The Physician Negotiator Podcast

EP 10 Passive Income investing during a Crisis by Docofalltradez | Dr. Jeff Anzalone http://traffic.libsyn.com/thephysiciannegotiator/Final20Jeff20No20Leveling.mp3 WHO’S ON THIS EPISODE  Website i Email Getting started with building an emergency fund and passive income- Dr. Jeff Anzalone In this episode, we invite Dr. Jeff Anzalone to talk about his strategies in building an emergency fund, taking advantage of the opportunity in crisis, and investing for passive income generation. Dr. Jeff is a periodontist who eliminated his over $300k worth of student debt after 7 years of practice. He is also an author and an expert in studying successful dental practices, reducing tax burdens, and earning passive income with real estate syndicates. Below are highlights from the conversation we had. The importance of having an emergency fund. It is no secret that we’re in the middle of an inevitable crisis that is the COVID-19. It is therefore imperative to have an emergency fund set up for time like this when even going to work is a risk.  Dr. Jeff came up with a modification of Dave Ramsey’s strategy of building a six months emergency fund to twelve months instead. He shares some actionable tips for setting up an emergency fund: Eliminate the scarcity mindset and adopt an abundant mindset. Have your emergency fund in cash and a money market account for easier access just in case a crisis ever affects how you can access it.  Opportunity in crisis. Dr. Jeff has adopted a quote: “be fearful when others are greedy and be greedy when others are fearful.” It is wise to invest now during the crisis since everything is cheap and affordable before they hike up again.  Most people are now looking for ways to sell the assets that they believe will lose value as the pandemic progresses. Dr. Jeff shares tips on how to seize the opportunity in crisis:  There’s probably never going to be a better time to invest in the market than now.  Do not get out of the market by selling- it will only create a loss and things are going to come back to normal or halfway there once the pandemic is over. This crisis could surpass the great depression with the number of millionaires made. You should engage the entrepreneurial spirit within you to start a business that you would have never started. As a business owner, think about customer care especially if in the healthcare sector. Investing in real estate syndicates. As a doctor, one source income that is highly taxed can be quite restrictive especially for doctors who want to be debt-free. It is therefore wise to find ways to make passive income like investing.  Tips on how to get started with investing: Get a good understanding of what you’re investing in by reading, listening to podcasts and networking. Learn from other people failed invests to look for better investment opportunities. Get a mentor in your field of investment that will lead you. Attend conferences to meet people who know things in your field of interest better than you do.   Why real estate syndicates investments rather than single-family homes: Real estate syndication investment is where an investor invests in large properties than they could ever manage to afford on their own. Their return on investment is 7-8% with a five-year hold and a profit split when they sell. This means that your investment could double in 5-7 years and is tax-free due to real estate depreciation. Dr. Jeff shares tips on what you need to know before investing in real estate:  If you’re not interested in dealing with tenants, then real estate syndication might be the best option for you.  It gives you the choice of not being an active investor. Attend meetings set up specifically for real estate syndication.   https://joefairless.com/ The risk in these types of investments highly depends on the asset class you’re in. Find an experienced real estate accountant to help you with your investments before you jump in. There are no deals negotiation done since you’re going in as a shareholder so no attorneys needed. “As a dentist and physician start building an emergency fund and for those who are at home during the COVID-19 pandemic, look for a way to a passive income once all this is over.”- Dr. Jeff Anzalone Resources: Website: https://www.debtfreedr.com/ Free Guide: https://www.debtfreedr.com/freeguide/ Joe Fairless:  https://joefairless.com/ Book: What They Don’t Teach You in Dental School Final Jeff No Leveling.mp3 transcript powered by Sonix—easily convert your audio to text with Sonix.Final Jeff No Leveling.mp3 was automatically transcribed by Sonix with the latest audio-to-text algorithms. This transcript may contain errors. Sonix is the best audio automated transcription service in 2020. Our automated transcription algorithms works with many of the popular audio file formats. Docofalltradez: Welcome to the Physician Negotiator podcast, where no decision is left to chance with your host doc of all trades.Docofalltradez: All right. Today on the show, I have Dr. Jeff Anzalone. Dr. Anzalone is a Perry or a dentist who started his career with over three hundred thousand dollars of student debt. He was able to eliminate this debt after seven years of practice. He's also an author of a book titled What They Don't Teach You in Dental School. He is now an expert in starting successful dental practices, reducing tax burdens and earning passive income with real estate syndicates. He shares this wisdom on his Web site and his blog called debt-free. Dr. Dot.com, that's debt free. d.r dot com. Dr. Jeff, welcome to the show. But, sir, it's a pleasure to be here. Well, hey, it's a pleasure to have you and you are the perfect guest given the set of circumstances that's going on in this country and the whole wide world right now. We're going through the pandemic of Cauvin 19. And I feel that physicians and surgeons, physicians and dentists, I'm sorry, are feeling the effects of this pandemic. During the last financial crisis, we really weren't impacted. And it seems like this time around we are severely impacted. And you wrote a really nice article on your Web site called Financial Stress during a Crisis Five Lessons Learned and the lessons that are really paramount for professionals. Is it all about debt? And the one thing that you advocated is having a rainy day fund. Now, traditionally, people advocate having a three to six month rainy day fund, but you advocate something a little bit differently. Would you mind explaining that?Jeff: Well, yeah, absolutely. I am a big Dave Ramsey person. I followed him when I first got out of my residency and but I didn't follow his. His baby is seven baby steps to the T. Because he didn't want anybody to do any type of investing while they were getting out of consumer debt. And with me not getting out until I was in my early thirties and I knew I gonna take several years to get out of there. I didn't want to lose those years of compound interest. So I decided to do both, you know, get out and get out of debt quicker. But also at the same time, Max, out of retirement accounts. But and that's where were we? We kind of differ in that aspect. The actually the his first baby step baby step one is to establish an emergency fund. And with with him, he just because you got to think about he's talking to the masses. You know, he's talking to, you know, the just the everyday blue-collar person. Like, you know, I just get a thousand dollars in that account, you know, just just get some because, you know, as you know, most people don't even have an emergency fund. So just getting something in an account. That's what he's recommended. Then after you get out of debt, consumer debt, which is baby step two, you go back to the emergency fund and build it up to three to six months of your expenses.Jeff: Now. What would things have taught me in the past was whenever I was giving out of my residency, I had a supposedly I had a job locked up with with a group here in my hometown in Louisiana. So about 10 to 14 days before I graduated, they basically just pulled the job out from under me. And, you know, I had a two month old. I was married. We'd already bought a house. You know, we were paying an interest only loan on it. I had, you know, almost three hundred thousand dollars of student loan debt, didn't have a clue how to start a practice or anything. And it was just like that. How it change, how things can change. So ever since then, I've I've always been real leery about how things could happen, just like with this crisis, how one day you're sitting here going to work, the next day everything's shut down. So that really changed my mindset about money and kind of fear because I was there for it for a long time. I always had this scarcity mindset. And that's really held me back with with a lot of things not having that bandit mindset.Jeff: You know, I was always like, OK, well, there's only so much money to go around and that's it. Which, as you know, that's that's not true. I mean, look at how they're printing money right now for the country. You know, so. So with with what this crisis has really taught me is that three to six months that he's recommending emergency fund living expenses. Well, when you're going through something like that, that could be like bare bone, minimal living expenses. You know, that could be just to keep the lights on, food on the table and a roof over our heads. But with the issue that I went with, with my residency, I didn't think that was enough. And I actually extended it out to 12 months or longer, and and now we've we have actually more than that just because, you know, I never knew when something could happen and unfortunately something has happened, but where we're a lot more prepared than I think that most people. But, you know, there still is going to be a point where your your money is going to run out at some point unless you can get back to work. So hopefully we'll see that sooner rather than later.Docofalltradez: So you're advocating for 12 months worth of an emergency fund, and I totally agree with that. Now. With respect to that emergency fund, would you have it in just cash or how would you where would you have that money sitting?Jeff: That that's a good question. It just depends on the person.Again, you would you would never think that if you had your money in a checking account or a savings account that you couldn't get to it. But but again, what if I mean, what if something happened? What if what if the banks shut down, which I know some banks were shutting down? What if the next crisis has to do with computers and you don't have any access to me? You never know.Jeff: And so I personally would recommend having some in both, you know, both just in cash.And then also, you know, just like in a, you know, a money market account or something where you can get to it quickly. You can write a check if you need to. That's that's typically how we use it.Docofalltradez: Right now, it's interesting, if you will, if you watch the media and if you watch just television, the crisis looks like the whole world is about to come to a screeching halt. And it may it may very well over the next 18 months. Economically, we may suffer tremendously. But in your article, you also talk about that with crisis's comes opportunities. And perhaps this might be a time of opportunity as well as a crisis.Jeff: Yeah. And I gave the quote that I've always heard Warren Buffett talk about. And I'm sure you have in your listeners and readers have. And he talks about fear. And he says, be fearful. When others are greedy.Jeff: And be greedy when others are fearful. So whenever the market has been going up forever, you know, I really didn't start investing until around.Jeff: 0 7 0 8, yeah. Ish. Has kind of. I started practicing a couple of years before, but we just didn't have any really money to invest. So I really started when the market had bottomed out. So really, this is the first time that I've that I've ever seen a bear market before. For me, investing and I couldn't understand, you know, when I started investing in Vanguard index funds way back when, you know, all these people were talking about, oh, my God, we're losing all this money and this and that. It's like, well, everything is really cheap right now, that bottom kind of like the stuff, you know. So. So that, you know, fast forward everything, as you know, is pretty much for the most part. Bingo has gone up, so. So that haven't had any issues. But now that the market has dropped to good because of this pandemic and you see people you know, it's a it's a perfect psychological principle. You've probably heard of the lawsuit also version. You know, we react more to laws than we do to gain, you know. And we just for the most part, we just we hate losing. We would we would lose. We would, you know, do whatever we can to protect it from losing something. Then then we are to gain. So when when we look at our accounts online and we see our four one KS and retirement accounts just everyday, just going down and down and see the market go down, we we we want to get rid of that. We want to prevent that fear.Jeff: So everyone is fearful. And what do they do? They unfortunately, they take their money and they get out. The market will. The thing is it, and I help my parents with with their retirement accounts and that sort of thing. And you know, there they were asking me the same questions that, you know, a lot of people asking is when should we start selling out? And then they put all of their automatic. You know, I'd set them up or all these automatic monthly investments, you know, they turned all that off. And I said, well, two things. Number one, if you start selling out now, you've you've automatically locked in those losses. Because I said right now you haven't lost any money. In the end, I just don't get that to you. So you all say money. On the other side and to you. So it's it's going up. You haven't gained any money either. So that's that was the first thing. The second thing is with my parents cutting off all of their automatic investments that I'd set up for monthly. They're not taking any advantage of of the everything being on sale. So this this is kind of going into Warren Buffett, quote, when he says be greedy, when others are fearful. You know, when when you kind of are in a good position, you don't have much debt or you have no debt. You have a good pile of cash. So you can kind of sit back and wait and and find opportunities like this when, you know, for instance, we've been on the total stock market index fund.Jeff: I think it was low 80s. You know, eighty one eighty to share something like that. And then it got down into the upper 50s. I mean you just sit back and as you're watching it go down. Eighties. Seventy five, 70s, 60s, 50s, you're like wow this is this is good stuff, you know, because you know the stock market and it holds like thirty three hundred, you know, stock you know, every stock in the stock market, the US, you know that our country is going to come back. And if it if it if you don't believe that, then you've got bigger issues. You know, maybe you need to move or something, whatever. But if you don't think that that Disney is not going to come back or if if Wal-Mart. You know, Murph. Murphy all. And, you know, Delta Airlines, all the all these big companies, if you don't think they're going to come back, then you probably shouldn't be invested anyway. But with this is with us knowing that, hey, look, these these stocks have been trading pretty steadily the last few years. And with them just dropping down and you know that they're at least going to come back. Let's just say worst case scenario, just at least 50 percent back, you know. So I just think that this is this is a great time. Again, I'm not a financial adviser. I'm not recommending any specific things to people. But that's just for me. Mark, my perspective on this, that again, and every crisis does prevent does present opportunities.Docofalltradez: And it seems like a time horizon matters. But having said that, in your parents case, it's still maybe it doesn't, because if your parents sell and they they they put those losses on their books, dealt them, they may never recover if they don't stay in the market. I have a lot of residents who come up to me and they're always panicking about this. And I always would tell them up until this point that they should pray they should pray for a market crash, because right now the prices well, they were so inflated that they were expensive. And now all of a sudden now they're cheap and they're afraid to get in. And I think you're absolutely right. I think what's going to happen is people will realize that there's been a turn. We'll hit the bottom, the double bottom or whatever it is, U-shaped, V-shaped, whatever type of recovery we have. By the time they realize it, it will be too late. So the idea is don't ever get out of the market in the first place. Just maybe keep on dollar cost averaging and adding to your position.Jeff: Right. It's funny because, you know, whenever people whether it's people online from my website or for friends that I know, you know, the they're they're talking about, they want to talk about this pandemic. And it's usually. It's usually a negative stuff. Well, not usually it always is negative stuff. Oh, gosh. I mean, you're not able to practice patience. What are you doing with paying your bills this now? I mean, how we're gonna make it. And I guess just being just, you know, thankfully being in the position that we're in and with with. Also with us getting support from our government. You know, being able to have our employees be able to furlough them, let them get unemployment, the different types of loans, small business loans, that could be could be a grant. So, you know, it's I'll look at it from a different standpoint. You know, I always talk about, you know, looking at it like that. You know, at least we do have some help right now. I'm not trying to be so negative, but. And then always encouraging them, say NSA. You know what? More than likely it is just like what you said. There's probably never good hope, you know. Hopefully there's not to be another pandemic or something like this. But more than likely, there's probably never going to be a better buying opportunity. And then we are now have now a friend of mine is also a periodontist.Jeff: He he he's up in Connecticut and he teaches part time at Yale to the residents. And there's there's also a 94 year old dentist that also teaches part time with him. And he said this guy is like sharp as a tack. He he knows his stuff. He knows he knows how to invest. He knows how to figure out. For instance, Hurricane Katrina. We were in New Orleans when Hurricane Katrina hit in 2005. And. I graduated in June 2005. You know, it's been hard hit in August 2005. So we really lucked out with that. But he he was thinking like, OK. What what businesses should invest in? What are those people going to need? Hey, hey, kid. Think he got to the point where he found the company that was providing all the FEMA trailers? I mean, that's how this guy's thinking and. So, my friend, ask him what all this stuff happened, you know about it. And you just they just said, you know what? I've live for 94 years and I've never seen anything like like this before. So that just kind of shows you that this this is probably, you know, for for me and, you know, people our age, you know, this is this is probably going to be the best time ever if you want to invest in a market to do it once in a lifetime.Docofalltradez: Well, and you mentioned it on that same post, the financial stressed financial stress during a crisis post that during our last depression, that's when most number of millionaires were made in this country. And you predicted it and you said it on your Web site. This will surpass the Great Depression and the number of millionaires made.Jeff: That was my prediction. I could be wrong. I've got a 50/50 shot. You know, exactly the wrong I could be right. But. I I do think that my grandmother, she lived through the Great Depression.Jeff: So I always got to hear stories of her, you know, growing up. And you know what? She was a child. And it was really, really bad. She said it. She had four brothers and a Christmas. You know what? Santa Claus would come, you know, now with your kids. You know, they get all these gifts and presence and all this. But when they would wake up in the morning for Santa Claus would come and they had a table with the chairs and each one had a chair, and Santa Claus would leave each one one piece of fruit. Wow. And that was that was I mean, they were just like a static. And that's just how bad it was. I mean, at least we have food available, at least we have, you know, the final bill. They didn't have all that back then. I mean, a lot of times if if you didn't have your own garden or somebody that you knew how to garden, I mean, you would you were hurt. So it was a really bad back then.Docofalltradez: Well, with respect to the opportunities and you mentioned your 94 year old doctor associate, you know, he was investing in FEMA trailers. Well, we have we've demonstrated the weak, the weakness in our country in this crisis with respect to supply chains, drugs, personal protective equipment and other things that we thought we had in place that are produced in China. We no longer have access to. So this might be an opportunity of a lifetime for somebody to invest in these companies and or start their own company. With the help of the government.Jeff: Yeah, that's that's true. I think I saw an interview, I've seen so much stuff in the last couple weeks. It's hard to keep up with it. But I believe it was an interview with Mark Cuban a short time. Right. And he said and they were asking him, you know, about what what they thought was going to happen. And he he'd said just what you said. He thinks with with the entrepreneurial spirit, there's so many people have that there are going to be people that start businesses and companies that come out of this, that if this pandemic would have happened, they would never started. So there you go. Every every crisis presents an opportunity. So I think you're right. Well.Docofalltradez: Well, with respect to your practice, so a lot of physicians and dentists are no longer practicing medicine right now. They've been mandated by the government is to cease all procedures until unless it's an emergency. So clearly it's impacted your practice.Docofalltradez: But my question for you is it's not like these patients that are going away. They still need these services. They still need to be cared for. So are you finding that you're just postponing their care? Are they as is all this demand and volume just building up?Jeff: That's a good question. I think there will always be a need for health care. Just like, you know, there's gonna be a need for anaesthesiologist once. What's all this gets back up and go? And it's it's kind of like, you know, nobody's ever seen this happen before. So it's it's just a guess, you know? I'm also in a mastermind group with a guy that used to be the president of the Magic Kingdom. Dan Cockerill and Leacock Roses dad, he's. He's written a lot of books. I want I'm co-creating Creating Magic and it's based on coccaro CEO C K E R E L L Li l e li cockerel. I think his Web site might be creating magic or something like that, but. As you as you know, if you know anything about Disney, you know that they're they're big on customer service. You know, you go you go to the park and it's just like spotless minutes. You're like you're scared to drop a piece of paper on the ground because you're going to make the place dirty. So, hey. I agree with him. That right now business owners should be thinking about customer service. Because when we do get back to work. Think about. What's what's going on in the customer's mind wherever they go? What are they going to be thinking about what you need to address at. They had the owner of the Houston Astros, a Houston Rockets, on the news the other night, and this guy, ?, he had a list of stuff.Jeff: He had all these Landry's restaurants and all these different restaurant. He owned a lot of stuff. And he is just a good old Texas guy, you know. I mean, if you've seen the interview, just like you know, who's there interviewing this redneck from Texas. You know, you never thought he was the owner of the Houston Rockets, but. He was just very passionate about it. He's like, you know what, he was talking about customer service. He said, when we get back going. He said there's not gonna be a single thing on our countertops, a single thing on our tables that our customers are going to see us wiping this place down between us there. They're not. We're not what you have to say anything to. They're gonna see it. So I think that needs do. Doesn't matter what business that you're in. You know, you really need to to express that to your employees or we're definitely going to do that. And we're going to tell each, you know, each patient before they come in. What we're doing. Because even if they don't ask or thinking it. You know, if your doctor calls you and a couple loves and says, hey, you want to come in for your AG, say you're going to be thinking, well, how are you going to prevent me from, didn't, you know, getting the virus? Right. So I think that's gonna be big.Docofalltradez: Yeah. And I imagine especially in the health care industry, we're gonna have to adapt in ways that we cannot imagine still, you know. So let's change gears a little. You are an expert in financial real estate syndicates. And I suspect you started doing this because you've already paid off all your debt. I'm sure you've Max maxed out all your four one KS and all your other I.R.A.s. And so you were looking for other ways to invest. So walk me through that journey how you kind of decided you're gonna take the plunge into into real estate.Jeff: I got real complacent after we got out of debt and I met some other financial goals. And, you know, I've always had goals to set, you know, as you as you probably did, too, you know, you graduated college. Your goal was to get in a medical school. Then your goal was to get into a residency and then join a group, so you always have these goals and then what? Once I did all that and hit that final goal, it was like. OK. Now what? And I think you're seeing a shift now. The Dave Ramsey Show. It used to always talk about getting out of debt. Well, now he's been on there for so long. He's helped he's helped so many people get out of debt. Now, what does he do it? He's shifted now to teaching people how to be millionaires. And a lot of it focuses on that. So, you know, you got to kind of pivot to to whatever whatever life throws you and that that's just part of it. So. Being complacent. That was that was one thing that kind of startled me in that direction. And then also. With after reading a couple books and rich dad, poor dad, Robert Kiyosaki, which really hit me hard because, you know, he had the cash flow quadrant, right. And then, you know, I was on that less of a quadrant, you know, even though I was the doctor owner. I was still, you know, quote an employee. You know, if if I didn't go to work. I didn't get paid, you know, so. And I realized that I only had one source of income. Which, as you know, as a doctor, that one source of income is active income and it's the highest tax income. So it's like two strikes right there, you got to go to work, and when you do go to work, the government takes a good bit of it. So that that really pushed me to start finding other streams of income, passive income, which led me to real estate.Docofalltradez: And so with real estate, you're able to get a passive income and get some tax relief. That was the whole strategy, right? Correct. Now, if you were to so obviously we want to talk to the audience members who already debt-free who Xed out there for one case in their IRAs and they're looking for an opportunity to start investing beyond these instruments.Docofalltradez: How would you advise them to get started? So, I mean, they have let's say they'd have it up to you to save between 50 to a hundred thousand dollars.Jeff: Well, I'm a big believer, don't invest in anything that you don't understand. Even, you know, most people have an accountant. Even though if you're not going to do your own taxes, you need to understand it to be able to know what your candidates are doing, you know? So I started reading books, listening to podcast, attending events, networking with people. It's a whole different like going from college to in the medical school. It's it's a whole different world. I mean, it's a whole different profession. You got to learn the lingo. You got to know what you're doing. Unfortunately, I didn't do that initially. I just started investing online on some of these crowdfunding sites. And did did well for a little bit. But then I got burned pretty, pretty good. The whole deal. Every every investor lost their money.Docofalltradez: Oh, wow. Yeah. And you're talking about these online real estate collections. Great.Jeff: Like it was it was a real T shares, which actually went under, which was bought out right at the time. That was the number one.Jeff: That was the big one. You mean these guys? That's all they were trying to get me to be.Docofalltradez: They're going to sponsor me. They're going to give me all this money for the podcast and then a month later, the whole thing collapsed. So, you know, I'm glad I never I never advocated for them. So. Plus, I didn't know enough about them to really.Docofalltradez: And I told them they gave me this country. I'm like, wow, I don't know enough about you to feel comfortable advocate for you. So I'm glad I did it. So I'm sorry that happened to you.Jeff: Well, it was actually a good thing because it really taught me that I didn't know what I was doing. And it really taught me to I need to start learning what I'm doing. And then it really helped me to focus on. Teaching people that come to my Web site. What? What's really going on? And at how to edge, you know, the different education that you need. I want to I wanted to be seen as, you know, the trusted person that wasn't selling anything that you come here. You get the information and whatever you want to do with it, that's fine. Versus going to a Web site like their Web site. You know, and they're pitching. All these different deals from all these different sponsors. And you don't know who you're dealing with. So now the only people that I'm best with, I know them. I've met them personally. Those are the only types of people that I recommend. Other people that I can vouch for. You know, people say with Jeff, what about, you know, this person, you heard about them and. No. I mean, they could be good. I don't know. But I don't if I don't know that at all. I don't recommend.Docofalltradez: So. So how would you get started, though? So you have 50 grand. You start you you obviously need to educate yourself. So you recommend books. What else do you recommend? Podcast. OK. And you had a mentor to write.Jeff: I've if you if you have somebody in your area, that would be great to have. My dad's friend, that huge, huge real estate investor. I set out with him. I told my wife I learned more in two hours than I did probably in two years of college. I mean, it was just mind boggling. It just opened my just complete is open my mouth. This was last year after I've been doing it for a while. So that that's another great place to start. And then events, conferences, which hopefully we can we can start going back to conferences pretty soon. But you'll meet so many different people just in that this weekend. So that's another great place to start.Docofalltradez: Now, you chose apartments syndication, is that correct? I did. So why why did you choose that versus a single, you know, single homes. Single up, Emily homes.Jeff: And I almost started into single family homes, but I realized that I didn't want to be an active investor. I don't want to be a landlord. Mm hmm. And and after talking to people.Jeff: That did it.Jeff: And my neighbor does it. He's got seven houses and he's always said, man. If I could just get 10, 10 houses, I'll be set. But he's always complaining about, you know, God, somebody just knocked a hole in the wall or somehow I just moved out. And I've got a I've got to try to rent it, but I've got to fix it back up first and to me. 10 houses, 30 houses, 50 houses, that's 50 different tenants you're dealing with. That's just. I don't want to deal with that, right. And I just dustups me, you know. You know, different strokes, different folks. But. I don't want to deal with 50 headaches and just seeing how hard and long it would take to scale that vs. having an investment in one, say, 300 door apartment complex. You know, if you have 50 houses, you've got to put on 50 different roofs. If you have one apartment complex with 300 doors, you're only going to one roof. Or just a few rows, you know. Right. And I don't want to be an active investor, so I chose the syndication route to where you pool your money in. You put it in and then every month, every quarter, you get a check. You have to deal with any of that right now.Docofalltradez: Did you set up your first indication or were able to? Did you find it or how did you go about your getting your first indication?Jeff: I went to a meeting network with people and asked them who they invested with or some of the groups. I wrote those names now and then went out and met with those people. And I have three people now that I know and trust and that I've done deals with, and they've they've pretty much all have done what they said they were gonna do.Docofalltradez: So you said meetings are there. Are there national meetings that you attended or just local meetings?Jeff: These were these are national meetings. That couple were in Dallas or Landow. But there are depending on where you live, if you live in one of those areas, they have local meetings. But where I live, there's there's what is too small to have them here. So I went to a little bit larger ones than others.Jeff: Regional meetings to which one would you recommend the most if you feel like a national one?Jeff: I would probably say Joe Fairless(https://joefairless.com/) is meeting the best ever conference. It's once a year. It's February. It was just just this past month. Last month. A couple of months ago. But that's probably probably the this as of now, probably like the Super Bowl of the real estate movement.Docofalltradez: Now, I know this is kind of unusual timing. You know, obviously, we just we're stunned and missed that pandemic. We have no idea what the bottom is. It come with real estate. I imagine real estate's going to take a correction here very soon, assuming none of that happened. What kind of return on your investment would you expect with a typical syndicate deal?Jeff: There there's all types of different returns out there, but the ones that that I'm currently in and the ones that are currently invest in, they pay roughly 7, 7, 8 percent a year and. Typically, there's a five year hold. And then once once they turn around and they sell and in seven years, then you get a. You get to part of the profits split. So if you take all the distributions that you've gotten over that five year period or seven year period plus, you get the the profit split that you get and you add it all together, then roughly you have a what they call a two X equity multiple. So basically, you're double in your money. Every five to seven years, which is a pretty good deal. And the cool thing is most of the distribution will all the distributions that you get are literally tax free. Because of the depreciation you get to take on the real estate. Had. Now, go ahead, I'm sorry. So. So, again, you know, you're you're kind of getting the both the best of both worlds. You know, you're you're getting the passive income every month or every quarter. But because of the accelerated depreciation costs that you can get with real estate, you don't have to pay any capital gains taxes on that.Docofalltradez: Wow. What's that? What's the risk in general?Jeff: The risk in general would be. You know, kind of what you're going through right now. You know, there's some there's some different classes of real estate or apartments or houses or whatever, that if people can't pay the rent, then you don't get paid. But there's some that some of the class-A apartments that are higher in people have money. They can pay self-storage mobile home park. You know, people, you know, stuff like that, that's doing real well now. So it just it just just kind of depends on, you know, what asset class that you're in. But but again, if you're also in the market. And in you. And you're also in real estate. You know, you're in that's kind of one of the reasons I want to do that. I wanted to diversify myself so, you know, with real estate. It really does depend too much on what the market goes up or down. It usually is pretty steady. For the most part. But I like being in the market, too, because you're getting you know, you're kind of getting that aspect of it as well, that different diversification.Docofalltradez: Can you can you offset any of your other income from the depreciation in these deals or is it just from the capital gains from the deal itself?Jeff: I'm not a I'm not a tax attorney, but I do believe that you can do that depending on how you have your structure, the way that your income and you have different Elsie's and that sort of thing. But I do think there is a way that you can offset others as well. So I would check with your attorney, your accountant, but. A lot of times a lot of these accounts don't really have a whole lot of experience with real estate. So you want to make sure that you work with one that does. I do know. The I think the Web site is called the real estate. I think it's the real estate CPA or the real estate accountant. And there they really work a lot with passive investors. That do syndications and that sort of thing, so they they know the ins and outs of it.Docofalltradez: Excellent. And with respect to negotiate these deals, do you use an attorney to negotiate the contract or you just kind of take what they give you? Does. How does negotiation work?Jeff: Well, when when you're a passive investor, you're buying a share within the LLC of that group. So with with that, you don't have to do any negotiating. That's how they put the deal together. There they have people that do all that by it. That sort of thing, sell it. So you're basically just kind of piggy piggybacking on their on their deal.Docofalltradez: Excellent. Well, hey, Jeff, I I've learned a lot myself. I I myself have been an accidental landlord. I tried commercial real estate and failed.Docofalltradez: I tried regular real estate and failed. I've never I've not done syndicates as of yet. I'm really curious to try it. I'm going to check out your Web site. I want to learn learn about it. I want to congratulate you on your Web site. Dr. debt-free dot com. It's awesome. I think there's a lot of information on your Web site. Your blog is amazing. It's very well-written. And you have a lot of podcasts that you've been on. And I think you're a wealth of information. What kind of what kind of ending advice would you like to give kind of to a physician or a dentist who's kind of mid-career and they're just kind of struggling with this whole pandemic right now, financially speaking?Jeff: Well, hope, hopefully, that you kind of look at where you're lacking in. And it it's a wakeup call, you know, for those that don't have much of emergency fund. Soon as you get back to work, I would focus on that, really building that up before you start doing anything else. For those that are sitting at home, not working, not seeing patients. Because they only have one stream of income. Maybe you need to focus on once this is all over. Looking at getting some alternate strains of income, passive income. If if any of your listeners would like I have a free god on my Web site that they can download and it and it basically talks about how to create passive income with real estate syndications. So if they're interested, it is go to debt-free d.r dot com slash free God. There they can they can download it and they can learn that'll be. They'll be there like the first start to start their path with passive income.Docofalltradez: Excellent. Hey, Jeff, is that the best way to get a hold view is debt free? Dr. Dot com yep.Jeff: Debt free d.r dot com or Jeff Jeff at debt free d.r dot com.Docofalltradez: Excellent. Well, hey, Jeff, I want to thank you for being on the show. I really appreciate it. And I look forward to working with you and learning a lot.Jeff: Thank you. Thank you very much. And keep up the great work with your website and your podcasts, too, as wealth of information there.Docofalltradez: Well, hey, I appreciate it. And just to let everybody know if you'd like to get a hold of the show notes, some of put all the links that Jeff mentioned in on my Web site, doc of all trades and the physician negotiator dot com. You could. You'll have all the links there. And again, we're on the Apple iPod. Apple podcasts and. Great to have you. Thank you for listening. And hope to see you soon. Thank you for listening.We hope you enjoyed the Physician Negotiator podcast, our show notes and other resources.Please visit the physician negotiator dot.com.Quickly and accurately automatically transcribe your audio audio files with Sonix, the best speech-to-text transcription service. Sonix uses cutting-edge artificial intelligence to convert your mp3 files to text. More computing power makes audio-to-text faster and more efficient. Are you a radio station? Better transcribe your radio shows with Sonix. Create and share better audio content with Sonix. Sometimes you don't have super fancy audio recording equipment around; here's how you can record better audio on your phone. Manual audio transcription is tedious and expensive. Do you have a lot of background noise in your audio files? Here's how you can remove background audio noise for free. Sonix uses cutting-edge artificial intelligence to convert your mp3 files to text. 