FTEs, RVUs, PSLF...WTF? Everything You Were Never Taught to Become a Successful Doctor

Dr. Ami DeWaters is a hospitalist, health systems scientist, and one of the fiercest advocates for teaching doctors what actually matters but is almost never covered in training. She’s an associate professor at Penn State College of Medicine and a national leader in rethinking residency education, with a special focus on preparing young physicians not just to survive, but to lead. From billing and FTEs to negotiation and PSLF, she’s helping trainees understand the rules of the system so they can stop being pawns and start becoming players.

On this episode of How I Doctor, Dr. Graham Walker talks with Ami about the hidden curriculum of becoming a practicing physician and why new doctors are often thrown into the deep end without knowing how the system really works. They explore why financial literacy and systems thinking are now core clinical skills, how to negotiate your first job without getting burned, and the surprising power residents already have to drive change. If you’ve ever felt like you missed the class on how medicine actually works, this is that class.

Here are five big takeaways from their conversation:

Absolutely—here’s the expanded article section with each takeaway built out, using a direct quote from the transcript and three supporting sentences per point:

1. Understand FTEs—It’s Not Just About Hours, It’s About Everything

“Most residents do not understand FTE… every single department, every single institution can define FTE however they want.”

If you don’t understand how your institution defines FTE—full-time equivalent—you’re flying blind. It affects not just your schedule and compensation, but also your eligibility for benefits and Public Service Loan Forgiveness (PSLF). As Dr. DeWaters explains, some hospitals define a 1.0 FTE as 26 weeks of service, others as 33—so asking the right questions isn’t just smart, it’s essential.

2. Don’t Just Ask About Salary—Ask Where You’ll Sit

“Everyone assumes they’re going to have a desk. Don’t assume.”

It sounds basic, but the details that go unasked in a job interview often become the biggest frustrations. Dr. DeWaters emphasizes that new attendings are often shocked to find themselves with no desk, no control over their schedule, and no real understanding of what their role entails. That mismatch between expectations and reality is a recipe for burnout—and it’s avoidable with a better negotiation upfront.

3. Residents Can—and Do—Fix Broken Systems

“We actually cut their reading time of emergent studies by about 20 minutes… That was a totally resident-identified problem.”

Residents aren’t powerless. In fact, they’re often best positioned to spot inefficiencies and lead improvements, like the radiology residents at Penn State who redesigned their overnight workflow to reduce interruptions. Dr. DeWaters argues that systems are often more responsive to residents than junior attendings—making training the perfect time to start practicing change leadership.

4. You Can’t Fix What You Don’t Understand

“You do need to understand RVU, and you do need to understand billing and coding and insurance regulation because that is the language around the table of the people who are designing the system.”

If doctors want a seat at the table, they need to speak the language being used—RVUs, billing codes, prior auths, and insurance reimbursement. Dr. DeWaters makes the case that these aren’t “admin” issues—they’re clinical realities that shape patient care. Ignoring them doesn’t make them go away; it just hands the reins to someone else.

5. The System Isn’t Broken—It’s Working Exactly as Designed

“Every system is perfectly designed to get the results it gets.”

This quote, borrowed by Dr. DeWaters from Paul Batalden, captures the heart of her systems-based teaching. If your patients are stuck in the hospital because social work isn’t aligned with physician rounding schedules, it’s not a fluke—it’s design. Helping interns grasp this early reframes frustration as a call to understand structure, not just struggle against it.

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Transcript

Ami DeWaters:
I do not know how physicians retain a voice in the design of the system if they can't speak the same language. So my first argument is always with students and residences. If you're not sitting at the table, you're on the table. So you better get a seat at the table and be able to speak the same language because you do need to understand RVU and you do need to understand billing and coding and insurance regulation because that is the language around the table of the people who are designing the system.

