Managing your moonlighting

Before you embark, review all your contracts thoroughly.

By Bruce D. Armon | Legal Matters | Summer 2013


For physicians who “moonlight,” their lives may be anything but tranquil. Aside from the personal challenges when a physician moonlights, there are many professional issues that must be addressed before and during the moonlighting opportunity.

What is moonlighting?
Some people refer to moonlighting as the unsupervised practice of medicine by residents before the completion of residency. Approximately 10 years ago, the Accreditation Council for Graduate Medical Education (ACGME) enacted common duty hour standards for every accredited residency program, including the well-known requirement that a resident have a workweek no greater than 80 hours, averaged over a four-week period.

But there are many physicians—aside from residents and fellows—and other professionals who moonlight to supplement their professional experience and to make extra income.

What you must do before beginning to moonlight
There are several critical steps for any physician who wishes to moonlight.

First, review your current employment agreement (assuming you have one). The employment agreement may have a very direct prohibition, such as, “Employee may not provide any clinical services for any entity besides Employer regardless of whether Employee is paid for the same without the express written permission of Employer.”

If there is language like this in your employment agreement, do not moonlight because it may cost you your main job.

Even if there is not a direct prohibition in your employment agreement, there may be language in the employer’s policies and procedures governing moonlighting opportunities. Most employment agreements require the employee to abide by the employer’s policies and procedures. Before you engage in moonlighting, be sure to review the current copy of your employer’s policies and procedures. Look to see if there is a blanket moonlighting prohibition or some other level of restriction.

Second, review the restrictive covenant in the employment agreement for your primary employer. Many physicians assume the restrictive covenant only applies to opportunities once the current employment is complete. This may not be the case. A restrictive covenant that states, “During the term of Employee’s employment and for two years following the termination or expiration of this Agreement, Employee shall not…” applies during and after the employment is complete. In this situation, you should understand the radius and restrictions in the noncompete.

Radius is fairly straightforward: miles, zip codes, counties, city blocks, etc. in which the employee may not provide certain clinical services.

The scope of services covered by the noncompete is also relevant. For instance, assume you are an internist with a largely outpatient based practice. A moonlighting opportunity presents for you to provide hospitalist-only services for a local community hospital. If the restriction in your primary employment agreement prohibits you from providing any internal medicine services, you will be precluded from taking advantage of the hospitalist moonlighting opportunity. If the restriction applies only to outpatient services, however, you could engage in the hospitalist activity assuming there are no other restrictions in your employment agreement.

If you think there is a possibility you would like to engage in moonlighting, you must address the moonlighting language in your primary employment agreement before you execute the employment agreement.

What a physician must do as part of the moonlighting activity
When presented with a moonlighting opportunity, a physician should ask for and review the moonlighting employment agreement. While the contract may not be as detailed as the primary employment agreement, it should clarify certain key provisions: scheduling; term and termination; compensation; and professional liability coverage.

Moonlighting by definition is a second job. A physician must know when he or she will be scheduled for the moonlighting job and ensure it does not conflict with the physician’s primary schedule. No one can be in two places at once. If a physician is on call for the primary employment, it will difficult if not impossible to tend to duties for another employer at the same time.

Some moonlighting opportunities have a regular schedule (such as every third weekend) and others are scheduled on an ad hoc basis when mutually agreed.

In addition to knowing your work schedule, you should understand the proposed length of the engagement. As your primary job responsibilities change or you are presented with new employment, you need to make sure your moonlighting endeavors remain in compliance with your principal employer.

Most physicians take on a moonlighting opportunity for the chance to earn some extra dollars. Be sure to understand how much you are paid for your moonlighting. Are you paid an hourly wage? Are you paid a wage for each “shift” worked? If so, make sure the shift is clearly defined. Are you paid based upon collections received for your efforts? Are you entitled to any bonus, and if so, are there any defined criteria to achieve the bonus, and are these realistic?

Professional liability coverage may be the most important element in any moonlighting arrangement. It would be highly unusual for the primary employer to provide professional liability coverage in the event the physician is sued (rightly or wrongly) for something that occurred during the moonlighting hours.

A moonlighting physician needs to be sure:

• The moonlighting employer is paying for professional liability coverage for the moonlighting activities;

• The physician knows the amount of coverage being provided; and

• The moonlighting employer is paying for the tail professional liability policy if the insurance is not provided on an occurrence basis.

A physician should never be in the position of having to purchase a tail policy to provide insurance coverage for activities that are part of a moonlighting engagement.

Nonclinical moonlighting considerations
Not every moonlighting opportunity is necessarily a clinical engagement. Lecturing, teaching, writing articles or providing consulting services each use a physician’s clinical skills even though the activities are not clinical, per se. Similarly, developing electronic medical record software or creating a new medical device or other intellectual property activities may have tremendous economic value to the physician without being direct clinical endeavors.

In addition to understanding what is permissible or prohibited from a clinical standpoint with respect to moonlighting activities, a physician should understand who retains the right to intellectual property developed and remuneration obtained from clinically related activities.
Serving as an expert witness (for defendants or plaintiffs) could be a lucrative source of income for a limited amount of work. A physician’s primary employer may view these types of activities as prohibited if the physician is doing work adverse to a member of the physician’s primary employer (for example, working for plaintiff’s counsel as an expert in which the defendant includes an affiliate of the physician’s primary employer).

Likewise, if a physician writes an article or develops a new medical device exclusively during periods when the physician is not providing scheduled services for the physician’s primary employer and uses no resources of the employer to do the same, the physician’s primary employer may have grounds to ownership of such activity depending upon the language in the employment agreement or the employer’s policies and procedures. If contract language provides, “Any remuneration and ownership related to any clinically related activity shall be the property of the Employer if such item(s) is produced, developed or refined when Employee is employed by the Employer.”

If a physician is interested in working on clinical or clinically related matters while employed by another employer, the physician is advised to ensure these activities are specifically excluded from the purview of the employer now and in the future.

Moonlighting is part of the journey
Like the stars in the sky, there are no limits to the opportunities that an entrepreneurial physician may pursue. It is imperative for the physician to ensure that the primary employer will permit such opportunities and the moonlighting employer can protect the physician’s time, interests and efforts accordingly.

Bruce D. Armon ( is managing partner of Saul Ewing’s Philadelphia office and co-chair of the firm’s health law practice group.



Interview Rx

Five keys for boosting your candidacy during the interview process.

By Michael Scott, Health care futurist | Job Doctor | Summer 2013 | Uncategorized


Several years ago, while director of human resources for a small Midwestern hospital, I led our search for a new anesthesiologist. One of the candidates who agreed to interview with us was a physician from Missouri whose general anesthetic and epidural background made him an ideal match for our surgery department. After a series of initial conversations by phone, he and his wife agreed to an in-person visit to further assess the opportunity.

Over the course of their two-day visit I found myself deeply impressed with their depth of preparation in terms of evaluating the opportunity. It was clear that they had given a great deal of thought regarding their professional and lifestyle desires and were determined to leave no stone unturned. In the end, we offered him the job.

These days, on the backdrop of changing economic conditions as well as an uncertain reimbursement future tied to Obamacare, interviewing for new physician practice opportunities have now reached a deeper level of complexity. Moreover, medical model shifts have led to a mass exodus of physicians from private practice to hospital employment opportunities, leading to an even more ominous job search environment.

Here are five key essentials for physicians seeking to boost their candidacy for new opportunities.

1. Be clear in your intent.
As a physician, you know about the importance of clarity and focus. In fact, it was likely a key factor in terms of your successfully completing medical school. But sometimes we unknowingly lose site of the importance of this in pursuing professional opportunities that will represent a good match.

Clarity about your direction in an interview may be the most important key to your success in landing your desired opportunity. What this involves is asking critical questions, which allow you to better define your “ideal picture” end result. Here are among the questions to ask as a part of this process.

• What are the physician call arrangements? Does this impact my personal lifestyle desires?

• What is my preferred geographic location? Am I more comfortable in an urban, suburban or rural setting?

• What variables are important to my family and I in terms of cost of living, diversity, recreational and sports opportunities, and raising a family?

• Will the work offer meaning and fulfillment as well as a sustainable compensation package?

• Is my preferred option a hospital/medical center, private physician practice or community health center?

• What is the state malpractice environment like?

Getting clear about what you really want will prevent both you and potential employers from wasting valuable time engaging in interview discussions that have no chance of gaining traction.

2. Research and prepare well.
Achieving extraordinary results in an interview process requires a thoughtful assessment of the practice opportunity. Therefore it is vital that you never walk into an interview without having done your homework.

In preparing for your interview, there are a number of key pieces of information that you ideally should have researched. Included here is a thorough understanding of the mission, vision and financial performance of the hospital or physician practice for which you are seeking to work. This information is particularly important because it allows you to gauge the extent to which your purpose and future direction are aligned with this potential employer.

The internet is obviously an invaluable tool in terms of your pre-interview research. But beyond online research, don’t discount the importance of reviewing written collateral materials such as annual reports and brochures that may offer you an in-depth perspective on the current culture and future of the organization. Also ask to speak with other physicians in the interview discussion or off the record to get their take on the professional climate.

3. Maximize your value positioning.
Conveying your professional value in an interview is paramount for a successful outcome. This is where you articulate what you can bring to the table with factors such as care quality, productivity and financial returns. Your ability to successfully demonstrate your return on investment proposition can give you a huge competitive advantage in the job market. The ideal value proposition is clear, concise and resonates to those with the highest levels of decision-making influence.

