How to negotiate time off

Maintaining a healthy work-life balance means allocating time for life—away from work.

By Megan Kimbal | Job Doctor | Winter 2018

 

Doctors and patients sit and talk. At the table near the window in the hospital. Doctors and patients sit and talk. At the table near the window in the hospital.

One of the more important things to consider when evaluating a potential job opportunity is the amount of paid time off you’ll receive.

Vacation time is usually forefront on most people’s minds, but it is also important to consider paid time off for continuing medical education (CME) courses and medical mission work. These items have a direct impact on your work-life balance.

Clarify “paid time off”

Does the language of your contract clearly define the amount and allocation of the paid time off you will receive?

Many physicians assume that the paid time off listed in the contract is a non-negotiable part of the benefits package, but that is not always the case. Aside from the amount of time offered, what is offered and/or how it is structured can vary by employer.

For example, you may notice that some employers offer both vacation and CME time off separately. Others combine them into one “paid time off” pool.

It does not matter exactly how it is structured, as long as you are aware whether or not CME time off is included. You can then attempt to negotiate for additional time if desired. Assign a priority to vacation time

Before going into a negotiation, it is crucial that you develop a strategy aimed at getting what you need above what you want. Rank your priorities in order of importance. This will serve as a visual reminder while you are in negotiations of where you should stay focused.

Once you see how your paid time off is allocated, you’ll have to determine if an opportunity’s vacation time fulfills what you need to maintain a healthy work-life balance. If not, what might you be willing to give up to get more? If vacation time is more important to you than a higher salary, for example, make sure you prioritize vacation time above salary during your negotiations.

Failure to prioritize weakens your position in the negotiation process, wastes valuable time, and may ultimately leave you with an unsatisfying contract. On average, most physician employees get three to four weeks of paid vacation time.

Address CME time

The cost and timing of CME courses should be discussed when negotiating your paid time off.

The CME credits required differ by state. Before you enter into negotiations, know how many hours you will be required to complete. More employers are now combining CME time, vacation time and sick leave into one “paid time off” bucket. Make sure you understand exactly how much of your paid time off is expected to be spent on CME.

Most employers will offer a week of paid CME time off with a stipend for expenses incurred in addition to paid vacation days.

Consider medical mission work

Your main focus as you negotiate your contract should be on your long-term personal goals and professional agenda.

If fulfilling a medical mission is a priority to you, then it is important to make sure your employer is aware of your goal. Medical missions can be short-term (1 to 2 weeks) or long-term (3 to 8 weeks). Before entering a contract negotiation, make sure you know what type of mission you are interested in, and how long you plan to be gone.

There are tax deductions available for medical missions, so this could be something for which your employer is willing to give you additional paid time off. If this is a priority, make sure you keep it high on your list—and ultimately be willing to give on something else you are not as passionate about.

Megan Kimbal is the director of client development at Premier Physician Agency, LLC, a national consulting firm specializing in physician job search and contracts.

 

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7 new apps for physicians to try

From guidelines for cancer patients to neurosurgery simulation, these apps—all free—help physicians through a variety of training and practice decisions.

By Iltifat Husain, M.D. | Tech Notes | Winter 2018

 

Women using a smartphone in the display and technology advances in stores. Take your screen to put on advertising.

From guidelines for cancer patients to neurosurgery simulation, these apps—all free—help physicians through a variety of training and practice decisions.

Usually, I use Tech Notes to cover three recently released apps in depth. But over the last few months, we’ve seen a flurry of interesting medical apps released. This time, instead of discussing three apps in detail, I’ll give you a summary of seven interesting, free medical apps that were released in the last few months.

Dx Challenge

Dx Challenge, from the University of Pennsylvania, gives you a case-based presentation of a patient and tests your responses. You have a limited amount of time to respond to the questions, and a limited number of attempts. The interesting thing about the app is that you actually can collect an honorarium for getting the answers right. The challenges and cases are live and only available for a limited time. This is the only medical app I know of that actually pays you for getting medical questions correct.

iTunes: appstore.com/dxchallenge

CorticoCalc

CorticoCalc

The CorticoCalc app helps you determine the appropriate topical steroid and coverage. The app would be useful not only for dermatologists, but also for pediatricians and primary care physicians. One of the best features of this app is the ability to separate pediatric cases from adult ones—there is a separate decision tree for patients 0 to 3 years old and those who are older.

Once you select the appropriate age, the app guides you through selecting the amount of coverage, such as right arm, and then gives steroid recommendations.

ASCO Guidelines

The ASCO Guidelines app from the American Society of Clinical Oncology helps clinicians with a range of management questions and treatment guidelines for their cancer patients. The app has point-of-care decision-making tools and is kept up to date when new evidence becomes available.

iTunes: itunes.apple.com/app/asco-guidelines/id1238827183?uo=5&at=10l9yE

Prescription Check by Warby Parker

Prescription Check by Warby ParkerPrescription Check by Warby Parker is an app that enables you to take a vision test at home and get a prescription for glasses. Simply by using a smartphone and laptop, you’re able to get a prescription assigned to you, approved by an optometrist. The key though is you don’t get a comprehensive medical eye exam, simply a prescription.

Warby Parker makes it clear their technology isn’t meant to replace visits to your eye doctor, but you can imagine there is concern by medical professionals.

The American Optometric Association (AOA) has submitted complaints about this technology to the FDA, and they are concerned that this type of technology will lead to harm by causing fewer patients to get medical eye screening exams.

The main reason I mention this medical app is because these types of eye prescription apps are gaining traction, and the technology itself is innovative. As medical professionals, we should know that we might have patients using these types of apps and should be ready to answer questions that patients have about their safety and use.

PsychoPharm Research

PsychoPharm Research was created by noted medical app developer Joongheum Park, M.D., who is an internal medical physician. Park has created several notable medical apps, and this current one provides an interactive version of medical decision support trees for psychopharmacology.

It should be noted that medication decision support trees have backing from a venerable institution. They are developed by the Psychopharmacology Algorithm Project at the Harvard Medical School Department of Psychiatry, South Shore Program (founded by David Osser, M.D., an associate professor of psychiatry at Harvard Medical School).

This application really is tremendous. It helps primary care physicians and psychiatrists with a decision tree for patients who have depression, bipolar and other psychiatric complaints that haven’t responded to the first line of therapy. It’s a must-have for primary care physicians to try, especially when choosing second line options for patients who have depression or general anxiety disorders. It’s remarkable that this application is available to download for free.

iTunes: itunes.apple.com/us/app/psychopharm-research/id1238087068?mt=8&uo=4&at=10l9yE

Pterional Craniotomy

Pterional Craniotomy is a real-time 3-D neurosurgery simulation app that shows you one of the most common neurosurgery procedures: the pterional craniotomy. The app teaches about and enables you to actually perform the surgery. Users are given controls at a granular level, even determining how to position the patient during the surgery by utilizing tap and zoom functions on your phone.

The team of neurosurgeons that helped develop the app state that it was built through “a systematic 3-D reproduction of real surgical scenes.” The app gives you an idea of how future medical students and residents might learn complex surgical procedures by using their phones.

iTunes: itunes.apple.com/app/pterional-craniotomy/id1239319725?uo=5&at=10l9yE

Android: play.google.com/store/apps/details?id=com.upsurgeon.pterionalcraniotomy&hl=en

REBEL EM

REBEL EM

REBEL EM by AgileMD organizes the content from the RebelEM website into easy to use, point-of-care accessible information. RebelEM.com was founded by Salim Rezaie, M.D., and is run by a group of academic emergency medicine physicians. The website provides great peer-reviewed blog posts that focus on various emergency medicine topics.

Instead of simply turning the website into an app, AgileMD divided the app into key systems, such as cardiovascular and gastroenterology. Within each of these sections, you’re given summary morsels of information. My only issue with the app is that I wish they put links to the full posts on each of the subsections for further reading. That said, this is a great example of distilling a website into an easy to use, point-of-care form.

Iltifat Husain, M.D., is editor-in-chief and founder of iMedicalApps.com, the leading physician publication on digital medicine. He’s also assistant professor of emergency medicine and director of medical app curriculum at Wake Forest School of Medicine.

 

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Growth in Medicare — and in proposals to change how it is funded

Congress is weighing proposals that include converting Medicare to a voucher system.

By Jeff Atkinson | Reform Recap | Winter 2018

 

Arrows up, increase and success business illustration
Medicare is a program undergoing significant growth, and there are several proposals on the table that could change it.

Two types of plans

Medicare delivers care through two main programs: Original Medicare (Part A and Part B) and the Medicare Advantage Plan (Part C). The original plan is fee-for-service with patients free to choose their physicians and hospitals (assuming the providers accept Medicare).

Under Medicare Advantage (MA), patients sign up with a private company approved by Medicare, and the plan is responsible for delivering care. Medicare Advantage plans generally are HMOs or PPOs where the patient’s choice of providers is more limited. A patient will pay a higher share (or potentially all) of the costs for out-of-network care. Medicare Advantage plans receive a fixed amount each month per enrollee from the federal government.