Graham Walker:
Welcome to How I Doctor, where we're bringing joy back to medicine. Today I'm joined by Dr. Ami DeWaters, a hospitalist educator and one of the leading voices in health system science. Ami's an associate professor of medicine at Penn State College of Medicine and I'm national leader at re-Imagining residency education. She spent years helping physicians in training understand something that most of us didn't learn until far too late, how medicine actually works beyond the bedside from billing to contracts and systems thinking. She's teaching residents not just how to treat patients, but also how to lead, negotiate and thrive in the business of medicine. What I admire about Ami is how she's grounded in the real world work of clinical care, yet how she boldly pushes for change. Today we're going to dig into what it really takes to repair residents to become attendings, not just clinically, but financially, professionally and systematically. Dr. Ami DeWaters, welcome to the show. Thank you for being here on How I, doctor,

AD:
Thank you so much. It's an honor to be here.

GW:

Understanding the Real Transition from Training to Practice

It being the summer like it's a perfect time to talk about med students becoming interns, interns becoming residents, residents becoming fellows and attendings.

AD:
Yeah, we're definitely in that transition period. We talk about a lot in medical education, the transitions.

GW:
When will your interns start, your residents become the next year and graduate?

AD:
So much like many programs across the country, our interns will start on July 1st, 2025. Everything kind of shifts in July. Our interns will then become residents and for many of the residents who are graduating, they don't really have the financial resources to delay their start date. So a lot of residents will start their attending positions immediately in July, sometimes even just a week after they graduate their residency program.

GW:
Wow. Yeah, I remember that feeling well and that fear well as well.

AD:
Yes, exactly. Me too.

GW:

Tell me a little bit about your journey and how you got started with this. Was there a moment in your own training where you thought, wait, why aren't they teaching me this?

AD:
There was definitely a really critical moment for me when I was coming out of my fellowship. So I did a general internal medicine fellowship program at UT Southwestern, and I had a phenomenal mentor while I was there who was guiding me through this whole process of finding a job. And I was just shocked at how much about the job search process and the negotiation process I knew nothing about. And I think without this mentor, I would've been completely and totally lost. And I really learned at that point the importance of having a team to be able to help you through the process of finding a job from a systems perspective, a little different in terms of learning about health system science. That I would say was more gradual. As I started to get through my residency into fellowship, into attending Hood, it just became more and more clear how much of my practice was really being shaped by the structure of the system and how my lack of understanding about that structure was affecting how well I could take care of my patients.

Doctors Aren’t in Charge—And Patients Don’t Know That

GW:

It's interesting, it seems like, I think in medical school, probably also in residency, there's kind of an ideal version of how healthcare should work or how care should get delivered to a patient and how everybody should work together. And then the invisible hand of the system that nobody wants to acknowledge or talk about comes into play and is kind of throwing us and throwing patients around and knocking us from side to side. But it's kind of like taboo to acknowledge that it even exists.

AD:
It's not just taboo to talk about it, but there's almost a reluctance to acknowledge that it plays such a significant role because the second you acknowledge that the system has the role it does, you have to kind of admit that patient care is not solely under your control as an expert sovereign physician, you kind of have to let go of that idea. So I think there is something about admitting how much a role the system plays in patient outcomes that makes us uncomfortable because we have to admit then that some of our patients' outcomes are almost outside of our own individual control.

GW:
And increasingly, I'm seeing patients talking more on social media, how frustrated they are. We hear from members of off call just talking about that they feel that barrier that the patient wants their doctor to be in control. The patient feels like their doctor's the one that is in control or should be in control, but the doctor, by acknowledging the system is at play, it's a really uncomfortable tension where the patient's frustrated with, I think the system, but they're blaming it on the doctor because the doctor's clearly in charge and the doctor's saying, wait, whoa, whoa, whoa. I am acknowledging that I'm actually not in charge. I don't like it, but it is important that we acknowledge I don't control whether you get this medicine or this test ultimately.

