What Else Doesn’t Residency Teach Physicians (Things They Didn’t Teach Us in Residency, Part 2) Ep. 85

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Hello, and welcome back to Chart Less, Live More, the show for physicians and APPs who want to practice excellent medicine, think clearly about hard stuff, and still have an actual life outside their EHR. I’m your host, Dr. Junaid Niazi.

What law school and medical school both leave out

A while back, someone asked third-year law students a simple question: Are you ready to practice law right now?

Seventy-six percent said, “Yes. Ready to go. Bring it on.”

Then they asked the lawyers already doing the work whether new graduates were ready. Twenty-three percent agreed.

Around that same time, a legal education institute surveyed more than 24,000 practicing attorneys and built a list of everything a new lawyer actually needs on day one, the things that separate someone with a degree from someone who can do the job. They came up with 77 things.

Sixteen were legal skills, out of seventy-seven. The other sixty-one were everything else: judgment, how to talk to a client who is furious and frightened at the same time, how to manage your own workload, how to keep your integrity, et cetera. Law students go through additional years of schooling, compile a mountain of debt, subconsciously undergo a personality restructuring, and mostly graduate with sixteen of the seventy-seven things the job requires.

Then they get a diploma, a handshake, and a “good luck out there.” Sound like anyone you know?

I looked for the medical version of that list, and surprise, surprise, I couldn’t find one. But you already know roughly what it would say, and I bet you’ve known since about your third month after graduating.

And we are not the only profession that does this. We’re just the profession where the gap carries the highest stakes.

So today’s question: What else doesn’t residency teach physicians?

A little while back, in episode 66, I did an episode called Things They Don’t Teach Us in Residency, and it’s one of the most listened-to episodes. It’s up there with burnout, boundaries, and AI scribes. I called it the second curriculum, and it covered things like money and negotiation.

But that episode didn’t cover everything. I didn’t get to a handful of things, and some of them catch people more off guard than money does. With money, if you’re bad at it, you probably know you’re bad at it. But these other gaps, you don’t see them until you hit them. In that episode, I mentioned that the not-knowing is conscious, and now you know, so now you can do something about it.

This next portion of the curriculum shows up in places you assumed you were fine. So let’s pick up where we left off. Four more.

One: Why don’t physicians understand disability insurance?

Nobody taught you to protect the asset, and the asset is you.

There’s a study out of an academic medical center where researchers surveyed residents about their actual financial lives. Not their knowledge in the abstract. Their real circumstances, how comfortable they felt with each topic, and how much they wanted to learn it.

A hundred and forty-four residents answered. Fewer than half of them had a retirement account of any kind. And when the researchers asked them to rate their comfort across every financial topic on the list, disability insurance came in dead last.

Think about that. These are people whose entire economic future, the loans, the deferred earnings, the retirement they haven’t started, the family they’re planning, rests on one single asset. Not a house, not a portfolio. The ability of their own body and mind to do this specific work. And the protection for that asset is the thing they understood least in the entire world of money.

Now, here’s what makes this a curriculum problem instead of a character problem. When those same residents were asked how interested they were in learning this material, they were highly interested. Near the top of the scale, across the board.

They wanted it. They knew the gap was there. They were people given a spectacular education in one domain, left entirely alone in another, and then, very predictably, blamed themselves for the gap.

And if you remember part one, I said, “Nobody pimped you on a Roth IRA at 6 AM rounds.” Nobody pimped you on disability insurance either.

What is own-occupation disability insurance?

I’m not going to turn this into an insurance seminar, but there are two words I want you to walk away with, and they do most of the work in this entire area: own occupation.

For highly trained, high-earning professionals such as physicians, surgeons, lawyers, and corporate executives, this is critical. It protects your education investment and earning capacity.

Own-occupation coverage pays you if you can no longer do your specialty. Any-occupation coverage, the other kind, only pays if you can’t do any job you’re reasonably suited for by education and experience. For a person with your résumé, that is a startlingly long list.

You are exceptionally well educated, and here that cuts against you. An insurer looking at your credentials can find an enormous number of things you are technically qualified to go do instead.

Take a surgeon with a hand injury. Under own-occupation, she’s covered. She can’t operate. Operating was the occupation. The policy pays. Under any-occupation, the insurer can argue she could do just clinic, go into administration, or teach, and that policy may pay her nothing at all.

A lot of employer group policies, the coverage you got automatically, the one in the benefits packet you skimmed during onboarding while someone talked at you about the parking structure, advertise own-occupation coverage and then specify in the fine print that it converts to any-occupation after twenty-four months.