Let’s return briefly to the physician scenario at the beginning of this article. What made this doctor such an attractive candidate for our hospital was that his value proposition was clearly aligned with the anesthesiology needs of our rural hospital. In particular, willingness to share call with our existing nurse anesthetist was a huge plus. And his experience with epidurals resolved a major issue we were facing in terms of patient demands for this procedure.

What all of this suggests is the importance of being able to summarize key points with respect to those competencies of yours that speak to the added value you can offer. At the end of the day, interviewers are seeking to determine whether what you have to offer addresses any and all value gaps necessary for the delivery of cost-effective patient care.

4. Pay attention to credentialing.
As a physician, you are well aware of the process called “credentialing,” which hospitals and medical practice undertake to verify the employment history, educational qualifications, licensure and references of medical providers. This process is designed to protect patient safety, reduce medical mistakes and enhance the quality of delivered services.

In an interview situation, the importance of being upfront about any potential credentialing-related issues is paramount to your success. Make sure that you also have up-to-date records of your licensure and certification, for this will help speed up the credentialing process if you are offered employment. Most importantly, resist the temptation to gloss over or cover up information that may come up in an interview discussion. With tools like the National Practitioner Data Bank, health care employers have easy access to your records and history.

5. Follow up.
In many respects, this final stage of the recruitment interview process may be the most important because it represents the final opportunity to cement a deal if the opportunity interests you. Unfortunately this is where the post-interview fog often sets in—a factor that can cloud your efforts at following through the finish line tape.

If you are fortunate enough to have been selected as a final candidate for a position and have an interest in pursuing the position further, don’t overlook the importance of formally stating your interest in the position and that you look forward to communicating with them in the immediate days ahead regarding next steps.
Nothing creates a more positive impression in follow-up to a final interview than a personalized, handwritten thank-you note.

The bottom line
At the end of the day, every new job opportunity that you engage can represent an important step in your physician career. So take your interviews seriously. If the opportunity appears to be a good match, then be sure to confidently act as though the position is yours. You never know—it just might be just the right prescription for your long-term success.

Michael Scott is a Denver-based health care futurist, speaker and writer.



Government sets “essential health benefits”

The Feds set broad coverage standards and ask states to work out the details.

By By Jeff Atkinson | Reform Recap | Summer 2013


This year, the federal government issued final regulations to set “essential health benefits” for individual and small group health plans operating under the Patient Protection and Affordable Care Act.

The regulations take effect January 1, 2014, and individual and small group health plans must provide the specified benefits after that date. Revised regulations for large groups and employer-sponsored health plans will be issued later and are likely to be similar in the nature of services that are covered.

Under the regulations, the federal government sets broad standards for what must be covered and then leaves it to each state to work out the details. The federal government lists 10 categories of services that must be covered. The list includes traditional areas of health insurance coverage, such as hospitalization, emergency services, ambulatory care and prescription drugs.

Expanded benefits in some areas
What is comparatively new—and often not covered by current health plans—is pediatric oral and vision care. In addition, there will be increased coverage for mental health services under the Affordable Care Act.

The Obama administration estimates that 32 million people will receive mental health coverage that did not have it before, and that the scope of coverage for many who already have mental health coverage will improve. (For the list of the 10 categories of services, see the sidebar on page 23.)

If a state wishes to require that insurance provided in the state cover benefits beyond those required by the federal government, the state is free to do so, but the state will need to absorb the added costs, such as the cost of providing extra insurance for Medicaid patients.

The regulations direct states to select a “base-benchmark plan” that will define specific benefits that will be covered under each of the 10 categories. The benchmark plan can be selected from several options, including one of the three largest small group insurance products offered in the state, the state employee health plan, or one of the three largest federal employee health plans. For most states, the benchmark will be a plan offered by BlueCross BlueShield; for California it will be the Kaiser Foundation Health Plan; and for New York it will be Oxford Health Insurance.

If a benchmark plan selected by a state does not provide benefits in one or more of the 10 categories, then the state must select another plan to define the benefits in the missing category.

Coverage between states may vary
The deference given to states in selecting benchmark plans means that package of specific health benefits will vary from state to state. Regarding drug benefits, for example, the formulary of a benchmark plan chosen in one state may list 500 drugs while the formulary of a benchmark plan in another state may offer 1,000 drugs.

Under the federal regulations, however, “A health plan providing essential health benefits must have procedures in place that allow an enrollee to request and gain access to clinically appropriate drugs not covered by the health plan.”

The federal regulations also affirm the principle under the Affordable Care Act that health plans may not discriminate against individuals on the basis of health condition, age or quality of life.

The regulations track the Affordable Care Act regarding giving consumers a choice of levels of coverage, which will affect the premium the consumers will pay. The different amounts of coverage are described as “metal levels.” A bronze level plan will cover 60 percent of a patient’s expenses; a silver plan, 70 percent; a gold plan, 80 percent; and a platinum plan, 90 percent.

Regardless of which metal plan a consumer chooses, there are limits to the annual deductible that can be imposed on people obtaining coverage through the small group market. For an individual, the maximum deductible is $2,000. For coverage of two or more people, the limit is $4,000. After 2014, the deductible limits may increase with inflation. In addition, if a patient is in a network plan and chooses to receive care out of network, the added cost of receiving out-of-network care is borne by the patient and is not part of the annual limit.

Trade-offs of expanded coverage  
The “essential benefit plan” is designed to accomplish at least two goals—to provide a base level of coverage for people obtaining coverage through the individual and small group markets (subject to variation between states), and to give consumers a better opportunity to compare insurance plans.
By requiring insurance companies to standardize their products regarding scope of coverage and the levels of deductibles, consumers will better be able to compare the value of products that are offered.

Under the new regulations, the cost of insurance is likely to go up, particularly for healthy young adults. More people will be covered by insurance, but the costs for some will be more difficult to bear.

Jeff Atkinson ( teaches health care law at DePaul University College of Law in Chicago.



Improve outcomes and relationships with apps

Mobile medical apps help children reach new heights, patients make appointments, and physicians manage referrals.

By By David Geer | Summer 2013 | Tech Notes


Physicians continue to welcome mobile medical apps that make their lives and work easier while increasing the length and quality of patients’ lives.
If you help children with leg bone length concerns, struggle with appointment scheduling, or lose track of patients between referrals and follow-up visits, then one of these apps is for you.

The Multiplier App takes human error out of calculations.

The Multiplier App
Links to download the free app for Android, iPhone, or iPad are at

Physicians have reliably used the Multiplier Method for predicting children’s mature height and bone length for years. This helps them determine the appropriate treatment for maladies such as limb length inconsistencies or short legs. But the math can be tricky, leading physicians to make errors. And the calculations take a long time by hand.

The International Center for Limb Lengthening (ICLL) at the Rubin Institute for Advanced Orthopedics (RIAO) of Sinai Hospital, Baltimore, has addressed these hurdles with a free mobile software tool called the Multiplier App. The app, which is available for Android, iPhone and iPad, runs Multiplier Method formulas instantly based on a child’s gender, date of birth, and the length of their body or limb.

The Multiplier App runs 22 growth, length, and developmental calculations for height and limb length. The app includes a user guide, standard leg and foot measurements and other resources. Members of the ICLL were on the team that originally developed the Multiplier Method.

L. Reid Nichols, M.D., a pediatric orthopedic surgeon at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., was looking for a tool to perform Multiplier Method calculations without error. “It used to take me quite a while to do the math manually,” she says. “The Multiplier app helps prevent mistakes.”

Nichols uses the app to run equations on large discrepancies between leg lengths. The app runs equations that determine how many times a limb will need surgery as it develops. “If I have a 20-cm discrepancy, I am not going to do all that lengthening in one procedure,” says Nichols.

The app helps Nichols predict overall height. “If the child’s parents are tall and the discrepancy is not much, I can just slow the growth of the leg that is too long,” she explains. The Multiplier App also helps determine when to do the procedures.

“The Multiplier App is very user friendly,” she says. It runs complicated equations accurately so she can save those extra minutes she would have wasted on recalculating each problem.

Though Nichols is happy with the Multiplier app, she does have a couple of suggestions: “Maybe they could add the ability to go back and forth between centimeters and inches. Maybe there will be an app for the Blackberry some day.”

Physicians use iTriage to enable patients to schedule their own appointments. Download free mobile versions at

When a practice’s staff are tied up all day on the phones scheduling patient visits, they’re unavailable for other duties. With iTriage, patients check a physician’s availability and schedule their appointments over a mobile app that works on Android and the iPhone.

With the iTriage app, patients can take better charge of their own health care needs.

The free iTriage app, which also comes in a .mobi version and a full web page for use on desktop computers, leads patients to their physician or an appropriate specialist based on symptoms and causes that are searchable inside the app. The app combines workflow improvements for physicians with timely, appropriate care for patients by searching ER wait times, pre-registering patients to alert medical staff about an incoming medical condition, and booking appointments anytime, anywhere.

William Gluckman, D.O., who runs the FastER Urgent Care center in Morris Plains, N.J., takes advantage of iTriage for the sake of his patients, his staff and his practice. “I was looking for a better system for scheduling patients. With iTriage, they go online to make appointments without having to get on the phone with staff. The patient selects an appointment time that is good for them, the application sends us a notification, and it’s a win for everyone,” Gluckman says.

“We save an hour a day in staff time by having patients who would normally call make their appointments through iTriage,” he says.

