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

And Why It Should Be The Resume You Use
by Robert F. Priddy

.By its definition, a functional resume serves three purposes. 

• It represents a supporting document leave-behind that reinforces the verbal presentation you’ve just made.
• It identifies and defines your accomplishments in an easy to follow categorical, functional listing.
• And at its best, if provided before a meeting, it can serve as an introduction that peaks the reader’s curiosity to learn more about you.

Recruiters and HR people hate functional resumes because they can make it harder for them to understand your current job title, because your years of experience may not be obvious, because specific jobs and specific duties probably aren’t linked and, well, just because they don't offer an easy to understand chronological check list of your past.

If you are a candidate who perfectly fits the career climbing ladder - one who has the requisite three to five or five to seven years of experience as defined by your job titles, and specific responsibilities coupled with an easily measured and tracked rise in title and responsibility, then, a chronologically arranged resume, as most recruiters and HR people prefer, is right for you. It shouts to the recruiter or HR person, “Look at this! I match your requirements and expectations perfectly! Look at me! And, they probably will.

This is why (and this is very important) I consistently advise my clients to never, never apply for a posted job and to never expect a recruiter or HR person to embrace them as a viable candidate unless their first interaction is a verbal one based on addressing specific job/organizational problems and a need for intervention they can specifically provide.

Here is a simple test. Would you be terminated by your employer if you were an excellent clinician or surgeon, but failed in all your administrative duties? Usually, let me stress usually, the answer to that question would be no. Sure, you may be replaced on the QA committee, but you would not be terminated from the organization. And that’s the answer most recruiters and HR people would expect. When they see the practicing physician who has had some administrative responsibilities, they immediately assume administration is a secondary or even tertiary responsibility for which little accountability has been expected.

The functional resume is not intended to address a specific job, rather it is intended to represent you. You might even consider it an expansive business card. Since your business card lists your Core Competencies, your functional resume just expands on those, and adds some additional qualifying information. 
 
If by contrast, you simply handed the recruiter your CV or resume that follows a chronological CV-type layout, the recruiter sees a practicing physician who may have some administrative responsibilities. They don’t see someone whose primary responsibilities have held them accountable to administrative results.
 
Back to the functional resume. Its objective is to dispel that perspective and to present you as a leader or executive who happens to carry a medical degree. And, after all, that’s the person you want to be seen as – right?
More advice by Robert Priddy- Self Protection is Self Defeating and Physician Career Change

By Robert F. Priddy
About 15 years ago I wandered into my own career change moment when I began speaking with a physician at a local healthcare consultants networking meeting. I learned about his counseling service for physicians dissatisfied with the state of medical practice and recognized a need that demanded and deserved high caliber career transition and management services.
That meeting resulted in a several years partnership and resulted in my third_Evolution in 2008. Since then, I’ve built on that base of understanding fostered both by my early physician partnerships as well as my 20-year career in hospital and consulting-based medical staff development and practice management.

What I’ve learned, you might say, is what I offer. Medical practice is a very demanding profession. Demanding, not just in the focus and the results, but demanding in the nearly single-minded attention to the daily activities of patient care. I speak with physicians every day who tell me they are open to nearly any job that uses their skills and knowledge and pays reasonably. And, as I usually reply, that’s not a job description, it’s a cry for help.

Effectively, asking other people to tell you what job they have for you or what job they believe would be good for you is a complete nonstarter. That why you, just like every patient you treat, need a focus… or a diagnosis, a Career Diagnosis™.
 
I conduct a formal, structured process with clients to construct a Career Diagnosis, but you can and should emulate that process if you’re going on this journey. I suggest a SOAP note format in order to follow a system that is both familiar and effective. Take your time… consider subjective elements like your interests and passions and then couple those items with more objective definitions of your skills and knowledge. As you build each of these three categories in lists – I suggest literally a three-column listing, you can then start connecting those words and phrases.

