Quitting Medicine To Become A Hedge Fund Trader: An Interview With Phillip Guerra of Sizemore Capital Management

February 4th, 2023
32

Making the jump from Wall Street to medicine is relatively uncommon.

Leaving medicine to work on Wall Street is even rarer. Those who do typically quit medicine during residency or shortly thereafter.

Michael Burry, the former Stanford neurology resident turned hedge fund manager who predicted the 2008 financial crisis and was featured in the book and movie The Big Short, comes to mind.

Making either career switch in your 40s is virtually unheard of.

So when Phillip Guerra, DO, reached out to me by e-mail, I wanted to talk more and get him on the blog.

Phillip Guerra, DO, cardiac anesthesiologist turned hedge fund portfolio manager

Dr. Guerra was a cardiac anesthesiologist until February 2019, when he officially quit medicine to devote full attention to his work as Head of Quantitative Strategies and Portfolio Manager of the ETF Flow and Futures Flow portfolios at Sizemore Capital Management.

In this Q&A, I ask Dr. Guerra about the current healthcare environment for physicians, FIRE, and how AI will change medicine. I also ask him how he got his current hedge fund job and to give advice to physicians who want to make the switch into finance.

WSP: Tell us about your background and start in medicine. Did you always want to be a doctor growing up? How did you decide on anesthesia as a specialty?

PG: I do come from a family of physicians and nurses. Dad was a neurosurgeon, mom an RN, grandfather an FP, sister an NP, etc. Aunts and uncles and cousins and in-laws too. Dad had operated on my 6th-grade math teacher, and she was so grateful throughout the school year – always mentioning my dad in class. In the end, I saw how much of a difference he had made in her life, and so by 6th grade, I just knew I was going to go into medicine.

Regarding my own specialty choosing cardiothoracic anesthesiology, well, Dad had an MI in my 3rd year of med school, and believe it or not, he was the first code I ever ran which occurred in the middle of a polo field of all things. I wasn’t able to save him, but because dad had a CABG at 45years old and died young at age 58, I realized that I could help other families stay a little bit longer together than what I had with my dad by choosing cardiac anesthesia.

By the way, I do feel like I could’ve saved dad with what I know now 11 years out of residency, but only if I had all the equipment and drugs immediately available. But this fact provides some sense of closure for me.

WSP: Is there something missing or wrong with medicine? Do you have any concerns about the future of medicine in the United States that may have prompted you to leave the field?

PG: At its core, medicine remains a noble profession and certainly still worthy of pursuit if you enjoy the biological sciences and want to directly care for people who are hurting and who are mothers, daughters, sons themselves – just like in your own family.

But outside of that core essence, there are several distractions, perversions, and conflicts of interest. Distractions include paperwork, EMR, meetings, profitability, and other non-clinical decision-making requirements – read: hours of your limited time.

These distractions make it difficult to care for the patient and further remove the physician away from the essence of clinical medicine which could be disappointing for some and contribute to physician burnout.

Perversions include single-manufacturer, generic drug makers who are acquired by hedge funds who then proceed to raise prices 1000%. Conflicts of interest include kickbacks and issues with insurance and Medicare fraud.

As a result, we see issues that include runaway costs, declining value per health care dollar spent, and declining provider reimbursements. My guess is that the cost pressures that hospitals and physicians are feeling will only continue to worsen as the ratio between the working-age population and Medicare/Medicaid beneficiaries continues to decrease. One would think countries could rely on our younger folk to help pick up the consumption slack and re-charge the tax revenue base, but these folks are unfortunately economically sapped from student debt burden (and guaranteed by the government no less) and, alas, health care costs too.

To be sure, some of these issues like insurance fraud involve only the 0.1% minority of physicians, and in addition, the working age demographic issue is not limited to the US but is also present in many other countries. But they are all important issues we face.

WSP: Are you maintaining your certifications and medical license? Because anesthesia is a shift-work job where doctors can work part-time, is returning to medicine a backup option in the future?

PG: I think of myself first as a physician, and I didn’t go through all those years of training just to stop practicing at age 42. I would miss the hospital environment, my colleagues; the OR environment is both fun and serious/professional at the same time.

So, yes, while my family will be moving to Spain where my wife is from and is wanting to go back home, we’ll also be back in the US during the summer months after the kids finish their school year in Spain (where school/university is both inexpensive and high-quality). I plan to work part-time during the time we are in the US.

While in Spain however, I’ll keep developing, managing, and adding algorithms to assimilate into our fund. If I can get my license validated in Spain, I might work a few shifts out of curiosity and comparison, but it is not a priority. To be sure, if the kids are unable to integrate into the culture or the school system, then we would move back to the US, and I would consider returning to practice anesthesia full-time or part-time while continuing to manage the fund.

WSP: Do you feel that you are financially independent and retiring early from medicine (FIRE), and that hedge fund trading is your “encore” career?

PG: Yes, I have heard about this phenomenon called “FIRE”, and I think it could worsen one’s financial health because it tends to gloss over important assumptions such as “what if the economic regime changes?”.

