In this solo episode of Direct Well-being Podcast, Dr. Anders Apgar examines the career contracts young physicians sign before they have lived the lives those contracts will create. He explores burnout as a warning light, the true ROI of a job beyond salary, the “ghost” of future selves and families, and assigns concrete homework to move from awareness to agency.
What if the most consequential contract of your life is negotiated by a version of you who has never owned the things that contract will ask you to price?
At twenty-six or thirty, physicians are asked to decide about the next thirty years while still operating on static beliefs about family, health, energy, and identity. Medical training teaches endurance and self-sacrifice; the salary looks clean and comparable; the real equation, money plus sustainability, agency, health, and relationships minus the cost to sanity, rarely appears on the offer letter.
This episode moves from awareness to agency. Dr. Apgar reflects on burnout measures, the impossibility of fully predicting the “ghost” of future children or caregiving needs, the accumulation of ordinary trade-offs, and the personal audit of time spent versus presence gained. He then assigns two concrete pieces of homework: a recognized burnout assessment and a Career Horizon Stress Test that forces valuation of reversibility, shadow prices, and optionality so that ambition does not sign away a future it has never bothered to calculate.
Download the career Horizon Stress Test at https://directwellbeingpodcast.com/career-horizon . Print it, or take the PDF.
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About the Show:
Direct Well-Being is hosted by Dr. Anders Apgar, MD, FACOG, M.S., An Ob/Gyn physician leader and nationally recognized voice in clinician well-being. The show is a trusted, peer-driven space for honest conversations about what actually supports physicians, beyond resilience training and surface level wellness.
Each week, Dr. Apgar sits down with physician leaders, partner organizations, and frontline clinicians to talk about the real drivers of distress: financial stress, mental and emotional health, family dynamics, and the systems in which physicians practice. Conversations are evidence-aligned, research informed, and grounded in lived clinical experience, never promotional, always physician first.
Produced as a Direct Self Care production in partnership with the Doctor Podcast Network, the show draws on insight from the Well-Being Index, Champions of Wellness, Tend Health, and the broader Direct ecosystem to move listeners from awareness to agency
About the Host:
Anders Apgar, MD, FACOG, M.S., is a physician leader dedicated to transforming clinician well-being. As host of the Direct Well Being Podcast, he leads honest conversations about the real drivers of distress : financial stress, mental health, family dynamics, and broken systems, for physicians and the organizations that support them.
A trusted voice in health care, Dr. Apgar blends lived clinical experience with evidence-aligned insights. He’s part of the Direct Ecosystem (Direct Self Care, Direct Wealth Care, Direct Practice Care), partnering with organizations like Tend Health, the Well-Being Index, and Champions of Wellness to move the conversation from awareness to agency.
Connect with Dr. Anders Apgar:
Website: directwellbeingpodcast.com
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What if the most consequential contract you'll ever sign is negotiated by a version of you who has never lived the life that the contract will create? In other words, at twenty-six or thirty, you may be asked to make decisions about the next thirty years or more, hopefully. You may not have children or a spouse or aging parents, a mortgage, or a body that takes longer to recover after a night without sleep, or in some cases, a night with sleep.
You're being asked to price things you have never owned and therefore do not yet know how painful they may be to lose. That's what we're gonna talk about today. This episode's shorter than usual, but it's gonna ask a little bit more of you. You're not just going to listen. You have homework
Welcome back to the Direct Well-Being Podcast, the place where clinicians will finally say the quiet part out loud. We have spent some time talking about burnout, identity, family, money, and what medicine offers us and [00:01:00] demands from us in return. Today, as promised, I want to offer an opportunity to move from awareness into agency.
I want you to examine the career you're building before you wake up inside a life you never consciously chose There are legitimate ways to measure burnout. The Mini Z is a brief and practical burnout study. The Maslach Burnout Inventory is more extensive, more studied, and measures several dimensions, but it's licensed.
The AMA's organizational biopsy goes beyond individual distress and examines organizational culture, practice efficiency, personal well-being, and retention. You'll remember I had a great conversation with John McMahon from the Well-Being Index about burnout being a symptom of a greater problem and not a diagnosis to be used as a label.
That distinction matters. Burnout is not simply a personal failure to tolerate work. It can reflect [00:02:00] workload, poor control, inefficient systems, weak leadership, moral conflict, isolation, or just a mismatch between the work and the life a person wants.
So like a score can tell you that a warning light is on, like the check engine light in your car. That's assuming these days that your car actually has an engine or an internal combustion engine. The light's important, but it's vague. It could be that your gas cap isn't on correctly or that there's no compression in one of the cylinders and the engine is about to seize.
A score is an indicator, but it doesn't tell you whether the road you chose still leads to somewhere you ultimately want to go Medical education teaches us that we can endure almost anything. We memorize concepts most people never need to consider. We work hours that sound absurd in many other professions.