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EP 09: Getting Started with Practice Management by Docofalltradez | Dr. Brent W. Lacey http://traffic.libsyn.com/thephysiciannegotiator/Ep0920Final20Brent20Lacey.mp3 WHO’S ON THIS EPISODE  Website i Email EP 09: Getting Started with Practice Management – Dr. Brent Lacey In this episode, we invite Dr. Brent Lacey to share effective strategies and actionable tips on how physicians can: achieve financial literacy, seek out mentorship, effectively negotiate their contracts and mitigate burnout.   Dr. Lacey is a full-time practicing gastroenterologist and physician blogger. As Founder and CEO of TheScopeofPractice.com, he specializes in personal finance, practice management, and early career strategies.  Highlights and insights from our discussion below. Reversing the trend: The importance of personal finance savviness to mitigate debt. Consider this: Eight out of 10 medical school graduates borrow to earn their degree. Most take on six-figure debt with 18% borrowing $300K or more. The average time taken to repay medical school debt? Thirteen years.1   Despite these astounding figures, nowhere along the pathway to earning a medical degree do educators teach medical students how to manage their personal finances, let alone their private practices or business. Dr. Lacey shares tried and true tips on how to: Seek out a mentor, sponsor or advisor outside of medicine. Understand simple business efficiencies [e.g. how to run a meeting effectively, negotiate diplomatically and more.] Establish your own personal board of directors to provide you with sound guidance when it comes to taxes or accounting, legal matters or estate planning. The art and science of contract negotiation With new graduates coming into the scene and more physicians moving away from independent practice, it’s critical to understand rights and responsibilities before signing a contract with a hospital or large organization. Among many tips offered in this episode, here are a few that standout: Be prepared and do your research ahead of time. Talk to other people in your specialty to get a good comparison point. Don’t just focus on salary. Think holistically about lifestyle, colleague skill sets, peer experience, work-life balance and workplace satisfaction. Don’t just take what’s offered at face value. Most contract items are negotiable so go in with the facts – not emotion. Think ‘mind over matter’ when it comes to physician burnout The U.S. physician shortage is expected to reach between 34,600 and 88,000 in 2025. With high demand for care and short supply of physicians, burnout is a real epidemic. In fact, an online survey of doctors found an overall physician burnout rate of 44%, with 15% saying they experienced colloquial or clinical forms of depression.2   While this is a very real issue and should not be diminished, Dr. Lacey emphasizes the power of a positive mindset and creating boundaries. Some tips include: Don’t take on too many extracurriculars and volunteering activities. Learn to say, “no” or “not now.” Find your outlet to release stress. How can you create balance and seek out what makes you happy [e.g. cooking, fitness, travel, etc.]? Identify your support system. Whether it’s family, friends or coworkers, surround yourself with people who create a positive energy and can give you constructive advice.   Sources: https://nces.ed.gov/programs/digest/d18/tables/dt18_332.45.asp https://www.medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056?faf=1#1 Ep09 Final Brent Lacey.mp3 transcript powered by Sonix—the best audio to text transcription serviceEp09 Final Brent Lacey.mp3 was automatically transcribed by Sonix with the latest audio-to-text algorithms. This transcript may contain errors. Sonix is the best way to convert your audio to text in 2020. Welcome to the Physician Negotiator podcast, where no decision is left to chance with your host doc of all trades.Docofalltradez: Hey, welcome back. And today on the show, we have Dr. Brent Lacy. Dr. Brent Lacey is a gastroenterologist and he is the founder of the Scope of Practice Dot.com. Dr. Lacy, welcome to the show. Thanks so much for having me. You know, in a crowded space, you have done an amazing job outlining the steps needed to take to have a very successful launch of a medical career. Your Web site focuses on personal finance, practice management and early career strategies for medical professionals. I've been doing this for about three years or so. I'm familiar with all the physician bloggers. And I got to tell you, your Web site is excellent and it's very, very thorough.Brent Lacey: Well, I appreciate that. Thank you. Yeah. Here's his pen. A lot of work, but it's been it's been a lot of fun, too.Docofalltradez: And, you know, I can tell you personally, I've been the amount of effort and time it takes to build a Web site like yours. I can't even imagine how many how many hours you spent at this. So for that, I commend you. I think your writing is very clear. It's very concise and is very linear. And that's really, really, really hard to find. That's what I struggle with more than anything else, is trying to be a linear thinker. And what I think the biggest challenge that physicians have is financial literacy. And so we hone in on our craft. We we we learn how to practice medicine, but we just struggle with financial literacy. And I think if you look at your what Web site, if you were to go through it from beginning to end, I think you would have a good foundation. So the question is, how did you get such an amazing foundation?Brent Lacey: Well, so my my journey is actually very fortunate. My parents were very good at dealing with money and very savvy, you know, from it, really ever since I was a little kid.Brent Lacey: And so I remember when I was when I was young, you know, doing budgets with my dad when I was really young. And, you know, learn how to do a checkbook, learn how to do mutual fund investing, learn how to build spreadsheets. When I was, you know, in my teens.Brent Lacey: So I was fortunate to grow up with with a lot of education and then, you know, really sort to try to continue that during college and med school and and into clinical training with just reading and reading and reading. I mean, I have a couple of bookshelves worth of business books and personal finance books. And so I've just been reading for over a decade now. And, you know, you know, we were talking a little bit earlier. One of the things we had, you know, I'd mentioned is that, you know, a long time ago, one of my mentors taught me that if you want to be a leader, you've got to be a reader. And I firmly believe that. So, you know, I think that's the number one thing that physicians can do for themselves is, you know, if you're not taught this stuff in medical school, which you know, you're not, unless you're forced to go to one of the five places that has somebody like you or somebody like me teaching this stuff just on their own. You know, you got to go out there and read. You know, there's all kinds of sites out there like yours. Like like the scope of practice, you know, and just books out there that you can get. I mean, you can get an MBA by just going to Barnes and Noble, spending a couple hundred dollars on, you know, on, you know, the top 20 business books and you'll just know so much.Docofalltradez: And based upon your parents teaching you how to how to make a budget, you chose to attend the University of Texas, San Antonio, on a Navy scholarship. What made you decide to do that?Brent Lacey: Well, so that was that was interesting. So Texas is unique in that they have their own match separate from the national. So suffer from like the national match. So I applied to all the different schools in Texas because that's where I grew up. And so I wanted to go to school close to home. And I loved the San Antonio program. I loved the clinical side of things. I loved the people that were there and ended up ranking them. Well, I ended up ranking them second, actually, as a matter of fact. But I vacillated between them and Houston 1A and 1B and then, you know, ended up ranking. And second. But they ranked me. They rank me first. Yes. And I loved it. It was a great place. Now, the one thing that we didn't really get there and I think, you know, you didn't and most people don't. Is the is how to manage a business, how to run your personal finances. And, you know, so that's one of the things that I really wanted to try to do well. And so I spent a lot of time reading and now I spend a lot of time writing about this.Docofalltradez: Fantastic. Now there's the application and there's the acquisition of knowledge, but then there's the application of knowledge. And sometimes it's hard to translate that without a mentor. Now, did you ever have somebody like that in your life to help you apply your knowledge?Brent Lacey: Yeah, it did. And yeah, I'd say my my biggest mentors over the course of my life have really been my parents. I mean, they've they've just I mean, I'm incredibly blessed to have two parents that are just really savvy about this kind of stuff and who are willing to teach me. You know, I was in the Boy Scouts for a very long time. So a 12 or 15 years and very active and says it's kind of a natural leadership laboratory. So I learned a lot about leadership and how to manage people and how to, you know, how to leverage influence to achieve a goal, a collective goal with a group, but didn't really get any business mentorship until I got to college. And so I had a really cool opportunity. I went to Texas A&M University for undergraduate gigging, Max.Brent Lacey: And when I went to when I started my junior year, I applied for a position on the leadership team of the the memorial student center, which is the student union there at Texas A&M. And it's the largest student run student union in the country. We had eighteen hundred student volunteers and we had a budget of about $6 million. Some is a huge, huge operation. And so my junior year, I was selected to be the director for leadership development and service organizations.Brent Lacey: And then I was selected to be the chief operating officer my senior year. And in that capacity, I got to lead all the programming for the entire student union at Texas A&M for the year. And one of things that was awesome about that is I got an opportunity to work one on one with the guy who is the now the director of the student union men and Luke Alton Dorf, who's one of my great mentors. And, you know, he and I worked one on one all year long to shepherd the programming committee, you know, through all the different programming seasons.Brent Lacey: And I just learned so much from him. Well, one of the things that you think about when you're you know, or I guess I should say, you really don't think about when you're in medical school and dental school is just the simplex, the some pluses of running a business.Brent Lacey: And I'll give you just a basic example. So one of the skills that I picked up from Luke that I think has been hugely valuable for me is just how to run a meeting effectively. And you think about how many times you've sat in a meeting and you just sit there looking at your phone, you're counting the seconds, because usually this is a waste of time. We're talking about nothing. I could read this in an email. What are we doing here? You know, we're just learning how to run. A meeting is a very basic skill that I think all leaders and and business people should have. But that's not something that's natural. It wouldn't even occur to me to seek that out. But I had the opportunity to study under someone who was willing to teach me about that and thought it was important that I learn. And so and so now that's the kind of thing that I have the opportunity to give to others.Docofalltradez: Now, typically, when you are in medical school, you would receive some type of mentorship from an attending or resident. Did you receive something like that?Brent Lacey: Yeah, our our program at the Naval Medical Center in San Diego.Brent Lacey: Our internal medicine program had a one on one mentorship program that they had where they would at the beginning of your intern year. They would pair up a an intern with an attending and it was either an internal medicine doc or a one of the subspecialists. And so I can't remember exactly the specific to the program.Brent Lacey: But I do remember that Alyssa Alissa Esposito, who was my mentor, she was gastroenterologist and actually very influential in getting me motivated to go for a fellowship in gastroenterology. She and I would meet I think we met probably every three to six months directly. And, you know, she would she would ask me some questions about, you know, how do I feel like I'm progressing in my in my training?Brent Lacey: Am I. Am I getting to where I'm, you know, moving on to the next level? She offer feedback from my rotation directors and things like that. And so I definitely learned a lot from that. But, you know, most of what I learned was was some leadership stuff, but mostly, mostly just medical things. Still, even with that, I wasn't getting a lot of direct business or practice management practical skills.Docofalltradez: Yeah. And essentially my understanding is I had I had something very, very similar in my. My mentor was so focused on the medical aspect of or teaching medicine that they really didn't teach me how to engage in business or what what's what is the what are the qualities of a good of a good company. I remember having one conversation with one of my mentors and I was trying to look for a job when I was a resident and I would try to bounce ideas off them. And when I would ask them questions directly, they rarely knew the answer because they were most of them were accum additions and I was more interested in working in private practice. And so even then I was I was pretty lost. And I think it's safe to say that most medical students and or residents get little to no financial education. and/or business education.Brent Lacey: Well, and I think that's I think that's true. And I think it even goes a step further. Like what?Brent Lacey: What did you I mean, did you get any kind of training on how to select the right specialty, how to know what specialty is right for you? I know. I sure didn't. You know, and one of the things that I think is, you know, I bet, you know, that is not taught very well is how to make simple decisions like that, because we tend to be very, very focused on learning medicine and learning how to be an excellent clinician or how to be or how to do research or how to do surgery or whatever. But all the rest of the stuff we're left to fend for ourselves.Docofalltradez: Exactly. And so even now I mentor students or residents or SRN A's. And when I find my colleagues constantly teaching them about medicine, I'll bring them to the side and try to teach them about business, or I try to teach them about certain simple choices, like if you live in a rural area versus a city. These are the consequences of that.Brent Lacey: Or, you know, if you are going to negotiate a contract, you need to basically have three or four contracts lined up so that you can compare them. And this is how you compare them. And when they talk to me like, oh, no one's ever said that to me. And my understanding is most of them will go into especially the younger students will go into their first job.Docofalltradez: And if you think about an SRO, any they typically graduate from their program at age 23 to 24. And now they have to make a huge decision as to where they're going to work, how much they're going to get compensated and what kind of shifts they're going to be working on. And they have no idea to even turn to. So I try to give them some kind of insight, but there's very little information out there for them.Brent Lacey: Well, and we see that we see that in the area of personal finance as well. So, you know, people are, I would say, equally ill equipped to handle their personal finances. I mean, when I got out of fellowship, I started doing well. I started a financial discipleship ministry at my church and then realized there's a great need for this at my hospital, too. So I started doing some lectures at the at the hospital. And the residents and the students and the nurses would come. And even the corpsman, like our medical assistance, would attend these things.Brent Lacey: And the the sheer lack of knowledge, the size of the knowledge gap was just absolutely staggering. Members sitting in a room or giving a lecture one time on, you know, how to how to save for retirement. We started talking about, you know, IRAs and falling case and I mentioned off hand. So, yeah, the IRA is basically, you know, how it's treated for tax purposes. But inside, you can invest in whatever you can invest in stocks or bonds or mutual funds. And then someone raised their hand and said, what's a mutual fund? I said, Oh, my goodness gracious. I didn't realize we needed to back it up that far. So just just giving people basic vocabulary and taking it down, just drilling it down to the roots.Brent Lacey: I mean, you know, most people don't need to be experts in, you know, the you know, a one exchange and, you know, all these, you know, crazy, you know, investment strategies and things. I mean, just the basics of how to do a budget. Why to have an emergency fund, the nature of compound interest, you know, what is dollar cost averaging? Just very, very basic investing concepts will take people so far. And it's amazing how ill equipped we are as physicians to handle that.Docofalltradez: I kind of feel like the financial industry tries to purposefully make it a little more complicated than it needs to be, because I remember when I first came out, I I struggled with this myself. And so some but the first thing one of my peers told me is I needed a financial advisor. So I remember looking, oh, you know, I literally looked at financial advisor and all over town and I went I just basically went from building to building. And I remember driving to one big firm and it was a beautiful building, three stories high, all black glass.Docofalltradez: And I walked in through these huge doors and sat on this big leather couch. And the guy looked at me and he said, what's your net worth and or how much you know, how much you wanted to ask? I said, well, right now I don't have anything. He's like, call me when you have five hundred thousand dollars. And then that was the that was the end was the end of our of our exchange, you know. And I said, wow, how can this be so complicated?Docofalltradez: So I did what you did and I just started reading and reading and reading and eventually I figured it out.Docofalltradez: What's interesting is the reception. So what type of reception did you get with the people that you've been teaching?Brent Lacey: It's overwhelmingly positive. I mean, there's it. I usually get one of a couple of things I used. I usually get either that people have sort of a baseline level of knowledge that, you know, they understand more or less how what's going on with their student loans. Maybe. Don't really have a concrete plan. And then just sitting down and talking to them gives them some concrete steps that they can take and an action plan to go, OK. Would do this first and then in six months we're going to have achieved this and this is the next step and then this is the next step after that. And then two years later, you're debt free.Brent Lacey: Or the other thing that I get a lot is people go from a feeling of hopelessness to hopefulness. It is amazing. I mean, the the average amount of medical school debt right now is the most recent statistic I read is that people graduate with about $200000 in student loan debt. That's the average. And that, I think is a dramatic underestimate, because that's not counting.Brent Lacey: That's not counting people like me who went to school on a Navy scholarship or who maybe did M.D. p._h._d program or something who come out with zero. So there's a bunch of zeros being averaged in there that's not really fair. And then it's also not counting a lot of foreign medical graduates who are coming over here after, you know, you know, having gotten their program paid for in their own country and then coming here to the states. So I think the real number of if you look at people who actually take out student loans, I think it's probably closer to 250, 300, maybe it's 400, I don't know. But I talked to lots of people that have three, four and five hundred thousand dollars worth of student loan debt from just medical school. And that's just for them. And that doesn't count necessarily. Undergrad doesn't count. Graduate school doesn't count their spouses. I mean, I work with people all the time that have five or six hundred thousand dollars between them and a spouse.Brent Lacey: And, you know, just you can imagine, you know, if you are sitting on a required monthly payment of five to six thousand dollars, and that's just to do the bare minimum and have the opportunity to pay off your student loans in 30 years. I mean, that would just be such an ankle weight would be so painful. So just giving people some hope and giving them the opportunity to see. OK. There is a way to get through this. There is a way, you know, to to battle this debt monster. There is a way to achieve financial success. And giving them that hope is is huge.Brent Lacey: And the number of people that come out of some of these lectures going, wow, no one's ever sat me down and just talked to me about this. I was just planning on keeping this around forever because I figured I didn't have a choice. Now I'm fired up. It's awesome to see that.Docofalltradez: That is amazing, you know? And on the other end of the spectrum, we have physicians who are about to retire. And I think the latest statistic I read was, according to the to the A.M.A., 30 to 40 percent of physicians, physicians have less than half a million dollars in their savings account or not in their retirement account, which is a. For like a whole year, I mean, a whole career worth of. Of earning to have that little amount is just utterly amazing. So I think it spans financial literacy, spans all ages. From what I can tell, absolutely.Brent Lacey: And I've done financial coaching for years. And I see as many people with, you know, the median household income in America is $50000 for that for a household. And I see as many people that are making less than that fighting to stay alive just paycheck to paycheck, as I see physicians. I mean, so, you know, I don't think physicians are immune to any of the typical mistakes that we see people make. Matter of fact, you know, in general, I find that everybody, regardless of income level, makes the same five or six mistakes financially. It's just that physicians make it with more zeros on it.Brent Lacey: Yeah, I remember reading one of your articles that says whatever you do, do not try to get rich quickly. And I thought I think that's very sage advice. How did you so how did you learn how to become a financial coach?Brent Lacey: So so actually, I actually learned about it through my church, so I know if you're familiar with with Dave Ramsey. Sure. Not to mention you probably are. Yeah. So I taught Financial Peace University. That's his that's his financial mastery class at my church a couple of times and then decided I wanted to expand our ah our ministry at the church. And so I took three other guys and we went to Nashville for a week for his financial coach, master trainer. And we we had a week long basically series of classes with 150 other people from around the country who were all interested in the same thing and just learned about bankruptcy and foreclosures and, you know, basics of coaching and, you know, how to get people's spouses together and budgeting, all this kind of stuff. And so that's kind of how I learned to be a financial coach. And then, you know, honed those skills over time, just meeting with people one on one and doing coaching. Both, you know, my hospital and then now also through the scope of practice.Brent Lacey: And so, you know, what's been interesting to me is see that people make mistakes in patterns. I mean, it's it's almost like it's almost like seeing a syndrome.Docofalltradez: Right. So you can diagnose somebody with a syndrome based on the pattern of symptoms that they present with. And it's the same thing. You know, I'm like, oh, this is the this is the student debt syndrome. Oh, this is the I can't get my spouse on the same page with me syndrome. You know, it's pretty funny.Docofalltradez: Oh, you know, the student debt syndrome. That would be a great blog post. So you got to write down one if you haven't already.Brent Lacey: Ok. I like that. I'll do that. That's fun.Docofalltradez: So let me ask you a question. So after you attended, Dave Ramsey's university has finished, what would you call a financial what university? Financial peace. University financial peace like? Okay, I get it. Like war and peace. War and peace. Got it. When you finish that 40 course, what do you get from that? Do you. Does is there a certification program? Do you get mentorship to follow up after that? How's that work?Brent Lacey: Yeah. So we had a we had a three month mentorship afterwards with somebody with their seasoned veteran financial coaches who had been doing this for, you know, 15, 18 years. There there was a certification.Brent Lacey: They have to be careful with what they call it, because it you know, if you call it a certification, then it's subject to, you know, different medical or medical to different education requirements, Kraus CS and that sort of thing. But basically, I mean, basically the most important thing that I got was the knowledge base and then the practical mentorship afterwards.Docofalltradez: So mainly just just getting the skill set developed was really the main value that I got out of that.Docofalltradez: Right. And I'm really careful too about not we do not give financial advice. This is really for entertainment purposes and or to help, you know, get you to the right person to help with your finances or help with your legal requirements or whatever. So.Docofalltradez: So, for example, when I talk about negotiation, I'll ultimately you need to speak to your lawyer. You need to speak to your account. You need to make sure all the people who are licensed and professionals look over your contracts and your finances to make sure you're making a good, solid decision.Brent Lacey: Yeah. And one of the posts that I wrote here in the last couple of months is called Why You Need a Personal Board of Directors. I love that post. That a great post as free as for exactly the same reason. I mean, you know you know, I don't I don't do a lot of my own mechanic work. You know, some. But I mean, you know, cars are basically space shuttles nowadays. So you need someone who's a professional at that. Well, you know, I'm not a tax guy. I have a guy who does Texas for me. I mean, I'm not I'm not an attorney. I have a guy who does, you know, contract work. I mean, and you've talked about this on your site. You know, the importance of having, like, for example, an attorney look over a contract with you because, hey, we're we're not we don't we don't go to law school. I don't know anything about that. I mean, I know enough to to know what questions to ask. And then I need to know how to find a person who I can trust to put in my corner, who's going to be a professional advisor for me in that area that I'm not a professional.Docofalltradez: And again, the whole board of directors is very, very important. You've mentioned to what are the other people that you would think are really paramount to have on your team?Brent Lacey: So. Well, what's it kind of depends on, you know, what you feel like your shortcomings are.Brent Lacey: So for me, I'll just be I'll just be, you know, like full disclosure, I don't use a financial adviser, like I don't have a CFP that that I work with just as an example, because like I said, I've been doing a, you know, sort of a DIY strategy for a very long time. But I've been reading this stuff for a decade. So that that's for me personally. But I think a financial advisor is definitely someone that you should consider. Having a tax professional or an accountant is huge for sure. I am not a tax guy and. I tell you, honestly, those things change so often that I think it's really valuable to have someone who just that is their life is knowing the ins and outs of that. I think an attorney is someone that's really important to have because you'll need it, you'll need it at some point, you know, for, you know, setting up your business. You know, if, you know, looking over at an employment contract, you know, things like that. So a financial planner, tax pro attorney and estate planner, I think is really valuable someone to have. And it could be an attorney, could be an accountant potentially, but someone who can help you set up your estate so that when you when you die and you know, your assets get distributed as you like, either to your kids or your spouse or but hopefully not, you know, a giant piece to the government.Brent Lacey: I mean, you know you know, you make sure that it's going gonna go where you want. I think an insurance broker is valuable for for most folks. So, I mean, I'm sure you've written on the subject and I know I have that, you know, there are just so many insurance companies that prey on our lack of knowledge. And so having someone that is not a captive agent, someone who can shop around for a bunch of different companies and find you, the best deal is really helpful. And then the other big one, I would say, would be some kind of a real estate professional.Brent Lacey: So at a minimum, you know, all physicians are likely to own their own home someday. But I would say a fairly substantial percentage are going to be in a position to invest in real estate also. And so knowing how to navigate the ins and outs of that for tax purposes, you know, like what can you do? What can you depreciate legally and what can't you know? Where do you buy? What was it worth the right things to consider as you're, you know, trying to figure out how much of a house can you buy, do you rent versus to buy commercial things like that?Docofalltradez: You know, I was surprised by the real estate professional, and I can't emphasize that enough because part of the problem with being a physician is people are always coming at us with exotic proposals for investments. And I have so many friends that have been burnt over the years. And me personally, I actually got involved in a commercial deal back in 2006 just before the real estate crash. And unfortunately for me, I did not have a somebody that I trusted. And so things could have gotten a lot worse. But, you know, my my very first two years out, I experienced something like that. So I didn't think that was necessary. But now I am convinced you must have somebody that you know, somebody that you trust on your side when it comes to real estate. So excellent, excellent suggestion.Brent Lacey: And for and for all these advisors, one of the things that I really try to coach my students and residents on is the the key thing that you want in any adviser is you want somebody who has the heart of a teacher. You want someone who is going to teach you and coach you to make the best decision for yourself. That's why I think of it as a board of directors. You know, you are the CEO of you Inc or of Yourself Inc or your family Inc. And so you need people that work for you. And so if you've got someone who's just trying to sell you stuff and all they want to do is make money off, you fire them, you need to have somebody that you can trust. And that person is going to be someone that after you sat down with them, you learned something, you know, more after talking to them than you did beforehand. And you are getting the answers to the questions to make the decisions you need for yourself.Docofalltradez: Well spoken. OK. Let's change gears a little bit here. You wrote an article called Top Ten Mistakes Top 10 Mistakes Physicians Make when negotiating the contract. I thought it was an excellent article. Clear, concise, very well written.Docofalltradez: Wouldn't you personally seen errors like no one would have you personally seen with physician contracts that are erroneous or you've personally experienced? And what advice do you give? Maybe the top two things that you think physicians and or dentists and or nurse professionals need to know about.Brent Lacey: So I think the number one thing I think the number one thing I would say is that and this is true, I think in general of any negotiation or any two way conversation, and that is the person that is the best prepared, that has the most knowledge tends to come out on top.Brent Lacey: So if you think about if you think about that from a standpoint of let's use an example of our everyday lives. So as physicians, when a patient comes in to see us like for like for my world, if someone comes in with abdominal pain, I understand abdominal pain at a level of 10 out of 10 and patient understands abdominal pain at a level of Web M.D. out of 10. Right. Which is an excellent judge. Yeah. So now we're working towards the same goal in that case. Right now, that is.Brent Lacey: But in general, you know, we are we're operating off of my understanding and my knowledge. My experience to get us towards the end point, so when physicians are trying to negotiate a contract, they really need to take the time to read the contract to know what's in the contract, and then especially to know how it compares to other contracts. Is, you know, similar specialties. So, you know, talking to other people in your specialty. Talking to junior employees at that exact firm. Talking to people who have been out of practice for a while and say, how much were they offering you and what kind of guarantees were they offering you when you started things like that. So the more knowledge you have going in, the better you can negotiate, because you know what is reasonable. So, you know, if they bring you a super lowball offer or have, you know, work our requirements or work out requirements that are just tremendously outside the bounds of normal. So I think that's probably the most important thing. And then I would say the second thing is that I would say is just sort of an overarching thing and we can get into specifics, if you like, as well. But it's just sort of philosophically, as I would say, is being afraid of actually negotiating.Brent Lacey: So as physicians, you know, we're we're constantly trying to help people. We're constantly trying to approach every interaction with as much empathy as possible, or at least, you know, we try to. And when you're when you're approaching a business negotiation, you really can't think of it like that. It's not it doesn't need to be adversarial, but you need to go into it with sort of a dispassionate view of things and say, OK, this is a business transaction. In this moment, I'm not trying to get someone to be my friend. I'm not trying to get someone to build a physician patient relationship. I'm trying to see to it that I end up with a fair deal at the end of this. And they're trying to see that they end up with a fair deal out of this, too. And so that's what we're trying to work with. And all they all things in a contract are potentially negotiable. And so I think recognizing that is very important and being willing to actually fight for your own side of the contract is is the second big philosophical thing that physicians need to take in mind.Docofalltradez: Me personally, I think if you're young and you're coming out of residency, that might be a great challenge. Even assuming that you're going up against somebody, they might be either in a mentor or somebody say you decided to stay in your department. The people that you've been taking orders from, now all of a sudden you have to negotiate with, it could pose a challenge. So in that regard, maybe that might be a situation where you want advice of somebody who can be a who cookie negotiate on your behalf. But like you said, you have to be prepared if you you got to know the numbers. You have to know what's fair so that if you do use a third party, they can advocate for you. That makes sense.Brent Lacey: Absolutely. And I'll tell you what's interesting that I've seen over the last I guess I've been hearing about it for the last four or five years. It's this year. We talked about syndromes a second ago. I think new graduates make mistakes in one of two different directions. It's very interesting how this has polarized. One mistake that people make is massively undervaluing themselves.Brent Lacey: So they go into a contract negotiation prepared to ask, basically prepare to take whatever is offered. And that's a huge mistake. But then I also see people go in with wildly unrealistic expectations. So, you know, I'll give you a saw. I'm joining a group in the, you know, this summer. And I remember talking with one of the with one of the senior docs there. And, you know, we were negotiating back and forth and he he said, listen, I really appreciate that you're coming.Brent Lacey: You're coming into this with a sensible view of what is realistic to ask for. So he said, you know, they've had three or four people in the last year that have been seeking jobs with them. And, you know, they were their expectations were just wildly unrealistic, like, yes, I'm going to come in. I'd like to make fifty thousand dollars a year with, you know, for the first couple years and then a million dollars after that. And then I'm going to have, you know, four weeks of call a year like wait on. On what planet do you think we are all living that this is this is the natural order of things, right? We just wildly unrealistic. So it's interesting to see people make mistakes either unrealistically high or unrealistically low.Docofalltradez: It's kind of interesting.Docofalltradez: You know, is fascinating. So I think this is a generational thing. I'm writing an article right now about the different generations of physicians and how they behave differently. And Robert Drago's. He's the physician investor. Are you familiar with him? Oh, OK. So he wrote an article recently talking about how he has a group of friends that that he's known for years. And as they've aged, they're trying to find replacements. And he said, well, as he's kept in touch with him. He will check in on them from time to time. Ask them how they're going and they said none of them can leave their practice or retire because they cannot find somebody to match their work ethic. So it's interesting that you say that because I'm kind of seeing that with this next generation coming up, who who have these expectations. Granted, you do want to have, you know, work life balance, but you you can't have it both. You can't expect to make big bucks and then not work hard. You know, something has to give.Brent Lacey: That is absolutely a great observation. I've observed the same. And so, you know, you and I you know, I think you graduated in really the era before work hour restrictions or.Docofalltradez: Correct. Right.Brent Lacey: And I just barely missed the work hour restrictions myself. So it's definitely something I've noticed with the newer graduates that are coming out.Brent Lacey: You know, they they typically, you know, if if they're used to training in a place where they only do twelve hour shifts or they only do 14 hour shifts and they have six handoffs in a given day. And, you know, they have the idea of all the weekends off or whatever.Brent Lacey: You know, it's I think it's doing people a disservice by making them think that they're going to be able to maintain the same level of work afterwards.I actually wrote a post last year called Debunking the Myth that Life Gets Easier When You Finish Residency.Brent Lacey: Addressing this exact problem, because people come out of that, people can get over that article. People come out of training thinking. Yeah. You know, all you know, they're thinking. I've paid my dues. Now I'm ready to be an attending and work less. And it's not that way in the majority of time in the majority of cases.Docofalltradez: You know, the funny thing about that is, though, I think if you are a brand new graduate and you recognize it, you have such a huge advantage against your peers, because if you walk into a practice, say, listen, I'm