You see, most physicians, regardless of background simply don’t and won’t meet the job requirements or qualifications criteria of published jobs. So, as I say to my clients, let’s define the problems you want to solve and then find people or companies with those problems. This means applying for jobs only 10% or perhaps 20% of the time and networking for problem solving opportunities 80% or 90% of the time.
More advice by Robert Priddy- Self Protection is Self Defeating and The Resume Recruiters and HR People Hate
Robert F. Priddy, President
  rfp@thirdevo.com
  720-339-3585 voice
  208-979-2134 fax

Sign# 1: You have high amount of monthly obligations
As I look at different physicians that I’ve worked with over the years, they fall into two different camps: there are savers and there are spenders (and of course many of us lie in-between). Check out the best 12 pieces of advice that I could possibly give to either of these groups.
The spender physicians are some of the kindest, most wonderful people. They are giving and they are dreamers. They take amazing trips and vacations. They work super hard and play hard.
They are also often burdened with a whole bunch of monthly payments. Here are some common examples:

• Car leases (usually on luxury vehicles- like Mercedes, Tesla, BMW, etc)
• Car loans
• Sending kids to private school
• Timeshare loans
• Have mortgages over $500,000 and payments that are over $3,000/month
• Taking home equity lines of credit to pay for home renovations (or separate loans for a pool)
• Tremendous amounts of student debt that are barely budging (avoiding to refinance)
• Own a second home that also has a mortgage

If this resonates with you, here are some immediate actions that you can take to improve your situation:

• Commit on a go-forward basis to buy big ticket items like cars in cash. This can be super hard, but you can do it!
• Find an amazing public school for your kids rather than an expensive private school
• Dump your timeshare by selling it to a reseller (for pennies on the dollar) or simply stop paying the maintenance dues
• Downsize your home (this could be easier said than done depending on the size of your family!)
• Consider finding a job in a place that pays a much more substantial salary and/or has a lower cost of living. For example, in Alaska, I’ve seen many primary care physicians make $300k+ a year- which is often $100k to $150k more than they’d make on the West Coast or East Coast (plus home prices are wayyyy lower there too)
• Refinance your student debts to get them paid off as soon as possible at a lower interest rate
• Sell your second home

Sign# 2: You are working a tremendous amount of hours to support your lifestyle
Due to all of these obligations, there’s this crushing pressure to perform financially.
I’ve seen many of these wonderful people taking on locums opportunities in order to stay ahead. Many of them are working a full-time gig plus locums on the side.
They are working more than 80 hours per week and they wonder if they can keep up the pace.
As a matter of fact, they are on the fast track to burnout.
How can they possibly get off the hamster wheel where they are racing, racing, and racing and never able to get off?

Here are some guidelines that may be helpful:

• If you are in a tough situation and need to do locums, commit to doing it for a short time period (less than 1 year)
• While you are in that period, block out time in your calendar every week to review over your finances. Keep a running total for the month of how much you’ve made, how much you’ve spent, and how much you kept. This doesn’t need to be super detailed. Actually, the simpler the better. Below is an example of a spreadsheet that my family & I use. Mint and other similar programs are great, but I think there’s power gained in manually typing in numbers. It forces you to review it carefully. You’ll see that we’re tracking a few goals and really keeping an eye on one category of our budget. We love traveling and we’re socking away money to fund those goals as well as buying a new car in cash.

Sign# 3: An early retirement is out of the question
Another way to track “does your stuff own you” is by examining if an early retirement may be out of the question.
You may be wondering- how do I know if that’s even a possibility?
If we go back to our earlier exercise of tracking personal expenses, a simple run of thumb to find out if you can retire today is to…

1. Find out your total amount of assets and your total liabilities. Write down those numbers.
2. Subtract your total assets and your liabilities- this is your net worth.
3. Multiply your net worth times 4%. Write down that number.
4. Multiply your monthly expenses time 12.  Write down that number.
5. If your 4% net worth is lower than the monthly expenses x 12, I’d suggest that you aren’t there yet (Heck, I’m not- but I’m also not looking to retire today).
   

Here’s another slightly more complex set of rules of thumb to track your progress if you have a significant amount of time away from ‘your number’.

1. Take those monthly expenses and find the average. (Hint: Use ALL the monthly expenses, don’t discount vacations or new cars, more than likely you’ll do those in retirement as well)
2. Then, multiply them times 240. Write down this number. This is your target number.
3. Take your monthly savings and find the average
4. Multiply that number times the number of months remaining for the target retirement date. Write down that number.
5. Find out your total amount of assets and your total liabilities. Write down that number.
6. Add together step#4 and step# 5. Compare that to step# 2.

If your assets minus your liabilities + savings (the total from step 6) are less than your target number (the total in step 2- in my case about $2,000,000), then I’d suggest that you still have some work to do to be financially free.

