Benjamin Goldstein, M.D.

Snapshot | Winter 2020

 

Benjamin Goldstein, M.D., found his job through the PracticeLink Job Messenger email! – Photo by Maryn Graves

Work: Internal medicine physician specializing in geriatric and hospice and palliative medicine at Western Maryland Health System

Residency: Interfaith Medical Center (2017)

Fellowship: New York Presbyterian Brooklyn Methodist Hospital (2018) in geriatric medicine; Jamaica Hospital Medical Center (2019) in hospice and palliative medicine

In practice since: 2019

Goldstein has completed four marathons and enjoys playing guitar, traveling, watching and playing sports.

What surprised you about your first post-residency job search? The large amount of opportunities and need for physicians across most of the country.

What’s your advice for residents who are beginning their job search? Spread your net far and wide to try to find the most suitable job for you. I found the best opportunity by being open to different options in a multitude of locations.

What was the most important factor in your search for a new job? Although there are several that I find to be crucial for a good fit, I believe one of the more important factors is to find people to work with who are collegial and want you to succeed.

How did you find your job? I received a Job Messenger email from PracticeLink with a position and location that were ideal for me.

I went about my search being very open-minded and willing to ask questions and learn further about opportunities that I was considering.

How did PracticeLink help you in your job search? I received daily Job Messenger emails, and I utilized the PracticeLink Job Bank to search for jobs. As PracticeLink has large groups of people advertising many jobs, it became a central and organized location for me to find what practice opportunities were available across the country.

Any other advice? I think it is important to find a job with room for growth. Also, with the epidemic of physician burnout, I believe it is important to find a job where you can maintain a work/life balance so that you will feel most happy and fulfilled and be most successful.

 

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Live & Practice: Family-Friendly Cities Winter 2020 Issue

By Liz Funk | Live & Practice | Winter 2020

 

Laine Young-Walker, M.D., is anchored in Columbia, Missouri – where she completed undergrad, medical school, residency and now practices. – Photo by Scott Myers

Choosing where to practice has many factors for physicians. What are the employment opportunities like? Will your spouse be able to find a job in his or her chosen field? Is the area a match for your interests outside of work? And, for many physicians: Is the area family-friendly?

In Danville, Pennsylvania, children can grow up playing in lush, green forests. The small town of Columbia, Missouri, offers scores of entertainment options (and a highly educated populace), because the city is also home to the University of Missouri. Gainesville, Florida, residents often raise their kids to be “Gators,” and the local passion for the University of Florida sports teams creates a strong sense of community. And Naperville, Illinois, is so charming that one physician who was born and raised there moved back after deciding “Naperthrill” trumped the tropical island of Antigua, where he was studying.

Columbia, Missouri

Columbia, Missouri, is nestled in the center of Missouri, and is a hub for sports, education and medicine. The University of Missouri Health System, commonly referred to as MU Health, is an academic health system that treats patients from around the state and is a supportive employer for physicians who want to break new ground in their fields.

Laine Young-Walker, M.D., knew she wanted to be a physician since she was 8 years old. But she still faced uncertainty: how, exactly, would she make this happen? “I come from inner-city Kansas City in a household where no one had gone to college. I knew what I wanted to do, but I didn’t have a roadmap. I didn’t have people in my life who were doctors,” says Young-Walker.

Nevertheless, things came together. “I was put in Catholic school from the beginning. I had counselors who really helped me understand what to do and get to the next level,” says Young-Walker. As a high school student, she spent time shadowing in an OB/GYN office and had very early ideas about specializing.

At the University of Missouri, Young-Walker found a second home. As she worked on her undergraduate degree, she entered a pipeline that would prepare her for medical school admissions. “The University of Missouri had a summer program for pre-meds. You have a research mentor; you do some research and you have MCAT prep. You get to know the school better,” says Young-Walker. “I was a counselor second year. I had relationships and contacts and experiences with the medical school that were positive. MU was the only medical school I applied to. Thank God I got in.”

Young-Walker built her entire medical career at MU. From med school and residency to her work as a child psychiatrist, she is deeply loyal to MU. MU Health Care operates five hospitals, including the Missouri Orthopedic Institute, the Missouri Psychiatric Center, and the Women’s and Children’s Hospital. University Hospital is the flagship hospital. Across the five hospitals, they have 602 beds. In addition, MU Health operates 50 outpatient clinics. MU Health Care employs 7,000 people, approximately 700 of whom are physicians.

It’s clear why Young-Walker planted roots in Columbia—there are scores of reasons to stay. Says Megan McConachie of the Columbia Convention and Visitors Bureau, “We have so many amenities and things to do that you’d expect to find in a much larger city. The University of Missouri creates a great opportunity for us to enjoy a pretty cosmopolitan small city, but still with that low cost of living. It has the best of all worlds.” Columbia’s downtown area is an attraction in and of itself with bars and restaurants that satisfy an area with lots of foodies.

The population of Columbia is more than 120,000. Something unique about Columbia is the number of journalists who live there, because of the University of Missouri’s elite journalism school. “It’s a media rich environment, and it’s definitely one of the hallmarks of the city,” says McConachie.

“We’re a city with all four seasons. We have a very distinct spring, summer, fall, winter. Our summers are warm and pretty humid. Our winters are generally not too harsh. We get a few snows but nothing too crazy.” McConachie says that occasionally the area experiences bitterly cold winters, but those are the exception to the rule.

“Another great thing about Columbia is that it is right in the center of the state. If you need to, you can get to Kansas City or to St. Louis in about two hours,” says McConachie.

But Young-Walker has anchored in Columbia, where she has had the support of the University of Missouri Health System to build two programs to reach and treat children who need psychological treatment but are unlikely to receive it.

Says Young-Walker, “I was able to create a program unique to this area where a child psychiatrist will go to a school with a nurse and do an evaluation, and then have three follow-up visits. While the child is waiting in between visits, she’s being treated and managed. She’s more stable, as opposed to going untreated and then being taken to the hospital or going to the ER when there’s an emergency. I’ve been able to focus on prevention and early intervention.”

The second program that Young-Walker created elevates the knowledge that pediatricians and family medicine practitioners have about child psychology.

“The Missouri Child Psychology Access Project focuses on creating relationships between child psychologists and family care doctors,” Young-Walker says. “Our program provides doctors with immediate telephone support and linkage and referral resources to get kids into cognitive behavioral therapy. We help doctors refer their patients to a provider who can provide services.”

Young-Walker has also created an online educational tool to educate family medicine practitioners on child psychology. Next year, the program will go state-wide.

This is especially interesting because Young-Walker had always pictured herself in a clinical setting and saw patients for years before training her focus on public health. She has advice for students and physicians in the early stages of their careers: “It’s important to accept the fact that your vision may not be the end vision. If all of us are in this for the right reasons, allow things to happen that you’re not used to, in a way that will change things and help others. I spent a lot of time resisting the opportunities for change in my career.”

Now, Young-Walker is in a place where she finds her work deeply impactful and motivating, even if it is not what she originally had in mind.

Danville, Pennsylvania

Physicians who yearn for a rural lifestyle or giving their children an upbringing in the great outdoors have the unique opportunity to live in a remote area and still build a career with cutting-edge health systems.

Michelle Cornacchia, M.D., had early ideas about her career. “I wanted to be a teacher for a long time,” she says. At the College of New Jersey, she started to pivot: “I thought it would be really cool if I could have a career where I help people feel better.” She started looking into careers in health care, and she volunteered at local hospitals and clinics. She was accepted at the Robert Wood Johnson Medical School (now part of Rutgers University, New Jersey’s flagship public university).

She was initially thinking pediatrics, but she was also intrigued by internal medicine. “So ultimately, I did a combined internal medicine and pediatrics program,” she says. Cornacchia carved out a unique specialty: she works with adults with complex medical needs that originate in childhood, such as autism, muscular dystrophy and other disabilities.

Cornacchia knew that there weren’t a lot of clinics for adults with developmental disabilities. Thus, she was excited to join Geisinger’s comprehensive care clinic in Danville.

“Living in a rural area, it’s more laid back,” says Michelle Cornacchia, M.D. “it’s OK to breathe.” – Photo by Stephanie Fletcher

Geisinger Medical Center is a 500-bed Level I trauma center and teaching hospital with over 50 residency and fellowship programs. The clinic is a patient-centered medical home for individuals with intellectual and development disabilities. The clinic has a multidisciplinary team with a care manager who triages, a health assistant who coordinates, pharmacists, and of course, several internal medicine physicians and specialists.

“We’re able to look at the big picture for our patients. If they need multiple specialists and medication from different specialists, our pharmacist makes sure there are no adverse effects from the interaction. It’s a primary care place, but it’s a place that patients can get the comprehensive care that they need.”