Medicare Advantage plans usually offer benefits to patients that are not available under original Medicare, such as coverage of vision and dental care. Enrollment in Medicare Advantage plans has increased more than 70 percent since 2010 to about 19 million, according to the Kaiser Family Foundation.

Infographic

Private contracting with patients

Among the proposals to change Medicare is to allow physicians who participate in Medicare to enter into contracts with patients to pay more than the Medicare rates. Under current law, physicians who participate in Medicare agree to accept the Medicare fee schedule and not balance-bill the patient for anything beyond the 20 percent copay that is paid by the patient or the patient’s supplemental insurance.

Physicians who opt out of Medicare are free to charge whatever they wish. Psychiatrists make up the largest portion of the opt-out group. Under current law, a physician who opts out must do so for all of the physician’s Medicare patients.

Proposals to change the law would allow physicians to obtain reimbursements at normal rates from Medicare and balance-bill the patient for an agreed additional amount. The additional payments could be determined on a patient-by-patient or service-by-service basis.

A report by the Kaiser Family Foundation notes three arguments in support of these changes:

  • Higher payments to physicians to offset what some view as unduly low payments from Medicare that do not keep up with practice costs.
  • Increasing the number of physicians willing to accept Medicare patients.
  • Reducing costs to patients who wish to see physicians who had opted out of Medicare since Medicare, under the new program, would pay part of the costs.

The Kaiser report also notes drawbacks to the proposal:

  • Costs would increase for patients who enter into such contracts with their physicians. Added payments may be unaffordable, especially for the half of Medicare enrollees who live on $24,000 or less per year.
  • If physicians decide to see only patients who are willing to pay more than the Medicare rates, access to physicians will be reduced.

Voucher plan

Another proposal is to convert Medicare into a system of “premium support”—also referred to as a “voucher” plan. Instead of having the government pay health care bills directly to providers, as is done under original Medicare, the government would provide a fixed dollar amount to Medicare beneficiaries who would use the money to purchase insurance in the private market or in the original Medicare program.

If the level of premium support does not cover the full cost of insurance (which is likely), the beneficiary would have to make up the difference. Some versions of the premium support proposal also would allow insurance companies to provide different levels of benefits. Under current law, all Medicare beneficiaries receive a base level of benefits.

Another uncertainty regarding the premium support proposal is the future of Graduate Medical Education (GME). The current Medicare program heavily subsidizes GME. The premium support plan does not specify how GME will be funded.

Jeff Atkinson is a professor for the Illinois Judicial Conference and has taught health care law at DePaul University College of Law in Chicago.

 

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Family-friendly cities

Finding a new place in which to practice is just as important to your family as it is to your career. Make it a good choice for both.

By Liz Funk | Live & Practice | Winter 2018

 

Amanda Beach, M.D.

Amanda Beach, M.D., convinced her brother and parents to relocate to Carmel, Indiana, about 25 minutes from downtown Indianapolis.

When deciding where to practice, physicians weigh many factors: what health systems operate hospitals and clinics in the area, opportunities for career growth, what the patient population is like, and proximity to family. Of course, for many physicians, whether the area is a good place to raise a family is a top priority. The quality of local schools, the availability of family-friendly leisure activities, and the general quality of life are all important considerations for physicians with families.

If you fall into this category (or think you may soon), consider Carmel, Indiana; Owensboro, Kentucky; Lincoln, Nebraska; and Rockville, Maryland as strong options.

Carmel, Indiana

In Carmel, physicians can enjoy the benefits of living in an area with several amenities and activities while enjoying a high quality of life, especially in the context of easy commutes and friendly people. Alternatively, physicians can take advantage of the ample career opportunities in nearby Indianapolis. This Midwest health system hub is a mere 25 to 30 minute drive from Carmel.

For Amanda Beach, M.D., life in Carmel is a family affair. “I have always loved science, and I come from a huge family of engineers. I thought I might want to do something biomedical. I really liked anatomy. But I also wanted to form connections with people. I thought, that’s what physicians do, especially pediatricians. You get to watch people grow up. That’s how I decided on pediatrics,” says Beach.

Beach attended the University of Dayton in Ohio. While an undergraduate, she volunteered with a children’s hospital in Dayton, which cemented her professional path. She attended the Loyola University Stritch School of Medicine in Chicago, and placed with Riley Hospital for Children in Indianapolis for her residency.

When Beach began job searching, she saw a pediatrician opportunity with St. Vincent Medical Group, a subsidiary of Ascension, the country’s largest nonprofit health system. She applied and was hired.

“One of my reasons for my move to St. Vincent was that I wanted to be somewhere for a long time and work with patients over a long period. Unless a family moves, when you’re a pediatrician, you stay with people for a while. You get to see people have siblings,” says Beach.

St. Vincent Carmel has a special focus on women and families. In 2015, the 121-bed hospital opened the St. Vincent Carmel Women’s Health Center. Says Seth Turner, a primary care physician recruiter for St. Vincent’s Health, the hospital is proactive about acquiring cutting-edge technology to support their patient care. Says Turner, “One of St. Vincent Carmel’s featured offerings is an Advanced Breast Care program with care navigators and the newest 3-D mammography technology, tomosynthesis, which is considered the ‘mammogram of the future,’ especially for women who have dense breast tissue. This machine can take a three-dimensional snapshot allowing radiologists to look for tumors layer by layer, almost like flipping the pages of a book.”

Additionally, says Turner, St. Vincent Carmel offers da Vinci robotic surgery for gynecological and other surgical procedures, and breast oncology and reconstruction surgery. The hospital also operates a Women’s Cardiac Risk Clinic. Turner is currently recruiting for hospitalists, internal medicine physicians and nocturnists.

St. Vincent’s main campus is in Indianapolis, 25 minutes from Carmel; St. Vincent Hospital is the flagship location of St. Vincent Health. Indianapolis has several prominent health systems that operate or are headquartered in the city. Franciscan Health operates Franciscan Health Indianapolis, a hospital known for its full-service heart and vascular care program. Indiana University Health (IU Health) operates three hospitals in Indianapolis, including IU Health University Hospital, IU Health Methodist Hospital, and Riley Hospital for Children.

IU Health also operates IU Health North Hospital in Carmel, a 189-bed hospital with all-private patient rooms, including private NICU and PICU rooms.

Says Mark Clarke, a recruitment associate for IU Health Physicians, “IU Health North Hospital features maternity suites with whirlpool labor tubs, two cesarean section suites conveniently located adjacent to maternity beds, and 16 technologically advanced surgical suites with a focus on non- and minimally-invasive procedures.”

IU Health North Hospital provides a broad range of services, including bariatrics, neurology, obstetrics, plastic and reconstructive surgery, radiology, sports medicine and urology. Clarke is part of the 12-person team of physician recruiters working to bring physician talent to Indiana and specifically to Carmel.

“There is a lot of growth in Carmel, especially in the city center area,” says Whitney Riggs, communications coordinator at Hamilton County Tourism. “This is one of the main areas where there are a lot of new restaurants and shops. Our midtown is also in the process of growing a lot.”

Despite being a small town, Riggs says that Carmel has “big city things to do.” In the summer, Riggs says there are scores of free concerts and events, including the popular annual Greekfest in August.

“I originally lived in Indianapolis,” says Beach. “My husband and I moved to Carmel a year and a half ago. We looked around and thought, ‘Hey, this is a great place to have a family.’ We have a 4-year-old, and we really like that it’s an active community. There are great schools. It’s really safe.”

Beach also appreciates that her work as a pediatrician helps her become better acquainted with local families. “One of the things I especially like about living and working here is that I see my patients out and about; I know their families and they get to know mine.”

Beach means this in more ways than one. She and her husband bought a house in Carmel, and they immediately clicked with the area. She shared with the rest of her family how much she enjoyed living in Carmel—and her brother decided to relocate there. Then, so did her parents. “My parents definitely wanted to be close to their only granddaughter,” says Beach.

“The area has great schools,” Beach says. “The city really cares about maintaining our school system. They try to keep the city and the community really nice.” Beach is emphatic that Carmel is not just a good place to have a family; it is a good place to be a parent with a career. “It’s very conducive to being a working physician mother. It was not hard to find a great day care. I live two minutes from my daughter’s day care, and my office is two doors down. When my daughter reaches kindergarten, her school will be walkable from my house.”

Lincoln, Nebraska

If you are looking for a city where you can have a fast-paced career with a high quality of life, Lincoln, Nebraska, may be the perfect fit. Physicians can practice in Lincoln, a city made especially colorful on game days by the University of Nebraska community and its red-clad sports fans who flock to the area. Physicians can even choose a rural lifestyle just outside the city limits, without adding too much time to their commute.

Daniel DeFreece, M.D., is a born-and-raised Nebraskan, and can vouch for it being a great place to grow up, to advance one’s medical career, and to raise a family.

“I grew up in a rural area, so raising our family in a rural area was appealing to my wife and I,” says DeFreece. “I think a lot of family practice doctors enjoy the relationships that they develop with patients over time—and especially so when you’re in a more moderately-sized market. That all appealed to me. So, 21 years later, here I am.”