We learn to eat quickly, sleep strategically, [00:03:00] postpone discomfort, and keep functioning. We learn responsibility, clinical independence, and service to others through self-sacrifice. And then someone puts a contract in front of us. The salary is exact, that's for sure, but the consequences are vague. The salary may
say some huge number, three hundred thousand, five hundred thousand, a million, or some crazy number. That number is clean. We can compare it. We can calculate what a mortgage, a loan payment, or a retirement contribution will do to that larger number. Undoubtedly, some of us will do that without considering the tax implication of that number first.
Yours truly. The job description fleshes out call, productivity, expectations, weekends, leadership responsibilities, inbox coverage, administrative time, or partnership track. Those words, those tasks, and the perceived hours look manageable [00:04:00] because the training taught us to believe that difficult and impossible are pretty much the same thing, and we can do both.
But the salary is not the value of the job. The salary isn't even close to what the, quote-unquote, take-home pay will look like anyway. The true value of the job, the ROI, as my buddy Jonathan Moss put it, is what remains after the job has collected its price. The real equation is not more money versus less money.
The career equation is money plus sustainability, money plus agency, money plus health, money plus relationships, money plus the ability to change your mind, money minus the cost to your sanity, your perspective, and your wellness of producing the RVU. Here's another wrinkle. As graduating residents looking at big number contracts, we make long-term career decisions, [00:05:00] often using static beliefs.
At twenty-eight or thirty-nine, you may honestly believe you never want children, and I've had plenty of conversations in my line of work with patients on these exact topics. For some, that fact remains very true, and that is completely a valid life with its own responsibilities and unforeseen costs.
For others, the desire to have a family may change. And see, the goal is not to force one future onto everyone. The goal is to stop pretending that today's preferences are guaranteed to remain unchanged. The person who can party all night, drink a Red Bull, and work the next day is not necessarily the person who will inhabit that same body at the age of forty-five or the age of fifty-five.
But at some point, that stuff's gonna change. The physician who enjoys every extra shift before having a family may [00:06:00] experience that same shift very differently when it means missing dinner, bedtime, a ball game, or a conversation that may never happen again.
Ask Dr. Darren Gerard or Dr. Ridge Salter about that. We spoke specifically. Recently, if you've listened to past episodes, as you should have been doing, I sat down with my children, albeit a subset of the cohort, to talk about what it was like growing up with two OBGYNs as parents. After that episode, many people told me how mature and thoughtful and grounded
my children sounded, and they were right. I'm enormously proud of them. My wife is too. But I heard that conversation differently than the DWB podcast listeners did. The audience heard two remarkable young people describing their upbringing. I was sitting across from two people I love more than I could have ever understood when I chose my career.
I was listening to them describe the consequences of decisions [00:07:00] I made before they even existed. My wife and I frequently discuss and still worry about the impact of our careers and career choices upon the lives of our children. I imagine those same questions haunt parents who aren't in medicine, too But as a service and a self-sacrifice industry, medicine comes home with parents.
You heard it in that episode, and that phantom exhumes a whole bunch of demons. Katie has lived twenty years of those consequences, Sean eighteen, Lauren sixteen. Immensely different consequence horizons for each one of our children, despite the appearance of only two unplanned years between each child.
Their maturity does not prove that my choices carried no cost or our choices carried no cost. It means they became thoughtful, grounded people while living within those choices, possibly despite those choices. [00:08:00] And those are not the same claim. Dr. Russell Barkley put it best when he said, "You're the shepherd.
You don't design the sheep." This has nothing to do with your brand of parenting. Recognizing that this is a unique individual before you allows you to enjoy the show. But if you think that what you did in your house is going to shape the life of this individual, you are sadly mistaken.
Let them grow, let them prosper, but you don't get to design them. Profoundly freeing. But at twenty-six or twenty-nine, I understood the word family, but I could not have understood this family. I could not have imagined these three specific people, the emotions I would feel sitting with them, or what it would be like to reconsider the previous sixteen, eighteen, and twenty years from their side of the table My children were once people I could not imagine.
[00:09:00] Then they became people that I could not imagine living without. And now, one by one, they are leaving the daily life of our home That is not a parenting failure. That guilt is softened by Dr. Barkley's words. In many ways, it's the purpose of parenting. Because of the environment my wife and I built together, our children are becoming independent enough to leave us.
Katie, Sean, and eventually Lauren are doing what we raised them to do, soar But successful parenting contains a strange kind of loss. They leave physically, the relationship changes, the ordinary disappears, the conversations in the kitchen, the noise in the house, the unplanned moments that are never seen on a calendar.