“Once my patients start using it, they no longer call us to make their appointments. Parents set up accounts for their children as well. A husband, wife and their children can each have individual accounts. They make separate appointments for each on their mobile devices in a minute’s time,” Gluckman explains. Patients make appointments in off hours, too. “If they feel sick at 2 a.m., they can make an appointment then and come in at appointment time.”

Gluckman really likes the web portal that he and his staff use on their end of the process. “Any approved staff can access it and see the name of the patient, what they are coming in for, and when they are scheduled. We can reschedule through the portal and it will send an email to the patient about the rescheduled time,” he says.

The only extra capability Gluckman could wish for is integration. “I would like to see it integrated directly with my practice management system from my EMR vendor. If they could make that happen, that would be ideal,” Gluckman says.

To learn more, visit

When a physician makes a referral, how does she know the patient actually made and kept the appointment? Without some help, she probably doesn’t. That’s where eReferrals comes in. More than a messaging service, HIPAA compliant eReferrals helps physicians track and manage referrals and referred patients.

The app’s dashboard presents data about whether the specialist accepted the patient for an appointment, scheduled it, and whether the patient showed up. By managing referrals instead of just making them, the app enables physicians to stay abreast of the all-important follow through.

Medicity offers the mobile application as a private web-based platform that physicians, practices and hospitals set up on their servers. Once installed, physicians and anyone with access rights can use the web-based application via any browser or handheld device.

James R. Morrow, M.D., a family physician at Morrow Family Medicine, runs a solo family practice with one physician assistant. “We see
35 to 45 patients a day; we pride ourselves on being a technology-
enabled practice, which is vital to our ability to provide high-quality, convenient care for patients, particularly considering the size of our practice,” Morrow says.

Morrow was looking for a better way to manage referrals, both to process them to other physicians and to follow up to get the results back from specialists who treat his patients. It was also important for Morrow to find ways to improve communication between practices.

“The app, unlike traditional approaches that try to retrofit a technology to solve a business problem, was designed to fit our practice workflow and enables us to take the time we used to spend tracking down referrals and direct that to focus on taking care of our patients,” says Morrow.

Morrow and his assistant access the app from an iPad as they move from room to room and on their desktop PC. “Using the Safari web browser on the iPad, I can monitor the status of my referrals and help improve communication with my staff and the specialists involved,” Morrow explains.

eReferrals helps physicians track and manage referrals and referred patients.

Previously, Morrow’s nurse would fill out a paper referral form for the patient to take to their appointment. Then his staff would begin the process of faxing the paper forms to the specialist and following up with phone calls to make sure they received the faxed information. “As you can imagine, this is a very time-consuming and inefficient process,” Morrow says.

The eReferrals app fully automates the process so that both Morrow’s practice and the specialist have better information.

“At the point of care, when I determine that I need to make a referral, my nurse enters the patient’s name into the app, selects the appropriate specialist, and the app automatically populates the referral with basic information to process the referral and relevant patient information for the specialist to effectively treat my patient,” says Morrow.

Then Morrow’s office can track the referral process through the app without all the extra manual processes. The app enables Morrow’s nurse to keep a work list with the ability to check the status of the referral. The specialist uses eReferrals to receive, accept and schedule an appointment and attach the results to the referral request to send them back to his office as completed.

Morrow would like to see Medicity someday add to the app the capacity to share EMR data like medication lists and to access medical imaging.

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



Physicians in the media

Share your knowledge with the general public by being willing and available for media interviews.

By Marcia Travelstead | Career Move | Summer 2013


Tracy Zivin-Tutela, M.D., provides medical context for various media outlets. If you’re interested in doing the same, Zivin-Tutela advises approaching your local newspapers, online health forums, local TV stations and the public relations department at your local hospital.

NAME:  Tracy Zivin-Tutela, M.D.

TITLE:  Physician at Westside Infectious Diseases; St. Luke’s-Roosevelt Hospital Center, Division of Infectious Diseases

RESIDENCY:  UMDNJ – Morristown Memorial Hospital

FELLOWSHIP:  St. Luke’s-Roosevelt Hospital Center-Columbia University, New York City

Zivin-Tutela has been featured on The Dr. Oz Show, local news stations in the New York City area, NBC National Affiliates, and numerous online articles.

What do you like best about doing media interviews?
I like to educate the broad population. As physicians, we are born educators. I especially like the opportunity to dispel myths among the community regarding the latest health issues and how people can protect themselves, as my specialty is Infectious Diseases.

What are the challenges?
The nature of the media business is time constricting, and so the thing I like the least is that I don’t always have the ability to leave my own patients to give advice to the larger audience of patients. The TV stations will call and ask if I can speak on a topic and will either arrange for a camera crew to come to me or will pick me up to take me to the studio. It’s usually their decision, not mine, and it’s usually within two hours. That’s really the biggest thing that I don’t like about it.

How do you prepare for an interview?
Being an expert is only as good as staying on top of things. Sometimes the TV station will give me a topic and I don’t even know the story that’s about to break because it’s not in the news. A lot of times, they’ll tell me to talk about a subject and I’ll have to ask what it’s regarding. Sometimes I don’t know the whole story and that’s a little frustrating.

Do you ever know in advance what your questions are going to be?
The Dr. Oz Show did go through questions in advance, but most of the others did not. I was literally asked the questions on camera at that moment, which is stressful. It’s not enough just to know the information. It’s my obligation to give honest, accurate and up-to-date information.

I also have to translate the information from doctor language into language everyone watching can understand. Sometimes when a physician takes some time to answer a question, it is not because they don’t know the answer. It’s because they are trying to word it in a way that basically a child can understand.

You mentioned doing an appearance on Dr. Oz. What other appearances have you made?
The local news channels in the New York tri-state area. I had an appearance on the NBC Nightly News with Brian Williams. I have probably done about 30 over the last five years in addition to phone and online interviews.

If a physician would like to appear on television, what recommendations would you give?
Don’t be afraid to approach your local newspapers, your online health forums, your local TV stations and the public relations department at your local hospital.

I’m not employed by the hospital, but the public relations department is thrilled when I do something that represents them. I think it’s very easy to go to your local newspaper and tell them about a topic that is interesting. It could be a new heart medicine for older people, for example. You could offer to do a series every once in a while on a medical brief. Having done that, it that could turn into an appearance on a local TV channel and can snowball after that.

For example, ABC, NBC and CBS take interviews and put them into a type of database that all of their affiliates all over the country have access to. That is another way that TV stations all over the country look for you because they have seen you on a local TV channel.

I don’t think it’s necessary to hire a public relations person, just reach out. Then, my main advice is to make sure you are responsible and honest with your information that you disseminate into the mass population, and to stay current. Even though I only get one to two hours from notification, I still go online to see what is going on. Something must have happened that’s going to be in the news today.

Medicine is ever changing. Things I learned in medical school are not necessarily fact today. I really need to stay on top of things. In addition, I’m obviously comfortable with the subject they’re asking about or I wouldn’t be doing the interview.

Is there anything about doing media interviews that surprised you?
What surprised me were the reactions of my patients, my parents and their friends. There were 70- and 80-year-olds that said they saw me on TV and remembered me when I was small. My patients send me emails, and they are proud and it makes me proud. That is something I was totally unprepared for.

Do you have future plans regarding TV appearances? Maybe have your own show?
I have a lot of people who ask me why I don’t do this full time. First of all, no one has approached me. And secondly, I really love practicing medicine and taking care of patients. I like doing TV interviews on the side. I don’t know if I’d like it as well if I wasn’t still practicing full time. I don’t know if I’d get skewed by the media or if I’d be out of touch with what’s current if I wasn’t still practicing. So, it’s a nice hybrid to do both.



Scott Salmon, D.O.

Snapshot | Summer 2013


Scott Salmon, D.O., found his new practice on

WORK: Urologist at Southwest Urologic Specialists in Gilbert, Ariz.

Medical school: Midwestern University, Glendale Campus
Residency: Detroit Medical Center

IN PRACTICE SINCE: Starts August 2013

Salmon and his wife, Jennifer, have four children: Cali (6), Isaac (4), Adam (2) and Maylee (4 months). He enjoys fly-fishing, snowboarding, wakeboarding, jogging and mountain biking. Salmon found his job using and will begin practice in August.

What’s your advice for residents beginning their job search?
Start early. I contacted office managers and began searching the internet for job opportunities in the area I wanted to live a year and a half before graduation.

PracticeLink helped me get in touch with two groups in the exact area I was looking for employment. I interviewed with five groups in the area I was looking to live in between nine months and one year before graduation. It still took another four and a half months to complete the contract.

I signed the contract and had four months prior to graduation to begin preparing for state licensing, credentialing, paperwork and moving. PracticeLink helped me make the connections to get the job I wanted in the community my wife and I wanted to raise our family.

What surprised you about your job search?
I was surprised to find the high demand for my specialty. A physician has to work hard to convince people that they are a good candidate to get into medical school and residency. It was nice to have the reversal, where groups wanted me to come work with them.

Any other advice?
First, decide what type of practice you want: academics, hospital employed or private practice. Then learn all you can about the nuances of the one you select so that you can ask the right questions to find out what group/employer is best for you.

At first, I didn’t know what I should be asking at the interview. I spoke with my mentor in urology, and he informed me about different things I should consider. He’d had three previous groups and let me know what pitfalls to watch out for and what things were optimal.

I made a mental list of these things to ask in each interview. This process helped me realize what I was ultimately looking for and made it easier to identify the right group for me.



