Away from the maddening crowd

These four small towns provide the balance of life and work that physicians crave.

By Eileen Lockwood | Live & Practice | Spring 2014

 

Thanks to state-of-the-art technology and high-rated hospitals, many physicians have found that “isolation” is no longer a synonym for small-town living. Daily amenities are conveniently located, the internet offers access to the world, patients are friendly and grateful, there’s often surprising prosperity, and nature isn’t far from the front door. Here are four examples of these small-town gems: Gillette, Wyo.; Batesville, Ark.; Fishersville, Va., and Hanover, N.H.

Chris Steel, M.D.

Chris Steel, M.D., returned to his hometown three years ago and is now director of anesthesiology for White River Health System. He and his family enjoy camping, fishing, hiking and—a favorite activity of the 2-and-under set—throwing rocks into the river.

Where the White River flows Batesville, Ark.

In America’s earlier days, transportation spurred the founding of many cities. In Arkansas, Batesville’s raison d’etre was the White River, a perfect avenue for transporting people and products. As a key port on the river, the town would also be influential in the settling of the Ozark Mountains region.

Eventually, the area’s natural beauty and outdoor recreational possibilities would be became an irresistible lure, and services for tourists would thrive, too.

These days, the city’s mainstay tourism and agriculture businesses are sharing the profit spotlight with several other enterprises—especially, but not exclusively, the poultry industry, which has helped develop the area into a regional manufacturing and distribution center. The Batesville Motor Speedway has also become a huge business and tourist enterprise, attracting as many as 8,000 spectators for its largest races.

The successful business climate was a serendipity for Chris Steel, M.D., who returned to his birthplace three years ago after attending medical school at the American University of the Caribbean and clinical rotations in Baltimore, Brooklyn and Pennsylvania State Medical Center in Hershey, Pa. The return to Batesville has been a happy one. He’s now director of anesthesiology with White River Health System, he’s near his family again, and he can enjoy the small-town feel and nature almost at his doorstep.

“The position gave me a lot of leeway to do the critical care stuff that I enjoy, regular anesthesia and a lot of administrative tasks,” he says. “I wanted to do all these things instead of being in the OR all the time.”

So far, he’s capitalized on other professional opportunities, especially the chance to be involved with Lyon College, a small liberal arts institution, where he can have a direct impact on student career choices—and help them decide if a medical career path is the right one for them. “We like the collaboration and hope to do more projects in the future,” he says. On a personal level, he adds, “I love teaching and trying to figure out how to do things better. I find different ways to explain things and how to answer questions. It always makes me learn better, too.”

In keeping with this philosophy, and as a regional referral center for north central Arkansas with service locations in nine counties, White River Health has its own student program. Partly with an eye on future employee recruitment, the administration offers clinical rotations for students in nine area colleges and universities. It has also established the Community Health Worksite Wellness program, which takes health education programs to various companies. A soon-to-start “health coach” program, also in cooperation with the college, will train students to make home visits to patients at high risk for readmission, assuring medication compliance, setting up home care assistance and taking note of readmission risk factors.

Steel’s variety of interests seems compatible with hospital policies. Some other examples: “I like talking with other physicians, trying to help them when they’ve got issues with patients and illnesses. I like projects that improve efficiency. And (of course) keeping up with new developments in physiology and pharmacology.” In addition, he’s been making presentations to various church groups to promote a community care network. He finds added satisfaction in these activities because, he says, “The administration has been nothing but supportive.”

Steel’s heavy work and community activity schedule leaves him a bit short on recreation time, but “every weekend without exception” he spends time camping, fishing, hiking and “throwing rocks in the river,” the latter a favorite activity for his children, ages 2 and 1.

Possibilities, both outdoors and indoors, expand greatly for the non-toddler age group, including a car show, the putt putt tournament, chicken wing cook-off, lawn mower race, annual Winter Carnival and the White River Water Carnival.

There are parks on both sides of the river with a new walking/biking trail, plus fishing and flat-water paddling on a nearby bayou. A golf course overlooks the river, there’s a shooting sports complex, and two baseball parks for kids’ games organized by the county Youth Athletics Association. Coming soon: a community center and aquatic park, complete with a gym.

When it comes to fun time, it seems there’s no lack of originality in the upper reaches of Arkansas.

Dr. Mansell

After training and practice, then military service and time abroad, John Mansell, M.D., and wife Dona landed in Gillette, Wyo. They’ve taken to the area well—and even own a farm.

A tale of cowboys and coal Gillette, Wyo.

Like many other American cities, Gillette came into being as a railroad stop—and was named for Edward Gillette, who surveyed the territory for the Chicago, Burlington and Quincy Railroad. Not long after 1892, lured by open land, farmers and ranchers began arriving. Today, herds of cattle and sheep still roam huge ranches and are a major source of revenue in the area.

Cowboy and western traditions are also alive and thriving, as rodeos one weekend after another prove­—not to mention bid calling contests, trade shows and rodeo dances. “We have a great western bar and dance hall, the Boot Hill Legendary Steak House & Nightclub,” says Mary Silvernell, executive director of the Campbell County Convention & Visitors Bureau. “There’s live national-quality talent here every week, with line dancing and lessons as well.”

But the current stars of the economic show come from beneath the ground. The boom came gradually, first with a 1909 “traditional” underground coal mine, followed in 1924 by surface mining, which was well-established and lucrative by the 1970s, when two other energy sources—oil and natural gas—joined the group. Today surface mines abound in the area.

Operators of 13,470 producing wells ship 7.5 million barrels of oil a year, and the area’s natural gas yield is enough to rank second in the U.S. Little wonder that Gillette has assumed the title “Energy Capital of the Nation.”

The boom has increased population from 29,000 in 2012 to its current 32,000 in the city, with a countywide total of 47,000, and housing has kept pace with the resulting demand. Still some residents worry about losing their hometown flavor. Not so, responds Silvernell. “We’re still small, and we have the wonderful benefits of a small town. But we also have a lot of great amenities because of our energy income.” Wyoming itself, she points out, is a wealthy state with a surplus in state coffers. There’s a sales tax, but no state income tax, and property taxes, she says, are “low, low, low.”

The new Campbell County Recreation Center, she says, is “another outward sign of the energy bonanza.”

“As you walk in, there’s a climbing wall that’s a mini-replica of the Devil’s Tower (the state’s spectacular national monument). There are two swimming pools, two flume rides and (all in all) it’s a premier multi-use sports facility.”

For John Mansell, M.D., now affiliated with Northern Plains Anesthesia Associates and  Campbell County Memorial Hospital (CCMH), the wide-open plains and in-town convenience of work, stores and restaurants make for a haven of calmness after years of an often-frenetic lifestyle. A degree from the University of Southern Alabama College of Medicine and residency experience in New Orleans was followed by work in Texas and Illinois. Military service, both regular and National Guard, saw him posted in Iraq and Kosovo—and loaned for two years to the Emirati government. His eclectic education, which included a degree in electrical engineering, made him a good candidate to digitize thousands of military medical records.

In the meantime, his wife was leading an on-the-run professional life. Work assignments took her across the world. Mansell can’t forget “a couple of times when she’d get off a plane (inbound) and I’d get on the same plane (outbound).” He adds, “The day I moved here (September 2011) was the day I retired from the Army Guard. We’re just happy to be on the same continent most of the time now.”

To complete their transition, the Mansells now own a farm. “I do the plants,” he says, “and my wife does the animals.” When the getaway urge beckons, top-notch ski areas aren’t far away, including Vail, Aspen, Big Sky and Park City.

But the small-town ambience continues to entrance the new physician in town. “If I need to go to Walgreen’s, Walmart, Office Depot, Home Depot, the grocery store and the dry cleaner, they’re all within 150 yards of each other. I dare you to do that in suburban Chicago.” Even more refreshing: “There are two stop signs and one red light between me and my office—and another stop sign and red light between the office and the hospital.”

A third aspect of Gillette life has made its own indelible stamp on Mansell’s approval list is the positive work ethic. Colleagues tell him it’s not unusual for a patient to say, “C’mon, Doc, you’ve got to get me better. I need to work overtime.”

Those who need hospital services find a comprehensive care system approved by district voters in 1977, with a public board of trustees and partly funded by tax dollars. CCMH recently has undergone a $68 million expansion, which upgraded the surgical service department and especially the operating theater. “We went from three teeny ORs to four, plus two separate procedure rooms, and from eight outpatient beds with curtains to 14 (regular) rooms,” reports Karen Clarke, the community relations manager. The health system itself includes 14 specialty clinics and an ambulatory surgery center.

LivThanks to a 2003 partnership with an orthopedics and spine practice, Clarke adds, “We now have one of the most comprehensive orthopedic outpatient surgery and rehabilitation facilities in the state.”

Keeping up with prosperous times, the Campbell County Chamber of Commerce has signed on for seminars that can help professionals create businesses and established business leaders to develop a code of ethics.

Prosperous industry and civilization aside, those who yearn for a Wild West respite don’t have far to go.

Between the beautiful mountains Fishersville, Va.

Testimonials in a recruitment brochure published by Augusta Health in Fishersville make it hard to resist at least a visit to this town in the Shenandoah Valley between the Blue Ridge and Appalachian Mountains. One especially compelling comment: “I love waking up.” The reason: “The most beautiful view in the world from our family room window.” The home just happens to be located on 21 acres “backed up to the George Washington National Forest,” where the lucky owner can view deer, bears, foxes, coyotes, bluebirds and “a billion” hummingbirds.

But landscape alone does not a livelihood make, and though tourism is a big industry, Fishersville can claim a surprising number of thriving businesses. Not to mention the hospital itself, with 2,300 employees and a 230-acre campus.

As director of a new occupational health and lifetime fitness program started by the hospital in 2012, David Krieger, D.O., has familiarized himself with several of the large employers in the area. Krieger reports that several companies, large and small, have signed on to the Augusta program, which includes employment exams, wellness programs and help for drug and alcohol problems.

The combination of highly regarded health institution, location and natural beauty—with many streams amenable to his fly fishing hobby—helped to clinch Krieger’s decision to get on board. He was mustering out of the U.S. Army at Fort Belvoir in northeastern Virginia after serving as a physician for 27 years—and hoping to find meaningful work within a reasonable distance of the base. Among other considerations, his wife was reluctant to move very far away because of a tightly knit connection with the Korean community there.

