Live like a resident

The single best piece of personal finance advice I ever received was to live like a resident.

Fall 2013 | Feature Articles | Uncategorized

 

This applies not only to residents who need to learn to live on their limited salary instead of taking on additional lifestyle loans, but especially to brand-new attendings.

The solution to the many financial dilemmas that physicians face resides in the choices they make in their first five years out of training. If they can just avoid growing into their attending salary (or beyond) all at once, then there is plenty of money available to pay off loans, purchase a nice home and catch up to their college roommates with regards to retirement savings.

Physicians who have been living off $40,000 per year who now have a $200,000 salary can live off $80,000 and easily cover the additional taxes, student loan payments, insurance expenses, and still carve out plenty of money to build wealth while living a significantly increased lifestyle.

But if they immediately upgrade their lifestyle to $150,000 a year, they’ll feel like they are living paycheck to paycheck the rest of their lives. The secret to a comfortable life lies on the spending side of the equation.

 

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Happiness without Babe Ruth

These four cities are major hot spots when it comes to physician opportunities and livability—even if their sports teams happen to make only the Minor League.

By Eileen Lockwood | Fall 2013 | Live & Practice

 

In many cities, it doesn’t take big sports names for the calendar to be busy and the stadiums kept full. The calendars are so packed with other athletic events that LeBron James, Peyton Manning and Derek Jeter are hardly missed. We scanned the map in search of happy Minor League havens and selected four good examples: Spokane, Wash.; Norfolk, Va.; Providence, R.I.; and Montgomery, Ala.

360 DEGREES OF HISTORY
Montgomery, Ala.

There’s a special street corner in Montgomery where all the major aspects of city history come into view.

Standing at the venerable Court Square Fountain, built atop an artesian basin in 1885, a history buff can view the important buildings involved in the city’s most notable upheavals. As Meg Lewis at the Convention & Visitor Bureau puts it, “There’s no other place in the world where you can stand on one street and see 360 degrees of (Civil War and) civil rights history.”

Straight ahead at the end of Bainbridge Street sits the state capitol where Jefferson Davis stood in February 1861 to take the oath of office as the Confederacy’s first president. (Montgomery was the capital for a short time before Richmond took its place.) South of the fountain is the Winter Building, where the telegram proclaiming the start of the war was sent. A block south is the first White House of the Confederacy.

Just a block before the capitol building is the now-named Dexter Avenue King Memorial Baptist Church, the first pastoral assignment of Martin Luther King and the starting point for many civil rights activities. One block south of the church, though out of sight from the fountain, two “newcomers” enhance the scene: the flat black marble Civil Rights Memorial fountain and, behind it, the new Civil Rights Memorial Center. Exhibits there include the stories of 40 activists who lost their lives between 1955 and 1968. Two blocks south on Court Street is the Greyhound station where Freedom Riders got off the bus on May 20, 1961.

And—somewhat visible on the street behind the fountain—is the Rosa L. Parks Library and Museum, built at the spot where Parks got off the bus after her defiant ride.

Though these monuments can conjure painful memories for them, capital city residents recognize their significance. But they’ve also moved on to create an atmosphere that’s brought the city into modern times.

Downtown Montgomery’s Riverfront Park includes an ampitheater, splash pad, riverboat and the Riverfront Stadium, home to the Tampa Bay Rays’ AA team, the Montgomery Biscuits.

Mobile native Brian Richardson, M.D., accepted a urology position in 2011 with the Jackson Clinic, affiliated with Jackson Hospital, following a University of Florida internship at Shands Hospital in Gainesville and surgical training as chief resident at Tulane University in New Orleans. He specializes in minimally invasive urologic surgery using state-of-the-art robotic, laparoscopic, percutaneous and endourologic techniques. “One of the best things about working here,” he says, “is the very close community of urologists. They provide top-notch care, and there’s a nice collegial atmosphere. We share information and get along very well, even when we have no financial ties.”

At Jackson, “state-of-the-art” isn’t confined to urology. Founded by a group of local physicians in 1946, it’s been steadfast in adopting new methods and technology. Most recently, it became the region’s sole provider of scarless robotic gallbladder surgery. This followed the installation of the STERIS Corporation integrated operating room and the new daVinci SiTM system. Five years ago, the hospital took the local lead with this center for robotic and minimally invasive procedures and now has the most comprehensive area program. The STERIS partnership has been fruitful for both parties. With a large manufacturing facility in Montgomery, the company has been able to show Jackson’s equipment to sales prospects from other cities.

The hospital has added another neurosurgeon to its staff for state-of-the-art minimally invasive spine procedures in two I-suites complete with new equipment. Thanks to these and other upgrades, spokesman Peter Frohmader notes the hospital “has all the services that would be found in a medium-sized community. The only things you need to leave Montgomery for are transplants and experimental procedures.”

In the meantime, the city’s two Baptist Medical Centers—East and South—have been preparing for the future by incorporating new methods to shorten treatment and recuperating times as well as introducing a wide range of wellness programs—and working to help patients reduce risks of illness and disease by teaching them to live healthier lives.

The city itself surprised Richardson. “We used to drive through Montgomery but never (spent time) here,” he remembers. “When I actually got here, I really was impressed with the growth of the city and the kind of direction (it was going in), as well as the vision of city leaders. It’s a much different city than it used to be.”

He soon discovered that fact when hospital representatives took him on a pre-arrival tour. “They showed me around several places and the nice neighborhoods. But when they showed me the downtown, I said, ‘Well, my decision’s already made. I’m moving downtown when I get here.’” He lives in a top-floor loft apartment with a balcony.

The downtown trend is likely to continue, he says, citing plans circulating for about 200 to 300 new condos in the next three years. “Now people are actually staying and enjoying the things that are going on down here.” Besides “all the good restaurants, there’s a performing arts center with concerts almost every weekend—and not by groups you’ve never heard of.” Adding to the congenial ambience, “There’s live music downtown literally seven days a week, both inside and outside, including bands in bars.”

Downtown is even a convenient location for some of the city’s sports events. The Tampa Bay Rays’ AA baseball team, the Montgomery Biscuits, plays at Riverwalk Stadium, once the site of a Confederate prison. If only those old prisoners could have known that the new land occupant would be rated among the top five best food arenas.

The stadium is only one of several recreational facilities in the park along the Alabama River. Among them are an amphitheater, the River Skate Park for skateboarders and bikers, and even a new Bark Park for canine recreation.

In fact, the city is inundated with sports events and opportunities, played at a large variety of arenas and outdoor complexes. There are kickball and softball leagues, as well as high school and college basketball games. A new YMCA soccer complex boasts eight fields. Tennis courts abound, and an annual highlight is the Blue Gray Tennis Tournament for college athletes.

Plus private and public golf courses. In fact, even a Robert Trent Jones course is a mere 10-minute drive away for Richardson.

Besides sports, new efforts are in progress to encourage healthier eating and to spark inquisitive minds. E.A.T South is a program in which participants establish urban gardens and learn how to prepare southern foods in much healthier ways. That includes starting school gardens and lobbying with school cafeteria managers to serve meals prepared from the crops.

Soon to come is Questplex, a dramatic new hub for learning, as promoters describe it. In the “all-purpose learning center,” people of all ages will explore nature, learn new career skills and participate in brainstorming exercises, complete with interactive technology “to customize the experience for each visitor.” The guiding force: “Children can be inspired for a lifetime of learning.” It’s hard to think of a more important goal.

The Creative Capital
Providence, R.I.

Strictly speaking, Providence is bereft of Class A renowned sports teams. But for residents, that’s a mere matter of opinion. “We’re closer to Gillette Stadium than Boston,” says Kristen Adamo at the Providence Warwick Convention & Visitors Bureau. “So we like to think of the Patriots as our team, too.”

Not only that. “New England” is an unwittingly apt title for the Patriots, because they help add greatly to the coffers in Rhode Island. Adds Adamo, “Their opponents—and the media—stay in the Providence area because it’s cheaper. And it’s wonderful when the Patriots make the playoffs. The economic benefits are terrific!”

“There are lots of Patriots fans around here, and sometimes they offer to take me to a game,” says Louis Rice, M.D. “But the games are usually in December, and it’s too cold.” Having moved to Providence from Cleveland three years ago, Rice also says, “I’m still a suffering Cleveland Browns fan.” As for baseball? “I was a Red Sox fan when I was in college (Harvard), but I was so disappointed the year that the Yankees beat them in the playoff game.” In Cleveland, the Indians became his baseball team of choice.

Now once again he’s caught in a love-hate situation. “I played football in college. My oldest son is a 2010 Yale graduate. He was a catcher on the baseball team, but now he coaches linebackers on the Yale football team. Bottom line: “It’s always difficult rooting for Yale.”

Nevertheless, for true Patriots fans, transportation is super-convenient, Adamo points out. “The Massachusetts Bay Transit Authority runs trains from the airport in nearby Warwick to the stadium, and there’s also a Massachusetts subway system.” And: “The Pawtucket Red Sox are five minutes away.”

For Adamo, this accessibility is a great asset. “That’s the beauty of Rhode Island,” she says. “It’s such a compact state that it’s easy to get from place to place.”

Providence, R.I., attracted Louis Rice, M.D., with a great job opportunity­—and the added bonus of being close to the ocean in a beautiful location. As for sports? “I’m still a suffering Cleveland Browns fan,” Rice says.

Rice couldn’t agree more. “Cleveland was a great place to live,” he says, “but there weren’t a whole lot of beautiful places nearby,” a contrast underscored when he and his wife decided to explore their new home area. “Going over that beautiful bridge to Newport, we couldn’t believe it was only 40 minutes away from Providence.” Even more important for Rice is the “real privilege” of being close to the ocean after 20 years in Cleveland, Lake Erie notwithstanding. In a way it was a homecoming because of his childhood years between New York and Boston, followed by college in Cambridge, medical education at Columbia University and a series of fellowships in Boston.