willing to kill it, I'll do whatever it takes. I'm you know, I'm a junior guy. I'll go to whatever meeting. I'll contribute. You're going to to be a rock star. You're going to skyrocket. You'll bribe, you know? Not only will you be partner within two years, you'll probably running the group and within five.Brent Lacey: Absolutely. And that it's it's so funny that, you know, just having an exceptional work ethic has become something of a superpower just by virtue of the fact that lots of people are ready to try to take it easy. And I one of things I was encouraged, my students and my my interns especially.Brent Lacey: So you know that you remember. Remember intern year. Right. Although we all try to forget.Brent Lacey: But, you know, the thing I always tell my interns is like, nobody is going to come out of this. Nobody is going to come to you in July and think, oh, my gosh, this guy is such a bad physician. Every time you screw something up, the only thing that people think is it's July.Brent Lacey: Everybody understands that you're new. Everybody understands you. You're inexperienced. The one mistake that you can make is coming in and being lazy or or or not or just not caring or just not really paying close attention. And those reputations have a way of following you. And you know, what I tell my interns is like what you need to do if you want to succeed here. You need to come in prepared to assassinate your first month. You're your first month. You need to be here an hour earlier than than you think you're supposed to. You need to read five more articles a day than you think you're supposed to. You need to be doing every single thing you can to just be awesome.Brent Lacey: Because if you can do that, then the next month, when you're when the new attending comes on, I'm going to be telling them, OK. Listen, Joe is fantastic. Dale really is kind of lazy and those reputations are very hard to shake. And I'd say what those kinds of things that that same phenomenon persist when you get out. And so if you go into a contract negotiation, you like.Brent Lacey: Yeah, I really expect to be making a million dollars a year and doing, you know, six weeks of Colyer. And then the senior guys are like, okay, I bring in three hundred fifty thousand dollars a year and I have 15 weeks of call year. And I've been doing this for 20 years longer than you. You know, it's going to be very hard. So it's going to be very hard to shake that reputation over time.Docofalltradez: Well, there are twenty six thousand anesthesiologists in practice right now in this country. And I can tell you right now, there are few anesthesiologists that are so notorious that they are known throughout that entire community. And so most of them work independently in the middle of nowhere because no one else will hire them. And I'm not sure how many gastroenterologists there are, but I'm sure it's very, very similar.Brent Lacey: Oh, yeah. There's you know, I mean, you know, the American college, a gastro every year is probably fifteen twenty thousand people.Brent Lacey: So that's just to the people that come. So yeah. I'm sure it's the same way. But you know, that kind of thing is is pervasive.Brent Lacey: And so now I think there are ways to overcome that. And certainly, you know, I. I think it's important for us to just the flip side and that you don't want to go into a contract negotiation, just prepared to take it on the chin with whatever they will, with whatever they offer you, you know, and that's part of being prepared, is being able to know what to expect and know what's reasonable to expect and then be able to stand up for what you actually are worth. And I think that there's there's real value in that. But like I said, it's easy to make a mistake both directions, either asking too much or having too high expectations or too low expectations.Brent Lacey: And so the more you can be prepared for that going into a negotiation of any kind. The better the better off you're gonna be in a better off your groups.Docofalltradez: I totally agree. What about focusing on money as your primary driver versus something else?Brent Lacey: I think that is both very common and a tremendous mistake. So, you know, I'm very much a fan of the saying that money can't buy you happiness, say money is money can buy you stuff and you should get some stuff. Go get you some stuff.Brent Lacey: I mean, stuff is great. I love stuff. But but money can't buy happiness. And so for me now I'm in a position right now where just in my in my practice, I mean, I'm a solo practitioner and have been for the last four years. And that has been one of the greatest regrets that I've had the last four years. I mean, I love my team. I love my patients. I still love my work. But, man, I miss being part of a great team. And so the group I'm joined in the summer is one of the best groups in the country and me, if not the best. I mean, it absolutely phenomenal guys and gals. So I think that's a very important thing. And, you know, we when you focus just on the money.Brent Lacey: I think. I think what you find is that is that you can easily get yourself into a situation where the where the daily grind is so intolerable that no amount of money, you know, can make up for it.Brent Lacey: I mean, you know, how many people do you know that have been in a relationship where like, let's say, you know, I've been in a marriage that, you know, everybody's, you know, making plenty money and everyone's you know, you're live in the right. You got a great house. You got a great car. And you just can't stand being around each other. What? You're gonna be miserable. And that's the same thing with the group.Brent Lacey: I think the things that you need to focus on if you're trying to pick the right group to join or trying to pick the right, you know, place to be, you need to think about lifestyle stuff as I think your most important set of criteria. And so that includes things like what part of the country do you want to live in? I mean, the farthest north I've ever lived is North Carolina because I grew up in Texas and I get cold really easily.Brent Lacey: So I don't I don't expect I'll be looking at groups ever in Minnesota and Maine as beautiful as those areas are.Brent Lacey: I can't stand the code or doctors don't tell a physician. I'll fire that.Brent Lacey: Well, yeah, he's he's welcome to have his face and I'll be in Texas. So that's just survive. But, you know, I think you need to think about geography. Think about proximity to family. I mean, if if you really want to be close to your family, you need to be looking at areas that allow for easy travel to your family. I think you really need to strongly consider who your partners are. So one of the things that that that I'm writing about, I'm actually working on a book and this is gonna be part of it is the importance of picking a group or picking a practice.Brent Lacey: Thinking of it the same way that you think about approaching dating from marriage. Because if you think about if you think about it in terms of of a marriage partnership, I think a group partnership is very, very similar.Brent Lacey: And in many ways it's actually more important. You know, my marriages I mean, I personally believe marriage is the most important relationship that you have in your life. But it's, I think, also reality that you will spend as much or more time with a lot of the people you work with in a 30 year period than you will with the people at home. If you're working full time and so you need to approach it in the same way. So don't just go pick a group based on, oh, I like their Web site and you know, they they have a pretty building. Well, that's that's pointless. You need to really enjoy the people you're working with. You need to have people that are eager to work together, people that are helpful, that are collegial, that really want to build each other up. You know, people that want to mentor you. So if you go join a group and everything's eat what you kill and you know, they don't have time to help you out because they're doing their own thing.Brent Lacey: That's not a great place to start a practice, especially if you're so green that you've, you know, never thought about building encoding, for example, or you've never thought about, well, how do I take the right m.a or how do I pick the right nurses or how do I hire a good executive assistant or whatever? So you need someone who's going to mentor you. I think those things are far more important than money. And then, you know, if you find the right place, you know, and you know, then you know and you and you're picking a place that has also decent compensation, you know, you're going to end up being happy and making more money in the long run.Docofalltradez: You know, what's interesting is you have to ask yourself if one job is. Is a stand out with respect to reimbursement and or income. There's probably a reason for that.Docofalltradez: So either the working conditions are terrible, the your partners might be terrible or the culture might be terrible. So, I mean, for me, when I see these super high compensation, it always raises an eyebrow. And I'm very, very you know, in fact, like I said, that the NSC community is so small, I can look and tell you which job is going to be more challenging than another job. And the only way you get me to go there is to pay them. And so the question is, do you want to set yourself up where the only thing you have to look forward to is money? And I think you're spot on.Brent Lacey: Yeah, I think it's a really, really important consideration. And, you know, we don't I don't think we pay enough attention to that. And that's definitely something that any new graduate or any anybody who's in medical school or anybody who's in fellowship residency, if you're listening to this, pay attention to that.Docofalltradez: I mean, what Dogville Trisha said. I mean, pay attention to those kinds of red flags. And so if something seems too good to be true, it probably is. You know, find you know, it's amazing if you talk to some of the junior partners, one on one or some of the junior employees one on one. It's amazing what you can get people to tell you, you know, if you're going to interviewing someplace.Brent Lacey: See if you can take one of the whoevers, their newest hire or whoever has been hired in the last two years. CV buy them a cup of coffee or take him to lunch and just pick their brain. You'll be amazed at how quickly people will be willing to just start talking about it. And so if you ask him questions like what's the best thing about working here? What's the worst thing about working here?Brent Lacey: You'll be amazed at the kind of stuff that people will tell you, like, hey, man, let me tell you about the stuff that they do here. They will just unload.Docofalltradez: Exactly. And I think this is a nice transition into physician burnout. So we're having a, you know, an epidemic of physician burnout, 70, 70 percent physicians are burned out. Is it entirely possible that some of these positions are burnt out because they don't like the people they're working with? They don't like the institution they're working with. They don't like the amount of work that they actually have to do for a given institution, you know? So these are these are factors that can potentially lead to physician burnout. But you have a very interesting perspective on physician burnout. Different than what I've heard elsewhere.Brent Lacey: Yeah, I think that's I think that's true. I so I tend to take the position that while burnout is very real, I think it is.Brent Lacey: A mistake of galactic proportions for physicians to claim that as a mantle and say, yeah, I am burn out or no use. Ah, I have I have burn out. Therefore, you know, that is what now defines me. I am a physician who is burnt out. You know, I've seen post going around here in the last maybe six months or so. Calling it moral injury, which frankly I think is just overly dramatic. I mean, you know, and again, I don't mean to make light of the situation at all. Believe me, I recognize burnout is a serious epidemic.Brent Lacey: But if if that's if that's as far as you take it and you say, OK, I am burned out. You know, I have just gotten burned out from this job. And you don't ever address it. You're claiming a mantle of victimhood that I think is putting you in a prison that is partly of your own making.Brent Lacey: And so one of the things that I talk to my students and my residents about is that it's it's very important to guard against burnout. And part of the way you do that is by not taking on too many things, not trying, not volunteering for every last committee and every last assignment. Learn to say no to some of these things for sure. But, you know, you also need to have a way of dealing with it when it happens. So, you know, what is your support system is your support system exercise? Your support system is being at home with family. Your support system is, you know, enjoying time with your team. You need a way to address this issue when it starts to come about. And in general, I would say that the best way to do that is by having a really good network of friends and colleagues with whom you can be open and vulnerable, because I don't know how does at your facility, but most facilities, the administration are really lousy at addressing this. You know, they'll bring in someone. They'll be like, okay. Yeah, we need more. You know, we need more yoga. We need more, you know, many more med guided meditation. We need more. No, no, no, no, no. We need more support. We need more people. We need more. Help me more. I know. Exactly. We all know what we need as physicians. But if we just claim the mantle of victim, then I think we've done ourselves and our patients, frankly, a tragic disservice, because what happens is we stay in this burnout mode until we just give up and we go part time. We go for non-clinical work or we just straight up retire. And then what? What's happening to our patients at that point? Well, I'll find somebody. But, you know, we're we're causing them to go through unnecessary transitions where, you know, limiting the number of doctors in there already, you know, shortage situation.Brent Lacey: So, you know, there are definitely ways to guard against it. I think we all should.Docofalltradez: So it's interesting. I I personally went through some burnout. And I think when you say victimhood, you are spot on. Being a victim is a choice. So if you look at you were in the military, for example, if you get injured in the military. That wasn't a choice. If somebody shot you, that wasn't a choice. How you react to how you've been shot. That's a choice. So if things happen to as a physician and you're not happy with what happened to you, how you react to it determines what the outcome is going to be. And if you choose to be a victim, then you become a victim. If you choose to take that situation and learn from it and then overcome it. And I think you even said this will become the master of your domain. You know, do something about it. You're not going to get burned out. And I think physicians one thing that we struggle with is the whole idea that we are important. The whole idea that we need significance in our life to be to have any meaning and derive meaning from our life. And sometimes in this new health care paradigm, we don't feel significant anymore. We have to do more paperwork than we've ever had to to do. We have to do more prior authorizations. So therefore, it's kind of an injury to to who we are. But again, if you look at it that way and you become a victim, you, of course, going to become burnt-out.Brent Lacey: Yeah. One of the things that I that I try very hard to do is anytime I find something that is starting to bother me or things that I don't enjoy is I try to turn that around and embrace it as something that I'm going to find a way to enjoy. So I'll give an example that I give to my students as they're trying to think about what specialty they want to go into. I call it embracing the 1 percent.Brent Lacey: And what that what I mean by that is that when you're trying to pick a specialty, you need to love. Ninety nine percent of what you're gonna be doing in that specialty. And you need to not hate anything. You need to not hate that last one percent. And that's not the same thing. It's a. Important distinction.Brent Lacey: So I'll give you the example from gastroenterology, and so I'm sure for. I'd be fascinated to know what you think the 1 percent is for anaesthesia because I've never even thought about it.Brent Lacey: Bufford But for G.I., the 1 percent is irritable bowel syndrome. So everybody in gastroenterology enjoys the majority of the stuff we love scoping. We love IBD. You know, most of us like liver stuff, you know, and we we enjoy all the intellectual side of things.Brent Lacey: We enjoy all the procedures, all that. But irritable bowel syndrome for many people is just the bane of their existence. You know, there are limited therapies. They have patients have severe symptoms at times. It's frustrating because trying to explain to somebody, listen, there's nothing there's not an organic cause of your symptoms. I mean, it's not imaginary pain, but there's you know, all the tests are normal.Brent Lacey: There's nothing I can point you to says this is your actual issue. And so if IBS is the only thing that you hate about gastroenterology, well, that's it's really not a good position for you to be in because you'll see four or five patients with IBS every single day. It will consume your life. And so when it comes to things like when it comes to burnout, I think it's really important to take the same approach. And so if paperwork is the thing that you hate the most. Find a way to make it an adventure or find a way to make it a game. I don't mean to make it sound trite, but, you know, find a way to say, OK, I'm going to figure out how to beat the system. Like I hate coding. I hate coding so much. But one of things that I decided a long time ago is like, okay, listen, it's gonna be part of my life. I have to just get over this. So I'm going to figure out a way to make this to make myself the most excellent guy with when it comes to coding. I'm going to be so good at this that you know, that I'm that, you know, it's like me against the world. Right. You know, the world's trying to make it so that I can't figure Cody out. No way, man. I'm going to figure this out. I'm going to beat him. I'm going to be the one who who takes it in this situation. So I think embracing those difficulties and and saying yourself, I'm going to overcome this. It doesn't matter. I will not be stopped. Is is critical. And having that mindset shift is just so important.Docofalltradez: So what you're saying is I have to start enjoying to go into the endoscopy suite as outracing.Brent Lacey: Well, I think the I think everybody should enjoy going into the adoption is not done.Docofalltradez: And that's so true. I think even everybody will have some aspect of their practice that they really don't like.Docofalltradez: And you know, for some people, maybe they did choose the wrong specialty. And you don't have to dig deep down inside and and face that face up to that. And if you don't like it, it's up to you. It's paramount that you do something about it.Brent Lacey: Well, and I am. Let me address something. I can I can hear. There is there are people out there listening to this that I can hear you guys rolling your eyes. Exactly. Oh, Brent. Guys, this is you don't know what I've been through. You don't know what's going on. Listen, we don't. We absolutely don't know everybody's situation.Brent Lacey: And what I do know, though, is I've seen way too many people that have decided that, you know, burnout is what I is. That is what defines me now.Brent Lacey: I am a burnt out physician, and unfortunately, no one cares about you as much as you are going to care about yourself. There are people that will help you if you reach out to them. There are people who want to be your support. But if you just decide that burnout is the end of your life, that that is all that there is now.Brent Lacey: The only one that is going to care about that, frankly, is going to be you. And if you will just decide that that is not going to be the thing that defines you. You will find people that will help you get out of it.Docofalltradez: Exactly. Interesting story. So. This helps put things into perspective. I recently met a gentleman. He has no arms and he has no legs. He has just nubs, OK? And he's born this way. And he says to himself. Everyone's if everybody feels sorry for him and he's like. People don't like looking at me, he said, but in my life I've accomplished becoming a scuba diver. I'm a surfer. I have my own company. I'm a motivational speaker. I'm married and I have a wife. He's like, what I don't understand with people. I have I have almost nothing and I do everything he said. And you all and you speaking to a big audience. You have everything and you do nothing. And so the point is it's exact. It's your perspective. It's all that matters.Docofalltradez: Your perspective on on how you can take that information and how you're going to process it and what you're going to do with it. And so, again, I agree with you. I don't want to belittle it.Docofalltradez: But at the same time, you know, so many people have so little and you have so much, you just have to make the best out of it.Brent Lacey: Couldn't agree more. Absolutely. Well, Brett, I was an amazing conversation. You've inspired me. I think I'm going to go start a program with my as asanas my residents and my nurses. How often do you do it at your institution?Brent Lacey: Well, I was doing it maybe three, four times a year, but I've started doing it about once every other month with our residents, and so we'll send out what I started doing as I just I'

EP 08: Starting a ketamine clinic from scratch by Docofalltradez | Dr. Cindy Van Praag http://traffic.libsyn.com/thephysiciannegotiator/2019-04-16-t03-05-09pm-final-mix.mp3 WHO’S ON THIS EPISODE ? Website i Email Have you heard of Ketamine or Ketamine Clinics?    Dr. Cindy Van Praag of springcenterofhope.com along with her business partner Tessa Benson, RN decided to open one two years ago without any prior experience.   Now they have a thriving clinic after some trial and error.   Find out why they opened their clinic and why some people would benefit from an infusion of Ketamine.    What are the obstacles, opportunities and investment requirements needed to be successful?  Is starting a ketamine clinic a viable way to transition out of the medical-industrial complex completely?    What are some of the mistakes she made and the advice she has for others?   In the Podcast: Spravato:  https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm632761.htm Cindy Van Praag Podcast.mp3 | Convert audio-to-text with the best AI technology by Sonix.ai Download the "Cindy Van Praag Podcast.mp3 audio file directly. This mp3 was automatically transcribed by Sonix (https://sonix.ai). Welcome to the physician negotiator podcast where no decision is left to chance with your host Doc of all trades. And welcome to the show. And today I have a special guest Dr. Cindy Van Praag. She is owner and operator of spring of Hope Center. I believe it's a Ketamine Infusion Center clinic in Spring Texas and the website is called I believe it is spring a Center of Hope dot com. Cindy welcome to the show. Cindy Van Praag: Hi. Thank you for having me. Docofalltradez: Well what a you know. So I've been wondering about the ketamine clinics for a long time. And I just you and I just met at the first annual physicians helping physicians conference and it's called the non physician non-clinical career celebration networking and meeting was just this past April 6th and 7th 2009 in Austin. And I had a blast. Docofalltradez: I had a blast meeting you and a funny thing happened during the conference. Tons of people came up to me and asked me what type of careers they could start specifically and the ketamine business. And I was like What a coincidence. I met somebody who's an expert at that too well I guess that's me. Cindy Van Praag: Yes yes. Docofalltradez: So. So you know I thought it was really really neat that I met you. I mean myself I've always had a curiosity about starting Academy clinic. I'm an anesthesiologist and I believe you are as well. Yes. I have numerous friends who are also been interested in starting ketamine clinics. So if you don't mind to introduce yourself tell us a little bit about your background and how did you get into the movie business. Cindy Van Praag: Sure. Well this all started out in Chicago and you know I went to med school and got my M.D. and went to residency in anesthesiology in Chicago well so I spent about nine years in Arizona as a partner of a large anaesthesia group. It was M.D. owned. So it was pretty fantastic but then moved to Houston for family reasons and did about four years of mobile anesthesia where I would be doing office based anesthesia or surgeons in their office which is a whole nother ballgame. About two years ago however I I moved on into the ketamine business so I opened up a business with a business partner who's a nurse and it's spring center of hope and we provide I.V. ketamine infusions for a variety of patients. And I think I have my whole career is kind of built up to this point. I have always been restless. I have always wanted something more. I attended the Sikh conference in Chicago years ago I attended this you know the BHP conference you just mentioned all of these things I think I'm an entrepreneur at heart and I am so fulfilled with this Ketamine Infusion clinic that started about two years ago now now. Docofalltradez: So with your office based practice did you start that business or did you did you get. Did you hire into that business. Cindy Van Praag: No I hired into that business. Cindy Van Praag: And that's that's basically the job that I took when I moved here to Houston and I worked with a great doctor who owns mobile anesthesiologists of Houston and so and together we did a lot of cases in office. Docofalltradez: So did you learn your business acumen through that practice. Cindy Van Praag: I think I honestly just learned it on the job. My husband is not a doctor which is great because he complement me and he is such a business minded fellow that I think I learned a lot from him and he's really supported me this whole time so I just learn on the job and when I say on the job I mean I've been with this spring's center Pope I just jumped right in and I learned this as I went. Docofalltradez: That's amazing. What gave you the courage to take the finals the final leap if you will. Cindy Van Praag: I was done being restless. I was done trying to search for what. What am I gonna do. What is my business going to be. Should I stay open a wellness center should I do this. I do that. And really the opportunity came along when my business partner had a family member. A 15 year old girl suicidal Cindy Van Praag: Who I knew personally and multiple multiple attempts almost successful many times and her psychiatrist told her and the mom he pretty much stood up as Hansen said I don't know what else to do for you. Cindy Van Praag: So the mom basically found through online research ketamine as an alternative and so we watch this transition or of this girl who is almost she's just lifeless to now. Cindy Van Praag: She's another person. It was a 180. So that's what really sparked you know my business partner and I saw that and we're like you know what we can do this. Absolutely we can set this up and save people's lives. And so I really have a heart for. Even though I'm in my background as an anesthesiology man. Cindy Van Praag: I have a heart for these mental health people that come in especially the suicidal patients you know and that just gives me chills because I think all of us got into medicine ultimately though to want to help people and I feel like at least in anaesthesia I'm not sure how you feel about this. Me personally sometimes I'm not sure if I'm helping people or not. You know some some days you just kind of go through the whole day and and I feel like I've accomplished nothing but you know it sounds like your work has purpose and meaning and you actually can see your your efforts and the lives that you're changing. Cindy Van Praag: Right. Right. And I used to think anesthesiology was perfect for me because I'm an introvert by nature. And so I thought Oh this is great. You know I interview the patient I talk to them for 10 15 minutes and then I put them to sleep. And so my only interaction has to be with the surgeon and the staff in the operating room but I guess as Cindy Van Praag: As time goes on I realize I do want more interaction with my patients and I do want to talk with them and I'm I'm there for each infusion that we do at our clinic and so I am very bald and I talk nonstop now. So we're being an introvert. I am I'm a different person now. Docofalltradez: Yeah. You know I would have never guessed that about you know when I met you in Austin you were very open I felt very comfortable talking to you didn't feel like you were guarded at all. Cindy Van Praag: That's great. Good. Docofalltradez: So you kind of I mean you let into a couple of my questions but let's let's back up a little bit and first you give me a one I want indication for academy clinic but basically again let's let's take a step back. So most of the audience is gonna be physicians there'll be some physicians though aren't really familiar with ketamine. So basically what is ketamine and what is it used for and how does it work right. Cindy Van Praag: So Ketamine has been around for over 60 years. It's I know it well from the operating room. So we use that as an anesthetic as an adjunct to our anaesthesia. It is also used in emergency rooms for. Acute pain control for setting you know let's say just location setting a bone. So E.R. docs are very familiar with it. And also it's been used on the battlefield and I think that's where it started. Cindy Van Praag: It's a drug that doesn't cause respiratory depression it doesn't cause a drop of blood pressure is actually a very safe drug to use in a situation like the battlefield for example when you can't monitor the patient as well. So it's been it has a long history of use in those three areas. Docofalltradez: Now the dose that you use in an anesthetic is much much higher than what you're using in your clinic Correct. Cindy Van Praag: Correct yeah. So I if I use a dose in the operating room I will be pushing or giving a bolus and in the clinic it might be that same dose but it's spread out over an hour. So we give it my eye in my clinic I give it by I.V. And I use that dose over an hour. So yeah but minute by minute it is a much much lower dose. Docofalltradez: And and why why I.V. Infusion versus other mechanisms of uptake. Cindy Van Praag: Well my chip Well it's you can give it in many different routes of administration you can give a nasally and I am an I.V.. The reason I chose I.V. is because it's 100 percent up to you know what you're giving is reaching the brain. And I have complete control over it. So I'm using an infusion pump and I can stop any time I can increase my rate I can decrease my rate. Cindy Van Praag: I have complete control over how much ketamine this patient's getting. That being said other docs and other ketamine clinics do primarily you know intramuscular injection and really they do a hand I think that might be more of the psychiatrist out there who maybe aren't as familiar with using I.V. routes and that is effective as well although as you can imagine once you give a shot you can't take it back. So if you're giving if they have a reaction to it or Cindy Van Praag: Or it doesn't have the same right effect that you want is hard to change that. So Docofalltradez: That's why I use it and I know for I have I can tell you a story that happened to me when I did I am infusion once but I won't get into that. Docofalltradez: But I agree with you. It's very unpredictable so with least with IBD you can always turn it off and then you're back to where you started right now. What are the risks associated with doing something like this. Like from a patient perspective. Cindy Van Praag: Well there are a couple of things so we screen our patients clip carefully for this. Cindy Van Praag: So ketamine is known to have an effect on your blood pressure. So for example it can raise your blood pressure it can raise the heart rate. So we screen for of course hyper uncontrolled hypertension many cardiovascular disease and. Other risks might be if we screen again for this other mental health disorders such as schizophrenia or mania. You don't want to give ketamine to these people or you might exacerbate their. That diagnosis. So if I find a few screen patients appropriately you minimize their risks of the scary things like heart problems or going into mania minor risks would be things like nausea. Or them not being comfortable with this dissociative feeling that you get under ketamine. Cindy Van Praag: So there is kind of runs the gamut of minor to major and we try to really screen out those that might have major effects from it so based upon that we know who not to go to who who's that who would be an ideal candidate for this type of therapy. Cindy Van Praag: The ideal candidate. Cindy Van Praag: So this both well back up this therapy can treat not just the mental health disorders that all this but also chronic pain. Cindy Van Praag: So starting with mental health disorders the ideal patient for depression for example of the treatment resistant depression. So that's a patient who's been struggling with depression who is trying at least two different courses of antidepressants and failed that therapy. That is our ideal patient for depression and moving on to suicidal ideations are the ideal patient is not the acutely suicidal person we're not you know that's for the emergency room but those chronic suicidal thoughts that are plaguing these people day by day and then you move on to other diagnosis we treat we have OCD and anxiety and. PTSD again those things are are issues that have been treated by a psychiatrist or a primary care physician and haven't responded to treatment. So we don't call ourselves the first in line at treating these things. Cindy Van Praag: We are second or third in line. We are after these patients have tried and tried traditional therapies and even psychotherapy and that just hasn't worked. And moving on to chronic pain it's you know we treat things like neuropathy and fibromyalgia and again these are patients who have not succeeded with traditional therapies. Docofalltradez: And I reviewed your Web site and I highly recommend everybody go check it out if you have any interest in this because you did a very very nice job explaining who are these who who these patients are and why they would benefit from it and what kind of success you had with these types of patients. Cindy Van Praag: So with our mental health patients I think our highest rate of success is for these the treatment resistant depression patients and the suicidal ideations. And when I say high rates I would say seven. I would say seven to eight out of 10 of our patients Cindy Van Praag: Have a significant improvement that affects our life and they are able to move on which is a pretty good rate. Docofalltradez: That's incredible. And also I guess your partner's daughter was impacted. So are you seeing a lot of teens as well. Cindy Van Praag: We are and we. It has. Cindy Van Praag: Has it's well known you know these teens these days as opposed to when I was a teenager or struggling with more depression and suicidal thoughts in particular. And so we are getting a large number of teens or partnering with. CBT therapists this summer. And she is her specialty. So maybe that's why we're seeing more. Cindy Van Praag: But yeah it's it breaks my heart but that's how we got into this specific business was that 15 year old girl. Docofalltradez: Well are you getting. Are you getting the clients who through referral or are you getting them through your Web site. How are they getting to you. Cindy Van Praag: I'd say the majority of our patients find us online and that we are getting more and more referrals direct from psychiatrist and therapists as as they're learning more about ketamine as an option. But usually what we have to do is you know a patient will come to us first and then we need to tell them what you really do need to have your mental health provider Cindy Van Praag: Onboard with this. I am not going to diagnose a mental health illness illness. I am not going to I'm not going to tweak your psychiatric medications I am not going to you know I'm not going to work on that side of it. I'm solely providing the ketamine infusion experience. So with those people who find us by themselves we do have them contact their psychiatrist or therapist or whoever is managing their mental health. Cindy Van Praag: And we work together. Docofalltradez: I see. So. So you can just walk off the street and get an infusion like today as an example. Cindy Van Praag: No it's a little hard to get into has been that good. Docofalltradez: And so again typically mental health referral with with already established diagnosis that way for you. Right. It's it's easy to justify doing the infusion RIGHT. I'LL DO THAT. DO YOU DO do any marketing. Cindy Van Praag: We do. And that's been a lot of trial and error as I said we learned on the job. Most of our marketing is online because that's where most of our patients find us. You know early on we did a radio marketing we did Facebook. We did you know we did everything we could think of but I think online has been the most successful what kind of marketing strategies have you been using online. Cindy Van Praag: Well honestly we did great with Facebook ads paid Facebook ads until they dropped our account because of the word ketamine. So you're kidding. Word to the wise. Yeah. That we are no longer able to run Facebook ads because they think we are promoting an illegal substance. So we've come up to some roadblocks like that but otherwise we've been using more SEO optimization. Cindy Van Praag: We've used Google AdWords and basically just getting ourselves out there everywhere we can online. Docofalltradez: I imagine online and in your practice I mean you if you've only been doing it for two years so you maybe you haven't even reached that critical number yet where you'll you'll go exponential I'm hoping. Cindy Van Praag: Yes. Cindy Van Praag: You know it's really built up over the past month and a half when the FDA approved as ketamine or bravado in early March of this year business has picked up not only in our location but across the country in ketamine clinics. Docofalltradez: And that's what was good for you and ask you about that. So what was the final verdict on that. Exactly. Cindy Van Praag: Right. The final verdict is the FDA has approved the drug from Johnson and Johnson calls bravado. It's it's also known as S ketamine and for treatment resistant depression. And that is a big win before March of this year. The FDA has not supported ketamine for everything I've talked about. So it's been used off label essentially at our clinic. So now we have FDA backing on the fact that this is a real treatment. The question going forward though is is our insurance companies going to support the use of ketamine so the ketamine and s ketamine are two different drugs really. Ketamine is is a risky drug it's a mix of you know going back to chemistry the two are in essence and tumors as ketamine is just half of that right it's just the aspirin handsomer. So it's as ketamine and that's what they call it. So that is the portion that is FDA approved. Docofalltradez: Are you getting both or are you just a or are you just gonna give us bravado. Cindy Van Praag: So in our clinic we are just giving ketamine. We are looking into giving spore vato. However since it was just approved it's going to take two or three months to really get that rolled out. They have a lot of restrictions on how they can distribute that drug to clinics. The patients have to there's a set protocol that we have to administer that drug in the office and there are a lot of hurdles to jump over. And just you know seeing what patients their feedback is provided they haven't been too happy right now because they have to show up in the clinic for two hours twice a week for the first month and then once a week and they stay for two hours once a week for a month and then every other week ongoing which is a terrible time investment and it's so however it's almost as if they're trying to run their own clinical trial and or kind of pad their pocketbook a little bit there. And I understand I understand that to bring this drug to market test takes millions and millions of dollars. Cindy Van Praag: I understand they need to get paid for that but the attitude of the patients is that they're feeling you know they're just getting soaked from these the big pharma. So it remains to be seen how well it's going to take off. Docofalltradez: Well OK. Well you did mention that a psychiatrist also administers I am ketamine who is who is legally licensed to administer ketamine so. Cindy Van Praag: Well