DeFreece lives in Nebraska City, just outside Lincoln, and works for The Physician Network, a subsidiary of Catholic Health Initiatives. CHI operates hospitals and clinics across Nebraska. “I’m half-time medical director for quality, and I spend the second half of my time working in family practice,” says DeFreece. “The network has multiple clinics and doctors in it, of which my clinic is one. I help them with the quality aspect for multiple locations in our area—Lincoln, Crete, Kearney, Grand Island. It’s a very large physician network.”

DeFreece learned early on that he was interested in family practice. “I went to the University of Kansas Medical Center. We spent two years in Kansas City, and then UK flips it and for the second half, you go to Wichita, Kansas,” he says. “It’s a clinical rotation, and it’s a much more community-based program where you are working with doctors in private practices.” Spending time learning from physicians in private practice “definitely flavored my decisions,” says DeFreece. “I went to Lincoln Medical Education Foundation for three years of family practice residency.”

DeFreece enjoys practicing with The Physician Network. “There is a much bigger emphasis on providing quality medical care, as far as patient satisfaction, providing the right medical care for the right person, and doing it in a cost-effective way,” he says. “We have a great network of doctors. It’s a rapidly changing health care world; being a supportive group with good leadership is a must because there are so many things changing. I think that’s why you see a lot of doctors joining groups.”

Says Terri Bangert, a physician recruitment specialist for The Physician Network/ CHI Health: “In Lincoln, because of the university, we’re a very active, very healthy system. Lincoln is the state’s capital, but it’s also home to the University of Nebraska.” The football stadium accommodates up to 92,000 people coming to see the Huskers play. “Saturday is a flood of red,” Bangert says.

In Lincoln, CHI operates CHI Health St. Elizabeth, a 260-bed full-service hospital. The hospital has a neonatal intensive care unit, a cardiovascular line and a pediatric surgery line. The hospital is also the accredited burn trauma center for the entire area. Says Bangert: “I’m recruiting for specialties across a broad spectrum: primary care, internal medicine, family medicine, cardiothoracic surgery, pulmonology, critical care, neurosurgery, neurology, nephrology and emergency medicine.”

Another employer of physicians in the Lincoln area is Bryan Health. Bryan Health operates the Bryan Medical Center West and East Campus. There are 640 beds between the two campuses. Carol Friesen, vice president of health system services for Bryan Health, sees her organization as an advantageous place for younger physicians to accelerate their careers. “Our medical staff leadership at Bryan has traditionally been very young,” says Friesen. “We’re not like, ‘You have to be in the last 10 years of your practice to become a leader.’ Physicians have this opportunity earlier in their careers than other communities.”

Friesen says that 80 to 90 percent of physicians who come for a site visit sign an offer letter. Outside of the professional development opportunities at Bryan Health, Friesen attributes the high level of interest to life in Lincoln. “When we’re recruiting, we get people with ties to Lincoln or to the state. But we have a lot of physicians we’ve recruited from the coasts who are looking for a great place to raise their families.”

Curtis Klein, director of talent and healthcare services for the Lincoln Partnership for Economic Development, says, “Lincoln is a big small town. We’re a quarter of a million people. …You can feel like you can be part of the scene pretty easily.”

There’s also no need to figure in costs for private education because Klein says Lincoln is known for the strength of its public schools. “The public school system has very high graduation rates and various acceleration programs,” he says. “Lincoln Public Schools does a really good job of keeping up with the times, offering all the services and programs to stay at the forefront of meeting students’ needs.” Klein notes that Lincoln high schools have just finished their second year of The Career Academy, a program that allows juniors and seniors in high school to enroll simultaneously in a local community college, where they can take classes that satisfy high school graduation requirements and help them earn college credits.

When they are not in class, students and their families can enjoy a variety of great activities in Lincoln. DeFreece has three children, ages 21, 19 and 15. He says that the outdoorsy nature of their Nebraskan lifestyle lends itself to active family activities. “We do a lot of things outdoors; we like to golf and go boating. The kids do baseball and soccer and participate on the swim team. When your kids are school-age, you get involved in lots of the school activities.”

Owensboro, Kentucky

Thomas Waring, M.D.

After time in New York and Connecticut, Thomas Waring, M.D., found a home in Owensboro, Kentucky.

Home to one of the nation’s most highly-regarded playgrounds, Owensboro takes “family friendly” to a new level. For families interested in Owensboro’s vibrant culinary scene, bibs are a must for kids and most adults: Owensboro takes its barbecue very, very seriously.

Thomas Waring, M.D., knew early on in life he was drawn to medicine, particularly helping individuals requiring urgent medical care. “I started working on an ambulance when I was 16. I was an EMT for many years, all through high school and college,” he says.

Waring attended Molloy College in Rockville Centre, New York, located on Long Island approximately 20 miles east of New York City. Waring was a senior in college on September 11, 2001, and he was one of the first ambulance responders. “They asked for additional ambulances to come. We got a crew together, and we went into the city,” says Waring. His ambulance was staged at New York-Presbyterian Lower Manhattan Hospital, blocks from ground zero, and the team stayed overnight. Waring described the situation as “chaotic.”

The experience fully solidified his interest in critical care. He attended Ross University School of Medicine and completed his residency at Rochester General Hospital in upstate New York. Waring completed a fellowship in pulmonary/critical care medicine at the University of Connecticut.

After two years in Connecticut, an advertisement from Owensboro Health caught Waring’s eye. “I came to visit the hospital and thought it was gorgeous,” Waring says. “I came down for a second look and decided it was where I wanted to be.” At Owensboro Health Regional Hospital, Waring works in a hospital-based private practice. He finds the combination of the work that he’s doing, the personality of the patient population, and the culture of the organization to be a winning combination. “I really like managing the very sick and critically ill. The patients are very appreciative. The hospital is more like a big family; everyone works well together and the patients really appreciate what we do.”

Owensboro Health Regional Hospital provides service to 14 counties, 2 in southern Indiana and 12 in western Kentucky. Says Mitchell Sims, manager of physician recruitment for Owensboro Health, “We are licensed for 477 beds. We have a Level III NICU, which is the largest NICU west of Louisville. We have two da Vinci robots and 16 operating room suites.” On average, 1,800 babies are born each year at the hospital.

Part of what keeps Owensboro Health Regional Hospital so busy is that it serves a large region and a large patient population. Located in Daviess County, Kentucky, Owensboro has a metropolitan population of about 100,000 people, yet Owensboro Health Regional Hospital is the only hospital that operates at that scope within a 45-mile radius.

Owensboro Health also operates 25 outpatient locations, with three more locations in progress. Owensboro Health Medical Group employs more than 180 providers, spanning over 30 specialties. Sims is currently recruiting for several new physicians across a wide range of specialties, including gastroenterology, neurology, pulmonary critical care, outpatient family medicine, non-invasive cardiology, rheumatology, psychiatry, outpatient pediatrics, geriatrics and sleep medicine.

Sims says that Owensboro offers more than just a job. The city has made a strong effort to offer big-city entertainment and facilitate residents’ active, vibrant lifestyles. Says Sims, “The community recently completed a $300 million renovation to the downtown area that has brought in a lot of new businesses and restaurants. Another big draw downtown is a park that was named the No. 1 playground in the world by Landscape Architects Network.” The park, Smothers Park, sits on the Owensboro waterfront and features a very large, fully accessible playground and interactive water fountains.

Says Mark Calitri, president and CEO of Visit Owensboro, “Owensboro has just been honored as a ‘2017 Playful City USA’ for the second time by KaBOOM!, a national nonprofit. This honor represents the city of Owensboro putting the needs of families first so kids can learn, grow and develop important life skills.” Calitri says that Owensboro Parks and Recreation runs a total of 23 parks and that Owensboro families tend to be active: walking, cycling and hiking are popular family activities.

“Owensboro is known for the three B’s: barbecue, bourbon and bluegrass,” Calitri says. A new International Bluegrass Music Museum is under construction, and families can also visit the Owensboro Museum of Fine Art and the Owensboro Museum of Science and History. The Owensboro riverfront is also host to an annual family-friendly event, the International Bar-B-Q Festival.

Waring sees many positives to life in Owensboro, particularly as it pertains to quality of life and cost of living. “The East Coast is much more fast-paced,” says Waring. In Owensboro, he says, “the lifestyle is much more laid back. The cost of living is much cheaper here. I’m paying about half of what I’d be paying for housing in New York or Connecticut. Sometimes it’s not how much you make, it’s how much you get to keep.”

Rockville, Maryland

If you are looking for a diverse, family-friendly family-friendly place to raise your kids, look no further than Rockville, Maryland. The average age of a Rockville resident is 39—meaning that most people are parents of young children, eager to bond on the sidelines of sports tournaments. The area’s proximity to Washington, D.C., provides ample job opportunity as well as access to world-class museums, restaurants and entertainment.

Jude Alexander, M.D., describes Rockville, Maryland, as embodying the “Goldilocks principle”: “It’s not too hot; it’s not too cold. It has history, and you can easily get to the beaches, to the mountains—anywhere you want to go.”

Alexander attended the University of Miami Miller School of Medicine, so more moderate temperatures were an appealing draw.

Alexander is an internist and psychiatrist. He moved to the Washington, D.C., area in 2003 and started a hospitalist company in the area with a business partner. “At that time, I was going around D.C. after residency building the business,” he says. Alexander says it was an era when hospitalist programs were taking off, and his was no exception.