AD:
Yeah, absolutely. So I'll give you an example that a friend gave me recently. I was talking to a friend and they were talking about how when their patients come in to see them, their patients still say, your staff don't x, Y, Z. Your staff don't this. They don't do that. And my friend was saying to me, it makes me feel horrible because what I want to say in response is actually I'm owned by an extremely, my practice is now owned by an extremely large health system, and these aren't actually my staff and these aren't my processes and these aren't my protocols. I'm simply along for the ride. I don't know how much understanding there is that many physicians don't have control over the processes or the protocols anymore of the places where they practice. And you're right, it does create a tension because I think most physicians don't want to throw their system under the bus, but you also want to continue to build trust with the patient. Yeah, I mean, when you're talking about tests and imaging, one of the things I talk about a lot with residents and students is understanding how to get prior authorization, understanding what insurance is looking for, when they're going to be determining whether or not they're going to pay for a study or how much of a study they're going to pay, and making sure you counsel patients on that before you place an order so that everyone's informed about how things are going to move forward

The Observation vs. Inpatient Admission Headache

GW:

As an emergency physician. The corollary that I think we see a lot and interfacing with our hospitalists as well is the observation admission versus the real inpatient admission. And if you're a healthcare worker, you may listening, you may have some sense of what that means and what I'm referring to. But if you're not, you probably don't. Most patients don't because why should they? Technically, they really shouldn't have to in any country besides our own, I mean, do you want to just explain observation admission versus inpatient

AD:
Admission? Right. So these are designations that get created that determine in large part how reimbursement is done. And so if you meet certain criteria,

GW:
All those criteria,

AD:
Criteria for admission, then there is a better chance of, I would say, better reimbursement from an insurance perspective. But if you don't meet the criteria for admission, then you may be placed into observation status, which might affect in the end, the bill and the bill can end up being worse for the patient. And so frequently what doctors are trying to decide when patients are coming through the door is, are we going to admit this person to observation or are we going to fully admit them to the hospital and how does that affect the bill they might get at the end of the day, there's plenty of times that I'm getting text messages from our billing people saying, can you please change this patient status? We need to change them to observation. We need to change them to admission in order to make sure that we're meeting the criteria and getting the reimbursement we deserve to get.

GW:
And that's the other friction that I think I've identified that I feel all the time is Ami, the way that you're taught in medical school and the way that you are taught in residency is that every patient that you see is a unique individual comes with unique combinations and patterns of medical problems, medications, social issues that all uniquely impact the plan that you have to put together every single time you are making a nuanced new plan for this patient based on all those factors versus the system. These criteria want the patients to be as uniform and same as possible for opportunities of scale and economies of scale. And that's the challenge. The criteria can sometimes be lab values or it can be vital signs, and sometimes it can be like, how many times did they get IV pain medicines? Bean counters have now said, well, that now counts as a more serious type of patient, and it now counts for different criteria as well, different rules.

AD:

And I think that that's one of the things that's really tough, and I talk about this a fair amount with the students, is you've got to understand the unintended consequences of trying to develop a new system. So I have no doubt that insurance criteria for payment and observation criteria and inpatient criteria were well-intentioned.

GW:
Absolutely. I completely agree with you. Completely agree. Yeah,

AD:
They were well intentioned. I get it. I get

GW:
It. Yeah.

AD:
It was like we have to figure out a way to make sure that people aren't getting overtreated, that people are getting high quality care. The problem is anytime you say take something as complex as medical care and reduce it down to an algorithmic checklist, there is a risk that you are going to lose capturing those individual nuances. Right. Nuance gets lost in checklists. Your job is to understand the checklist so that when you are looking at the nuance of the patient, you can make sure you're picking a course that makes sense for that patient. Where we struggle still in medical education and the training of future healthcare for professionals is that we continue to try to create this bifurcation where insurance checklists and things like that's other people's job. That's not physician work. I disagree when those are the things that are affecting where patients are getting treated and the kind of treatment they're getting. It is a physician job now, and I think that's where we need to have a little bit more emphasis on these kinds of things in our training.