Cornacchia has high praise for Geisinger as both an employer and as a steward of health care. Cornacchia recalls that when she was a resident elsewhere, she saw patients in 20-minute slots. At Geisinger, she has an hour with each patient. “There is a lot of good by allowing us that extended time. Our patient population is so thankful. I’ll have mothers who bring their children in for a first appointment, and they start frantically going through their children’s medical history in a very short time,” says Cornacchia. This is because patients often expect their time with physicians to be limited.

“Geisinger has moved away from fee-for-service to value-based care,” says Matthew McKinney, director of talent management for Geisinger. “The experience our patients receive, as well as the health and well-being of the communities we serve, come first. Providers’ performance is not strictly related to seeing X number of patients or performing X number of procedures. That has really resonated with the providers we recruit,” says McKinney.

Geisinger attracts physicians with its cutting-edge technology. The health system has had electronic health records since 1996; Geisinger was one of Epic’s first clients. “We were one of the first health care organizations in the country to begin using electronic health records. We have more than 20 years of patient data that has allowed us to deploy a lot of evidence-based best practices,” says McKinney. In fact, “we have two research centers—one clinical and one outcomes research. We have the largest biobank in the world; we do human DNA sequencing and are able to notify patients if they may have a genetic predisposition. That’s something we offer all Geisinger patients through primary care, specialty care and even online.”

“You wouldn’t think in Danville that there would be amazing access to technology, research, data and educational opportunities for our employees and providers,” says McKinney.

About 20 minutes from Danville is Lewisburg, another area health care hub and home to Evangelical Community Hospital—a fiscally strong community hospital that has retained its independence and is growing.

“Evangelical is currently undertaking the largest construction project in its history,” says Elyse Stefanowicz, provider recruiter and retention coordinator for Evangelical. That project includes the construction of a four-story, nearly 112,000-square-foot addition slated to be finished in August 2020. It will create modern, single-occupancy rooms and private bathrooms.

Also on Evangelical’s list is adopting the Epic electronic medical record platform, a transition that will be complete in summer 2021 and result in a single, fully integrated information technology system.

Evangelical is currently recruiting in anesthesia, cardiology (both invasive and non-invasive), critical care medicine, family medicine, gastroenterology, general neurology and obstetrics and gynecology.

“It is a perfect place to raise a family and practice medicine,” says Stefanowicz of Lewisburg and the Greater Susquehanna Valley. “The small community feel of Lewisburg includes great shopping, fantastic dining, and the renowned Bucknell University, which provides arts and entertainment to the community.”

Cornacchia says the patient population is overall easygoing and grateful. “Quality of life is really fantastic, and the patient population is nice. Living in a rural area, it’s more laid back. It’s OK to breathe. It’s okay to take the time to enjoy the simple things, to take a walk, to spend time outside.”

McKinney echoes the sentiment that there is a high quality of life, especially for families with kids. He says, “It’s small-town living. The people in the community are very friendly and engaging. There are great school systems. When you factor in how wonderful the people are and the educational opportunities that exist for our providers’ children of all ages, it’s really a great place to live.”

Naperville, Illinois

Naperville is a suburb of Chicago, 30 minutes west of the city. While there are scores of health systems and hospitals with facilities in Chicago, physicians who practice in Naperville have the advantage of potentially accelerating their careers by practicing in a smaller market. Not to mention, Naperville is an ideal place to raise a family, where community is king, but big city culture is an hour’s drive away.

Amish Doshi, M.D., is another physician who knew in childhood, growing up in Naperville, that he wanted to be a doctor. “A second-grade school assignment asked us to complete the following sentence: ‘When I grow up, I will be a…’ and I wrote ‘a doctor!’ Even as a 7-year-old, I knew I wanted to be a part of health care. My passion was solidified through my undergraduate studies, work and volunteer experiences.”

Doshi graduated from the University of Michigan before setting off to medical school in Antigua. Says Doshi, “Although a vacation destination for many, my regular date night with the books meant days at the beach were few and far between. After completing my rotations in various health care systems across the states, I completed two years of research with the University of Michigan in diabetes, before undergoing my training in internal medicine at St. Joseph Mercy Oakland Hospital in Michigan.”

After residency, Doshi left Michigan to return to his hometown of Naperville, Illinois, to join Edward-Elmhurst Health.

Edward-Elmhurst Health includes three hospitals—Edward Hospital, Elmhurst Hospital and Linden Oaks Behavioral Health (a mental health hospital)—and an extensive ambulatory care network for residents of the west and southwest suburbs of Chicago. Edward Hospital has 354 beds, and Edward-Elmhurst Health has approximately 60 outpatient locations in the Chicago suburbs.

Says Keith Hartenberger, system director of public relations for Edward-Elmhurst Health, “The system has annual revenues of more than $1.3 billion; more than 60 locations across a service area of 1.7 million residents; nearly 8,500 employees, including 1,900 nurses with 2,000 physicians on staff; plus 1,300 volunteers.”

Doshi says that Edward-Elmhurst Health is well-regarded by the community, and it contributes to Naperville’s strong sense of community. He says, “Edward Medical Group has a warm community feel that helps patients and family members feel assured during their times of need. I believe it is Edward’s deep involvement with the community that has created this trust and achieved an intimate role in the well-being of the members of the local and neighboring communities.”

Hartenberger says that physicians at Edward Hospital appreciate being part of a physician-led organization and the positive culture, with a “focus on physician well-being and leadership.”

Then, there is the excitement outside of work. Says Doshi, “I grew up in Naperville, which is better known as ‘Naperthrill’ to some. I wanted to give my family the same great experience I had. Naperville has an unrivaled combination of education, entertainment and outdoor recreation. …To add to the excitement, Naperville also has several fairs and festivals throughout the year. Last year, I was even lucky enough to see Pitbull and to meet [Aerosmith lead singer] Steven Tyler!”

Doshi and his wife, Christine Elyse, have a baby son named Shyam. Doshi says, “We enjoy the simple things like taking a walk around the miles of local forest preserves and nature centers. We are excited to bring him to the local swimming pool in the summer. We also frequent the various restaurants in the area. Being that it is so very family-friendly and kid-friendly, Shyam is beginning to love his regular stroller stroll through the thriving streets of downtown Naperville.”

Gainesville, Florida

Gainesville is all about the Gators. This is not to say that alligators are an omnipresent threat—rather, the community is wildly supportive of the University of Florida Gators. The University of Florida is Gainesville’s largest employer. UF Health, the university’s health system and teaching hospital, is the area’s second-largest, with approximately 12,000 employees. There’s a unique trend among medical students and medical residents: once they come to Gainesville and become part of UF Health, they tend to stay. This speaks volumes to UF Health as a quality employer, and Gainesville as a place to build a life and raise a family.

When Julia Close, M.D., was a child in elementary school, she was fascinated to learn how the heart pumps blood around the body. She knew then that she wanted to be a physician. She says, “Later I remained interested as I came to realize that doctors can provide comfort and cure, all while being on the cutting-edge of science.”

“I attended medical school at the University of Florida in Gainesville, and I never left!” Close says. She was drawn to oncology for many reasons. She wanted to care for patients along a continuum, and she was interested in learning about the growing number of effective and less toxic therapies for cancer patients.

“What made me most want to be an oncologist was when I attended my mother’s first appointment with her oncologist while I was a second-year medical student. Her doctor sat with her and explained chemotherapy with patience, knowledge and grace. It was such a relief to my family. I hope I provide the same to my patients and their families,” says Close. Thankfully, Close’s mother is now a 20-year survivor of breast cancer and still sees the same oncologist—a testament to the longevity of the relationships that oncologists can build with their patients.

Close completed her residency in internal medicine and her fellowship in hematology/oncology all at the University of Florida. Close says that UF Health is an especially supportive place to train and practice. “There is a reason why so many of us attended medical school here and never left. As a trainee, I noticed attending physicians were approachable and units worked as a team. UF Health has great nurses, pharmacists, therapists, techs. They have great, knowledgeable staff whose opinions and input are valuable. This allows us to take great care of patients,” says Close.

UF Health Shands Hospital is a teaching hospital, and the anchor of the University of Florida Health System (commonly referred to as UF Health). The hospital is a Level I trauma center licensed for 961 beds and 241 ICU beds. UF Health Shands Hospital is also home to the University of Florida Health Science Center: the umbrella organization for the University of Florida’s medical, dental, nursing, pharmacy and public health schools.

Says Elizabeth Reyes, the marketing coordinator for Visit Gainesville, “The Gainesville region is very family-friendly, with numerous parks, splash pads, public pools, museums, a children’s theater, trails, farmer’s markets, and free activities such as the downtown Free Fridays Concert Series that runs from May to October. There are also many educational programs and activities for every type of interest.” She says that Gainesville is a college town that “hits way above its weight. Meaning, you can still find southern hospitality here and an easy lifestyle, but also with all the modern conveniences that you might expect from larger cities.”