“The hospitals feel like they get more value for the dollar, and they’re working with a group that’s really far ahead of other hospitalist groups. They are getting best of breed and more value for the dollars they invest,” says Alexander. It was a good deal for the doctors, too. “My doctors have loved it. It has worked out both ways.”

In 2014, Alexander reflected on the company’s success and started brainstorming how to take it to the next level. It was time to explore having the practice acquired by a larger health care company that could scale and grow the hospitalist group.

“We looked at every conceivable option under the sun. To me, the only option was Sound Physicians,” a physician-owned hospitalist management health care organization. Says Alexander: “We looked at big groups along the Atlantic and national health systems, and Sound Physicians had the right culture, the right leadership, the right reputation, and all the right structure and tools to sharpen our game and take us to the next level.”

Sound Physicians acquired Alexander’s company and named him Regional Medical Director for the Capital Area. “It’s been easily the most important and successful decision I’ve made; it turned out absolutely wonderful,” Alexander says.

Says Jill Albach, clinical recruiter for Sound Physicians: “Quality, teamwork, service, integrity and innovation are of paramount importance to Sound Physicians, and they are the cornerstones of each of our programs nationwide.” Sound Physicians has a large presence in Rockville, with many of their providers working at Adventist HealthCare Shady Grove Medical Center, a 331-bed acute care facility that is part of the Adventist HealthCare network.

Sound Physicians is expanding, especially in Rockville, and recruiters are looking to bring top medical talent to the area. Says Albach, “We are hiring for day and night hospitalists for this program at Adventist HealthCare Shady Grove Medical Center and other locations in the greater Baltimore/D.C. area, as well as hospitalists, intensivists, emergency physicians and transitional care providers nationwide.”

Albach says Rockville is an excellent place for physicians to consider relocating, especially if they have a family and school-age children. “It is a vibrant, highly-educated community that offers cultural and historical experiences,” says Albach. “Rockville’s public schools are ranked second overall in the state of Maryland.”

Kelly Groff, president and CEO of Visit Montgomery County, says Rockville is especially family-friendly. “One of the especially appealing things is that the city of Rockville, which manages the community and provides services for residents, does a really good job with parks and recreation. They have great classes for kids, and sports teams and leagues for kids year-round.”

Groff says Montgomery County also has one of the best public school systems in the country. Montgomery County also offers a rich, informal cultural education. “Thirty-four percent of the population was born outside of the U.S. It’s a very diverse community.” Additionally, Groff said nearby D.C. is like “a historic playground” and just a short ride away via the Metro.

Alexander, who is married and has two children, describes the experience of raising a family in Rockville as “fantastic.” “You want to have access to good public schools. Some of these schools are number one in the country,” he says. “Montgomery County overall is full of affluent, international, well-educated people. The cultural exposure that your family gets is great.”

 

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Mission medicine 2.0

These medical missions make it possible to give back even with a busy schedule.

By Jane Brannen | Feature Articles | Winter 2018

 

Shortly after emigrating from Italy to Washington, D.C., in the 1940s, Joseph Aloi, M.D.’s grandmother and her brother became ill.

“They were taken care of by physicians—providers that volunteered their time to take care of people without resources in Washington, D.C.,” says Aloi, who is chief of endocrinology at Wake Forest Baptist Health. “I’m very much aware that my family experienced the generosity of strangers, so I feel that it’s important to help pay that back.”

Aloi has been able to do just that after finding a nonprofit health organization that made volunteering possible with his busy schedule. He has served annually for almost a decade and a half, proving that even with a full-time workload, physicians can find ways to volunteer. Read on to learn more about three organizations helping physicians serve patients across the world—even from the comfort of their own homes.

Reaching the world: International Medical Relief

Lynette Morrison, M.D.

Lynnette Morrison, M.D., went on her first medical missions trip in 2011—and has traveled with IMR five more times since.

From booking travel plans and learning about another culture to getting the proper licenses and ensuring safety, there is a lot to do to prepare for an overseas medical missions trip. It can be daunting for many first-time volunteers who want to give back, but who don’t know where to start or who don’t have time to do all the legwork themselves.

That is what inspired Shauna King, MPH, to found International Medical Relief (IMR). She was working for a nonprofit health care system in Colorado at the time and realized there was a need for simple, worry-free ways for physicians to volunteer. “I had a lot of doctors looking for opportunities to serve and was just trying to find one that was a really simple way for them to give back,” she says. “It became a calling to start the organization.”

King now leads a team that makes overseas missions as turnkey as possible.

Lynnette Morrison, M.D., saw this turnkey experience firsthand when she first traveled with IMR to Ghana in 2011. “I was so impressed by their organization—just how everything was set up,” she says.

Morrison was a medical school student at the time. That first experience with IMR influenced her career path. “I actually went to a rural family medicine program because I was inspired by the work overseas,” she says. “In rural family medicine, it’s more like what we do in the mission trips. You don’t have specialists. You’re relying on what you can do, what you have access to.”

Since that trip to Ghana, Morrison has traveled with IMR five more times: twice as a resident and three times as a practicing physician. It has taken her around the world, including Uganda, the Philippines, Panama, Zambia and Senegal. She says these experiences have made her a more well-rounded physician for her patients back home, where she works as a family physician with a specialty in wound care at MedExpress Urgent Care in Springdale, Arkansas.

Her mission work has also influenced her personal outlook on life. “It really is rewarding,” she says. After seeing families in developing countries make do with so little, she has found herself focusing less on material goods.

IMR offers a wide variety of trips, some more rugged than others. “We work with a lot of indigenous tribes, so when we do that, we are obviously in a much more remote area,” explains King. “But then we work in some locations where they have really, really beautiful accommodations or resorts. There’s still a lot of need, but team members can be more comfortable.”

For each of these trips, IMR prepares its volunteers ahead of time. “We want our teams to go into the field feeling comfortable and confident,” says King. “We do a lot of pre-field training.” King and her staff use online training and conference calls to help team members prepare. These calls, along with Facebook groups, also allow team members to get better acquainted before they travel together.

IMR offers continuing education credits through pre-field training, so some employers may reimburse part or all of the cost of the trip. A trip with IMR can cost anywhere from $2,500 to $4,500 per person, according to King. Some physicians pay these expenses out of pocket and view it as a donation, while others raise funds for their trips.

“We actually have a customized fundraising portal,” says King. “It already has a sample letter in it, so they don’t need to do anything except send it out. And then 100 percent of the money that they raise goes directly into their account to offset their trip.”

Most of IMR’s clinics have a primary care focus, but physicians of all specialties are needed. “We take physicians of all capabilities and varieties,” says King. “Our clinics are really basic…so if a physician has been specializing in a particular area for a long time, they might be getting back to the basics of the grassroots of medicine.”

A typical IMR trip lasts just seven to 10 days, but IMR maintains long-term relationships in the area to ensure continuity of care. “We want to have sustainable solutions for the communities that we serve,” explains King. “We have long-term solutions with short-term opportunities.”

This flexibility allows many physicians to work with IMR who would not otherwise be able to serve abroad. “I’ve talked to colleagues that have said, ‘I really want to go, but I don’t have the time,’” says Morrison. “I would say, ‘Go on one. Just go on one. It doesn’t matter where. Just go on one and have that experience.’ It’s very good to go somewhere that’s out of your comfort zone. You’re going to see things that’ll help you practice.”

For more information about serving with IMR, visit internationalmedicalrelief.org.

Serving stateside: The Health Wagon

Ernani Sadural, M.D.

Ernani Sadural, M.D., serves central Appalachia through The Health Wagon. Of the experience, he says: “One comes back enriched and invigorated, hopefully even renewed in their faith in their life’s work and purpose.”

You do not have to go overseas to make a tangible impact in the lives of patients who lack access to health care.

The Health Wagon, a nonprofit based in southwest Virginia, is just one of the many organizations working to provide free, accessible care. They offer a wide array of volunteer opportunities that do not require international travel, and are ideal for a physician’s busy schedule.

“We serve the most vulnerable in our population that do not have access to health care,” explains Ashley Fleming, outreach coordinator for The Health Wagon. “The Health Wagon, with its mobile clinic and two stationary clinics, has remained a pioneer in the delivery of health care in the central Appalachian region for more than three decades.”

“The Health Wagon is probably the gold standard as far as the volunteer free clinic,” says Ernani Sadural, M.D., director of global health at RWJBarnabas Health and co-founder and chief medical officer at LIG Global. “It’s just run by extremely dedicated, compassionate people, then add in the southern charm of the people that work in The Health Wagon with the beauty of the landscape of Appalachia.”

The Health Wagon’s largest annual event, a three-day health clinic, happens every July in Wise, Virginia. They find creative ways to work with the resources available. The event is held at a community fairgrounds, providers see patients in barns, and the pharmacy is in an 18-wheeler. Patients come from all over Appalachia to be seen. Some even spend the night in the parking lots for a chance to see a doctor.

“They’re very appreciative, so that’s a big reward of being a provider there,” says Aloi, who has served with The Health Wagon annually for almost 15 years.