Following a biochemistry degree from the University of Iowa, Krieger earned a medical degree from the Kirksville College of Osteopathic Medicine, followed eventually by master’s degrees in public health from Harvard and in business administration from Colorado State University. In his new job, he’s been putting all three pieces to good use. His military experience added to his capabilities. During an overseas assignment, he was commander of the military hospital in Heidelberg, Germany, and in the U.S. he served as chief of staff for a hospital at Fort Knox.

In his new life phase, he says, “I didn’t want to go where I would be just another doctor. I wanted a chance to mold a program into what I think a great occupational medicine program should be, meet industry leaders and tell them what we were expecting to do—and get their support. It’s been challenging, especially trying to put together a program under one roof where you have bits and pieces throughout the hospital’s framework. But it’s been really fun to do, and the people have been great.”

Augusta Health’s reach includes all of Augusta County and parts of two others, with two urgent care centers and three convenient care clinics, and it provides care in traditional areas, plus wound care, a sleep center and pain management center. A new Heart and Vascular Center opened last year, as did a joint center complete with the newest recovery practices.

As for leisure possibilities, Krieger says, “This is a real gem in the area, to tell the truth. There’s a lot to do.” The great outdoors awaits, with almost 2 million acres of trails (including the famed Appalachian Trail, which also meanders for a few blocks along Main Street in town) for hiking, biking and camping, plus trout streams and boating areas. There’s no shortage of golf resorts in the area, either. Not to mention spelunking possibilities in some of the U.S.’ best-known caves.

Nearby Staunton is also home to the American Shakespeare Center’s Blackfriars Playhouse, the world’s only recreation of London’s renowned Globe Theater. In addition, there are many performances of various kinds at Gypsy Hill Park. And architecture devotees can take in Staunton’s well-preserved historic buildings, plus the Woodrow Wilson Presidential Library. A little farther afield, but not too far away, over the mountain, lies the fascinating historic—and busy—city of Charlottesville, where the main historic attraction is none other than Thomas Jefferson’s Monticello.

A welcoming medical and intellectual center Hanover, N.H.

Some 40,000 people live in several clustered towns including Hanover, Lebanon (where the hospital is actually located) and Norwich, Vt. And the go-to place for in the entire upper Connecticut River valley for patients needing sophisticated care? Dartmouth-Hitchcock Medical Center, which provides conveniently located cardiovascular surgery for a wide population swath, as well as most other procedures usually associated with big-city institutions.

Dartmouth-Hitchcock was founded in 1893, but Hanover’s best-known establishment, Dartmouth College, preceded it by more than a century. In 1769 it would be one of the nine Colonial Colleges founded before the American Revolution. Today, the combination of the two institutions has made the area a center of intellectual and medical renown, with great interchange of services.

The hospital benefits from the college’s Audrey & Theodor Geisel School of Medicine, and the college benefits from having a convenient supply of practicing physicians as teachers, not to mention intern opportunities at the hospital. (Yes, Theodor Geisel is the given name of the internationally known Dr. Seuss.) And the community benefits from the many cultural events sponsored by the college, including concerts featuring world-famous musicians.

As the hospital’s media relations manager, Mike Barwell, says, “There’s a lot of flowback between the school and the hospital.” He adds: “One of our hallmarks is the incredible research that we do here, including an enormous amount of studies on patient outcomes. In fact, the whole idea for the Affordable Care Act came out of the research institute.”

The Dartmouth Institute for Health Policy and Clinical Practice, its full name, was founded in 1988. Its projects have included research on ways to improve health care methods and determining efficiencies that can make it possible for physicians to take on millions more patients per year.

The hospital itself operates both the state’s only Children’s Hospital Association-approved full service children’s hospital as well as its sole Level 1 trauma center.

Scott Rodi, M.D., MPH, now a 14-year area resident, is the emergency medicine section chief as well as medical director of the Center for Rural Emergency Services. He’s also an assistant professor of medicine at the Geisel School. He himself is a Dartmouth graduate, but his medical education took him literally from one end of the country to the other, first for a medical degree at Weill Cornell Medical College in New York City, then back to Dartmouth for a master’s in public health, followed by a surgical internship in Santa Barbara, Calif., and finally residencies at hospitals in Ithaca, N.Y., and Los Angeles.

Thanks to Dartmouth-Hitchcock’s air transport system—two helicopters and three ambulances—Rodi and his staff may treat patients from several states, and patients from local areas in need of specialty care can be flown quickly to or from rather far-flung areas. “We can cut a multi-hour transport time to minutes,” Barwell notes.

On the other side of the coin, adds Rodi, is the fact that area patients can now stay near home for intricate procedures like heart surgery instead of having to make the long trip to Burlington, Boston or Portland, Me.

After experiencing life in big cities during two of his post-degree tours, Rodi and his wife had “formulated the idea of raising a family in a rural location with access to an academic medical center and a good academic college. We’d have all the benefits that (they provide) to a community, but still a rural setting. It turns out that there are not a lot of places like that in the country.” They now have three daughters, ages 15, 13 and 10, and live in Lyme, a tiny community bordering Hanover. “In the town,” Rodi says, “there’s a lot of focus on children, they learn to appreciate the outdoors and there are excellent public schools.”

After eighth grade, students must choose out-of-town high schools. His two older daughters are now enrolled at Hanover High School. One downside, as Rodi puts it, since there’s no school bus, “Every day we have a circus of trying to figure out how to get them there.” Ditto for extracurricular activities such as swimming meets and basketball games.

But he and his wife are enjoying the ambience of “a really nice community,” not to mention the fact that “you can get to everything within 10 to 30 minutes.” Then he corrects himself: “Actually, most are within two minutes. When I trained in New York and Los Angeles, it took two or three hours to get errands all done.”

The nearness of off-duty activities also enhances life, such as a close drive to enjoy Rodi’s current favorite, cross-country skiing. “There are lots of places all over for downhill skiing, at least six that are within an hour’s drive. One is about 10 minutes from my house,” he says.

In other seasons, the outdoor possibilities include biking, hiking, fly fishing and golf. A warm-weather passion for Rodi’s family is kayaking. “I have a boat I keep on a pond near my house.” What could be more convenient?

Eileen Lockwood is a frequent contributor to PracticeLink Magazine.

 

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Amanda Reese, D.O.

By Amanda Reese, D.O. | Snapshot | Spring 2014

 

Amanda Reese and her family

“I read [PracticeLink Magazine] religiously and used it to prepare for my interview and to tailor questions to ask potential employers. The magazine articles gave me confidence and courage to ask for the things that I wanted.” –Amdana Reese, D.O.

WORK: General surgeon in practice since 2013. Community Health Systems, Bluefield Regional Medical Center, Bluefield, W.Va.

EDUCATION/TRAINING:
Medical school: Edward Via Virginia College of Osteopathic Medicine (2008)

Residency: Carilion Clinic-Virginia Tech, General Surgery Residency Program, Roanoke, Va. (2013)

Reese enjoys Crossfit, skiing, gymnastics and outdoor activities. She also enjoys spending time with her family—husband Phillip and their daughters, Braelyn and Gabrielle.

What’s your advice for residents beginning their job search?

Make sure to have a clear understanding of what you are looking for before you begin the search. Consider location, size of practice, call responsibilities, size of hospital, supporting staff/specialties before you begin to look. It will narrow the field considerably and make the search manageable.

What surprised you about your post-residency job search?

I was surprised that hospital recruiters pursued me! I was recruited more than one year prior to graduation, which was a nice change from the stress of applications, test scores and requests for recommendation letters. For once I could be picky and make demands for what I was looking for.

What do you wish they had taught in med school but didn’t?

I wish medical school would have taught me how to write orders and a systematic process for working through acute patient problems. I wish residency would have prepared me for the business side of practice, including billing, coding, networking with other physicians and advertising.

Anything particularly unique about your job search?

I read [PracticeLink Magazine] religiously and used it to prepare for my interview and to tailor questions to ask potential employers. The magazine articles gave me confidence and courage to ask for the things that I wanted.

Any other advice?

Talk to nurses, staff, drug/equipment representatives, other physicians and everyone else that you can about your practice of interest. You will find out the good, bad and ugly about a job. Also, ask your mentors the things that they considered when deciding between various positions. Hearing other people’s experiences may help you avoid pitfalls.

 

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Where will you work?

Health care delivery models are ever-evolving. How might that affect your job search?

By Karen Childress | Feature Articles | Spring 2014

 

The future of medical practice is—and has long been—up for debate. Some doctors decry that it’s impossible to survive in a small practice anymore. Others work in large clinics or health systems for the relative security that model offers, but complain that they don’t have enough autonomy.

Many are happily ensconced in medium-sized single specialty partnerships. A few are bucking tradition and coming up with entirely new ways to deliver care to patients.

Of late, the discussion of hospital employment has become a hot topic in medical circles.Jeff Goldsmith, Ph.D., founder of Health Futures, Inc. based in Charlottesville, Va., conducts research, writes, and speaks nationally about the changing health care landscape.

“Only 15 to 17 percent of doctors are employed by hospitals,” Goldsmith says, citing the 2012 AMA Physician Practice Benchmark Study. “It has grown if you look at the trend data, but 20 percent of doctors are still in solo practices and another 20 percent are in groups of two to four. Overall, just short of 60 percent are in groups smaller than nine.”

These figures don’t, however, factor in the age of physicians. “Only between five and 10 percent of doctors under 40 are in small practices,” says Goldsmith. “If you look forward five to eight years, the structure of medical practice will tilt in favor of larger groups.” This is, in part, due to the fact that baby boomer physicians will be retiring en masse over the next decade or so and doctors coming out of training to take their places will opt for larger groups and employed situations. “That’s certainly an economically rational decision when you have a couple hundred thousand dollars in debt,” says Goldsmith.

Back to the issue of hospital employment, Goldsmith says the institutions are not taking on physician practices because they want to or because they think they’ll be profitable. “The impetus for this is coming from the physician community,” he says. “If you take your local health system CEO out for a couple of drinks, by the third one he’ll tell you he doesn’t want to do this. But when your cardiology group comes to you and says we don’t want to be independent anymore and if we can work something out you’ll get all our caths and stents, and if we can’t work something out then they’ll all go away, there is a not-so-subtle element of coercion.” Hospitals are essentially buying ambulatory utilization. “If hospitals had not been aggressively purchasing practices [in recent years], their outpatient utilization would be declining right along with their inpatient utilization.”