I, and by I, I definitely mean we, are learning what it means to live a life without their daily presence while still loving them as fiercely as ever. they leave us with immense pride and immense hope for their futures. They also leave me with an [00:10:00] audit. Did I invest correctly when I made those career decisions at twenty-nine?
Did the income, achievement, security, and professional identity produce a return that justified the time, presence, and flexibility that was spent because there are no free returns on those expenditures?
Which sacrifices were necessary? Which ones did I merely assume were necessary because medicine rewarded my willingness to make them? The children themselves are not the investment, and they are not the return.
The investment was the finite capital of my life: time, attention, energy, and health. I allocated some of that capital to medicine and some to home. All of them are now sunk costs with associated opportunity costs disguised as regret. Now that the years have matured, I have come to examine the allocation honestly.
And the ghost I was trying to predict was never simply, [00:11:00] will I someday have children? A future child is not a generic line item. That child could be healthy and independent. That child could have significant medical, developmental, or emotional needs that reorganize an entire family life.
A partner could become ill. A parent could need care. I could have become the person who needs care. I still can. I'm not far from that, this creaking body. The future does not promise to arrive in the form of our career plan assumed
Somewhere between the family I could not imagine and the departure I could not feel, I made career decisions. We all do. But how do you predict a ghost? You cannot, not completely. And hey, quote, "Listen to the people farther down the road," end quote, is not an adequate answer. Young people entering medicine already receive plenty of, quote-unquote, "advice" from experienced physicians.
Too often, the advice is simply, "Don't go into medicine." We've been over [00:12:00] that with our son and Dr. Salter with his. My wife and I both received the same constructive advice, and that was over thirty years ago. The tune hasn't changed much, I gotta tell you. To keep moving, students and residents learn to protect themselves from that negativity.
They learn to discount the people ahead of them. Heck, in some ways, they have to. But once you train someone to ignore the sage who says, "Don't do this," why would that person suddenly listen when the same sage says, "You may regret what this does to your family"? They probably will not. So the assignment cannot depend on borrowed regret.
It has to help people perform their own valuation You may have heard the short videos that ask, "If I gave you ten million dollars today, would you take it?" You know, and the person being interviewed, most people say yes. Then comes the condition: "You can have the money, but you won't wake up tomorrow."
Suddenly, almost everyone says no. I thought about this a lot. I [00:13:00] thought about why do people make that choice, and who would say, "Yeah, sure, give it to me because I'll just give it to my family"? Strictly speaking, it doesn't calculate what a life is actually worth. It demonstrates something more useful for this conversation.
Money has value only when you retain the future in which you can use it. Ten million dollars cannot compensate you for eliminating every tomorrow. But a career decision is rarely that dramatic. No one offers you a salary in exchange for your entire future, at least not immediately. The transaction happens quietly and incrementally, one night, one weekend, one missed dinner, one postponed relationship, one recovery day, one year at a time, fifty-two ordinary Tuesdays, and suddenly you're in the passenger seat teaching your kid the rules of the road.
So the better question is not what is my future family worth? People are [00:14:00] not assets to be priced, and a person you have never met cannot be made emotionally real by a questionnaire. The better questions are, how much would you have paid to surrender the possibility of that future?
How much for two hundred evenings a year? How much for half your weekends? How much for the inability to change your schedule when a person you do not yet know becomes the most important person in your life? If you cannot name that price, do not give the option away for free. This is where financial language will help us.
We do not have to predict exactly which future will occur in order to protect against a devastating loss. We buy insurance for that stuff. We buy homeowners insurance hoping the house will not catch fire. We buy life insurance hoping we don't cross the X-axis. Brian? We maintain liquidity because we do not know when emergency arises.
Or more fun to consider, an opportunity that presents itself that needs that [00:15:00] liquidity. We diversify because we admit that our forecast may be wrong. And we value an option because having the right but not the obligation to make a future choice is in itself valuable.
your life deserves the same financial discipline. You do not need to know whether you will want children. You need to know whether today's decision permanently destroys that option. You do not need to predict illness, caregiving, or a new calling or a changing body. You need enough liquidity in money, time, health, skills, and contractual freedom to respond if one of them appears
The goal is not to feel the ghost perfectly. The goal is to stop selling the ghost's future at a price you have never calculated. It's not to make the twenty-six-year-old afraid of ambition or understand the ghost perfectly. The goal is to prevent ambition from signing away a future it has not bothered to envision.
Get comfortable with your ghost. [00:16:00] Price the trade-offs. Preserve the ability to change So now you have homework. I want you to think of three conversations across time, and this is gonna sound like one of those Christmas shows, I'm sure. But picture three people sitting at a table. The first is your younger self, the one who chose the career, the one who got you here.