Rather than “FIRE”, the reasoning for me is a little more statistical in nature: if the average lifespan is very roughly 80 yrs old, and my dad had a bypass at 45, died at 58, and I’m 42, then I could be potentially past the 50% point of my lifespan depending on gene penetrance, homozygosity, stochastic luck, etc.

Therefore, managing/developing code for a fund isn’t an encore; it’s out of necessity and the pure enjoyment of financial data science.

It’s out of necessity because:

  1. I’d like more time with family/kids given my potentially shorter life span and running a fund makes this a little more possible (but not much)
  2. Self-preservation of my own assets given global government/corporate debt-to-GDP levels and declining working-age to population ratios.
  3. There is a pension crisis happening right now – again mothers, daughters, sons – who’ve followed all the rules, worked 30 yrs of their irreplaceable lives – and are getting shafted in the end (with underfunded pension liabilities again guaranteed by gov’t/corporations)

I know we can help. Even if our help is just a drop in the bucket, that drop could count as real money for someone who has already put their time in at their jobs – and really should be allowed to spend a retirement with more family time – which sounds surprisingly like a physician’s goals too in ultimately being able to provide his/her patients with more family time together.

Evidence of pure enjoyment of financial data science can be seen in my talk on auto-trading at R Finance in 2018 – as I haven’t done any public speaking anywhere, at all, in over 10 years (it’s the worst of my soft skills). But I felt strongly enough to do so, and I did receive good feedback afterward.

WSP: What’s your background with finance and quantitative modeling? Did you take formal coursework, or are you self-taught?

PG: Mostly self-taught because the only formal coding class I’ve ever had was at age 9. I did have some nerdy coding tendencies and while in anesthesia residency, I hand coded a free, weighted-analysis web app mostly as a joke with utility, Decisionking.com.

However, after college and prior to med school, I did all the coursework for a Masters in Public Health but dropped out at the end once I was accepted into medical school. The MPH degree is heavy in both statistics and epidemiology and also in (healthcare) finance if you choose that concentration as I did. It doesn’t seem like there would be much cross-over from MPH to quant finance and modeling, but MPH is essentially data science in disguise.

For example, in medicine we call a screening test’s ability to detect true positives as “sensitivity;” in machine learning, it’s called “recall.” What we call “positive predictive value,” quants say “precision.” But they are all the same thing. Even pathophysiology and global macro concepts retain a lot of similarities and interconnected, feedback loops.

WSP: In general terms, what is your trading strategy at your hedge fund?

PG: In 2015, we started out as a modified risk parity, single-strategy fund using ETFs, and gradually with lots of R&D, we have upgraded to an AI-assisted (supervised machine learning), risk-offset fund that trades the futures market and is platformed at TD Ameritrade and custodied at Interactive Brokers.

A common-sense thought experiment explains our reasoning further that not all strategies, active nor passive, work 100% of the time in perpetuity: If you invested in a passive ETF that tracked a hypothetical Roman Stock Market that started in year 1 AD, how much would the index be worth today? [WSP: Probably enough to buy the Roman Empire! But that’s why you buy international stocks.]

We chose the futures markets on the advice of some of our family office clients due to futures’ tax benefits for high-income earners, efficiency, and liquidity. Our goal as a risk-offset fund is “U20M” – Uncorrelated, 20% CAGRs, with minimal drawdowns. Even as the market is down -1.5% today (January 22, 2023), our fund is up 1%. [WSP: The usual compliance small print applies here: I did not audit and cannot verify his performance claims.]

Basically, I’m not going to go through 2008 again, and I don’t believe the pundits who claim “it can’t happen again” – and then offer recent financial policy changes, new Tier 1 ratios / Basel III, and bank rules as evidence that things are now safe and that economic assumptions will always remain the same.

WSP: How did you find your current position at Sizemore Capital?

PG: Before I learned how to automate trading – data download, processing, trading, compliance, etc, I called up the firm asking if they could simply trade my computer-based strategies for me because I couldn’t take time out of the OR to trade the strategies myself – most especially in cardiac anesthesia. However, the firm recognized the direction of the way things were headed in finance and asset management, and the idea was floated for me to pass the securities licensing exams to become an advisor and help manage assets. I remember the day I received my test scores – the Fed had just embarked on their very first interest rate hike of this most recent cycle after years of zero-bound rates. Since I knew moving to Spain was on the horizon, I didn’t really have too much of a choice.

WSP: As someone who uses artificial intelligence for trading, how do you think AI will transform medicine in the future (if at all)?

PG: It’s a game changer. It will increase productivity per physician in cases like radiology and ease/filter their image reading burden. It’ll lower hospital costs and improve outcomes as models are developed that predict and alert physicians to impending readmission probabilities, surgical site infections, sepsis-risk, OR death, etc. given certain patient state variables i.e. obtain real-time, local-population based, risk stratification. Compliant data has to be opened up and shared, however; APIs need to be developed and remain non-proprietary. CMS is already on top of some of this which is great, but more can be done.

