From the OR to the Brokerage Office: What I Saw Behind the Curtain

Before starting my own fiduciary advisory firm working with physicians, I worked at a major brokerage where we worked with tons of physicians.

One of my early jobs in that firm was to go back through clients accounts anytime there was a lawsuit and figure out if they owned any shares for their claims forms. The system of tracking trades wasn't that great and there was no way to really search for it, except by going through each transaction of each account over the last 20 years. In doing this, I learned all of our clients financial decisions, intimately.

Who were the most confident investors of all our clients?

Almost always the anesthesiologists.

And to a degree this always made sense to me. Anestheologists in their day jobs are used to managing high-stakes situations. They’re calm, quick, and often feel like the smartest person in the room. And in their area of knowledge it is clear to me that they are super smart.

But here’s what shocked me:

The worst investment decisions I saw — multi-million-dollar mistakes — didn’t come from burnt out emergency medicine docs or people in other highly paid specialties

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They almost always came from anesthesiologists in their 50s.

It is not because they weren't capable. But because the same mindset that makes you successful in medicine — independence, confidence, self-reliance — can backfire in finance.

Which brings me to this:

Be the CEO — Not Just the Technician

Think about how a great hospital works. The anesthesiologist is a technical expert — they go deep in one field, just like a tax attorney or a cardiac surgeon or a financial advisor.

But the CEO of the hospital? They’re not the best at any one thing — they’re not the most capable surgeon, the best lawyer, or the best CPA. What they are is the best decision-maker. They know how to ask smart questions. They know how to build a great team. And most importantly?

They know when to lean on someone else's expertise and they understand the power of leveraging other people's knowledge bases.

A smart CEO doesn’t try to out-lawyer the General Counsel. They don’t pretend to know GAAP accounting better than the CFO. They don’t make HR decisions without listening to their HR leader.

They don’t lead with ego — they lead with leverage.

And that’s the difference between someone who works in a system and someone who runs one.

I think the same applies to your financial life.

You could probably be a great investor if you did it full-time. You’re smart enough. But you already have a full-time job — and it’s a critical one. You may have more free time than some other specialties, but not enough to become an expert in tax law, estate planning, risk management, retirement distributions, and portfolio design. Not at scale. Not across edge cases. Not while staying on top of surgical readiness.

And just like a CEO, the smartest move you can make isn’t trying to master another field.

It’s building a system that lets other experts work for you — so you can make better decisions, faster, with more confidence and fewer blind spots.

That’s how you lead. That’s how you retire well. That’s how you win.

This may seem counterintuitive but in any article I write about retirement plans, if it is an anesthesiologist plan I always have to start with mindset because the desire to be the "smartest person in the room" about everything is one of the primary ways in which I've personally observed anestheiologists shoot themselves in the foot financially more than any other medical specialty - despite having a lot more time than other specialties to learn about and focus on things outside of medicine.

Because sometimes a big ego can block us from acquiring more knowledge that ends up helping us. No one questions that anestheologists are super smart and incredibly important at what they do - but I've also observed in my 15+ year career working with physicians than anestheologists tend to be the most resistant to professional advice in all forms and at least from what I saw at our brokerage they had the most frequent financial blowups that almost bankrupted some of their 50s and early 60s, which was incredible because no other medical speciality had near bankruptices in their late 50s or early 60s, from what I observed.

Okay with that side let's switch to analyzing the East Carolina Anesthesia Associates PLLC 401(k) Plan.

What This Means for Your 401(k) with East Carolina Anesthesiology Associates (ECAA)

Now let’s talk about the ECAA 401(k) plan itself.

It appears to be a plan with some good features — it gives you access to solid investment options and an employer match, which is always free money you don’t want to leave on the table.

