by Andrew Wilner, MD, FACP, FAAN
 
Have you heard about locum tenens? Locums physicians act as "placeholders" in clinics and hospitals that need temporary help. Doctors may work locum tenens in addition to a regular job (moonlighting) or move from one assignment to another, traveling to different destinations and experiencing a variety of practice environments. If you've considered joining the approximately 50,000 locum tenens physicians in the US, here are five tips to get you started.
 
1. Why?
Why work locum tenens? This decision depends on your stage of career. For example, newly graduated residents may travel to a part of the country they have never seen or experiment with different types of practices. Mid-career docs often need extra income or want to test the waters for a practice change. Pre-retirement physicians may wish to cut back a little, but their full-time job won't permit a part-time option. As a locum tenens physician, how often you work is up to you.

2. Find a good staffing agent.  
A staffing agent can offer invaluable assistance, particularly if this is your first foray into the world of locum tenens. When you chat with an agent, ask questions and communicate your needs. Agents focus on certain medical specialties, and it's their job to know the market. Agents work on commission, so there's no cost to you.
 
Select a staffing agency that belongs to the National Association of Locum Tenens Organization (NALTO), which sets standards and sound business practices for locum tenens companies. Two NALTO members that I have contracted with are CompHealth and Staffcare. See the NALTO website for an updated list of NALTO staffing agencies.
 
3. Where and when?
Decide where you want to travel and your timeframe. Once your agent knows where and when you wish to work, he or she will search for an appropriate opportunity that fits your schedule and offers the best compensation.

About the author: Andrew Wilner, MD, FACP, FAAN is the author of The Locum Life: A Physician's Guide to Locum Tenens Dr. Wilner can be reached at www.andrewwilner.com

By Maiysha Clairborne MD

It was 2004 straight out of residency that I started my first business.  I didn’t know a thing about business, much less running a practice. However, I jumped in headfirst without a life vest.  The journey that began in August of 2004  became one the scariest and most exhilarating journeys of my career.  Now, almost 15 years later, I share the knowledge, expertise, and learnings that I’ve acquired about stepping into physician entrepreneurship and what it takes to start, grow, and successfully maintain a business without pulling your hair out with other doctors wanting to do the same. I speak with women physicians and other moms in medicine daily who are thinking about quitting medicine, but aren’t sure they have what it takes to start their own business.  They have this grand view that starting a business is this impossible mountain.  Here are some of the top 5 myths I hear about becoming a physician entrepreneur and starting a business.
 
You have to have an MBA or have a business background
 
I have known many physicians (and non-physicians) who have had MBA’s who are either not utilizing the degree (meaning they have not started their own business), or who are failing at starting, growing, or maintaining a successful business. On the contrary, I know even more physicians (and non-physicians) who have no such degree and have started and grown multiple businesses.  The point is, while having an MBA or business background is not a bad thing, it’s certainly not an indicator of whether or not you can start or be successful as a business or practice owner.

You have to have business experience to start a business
 
This is like saying to a newly graduated college student that they have to have experience in a position before they can get a job.  While, the former helps, it doesn’t predict one’s success in the field.  Having prior exposure to running a business (through family or other ties) is an added benefit, but not a necessity to be able to successfully run a business. What is required is the willingness to educate oneself, learn from mentors or coaches, and grow into the expertise. I grew up in an entrepreneurial household.  However, when I first started my practice, it failed because I knew nothing about business. I knew I wasn’t going to spend $40K and 2 years on a business degree, but what I did know is that I could attend workshops, conferences, and seminars. I bought programs, hired coaches, and participated in masterminds. This willingness to learn is what has made me successful in my businesses.

If you fail, you are obviously a bad business person
 
I am the poster child for not letting failure define me as a business person. Not only did my first practice fail, I’ve probably had more failures in business than successes. However, it’s the failures that have led me to those major successes, and it’s the mindset that failure is feedback that keeps me in the game.  If you are going to be a physician entrepreneur and be in business, you have to get that failure is just part of the game. If you are not willing to fail, then you are really not willing to succeed. 
 
14 years after my first business adventure, I continue to step into new territory.  It is the life of an entrepreneur… always “leveling up”.  I take the lessons I learned over the last more than decade, and not only re-apply them in new ventures, but also teach my physician entrepreneur mentees and students everything I’m learning along the way. The most important thing for physicians who want to embark upon starting a business to know is that it’s not so much a destination but a journey. When you choose business ownership you choose the mountain with no top. It can be a scary journey, but the biggest failure in business is to not try at all.
 
Maiysha Clairborne MD is an integrative medicine physician and coach, who blogs at Stress Free Mom MD is the founder of the  Next Level Physicians Entrepreneurs Institute. She is also the creator of Next Level Physicians Doctors in Business Facebook Groups

By Eric Brown
USMLE Course Consultant
After spending two years in the classroom, now it’s time to begin your third-year with clinical rotations. During clinical rotations, you get to immerse yourself in patient care, know more about the different specialties and put your bookish knowledge to good use.
Although clinical rotation is exciting, this transition can be a stressful time. It may fill you with tons of anxiety. Therefore, it is important that you enter into clinical rotations with a growth mindset. They may seem daunting, but you get only one shot at it. So, make it count.
With that said, here are 5 tips to succeed in clinical rotations.
1. Choose your rotations wisely
Clinical rotations help medical students in figuring out what medical residencies are best for them. During the rotations, the students shadow physicians in variety of medical disciplines. This helps them in making an educated decision about what specialty they want to join and later practice. To choose the right clinical rotations that is aligned with your future plans is not easy.
Some tips to choose the right clinical rotations:

• Explore as many rotations as you can to help you identify the specialty you are truly passionate about.
• Ask yourself these questions: What are your needs and special interests? In what areas would you like gain more experience? What kinds of experiences in clinical rotations would you like to go through before you choose a residency program? Are there any clinical rotation experiences that will help you shortlist your specialty choices or discover your passion?
• Spend time researching possible opportunities and options. Find information about opportunities in clinical electives of your interest from sources such as the clinical department, past medical students, and faculty members.