Closeness is a key word for those whose sports interests go beyond the Patriots. Cheering fans flock to the newly refurbished Dunkin’ Donuts Center to watch the Providence Bruins of the American Hockey League and the Providence College Friars as they take on Division I basketball opponents. “The Dunk” is also a concert and large-event venue. In the great outdoors, Brown University football and Bryant University lacrosse can also boast big attendances.

There’s also an impressive lineup of other sports, spectator and participatory, and some more exotic than others, including the Rhode Island Rebellion (rugby), the Roller Derby (roller skating) and bocce ball, with teams sponsored by local businesses. There’s a Rock ‘n Roll Providence half marathon, plus road races and ice skating at the Bank of America Center. And sailing along a seemingly endless coastline.

Rice was chief of the medical service at the VA Medical Center in Cleveland when he was offered “new challenges” in Providence—positions as physician-in-chief with Rhode Island and Miriam Hospitals, as well as executive physician-in-chief at three other hospitals. He’s also a professor of medicine at Brown University’s Warren Alpert Medical School. Rhode Island Hospital is the school’s principal teaching hospital and is one of three acute care Providence facilities of Lifespan, the state’s largest health care system. One is Hasbro Children’s Hospital, which is incorporated within Rhode Island Hospital, and The Miriam Hospital is the third. There are three other acute care institutions in the city.

Lifespan’s two “adult” hospitals are working hard to cut costs by merging key programs such as cardiac services, orthopedics and bariatric surgery. For instance, all open-heart surgery is now performed at Rhode Island. A newly created Total Joint Center is located at The Miriam. To ensure that more patients keep up with medications, Lifespan has opened an on-site pharmacy at RIH to dispense prescriptions and, for the general public, to provide adult vaccinations. Ambulatory care centers have been set up around the state and include lab testing, checks on implantable devices and, coming soon, infusion facilities for cancer patients. The impetus for the centers, as spokesperson Ellen Slingsby explains it: “We’re going from a hospital system to a health care system with a focus on making care more convenient for our patients.”

Roger Williams Medical Center, named for the revered founder of the state, is one of two member hospitals of CharterCARE Health Partners. The two institutions have been promoting collaboration, especially in efforts to reduce costs, strengthen core services, add new ones and increase patient access. Among most recent initiatives has been geriatric-specific training for all staff members, with special emphasis on safer and more agreeable surroundings for patients, such as non-skid floors, portable hearing aids, magnifying devices and soft music.

The presence of Brown University and four other higher learning institutions is bound to influence local culture, which Rice suspects has something to do with “the terrific theater here for reasonable prices.”

With all the culture to experience in Providence, there’s still a sports-related goal on Rice’s “to do” list: “My hope is to turn a not-very-good golf game into a reasonable game.”

With the city’s considerable number of courses, that seems like a reasonable plan.

Dynamo of the Inland Northwest
Spokane, Wash.

‘‘Sports don’t just entertain. They improve communities. They drive economies.” Thus sayeth the sages from the Spokane Sports Commission, a dedicated organization that recruits and often manages athletic tournaments, nurtures a mind-boggling array of local sports activities and lobbies for more sports venues. “And it’s not all about (Major League) baseball,basketball and football,” says Eric Sawyer, the commission’s CEO.

Think sellouts like NCAA tournaments and figure skating events. Consider 100,000 players in Hoopfest, the world’s largest three-on-three basketball tournament; Bloomsday, the U.S.’ largest timed road race; a dual lane roller derby, and—one of Sawyer’s favorites—the National Blind Bowlers Championship. “We encourage any ‘adaptive sports,’ such as wheelchair events and almost any competition with opportunities for the handicapped,” he says.

Other options include the Spokane Indians (baseball), Shock (arena football), Shine (soccer) and Chiefs (junior ice hockey). The Indians, a short-season single-A affiliate of the Texas Rangers, consistently fill their 6,800-seat stadium. The list of spectator and participatory sports goes on and on: volleyball, gymnastics, wrestling, boxing, figure skating, polo, table tennis, Ultimate Frisbee, chess…. Then add college sports at Gonzaga University, Washington State University Spokane and Whitworth University.

Not enough? Try the volleyball Border Smackdown for U.S. and Canadian boys; the eight bike races in the Lilac City Twilight Criterium; the Citizens Ragtag Rally, welcoming “every kind of bike”; and the Dirty Dash, a mud course obstacle race.

Little wonder that Outside magazine has cited Spokane as “one of the most active cities in the U.S.”

Less publicized is the economic advantage of sports tournaments. In Spokane, the related hotel income alone is $30 to $40 million a year.

After moving to the city two years ago, Anna Barber, M.D., quickly became immersed in the Bloomsday race and was definitely impressed by the number of participants—50,000. She and her perinatologist husband couldn’t resist watching the horde of young participants at Hoopfest, either. “They shut down downtown and turn it all into 3-on-3 basketball courts,” she says. They’ve also taken in baseball games, and have cheered on the Gonzaga hoopsters at least once even though, she says, “It’s ridiculously hard to get tickets.”

The original goal for the Doctors Barber was to locate to a big city—but not too big—conveniently located near where they grew up: She in Seattle and he in Great Falls, Mont. She had graduated from the University of Washington School of Medicine and finished her residency at the University of California–Davis, then hired on for four years as a general pediatrician with Kaiser Permanente.

But for more permanent job placements, Spokane became the obvious solution. Two years ago, she signed on as a pediatrician working out of Providence Holy Family Hospital, one of four vicinity facilities in the Providence Health & Services group.

Though the sports lineup is massively impressive, it’s hardly the only act in town. According to chamber of commerce Greater Spokane Inc., the city has been “the state’s primary inland distribution center and transportation hub since 1881.” It also holds its own as a center of medical care, shopping and entertainment. Today’s corporate mix includes health-related companies such as Signature Genomics Laboratories, Jubilant HollisterStier and Applied Science Laboratories.

There’s another less-noted plus, according to Wendy Smith at Greater Spokane, Inc. The city has been ranked America’s sixth geographically safest city by the data analyst Sperling’s Best Places. There are no tornados, nor hurricanes, earthquakes, flooding, drought or hailstorms.

Health care is no small part of the mix. Providence Health Care is now the major medical presence and a top employer in Spokane. A second large medical presence is the Rockwood Health System, with its Deaconess and Valley Hospitals. Spokane is also one of 22 U.S. locations of the Shriners Hospitals for Children.

Founded with 29 beds in 1896, Deaconess has grown to 388 beds and offers exclusive care as a bariatric surgery center, certified chest pain center and accredited stroke pain center. Valley Hospital, founded more recently (1969) by 14 physicians and located in the nearby city of Spokane Valley, was the first area facility to be accredited for joint, hip and knee surgery. Recently, the hospital was the sole recipient in northwest Washington of an “A” grade for quality and safety from the Leapfrog Group.

Most recently, the Providence group has made strong efforts to collaborate with “like-minded organizations to advance health care access, affordability and excellence.” In May it signed a memorandum of understanding with two other groups to form a regional cancer alliance that can coordinate services and information, resulting in the most modern care available. A Surgical Plus program has added to its minimally invasive capabilities, enabling better and safer results from neurological procedures. Other recent and projected services include an emergency department expansion, upgraded maternity services and a pain management clinic.

However, the current local medical highlight is the August consolidation of Washington State University’s School of Medicine on its Spokane campus. Now medical students can complete all four years there. WSU Spokane plans to create a comprehensive health sciences curriculum that will include colleges of pharmacy and nursing, public health and health policy and a collaborative dental program. “This is all part of our attempt to create an urban research campus using medicine as a jumping-off point,” says spokesman Doug Nadvornick. Equally important: “There are currently 70 medical residency slots in Spokane. One of our (other) big issues is the need to create new opportunities. We’d like to keep (those doctors) here.”

Those who do stay get 260 days of sunshine­­—conducive to any outdoor sports they’d like to try on their own.

Nautical—And Then Some
Norfolk, Va.

With the U.S.’ largest Naval base—not to mention shipbuilding, shipping and cruise businesses—water-related breadwinners create an impressive percentage of residents. The five-city Coastal Virginia region (including Norfolk) is also one of the top five U.S. retirement havens for veterans.

The story of Coastal Virginia is “the story of water,” says Sarah Martin Lampert, development vice president at the area Chamber of Commerce. It’s hard to deny.

The Virginia Port Authority continues to move toward its goal to handle the greatest shipping tonnage on the East Coast, especially promoting its ability to handle deep-draft containers.

Water proximity also played a role in the decision by Aaron Bleznak, M.D., to relocate to the Coastal Virginia region, although the job was his main lure. A specialist in breast surgery and surgical oncology, he’s now vice president and senior medical director with the Sentara Medical Group, a division of Sentara Healthcare. His responsibility covers all seven Sentara hospitals in the Coastal Virginia area, but he’s headquartered in Norfolk, where Sentara Norfolk General Hospital is located. The job enticement was the opportunity to combine an administrative role over hospital-based physicians with a clinical role. Previously, in Lehigh, Pa., his administrative role as vice chair of surgery was confined to supervising surgeons only.

The water-related consideration in his relocation choice was his calculation that a shore ambience would be a more enticing place for his four children, as adults, to visit. Also with the offspring in mind, he and his wife chose to live in nearby Virginia Beach. “My youngest daughter is an equestrian, and that’s where we keep her horse,” he says.

Another plus for Bleznak: “There’s more sunshine here, and   we can be out of doors more,” including on the nearby beach. It’s also a better place for people with allergies, he says.