Twenty-four months sounds like roughly how long it takes for a serious disability to stop being an acute crisis and start being your life.

I’m not telling you what to buy. I’m telling you to find out what you already have.

Two: Why is becoming an attending so hard?

Okay, number two. Nobody taught you to be somebody’s boss. This one arrives with no warning at all.

For ten, twelve, fourteen years, you were one of the most, if not the most, junior person in every room. That was the whole architecture. Someone above you set the plan. You executed it brilliantly. They evaluated you on it. The hierarchy went one way, and you were reliably near the bottom.

And then one day, you’re suddenly an attending, and there is a medical assistant, a nurse, a resident, a student, a human being with a career and a mortgage and a bad week, looking directly at you and waiting to be led.

Actually, the nurse probably doesn’t need to be led. They’re just waiting to see what you do and how well you listen.

Nobody taught you about all that. Not one hour of it.

There’s a study out of Switzerland where researchers interviewed newly appointed attendings across twelve hospitals about what was actually hard in that first stretch of being newly appointed. Four big themes emerged, and half of them were about people, not medicine.

One was supervision. Learning to let a resident do the thing badly, slowly, in a way that makes your skin crawl, since that is how a resident becomes a doctor. One new attending put it plainly: “Trusting residents is extremely hard for me. When I do it myself, I know it’s done.”

The other was leading a team you have no real authority over: specialists, nurses, therapists, pharmacists, the person from case management who has opinions. One department head described the attending role as a classic sandwich, caught between the department head, the patient, the residents, the nursing staff, and consultants from every other specialty.

That’s the job. Nobody described it to you that way, and it’s not very flattering.

The finding that’s hardest for me: most of these new attendings went through all of it without regular, structured coaching. Those who had it found it very helpful, but most of them simply didn’t have it.

Now, think about what training actually taught you about hierarchy. It taught you one relationship extremely well: deference upward. How to be managed, how to take feedback, how to read what the attending wants, how to be excellent under supervision.

It never taught you downward. How to give someone difficult feedback without crushing them, how to delegate without abandoning, what to do when someone on your team is underperforming and everyone knows it.

And it never taught you how to lead alongside your peers. How to tell a colleague you read that scan differently, knowing you’ll still be working beside them fifteen years from now.

You were trained in one of the three directions. You now work in all three.

Three: How long do physicians stay at their first job?

Three: nobody taught you how to leave.

Listen to this number from a 2023 survey of physicians and the groups that hire them, and see what you think.

Physicians who’ve been practicing for a while averaged about six years at their first job after training. You’d sign on, put down roots, and grow into the place. You stayed long enough to learn where the good parking was, which vending machine actually takes dollar bills, and which nurse to ask when you need something done right.

For physicians who finished training in the past six years, that average has dropped to under two years.

Here’s how it usually goes. You take job number one. Somewhere in year one or two, you start to feel something like this: the culture isn’t what they described, the schedule isn’t what they promised, and the autonomy you were told about turns out to have an asterisk. And the story that shows up in your head at 11:00 PM is, “I chose wrong. I’m bad at this. Everyone else figured out how to be happy here, and I couldn’t.”

If that’s you, you’re not the exception. You’re most of the room.

Nobody told you job number one is a first job.

In most other professions, this is understood. Your first position is where you learn what you actually want: what kind of team, what kind of pace, what kind of leadership you can tolerate. Nobody in consulting or engineering thinks their first job is a life sentence. In medicine, we somehow absorbed the idea that leaving is a referendum on our character.

Why do physicians leave their first job?

And let’s talk about the reasons people leave. They might not be what you’d guess.

In that same survey, half of physicians in training said compensation was what they needed most from a job. But when physicians were asked what actually drove them out of their first job, the single biggest factor wasn’t pay, and it wasn’t work-life balance. It was ownership and governance. Having some actual say in how the place runs.

Not more money. A voice.

Which tells you what to ask about in your next interview, and it isn’t the RVU rate.

One more thing here, and it ties straight back to part one. Remember the negotiation conversation? Those clauses that matter most when you leave, the notice period, the non-compete, the tail coverage, are the ones you signed on day one, when leaving was the furthest thing from your mind.

Your exit was written before your first shift. Most of us have no idea what it says until it becomes the most important thing.

You don’t have to be planning to leave to read it. Read it and make sure it fits with what you want.