If we look at my situation, we’re averaging $4k/month savings. I’ve got about 14 years (168 months) until target retirement. That’s a total savings of about $672k (with no growth). Our total assets minus liabilities are around $1 million. So, we’re currently quite shy of that goal!
55 might be more realistic for us based on our current savings habits based on these rules of thumb.
Keep in mind these are just a couple of simple exercises. Financial planning is significantly more complicated when you take into consideration inflation, growth rates, salaries, taxes, etc.
As you do a little bit of math and if retiring by 45 or 50 or 55 is completely out of the question- I suggest that it’s time for us to take a long look in the mirror and re-examining our habits.
Did you realize the impact that some small tweaks could have financially?
It’s all about putting yourself in the position to succeed.

More Advice by Dave Denniston- The New Retirement 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
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 Sabine Fonderson MD
I have asked myself many times why some people wait till the moment before the break of dawn to have their most pressing issues resolved in the emergency department.
A 52-year-old male had come in by ambulance with difficulties breathing. The paramedic had also noted that, ‘the patient is known to have asthma and is on inhalers. All observations are fine’.
Yes, I admit there are also many times I wonder why paramedics decide to bring non-emergency cases to the emergency department for “assessment”. What more can be assessed if someone is fine?
When I ushered the patient into the cubicle I remembered how he gestured to his wife not to come in with him. But she ignored it and just walked right in.
‘What can I do for you?’ I asked the husband as he sat down on the chair.
‘I was having difficulties breathing tonight’
‘Yes, I read the ambulance triage sheet. How do you feel now?’
‘Better, I am not having breathing difficulties anymore. But doctor, can you please tell me why I am feeling this way?’

‘I do not know.’ I replied and thought to myself, if he had any sense, he would have thanked me and apologized for wasting everyone’s time and left the department.
But instead he sat there, staring at the floor as if he would find the answers to the breathing difficulties he no longer had and where they came from.
I rolled my eyes. Yes! I rolled them way up to the ceiling and back at him again because he was not even looking at me, and neither was his wife. She sat practically facing the door, ready to leap out.  I proceeded with more questions. The more I asked open ended question the longer it would take for him to give me a straight response, so I quickly reverted to questions that required a simple ‘yes’ or ‘no’ answer. It took me almost 6 minutes to get to the simple conclusion that he smoked despite his asthmatic condition. I felt the need to explain the effects of smoking.  As I proceeded to elaborate on how smoking can exacerbate an asthma attack, he felt the need to remain silent, and, to my amazement, he had fallen asleep. 
‘Why are you sleeping? Am I boring you’ I said in a raised tone. Even his wife startled and turned towards him.
‘Oh, sorry doctor. You see I have not slept in days.’
‘Yes, doctor, that is true,’ His wife confirmed. Speaking of sleep, I was so desperate to get out of the department and get some of it myself.

‘Why have you not been sleeping then?’ I was getting quite agitated at this point because that is not the main reason he was brought to the department and now he was forcing me to dig deeper into issues that, frankly, I could not care about, especially not when I had 5 minutes remaining till the end of my night shift from hell.
‘It is my wife….’ Long pause. Very long pause. ‘She is having an affair’
Well, I sure as hell did not see that coming. Daytime soap opera in the emergency department.
 
Soon a bickering match between husband and wife ensued. To my amazement, he had found his voice and started relaying all the events that led to the affair. He depicted in detail how when he was in the basement he could here her with her lover making love in the bed he brought.  Her lover was a nobody in India, and since he had lost his shop she had made it very clear how she despised him. She would not even look at him, and that is why he found himself hiding away in the basement, abandoned by his own wife. The shame he had felt was incredible. He could not talk to family and friends about this because he would be laughed at. He had already lost his shop and now his wife was having an affair with a poor boy from India.
She turned on him, repeating and confirming everything he said and looked at me as if I would take her side. 
I just sat there and listened as both husband and wife conversed with each other. I think something good did come out of this. There was some form of communication established between the two and for that second they must have felt like a married couple again. And I unintentionally became a marriage counselor

About the Author
Sabine Fonderson MD is an emergency medicine doctor in Scotland.  She is passionate about writing and is a freelance editor and content author for blogs and medical startups. Sabine is author of Unbelievable stories from the emergency department, published in May 2016.  She writes about her experiences as an ER doctor on her website www.sabinefonderson.com There you can also read how she has found creativity and flexibility in her professional life.