Close agrees Gainesville has a little bit of everything. Says Close, “There is so much I like about Gainesville. What could be better than living in a college town, in a state without snow, but in a region with seasons? My family likes being outside year-round. We play a lot of sports, and while I’m not very fast, I enjoy running our trails. We have great restaurants and access to arts, but I can live on enough land to have ducks, chickens and a stocked pond.”

Then, of course, there is University of Florida sports. “The University of Florida football, basketball and other sports events create great opportunities for entertainment and community activities,” says Reyes.

Close agrees, “My kids were born at UF and are Gators through and through. Taking them to all sorts of sports on campus and feeling the camaraderie is something I hope they look back on as an important part of growing up.”

 

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Finding the right practice fit—the first time

Right out of training, the money can seem the most important. But taking a more holistic view of your job search can land you at a place you’ll be happy to stay.

By Karen Edwards | Feature Articles | Winter 2020

 

Spend some time ideating your ideal job. “If you know the answers,” says Penelope Hsu, M.D.,“it will inform the kinds of questions you ask at the interview.” – Photo by TL Wedding

Penelope Hsu, M.D., walked into the job with high hopes. “I didn’t notice how toxic the workplace was at the interview,” she says. “I was nervous, I was worried about getting the job, and I wasn’t paying attention.” In hindsight, she says the clues were there. “I was on a unit and heard the phone ring. It kept ringing—no one answered it.”

A short time in, Hsu realized that she wasn’t in the kind of workplace culture she wanted. She had just come from working in the ER for six years, where she’d experienced a completely different culture: “There, everybody was focused on the same goal. We were motivated, we collaborated, we pulled for each other.” Her new job, however, soon showed a workplace that was inefficient and non-communicative. “No one talked with anyone,” she says. Three or four months into the job, Hsu realized the position she had taken was not going to work out. Six to seven months in, she was looking for a new opportunity.

Stacy Smith-Foley, M.D., loved her first job. She was in a radiology group that practiced at the top of its game, and its philosophy of putting patients first was morally and ethically aligned with her values. She stayed 10 years and only left when the practice was destroyed by a fire.

Finding a first job where you’ll be happy to stay a while isn’t easy. A recent survey by an Atlanta-based recruiting company found that half of the 500 physicians the company surveyed left their first job after five years. More than half of those stayed on the job only one or two years.

Jonathan Pagan, M.D., left his first job after a year. “It was a tough decision,” he says. “But if you’ve made the wrong decision the first time, admit it. The longer you stay, the harder it will be to leave.”

Not to mention that, the longer you stay in a culture that doesn’t fit your goals or values, the greater your chances are for burnout and medical errors. A 2018 study by the New York University School of Medicine and another 2018 study by the Stanford University School of Medicine suggest that workplace culture can play a more important role in reducing physician burnout and medical errors than improving safety protocols or using checklists.

“Workplace culture is huge when considering a job,” says Gretchen Nolte, team lead for physician and advanced provider recruitment for Indiana University Health. “But each person’s right fit is going to be different. You have to follow your instincts.”

So how do you determine what the right workplace culture is for you?

Consider these five steps.

1 Determine what you want in a workplace

You won’t be able to recognize the right practice fit until you first determine what you want in a workplace.

“As new physicians, we are told where to be,” says Pagan. “Fit doesn’t play into it. We’re at the whim of match algorithms. We’re programmed to take what we get.”

“As a new attending looking for a job, we think we are lucky enough to be given a job,” says Hsu. “But the best part about being an attending is that you finally become in control of your destiny, to a degree. That provides the freedom to ask yourself what is it that I want, does this job fit me, is this job good enough for me rather than the other way around.”

Hsu suggests before starting a job search, decide what your values are, what’s important to you, and what your ideal job would look like. What kind of environment do you want to work in? “If you know the answers,” Hsu says, “it will inform the kinds of questions you ask at the interview.”

“Ask yourself what your typical day should look like,” says Smith-Foley. “What would your worst day look like? Know what you value before you look for a job.”

Physicians seeking their first jobs often prioritize the wrong things, like salary or location, says Pagan. “Of course, salary is a pre-requisite. You need to know you’ll make enough money to take care of yourself and your family. And location can be important. But if you want to be happy on the job, you need to prioritize what a comfortable environment would be for you.”

For Pagan, it was important to work in a place where he felt he could make a contribution and a difference in people’s lives. He wanted to work where other people shared those values.

Yes, money is important. “But if you want to be happy on the job, you need to prioritize what a comfortable environment would be for you,” says Jonathan Pagan, M.D. – Photo by Jon Yoder

Don’t forget to also discuss your goals, values and priorities with your family. Consider their input. “My wife has had to sacrifice a lot along the way, so I prioritize her views more than my own,” says Pagan.

“I had a lot of conversations with my spouse before making our move,” says Smith-Foley. “We made a pros and cons list and finally decided that the opportunity I was given was one that we couldn’t say no to.”

Michelle Roland, M.D., has moved around a lot in her career, including jobs in Tanzania and Botswana before returning to her home state of California. With each move, Roland says she first received “100% input from my family.”

2 Research the workplace before you make your site visit

“The first thing you can do, if you’re interested in a job, is to research the company’s website,” says Nolte. “Go to the ‘About Us’ section and look for the kind of buzz words that reflect what you’re looking for.” If teamwork, compassion, patient-centric care and leadership are among the values you’re looking for, see if they are listed in this section.

“If you can speak to someone with firsthand knowledge of the employer, that’s even better,” says Nolte.

“If you have a network, use it,” says Hsu. She had learned some red flags about the poor fit from an old co-worker, but by then the information came too late to help. “My suggestion is to reach out to your network while you are still researching,” Hsu advises.

Roland did her primary research online, “but I spoke with my colleagues for a reality check. I wanted to know what the place was really like and if they thought I would be happy with the work.”

Brendan Kolber, national sales director with MGMA, says you can often find those with firsthand knowledge of a facility by networking at the local medical association. “Members will give you the inside scoop and let you know about the pros and cons of the place. What you don’t want to get hung up on is reading patient reviews on a website,” he says.

Pagan read local publications to learn more about the organization with which he was interviewing and was pleased to see articles about the growth and expansion of the facility. “That’s usually a pretty good indicator of the employer’s financial health as well as its leadership position in the community,” he says.

Smith-Foley also checks a facility’s financial health online to understand its business health. “Is it in the black or in the red? If it’s in the red, how has it changed, or how is it changing, to turn things around?”

3 On the site visit, notice everything

The site visit will reveal much about a workplace culture if you take the time to notice everything—like Hsu’s experience with the ringing telephone that went unanswered.

“Look around you,” says Nolte. “How happy do the employees look? Do they look like they want to be there?” And when you meet team members, Nolte adds, pay attention to their demeanor. Are they professional, respectful, open?

“Spend as much time at the workplace as you can,” says Pagan. “Two days is best, because you will learn more on your second day there. You’ll have more candid conversations with the people who work there.”

“You might even ask if you can shadow one of their physicians for a day,” Hsu says. That way, you’ll see for yourself how things work and how communication is handled. “But,” she adds, “You should strive to meet as many people as you can, including other team members. Talk to them about why they work there. Are they happy? What do they like about the job? What’s the worst part?”

Smith-Foley also suggests paying attention to how things are done while on the site visit. For example, notice if handwritten records are still a feature of an organization that might become a time-consuming task likely to be an impediment to your work/life balance.

There are other red flags to watch for, says Andrew Walker, national director of business development-organizational membership with MGMA. “Make sure you receive a detailed agenda prior to an on-site visit,” he says. Is the agenda a “mixed bag” – including visits with both physicians and non-physicians? That’s a good sign. “It should be a grab bag of people, a wide array, because you’ll get a more truthful picture of the workplace.”

“If you witness a conversation that is disrespectful, or it’s unfriendly or uncomfortable in some way, ask about it,” says Nolte. “If there is not a good answer, the workplace may not be a great place to work.”

“Watch for a lack of transparency,” says Pagan. “If you can’t meet with everyone, like the CEO, or with any of the support staff, that’s a red flag. You should be able to talk with anyone, about anything. If the only questions that are being answered are business questions, then you have the right to be worried.”

“How much time did they spend with you? How engaged were they when they were with you? That will tell you a lot about a place and the people who work there,” says Walker.

Here again, says Nolte, trust your instincts. “Consider the entire process,” she says. “If you go through the process, and if something doesn’t feel right, then that position is probably not the right fit for you.”

4 Ask the right questions at the interview

Communication and transparency are key during the interview. You should receive open, honest answers to every question you ask, says Nolte.

