Letizia Alto, MD on why to become a semi-retired MD [PODCAST]

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“Something had to give, and it would either be clinical medicine, or my business. I finally had to admit I was no longer fulfilled to the same level doing hospitalist work.

So I made the decision to leave my clinical job.

It was so terrifying that I put off making a decision for months. I thought about what it would mean for my blog readers that I wouldn’t be in the trenches with them anymore. I thought about how it would affect my family if our real estate portfolio ever fell apart and I needed to be able to make money.

I had a lot of fears.

But I’d made the decision, long ago, that I would never make decisions from fear alone. So I submitted my resignation. And I threw out my Danskos.”

Letizia Alto is a hospitalist and who blogs at Semi-Retired MD.

She shares her story and discusses her KevinMD article, “After 4,380 days, a pair of Danskos — and a calling — fall apart.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Letty Alto. She is a family physician, and she is the co-founder of Semi-Retired MD. She wrote the KevinMD article “After 4,380 days, a pair of Danskos, and a calling, fall apart.” Letty, welcome to the show.

Letizia Alto: Thank you, Kevin. I’m so excited to be here.

Kevin Pho: We’ll get into your article in a little bit, but first off, I’m super interested in hearing your story and your journey to where you are today.

Letizia Alto: Yeah. I’m family medicine trained, like you mentioned, and I actually did a hospitalist fellowship. My intention going to med school was to work abroad, and then I thought, “Well, maybe I’ll work abroad in the hospital.” And so I did my fellowship, and then I ended up actually staying in the U.S., staying in the Seattle area and working. But then I kind of realized, well, I still had this kind of itch for a different life, just something unusual, something different. And so I did a bunch of things. I went to Hawaii and worked there for a year, was involved in a couple of startups, and at one point was working half time as a hospitalist in Seattle and actually doing a startup in Atlanta, so flying back and forth.

And then eventually, my husband, yeah, we moved to Hawaii. At that point, we were teaching so many of our friends to do real estate, which we had started in 2015. We had had this kind of epiphany that we wanted to create another source of income besides our medical careers, because we were both working more than full time, doing a startup on the side, just running all the time. We had to schedule days together a month, a month and a half out. We realized, “You know, we’ve got to make another source of income so we can work in medicine how we want to.”

So in 2015, we were building a real estate portfolio, and we were helping all of our physician friends do that too. And so in 2018, we started a blog on real estate, and that’s kind of how Semi-Retired MD grew, and how eventually I ended up writing this article, when I really left my half-time job as a hospitalist, something I had been doing, either half time or full time, for years, and about that transition, which was a very, very emotional one for me.

Kevin Pho: Now, you mentioned real estate, you mentioned startups. Now, did you have that type of background during your medical school training?

Letizia Alto: Absolutely not. No, I had none. I was raised by a family doc as well, who worked abroad, so I lived internationally, in Papua New Guinea, things like that. And so I was always trained that you become a doctor and you give your whole life to being a doctor, and there’s really not anything else. That’s kind of how I was raised. So I had no idea that I would ever be a startup founder. This is the third startup I’ve been involved in. I never thought I’d be a business owner. It’s remarkable.

And I think that’s one of the messages I really wanted to convey to your listeners: You don’t know what you’re capable of until you try it, you know? And you don’t even consider it as an option at all. But physicians are so incredible as thinkers, and we have so much talent. We can do so much more than we think we can, and it’s just a matter of opening your mind to what’s possible for you.

Kevin Pho: So tell me a story of how exactly you first got interested in interests outside of medicine, whether it’s startups or real estate.

Letizia Alto: Actually, I would say I loved real estate always. I’ve always been really interested in property and land, and I thought about the idea fleetingly of owning a rental before. But when I really met Kenji, my husband, he was involved in a startup at that point when I met him. And so I naturally kind of ended up helping out with the startup, and I use the words “helping out” very specifically, because it really was helping out in my mind. And so I never took a whole lot of responsibility, and I never really showed up 100 percent for it, because I was helping out.