The Great Outdoors – The call of the wild

In some American cities, the appreciation of nature is, well, “second nature” to residents, who have made concerted efforts to protect, promote and enjoy it.

By Eileen Lockwood | Live & Practice | Summer 2013


There’s still more than a trace of rugged independence in these four cities spread across the U.S., and it translates, among other things, to a near-multitude of opportunities for outdoor enjoyment and sports from kayaking along the coast to speeding down ski hills in the scenic Northwest. Take a look at Asheville, N.C.; Portland, Maine; Bozeman, Mont.; and Knoxville, Tenn.

Where Nature’s Never Far Away
Knoxville, Tenn.

If recent efforts are any indication, Knoxville may be the American City of the Year in terms of efforts to promote outdoor activity.

Eastern Tennessee called back native Katy Stordahl, M.D., who grew up about 35 miles east of Knoxville. “We are very blessed to have the resources of the Great Smoky Mountains National Park,” she says.

The evidence includes three major city and volunteer developments in recent years. Work has been completed on the Volunteer Landing and Marina at the edge of the Tennessee River. The Ijams (pronounced “Eye-ams”) Nature Center is a 300-acre wilderness paradise. And Outdoor Knoxville, with hundreds of acres of al fresco opportunities, is the result of a recent mayor’s “urban wilderness” initiative to assure that nature is never far from city hustle and bustle.

“I am so thankful to be back in my home of East Tennessee,” wrote Katy Stordahl, M.D., in a recent web site testimonial for East Tennessee Children’s Hospital (ETCH), where she has worked as a pediatrician in the emergency room since last July. “We are very blessed here to have the resources of the Great Smoky Mountains National Park.”

Stordahl grew up in Gatlinburg, about 35 miles east, a descendant of a family that had lived, since the 1890s, in what is now the national park. “My mom was in one of the families that had to leave when it (was established),” she notes. “My husband’s family is all in Minnesota. They’re also outdoorsy people, because there are so many lakes in the state.” One of the things her husband misses, she says, is the northern cold weather. “He says it’s not cold until the temperature is 0.”

ETCH serves 16 counties in East Tennessee and provides care in at least 30 pediatric specialties, including several advanced procedures. It’s a center of excellence for cystic fibrosis, has one of the largest cochlear ear implant programs in its part of the state and one of the locale’s most comprehensive cleft lip and palate programs.

Although ETCH and several others have remained “untouched” in recent years, there have been a few dramatic changes in Knoxville hospital ownership. The former St. Mary’s Medical Center and three Baptist hospitals developed untenable financial problems and were forced to close a few years ago. Two of the Baptist institutions closed permanently, but the third, as well as St. Mary’s, was purchased by Tennova Healthcare, an area group whose title is a combination of “Tennessee” and “innovation.” They now operate as Turkey Creek Medical Center (formerly Baptist) and Physicians Regional Medical Center (formerly St. Mary’s). Both have made impressive strides since the change. As spokesperson Lisa Stearns summarizes, “Tons of exciting things are happening.”

One development: “Turkey Creek quickly became a technical center for our system—and maybe the area.” Among current stars of the show: 1. MAKOplasty, a robotic and minimally invasive procedure to treat hip and knee pain. The hospital itself has become one of 24 hospitals nationwide designated to train other surgeons in the technique. 2. A unit dedicated to bariatric surgery, also using robotic procedures. 3. Use of the Parachute IV device to reverse congestive heart failure. As she summarizes, “Knoxville is now on the cutting edge of heart care.”

The flagship service line at Physicians Regional is orthopedics. It was recently named a “Blue Distinction Center Plus” by BlueCross BlueShield. Tennova also holds an option on land to build a replacement for the now landlocked 1930 current facility. In addition, the former St. Mary’s Medical Center North, now North Knoxville Medical Center, which was opened as a boutique extension, is now being groomed to expand into full general-hospital status.

There are currently seven full-service hospitals serving the area. The largest, University of Tennessee Medical Center, holds the distinction, among others, of being the region’s first certified primary care stroke center, first dedicated heart hospital and sole Level I trauma center, with centers of excellence including brain and spine, cancer, women and children and a heart-lung vascular institute. Its medical staff is now developing plans to deliver high-quality, lower-cost care.

Knoxville’s business life has hardly been neglected. With memories of its successful 1982 World’s Fair still lingering, companies and organizations have been redefining the site. “There’s been significant new corporate investment,” reports Doug Lawyer at the Knoxville Chamber. Among new arrivals are a large manufacturing facility of Green Mountain Coffee and ProNova, a manufacturer of proton therapy cancer treatment equipment. The Knoxville Museum of Art is also on the site, Scripps Network (HGTV, Food Network et al.) is expanding its corporate headquarters, and a new hotel is in the works. Another growth area is the Knoxville Oak Ridge Innovation Valley, which welcomes new “idea” firms to set up shop.

Meanwhile, Outdoor Knoxville offers opportunities for getting acquainted with the area’s many natural resources, including forests, park and greenway settings, fields of flowers, lakes developed from former marble quarries, creeks and bluffs to climb. And miles of hiking trails. A new nature center oversees activities and adventures open to all ages during all seasons.

The Ijams Nature Center may be the granddad of area outdoor sanctuaries. It was founded in 1910 by Harry Ijams, a commercial illustrator and dedicated birder, and his wife, Alice, who was known as the “First Lady of Knoxville Garden Clubs.” Among its organized offerings, all aimed at spreading knowledge of nature, are field trips for kids and camps where they can learn crafts such as making bird nests.

Reports Jennifer Roder, the education program officer: “Our main goal is to get folks outdoors and learning about nature.”

High Mountains, Big Snows
Bozeman, Mont.

The southwestern Montana town of Bozeman is the northern gateway to Yellowstone National Park, but it seems equally well-known to sports enthusiasts for its outdoor opportunities, winter and summer.

James Loeffelholz, M.D., president of Bozeman Deaconess Health Group, settled in the area about eight years ago. The area offers a wealth of opportunities for fishing, skiing, mountain biking and more.

For James Loeffelholz, M.D., it’s the capital of mountain climbing and backpacking, activities that have consumed his leisure time since his high school days. And when the snow gathers on the nearby Bridger Range and Spanish Peaks, he’s ready for cross-country and downhill skiing. Among popular destinations for the snow crowd is the Big Sky Ski Resort about 40 miles south, created by one-time renowned network newsman Chet Huntley. The Bridger Bowl, opened in 1955, was Bozeman’s first public ski area. According to Daryl Schleim, president/CEO of the area chamber of commerce, “A nice thing about the area is that you can ski four different types of slopes in a three-day time period. They’re within an hour and a half of each other.”

Alternative winter sports include ice skating, snowmobiling, ice fishing, Nordic and cross-country skiing. Warm-weather possibilities also abound, such as hiking, biking, horseback riding, fishing, rafting and golfing.    Loeffelholz was no stranger to the locale. “I have been coming out here for years,” he says. He had considered relocating several times, but the clincher was an opportunity too good to ignore.

Surprisingly, considering the dramatically different natural environments, he discovered an unexpected comfort zone in his new location, a certain Midwestern flavor not unlike Iowa City, Iowa, where he grew up and earned his medical degree.

He moved to Bozeman eight years ago to join a group of internists and subspecialists. “Then we sold the practice to the hospital and now have 52 physicians and about 65 providers.” It’s now the Bozeman Deaconess Health Group, and Loeffelholz is the president. His clinical practice, he says, is “old-time internal medicine,” and that’s what he likes, although treatment is 21st-century state-of-the-art, and several top-line specialists have joined the practice in recent years.

Bozeman Deaconess Hospital celebrated its 100th anniversary two years ago, growing from a small 1911 sanitarium to a modern hospital in 1986 with 86 all-private rooms. In recent years, Deaconess has been renovated, and more specialists and treatment centers have been added, including a wound clinic, and centers for sleep disorders and diabetes. A health partnership has been formed with 16 area school districts, and a new Community Care Connect bus travels to three counties providing health screens and vaccines. In recent years, the hospital has also received several high-grade awards.

Plunging down mountainsides on long, skinny wooden boards was not what John Bozeman had in mind when he made his way west in the early 1860s to join the Pike’s Peak Gold Rush. The trail that would be named for him was a new northern offshoot of the Oregon Trail. It provided the easiest access to the Montana gold fields. He was a key founder of his namesake city in 1864, but didn’t live to celebrate its incorporation 19 years later. He was murdered along the Yellowstone River in 1867 at age 32.

Eventually the open and fertile land attracted settlers. The arrival of the Northern Pacific Railroad in 1883 also helped. So did the founding 10 years later of the land grant college that would become Montana State University. Today its student body of 14,500 is equal to almost two-fifths of the city population. Local residents are welcome at concerts and Bobcat sports events, as well as MSU’s Arboretum and Gardens and its Museum of the Rockies with the largest collection of dinosaur remains in the U.S. and the largest Tyrannosaurus skull yet to be discovered. (Prehistory aficionados can also follow Montana’s Dinosaur Trail, with 14 museums, state parks and other attractions in 12 communities.)

By the early 1900s, farmers were planting more than 17,000 acres of peas for processing by major area canneries. The one-time label of “Sweet Pea Capital of the Nation” soon segued into an annual Sweet Pea Carnival. It was short-lived but was resurrected as a three-day arts festival in 1977 and is one of the state’s largest events of kind.

The city also offers a good variety of children’s activities as well as, according to Loeffelholz, “fantastic public schools.” The elementary school attended by his three children is considered a Blue Ribbon School nationally, he reports.