GW:
Yeah, it's like I tell residents, if you want to use an algorithm to help you work up pulmonary embolism or something like that, that's actually fine. But the other skill you also need to develop is when to abandon the algorithm or when to hop off the algorithm and say, we're outside the realms of norm, and so I actually need to decide I'm going to abandon the algorithm because oh, they have new symptoms or their patient's unique and certainly would never have been considered for this algorithm. Ami, getting back to your expertise, how do you teach those two kind of diametrically opposed viewpoints to medical students and residents?

Teaching Systems Thinking and Human-Centered Design

AD:

Sometimes trying to teach it is a little bit depressing. I'm being honest. The first year students come in to our health system science curriculum, we're really taking, the system has a lot that needs to be improved approach. And when people are brand new to healthcare, that can feel very overwhelming because we lay it all out. We say, here's how the prior authorization process works, and here's many of the things that are problematic with it. Here's how pharmacy benefit managers work, and here's many of the problems with those. And we take deep dives into those kinds of problems that exist in the system. And so a lot of it is trying to get the students to learn what we call systems thinking, which a lot of people think is thinking about the system, but it's not. Systems thinking is a form of critical thinking that is understanding that each and every part is interdependent on one another.

So you cannot do one thing over here and expect that it's not going to have an effect over there. And so by teaching those systems thinking skills, we're trying to get trainees to understand how to analyze what pieces of the system work, what needs to be better, and then we say, okay, now here are some skills to try to make it better. Let's teach you lean six Sigma and quality improvement basics and let's teach you human-centered design, another method you can use to try to make the system better. So it's really about laying out a very firm understanding of the system first, understanding where the flaws are and where the strengths are, and then learning how to actually improve the system and how to make it work for your own individual patient.

GW:
If I was taking your course as a medical student, I mean, do I have any control until I make it to whatever a VP SVP level of a system? I mean that may be 20 years away. Even for your new residents that are about to graduate and become attendings, they're probably just going to be expected to go see patients for several years, nine to five Monday through Friday.

Yes, Trainees Have Real Power to Make Change

AD:

That is 100% the challenge. So you're trying to give trainees change agency in a system that is not very amenable to change? A couple of things I would say first thing is I think we've all seen the graphs of administration rise within US healthcare. I mean some graphs from CDC that show a 1500% increase in administrative costs in the US over the last 30 years. Large parts of that are related to administrative roles related to billing and coding. But there's also been an influx of MBAs at the leadership position of healthcare systems. And I think I'm constantly looking to see how many healthcare systems are run by MBAs and not physicians. I never feel quite confident about the data, but I feel like frequently I see that it's half and half.

I do not know how physicians retain a voice in the design of the system if they can't speak the same language. So my first argument is always with students and residences, if you're not sitting at the table, you're on the table. So you better get a seat at the table and be able to speak the same language because you do need to understand RVU and you do need to understand billing and coding and insurance regulation because that is the language around the table of the people who are designing the system. I think the second thing is there is really, I would really try to challenge trainees against believing that power comes with more time and more experience. I think that many trainees have tremendous power to change their healthcare systems. I would look at a lot of the unionization that has happened in residency programs as an example, and I would just say that I think many times health systems are committed to trying to keep their trainees within the system, trying to keep them happy for accreditation purposes and survey purposes. And so one of the things I try to emphasize is you actually might have more power here as a trainee, as a student and a resident than you'll have for the first few years as junior faculty.

GW:
Oh, that's interesting. Yeah.

AD:
Now to try to learn how to create change, and then once you have that experience, you can take that into your first junior faculty job and keep doing it if you love it.

GW:

Ami, can you tell me about a time a resident identified a problem, whether big or small, and was able to fix it?