By Mani Saint-Victor MD
The biggest mistake physicians make in career transition is not imagining the possibilities broad, bright, and inspiring.  Whether fresh out of residency or haggard from a decade or two in industrialized medicine, when it’s time to think nonclinical it’s time to dig deep.

You’ve gotta reach inside to reawaken the inner child that you’ve been hushing in the corner as you built up discipline, practiced delay of gratification, and developed professional physician ways.  You’ve accomplished that piece. Celebrate it! Now it’s time for wide open, dreamy-eyed idealism.
This sounds ridiculously irresponsible.  It is- if you go about it without a plan.  In the age of the internet the best plan is to Google first.  Yep. Search and ye shall find.  But only if you are certain of what it is you want to find. 

Don’t fall for the usual trap of starting from a place of frustration.  You can tell you’re doing that when you start listing the stuff you don’t want:

1. Less hours at the hospital
2. Less tired
3. Less paperwork
4. No arguing with insurance providers
5. Less interruptions of my time with family

The list could go on.  That trap is bottomless and the relief that comes from catharsis feels good enough in the moment to pass for inspiration.
It’s not.
Instead start surfing the net for stories of inspiration.  What have other doctors done after they quit clinical medicine?  Beyond the obvious. Look for the meaningful.  Sure jumping over to a biotech firm, joining a healthcare startup, medical writing, public speaking, and even management consulting or joining venture capital firms are some frequent paths transitioning docs choose. 

But you’re a doctor, for goodness sake!  You went after one of the most challenging careers out there and you nailed it.  Bring back that indomitable spirit and imagine something wild yet aligned with your sense of purpose and go for it.
Most of us have forgotten how to freely imagine.  Cultural conditioning whispers:
“You’re too old to start that.”
“You’ve got bills to pay and that won’t make enough money to maintain your lifestyle.”
“Can you even imagine how much hard work it’s gonna take to work up from the bottom in another career?”
Again, Google to the rescue.

My single biggest lesson in my transition from clinical medicine has been to unlearn the beliefs I hold limiting my own potential. I’ve done this in three broad steps.  
First step: I looked at all of the stories about doctors who had made successful transitions that I could get my hands on. I studied their thoughts, feelings, actions, and mistakes.
Second step: I looked at at what people who made changes from other careers had done.  I looked for the same stuff but with an eye on perspectives from outside of medicine. The more mistakes I could see coming from different points of view the more confident I felt.
Third step: I got a coach. You need someone to keep you on track and to catch you shrinking your vision in moments of temporary defeat.

Read a ton of success stories. Notice the ones that set your spirit on fire. Notice which principles inspire you. Find communities who share those principles. You’ll learn fastest from like minded people.  Your curiosity and passion will drive you in pursuit of a career that matches and expresses your core identity.  
If you’d like to read a collection of revealing stories from inspiring physicians who have transitioned from clinical medicine then visit Thinking About Quitting Medicine.
 
Dr. Mani Saint-Victor, MD,  The Dropout Doctor

Physicians and medical students are often helping others and neglecting their own physical or mental health. Pamela Wible MD has done a lot of research in the area of physician despair, depression, and suicide. She also knows firsthand how being a doctor can take a toll. She knows how it feels when you hit rock bottom. Sometimes despair is related to your job, and sometimes it goes deeper than that.

If you feel overwhelmed, depressed or do not have the words to describe your needs- reach out to idealmedicalcare.org for help

By Reem Messeih
In today’s unpredictable economy, and the ever changing landscape of the healthcare industry, many medical professionals are looking for opportunities to diversify their income; and in particular, build a residual income that allows them to achieve optimal financial goals in their limited free time. While there are several ways to accomplish this plan, many are looking to the industry of direct sales. In this vast industry offering a variety of products and services, ensuring that a product/company’s mission and values compliments their own is critical in finding the right match.

Not surprisingly, many healthcare professionals are choosing to partner with the doctors and creators of Proactiv® Solution in their newest skincare endeavor, Rodan + Fields.

Many physicians, such as Dr. David Wiles, a neurosurgeon, have joined Rodan and Fields. Dr. Wiles posted this quote on his Facebook page: "I became a physician and neurosurgeon to help people. I still do that today, but the challenges to provide help to people have become exhausting. The practice and art of medicine is dying and is being replaced by the business of medicine. I am actively joining a business that allows me to help. Rodan+Fields is positive and uplifts people while offering a greater income potential than medicine offers. I will continue to fight insurance companies, CMS, hospitals, etc. for treatment for patients with neurologic diseases. And then, I will go home and relax with Rodan+Fields."