Sometimes the out of doors involves viewing the Norfolk Tides, a farm team of the Baltimore Orioles. But Bleznak is selective. “We’re Philly fans, so we go (to the stadium) when the Lehigh Valley IronPigs come in.” Ditto for the Norfolk Admirals of the American Hockey League. Bleznak holds out for the Phantoms, the Philadelphia Flyers farm team.

Other residents can find good sports alternatives to the major leagues. Says Alan Boring, Norfolk’s business development manager, “If you like baseball, hockey, basketball, football, soccer…you’ve got it.”

Old Dominion University fields a very popular men’s basketball team, and its Division I football games have sold out every home game. “The oceanfront,” he adds, “is just 15 minutes away, with beach volleyball, surfing and beach marathons.” Or just plain swimming, relaxing and watching giant ships coming into port.

Nautical history buffs should be prepared to spend hours—and hours—in two area museums, plus a tour of Battleship Wisconsin anchored alongside the exhibit-filled Nauticus National Maritime Center, and harbor cruises take passengers past other ships and unloading piers for huge commercial cargos. According to one tour guide, “It’s said that all the ships in the world could anchor there and still leave room for more.” A few miles north, in Newport News, is the spectacular Mariners’ Museum, cited as one of the world’s largest of kind.

But when it comes to well-being, most Norfolk residents feel more reassured by the presence of the city’s four acute care hospitals. Under Sentara’s aegis are two acute care facilities—Sentara Norfolk General Hospital and Sentara Leigh Hospital. The mix also includes the specialty Sentara Heart Hospital, as well as several subsidiary facilities.

Norfolk General was founded as the 25-bed Retreat for the Sick in 1888. Almost a century later, its modern-day facility was the setting for the birth of America’s first in-vitro baby.

As of today, its surgeons have checked off more than 2,200 heart, kidney, pancreas and kidney/pancreas transplants and saved hundreds of lives because of its eICU remote monitoring capability. It was the region’s first magnet hospital, recognizing its quality care, nursing care and innovation—and first in the U.S. to fully deploy and independently test the intensive care management system.

Its full-service maternity pavilion is a mere down-the-hall walk from the NICU in the Children’s Hospital of the King’s Daughters. The two hospitals are physically linked but part of separate corporations. Its modern version is still the only freestanding facility of kind in Virginia. Not only is it connected to Sentara Norfolk General, but, says marketing/public relations manager Sharon Cindrich, “Our physicians and surgeons can go over to Sentara to check on babies, if needed.”

With a network of 109 pediatricians, Cindrich says, “We’re constantly innovating and updating.” Physicians in Cancer and Blood Disorders Center follow hundreds of patients with cancer, sickle cell and coagulation disorders, but its worldwide attention-getter has been a minimally invasive surgical technique devised by Donald Nuss, M.D., to repair chest wall deformities.

On the lighter side is the Buddy Brigade, organized in 2005. Volunteers bring dozens of dogs, reports Cindrich, “in every size and breed and age” to cheer bedridden patients.

“It’s wonderful and highly appealing to the folks here,” she says.

Norfolk’s Bon Secours DePaul Medical Center dates to 1855 when nuns went door-to-door treating yellow fever victims. Fast forward to 2013 and a Catholic health system with 19 acute-care hospitals and other facilities in six states. Among its notable state-of-the-art services are its hyperbaric and neurovascular centers and the region’s only Midwifery Birth Center, complete with private family rooms and queen-sized beds, plus Jacuzzis for relaxation during labor.

An important medically related source of pride for Norfolk residents—and hospital personnel—is the Eastern Virginia Medical School, which opened in 1973 with a student body of 23. In 2013, there were 332 graduates, about half from its companion School of Medical Health Professions composed of 11 nationally recognized disciplines. Its first building was completed in 1978.

There are 10 today, with a full- and part-time faculty of 461, complemented by 1,387 volunteer teaching physicians. As an aside to the benefits of producing so many valuable graduates, the 2012 economic impact for the community was $824 million, equivalent to $1 billion in good economic times. The local Economics Club cited the school as “one of the region’s most powerful economic engines.” And that’s no old seaman’s tale.

Eileen Lockwood is a frequent contributor to PracticeLink Magazine.

 

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Making $$ Moonlighting

Moonlighting—working during your off hours while you’re finishing your training—might eat up your free time but can help ease your financial stress.

By By Chris Hinz | Fall 2013 | Feature Articles

 

Brian Hurley, M.D., didn’t go into his psychiatry residency at Boston’s Massachusetts General Hospital aiming for a mix of moonlighting shifts. Although working part-time was a definite senior-year goal, he hadn’t thought initially of spreading his talents over several places.

“Being a good moonlighter for me has always been about being a good resident,” says Brian Hurley, M.D. “…The stronger I am clinically, the better I’d be taking care of my patients.”

But as a business school graduate, Hurley sensed the value of his skills and the fact that he could stabilize his moonlighting income by parlaying his abilities in several places. He wouldn’t have to depend on pay based only on an hourly rate, which may not be that high, or patient volumes, which can vary with each shift. Instead, he’d benefit from differing compensation approaches.

If McLean Hospital, the second facility in his residency program and one of his part-time employers, doesn’t need him, he can pick up shifts at other hospitals.

For Hurley, it’s a win-win. By averaging 10 to 15 part-time hours a week, he’s not only supplementing his income in an effort to shave $400,000 in school loans, but also expanding his skills. He excels at emergency psychiatric evaluations and consultations on patients in distress. Moreover, Hurley is demonstrating that maximizing your moonlighting experience starts by prioritizing training.

“Being a good moonlighter for me has always been about being a good resident,” he says. “I spent the first years of my program becoming the best clinician possible. I believed the stronger I am clinically, the better I’d be taking care of my patients…the better I’d be at moonlighting.”

Is moonlighting for you?
Perhaps you’re of the same thinking. Saddled with debt and the economic realities of living on a stipend, part-time work can be very alluring. The money you earn in a night or on a weekend can ease the financial pressure, adding favorably to your compensation mix. But how do make the best of the experience? How do you ensure that in earning and learning from moonlighting, you’re not cheating your residency or putting patients at risk?

Truth is, every residency or fellowship program must craft moonlighting policies that reflect strict guidelines of the Accreditation Council for Graduate Medical Education (ACGME) for when, where and how you can act independently outside the scope of training. Included are a bevy of items, from requesting permission of your program director to logging your part-time hours. In between are stipulations for obtaining a full medical license and presenting a signed contract plus proof of professional liability coverage when you go beyond the protections of training.

Since program directors don’t usually deviate from those rules, you need to be aware of precisely what’s required of you in satisfying them. But you’ll also have other things to keep in mind in reaping the full financial and educational benefits of any part-time position. Even if you can’t start moonlighting until you’re a few years down the training pike, you can get your credentials in order, explore your options and set realistic goals for your skills.

“Transparency is great for all things in life,” says Gary Frishman, M.D., director of the OB/Gyn residency program at Providence, R.I.-based Women & Infants’ Hospital/Warren Alpert Medical School of Brown University. “So make sure that you know in your heart that this is within your scope of experience, since no program director wants to read about his or her resident getting into problems on the front page of the paper.”

Follow the rules
Since program directors are serious about every aspect of training, not surprisingly many have concerns about extra responsibilities. The common worry is that the time you spend elsewhere will impinge on your program tasks by zapping your energy and mental alertness.

As Thomas Swoboda, M.D., residency program director for emergency medicine at Louisiana State University (LSU) Health-Shreveport, observes: “The main job of our residents is residency, not moonlighting. It’s to learn and take care of patients in the facility where they’re hired to train. Moonlighting cannot affect those obligations. It simply cannot.”

Adds Barrett Bradt, M.D., chief resident of the same program and a seasoned moonlighter: “Our chairman obviously understands that the major motivation for any young doctor to do this is money. But he really hammers home that our primary objective needs to be experience. My motivator initially was the money but I can honestly say that the most beneficial aspect has been the experience.”

If, like Swoboda, your chief is open to the concept of part-time work, however, it can be a positive proposition for everyone. But nothing will short-circuit your efforts faster than going behind your director’s back. Instead, by first asking permission and then following every directive, you’re on track to maximize this experience.

From there, the most critical requirements will be that you remain in good academic standing and don’t push the envelope in terms of your duty hours. “The deal breaker for us is that they have to be academically strong,” Frishman says of young doctors in his program who are allowed to take graduated part-time assignments as they progress from years two to four. “It would be inexcusable if moonlighting took away from them graduating as the best OB/Gyns possible.”

No matter how much you want to earn, remember that any part-time job has to fit ACGME’s 80-hour averaged workweek with appropriate consecutive hours off between shifts. And don’t be surprised if your director limits what you can do, especially if he or she senses that you’re overwhelmed by your academic requirements or facing a demanding rotation. Upper-level residents working in the internal medicine program of Cleveland-based University Hospitals Case Medical Center, for instance, are forbidden to moonlight when they’re assigned to an acute, critical care or other rotation that’s likely to approach 80 hours. But they’re free to spread their wings during shifts with small enough time commitments to buffer their part-time pursuits.

In either case, Keith B. Armitage, M.D., vice chair for education and residency director for the department of medicine, is always monitoring his residents for their mental and physical well-being, especially if he’s concerned that someone is moonlighting excessively to cover a personal issue. “We don’t want people to exhaust themselves,” says Armitage. “We promote a work-life balance in our training program, so we want to make sure that our residents aren’t working too much.”

As a third-year psychiatry resident training at Northeast Ohio Medical University, Elizabeth Menefee, M.D., recognizes that any moonlighting shift can be labor-intensive and exhausting, given the fact that it has to fit between her regular shifts. So she limits her overnight moonlighting on-calls to no more than once a week or three times a month at a psychiatric emergency facility that’s also a required external rotation for part of her training.