medical doctor you know MDD those are can administer ketamine off for off label uses. So psychotic there and to take that back some psychiatrist use I.V. also because they believe it's more effective. There but their guess. Having said that there are many clinics that are run by. Other. Providers such as nurse practitioners C.R. and A's which are. Basically certified nurse anesthetist. And I think those providers are having a medical director that's an M.D. that basically signs off on the ketamine infusions. Now this you know the rules vary state by state. So you know I'm not a lawyer and I know as soon as it can be it can be sticky with each state. But. Any medical doctor for sure can prescribe this. Docofalltradez: Did you look into that for Texas yourself. Cindy Van Praag: Well I honestly didn't need to since I'm an M.D. and I already knew I could I could. But you know going forward if I want to expand and have more clinics in Texas I think it still wouldn't be a problem because I would be overseeing those clinics. So for example if I had a second clinic can I hire a nurse practitioner to oversee that clinic. I could. I was still the medical director so. That's why I guess I don't have all the great answers on. Cindy Van Praag: You know what the other more mid-level providers can do because I was thinking that exact same thing in terms of scaling. But you did mention you there and you like it. You enjoy speaking to your patients. So right now seems to me the limiting factor would be you being there. Right. Usually so many hours in a day. Docofalltradez: It is. You're absolutely right. There is a cap on how much time I can spend there. Docofalltradez: But at the same time it sounds like you really enjoy it. So it's kind of nice too though right. Exactly. Well that well that answers that question. I noticed I go to your Web site and I started looking at the pictures by the way your Web site is fantastic. I enjoyed being on there. Oh thank you. And there was a picture of you actually have a video of you kind of giving a good example of what a patient would go through through the whole experience right. I noticed in the corner of the office you had a defibrillator. Docofalltradez: And what kind of monitors do you use when when you have patients in the room and you're you're administering the ketamine. Cindy Van Praag: Right. So we use. Yeah I like her different color. We use continuous monitoring. Cindy Van Praag: So and this is probably my anesthesia background and I am doing office based anesthesia so I adhere to essentially adhere to office based anesthesia rules and regulations. So they have continuous EEG monitoring. Cindy Van Praag: We I do a blood pressure check every five minutes they have continuous pulse ox imagery monitoring. I one step beyond that would be entitled CO2 monitoring which I have not needed to do because I'm not getting down to moderate to deep sedation levels so we do have backup as you saw we have defibrillator actually we have that in the each room it's part of our monitor which makes it convenient and we do have everything else you could possibly need. We have suction we have oxygen we have a crash cart we have. All of my airway devices that I might need to secure an airway. Cindy Van Praag: So we have outfitted our office with everything you could need and would you say that's the norm or because you're an anesthesiologist. You that's that's the standard that you set yourself to. I would say just in talking with other ketamine docs and the majority of them I'm sure have at least a crash cart Cindy Van Praag: And all of the emergency backup supplies. As far as actual monitoring I think that might very connect a clinic as far as how often they take their blood pressure or even if they do continuously see. Cindy Van Praag: I think that's more variable from a clinical now. Now how many patients do. Docofalltradez: Typically when concurrently we don't we only do two at a time. Cindy Van Praag: So I am there were small clinic I am there with my nurse and I feel comfortable with having at least a one on one to one ratio for each of our patients. We have the capability to run three at a time but I prefer to have at least one person available for each patient if they need us. Docofalltradez: And so you're kind of sitting there like you wouldn't know or just kind of keeping keeping vitals or what do you do what are you doing with them the whole time just talking. Cindy Van Praag: No I. Well the rooms are close together. I keep the door open partially. I can see the monitor I can hear the beeping I can hear the tone. And oftentimes our patients will have a family member with them or a therapist with them. And so we let them just do whatever works for the patient sometimes they just want to listen to music. Sometimes they want to hold a therapy session. Other times they just want to close your eyes and not interact with anybody. So it's depends on the patient. But I do check in frequently I'm always listening and I'm always watching the monitor but I'm not always right next to my patient. I'm about 10 to 15 feet away at all times. Docofalltradez: That's that's awesome. What kind of recovery do so you run the infusion 40 minutes. How long do you watch them for the recovery period. Cindy Van Praag: The recovery is usually about 20 minutes and I've been running my patients a little bit longer. So 40 minutes 50 minutes even up to an hour depending on what dose they're getting and how they respond. Cindy Van Praag: But even if I run them up to an hour since it's such a low dose they're usually ready to go home in about 20 minutes. And these are for the mental health infusions. Now also you know you mentioned the the regiment for this bravado. Docofalltradez: What type of regiment do you do for your patients in terms of frequency and length of follow up. Cindy Van Praag: So for the initial regimen is to complete a series of six infusions over the course of about two to three weeks. And we don't require patients to commit to this upfront so they take it day by day and they they show up at the office and pay for that day and almost all of them complete the series of six and and we base that off of Cindy Van Praag: Research multiple research papers that shown that that's what's effective when we picked that number six. And I think you'll find that across the country too. So as far as follow up once they complete that series depending on how severe their mental health issue was some people come back two weeks later for a booster as we call it. So a booster would be one infusion and then they might come back two or three weeks after that. Other patients do so well that they don't come back for two or three months after that series of six. So it really is patient dependent as far as how often we see them again in the office. We do call them by phone and make sure they're doing OK. But if they're doing OK. We just we let them come to us after that initial follow up to make sure the infusion we're OK and they they let us know when their mood is starting to dip and then they might need an infusion soon has ever been a case where you've had a series and then they never needed an additional booster. Cindy Van Praag: Well that's a great question because those patients either they never needed one and went into remission for a year or they were lost to follow up. So Docofalltradez: Right. So the point is it's not really a cure. It's just it requires maintenance. Cindy Van Praag: Right. Exactly. This is not a one time cure. This is not a magic bullet. This will require maintenance. This will require hard work on the part of the patient in other ways too. They must follow up with their psychiatrist or psychologist. They must participate in self care. We have a lot of suggestions for this. They must be apart in their own healing. So they they we stress this to our patients before they come in and when they come in. This is this is you don't just show up for this one drug and it's going to fix your life. It's one key you know it's one tool in the toolbox. I guess we should say it's they must be involved with all these other aspects of their Cindy Van Praag: Recovery for it to be successful it sounds as a business model it does sound really really really nice. Could you actually are helping some some of the most resistant patients out there. But to do a quick commercial break and we'll be right back. Docofalltradez: Are you feeling a little tired of clinical practice. What if you knew how to get it non Docofalltradez: Are you feeling a little tired of clinical practice. What if you knew how to get a non-clinical job you love. What did you could transform your current practice to suit your life and needs. Well believe it or not you're not the first physician or medical profession to feel this way. Hundreds of your peers have also felt this way and did something about it. Don't feel alone or isolated. Take the steps to make your life and career everything you wanted to be. Dr. Michelle Mudge royally owner and founder of Physicians helping physicians have helped many people just like you escape the medical rat race and helped them transform their careers and lives in the process. Really. Now all you need is to take the first step. Head over to P.H. physicians dot.com and see if Michelle could help you if you sign up today using my coupon code. You could even get 25 percent off. The code is X Y W Z 6 1 3 3 3 J. Docofalltradez: That's x y w z 6 1 3 3 3 J. You don't have to be stuck anymore. You didn't get this far without intelligence hard work and compassion. You owe it to yourself to have the career you always wanted. Don't let it limiting believes hold you back. Head over to P. HP that is physicians helping physicians at P.H. physicians. That's p h. Physicians dot com Docofalltradez: All right we're back. And so this is the physician negotiated podcast. Get on with Dr. Cindy Van Craig correct. That's correct. OK. And so it wouldn't be a negotiation podcast if we didn't talk about negotiation in business. So we've talked about what ketamine businesses and what who you serve. But the question is how hard is it to open one of these clinics. Now you've talked a little bit about some of the struggles you've had. What what more can you share with us about. About the whole process. Cindy Van Praag: Well so we started two years ago before there were as many options for help as there are today. So for me it may have been a little more of a struggle. Cindy Van Praag: And so I think it starts with research and we I started with reading everything I could get my hands on about ketamine and can I find protocols and doesn't really work in and am I going to hurt my patients or help them and so all of this you know intense reading went on before I decided to open my business. And once I was sure that this was a great great drug to provide. Cindy Van Praag: Then came the just the nuts and bolts of how to open a business. And. That was actually really exciting for me because I love to learn and so it just comes with you know picking your name and and finding a facility. And once you have an address and you can move on and you need your DEA license I mean you look up regulations and they're just you you do a market analysis and a business plan and so all these things were a challenge but very exciting and that took a little time. Well little by I mean maybe a couple months when we just spent time setting up the business structure. And then we opened our doors and. Is just really learning as we go. Now when I mentioned today I think folks have a little bit easier time because there are resources. So. For example there is a Facebook group I stumbled upon a few days ago that's called ketamine startup. Oh gosh. Ketamine startup clinic I believe and it has over twenty three hundred people signed up on this Facebook group. And that's where they can go and just ask other people all the you know how how do you set up a kind of clinic. And there are other people out there who are who are literally you know being consultants and helping individual individuals set up their own clinic. So I think there are a lot more of us out there that know how to do it. Cindy Van Praag: So I think we're able to speed up the process for those folks that are looking into it now versus two years ago. Docofalltradez: Now who did you hired to develop your business plan. We just. Cindy Van Praag: We did it ourselves. And I think was just input from my husband. We did have a business lawyer. We have our own Web webmaster. So it was just pulling together these people around us and we figured it out. Cindy Van Praag: And you know it's a great way to do it. Cindy Van Praag: But I think it might be a little slower than hiring someone to help you and what kind of investment requirement did it did you did you need to put forth to start. Cindy Van Praag: I think the biggest part of the investment was honestly the property the lease. Cindy Van Praag: So we signed for rented an office. Cindy Van Praag: And you know if I could go back and change one thing I would not have spent as much money on rent as we did then that just that was a big big loss for money. Docofalltradez: So what would happen. How did how did that become a problem. It was a space to. Cindy Van Praag: I think our space was too big. Our business plan that we put together was probably a little too optimistic. So we were spending a lot of money on overhead which could have trickle down to us. So going back I would have chosen a smaller space and ideally maybe just rented a space a room or two rooms from from another practice and just let it grow and then moved on to a bigger space. Cindy Van Praag: So you know if you take that part out of it it really doesn't take too much money to get this started. Cindy Van Praag: I think the bulk of the money was on our rent and you know typically when you rent of it did you rent like a vanilla box and then you had it outfitted with him with the walls that you needed in all the other different things that you needed or did you buy a space that was already reconstruct. Cindy Van Praag: Oh no. Yeah. No it was it was move in ready. Cindy Van Praag: We did not have to spend any money on outfitting that space now when you say you wish you would have not done that what you've done would you've hired somebody to help you with that process or how would you know you said you would have just rented a room and then maybe slowly grow. Have you spoken to somebody about doing this. In the process I'd. Cindy Van Praag: I might get I guess it all construct my husband and Kim but that was his idea and I I didn't listen. I said No I'm going to do this my way and I'm because I'm independent right. Now. So I I. That's what I recommend to people now who'd come up and talk to me and ask me how to get started I say look you know just you can get some great rooms and a great office space where you don't you're not responsible for the entire rooms. And so I think that's a great idea to get started while being a cash only business. Docofalltradez: I guess that's that's really what comes down to it. There's cash flow issues and if you have overhead you want to reduce your overhead so that you can. You could have at least some money coming into that into the process. Now one thing you did online which I thought was very interesting is you have transparent pricing you can just go to your Web site right now. Sprint Center of Hope dot com and there it is right there. Right. So why did you decide to do that I'm curious. Cindy Van Praag: Well I think we have always left those numbers up there. I think we've always been transparent because I mean no one is that some people are looking based solely on price and they're comparing prices across town and I think we picked a competitive price range. And number two is I think people honestly get annoyed when the price isn't there and they have to call you to find out. And we didn't want to limit those people either. We wanted as many people call and as many people coming to us as possible. So we didn't really want those phone calls or just says you know answer the phone. How much does it cost. OK. Thank you bye. You know we didn't we didn't want that. We wanted people who were serious. Docofalltradez: No I think that's amazing. I really really like that model. Now in terms of the price you chose you said you. Did you look at your competitors or how did you come up with that particular price. Cindy Van Praag: Definitely. So in our market analysis we studied all of the other clinics and in Houston. And that was you know two years ago. But that keeps going and we're always looking at our competitors. Cindy Van Praag: And so that's how we chose our price range. We don't want to undercut everybody in town and have the lowest price in town and I don't think that's a smart idea. Cindy Van Praag: But we do want to stay competitive in terms of competition. Would you say that at least in Houston is there a lot of competition or is it manageable. Cindy Van Praag: I think we're building up to a fair amount of competition. We've when we started out we may have had another four clinics or five clinics and that's probably doubled since since we started a couple of years ago so you did mention at some point that you would consider doing a second clinic. Docofalltradez: Are there any areas that are available in Houston now with that kind of growth. Cindy Van Praag: I think there. I think there are. I think there are some you know thankfully Houston is as I recall correctly the third largest city in the United States if not force. So it is very large metropolitan areas and not everyone's able to drive all the way into into town. Cindy Van Praag: So we are located on the north side actually the suburbs but I think there are some parts of the outskirts of Houston that can be serviced by a new ketamine clinic excellent do it or is it is your business have any seasonality at all or is it always consistent or what it what do you find with that with your business. Cindy Van Praag: We have found cycles for sure. We have found that it drops off in January around the holidays. End of December early January. It's dropped off again. I think it is in about summertime we have a little bit of a dip so it does go up and down and again know we've only been open for almost a couple of years but I think it will go in cycles for any clinic as your cash flow then grown like year by year. Cindy Van Praag: Definitely it has and especially in the past month and a half. So we're much more happy. Docofalltradez: And you said the month of the half you had you had a key was it a some type of clinician who was starting to refer to you. Cindy Van Praag: Well I think I think it was education with us for Bartow coming to market and the FDA. That's right. That was a big turning point. Cindy Van Praag: We know that they almost did the marketing for us. So who he you know you saw doctors on Good Morning America talking about ketamine and so we actually had a lot of calls from people saying wow I didn't know this was out there and I saw this on TV. Cindy Van Praag: And then I just googled you know ketamine near me and you popped up and while out there on the phone with me and once we get people on the phone. That's that's that's what we want but that's a conversion does when we can talk to someone on the phone and have a chance to explain it and let them hear how passionate we are about it Cindy Van Praag: And let them learn how it can help them. Cindy Van Praag: And that's what brings in customers and that's that's what they want and you know I think I think your passion for it really really shines through. Lisa my conversation with you and I'm sure when you're talking to him on the phone the same thing comes through. They really could I could sense that you really care about people and you're not in it just for the money. Docofalltradez: Having said that so you transitioned would you say you've transitioned out of medicine or you've transitioned into a maybe you've transitioned into retail medicine. And how would you say you feel now that you've done that. Cindy Van Praag: Well so I am a part timer so I still practice anesthesia part time and I and I do this kept my ketamine business. It's technically part time that I'm there but really it's on my mind full time. Cindy Van Praag: So I have I am slowly backing out of the anesthesia business and moving into something where I have more control and something that brings me a lot more joy and makes me more happy. So I consider myself still transitioning and still always looking for something else that excites me. And I will always. I think I will always compliment the compliment the ketamine business with something else whether it's sticking with anesthesia or whether it's doing a consulting business or Cindy Van Praag: Podcasting maybe. So it's it's going. I will always be looking for something else too. Docofalltradez: Well you're definitely a natural the podcasting by the way that had mentioned this to everybody but this is your inaugural podcast right. Cindy Van Praag: It is first time ever. You're a natural I'm telling you. And I think you sound really happy with this academy business. Cindy Van Praag: Oh absolutely. I I'm I'm sure that's coming through today do so. Cindy Van Praag: So you mentioned that you're still part time Anastasia. Do you think if someone else were to start ketamine clinic you think there'd be enough to sustain them as a as a sole source of income. Cindy Van Praag: Not in the beginning. No it is not even now if I was to stop doing anesthesia. This is not enough to live on. This is not so. This is not a business to go into. It's not a get rich quick business. It definitely has a potential for growth which will take time and it doesn't mean that in the future it won't be couldn't be a sort of a sole source of income. Cindy Van Praag: There are some great success stories of a couple. You know Steve Levine is a doctor who is head over 10 ketamine clinics. So he's doing fantastic right. He doesn't need to do another job. But most of the clinics are probably like mine where the docs are the providers are doing other jobs at the same time. Docofalltradez: Well you know I think you know you and I both obviously attended the physicians helping physicians conference and you know I'm also part time. I'm not full time. And I think it is nice to have multiple streams of income. So congratulations. So this is awesome. You have a second stream of income and I think the more we do that the more we can take control over lives and you did mention that the more control I felt like physicians in general especially employed physicians feel like they have such little control over their lives and so the more streams of income you could have the better. And so I do think that ketamine clinic is a viable option. I personally have contemplated many times people come up to me many times asking me to be their medical director. I just didn't know enough about it to take it seriously and then you know it sounds like a pretty big time commitment too. So I'm not sure if I'm ready for that but Bannister is shrewd. It sure feels good to hear your perspective and what you've gone through because it sounds like it's been very positive for the most part and I think anybody who cares about patients and cares about mental illness they would they would probably enjoy it. Cindy Van Praag: I agree 100 percent like you said. Docofalltradez: Well Cindy any last words you'd like to set us off. Cindy Van Praag: Well I'll just you know if anyone wants to reach out to me the easiest way to find me is on my LinkedIn profile. If you just let me know that you heard about Cindy Van Praag: Me through this podcast I'd be happy to connect with you for you have any additional follow up questions or just want to learn more about it. Docofalltradez: There may be a second business could you. For you could be a ketamine consultant and or you could become a franchisor. You could start searching on franchise. I know I might be a great customer Docofalltradez: Right. Docofalltradez: Well hey it was great talking to you. I'm so glad I met you. I hope tons of people get value from this podcast. I certainly did and I look forward to talk on you. Cindy Van Praag: Thank you for having me my pleasure sir. Docofalltradez: Thank you for listening. We hope you enjoyed the physician negotiator podcast show notes and other resources. Please visit the physician negotiator dot.com. 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EP 06: Exploring Employment Contracts for New Physicians by Docofalltradez | Leigh Ann O'Neill http://traffic.libsyn.com/thephysiciannegotiator/EP07_Leigh_Ann.mp3 WHO’S ON THIS EPISODE ? Website i Email You are a trained professional, and you are the best in the business.  You have the best outcomes, have the best patient scores, and have the highest productivity.  Many if not all others envy your skill and respect your success.  In school, you studied harder than everyone else and earned high marks and are one of the top ranked in your class. But there is one problem, you went to Medical School,  NOT Law school and NOT a business school. The problem with modern physicians(myself included) is that we believe our skill, experience, and knowledge translate to any profession outside of Medicine.  Well, remember Julius Irving aka Dr. J only made $230,000 in 1976 and topped off over 1 million in 1950 which by today’s standards are what the benchwarmers make in the off-season.  The problem back then was a lopsided negotiation with a team owner who had appropriate legal and business representation with a player who had the best talent at the time but who lack any understanding of the Business of Basketball.  The same hold true for healthcare professionals,  we understand the delivery of healthcare and are a healer, but we are not Ballers(business minded).  Not only is it unwise to navigate the business of Medicine alone, since there is strength in numbers, it is also unwise to use your precious time to negotiate a contract or even find a job when you should be focusing on things that matter like passing your Boards.  I am still amazed at how much I have learned over the years outside of Medicine and equally surprised how little physicians and other healthcare providers know about the business of medicine and have absolutely no representation. Join me as I explore the concept of the Physician Agent.  I will hopefully have a series of podcasts and blog posts looking at the various aspects of the idea.   The first step was meeting Leigh Ann O’Neill Who as a specialist in physician contracts who understands how disadvantaged physicians are in a complex business environment.  She understands not only contract law but also the market value of physicians.   If physicians do not fully understand all the complexities of contracts, it can lead to a job where you overperform and get underpaid which is a recipe for disaster and ultimately Burnout.   Please leave comments, and if you would like for me to explore anything else in this concept, please leave me some comments! DOWNLOADS EP07_Leigh_Ann.mp3 (transcribed by Sonix) Docofalltradez: Welcome to the physician negotiator podcast where no decision is left to chance with your host Doc of all trades today on our show we have Leann O'Neal Leann is an attorney who received her J.D. from Indiana University. Docofalltradez: Leann has a website and practice called laws O'Neil and she could be found at Lord O'Neill dot com. She specializes in helping physicians find the best possible job and negotiate contracts. She also has invented a concept known as the physician agent a physician agent basically is similar to a sports agent. Your job is to become the best possible physician that you can be. You do not necessarily have the time or the energy to focus on the financial and legal aspects of your job. So you hire an agent to help represent you in those matters thereby freeing you up to be the best clinician. So without further ado I'd like to introduce you to Leon hi Leon. Welcome to the show. Leign Ann : Thank you for having me. Docofalltradez: Oh great. Now currently Leon where do you live. Leign Ann : I live in Indianapolis. OK. Leign Ann : And that's where that's where your main practice is that right. Yeah. Great. OK. Briefly could you tell us a little bit about yourself. Leign Ann : So I finished law school in 2006 and right out of law school started with a medium sized law firm that had a really robust health care group. And so I spent a lot of my time working both for health care providers as well as individual field irons under Medicare and Medicaid rules also and regulations that apply to physicians and hospitals and then also worked a lot of physicians as they looking at their employment agreements. Leign Ann : And so after being with that firm for a while my husband was actually in his surgical residency at that time and once he was finished with that and started looking for a job as a result I was watching as he was sort of struggling with that process and realized that the full job search process and certainly you know doing a legal review of contracts and making sure that everything is as it should be is not something that a physician can do on his or her own. It certainly worked for physicians in the past but decided that I wanted to focus my work to help physicians specifically job search and contract negotiation phase of their careers. Docofalltradez: So when you were in law school did you ever did you automatically one go into health care. Was that kind of when you were in law school itself was that what you're specializing in. Leign Ann : Yes I did. I actually I always say did I get another life a secretly want to be a doctor but don't feel like I probably could pass the requisite chemistry courses. And so Holly kind of was my goal to help health care providers in a meaningful other way. And I couldn't necessarily I didn't feel like that was my path to be one my my stop. So I wanted to get in health care law to support health care providers. And so it kind of took awhile to morph into what it is today but now I have my company law. All physician agency and we exclusively work for physicians and nurse practitioners and physician assistants help them through the job search and contract negotiation process. Docofalltradez: All right. And you do the next best thing. You married a physician so you guys are or a couple physician and oh my wow. Well so you know short of being able to marry a lawyer what's the next best thing a physician can do to kind of get his or her contract off off to the right start from the get go. Leign Ann : Whenever I talk to a group we offer our educational sessions a lot of time we talk to groups of physicians about this process. I always say that it's important to find a lawyer who specializes in this type of work. So of course lots of people have kind of like their uncle or cousin who's a lawyer and dabbles in this or that and can kind of look over their contract. But I really stress that when you are looking for someone to check out your employment contract or a partnership agreement if you're at that stage and with a private group it's important to find someone who specializes in that type of physician employment work because they are very specific provisions in each contract that apply specifically that you own a mess and there market standards and forms of what physicians are offered today and it's to your benefit to have a lawyer working for you. Who knows what those are. Docofalltradez: And you know most physicians I think we feel like if they were to even consider asking an employer and or partnership to look over the contract with a lawyer and to make changes it almost seems like the lawyer the physician would be afraid because they would don't want to offend that potential employer. Leign Ann : Yes and we actually hear that all the time that's a concern that a lot of clients have when they come to us it's kind of they're worried that it might come off badly if they know if their potential employer knows that it engaged a lawyer. And so the thing I always like to talk to clients about though is that especially when you're coming out of training your relationship with your employer up to that point has been very much of a mentor mentee type relationship versus once you're out of training it's more of a traditional employer employee model and the employer is not able to look out for your own best for your best interests as well as their own best interests. And a lawyer drafted that contract for that employer. Right. And that means that they kind of have the upper hand when it at least when it starts off. And so you know they're protecting their best interests and you owe it to yourself family to protect your best interests as well. And so you know actually a lot of employers I think are becoming more sophisticated about this as well and oftentimes we hear you find a provision in a contract that specifies you've been given the opportunity to consult your own legal account. A lot of employers are really interested in entering a relationship that's been very well thought out and considered and they do not want you to move ahead and sign the contract if they don't feel like you've had your fair review with your own legal counsel. Docofalltradez: So that would be kind of a warning sign right. So if you have a group or private practice it comes to says hey well what we voted you got the job so are you to join us. Right. And by the way you've got two days to review the contract and get bachelor's would you say that's a warning sign. Leign Ann : Absolutely and that's another thing we hear a fair amount. Is a client will call us and say well you know how fast can you guys do this because they told me the deadline is Friday and if I don't sign the contract then they're going to offer it to someone else. Well first of all that would definitely be a red flag to me. Any employer that's trying to pressure you into accepting a job in you know in a big disingenuous about that. Also most employers even if they do have a deadline a lot of times it's sort of an arbitrary deadline that was set just by way of default when they draft their legal documents. They have an expiration date right. And it's not something that's set in stone. So I mean all the time we encourage clients in this work successfully for them to contact the employer and say hey really just want make sure I'm giving due consideration to this prospect I'm really excited about this job. But I need another week or so to go through this with my own attorney and make sure that I understand it fully and employers are usually very gracious about extending those deadlines with no problem. Docofalltradez: So you know what's happening right now in the medical community in the medical field is more and more physicians are becoming quote unquote W2 employees and of hospitals or super groups and so do you find it's happening more often like the pressure tactics with smaller private practices or these more or hospitals or the bigger groups it to be more one way or another necessarily. Leign Ann : But certainly when you're dealing with a larger hospital system or one of the super group type of employers there is you know it's more likely that they would have a sort of an automated mechanism for asking for a return contract. You know on a tighter I am frame and I just think that it's more symptomatic of having kind of a very process oriented human resources division then their intention to be a kind of bully someone into signing something. So honestly I've never really run into the scenario where a client called back an employer and asked for additional time and they said never mind we're taking we're withdrawing the offer or no you don't have any more time we need it. Hard deadline by X day. Certainly that's kind of a judgment call yo come upon it. You know that the position that you're interviewing for and you have an offer for if they have kind of a line of candidate you know ready to act then they may not be bluffing if they have a dire need to fill a position then you know they may require a quicker turnaround time just because they can and they have someone else right behind you ready to sign the contract. But most the time when physicians are taking a job at such a particular need that's being filled it's usually happening very far out in advance months sometimes more than a year. So it's not typical that it's you know a serious deadline has to be met immediately. Docofalltradez: Do you find is it easier to deal with the bigger groups or the smaller groups you find there's a difference between the two in general. Leign Ann : You know it's interesting because there is sometimes there are but I wouldn't say that it's kind of a blanket difference I wouldn't generalize it but some of the differences you notice just hospital systems do tend to be more since they're more business minded. Leign Ann : They seem to be more sophisticated from a legal standpoint and so they have their own legal division. They have a more it's more of a standard expectation that legal would be consulted on all aspects of a contract being signed. And so in those situations particularly they do encourage the candidates to go and have their own lawyer look at the contract and they're not at all you know offended or scared off by the prospect of being contacted by a lawyer. Whereas on the private groups side and I've only really seen this one time is where you kind of get into the good ole boys situations where you know it's a partnership of five physicians that are in the latter part of their careers and they themselves no sign contracts and they go to bring in the new young physician. And the idea of a contract at all is sort of laughable to them it seems lacks or sparkle. And in that case you know we'll sometimes have a little bit of a hesitancy on their part to involve the lawyers but that's very very atypical. Docofalltradez: You know when you're you've negotiated your husband's contract right. Yes. Did you run into any landmines when you were doing that. I think you and I talked about it before right. Leign Ann : Yeah. Oh I can't remember if we discussed nothing. There was nothing that was a landmine in the contract that he's ever signing thankfully. Leign Ann : But you know we do come on particular aspects of agreement are concerning and really one that we take away from doing this for physicians is just making sure that we have a very thorough process. Like for instance one of the things that we found when we do work for physicians is if you have revisions made to contract you get the revised version back and suddenly I'm back. They wanted left along was now a contract. And if you can review the new version you might not know that it's important to obviously be very thorough. Leign Ann : We are doing the review and making sure that everything is in place especially when we sign the final version that it is. And there remained what you thought it was. Docofalltradez: We know we haven't spoken about the money in terms of the contract which was the same as the one the most important aspect of the contract. What would it be. Would it still be on computer or would it be something else. Leign Ann : You mean other than the compensation also. Docofalltradez: Well so so would you say the compensation would then be the most important aspect. Leign Ann : I mean it's kind of hard to say that it's not up there because you know you're the way you're making a living of course. And so another reason that it's really important because kind of along the same lines the line you distrust or unhappiness by way of comparing notes with other employees. Leign Ann : You know I've seen clients that will come to me and they'll say you know I just found out that this job I took when I got out of training you know they're paying their way underpaying me compared to what someone who does the exact same thing getting paid down the road that breeds all sorts of unhappiness and resentment of the employer. And so let alone you know just the feeling that you could have been doing better all these years. And so it's not that what the number amount is the end all be all but knowing that it's fair as compared to market standards is hugely important for many reasons. And so one you know one common misconception or I think something that people often get wrapped up in especially when they're entering their first job out of training is looking at what a base salary would be. And for certain specialties the base salary will become very quickly irrelevant once they are you know kind of ramped up and providing services on a full time basis and producing you know the median level of services. And at that point a lot of contracts will roll you on to a production model compensation. And so that's where. I always recommend a lot of focus be given to make sure that a productivity model is also in line with what market standards you know other employers in the area are offering because that will end up being your main mode of compensation. Once you are ramped up and offering you know a full four weeks worth of services. Docofalltradez: And generally speaking how do you determine that calculation. Leign Ann : We look at MGM a data estimate the Medical Group Management Association and they put out a survey every year that is based on data they collect from every different