Goldsmith says to expect more practice aggregation in the coming years with groups joining forces to give physicians both independence and greater choices about how they practice.

What doctors want

Jim Stone is board president for the National Association of Physician Recruiters (napr.org). Each spring, The Medicus Firm, of which Stone is president, conducts a survey on physician practice preferences. More than 2,500 physicians in 19 specialties in 50 states responded to the most recent survey. What doctors say they want in terms of a practice model has been shifting back and forth between hospital employment and working in a single-specialty group partnership.

“This last year, the single-specialty group was the preferred choice,” says Stone. But the numbers were very close. Twenty-four percent of physicians in training said they were looking to join a single-specialty group, while 28 percent were seeking hospital employment. Among practicing physicians, those numbers were almost exactly reversed at 28 percent and 22 percent, respectively. Only 2.6 percent of physicians currently in training said they wanted to open their own solo practice.

“A lot of it is driven by fear, both in terms of wanting to be part of a group or being employed by a hospital,” says Stone. “It’s fear of regulation, fear of the financial downside, and the perception that there is strength numbers, which is probably accurate.”

In their 2013 In-House Physician Recruitment Benchmarking Report, The Association of Staff Physician Recruiters (ASPR, aspr.org) reported on open job numbers. Sixty-four percent of openings were for opportunities in hospitals or other integrated delivery systems and 13 percent were for physician-owned practices at the time of the survey. By practice type, those numbers were 72 percent for multi-specialty groups, 25 percent for single-specialty groups, and less than 2 percent for solo practices.

Dr. Don Moore

Don Moore, M.D., left his group in Florida for the stability of the Cleveland Clinic. “Once I decided to become employed, it was a freeing experience,” Moore says. “I’m required to do one thing, which is take care of my patients.”

Hospital employment:  Joining the group

Don Moore, M.D., was delighted to return to Florida to practice in 1997 upon finishing his spine surgery fellowship. He’d done part of his orthopedic residency in Tampa and, having been brought up in Detroit, was looking forward to the warm, sunny weather and beaches that his new home offered. “It was like a dream come true,” says Moore. And it was all he’d hoped for, until recently.

“I was in a group and it was very exciting. We built a building. We were all fellowship trained and we each specialized in one thing that we were trained to do. Our practice had a good reputation,” says Moore. Around 2009 or 2010 when the housing market got pummeled, Moore began to notice that primary care physicians in the area were starting to struggle. “We didn’t see a problem as specialists,” says Moore.

“Around that same time, there was a significant push in the field toward regulatory medicine. We had to comply with other mandatory processes as well,” says Moore. “We didn’t have the joy of practicing medicine like we wanted to, and it became more and more challenging.” Like many physicians, Moore and his partners were working longer and harder just to stay afloat.

Added to all of this was the fact that local hospitals were hiring doctors of their own. And Moore, like many physicians, was concerned about the implementation and many unknowns associated with the Affordable Care Act.

Having always been his own boss, Moore says he never understood why some doctors would work for hospitals or other large institutions. “It seemed like giving up quite a bit,” he says. But as the handwriting on the wall became clearer, Moore began to explore his options. Eventually, he interviewed with the Cleveland Clinic and decided that giving up some autonomy in exchange for not having to worry about running a business wasn’t such a bad tradeoff. Also, the timing was good as his two children were on their way to college. “We no longer had any ties to Florida in terms of schooling. My wife was on board with the move. She understood my frustration with where things were headed,” says Moore.

Still, making a mid-career move wasn’t an easy decision. “I was 16 years in one place and I loved the patients,” says Moore. “My partners were like family and I felt like I was divorcing them.” The Florida group has remained intact and they have hired a replacement for Moore.

Moore’s new practice at Fisher-Titus Medical Center in the small town of Norwalk, Ohio, is about an hour away from the Cleveland Clinic campus. He began practicing at Fisher-Titus on September 1, 2013. “Once I decided to become employed, it was a freeing experience. I’m required to do one thing, which is [take care of] my patients,” says Moore. “It’s not that I don’t care about what things cost, but I can just do what I do best. It’s amazing what’s available here at Fisher-Titus and through our affiliation with Cleveland Clinic.”

Moore says any physician contemplating a career move should examine what they’re passionate about. “Prioritize what’s important in your life. If making money is your thing, then find a job that pays a lot, and you may have to make compromises. If you don’t want to be inundated with the business aspect [of medicine] and competition, think about that,” says Moore. “And never say never. Up until December last year, I thought I’d die in Florida. People asked why I’d leave sunny Florida to go to Ohio. I’m a physician first, and this is where the Cleveland Clinic is.”

National staffing agency: Expanded options

The Cleveland Clinic has more than 3,000 physicians and scientists on staff, and yet there are even larger organizations where doctors can choose to practice.

National staffing and management companies offer opportunities in emergency medicine, anesthesiology, radiology, hospital medicine, trauma surgery and other specialties. EmCare (emcare.com) is one such organization.

“We’re the largest in the country and growing fast,” says Andy Mulvey, M.D., FACEP, Regional Medical Director for EmCare’s North Division, based in Indianapolis. EmCare staffs more than 400 emergency departments nationwide and added more than 100 in 2013 alone.

Mulvey says that 10 to 15 years ago there was a degree of skepticism among doctors about working in “corporate medicine.” Today, due to pressures on reimbursement and ever-increasing regulations applied to health care, doctors are gravitating toward large organizations so that they can take care of patients without being distracted with the administrative side of practice. “This is the way of the future,” says Mulvey.

One big advantage that a model like EmCare offers is flexibility and opportunities for career advancement. “If you’re looking for a job in Southern California and choose EmCare, if in two years you marry someone from Michigan and want to live there, there is probably something for you. It’s a national solution,” says Mulvey. Each regional office at EmCare has its own recruiting and credentialing department to support physicians. “In my office we have full-time credentialing, recruiting and scheduling personnel to support our practices. They handle all kinds of activities that physicians don’t enjoy and aren’t very good at,” says Mulvey.

The ability for ED directors to gather and exchange ideas about best practices is another benefit of this model. “Here in Indiana we have 20 contracts that we manage,” says Mulvey. “At monthly meetings with all of our directors, we go through different ideas, talk about issues and concerns, and make wish lists for things we’d like to have done.” Networking and professional development isn’t limited to management, however. Physicians who staff EmCare’s emergency departments regularly attend regional meetings where they participate in basic skills labs, receive training in ultrasound, get updates on best practices in their specialty, and engage in other continuing education opportunities.

Concierge practice: Life on the mountain

Large groups and employed situations are not for everyone, however. Some doctors who choose to maintain their independence become quite creative in how they practice by opting for concierge or subscription-based practice models. The concierge model has been around for years and, with some exceptions, tends to attract more affluent patients who pay an annual fee in exchange for nearly unlimited access to their doctors. The subscription-based practice model is newer and usually charges patients a flat monthly fee for fairly comprehensive primary care. A handful of doctors have gravitated toward small and even “micro-practices” in which they operate from small offices with minimal staff to keep overhead low.

One such doctor is family physician Julie Monroe, D.O., who most definitely charts her own course. She worked as an ER nurse while attending medical school and after residency joined the Air Force, where she practiced for four years. She then moved to the beautiful, remote community of Lake Arrowhead, Calif., in the mountains above Los Angeles and worked in a rural health clinic for another four years. It was there that she experienced the “last straw” that led her to open a solo, cash-only practice where she has been for the last five years.

“I was taking care of a young girl who was making minimum wage and going to school. She’d been sick for a couple of weeks and she had the choice of seeing a doctor or making her car payment,” says Monroe. The patient finally did seek care but then could not afford the medication Monroe prescribed. “That’s when I knew I had to do something,” she says. The rural health clinic where Monroe had been working accepted Medicare and Medicaid patients—to their credit—but had no system in place to offer discounts for uninsured individuals.

Monroe opened her small practice in 2008 with one medical assistant and two exam rooms furnished partly with what she could find on eBay. She’s since expanded to three exam rooms and has two full-time medical assistants. No insurance billing means the office can operate with a lean staff. “It’s working out pretty well,” says Monroe. “We’re not-for-profit and get some donations from the community.” Four fundraisers have been held to support the clinic since it opened and a local women’s group has raised an additional $12,000. But overall the practice is fairly self-sufficient.

Some grant money helped with the start-up phase of Monroe’s practice, but she says that source of funding is difficult to come by because organizations that offer grants don’t “get” her practice model. “We’re not trying to help people get on Medicare and Medicaid. I’m just taking care of them,” says Monroe. The practice charges a flat $35 for each office visit. Monroe sees 20 to 25 patients a day. Patients who need inpatient care are seen by hospitalists.

Monroe has worked out special rates for her patients with nearby Mountains Community Hospital and their affiliated radiologists for imaging, and works with another group that offers MRIs for $350 and CT scans for $225 if patients pay cash for those studies. She is also set up to offer free vaccines for children up to age 18 through a state-sponsored program and has a contract with Council Connections (councilconnections.com), which allows her to offer low-cost laboratory diagnostics and medication dispensing. “I can do complete fasting labs, CBCs, cholesterol, thyroid and liver testing for $26 through Quest Diagnostics. We draw and they pick up,” says Monroe.

Lake Arrowhead’s economy is based largely on tourism. Jobs are not plentiful and wages in the area are not high. “With Obamacare, a lot of people worried that I’d close,” says Monroe. “But if you look at California’s plan, people can’t afford the monthly premiums. If they’re just scraping by they can’t pay $300 to $500 a month for insurance,” says Monroe. In other words, there will likely still be plenty of people in the area grateful that they can see a doctor for $35. “We’ll keep going. There will always be a need,” says Monroe.

Asked what advice she might have for physicians considering a practice similar to hers, Monroe says they should determine what the needs are in the community and crunch the numbers. “Figure out how much you want to make after taxes and what can you afford to pay in overhead,” she says. Monroe says she’s extremely satisfied with her practice. “Patients are so grateful that there is someone on the mountain who cares and where they can receive quality care. It’s just amazing,” says Monroe.