4. Be attentive to what your patients are saying
Listen carefully. It is one important clinical skill that will help you be a better doctor. Each patient encounter will give you an opportunity to learn something new, if you pay close attention to what your patients are saying.    
5. Be friends with your fourth-year peers
A friend who is in the fourth year can be an excellent mentor to you. You’ll get invaluable advice from students who have been through what you are going through now. Talking with them will keep you informed and updated about the forthcoming challenge.
6. Ask questions
You have got into the third year without much hands-on experience of examining real patients and dealing in logistics of the hospital. Now you are in the real world, seeing real patients; you’ve got a lot to learn. The only way you can learn better is by asking questions. Let no doubts remain in your mind; ask questions, however silly they may seem.
While it may be perfectly alright to ask genuine questions, do not ask questions that could reflect poorly on you. Don’t ask questions that you can easily look up.

About the author:
Eric Brown is a standardized patient (SP) who lives in New York and advises NYCSPREP with their Clinical Skills course. He has a BA from a liberal arts college in the Northeast, where he majored in the theatrical arts and business (he credits the first for his ability to simulate real patients). He’s amassed years of experience as an SP and keeps up to date with CS exam expectations, trends and developments. When the Phillies are in town, Eric considers it his duty to support his home team. He won’t be seen without his trusty catcher’s mitt on these occasions, and prides himself on having caught more than one foul ball with it. If you have any questions about standardized CS exams or courses at NYCSPREP, email Eric at eric.brown@nycsprep.com or visit http://www.nycsprep.com.
More advice from Eric Brown:
How International Medical  School Graduates Can Obtain US Clinical Experience

By Robert F. Priddy
Loss of license is a devastating event for a physician. It's not just the absence of a license and a mechanism for making a living, but the act or issues that led to the revocation of the license. Whether it's malpractice, substance abuse, some alleged egregious administrative act or other, it's a challenge to your professionalism, to your identity and to who and what you've worked your entire life to be.
It may seem like the end, but it's not. One of the unfortunate realities of medical practice and the medical profession is that everyone you've encountered, from your first day of medical school to you last day of residency or fellowship, and even on into the "doctors lounge," has expected you to practice medicine until you can no longer work.

As background, I provide my clients with what I call a CareerDiagnosis™. It's two days focused on learning about desirable and appropriate career paths to follow. I follow a SOAP note to collect that information. So, you can see, transitioning is a process, but it should be a structured and orderly process that takes you to a positive and rewarding career. 
If you'd like to learn more, don't hesitate to contact me for an initial, no-charge, no-obligation Hallway Consult... call/text 720-339-3585or email rfp@thirdevo.com. 

Always Act Like You've Been There Before
by Robert Priddy
I try to refrain from sports analogies, but this is one of my favorites. I'm from Ohio, so, yes, I'm a buckeye at heart, and one from the Woody Hayes era of The Ohio State University football. So, the legend goes, a young Ohio State player scored his first touchdown for the Scarlet and Gray. He then performed some celebration in the end-zone before returning to the sidelines, whereupon Coach Hayes reportedly grabbed him by the front of the jersey and pulling him in close growled, "Son, when you play for THE Ohio State University, you act like you've been there before."

by Robert Priddy

Put another way, most markets have plenty of room for expansion and growth, and that includes you as a new entrant.
 

Physician "Sell" Thyself
by Robert Priddy

by Robert Priddy
I’m always meeting with clients who are quick to say, just call me Jane or John…., and I always say to them, don’t give up “doctor.” There is a simple reason for that, it’s called credibility. Regardless of how you may feel today when it comes to the respect you receive from staff, colleagues or even patients, Physician is still the top or nearly at the top of any list of the most respected professions in America.
 
So, if you have the ability to walk into nearly any meeting with the expectation of “trust me” already on your side, why would you not? 
 
Presenting and selling ideas in business is challenging for everyone. Establishing credibility is a tough job. Becoming a physician is also a tough job, so you’ve earned everything you have. Don’t be afraid or too timid or wishing to just be a part of the gang, to use the trust and the power you’ve earned. In time, once the boundaries have been established, you can drop the “doctor,” if you wish. But initially, use the respect you’ve earned.

If you’d like to learn more, don’t hesitate to contact me for an initial Hallway Consult... Call or Text 720-339-3585 or email rfp@thirdevo.com.
More advice by Robert Priddy-The Resume Recruiters and HR People Hate, Physician Career Change, Never Overestimate the Knowledge of Your Audience, and Self Protection Is Self Defeating

If you’d like to learn more, don’t hesitate to contact me for an initial Hallway Consult... Call or Text 720-339-3585 or email rfp@thirdevo.com.
More advice by Robert Priddy-The Resume Recruiters and HR People Hate, Physician Career Change,
and Self Protection Is Self Defeating

DANGER WILL ROBINSON! Is a Recession about to strike?
By Mark J. McCandless, CPA, CFP®, MTax
President, Pathfinder Wealth Advisors LLC

In the 1960s television series Lost In Space, my favorite character was the Robot. Whenever the Robot sensed a meteor storm or an unknown presence, he would shout “Danger Will Robinson!” Here is a short clip.   An impressionable nine year old, I would play Lost in Space with my friends. I would run through my yard waving my arms and holding my hands in the “hook ‘m horns” position (You know, University of Texas) and yelling “Danger!” like the Robot with his claw hands would.  I believe my Mom wondered if she had dropped me on my head as a baby.

Today, some investment firms have started to yell “Danger” that a recession will descend upon us within the next two years. Should we change strategy? What should we do? Rather than run around the halls of our office like the Robot, I thought something else might be more useful for our clients. With some research help from our partners at Dimensional Fund Advisors, we created our Pathfinder report “Pursuing a Better Investment Experience – Ten Recommendations For Dealing with the Noise of Volatile Markets.” One of the most important recommendations is to “Focus on What You Can Control.” This means you can control creating a portfolio that is geared to your risk tolerance, globally diversified, uses funds or other investments with lower expenses than most funds, has lower turnover and is sensitive to the impact of income taxes. You can do this yourself or with the help of an investment advisor.

We tell our clients that the purpose of this is to remind all of us what we should and should not do in order to have an opportunity for success in investing. Will we have a recession? Of course. When will we have a recession? No one knows. Not even the Robot. The key is to be patient, avoid loud promoters that promise unrealistic results, communicate with us, and let us do the necessary rebalancing that will adjust the portfolio due to market changes. The worst investment returns were incurred by those that sold out during the last significant downturn. Investors that rebalanced to their target allocation and were patient achieved outstanding returns.
 