Bozeman’s modern-day prosperity is also fueled by a variety of businesses from laser and biotech companies to three breweries using local barley seed in its beer production. One of the country’s three Gibson Guitar facilities strums along in the city, and, for fine liquor connoisseurs, there’s the RoughStock Distillery, creating “pure mountain whiskey,” from homegrown grain and pure mountain water.
Daryl Schleim, president/CEO of the Bozeman Area Chamber of Commerce, notes a major upswing in area highway construction, allowing better traffic flow to Yellowstone. A $38 million airport renovation is also underway. Adds Schleim, “For a community of our size, we could end up with three or four large airlines.”

Loeffelholz himself has noticed a considerable amount of change, such as an increasing population, since he settled into the Bozeman environment. “The hospital,” he says, “has been transitioning from a primary-care-based community to a regional care center and gradually increasing services. We’re still in the awkward stage of ones and twos (in terms of patients needing specialty care), so it’s hard to offer 24/7 service from certain specialists.” But with an increasing population, that problem is likely to resolve itself before long. He calls it an evolutionary stage.

Growing prosperity has spawned enough higher living standards to support at least one luxury housing development called the Yellowstone Club. And the outdoor opportunities have attracted celebrities temporarily escaping the Hollywood razzmatazz. Among them, Loeffelholz himself has spotted Dennis Quaid, Johnny Depp and Jane Fonda.

“The interesting thing about practicing here,” Loeffelholz notes, “is that one afternoon I can see a farmer, and the next day a retired president of Paramount Pictures. People in other parts of Montana are beginning to call this city Boze-angeles.”

The Biltmore Estate has more rooms than any other private home in America. Built by George Vanderbilt, the Estate’s 8,000 acres include beautiful gardens and a winery among its attractions. Many of the Estate’s sweeping views were designed by Frederick Law Olmstead.

The Land of the Sky
Asheville, N.C.

As long ago as the 1790s, Americans were hearing about the healing effects of the Appalachian Mountain areas, none more than the town of Asheville, nestled among the Blue Ridge and Smokies. Thousands of hopeful patients made their way to the picturesque North Carolina town, where many grand facilities were built to accommodate them. The trend finally petered out in the 1950s and the advent of antibiotics. But some of the “hospitals” survive today as homes, offices and apartment buildings.

One wealthy patient was George Vanderbilt’s mother. He himself is well remembered today, thanks to his celebrated home, the Biltmore Estate, with more rooms, even today, than any other private home in the U.S.

Another remnant of the “TB era” is the 6,000-square-foot, 29-room boarding house where many of the patients lived and ate. It was owned by Julia Wolfe, whose famous son, writer Thomas Wolfe, lived there and later fictionalized in the novel, “Look Homeward, Angel.”

The rush for “nature’s cure” ended, but the lure of Asheville did not, thanks to its magical scenic ambience and almost unlimited outdoor adventure possibilities. Two major rivers, the Swannanoa and the French Broad, converge at the city, providing boating opportunities from whitewater rafting to placid float trips. The demand for kayaks alone is great enough to support a local manufacturer. Within an hour and a half, winter fanatics can get to some of the highest peaks east of the Mississippi River and enjoy gliding down more than 30 slopes. Children’s tubing slopes are also available. Less snowy pursuits seem endless, including hiking, biking, camping, tennis and golf.

According to the Convention and Visitors Bureau, “Mild winters are the norm, and they go hand-in-hand with snowy slopes, while downtown remains cozy, dry and romantic.” As for the city’s lure, spokeswoman Cat Kessler adds, “People visit here for vacation, wellness and recreational purposes and decide they want to come back. I’ve heard of people who have gone home, sold their houses and moved here, some in just a few months’ time.”

Christopher Sander, M.D., fits into another category—people who move away and then pine to come back. “I had lived in Watauga County, about an hour from here,” he reports. “My mother and brothers live in Raleigh, and I wanted to be near them.” Not to mention that the mountainous area is “a very special place.” He got an undergraduate degree from Appalachian State University in nearby Boone, but interrupted his education with a volunteer stint in Angola. “I was an average student,” he says, “and I wanted to see another part of the world, so I did that. I returned a different student.”

His life from there included medical training in Puerto Rico and residency with the Lehigh Valley Health Network in Allentown, Pa., interspersed with another volunteer stint in Africa, this time in Kenya. He had met his Spanish wife, Susana, in Angola, and she had joined him in medical school. They now work together in nearby Arden at Vista Family Health, an affiliate of Asheville’s Mission Health. They recently moved into a home in Asheville with their 6-month-old son.

“We used demographics to make our decision,” Sander reports. “Basically, there was one place where we wanted to live, and this was it.” Bottom line: “We just called Mission Health and asked what they could offer us—a cold call.” It worked.

The result, as he explains it: “I love where I work. I couldn’t have landed myself in any better place. I took over more than 2,100 patients from a guy who had opened a bilingual practice coming out of his residency. He was a well-respected and loved member of the community. It made for a rocky transition, but I think I’ve won over the hearts of these people, so it feels good.” Not only that, “Everyone I work with is young and vibrant and always looks for new things to learn.”

Sander loves outdoor opportunities and savors tennis, camping, hiking, mountain biking and “all things outdoors.” The Blue Ridge Parkway and well-kept mountain roads also beckon for spins on his Harley-Davidson.

Sander’s employer is affiliated with Mission Health, which has roots dating back to 1885. Asheville is home to Mission Hospital, its flagship institution. The hospital is known as the second busiest surgical center in the state. It recently expanded services to two outlying total-service clinics in a program titled Mission My Care Plus, where comprehensive care, X-rays, lab tests, pharmacies and physical therapy facilities are available for the whole family.

Nature and health care have combined as cordial hosts for several related Asheville industries, especially the Bent Creek Institute, whose research materials are found in the large variety of plants and flowers growing in the nearby North Carolina Arboretum and in many local species.

Among other medical-related Asheville manufacturers or branches are Thermo Fisher Scientific (immense production of lab equipment, research supplies, chemicals, etc.), Emdeon (computer programs for health care systems) and G3Medical (sterilized medical equipment).

Over the years, Asheville’s general atmosphere has made it a mecca for artists and other free spirits. These days, tree-lined brick streets are alive with buskers, bars, boutiques, cafes and more than 30 galleries featuring frequent art walks.

Today, the city has more Art Deco structures than any Southeastern city but Miami Beach, including City Hall with its unusual octagonal tower and the Grove Arcade with its open hallways, high atrium and “greenhouse” roof. Its current lineup includes 38 shops, plus offices and apartments.

Rugged and Beautiful
Portland, Maine

The Portland Head Light Station in Cape Elizabeth, Maine was commissioned by George Washington in 1787.

Joseph Yu, M.D., was in private practice in the New Haven, Conn., area when he received an out-of-the-blue letter from the recruiter for Mercy
Hospital in Portland, on Maine’s southern coast.

“I’d never been up to (that area of) Maine, so I said, ‘Let me just check this one out.’ I really liked the place,” Yu says. “It has many beautiful surrounding areas, and a lot of natural beauty—and I liked the city itself.” Bottom line: “My wife and I decided to make the move.” As of February 2012, he’s been part of Mercy Gastroenterology at Casco Bay.

Getting to work now is an easy commute across the Casco Bay Bridge, and, unlike the New Haven area, Yu says, “There’s no traffic.” This also means somewhat easy going if he decides to visit his son and daughter in New York, where he grew up. “I can leave on Friday evening, get to Connecticut on Saturday, then to New York, and on Sunday I can come back to Maine.”

Since their move, Yu and his wife have savored the outdoors, the culture and restaurants known, of course, for their abundance of fresh-from-the-sea fare. They’ve discovered picnic areas in parks and on beaches, as well at lighthouse sites, especially the Portland Head “sentinel,” which dates back to 1791.

“You can picnic there and visit the museum and watch the ocean hitting the rocks,” Yu reports. “At one park, you can bike or hike all the way to the Bug Light.” (It’s actually the Portland Breakwater Light, but got its nickname because it’s so tiny.)

It’s a short trip from Portland to other interesting locales, such as Freeport, home of the celebrated L.L. Bean store.

Portland is actually a collar-shaped piece of land jutting between two bodies of water: Casco Bay, formed when the Fore River reaches the ocean, and Back Cove. The setting creates irresistible opportunities for sailing, canoeing, kayaking, seal watching, plus lobster catching expeditions. Yu also mentions daily ferry rides to some of the Bay’s 108 islands. “I took a boat last summer,” he says, “and it was nice, very nice!”

Portland’s location has also made it a mecca for cruise lines. At least a hundred ships now make stops there. Nearby, entrepreneurs and shopkeepers have transformed a once-seedy wharf area into a thriving shoppers’ haven.

On the more practical side is the cost of living. Yu reports that property and income taxes are lower than those in Connecticut, where he practiced for 20 years, and in New York, where he grew up. Another serendipity: a much lower crime rate than in either location.

Before establishing his previous practice near New Haven, he had been educated at Yale University and the Albert Einstein College of Medicine, followed by a GI fellowship at New York-Presbyterian Hospital and four years of treating inmates at Rikers Island, a payback to the National Health Service for his medical education.

As for Mercy Hospital itself, it’s much smaller than in his previous location. “The hospital there was kind of impersonal. You were just one among thousands of people. But in this hospital, everybody knows you right off the bat. I think the patients are also very friendly people. When I first came here, I told my wife, ‘This place kind of reminds me of the U.S. in the 1960s when I was a little kid.’”