Although the lure of additional income initially drove her interest in part-time work, she and her husband aren’t dependent on it, so she’s fashioned a schedule that’s doesn’t intrude on their personal lives. “For me, it’s really been about finding that balance and making sure that I set limits,” she says of the part-time shifts during which she’s evaluating and treating patients in crisis. “If you’re doing this for financial reasons, it can be very appealing to work up to 80 hours, but you can burn yourself out. For me the answer to that was ‘No.’”

Credentials are critical
Whether a second job is in your near or far future, you’ll want to secure the credentials you’ll need to work outside your program sooner rather than later. Since the only way to practice independently in a setting separate or “external” to your residency is via a full license, you’ll want to apply when you’re first eligible, depending on your state licensing board.

In the meantime, you may find an “internal” opportunity within the same location or system as your residency for which you can use your training license. Frishman’s program, for instance, allows OB/Gyn residents to work outside the hospital during their fourth year. It’s not always an attractive option, however, especially for doctors who aren’t sure they’re staying in Rhode Island post-training. The hassles and cost of securing a license they may not need long-term can discourage them from jumping through the hoops.

Instead, residents often participate in hospital-sponsored moonlighting opportunities, handed down year-to-year. By focusing on non-direct-patient-care tasks (such as teaching medical students about physical exams), they can use their training licenses to make extra money as early as year two. More importantly, besides being within their scope of abilities, the jobs are in-house so they’re still under direct supervision.

“This is a win-win for everyone,” Frishman says. “Our residents are helping out with teaching, which we take great pride in. They’re also performing a service at the same time it’s educational for them.”

If your target is that external position, however, make sure that your DEA number and other pertinent certifications are up-to-date, especially if you’re headed to a setting where they’re paramount. And above all, allow plenty of time for the paper chase.

At Fairview Health Services, a Minneapolis-based health system, for instance, once physician leaders have approved a moonlighting resident or fellow, managers start the necessary processing to ensure that a person’s privileges and payer enrollment status are approved so the facility can bill for their services.

“We try to streamline this as much as possible but it’s still an important activity,” says Lynne Peterson, Fairview’s manager of physician recruitment. “Residents can’t just say, ‘Hey, I want to moonlight’ and expect to do it next week. They really need to think about it sooner rather than later.”

When her moonlighting opportunity got cut due to budget cuts, Danielle McDermott, a Colorado neurologist, was fine with the change, which gave her more time with her family. “You really need to think, ‘Is this worth sacrificing the little time that you have outside your program?’” she says.

Danielle McDermott, M.D., MS, a University of Colorado-Denver epilepsy fellow, was a third-year neurology resident when she secured a full Colorado medical license to facilitate her integrated medicine practice part-time position. Although McDermott’s program doesn’t allow residents to practice independently within the scope of their specialty until they’re finished with training, she was able to perform basic assessments on the patients who sought the clinic for treatment of their headaches, backaches and other chronic pain. She also negotiated for her employer to pay her malpractice coverage and DEA certification.

When McDermott’s part-time job, which spanned her last year of residency through her first year of fellowship, ended in a cost-cutting move, she was fine with it. Even though the money had drawn her in, she decided that with a husband, child and demanding program she needed to prioritize family and studying. “You really need to think, ‘Is this worth sacrificing the little time that you have outside your program?’” she says. “I realized that there were better things I could do with my time.”

Back to business basics
Because making good business decisions is as important to moonlighting as it is to other parts of your career, you want to nail down any items, such as your contracts and professional liability coverage, that might affect your availability for extra work.

Nothing will take the wind out of your sails faster, for instance, than realizing after you’ve lined up a position that your residency or fellowship agreement doesn’t allow it. Even if the contract permits it, be aware of the language since it can vary significantly, from policy particulars to innocuous clauses such as “at the discretion of your director.” You want to know what you need to do to stay in good standing.

As to a moonlighting contract, if you’re doing “extra duty” or part-time work in-house, you probably won’t have to sign elsewhere since it’s all part of the same structure. But if you’re going outside your program or system, expect (or even ask for) a contract that details hours, duties and malpractice coverage. Also make sure it doesn’t contain clauses that impinge on your residency commitment. A restrictive covenant, for instance, can actually prohibit a doctor from renewing his or her program contract, says Eric Katz, M.D., program director and vice chair for education for the department of emergency medicine at Maricopa Medical Center in Phoenix.

For that reason alone, Katz recommends sharing your moonlighting contract with your director if it’s not already required. “Our job as program directors is to be a little bit paternal,” he says. “But it has to be made clear for everybody involved that a person’s residency is his or her primary job.”

The contract McDermott signed not only covered the basics but detailed specific items important to her. Besides indicating that either of the two parties could end the agreement at any time, McDermott wanted a stipulation that it would be her choice as to whether or not she would prescribe a narcotic medication. As a neurologist, she’s well aware of the addictive nature of such powerful drugs. “I wanted to make that decision on my own,” McDermott says. “I felt strongly that I needed to be in control.”

You want to be equally certain that your malpractice coverage is sufficient. If your part-time work is internal, you may or may not have to get a separate policy, depending on what you’re doing and where you’re doing it. If it’s extra duty work for pay at your training location, for instance, your services may fall under your existing policy, even if you have to obtain an extension. Then again, if you’re working at another facility that’s part of your program, you might have to show proof of separate coverage.

If you’re moonlighting externally, the usual scenario is that you have to get separate malpractice coverage, either from your new employer or on your own. It’s unlikely that your training coverage will follow you, even though you might be lucky. Hurley, for instance, doesn’t have to purchase anything on top of what his program already provides for the places where he moonlights as long as his director has signed off on them. “That’s been of real value to me.”

Besides proving that you have coverage, make sure that you understand the parameters. Is the policy occurrence or claims made and what does that mean for coverage now and with future claims? Do both require a tail policy or just a certificate of insurance to show that you were covered for services rendered during your moonlighting stint? Will you be safe if you were under an umbrella policy that’s still in place for the practice or once you leave are you on your own? You need to know.

Despite her employer’s willingness to provide malpractice coverage, McDermott hadn’t pushed for a tail policy, partly because she was unfamiliar with the nuances of professional liability. So when her original coverage expired after she left, she was shocked that she’d have to buy additional coverage at an unaffordable price. Instead, McDermott reviewed her notes on each of the patients she assessed or followed during her tenure, deciding that her potential exposure was relatively low. Also since Colorado has a two-year-statue-of-limitations on malpractice lawsuits, she knew the time for being sued was short; one year had already passed. But it’s still a cautionary tale. “When residents tell me that they’re thinking about moonlighting,” says McDermott, “I say the same thing: ‘Make sure you have tail coverage.’ I was a little naïve about it but it’s a huge issue.”

Be realistic in your choices
Although you need to be business savvy in maximizing the experience, you also need to be pragmatic in using your skills. Since programs usually limit residents from doing jobs that they’re not technically ready to do—e.g. surgeons-in-training can’t operate and anesthesiologists-in-training can’t put people out—you’ll likely have to land a more general position. If you’re a fellow, your choices may be broader simply because you have a specialty under your belt.

Whatever the position, it needs to be appropriate in scope, obligations and demands. Whether you’re about to be one of many urgent care physicians on the weekend or the only rural hospital emergency doctor overnight, do you have the right stuff to safely and confidently perform those duties? Make sure that you’re clear as to the number and types of patients and duties and don’t be afraid to ask yourself: “Will the work put me at risk for a malpractice lawsuit?” “Who will be my backup to avert any such possibility?”

“You need to look at what’s expected of you and what you’re actually capable of providing,” says Bradt. “Those things can be very different. You have to know that your skill set is where it needs to be to accomplish what you’re going to be called on to do.”

Also, since you’ll likely encounter things you don’t know, haven’t seen before or don’t normally do, at least initially, it’s prudent to have a backup. In Swoboda’s program, for instance, if residents need help moonlighting, they can run the problem by any faculty member. “We want the best for the patient,” he says. “We don’t want to take any chances or have anything bad happen.”

For his part, Bradt isn’t shy about calling when he’s stumped and asking the attending, “This is what I have with my patient. What do you think?” Then again, nothing tests the limits of someone’s knowledge more than working without faculty or senior resident level to cover you. You have to figure out what’s going on with the patient and come up with ideas on treatment. “You don’t realize how beneficial it is to have back-up until you’re out there by yourself in a situation where there is no one,” says Bradt. “You start thinking, ‘What do I do next? How do I take care of this patient?’ That’s when you start asking, ‘What do I really know? What don’t I know? What do I need to work on?’”

Indeed, any patient-centered experience can sharpen your clinical wits and skills. But the ACGME is very clear that your program must graduate you as a capable, independent practitioner based solely on its requirements without any extras. As Katz notes, “When a resident says to me, ‘I’ll be a better doctor if you let me moonlight,’ my answer is ‘You’re going to be a perfectly fine doctor whether or not you moonlight.’”

One final note
It’s enticing to think of the extra money you can earn by moonlighting. After all, you’ll only have to expend the energy for a short time and be done with it. In the meantime, it may help you alleviate your financial stress. In rare instances, Katz will approve a second-year student’s moonlighting request. “I think we underestimate just how much finances can dominate someone’s thoughts and life,” he says. “My theory is that by working a bit more to relieve stress, a resident may actually learn more.”

Yet it’s difficult to maximize the experience if you’re spreading yourself too thin. At the least, you need to be cognizant of the challenges; at the most, build in safeguards to protect your personal time. Although Bradt has been able to finesse his schedule to accomplish his work tasks, for instance, carving out time for his wife and two children is still challenging. They take solace in the fact, however, that after graduation his work life won’t be so hectic. “The biggest juggling act is weighing the benefits of making extra money to help pay off your debt and better yourself and your family,” he says, “versus spending more time with them.”