Dr. Leslie Kernisan

Geriatrician Leslie Kernisan, M.D., MPH, has a practice so lean she doesn’t even have an office. “I do house calls and visits to assisted-living facilities,” she says. She also makes good use of technology to communicate with patients and caregivers.

Micro-practice:  Who needs an office?

Farther north in the Golden State, geriatrician Leslie Kernisan, M.D., MPH, has a micro-practice. That term, reportedly coined by family physician Gordon Moore, M.D., describes a medical practice that is very small, very lean, and often operated without any staff at all. In Kernisan’s case, it also means operating without an office.

Before launching her micro-practice in October of 2012, Kernisan was the associate medical director at a federally qualified health clinic for older adults in the Bay Area. “My practice time was limited to just a few clinic sessions and house calls,” says Kernisan, who was responsible for overseeing several clinical and quality projects for the organization.

Although she was technically working part time, the work was stressful and routinely required extra hours. Kernisan felt she didn’t have enough time for her two young children and for other projects related to the care of older adults that she wanted to pursue.

Today, she makes full use of technology to deliver care to older adults and work closely with family-member and non-family member caregivers to ensure that patients remain as healthy as they can be as they age. “I do house calls and visits to assisted-living facilities,” says Kernisan. She also corresponds with patients and caregivers by phone, email, and through a sophisticated portal on her website (drkernisan.net). “My patients are elderly and often have difficulty coming to clinic, so this works well,” says Kernisan.

Rather than charging an annual or monthly fee for her services, Kernisan keeps it simple by charging $200 per hour. She does not accept insurance or Medicare. “I believe in the Medicare system, but they don’t reimburse for phones calls or care coordination,” says Kernisan, explaining why, given her practice model, she had to opt out.

Kernisan’s primary focus is on how to improve the lives of older adults with an emphasis on how caregivers factor into the equation. “I spend a lot of time blogging and writing about geriatrics and how to leverage technology,” says Kernisan. For example, one recent post on her blog, geritech.org, is titled Helping Caregivers Organize Information. In it, she offers four key categories of data that should be tracked so that older patients receive good care and have the best possible quality of life. Kernisan also lectures for lay and professional groups about the care of geriatric patients.

Kernisan spends about a quarter of her time on clinical care and the remainder researching, writing and educating. “It’s important for us to find practice models that are sustainable. Different people have different ideas about what works,” says Kernisan. “I am a bit of a geriatric health care redesign wonk, so my practice is my own little laboratory. It’s a way to keep a foot in the clinical trench while I write and work on caregiver education.”

You have options

Statistics tell us stories about what the trends are, but keep in mind that a dream job for one doctor might be a nightmare for another.

Whether you are starting your job search looking for your first practice right out of training or considering a mid-career move, take time to seriously think about where you want to live, how you want to deliver care, and what will be best for your family if you have one. Engage your brain to make this important decision, but don’t forget to listen to your gut and your heart.

Karen Childress is a frequent contributor to PracticeLink Magazine.

 

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CV Makeovers

Are you communicating your best self on your CV?

By Anish Majumdar | Feature Articles | Spring 2014

 

Dr. Kalore

Orthopedic surgeon Niraj Kalore, M.D., revised his CV to better communicate his career accomplishments. The result helped him articulate the depth of his experience.

The best medical CVs strike a balance between getting across your key details while also containing that extra element that makes you stand out.

What that extra element actually looks like varies.

It could be an effective opening section that presents a vision of where you’d like to go instead of strictly where you are. It could be a CV that’s structured in a way that communicates an understanding of what matters most (while leaving out the fluff). The ultimate test lies in those moments when your CV is being evaluated by a recruiter. If there’s a strong mix of positive elements, at some point the recruiter’s review stops being about where you trained or what journals you’ve been published in and turns into curiosity about who you are.

That’s the moment your phone rings and an interview is scheduled.

In my work as a Certified Professional Resume Writer and owner of a firm called ResumeOrbit.com, I’ve had the opportunity to work closely with physicians spanning many different specialties in addressing issues related to their CVs.

On the following pages are three before-and-after examples meant to demonstrate the strategies I use on a daily basis. By implementing them, you can expect to see a significant improvement in the response rate your CV receives.

CV Makeover 1

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CV makeover #1: The all-over-the-map CV

Developing a physician CV for academic positions can be daunting. Many institutions are more than happy to provide interested job-seekers with templates outlining all that’s required within an academic CV, from formatting suggestions to subject categories. The problem is that, in practice, it’s almost impossible to create an appealing document while rigidly following a template.

Bucking the rules can seem risky, but take heart: No job-seeker in the history of gainful employment ever secured a position due to how guideline-friendly his CV was. He got it through standing out in a meaningful way and asserting his suitability for the job.

Niraj Kalore, M.D., is a fellowship-trained Orthopedic Surgeon with a background of excellence in patient care and research. He possesses extensive teaching and mentoring experience (always a plus for academic positions), all necessary licenses and certifications, and an impressive list of publication and presentation credits to his name. And yet interest throughout the job search had been muted.

A quick glance at his existing CV demonstrates a challenge many of the most experienced physicians in the industry face: How do you get across the scope of a multifaceted career within the limited length of a CV?

Suggested areas of improvement Kalore’s old CV didn’t really do much in terms of communicating the high-level hospital appointments and incredibly relevant postdoctoral training he received in Orthopedic Surgery. By structuring the most relevant credits in this section by first describing unique responsibilities, followed by a few bullet points outlining accomplishments and other distinguishing successes, you naturally draw a reader’s gaze toward what you want them to know.

CV Makeover 2

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CV makeover #2: The ineffectively written CV

It’s tempting to believe, in an era of ever-increasing competition and rapid change within the health care industry, that a good CV is one that is about as dry as your typical job posting. After all, the thinking goes, if they’re requesting a laundry list of skills, why not simply respond in kind? Wouldn’t that automatically put you at the top of the list of candidates they’d be interested in hiring?

The error with this line of thinking is believing that a job posting is a company’s summarization of the ideal candidate. It isn’t. Instead, think of the job posting as a kind of skeletal outline; the exact details (beyond required education and training) and mixture of goals, personality and overall fit remain to be seen. As the CV will be, in most cases, the first impression someone will have of you, it pays to be as clear and confident as possible. Much of this comes down to effective writing.

Mani Ehteshami, M.D., is a Board Certified physician with more than 18 years of anatomic and clinical pathology experience. During the course of a distinguished career, he successfully launched diverse outreach programs and web-based laboratory information systems (LIS), negotiated critical contracts with hospitals and ensured the timely procurement of CLIA Certificate, state, Medicare and Medicaid Licenses. He is highly skilled in surgical pathology with expertise in GI, GU, and oncologic pathology, immunohistochemistry, performance and interpretation of fine needle aspiration (FNA), and bone marrow aspiration and biopsy.

Now take a look at the opening sections of his “before” CV and see how many of these key traits come across clearly.

Suggested areas of improvementCV Tips

Though all the necessary details were there, what’s missing was the kind of language that relayed a true understanding of Ehteshami’s worth as a candidate. Sometimes the most effective CV strategy is going back to the drawing board, essentially using everything you’ve created to date as raw materials for a new presentation.

With considerable input from Ehteshami to make sure we were on the right track, we eventually developed a CV that turned around his job search and brought a host of wonderful career opportunities his way.

CV Makeover 3

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CV makeover #3: The lack-of-confidence CV

The most valuable quality a CV can possess is an awareness, on the part of the candidate, that securing a position is a two-way street.

You’re looking for the right fit as selectively as any employer. When we hear of professionals accepting positions that do not rise to the level of their expectations, be it in terms of responsibilities, salary or any other factor, oftentimes the culprit is miscommunication during the earliest phases of the hiring process.

The worth a potential employer sees in you is directly linked to the worth you place in yourself, and whether that’s successfully communicated.

Dipti Patil, M.D., had just completed her residency and was looking to practice as a family medicine physician. Even a cursory review of her existing CV showed a range of relevant experience. However, the document read like a great CV for a med student, not a physician who understands her value and can communicate it with confidence.

Suggested areas of improvement

By thinking in terms of what a potential employer would most like to see in a candidate like Patil, I created a succinct but impactful opening, immediately followed by education and licensure information. The Postdoctoral Training section comes next, with a particular emphasis on showing how her experiences can be directly applied to a role as a Family Medicine physician.

When the right elements of a CV are in place, the stage is set for a successful interview, one where the key ideas expressed in the document can be naturally expounded.

It’s important to listen to your gut. Though none of us begin as experts in this area, all of us have reviewed untold thousands of documents, the basic elements of which still apply. Is it written well? Is it effective in communicating who you are? Are you excited by the prospect of getting it out there? The higher the bar you set for yourself here, the greater the results.

Anish Majumdar is a Certified Professional Resume Writer (CPRW) and owner of ResumeOrbit.com, a career development firm. He lives with his wife, son and pets in Rochester, N.Y.

 

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Launch your job search

A countdown for your search for your first or next practice.

By Tim Boden | Feature Articles | Spring 2014

 

As you head into your final year of training, you’ll soon find yourself face to face with the daunting project of landing your dream job. You’ve made an astounding investment of money, time and effort designing and building your professional career—and now you’re almost ready to launch. It may not be rocket science, but it certainly can feel about as complicated as a shuttle mission!

Sadly, a disturbing number of physician career launches seem to misfire. Common wisdom says that about half of young doctors are dissatisfied with their first jobs and end up looking for another position within two years. Actual studies by professional recruiting services indicate a lower percentage of two-year turnovers. About a third of survey respondents left their first position within two years. But about half left their first positions within five years.

Philip Yen, M.D., completed a fellowship in musculoskeletal radiology in 2012 and went to work in July at University Hospitals affiliated with Case Western Reserve University in Cleveland. Based on his recent experience, he recommends targeting six months before your start date as a reasonable goal for signing an employment agreement. That, he says, allows plenty of time for credentialing.

MirrorT MINUS 18 months: Physician, know thyself

Deborah Gleason, physician development administrator at The Nebraska Medical Center (NMC), is president of the Association of Staff Physician Recruiters (ASPR), the professional organization for in-house physician recruitment professionals.