You should be prepared to ask lots of good questions, says Kolber. Of course, you are going to ask the inevitable: How much will I be paid and for what? “You need clarity on that,” says Kolber. “Changes in the marketplace and new pay structures have placed increased pressures and stress on physicians. Attaining all the facts you can upfront will allow you to make an informed decision about your job opportunity.”

Those stresses, as already discussed, can lead to burnout, along with uneven call distribution. “You’ll want to ask about that as well,” Walker adds. But he suggests going even further with your questions. “Ask employers what steps they’ve taken to provide physician health and wellness opportunities. That’s going to show you how they value physicians at their workplace and their well-being.”

5 After the site visit, keep investigating

You should have a good idea after your research, your site visit and the interview whether the workplace is going to be the right cultural fit for you, but don’t forget to check out the area to make sure it’ll be a good fit as well.

“Does the community meet your needs and the needs of your family?” asks Nolte. Most workplaces will connect you with a local realtor who can take you on a tour of the area and show you places where you might want to live, she says.

“My wife and I went on school tours as well,” says Pagan.

“We wanted to live in a small, tight-knit community,” says Roland, but it was also important to her to connect with people who are like-minded. She found that in the small California town where she’s living now—but it took research and some searching.

Just as you did when you initially sat down to determine your values and the kind of workplace you wanted to be a part of, now is the time to sit down and assess your experience.

“Were you treated with respect while you were there?” asks Kolber. “How were you received? Did you feel welcomed, or was there a sense that something didn’t feel right? Spending time to evaluate your feelings, both good and bad, about the environment, staff and fellow physicians is an exercise I encourage.”

“How was your family treated?” Walker adds. If you still have questions or hesitations, now is the time to ask why. “Use your instincts to uncover and ask more questions.”

After his site visit, Pagan spoke with colleagues, mentors and those familiar with the practice patterns at the facility before he accepted the offer.

“Set up a vision of your ideal life for you and your family. What would it be like?” asks Hsu. After the interview and the site visit, compare your vision to the job that’s open. Is it the job—and life—you want it to be?

“Ask yourself, does it match what I want?” If it doesn’t, keep looking. “It’s easy, when you’re first starting out, to have a feeling of desperation.” But accepting a job offer out of that feeling is no way to start your career.

“If you’re not sure about the job, be honest,” says Smith-Foley. “Make a second visit. Advocate for yourself and what you want.”

But what happens if you take the job, and, like Hsu, soon realize that this is not the workplace for you?

“It’s a situational problem,” says Nolte. “If you’ve uprooted your whole life by moving there, give it some time. Talk to your direct supervisor about any issues that are troubling you—the sooner the better.”

“In some cases, you can help shape the culture of the place, in terms of communication or patient care,” Pagan says. “But give yourself a time limit to affect the change. You don’t have to stay there.”

…Unless, of course, you have slipped on a pair of what Walker calls “golden handcuffs.” “If you’ve earned a signing bonus when you took the job, you’re on the hook for that money if you leave,” he says. Just be aware of that when you enter into negotiations. “Be aware of what you can do if you want to exit a three-year contract in the first year,” says Kolber. “The new workplace might help you repay the signing bonus if they really want you.”

If you do decide to leave shortly after accepting a job offer, use it as a learning tool, says Kolber. “Ask yourself what worked, what didn’t so you know what to look for at your next workplace.”

“Stay open to opportunities, and remain flexible,” suggests Roland. “Don’t worry if your first job doesn’t last forever. In fact, that can be a really good thing.”

Furthermore, says Hsu, “It’s unrealistic to think your first job will last forever. Priorities change, especially with families. Your own values and priorities may change. If you can’t incorporate those changes into the job you have, it’s time to leave.”

“All you can do,” says Pagan, “is to make the best decision you can at the time, and work hard while you’re there. If it doesn’t work out, it’s not your fault.”

But by following the tips provided here, chances are you will find the perfect job fit for you—even on your first try.

Karen Edwards is a frequent contributor to PracticeLink Magazine.

 

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Putting lifestyle first

When physicians need a better work/life balance, some turn to creative scheduling solutions.

By Debbie Swanson | Feature Articles | Winter 2020

 

Ashish Goyal, M.D., created a flexible schedule that allows him to practice, teach and run a board review company. – Photo by Jenna Lee

The traditional expectations for a physician’s workload is one of churning out long hours without complaint, particularly those in the early years of their careers.

But today’s thinking is shifting. With the increased awareness of the dangers of stress and burnout and the importance of work/life balance, both physicians and employers are increasingly more responsive to a schedule that allows for some breathing room.

Stress and overload: not issues to ignore

Physician burnout, as defined by the Agency for Healthcare Research and Quality, is a “long-term stress reaction marked by emotional exhaustion, depersonalization and a lack of a sense of personal accomplishment.”

Burnout is a widespread problem. Medscape’s 2019 report states that 44% of physicians reported feeling burned out, 11% were colloquially depressed, and 4% were clinically depressed. It spans the specialties, and is reported slightly more by females (50%) than by males (39%), although a common belief is that males are less apt to discuss emotional problems. Even more worrisome: The report also states that 14% of respondents admit to having had thoughts of—yet have not attempted—suicide.

One of the best ways to alleviate burnout, as well as anxiety-related problems, is to maintain an adequate balance between your personal and professional life. Having enough time to spend with family, to engage in fitness and to simply unplug are important components to everyone’s physical and emotional wellbeing. Yet this is often out of reach for the physician running to uphold a 40-plus-hour work week. Sporadic vacations or personal days can help to periodically tamper mounting stress, but they aren’t long-term solutions.

So what can you do?

Today’s physicians are beginning to explore other options. In the 2018 Survey of America’s Physicians by The Physicians Foundation, nearly one-quarter of physician responders—22.3%— indicated they plan to cut back their hours in the next three years. That’s the largest number recorded since the survey began in 2012. Another 8.5% plan a switch to part-time, and 8.4% will turn to locum tenens. These are just a few of the avenues available to those eager to get a handle on their work hours.

Moving to a part-time role enabled Linda Hertzberg, M.D., to serve a greater role in professional associations. – Photo by Derek Lapsley.

Part time: not a bad career move

Working fewer than 40 hours a week may seem like a dream, but it’s becoming a regular arrangement. And according to the American College of Physicians, if you’re in need of a break, going that route may be better for your career than ceasing work completely.

“It can be difficult to return after a hiatus of as little as six months, since the break in CME credit accumulation, referral patterns and so on is hard to overcome. Working part time allows continuity with the addition of flexibility,” states ACP in a report.

Today’s climate is favorable for physicians negotiating for a reduced schedule.

“The impact of having to re-train someone is so significant, both financially and time-wise, that employers are much more interested in retaining good talent, than allowing them to go elsewhere,” says Honolulu-based physician Ashish Goyal, M.D. Goyal’s schedule accommodates his own multi-faceted career: he runs PediatricsBoardReview.com, practices clinical medicine and teaches.

Job sharing: finding your other half

If you don’t feel your current employer would accommodate a reduced schedule, consider instead asking to set up a job-share arrangement, in which two part-time physicians split the hours and responsibilities of one full-time position. This situation is potentially favorable to an employer, reports the ACP, since it avoids some of the issues raised with part-time shifts. Because a job-sharing arrangement is the same as employing one full-time provider, it creates minimal, if any, negative impact on the use of staff or office resources.

From the viewpoint of the two physicians involved, the arrangement is similar to a part-time position, with adding the need for routine communications between the two. Initially, the logistics need to spelled out: divvying up hours, shifts, holidays and call. Regular patients need to be informed of each physician’s schedule, and if any patients choose to overlap, both physicians should remain in contact to present unified, consistent care.

Locum tenens: you choose

Locum tenens work is another way to maintain some control over your work hours. With this, you temporarily fill in at different hospitals and/or practice groups for a pre-defined period of time. This may mean covering for a vacationing physician for a few weeks, taking over while someone is on leave, or providing extra help during a period of increased patient loads.

These opportunities are available through locum tenens agencies and exist everywhere, from the hospital a short drive from your home to the large medial group in a completely different state (provided you meet licensing requirements).

While many of the locum assignments are full time, it is still a means of reducing your workload over the course of a calendar year. Because you choose when you’ll work, the option exists to create respites between assignments as needed.

Telemedicine: not so futuristic

Decades ago, a physician working from home simply hung a shingle at their residence. Today, that idea may be obsolete, but the concept of working remotely isn’t. With today’s technology, more and more companies are hiring physicians who regularly consult with patients via mobile technology or video conferencing.

“Telemedicine is very much on the rise, (especially) in remote parts of the country, where patients don’t have access to specialists or even GPS,” says Goyal.

In addition to companies that specifically offer virtual encounters, many practices are accommodating such encounters as an enhancement to their routine services. This creates another way to reach a patient, meeting the needs of those with a demanding work schedule, who have mobility or transportation issues, or who are more comfortable in the privacy of their own home. It may be more suitable for certain specialties, such as psychiatry, radiology or follow-up care.