In the heat of a market downturn that feels like a meteor storm, when even the Robot can only yell “Danger” but can’t tell you what to do, remember the recommendations for Pursuing a Better Investment Experience. If you would like a copy of all of the recommendations, please send an e mail to me at mark@pathfinderwealthadvisors.com and include “Ten Recommendations” in the subject line.
More advice from Mark McCandless: Generating Tax Savings and Retirement Savings With SEP-IRA

The author:
Mark J. McCandless, CPA, CFP®, MTax, President
Pathfinder Wealth Advisors, LLC
6100 Oak Tree Blvd. Suite 200, Independence, Ohio 44131
mark@pathfinderwealthadvisors.com
www.pathfinderwealthadvisors.com
"Dedicated to our clients and their success"
Investment advisory services are offered by Pathfinder Wealth Advisors, LLC a registered investment advisor firm. We cannot accept orders for trades or any other transactions via e mail or voice mail. This e-mail message is sent to the intended recipient for their confidential use. If you received this message in error, or are not the intended recipient, please reply immediately to the sender and delete immediately from your system. 

By Mark J. McCandless, CPA, CFP®, MTax
President, Pathfinder Wealth Advisors LLC
 
In an era when many individuals are either full time self-employed consultants or doing some type of consulting in addition to being employed full time by an organization, a question often arises regarding how to “capture” some of those earnings for retirement. One solution that is easy to establish and has great flexibility is a SEP-IRA. A SEP-IRA is a written employer plan that permits an employer to make deductible contributions into an IRA for the employee. The SEP – IRA is controlled by the employee or the self-employed individual. If you are the one doing the consulting, you could make a contribution to your SEP-IRA out of your net earnings from consulting (also known as “self-employment income”).

The amount you can contribute is based upon a percentage up to 25% of your “net” earnings from self-employment. The “net” is important because it is defined as:
 Your consulting revenue
 Less your business expenses
 Less one half of the self-employment tax you pay
Less your SEP-IRA contribution
= Net Earnings from Self - Employment
You may be thinking “How can I know what I can deduct if I have to base my contribution on what I’m going to contribute?” Fortunately, the IRS provides helpful tables to determine the exact percentage to contribute assuming various contribution rates. The maximum contribution to a SEP-IRA for 2018 is $55,000. However you can contribute a smaller amount based upon your cash flow.

The plan is also easy to set up. You complete the IRS form 5305-SEP and maintain it in your files to show you adopted the plan. If you have employees, you must provide a copy of this form and additional information indicated in the instructions regarding the accounts. If you have employees, you must contribute to their IRAs in the same percentage as your own contribution.
I have helped many individuals over the years supplement their retirement contributions and save taxes through the use of plans like SEP-IRAs. Every situation is unique and every solution does not fit all situations. If you would like guidance on retirement, investment or other tax planning ideas, please feel free to contact me at Mark@PathfinderWealthAdvisors.com
More advice from Mark McCandless: Dealing With Volatile Markets
The author:
Mark J. McCandless, CPA, CFP®, MTax, President
Pathfinder Wealth Advisors, LLC
6100 Oak Tree Blvd. Suite 200, Independence, Ohio 44131
mark@pathfinderwealthadvisors.com
www.pathfinderwealthadvisors.com
"Dedicated to our clients and their success"
Investment advisory services are offered by Pathfinder Wealth Advisors, LLC a registered investment advisor firm. We cannot accept orders for trades or any other transactions via e mail or voice mail. This e-mail message is sent to the intended recipient for their confidential use. If you received this message in error, or are not the intended recipient, please reply immediately to the sender and delete immediately from your system. 

Most physicians come from a culture high on self-reliance. You may have belonged to a group practice, but you didn’t treat patients or perform surgery in a “group.” Medical practice is one patient at a by one physician at a time. It’s a pretty simple calculation. And anytime another physician is brought into a patient care situation it’s usually because that patient is being handed off… or taken away from you. Now you’re being asked to bring in another physician. Does this mean your job is being handed off… taken away from you? No, not if paragraph one accurately describes your work environment.
What this means is it is time to grow, to expand your span of influence and control. It’s time to offload some of your lesser tasks to someone else, and time to possibly acquire a slightly different skill set to open new opportunities – opportunities that will involve you if you allow them.

Shutting the door to staff expansion may appear to be self-protective, but you’re actually closing the door to growth, both intellectual and career. One of my adages when I was in the corporate world was that I could never have too many staff, have too much office space or too large a budget. In most corporate or organizational environments, the more your control, people, space and money, the more powerful you are and, and get this…, the more you have to give away if things get tight. Think about it, if you have a department of two and the corporate mantra becomes, we’re cutting back, you may soon be a department of one. Growth equals control, power, influence and viability. Don't shy away from adding that next physician, then the next and the next. There is safety in numbers.
More advice by Robert Priddy-The Resume Recruiters and HR People Hate, and Physician Career Change

If you’d like to strategize the new nonclinical job you have, one you hope to have or you’re just starting to test the nonclinical waters, call me, Robert F. Priddy, for a no charge, no hassle, hallway consult. Contact me at 720-339-3585 for voice or text or email rfp@thirdevo.com. You can also visit me anytime at http://www.thirdevo.com.

By Eric Brown
USMLE Course Consultant

Every year a large number of physicians apply to pursue their residency in the United States of America. Each physician who plans to pursue residency in America has to learn about the intricacies of the American system in order to make a seamless transition from a foreign medical graduate to a successful practicing physician.
If you are planning to pursue your residency in America, there are various aspects an International Medical Graduate has to consider while applying for clinical experience and residency programs in the U.S.

Which Students Are Considered as International Medical Graduates?
 
If you graduate from a medical school outside America, irrespective of whether you are a U.S citizen, you will be considered as an International Medical Graduate (IMG) when applying for residency programs.  This will require you to take the USMLE and apply for clinical experience.
 
But first, in order to take the USMLE and pursue your residency in U.S.A, being an IMG, you will first have to confirm that the medical school you graduate from is listed in the World Directory of Medical Schools. This is because medical schools listed in this directory meet the eligibility requirements set by the Educational Commission for Foreign Medical Graduates (ECFMG). Thereby, allowing you the register for the USMLE Step 1, Step 2 CK and Step 2 CS as an IMG.