As for Hurley, an evening spent moonlighting is in an evening he can’t talk to friends, read his emails or carry on other activities. “When you don’t do that, your social life feels different,” he says. “For me, it’s been a matter of figuring out the right titration of doing everything possible so moonlighting, while a good opportunity, is not at the expense of other parts of my life.”

Chris Hinz is a frequent contributor to PracticeLink Magazine.

 

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The art of contract negotiation

When considering a new employment contract, knowing what’s negotiable, how to ask for it and when to get help are important parts of the process.

By By Jon VanZile | Fall 2013 | Feature Articles

 

Kristie Rivers, M.D., FAAP, was like a lot of young physicians when she got out of medical school in 2005: She knew a lot about her chosen specialty, pediatrics, but almost nothing about the business of medicine.

Kristie Rivers, M.D., was chief resident of her pediatric residency program in Orlando. But when it came to signing her first employment contract, she had no idea what to expect. “I wish I had known that everything was negotiable,” she says.

Her resulting job search would look familiar to experts in the physician employment field. The chief resident interviewed and received an offer from the Chris Evert Children’s Hospital in South Florida to join the staff. As part of the offer, she got a contract that included lots of “standard” clauses—and that’s where things started to get more confusing.

Like almost every new doctor with their first employment contract, Rivers had never negotiated an employment contract. Indeed, except for second-hand stories from colleagues, in all the rigors of medical school and her residency, she had never been exposed to standard contract language and had no idea where she could push back and what was non-negotiable.

Part of the contract involved moving from Orlando, where she performed her residency, to Boca Raton, which meant paying for her own moving expenses.

“I knew nothing when I first got out of residency,” she says. “So I showed (the contract) to my dad, who’s not a doctor but runs a business. He said I should have an attorney look at it and recommended someone for me.”

This was the first exposure Rivers had to the high-level negotiating that physician employment contracts often involve. Turns out, more was negotiable than she originally thought, and she ended up getting better on-call hours and having her moving expenses paid for.

Since that first contract experience, Rivers has gone back for contract negotiations and each time has gotten a little more of what she wanted. But still, she says, it would have been nice to know what was possible going in.

“I wish I had known that everything was negotiable,” she says. “I wish I knew that if I pushed hard enough or asked in the right way, everything was negotiable.”

No doubt this is a common wish among younger doctors who leave their residencies and fellowships and suddenly find themselves negotiating complex contracts with recruiters, older physicians and human resource managers who have much more experience in negotiating. And it’s far too important to leave to chance. Your employment contract can lay the groundwork for everything from long-term career advancement to where you live and practice. Yet it’s almost universally recognized that young doctors are poorly equipped to handle contract negotiations.

“I’ve been harping on this for years,” says Jeff Brown, M.D., a consultant for Stanford Business School, medical columnist for Physician’s Money Digest and medical director of The Meadows. “Physicians get no preparation as part of their training for business affairs. It ends up costing them individually and us as a society a great deal of money. They are organizationally and business naïve.”

Related: The who, where, what, why and when of contracts

The view from 5,000 feet
Most contract negotiations begin with salary—but there are plenty of good reasons to think that’s a mistake and can even end up costing the doctor later.

According to Chris Nuland, a health care attorney in Jacksonville who represents hundreds of physicians and physician groups, the first thing doctors should do with a potential job offer is ignore the salary.

“Salary is important,” Nuland says, “but it’s not the most important part. The most important part is whether you’re going to be doing what you want with people you want to do it with, and does your contract get you where you want to be long-term.”

Unfortunately, many new doctors are uniquely vulnerable to making trade-offs for a higher salary.

As Rivers points out, a lot of residents are coming out of their programs after earning $40,000 a year and working 60+ hour weeks. They are often carrying tens if not hundreds of thousands of dollars in medical school debt. And they simply have a hard time believing that someone will pay them four or five times their previous salary for doing basically the same job.

“When you’re coming out of your residency, you feel like anything they offer is so much more than you made in residency,” Rivers says. “So you take anything.”
The result is that young doctors frequently underestimate their own value or let employers set the terms of the negotiation because they’re intimidated by the relatively higher salary.

“The tendency is to take the first offer,” Brown says. “They are under crushing debt and there is a long pent-up desire to get a salary, replace the old beater, get a house and start saving for college for their kids.”

So here’s negotiating tip number one: Don’t be the one to bring up money, even if it was mentioned in the job posting you responded to.

“Never, ever mention salary,” Brown says. “Whoever mentions salary first is at a disadvantage. But docs under pressure will look at a series of ads and go to the ones that offer a high salary. That’s a mistake. Young docs rarely see the tree in front of their face. You’re looking to build a long-term relationship. I tell them to go to 5,000 feet.”

If you’re not supposed to look at salary first, then where do you begin? According to the experts, a contract negotiation is a time to think strategically about your long-term career and life goals so you can drill into the particulars and fight for what’s important to you.

“Quality of life is the most important thing for many young physicians, especially as we move toward an employment setting instead of an individual practice setting,” says Kyle Claussen, JD, LLM, vice president of Resolve Physician Agency.

This means paying attention to every clause of the contract and asking if it fits into your career plan and your lifestyle. If you have young children, for example, you might want reduced or at least more flexible weekend on-call hours. If you’re in major debt and need to pay it down, you might be willing to trade some on-call hours for a higher salary, or even push for a signing bonus.

Related: A physician’s guide to employment contracts

Some of the elements of your contract you might be able to negotiate include:

On-call hours. In terms of importance, this one typically tops the list—even over salary for many physicians. It’s understandable that the most junior employees should expect to have the worst hours, including weekends and holidays. But if the terms are particularly onerous, including every weekend and holiday, they might be negotiable. At the very least, the on-call hours should be equitable with physicians of similar experience and tenure levels. Also, the on-call schedule should be clearly spelled out. Don’t agree to a contract with “hours to be specified by employer” in it, or you might end up working every weekend and holiday and 80-hour workweeks for the indefinite future.

Salary is an important aspect of a contract negotiation—but it’s not the first thing you should consider. “The most important part is whether you’re going to be doing what you want with people you want to do it with, and does your contract get you where you want to be long-term,” says health care attorney Chris Nuland

A track to advancement. This can be a tricky area, but Nuland says it shouldn’t be underestimated. Especially physicians who are looking at employment in medical practices (as opposed to hospitals) should try to get insight into the “path to partnership.”

“I believe every contract for a new doctor should have a partnership track somewhere in the contract,” Nuland says. “I want it to say in the contract if they’re eligible for shareholder status and have a track to get there.”

Practices are naturally hesitant to spell this out for new hires, but Nuland says there should at least be an understanding about when a new doctor would be eligible to begin earning partnership status and how it can be attained. The alternative—vague, open-ended clauses with no enforceable statements—works against the doctors and for the practice, which can indefinitely postpone a track to partnership.

Related: Negotiate an employment contract with ease

“Ten or 15 years ago, it used to be you’d make partner in two or three years,” Claussen says. “It’s not like that anymore. We like to see goals or structure in how a partnership is run.”

This clause is much different for hospitalists, who are often joining large health care networks as employees. In this case, it may be impossible to delineate a path to advancement in the original employment contract.

The non-compete clause. Depending on the state, this can be a major long-term issue that’s easy to overlook during the initial negotiation. In many states, physician contracts often include a non-compete clause that prohibits a doctor from competing against a former employer for a certain length of time and/or a certain distance.“The standard is two years, 20 miles,” Nuland says.

As Nuland points out, however, this can be a major issue for some doctors. In general, he recommends negotiating to reduce the distance and increase the timeframe, instead asking for three years and 10 miles.

The reason for this is simple: in some crowded, urban areas, a 15-mile non-compete radius might mean a two-hour drive each way. Thus, quitting the practice means moving to continue in your specialty or facing an extremely inconvenient and long commute.

“If you’re staying in the same area, distance becomes a problem,” Nuland says.

Bonuses. Bonuses come in many shapes and forms—and all of them are negotiable. Looking back on her negotiating experience, Rivers wished she had negotiated for a signing bonus. End-of-year bonuses can also be valuable.

“I want all of my physicians to have some kind of incentive, but I don’t want it based on receivables,” Nuland says. “Here’s why: In your first year, you only get to collect nine months of receivable, because of the insurance billing cycle. Second, you’re basing your effectiveness and incentive on the front office staff. In any contract, you don’t want to be held hostage to things that are not under your control.”

Malpractice tail insurance. This is something of a “back door” clause that many physicians don’t appreciate until long into their employment, when it can be disastrous. Tail insurance covers a doctor for malpractice claims that might arise after they leave a practice. It can be very expensive—sometimes as much as 200 percent of the face value of the original insurance policy. From a physician’s point of view, tail insurance should be included in the original contract. If it isn’t, you might find yourself held hostage to your employer, unable to leave a practice because of the high cost of purchasing your own tail insurance.

Membership in insurance plans. Again, this applies primarily to doctors working for practices, but it can be a problematic area. Many practices insist that their doctors accept all of the practice’s managed care plans. This isn’t always possible, however, and just like the issue of bonuses, it’s beyond your control. Instead, Nuland recommends revising the clause to say that you’ll make your “best effort” to join every managed care plan, but that you can’t guarantee it.

Scope of work. This frequently overlooked item can mean the difference between a positive and negative work experience. “As a new employee, you don’t want to perform ‘duties specified by the employer,’” Nuland said. “They could have you sweeping the floors. And if you’re a specialist, you want the contract to say you’ll perform that specialty.”