But neither of Portland’s two hospitals fall into the 1960s category, although their roots go back as far as 1872.

Maine Medical Center today is the state’s premier referral hospital. It’s rated fourth safest in the U.S. and its nursing staff is rated among the top 3 percent in the world for excellence. It’s also the largest hospital in northern New England.

Mercy Hospital recently became part of the Eastern Maine Medical Center group headquartered in Bangor, which includes seven hospitals plus nine nursing homes and retirement communities. In 2011, Mercy was the first all-private-room hospital in Greater Portland.

Portland’s ethnic complexion has also changed considerably in recent years when the city became an official refugee resettlement location. With newcomers from African countries as well as Vietnam, Cambodia and China, the locally spoken languages have increased to 59 or more. Schools, hospitals and other institutions have adapted well to the changes.

About 20 years ago, when an economic slump brought Portland’s downtown to its knees with a vacancy rate of 40 percent, city leaders decided on a new tactic, turning the long main artery, Congress Street, into a haven for the arts. Today designers of all kinds are ensconced in former store spaces. There’s a law firm concentrating on the arts, the nearby Museum of Art, offices and performing spaces for arts organizations and antique shops.

Eileen Lockwood is a frequent contributor to PracticeLink Magazine.



The Nuts & Bolts of a Site Visit

Answers to your questions about who pays for what, who makes the arrangements, and what you should pay particular attention to while you’re on a site visit.

By Marcia Layton Turner | Feature Articles | Summer 2013


When Santhosshi Narayanan, M.D., began applying for hospitalist positions in 2008 after finishing her internal medicine residency at Michigan State University, she was much more concerned about finding the right program than about where it was located.

“I wasn’t focused on any particular geographic region initially,” she says. However, she had crossed Texas and California off her list because of the lengthy licensure process and was leaning toward staying in the Midwest, with Michigan, Ohio and Indiana higher on her list of desirable locales.

So when she saw an online job posting at for a hospitalist opening at St. Mary’s Medical Center in Evansville, Ind., she immediately applied.

Within a matter of days, she had received a phone call from the medical director at St. Mary’s, who offered to answer her questions about the position, the program, and to learn more about what she was looking for. Not only did Narayanan like what she heard, she also was impressed that he had dropped what he was doing to make contact with her. After that initial phone call, Narayanan was invited for a site visit to continue exploring whether St. Mary’s might be the place for her.

Hanika Gupta, M.D., set her sights on San Francisco for her first post-residency job. She advises physician job seekers not to make a decision on the day of the site visit—go home and consider your options first.

Hanika Gupta, M.D., in contrast, knew exactly where she wanted to be. A third-year family medicine resident at the University of Pittsburgh Medical Center in McKeesport, Pa., Gupta decided early on that she, her husband and young son were destined for northern California, where they had spent time and had family. Identifying where she wanted to work made life simpler in some ways, and more difficult in others, only because her employment options were then more limited. Fortunately, the East Bay area of San Francisco, where they wanted to live, has many health facilities. Gupta was contacted by recruiters regarding two openings in the area and uncovered another opportunity on her own, subsequently conducting site visits at all three.

Dan Mumme, M.D., a cardiothoracic surgeon who recently joined the MultiCare team at Tacoma General Hospital, thought initially that he and his wife would return to the Minnesota area, where he did his undergrad, or Wisconsin, where he spent five years in the general surgery residency. But when a former colleague from Wisconsin who had moved to Tacoma alerted Mumme to an opening in the cardiothoracic unit, he decided to explore it.

He had not spent time in the Pacific Northwest but had heard good things about it. After an initial phone meeting with a MultiCare recruiter and a follow-up discussion with one of the surgeons at a national meeting, Mumme was offered a site visit to see if there might be a fit.

Taking the next step
Mike Peterson, CMSR, AASPR, manager of provider services with MultiCare Health System, typically does an initial interview with physician candidates to answer their questions, describe the practice and detail standard compensation packages. If, after that interview, it looks like a good match, Peterson will then forward the candidate to the lead physician in the practice for a next-level evaluation. If it doesn’t look like a good fit, applicants go no further.

Recruiters can answer your questions about a position­—and they can become your biggest advocate and often your personal guide through the interviewing process.

After demonstrating to the recruiter or hiring manager that you are qualified for the open position and interested in pursuing it, additional interviews typically follow. Although Narayanan went straight from an interview with the medical director to a site visit, other facilities may have more steps in the process.

At MultiCare, if all goes well during both the recruiter and the lead physician interview, MultiCare may schedule a video interview, depending on the candidate’s location and availability, or plan an in-person site visit.

Related: Site visit savvy

Getting there
Making travel plans is your next step, which, thankfully, most recruiters are happy to handle on your behalf. “There are very few expenses a doctor has to pay on a site visit,” Peterson says. Airfare, hotel, rental car, meals and gas are all covered by the potential employer.

The larger expenses, such as airfare, hotel reservations and car rental, are often direct billed back to the hospital, eliminating the need for candidates to lay out any cash.

However, some facilities will allow you the option to book your own travel arrangements and then submit receipts for reimbursement later, which was the case for Narayanan. Because of her close proximity to Evansville, the medical director made it clear that Narayanan could drive or fly, whichever she preferred, and that the medical center’s recruiter could take care of making travel arrangements for her or that Narayanan could plan her travel and be reimbursed. He then had the recruiter make contact with Narayanan to choose a date that was convenient for her and to make sure all of her travel needs were met.

The same was true for Mumme—the MultiCare recruiter booked his flights, made hotel reservations, and took care of scheduling his entire visit. Gupta was able to combine three site visits into one and split the expenses between two facilities, which they appreciated.

The site visit experience
Most candidates opt to do a site visit on a Friday or Monday, says Peterson, so they can use at least one weekend day for their visit and minimize the days off they need to request from their current residency program or position.

In Narayanan’s case, she visited Evansville on Friday and Saturday. The first evening, she had dinner with other hospitalists to get to know them, to see how they got along with each other, and to allow them to get to know her. She asked them questions, such as, “Do you have a back up plan for unusual patient numbers?” as well as questions regarding physician retention and the stability of the group. In turn, they asked questions related to her family, her confidence level with procedures, and generally assessed her personality to determine if they could all get along, she says.

The second day, Saturday, was Narayanan’s official interview day. First thing in the morning, she had a meeting with fellow hospitalists to talk about the types of patients they serve and about their work process, and then had formal interviews with the medical director, chief medical officer and a hospitalist, followed by lunch with several hospitalists. In addition to meeting them and evaluating how friendly they were, Narayanan asked how many patients they typically saw in a day and how strong the critical care support was from specialists—issues that were foremost in her mind.

“There are very few expenses a doctor has to pay on a site visit,” says Mike Peterson, CMSR, AASPR, manager of provider services for MultiCare Health System in Tacoma.

In the afternoon, a real estate agent retained by the recruiter gave her a driving tour of the area and then took her to the airport for her flight back. Since she and her fiancé did not have children at the time, schools were not a major concern, but she did want to know about housing and recreational activities in the area.

Mumme was impressed from the get-go at his site visit in Tacoma. “The recruiter did a phenomenal job,” he says, from picking him up to shuttling him to his many interviews and appointments, to answering his questions and making note of questions she needed to research for him. In between a series of interviews the first day with administrators and potential colleagues, Mumme met with two surgeons, anesthesiologists and PAs in a conference room. While meant to be informal, the session proved pivotal in his decision-making.

“I could see the interactions between surgeons, anesthesiologists and PAs and that they genuinely got along; I could tell it wasn’t a fake environment.” He saw firsthand that they weren’t putting on a show for his benefit. Dinner that night was with two surgeons and the medical director.

His wife flew in the next day to take advantage of a tour of the community provided by a local real estate agent and then had the chance to walk around Tacoma and see the ocean. That evening, the Mummes were invited to a casual dinner at a local pizza joint, where several doctors and kids came to hang out. The Mummes left feeling like Tacoma could be home.

Gupta’s site visits were similar, but more condensed. In both cases, she arrived for a morning full of interviews followed by an afternoon of house hunting. During her visits at each facility, she spent considerable time getting to know her potential future colleagues, the nurses, even those at the front desk. “It’s crucial to get to know the people you could be working with,” she says. “I wanted to know if our values matched.”

Viewing her employment as a long-term commitment, Gupta was concerned about the people more than anything else. And it was the people who ultimately helped her make her choice. “On one visit, I met a nurse who had been there 37 years. That spoke volumes about the facility.”

Related: Your before, during and after moving guide

Though spouses and children typically accompany physicians on site visit trips, children generally do not attend professional dinners. In some cases, MultiCare has gone so far as to fly a family member to the physician’s home to provide childcare so that the parents can focus on the people and scheduled events during the site visit and not worry about their children while they are away, says Peterson.

Shadowing a shift
Although the focal points of most site visits are interviews and discussions with potential colleagues, Emergency Medical Associates (EMA), headquartered in Parsippany, N.J., also offers physicians the opportunity to spend a shift with a fellow physician. Shilpa Amin, M.D., an attending emergency physician at Saint Barnabas Medical Center in Livingston, N.J., had the opportunity to observe a four-hour shift during one of her site visits at another hospital and found it extremely useful. So when she accepted a position with EMA, which did not have a structured position to help with recruiting, Amin offered to be the liaison between physician candidates and recruiters and to schedule “shadow shift” opportunities as requested. The program officially launched in October 2012.