If it works for you and your employer, virtual patient encounters can result in both reduced hours at the office and less stress from commuting.

Is a reduced schedule right for you financially?

The idea of a lighter work schedule is almost always appealing, but for most people, it comes down to the numbers. Before you reduce your hours—and income—take a hard look at your minimum expenses, including:

  • Monthly living expenses: rent/mortgage, food, utilities, household support
  • Daily expenses: gas and commuting expenses, coffee/meals purchased out, sundries
  • Loans: auto, educational, personal
  • Insurance: malpractice, auto, disability, homeowners
  • Family/household support: child care, cleaning, landscape care, senior care or financial support, veterinary bills
  • Recreation: gym memberships, dining out, hobbies, sports
  • Long-term needs: retirement, home purchase, college plans, emergency fund

Identify both your “must-haves” as well as those things you could do without if need be. Adjust for how the situation might change after you reduce your hours; for example, you’d likely have a drop in commuting expenses, or less child care.

Also be aware of how your benefits may be affected by a drop from full-time status. Consider how your personal situation may add or subtract from the picture; for example, married physicians may be eligible for certain benefits through their spouse.

“Health insurance may be the biggest area affected,” Goyal adds. “(Your employer) may have a tie to full-time employees or those meeting a certain minimum number of hours per week. Other areas potentially affected include malpractice insurance, financial benefits such as 401(k) matching programs, retirement programs, pension or CME stipends.”

Another perk: room to grow

When caught up in the daily grind, you can probably think of a million things you’d do with an afternoon all to yourself. But when actually faced with extra free time on a repeat basis, you may find yourself restless or feeling idle. Before you make a schedule change, carefully think about out how you’d spend the time.

After working as a clinical anesthesiologist for 29 years and as an academic anesthesiologist prior to that, Linda B. Hertzberg, M.D., left her full-time position in private practice and switched to part time. While the change proved to be positive, she admits that at first, it was an adjustment.

“Initially, I felt like part of my identity was ripped away, especially since I felt that after all those years of practicing anesthesiology I was at the top of my game,” she recalls.

But she soon relished the time available. In addition to enjoying being able to pursue her personal interests, such as skiing, traveling, visiting friends and wine collecting, Hertzberg increased her involvement with professional organizations. She’s been a board member, officer, and (past) president of the California Society of Anesthesiologists (CSA); served as a California delegate to the American Society of Anesthesiologists (ASA) and is currently the ASA Director from California; serves on the ASA Board of Directors; and is the chair of the ASA’s Ad-Hoc Committee on Women in Anesthesia.

“This has always been work that I found professionally rewarding, so it is wonderful to have time to really focus on it,” she says.

Appealing to your employer

When you’re ready to negotiate with your employer, first switch your way of thinking. View your proposed arrangement from their perspective, and present it in a way that would highlight why it’s appealing to them. The ACP shares a few suggestions:

  • Has the practice has been trying, unsuccessfully, to hire a full-time physician? This can support your quest; advertising for part-time physicians may open up the field of applicants. “Women are the physicians most likely to want to work part-time and they represent 35% of all internists between the ages of 35 and 44, more than 40% of physicians under 35, and over 50% of medical school entrants,” the ACP reports.
  • In exchange for reducing your hours, are you willing to work some of the less-desirable shifts, or adjust your hours as needed to help when the practice has normal fluctuations in demand, or when other physicians are on vacation, or during busy times?
  • How will you participate in call rotations, and in what capacity?

The success of making such a switch also depends somewhat on your specialty.

“Anesthesiology definitely lends itself to per diem work, as may other specialties such as emergency medicine, hospitalist medicine, pathology and radiology that do not require an office-based practice, with continuity of patient care,” Hertzberg says. “The limiting factor in any specialty may be the overhead costs, and how willing your group or partners are to work out a part-time arrangement.”

Unwanted attention: dealing with coworkers

Deviating from the norm almost always invites opinions, so expect to become a topic of workplace conversations. You may face negativity, such as assumptions that you’re not fully committed to your career, that you’re not carrying equal weight. Or, you may hear belittling comments or outward jealousy.

But it may not all be negative. Co-workers who have been entertaining similar notions or feeling frustrated with their careers may applaud you for taking the initiative, and even seek you out for advice, questions, or moral support.

Regardless of the perceptions you face, remember that your business is your own, and you don’t need to explain or defend yourself to anyone aside from your supervisors. Your needs and opinions, and those of your family, are the only ones that really matter. Maintain your standards of professionalism and boundaries, stay committed to your decision, and any chaos among your coworkers will soon subside.

There’s no denying the demands of a physician’s career, and the high level of job dissatisfaction, anxiety and burnout physicians routinely experience. Working toward a more friendly, flexible schedule is one of the best ways to avoid sending your career into a downward spiral.

“It’s critical to find work/life balance so you can still enjoy your life,” says Goyal.

With a solid look at your own needs and aspirations, coupled with a careful analysis of your financial situation and your family’s needs, it’s possible for physicians today to create a more comfortable allocation of personal and professional time.

 

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Rainy day planning

What physicians need to know about liability, disability and life insurance and saving up.

By James M. Dahle, M.D. | Feature Articles | Winter 2020

 

“It is very easy as a physician to get this bulletproof mentality, but we can all get the same problems as our patients,” says Michael Lieb, D.O. – Photo by J&J Studios.

Thy fate is the common fate of all; into each life some rain must fall.” –Henry Wadsworth Longfellow

Physicians, more than most people, are well aware that bad things happen to good people. These “rainy days” may not be common, but they can be life-changing, especially if you are not prepared for them. In my work at The White Coat Investor over the years, I have run into dozens of physicians who encountered a “rainy day.” In this article, I’ll discuss four financial “rainy day” events common to physicians and how you can prepare for them while the sun is still shining.

Rainy Day 1: Being sued

Many doctors have an illogical, even unhealthy, fear of lawsuits. While the attorneys involved view a lawsuit as “just business,” it becomes personal for the doctor with the resulting lost sleep, defensive medicine and shortened career. Though a lawsuit is never pleasant, viewing it from the proper perspective is helpful. A lawsuit is a civil tort, not a criminal prosecution. It’s about money, not crime, and the vast majority of the time, it does not even involve the doctor’s money. Most of the time, the physician is essentially serving as a defense witness for an insurance company, whose money is really at stake. The doctor already spent her money when she paid the insurance premiums!

Avoiding lawsuits by practicing good medicine, communicating well with patients and their family members, and documenting well is obviously critical. An ounce of prevention is worth a pound of cure. However, once a lawsuit is initiated, insurance becomes the first line of defense. Insurance not only pays for any settlements or judgments, but it also covers the cost of defense.

The rule of thumb is to buy the same amount of malpractice insurance coverage as other doctors of your specialty and geographical area. A common benefit limit is $1 million per incident and $3 million per year. Each of the doctors interviewed for this article carried that limit, although higher limits (usually $2 million/$5 million) can be seen, particularly among high-risk specialties such as OB/GYN.

As Michael Lieb, D.O., a vascular surgeon in Hainesport, New Jersey, explained, “these are the minimum limits set by the state and I have not really heard of many people going above this.”

Be sure you understand how your policy works. If you (or your employer on your behalf) purchase a “claims-made” policy instead of an “occurrence” policy, be sure one of you purchases a “tail” policy in case you are sued after the policy ends.

Professional liability is not the only lawsuit risk you face. Personal liability coverage is also essential to purchase. Property coverage including auto, recreational vehicle, homeowner’s, and renter’s policies also include a liability component. However, the liability coverage on these policies is often much too low for the real risks you face. Increase the coverage and stack an “umbrella” (excess personal liability) policy on top of your property policies.

Lieb carries a $3 million umbrella policy because “it is quite affordable and more than my net worth currently. This level of coverage only added $500 to my annual insurance premium, as I already had the highest deductibles set on my homeowner and auto insurance. …I will likely increase this along the way.”

Despite common recommendations, the amount of needed coverage has nothing to do with your net worth, but more to do with the actual risks faced. Commonly recommended limits range from $1 million to $5 million. Luckily, personal liability insurance is dramatically cheaper than malpractice insurance, usually only a few hundred dollars a year.

Many physicians are concerned about the possibility of being successfully sued for an amount above their insurance policy limits. This is an extremely rare occurrence, but it is prudent to at least take a few basic “asset protection” steps as additional protection. These include knowing your state asset protection laws, titling property properly (married couples should use “tenants by the entirety” titling where available), maximizing the use of retirement accounts, and placing “toxic assets” such as rental property into limited liability companies. More advanced techniques such as overseas trusts, equity-stripping, irrevocable trusts, cash value insurance, and family limited partnerships may also be appropriate for some physicians in some states.