AD:
Yeah, we, we've been working on some projects at Penn State. I mean, one of the things that we identified is our radiology residents overnight said, listen, there's only one of us here overnight, and we get phone calls a lot to do reads, but we're also trying to read emergently things that are coming out of the er. So if you're the only person reading any images being done overnight in a hospital and you have to read everything that comes through the er, but you're also taking phone calls, how do you get all of that done at the same time? So we started a project where we monitored it, and sure enough, they were getting a dozen phone calls overnight that was interrupting their work. And so we decided to design a whole new system for how people could reach out without interrupting their current reading to get answers. And it's worked beautifully. We actually cut their reading time of emergent studies by about 20 minutes. So that was a totally resident identified problem. We helped facilitate using design thinking actually that we helped facilitate a solution for, but it was designed by the residents. And so those kinds of things are the things that can make or break your workday. And if you can start to design projects that make that better, that can really improve your morale and your sense of wellness in terms of being able to improve your workday

GW:
And agency feeling that you are listened to, that you matter. Exactly. Feels really fricking good.

AD:
Yeah, exactly. No one wants to feel like a cog in a machine, right? And that feeling can really impact people's wellness. So yeah, getting away from that feeling can be very powerful.

GW:
And Ami, I'll connect this back to your first point of speaking, the same language you mentioned that you collected some data. I mean, data matters, and so being able to collect the data to say, Hey, on average the residents are getting 12 calls a night and their current reading time for head CT or belly CT or whatever is this much. And then you can also connect that back to ER bed utilization as well, right? I mean, an ER bed is worth, I think probably a couple hundred bucks an hour. And so if you cutting, I bet you were going to say like five minutes, cutting 20 minutes off an ED imaging result is a massive improvement for not just radiology, but in the patient, the ED as well.

AD:
Exactly, exactly. And being able to connect it to things that everyone can understand matter getting faster results from imaging studies. Everybody understands

GW:
We like that. Yeah. Yeah.

AD:
So this was a win in terms of yeah, this is something that's better for patients and better for providers.

GW:
And I think the converse inverse whatever is true as well. If you can have your physicians, your nps and PAs be a little bit happier a little bit, feel like they have a little bit more agency power, knowledge, control, hopefully that's going to trickle down to the patients having a better experience with the clinician, having more time to listen and communicate as well.

AD:
Exactly. Exactly right.

The Most Important Lesson Every Intern Should Learn

GW:

What's the one lesson about the system that you wish every intern understood by maybe the end of their intern year?

AD:
I have to steal a quote from Paul Alden for that one because we say this all the time, every system is perfectly designed to get the results it gets.

GW:
I love that one, Ami. I use that all the time. Maybe can you give listeners an explanation of what that actually means in practice?

AD:
Oftentimes when I say this, every system is perfectly designed to get the results it gets. I'll put up this picture that I have, that's my favorite picture, and it's of a watering bucket whose spout circles back to water itself. If you design a watering bucket to water itself, that's what it's going to do. It's not going to water your flowers.

GW:
It literally cannot.

AD:
It literally cannot. So that's my everyday example. My clinical would be, and I see this all the time, I come onto service a few years ago and I hear a lot of people expressing concern that the social workers aren't joining us on rounds. Where are the social workers? Why aren't they joining us? They have a required meeting from

GW:
A, at the same time,

AD:
That's why it's not a mystery, but it causes a lot of frustration because there's no understanding of the social worker structure and what they have to do and what their workday looks like, and their workday hasn't been aligned with the physician workday. And so now you're trying to mesh together two things that were never designed structurally to be together, and now we can't communicate and we can never see each other. And as a result, we can't figure out discharge plans. And patients are sitting in the hospital and everybody wants to know why length of stay is up and every CAO in the country wants to know why we can't get our length of stay down. The system is perfectly designed to get what it gets.

Your Job Offer Might Be Missing a Desk

GW:

I want to move a little bit to talking more about business and billing and risk. We just had something for the interns. Let's give something to the graduating seniors. You've worked with a lot of graduating residents. What's one question that they maybe forget to ask before signing that job offer letter or that contract?

AD:
One question that has come up repeatedly is, will I have a desk? Everyone assumes they're going to have a desk, don't assume.