subspecialty extradition and it will show you things like total compensation what compensation to collections ratio is which is pertinent if you're in a private group what compensation per WRVA you rates are. We'll break it down by practice or employer type by geographic region of the country. And so we like to look at that data. And my goal is always to be able to say OK yes we've looked at the compensation model they're offering you. And if you produce the median amount of services as compared to everybody else in your region of the country or the nation you are capable of earning at the end of the day under this contract the median total compensation that's being earned by everybody else. So that's just a good benchmark to use. Docofalltradez: So generally speaking and for people who don't want them MGMA is so like you said it's a database of get contributed data from different practices all over the country and they break it down into percentile right. And so you mentioned the word median and so the median percentile would be the number of people who make a certain salary based upon production based upon their specialty etc. and then they could fall either into the 25th percentile or the seventieth percentile 25th percentile or the 98 percentile. So generally speaking do you feel that the median is a median salary for a particular specialty is a fair goal to shoot for or do you do shoot above that. What would you typically advise on a situation. Leign Ann : The median is what we typically shoot for and when you're talking about someone who's then you're wanted to have training that might not be necessarily attainable because it is it is so it does take a good amount of time to build a practice depending on your specialty. Again this is totally specialty dependent. So it really depends. But it's good to at least I mean the goal is to at least see if you're producing at the level whether it be the 25th percentile of the median or the 70 percentile then you should be able to see that under this contract you've been offered. You would also be compensated at that level. Leign Ann : So the thing to look out for is let's say you're producing at the seventy third percentile in WRVA that you produce. But at the end of the day you're only going to get paid the 25th percentile. There we have a problem right. Docofalltradez: And so that's what MGMA is really good at. It shows what were different like for example you say units versus RVU use with those. What would a median person would produce. And so you're saying if the decent layman define what you do and then what you earn there's a huge problem there. But right do contracts typically say that we'll we'll pay you you know X number of dollars for X number of revenue based upon the MDMA would they actually use that type of language. Leign Ann : Sometimes they do specifically say we'll pay the median MDMA rate per GABA our view in that most the year you know that years most current survey sometimes is that reliant on the MDMA data other times we'll just publish the number you know the number will be put in the contract and it is based on sometime in blend blended review of different surveys that MGMA survey and others that are specific to certain specialties that it really just is you know variable between specialty and employer but MGMA. I have found is the most widely used. Docofalltradez: And that's what you would recommend any physician have that in their contract or not necessarily. Leign Ann : Well I don't think that it has necessarily reference to MGMA. But it should be structured so that you are capable of earning in those median ranges. Docofalltradez: And in terms of So my other my other understanding about it is that anybody can have access to it. The data itself is very expensive so I think what sixteen hundred dollars just for an annual book or something like that. Leign Ann : I'm not sure we pay a much higher fee for a license to use it. So yeah but even if you think that if you are a health care provider let's say you're a family practitioner and you want to hire a new doctor you would want to look at the MGMA data. I don't want to go out buy it. I mean I think the minimum you pay is like a thousand dollars in any form of it. So yeah oftentimes we can find lawyers or consult the various types to that know have already purchased the data and obviously can pass that along to their client. Docofalltradez: And the advantage of somebody like you you actually know what the data means which actually is pro even more important. Right. Leign Ann : Right. Right. And we're able to sort of you know look at the different pieces of the data and relate it specifically to your contract. You're looking at a table of data. It doesn't really mean much until you're able to compare it to what the compensation model you've been offered of course. So yes variable to easily relate to. Docofalltradez: Wow that's awesome. In terms of so so let's say we have a contract down where we were totally in agreement with the contract. You looked at it you signed off on it. You're happy. The physicians happy the employees happy and then two years down the road something happens and we need to renegotiate. And do you maintain the relationship with physicians typically during that renegotiation and it could be maybe a problem that you have with your employer or a colleague or maybe you find out something down the road makes a lot more money than you. You could basically then initiate that contract renegotiation. Leign Ann : Yes. And it will depend on the terms will be specific in your contract though. What we most commonly see is for a first time contract will say that the contract is for a period of two years and that it will automatically renew for one year period after the for the first term is over. So in other words it's to your contract at the end of the second year it's going to not auto renew for another year. And so you have to be careful what the renewal provisions say. A lot of times it'll say that it will automatically run or do if either party gives notice of their intent not to renew within 60 days before the expiration date. So if you're unhappy and you're coming up on the end of your second year and you need to tell them within 60 days if you intend to not let it automatically renew then you need to give that notice and that will force the renegotiation of the contract. Docofalltradez: And yeah I think that's that's why it's incredibly important and usually that's to the physician's benefit. Have you ever seen a situation where it's been to the employer's benefit where they've actually had to give less and less less money to the physician as a result of changes in markets market forces etc.. Leign Ann : There are a lot of times we'll see contracts that have a provision that say it's like overall Medicare reimbursement drops more than a certain percent then we can unilaterally amend your compensation. And so in those instances it becomes hugely important to make sure that those other provisions of the contract that are impacted at termination or that are triggered by termination don't negatively impact you like for instance the non compete if you get a pay cut because of a reimbursement change that happened at the government level and over which you have zero control you're going to take a giant pay cut now because your employer was able to unilaterally amend your compensation you're like You know I'm going to get out of here and go find a different job where I can be paid more. Or at the level I was being paid before. So it's not your fault that you had to terminate the contract for that reason. So we want to make sure that the not repeat not can apply in that instance of termination. Right. But things like that and that's getting really into the weeds kind of but and it's always very taboo for folks to think about situations like that. You know you're like coming out of training you're so excited to start your first job. So I think you want to do is talk to your employer about how we're going to deal with. You know the termination of this contract you know when we're just now getting started but those are kind of the you know doomsday scenarios that we know lawyers are here to help you plan for and to avoid you know the worst case scenario. Docofalltradez: And I think you said it to at one point that that's why you really do want to negotiate your contract with your employer so that you can save face. Right. If you negotiate better contract as as my attorney therefore you know you're the one who's dealing with the terms and it doesn't harm the relationship and you've you're right. Leign Ann : Exactly right. Yes. OK. Leign Ann : Excellent. I mean and not only does it remove you from having to be you know the person who's asking what might feel like these awkward questions right. Because it's at that point it's kind of personal if I'm doing it or a lawyer you've hired is doing it for you purely technical and it's a business and beyond that you know we can say it's not because I don't want this client to get you know the right of a deal here it's because I do this all the time and no one else in contract has it in it. So why are you guys trying to have your employees sign a provision like this. Is the typical. So you know we can kind of look out for position for our clients based on our knowledge. That's very specific to what's going on in the market in general. Docofalltradez: And you know Leon and the whole basis for our conversation was that the whole I know you've created this concept known as the physician agent. And so like sports agents you know you can always look after your your client and in this case it would be a physician as opposed to sports agent such that you know you don't have to kind of go at this on your own. And I just came back from a conference where a lot of burnt out physicians who were in the process of quitting medicine entirely because you know for one reason or another they were overburdened by the workload. Maybe they had a falling out with a colleague and or a practice. And so their solution is what I'm going to get out of medicine altogether. But I kind of like if they had been protected in the first place had they had good counsel maybe they could have either avoided the situation or be come up with a better situation such that they wouldn't get to the point of nice when to quit medicine because it's not working out for me right. Leign Ann : Exactly. And you know one of the things that I think physicians run into a lot is that they feel they sometimes get to situations or they end up feeling that they were taken advantage of and they didn't have a fair crack at the negotiation process on the front end. So they come out kind of disgruntled you know after they've been with a particular employer for a certain amount of time and they feel like you know it was an unfair relationship to begin with but also physicians are good at taking care of their patients like what they went to school for that's what they've trained for years and years for and that's within their heart to care for their patients if not necessarily first nature to physicians to be honing in on particular provisions of a contract or looking out for themselves at all. I mean that's there in the business of looking out for other people for their patients. And so they're not necessarily good at sort of thinking tactically about how to avoid being in that situation where they feel taken advantage of. So for instance the one thing that I would tell a physician you know any of my clients who I operate in this position agent role like you said you know like a sport like an NFL player has their own fourth agent someone is looking out for them if you're unhappy in your job you need to go out and interview for a different job even if you really don't think you'll ever move and take a different job. You need to know what's out there and you need to know the ways in which different opportunities could be a better fit for you or how your current opportunity actually ends up being better than you thought it was. Leign Ann : All right here's the other one. You just interviewed for one of the worst things that I see. You know when clients come to me happen tends to happen like in March April of every year we'll have clients call and they're like totally freaking out because they have to sign this contract and they only want to take this job but they have to because they didn't you know get a job offer until now. You know the timing has to be right and it has to be well in advance of when you need to start getting that paycheck and putting yourself out there and having multiple interviews is the only way for you to a see all the different types of practices that are out there and what would be a good fit for you. B See what the markets truly offering Yo so I can't recommend enough that physicians do a very detailed in-depth and it's kind of like Doc in a job search to get out there and see what's available and don't get stuck in the point where you feel like you have to stay at your current job or you have to take the first job that comes your way because there is a lot of opportunity out there for your position. And if you approach it in the right manner. You know you're going to have a better result long term. Docofalltradez: And you know it's funny that's funny you say that because that's how residency works right out of medical school. You're going to apply to as many residency spots to maximize your chances of getting matched and being the right match the right fit right. So right. So this has been the most funny and most interesting time in my life because I'm a mid career I'd say and I'm going to mid career crisis and so I'm not consciously I I've followed your advice exactly in that I was kind of feeling unhappy with my current position. I'm very well-established. I'm very you know as you become a mature physician you become decorated you earn the trust of your colleagues of surgeons of various people and then you're willing to basically say well I'm Burns I'm going to walk away from this not realizing walking away from it you just think about the new grad like you said it takes some time to even get to the point where they're going to make to the median salary and when you walk away from it it's not like you can just go back and get it. So what it was. I was just on the phone with a friend of mine and he says Oh yeah we're hanging at my job. Docofalltradez: You should come check it out. So I go and I interview and I do a two day interview with them and I'm talking to them and kind of getting a sense of how they practice medicine you know what's what's there. Is it justice fair place. What kind of money they make. And as it turns out my current practice is probably slightly better than there is but dread. Granted I tested out the marketplace. I saw it right out there and I'm like well you know I could move but then I'm going to have to establish relationships with people all over again. I'm going to have to earn partnership again. It just takes one or two guys to not accept you as a partner and then you don't get in the group. And then all for what you might you might have been better off trusting where you're at but at least now. Right. I did the litmus test and now I know that what's out there is not necessarily better than what I have. Leign Ann : Yes exactly. Exactly. And you know even to take it one step further if you had you know found certain things looked better to you about the potential new opportunity you could bring that back when you come to negotiate your existing contract and say look you know here's that opportunity. This is better. You know I'd like to stay here because I have you know I've established here I have a good relationship here. But you know it's kind of hard for me to ignore that this other opportunity is offering X Y and Z that you don't offer. Right. Well you can get them to do there. Docofalltradez: And so for me that's a little nerve wracking. I'm a little bit nervous about Doing that because you know on the one hand there's still your employer and you don't want to push it too far. Such that I lose social credit but at the same time you're right. Obviously I took the steps to go look for another job and interview so clearly I'm not happy right. So I think you're absolutely right you have to leverage that. Docofalltradez: You have to say hey you know where do the steps that I can take in order to make my current situation happy by leveraging another interview process and seeing what's out there and going back to my employer and saying hey this is really what I need to make me happy or if not I can always go to this other job and make it work. So either way you have. The key is to give yourself as many options as possible. Docofalltradez: That's going to wrap this up. Now you you like you said you practice Indiana and I think you and I mentioned that you you could still potentially represent a physician anywhere in the country so long as you have a you said you have an agreement with somebody in your in their current state All right. Leign Ann : We actually work here. We work with. We have co counsel relationships with lawyers all over the country. So we literally provide services for clients taking jobs in every different state. I mean I mean literally I can't think of a state we haven't worked for somebody. So we always consult our co counsel that are local to make sure that we've covered any state specific issues typically. I mean 98 percent of contracts are general and they're not tied to state law concern. But of course we have to make sure we've covered all of the big bases though we do always consult with someone in that state and that we do that at no additional expense our clients that we've established with our co counsel relationship. So we are able that third client in all different states and we do the job search service for our clients. Leign Ann : Also some of them come up. I don't know where I want to work exactly I just know I want to have. This type of job I want it to be in a city with at least as many people and really good hiking trails. And please call me everywhere you think would be a good family do that for for people to forget you did that. Docofalltradez: Yeah so that would be great. So if me wanted to say target a city you know Indianapolis. You could then basically call every hospital where we practice. Yeah. We scout for them. Leign Ann : Yes we I mean we even do it like on a large scale. I mean right now I'm looking for a client who wants to join a private practice where I'll be a partner one day hopefully have ancillary income so we're identifying literally like in every state all of the practices that we think meet those criteria and find all the contact information and we email for the client to you know. So they don't have to go through kind of that you know grunt work for lack of a better phrase of you know drafting 80 e-mails and attaching their cover letter and CV. So we do all that work for our client help out. Docofalltradez: Especially when you're in your fellowship and or residency and you're trying to practice for your boards right. Leign Ann : Yeah I mean there's I mean you got to put yourself in a position where you feel confident that you have literally left no stone unturned that you've looked at every feasible opportunity that's out there for you. That's where we come in and do so much research and legwork and you. We want you to go to interview with me that you can for that when you sign on the dotted line you feel like Yep I checked out everywhere you see the wall and this is the best fit for me. Docofalltradez: That's awesome yeah. And today I have so many friends who don't use attorneys that they just deal with internal battles in their practices legal battles and then you never see counsel and I'm like What are you doing. I don't comprehend that so. Great well yeah. Leign Ann : I mean always remember the employer has their lawyer the executor looking out for the. Leign Ann : Well your no reason why plural lockable lawyers like an entire firm of them and there is no reason why someone is highly educated and trained at best why if there's any provision is should not have their own legal counsel especially especially like your law firm because you guys actually this is what you focus on above all else. It looks like yes. Docofalltradez: Yeah. Yeah. So whereas it was the best way to get a hold of you. Docofalltradez: How should we actually read you. I'm going to put it in that note on the show notes as well but I would think this way to. Leign Ann : Get all our law firm or our position agency in law O'Neill dot com that's L.A. u t h o and e i l l dot com it's lop O'Neill position agency you go to that Web site you'll be able to find easily my phone number and email address and E are available any time outstanding. Docofalltradez: Well hey it was great talking to you it's kind of weird how was. Well I mean it's so coincidental how life you know intercedes. Yeah. Maybe subconsciously I was seeking you out because I was seeking for another employer you know it's so funny. Leign Ann : Right. Right. Says yes. Docofalltradez: The student will on this the student will always find the teacher. I think that's how the expression goes something like that. Leign Ann : Yes. When they're ready. Yeah. Docofalltradez: When they're ready the student will find the teacher right. Leign Ann : Right. That's too funny. No I'm so glad that you found us and that we're able to have this conversation. I hope that it helps others you know who are in the same position are beginning to like a job you know to be very diligent and thorough. Docofalltradez: Oh absolutely. And David in mid career you know anybody goes through a Medicare crime mid career crisis like me I mean this the amount of information that information is valuable and. Docofalltradez: Right. And you know I to you know certainly I'm going to let as many people I know who who are struggling to reach out to you as well. Leign Ann : Thank you all. Thank you. We would be very very happy to help. Docofalltradez: Excellent. It was a pleasure talking to you and I think we'll be talking to you as well I hope. Yeah. Hopefully we can talk again soon. Noel thank you so much for having me. Great. Again it was great talking to you. We'll talk to you too. Thanks so much. OK. Bye bye. OK. Docofalltradez: I you would like to learn more about Leann and or her concept of physician agent. Head over to our Web site at or head over to my Web site at the That's There you'll find show notes and links to Leigh Ann and her Web If you have any other questions for me or the podcast if there's something in particular you'd like to hear from LeAnn or something a topic you would like for me to discuss on the podcast. Please leave it in my show notes or during the Web site itself. You can leave comments. Thanks for listening. I really appreciate it. Talk to you soon. Docofalltradez: Thank you for listening. We hope you enjoyed the position negotiate a podcast show notes and other resources. Docofalltradez: Please visit the physician negotiator dot com. Sonix is the best audio transcription software in 2018. The above audio transcript of "EP07_Leigh_Ann.mp3" was transcribed by the best audio transcription service called Sonix. If you have to convert audio to text in 2018, then you should try Sonix. Transcribing audio files is painful. Sonix makes it fast, easy, and affordable. I love using Sonix to transcribe my audio files. get every episode of the physician negotiator in you inbox! Thanks for subscribing to our weekly show! Check us out at iTunes, Stitcher and Spotify too! Name Email Subscribe ? Previous Podcast Next Podcast ? YOU MAY ALSO LIKE No Results Found The page you requested could not be found. 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EP 06: Academic Versus Private Practice by Docofalltradez http://traffic.libsyn.com/thephysiciannegotiator/EP06_The_Physician_Philosopher.mp3 WHO’S ON THIS EPISODE ? Website   ? TPP on Facebook ? TPP on Twitter   Feeling refreshed coming back from Fincon, the physician-philosopher got his voice back and we hit the ground running with a very nice discussion on the current state of Academic versus Private practice in Anesthesia.   Now since we are only two people working in two different institutions this discussion is far from all being all encompassing.  Despite this were able to cover quite a bit of ground in looking at compensation models, working conditions, common challenges with new graduating residents, Debt, fellowship training dilemmas, generational differences in medical practice and of course lots of PHILOSOPHY.   Which did we decide was the better choice after all the dust had settled?  I guess that decision will be up to you after you listen to the podcast.    RESOURCES & LINKS Academic, Group and Solo Practice White Coat Investor Topic  ACP on Types of Practices Ob/Gyn Practice Patterns AAMC Tool Box for your 1st job Dr. Jonathan Kaplan Post  DOWNLOADS EP06_The_Physician_Philosopher.mp3 (transcribed by Sonix) Download the "EP06_The_Physician_Philosopher.mp3" audio file directly from here. It was automatically transcribed by Sonix.ai below: Docofalltradez: Welcome to the physician negotiator podcast where no decision is left to chance with your host Doc of all trades. Docofalltradez: So today on our show we have the physician philosopher. Hopefully this might be his inaugural podcast but depending on the other podcast. Well I'm just hoping I'm hoping I get to be your first anyway. The physician philosopher on today. He is an expert on wealth and wealth and wealth and wellness and he has a website called The He's done numerous post has an amazing website and he's been featured on websites such as the White Coat Investor and I believe on Physician That is correct. Excellent. Well hey I'm going to call you TPP welcome to the show. Physician Philosopher: Thanks for having me. I appreciate the opportunity to be on here. Docofalltradez: And you know we you and I met at fin con and we had an awesome time. And one thing we both realized early on is we're both anesthesiologists and we have a very similar but different practice models. And so I reached out to you and thought we could discuss that. Now you are a academic anesthesiologist and I'm an employed anesthesiologist so I'd like to kind of just talk about the difference between being an employee in a non not for profit large institution versus an academic institution. Docofalltradez: So let's go and get started. Now how did you go about choosing that you wanted to be an academic because there are numerous choices that you can make as an anesthesiologist. Me personally I chose to go into private practice but you chose group practice. I mean academic practice. How did that choice take place. Physician Philosopher:  Yes it is kind of an interesting journey. I mean I do work at a large academic hospital now and when I was a resident I knew a few things about myself. I knew that I like to teach. I knew that I liked practicing anaesthesia and I really didn't have much of a love for research at the time but fortunately I'm in a group at a hospital that doesn't really force that on you. And so it wasn't demanded for me to do research. And ironically in my third year of residency I stumbled upon a couple of questions clinical questions that I felt like weren't answered adequately and started a couple of randomized controlled trials in my last year of residency that I ended up concluding as my first year in attending so as I started the road not really enjoying research I found that when I was asking a question myself and designing a project to answer it I actually did enjoy it. So it produced a situation where I wanted to be good at all three things that are academics which is clinical work teaching and research and to this day that remains my focus. My main gig is being good at all three of those things and that pushed me towards academics because some of those options are limited in private practice. Docofalltradez: So did you do you even consider going into private practice at any point. Physician Philosopher: I did yeah. There's actually a few groups that I looked at. And you know the big draw of course in anesthesia at least is that you get to maintain the breadth of practice whereas in academics I'm very defined in a specific niche. I did a fellowship in regional anaesthesia but before I did that I did consider going into private practice and the idea of maintaining a very broad scope of skills was appealing to me. In addition to you know the various differences between private practice in academics. But yeah I guess I thought about it. Docofalltradez: Well there's going to be a difference in terms of reimbursement between academics and private practice. Was that ever a consideration in your decision. Physician Philosopher: It was you know just like anyone else I came out with with student loan debt though I had less than the average. So you know money certainly played a part for me it wasn't the substantial part though I you know I really looked at it as what I want to do with my life where I want to see myself in five or 10 or 15 years and made the decision based on that information. Money did play a part in that. You know if there was a massive difference between the two I know I might have been pushed one direction or the other. But nowadays that difference is getting smaller and smaller with each day. And I work at an academic hospital where I'm paid pretty well. Docofalltradez: And you know it's funny I haven't really been looking at the differences lately but when I was coming out of residency that the difference was rather large. And back in 2005 when I graduated they were offering pretty enticing signing bonuses which then really went away. Around 2011 2012 and now they've come back with a vengeance. And there are people in my who are graduating that that I'm currently teaching teaching and mentoring we're offered massive signing bonuses. Do you find that they're giving signing bonuses at academic institutions or have you been enticed with any signing bonuses yourself. Physician Philosopher: There are you know it's just different than ever every hospital and every anesthesiology group whether academic or private practice has a different model and so where I am you can get kind of a signing bonus. They may help you with moving expenses they may help you with the number of shifts that you required to work that year in decreasing that such that. You make more money for less shifts and sometimes they will give you an outright bonus to start. But I would say that that I'd imagine at least in my experience that those numbers are going to be smaller than what they are in private practice. Docofalltradez: Well you know and you also mentioned that you graduated with some student debt and I imagine there are more opportunities to get that student debt forgiven in an academic than versus private practice. Physician Philosopher: Yeah it's actually interesting. You know I I'm doing a study in my academic job where you know we're looking at student loan debt surveys and determining financial literacy is regarding student loan debt management and you know in doing that I discovered that about 75 percent of hospitals you know all comers are 501c3 or governmental hospitals that would qualify for public service loan forgiveness. The implicit assumption there is that you are in fact employed by that hospital though and not working in a private practice group that contracts for the hospital difference there. Right. But if you are employed by the hospital itself then you have a 75 percent chance of going anywhere in the country that your hospital whether academic or not is going to qualify for public service loan forgiveness. Obviously all academic institutions do for the most part. And so that did provide an opportunity there although that's not the route that I'm going personally. Docofalltradez: Well you know I think that would be something really to look into. If 75 percent like you said there's a there's a good chance and then if you could potentially tie that to a signing bonus you could take quite a good dent out of your student loans coming out. Oh sure absolutely. You know a very different choice would be going into solo practice then. Now the problem is if you do have a lot of debt a lot of these private practices will have a b I looked at two different jobs my current job there was no buying but I looked at another job and the buying was you get a reduced reimbursement the first year and that that reduced reimbursement then becomes your buying and it could be upwards. In my case I was gonna be something like one hundred thousand dollars so I imagine for a student who's kind of with debt they'd be more they'd probably less willing to take on that risk. And so of the graduating residents that I'm mentoring right now most of them you mean they have absolutely no desire to take on the risk given their student loans. Are you finding that to be the case with your with your graduating residents. Physician Philosopher: Yeah you know I don't know too many they get excited about having a buy in when they're carrying three or four hundred thousand dollars in student loans having to buy another one hundred thousand dollars off of their salary to do that. Most people are trying to find a job that balances work and life and then also allows them to have a high enough income that they can really put a dent in their debt. And of course that all assumes that the person knows anything about personal or physician finance which I find is not the majority of people you know but those that do yeah. I think that they certainly consider that in the possibility of paying off their debt quickly so they can move on with her life and try to get ahead financially. Docofalltradez: Well you know again it also depends on the specialty so some specialties are obviously much more lucrative and buying into a surgical center. As an orthopedic surgeon or another type of surgical specialists could be fairly lucrative whereas you know other you know other professions like ours those opportunities really don't exist so it's really I think it's specialty specific as well. No I completely agree. Let's see here. So part of the problem that I was looking at a recent survey of graduating attendings and it seems like these they seemed to change jobs rather quickly within the first two years something like as high as 50 percent of them will will change jobs. Have you noticed that at your institution. Physician Philosopher: Yeah I have. It's actually it's actually funny I was having this conversation with a resident the other day who is just you know bent on buying a house when they move out for residency or out when they graduate residency into their in their private practice job. And I really just encouraged the person I said you know the smart thing to do is to rent a house for a year or two and make sure that you like the job. And you know they asked me why and I said Well because I can't tell you the number of people that go to a job and then a year or two later they come back in the interview where I am where they trained you know a year or two later. And the reason why is because a vast majority of them sign on to a job that's presented one way and the expectations don't meet reality when they get there. So yes I absolutely found this to be true and I'd say the number is probably pretty large. I think that I heard someone mentioned noted numbers almost 50 percent of doctors will change jobs within the first five years of finishing training so you know as a financial expert do you think this is a good idea to change jobs that early. Oh man it hurts particularly if you buy a house. Physician Philosopher: I mean you know if you buy $500,000 our house and you know you're gonna expect to cost 10 percent to sell that house I mean you have to come up with 50 grand and most physician loans which is what most graduating residents are gonna use requires zero percent down payment. So now what do they have hundreds of thousands of dollars in debt and now they have to come up with fifty or seventy five thousand dollars to sell their house a year or two later. And they definitely have that equity at that point. And so it definitely is a big decision and the other thing too is that you know academics in private practice both have tracks you know in academics. It's your track to become an associate professor from assistant and then from associate to full professor later. And so if you delay that for two years or three years or five years because you went to a job you didn't enjoy that's gonna be a problem. And the same thing for private practice if you join a different group your partnership track and start all over again and you're now two or three years behind your peers because you signed up for a job that you know isn't what you wanted. So it has financial and you know wellness implications all around. Docofalltradez: What's interesting as physicians I don't think other professionals realize that as physicians when we change jobs in many cases you have to start over again. Whereas we'd like us here and is a perfect example I see Arnie will get compensated based upon years of experience whereas with us we actually have to then rebuild the practice and so you'd actually lose money with every change in transaction. Physician Philosopher: Yeah. That's that stuff. True and you know I think it's it's such an important decision you really do want to try to get it right but you're also making that decision off of you know based off of incomplete information. I mean you can only know so much about a group before you join. Physician Philosopher: And so I think the best thing to do is just to minimize the amount of damage that could happen if you tried to change jobs later if you didn't like it. And you know of course none of that conversation even involves covering you know your tail for malpractice and whether you know the person is gonna let you do that and if you got money upfront that signing bonus that we talked about earlier or money toward your loans oftentimes they'll make you pay back. And so you know you just get further and further and further into the hole so as many of those things as you can mitigate when you make that decision I think that that's the way to go. Docofalltradez: Yeah. You know I was talking to a Physician on Fire about that and he actually got a hundred thousand dollar signing bonus but after he had you know had attended that particular job for a period of time decided it wasn't for him. He ended up having to pay back part of that money with interest. And so the more you talk to people the more more common you realize it is a hassle. I just recently talked to a guy named Alexi Nazem and he is the owner of Nomad health marketplace. You've heard of him. I haven't. OK. So nomad marketplace is a place where you can traditional you know traditionally when you're trying to find a job you might use job boards or go to you know your various Web sites that have you know like the back of a magazine or your. Sure publications et cetera. Well he's created something where you can actually go there enter your name enter your specialty and then find a job. So he's trying to create the like Uber of job boards and it's a brilliant idea. And you're talking about this and we. And he he had a really interesting insight his marketplace really is looking to help increase and improve locum tenants. So for example if you're if you're an employer looking for a high quality provider and or if you're a provider looking for high quality employer it's a way to skip the middleman and find the person directly. And so he actually recommends doing locums for a couple of years to kind of get a feel for the you know maybe the marketplace location which which I thought was very interesting. And you know with a new gig economy and the way millennials think it sounds like more and more people are doing that. Have you noticed that at all in your institution. Physician Philosopher: No I have not seen a lot of people go directly into locums tenants like I completely understand why it's appealing why that would be helpful. I haven't seen a lot of my residents you know personally do that. The ability to have a ten ninety nine and then pay for you know lodging and travel and you know pay you a pretty good fee is is really appealing but I haven't noticed that you know down in the south where I work. It's a good idea though very good idea. Docofalltradez: OK. So would you consider yourself a millennial. Yeah. I just meet the criteria. Ok. Now I've noticed that millennials tend to emphasize work good work life balance more than compensation and or other things. Where do you stand on this. Physician Philosopher: I'm absolutely a fan of that thought process. You know. On my Web I really talk a lot about balancing life and making sure that you're making smart financial decisions and making the head happy and then also making the heart happy. You know I don't think that you can really have profound wellness without without doing that. And you know that they're just they're just things that you know I talk about a lot about self identity on sort of my posts and really what I'm getting out there is that as a profession physicians often lose themselves in who they are and and being a physician ends