"Dollar Signs In My Eyes"

A colleague's off-hand comment, thoughts on physician burnout, and rekindling the idealism of youth with the wisdom of age

I was once told by a physician colleague, for whom I had deep admiration, that I was “the physician leader on our team with the dollar signs in his eyes”.

I was floored. Was she right? If so, how had I become that way?

How could it possibly be that I — the radical who had slept in the tents of the Occupy Wall Street during residency because of my horror over the corruptive influence of money in medicine — was now that one viewed by a respected colleague as the doctor “with dollar signs in my eyes”?

You probably need some context reading this.

A quick summary on my career path to this point :

I am the first physician an upper-middle-class family. I spent four post-college years wandering— I was a playwright, a museum science educator, and high school biology teacher— before I went to med school. Following an emotionally challenging period, I applied to medical school. I loved med school. It gave me meaning and purpose. During my med-peds residency in Buffalo, the Occupy movement broke out. I got deeply involved, sleeping in the tents on off days from NICU shifts. I was inspired by how the apparently disorganized volunteers were more effective at helping the unhoused than the bureaucratic systems I referred patients into. After witnessing riot police raid the camp in the middle of the night, I decided maybe an insider's approach to social change would be more effective (still on the fence with this). From here, awarded a fellowship at an Ivy League institution, offering exposure to high-level national, government, and corporate health sectors.

After fellowship, I relocated to upstate New York and established a direct primary care practice. Despite my patients' high praises of my clinical work, my utter ignorance on how to build a business caught up with me and I couldn’t make the bills. This is lesson number one. Medical culture and education deeply undercuts its own by denying a need to understand the business of healthcare. To get out of debt, I joined a multi-speciality group as an employed physician.

Then, at the office holiday party and 35th anniversary celebration, I asked the practice owner what the next 35 years would look like, and if there were any paths to partnership for the nearly 100 of us employed physicians. I was met with a blank stare.

Without a ton for foresight I went to a hackathon a friend of mine invited me to a Yale. There I made a connection that led to a medical officer role at the care delivery arm of a medicare advantage plan. This was incredible. We were a full-risk wrap around house calls based primary care practice for the highest risk patients in the state, with comprehensive teams of social workers, providers, nurse care managers, community health workers, and data analysts all working side-by-side. it was how medicine should be. Until the layoffs started happening.

I “survived” the layoff. But this meant as the team leader, I had to personally fire, just before Christmas, an entire team of some of the hardest working, caring, and amazing people I’ve ever met, despite the fact that it wasn’t me that made the decision to lay them off. This happened several more times as I jumped around corporate jobs in healthcare.

Having suffered through those lay-offs, I forced myself to swallow the corporate Kool-Aid of “unit economics” and “right sizing” and learn management-speak. I got good at reading the corporate tea leaves, and moved to a new company. After being at the new company for a year, I smelled a lay off coming. The C-suite’s quarterly public reports became increasingly littered with code words like “profitability” and “business transformation”. Lay-offs were becoming popular among CXOs and there is good data to support that they are contagious. I foolishly believed as a mid-tier executive, I actually had some power to prevent the layoff among our team.

I started getting fairly obsessed with business model integrity, our teams’ efficiency and productivity, and out fiscal KPIs. I started tracking these tightly and developed systems to report these among our clinical teams. It was during a 1:1 with one of my physician colleagues during this period, that she told me she thought of me as the physician leader (there were 3 of us on this team) with the “dollar signs in his eyes”.

My immediate response was “but I’m just trying to keep us afloat so we can survive another day to continue serving our patients!”, This is the classic “no margin, no mission” bullshit that healthcare management always seems to use to excuse bad behavior. But reflection made me realize how right she was and how subservient to corporate power I had become. Six months later, despite dramatic improvements in our teams’ quality metrics and financial performance, I was out along with 10% of the company.

Image is a mix between an AI prompt (couldn’t get it right) and good old fashion photoshop

Now, I’ve come full circle. I’m revisiting my Occupy roots. I’m exploring how regular everyday people and frontline clinicians can wrest back power in this industry from corporate behemoths and non-clinically focused actors. Yet, I’m also not nearly as naive as I once was about money and power.

After 13 years in this business, I’ve come to believe our collective refusal as physicians to understand money, time, and your personal societal value as just irresponsible. You don’t overcome the corrupting influence of money in medicine by ignoring its existence. Here’s a few of the things I’ve been thinking about and will explore in future articles on this topic:

• Physician ownership over physician employment,

• creative business models for clinical programs

• the “portfolio career”

• leveraging our high wages for social good— a way to do this by focusing on leveraging it for creation of new power structures that makes us not dependent on the old wealth and power structures. In other words, live way below your means and actually own something.

• building things that serve patients with a business model that works (but not necessarily one that scales, there is a difference)

Small can be beautiful, but only if it can withstand larger power structures. Therefore we need small and many. If many physicians leave the “employed at high wages” power structure and leverage our skills for wealth-building that enables social power structure building, we have a chance at wrestling the healthcare system from the monster with the dollar signs in its eyes it has become.

To slay the dollar-eyed dragon we must be able to see like the dollar-eyed dragon.