Once you have cleared your USMLE exams, you then have to work on building your portfolio in order to secure admissions in a U.S. residency program. This will require you to obtain U.S clinical experience. Your clinical experience will be a part of your CV and other documents you will be required to submit when applying for a residency programs. The most common forms of clinical experience for IMGs are observerships, clinical rotations, clerkships or research positions. However, finding a clinical position in the US is not an easy feat, and being an IMG, your chances of securing a spot in a U.S residency program is much lower than that of a typical U.S. graduate. This generally happens due to the difference of medical laws and practicing patterns in various countries.

How Can IMGs Apply for U.S. Clinical Experience?
Being an IMG, finding the right type of clinical experience may be tough, but with the right methods, persistence and ingenuity, there are several ways to find the right type of opportunity, such as:
1. Use Renowned Online Resources
The most trusted online resource when it comes to an all-encompassing database of medical schools, hospitals and clinics is a website sponsored by the Association of American Medical Colleges known as Extramural Electives Compendium. It is a free database lets you search institutions based on their geographic location. It also offers useful information about medical school campuses, application procedures, elective time, and fee structures of such institutions.

2. Go to Direct Placement Clinics
Since IMGs face such difficulties finding clinical experience, some clinics even offer clinical experience programs that you can attend by paying to participate. Such clinics even provide letters of recommendation in case of well-performing students.  However, such direct placement clinics operate independently, be sure to ascertain whether they are certified by the American Medical Association, among other qualifications.
Why is U.S. Clinical Experience Important for IMGs?
Considering the highly competitive nature of this field, it has been observed that IMGs who participate in observer-ship programs to gain clinical experience are more likely to match. Many hospitals, research institutes, and private practices provide valuable opportunities to foreign graduates for internship, externship, volunteer-ship, and research assistance.

• it boosts your resume for the residency match
• it allows you to gain first-hand experience of the healthcare practices and environment in U.S.A
• it helps you increase your network in terms of peers, experienced doctors and mentors
• it helps you in getting recommendations and references once your clinical experience is complete

About the author:
Eric Brown is a standardized patient (SP) who lives in New York and advises NYCSPREP with their Clinical Skills course. He has a BA from a liberal arts college in the Northeast, where he majored in the theatrical arts and business (he credits the first for his ability to simulate real patients). He’s amassed years of experience as an SP and keeps up to date with CS exam expectations, trends and developments. When the Phillies are in town, Eric considers it his duty to support his home team. He won’t be seen without his trusty catcher’s mitt on these occasions, and prides himself on having caught more than one foul ball with it. If you have any questions about standardized CS exams or courses at NYCSPREP, email Eric at eric.brown@nycsprep.com or visit http://www.nycsprep.com/

As a healthcare provider, your reputation matters. Traditionally, patients have depended on word of mouth when it comes to which doctor to go to. Everyone would tell family and friends which doctors they liked or didn't like, while referring physicians would refer to the specialists whom they trusted as good doctors to take care of their patients. 
 
Online rating sites are starting to change things. The truth is that the vast majority of people don't bother to rate their physician at all- so there are very few ratings out there. But, terrible ratings and comments from irate patients is a real cause of distress for doctors. 

Unfair negative comments 
Many doctors want to know what to do about unfair, potentially damaging comments. Unfair negative comments can happen when a patient doesn't understand the bill (the doctor doesn't personally send the bill, but medical bills reflect poorly on the doctor) Negative ratings can happen when a patient doesn't receive disability or other benefits. And unfair negative ratings can happen when a patient doesn't receive certain substances he may have demanded from the physician. The medical community is aware of these biases, but most patients aren't aware of these factors when they look up a physician online. 
 
And, doctors are often frustrated because the negative comments are not usually directly related to the particular dispute, but are often falsified. Nevertheless, they are out there for everyone to see. 
 
Bad comments that are true
No one is perfect, and unfortunately, people are more likely to post bad comments on rating sites when they are unhappy with the outcome than they are to post good comments when things turn out well. Many of us achieve a sense of satisfaction and feel more 'in control' of life after posting a negative review. 
This tips the factual comments in favor of the negative.
 
What should you do?
*Often, doctors try to redirect practice away from medical conditions that are commonly associated with patients who are more likely to be 'toxic.' This can be unfair to patients because even angry or vindictive people have real medical problems and need medical care. 

*Some doctors have been able to contact administrators of physician rating sites, as negative ratings can have a harmful impact on referrals and on the livelihood of good physicians who are treated unfairly online. 

*Because of patient privacy concerns, physicians, unlike other business owners, cannot rebut a complaint by explaining in a comment on the website, 'this patient asked for ...'  

*Some doctors have tried litigation, which is a costly and lengthy process. But, as with all legal issues, precedents may change things over time.

*Some physician rating sites are starting to charge a fee for services such as 'enhanced search engine optimization' and 'high rating profiles.' This is still a very new concept and it may turn out to benefit doctors who jump on the idea early, or it may not make a difference.

*One way to control your professional online presence is by presenting yourself online as yourself. When old-fashioned word of mouth was the way things were done, a doctor's personality could shine through. Now, doctors can show who they really are through writing patient-centered articles that demonstrate to patients how a doctor may interact in person. Consider writing an article for nonclinicaldoctors.com or for another website as a way to control your own online reputation.

By Dave Denniston CFA
The world is changing.
The concept of retirement is changing.
Is an early retirement even possible? Heck, is retirement by 60 or 65 even possible?
As a matter of fact, I’m seeing many folks work longer and longer- some even well into their 70’s. Truly, it’s not full time for the most part, but part time to scrape some extra dough for some of the extras that make retirement enjoyable- the hobbies, the travel, and the grandkiddos.

In a previous post, I made a big leap and even suggested that Retirement is Dead.
For newly minted attending physicians with student debt burdens over $300,000 and rising, a traditional retirement is getting further and further out of reach. My feeling is that we will be seeing more and more physicians experience what I am coining “The New Retirement.”
Yes, I know that we currently have a physician shortage, but with more “cheaper” PAs and NPs gradually taking over the work for physicians in certain areas- we could see the landscape for physicians changing more and more.
In this post, discover the three components of the New Retirement and how that may fit into your future plans.