Benefits. Finally, as more and more physicians become employees of larger practices or hospital groups, it’s a good idea to look at the standard benefits package. This includes health insurance, termination policies, vacation, time off for professional training and any other factors that are important. They key here, says Brown, is knowing what’s important to you and being prepared to ask for it.

“Everything in life is a negotiation,” Brown says. “Instinctively, we know some things about negotiation, but docs really are at an immediate disadvantage when it comes to looking for a job. The bottom line is your prospects are bleak if you do nothing. They’ll only get better if you do something.”

Getting outside help
If this all seems like a lot to handle, it is—which is why most experts suggest hiring a professional to represent you in the negotiation.

“I don’t think you can go into signing a contract without an attorney,” Rivers says. “There’s so much you don’t know. I know colleagues who’ve been burned or owed thousands for a malpractice tail or had to move.”

Besides sheer experience in contract negotiations, attorneys who specialize in physician contracts have another major advantage: They know the job market. The value of this knowledge is hard to understate, as job offers vary widely between specialties and by region, and there’s typically a difference in offers between practices and hospitals.

“The number-one mistake I see is people not understanding the market,” Claussen says. “The second mistake is not getting professional help. The physician contract is a $2 or $3 million contract over time. It’s a big contract.”

This wisdom is echoed by Brown, who has been giving talks to young physicians for years about how to successfully negotiate their first contract.

“As much as you can cram and learn this stuff, it’s always better to pay someone to do it for you,” he says. “Entertainers have agents. Why shouldn’t doctors? In the next few years, I predict there will be people who do nothing but help doctors negotiate.”

In fact, this cottage industry is already being organized. Law firms and physician employment specialists are available in most regions and many big cities. If you don’t already know of one, or are looking at moving to a new region, Brown recommends tapping into your network and even going online to find local agents to help in the negotiation.

It’s important, however, to find a lawyer who specializes in physician contracts and who works for you, rather than for an employment agency or headhunter. Headhunters are typically paid by the employers; an independent lawyer will work directly for you.

“Part of the problem is the typical young doc has no money, so they have to find someone who will handle the negotiation for little money,” Brown says. “Maybe you can find someone who will do it on contingency or maybe take a percentage of the salary.”

But independence is important. “We provide guidance and market data,” Claussen says of his firm. “All of the things the doctors themselves don’t have time to handle. We’re not trying to tell them one practice is better than another. We try to find out what’s important to them and guide them through the process and let them know what their value is. A lot of doctors are timid and embarrassed at first because there’s such a jump in that first year. It helps to have something telling them it’s OK to make that much, and that’s the fair market value.”

Jon VanZile is a frequent contributor to PracticeLink Magazine.

 

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Wolf Point, Montana

Three hundred miles from the nearest big city, the Listerud Rural Health Clinic serves a small community in Big Sky country.

By Marcia Travelstead | Fall 2013 | Practice Extreme

 

NAME:  Mark Zilkoski, M.D.

PRACTICE:  Listerud Rural Health Clinic in Wolf Point, Mont.

Wolf Point, Mont., is the largest community on the Fort Peck Indian Reservation (population 2,600) and is located in Roosevelt County in the historic Missouri River Valley.

The nearest large city is Billings, Mont., which is 320 miles away with a population of approximately 100,000. It’s 92 miles from Williston, N.D., which has about 16,000 people. Approximately every 55 miles, there’s a little town with anywhere from 3,000 to 5,000 people.

For Mark Zilkoski, M.D., owner of the Doc’Z pub in Wolf Point, Mont., medicine and pub tending have a lot in common. “For me, it’s all about relationships,” he says.

Mark Zilkoski, M.D., a native of upstate New York, is a family practice physician in rural Montana. After completing his family medicine residency in Stockton, Calif., he practiced in Wolf Point, Mont., for four years then left to teach at a medical college in Ohio until 1992. Zilkoski returned to Wolf Point in 1992 and has practiced there ever since.

The Listerud Rural Health Clinic, named after a physician who grew up in the area and returned to practice surgery there, is a federal rural health clinic in an underserved area. The clinic was built beside the hospital and was attached later. The hospital owns and runs the clinic.

What role does Listerud Rural Health Clinic play in the community?
In terms of providing health care, it’s pivotal. We have the Indian Health Clinic in town but they don’t do anything in the hospital. They provide only clinic-based health care. Anything more complicated than that is referred to our clinic or the hospital.

How many people are employed in your facility?
Two doctors, two midwives, a nurse practitioner and a physician assistant.

Are you currently recruiting?
We just had two midwives sign. We had another physician but his wife did not like the area, so they ended up leaving. I’m a family practice physician who does mostly internal medicine now, but I’m the only surgeon in town. I do C-sections and occasionally deliver babies when I have to.
The physician who is leaving is in family practice with two years of OB fellowship. So it will be up to me to be the primary surgeon with two midwives doing the deliveries.

Will you be looking for another physician?
Maybe at some point in the future. I think our administrators are always looking for one. We have a sister clinic in Poplar, which is 22 miles away, and they are looking for a physician. It has a population of 800 people.

The one doctor that works with me occasionally goes over there. They currently have two nurse practitioners. We are a part of Northeast Montana Health Services, Inc. Within the 22 miles, there are two clinics and two hospitals.

What are some advantages for physicians to practice here?
I was here from 1980 to 1984 and practiced with the Indian Health Services. I owed them time because they put me through medical school. I left and taught in Ohio for eight years. I came back for a sabbatical and just stayed.

I love it here and I love the type of detailed medicine I am able to practice. If I need help from another physician or specialist, it’s just a phone call away. I love the area, the Badlands. I live on the Missouri River.

I’m a brewer and own a pub (see sidebar). This is a wonderful community in terms of people being united together. Thirty-two miles away is Fort Peck Reservoir and Dam, which is the largest earth-filled dam in the country. It has more coastline than the coast of California. If a person is a hunter or fisherman, there are tons of places to do both things.

What is your typical day like?
On Mondays, I see patients from 8 to 5:30. I see around 22 patients. Tuesday mornings, I do procedures such as C-sections, colonoscopies, breast biopsies, etc. Tuesday afternoons, I see patients.

There is a nursing home not far from here, so on Wednesday mornings I see those patients. Wednesday afternoons, I see our clinic’s patients. Thursday is dedicated to patients unless an emergency comes up.

On Fridays, I do paperwork, charts, fill prescriptions and make phone calls. I try not to schedule patients. I will make hospital rounds if I have a patient in the hospital. I will also do endoscopic exams if needed.

—By Marcia Travelstead

 

 

 

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Medicare’s Sustainable Growth Rate formula may finally be repealed

Democrats, Republicans, the White House and the AMA all agree: The Sustainable Growth Rate formula is not working. What’s next?

By Jeff Atkinson | Fall 2013 | Reform Recap

 

This may be the year in which  which Medicare’s Sustainable Growth Rate (SGR) formula is finally repealed. The formula is one of Congress’s less-successful attempts at controlling health care costs. It is part of a law that each year threatened to cut physicians’ pay for Medicare services by a substantial percent, but then Congress stepped in and canceled the cut for that year.

The SGR was enacted as part of the Balanced Budget Act of 1997. Congress was concerned that the Medicare fee schedule would not sufficiently constrain spending for physicians’ services under Part B of the Medicare program because physicians, for example, might increase the volume of services to make up for a loss in revenue on per-service payments. If the cost of Part B exceeded limits specified by the formula, Medicare rates for the following year would be reduced.

Formula tied to growth in economy
The formula is a complex one. It takes into account multiple variables, including change in physicians’ fees, the number of Medicare beneficiaries, growth in the gross domestic product (GDP) per capita, and changes in health care spending due to laws and regulations. The broad goal of the formula is to not allow spending for physicians’ services to increase faster than the growth of the economy.

For the first four years of the program, there was not a problem. Actual expenditures were less than or close to the target expenditures. So the updates to the physicians’ fee schedule provided increased reimbursements to physicians for each of those years. In 2002, expenditures exceeded targets, and physician reimbursements were cut by 4.8 percent.

That was not acceptable to physicians and lawmakers. So for all years after 2002, Congress provided what has been referred to as the “doc fix” or “pay patch”—a law that suspended the payment cuts and usually provided a moderate increase for physicians.

The underlying formula, however, was not changed or repealed. Each year, the amount of payment cuts that would have to be made in order to balance the books under the formula increased. Under the formula, if Congress does not solve the problem between now and the end of the year, Medicare reimbursement rates for physicians in 2014 will be reduced by about 25 percent.

Broad support for repeal
There is near-universal agreement that the SGR formula needs to be repealed or changed. The formula has not served to cut costs, and if the formula were applied, the number of physicians willing to treat Medicare beneficiaries would be reduced. Support for change comes from Republicans, Democrats, the White House, the Medicare Payment Advisory Commission, and the American Medical Association (AMA).

In a letter to Congressional leaders urging repeal of the SGR formula, the AMA’s Executive Vice President and CEO, James Madara, M.D., said, “Stable and predictable payment models are necessary to ensure physicians can plan for investments in capital improvements and continuously make advancements in delivering higher quality and more efficient care.”

Part of what has delayed coming up with a permanent remedy has been the cost of repeal. The Congressional Budget Office (CBO) scores legislative proposals to determine their cost. Until recently, the cost of repeal of the SGR formula had been set at $244 billion over 10 years. This year, the CBO reduced its estimate to $138 billion over 10 years. That will make repeal more politically palatable.

The Affordable Care Act provides alternate ways to save health care dollars, particularly in the Medicare program. The act provides for an increase in “value-based purchasing” by which the government (and private payors) will make more payments based on value received rather than just fee-for-service. Providers with good outcomes and cost-effective care may receive bonuses; providers who do not meet quality and cost targets may find their reimbursement rates cut.