up defining them. And I am so many more things outside of being a physician that I care more about and that doesn't mean I don't love my job. Physician Philosopher: It does me I'm not passionate about it or good at it but I am you know I'm a father I'm a husband you know I'm an author an inventor craft beer lover and there's so many things I love outside of medicine. And so you have to find balance no matter how much money you make if you don't have that balance you're not going to be happy. And so I think that money plays a part but it is certainly not the most important aspect. Docofalltradez: Well you know it's interesting I I've been meeting a lot of not only an older older Gen Xers but baby boomers and they are so defined by by their work that they you know even when they when they come to retirement they want to put in another year or another year because they can't see themselves outside of medicine yet. Physician Philosopher: It's actually been a fascinating time because you know we do have that mix of different generations. And I think that you know a lot more than anything I'd probably call myself so I feel when I read this but it's called being a Xenical. So in between a millennial and a generation Xer and I can relate to both of those ideas you know I can relate to the thought process of the Generation X that millennials are entitled and want a bunch of stuff for for nothing. Physician Philosopher: That's kind of what they argue which isn't always true. And then millennials just want to know why they want to know why things are the way they are and why they have to remain that way. If there is a better way to do it and there's been a lot of tension honestly between the upcoming resident classes and the people that are in leadership of them because of that you know and I think that's a good tension. I think that promotes positive discussions if they're allowed to be had and can result in some good change. But it's been really interesting being in the midst of that Docofalltradez: Well you know there's so much dogma in medicine that the mere idea of even questioning it especially back when I was training was unheard of. And now the millennials they're very bold and they have you know they know they can command an audience because they're going to be the majority of the workforce here very very soon. So I've learned a ton from them. I applaud their efforts. And in many ways I kind of kind of wish I was a millennial. Physician Philosopher: Yeah it's it's definitely interesting time. Docofalltradez: Well you know the interesting thing about millennials and the marketplace and I've been kind of thinking about this quite a bit in terms of the job choice. So if we want to emphasize work life balance if we want to have the ability to have lives outside of medicine in exchange for less control in the workplace there seems to be an issue with that. So for example when I came out of medicine 30 percent of people of physicians were employed whereas now 30 percent of physicians are. Going into private practice. Now the downside of being employed is you really don't have control over your schedule. You don't have control over. You have no control over the business and you kind of dictated by people who were running the business what what your your hours need to look like. Now we do that in exchange that we don't have to run a business but it seems to me that the long game it may be to our benefit to be controlled by others. And so I'm wondering if that's going to interfere in work life balance in the near future. Physician Philosopher: Yeah definitely can. You know there are there are pluses and minuses to this. You know the the true solo practice that was granted for anesthesia that's never really been a thing. It's been very tough to cover something 24 hours a day for three and six five days here by herself. But you know that's the ultimate autonomy when you have a family practitioner or an ophthalmologist dermatologists that that owns their own practice and they can dictate their schedule however they want. So from that end of the spectrum to being an employee where you were told when and where to show up for work every day and how you're going to do your job that that's a spectrum. And I do agree. But you know the benefit of being employees is exactly what you said. I don't have to worry about any of the overhead. I don't have to worry about billing. I don't have to worry about you know any of the business aspect of medicine in terms of my main job. And that is a benefit for me. But it does come with the cost of not having as much flexibility in the schedule. And also you know this may be true for private practice groups too with you know senior partners but you know a lot of my job is is dictated by those that are above me and you know what they think is best for my career. And that's that's an interesting place to be. Being a very proud independent person. So you know there are pros and cons to it for sure. Docofalltradez: Well let's get into the weeds a little bit then. So you mentioned it that if you're in solo practice obviously you eat what you kill. And so if you don't kill anything you're not going to get a you know this can be a lot of comp at risk. And with most employed positions and I'm sure that's the case with the academic positions you have a guaranteed comp right. You're so you'll have a portion of your contract that says this is how much money you're going to make it regardless of how productive you are. And usually they'll put some money at risk as to incentivize you to do something. And in the case of my job I'm incentivized to not only work to meet a certain level of you know ASA units or RVUs use but also there are quality indicators that we're expected to meet like cancellations. There are staff satisfaction scores patient satisfaction scores, showing up on time. So they created this what we call a balanced scorecard to make sure that you know not only do we meet the requirements to generate money for the hospital but also that we're being good stewards of that of our institution. Do you have something similar to that in your institution. Physician Philosopher: We definitely have a base salary and then incentives they're not the same as yours though which I felt was fair instead listening to what you were listing off there. So we have incentives for academics officers and non-clinical incentive which might include attendance at certain things like grand rounds or in faculty meetings. It also includes billing. So you know how frequently do you close your charts on time and you know there are other things that incentivize us for academics. And so in terms of you know just pure research or teaching and there's a point system and depending on where you fall in that point system you get a certain incentive. We are also incentivized in that when we pick up an extra shift we make more money. So we're not paid a flat salary. We do have a base salary but if we increase our work and provide more shifts then we're required then we get paid more. And I do know that you know at least the surgeons at my institution you know they they are they definitely have RVU to how they get paid. And so that allows them to do more cases and to make more money that way as opposed to picking up shifts like we do Mm hmm. Docofalltradez: Yeah. That's interesting how you can you know I guess each each at each employer will have certain things that they deem very important so like for example meetings attending meetings for some employers is very important. So we I personally can't stand meetings I used to attend them all the time and now. We no longer have to attend these meetings. But I can see I could see the value in forcing people to attend meetings especially if they are trying to enhance the your department like for example teaching residents or or grand rounds. So do you do they pay per meeting or do you have to meet a certain threshold of meetings at your institution. Physician Philosopher: Yeah. So the way that works for us is that we we have to meet a certain percentage of attendance and that's that's how we get paid. you know the conversation kind of reminds me of Tim Ferriss his book The Four Hour Work Week. Physician Philosopher: And you know I'd reading that book a lot of it can apply to to medicine just because people are sick all the time so you can't work four hours a week. But he had some really interesting ideas about meetings and stuff and basically talked about the fact that you know very little gets done at meetings. And so he would make a point to try not to ever attend them unless he was made to. And if he was made to attend meetings he would try to make a very clear idea of when he needed to leave. Physician Philosopher: And you know I fall somewhere in between the spectrums I do think that some helpful things can be done in meetings but it is exactly what you said it depends on what the meeting is for and what it's about. What we're trying to accomplish because otherwise people just talk and nothing happens. And that is kind of the opposite of my personality. So I do talk a lot but I like to get a lot done to. Docofalltradez: I want to talk about the opportunity cost and return on investment of fellowships. You wrote it and you wrote an awesome article on the white coat investor that really generated a ton of traffic and questions and that's come up recently in my practice one of my partners recently after working for five years decided to go back to do a fellowship and you know the argument really went back and forth about you know when is it a good idea to do a fellowship and under what circumstances. Now you did a fellowship in a non accredited fellowship and you have. How do you do you have any regrets about doing that or you're totally happy that you did that. Physician Philosopher: No I'm completely happy that I did what I did was not accredited so that means I got paid more I got paid about double what I made as a last year resident a fourth year resident. So that was part of the benefits and my opportunity cost a little less there. And I do what I love you know I love regional anesthesia. I love doing it. I love teaching it. I love performing the blocks of studying it. And so if I had not done a fellowship I would have regretted it honestly and so knowing that about myself regardless of how the money turned out I was I was pretty happy with the decision. But I do think that there is an opportunity cost that has to be considered. You know when we're having this conversation you know you're going to you're gonna lose salary which is you know I talked about in the white coat investor post but you're going to lose salary and most people mistakenly think that that's the first year salary that you're gonna miss. In actuality what happens is that the last year you would've been a partner. You're going to miss one year of that. So that last year salary in my opinion is the one that needs to be counted. Physician Philosopher: So whatever your top pay is expected to be is the money that you're losing and you're obviously not going to be able to pay down debt or invest in the market as you know as heavily while you're in training. And so if you're earning a fraction of the money you'd be earning as a as an attending then you're gonna have to delay you know really destroying your debt or investing aggressively for just one more year. And I've actually heard it said that you know a way to use this time is to basically use it as a financial fellowship. So you know I don't regret the decision at all. Docofalltradez: Well so I guess when what circumstances would it be a bad idea to do a fellowship then. Physician Philosopher: So I think that a fellowship is a waste of time if it's not going to help you get a job and you're not going to be doing what you did the fellowship. So it's it's not uncommon that someone will do a fellowship in something I can use my own just I'm not pointing fingers but they do a fellowship in regional and they sign up for a job where they're going to be sitting there on cases you know as it's physician only anaesthesia and and the group does you know 5 percent of their cases under blocks. That's kind of a waste of a year because you're not really gonna be using your skill set. And in addition to that you lost all the opportunity for the money that you would have made that year. So I think that that's one classic example of that situation and in the other honestly is is that if you're doing it for the money. Physician Philosopher: I mean if you're just doing it as a purely financial reason you know that's probably not gonna make you happy you know and I think that that comes first. Docofalltradez: Well and then there's also the break even point and so depending on the specialty. I think I was reading that love. Sure. What is it infectious diseases and pediatrics and then trauma trained orthopedic surgeons. Their break even point is like infinity they'll never break even. So I think to your point as you kind of have to you kind of have to love that to even consider doing it. I completely agree. Physician Philosopher: It's ironic that you mentioned that specialty so despite the fact that I wanted to anesthesiology I really like my pediatric infectious disease rotation because we had some of the most hilarious physicians that were heading that group. And so we got around round with them every day and they make fun of each other and had a great time and they're just a great group of doctors. And so for a little bit I teased around the idea of doing that. You know I've come to find out it's just because I liked those physicians and I realized I could be a great physician in other fields but I looked at their salary and I couldn't believe it. Physician Philosopher: You know they spend an extra three years after pediatrics to do that. And I mean they make less than a general pediatrician typically. It was incredible. Docofalltradez: Well you know there's such awesome people that they would have to be awesome to even consider doing that. Now I kind of want to reach out and give them a big giant hug and and introduce them to a couple of my attorney friends to help them start negotiating their contracts. Absolutely. You know but but you know again I think it lends to the fact that they have such nice personalities that they would never even consider putting their patients in harm's way. They they they put taking care of their patients above all else and you got to admire that. And I absolutely do. But I think you nailed it man. If you want to go into a fellowship just for the money it's going to it's going to leave you empty. I totally agree with that 100 percent. My fear is when one of my peers he's he just left general anaesthesia to do cardiac anaesthesia and I'm hoping he's doing it because he really really loves it. His main I think his main fear is that that given that we have other market factors playing into anaesthesia such and specifically see our knees that his concern is if CNN's were ever made equal to anesthesiologists that could put a lot of downward pressure on our on our specialty not only in what we're doing but also in reimbursement. And so his argument is if you have a specialty like cardiac anesthesia that that you'll never be at risk. And I'm not sure if that's entirely true but it certainly gives you some level of protection. Physician Philosopher: Yeah I think it's an interesting time to practice anesthesia. This is a question that a lot of my students ask me when they're thinking about going in anesthesiology. Physician Philosopher: But yeah I think that it's tough because some of those things are really just emotional support. I mean it makes you feel like your job's more protected but ultimately a lot of these decisions are made by politicians and bureaucrats that may or may not know anything about medicine. And so you know it's it's one of the reasons why advocacy is important. But you know it's it's also a conversation about you know where exactly we'll fit in in the future of of medicine and how our role might change. But you know the idea that someone else can't get you know someone to accredit them for for something is kind of it's kind of strange because even even in my world that's happening there are programs for advanced practice providers to get pain fellowships and that's a thing. And so you know it's interesting. Docofalltradez: So are you talking about nurse practitioners. Physician Philosopher: CRNAs ones that I've seen. Yeah. And so they can you know or the idea that you can go get a weekend training and in doing blocks and then come back and do it. You know it's the question always is is you know what is competent and there are disagreeing opinions on that you know. Physician Philosopher: But I will say that by and large I absolutely love where I work where you know we supervise. But I have very very little problems with this in real life. You know at all and a lot of it ends up being conversations that are in our head you know about how we're gonna protect our know our job or our field. And I think and what I tell my residents is that if you're at the tip of the spear you know practicing Anaesthesia at the intricacies and the furthest science that we have at that point and you continue to push that spear further you're always going to be protected. There's always a need for someone like that you know. But if you want to go and you know do a practice job and have you know No weekends no nights and do G.I. sedation then yeah I mean there may be an issue in the future. Docofalltradez: Very good point. And again there's there's ample evidence that the care team model in other words anesthesiologist supervising multiple CRNAs a safety net that you wouldn't you would otherwise have if you're by yourself either as a physician and or as a So I'm not really worried about it myself you know for people who were considering anesthesia and worrying about the longevity of this specialty I really don't think it's gonna be a practice in fact I think with the advent of artificial intelligence and just improving technology I think I think we have a very bright future I agree. Physician Philosopher: You know and like I said I love what I do at work and I have great relationships with you know all the CRNASs and residents that I work with and think the model works well and you know I've definitely had experiences where you know as part of that care team model I helped save patients when things were missed and I've definitely had you know people help me. Physician Philosopher: That's why it's a team you know. And people talk about that. That's the idea behind systems based safety systems you know. And the idea that the team is more likely to catch an error than a single individual. And so I'm definitely big proponent of that. Docofalltradez: Excellent. Well so let's let's talk about the podcast so this podcast is about negotiating and the whole premise is I believe very strong in researching every topic before proceeding with important decisions. We've kind of already talked about this but one of the most important decisions you can make in your career is your first job and your first contract. And it's because what it really does is sets into motion your future earning for years to come which will then compound over many years. So what what is the most important piece advice you would give a new grad given all your recent experience and what you've gone through up until this point. Physician Philosopher: You know we talked about some of that earlier but this is kind of one of those situations where you need to trust but verify. And that's kind of the anesthesiology creed but you need to do your due diligence. You need to go and research the potential opportunities that are out there but before you do any of that. Honestly the most important thing is figuring out who you are. And what you want because the right job for someone else may maybe the completely wrong job for you. And so I think that time well spent deciding how you want to live your life and what your next five years are going to look like in 10 years and 15 where do you see yourself in 20 years. You know what do you want your life to be. And after you have decided that you discuss that with significant others or family members then you can consider looking for a job that can help you get there. And that's gonna look different for everybody. But I do think that is very difficult to get the information you need sometimes you can talk to prior grads you can talk to the current partners sometimes there's questions that you that you have that you feel uncomfortable asking in an interview setting or even afterwards. Physician Philosopher: And they're important questions. And so I you know I do think you have to do as much research as you can. But the other you know other side of that is that you have to protect yourself and realize that 50 percent or so of residents who leave and go pick out pick a job end up coming back or Or you know changing jobs at least in the first five years and so you can't you know bear your anchor at the first job that you have expecting to stay for eternity when you know that's not the case for a lot of people. So I think that you need to first know yourself and figure out who you are what you want and then you need to do your due diligence do your research and ask all the questions that are important for you to get there and then also to have a safety net to fall back on that you don't make a ton of financial decisions early on and inflate your lifestyle to a point that you can't leave the job if you want to. Docofalltradez: Well I think your website does a really nice job about that. You talk about financial wellness and of course work life balance. So your website is grown considerably. You've written some amazing articles. What are your plans for the future of for for your Web site. You know I think that Physician Philosopher: I've got lots of plans obviously to continue to produce content and all I've ever really wanted is to help people and to get this message out there that financial independence can be used as a tool to prevent and treat burnout and then to help protect people from the conflicts of interest that exist on the financial world you know and so I'll continue to produce content. You know I'd like to get it in front of the right audience because obviously resonates with the right person but they have to see it first. I'm writing a book right now. I've been writing a book for I guess six months now and it's currently being revised and I have to decide how I'm going to publish that if I'm going to just do it on Kindle Direct Publishing or if I want to go the formal route. Physician Philosopher: So I'm still kind of thinking through that and you know at some point I'd like to make courses for people to kind of sort through these these issues when they finish training because my target audience is medical students residents and early career attending physicians and other high income earning medical professionals. So that's kind of on the docket for four for me right now. Docofalltradez: Sounds awesome. You know you did mention just now that you can use financial independence to fight burnout. What's your philosophy for for how do you use financial independence to do that. Physician Philosopher: So I think that what financial independence does. You know people talk about money a lot. We talk about wealth a lot. And ultimately that's not really the you know what you're shooting for you're not aiming to just get a bunch of money. What you're aiming to do is to get enough money that it provides options and those options allow you to design your life how you want to live it. So you know the idea there is that you know we talked about these you know employee jobs or situations where you don't have complete control and this allows you to take further ownership of your life and kind of have some leverage. Physician Philosopher: You can leave a job that you don't like. You can go part time because you have the money to do that you can decide to work outside of medicine or do a side hustle to help produce financial independence and you may find that you enjoy that. So I think that all of those things really what they do is they provide options and those options allow you to fight burnout and then the causes of it. Docofalltradez: Very well spoken well great. Hey it was a pleasure having you on the show. I want to encourage every single person to go ahead and read your blog posts. They're amazing. I think you've done an amazing job reaching out and connecting with all the other physician influencers. And I look forward to reading more of your stuff man. It's awesome. Physician Philosopher: Yeah thanks I appreciate. Thanks for the opportunity to be on air. It's great fun. Docofalltradez: And hopefully you will be. This will be your first podcast. You heard it here folks. Physician Philosopher: That's right where I was made famous. Docofalltradez: Yeah that's right. Well hey I just think again once again I like to think that physician philosopher for being on my show if you'd like to learn more about him head over to his Web site. The physician philosopher dot com. If you'd like to get the show notes on this podcast head over to the There you'll find a little more information about the physician philosopher a PDF on the show notes. You can subscribe to the Web for updates on every single podcast and you can also subscribe to the podcast on stitcher on iTunes on Google podcasts and possibly even Spotify if they ever get their act together. Anyway once again I'd like to thank everybody for listening and please subscribe please give me some feedback please give me some comments. Would you'd like to learn more about some future episodes if you'd like to have any tips or tricks or if you want to be a guest on my podcast. Hit me up. Thanks for listening. Docofalltradez: Thank you for listening. We hope you enjoyed the position a podcast show notes and other resources. Docofalltradez: Please visit the physician negotiator dot com. Sonix is the best audio transcription software in 2018. The above audio transcript of "EP06_The_Physician_Philosopher.mp3" was transcribed by the best audio transcription service called Sonix. If you have to convert audio to text in 2018, then you should try Sonix. 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EP05: How to find a medical job with disruptive technology using Nomad Health by Docofalltradez | Alexi Nazem http://traffic.libsyn.com/thephysiciannegotiator/EP05_Alexi_Nazem.mp3 WHO’S ON THIS EPISODE ? Nomad Health ? Twitter ? Facebook link ? Linkedin ? Youtube Channel RESOURCES & LINKS 5 Mistakes in searching for a job EP05:  How to find a medical job with disruptive technology using Nomad Health Searching for a job will be the second most difficult thing we deal with second only to studying and passing our medical boards.  One of the reasons has to do with the antiquated system that requires 3rd parties and massive redundant paperwork for credentialing, onboarding and verifying.  This is busy work and having spent nearly a decade in medical school and residency the last thing we need is more busy work.    Nomad health is trying to change and disrupt the system by streamlining this process with the use of cleaver yet simple technology.    To Err is human and we are no exception.  Dr. Nazem and I discuss the top mistakes physicians make when searching for a job from an industry insider.  Also, we touch on the idea that Medicine is ultimately a business: The medicine is a business and equipping doctors and nurses and other clinicians around the frontline is a smart thing to do because then they can actually lead lead to changes that need to be made instead of people who are non-clinical and don’t really understand the nuances of medicine You don’t need to have an MBA but taking the time to gain business acumen will pay off in dividends in not only in your career but in your entire life.   DOWNLOADS Show Notes EP05_Alexi_Nazem.mp3 (transcribed by Sonix) Download the "EP05_Alexi_Nazem.mp3" audio file directly from here. It was automatically transcribed by Sonix.ai below: Docofalltradez: Welcome to the physician negotiator podcast where no decision is left to chance with your host Doc of all trades. Docofalltradez: Today I would like to introduce Dr. Alexi Nassim. He is the co-founder and CEO of nomad health. Well many health care startups have non-clinical founders Dr. nauseum continues to practice internal medicine at Will Cornell Medical College while building his business. He graduated from Yale Medical School and carries an MBA from Harvard. He feels passionate about fixing the broken health care system and solving the upcoming physician shortage by directly connecting major stakeholders in the delivery of health care namely the employers and medical professionals. His company nomad health accomplishes this by creating an online marketplace for physicians and nurses and skipping the middleman Alexi welcome to the show. Alexi: Thank you so much it's great to be on. Docofalltradez: Excellent. Hey you know Alexi you have an amazing background. I did a little bit of stalking on you. Hope you don't mind. No. I read an article you had written on Kevin M.D. about immigrants making America great. Yeah. And you have quite a legacy in your background your granddad was an anesthesiologist and your dad was a Buckeye graduated from Ohio State which practically makes us related since I'm a Buckeye Anesthesiologist. Alexi: Oh wow okay. Well nice to meet you brother. Docofalltradez: Yeah likewise. And your entire family is filled with medical physicians and pioneers. It's incredible. Alexi: Yes and I'm very lucky to have grown up in that environment. Docofalltradez: And do you feel like that is kind of played a role in your entrepreneurial spirit. Alexi: Oh most absolutely. I had actually interestingly both entrepreneurs in my family and physicians so I guess one could say that I was predestined to go down the path that I'm going down. I grew up in a household where most of my extended family were in some way shape or form involved in the medical profession. And so that originally served as an inspiration for me and as I have actually entered and practiced in the profession. Having all of those family members who are actually colleagues is now served as a support and a push and really sort of like a great set of consultants for me. And then on the entrepreneurial side especially through my dad I was exposed at a very young age to the concept of creating something from nothing making companies that use technology to solve real world problems. And so that brew at home really set me as I said on this pathway and so for sure I'm indebted to my family for what I'm doing today. Docofalltradez: So lucky and you know couldn't come at a better time. Medicine right now is just struggling. I just read an article yesterday on The Wall Street Journal about how health care in general is not now the number one employer of all people living in the United States. And to say that it's not in the best shape is an understatement. And I'd like what you're really doing a nomad health in and trying to help solve those problems. So if you wouldn't mind can you share a little bit of a little bit with us about how nomad health works. Alexi: Sure. So Nomad the problem that we are confronting head on is the challenge with providing enough staff clinical staff to patients in American hospitals clinics and other venues of care. I'm sure you've heard that there are huge shortages of doctors nurses advanced practice providers and many others. And solving that problem is going to be critical to the future functioning of the health care system. And so what Nomad is trying to do is to introduce technology solutions to provide more efficient more effective health care staffing myself as a doctor and some of my co-founders also doctors really felt the pain of this problem trying to get recruited into a job or or even just looking for a job yourself is a very inefficient very frustrating process that involves third parties that involves lots of paper and fax machines and phone calls and it's just not a very modern process and in a world where we really need to have the best clinicians at the bedside it's crazy that we're spending so much time energy and money on getting patients the doctors and nurses to the bedside. Alexi: And so the problem that we're trying to solve is actually sort of shortening the distance and the time between the clinician and the bedside and that's what we do know that. Docofalltradez: And so with so how is it different from a traditional recruitment company then yeah. Alexi: So a traditional recruiter is a third party. So there is let's say a hospital and a doctor that want to work with each other well traditionally haven't you. In order for them to find each other and connect they've got to go through a staffing recruiter what Nomad does is eliminate those staffing recruiters and using technology replaces all the functions that those recruiters provide and allows the doctor in the hospital to connect directly and consummate that relationship directly using technology. So instead of having to interview on the phone with a broker and then with a friend with the hospital and the medical director and all that kind of stuff instead of having to mail in paper forms instead of having to sort of look for credentials all over the place we've centralized all of those processes online in a very easy to use technology based platform. So it had that same ease of use to something like air PNB or kayak where you do very high cost complex transactions very easily very quickly online without the intervention of a third party. We're trying to bring that same level of convenience to staffing. And so basically we're cutting out the middleman and allowing the two parties that are interested in working with each other to do that without any outside assistance. Docofalltradez: And that is a fascinating concept because if if you know the modern physician orders looking for a job today and if they have multiple recruiters they may have to go through multiple processes multiple credentialing especially if you're a traveling provider. And so each time you go through the process you have to replicate that paperwork over and over and over again. So is no nomad then creating a database where you would just have to submit it once. Alexi: Exactly. That this company was born out of that very frustration. I I tried to do a locum tenant's job which is that kind of traveling Doctor job that you talked about. And it took me 10 months to organize just three days worth of work and it's because I had to talk to and submit. So I talked to so many brokers and met so many different applications and that just takes a lot of time. Alexi: And so what Nomad does is we essentially have a common app you apply one time to our platform you upload your information and your preferences etc. and then all you need to do is to just point out the job that you like and you don't have to re upload your ACL as current anymore or tell us again about where you went to med school. Alexi: And so that substantially cuts out the sort of hassle of working working with multiple of multiple places. And so ultimately what we want to be is the one stop shop for a doctor the one stop shop for a nurse trying to find a job or leverage the clinical skill set that they have. Docofalltradez: So there are traditional credentialing companies that you can upload all this information to as well with wood would then if you were to get hired through nomad would you be able to then use the information that you submitted to nomad to get your credentialing at a particular institution. Alexi: Yes I mean it varies a little bit based on institution and we try to automate as much in the process as possible but of course there are local rules and regs for every institution and so sometimes they require you know their own their own additional credentialing and that's unfortunate something that we can't control. But we hope that over time nomads quality become so well trusted by health care institutions that when nomad credential somebody that say so is enough and wouldn't require any additional we're not there yet but I hope and expect that we'll get there eventually well and that seems to be the problem you have all these different institutions and different state medical boards and who all have their own systems that have never once really taken the time to talk to each other for the most part and would like to win them. Yeah I mean I think that as much as possible we're trying to integrate with existing systems so that we're not asking people to duplicate efforts that they've already made. And then you know as you said make them talk to each other biotechnology and that hopefully will move the needle and really get us back to the things that actually matter taking care of patients and stop doing things that don't matter like filling out paperwork. Docofalltradez: So the original concept was for temporary employment. Was it always your intention to do this for permanent work. Alexi: Yes it always has been our goal at Nomad is to become the jobs marketplace for health care. So any kind of job for any kind of clinician should be something that you can find and do on Nomad. So if you're a doctor we want you to be able to find locums in plain then full time employment in telemedicine employment and many other kinds of jobs that would take advantage of the clinical skills that you have. And then we also want to offer that same that same upper set of opportunities to nurses in peace space and in the future other types of clinical providers. So all along it's been our goal to provide a one stop shop as I said before. And just takes time to grow a company like that. Docofalltradez: Now you've been growing for about three years and you you covered 30 states with the expectation of covering all of them. Is that correct. Alexi: That's exactly right. Docofalltradez: So what percentage of jobs do you expect your system to have in the database. Alexi: Well so ultimately the goal is that every job that's available in the world of medicine is going to be on Nomad. We're obviously not there yet today but there are literally thousands of jobs on the nomad platform today. We're in as you said about 30 states mostly the east coast the west coast and the upper Midwest. And obviously trying to get to to all 50 in short order but you know thousands of jobs are up there. So it's it's a pretty good sample of what's out there but of course not every single job in American hospitals and clinics. But we're working our way towards that. Docofalltradez: Now you mentioned that this is a billion dollar industry which really surprised me. I was listening to one of your speakers talks and that's a lot of money. And that tells me that this industry is pretty dug in. So how is no no no man is going to be able to compete with such a large industry and scale. Alexi: Yeah well so first of all it's a 20 billion dollar industry. So it's a very huge market and it's growing rapidly because of that growing shortage of clinicians how Nomad is going to win in the spaces that we provide better service at a lower price. And this is a classic disruption story. We are using technology to as I said offer better service at a lower price. And that's kind of unbeatable. Really what we need to do is just continue offering a high quality experience that serves the real needs of our of our users doctors nurses clinicians. Alexi: And on one side and employers on the other I have no doubt that what we're offering is head and shoulders better than anything that a traditional company can offer. And so I think it's really a question of if but when we will. Docofalltradez: I was really surprised how how much of a commission these companies get when recruiting a physician now. I think you mentioned at some point like ten thousand dollars or upwards of 40 percent of the transaction. Alexi: Yeah. So it is an extraordinarily expensive industry today. So a traditional staffing agency for temp work. So in other words locums for doctors or travel in nursing for nurses they're charging 40 50 60 sometimes 70 percent commission which is unbelievably high. We're able to do it for a fraction of that cost you know 20 percent of that cost are 15 percent of that cost. So is it because we don't have the legions of of manual laborers on call centers and filling out paper forms and stuff. We're using technology so we're able to cut a lot of costs out of the system. So you know in our marketplace we're not only as I said offering a better service but we're able to do it at a much lower price for the clinic for the employers and then the clinicians end up getting paid a little bit more as well. So it's a win win win. Docofalltradez: How is the disclosure process or how's the discovery process of reimbursement for a clinician take place on Nomad. You mean reimbursement for clinical services matters. Weather and I'm thinking mostly like locums because typically they charge by the hour or by the day. Alexi: Oh yeah. So the way it works is that we don't actually at Noma get involved in clinical reimbursement. So what ends up happening a typical locum for example will in their contract with the facility which is signed through Nomad is saying look I'm going to