GW:
Oh, that's interesting. Yeah, I don't personally. Yeah,

AD:
Don't assume you're going to have a desk. Sometimes. I've watched people over and over be absolutely shocked when they show up to their new job and they have nowhere to actually sit when they get to their new job.

GW:
Where would you like me to go? Yeah,

AD:
So on the hugely pragmatic side, there's the will I have a desk on the other side. I think that the thing that I have found most often is that most residents do not understand fte. And so if they're going into an academic medical center position, they actually don't understand how FTE works, how it's calculated, who pays for which portion of FTE and then how to actually negotiate to get changes in their fte. And that's where my mentor in fellowship was invaluable because she explained to the entire FTE system to me.

What the Hell Is an FTE? And Why It Matters

GW:

So let's do it. Let's do it for all the listeners, what is FTE? What does it even stand for and how did you explain it to your residents? Maybe? Maybe pretend I'm your resident.

AD:
Yes. So I explain it that FTE stands for full-time equivalent. That's what it stands for. Full-time.

GW:
Talk about the business of healthcare. We're deep in it now.

AD:
Deep in it. Now, the first thing I say to people is it really depends what kind of practice you want. If you want a community practice, FTE probably doesn't matter. You're probably going to negotiate more for money than you are time. But if you're going for an academic medical center position, you are more likely to negotiate for time than you are money. Those are general principles. Of course, there are exceptions to the rule. Full-time equivalent is 1.0, which actually means a hundred percent as you just said. And what you got to understand is someone has to pay for every single piece of that 100%. So if you are practicing clinically, you make rvu and those rbu generate income for the health system, which theoretically helps to cover your salary. So the health system might pay you to be, let's say 50% clinical 0.5. If the health system is paying only for 0.5, then someone else has to pay for the other 0.5.

And who is that someone else going to be? It could be the NIH paying you through a grant that you receive. It could be your college of medicine paying you for teaching you due. Someone has to pick up that additional for you to be full-time. The most important thing to recognize though is that math does not exist in the world of FTE. It doesn't exist. It's one of the strangest phenomenon I think that exists in medicine that there's no math that makes sense. With FTE E, essentially what you have to understand is that every single department, every single institution can define FTE however they want. So I'm a hospitalist. When I went out to interview for jobs in 20 15, 20 17, I interviewed at 12 different institutions across the country. None of them defined FTE the same. So at one institution it was 33 weeks of inpatient service plus three weeks of risk. That's a lot at another institution.

GW:
I'll just ask you to clarify, is that seven days a week or five days?

AD:
Seven days a week.

GW:
Okay. That is a lot. That does seem like a lot. Yeah.

AD:
The other institution that I interviewed at a 1.0 FTE was 26 weeks. So at every institution you go to, they can define it however they want, not just that they can decide what 0.5 means. So just because 1.0 is 26 weeks does not mean that 0.5 equals 13 weeks. Point five could actually equal 16 weeks depending on how the institution handles all of that other time that you're getting for. So FTE is one of those things that you really need to understand and at least know how to ask about. You get out there on the interview trail, you need to ask how much is full-time here? Does that include call? Does that include, one of my favorite examples is Heon colleagues who are in clinic, all of the follow-up from the chemotherapy orders. That is an extreme amount of paperwork. So sometimes they need to have blank days included in clinical time just so they can follow up even if they're not seeing patients. So that's something that you really have to understand when you're on the job hunt.

GW:
This is exactly why I wanted to talk to you, Ami, because we've talked to fantastic other guests who are lawyers and reviewing contracts and everything like that, but I don't think any of us, I don't think we've really dove into FTE before. There's other places where FTE is 40 hours a week or for everybody, or it might be 32 if you're an ER doctor and 36 if you're a hospitalist. And then I guess the last thing I'll say on FTE as well is just that the reason Ami is saying that it comes down to who's paying you is everybody has a budget and a hospitalist and an ER doctor might not make the same amount of money per unit or per hour, but ultimately the way that we've decided in society to allot things is by dollars and cents.