And Stephanie Moore MD, a cardiologist at Mass General, turned her Rodan and Fields business into the staring point for building her Medi-Spa, Vega Vitality, in the heart of Boston.
Female and male alike, medical professionals ranging from nurses, pharmacists, physicians or hospital administrators are all adding Rodan + Fields to their investment portfolios and resumes. So just what is attracting them to this company? In short, three things: the doctors; the products; the unprecedented opportunity. 

The Doctors:
Rodan + Fields products are not created by chemists or sole entrepreneurs.  These products are developed by two of the most esteemed dermatologists, with years of clinical experience, patents and accolades in the industry. Innovators in the dermatology industry, Stanford trained dermatologists, Drs. Katie Rodan and Kathy Fields had phenomenal global success with Proactiv® Solution. The doctors wanted to further their vision of bringing dermatology based skincare to the masses. A skincare solution developed for retail, originally, Rodan + Fields was sold in high end department stores and was among the top selling retail clinical skincare brands. However, the doctors recognized that given inevitable demise of the retail environment: their vision would never fully be realized behind the department store counter. Seeking to take advantage of the rise of social commerce in 2008, Rodan + Fields became the first premium skincare line to exit retail, and enter the world of direct sales, putting their own spin on the industry: no parties, no paperwork, no inventory.

Allowing their loyal consumer base to partner with them, open their own virtual franchises and share R+F’s clinically proven products with their networks has allowed the company to far exceed its retail sales volume and experience unprecedented growth. In 6 years, they became the “Fastest Growing Premium Skincare Brand”, and the “2nd Largest Premium Skincare Brand in America” (according to Euromonitor independent studies). 
They are among the Top 10 Female Entrepreneurs of the Decade. Still practicing physicians and educators, these women have a true passion for dermatology, and it shows in their practice and their products.
The Products:
Regardless of age, gender or skin concern, Rodan + Fields products appeal to a broad spectrum of consumers. That expansive potential market-share is quite appealing, as their target demographic is everyone that has SKIN. Rodan+Fields products are clinically proven and results driven.

The Opportunity:
Partnering with Rodan + Fields allows consultants to diversify their income potential and share in the growing multi-billion dollar anti-aging industry. Because these products are effective and consumable, not only are R+F clients loyal, but they also recognize the incredible opportunity in sharing these products and building their own businesses. While in the medical industry, a practitioner’s reach is limited by proximity to the patient, this business model allows consultants to reach beyond their location: consultants can share products with their networks nationwide, in Canada, and soon, in Australia. As a consultant builds a team, he/she can earn income on not only his/her own sales, but on the sales of team members as well. This residual income allows consultants to more quickly meet their financial goals without having to sacrifice time, while knowing that consumers across the country are getting the best products and achieving their best skin. 

Additionally, compared to the time and financial investment it takes to earn a medical/advanced degree in the industry, the investment and fixed overhead in Rodan+Fields is minimal, and virtually risk free.
The desire to impact people’s lives and help others is a common core value for medical professionals.  Rodan + Fields helps foster that impact, not only in terms of giving people the gift of great skin and confidence, but in building entrepreneurs that can then change their own financial future and the lives of others.  The markets’ embrace of social commerce, combined with the power of these doctors reputation and legacy, clinically proven products and their refreshing approach to entrepreneurship makes the opportunity to partner with Rodan+Fields unique.

Student Loan Management: Refinance Student Loans or Public Service Loan Forgiveness with Income Driven Repayment Plans by Amanda Liu DO
Not only has average educational debt grown drastically more cumbersome over the past decade, but decisions on how to manage one’s student loans have also become much more complex.
For the 2016 class of graduating medical students, there are 4 federal income driven repyament (IDR) plans: ICR (Income Contingent Repayment), IBR (Income Based Repayment), PAYE (Pay as You Earn) and REPAYE (Reviwed Pay as You Earn), in addition to standard, graduated, extended repayment plans.
Adding further complexity, for the first time in early 2015, residents and fellows are given the opportunity to refinance their federal and private student loans with 2 private banks: LinkCapital (currently out of funds to lend) and DRB. Upon becoming an attending, many more banks are willing to refinance doctors with large debt as well as high income.
Here’s a flow chart which summarizes the most beneficial repayment options for a typical post-graduate trainee with high debt-to-income ratio (50-70k income; 200k student debt). These options include IBR, PAYE, REPAYE, & refinancing student loans.