The second is you today, and maybe that's a short duration interval. The third is your future self at whatever future that is. Maybe it's fifty-five, maybe it's forty-five, maybe it's sixty-five, or whenever that time horizon becomes real for you. None of these people gets absolute control. Your younger self does not get to impose a dream forever simply because they dreamed it first.
Your current self does not get to spend every resource because the consequences arrive later, and your future self does not get to condemn the past as though every outcome could have been known. The job at the table is to negotiate. So this week, complete two [00:17:00] parts. First, take a recognized burnout assessment, especially one for the wellbeing index.
I think it's a great one. John McMahon did a great job with it, and I think it's a fantastic way to evaluate things. It's at mywellbeingindex.org. and go into the demo section. The demo section will ask a couple of quick questions. there's some that you have to answer in order to get into it, but they're very generic questions, and you'll get your demo.
I'll have this stuff on the Direct Wellbeing Podcast website. You don't have to copy it down now, and certainly don't pull out a pen and paper if you're driving, please. But answer for your actual recent experience, not the position you think you're supposed to be. And then second, complete the career horizon stress test that I'm gonna put in the show notes, and it'll be on the website.
It's not a medical test. It does not diagnose burnout. It's a decision exercise. You'll walk through several plausible futures: the prestigious job with a relentless call, the lower-paying job with control of your time, a [00:18:00] future with children, a future without children, a future in which a parent needs you, a future in which your health changes, maybe a future in which you simply stop loving the work you once chose.
For each one, you'll ask four questions: What does this choice give me? What does it take from me? How reversible is it? And what will it cost me to change my mind?
I had to leave, my first job, great job in Kentucky, Maysville, Kentucky. great little city in Kentucky down the Ohio River. Wonderful people. I was in the job for 366 days. It cost me $40,000 in tail coverage to leave. and at that point, That was about 25, 30% of my salary. and it was a larger percentage of the salary I was walking into.
You also complete a reverse auction in this homework assignment. Instead of asking how much a job pays, you'll ask how much someone would have to pay you to surrender specific pieces of a possible future. [00:19:00] So this is not about putting a price on children or relationships or health. It's about exposing the absurdity of giving away future choices merely because no one listed them on the compensation sheet When you evaluate a job, don't stop at compensation.
Calculate what I wanna call the shadow price, the things the job consumes that never appear on a W-2. How many nights? How many weekends? That stuff's kind of easy. How much control over your calendar? not as easy to predict. How often will work follow you home? Really hard to predict. How much recovery time will the schedule require?
what relationships will absorb the unpredictability? What parts of your identity must shrink to make the job fit? Examine financial freedom, personal freedom, not just income. If the higher salary immediately becomes a larger house, private school tuition, expensive cars, or a lifestyle that requires the income to continue, that salary may not have purchased freedom.
It may have purchased golden [00:20:00] handcuffs. Then ask yourself some real questions in the mirror. How much of this compensation could I save to create options? How long until I could reduce my hours? Think of the conversation with Jonathan Moss. What is the minimum FTE that would be sufficient to sustain a desired lifestyle based on my initial income and my initial FTE status?
What fixed expenses do I have? Which ones do I want? Or which ones do I need that would make leaving a job difficult?
And the career ROI question: Does this job pay me enough for its burden or merely enough to persuade me to tolerate it? Decisions aren't forever though. Decisions aren't forever, but the accumulation is real One missed dinner is not a ruined family. One hard day or hard year is not a ruined career.
A demanding job can be purposeful, temporary, and worth doing. But repeated decisions accumulate. That's why your homework ends with three [00:21:00] commitments. One boundary you'll protect, one boundary you will protect now, one option you will preserve for later, and one person who is allowed to tell you when your career is changing you in ways you can no longer see.
Your boundary might be one weekend a month or a vacation you actually take, one that might be actually more than one week long, or a hard ceiling on a call schedule. Your option may be building savings, maintaining a skill outside your current role, avoiding lifestyle inflation, or negotiating a contract with a real exit path.
Your truth teller may be a spouse, a sibling, a friend, a colleague, or a therapist. Pick someone who is not impressed by your title and is not financially dependent on your denial. That's why you can't pick your kids. They're clearly not impressed by your title, but they are financially dependent on you Hey, look, ambition can build a remarkable life.
You deserve to make decisions [00:22:00] with more than today's stamina, today's priorities, and today's salary in mind. Imagine the future. Price the trade-offs.
Preserve the ability to change. Then ask the question that sits underneath this entire podcast: What are we not talking about that we should be? This week, maybe the answer is this: We are not talking honestly enough about the person who will eventually have to live with the choices we are making today.
So complete your homework, sit with it, share it with somebody whose life is affected by your career, And choose one change you can make tomorrow Until next time, take care of your current self, honor the younger version of yourself that worked their tail off to get you here, and take care of the person you're becoming