AD:

And the other thing that's really critical right now for people to understand about FTE is how it connects back to PSLF. So for many residents,

GW:
Public student loan forgiveness,

AD:
Exactly. For many residents, they're coming out of medical school with an average of about $250,000 worth of debt. Mine was higher than that when I came out of medical school. And so they entered into the public service loan forgiveness program. Now to qualify for that program, you have to be full-time. And so the one thing I want to make sure residents always understand is full-time is 0.9 FT or higher. So if you drop,

GW:
That's great.

AD:
Yeah. Below 0.9, you will not qualify. And that's a decision you have to make sometimes when you're looking at what you want your job mix to be. People should also be aware that at every institution usually benefits short-term disability, things like that drop off at certain criteria of FTE. So if you try to go, you have to be aware that not only do you take a pay cut, but you could be affecting your benefits as well.

GW:
Yeah, it is interesting that we really have not agreed on what the language of all this stuff is. I mean, what you're saying to me as part-time, I'm interpreting potentially differently than what full-time is.

Why Medical Education Needs a Total Overhaul

Ami, maybe I can just ask you as well. Do you get a sense that the design of residency really it comes from the report from the 1910s and this concept of the resident? I mean, they're called the resident we used to live in the hospital. I mean, do you get a sense that residency needs to be fundamentally

AD:
Overhauled? Oh boy. I think the whole medical education system needs overhauled. Yeah, I

GW:
Would

AD:
Good person to ask about

GW:
This. I would completely agree with you. I mean, we are taught from a acute care model of how to manage disease and manage conditions and diagnose that way as well. Most residents spend most of their time during their training taking care of inpatients in the hospital, but then most doctors most of the time, as for the rest of their 30 year career are working in an outpatient setting.

AD:
Yes, I mean, where the training is happening and how it is happening, I think is a real concern. I think there are multiple areas in medical education right now that I think are not sustainable. So I think first and foremost, it is not sustainable to expect people to continue to incur hundreds of thousands of dollars of debt for an education that then puts them out into a job where depending on their family size, they might be below the federal poverty line for multiple years and then say, but that's okay because later on, hopefully your salary will increase and you can make it up. That is not a feasible model, and the damage that that's doing is substantial. I think it's causing significant burnout. I think it's causing moral injury. I think it's really truly hurting the profession as a whole, if not at least contributing to the position shortage. Then you have the entire pre clerkship space in medical school where students are mostly using third port party resources online to study for step one, and yet still paying to come to medical school to get the same courses that you can get anywhere.

GW:
Wait, Ami, tell me because I'm 20 years out of med school, when you say they're using online resources, I mean, I know anky flashcards for memorization and stuff, but what resources are they using mostly to learn these days?

AD:
Anky sketchy for antibiotics, us e world prep for Step one, Khan Academy. So all of the third party resources that could we actually standardize the pre clerkship space and have one offering or connect it back to college more in a European type system. But then I think medical school should really be about the clinical training. But then you've got the problem of how many medical schools in the country struggle to have spots for the students to actually train in rotations. And I was talking to a group from the ACP a couple nights ago, and I was saying it's approaching unethical, in my opinion, to continue to admit students when you don't have clinical space to train them, they are paying $60,000 a year to get training and we don't have the space to train them within our health system. That to me, approach is unethical.

And so again, why don't we have space to train them? That's an incredibly complex systems issue, but the bottom line is we're really developing this system where the students can't get what they need. And so then by the time they get to residency training, I think there's already a pretty significant amount of burnout by the time they get to residency training. And then exactly as you mentioned, when you get into residency training, you're now talking about people who are still working 80 hours a week for low salaries trying to repay now their hundred thousands of dollars worth of debt. And in those scenarios, they're oftentimes training in a place where the healthcare system needs them, not where they necessarily need to be for the best possible learning for them. And I think a lot about that could be reconsidered, it would take major structural overhaul for any of that to be addressed. But I do think that there's a lot right now in medical education that needs to be reconsidered.