Her job involves recruiting and retaining physicians for NMC, the teaching hospital for the University of Nebraska Medical Center. Her connection with the medical school finds her serving as a coach and advisor for doctors in training as they prepare to start their job searches.

She advises physicians to begin their searches at least 18 months prior to their anticipated first day. Her mantra for those wondering where to begin is: “Physician, know thyself.” A successful job search starts with figuring out where you want to practice and what kind of practice you want to join (or create).

In fact, Gleason says, “If you don’t have a clue about what you want by the beginning of your last training year, you’ll be playing catch-up throughout your search.”

The more you know about what you want (or don’t want) up front, the more efficiently you will be able to use the scant time available for conducting a thorough job search while finishing up your training. Gleason observes that residents and fellows are starting their searches earlier and earlier these days. You simply can’t afford to wait too long.

Yen urges job-seekers to spend a lot of time writing the perfect cover letter to accompany their CVs. The letter must grab an employer’s attention and describe how you will benefit the organization. (See the article starting on page 46 for more CV tips.)

Career coach Jack Valancy agrees with Gleason and challenges job-seekers to begin articulating their key career issues at least 18 months out. He asks residents, “How would you describe a job that you’d like to go to every day?” To answer that question, you’ll have to get in touch with your personal and professional preferences and priorities. In other words, what would you like to do, with whom would you like to do it, and where would you like to do it?

Drs. Naji and Khatibi

When Omar Naji, M.D., and Bita Khatibi, M.D., were job searching, they looked for the most hard-to-find practice first. “Don’t waste your time finding a great job, getting your hopes up, and then discovering there’s no job for
your spouse,” Naji says.

The three “C’s”…plus one

What’s important to you? What kinds of day-to-day job duties interest you? What would you consider a “reasonable” workload? Valancy guides physicians to consider what he calls the “three Cs”:

• Culture: In what kind of organization would you feel most comfortable? • Colleagues: Are you interested in finding a group of older, more experienced physicians who can mentor you? Would you rather find other young physicians who share similar interests and values? • Career: How do you envision your personal career path? Do you want to settle into a community where you can remain until your golden years? Do you aspire to administrative or executive work? Do you want to teach? Does research interest you?

Most physicians can find jobs that more or less meet their criteria and satisfy their major preferences—but they may have to make some compromises regarding geographic location or personal and family lifestyle. You’ll have to decide what’s most important to you and your spouse or significant other. What if you find your dream job in a major city, but you have no taste for urban life? What if you have always dreamed of living near the ocean in a warm, southern clime, but your best opportunity opens up in northern Minnesota?

Do your recreational activities and interests rely on location? An avid rock-climber probably wants to live near some climbable rocks. A boating enthusiast needs convenient water. A couple with children may desire an idyllic suburban setting; a two-career couple might like the pace of Manhattan or Chicago’s Gold Coast. Maybe you’d like to live and work in your own version of Mayberry.

What about family proximity? Do you wish to live near relatives—or do you want to avoid being too close to certain family members?

When it comes to location preferences, the critical issues revolve around your priorities. What’s most important to you: what you do, or where you do it?

Married physicians with “his-and-hers” career paths face extra challenges. When both spouses are doctors, those challenges only grow. Omar Naji, M.D., a family practitioner with a fellowship in sports medicine, jumped enthusiastically into the search for jobs for both him and his wife, Bita Khatibi, M.D. Khatibi is also trained in family medicine, but her additional training is in obstetrics, with a focus on caesarean sections.

“In our case,” says Naji, “my wife was feeling a little burned out at the end of her fellowship, so I more or less took charge of the job search. Since I wasn’t completely focused on sports medicine, I quickly found many family practice opportunities for myself. But when I came a cross something really interesting, I would ask, ‘Is there a position in your community for my wife, a family medicine specialist with additional OB training?’ I quickly learned that there were far fewer openings for what she had to offer.”

“I had to completely switch gears,” he says. “I started searching primarily for a job for my wife. Physician couples need to figure out what the rate-limiting factor is for them, and adjust accordingly. Don’t waste your time finding a great job, getting your hopes up, and then discovering there’s no job for your spouse.”

Though wedded to each other, Drs. Naji and Khatibi didn’t feel wedded to any particular geographic region. They searched all over the United States, and even considered international opportunities. They successfully landed jobs in Vancouver, Wash., which they found through PracticeLink.

Finally—and Valancy emphasizes finally—develop realistic expectations about a fourth “C”: compensation. He has met too many job-seekers over-emphasizing money to the neglect of other factors that can have a bigger impact on their well-being and job satisfaction.

Look and learn Take advantage of the wide range of opportunities opening before you. This is your chance to take a look at different practice types. (For a deeper look into your practice options, see page 53.) Valancy urges candidates to keep an open mind—especially early on. “You may find something you love about a job that you hadn’t previously considered.” On the other hand, he says you also just might discover some unattractive things about a job you thought would be ideal.

With so many of your colleagues (and competitors) diving into the candidate pool earlier and earlier, you might be tempted to commit to an apparently good opportunity prematurely. Hospitals and practices desperate to secure certain hard-to-recruit specialists might offer generous signing bonuses or monthly stipends for residents who sign a contract or binding commitment letter.

But there’s a good reason why we refer to these sweet offers as golden handcuffs. If you change your mind, you’ll likely have to repay the bonus—an expensive prospect at best.

NetT MINUS 12 months:   Cast a broad net

At about the 12-month mark, you’ll likely be looking at specific job opportunities that have attracted your attention. If you’ve already been making inquiries for six months or so, your name has probably found its way into a number of recruiter databases. Depending on your specialty and other factors, you could already feel overwhelmed by the sheer number of interested employers.

Gleason advises physicians to create a new email account and use it exclusively for your job search. This strategy segregates the potentially voluminous job-search emails, and it makes it easier to organize the offers.

She also recommends using your computer to track the interesting jobs. You can set up a spreadsheet to record each job’s crucial data points. A tool like that can help minimize your confusion as you sort through many opportunities.

“Follow up on any employers who don’t acknowledge receiving your CV,” Yen advises. Your package may get lost—especially when we’re talking about an enticing job with many applicants.

First contact Your first serious contacts will probably begin with phone conversations. Remember that you don’t have to agree to a phone call with every employer who shows interest in you.

Naji was surprised at the number of emails and phone calls from practices, health systems and professional recruiters that he received. On the other hand, there’s still time to keep an open mind, and a phone call won’t cost you anything but some of your time.

That’s not to say your time isn’t valuable. Make the most of your phone conversations by asking good questions that elicit useful information. Valancy likes to open with a broad, open question: “Tell me about your practice.” Listen carefully to what the caller says—and what he or she doesn’t say.

Dr. Phillip Yen

When should you aim to sign your first employment contract? Philip Yen, M.D., who recently completed his own post-fellowship job search, recommends signing six months before your training completion date.

Note especially what the person talks about first. What topic or theme comes up the most? You can get a sense of what’s important in each organization. Similarly, you might pick up on potential problem areas by paying attention to topics they seem to avoid. An employer who brushes off a question or fails to answer directly signals to you an area that you’ll need to explore more in depth.

Focus a lot of your questions on the job itself. Get them to describe what day-to-day life on the job will be like. Ask about duties, practice setting and call schedules. How much of the work will be inpatient or facility-based? What will your weekly office schedule look like? Does the practice maintain extended hours in the evenings or on weekends?

As you look at interesting opportunities, you will probably develop a routine and a list of “standard” questions. The more consistently you ask your questions, the better you’ll be able to compare and contrast your findings. Along with questions about the job itself, be sure you include inquiries regarding:

• The organization itself: Is it physician owned or part of a health system or larger corporation? Who manages practice operations and oversees executive administration? How is the organization governed? Is there a medical director? A board of directors? • The practice culture: Ask questions to find out if this group is “all business” or more “laid back.” How does it integrate, train and mentor new physicians? How much control do individual physicians have? How does the group seek individual input? • The community: Find out what’s remarkable about the patient base—regional demographics and community health. Ask about local amenities, lifestyle, education and real estate. Cover whatever is important to you. • The compensation structure: Ask general questions about the way the group pays physicians. Ask about base salary and productivity. See what you can find out about time off for vacation. Does the group pay malpractice premiums? How does the group generally distribute expenses?

Structure your inquiries around what’s important to you. When it comes to investigating job openings, Gleason says, “Any question is a good question—this is your career we’re talking about!”

Valancy agrees: “Find out about a practice before accepting an invitation to visit. Why waste everyone’s time and expense” on a costly interview trip to a job you’re not likely to accept?

Yen found that it took him about four months from first hearing about an opening to having a face-to-face interview.

Bags PackedT MINUS 9 months: Take your show on the road

You’ll probably find your first few practice visits exciting and fun as some practices expend tremendous effort (and expense) to “wine and dine” prospective recruits. This can prove eye-opening as you begin to get a sense of the value you bring to the table. But beware: It can just as easily blur your vision. Don’t be dazzled by the star treatment. Get past the hotel suites, fancy dinners and real estate tours and dig for a realistic understanding of what it will be like to work with the group from day to day.

Yen reports that he narrowed his search down to two competing opportunities in divergent practice settings—one in California, and the job he accepted in Ohio. He had developed an organized priority list (work schedule and earning potential topped his list), and University Hospitals best met his criteria.

According to Valancy, you can best catch a glimpse of daily life by asking for—insisting—on shadowing one or two physicians as they go about their usual routines. Even when everyone’s on their best behavior for the visiting physician, you can learn a lot about the practice. As you follow the veteran doctor, watch for indicators like these:

• How smoothly does the operation run? • How cooperative and congenial are the support staffers? • How well-maintained are the facilities and equipment? • How happy do the physicians seem to be? Their sense of satisfaction and well-being can be pretty reliable predictors of your own job satisfaction if you decide to settle there. • How happy do the patients seem to be? Not a one-way glass

Of course, while you’re looking over the practice opportunity and community, the prospective employer is sizing you up as well. Arrive at the practice well-prepared and ready to present the value you bring to the practice. Ask yourself, “Why would this group want to hire me?” If you can’t answer that clearly and succinctly, you won’t make the kind of impression that takes you to the top of their list.