But that startup, actually, he ended up leaving, and we ended up setting up a competitive startup with one of his friends who had been involved in the other one too. So basically, we left one and within three months started a competitor startup. And at that point, I actually took a role and took some responsibility, and I was the CMO of that one.

Kevin Pho: All right, so let’s transition now into your KevinMD article, and it’s titled “After 4,380 days, a pair of Danskos, and a calling, fall apart.” Now, for those who didn’t read that article, can you just walk my audience through it and share the story of why you decided to write it?

Letizia Alto: It was in a phase where I was really struggling about leaving my half-time job. For me, it wasn’t leaving medicine fully. I knew I could be a moonlighter, and I had done that at different stages in different hospitals while also maintaining a job. But I’d really always had a job as a physician, right? And it was my security blanket. I hadn’t needed to work as a physician for years at that point. I had enough real estate income that I didn’t need it, but it really was this emotional identity, and also just my security blanket is the way to put it. And I was really afraid of stepping out for even a month or two and feeling like I would lose my skills, that I would kind of become an outsider in the system. And there are parts of medicine I love. I love taking care of patients, and so I was struggling with it.

And what I was finding was, I’m CEO of our Semi-Retired MD, my husband is CEO of our real estate company, but I’m literally running a team. Right now it’s 14, but at that point it was probably six or eight of us. And I’m trying to run a team, trying to work a week a month in the hospital. I’ve got two little kids, a two-year-old and a five-year-old, and then I’m also involved in our real estate portfolio too. And I would literally go to work at 7 a.m., work until five, come home, and cook dinner. I had an au pair, we have an au pair too, so I was cooking dinner for six people. And then I would get to my email for the startup that had six team members, and it was just crazy.

I realized something had to give. I didn’t want to stretch myself this thin. And so I had to have some deep thoughts about what was most fulfilling to me, and it ultimately came down to delivering for my students, my physicians, and helping them get financial freedom. That was extremely fulfilling, because when you see them have success, it just filled me in ways that I can’t explain, that I wasn’t getting from showing up as a hospitalist for a week a month. And so I made that decision. I was like, “I have to leave.” And I dragged it out for like a year, because I just couldn’t do it, and I had all kinds of excuses why I couldn’t, but eventually I just had to do it, and I did it.

And so, probably, I think it was the last month, my last week of shifts as an employed physician, that my Danskos fell apart. And these are things you buy in residency, right? Not residency, actually. I think, yeah, I bought mine in residency, because I just would not do it in med school. I was like, “I am not going to do it.” But I finally bought them in residency, and they had been through so much: family medicine training, OB experiences that I had let go. These are things that I let go little by little. I let go of my OB, I let go of my training, my family medicine residency. And then finally I was at the stage where I said, “OK, I’ve got to let go of my half-time job too.”

Kevin Pho: Sure. So I hear the words “financial freedom” often on my physician Facebook finance groups. What does that mean to you, and why is financial freedom important for physicians?

Letizia Alto: Yeah, for me, it was the point that I didn’t feel like I needed to work at all, besides just having my real estate portfolio. Originally, I thought it was going to be, “Oh, I need to replace both my husband’s and my hospitalist salaries, and that’s going to be the point.” But actually, I realized we had about 200,000 in cash flow coming in every year, and that’s tax-free because it’s real estate cash flow. It’s like, what do I need more than this for? I don’t. I can live anywhere, I can do anything. So for me, it was a lot smaller number than I originally thought. But when I achieved it, I canceled my disability insurance and canceled my life insurance, because I was like, “You know, my kids are going to inherit this now, and this sets them up for life.” So that’s what it meant for me.

And why I think it’s so important for physicians is, I mean, physician burnout and the lack of autonomy and the way that we’ve really had a lot of how we practice dictated. I see all the suffering. We’ve actually lost two of the physicians in our hospital to suicide, two hospitalists, in the last two years. And I see it when I walk in the team room, people just totally burned out, people with sick family members, and they can’t be there. And I’ve seen people’s bodies just falling apart from doing this job and the stress for all these years.