Component#1: House Debt Forces You To Work Longer
What are we taught about buying our first place? What matters more than anything else?
Location, location, and of course… location
When it comes to the new retirement, location is everything and I’ll change those 3 words to:
Home price, home price, and home price
For many of us that are labeled gen x, gen y, and millennials- I see time and time again the impact of the price of your home on retirement.
Consider a client in Southern California- they bought a fairly modest home for $900k.
In comparison, here in the good ol’ Midwest, our place of similar size was worth around $250k around the same time.
Can you imagine how much more quickly we’ll be out of mortgage debt and able to save more? Our friends on the coast are being FORCED to work much longer.
Ironically, not only are costs higher- particularly homes…. but the salaries are also lower!!!
This means that our physician friends on the coasts are likely to experience the new retirement- unless they do some creative investing or instead, force themselves to live like a resident for a big chunk of their careers.
And it’s awfully hard to live like a resident and when you’re paying a resident’s salary for your home…

Component#3: Creating (or Acquiring) A Business
Can’t find that passion for medicine again? Are you eager to try something else?
For some of us… maybe you don’t want to start from scratch and you don’t want to work ‘for the man’. Wouldn’t it be great to have a business that you can get cash from immediately?
Check out what I did by buying an existing business.
I’m not going to lie. It’s not all rainbows and sunshine, BUT if you structure the acquisition right- you can protect yourself and your future while creating multiple streams of income.
As a matter of fact, I like it so much- I am planning on acquiring or starting 1 new business every year the next 2 to 3 years.
This should allow us to generate a few thousand extra dollars a month. As we develop more systems and automation, each business should be on autopilot with some course correction from time-to-time.

Final Thoughts
Doctors like you are the best and brightest that our country has to offer.
As you may explore the “New Retirement”, keep an open mind.
You have the capacity and ability to contribute so much to the world- whether you are treating patients or starting a new business.
Keep trying, keep testing, and above all else, keep pursuing the financial freedom you so richly deserve.
More Advice by Dave Denniston- Does Stuff Own You? and Finances of Business vs. Hobby

About the Author
Dave Denniston, Chartered Financial Analyst (CFA), is an author and authority for physicians providing a voice and an advocate for all of the financial issues that doctors deal with. He also has 1 wife, 2 kids, and a bunny named Black Snow (which is a lot better of a name than Yellow Snow).
If you’ve enjoyed this guest post, you can learn more about his adventures in financial planning, liquid investments, illiquid investments, & much more nonsense by finding his latest blog post and videos
*Several of the links in this article have listed 3rd party firm/individual are not affiliated with or employees of United Planners Financial Services. United Planners does not supervise this firm/individual and take no responsibility to monitor the information/services they provide to you.
The opinions expressed are those of Dave Denniston and The Capital Advisory Group and are subject to change based on market, tax, and other conditions. The information provided is general in nature. Consult your investment professional regarding your unique situation. Securities offered through United Planners Financial Services 800-966-8737, Member FINRA, SIPC. Advisory Services offered through Capital Advisory Group Advisory Services, LLC. 5270 W. 84th Street, Suite 310, Bloomington, MN 55437, 952-831-8243, United Planners and Capital Advisory Group Advisory Services LLC are not affiliated.

By Bishoy Gad MD, MS, MBA
After spending the 4 years in medical school, and then additional time in residency and often fellowships, most trainees feel appropriately trained to practice medicine. The challenge is that very little time in a resident’s education is devoted to some of the most important aspects of this profession; finding a job that is the best fit and developing the foundation for a strong practice for the future.

In some specialties, 70-80% of newly hired physicians change jobs within their first two years of practice[1].  The majority of mentors to young physicians are academics who have not changed jobs for many years.  However, a large portion of physicians in the United States are in private practice[2]
Practice types
There are a variety of practice models available for potential employment opportunities. They can essentially be broken down into three major groups: private practice, hospital employment, and academic medicine. There are other practice types and hybrids of these types, but for simplicity we will discuss these major practice types.

*Private Practice
There are a variety of ways to be in private practice; either as a solo practitioner, a member of a single specialty group or a member of a multispecialty group. Solo practitioners essentially function on their own and manage their own billing and collections. These physicians must have a good understanding of their market, ancillary sources of income, staffing, and efficiency to survive[3]. A single specialty group is typically a group of specialists who may hire adjuncts that complement their practice. There are many benefits of being a member of these groups. There are economies of scale, increased leverage in dealing with hospitals and insurance companies, and can be powerful academically[4]. Being a member of a single specialty group gives the physician an opportunity to make additional income from ancillary sources such as imaging, durable medical equipment, ownership of a surgery center, ownership of physical or occupational therapy, and so on. Typically there is equity involved and the shares should be purchased if the practitioner is interested in partnership and ancillary sources of income. Purchasing of equity is commonly known as a buy in. The buy in can often be multifaceted depending on what assets are purchased.
Multispecialty groups are typically larger groups comprised of general practitioners such as family medicine doctors and internal medicine doctors. These groups often will hire specialists to capture some patients that are being referred out of the group for common services. There may or may not be equity involved in employment. Often there are also ancillary sources of income, however these sources are divided among a larger number of individuals. Being a member of such a group does have benefits for specialists including an automatic referral base that will assist in starting a practice.
Many private practice groups will offer a stipend for the first few years of practice until the physician is able to sustain himself or herself on the revenue produced by their practice. Some groups offer this as a stipend payment, and others will offer it as a loan. It is imperative to understand the basics of finance and how these particular practices collect in order to avoid unnecessary losses. This includes having discussions with the practice manager and/or collection agents and the group prior to joining. The benefit of this practice type is the high income potential as the practice develops, in addition to being able to use the practice and many practice related purchases as business expenses- such as a car, cell phone, computer, and educational expenses.