sign over my billings to to the employers or the hospital for example. And in exchange I'm going to be paid an hourly or shift based wage. Alexi: And so that's that's sort of that's sort of what the mechanic. Docofalltradez: So in terms of the actual amount and would that transaction or negotiation take place between the two parties between the doctor and the employer the nurse and the employer and that happens directly on the nomad platform. Alexi: So a hospital might pose a locums job and say hey we're looking for an emergency department physician and we want to pay them you know one hundred eighty five dollars an hour. That'll be up on the job plus very transparently unlike in any other traditional agency. And then the doctor can say Yeah I'm interested in that job but could you possibly do two hundred and then the hospital might come back and say oh well let's do it for one ninety and then they sign a deal through through the nose that's like that. All that negotiation happens right on the pile. Docofalltradez: It's amazing. So then you could probably can you negotiate other things like transportation housing and that sort of thing. Alexi: Exactly. Yeah. So all of that stuff you can negotiate right on no matter whether it's expense reimbursement travel or reimbursement housing you name it really anything can be can be negotiated. Docofalltradez: And the interesting thing about that is it gives the hospital more leverage because they get to get a a better clinician for a cheaper price because they're not paying for the commission. And then it sounds like the physician and the nurse will win because then they could ask for more and the hospital would be more willing to give it. So that makes sense right. Alexi: That's exactly right. So because the clinician is getting paid more you might actually get better people more quickly and because the hospital is paying less they can hire more people more quickly. So it's ultimately serving that core problem which is the shortage. So I think one of the things that we're very excited about it Nomad is the ability not only to improve the efficiency of the existing staffing market but also to draw more people into the contingent gig part of it. So get more people to do locums get more people to do travel nursing. I think there are substantial and substantial numbers of doctors and nurses who want to do this work but have shied away from it traditionally because it is so frustrating and difficult to engage in that market. And so by creating an easier system where you can possibly get paid more you know we can possibly increase the supply side of the equation and address at least a portion of the shortage problem. Docofalltradez: And you know I set up my own account and it was free and it was actually pretty pretty easy. I was really impressed by how the interface was fairly simple so for the it doesn't take a technocrat in order to figure out how to navigate it Yeah absolutely. Alexi: I mean that's our that is our whole goal is to make this so easy to use that you want to the the the sort of bar that we're trying to cross. Sort of the bar that is set by the traditional agencies is so low that it's very easy to clear it but we don't want to just step over it. We want to leave home. We want to make it incredibly easy to use nomad so that you know it reduces the friction to getting into this market. Docofalltradez: It's a relief. Interacting with the computer that's not easy. JHA you know because right now I think on the my average patient that I see I'm probably doing 100 clicks and I know many of my peers feel the exact same way. So it's refreshing to see something that actually is pretty simple and it works the way it's supposed to. Alexi: Oh yeah totally. I mean technology typically in healthcare has been so disappointing and we want to reverse that trend and just offer something that is consumer great. Alexi: You know that has the same ease of use as the things I mentioned before like Air B and B we don't want to our competitive set in terms of technology ease of use is not an EMR but rather you know the app that you use on your phone every day nice. Docofalltradez: Well let's switch gears a little bit I'd like to start talking a little bit about how we can help graduating residents and you know it is job season right now. You know physicians are looking for their jobs and it seems to me they're securing employment earlier and earlier. I have numerous peers and mentees who've already secured jobs for July which is just incredible. And that seems to be the norm. I also work at a place where we have a a school. Same thing. We're currently interviewing for four jobs for next year. And despite that we're still struggling to get get employees. Docofalltradez: It's incredible. But I think there's a lot of stress involved with trying to secure a job when you're a resident. And I think that if you're spending most of your time focusing on studying for your boards finishing your clinical is I think the last thing that you want to do is really spend that much time and effort looking for job. But it's also the most important thing. Docofalltradez: How will see me make sure I phrase this right. A lot of physicians when they first graduate whether in this process of looking for a job don't even understand how they begin looking for a job. It's a good fit for them. Does does nomad have tools in it. That kind of help them understand what's going to be the best fit for them in terms of location lifestyle etc. Alexi: Yeah I mean this is a very challenging thing figuring out what your first job post residency should be in fact you know during residency you're hardly given any exposure to the variety of opportunities that might be out there and certainly not equipped with the tools to help you make decisions about what the right and what the right job is for you and you don't even think about things that you're gonna end up having to negotiate. Well tell me about the malpractice insurance that you're going to give me. Tell me about what an RV you is. Tell me about scheduling and call and things that you don't typically think about when you're a trainee and certainly aren't given any real training on and so there's a couple of things I think that nomad does to help with the with the first time first time job seeker. First and foremost we try to give as much information as possible upfront about the various job opportunities that you can have it. So we're not trying to hide any information we're trying to take everything you could possibly want to a need to know in order to select a job. So try to tell you about the facility that you might work in and tell you about the nature of the work the kinds of patients that you have all that kind of stuff. So that's one thing. Just having more information is super helpful. Additionally we have a bunch of resources on our site to help you learn about what you're supposed to do to effectively take a job or decide between job opportunities. Alexi: So for example I mentioned that practicing come on our resource center and our blog. And you can see some guidance about how to how to approach that question. And then at the very end of it also there is no substitute sometimes for talking to someone who is an expert in the field and so at any moment despite the fact that we're a technology company in China replace as many steps as possible with tech. We have great people here. We have what are called nomad navigators and they help you navigate your job search. And so if you'd like we can reach out to us directly and and ask those kinds of questions and say hey you know what should I be looking for. How should I even prepare my resonate and put my best foot forward kinds of things that you wouldn't necessarily think about in your training but are certainly very important to when you are actually seeking a job. So we try our best to be your your supporter and your advocate and try to give you resources from start to finish. Docofalltradez: What a fascinating prospect. So you just this nomad Navigator is a person that you can contact very early on is it is it can still considered free of charge until you get the job. Alexi: Well absolutely yeah. So the moment you sign up for a nomad you can schedule time to speak with a nomad navigator and they can help you in any way that you see fit. We want to enable you to do everything and as much as you want self-service but when you feel like you need a little bit of guidance there's always a an expert a person that is available to talk to you. Docofalltradez: That's amazing. In terms of the contractual sale. So we've talked about the salary negotiation process in terms of the contract. Once the contract or there's a letter of intent that's been signed nomad no longer is involved in the process beyond that. Correct. Alexi: That's correct. Yes. So for for these full time jobs permanent jobs. Yeah. We primarily serve that the purpose of connecting the two helping you sort of get the relationship off the ground but then when it gets to you know actually doing the formal employment that becomes a transaction between the doctor the nurse and the in the facility. Docofalltradez: Ok. Now there are various practice type models in the industry today. So we there's still you know a couple of people to do solo practice. We have a group practice. We have hospital employees and then we have academic does nomad really focus on any one particular area or is the goal to have all those modalities represented all the different job types. Alexi: Yeah we're trying to have all those different job types available on Nomad. So are job opportunities are pretty reflective of the opportunities that are in the market at large. Docofalltradez: So you wrote an article. Well I actually didn't write somebody on your Web site wrote an article called The Five mistakes doctors make when looking for a job. And I see these mistakes all the time and I'd like to go through them because I think they're really important. And the first thing that you say is mistake number one is keeping your job search narrow. Alexi: I think I think that is a very common problem. It's very easy especially for a first time job seeker to really only default to the things that they know. So the location that they're comfortable with the practice setting that they're comfortable with and that can you know that can be great. I mean if you love practicing in an urban academic environment just like the place you train fantastic but you may also like other you may also like other types of opportunities. A suburban or rural location a non teaching facility private practice. So there are so many different kinds of things that you can do and a lot of them you don't get exposure to while you're training. So keeping the search narrows is not serving you're not serving you. As well as it could mean eventually you have to narrow your search but start start broader. Docofalltradez: You know it's interesting you said that you have a very narrow exposure and I've read a couple of articles where some people have actually advocated doing locums for a period of time in order to get that exposure. Where do you stand on that. Alexi: Yeah actually that's a great idea. It's kind of like a tribe before you buy approach. You know when you work as a locum you can work for months at a time in a facility really get to know the facility the patient population the geography etc. and kind of figure out hey is this for me or not. Is this style of practice for me or not. Is location for me or not. And so I am totally supportive of this concept and I think actually more and more people are starting to approach their first jobs this way whereas traditionally attendings at least my attendings would would encourage me not to do that. Docofalltradez: So it's such that you can build relationships but I think that the trend is changing. I think you know if you can find a location based upon like for example the way nomad illustrates what each job entails you can feel more comfortable going into a situation and feel like you're being supported as opposed to traditional you go into a locums you may feel like you might be the odd man out. Alexi: So yeah no that's absolutely right. The I think there is a changing attitude amongst the millennial generation that would like this kind of gig work. And then additionally I think there's a changing attitude towards locums. I think that there you know some of the unfortunate stigma that may have been associated with that type of work in those type of clinicians is fading away as more and more people start to do it. So I think it's a I think it's a reasonable and in fact a very good thing to start doing. Docofalltradez: So I go jumping in a mistake number two jumping at the first opportunity which I think is basically we've kind of illustrated with mistake number one. If you jump at the first opportunity you may not necessarily find the right fit right off the bat that's exactly right yeah. Alexi: So just keep looking and you'll remember always that as a doctor you're the scarce resource. And so you are highly desired and so you should find you should feel the right to be selective. And so don't jump at that first opportunity you know on and on. Docofalltradez: The other interesting thing about that is I think recruiting companies in general are upping their strategies to try to get these doctors earlier on. I went to a dinner two weeks ago a recruitment dinner where they were inviting interns. I've never seen that before. And the topic was to be tried to keep it as light as possible and try to be unbiased as possible but at the end of the day what they really wanted to do was put their name in front of that physician. And this particular health care system was offering residents a stipend that they could sign up immediately so they could they can get them onto their system. So I think you have to be really careful with something like that because you're going to commit as an intern might be a little bit too early in the game in my opinion. Alexi: Yeah absolutely. I mean look I don't think that any of these systems are approaching things with any nefarious intention. I mean that could be the right job for you and so think about it. You know consider it. Alexi: And you know it may not be the wrong thing to do but at the same time remember that you do have lots of options and you should feel as I said the right to be selective. Docofalltradez: I agree. So Mistake number three is only considering large cities or facilities. Alexi: Yeah. And so that gets back to the thing that I was saying before which is that you know most of us end up training in large facilities and usually in cities. And so we only have less and less exposure to environments that are not like that. And so it's a very easy thing to default to to say hey I'm used to practicing in a 500 bed academic facility in a city with a million plus people. And it's the only place I could ever feel comfortable. But you know that's not necessarily true. So you think about different types of locations and and facilities. Docofalltradez: Where do you think there's greater demand right now with respect to city size or population size. Alexi: Well I mean nationally there is greater demand. Patient demand in places that our population centers. But there's a relative oversupply of clinicians in those places when compared to lesser populated area. So what we see is is that some of the greatest demand for clinicians is coming in suburban and rural locations and less so in in urban locations. But across the board there's a physician shortage. So again you know the doctor and the nurses that is the scarce resource. Docofalltradez: Right. And just take them before negotiating contracts poorly. Now that's kind of the basis of my podcast. The physician negotiator because I've seen it time and time again and I think the biggest thing physicians fail to realize is when they're actually in a negotiation perfect example this morning I was at a meeting with my hospital and we're about to go down a person. And so the hospital was trying to tell us how we're going to take extra call and and all of a sudden I realize I'm in a negotiation and I'm just at a meeting. So it was pretty funny. Alexi: Yeah I mean at the end of the day I mean medicine is a business and that's not something that any of us are really confronted with as medical students or trainees. And so getting smart on what matters economically is really important because then you know what to negotiate on. So do things like look at the at the data about the specialty and the location that you're in to see Hey what should I be getting paid. And then also learn about other finer points I mentioned briefly before about malpractice and our views and other things like that. So just talk to your colleagues. There's lots of great resources online also I nomad to learn about the various things that you can negotiate. Knowledge is power. If you don't know about these things you're definitely not going to negotiate well if even just know that you should negotiate about them your 10 steps ahead of the game. So I'd say you know learn about those things and and bring them up. Alexi: And you'd mentioned on a prior podcast that the physicians really struggle with understanding the business of medicine and you have great business acumen and successfully negotiated this thriving startup. But you also got an MBA. What would you recommend physicians do to educate themselves. Short of short of getting an MBA or you do you recommend they get an MBA. Alexi: Well I mean of course I endorse the idea of an MBA. It's been great for me but I don't think that it's necessary to get an MBA to be an effective doctor. But there are a lot of things that you learn in that education that would be valuable. You don't need to go to school for like there's lots of great resources online to help you sort of have a little bit better business acumen when it comes to the business of your profession as a physician. Tons of great Web sites out there to get smart. I'd also think about you know start start planning. I'm not a financial advisor or anything so please take everything I say with a grain of salt. But you know it's not too early when you're a resident to start thinking about your financial future and you know how to to save and invest for the long term. And so beyond things that are dedicated specifically to clinicians there's a ton of really just financial smarts education that you can that you can engage in early on. And so I would I would encourage you to sort of continue to be a student just a different topic. I think sort of separately. I personally advocate for and have done some of this advocacy formally to get more of this kind of education into a traditional medical school curriculum nursing school curriculum and later in postgraduate training curricula. It is so important at the end of the day as I said Medicine is a business and you will be a better clinician if you recognize that and have some of the tools we should do everything we possibly can to get more of that on more of those topics under the curricula but short of that all of us should recognize that it's an important topic and get smart on it on our own. Docofalltradez: Have you met any resistance from these centers who from from whom you advocate. Alexi: Not not in recent times. Early on in my career when I was you know when I was applying for medical school I knew that I wanted to also go down this business pathway and I had to be very secretive about it because most I didn't really find a lot of receptive ears to that type of approach. Alexi: But in the last 15 years there's been a huge sea change in the medical profession and people really recognize exactly what I said. The medicine is a business and equipping doctors and nurses and other clinicians around the frontline is a smart thing to do because then they can actually lead lead to changes that need to be made instead of people who are non-clinical and don't really understand the nuances of medicine to suggest and make a change in the system without clinical influence so that's a long answer to your question. The short answer is there's not much less resistance than they once used to be. Docofalltradez: Well there seems to be a proliferation of physician led websites teaching such education now so that's reassuring and certain medical societies have actually reached out to my peers asking them if they understand or know any resources so they can teach the medical student so I'm glad you're your leading that effort. I really appreciate that. I think I wish that something like that existed when I was a medical student. I kind of had to learn this on the fly so again double kudos to you for that doing that. Q Alexi: I think you're doing a great service here too my trying to raise awareness and to educate. Docofalltradez: I'm trying I'm trying. Last question is mistake number five I don't want to over. We kind of went on a little bit of a tangent but not looking at the big picture is a mistake number five and this is this is for me I think a big one. Alexi: Yeah I mean I think that one of the topics that we hear a lot about in medicine these days is burnout and I think that's because you know people aren't considering the big picture what does it mean to sustain a life a life and a lifestyle. Alexi: And so thinking about what matters to you and what's going to nurture you and your ability to keep doing great work is really important when taking a job you don't want to sort of keep that same pace that you had in your residency. Alexi: This is probably not sustainable. And so you think about things like All right well where and where do I want to be physically I mean do I want to be close to family friends I love you know am I an outdoorsman and do I need that. Do I need lots of culture and you know sort of like access to theaters and museums and things like that. So just consider some of those non-clinical non-professional things and think about how much you want to work think about with whom you want to work. Think about you know the social circles that you want to maintain. There are so many considerations beyond sort of peculiarities of your job you know how many hours how many calls how many whatever that will matter to your ability to do your job. Alexi: And so we we strongly advocate here to take a holistic look at at job opportunities before taking the plunge. Docofalltradez: Well you know on that note the most recent Physician Survey talking about new grads that the survey suggested that positions after two years changed jobs such like more than 50 percent. And I think a lot of it has to do with them not looking at the big picture you know what's a what's a nuisance to you. Day one may you know may be an irritant and by year or two. So I think the big picture is key is finding figuring out what you like and what you what's important to you is the challenge. And so I think that's why when we look back and we're saying you know you got to keep your job search wide. I think that's one way one way you can do that. Docofalltradez: That's right. And also the flip side is I wouldn't say it's a failure if you take a job and end up needing to switch after two years you know you don't want to put so much pressure on that first choice. You know it's okay to adjust and adapt over time but at the same time very important to take as I said a holistic view so that you make as good a decision as possible. Docofalltradez: And that's a fair statement which is why you know you can make an argument that doing locums work at first might be a good idea it might be a good strategy for you. Alexi: Well I couldn't agree more and then I hope that all of your listeners will give it a shot by coming on over to. Docofalltradez: No. Exactly. All right Lexie Well hey how how can we learn more about Nomad and how do we sign up. Well it's super easy. Alexi: Just go to w w w dot nomad health dot com and everything else should be pretty self-explanatory. We worked very hard to make it easy but it doesn't need any extra explanation. So help me come on over and we look forward to working with all of you. Docofalltradez: Well Alexi Hey thank you for joining us. You know I think it's really important that we disrupt all the different medical norms that we have right now. There's so much room for improvement so I applaud you and your and all your peers for trying to make a dent in this and this problem. Alexi: Thank you very much and thank you for what you're doing too. I think it's so important. Once again I'd like to think Dr. Nazem for being on the show. If you'd like to learn more about Dr. Nazem or Nomad Health over to the physician negotiator dot.com forward slash E.P. dash 0 5 that's episode 5 as I'm growing the show I would really appreciate some comments either on the Web site or on I Tunes head over to my Web site. The physician negotiator dot com and there you'll find a button for leaving us some feedback or if you'd like to make the show better. Click on the button that says get answers. Once again thanks for listening. Thank you for listening. We hope you enjoyed the position negotiate a podcast show notes and other resources. Please visit the physician negotiator dot com. Sonix is the best audio transcription software I love using Sonix to transcribe my audio file: EP05_Alexi_Nazem.mp3! Use Sonix to automatically transcribe your audio files; Sonix is the best way to convert audio to text online. get every episode of the physician negotiator in you inbox! Thanks for subscribing to our weekly show! Check us out at iTunes, Stitcher and Spotify too! Name Email Subscribe ? Previous Podcast Next Podcast ? YOU MAY ALSO LIKE No Results Found The page you requested could not be found. Try refining your search, or use the navigation above to locate the post.

EP04: How To Protect Yourself From Your Group Disability Insurance Policy by Docofalltradez | Christopher Yerington http://traffic.libsyn.com/thephysiciannegotiator/Christopher20Yerington20Final.mp3 WHO’S ON THIS EPISODE ? Physicians Income Protection Website ? Chris Email ? Facebook link ? Linkedin RESOURCES & LINKS Kevin MD Article on Disability Articles On Medium Cory Fawcett’s Article EP04: How To Protect Yourself From Your Group Disability Insurance Policy Dr. Chris Yerington is a retired cardiac and trauma anesthesiologist. Chris also attended law and business schools. After his clinical medical career ended due to a disability, Chris used his entire education and experiences to assist start-ups and entrepreneurs in Central Ohio. Chris often volunteers as a spokesperson or consultant for the companies and people he assists. He has a passion for working with professionals and physicians individually to ensure they have the best education and advice about disability insurance. Chris speaks to groups of resident physicians, dentists, and professionals and works diligently to provide income protection. Chris likes to talk about “Why you need great disability insurance” which is usually the last thing a graduating medical student would like to discuss, right up there with flossing and colonoscopies.  But when it comes to protecting your investment of 8 years or more of education the single most important decision you may not even make is private individual disability insurance.   There are very important distinctions between group and individual insurance which may seem trivial to some who has just started their career but It could have devastating consequences if not handled properly early on.    He also teaches finance in the following way.   The foundation of your career has to be financial protection in the form of individual disability insurance since when you first start out, you have no money and/or a negative net worth.   As you save part of your income (hopefully >20+%) over the course of many years you will achieve some level of savings until you reach financial independence.  From this point forward you have successfully navigated your career and then spend the rest of your life continuing to help others.   Without having a solid foundation your entire career could be a house of cards with a disability ending it all.    Approximately 30% of all people ages 35 to 65 will suffer a disability for at least 90 days, and about one in seven can expect to become disabled for five years or more. ( Source: Health Insurance Association of America, The New York Times, February 2000) And as you age the chance of disability increases drastically.   A simple mistake can early in your career could cause havoc if not handled properly.  In Dr. Yearingtons case, although he had great insurance during his career-ending injury, not knowing the nuances of his group disability policy cost him money when he could no longer earn it through practicing Anesthesiology.  Since he has gone through the process of making a claim and having lived through the process he has some amazing insight into how this industry works.  He advocates having the right policy and having it set up correctly will help protect your income.    In this episode Dr. Yerington discusses: Why we need disability insurance? What is the difference between group and individual policies? When is the best time to purchase individual disability insurance? What to do if you are under 40, over 40 and over 60? Why have new graduating physicians elected not to obtain their own DI policy over the past 20 years? A word of warning.  This episode is very long but I assure you it will be worth your time! DOWNLOADS Show Notes EP 04: How To Protect Yourself From Your Group Disability Insurance Policy : Very good. All right. Today on the physician negotiator podcast I have Dr. Christopher you bring in Dr. Christopher Yerington has a website called Physiciansincomeprotection.com. And he was recently did a guest post on CoreyFawcett.com for Financial Prescription Success. I met Dr. Yerington through Corey Fawcett. And I was just so compelled by his content that I had to have him on the show. So Dr. Yearington welcome to the show. : Thank you very much. It's it's great to be here. : Thank you so much. Now I read your article on Corey Fawcett's Website and you said it's really generated a ton of interest since you said you did that guest post. : Yes I I definitely got several hundred new connections electronically and I have been chatting electronically to a lot of stuff online through LinkedIn and Facebook with several several new doctors a lot of them younger attendings and residents. : And you know the one thing that's unique about your Web site physician income protection is that you sell disability insurance but in your previous life you were an anesthesiologist. Is that correct. : Correct I practiced anesthesia from 1998 to 2010 October I'm sorry October 2009 was my last clinical month. And then I was forced to take disability in January of 2010. : And why was that. : In 2009 I began becoming weak and it was more on my left side than my right. And. The I started not being able to even lift an I.V. bag mask ventilation became difficult. I had a lot of shoulder pain. I went ahead and had the shoulder taken care of where every you know everyone thought that was the issue. And then after surgery it turned out I had much more of a neurological component. Eventually I saw three neurologists and a peripheral nerve specialist and I was diagnosed with a left brachial plexopathy stemming from being a high forceps delivery in 1972 and I have the resulting brachial plexopathy from that I was born with an erbs and klumpke's palsy but those had resolved by the time I was a year, year and a half old so completely that you know there there was you know there was no residual. I was a swimmer and in fact my freestyle and backstroke Times were among the top in the United States when I was 19 and 20. And you know you would never think that I had a physical problem and yet my body failed me in my upper 30s and I ended up on disability really out of left field. : Now when start with something with a palsy like that would have it happened anyway or was there something about practicing anesthesia that led to it. : That's interesting. So the way that my peripheral neurologist explained it was that if I had had any more damage at birth than I probably would have retained the palsy for life. Much like the actor Martin Sheen has a policy of his arm and had it recovered very quickly in a month or two then I would have likely still had a problem but it wouldn't have showed up till my eighth or ninth decade of life. And you know when you're when you're 78 years old and you can't put your ketchup up on the top shelf well then that's you know that's a problem you can deal with. But mine was just enough injury that I only made it to about my fifth decade of life and then started having symptoms. So you know do I think that working 80 hours a week hurt me perhaps. But you know I was going to end up with weakness on my left hand side no matter what. You know my career may have contributed to it having earlier in my life than I would have liked. But you know it is it is what it is. : Well I attended an ASA conference several years ago on finance in one of the speakers basically had said that everybody in the audience he said about two in 10 of you would get a disability and the entire audience was shocked. And I think there's a lot of people out there did they don't really understand the odds of them getting disabled in their in their career well I can certainly speak to that. : I. I have spent the last few years becoming somewhat of an expert on physician disability. I like a lot of doctors. I had a policy myself and individual policy and then I also had a group policy and I had two different experiences with those companies and in educating myself over the last few years I found out that the the rate of disability for physicians is approximately three in ten over a 35 year career. And of the 30 percent that get disabled about half of them are disabled for up to a year and then another portion will be disabled between 1 and 7 years and then a smaller portion of that will be permanently disabled from the major duties of their clinical career. Like me nobody wants a one handed anesthesiologist. I mean I can tell you that with 100 percent certainty that if you're left thumb doesn't work in your left hand doesn't grip. You can't be in the operating rooms handling airways. So you know it is a.. The reality is it is a 3 in 10 chance. Well most of those a majority of them are going to be up to that year. Another portion will be one to seven years and then a smaller majority a smaller minority will be permanently disabled from your clinical career. And that that is devastating for somebody who's put so much time and effort into their education and their experience and skills. : Now it happened to you early in your career. Is there any data that would suggest about what time it would occur in their career. : Well obviously disabilities tend to be age related. More of them occur after the age of 55 than before the age of fifty five. And that makes sense from. From what we know practicing medicine is is hard on the body but it's also hard on the mind of those that are procedural lead based tend to get more physical problems than the non procedurally based physicians. But that's not by enough of a percent that you know I think that family doc shouldn't worry about getting carpal tunnel because the reality is that the way we practice medicine has changed dramatically over the last 15 years and the advent of the computer instead of being a occasional interface it's now an every hour interface. So the those cases are slowly climbing up but the one disturbing trend in medical professional disabilities is that the number of mental nervous claims has been climbing every year for approximately 10 years. And that really is a change overall in the nature of disabilities for physicians. : And with respect to that change it sounds like the insurance industry has caught on to that and indeed since then kind of adjusted the way they make their policies on disability correct. : Well for for all group policies you'll find the limitation on mental nervous conditions to be two years and for many individual disability insurance Sharon's policies those would be the private ones that you go out and purchase yourself many of them. The stock option the the the baseline charity option will be two years mental nervous and then you would have to add on an additional premium if you wanted to have mental nervous conditions covered for the life of the policy. And that's so they've they've made it so that they have reduced their risk. But there are options if you want to price in that possibility for yourself. : And in light of the latest data on burnout that may not be a bad option. : Correct. And there are a few of the major carriers that distinguish themselves by offering mental nervous for life but they price it accordingly and they change other aspects of the language in the policy to adjust for that risk premium. So you know it is it's something they've definitely taken notice of. I will tell you that in get team individual disability insurance a lot of the carriers are much more cognizant of asking questions that direct whether or not a person's mental nervous personality or baseline puts them at higher risk of that. So it's not so much in asking you know what your physical problems have been. They they are really attuned to asking Have you ever seen a therapist for any reason ever you know. And they also look at activity. So that's one thing that doctors need to be aware of especially young doctors in residency and medical school. We can all get stressed out in medical school and residency but as soon as you go see a therapist you've eliminated your ability to ever be covered for a mental nervous condition by a disability carrier. Wow. And that really is that is one of the reasons I push interns to get there of their get their individual disability insurance as quickly as they can upon entering residency because that is really as young and healthy as they're ever going to be. : Wow. Well you know with respect to the cost of individual disability insurance it's never been cheaper. Is that right? : It actually has never been cheaper and it is still very expensive and it is worth every dollar if you become disabled you know we'd all like to buy that lottery ticket the night before. It's one point six billion precisely. And just like you'd love to make your first disability premium payment the month before you go on disability. But that's that's not really how insurance works insurance works to pool risk of individuals so that the group itself is safer proceeding through time because there's a known risk you know in this case 30 percent of the pool of physicians will have some sort of disability at some time and because they don't all have disability at the same time and their careers are thirty five years you can price in a structure as an insurance carrier to cover the the the risk. But you know and the more people that participate in it the lower the insurance cost per individual. The problem though is it's it's expensive because of the what it does pay out for somebody in my my case if you get injured 11 years into your career they're going to be paying for twenty to twenty three years. And so it can add up to like millions of dollars and it can it can add up to millions of dollars but it still would not be the same. Millions and millions of dollars I would have earned as a physician. But the the idea that you would trust the 30 percent chance that you get disabled to a group policy that was priced out by executives for the cheapest amount of dollars is not a real smart way to conduct yourself as a physician Exactly. : Now the question with respect to cost. OK. So sure. As a rule of thumb you said I think at one point that you get pay for all those every ten thousand dollars of coverage is correct. : Right. So the real range is closer to three hundred to five hundred dollars for quality individual disability insurance per ten thousand dollars of coverage. And I'm pricing that ad in the middle so that's not like if you're an absolute premium person never had a health problem. Never done anything to see a doctor except forget your vaccines. You know your pricing is gonna be better if you were let's say you were an athlete but you suffered a bunch of injuries playing in the NCAA Division One sport you may not get the premium pricing and there may even be some limitation language in your policy concerning those injuries that you got in athletics and that would of course push your price up. There is some differential also between the sexes. Males tend to not males tend to be less expensive as a as a as a risk category than females overall. And so some of the carriers charge females more than males. However there are still a few states that require what's known as unisex pricing. So they basically average out the men and the women and the price you pay is in the middle. So if you're a man in a state with unisex pricing you can end up paying more for your policy. But if you're a female you'll end up paying less for your policy. : So explain to me how that works then with respect to the price. So if you or you're going to get ten thousand dollars worth of coverage right. Is that over the course of the year? : No. So that benefits