Rainy Day 2: Personal disability

By the time they finish college, medical school, and three to seven years of post-graduate training, the most valuable financial asset of a doctor is the ability to turn their specialized knowledge and skills into a revenue stream, i.e. their ability to practice medicine.

A physician’s future income is primarily protected with disability insurance. This insurance not only protects those depending on you from the loss of your income, but it also protects you! The most important thing to know about disability insurance is that you need to get something in place early in your career, when the cost is lowest, when you are healthiest, and when a permanent disability would be most devastating. The second most important thing to know is the definition of disability in your policy. You want the broadest possible definition of disability—specialty-specific, own-occupation. Consider the story of Stephanie Pearson, M.D., FACOG:

“At the height of my career as an OB/GYN in Philadelphia, I was kicked by a patient during an exceptionally difficult delivery,” she says. “I sustained a torn labrum that developed into a frozen shoulder. After surgery, I had considerable range of motion deficits and nerve damage that prevented me from performing the material and substantial duties of my job. Unknown to me at the time, my health system’s group disability insurance did not cover work-related injuries, and I was eventually terminated for being unable to satisfy my contract. Workman’s Compensation did not kick in immediately; I actually had to go to court to get the benefits that I deserved. Without the private disability insurance that I had obtained early in my career, we would have certainly had to sell our home. My children did not have to change schools or feel the brunt of my career-ending injury. While I was going through rehabilitation and trying to figure out what to do next with my career, my family did not have to worry about financial ruin.”

Private disability insurance helped Stephanie Pearson, M.D., navigate a career-ending injury without completely disrupting her family. – Photo by J&J Studios

Pearson transitioned to a career as an insurance agent and opened her own firm (Pearson Ravitz) to help physicians understand and protect against this significant risk. Her story illustrates not only the importance of having a policy, but also the differences between a group and an individual policy. While individual policies are more expensive and difficult to qualify for, they usually have a stronger definition of disability, and thus are more likely to pay out in the event there is any “gray” in your disability—and there often is. Individual policies are also portable when you change employers and generally have level pricing throughout your career.

David Antonio Mateo de Acosta Andino, M.D., is a plastic and reconstructive surgeon practicing in McAllen, Texas, married to a nurse anesthetist. They found the process of applying for disability insurance frustrating because “the insurance company really had very little grasp of what could represent a pathology down the line that could prevent either of us from practicing our professions.” He ended up with a $15,000 policy from Mass Mutual, one of the “Big Six” companies who offer own-occupation coverage to doctors. (The others are Guardian, The Standard, Ameritas, Principal, and Ohio National.)

As a general rule, one should buy a large enough disability benefit to cover spending needs and retirement savings, as most policies stop paying around age 65. However, some physicians may not need any disability insurance at all. Myung Sun Kim, M.D., an internist in Eugene, Oregon, doesn’t carry any at all. “With a financially independent spouse and extended family, I believe it is an option to ‘self insure’ for disability,” Kim says. Most physicians end up with policies with a disability benefit of $10,000 to $25,000 per month, although residents can often only afford $5,000 to $7,500 until they finish their training. They should buy a future purchase option rider on their policy. Lieb did not, and relates the following anecdote about his mistake:

“I did not get the future increase option as a resident. …Unfortunately, at the end of my fellowship I was diagnosed with hemachromatosis and when I went to get my new policy as an attending, my premium was going to be four times the standard policy for my level of coverage, and they would only offer benefits for a 10-year period instead of up to age 65. Obviously, this was a shock and not something I could afford. I shopped around and after medical underwriting, Ohio National gave me their highest health rating, as the disease was caught very early and with continuous medical management would have a low likelihood of future problems.”

Riders are extra “bells and whistles” on a policy that usually come with an additional cost. In general, every doctor should have a partial/residual disability option, which pays a benefit while they are partially disabled. Residents and other doctors expecting dramatically increased income should buy a future purchase option rider. Doctors in the first half of their career should consider an inflation protection rider as well.

Rainy Day 3: Death

Another important “rainy day” to discuss is the death of a doctor. If other people depend on your income, you need life insurance, and lots of it. The idea behind life insurance is that the financial life of your loved ones should be the same whether you die prematurely or not. Early in your career, when you are broke or worse, you likely have a large need for life insurance. Later in your career, that need decreases until it disappears completely when you become financially independent. If you and your family can live the rest of your lives on your nest egg, then they can certainly do so without you!

Since the need for a death benefit is temporary, it is almost always best to buy a term life insurance policy. Due to very high commissions, many insurance agents try to sell physicians whole life or other types of permanent life insurance policies, with a lifelong death benefit. Since everyone will die eventually, this benefit is much more expensive to provide, and so the policy premiums to pay for it are much more expensive, often eight to 20 times as much as a term policy.

The policy then becomes so unattractive in comparison that the agents often use secondary benefits to get people to buy the policy. The main secondary benefit used is the ability to borrow against the death benefit, which like all borrowing is tax-free but not interest-free. The problem with mixing insurance and investing in this manner is that you end up with the worst of both worlds—expensive life insurance you don’t need and a very low returning investment!

Since death does not involve all of the shades of gray that come into play with disability, life insurance contracts are much simpler and easier to understand than disability insurance contracts. If you are healthy, the process is very simple. Determine how much insurance you want, how long you will need it for, and who will sell it to you the cheapest. You will then need to provide vital signs, blood and urine lab tests, and a questionnaire about your health history and habits. Sign your contract, make your first premium payment, and you are all set.

How much insurance do you need? Well, first determine what you want insurance to pay for. What is the financial plan in the event of your untimely death? Perhaps you want the mortgage paid off. Perhaps you want $100,000 per child for college expenses. Perhaps you want your spouse to never have to work again. Even stay-at-home parents may wish to carry some insurance, as there would be significant costs involved to hire someone to replace their child care, food preparation, shopping, cleaning, laundry, money management and transportation duties. Add all of this up, round up to the nearest million, and that should be the amount of term life insurance that is purchased. A typical physician will be covered with $1 to $5 million in term life insurance. The good news is that the premiums on even those large amounts are much cheaper than disability insurance, not to mention malpractice insurance!

Some physicians, recognizing that their need for insurance will go down over the course of their career, opt to “ladder” their policies. Agnes Wang, M.D., a urologist in San Francisco, carries $4 million in coverage split between a 20-year and a 30-year policy. Even in expensive San Francisco, “It would be enough off our mortgage,” she says. Other doctors don’t buy insurance at all. For example, Dhaval Pau, M.D., a critical care physician, does not own a life insurance policy because he has a physician spouse, no children, and no debt. Lieb found himself in a different situation, and says:

“I chose a $3 million, 20-year term policy, as this will be enough for my family to live comfortably until the kids go to college. My wife and I discussed this and she would ultimately go back to work, but this amount of benefit would allow her to continue to stay home with the kids until they go to college. I did not choose a larger policy as I do not believe it will change their lifestyle dramatically from $3 million to $5 million and so was not worth the extra premiums. We also already have college funds set up for the kids.”

Determining how much life insurance to carry may not be an exact science, but it is important to personalize it to your situation. The length of term is similarly customizable, but most doctors end up with 20- to 30-year, level premium term policies. It is relatively easy to use online websites to determine the going rate for your policy. Buying from an independent agent allows you to buy the least expensive policy that meets your needs. The expertise of the independent agent becomes even more important if you are not healthy or have dangerous hobbies. They can “shop you around” to the various companies informally before making a formal application that could be denied and cause you difficulties getting adequate coverage later in life.

Rainy Day 4: Emergency fund

While most attending physicians can easily pay for minor emergencies such as a plane ticket or a broken appliance out of their monthly cash flow, many early career doctors would be well served to have a traditional emergency fund equal to three to six months of expenses invested in very safe, liquid assets.

Perhaps the most significant emergency a doctor is likely to face is job loss. Even if you have long-term disability coverage, it usually does not kick in for 90 days, and there are plenty of reasons for job loss besides disability. A traditional emergency fund reduces the stress of knowing how to pay household expenses for months while you seek out new work and wait on licensing and credentialing. Of course, the less you spend, the smaller your emergency fund can be.

Andino’s emergency fund is a year’s worth of expenses, and Lieb’s is currently similarly sized, although he says it is far more than he really needs and plans to invest a good chunk of it soon.

Other doctors interviewed for this article find themselves in the middle, with emergency funds of $20,000 to $25,000. The main point is to have something. Not only does it get you in the habit of saving, but it also prevents the use of high interest rate credit cards for emergencies and the psychological reassurance that you can take some profitable risks with your investments and your career.

Money is a lot like oxygen. You don’t think about it until you don’t have quite enough of it, and then you can think of nothing else. An emergency fund prevents a lot of financial worries. Thankfully, none of the doctors interviewed for this article have ever had to use their emergency fund, but each of them is still grateful to have it.