And so my mission is really to help physicians achieve financial freedom so we can change the culture of medicine, because I think ultimately we are the ones who know how the system should be run. We know how it can perform the best for the patients that we can care for. But I think physicians feel stuck, you know, because they only have that one source of income. They have to trade the time for money. But if we were all free from that, we could literally stand up and say, “You know, I don’t like how you’re running this program. We’re going to all walk together.” And we have that freedom to do that. And so I think that’s my contribution to changing medicine: to help physicians get that financial freedom and to step up and take control.

Kevin Pho: Well, I think what you said has tremendous resonance. Even before the pandemic, more than 50 percent of physicians, as you said, experience symptoms of burnout, and now that number is even going higher during and after the pandemic. Financial freedom certainly is one tool where, like you said, physicians can walk, and that’s one of the most powerful negotiating tools. Now, for those physicians who may be listening to this and perhaps want to start becoming a little bit more financially free, where can they start?

Letizia Alto: So I think the first place to start is actually believing that it’s possible for you. And the reason I say that is just because I see a lot of people, and the dream seems too big. And so, I don’t know, if you don’t know Dr. Sunny Smith, she’s a phenomenal, she’s a family doc and a life coach, and one thing she says is, “We fail before we even start because we don’t put ourselves in the arena.” And I think that’s what a lot of us do. We just don’t even believe that we could have a life that we could completely dictate, that it could be whatever we want it to be. So I would say start with the mindset, and start with working on believing that you can achieve whatever you want to achieve, and that life doesn’t have to look like working, you know, full time until you’re 65. It truly does not.

And then once you do that, the next thing is to really take control and to get that financial education. One book that really changed my life was Rich Dad Poor Dad by Robert Kiyosaki, and just reading it and saying, “You know, a lot of us just hand over our money to financial advisors or to other people and just expect other people to take care of it for us.” And we don’t get that financial education, and so we never gain that confidence of knowing we can get through anything, like any financial catastrophe that comes my way, I can handle now, because even if I lost it all tomorrow, I know I could make it back, because I know how to make money. And so I think that getting that financial education, and maybe real estate’s not your thing, but maybe you’re into making sure that you manage your money in your stock market or whatever it is, just learning how to make money and believing you can do it, I think, are the two most powerful tools for any doc.

Kevin Pho: Now, on average, from the courses that you run, let’s say an average physician wants to supplement some of his or her income through real estate. On average, how successful are they in doing that? They can make so much income that they could actually cut back on their clinical hours?

Letizia Alto: It totally depends on the doc. I can’t give you averages, because unfortunately, we haven’t really tracked it. But I can tell you that some docs just take action, believe they can do it, and within a year they’re making 100,000 in income from their real estate, and they’re at the stage where maybe they or maybe their partner can claim real estate professional, so they’re saving six figures in taxes too. But it takes sacrifice, and it takes focus, and it takes work, right?

And so when Kenji and I first started out, we had 200,000 in savings, but we were like, “We’re doing this.” We had Kenji cut back to half time so that he could qualify as a real estate professional, and we just focused so much of our energy on finding properties. We decided not to get a primary residence. We were searching for a house at the time, and we made the decision. We said, “We’re not going to own a home,” and we still don’t own a house. We make all our money work for us, you know? We made a lot of cuts in our lifestyle to support that, made a lot of choices that really allowed us to get that growth going. And once it is out a couple of years, it turns into a snowball. And I see my physician students doing it, but it really is dependent on the person and how they believe if they can do it, and then how much focus and effort and energy they’re willing to put into it.