Amin now has a team of seven physicians who have been educated in how to effectively respond to doctors’ frequently asked questions and how to host physicians who want to shadow a shift.

During that shift, “You can learn a lot about how the physicians work with PAs, how easy it is to use the emergency medical records system, and how to work with scribes,” among many other things, says Amin.

Surprisingly, despite how useful and eye-opening a shadow shift can be, few candidates take advantage of the opportunity. Amin estimates between 15 and 20 percent say yes to a two- to three-hour shadow shift when offered, despite the fact that it can give an accurate picture of what life at the hospital would really be like.

The offer
Going on a site visit does not necessarily mean that an offer will immediately follow. Sometimes they do, and other times it can take weeks to hear news—good or bad—or even months, as in the case of Amin, who interviewed with a program only to learn during the site visit that there were no current job openings. While on one hand flattered that they were so interested in meeting her, Amin was also frustrated that she might have an extremely long wait before an opening occurred in emergency medicine.

Within a couple of weeks of her site visit, Narayanan received an offer from St. Mary’s. Before signing it, however, she wanted to bring her fiancé back to make sure he liked the community. About a month later the two headed back to Evansville, also on St. Mary’s dime, to be sure it was where they wanted to live and work. After that visit she signed the contract. Six months later, in June 2011, she started work.

Mumme also received an offer in about two weeks, but heard status updates regularly from the recruiter, “which was helpful,” he says. He never had to wonder where things stood.

At MultiCare, job offers are not typically made during the site visit but can come soon after, says Peterson. The health system then gives physicians up to two weeks to make a decision. They can have more time if needed, but after that two-week window, Peterson and his colleagues will continue the hunt for a doctor to fill the opening. In some cases, an offer will be rescinded if the first candidate cannot commit and an alternate candidate has been found and has accepted an offer.

Gupta strongly advises against jumping at an offer too soon. “Don’t make a decision the day of the site visit. Go home and consider [what you’ve been offered] before jumping,” she suggests, mainly because you want to be sure when you do say yes, you and your family will stay put for a few years.

Evaluating the community
In addition to considering the job opportunity, it is equally important—perhaps even more so—to become familiar with the community in which you would live and work. Housing is one of the biggest issues, especially in cities where housing prices are well above the national average. Are you certain you can find a nice place to live given the compensation package you may be offered?

As part of the site visit process, Peterson connects candidates with one of the five area real estate agents who have offered to be a resource to potential new hires. They provide tours of the area, give them an overview of the different neighborhoods, show them houses if they request, as well as shopping, schools, even golf courses. The idea on the site visit is not so much to go house hunting, but to decide whether the practice and the community are a good fit for what the doctor is looking for.

Other questions Gupta needed to have answered had to do with the safety of the area, whether there was a quality day care close by, and the quality of the schools. She really wanted to find a community similar to the one she was leaving.

Peterson recommends looking closely to see how happy the doctors in the practice are. Does this look like a place where you would want to work? What kind of interactions do the physicians and nurses and PAs have with each other? Did you connect with potential colleagues? Can you see yourself there? Those are the bigger questions that should guide any employment decision­—and after the site visit, many times the ball will soon be in your court.

“If you get to a site visit, we’ve already been impressed by you,” explains Peterson. It is at that point that you need to start considering whether you truly want to work there and become part of the community.

Marcia Layton Turner is a frequent contributor to PracticeLink Magazine.



20 Questions

Evaluating a practice opportunity is easier when you know what to ask. Try these questions.

Feature Articles | Summer 2013


1.     What is the organizational structure of the practice?

2.    How much revenue does the average group member generate annually?

3.    What is your overhead percentage?

4.    Who is your malpractice insurance carrier and what type of policy do you have?

5.    How many hospitals will I have privileges at and where are they located?

6.    How long has the practice manager been on board?

7.    What is the turnover rate among physicians? Support staff?

8.    How are major decisions made within the group?

9.    How would you describe the work ethic of the physicians in the group?

10.  How is after-hours call handled?

11.   What is the orientation process like for new physicians?

12.   How do you balance making a profit with providing  services to patients in need?

13.   Who are your primary competitors in the community?

14.   Where do you see this practice 10 years from now?

15.    What is the compensation package based on?

16.    What does the benefit package include?

17.    How often is the income distribution plan re-evaluated?

18.    What is the formula for a new partner to buy into the practice?

19.    Have any physicians left the group within the last few years, and if so, why did they leave?

20.   Are there any significant changes under consideration by the practice that I should know
about as I make my decision?



How To Evaluate A Practice

A group’s structure, finances, stability, perception and culture warrant your careful scrutiny throughout the interview process.

By Karen Childress | Feature Articles | Summer 2013


“When you’re working in a small group like this, it’s almost like an extended family…it’s important to get to know everyone…what their strengths are and what they have going on in their lives,” says Emergency Medicine physician Christopher Gentle, M.D.

When you’ve seen one medical practice…well, you’ve seen one medical practice.

The huge number of variables among them make it next to impossible to conduct a true apples-to-apples comparison when weighing options and deciding which offer to accept. Add to the equation the fact that what’s important in a practice opportunity varies from physician to physician, and the picture becomes even more complex. One physician will put great pay and benefits at the top of the criteria list; another will place a high value on the reputation of the group; and yet another will be most concerned about how new associates become partners.

When evaluating a practice, it’s essential to do the research and take the time to get clear answers to your most important questions before inking a deal with a new employer. The history of a practice, how it’s structured, the group’s financial stability, the perception of its doctors within the community, how compensation and benefit packages are structured, and the culture of the organization are just a few of the points that warrant careful scrutiny.

Business basics
Mike Fleischman, a management consultant with Stroudwater Associates in Atlanta, says that physicians—even those who are not particularly interested in the business side of medicine—should familiarize themselves with the basics so they can ask the right questions when evaluating a practice opportunity.

“First, they should find out how much doctors in their specialty generate in average annual revenue,” says Fleischman. Keep in mind that revenue means fees collected, not what’s charged. Those are two very different numbers due to discounts and write-offs that are common in all medical and surgical specialties.

Some of the revenue figures are pretty impressive, until you factor in practice overhead —another number that doctors should understand and ask about when interviewing. “Overhead means all expenses that the practice incurs aside from physician compensation. In orthopedics or general surgery, overhead might run 40 to 45 percent,” says Fleischman. “In family practice, it can be up to 65 percent.” Find out the average for your specialty (and by group size) and compare that figure with what your potential new practice reports as their overhead percentage.

Another important concept to study before interviewing is the RVU, or relative value unit. If your compensation is based, in part, on productivity, chances are good that your work will be measured in RVUs. Learn about RVUs at the Centers for Medicare and Medicaid Services website ( and at the American Medical Association website ( All third-party payers—not just Medicare and Medicaid—use the RVU system to calculate reimbursement. “Physicians should find out how much they’ll be paid for a work RVU,” says Fleischman.

“I always also have new physicians ask about how often the income distribution plan is updated. A follow-up question should be, ‘What is the income distribution plan once I become a partner?’” says Fleischman. If the answers to these questions are vague, proceed with caution. “Marriages end because of money, and practices are no different,” he says.

If becoming a partner means making a financial contribution to the practice, Fleischman says it’s important to find out how much debt a group is carrying and what is included in an expected buy-in amount. “I had one situation in which an orthopedist was asked to pay $250,000 to become a partner after two years,” says Fleischman. That number sounds high until you realize what the young doctor was getting for his money. “The group has four operating rooms, two MRIs, and a physical therapy department. He was buying into an established revenue stream,” he says. “Some practices have a lot of toys.”

Related: Physician compensation: What’s it worth to you?

Organizational structure
There are entrepreneurial physicians who still “hang out a shingle” and maintain a solo practice, but they are few and far between. The financial realities of practicing medicine—ever-increasing overhead coupled with stagnant (at best) levels of reimbursement from third-party payers—make it difficult for soloists today. Much more common are arrangements in which doctors are employed by a group practice, hospital or health system, either with or without the option to eventually buy into the group and become a shareholder partner. When considering a new opportunity, understanding the organizational structure is key.

Birmingham Heart Clinic in Alabama, an 11-member cardiology group, is a “hybrid,” according to business administrator William Sester. “We’re an independent group, privately owned by shareholder physicians, and we’ve entered into a clinical co-management agreement with the Cardiovascular Institute of the South (CIS),” says Sester. With more than a dozen locations around the South, CIS provides practices with executive management services, quality improvement initiatives, and leverage to negotiate contracts that smaller organizations might not have access to.

Birmingham Heart was in the process of solidifying their arrangement with CIS last year at the same time they were recruiting their newest associate, Brian Flowers, M.D., who will join the practice this July. “We told him what we were doing and he came on knowing what was going to happen,” says Sester.

“They saw and sensed that health care was changing and that they couldn’t continue the same model that had been in place,” says Flowers. “They were working out the logistics. It wasn’t completely clear how it would impact the schedule and call, but I knew they were interested in doing a good job, that they trusted each other, and were well-respected and competent.”

Flowers had investigated practice opportunities throughout his fellowship. As the end of his training drew near, he became more intentional about his job search and went on a weeklong road trip around the South to interview with several practices. Flowers’ family is in Mississippi and his wife’s family is in Georgia. “I knew the Southeast was where I wanted to raise my family,” he says.

Even as Flowers was planning to move to Charleston, S.C., for his cardiology fellowship, he knew he’d eventually return to the Southeast to practice. He had done his internal medicine residency in Birmingham, so he was familiar with the area.