*Hospital Employment
The second major type of practice is hospital employment. Typically, but not always, a new physician is given a salary and potentially a bonus. Given that hospitals are often non-profit or not-for-profit organizations, they are required to see a certain amount of patients who are either uninsured or cannot pay. Often physicians who work in this setting are measured by work relative value units (wRVUs).  Medicare assigns wRVUs they will give credit per office visit, hospital visit or procedure. For example in 2015 the number of wRVUs for a level 4 new patient outpatient encounter was 3.17[5]. Typically physicians are paid a multiple of the number of wRVUs they produce. That multiple is typically determined contractually and usually varies by specialty. Often, a set number of wRVUs is expected to be hit by the physician annually. After this threshold is hit, the physician, depending on the structure of his or her contract, may be eligible for a bonus based on production. A recent Merritt Hawkins survey found that 74% of physician search assignments offered a bonus with 52% of those being based on wRVUs[6]. The benefit of this practice type is that the doctor is not responsible for managing overhead and other employees. Typically these jobs will pay more than private practice stipends will initially. However, long term these jobs from an income standpoint typically will not pay as much as practice jobs because there is no access to ancillary income. In addition, be aware of the leadership of these hospital systems. Nine of the top 10 most economically efficient and clinically effective hospital systems were owned by physicians[7].

*Academic Practice
The third major practice type is that of an academic doctor. Many of these opportunities are functionally hospital-employed physicians, and while there may also be a threshold for production as in standard hospital employed positions, an emphasis on other metrics is often placed. For example, additional payment may be tied to education of medical students or residents. There may be additional compensation for academic tenure or productivity in research. The benefit of this type of work is often the flexibility of schedule in order to be able to engage in non-clinical activities.
*Other
There are still other practice types as well. Those include employment by a health maintenance organizations (HMOs), locum tenens positions, military employment, and administration[8]. Of course there are a variety of practices that do not fit in these clean categories. Many single specialty surgery groups are large enough where they have affiliations with academic centers and do place value on education and research, but also have an interest in production as well as opportunities for obtaining ancillary income. It is important to have a very good understanding of what the practice goals are prior to joining the group.

Malpractice considerations
There are two major types of malpractice insurance: claims-made and occurrence-made[9]. Claims-made insurance is the less expensive form of insurance that many groups and practices may offer. Essentially, in order to be covered, the physician must carry the insurance policy both when the claim is made and when the event occurred. For example if a new internist works for a practice in the month of July and performs a lumbar puncture for meningitis, quits the job in August losing her claims-made insurance, and gets sued in September, she is not covered for that claim. At this point she is essentially putting her assets at risk. It would be prudent for the doctor to obtain additional insurance coverage where the prior claims-made insurance policy lapsed.  This additional coverage is known as tail coverage[10]. The cost of tail coverage often is 150% to 300% of the cost of an annual claims-made malpractice insurance policy and can be over $100,000[10] for some specialists. The new employer may also purchase nose coverage which covers incidents that occurred before the beginning of employment for which a claim has not yet been made[10].
Occurrence-made insurance is more expensive than claims-made insurance. Often, many larger systems will carry this insurance because they are self-insured. Occurrence-made insurance implies that if the physician carries this particular type of insurance at the time the event occurred regardless of when the claim is made the physician is covered by this insurance. Returning to the previous example the physician performs a lumbar puncture in July, leaves her job in August, and gets sued in September. She is covered by her prior employers’ malpractice insurance.
There are other considerations when evaluating malpractice. Some institutions have a policy of trying to remove named individuals in a lawsuit and essentially will have the lawsuit placed against the institution. This has obvious benefits, as lawsuits and settlements are reportable to the national provider database (NPDB). In addition, the state of practice has a large bearing on malpractice. States with tort reform often have lower malpractice rates than others.  All these are important considerations when evaluating job opportunities.

Market considerations
It is important to be mindful of location when looking at employment opportunities. Planning on an exclusive colonoscopy practice in New York City is not a novel concept. Depending on the saturation of a region, the services of a subspecialty may be commoditized to a degree and will be reflected in a physician’s salary and benefits package.
Opportunities may be different in different areas of the country at different times. Retirements and relocations of other doctors as the particular skill set of the new physician may affect the availability of positions and potentially the quality of the contract that can be obtained. If there is a great need for a particular type of service in a particular area, compensation and benefits packages tend to be more lucrative.

Tips on negotiating
Probably the most important thing to realize is that if something is not explicitly written in the contract, it will not happen. The concept of a handshake or verbal promise does not hold the same weight it did in prior generations. The practice manager handling the contract negotiation may be fired the day after a new physician signs his or her contract, thereby nullifying any verbal promises made previously. Negotiating the terms of the contract can be extremely uncomfortable, especially if it is with people the prospective employee may view as a mentor. Hiring an attorney to review the contract or an intermediary/negotiator to help with the terms of a contract may be beneficial [8, 11]. It is critically important that the details of the contract and the details of the employment opportunity are outlined explicitly prior to signing any contract.

Determining value
There are many definitions to value.  From a compensation standpoint, a variety of sources report medians for a physician’s income. Some of those include the Medical Group Management Association (MGMA) the American Medical Group Association (AMGA), and many recruitment firms. For example, according to the compensation 2013 publication by the AMGA the median pay per wRVU for an internal medicine physician was $47.47[13]. Depending on the practice type this number can vary. Practices that are based on collections are not necessarily concerned with wRVUs.  Academic practices may offer payment based on academic appointments. Payment also varies by region as well as population density. More rural areas tend to offer larger salaries for hospital employed physicians due to their challenges with recruitment. However that does not mean that a physician cannot earn more being employed in a large city, It might just be more difficult to find. Even if a doctor finds a job that is willing to pay two million dollars per year, the terms of employment and the people the physician will work with are also of great importance.
Understanding value will give the physician confidence in his or her negotiation. It is important to have a plan on which terms of the contract are negotiable, and which terms are not. If an impasse is reached or the employer or partners are unwilling to negotiate on certain terms that are of critical importance, an option may be to politely walk away. 

Partnership and employee morale
Discussion of contracts, compensation, and markets are important, but an item that should not be neglected is the overall picture of the practice and the relationship between partners and/or fellow employees at a workplace. Everyone has different tolerances for different types of environments. Some thrive in very high stress, high pressure environments, and find it thrilling. Others thrive in more relaxed environments. It is important that the physician understands himself or herself in order to select the proper practice that fits their personality well. It is important to talk to and meet as many people as possible to determine the overall morale of a practice or employment opportunity.
 