Work out what Valancy calls your “elevator pitch” before you make your first practice visit. Interview itineraries tend to be packed tightly, giving you limited time to have in-depth conversations with each of the existing partners and associates. Carefully plan what you can say in just a couple minutes that will leave them thinking, This doctor will add value to our practice.

ContractT MINUS 6 months:  Contract negotiations

If you’ve truly done your due diligence over the preceding 12 months, you should have at least one or two attractive, concrete offers by the six-month mark. If you’ve never seen a modern-day physician employment contract, brace yourself: Its size and complexity might surprise you. This is no time for a do-it-yourself approach. Find appropriate professional advice, including qualified legal counsel, to help you understand the provisions and details of the contract.

Receiving a contract, reviewing it with your attorney and finalizing all the details can easily eat up three months or more. If you ask for significant changes in the terms, the discussions and correspondence can drag on even longer. The type of organization trying to recruit you can have quite an impact on how much time is required for contract negotiations. A physician-owned practice hiring its first new doctor in a long time will move much more slowly than a large organization that regularly hires staff members.

Yen was surprised by how long it took to hammer out the contract, and by what felt like a lopsided exchange. It seemed to take forever for the employer to send a contract or a revision, but it pushed hard for the candidate to review and return it quickly. He strongly advises using a lawyer: “Most of the contract details never came up in the interview process; you need help sorting through it intelligently.”

CertifiedT MINUS 3 months: Seal the deal in time for credentialing

Hopefully, you will have applied ink to a signature line at least three months before Day 1 on the job. “The time required for credentialing often surprises young job-seekers,” says Gleason. “In Nebraska, it will take at least a month—so I recommend allowing two months.” And that’s after spending at least two months getting licensed with the state. She urges residents to allow four months for licensing and general credentialing. “And these,” she adds, “are best-case-scenario estimates.”

“Measure twice, cut once…”

“…Measure once, cut twice.” The old carpenter’s adage reminds young craftsman that it never hurts to double-check your measurements before turning on the power saw. You can’t “un-saw” an expensive piece of lumber. Committing to a job with a medical practice without thoroughly examining your options could lead you to a regrettable choice.

If you find yourself near the end of your training program without having settled on a job offer, Gleason notes that locum tenens work might be a reasonable, though temporary, alternative. She sees more physicians these days opting for temp work as a way to pay the bills and test drive different practice settings. She recognizes the differences between candidates when she notes that there’s no one-size-fits-all job-search strategy or timeline.

Nevertheless, when you consider what it takes for the average physician job candidate to find, negotiate and settle into a new position, who would want to go through all that again in just a few short years? Nearly everyone in the industry agrees that your best job-hunt strategies include an early start—thus allowing yourself plenty of time to make the sound decisions that will launch your career on a successful trajectory.

Tim Boden, CMPE, is an author, editor and a group medical practice management expert.

 

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Making sure three’s not a crowd

Negotiating a contract gets a little trickier when it involves income guarantees, loan repayments and third parties.

By Roderick J. Holloman | Legal Matters | Spring 2014

 

Physicians have enough to think about when it comes to their contracts when joining a new practice. Those nuances are heightened when a hospital recruits a physician to establish their practice within the hospital’s community—not as a hospital employee, but as an employee of an established practice (with a salary guarantee, which the hospital subsidizes), or in particularly underserved areas as the founder and sole owner of the practice (which requires a set of business skills in addition to medical ones).

Instead of being a contract between just two parties, these kinds of recruitment arrangements involve three: the recruited physician, the employing practice, and the recruiting hospital.

These contracts are generally structured such that in exchange for compensation from a hospital, most commonly in the form of a salary subsidy, repayment of student loans, or a sign-on bonus, a physician agrees to maintain a full-time practice in the community for three years.

The compensation offered by a recruiting hospital is structured as a loan, which is incrementally forgiven monthly or annually due to the physician maintaining a full-time practice in the hospital’s community.

The recruiting hospital’s real incentive is to generate revenue by virtue of referrals from the physician’s practice within the community. Such treatments allow a recruiting hospital to generate additional revenue from outpatient procedures and inpatient stays.

For the recruited physician, it is important to consider the respective motivations of the employing practice and the recruiting hospital, as these motivations both align and divide.

The motivations behind recruitment arrangements

In this particular kind of recruitment arrangement, the hospital supplements the recruitment expenses commonly incurred by the employing practice. Additionally, the employing practice has the ability to evaluate whether the physician employee is a good fit without realizing the expenses usually incident to such evaluation (most notably, paying the physician a base salary).

The recruiting hospital’s benefit is much more indirect than the employer’s benefit. In theory, the hospital receives no direct benefit in exchange for its payments to the employing practice or recruited physician. However, in reality, hospitals often benefit handsomely in the form of facility fees generated from the treatment of the recruited physician’s patients (and those of his practice) when they’re treated in the hospital.

Key considerations for the physician

When you’re considering signing on to a recruiting contract, it’s important to consider these seven aspects.

1. Commitment to the geographic area

If you can’t, after an honest assessment, reasonably foresee remaining in the geographic area served by the recruiting hospital for the duration of the recruitment contract, you should seriously reconsider executing the recruitment agreement.

Once the recruitment agreement is signed, it becomes legally binding and enforceable, no matter any change of heart or desire to relocate. Therefore, if there are specific, legitimate and foreseeable events that could necessitate premature relocation, such as immigration concerns or the passing of an immediate family member, carve out exceptions to enforce the recruitment agreement in such instances.

2. Negotiable terms

Understand that the arrangement terms are negotiable and you have a degree of leverage. Physicians may believe the hospital recruitment agreement is entirely non-negotiable, but this is rarely the case.

Though it is true that the majority of the negotiable terms will be found in the employment contract, the recruitment contract is negotiable to a degree. Commonly negotiated provisions are: liability in the event employment with the initial practice terminates; hospital call coverage responsibilities; and whether the recruitment contract will preclude the employing practice from imposing a post-employment restrictive covenant prohibiting the physician from practicing within the hospital’s catchment area.

3. Compensation

Physician compensation is obviously a key consideration in any recruitment arrangement. Make sure you have a particularly keen understanding of the compensation calculation when the compensation is not fixed, but is instead based on productivity, such as a work relative value units (wRVUs) model.

4. Duties

The recruitment contract should specify what duties are to be performed in exchange for the hospital’s financial assistance. In addition to the requirement to maintain a full-time medical practice within the hospital’s service area, physician recruitment arrangements often also require that the physician participate in the hospital’s call coverage schedule.

5. Term

A physician recruitment contract will have two terms: a guaranteed income period, generally 24 months or less; and a period during which the physician commits to practice within his or her specialty on a full-time basis in the hospital’s service area (called the commitment period).

If the physician fails to maintain a full-time medical practice for the duration of the commitment period, the recruitment agreement would be breached and the hospital would be entitled to all or a portion of the sum it paid in association with the physician’s recruitment.

6. Reimbursement obligations

Essentially, the hospital’s payment to the employing practice is treated as a forgivable loan to both the recruited physician and the employing practice, repaid either in cash or forgiven on a pro rata basis via the physician’s full-time practice in the hospital’s service area.

In certain situations, for example due to immigration-related limitations, a physician does not have the option of self-employment.

Therefore, should employment with the initial employer end before the commitment period ends, the physician would be dependent on a subsequent employer to hire him or her, else the physician will be forced into a breach of the recruitment agreement, and consequently jointly liable with the practice to reimburse the hospital all or a portion of the sum paid in association with the physician’s recruitment.

7. Restrictive covenants

In the event the physician’s employment is terminated, the physician will likely remain bound by the terms of the recruitment agreement and must still remain in full-time medical practice in his or her specialty within the hospital’s service area.

Therefore, the recruitment agreement should expressly state that the employment contract cannot restrict you from practicing within the hospital’s service area should the employment contract terminate prior to the expiration of the recruitment contract.

If on the one hand the recruitment contract requires a physician to practice on a full-time basis through the commitment period, and on the other hand the employment contract requires the physician not to practice within the hospital’s service area and resign all medical staff privileges upon the termination of employment, a physician could be in the unenviable position of determining which contract to breach.

A physician contemplating a recruitment arrangement must fully understand the employment contract, the recruitment contract, and how each reconciles with the other.

An ounce of prevention is worth a pound of cure. The nominal fee to have your contracts reviewed by an attorney specializing in health care transactions will undoubtedly pale in comparison to the legal fees you will incur should you intentionally or unintentionally breach a covenant contained in the contracts you sign. l

Roderick J. Holloman (rjholloman@hollomanlawgroup.com) is the principal of The Holloman Law Group, PLLC (HLG) (hollomanlawgroup.com), a health care law firm with clients throughout the country.

 

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What’s your exit strategy?

Before you join your next practice, give thought to how you’ll leave it.

By Steven Abernathy and Brian Luster | Financial Fitness | Spring 2014

 

When you’re considering an offer of employment, going over your exit strategy before you sign on the dotted line might be the last thing on your mind. However, paying attention to some of the more common issues can save you time and spare you undue stress.

These days, there is no question that changes throughout a physician’s career—moving from private practice to hospital or corporate employment, for example, can be stressful. What do you need to do to plan a smooth conversion or exit strategy before closing your office door one last time? How are loose ends resolved upon your departure? Is there a succession plan in place? If loyal patients wish to see you at the new practice, are you contracted to honor a pre-existing residual payment plan with your old employer?

Countless issues may rear their heads, including non-competes, buyouts, client communication and succession planning. Successful transitions begin with a sensible,  realistic outlook about your career path and careful planning from your early working life through retirement.

Of course, after you’ve signed on and helped build a thriving practice, you may not be the one leaving. A partner’s departure will greatly affect your professional situation—and also your financial one.

Imagine this example: One of your junior medical partners, enticed by a lucrative offer from a nearby university hospital, decides to jump ship. There’s nothing too controversial about this…until the defector begins not only to poach clients, but also to divulge certain trade secrets and procedures that you developed.

What could you learn from that example?

Lesson 1: When you or your medical partners are transitioning, properly drafted non-compete agreements are essential.

In the imagined example, if you had prepared such an agreement, you would have had leverage to fight against the departing physician’s actions. Though non-compete agreements are generally disfavored on public policy grounds, if they are necessary to protect business interests and limited in duration and geographic proximity, they can help preclude this type of issue.