At the end of the day, Birmingham Heart Clinic won out for a number of reasons in addition to being the ideal location. “I looked at several larger groups with 20 to 30 physicians. Their roles were fairly defined, and if you have a niche that you wanted to work in, that was a great scenario,” says Flowers. He, however, wanted to practice a broad scope of general cardiology.

One aspect of Birmingham Heart that appealed to Flowers was that he would be working in an outlying rural office part of the time.

Near the top of Flowers’ list for what was important in a practice was joining a group of doctors who got along well and respected one another.

“The atmosphere [at Birmingham Heart] was what I was looking for. They all enjoy one another and during the interview they were talking about things going on in their lives,” says Flowers. “They trained in many different places, but they all have similar backgrounds.” Flowers’ interview included a night out for dinner. “My wife Meg got to meet all the doctors and spouses and I could see she was comfortable and excited,” says Flowers.

It was attractive to Flowers that Birmingham Heart has very little turnover among its physicians, and that they are in different stages of practice. “My intent is to stay here for 25 to 30 years, and knowing that they are in it for the long haul and that I’d be practicing with the same people for a long time was a plus,” he says.

Flowers says he’s intent on pulling his own weight, including eventually being involved in some of the business aspects of the practice, but he wanted assurance that as the “new guy” he wouldn’t be expected to generate income to compensate for others in the group who were taking it easy. Fortunately, that didn’t appear to be the case. “They told me I’d be signing a contract similar to the people just ahead of me. They seemed interested in everyone being happy and being on equal footing,” says Flowers.

Reputation matters
Fresh out of training, family physician Constance Beckom, M.D., bravely opened a private practice in Virginia with three of her fellow residents. She stayed with that group for 10 years before moving to the Las Vegas area earlier this year to be closer to her children and grandchildren. Beckom, a former nurse, says she went to medical school “later in life” and her partners in Virginia were all quite a bit younger then she was. “They were going in a different direction,” says Beckom, which also factored into her decision to relocate.

In deciding which group to go with, the reputation of the physicians she would be joining was important to Beckom. When contacted by Southwest Medical Associates (SMA), Beckom researched how they were regarded using LinkedIn, and Angie’s List. “Don’t believe everything you read on the internet,” she says. “But when you see the same thing over and over, that isn’t just one individual who is unhappy with a practice.” Beckom advises anyone looking for a new practice opportunity to simply Google the names of some of the doctors in the group and see what shows up.

In doing her homework about SMA, they came up clean. “It looked like a good, solid group,” says Beckom, who also assessed SMA’s financial health using the internet. The practice is owned by UnitedHealth Group, a publicly traded company.

Another way to find out about a group’s reputation involves a little sleuthing. “I tell physicians to go into town a day early and meet with the hospital CEO and then get permission to go onto the floor and talk to nurses,” says management consultant Fleischman. “You can also walk into the local Walgreens, say you’re new to town, and ask the pharmacist who they’d recommend for a doctor.”

In addition, strike up conversations with the desk clerk at your hotel, waiters when you’re out to eat, and anyone else who seems open to talking. You can find out a lot about how people perceive the local health care scene by asking open-ended questions and listening carefully to what is shared.

Doing her internet research provided Beckom with information she used during the interview process. “You should go in knowing something,” she says. “You need to know what the policies are, what they believe in, what they’re trying to accomplish.”

How she would be oriented to her new practice once on board was also of interest to Beckom, so she asked about it during interviews. “Are they just going to put you in an office and then it’s trial by fire?” she says. “SMA has a wonderful orientation program.” Another check mark in the plus column for the organization.

Beckom says SMA was quite transparent with her during the interviews. “Coming from my own practice, I know what it takes to make money, what it costs to keep a practice running,” she says. Beckom also inquired about base salary, productivity pay, patient scheduling, how flexible things were in terms of what doctors could and could not order, and—most important—the culture of the practice. “The biggest thing to know is their philosophy and whether it fits with yours,” says Beckom. “I wanted a company that held itself accountable and treated employees with respect. I love my job. SMA has great policies and they try very hard to take good care of patients,” she says.

The right fit

Before accepting a position at Citizens Memorial Healthcare in Bolivar, Mo., Matthew Cherry, D.O., interviewed at both very large and very small hospitals.

For Matthew Cherry, D.O., the two main factors in settling on a practice opportunity after he completed his radiology residency and musculoskeletal fellowship training in 2012 were location and fitting in well with the people he’d be working with every day. “We knew we wanted to stay in the Midwest. Both of our families are here and family is really big for us,” says Cherry who, with his wife, Mary, has a 6-year-old son and a 3-year-old daughter.

“We prayed for guidance about where to start looking for a practice opportunity. It can be quite overwhelming. It was the good Lord who showed us how to narrow our search,” says Cherry. That search ended in Springfield, Mo. The couple reside there and Cherry practices in nearby Bolivar at Citizens Memorial Healthcare (CMH) in a three-man radiology group. Although employed by the hospital, Cherry says the group runs more like a private practice.

Before accepting the job in Bolivar, Cherry interviewed at very large and very small hospitals. “I wasn’t sure what kind of practice I wanted to be in, but I quickly realized that a 20-man group wasn’t for me. If you put 20 docs in a room, someone’s not going to get along,” says Cherry. “I didn’t want to be involved in the politics and extra stress involved with big groups.”

When he interviewed with CMH, Cherry took note of the fact that everyone seemed to know everyone else. They made him feel welcome and needed. “I had one interview and liked the family atmosphere. I could see myself there. My partners had a lot in common. A week later I had a contract in the mail and that was that,” he says.

Cherry appreciated the fact that the contract itself was straightforward. “It was extremely easy to read. Some others I looked at you couldn’t even understand and it was like they were trying to hide something,” he says. “This one was clear cut. I had it reviewed by a lawyer and they couldn’t find anything wrong with it.”

New to the staff and with the benefit of the fresh perspective that goes along with that newness, Cherry has become an asset to CMH’s in-house recruiter Donna Shelby. “She has me sit in on candidate interviews now,” says Cherry. He’s noticed that physicians interviewing to relocate to Bolivar are interested in what the community has to offer as well as the quality of the facility.

Cherry says physicians, especially those coming right out of training, should do their homework and not necessarily accept the first offer they get. “The first hospital that offers you a job…it’s going to look like a lot of money compared with residency. Don’t let that cloud the picture. Interview with at least four or five places and get a feel for how things are run and how involved administration is in day-to-day decision-making. Talk to as many people on staff as you can. The doctors who are in the thick of it will have good insight as to what your future there would look like,” says Cherry.

Related: Finding a practice that fits your life

Putting in the time
Emergency medicine specialist Christopher Gentle, M.D., got to experience first-hand the old adage that “nothing is certain except death and taxes” when he received a phone call a couple of months before completing his residency. He’d signed on with an emergency medicine group to practice at one of their hospitals in Maryland when he got news that the group had lost their contract and a new company was taking over.

“They told me I had options. I could stay and work with the new group or get out of the contract,” says Gentle. “That’s the nature of emergency medicine. A contract can change hands at any time, and you have to be aware and flexible.”

Gentle decided to give the new group a go and stayed for about four years. During that time he discovered that he liked the administrative side of emergency medicine while serving as peer review chairman and being in charge of quality assurance functions for the group. “I wanted to take the next step and look toward becoming a medical director,” says Gentle.

As luck (or good fortune or positive intentions or whatever else might have been at play) would have it, an opportunity came up in nearby Martinsburg, W. Va. The medical director of Salutis Emergency Specialists was ready to step down after 19 years at the helm.

“This was very appealing to me. It was only 20 minutes away and exactly what I was looking for, which was being mentored and then, when I was ready, being able to step into the medical director role,” says Gentle.

As good as it all sounded, Gentle knew he needed to do his homework. He met with the medical director to get an overview and then had a day-long meeting with members of the group. “I got a sense of the history, the philosophy, and the structure of the partnership,” says Gentle. “You look at the basic things, too, like compensation, benefits, clinical hours and standard package.”

A third meeting was held at a restaurant where Gentle and his wife, Madonna, got to know members of the group and their significant others in a more casual setting. “When you’re working in a small group like this, it’s almost like an extended family…it’s important to get to know everyone…what their strengths are and what they have going on in their lives,” says Gentle.

He also took the time to meet with the hospital CEO, the dean of the local medical school, and nursing administrators. “Separately, I also talked to people who had worked there before to get a sense of why they left,” says Gentle. “I didn’t find anything worrisome. I met all the major players and gathered a lot of information.”

Putting in the time to get to know the ins and outs of the group before signing a contract paid off. Gentle started work in May of 2012 and took over as assistant medical director this past January. “Next year I’ll be medical director,” he says.

Related: Love where you land

The final decision
Fleischman says that there are certain warning signs that physicians should be aware of as they evaluate a new practice opportunity. These include high turnover among physicians or staff, family members working in the office (not usually a good idea), a group not keeping up with technology, any hint of poor relationships among physicians, an inexperienced practice manager, too many people involved in day-to-day management, and inequality in a call schedule. “Don’t be afraid to walk away if you see red flags. There are plenty of openings right now.

If something doesn’t seem right, it probably isn’t.”

After you’ve done your research, made your decision, and have an offer on the table, Fleischman advises donning your business hat. “You can’t do this on a handshake. At minimum, get a letter of intent that spells out pay and benefits,” he says. “Never start work without a contract, and have someone who is familiar with physician employment agreements review that contract before you sign.”

Karen Childress is a frequent contributor to PracticeLink Magazine.




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