“The fact that we were able to practice medicine just for the pure sake of medicine for the fellow man without respect to compensation … makes for a purely enjoyable experience, whether it’s for one day or one week,” says Sadural. “One comes back enriched and invigorated, hopefully even renewed in their faith in their life’s work and purpose.”

To allow volunteers to make a big impact in a short amount of time, The Health Wagon stays highly organized. “It’s remarkably efficient,” Aloi says. “Your time won’t be wasted.” Because The Health Wagon has a permanent presence in the area, they are able to help with continuity of care after a physician’s trip is over.

“We tailor patient schedules to fit the needs of our volunteers,” says Fleming. “Volunteers can come for a few days or for a couple weeks—whatever works best for them.” Plus, physicians from all specialties are welcome.

Volunteers cover their own travel and lodging, and out-of-state providers must have a temporary volunteer medical license through the Virginia Board of Medicine. The Health Wagon recommends allowing two or more weeks for this. Aloi says the state of Virginia typically makes licensing a smooth and fairly inexpensive process. “For people coming out of state, it’s very easy to stay licensed.”

Volunteering with The Health Wagon or a similar stateside organization is a chance to learn more about life in other parts of the U.S. and develop a deeper understanding of others.

“I’m originally from Chicago,” says Sadural. “I’d never been to Appalachia, and I admit that I had my own preconceived notions.” Volunteering with The Health Wagon opened his eyes to what life was like for patients who did not qualify for Medicaid, yet could not afford health care premiums.

“I gained a deeper understanding and appreciation of these people” Sadural says. “For me, that was the biggest joy—being accepted into their community and allowed to learn from them.”

For more information about serving with The Health Wagon, visit thehealthwagon.org.

Making a difference without making a trek: The MAVEN Project

If you are looking for a flexible opportunity closer to home, you can’t get much closer than volunteering right from your laptop. New telehealth technologies have made that possible, and innovative nonprofits like The MAVEN Project are using them to overcome geographic barriers and fill gaps in health care access.

“What we’re trying to be is Match.com meets Peace Corps for volunteer doctors,” says Lisa Shmerling, JD, MPH, executive director of The MAVEN Project. “We’re really targeting health care organizations where a primary care provider is accountable for the care of uninsured and/or Medicaid patients that have a problem getting access.”

The time commitment is a minimum of just four hours per month, with no travel time required. By pairing volunteer physicians with understaffed clinics, The MAVEN Project helps rural and low-income patients who normally wouldn’t get timely access to health care. In many cases, timing makes all the difference.

Shmerling recalls the story of one hematologist volunteer who realized a patient had a treatable form of cancer. “The patient was going to go into renal failure within days if they didn’t get seen,” says Shmerling. “We were told that the patient was scheduled to see an oncologist, but not for another month. So, that was an example where we really escalated the issue, and the patient was seen within days.”

David Hurwitz, M.D., a California-based rheumatologist who has logged over 100 volunteer hours with The MAVEN Project, echoes this. “The patients have been waiting forever to see a rheumatologist, and they’re very grateful for getting a consultation,” he says. “Both the clinic staff and the patients seemed on the whole very grateful for my help.”

Hurwitz says volunteering through the The MAVEN Project has helped him carry out his passion for treating patients who otherwise couldn’t see a provider. “I’m a big believer in extending medical care to the population as a whole,” he says, adding that often there simply aren’t enough physicians to see all the patients who need to be cared for. “I saw that there was some way to help meet that need, which is what MAVEN was structured for.”

Depending on what each clinic needs and whether a volunteer physician is licensed in the same state as the clinic, MAVEN volunteers may serve through direct consultations, curbside consultations or mentoring. In direct consultations, the physician builds patient relationships and consults on individual cases. This typically happens with more complex cases and requires a physician to be licensed in the same state as the patient.

A day before each direct consultation appointment, Hurwitz says he typically gets a summary from a secretary, as well as access to electronic medical records. “A nurse would bring the patient in and introduce the patient to me,” he explains. “Then I’d see the patient, and a doctor would come in, and I would discuss the diagnosis and the plan with the doctor.”

In curbside consultations, however, a volunteer physician is not directly involved with an individual patient. Instead, he or she offers advice about a panel of cases. “Each state defines it differently,” says Shmerling. “It’s as if you were in the office and you’re getting a walk down the hall and you ask your pal, ‘What do you think about this case?’”

In mentoring relationships, a seasoned physician volunteer offers expertise to help clinic staff improve their services. “You get paired up with a nurse practitioner, for example, on a regular basis,” Shmerling explains. Mentees can use the sessions to learn about specific medical issues, get business advice or simply ask questions they have never had a chance to ask elsewhere. Says Shmerling: “Our ultimate goal is to increase the capacity at the health center.”

Shmerling says the organization works to make the technological side of things easy for volunteers. “We use a technology called Zoom,” she explains. The HIPPA-compliant application is quick to download, and it allows physicians to video conference, see patients and even share screens.

The MAVEN Project also smooths the process by covering malpractice insurance. Any physician who has been in practice for at least two years is welcome. Some of The MAVEN Project’s volunteers are retired physicians who want to continue making an impact.

Without the barriers of travel time, insurance costs or technological difficulty, you can easily get involved and help fill gaps in health care availability across the U.S.

Shmerling, who has been with The MAVEN Project since it was founded in 2013, hopes the number of physicians who regularly volunteer with health care organizations like hers will continue to grow. She says, “We would like to see a trend where someday everyone who’s in practice gives back by volunteering for some of these most vulnerable populations.”

For more information about serving with The MAVEN Project, visit mavenproject.org.

 

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How to triage your debt

Your income—and your outflow—are high contributing factors to your family’s overall quality of life. From student loans to mortgages, this guide helps you get your debt under control.

By Debbie Swanson | Feature Articles | Winter 2018

 

Caleb Butts, M.D.

A shared focus and commitment to the end goal helped Caleb Butts, M.D., and his wife, Tricia, pay off student loans in just a little more than four years.

When Caleb Butts, M.D., was visiting his alma mater, the University of South Alabama College of Medicine, he made a quick stop into the financial aid office.

“I’d been in there so much as a student, asking questions about loans, that I thought I’d stop in to say that I’d finished paying my loans back,” he says. His visit was unexpected by the financial aid officer. “She cried,” says Butts. “She knows all these medical students taking out loans, and never hears how it turns out.”

What was even more noteworthy than his visit was the speed with which Butts reached debt-free status: 4 years and 4 months after starting repayments. Butts credits the discipline and goal-oriented mindset of both himself and his wife, Tricia.

“We wanted to aggressively address the loans now, rather than let them linger,” he says. They based their budget on one income, despite their dual-income status. “We didn’t want to have to go backward [after having children], so we lived off one income, and used the other to pay down the loans.”

Whether you’re just getting started or you’re unsatisfied with your present payback plan, there’s a wide spectrum of approaches to use to pay off your educational loans. Key to success is knowing what’s available, and choosing the best plan for your family.

Devising a plan

It can feel overwhelming when it’s time to repay your medical school loans. But rest assured: Most physicians start their professional careers in the exact same situation.

Three-quarters of medical school graduates leave school with a significant amount of debt, according to the Association of American Medical Colleges. The AAMC’s survey shows that in the class of 2016, 76 percent of new medical school graduates began their career with loans to pay back, with the median educational debt level for that year’s graduates at $190,000. Thirty-two percent of graduates carry debt from undergraduate school, while 73 percent accumulate debt in medical school.

“Despite the high cost of education, it is absolutely possible to pay off [medical school] loans and have a perfectly nice lifestyle,” assures Julie Fresne, the AAMC’s director of student financial services. “There’s strong job security and excellent income potential with the career.”

If you’re searching for the best approach, start by brushing up on the programs available to you. The AAMC’s website is a good place to begin, and they also offer counseling at many different medical schools. Your medical school may also have financial experts or counselors on site, or provide referrals to trusted advisors.

One thing to keep in mind: The best payback options that may have existed for your mentors or even colleagues not much older than you may actually cost you thousands if used today.

“The menu of options is much broader than it was 10 years ago, when graduates had lower debt and rates were variable,” notes Jason DiLorenzo, founder and executive director of Doctors Without Quarters (dwoq.com), a firm that helps early-career physicians approach their student loan repayment strategically. “The newer income-driven options make the most sense for many of today’s house staff, federal forgiveness is now available, and the private marketplace offers lower rates in many cases.”

Justin Kribs, CFP, counsels medical students and recent graduates at Oregon Health and Science University. He says there’s no one-size-fits-all advice for managing your debt.

But there is a solution to fit everyone’s situation, Kribs assures, and tells students to start by making an evaluation of their goals and plans. “You’ve worked hard to get this far, now look ahead to what is in your future: buy a house, retirement, household obligations? What are your career plans?”

The right plan will be a balance of your own priorities and the best available payback solutions.

Public Service Loan Forgiveness

Erica Marden, M.D.

Resident Erica Marden, M.D., chose a repayment plan that maintained her eligibility for PSLF.