There also will be increased use of “bundled payments” by which groups of providers—including hospitals, physicians and home care agencies—will receive a single fixed payment for treatment for an episode of care or of a particular condition. For example, the care of a patient with a broken hip or the care of a patient with diabetes for a certain period of time would be a fixed global payment that would be divided among providers. The payments likely will utilize adjustment factors for severity of the patients’ conditions and case mix.

Getting the details right on adjustment factors will be challenging. The AMA’s Madara said the Centers for Medicare and Medicaid Services “is not ready to implement the value-based payment modifier and…any efficiency measures [should] be tested in large group practices before they are imposed more broadly.”

Some political leaders view health care spending as a zero-sum game. If payments to physicians go up, payments to other health care providers will need to be reduced or at least not rise as rapidly as in years past. Thus, it is expected that payments to hospitals, skilled nursing facilities and home health agencies will be cut or rise more slowly. In a recent “doc fix,” the physicians’ rates did not drop, but the money for physicians came by reducing payments for public health, prevention and hospitals.

Health care reform has some similarities to squeezing a balloon. If one tries to fix a problem on one part of the balloon by squeezing it, another part of the balloon will bulge out and need its own fix.

Jeff Atkinson (JAtkin747@aol.com) teaches health care law at DePaul University College of Law in Chicago.

 

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High School Sports Physician

Volunteer with your local high school teams to provide care on the field and goodwill to the community.

By Marcia Travelstead | Career Move | Fall 2013

 

Jeff McDaniel, M.D., volunteers as a team physician for several high school sports teams. His involvement is voluntary but has the added benefit of driving young athletes to his practice, too.

NAME:  Jeff McDaniel, M.D.

SPECIALTY:  Family Medicine, Sports Medicine at Methodist Family Health Center.

LOCATION:  Midlothian, Texas

RESIDENCY:  Palmetto Health Family Medicine, Columbia, S.C.

FELLOWSHIP:  Primary Care Sports Medicine Specialty; Graduated 2010

During his fellowship year, McDaniel served as a team physician for the University of South Carolina Gamecocks, Benedict College Tigers and Airport High School. He currently is a team physician for the Midlothian High School football team and several Mansfield area high schools. Although he works with five high schools in Mansfield, he primarily works with Lake Ridge High School and Mansfield High School.

What do you like best about being a high school sports team physician?

It combines my two loves: medicine and sports. It’s a patient population that is young, active and fun to work with. I grew up in Texas and played football, so I think I can relate and understand to some degree what the athletes are going through and help them recover from their injury and get back on the field.

What kind of commitment is expected?

Usually it’s a Friday night once a week or occasionally a Saturday for the whole season. I do their sports physicals prior to the practice season as well. Generally, the season runs from the end of August through the first part of November unless they go into the playoffs, where that could run into an extra few games. It generally involves four to five hours on a Friday night.

Is there anything that surprised you about being a high school sports physician?

The coaching staff may have one agenda, the physician may have another and the parents may have their own as well. I’ve often run across parents who really want their child to excel. For the physician, that can mean walking the fine line to getting the athlete better yet making mom and dad happy. A lot of it is educating and reassuring the parents. Their child wants to be out on the field but the physician has to make sure the athlete has recovered enough to be on the field as soon as possible but not risking permanent injury.

Have you found being a high school sports physician has benefited your practice?

I feel it has. I’m not paid to be on the sidelines and it’s completely volunteer on my part, but I’m being an active role model. It has given me exposure to this particular patient population as well as to the community. It opens up conversations with regards to being seen on the field. People find out who I am, and that’s the best way to build a practice—word of mouth. I’ve also acquired a number of patients from athletic trainers who know I specialize in concussions.

Are you a team physician for other high school sports besides football?

I do provide care to athletes competing in all sports with the high schools in this area. I don’t get the chance to make it to all the games and be on the sidelines due to scheduling conflicts. For example, the soccer games are often held during the week or over a time when I am working in the office.

What advice do you have for physicians interested in being involved in high school sports?

A fellowship in sports medicine would be one way to start because you get exposure to several levels of competition. Apart from that, one of the best ways for a physician to get involved is to locate and meet with the athletic trainers of a particular program. Really make yourself available to them. If you make it difficult for them to contact you then they are not going to want to work with you. I take the team approach and make myself available to them during practice, weekends or whenever they have a question. I don’t think they have ever abused that and have always been very respectful.

 

NAME:  Jerry Bornstein, M.D.

TITLE:  Semiretired Orthopedic Surgeon; Medical Director for Los Angeles Unified School District Department Of Athletics.

RESIDENCY:  Los Angeles County General Hospital

Bornstein has been a physician and consultant for high school, college and professional sports teams for more than 50 years.

What do you like best about being a high school sports team physician?

The satisfaction of seeing athletes return to the high functioning ability that may have not been possible without adequate medical care. They may have been unable to continue, resulting in lost scholarship opportunities. In addition, they may have had permanent residuals from the injuries. It is gratifying to see them return to play (RTP) and continue to advance further in their athletic career.

In addition, there is gratification in the contribution of community service in areas where family or other funding for medical care is not easily available.

Is there anything you don’t like about it?

The difficulty in obtaining necessary care for those unable to afford private services. Also, parental interferences both on and off the field, which can affect proper evaluation and care. The medic needs to be able to do his or her job. I have also witnessed an increasing feeling of entitlement some athletes are developing, even at the high school level, in addition to disrespect for upper authorities.

What is your role as Medical Director of Los Angeles Unified School District Department of Athletics?

Training health care professionals such as resident physicians, EMTs, ATCs, RNs, etc. in on-field protocol and the initial evaluation/care of injuries. This is done via seminars and on-field supervision. They evaluate injuries and determine whether the athlete is able to return to play and to initiate treatment as indicated.

I deal with assigning medics’ schedules, intra-week schedule changes and other emergencies as they arise. I am on-field game day either covering a game or at a game with one of the medics, supervising and teaching. In addition, I am always available by phone to medics, athletic directors and coaches to answer any questions they might have.

Is there a problem getting physicians to volunteer?

There can be difficulty getting medical coverage for games in many areas. For physicians, there could be insurance concerns, time constraints and/or the feeling of incomplete knowledge/training for on-field tasks. Therefore, the use of other health care professionals becomes necessary.

Is there anything that surprises you after all these years of being involved as a high school team physician?

The lack of commitment and involvement on the part of some athletic directors and administrators in an important segment of a high school student’s educational life.

What’s your advice for physicians who are interested in getting involved in high school sports?

Gain training, which is readily accessible in a number of ways. First, become involved by shadowing or following a team physician who has experience. Secondly, read books or access the internet. There are a number of publications on team physician protocol. Thirdly, take a course. The American Association of Sports Medicine offers courses every year on team physician care. By doing all of these things, the physician will feel more comfortable on the field.

—By Marcia Travelstead

 

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Fatal financial planning flaws

Are you making one (or both) of these mistakes physicians make?

By By David B. Mandell, JD, MBA and Jason M. O’Dell, MS, CWM | Fall 2013 | Financial Fitness

 

 

As authors of 11 books for physicians, including For Doctors Only: A Guide to Working Less & Building More, we have consulted with thousands of doctors of all specialties during the last decade.

From this experience, we have become intimately familiar with the mistakes physicians make when working with their CPAs, attorneys and other financial advisors. Whether it is in the area of tax, asset protection, retirement planning or other areas, the result is almost always the same. We leave the meetings or conference calls asking ourselves, “How could this doctor get such poor, uncreative, or just plain wrong advice?” It would be laughable if it weren’t so troubling.

It is not surprising that physicians do not get the value they should out of their professional advisors. While the typical specialty physician has nearly 25,000 hours of training in his or her profession, there is a grand total of zero hours of training in business or financial issues related to the business of being a doctor.

After learning how to use specialists in other areas of medicine, doctors receive no training in how to choose or evaluate the advisors whose advice and experience will be the backbone of the their financial plans for their entire careers.

Doctors lack the spare time and training to do their own planning and have virtually no training on how to find and evaluate the right specialists to assist them, so it is no wonder that most are ill-served by their professional advisors. In our experience, fewer than 5 percent of physicians are properly advised by a professional team.

In this article, we will point out the common flaws we see in physician-advisor relationships.

 

FLAW #1: Staying with an advisor you’ve outgrown
The first mistake the overwhelming majority of physicians make in the financial, legal or tax aspect of their careers is how they initially choose their professional advisor. Whether it is their CPA, investment professional or attorney, many physicians make a poor choice because their method of choosing an advisor is flawed.

When you consider the typical pattern, this is not surprising. Most doctors choose their advisors when they are in residency or fellowship, as this is the time when most doctors begin to make money or start a family. The doctors may need some life or disability insurance, a will, and someone to prepare and file tax returns. Working long hours without financial training or the means by which to evaluate an advisor, doctors typically do what other busy people do and take the path of least resistance (and minimum time commitment). They use the advisor the older residents use, find someone the local medical society recommends, or hire a friend or family member.

Though this unscientific approach is obviously flawed, it serves its purpose when there are bigger challenges at hand (like 20-hour workdays and finding a job). Your life is so hectic, you just need to “get it done fast.” The advisor you choose at this point simply has to be decent and cheap—and that is good enough. Like a triage nurse in an emergency room, a top-trained specialist is unnecessary when all you need are a few basic stitches.

What is alarming to us is not this initial choice of advisor, but rather the fact that most physicians actually stay with these same advisors who handled their triage planning in residency for the rest of their careers. The typical justification for this is, in our opinion, rarely anything concrete or acceptable. Doctors give us explanations like, “we have been together so long, I’d hate to change now,” or “if it ain’t broke, don’t fix it.” This begs the question: How do you know “it ain’t broke” if you don’t get a second opinion?