The search for employment is one of the few times a surgeon may yield significant power. It is important to be thorough in an employment search and honest about expectations of specific contract terms. The contract negotiation period is the time that will determine the foundation of the future practice.   Understanding the basics of business and contracts is critical to creating a job opportunity that is right for you.
The intention of this article is not to be a step-by-step guide on how to find the right job. However it is an introduction to basic concepts that will assist in making a more informed decision. This article is not a substitute for a mediator or an individual experienced at reading terms in a contract and also no substitute for an attorney reviewing the language of the contract.

Bishoy Gad, MD, MS, MBA is a board-eligible Orthopaedic Surgeon currently at New England Baptist Hospital for an adult reconstruction fellowship who trained at the Cleveland Clinic for residency.  He has a special interest in healthcare process and delivery improvement. He currently serves as the chair of the practice management committee for the American Academy of Orthopaedic Surgeons' Resident Assembly.

References
1.              Dyrda, L. 25 Key Concepts for Young Orthopedic & Spine Surgeons to Build a Successful Practice. 2012; Available from: http://www.beckersspine.com/spine/item/11832-25-key-concepts-for-young-orthopedic-spine-surgeons-to-build-a-successful-practice.html.
2.              Orthopaedic Practice in the US 2014, in AAOS, A.D.o.R.a.S. Affairs, Editor. 2015: Chicago.
3.              Soyer, A. The solo practice: Strategies for success. AAOS Now, 2010.
4.              Collon, D. Super Groups: Are They the Future of Private Practice? AAOS Now, 2013.
5.              Coberly, S. Relative Value Units. 2015.
6.              RVU BASED PHYSICIAN COMPENSATION AND PRODUCTIVITY: Ten Recommendations for Determining Physician Compensation/Productivity Through Relative Value Units. 2011.
7.              Heiney, J.P., An examination and discussion of unintended consequences of being an employed physician. J Orthop Trauma, 2013. 27 Suppl 1: p. S17-21.
8.              Henley, M.B., Finding your ideal job and negotiating your contract: where to get the information and numbers you need to know. J Orthop Trauma, 2012. 26 Suppl 1: p. S9-S13.
9.              Malpractice Insurance. 2016.
10.           Fleeter, T. The Hidden Cost of “Tail” Insurance. AAOS Now, 2012.
11.           Harolds, J., Tips for a physician in getting the right job, part XIX: introduction to employment contracts. Clin Nucl Med, 2015. 40(2): p. 128-30.
12.           Porter, M.E., What is value in health care? N Engl J Med, 2010. 363(26): p. 2477-81.
13.           Vaudrey, B.S.a.L., Sara, Compensation 2013: Evolving Models, Emerging Approaches:  Results from the AMGA 2013 Medical Group Compensation and Financial Survey American Medical Group Association, 2013.

When should physicians seek career advice? By Alexis R Small, Physician Career Agent

“The Medscape Physician Lifestyle Report,  says that 46% of all physicians responded that they had burnout, which is a substantial increase since the Medscape 2013 Lifestyle Report, in which burnout was reported in slightly under 40% of respondents. Burnout is commonly defined as loss of enthusiasm for work, feelings of cynicism, and a low sense of personal accomplishment.” (Medscape.com – January 26, 2015)

Physicians labor through 4 years of medical school acquiring 6-figure debt. Then, they fight through 4 more years of residency with little to no sleep. Finally, they start a much-anticipated career in medicine, only to constantly worry about how they are going to pay back that 6-figure debt in this current healthcare environment that offers less freedom to practice medicine. Or, after all the time and money they’ve invested, some come to the realization that a career in clinical medicine is not for them. At what point during those 8 years of medical training do physicians receive any guidance related to career development and planning? One option is the Careers in Medicine website offered by the Association of American Medical Colleges.

But, what do you do if you are several years into your medical career before you come to the conclusion that clinical practice or medicine, in general, is not the career for you? Who’s going to help you navigate the winding highways of career options available to you at this stage in your career or decide which way to travel at the crossroads of your career journey? Are you even comfortable seeking the advice of a career professional? I mean, you’re a physician, deemed a member of one of the most intelligent professional groups, as well as one of the most sought after professionals in the world. Why would you even need any career advice? You can figure this out on your own, right? You make 6 figures or more on an annual basis. You own your own practice or you work for one of the most highly accredited institutions in the country. You diagnose chronic diseases and treat complex illnesses. Surely you can figure out this career thing!

Dear Physician, If you struggle to get out of bed in the morning to go to work and have decided that it is time to make a change, you might want to seek some career advice.
If you know that you want to pursue a different career, but have no clue where to start, you should seek some career advice.
If you know that you want to change jobs, but don’t have the time to look for available openings, then you should consider seeking career advice.
If you love medicine, but hate clinical practice, you should seek some career advice to help you research your career options.
If you enjoy your job, but can no longer stand the people you work with or the environment you work in, you might want to seek some career advice.
If you are in private practice, but have become exhausted by all the red tape, then maybe you ought to consider getting some career advice.

If any of these reasons or scenarios apply to you, then you should consider reaching out to a career professional who:
*Has experience working with physicians
*Enjoys helping physicians find the best career/job fit
*Understands the healthcare landscape
*Is adept at navigating the recruiting/hiring process
*Has your best career interest in mind
This career professional could be a Career Advisor, a Physician Recruiter or an Executive Coach. Take your pick. Just make sure you get the help or advice you need to move forward in your career. The options are endless!

Contact Alexis Small by email at alexis@purposefullyconnected.com or by phone at 704-975-0844

Batch processing, by Sameer Islam MD

I thought being a doctor was going to be pretty straight-forward: take care of my patients, update my knowledge up on topics I was not clear about, and repeat the process.
Boy, was I wrong.

As a new doctor, I soon got overwhelmed by all the things that came up in my day: patient questions, messages from my electronic health record, labs results, staff queries, etc. It seemed like as soon as I got one thing done, another pile of stuff came crashing down on me. And this didn’t even include seeing patients, running a clinical practice, doing procedures or having a family life.
I was allowing the priorities of something else take over and in return my personal life and well-being suffered. I knew that something had to be done or I would go insane.
So I started to look into different productivity ideas from the business world to help me out, and I found one that changed my outlook: batch processing
WHAT IS BATCH PROCESSING?
Batch processing is the idea of grouping similar tasks requiring similar resources in order to streamline their completion. You ONLY do these tasks during the allotted time and no other tasks are performed. There is little change in cognition while doing these items - they take up the same mental bandwidth.