Rainy days affect doctors just as much as their non-physician peers. Insuring against financial catastrophe and making sure you have cash on hand to cover deductibles and waiting periods will enable you to ride out financial storms until your retirement savings become large enough to provide financial independence. As Lieb explains, “Just like the weathermen, no one seems to be very good at predicting when it is going to rain, and how much. I have seen many colleagues have terrible things happen that they were not financially prepared for. It is very easy as a physician to get this bulletproof mentality, but we can all get the same problems as our patients. …I sleep a lot better at night knowing that my family is protected.”

Wang agrees: “It seems like a lot of money to spend on something you hope to never use, but I hope that my family and I are lucky enough to never need it.”

Real physicians just like you are sued, become disabled, die, lose their jobs, and encounter other rainy day emergencies all the time. Be prepared for them with a smart insurance plan and an emergency fund.

James M. Dahle, M.D., is the founder of The White Coat Investor.

 

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How tight is the job market in your specialty? Winter 2020 Issue

The PracticeLink Physician Recruitment Index can help you gauge the relative ease or difficulty of your job search.

Vital Stats | Winter 2020

 

What’s your competition like? For job-seekers of all kinds, it can be hard to know. A simple PracticeLink.com search for opportunities in your specialty will give you an indication of the demand for physicians like you, but without knowing who else is vying for those jobs, it’s hard to get an accurate picture of supply.

How many other candidates in your specialty are actively looking for jobs at the same time? And how does that number correspond to the number of opportunities available?

That’s where the PracticeLink Physician Recruitment Index comes in. The Index is a relative indication of the ease or difficulty of job searches in various specialties based on supply and demand information gathered by the PracticeLink system quarterly. The larger the “jobs per candidate” number for your specialty, the better your potential standing in the market.

The change in rank reflects the specialty’s movement since last quarter.

The Most-Challenging-to-Recruit Specialties are those specialties with the highest demand-to-supply ratio in the PracticeLink system. The specialties on this list likely won’t come as a surprise to candidates; they’re often narrow fields.

The Most-In-Demand Specialties represent the specialties that have the most jobs overall posted on PracticeLink—specialties for which the demand for physicians is highest. For the Index, we then rank those in-demand specialties according to the supply. Those at the top represent specialties with the most jobs available and the fewest candidates per job.

After reading these Indexes, ask yourself: Do these Indexes match my experience of searching for a job in my specialty? Do I need to widen or narrow my job-search parameters as a result?

This PracticeLink Physician Recruitment Index was pulled October, 2019. Candidate ratios include physicians who have registered with PracticeLink.com within the past 24 months.

 

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App roundup

From pediatrics to menopause management, these free apps help physicians.

By Iltifat Husain, M.D. | Tech Notes | Winter 2020

 

In this edition of Tech Notes, I look at three exciting medical applications. One is a pediatric patient management app that manages to be one of the best pediatric focused apps ever released; one puts a dermatologist in your pocket; and the other helps with a key area of women’s health.

Price: Free. iPhone, iPad: apple.co/2m2MmAS Android: bit.ly/2kYhQI6

PedsGuide

The PedsGuide medical app is created and developed by Children’s Mercy Hospital in Kansas City. What separates PedsGuide from other traditional pediatric patient management applications is how specific it is. The medical app doesn’t cover 30 different pathologies; it focuses on just two types of presentations of pediatric patients: the febrile infant and the child with an asthma exacerbation.

The important thing to realize is that these two presentations alone consist of a large portion of pediatric patient population presentations. Further, these specific types of presentations often present variability in practice.

I cannot emphasize enough how stunning the user interface and overall medical functionality of this app is.

The PedsGuide is one of the best-designed medical decision pathway apps ever created. It bundles chief complaint, assessment calculators, checklists, treatment recommendations and re-evaluation protocols all into one app. Children’s Mercy Hospital should be proud of the work they have done with this app, and other medical app developers should take notice.

An important note: It is critical that this application should not trump your own hospital’s and local practice standards for the management of these specific patient presentations.

Price: Free. iPhone, iPad: apple.co/2m6vAke Android: bit.ly/2mo0uEV

AOCD Dermatology Database App Review

The Dermatology Database medical app by the American Osteopathic College of Dermatology is one of the most exciting apps to be released this year. It has more than 300 dermatologic pathologies detailed out with several pictures and specific treatments.

When you open the app, you’re presented with three sections: diseases, drugs and procedures. In the diseases section, you can search for specific pathologies. When you find what you’re looking for, you’re given multiple pictures of that pathology with the ability to zoom in on the pictures, and a brief description of the disease. The drugs section of the app shows applications for particular drugs as well as the side effects.

I am a huge fan of the detailed pictures, user interface, and the wealth of information provided. However, there are two specific areas the app could have improved. It would be great to see a section focused on primary care, urgent care and emergency medicine; and it could have improved its references. There are great review articles on each of the pathologies mentioned, and a simple PubMed reference to key journal papers would have been a great feature to include.

Price: Free. iPhone, iPad: apple.co/2krmH4o

Johns Hopkins Menopause Guide

In 2002, the Women’s Health Initiative, the first randomized trial to directly look at the effect of estrogen plus progestin in relation to coronary heart disease, published remarkable results. The results showed overall health risks exceeded benefits of using combined estrogen plus progestin in healthy postmenopausal U.S. women.

These are the types of studies and treatment discussions the Johns Hopkins Menopause Guide, created with Unbound Medicine, addresses.

The guide goes through critical research studies related to women who are post menopause, perimenopause, and early menopause, and goes through all the major critical treatment options for this patient population.

The treatment section alone has more than 15 various drug therapies mentioned that treat a variety of postmenopausal conditions. The symptoms section is the part of the app that medical providers will use most.

 

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Measles vaccinations and exemptions

As outbreaks increase, pressure mounts to eliminate exemptions from vaccinations based on religious or philosophical beliefs.

By Jeff Atkinson | Reform Recap | Winter 2020

 

The number of confirmed cases of measles in the United States in 2019 exceeded 1,000. The Centers for Disease Control and Prevention (CDC) reported that this is the largest number of cases since 1992 and since measles was declared eliminated in the U.S. in 2000.

States with the most outbreaks as of June 2019 include New York, Washington, Oregon and California.

Prior to initiation of the measles vaccination program in 1963, 3 to 4 million people in the U.S. contracted measles each year.

Worldwide, there also has been an upsurge in measles, particularly in Madagascar, Ukraine, India, Philippines, India and Nigeria. The World Health Organization reports that in 2016 approximately 7 million people were infected by measles and 89,780 died.

Failure to vaccinate

The reason for measles outbreaks is failure to vaccinate. In the U.S., a significant number of parents have chosen not to vaccinate their children for religious or other reasons. In an ultra-orthodox Jewish community in Brooklyn, for example, several hundred cases have been reported, and the city closed seven orthodox schools that did not comply with vaccination requirements. Some conservative Muslim and Christian groups also oppose vaccinations.

The anti-vaccination movement was fueled by a 1998 article in The Lancet by Andrew Wakefield and his colleagues that linked the measles, mumps, rubella (MMR) vaccination with autism. The article was based on cases of 12 children. The Lancet later retracted the article, stating that “several elements” of the article are “incorrect [and] contrary to the findings of an earlier investigation.”

Wakefield lost his license to practice medicine after the British General Medical Council found that he falsified data and acted unethically in the treatment of the children. In addition, Wakefield did not disclose that his research was funded by lawyers who were suing vaccine manufacturers.

The CDC and multiple other organizations have concluded that MMR vaccinations do not cause autism.

State laws on vaccination

All states have laws requiring students to have vaccinations, including for MMR, but the scope of exemptions from the requirement varies from state to state. The National Conference of State Legislatures reports that all states allow medical exemptions. Medical exemptions include allergy to the ingredients of the vaccination and immune suppressed conditions.

A controversial issue in the vaccine debate is whether exemptions should be granted for religious or philosophical reasons. As of June 2019, most states grant exemptions for religious reasons, and 15 states allow exemptions for philosophical reasons.

States that to not allow either religious or philosophical exemptions include California, Maine, Mississippi, New York and West Virginia.

Medical organizations weigh in

In light of the measles outbreaks, there has been pressure to eliminate exemptions based on religious or philosophical reasons. Both the American Medical Association and American Academy of Pediatrics strongly support elimination of non-medical exemptions for students entering school.

The American Academy of Pediatrics said: “To protect those who cannot be vaccinated, community or ‘herd’ immunity requires at least 90 percent of the population to be immunized (95 percent for highly contagious diseases such as measles and pertussis).”

President of the AMA Barbara McAneny, M.D., issued this statement: “[W]hen individuals are not immunized as a matter of personal preference or misinformation, they put themselves and others at risk of disease. …We are also reminding physicians to talk with their patients about the health risks associated with not being vaccinated and make a strong recommendation for vaccinations, unless medically inadvisable.”