WSP: What advice do you have for readers who might be interested in exploring a switch from medicine into finance?

PG: Remember why you chose medicine in the first place, and then really think again. Consider using a weighted analysis technique i.e. Decisionking.com. You will almost always have a job and can make a living in medicine, but the same may not be true for finance. Finally, be prepared for your work in medicine to actually be several steps removed from clinical diagnosis and treatment.

WSP: How can readers reach out to you if they have any additional questions about you or your firm?

PG: phillip(at)sizemorecapital(dot)com and thank you.

[WSP: Thank you so much, Dr. Guerra, for reaching out to me and allowing me to share your story with my readers. While I’m still going to stick with my three-fund index portfolio for my personal investments and am not going to be investing in his hedge fund, I hope you found Dr. Guerra life story and pathway from medicine to finance as fascinating as I did.]

What do you think? Do you have any questions for Dr. Guerra?

32 COMMENTS

  1. Best wishes on this new journey, Dr. Guerra. I recall your guest post on the White Coat Investor and was interested to see you’ve decided to pursue this alternative career path nearly full-time. Your family history certainly makes the choice to spend more time with family an easy one.

    I’ll be moving on from my anesthesia job later this year, and we plan to spend long stretches of time exploring the world, and Spain is high on our list. I’ll be running a blog rather than a hedge fund, but look forward to the life of a digital nomad.

    Cheers!
    -PoF

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  2. Engrossing story, thanks for the fascinating interview WSJ and Dr. Guerra!

    I applaud your desire to get more time with family, although I’m uncertain if a hedge fund job will accomplish that goal (Spain is a brilliant choice to test it out).

    I was just emailing a friend with a senior position at a hedge fund. He enjoys the income but expressed it is a ton of work and travel. I sincerely hope you’ve pulled off the most brilliant exit strategy from medicine to date.

    Please do keep us posted, and thanks for sharing your story.

    Fondly

    CD

  3. Really fascinating. While I’ve never thought about going the hedge-fund route, I’ve certainly entertained the idea of financial advising/coaching. I even registered for the series 65 (And eventually unregistered after giving it more thought).

    This is a fascinating story, and I like that you are continuing to practice medicine at least part-time to keep your skills up. Is there any hindrance to getting your echo numbers? Will that prevent you from practicing cardiac anesthesia in the future, if you decided to go back?

    TPP

  4. PoF: Reach out to me if you ever find yourself around Salamanca; we live in a nearby city. Best wishes to you too.
    CD: I’m not even a week out and already traveling to a manager’s conference tomorrow; I agree with your friend. While I prefer to remain low-key and am unsure if I’ll be sharing my story further, I can say that a hedge fund job is not really an exit strategy. It is just an optional vehicle with which the firm is able to offer our crisis risk-offset algo to public funds and family offices. For example, I would simply be classified as an independent, systematic futures trader if I kept to myself and didn’t manage client assets.
    TPP: I listened to your story on anesthesiasuccess.com. I think it is excellent that you are helping teach residents the business/financial side of things since those languages are key in private practice. Thank you for guiding the next generation of providers. I agree that money should never be taboo – especially if all citizens have to be portfolio managers of their own DC plans. I found the anecdote about disability insurance particularly fascinating. And you’re right about TEE numbers; there’s a risk that I will not be able to return to hearts – and perhaps even medicine – when we come back stateside.

    I would add: I believe in passive indexing also. In fact, our futures strategy is actually a combination of both passive and active strategies. That’s how we were able to navigate 2018’s 4th qtr which included the worst December since the Great Depression. Just like in anesthesia, there are multiple ways of approaching the same problem. However, I’ve found that it is usually a combination of best ways that leads to increased efficiency/outcomes in both anesthesia and portfolio optimization/management. https://drive.google.com/file/d/1qxfLd_TVzuPdXiIMV9W0zj8TB7TvWqEv/view?usp=sharing

    Be wary of anesthesia and financial dogma, and verify assumptions often because conditional probability doesn’t care about “expert” opinion.

  5. This was a great article, especially for those who have been on both sides of Wall Street and medicine. I build AI healthcare products like the ones Phillip mentioned and worked on Wall Street earlier. As AI rapidly changes and grows we are going to see rapid changes in medicine, e.g. transformers in NLP or radiology assistance. Maybe one day AI will be smart enough to learn from every single patient that enters through the hospital doors.

    Side note; funnily enough, the image used in the title doesn’t have much to do with AI coding. Its showing a front-end UI coder searching for a database id variable.

  6. It’s really a relatively uncommon journey. I think that must be a very interesting life trip. Although I’m a medical student now, I also will make some changes if my job doesn’t make me happy or feeling interesting.
    Thanks for the different story sharing.

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  24. A MUST READ FOR ANYONE WHO HAS EVER FALLEN FOR CRYPTO SCAM BEFORE!!!

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