Lesson 2: Put agreements in writing as soon as employment is confirmed.

Much like a prenuptial agreement, a well-drafted non-compete can serve as a blueprint delineating what type of post-employment behavior is or is not permitted.

If you are an employer, we recommend you also add the essential verbiage to your employee handbook.

If you still have years of work ahead of you, be advised to clarify the specifics around what “assets” are yours (patients, patient files, procedures/techniques, proprietary information) and what are not. Though your patients are free to visit any doctor they wish, an employer with foresight may write any number of “non-compete” type restrictions into your contract. For example: “For any patient who sees you at your new practice, you owe the old practice two times the cost of the office visit.”

This may not be top of mind for many new physicians; attractive salaries, employee benefits and an institution at-the-ready to handle insurance claims, EMR conversions and other pesky administrative and system tasks have led many physicians to sign on the dotted line. Be sure to know what you are to receive—and what you may be giving up.

Lesson 3: If you are planning to move to another practice, or you are retiring, let your patients know well ahead of time.

What constitutes ample notice varies around the country, but a good place to start would be your state’s licensing board or medical societies. Different notice requirements may be required for specific specialties, as well. According to The New England Journal of Medicine, internal medicine physicians are advised to provide at least three months of notice; psychiatrists are counseled to provide six.

The obvious import of providing notice is to both thank the patients and to ensure they understand they have the option of remaining with the practice. Patients will undoubtedly appreciate this courtesy.

Timely notification is not simply a manner of courtesy, but also of protection. Imagine that you’re about to retire. Eager to begin traveling the country with your wife, you neglect to arrange permission to access your patients’ records after retirement and, at least in one patient’s case, to release medical records. Three months later, your cross-country journey is rudely interrupted by a malpractice suit. Your failure to release the patient’s records was a major cornerstone of the suit; worse yet, your main line of defense is tied up in the patient’s medical records—records that you now have trouble accessing.

Lesson 4: Make sure you are not disqualified on careless technicalities.

Before leaving a practice, be aware of the type of malpractice insurance you’ll need. The amount of doctors who don’t know the difference between “claims made” and “occurrence” coverage is baffling. Such ignorance can be costly.

If our fictitious traveling retired physician, for example, had “claims made” coverage and neglected to purchase “tail insurance” for claims filed after the termination of his policy, he would be unprotected. This may have been the case if he mistakenly believed he had “occurrence” coverage, where his carrier would be responsible for claims that arose while he was being covered (which presumably would have been when he was practicing). Few things are more disconcerting than being sued after crossing the finish line.

Make sure you have the proper professionals handling the transaction to propose the right questions and get the answers you need to move forward worry-free. This is complicated work and the risks involved can be foreboding.

Steven Abernathy (sabernathy@abbygroup.com) is founder, principal and chairman of The Abernathy Group II where Brian Luster (bluster@abbygroup.com) is a principal. They can be reached at (888) 422-2947. The Abernathy Group II Family Office sells no products and receives no commissions. It is independent, employee-owned and governed by its Advisory Board comprised entirely of thought-leading physicians and professionals.

 

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Spring medical app roundup

Apps for sharing securely and making reference checks easy.

By David Geer | Spring 2014 | Tech Notes

 

As everyone knows, the vast majority of physicians use medical apps on their smartphones and mobile devices. It’s no surprise then that colleagues’ reviews of medical apps make for popular reading material. This time, PracticeLink presents apps for secure file sharing, communications and physician reference.

Share securely with DocbookMDdocbookMD

Securely share patient files and message colleagues from your phone or tablet.  DocbookMD.com

DocbookMD (docbookmd.com) is a secure, real-time messaging and file sharing app for contacting colleagues and staff members and sharing files such as X-rays, EKGs, lab reports and wound images. The app comes in versions for the iPhone, iPad and iPod Touch as well as Android smartphones and tablets. The app is free to members of the more than 200 state and county medical societies that partner with DocbookMD.

Docbook Enterprise versions are available to physicians whose hospitals, groups or other organizations sponsor them. DocbookMD bases pricing for Docbook Enterprise on group size and need.

DocbookMD includes a virtual directory of local colleagues the physician can instantly message with files and important communications.

The app enables quick collaborations, test result updates and specialist consultations. DocbookMD intends to transcend practice settings and medical technologies including EHR systems to enable immediate, secure communication and critical alerts to improve daily workflow, according to Tracey Haas, D.O., MPH, chief medical officer and cofounder.

According to Haas, DocbookMD exceeds HIPAA/HITECH standards for mobile technology by using 256-bit encryption and a secure cloud-based server to keep health information private. Physicians, hospitals and groups can discuss patient care and share data in real time without fear of falling out of compliance with HIPAA regulations.

Tammy S. McConnell, D.O., a pediatrician at Children’s Medical Group in Austin, works in private practice with another pediatrician. “It challenges me to touch base with subspecialists when we are seeing patients every 10 to 15 minutes,” McConnell says. Carving out time to call with so many layers of contacts to wade through can put a strain on both McConnell’s and the subspecialists’ schedules. “It’s often very challenging to communicate valuable information in a time-effective manner,” she says.

DocbookMD helps resolve these challenges in a number of ways. “Sometimes I may want to give subspecialists a heads up about a patient they are seeing or a follow up about one they saw. We can often do this through DocbookMD without interrupting their day. They can choose to deal with the information at their convenience. This helps with point of care continuity enhancement,” says McConnell.

DocbookMD helps with urgent matters such as sending films/X-rays to a subspecialist to make a decision about fracture management, such as whether to splint and send the patient over immediately; splint and send them over in the morning; or simply observe. “It saves the specialist from unnecessary appointments and helps them to expedite more urgent appointments,” McConnell says.

As for future improvements in the app, McConnell suggests that DocbookMD included a way to tag messages as urgent vs. FYI vs. respond at your convenience. “It would be a good way for physicians to use DocbookMD in a time-effective manner,” she says.

Reference roundup:  OmnioOmnio

Access several reference sources through one central app. Omnio.com

Omnio, a physician reference tool, offers more than 1,200 medical journals and news sites so physicians can turn to one resource for many things. Omnio includes a revamped reference section and more fully integrated drug information and interaction checker as well as resources with medical conditions, symptoms and medical images.

Omnio ScreenshotOmnio is available for the iPad, the iPhone (as of this winter), and will be available for Android tablets later in 2014, according to Guatam Gulati, M.D., senior vice president of the app’s producer, Physicians Interactive.

Omnio enables physicians to access, digest and share health care information in a simple and effective manner, applying it at the point of care. “Rather than having health care professionals go through emails, websites, different medical organizations, pharmaceutical companies and reference books to get the information they need, we enable them to access all that information in one place, through Omnio,” says Gulati.

Omnio uses an open infrastructure to integrate third-party content directly into the app. Omnio offers a social infrastructure that enables physicians to better communicate and share information among their peers. Omnio includes elements such as My Pages and Omnio Pages, which help customize the content for the end user so it is one tap away when they need it. It also lets physicians organize their content into as many custom pages as they need, according to Gulati. The Omnio sharing function alerts physicians to new information from different resources.

“Omnio is launching new content sources via a partnership with DocWise, which will give physicians the ability to use DocWise’s aggregated content reader for personalized, curated content. Physicians will also be able to create collections of information sources and share content via Facebook and Twitter,” Gulati says.

Jason S. Levitz, M.D., is an oncologist and hematologist at Oncology & Hematology Specialists in Denville, N.J. He offers a comprehensive range of diagnostic, therapeutic and treatment-related services including treatment for cancers and diseases of the blood. “I used to have to shuffle between different applications on the phone, closing one and opening another, then going back to the previous application again,” Levitz says.

“Omnio is a one-stop resource for medical applications. I don’t have to go to several different applications on my iPad to find what I am looking for. I can look up a drug reference, check out the latest literature on treating lung cancer patients and research the standards of care for the same patient, all at the same time.”

“With Omnio, I can dedicate my own pages to lung cancer or prostate cancer or any particular malignancy. I can include treatment protocols that I want to have easy access to, and have the calculators also as part of that. So it’s all integrated and easy to use within that one page.”

Empowered by the cloud: Sookasa Sookasa

Use the cloud to store and transfer files in a HIPAA-compliant manner. Sookasa.com

Sookasa enables physicians to use Dropbox and other cloud applications for sharing medical files in a HIPAA-compliant fashion through the use of encryption and audit trails. Sookasa currently works on both Mac and Windows desktop computers and mobile devices.

Asaf Cidon, Sookasa’s cofounder, says that an Android version will also be released later.

The Sookasa app in the full HIPAA-compliant package with audit trails and encryption is $150 per year, per user. With only the encryption, the app is available free.

“Sookasa protects medical files in the cloud and on mobile devices. The app not only encrypts the files, but also controls who can access them,” says Cidon. So if an employee leaves the practice, the physician can remove their access privileges and even wipe files from their mobile devices, protecting the private data. “You can also authorize or block access for third-party contractors,” Cidon says.

Many health care practices are using outdated technology that is costly and prohibits productivity. “Now you can use an application like Dropbox to transfer medical images from one office to another, between organizations, or transcripts to medical transcriptionists,” says Cidon.

Sookasa enables file access and sharing on the go. “There are stories where people had to drive for hours to pick up a DVD with medical images. Now they can just drag the image into a folder and synchronize it to the recipient,” Cidon says. The time and cost savings are tremendous.

Jonathan Kaplan, M.D., a plastic surgeon with Pacific Heights Plastic Surgery in San Francisco, couldn’t afford a traditional secure server like the one available at the hospital where he practiced previously in Louisiana. “I needed a more secure server than Dropbox by itself. I searched on Google for ‘how to make Dropbox HIPAA compliant,’ and Sookasa was at the top of the search results,” he says.

“I looked into other electronic health record systems but couldn’t find anything that met my needs in the way that my privately-built EHR system worked on Dropbox with Sookasa,” says Kaplan. He uses the secure, compliant version of the app. “It provides me with peace of mind that my patients’ records are safe, secure and encrypted.”

Kaplan uses Sookasa and his patient records on password-protected office computers and a password-secured iPhone. With Sookasa, patient data is available only to providers in Kaplan’s practice who need access. “If a provider is no longer employed by the practice,” he says, “we can easily exclude them from access to patient records.”