Student Loan Management for 4th Year Medical School Students & Post Graduate Trainees (Residents and Fellows)

Once you’ve decided to refinance your student loans, rather than going for income-driven-repayment & Public Service Loan Forgiveness, it is critical but challenging to shop for the best interest rate and term. One way to start shopping around includes asking friends for recommendations and applying to multiple banks simultaneously. When you apply to multiple banks within a short period of time, these inquiries will only count as one ding to your credit score. It is understood that you are simply shopping around for a big-ticket item such as student loan refinancing and or home mortgage.

I have been paying very close attention to the interest rates and terms that banks are offering for student loan refinancing and this is what my research has shown me. A friend of mine from Touro University in California who is now a practicing pharmacist refinanced her student loans with to a 15-year fixed 3.5% interest rate loan (she refinanced before the feds adjusted the prime rate up by 0.25%; the current 15 year fixed is 3.75%.) She is happy that not only is her  interest rate ½ of what she was paying before refinancing her federal student loans, but also the long 15 year term allows her to reserve more cash flow (than a shorter term loan) for retirement savings and down payment for buying a home in California.
I am happy to see that there’s finally a break for the medical professionals, especially those living in high cost of living areas such as many cities in California.
So I reached out to First Republic Bank, and after several weeks, I heard back from Kerry Berchtold, Relationship Manager at FRB.
FRB Rates (March 2016):

• 5 Year Fixed: 1.95%
• 7 Year Fixed: 2.65%
• 10 Year Fixed: 2.95%
• 15 Year Fixed: 3.75%

This is a 5 year fixed rate that is 1.55% lower* than competitors lowest rates in their published interest rate ranges. By paying 0.25% more with FRB, you get much better cash flow on a 15 year term rather vs. the 5 year term offered by most competitors.
*The lowest 5 year fixed rate with CommonBond, DRB, Creidble, or Sofi right now is 3.5%. If you qualify to refinance your student loans with FRB, you get the ONE published rate and term, not an interest rate somewhere in the range of rates offered by most other refinancing banks. For example, my friend with 800+ FICO score refinanced with DRB and got 5.65% interest rate (which initially surprised me as it was at the high end of the advertised range of interest rates for 10 year fixed loan). DRB explained that he didn’t get the low end of the range because his debt/income ratio was high, which is true of most typical PGY's with 200k+ debt and 50-75k in While DRB was the best option for him as a PGY4 (he would not have qualified with FRB due to geographic requirement and debt-to-income ratio requirements by FRB), I definitely encourage him to refinance again, when he becomes an attending.

To qualify:
#1:
It all hinges on debt-to-income ratio, which differs by individual circumstances. In general, attending physicians can qualify; tougher for PGY’s to qualify but never hurts to find out.
#2:
You have to live or work in locations FRB have banking branches, which include:
California, specifically San Francisco, Palo Alto, Newport Beach, Palm Desert, Los Angeles, San Diego, and Santa Barbara
New York, NY
Boston, MA
Portland, OR
Palm Beach, FL
Greenwich, CT
#3:
You Forego Potential Forgiveness such as PSLF like refinancing with other private banks.
This loan is a personal, unsecured loan with all that entails. It doesn’t go away if you die (and will be assessed against your estate.) It goes away in bankruptcy. There are no provisions made for unemployment, underemployment, death, or disability. So be sure you have enough life and disability insurance to cover the amount borrowed.
#4:
 $60k-$300k Range: FRB won’t refinance loan amounts lower or higher than this range. If you have 300k+ in student loans, refinance 300k with them to get the lowest rate/best term, and then refinance the excess portion with another bank. If you have less than 60k in student loans, you are in pretty good shape. You can still refinance with other banks like DRB, common bond, Linkcapital, Earnest, etc.
Dr. Wise Money (DWM) is a 1st year resident (PGY2) in the Department of Medical Imaging at Banner University Medical Center. As DWM achieves her financial goals of purchasing a home (MS4), paying off student loans (PGY1), & maxing out retirement savings (starting PGY2), she begins writing and giving talks on personal finances for doctors to help her colleagues also achieve financial success. DWM firmly believes that financial freedom makes better and happier doctors. DMW is featured websites including White Coat Investor and nonclinicaldoctors.com. You can follow DWM at drwisemoney.com. Email me at drwisemoney@gmail.com for more information.