Studies have shown it can take up to an average of 15 minutes to completely regain focus, and by multi-tasking we can lose up to 40% of our productivity. In fact, working in a perpetual state of shifting tasks and refocusing attention creates fatigue, stress, and decreased productivity. If that’s the case, we are not being nearly as effective as we could be and we are not giving ourselves or our patients our full attention.
I have personally experienced this when I am deep in the middle of a task, and then an email pops up and I get distracted with the email. As soon as I am done with the email, it takes me a while to remember my previous task and even longer to get back into the flow of things. Once I get going, someone will interrupt me about a non-urgent issue. I address that, but the cycle of unproductivity continues. That is wasted time that ends up eating my day.
HOW DO I CHANGE?
So now that I knew what to do, the question in my mind was HOW can I do this. It took some trial and error, but I think I got my system down.
I use my calendar as the guidepost for batch processing.

I also made a list of what I need to get done to make sure I cover all my bases. This is important because there is a huge difference between need and want. There a lot of things I want to do but very few I need to do. I had to think hard about what really was necessary. My list is comprised of:

1. Review patient labs, imaging, etc
2. Review messages from staff and patients
3. Contact or delegate the information to the right people

I felt I needed to get  these items done. I also set some ground rules for my staff so things didn’t get left behind or missed:

1. If there was ANYTHING critical, the staff were to text me or call me personally
2. Non-critical items were to be messaged or emailed to me
3. I would only work on one batch ONCE per day so as to not have this continually on my mind
4. I would schedule a time to start and a time to finish
   

What I did:
1130-1230: “Patient Stuff”. Every day I blocked out this time to review patient labs/imaging and contact the appropriate staff. I only worked on this and I made sure to finish within the allotted time. I turned off my email, closed my other internet browsers, turned my phone to silent, and closed my door.
430-500: “Review.” Here I reviewed any pre-authorizations from my staff, delegate tasks, cover any emergencies or overflow from before. Same process as above.
Weekly Review: Also, once a week I did a “weekly review” to assess what was coming up next week and to capture anything I might have missed from the week before (more on this later).

After experimenting on this for a while, what I found was:

1. I became MUCH more productive with my time
2. The day became much more manageable - I knew I had a prearranged block of time to get things done, so I wasn't concerned I was missing out on something
3. I actually became happier - the stress of not knowing if I missed something or stress of things piling on went away.

It is still a work in progress. There are days when I am able to be very efficient with my time and then there are other days where everything goes crazy. But it it has been a good starting point and I am building on this each and every day.
 
What do you think? What have you done to make your time easier?

By Sanjana Vig MD
I made the decision to get an MD/MBA when I was still in high school. I had an interest in medicine but I hated the idea of being yet another Indian doctor. How unoriginal. So when my dad introduced me to someone who had done this dual degree, it was my “aha!” moment. As far as I knew, this was something different, could set me apart and no one else I knew was doing it. Perfect!

Now, we are paying the price. Literally.
We dance to the tune that managers play for us, not quite understanding why certain things are done or why certain policies exist.   On more than one occasion, I have heard, or even myself have asked: “why do I have to fill out this form” or “there has to be a better way”, or “I know a better way!”
Hospitals are, at its most basic form, a business. Yet we are never taught about even the most basic business components, let alone how to run one. We have no exposure to accounting and financial topics; we passively gain teamwork and team building experience during residency, but there are also business leadership concepts and communication strategies that we do not learn.

Healthcare is dynamic and constantly changing. With the Affordable Care Act and whatever congress is trying to accomplish now, changes are happening, and will be coming, that directly affect how hospitals are managed, how insurance is handled and ultimately how we get paid.
 There is clearly a gap between physicians and managers, not just in communication, but in understanding as well, and it needs to be bridged. Doing so requires physician leadership that can be present at the table, engage in administrative discussions, assist in formulating business decisions and be a voice for clinicians.

Why an MBA?
Much of the push back I got as a student was, sadly, from other students. I was regarded as a sell out for wanting another degree, because, apparently, this meant I wasn’t serious about medicine. In addition to that accusation, I was questioned for not getting and MPH (Masters in Public Health) or MHA (Masters in Healthcare Administration), as those degrees were seen as being more in-line with a medical career.
My response: I wanted a broad understanding of business and finance. In my mind, while those degrees are certainly helpful, they would not help me achieve my goal. I wanted to understand all business, not just healthcare. I wanted all related business topics on my plate, not just public health issues. I wanted to understand consumers as a whole, not just hospital and clinic patient populations. I wanted to understand money making from the perspective of any business, not just medicine.
For me, personally, an MBA means I can work in any hospital, any clinic, or any government or private sector healthcare organization, and I wanted those options.

Benefits of a dual degree
A 2011 study by Dr. Amanda Goodall examined the top 100 hospitals, as determined by US News and World Report, and compared their CEO’s. Those with physician based leadership scored 25% higher in hospital quality measurements. While there’s no direct causal relationship identified here, there is support for the idea that leadership without clinical expertise can lead to inferior management abilities in the hospital setting.
Plus, a physician leader has instant credibility with both clinicians and managers, making it easier to bridge that gap between both parties.  Managers are more likely to trust someone with some business acumen and physicians are more likely to trust someone who understands the daily clinical issues they face. Having a physician be a part of administrative discussions also helps protect other physicians and related clinical interests.

On a more personal note, the additional degree can serve as a point of leverage to advance career goals and move up the managerial chain much faster than would otherwise be possible.  If moving up the chain isn’t part of your goal, then just having the knowledge, period, can help you develop a better understanding of why certain decisions are made and at the very least, help you converse intelligently with administrators in a way that is effective and productive.
In todays’ climate, where hiring mid level providers is seen as more cost effective and MD’s are too expensive, giving yourself another skill set will make you irreplaceable and even desirable.
While a second degree, or a career in leadership, is not for everyone, I believe that physicians owe it to themselves to take back control of their careers. Even without a degree, you can be proactive about paying attention to the business aspects of your jobs, asking questions, obtaining information and empowering yourself with business knowledge so that you don’t get left behind.
Be a boss. (You already are one)
 
--YouBeThree