David Geer is a frequent contributor to PracticeLink Magazine’s Tech Notes department.  

 

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Peeking into physician pockets

New federal regulations allow the public to seek information about the amount of money physicians receive from Medicare and the health care industry.

By Jeff Atkinson | Reform Recap | Spring 2014

 

Transparency has become a theme in health care reform. In 2014, the transparency spotlight has turned to payments received by physicians from Medicare and the health care industry.

For 33 years, the amount of money that individual physicians received from Medicare was confidential. A lawsuit brought by the American Medical Association and the Florida Medical Association in the 1970’s resulted in an injunction prohibiting the release of Medicare reimbursement information for individual physicians.

In 2013, a Florida federal court judge revisited the issue and held that the federal Privacy Act no longer barred release of reimbursement information under the Freedom of Information Act.

The Centers for Medicare & Medicaid Services (CMS) then drafted regulations to comply with the court ruling. The regulations were announced in January and took effect March 18. Under the regulations, the public—including the news media—does not have an automatic right to the reimbursement records for individual physicians, and, in no case, will names of individual patients be released.

“Case-by-case determination” regarding release 

Instead, in the words of the new policy, CMS “will make a case-by-case determination” about whether to release the information after balancing “the privacy interest of individual physicians and the public interest in disclosure of such information.”

The legal issue involves exemption 6 of the federal Freedom of Information Act, which exempts from the requirement of release of information “personnel and medical files and similar files the disclosure of which would constitute a clearly unwarranted invasion of personal privacy.”

The details of how CMS will administer the new policy are not clear, but the tenor of the policy seems to favor release of information.

Jonathan Blum, Principal Deputy Administrator of CMS, said in the CMS Blog (Jan. 14), “Given the advantages of releasing information on Medicare payment to physicians and the agency’s commitment to data transparency, we believe replacing the prior policy with a new policy in which CMS will make case-by-case determinations is the best next step for the agency.”

Among the benefits projected from the new policy are letting patients see which physicians have the most experience in areas of practice and particular procedures as well as providing data that could help determine if fraud, abuse and waste have occurred.

Broad access vs. safeguards

Some wish CMS had gone further and had opened reimbursement records to the public in a searchable database. The Association of Health Care Journalists, for example, said, “As long as patient confidentiality is protected, we see no reason why taxpayers should not know how individual physicians are spending public dollars.”

Medical associations generally prefer a go-slow approach. The American Medical Association and other physician groups told CMS: “Steps must be taken to ensure that the release of data does not mislead the public into making inappropriate and potentially harmful health care treatment decisions. In light of these considerations, the release of raw data regarding physician claims for providing medical services should be limited for specific purposes and with appropriate safeguards.”

Some physicians also would like a vehicle for presenting the data in context. If a physician received a very high amount of income from Medicare, the physician might want it known if they had very high expenses that offset the income, including rent, office staff, malpractice insurance and equipment.

Sunshine Act to illuminate industry payments

Another area in which the public will be able to obtain information is payments made to physicians by manufacturers of drugs, biologicals, devices and medical supplies. The Affordable Care Act contains a provision called “The Physician Payments Sunshine Act.” The act is modeled on proposals by the Medicare Payment Advisory Commission and the Institute of Medicine.

Under the act, beginning Aug. 1, 2013, manufacturers were obliged to collect data on payments they make to physicians. The payments include consulting fees, honoraria, fees from serving as a speaker at education programs, food and beverages. (For a full list of payments that need to be reported, see the sidebar at the bottom of this page.)

Reports also need to be made if a physician or an immediate family member of the physician have an ownership interest or investment interest in the manufacturer.

Manufacturers are to report the data annually to CMS with the first report due March 31, 2014. The public will have access to the data, including via a searchable website, beginning Sept. 30, 2014.

Payments that do not need to be reported include: ownership of shares in publicly traded companies and mutual funds; loans of devices for periods of 90 days or less; product samples that are provided at no cost to patients; payments with a value of $10 or less (provided the annual total payment to an individual physician does not exceed $100 per year); and educational materials that are of direct benefit to patients.

Physicians are encouraged to contact manufacturers with whom they work to review the manufacturer’s report for accuracy. In addition, under the statute and regulations, after the manufacturers submit reports to CMS, physicians must have at least 45 days to review the report and request corrections before the information is made available to the public.

To assist physicians in tracking payments made to them by manufacturers, free smartphone apps are available through the Google Play Store and the Apple App Store. The title of the app is “Open Payments Mobile for Physicians.”

Health care is increasingly data-driven in efforts to promote quality, control costs and inform consumers. Part of that effort is making available information regarding payments physicians receive from Medicare and from health care manufacturers.

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

 

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Direct primary care

Give up the grind for a practice that gets closer to your patients.

By Marcia Travelstead | Career Move | Spring 2014

 

Albert Fuchs

“I don’t know of any doctor who’s doing it this way and wants to go back to seeing 20 patients a day, spending 7 minutes with each of them and then looking to some third party to collect the fee for that encounter,” says Albert Fuchs, M.D., owner of his own direct care practice in California.

NAME:  Albert Fuchs, M.D., FACP

WORK:  Owner of his own direct primary care practice in Beverly Hills, Calif. (albertfuchs.com)

MEDICAL SCHOOLUniversity of California, Los Angeles

RESIDENCYUniversity of California, Los Angeles

Spending more time with patients is an attractive idea for both physicians and those who need their care. Internist Albert Fuchs, M.D., began his direct care practice about six years ago to enable him to do just that. Paying an annual retainer fee—typically $2,800 at his practice—grants patients 24/7 access to Fuchs, same-day appointments and predictable primary care service fees. What’s the difference between direct primary care and concierge medicine?

I don’t think there is any. My website does not use the word “concierge,” although I don’t object to it. It sounds much fancier than what I do—and much more expensive. Although, a lot of people call what I do concierge medicine.

I think eventually patients will settle on a name for it. I don’t think paying directly for a service deserves a special name. When you go to an accountant or lawyer and you write a check, it’s not “direct” legal care or “concierge” accounting. It’s just getting an accountant or a lawyer. So what I do should be called medicine and the traditional model should be called “insurance” care or “third-party” care. As this catches on, it will be called medicine. A patient goes and sees any doctor and they pay for them. You may have to have a catastrophic policy such as when you wreck your car. However, for an oil change or tire change, you don’t go to some third party to figure out what’s covered, how much you pay and who’s in your mechanic network.

What do you like best about  practicing direct primary care?

I love the time I have to spend with each patient. I love not having to think of excuses to run out of the room and having the time to answer all of the patient’s questions and be available. If one of them has an issue today, I can see them today, not two weeks from now. The extra pay isn’t bad either, although that took a few years.

Are you available 365 days a year to your annual fee patients?

I am, but the office isn’t open every day. We still have office hours, which are Monday through Friday, 9 to 5. All my patients have my cell number,  and over the phone I am available 24/7.

You have four kids. How does that work with your on-call hours?

Daddy has to occasionally get up and take a phone call from a patient.

What are the challenges of this type of practice?

The rough part is the transition. There are some short-term risks because there’s no guarantee that any physician will get enough patients to succeed. However, I don’t know of any doctor who’s doing it this way and wants to go back to seeing 20 patients a day, spending 7 minutes with each of them and then looking to some third party to collect the fee for that encounter. Patients and doctors both hate that. The only reason that’s happening is that it’s status quo.

Why did you choose direct primary care?

It actually wasn’t my idea. My wife was thinking of ideas such as this and bouncing them past me. One of my patients, who I had been taking care of for a long time, said she felt bad because she has a lot of questions and would call me on the phone, and she knew I wasn’t getting compensated for that. She said she would much rather pay me a retainer, know that I was there when she needed me and didn’t have to compete with a lot of other people for my time. That’s what planted the seed. I spent about a year investigating it and finding out what was legal and how it might work, and then I made the jump.

It sounds as though you would have to build up a clientele before doing this. Is this a practice model that would work for a newer physician?

For the most part, doctors are afraid to try it. I don’t know what the experience of a physician right out of residency would be. When I started it five or six years ago, people hadn’t heard of it. It’s a much better known practice model now and patients might be much more willing to enter a new practice of a direct primary care physician. I’m just not sure. I think 90 percent of the hesitation is that as an industry, we’re all scared. I wouldn’t discourage a trainee from trying it.

Do you have any advice for how a physician should get into this?

I would make phone calls to people who have been doing this for a few years and ask very specific questions about how to make the transition. Twice a year, I get calls from physicians thinking about it who find me on the web. They have questions about how to set up contracts, how to break the news to their existing patients and what to expect during the transition. You don’t want to reinvent those steps. Far from wanting more competition, I think most of us are delighted to talk with physicians because we think this is better for both doctors and patients.

Did you end up losing a number of patients in the transition?

Yes, I have a very small practice now in terms of numbers of patients. However, it’s much better in terms of revenue. I knew going into this I would lose over 90 percent of my patients. From that small nucleus that stayed, I built up a new practice, essentially.

That’s why I’m not sure that having a large successful practice before transition is important because most of those patients aren’t going to stay with you. Most of those people want somebody in their insurance network. One important point I want to make is the 90 percent of your patients who go to other doctors…you want them to leave happy. So the way you present it to them and the way you handle your separation needs to be pleasant. You don’t want them to refer to you as the jerk that fired them. You want them to leave happy thinking you are a terrific doctor but they just can’t afford your services right now. You want them to understand why you are doing what you are doing.

Have you ever had a patient leave and then come back to try your new practice?

Yes, in fact just last week I had that experience. That happens all the time. They’re frustrated by the primary care they are getting so they come back.

Is there anything that surprised you about this once you got into it?

The biggest surprise was how many of my older patients saw the value in this and wanted to keep me. The older, sicker patients already saw how the Medicare system is failing them and they are happy to pay more for the attentive care.

Physicians should ask themselves, especially the younger ones, whether they want to spend their careers working for insurance companies or for patients. There is plenty of room in our niche and physicians and patients both will like it better. Physicians owe it to themselves to spend the next several decades getting paid for what they love to do, not to be getting paid for what disappoints them and the patients both.

Marcia Travelstead

 

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