If you’re planning to go into public service, you may be eligible for Public Service Loan Forgiveness (PSLF). Eligible borrowers in this program make 120 qualifying monthly payments toward their federal direct loan over 10 years, after which any remaining principal and interest is forgiven. According to the IRS, the amount forgiven through PSLF is not considered taxable income. Repayments can begin as early as residency. Presently nearing it’s 10-year anniversary, PSLF is approaching the first year anyone could be eligible for forgiveness.

PSLF appeals to Erica Marden, M.D., a second year psychiatry resident at the University of Vermont. She is currently making payments through a PAYE repayment plan.

“These payments will count as qualifying payments toward PSLF,” she says, adding that she hopes to receive forgiveness after 10 years.

While PSLF presents a great opportunity for those whose professional plans align with the program, new participants should proceed carefully. Thoroughly research what constitutes a qualifying position, and remain informed. Changing legislation (or changing jobs to a non-qualifying employer) could affect your participation.

If you’re concerned about Congress changing the PSLF rules, consider making large payments to cover the debt in an accessible vehicle. Then, if the benefits change unfavorably, redirect the investment toward your loans.

The standard route

All federal student loan borrowers are eligible to enroll in the default standard repayment plan. This simply calculates your total amount due over 10 years and derives a monthly repayment amount.

This plan offers the lowest overall cost to the borrower over any other repayment plan when loan forgiveness isn’t an option, but it comes at the cost of a potentially high (and for trainees, likely untenable) monthly payment. For those who carry a low balance, have an achievable plan for making the payments, and aren’t considering career options with loan forgiveness available, this could be a good option.

Butts chose to tackle his loans with the Graduated Repayment Plan, which begins with a lower monthly payment, then increases periodically over the next 10 years. “I was able to make the monthly payment, but most months I planned to add extra. Also at the end of the month, whatever we had left over was used to further drive down the principal.”

Though the standard payment plan can work for some, many physicians seek other, more accommodating options.

Income-driven repayment plans

Income-driven repayment plans are critical for physicians just starting out.

“These plans are based on income, not debt. And if you keep to the plan, after time, the balance is forgiven,” says Fresne. “The payment amount is usually comfortable, something which most residents can make.”

In 2007, as a result of the College Cost Reduction and Access Act, Income-Based Repayment (IBR) was created. It went into effect in 2009. The Pay As You Earn (PAYE) program came later, in 2012. Under these plans, you can calculate your monthly loan payment based on a percent of your discretionary income.

Pay As You Earn (PAYE)

Pay As You Earn (PAYE) usually offers the lowest monthly payment, which is set at 10 percent of your discretionary income. According to the Federal Student Aid website, “your spouse’s income or loan debt will be considered [for PAYE] only if you file a joint tax return.”

After 20 years of making qualified payments, any remaining debt is forgiven.

Federal Student Aid reports that, to be eligible for PAYE, you must be a new federal borrower on or after October 1, 2007, have received a Direct Loan disbursement on or after October 1, 2011, and demonstrate financial hardship.

Income-Based Repayment

IBR determines your monthly payment based on your discretionary income. For borrowers on or after July 1, 2014, payments are based on 10 percent of your discretionary income, with a repayment term of 20 years. Those who borrowed prior to this date are capped at 15 percent for a 25-year repayment term. You must demonstrate financial hardship to qualify. (Most residents and fellows will meet this requirement.) Stafford Loans, PLUS Loans and Federal Consolidation Loans are eligible. Loans refinanced with private lenders aren’t eligible for IBR.

Revised Pay As You Earn (REPAYE)

The most recent option, created in 2015, is the Revised Pay As You Earn (REPAYE) plan. Borrowers who have a Direct Loan and financial hardship may qualify, regardless of the loan origination date. REPAYE calculates monthly payments no higher than 10 percent of your discretionary income. Payment is calculated over either 20 or 25 years, depending on if the loans were for undergraduate study or graduate/professional study.

“The most attractive benefit of REPAYE is that only half of outstanding interest is charged during periods of negative amortization,” DiLorenzo says.

With all income-driven payment plans, you need to supply documentation to verify your income and profile, and resubmit this each year, even if your financial situation hasn’t changed. Failure to do so risks losing your plan and being converted back to a standard plan.

If you qualify for PSLF, payments made under these income-driven payment plans are presently considered qualifying payments.

Balance forgiveness

Another benefit of the income-driven plans is balance forgiveness. At the end of your payback period of either 20 or 25 years (depending on your plan), any remaining debt is forgiven.

While that is enticing, it’s not completely without warning, says James M. Dahle, M.D., founder and editor of The White Coat Investor (whitecoatinvestor.com), a financial blog for physicians.

“That forgiveness, unlike PSLF, is taxable—meaning you’ll owe a tax bill that could be substantial,” says Dahle. “For most docs with anything but a terrible debt-to-income ratio, the debt will have been paid off in less than 20 years anyway, so there won’t be anything left to forgive.”

Shopping around: refinancing

Interest rates on federal loans are not always the most competitive, so physicians often refinance to a private company to gain a more attractive rate.

A note about refinancing: to qualify for Public Service Loan Forgiveness, you’re required to remain with a federal loan program.

In his blog, Dahle says a determining factor to consider in refinancing is at what point you are in your career. If you’re an attending physician who is not pursuing PSLF, refinancing could save you significant interest. Residents, however, should usually only refinance private loans that are ineligible for income-driven repayment plans (see the sidebar on page 45).

“If you are a resident, the government REPAYE program is often a better choice than refinancing as it effectively subsidizes your interest rate to an amount less than you can currently refinance the debt to,” he says. Plus, once you refinance your loans with a private lender, you cannot go back to the income-driven repayment programs or PSLF.

Frugal living

For Butts, good, old-fashioned frugal living was his route to repaying quickly.

“It may seem like simple advice, but live on less than you earn, use the rest to pay back loans. Make a budget every month with what’s coming in and what’s going out,” he says.

Dahle suggests that, rather than upgrading your lifestyle in parallel with increases in income, you delay lifestyle upgrades, and instead direct new income toward your educational debt.

“It will be far harder to cut back your lifestyle later than never to have upgraded it in the first place,” Dahle says.

Delaying repayment

Rather than defaulting on your loan, which will have lasting negative consequences, some physicians have considered one of two programs that permit temporary pauses in payments: deferment and forbearance.

Deferment is granted based upon certain issues, including financial hardship and status as a student. When loans are in deferment, you do not have to make payments, and you aren’t responsible for any interest that accrues on subsidized loans. You must apply for deferment and supply documentation to support your case.

Forbearance is another option that may sound appealing, but keep in mind that your loans will continue to accrue interest during this time, which will capitalize once the forbearance period ends. Over years, your loan balance will significantly increase.

Lynn M. O’Connor, M.D., M.P.H., now director of the Women’s Colorectal Care Program at ProHealth Care Associates in New York, used forbearance while in residency at The Johns Hopkins Hospital and Union Memorial Hospital in Baltimore. However, while in forbearance, the compounded interest added up— increasing her balance due when it came time to begin paying.

“I needed to put a large lump sum towards my loans just to bring my loans out of arrears [and] get them to a point where they could be refinanced,” she recalls.

That’s why DiLorenzo doesn’t recommend forbearance for physicians starting their careers now. “You don’t want all that interest accruing and capitalizing against you. Loan forgiveness and the reduction of accruing interest is much more favorable using income-driven repayment rather than forbearance or deferment.”

With an income-based repayment plan, DiLorenzo points out, your payment amount in residency can be as low as $0—and still position you for loan forgiveness while reducing accrued interest.

Protecting yourself and family

Whatever your loan balance, consider how your family would manage an unforeseen loss of income.

“It’s important to have a risk management plan in place,” says Kribs, advising that the ideal components include disability insurance, life insurance, health insurance and umbrella insurance. Read your employment contract carefully to understand what is offered, and if any additional coverage is needed.

During loan repayment, the more important elements are disability insurance and life insurance. Some advisors recommend you purchase the maximum amount of individual disability insurance you qualify for, which provides a tax-free benefit of about two-thirds of your income in the event of total disability. They also recommend purchasing 8 to 10 times your income in term life insurance. However, many residents find it difficult to afford as much insurance as they need at this critical time in their careers.

Though no one likes to think about life insurance, it’s essential if your payback plan is based on a dual income.

“Honestly, it is usually the spouse that is under-covered; if the individual with the loans passes away, then the loans could possibly be discharged due to death. However, if the spouse passes away, then the person with the loans still has the loans,” Kribs says.

Buying a home

Educational debt and minimal employment history often present obstacles to new physicians hoping to qualify for mortgages. That’s why lending institutions have created doctor’s mortgages, often offering:

  • A lower down payment, often under 10 percent
  • No required private mortgage insurance
  • An employment contract in lieu of pay stubs as proof of employment

Doctor mortgages may carry a higher interest rate, and typically require you to use some of the bank’s other services, such as a checking account. But if you are set on making a home purchase with less than a 20 percent down payment, it can make a lot of sense, freeing up cash that can be used to pay down student loans.

Most physicians eventually establish a doable method for getting ahead of their medical school debt.

“Use the resources at your medical school or residency to educate yourself as much as you can,” says Marden.

And don’t feel you have to have it all figured out; as your career evolves and federal programs change, reevaluate your situation and adjust your plans accordingly.