Kevin Pho: We’re talking to Letty Alto. She is a family physician, and she wrote the KevinMD article “After 4,380 days, a pair of Danskos, and a calling, fall apart.” She is a co-founder of Semi-Retired MD. Letty, for those physicians who perhaps have some reservations about doctors cutting back, they say maybe those types of doctors aren’t real physicians. Who’s going to take care of the patients if all doctors cut back to half time? What’s your response to that type of reaction?

Letizia Alto: Yeah, I totally understand that. I think that was part of what held me back for a long time too, feeling the sense that, you know, my medical education was always supplemented, right, by the government, by taxpayers, right? And feeling that sort of guilt that potentially I wasn’t contributing in the way that I should be contributing.

I think ultimately what you want is happy doctors, you know, because those are the doctors that are going to take care of their patients, as the people who are going to really deliver the quality of health care. And I don’t think, you know, somebody staying in the system who’s unhappy, which, you know, a lot of people out there are extremely, extremely unhappy. I mean, you see the kind of vitriol that is just every day, to nurses, to everybody around them, and actually to the patients. I think that actually injures the health care system.

And I don’t pretend to have the solution, but I almost wonder if medicine itself needs to change so that everybody’s working half time, and that’s just what medicine is. I mean, the complexity of what we take care of now versus 10, 20, 30 years ago. I almost wonder if this type of workload is untenable for the mass population without having burnout as a natural side effect, and perhaps we need to retool medicine and what a full-time position is for a doc, and get more people interested in being docs, to make sure that we’re all showing up as our best selves. Because I know when I was burned out, I wasn’t the best doctor I could be, right? It was like everyone’s always making demands on me, this really negative kind of victimhood approach to things, and just one more page was like a stab in the heart, you know, to give it a little bit of drama. But yeah, I don’t know what the solution is, but I don’t think the road we’re going on is good.

Kevin Pho: Now, for those physicians who are interested in becoming a little bit financially free from medicine, what are some resources that you recommend?

Letizia Alto: I definitely recommend reading Rich Dad Poor Dad by Robert Kiyosaki. It really changes your mindset from being just an employee to having multiple sources of ways you’re making money, so being an investor, being a business owner, potentially being an employee. Self-employed is where you run a business, but you’re actually still an operator within it.

And if you’re interested in real estate, Gary Keller has an excellent book called The Real Estate Millionaire, which is phenomenal, and it’s all stories about people who have become real estate millionaires through real estate. You can see how many different paths there are. Some people don’t want to use leverage, and they pursued this path. Other people were really aggressive about developing a niche, and they pursued this path. And it gives you an example of how this is possible for the average person.

And again, I would spend a lot of time on mindset work. There are a lot of great physician life coaches. I mentioned Sunny Smith, but there are phenomenal life coaches in the physician space who can help you start enjoying your job more today, your physician job, which I think is absolutely key, like taking back that control today. But then also realizing you can do whatever you want to do, and whatever your passion is, that you can go and get it.

Kevin Pho: And my final question, what’s your take-home message that you want to leave with the KevinMD audience?

Letizia Alto: I think, again, it’s just reiterating that everyone is capable of doing whatever they want to do. I think we’re raised to believe there’s what’s reasonable and what’s the path you’re supposed to be on. And if you’re unhappy on that path, the fact is you have a choice to change it. And I think a lot of us forget every decision we make is a choice. We feel like we’re forced into something, like we’re forced into staying at a job, but the fact is, it’s not true. It’s a choice to stay in that job. And I think when you flip that around and realize, “Hey, it’s my decision to stay at this job,” then you take back some power, you take back some control, and you take back some ownership. And all of a sudden, “OK, if I’m going to stay at this job and that’s my choice, what am I going to do to make it better?” And it empowers you to just approach every day differently.

Kevin Pho: And how can people reach you?

Letizia Alto: You can find me on semiretiredmd.com, or we have Facebook groups, Semi-Retired Physicians and Semi-Retired Professionals.

Kevin Pho: Wonderful. Thank you so much for sharing your time and insight, and thanks again for being on the show.

Letizia Alto: Thank you, Kevin.

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