GW:
I mean, you raise a really good point. What if we had the best lectures and the best teachers of renal physiology give it once with YouTube, Khan Academy, whatever. People all learn from that. There are online forums that they can ask questions and work together. And I mean, just one thing I always harp on is just the importance of communication skills and soft skills in medicine that never have time to get taught. I mean, imagine if we could get rid of the Krebs cycle memorization and have every med student go work in a waffle house for a month to learn how to communicate from others and work with all sorts of people of different backgrounds and learn how to communicate. And

AD:
Absolutely, I would love, there are many medical schools across the country who are trying so hard to bring in great communication humanity systems, but in all honesty, as wonderful as that attempt is, we need that integration to happen after they have some experience in the clinical space, before they have experience in the clinical space. It's hard for anyone to understand why those things matter. And so for students frequently, that just feels like busy work compared to the necessity of being prepped for step one. Again, the system is designing its own results, put step one in, and that's what people are going to focus on. And so wouldn't it be great if we could do the humanities and the systems and the communication, but have that after they have some experience where they have some context to process and really develop and enhance their skills a lot. You could flip about how current medical education works

What Sets New Attendings Up to Thrive

GW:

We'll now move on to maybe getting something for the brand new attendings as well. From you, from your wisdom, what separates the new attending who survives their first year versus the one who thrives in their first year as an attending?

AD:
I truly believe that what separates them is their negotiation. Taking the job, how much you understand about the job you're taking is what separates the thrive from the survive. What's the equation? I always mess up the equation, but it's something like reality minus expectations equals happiness.

GW:
I was just going to say, so they're going into it with the right expectations because they know exactly what they're walking into and they've agreed to it.

AD:
Exactly. The person who understands the job they took, who goes in with correct expectations, that's the person who can thrive. The person who walks into their first job and realizes for the first time that they don't have a desk, they have no control over their own clinic schedule. They thought they were going to be a big bad attending and all of a sudden could do whatever they wanted with their schedule. And it turns out they have less flexibility with their schedule than they did as a resident, and they didn't think they were going to have to take call, but they do. The person who walks into that, that is the person who only survives their first year, isn't it? So it really starts at that negotiation standpoint.

GW:
Okay, so let's say the person negotiated perfectly. They know everything that they need to know, and they want to just set themselves up for this first year to really thrive. What do you wish somebody could whisper in their ear before they walk into the hospital on day one?

AD:
Burnout is hard to reverse.

GW:
Oh, that's good.

AD:
I got a lot of advice when I was starting out as a junior faculty. You need to say yes to everything.

GW:
Yeah, I heard that all the time. Yeah.

AD:
Say yes, say

GW:
Make yourself available. Oh, yeah, yeah.

AD:
I understand the wisdom behind it, and I do think that there's, I understand the principle and I think there is a lot of wisdom in it. However, what I have seen is that when you come in as a junior faculty and you start saying yes to everything and you sign up for everything, what inevitably happens is it catches up and people burn out. And burning out is really hard to reverse as opposed to the people who come in tortoise wins at the race, the people who come in slow and steady and they're just slow and steady going along their own course and they don't burn out, and they just slowly build their career. And that's what I would say to someone as they were starting out as a junior faculty.

GW:
Dr. Ami de Waters, it's been wonderful. Thank you so much for being on. How Doctor Today, Ami, where can people find you and support the work that you're doing?

AD:
Oh, they can Feel free to email me anytime. It's a to Waters at PennState Health psu do edu and always happy to hear from people. And thank you so much for having me. This was a blast.

GW:
Thanks for joining me today for interviews with Physicians Creating Meaningful Change. Check out off call.com/podcast. You can find how Doctor on Apple, Spotify, or wherever you listen to podcasts, we'll have new episodes weekly. This has been and continues to be Dr. Graham Walker. Stay well stay inspired and practice with purpose.