 

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Serving the military, civilian style

A move to a military base community could mean a higher quality of life—even for civilian physicians.

By Marcia Travelstead | Career Move | Winter 2018

 

Frank Roam, D.O.

Frank Roam, D.O., is a civilian physician at a military hospital—a career move that allowed him to move back to his hometown and achieve a favorable work – life balance.

Fort Leonard Wood, Missouri, is home to a military base. The community is nestled in the heart of the Ozarks about 134 miles southwest of St. Louis on Interstate 44. There’s boating, fishing, hunting, hiking and camping for those who wish to pursue outdoor sports. The low cost of living makes it a great place to retire or raise a family—and there are practice opportunities for civilian physicians.

What do you like about being a civilian physician at a military hospital? I was able to move back to my hometown, and my family is here. Previously, I was part of a large conglomerate for several years, and there was a lot of micromanagement and inconsistency. It was somewhat of a bureaucracy, so I was ready to leave when I discovered there was an opportunity to come here. There isn’t as much pressure here.

What’s the most challenging part of your role? The practice I have here is a two-edged sword. I’m still busy, but it’s a different type of busy. It’s more focused on patient-related issues such as surgery, clinical follow-ups, etc. I no longer have the time-consuming collateral duties that a civilian hospital can overwhelm an experienced physician with.

I perform a lot of the same types of surgeries, such as hernias, endoscopies, gall bladder, etc. So, there’s a trade-off, as there is not as much pathology.

The environment is a little more relaxed. Earlier in my career, I would have wanted to be busier and have the variety. Today, my days tend to be over by 4 or 5 p.m. as opposed to 7 or 8 p.m. in my private civilian practice. Depending on the call schedule, it might be much later. If someone wanted to do 60 to 70 major cases a month, the practice I have now might not be what they are looking for. However, I find it very gratifying—especially at this point in my career.

Was there anything about practicing as a civilian physician at a military hospital that surprised you? Not really. The physician recruiter was open and honest about what to expect. I was able to speak with some of the other physicians before I actually signed up, so I knew what I was getting into and what the practice was like in the hospital.

Where I was previously, I wore a lot of hats. I had to be on a lot of different committees, such as credentialing, infectious diseases, etc. As far as my time was concerned, I had to split it with these meetings and my practice. They have the same meetings here, but the physicians on the committees are military. In a way, I gave up a little bit of control from where I was before. I had input as to the rules and the way things were going to be done. For me personally, it is refreshing to no longer have to deal with that.

What advice would you give to physicians who want to pursue a similar career move? I can only speak to Fort Leonard Wood. Even though it’s a fairly large military base and hospital, the area is rural. It isn’t for everyone. However, if the physician is willing to drive a few hours, they would be in St. Louis.

Although a physician can read about the area they are interested in, the number of surgeries being conducted here and other statistics, that’s not the same as coming and actually seeing what is available.

Also, I would tell physicians not to be afraid to ask questions specific to their military hospital of interest.

Anything else? I have found this to be a much more relaxed schedule for me. I realize that might not be what a young physician is looking for. I can only speak for here, as there might be other military institutions that are busier and have a larger surgical practice.

One thing I would like to mention: There aren’t really malpractice issues in the military. Although patients do have recourse and may file claims in the event they think something is wrong, in the military, the physician is somewhat protected. The physician doesn’t have to pay any malpractice insurance. I was previously paying between $75,000 to $80,000. That’s one of the other enhancements here and can have some bearing on where a physician practices and the money they can make. That’s a real benefit.

 

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What’s your job-search action plan?

Make a list of your priorities, expand your network, and use PracticeLink to find your dream practice.

By Tammy Hager | PracticeLink Tips | Winter 2018

 

Job search word written on wood block. Wooden ABC

Many physicians find their final year of training stimulating, challenging…and overwhelming! Developing an action plan with a well-thought-out list of your priorities can help you manage your transition from training to practice.

Step 1: List your priorities

At PracticeLink, we recommend that you begin your job search by thinking about what is important to you in this stage of your life. Some questions to ask yourself are:

  • What is most important to you?
  • What is important to your family?
  • What type of practice do you want?
  • Where do you want to live and work?

Step 2: Consult with practicing physicians

Most physicians agree that the most important things to think about during the transition from training to practice are geographic location and the key features and scope of a practice.

To help you through this phase, your action plan should include talking with colleagues who have been practicing for five or more years to learn about the realities of various practice settings.

Step 3: Hit the road

Another way to explore geographic locations and types of practices is to attend the state or national meetings of your specialty’s association or society. Many of these organizations can help link newly trained physicians to practicing physicians from all over the country.

PracticeLink Live! Physician Career Fairs (info.PracticeLink.com/CareerFair2018) are also good networking opportunities. There, physicians talk with recruiters from the local area, as well as from different states and cities, to determine if a location and organization is a good fit for them and their families.

Step 4: Use PracticeLink.com

PracticeLink helps physicians in all specialties find jobs nationwide. You can also create a free PracticeLink profile to allow recruiters who work in health care facilities across the country know when you are actively looking for a job. (You also have full control over your profile to protect your privacy.)

Step 5: Remember this advice

It can be overwhelming for residents in their final year of training to think of suddenly becoming a practicing physician. To help you manage through this discomfort, remember a few key last pieces of advice.

Narrow where and how you want to practice. Though it may seem frightening to choose a specific location and practice, remember that your first job is not likely to be your last job.

Make a list of priorities, and make your career decisions based on those priorities.

Seek to understand different practice settings. For example, try to gauge how decisions are made in the practices in which you’re interviewing, and who is involved in those decisions.

Remember that compensation isn’t everything. Money may not be the major decision maker if quality of life is higher on your list of priorities.

Your first practice may not have everything that is on your priority list, but creating that list is still worth doing. Use your list, ask colleagues, network and attend conferences to do the research and find your dream practice.

 

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Does work-life balance exist for physicians?

Striving for balance is a thing of the past. Think “integrated” instead.

By Marcia Layton Turner | Feature Articles | Winter 2018

 

work life balance word cloud

Yes, work-life balance is possible in medicine. That’s the good news. You can have a personal life and a fulfilling career simultaneously. But unlike in previous generations, when you were either working or not working, work and personal lives are now commingled. That’s not necessarily bad news, but effective time management becomes the key to feeling like you have time to yourself.

Work-life balance looks different today than even a few decades ago, says Peter Angood, M.D., CEO of the American Association for Physician Leadership. Where prior generations were able to switch back and forth between their many roles—physician, spouse or partner, parent, child, friend, volunteer, caregiver—today’s physicians have to juggle multiple roles.

Years ago, physicians were much better able to control the amount of work they did. It was possible to move between working and not working, explains Angood. During the times you weren’t working, you would spend time with family and friends at home, or enjoy time engaged in your hobbies and outside interests. And at work, there was no outside interference from your personal life.

Today, it’s nearly impossible to separate your life into two clearly distinct states of being. “Doctors are more accessible, causing a disproportionate amount of time to be spent on work,” says Kyle Etter, vice president/partner at Consilium Staffing in Irving, Texas.

Consequently, an “integrated lifestyle” is more the possibility than being able to separate work from personal life, according to Angood.

Instead of balance, we need to strive for a better blend.

Making time for life

Cedric "Jamie" Rutland, M.D.

Even with a formidable work schedule, Cedric “Jamie” Rutland, M.D., feels he has a balanced life. “It’s OK if you don’t have balance at the beginning
of your career,” he says. “You work your way up the mountain. You can’t expect to start at the peak.”

Cedric “Jamie” Rutland, M.D., a pulmonary and critical care physician with Pacific Pulmonary Medical Group in Riverside, Calif., estimates that he works more than 100 hours a week, including spending one to two nights a week at the hospital. “Work-life balance? I feel like I have it,” he says. Work-life balance, he explains, doesn’t necessarily mean that you’re spending equal time on both.

Rutland, who has a wife and two children, may arrive home tired from a long stretch at work, but says, “Being tired is not an excuse for not doing anything” with his children, who are often excited to see him. So he pushes through, gives his family time and attention when he’s home, and sleeps when he can.

It’s a challenge to be both physician and family man, but Rutland feels a personal responsibility to be there when his patients need him. “You take an oath to care for patients,” he says, and people get sick 24 hours a day. “If someone gets sick at 5 and my shift is over at 7, I stay,” he says. “You have to take care of them.”

Setting boundaries

Jill Garripoli, D.O., owner and physician at Healthy Kids Pediatrics in Nutley, New Jersey, says that, “Good people go into medicine to help people.” Perhaps for that reason, it’s so easy to let work consume all your waking hours. Early in her career, Garripoli believed she needed to be at work all the time. Her thinking has shifted in recent years, especially after hearing about a doctor who got an ulcer after working 12-hour days, six days a week. That was a wake-up call.

Her typical day involves seeing patients in the morning, taking a lunch break during which she will often run, and then seeing patients in the afternoon and sometimes into the evening. She works five days a week plus alternating Saturdays with her P.A. She’ll be at work 8:30 a.m. to 5 p.m. most days, but only 2 to 5 p.m. on Wednesdays, so she can have a break from patient care in the morning.