But here’s the catch:

• The annual fees appear to be around 0.50% — which can be a bit high for a plan where 3/4 of the assets are self directed. What this really turns is are the anestheologists in the group making their own investments decisions and paying 0.50% in fees for the benefit of having a plan, or are they individually electing to use the plan's investment advisor and choosing to pay them a 0.50% to select the investments for them. A 0.50% fee is reasonable in my view if it is an individually made opt in choice to use the plans investment advisor to make their investments for them, but if the physicians are forced to pay a 0.50% fee even if they are making their own investment choices and not using the advisor, that fee would not be ideal in my opinion. The reason why those kind of fees are not ideal, and even suscept the plan trustee to liability, is because if you force an employee to pay $5k or $7.5k a year in fees to someone they don't want to work with, that can create a tension. This is especially true as account balances gro because it is $5k a year at $1m and $10k a year at $2m and over a 30 year career someone might be forced to pay hundreds of thousands of dollars in fees to someone who they didn't personally choose to use. This tends to frustrate the physicians, and if it goes on long enough, exposes the plan sponsor to personal liability because an employee is being forced to pay someone more than they want to and more than they have to by industry standards. A far better way to set up these plans in my view, is to have administrative fixed costs that is charged a flat fee so it doesn't go up as much as assets in the plan go up, and if you allow one investment advisor on the plan to allow any investment advisor on the plan (i.e. people get to pick their own advisor and use them). Or don't allow advisors on the plan and let people pay any financial advisor they want to work with out of their own non-retirement assets. Most financial advisors cost $5k-$10k a year or sometimes even less, and most people can afford to pay their fees outside of their plan assets and in many states they may be able to get a partial state tax deduction on those fees.

• You have to wait a year to participate despite a 4 year vesting schedule on some employer contributions to our knowledge and what looks like low total contributions to this plan. To me something doesn't look right about this plan - unless there is another hidden employee retirement benefit like a cash balance plan or a defined benefit plan this looks like a retirement plan with lots more restrictions than I usually see for anestheology positions.

• Both employer and employee contributions tend to be smaller than they could be — many don’t max out the benefits.

• Because of these factors, a lot of people don’t fully utilize the plan’s potential.

  
  

How to Make This Work for You

If you’re early in your career, this plan can be a great foundation. But don’t stop here. Think bigger: max out your contributions, look for lower-fee investment options outside the plan, and get a second opinion on your overall strategy.

If you’re mid-career or within 10 years of retirement, it’s time to get serious. Those fees and missed opportunities add up, and with retirement around the corner, every decision counts. Don’t leave your future to chance or your own assumptions.

When you run up against a plan like this the key is to advocate for yourselves. Sometimes using a fiduciary advisor to help you can really help with the process because they've been through many plan negotiations on behalf of physicians and you can leverage their knowledge for your benefit.

Rememeber, it is your retirement. If you don't fight for it - no one else will. But to make it a fair fight, you have to be equipped with sufficient knowledge to advocate for yourself.

If I was an anestheiologist at ECAA, especially if I was a younger one, I would definitiely advocate to improve this plan.

The Mindset That Wins: Be Open, Know Your Limits, Use Your Network

Just like in anesthesia, where you balance risk and precision every day, investing needs a mindset that’s:

• Open to new ideas, even when they challenge your instincts.

• Aware of your knowledge limits — nobody is an expert at everything.

• Willing to leverage outside experts and trusted networks to improve your outcomes.

If you can bring that same humility and precision to your financial life, you’ll avoid costly mistakes and build the secure retirement you deserve.

Final Thought

Your 401(k) plan at East Carolina Anesthesiology Associates is a 401(k) plan— but it has elements to it that make me suspect that it might not be a good plan or a plan that should be improved over time.

If you want to avoid the pitfalls that have caught so many anesthesiologists before you, it’s worth getting a financial advocate who understands your world, your mindset, and your goals.

Because at the end of the day, being the smartest person in the room shouldn’t mean you have to go it alone.

If you are interested in learning more about Daniel Harris or D.R. Harris & Co. you can do so here.

Or if you'd like to schedule a 15 minute get to know each other call you can do so here.

Before scheduling a call you should know that our firm more commonly works with people closer to retirement and those who are comfortable paying around industry average fees (which typically average about $5k a year) and our get to know you calls are meant for people who fit that profile.