Court rulings

Legal issues regarding vaccinations are not new. In 1905, a case involving smallpox vaccinations came before the U.S. Supreme Court (Jacobson v. Massachusetts). In the early 1900s, smallpox was prevalent and increasing in Cambridge, Massachusetts. Acting under authority of a state statute, the city’s Board of Health ordered vaccination of all inhabitants of the city.

The vaccinations were available at no cost to the recipient. The penalty for not being vaccinated was a fine of $5. Henning Jacobson refused the vaccination, was found guilty of a criminal offense, and was fined.

Jacobson appealed to the Supreme Court, arguing that the statute was an unconstitutional infringement of his liberty. The Court upheld the statute as a legitimate use of the state’s “police power” to “protect the public health and safety.”

The Court acknowledged that, at that time, medical professionals differed about the value of vaccinations. The Court nonetheless said that the legislature and health boards had the power to weigh the evidence and impose vaccination requirements as long as the governmental units did not act in an arbitrary or oppressive manner.

In a later court case not related to vaccinations, the Supreme Court (Prince v. Massachusetts, 1944) commented: “The right to practice religion freely does not include liberty to expose the community or the child to communicable disease or the latter to ill health or death.”

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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It’s not just the job

You may have found a place to work…but can you actually be happy living in the community?

By Chris Scites | PracticeLink Tips | Winter 2020

 

Have you ever lived somewhere you didn’t like? Not just your apartment or house, but the actual community? Maybe when you moved there, you thought that you could make it work…after all, if you like your job and there’s running water, how bad could it be?

Picture this…

During the honeymoon phase, things are OK. But then you settled in at your new job, you’ve unpacked all your moving boxes (or given up and stacked them in a closet) and decide to treat yourself to a curry. That’s when you realize the closest curry place is over an hour away, and they close at 7.

Undaunted, you learn to make your own curry and keep trying to find things to like about where you live. You start to forget about all the things you used to do after work…and then you go on a vacation, or a trip to a CME conference. Suddenly, all the things you used to do are there again. When you get home, you realize that you’re actually kind of miserable, but you better get used to it because there are two more years on your contract and you won’t be going anywhere soon.

Finding a great place

Considering where you want to live is one of the most important parts of your job search. There are undoubtedly things you do love that are unique to you. Start keeping a journal of what you enjoy doing in your off hours, and note how important it is that you have easy access to them. Is a good trout stream a need-to-have? What about art galleries? What’s crucial, what’s nice, and what are you OK doing only on vacation?

It’s not just the activities, either. Also consider the area’s culture and the practice type. What kind of procedures do you want to do most often? What kind of call arrangement are you hoping to find? What kind of relationship are you hoping to have with colleagues? In what kind of environment will you best fit?

Make your need-to-have, nice-to-have and doesn’t-really-matter lists. If you have a significant other or kids, make sure they make one, too. Figure out the places that have these things available, and let that guide your job search.

PracticeLink can help

Make sure you update or add an inDepth Interview to your PracticeLink profile. The inDepth Interview expands on what’s in your profile so in-house physician recruiters can understand the why behind your interest in an area or opportunity.

The process helps you, too, narrow in on what you’re looking for in a new opportunity. An inDepth Interview added to your PracticeLink profile will help you find opportunities you might not have found in your own search but that might be the perfect fit.

You may be a city person, a country person, or a person who doesn’t care which as long as there’s at least a solid week a year where the ground is completely covered in snow. These are things you need to know about yourself and your family to help can guide your search.

No employer wants one of its physicians actively planning their escape a year before their contract has ended. An employer wants you to be happy where you live and work. They don’t want to find a replacement!

PracticeLink and our inDepth Interview team are here to help you let potential employers know what you’re looking for in your next opportunity—and your next place to live.

Chris Scites is PracticeLink’s director of physician relations. Reach his team for free job-search help and to complete an inDepth Interview at (800) 776-8383.

 

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Navigating the job search as a foreign medical graduate

FMGs looking to stay in the U.S. need to take the time and complexity of the visa system into account.

By Bruce Armon & Amy Link | Legal Matters | Winter 2020

 

According to the American Immigration Council (AIC), there are more than 247,000 physicians with medical degrees from outside the United States who practice medicine in the United States—slightly more than a quarter of all practicing physicians in the United States.

These foreign medical graduates (FMGs) have specific legal issues to address when applying for their initial work visa.

This article describes the visa process generally—there is a veritable alphabet soup of immigration terms and acronyms—and important considerations for FMGs and prospective employers to address for physicians who wish to practice medicine in the United States upon the completion of a formal training program.

The importance of FMGs

From a health care delivery perspective, FMGs play a critical role in ensuring access to care throughout the United States. For example, the AIC reports that nearly a third of all physicians in areas across the U.S. with the highest poverty rates are foreign trained. Without FMGs, many areas of the United States would have even less access to physician care.

H1B, J1 and O1 visas

Most FMGs enter the United States to complete their residency or fellowship program on the J1 visa, with a smaller number entering on the H1B visa. The J1 visa is a non-immigrant visa issued by the U.S. Department of State to research scholars, professors and exchange visitors who participate in programs that promote cultural exchange, especially to obtain medical or business training in the United States.

As an “exchange visa,” the J1 FMGs are subject to a “two-year home rule.” Under the home rule, J1 visa holders commit to return to their home countries after completion of their residency for a period of two years before they can apply for the H1B professional work visa and return to work in the United States.

If a J1 FMG desires to work in the United States prior to spending two full years abroad, the physician must first apply and obtain a waiver from the U.S. Department of State.

The only exception to the two-year home rule is the O1 visa, which is for people with extraordinary ability in their field that has been demonstrated by sustained national or international acclaim. The O1 visa requires a very high standard to qualify.

If a J1 visa holder qualifies for the O1 visa, they can change status from J1 to O1 without a waiver. Otherwise, all other J1 FMGs must first obtain a waiver or spend two years abroad before returning to work in the U.S.

There are various J1 waivers available, each with different requirements:

Conrad 30 Waiver. These are available to primary care and some specialist physicians. The Conrad 30 program permits individual states to accept up to 30 medical students per year. Requirements vary from state to state.

HHS Waiver. HHS waivers are only for primary care physicians working in locations with HPSA scores of 7+ that are:

  1. a health center as defined in the Public Health Service Act, and receiving a grant from the U.S. Health Resources and Services Administration; or
  2. a rural health clinic as defined in the Social Security Act; or
  3. a Native American/Alaskan Native tribal medical facility as defined by the Indian Self-Determination and Education Assistance Act

Appalachian Regional Commission (ARC). The ARC is available in Alabama, Georgia, Kentucky, Maryland, Mississippi, New York, North Carolina, Ohio, Pennsylvania, South Carolina, Tennessee, Virginia and West Virginia.

Delta Regional Authority (DRA). The DRA is available in Alabama, Arkansas, Illinois, Mississippi, Missouri, Kentucky, Louisiana and Tennessee.

Hardship Waiver. The FMG must have a qualifying USC spouse or child.

Persecution Waiver.

Cap-subject and cap-exempt employers

In contrast to the J1 visa, FMGs in the United States on H1B professional work visas are not subject to the two-year home rule.

Upon completion of their training program, FMGs in H1B status are eligible to file a petition with U.S. Citizenship and Immigration Services (USCIS) to change employers. However, you must confirm whether the employer is a “cap-subject” or “cap-exempt” entity to better understand when you can begin employment.

The H1B visa program allots 65,000 visas plus an additional 20,000 visas for beneficiaries with U.S. master’s or higher degrees per fiscal year via a random lottery system. FMGs are included in the total 85,000 visas.

Traditionally, the annual lottery is held the first week in April and allows H1B cap-subject employers to file visa petitions for workers to start on October 1 of the same year.

A prospective employer should initially determine whether your current H1B visa is with a cap-subject or cap-exempt entity. If you’re with a cap-subject entity, you’ve already been counted against the annual cap and are eligible to change your employer immediately. However, if your H1B is with a cap-exempt entity, and the new employer is a cap-subject entity, you would be subject to the annual lottery.

Additionally, your prospective employer must determine if they qualify as a cap-subject or cap-exempt entity for H1B purposes.

The United States immigration system is very complicated—and is the subject of intense national debate. FMGs are an important component of ensuring access in many geographic areas in multiple specialties during an era when the demand for physicians outpaces supply.

Bruce Armon is chair of Saul Ewing Arnstein & Lehr’s health care group and has worked with hundreds of physicians and employers with regard to transactional, contract, compliance and regulatory and reimbursement matters. Amy Link is a highly skilled immigration practitioner and member of the firm’s global immigration practice group, where she specializes in all employment-based immigration matters.

 

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