Garripoli defines work-life balance as having enough time to be a good physician and still have enough time to be with her family. And she’s made some changes recently to ensure there is a balance of activities outside of work, starting with “giving myself the freedom to say, ‘I don’t have to be there 24 hours a day.’”

She also surrounded herself with people who help her have a life outside of work. “I found a partner who helps keep me balanced, who forces me to see there is life outside work,” she says. She also found a skilled P.A. to share some of the weight of call.

Finally, she asked herself, “What makes me happy?,” which, she believes, “is a simple thing to do yet no one thinks about it.” Having a demanding and stressful career requires an equally relaxing and rejuvenating time away from work in order to achieve balance. So Garripoli tries to set up things she can look forward to and that make her happy outside of work. This could be a weekend getaway or a monthly massage, she offers as examples. They help motivate her during grueling times at work.

Jill Garripoli, D.O.

Another physician’s health scare was a wake-up call for Jill Garripoli, D.O., to introduce more balance to her work life.

Shifting focus

Balance means something different to each individual, and it can evolve over time.

For Khadeja Haye, M.D., national medical director for OB/GYN Hospitalists for TeamHealth in Atlanta, “Work-life balance is the flexibility to enjoy life outside of medicine. To be there for your family, to be there for personal events, to pursue interests outside of work…while still having the opportunity to take good care of your patients.” Haye’s outside interests include yoga, cello (which she recently picked up again after having played in high school) and golf (which she played in college).

Early on in her career, Haye says that her work-life balance “tipped more toward work.” Her focus was on her career and on building a foundation. “It was a conscious choice to work more on my career early on,” she says. “I felt fulfilled,” she says, and was very comfortable with the decision she made. When she wasn’t working, she traveled and spent time with her friends.

But now as a wife and mother, Haye has shifted that balance to allow for more time on the personal side of the equation. She made the choice to transition from a role in private practice to a hospitalist with a leadership role. That change also gave her the time to pursue an MBA degree. Now Haye works three to four 24-hour shifts a month, travels about one night a week, and then works as many as 40 to 60 hours a week from home on administrative responsibilities. “Now I have to be more creative in my scheduling, to maximize the time when I’m not working in order to achieve balance,” she says.

Finding the right fit

What does balance look like for you? What do you want your schedule to look like? What do you want time for? Do you need blocks of time to compete in downhill ski competitions during the winter, or evenings off so you can tuck your kids into bed? When you’re clear about that, it becomes easier to find a position that can offer the mix you seek.

“The key is early conversations,” says Etter. During the initial interviews, “Be upfront about your motivations. Emphasize work-life balance. Set expectations and be honest,” he advises.

For many physicians, finding the right employment fit is vital to obtaining work-life balance. One way to determine if a position offers enough balance is to ask questions during the interview process to understand the culture, says Eric Dickerson, managing director and senior practice leader, academic medicine, with Kaye/Bassman International in Plano, Texas. Some of the best questions that get at balance and workload expectations are:

  • What is a typical day like here?
  • What’s the number-one challenge you’re trying to solve by hiring someone in this position?
  • What would you want the person selected for this position to accomplish in the next two to three months? In the next year?
  • Is this a new role or a replacement role? Why did the previous person leave? Or why is the role now needed?

The responses to these questions can help you assess whether you’re willing to invest the kind of time and energy that will be necessary to be successful in that role.

“Organizations realize they have to be honest to prevent physicians from leaving quickly,” says Dickerson. While only 5 to 7 percent make a career move because the job they were promised is different from what they were given, Dickerson says, the cost to recruit a replacement is significant. And employers want to avoid setting anyone up to be disappointed.

Dickerson recommends looking for signs of the organization’s culture, such as:

  • Are people smiling?
  • Do they greet one another?
  • Is the interviewer greeting others? Does he or she know everyone?

“A culture of friendliness is aligned with balance,” observes Dickerson, so look for indicators that employees are happy and like each other if balance is important to you.

Haye recommends asking pointed questions about the amount of personal time that will be available to meet your needs. For example:

  • “I try to travel to see my parents who live overseas once a quarter. What is the amount of vacation time allocated for this position?”
  • “I’m in the middle of pursuing an MBA. How flexible are the work hours?”
  • “I’m also a caregiver for my grandmother. Would I have the ability to work from home part of the week?”

Ideally, the response you hear acknowledges your needs and explains how the hospital or practice can make the situation work. And if you don’t hear that, that may be a clue that perhaps a fit does not exist.

It’s especially helpful, says Dickerson, if you have the opportunity to speak with someone already on staff who is in a similar life stage, since each stage has different needs, and a different definition of balance.

The generational shift underway

When Garripoli was interviewing for her first job 11 or 12 years ago, her potential boss asked about her vacation expectations. “Oh, we can talk about that later,” Garripoli replied, fearing that talking about time off would make her sound like she wasn’t willing to work hard. That fear seems to be completely gone with the latest crop of physicians, she observes. “Newer doctors are very forthcoming about what they want,” she says, and what they want is work-life balance.

Rutland, on the other hand, thinks that discussions about vacation, flex time, and time off shouldn’t occur right off the bat. When he interviews a newer physician for an opening and is asked, “How much time do I have to spend at work?” he knows they’re not a fit for his particular practice. He recommends staying away from that question altogether.

“Medical schools don’t teach about business,” says Rutland, leading some new physicians to have high salary expectations despite only wanting to work a few hours a week.

That is not true of all newer physicians, of course. Many others, facing huge student loan debt, are more likely to do extra work to supplement their income, says Etter, even working during downtime to make some financial headway.

Understanding your power

Though not all positions can be shaped to fit a physician’s personal needs when it comes to work-life balance, many can be. And because of the huge shortage of physicians, it may be possible for organizations to meet specific schedule requests. It depends on the severity of the need and the individual demands being made, Etter explains. For example, if a candidate wants to work three days a week and a client wants them to work five days, there may be room for compromise.

Angood explains that the demand for work-life balance reflects a business cycle. Earlier generations had more patient time, less paperwork, and clear delineation between work and personal life. Then, physicians became overworked, saddled with administrative tasks, hit with huge insurance premiums, and accessible to patients at any hour. The industry, and newer physicians, are now reacting to compensate for all this extra work, says Angood. “The workforce is caught in the middle.”

“The driver needs to be a focus on quality and efficiency of system performance” in order to be able to provide any type of work-life balance, says Angood.

Balance through the years

While establishing a reputation through hard work early on in one’s career seems to be a common experience among many newer physicians, that doesn’t mean that work will remain the focus forever. Says Rutland, “It’s OK if you don’t have balance at the beginning of your career. You work your way up the mountain. You can’t expect to start at the peak.” That climb also allows you to gain experience you might never have had otherwise.

Now that Rutland is several years into his career, he acknowledges that his goals are shifting. “My goal isn’t to work 137 hours a week for the rest of my life.” To that end, he and his wife set five goals for the next 18 months that they work toward together. It helps them remember why he is investing so much time right now at work. At the end of 18 months, the duo sits down again to review their progress and to set new ones.

While Garripoli focused heavily on work early in her career, once she was established, she made conscious changes because she recognized she “was losing sight of [her] personal life.” Today she is taking steps to delegate more of her workload to her skilled team members.

Haye, too, chose to rebalance her life away from work and more toward a personal life, changing jobs in order to achieve a balance that better met her needs and career goals.

Toward a more integrated lifestyle

We’re in a transition phase from the on/off cycle of work to a more integrated lifestyle, says Angood.

Haye is witnessing this evolution. “I’m not sure if it’s good or bad,” she says. Thanks to technology that connects physicians to work and home 24/7, you can take care of personal tasks while at work. That’s in the plus column. “But it’s bad when you get emails while on vacation,” she points out.

Haye believes it’s up to the individual to manage the amount of access their work life has to their personal. “It’s up to the individual to set boundaries and make it less intrusive.”

 

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Nitasa Sahu, M.D.

Snapshot | Winter 2018

 

Nitasa Sahu, M.D.

Nitasa Sahu, M.D., read PracticeLink Magazine as a resident—and found her job at Penn State Health’s Hershey Medical Center on PracticeLink.com!

Title: Hospitalist/assistant professor

Employer: Penn State Health’s Hershey Medical Center

City/State: Hershey, Pennsylvania

Residency: St. Joseph’s Regional Medical Center (2016)

Sahu enjoys running, tennis, swimming, basketball, volunteering, reading and traveling.

What surprised you about your first post-residency job search? How long it took to get licensed/credentialed!

What’s your advice for residents who are beginning their job search? Start early, and don’t be pressured into accepting an offer right away. Look over the contract, talk to experienced physicians, and negotiate before taking the job.

What were the most important factors in your job search? I was most interested in the type of facility, maximum census and the opportunities for growth.

How did you find your job? I started receiving PracticeLink Magazine as a third-year resident to explore my options, and applied to my job on PracticeLink.com. PracticeLink was easy to navigate, shows when the jobs were posted, and I received many offers. I am very happy with my decision and grateful that PracticeLink exists—and I can help my colleagues who are graduating in the near future learn about it as well!

Any other advice? It’s not the end of the world if you don’t find your dream practice right away—it may take time. Good luck!

 

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