, and I had hoped to improve the admission process. I enjoyed making meaningful, albeit small, improvements in our ED environment.
My efforts to improve clinical care had a force-multiplier effect, which was professionally satisfying. I also found that I really enjoyed doing the recruiting and retention work as well as helping to improve quality of care. In some ways, being a director allows us to incorporate into our professional duties the aspect of academia many of us enjoyed most – mentorship. I’ve had the opportunity to guide APPs and docs on their journey from inexperienced trepidation to competence and clinical mastery–there is nothing more gratifying.
It can also be enjoyable to function as the representative/advocate/spokesperson for Emergency Medicine in a hospital or healthcare system. We have a unique perspective on healthcare delivery from our harried vantage point and it’s one that I’ve been happy to share with hospital colleagues and leaders. I’ve enjoyed working with colleagues outside of the ED to improve patient quality of care and make life a little easier for our team. While my wife would tell you that with each new job and responsibility, my life got a little more complex and our family life more complicated, I have generally enjoyed my admin jobs and the workload.
Time for a Reality Check Up
Just like you meet with your financial advisor regularly to make sure your financial plan and retirement trajectory is on track, all of us should spend a little time (at least) every few years reflecting on our career. Our lives are not static. Each of us needs to consider our values and how we balance family, career, and personal time for health and hobbies. The first question to ask yourself is whether you are on the right path that supports your personal values and life plan. If so, maybe no change is needed.
If the job fits your personal values and plan, then ask yourself whether the job is fun, energizing, challenging, professionally fulfilling, overwhelming, or painful. If you find more negatives than positives, maybe it’s time to consider changing roles. What might have been fun, challenging, and fulfilling at the start of the job, may not outweigh some of the negatives of the job.
The medical director job has gotten more challenging over the years—more metrics, more pressures, more burned-out docs, just to name a few things that have changed since I became a director almost 20 years ago. It’s not unusual to feel like you’re in a position with a lot of responsibility but not in a position to effect change and this can create frustration and contribute to burnout.
(As an aside, working with an executive coach can be very helpful when considering these kind of professional and life choices)
Fear of Change
Everyone is afraid of change. It’s normal. I think the first fear we all have is what the financial impact will be with a change. Obviously, this is tied to what your admin stipend is and how many shifts you were doing as a chair, but it’s not a given that you are trading away your salary.
Through the years, I’ve certainly had plenty of docs on my team who outearned me. Now, more than ever, there are opportunities to get higher clinical rates if you’re willing to do locums, be a nocturnist, or are willing to work a heavy clinical load. Very few jobs have hourly rates like emergency physicians so the income can still be excellent.
Most chairs work a lot of hours but in return for being chair, have pretty good control over their schedule. Two common fears are giving up control of your calendar and working nights. As a full-time clinician, you’ll definitely give up calendar control though schedule requests haven’t disappeared. Also, you’ll have way more white space in your calendar so your time off, will truly be time off.
As someone who is typically reviewing email and Epic dashboards by 630am each day and looking at emails, data, and the track board, most evenings, I can appreciate adding white space to the calendar. I was out with a friend recently who had just stepped down as a chair a few months ago and asked him how it was going. His response was that he “f’ing loved the change.” His days off belonged to him again and he could spend time on hobbies and passions that he didn’t have the time for when he was a chair.
Just having clinical responsibilities generally creates a clear demarcation between work time and personal time. There are numerous downstream benefits—more time with kids, hobbies, friends. Plus, you are not confronted with the guilt-ridden choice of responding to work issues or maintaining uninterrupted family time.
In some ways, being a medical director is a 24/7 job. This is true whether you’re working clinically, administratively, or are off. As a full-time clinician, your focus is providing the best care that you can during your shift. A friend described it to me as having a weight lifted off his back when he stepped down. If a parent is only as happy as their saddest child, as a director, you’re only as professionally content as the weakest link in the department. That weakest link is your perpetual problem. It’s hard to ever achieve professional satisfaction while always worrying about the next fire.
It is a scientific fact that nights get harder as you age. But nowadays, most EDs prioritize having nocturnists, so the night burden might be less than you anticipate. I have a friend who has a waiting list of docs to take nocturnist spots at his ED. And essentially every ED director I speak with, has nocturnists covering a significant portion of the nights at their ED.
I spoke with one doc recently who did very little clinical time as a chair. He then moved to another state and took a 100% clinical job. The increase in clinical time is of course proportional to have much you were working as a chair. I know plenty of chairs who are working 8+ shifts a month as they do their shifts and then fill in empty slots. Going to 13-14 may not be a big stretch given all of the time they’ll now have free. But if you’re working once a week clinically, going to 3-4 shifts a week will be an adjustment.
This chair admitted that he had to build back some endurance, but the stress level was not the same as being a new attending. As a new doc, clinical work may be cognitively stressful so many people look to get into admin to decrease clinical time. So much of emergency medicine is about pattern recognition, so fortunately, if you’re considering going back to full time clinical work, after 10-15 years of experience, the cognitive stress of a shift isn’t as bad.
Therefore, the increased clinical time may not feel as stressful or exhausting. Skills return very quickly with practice. Additionally, as a medical director, you’ve learned a ton from chart reviews, complaints, and performance improvement work about bad outcomes, mistakes, and management of high-risk cases. This should also pay dividends as a clinician.
Finally, you may be concerned about your legacy or how you will be viewed by your team or colleagues around the hospital. The short answer is almost everyone will understand and respect your decision to change jobs. While it’s ultimately none of their business, most people know how hard the job of medical director is and most of our docs don’t want the job. Do what’s best for you.
Next Steps
If you’re going to make this type of move mid-career, it’s important to try to do it in such a way that leaves possible career windows open in the future and secures the legacy of what you accomplished as a leader:
- Give a sufficient off-ramp to allow for a smooth leadership transition. There’s a little bit of needle threading here because if you’re too flexible and/or the time window is too long, you may get strung along in the position indefinitely and if you’re already feeling de-energized, you may run out of steam before being able to transition the job. The goal is to be reasonable but firm. Just like I hope that docs will give me 6-12 months notice if they think they’re leaving, even though they’re just required to give 3, as a chair, giving 6 months notice allows for recruitment and transition time. This is long enough in most situations to secure and train up a replacement but also short enough that one can see the light at the end of the tunnel and feel motivated to shore things up properly.
- Race to the finish line. There’s always going to be an inertia to overcome as you wrap up a position, pulling you a bit towards apathy. It’s important to consciously resist this and finish strong so that all the work you put in the previous years, along with your reputation, is preserved. There’s also a Golden Rule element here when it comes to your successor, as you would want to be stepping into a stable situation versus chaos.
- Keep in touch. You’ve probably built relationships over the years with colleagues, fellow hospital leaders, etc., some of which extend beyond transactional work relationships into true friendships. I think it’s important to maintain these because 1) meaningful relationships are essential to having a good life, and 2) you never know exactly where your career path will take you and these relationships can provide valuable insight, connections, and opportunities.
Conclusions
Working as a physician leader in administration can be very rewarding. And we need good leaders now more than ever. But it’s important to recognize that we need to individualize our career paths and that with every change comes opportunity. I’ve known docs who have been ED chairs for 30 years and completely love it. I also know several that happily walked away after 5-7 successful years.
They were just ready for something else. We all like to create a mental model where we can have it all, but life is about making choices. Taking time to reflect and analyze your values and goals is critical. Fortunately, the skill set that you develop as a chair will stick around and you will find other uses for it. And who knows, maybe you’ll jump back in after a hiatus away.