Four: Why do physicians feel lost after training ends?

Four: nobody taught you who you are when the title stops doing the work.

For over a decade, one descriptor answered the question, who are you? Med student, resident, fellow. It got answered at parties, at family dinners, in your own head at 3 AM when you were awake and attempting to think. And it did something else too. It pointed forward. It described a person in motion, on the way somewhere, and everything hard about your life could be filed under, “This is temporary. I’m becoming something.”

Then you become it, and that descriptor stops pointing anywhere. It’s not a direction anymore. It’s just a word. You’re here. This is the place you were going.

Nobody warns you about the quiet on the other side of achieving the thing. It’s not depression, exactly. It’s not ingratitude, though most of us feel guilty for even noticing it, which is its own particular trap. It’s more like arriving at a destination you spent eleven years driving toward and discovering that arriving is not the same as being there.

There’s no next envelope to open, no next Match Day. Nobody hands you the next thing to become.

And then there’s the other half of this: the people who waited.

A partner who spent their twenties or thirties scheduling an entire life around a call schedule they had no say in. Friends who eventually stop inviting you, not out of anger, but because you always said no. Parents who got the distracted version of you, the version answering pages at Thanksgiving. Kids, for some of you, who have never known a version of their parent that wasn’t tired.

You were never absent by choice, but those people still experienced an absence. And here’s something you might not have thought about: they’ve been waiting for the version of you that shows up when training ends, and that version has to be built. It doesn’t arrive automatically with the new badge.

The marriage doesn’t repair itself the day your schedule improves. The friendships don’t reconstitute because you’re finally free on a Saturday. Those are things you have to go and do, deliberately, as a beginner. And you will be a beginner, and that will feel strange for a person who is very good at something else.

I don’t have a study for this one. I looked, and the research here is thin, which is its own kind of commentary about what we’ve decided is worth measuring.

What I have instead is this: if you finished training and felt something other than pure triumph, you are not broken, you are not ungrateful, and you are not alone. You are a person who spent a decade postponing an entire life, and postponed things do not resume on their own.

Medicine trains you to be very good at delayed gratification, and you got the delayed part for years. Now comes the gratification, and you have to go out and claim it.

The second curriculum is learnable

So, four more added to the second curriculum.

Same message as last time: this is not blame. Not of you, and not even of the training. Nobody set out to leave these holes. They’re just what happens when the system you’re in is optimized ferociously for one thing, making you clinically excellent, and it worked.

But all of this is yours now. Not your fault. Your responsibility. Blame looks back at people who can’t help you, while responsibility helps you focus on the one person who can: you.

And every single thing is learnable. None of it requires some gift you weren’t issued.

You memorized the Krebs cycle, the full cast of enzymes with names that sound like minor Tolkien characters, and you drew it from memory under time pressure while a person you’d never met decided your future. You have used it exactly zero times since. It has never once come up during a routine visit, and yet it is still in there, rent-free, taking up space you could have used for the fine print of your disability policy.

Compared to the citric acid cycle, reading a benefits packet is a spa day.

This second curriculum feels so heavy because nobody ever handed it to you as a curriculum. It came at you disguised as random adult stress, one ambush at a time, and felt like a personal failing instead of a missed study session.

Name it as a curriculum, and it stops being shame. It becomes a syllabus. And you, of all the people on this earth, know what to do with a syllabus.

This week: check your disability coverage

So here’s what I want you to do this week, and as usual, it’s almost embarrassingly small.

Find out whether your disability coverage is own-occupation.

That’s the whole assignment. Open the benefits portal, or dig out the policy, or email HR and ask in one sentence. You’re looking for two words, and whether there’s a time limit attached to them. It will take you about eleven minutes.

It might be the highest-value eleven minutes of your year.

Remember, you can be a magnificent clinician and still be getting quietly worn down by the things nobody taught you, and you don’t have to be. You are, of all people, an exceptional learner.

If this episode was useful, like it, share it with a colleague, subscribe, and if you have time, leave a review. All of those help more physicians and APPs find the show. I’ll see you next time.

Content for this episode includes proprietary information from Prosperous Life MD and Charting Conquered, along with published research from IAALS and the National Conference of Bar Examiners, Cureus, BMC Medical Education, and the Medical Group Management Association with Jackson Physician Search. It also includes the personal opinions and experiences of Dr. Junaid Niazi, and nothing in it is financial or insurance advice. For questions or comments, please email support@prosperouslifemd.com and include “podcast” in your subject line.