Most alarming to us (and something we see every day) is when a physician stays with an advisor when the doctor has clearly outgrown the expertise of the advisor. Consider the following real-life example:

 

Case Study: Oscar the Orthopedic Surgeon
Oscar, an orthopedic surgeon living in Nevada, contacted us after reading one of our books. Though his income was over $1 million per year and he was part of an extremely successful practice, he used the same New York-based lawyer he retained to create his wills 10 years before, when he was a resident.

Not only was this attorney not licensed in Nevada, but he continued to advise Oscar in areas that were clearly beyond his expertise. While he was certainly a nice gentleman, and perhaps was competent for doing basic planning for someone with minimal tax or estate planning concerns, he had no concept of advanced techniques that a physician making over $1 million per year should be considering. He had no knowledge of fringe benefit plans, asset protection planning or other fairly routine planning that we routinely implement for high-income physicians. While this gentleman may have been an acceptable choice for Oscar when he was a resident, it was a total disservice to the surgeon at this point to continue to use this attorney as his primary advisor.

 

Doctors advise patients to get a second opinion before opting for surgery or chemotherapy, but they don’t get their own second opinion before agreeing to pay hundreds of thousands of dollars each year in taxes. Oscar’s desire to not hurt his attorney’s feelings had potentially cost him more than $1 million so far.

The idea that you can outgrow an advisor may seem obvious to you in the medical arena—you would no longer send your child to a pediatrician when the child becomes an adult. Yet for some inexplicable reason, this surgeon continued to use his attorney as his lead advisor, despite our numerous recommendations that someone else (not necessarily us) may be more appropriate.

•    How did you choose the professional advisors you work with today?
•    How many other professionals did you interview prior to choosing one?
•    Have you periodically interviewed others as your needs have changed?

 

Flaw #2: Failing to understand sub-specialties in tax, law and finance
If you needed a stent put into your aortic valve, you would not go to a general practitioner. Moreover, you would not consult with any specialists outside of cardiology. In fact, you wouldn’t even settle with seeing the standard cardiologist. You would only seek the help of an interventional cardiologist to handle this procedure. The point is that medicine is a highly specialized discipline. If you have a specific issue, you will seek out a physician properly trained and experienced with that particular issue.

Utilizing a specialist to assist you with your heath concerns seems obvious. However, our experience has shown that, in the areas of law, taxation and finance, doctors completely fail to apply this same concept. To illustrate this, let’s consider the area of taxation.

The ever-changing United States tax law is the most complex set of rules ever created by one society. The lengthy and confusing Internal Revenue Code is only the beginning. IRS revenue rulings, private letter rulings, tax memoranda, announcements, and circulars—as well as tax court and federal court cases—only serve to make the field that much more difficult to understand. The quantity of information is so vast that many law libraries devote an entire floor to tax materials. No single person can possibly be an expert in all areas of tax law.

Nevertheless, each physician typically relies on one CPA to serve as their “tax advisor” in all areas of tax. The taxation issues that require guidance typically include retirement planning, income structuring (salary vs. bonus), payroll tax, corporate structure (whether to be an “S” or “C” corporation), compensation (whether to implement a deferred compensation plan), estate tax planning, taxation on sales of real estate, individual tax returns, corporate tax returns, and buying or selling a practice. While these issues all fall within the scope of “tax,” each exists as a discrete sub-specialty with its own unique knowledge base. As if the generic “tax advisor” weren’t yet over-extended, we have seen many physicians ask their tax advisor to provide guidance in areas far outside of tax altogether, such as asset protection or investing.

One method to overcome this problem is to bring in a firm that will bring new “value-added” subspecialty knowledge.

However, the key success factor here is to make sure that your local CPA and the outside firm can work together for your benefit. If additional expertise can be brought to bear for your planning, and your current CPA understands that this outside firm is not trying to take you as an accounting client, you can benefit significantly.

Physicians need to take their own advice.  You encourage your patients to seek second opinions and rely on specialists to address their complex medical needs. Your financial needs are similarly complex, and getting a second opinion and utilizing specialized advisors is critical to your long-term financial well-being.

 

David B. Mandell, JD, MBA, is an attorney and author of five national books for doctors, including FOR DOCTORS Only: A Guide to Working Less & Building More, as well a number of state books. He is a principal of the financial consulting firm OJM Group (ojmgroup.com) along with Jason M. O’Dell, MS, CWM, who is also a principal and author. They can be reached at (877) 656-4362 or mandell@ojmgroup.com.

 

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What “managing up” can do

Better communication among physicians and between physician and patient can help improve the entire health care experience.

By By E. Coy Irvin, M.D., MBA | Fall 2013 | Remarks

 

As more family physicians and  internists have decided to concentrate on outpatient medicine, positive relationships and effective patient hand-offs have become critical for good patient care.

The technique of “managing up” has been taught by many experts over the past few years as a way of improving the customer service experience. Managing up helps the patient experience by alleviating their concerns about the service and quality of care they will experience in our system. In addition, managing up can improve the relationship between referring physicians and the hospitalists who care for their patients while they are in the hospital.

As we see the separation of inpatient care and outpatient care become more common, patients rightfully are concerned about who will care for them during a severe illness, the very time when they need the most attentive care. Not only will the new doctor be a stranger to them, but so will many of the staff at the hospital. Quite possibly, the attending hospitalist will change during the patient’s hospital stay, shaking the patient’s floundering sense of security even further. This all leads to the clear need for exceptional hand-offs of the patient, their information and the intended plan of care.

Many times we have witnessed patients questioning whether one physician communicates with the other physician when they say, “Do you guys talk to each other?”

This can seriously undermine confidence in our medical care. It also puts our patients and ourselves at risk for unintentional catastrophic accidents and possible legal action.

It is imperative that physicians improve communication and relationships so that when an outpatient physician hands off the patient to an inpatient physician, or when one inpatient physician hands off to another, there is true communication of the needs, status and intended treatment plan of the patient’s medical condition.

Part of the process can be aided by using managing up techniques to educate the patient so that they understand the transfer of care that is about to occur. Remember, this is a two-way street: Not only does communication and managing up need to occur at the time the patient enters the hospital, but it also has to occur during the hospitalization if there is a transfer of care. Finally, it occurs again at discharge of the patient back to the outpatient physician.

So not only does managing up improve the patient’s perception of the hospitalist, it can also improve the perception of the outpatient physician in the eyes of their patient.

Imagine a scenario where the outpatient physician, upon deciding to admit the patient to the hospital, tells the patient, “Mrs. Williams, I am sending you to the hospital. I no longer go to the hospital, so I’m going to place you with the hospitalist service. I’m not sure who the hospitalist is today, and I am not sure you will see the same doctor each day. I’m sorry for this, but I can no longer make rounds on hospitalized patients.”

What would you think if you were Mrs. Williams? You probably wouldn’t have much faith in the hospitalist that would care for you.
Now what if the outpatient physician had said, “Mrs. Williams, I am sending you to the hospital. You will be cared for by my hospitalist service. The hospitalists are an extension of my office practice, and they care for my patients on a daily basis. The hospitalists are experts in inpatient medicine and will know just what to do to help you get better. I trust them to care for my patients as I would trust them to care for my family. We will give them all the information we have on you, and upon discharge, they will share with me the information about your hospital stay.”

Now Mrs. Williams feels reassured that not only will she get good medical care, but also that her information will be passed from one physician to the other. The accepting hospitalist will feel better about taking care of the outpatient physician’s patients, and we will all find taking care of Mrs. Williams to be easier because she trusts the physician’s judgment.

As a physician and consultant who works with both hospitalist programs and medical staff, I see daily the need for better communication across the system. Not only do we need to communicate better physician-to-physician and physician-to-patient, but we also need to improve communication between physicians and hospital staff. Using the techniques of managing up can result in a marked improvement in the final goal for all health care providers, both clinical and non-clinical: Providing the best and the safest care of the patient. Why? Because it improves teamwork, something on which our patients directly rate us. Another positive effect of managing up is that the technique helps to reassure the patient who is nervous and scared about their illness. And our patients will directly benefit from a better coordination of care.

E. Coy Irvin, M.D., MBA, is Chief Medical Officer and Vice President of Medical Affairs for McLeod Regional Medical Center in Florence, S.C.

 

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Monique Cunningham-Lindsay, D.O.

Fall 2013 | Snapshot

 

WORK: Pediatric resident.

EDUCATION/TRAINING:

Medical school: University of Medicine and Dentistry of New Jersey, School of Osteopathic Medicine, 2011
Residency: Morehouse School of Medicine Community Pediatric Residency in Atlanta

Cunningham-Lindsay and her husband, Philip Adu, Ph.D., have two daughters— Miriam and Olivia (the baby). She loves spending time with her family, traveling and writing inspirational pieces. She will finish residency in 2014.

What’s your advice for residents beginning their job search?
It is so important to begin your job search very early. Start identifying where you would like to see yourself, and if you have family, the area that would work the best for all of you. Setting up an online profile and updating your CV as you go along is also a great help, and will save you so much time in the long run. The online tools and tips that PracticeLink provides, in addition to biweekly updates, has already helped me to identify potential job interests.

What surprises you about your first job search so far?
I was surprised at how many options there are out there, and really how much time is needed to zero in on your perfect fit.

What do you wish they had taught in med school but didn’t?
There will be times when caring for patients that you’ve given your all, and still you’ll feel like you could give so much more.

Anything particularly unique about your job search?
I started scanning and reviewing potential areas of interest early in my second year of residency, as I wanted my choice to be located in a place that my husband and I could both develop our careers in, and also provide our daughters with good options for their own growth and development.

Any other advice?
Seek advice from physician mentors. They can be such a wealth of knowledge for you.

 

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