benefits are all priced in in dollars per month. So OK ten thousand dollar benefit level would mean that you get paid ten thousand dollars each month. : So it's gonna be roughly three to five hundred times twelve then you can multiply the number of months in a year. : Correct. So you get a ten thousand dollar benefit would be one hundred and twenty thousand dollars a year. You can purchase depending on the carrier up to between 60 and 75 percent of your salary if you purchase your disability insurance with pre-tax dollars. In other words it's some sort of benefit that your group offers and you pay with pre-tax dollars you'll actually receive your ten thousand dollar benefit as pre-tax money which means you'll owe taxes on it. So you'll take home ten thousand bucks you'll pay 30 percent in taxes. And so that will be seven thousand other policies you pay with post-tax dollars and then you'll receive them in post-tax dollars. So that's that also will change the pricing because it's whether or not the company is taking you know that tax equation into into part of the the pricing of the premiums. So there's there's actually a lot of things that go into the pricing but it isn't in so far as your listeners need to understand. You purchase individual disability insurance with post-tax dollars from your own checking account so that you receive those benefits as post-tax dollars and they do not show up as income if your group allows you to buy a group benefit with post-tax dollars. You definitely want to take advantage of that that benefit within your group or hospital. : Is there ever a situation where you want to do the pretext paper with pre-tax dollars. : Oh absolutely. If you are. Well let's say that you went into medicine because you have medical problems yourself and a lot of the great carriers are not going to offer you good policies. You may want to look specifically for groups or hospitals to work for that offer a great group benefit. As far as disability insurance goes and you may not have a choice about it being paid with pre-tax dollars but you could have a choice with how much you maximize it or whether there is a supplemental policy that you can purchase on top of that a lot of times those supplemental purchases must be made in pre-tax dollars because that's how they're priced. So you know with each specific physician depending on their own history medical history they there are different policies from different carriers that work better for their situation. : And with respect to So So let's say you have. I mean obviously you want to be. You want to purchase your your disability policy is early as possible. And if you're as healthy as possible. Yes. So let's say let's say you start. You recommend doing it when you're an intern. What if you wait until you're 10 years into your practice and now you've I'm assuming even if you've aged 10 years and nothing's changed in your medical health it's still going to be more expensive rather than had you purchased it when you were an intern. : It is. And that's actually a really easy way to understand that if you start paying for disability insurance when you're an intern your premiums are priced based on you paying for thirty five years into the system I get wrecked. If you start at 10 years later your premium is based on you paying in for only twenty five years. And it's the same amount though. It's no matter what exactly because you as an individual have a specific risk and that's pooled with everybody else's risk. So that's one of the reasons disability pricing goes up as we age and it also goes up depending on our own medical conditions. So because that premium has to be asked to be priced in their. : OK so in your situation you had a group and an individual. : Yes. So I I started residency and we had a financial lecture. And part of that was to steer us towards purchasing individual disability insurance which I did. I've always been a big believer in savings and insurance. I don't know whether I learned that from my family or where I learned that exactly. But I I've always thought that that's what everybody did. Everybody saves 20 percent and everybody maximally insures everything because that's the best way to be safe and secure financially. So I went ahead and bought that individual disability insurance policy as an intern and then about six months before I graduated I I took my employment contract as an attending and went ahead and raised the premium to coincide with the additional income I made as an attending and then I also that hospital that I initially worked for offered me an additional 5000 on top of that as a group benefit. So you know for my income at the time I was very well protected when I. Then several years later entered private practice. There was a group policy offered with the private practice contract and I had the choice of either purchasing it with pre-tax or post-tax dollars and I opt for the post tax dollars. At the time because that just made sense to me I didn't want to deal with the taxes because I had no idea what the tax code was going to look like for the next 30 years. So that's the situation I was in when I got disabled was I had one individual disability insurance policy and one group Disability insurance policy. : Well you know what you said was very interesting was that you assumed everybody else did it but that's not the case. Very few people or there's a I would say the majority of people still don't produce it isn't. : Yeah it's actually declining participation over the last 10 years has been noted by every carrier. The truth is back in nineteen ninety to ninety five actually two thirds to 75 percent of all physicians had some sort of individual disability insurance. And there are some programs here in Ohio that are now graduating residents and less than 40 percent of them have an individual disability insurance policy the day they graduate from residency or fellowship and they don't understand what an amazing amount of harm they are potentially doing to their lives by by not having secured this while they were in in residency well.Correction, Interns make money. Just not very much. Hierarchy of "Financial" Needs : And you wrote a really nice article about this. You talked about Maslow's hierarchy of needs and put a little spin on it. And you showed the hierarchy of needs with respect to finance the bottom level being financial protection. Correct. And as an intern you have absolutely no income in fact you probably have negative income because you're paying off your student loans but your ability to grow a nest egg is going to take a long time. And so in your hierarchy of needs you have financial protection at the bottom and then financial savings as the next level. And that's where you mentioned your 20 percent and then financial independence which which is not really the focus of this topic but that's the goal is to get to the point where your passive income exceeds your current income which then can lead to your own personal legacy which would then hopefully give you enough money not only to take care of yourself but all of your loved ones as well. : Yeah I mean my my career focus as my second career in life is to work with as many physicians as possible to make sure that they're financially protected and that they have a financial savings plan that puts them on the path to financial independence. Too many financial representatives, And this is from many companies, they focus on the doctors that are financially independent that have excess income every month and they want to invest it for them and there is not enough time or patience to work with somebody who is six hundred thousand dollars in the hole and is just graduating and they have really no income or they haven't done any of the prerequisites. : And so unfortunately the financial representatives that they do meet really are biding their time for when those physicians quote unquote get their act together and then in today's world it doesn't happen because the financial underpinnings underpinnings that they're taught are are not really in alignment with with with what a resident faces today. Our average resident entering residency as an intern is two hundred and five thousand dollars in the hole from educational loans. They are then swamped with in the first three months probably the equivalent of an average person's first two years at a job any job other than medicine. They are swamped with that amount of data about how to do their job. : It's not only the hospital EMR cars and human resources and all the other things that have to do with having a real job and income but they they have a they have a focus that is on learning their career not on learning how to manage their life. And in fact they they they are rewarded for managing their career and dealing with patients and working inside the system. In the hierarchy of residences of residents and if they go to spend time on themselves you know often and I don't know why we do this still as physicians but we kind of we discourage our fellow residents from taking the time on themselves when all of them should be. And maybe it's human nature. You know we feel better in misery we don't want to leave this one person taking time to eat right and sleep right and to exercise every day and then they they save 20 percent and they drive you know a three year old Toyota Camry or Honda Accord and they're doing everything they can to protect themselves and to save for their future selves. : And I think sometimes that that is that's that's another stress on residences. You know I'm barely hanging on dealing with my patient load and my 80 hours a week and I don't have time for all this other stuff. And so when I work with doctors I I actually address both problems. I do a lot of life coaching on work life balance because part of the problem with with modern medicine is there's there is a tremendous amount of stress. It's leading to burnout and you know if anybody who's read any of the articles even the rates of Physician suicide have slowly been climbing over the last 20 years. And in fact the American physician as a profession we have the highest suicide rate in the world of any profession in any country. And that is that is really a statement as to how stressful it is to enter medicine in in the 20 20 years here. : And what I've done is I've taken my disability and my experience and education of being a physician I'm married to a physician my younger brother's a physician. I've really had this front row seat to watch medicine change over the last eight years and I've also experienced the entire system as a patient which really opened my eyes to a lot of things that are wrong with the health care system and how I chose to address it was well the basic problem I see is doctors get in way over their heads eight to 10 years out of medical school and residency and they've dug this huge hole and it would be better to not have ever dug the hole in the first place. But that means they need to be taught as an intern or as a medical student. And so that's why I'm putting a lot of the materials that I put out in order to help educate that younger physician so that their career is is really supported underneath by a really strong financial life and financial understanding of keeping themselves healthy both financially and personally. : Well you know this Physician suicide is officially at an epidemic level. The most recent story was out of Stanford where they had one of their graduating resident surgical resident who went out to practice and within six months of practice committed suicide. And you know that the entire city and community mourn for this person because he was very well liked and so Stanford reactively started their wellness program which every other medical school now is modeling. Now part of the problem with that program in my opinion this is 100 percent my opinion is that they're looking at they're looking at ways to promote resilience amongst these these residents and you know they're promoting health in that sort of thing but they're really I think they're failing to see the underlying cause. And I think I applaud what you're doing you want to start early on their journey to to not let them get them into that position where they get overwhelmed. So even you know at other institutions that I've been to they're focusing on you know eating well and being part of the community. But it seems to me there's more that needs to be done with respect to the infrastructure that's leading these people to be burnt out and to commit suicide in the first place. : And you know that that leads to the why would you not be including basic financial literacy and financial health in a wellness program. And I'll tell you that. Next to sex itself finances are about the most taboo subject to discuss between one human and another in American society and I was going to say especially in medicine because it is there is this assumption leftover from the 80s and 90s that physicians make a tremendous amount of money I have several friends in non-medical Fields who way out earn any of my doctor relatives or doctor friends. And it is there is a growing parity now between medical and nonmedical careers."But publicly there is this perception that if you're a doctor you're automatically financially successful." : And so it's just not true anymore. But publicly there is this perception that if you're a doctor you're automatically financially successful. That perception leads to an expectation in doctors themselves that expectation leads to stress and residents and interns measuring themselves against this mythical perspective that physicians are financially successful and they look at themselves and say well how is that possible. I'm foreigner and fifty thousand dollars in the hole making forty eight thousand dollars a year. And I am I am I. I don't. There's no there's no light at the end of my tunnel because I'm in a cave. : Oh my God. So there's there's a basically disconnect between perception and reality. Absolutely. Society hold you to a certain high level of expectation which you yourself will never live up to. And so it leads to more stress more."you will hold yourself up to that same high level of expectation right. It's a public image and it is very difficult for a doctor to remove themselves from the public doctor image" : But you will hold yourself up to that same high level of expectation right. It's a public image and it is very difficult for a doctor to remove themselves from the public doctor image. This is you know there is some obviously some psychology and sociology that I am not an expert on going on. And so you know I only have a few hundred physician friends and I only have talked to several hundred other physicians. And so my perspective is that it's the same story over and over again. It's the same stresses and mismatch between perception and expectation and reality. And so you know again the way to combat that is to say hey yes you're in a pile of debt. The average is two hundred and five thousand but you can get out of it OK."That's and that's why on my pyramid as you pointed out my base is this big financial protection because if you don't do that psychologically you're really undervaluing yourself." : This is how you build a triangle to be successful. You've got to protect what you've done because you did something that only a very very few number of people in the United States did and that's attend medical school. Then you survived into residency and you are headed towards being a doctor. Why would you not protect your next thirty five years as your first and foremost move to tell yourself I am valuable I'm valuable to me now and I'm valuable to all the mes. Five years 10 years 20 years 30 years from now. So why would you not. That's and that's why on my pyramid as you pointed out my base is this big financial protection because if you don't do that psychologically you're really undervaluing yourself. And if you psychologically undervalue yourself it leads to a lot of other stresses. : Well and on that note you do write about financial safety and physician suicide and burnout. Now with respect to what had happened to you with your group disability policy that led to a tremendous amount of stress as well."you out there in the audience who think you're totally protected because your hospital or your medical system has given you a group disability plan ,you are not" "Let me tell you stressful is going for making you know twenty thousand dollars a month to making three because you only have a five thousand dollar group benefit that is pre-tax so you lose the taxes and then it disappears two years later." : Yeah. So in my particular case in this you'll find this happens with group carriers all the time so those of you out there in the audience who think you're totally protected because your hospital or your medical system has given you a group disability plan you are not most of your plans are they will sell it to you as an own occupation. And if you look at the language you'll find that the own occupation period is mostly two years in group plans. There are a few out there that are about four years but that's it. You have you have a small period where it's own occupation and after that the language will shift to any occupation and they do mean any if you can physically be driven to a toll booth and hand out tickets on a highway. That's a job if you can answer phones. That's a job. If you have your medical knowledge intact and you can review insurance cases that's a job. And so whether or not you do those jobs is irrelevant the fact that you have the potential to do any occupation means that your claim will terminate. So a lot of people that think they have disability insurance if they're disabled at 40 they will get two years of benefits as a doctor and then that's it they're done. They've been learning to flip burgers very quickly. Right. And so if you think you are stressed out in medicine right now because your hospital changed you know electronic medical records three times in the last five years. Let me tell you stressful is going for making you know twenty thousand dollars a month to making three because you only have a five thousand dollar group benefit that is pre-tax so you lose the taxes and then it disappears two years later."The group carriers have been collapsing through mergers and acquisitions pretty steadily over the last 30 years. There used to be over one hundred carriers and now it's down to just a couple dozen for the individual side." : That's stressful. That is true. But it doesn't have to be that way for my my own. What happened in my case was really kind of unique. So. The group carriers have been collapsing through mergers and acquisitions pretty steadily over the last 30 years. There used to be over one hundred carriers and now it's down to just a couple dozen for the individual side. There were about 70 or 80 carriers in the 90s and now there are 12 carriers left and it might be down to 10 because there are some other mergers going on and there's really only five or six really superior individual disability insurance carriers that you would want a policy issued from in 2018 the group carriers themselves. What happened was 19 days before my last day of work the carrier got bought out and or sold their book of business would be the industry term in insurance and I was part of that book of business and so I got sold and a new policy got issued but my policy was misconstrued. It was it was mis written it had errors in it it had sections missing it had sections that were left blank that in big capital words said use custom wording here. Unfortunately when you go on claim your policy is frozen in time. So for all my colleagues a year later all those policy errors got fixed and they got issued a new policy and that's the other thing about group policies with doctors."Your policy is only as good as this year. As soon as it reaches the anniversary date they issue a new policy with new language." : Your policy is only as good as this year. As soon as it reaches the anniversary date they issue a new policy with new language. Could that language stay the same. Yes but on a whim they could change it and most of us meaning ninety nine percent of us will never read the new anniversary edition of our disability insurance product through our hospital or medical group. So with my misconstrued. There was a it was very difficult to determine what would happen to my benefit should I ever even earn a single dollar and I finally got so frustrated in five or six years later from not doing gainfully employable work that I took them to federal court and I learned painfully under (The Employee Retirement Income Security Act of 1974) ERISA law which is what insurance companies function under at the federal level. My carrier actually didn't have to answer any of my questions they didn't have to tell me what happened and that that put so much stress on me that I became very very very depressed and in fact I started having images of my life without me. So my wife moving on my kids older but I was never in the picture anymore and I had to I had to seek psychological help and I'm not afraid to say this but I. It took me a long time to come to terms with the phrase suicidal ideation but I was I was suicidal whether I wanted to admit it at the time or not and I needed help and I got help. : I ended up being a very good patient. I went through a wonderful program. I continued for an entire year with therapy after that and part of that led to my passion of preventing other doctors from going through what I went through. So you know really there's two parts of my story. I did a lot of things really fundamentally right in my financial life that allowed me to take a huge hit through disability. Eleven years into my career and I want to teach that but at the same time I also want to teach people if you really protect yourself properly then you will be able to focus on your health and getting back to your what your life and not spend six years fighting a hundred and seventy billion dollar company that really doesn't care about you. : So as a fun thought experiment I sent you my group disability policy and the funny thing about that was as I went into my own H.R. website I couldn't find it anywhere. After making about 10 phone calls that actually is that actually is absolutely the modus operandi because they don't want you to know well it's not that they don't want you to know you can do it as long as you follow all the steps which you did. The reason they don't do it is because it changes every single year so they can't exactly put a static PD f up because that PD F will change the next year. : What was incredible is how little knowledge H.R. had about it I had to know. People didn't even understand that physicians actually operated under a different policy than the the non physicians yes."So the insurance carrier might start off with all these things on a platter but in order to maintain the pricing through the years they'll take a few things off the menu each year on that anniversary date" : And so. So at large hospitals that's actually right. So the way disability insurance works is that depending on your occupation you're broken into different classes that have different premium structures to them. So for example and this also has to do with income. So you know non physicians who are not medical professionals are in kind of one class and then there'll be another class of medical professionals at at hospitals or groups that sometimes includes docs and sometimes doesn't. And then normally physicians are their own class. And then in really large groups you'll usually even have an executive class above that because they have a completely different salary and compensation structure so. The policy for all of the non medical professional people will be a baseline to year policy. It will often be I hate to use the word cheapest but what they do is they control the premium by adjusting the benefits downward in order to maintain the contract with the hospital system. So the insurance carrier might start off with all these things on a platter but in order to maintain the pricing through the years they'll take a few things off the menu each year on that anniversary date. Physicians it's the same thing when you get a lot of physicians together they'll create a physician group Disability product like they have it for your organization and the they will take off things on the platter or if they have to keep them on they'll raise the price."And the reason H.R. doesn't really care about it is because if you go on claim you don't deal with H.R. you are put into a completely separate organization where you have a disability claims manager that has nothing to do with your other organization and you are strictly dealing with the insurance company." : And that's that's why it's not there because it's a moving target. And the reason they don't teach H.R. about it is it's a moving target. And the reason H.R. doesn't really care about it is because if you go on claim you don't deal with H.R. you are put into a completely separate organization where you have a disability claims manager that has nothing to do with your other organization and you are strictly dealing with the insurance company. And so you are and you're even separated from you know let's say that there is a representative that talks to all the docs when they're on board and at your hospital and says you have this group policy and it's from my company and it's wonderful and it's own occupation and all this that Representative can't talk to you if you go on claim they're not allowed to. The industry forces all claimants into one bucket of communication with an insurance company and all sales into another one. : And is that because of a contractual obligation that they signed when they work for the organization.It actually actually has to do with liability. So if the sales person has said something that's not true but then they're saying it to the claims person. You could get the carrier could be an a liability mess because the salesperson is a representative of the carrier. So what they do is they separate the humans so that the humans that are on the sales side don't talk to the humans that are on the claim side so that the carrier can broadly teach the claimants side to only say these things whereas the salespeople often have more latitude to sell a policy" : It actually actually has to do with liability. So if the sales person has said something that's not true but then they're saying it to the claims person. You could get the carrier could be an a liability mess because the salesperson is a representative of the carrier. So what they do is they separate the humans so that the humans that are on the sales side don't talk to the humans that are on the claim side so that the carrier can broadly teach the claimants side to only say these things whereas the salespeople often have more latitude to sell a policy. And. I could even use your group policy as an example when you were onboard and they likely told you it was an own occupation product which sounds fantastic right because all dogs one own occupation. : Well as of today I had a it was a mildly heated discussion as to whether from with other members of my department as to whether or not we had on OK and certain members were convinced this was a great policy in and all is well in the world and I said Well I'm not sure that's the case. And so and that's when I went ahead and reached out to you."But I'll tell you with your policy you don't have to worry about it anyway because your own occupation period is only 48 months after 48 months this policy switches to an any occupation definition and it is very very loose definition of any occupation." : Well I mean your policy and you know this. We could've pulled this from 60 different systems across the United States. Your your policy is a it's good in some some regard. Let me tell you the good things the good things are. It offers fifteen thousand dollars post-tax per month as a benefit as a maximum. And that would be up to 60 percent of your salary. So if you were making you know if you're making five hundred thousand dollars a year 60 percent would be three hundred thousand. And since fifteen thousand times twelve is one hundred and eighty thousand that's below three hundred thousand you would get paid fifteen thousand dollars a month because you're well below that 60 percent max. But if you were only making two hundred thousand dollars a year then 60 percent of that is one hundred and twenty thousand your benefit would be reduced to ten thousand dollars a month. OK. Now because that money is post-tax you don't have to really worry about the tax code through time. If you are able to hand out tickets at a toll booth on a highway that will count as any occupation if you can flip burgers one handed that will count as any occupation if you can review a chart."There'll be lots of jobs available to you so your insurance company at in that forty ninth month will take a determination from all the doctors you've seen. They will tell you which occupations you can do and because you can do them. They will then terminate your claim." : There'll be lots of jobs available to you so your insurance company at in that forty ninth month will take a determination from all the doctors you've seen. They will tell you which occupations you can do and because you can do them. They will then terminate your claim. So this is not a this is not a policy designed for anybody who experiences a disability that is short of a total catastrophic disability. So if you were a doctor and had a stroke. This policy would be great because it would literally pay you 60 percent up to fifteen thousand a month post-tax through the entire occupation period of age sixty five and that's great if you have a total catastrophic disability for your family to be able to take care of you. But if you have anything short of that of loss of limb or the loss of use of your mind you really are boxed in to a 48 month benefit period and that's it. You're gonna be off claim at the end of that they are going to terminate it and and the the sad part about a generous product like this one meaning that it goes up to fifteen thousand is it removes the possibility of a doctor like yourself saying hey I don't like being only covered for four years I'm going to go out and look at a great carrier and I'm going to get an independent disability insurance product for myself. And what you're gonna find out is that unless you make substantially over three hundred thousand dollars all of your benefit has already been taken up by your group product so you can't even purchase individual disability insurance."So that's one of the reasons that it's so critically important to get your individual disability insurance while you are in residency." : That's the real the real rub in these group policies and that's where I see a lot of young attendings there. They're making one hundred and eighty thousand they're making two hundred and they've got this great ten thousand dollar a month group benefit that only lasts for two years. But they can't physically apply and and acquire individual disability insurance because they already are covered 60 percent or 70 percent of their income. So that's one of the reasons that it's so critically important to get your individual disability insurance while you are in residency. I wrote a short article about you know I think was called P.G. y one and done. But the point was that if you want to get your individual disability insurance your intern year and you want to make sure that you maximize that contract with the ability for the future increase options so that you can go up to 17 or twenty thousand dollars depending on the carrier and for 75 percent of docs out there that is the only policy they will ever need for their entire career. They got it at the lowest price they got it from a great carrier. They they they have it available for their entire career and they can have it increase or decrease with the years."So you'll stack to individual policies on top of each other and that'll get you up to an industry maximum depending on the carriers for disability insurance. " : So then let's say you are in a specialty where you go on from residency to a fellowship and you go on from that fellowship to another fellowship and you are looking at an income that might exceed six hundred thousand dollars coming out because that's the specialty you're in. Well then what you want to do is in that six month will that last year of training you will want to look at your disability insurance and you may want to actually purchase a second individual disability insurance policy. And that in the industry is known as stacking. So you'll stack to individual policies on top of each other and that'll get you up to an industry maximum depending on the carriers for disability insurance. Then you go join a group. In that group insurance product will stack on top of those. And that's really how you maximally cover yourself. So. : So it has to do with timing then really more than anything else."And so and even a doctor that's coming onto your organization within those first 90 days that they become a doctor they can actually get an individual disability insurance products without the group Disability insurance product interfering with their benefit amount." : Yes. And so and even a doctor that's coming onto your organization within those first 90 days that they become a doctor they can actually get an individual disability insurance products without the group Disability insurance product interfering with their benefit amount. So it's critical but I'm sure you weren't told that when you were onboard it I'm sure when you join. They didn't say hey this is a group Disability product but it's really good if you're totally disabled if you stroke out if your heart doesn't work or your spine fails. But if anything less than that happens to you and it will to 30 percent of you we're going to pay you for four years and then you're on your own extra. : Well you know goes back to what we were talking about earlier though they changed every year. Yes. And if you go if you go based upon which recommended by your peers without really getting you know getting the document which you later have access to and then getting you know a third party to give you an actual appraisal you wouldn't even know."That is a huge struggle through hospital administration and anybody who works for a hospital certainly understands how difficult it is to do things in their departments' : That's right. You would not even know. And that's and that is the sad part because they're not teaching this to interns and residents anymore. And then trying to get in to teach residents and interns. That is a huge struggle through hospital administration and anybody who works for a hospital certainly understands how difficult it is to do things in their departments so for instance when you want to go speak to a resident group you have to get your entire talking points and everything through. Normally the Graduate Medical Education Office everything has to be approved and then if you're doing any sort of solicitation in there that all has to be removed and so you know I'm kind of in a unique position in that I have been able to talk with residents and some medical students without those restrictions because I teach one to one physician to physician not as a financial representative although I have the ability to sell insurance. I really do what I do more for the education component than I do for the insurance sales component. : And you know I can see way that you know the Graduate Medical Education Committees would want to protect their residents but at the same time they're kind of hurting them."Well when when that system folded in on itself because they found that physicians were biased towards using those products they collapsed all of the external activities and they've tried to internalize those in large bureaucratic systems. " : Well they are and it's you know I would blame them. But when you talk to program directors over the last 20 years and my understanding is you came into medicine right around 2000 so you probably saw the very tail end of the pharmaceutical reps coming in and bringing lunches and giving out pens and did notes. Well when when that system folded in on itself because they found that physicians were biased towards using those products they collapsed all of the external activities and they've tried to internalize those in large bureaucratic systems. And it's not working very well. I know that I'm working with the hospital system right now where they are struggling to create a professional development didactic and curriculum for their graduating residents because they have seen over the last five years they're graduating residents are not doing as well as the ones from five years before that. And it's because they simply are not exposed to the other parts of being a human being who also happens to be a physician. And the other thing is obviously the debts have increased substantially over the last five 10 years."And so you know when you are a compassionate intelligent dedicated tenacious personality that self selected to go into medicine and then work your tail off to get educated far beyond what most people are to then run into a situation where you don't know what the right answer is it is profoundly disappointing to you." : So those those two components together is you know you've got a debt servitude type component to a graduating resident. At the same time a complete lack of education. And so you know when you are a compassionate intelligent dedicated tenacious personality that self selected to go into medicine and then work your tail off to get educated far beyond what most people are to then run into a situation where you don't know what the right answer is it is profoundly disappointing to you. So when somebody says hey you should be you should have an individual disability insurance products. Right. And you don't know anything about that because you've not been taught anything and then this you know happy salesperson tells you that hey if you join Hospital X we have a group Disability product and you're covered. Well you don't know anything about it so are you going to start asking questions that you believe might make you look stupid in front of other people. : And you mentioned that the previous generations of people who actually had that business acumen are now fading away. So it's not like human access to a generation of people to to mentor you."They tell me they say Chris I don't know what medicine looks like five years from now so I don't have any business telling this young doctor what they should do or shouldn't do" Right. And so that is another dynamic to physician stresses that are older physicians and I'll say for those fifty three and older if you're listening. One of the things that you guys have done is with the invention of the electronic medical record your personal satisfaction and has gone down and your stress has gone up. Practicing medicine and in in part of that frustration. There is less confidence about mentoring the younger generation those under fifty three and especially those under 40 in mentoring them because a lot of them. And you know these are my contemporaries now in their upper 40s and lower 50s. They tell me they say Chris I don't know what medicine looks like five years from now so I don't have any business telling this young doctor what they should do or shouldn't do and instead of just applying to medical knowledge and the practice of medicine and the infrastructure of health care it's gone global into this bucket of. I don't teach anything because I don't want to be wrong for these young kids. : Which then further adds to their stress. : Yes. And that is that is the the domino effect of what's happening and know technology is wonderful but the adoption of any new medium by by humans takes a little bit of time. And some are early adopters some get it and then there's public acceptance. But those often take a generation or two generations to really become part of the culture and in what you've seen in medicine and a half a generation we have really advanced on on communications and documentation. : But then taking a giant step back with respect to personal development. : And well we've taken a giant step back on the quality of that communication and Doc right. So it is. And I'll use an example. I have a little bit of law school under my belt and a little bit of business school and one of the things I did when I was practicing was I was an expert witness for surgery ICU Anastasia and even pain management which I practiced for about a year. I I found that when I would look at a case in two thousand three four or five that often I was looking at anywhere between three and five hundred pages of material for an entire week or 10 days hospitalization."I reviewed a case from 2013 the same six day hospitalization had fourteen thousand pages from the EMR" "So there's all those challenges that are going on right now with technology and in the administration and practice of medicine. And at the same time we've removed this kind of doctor to doctor mentoring about your own life." : That as recently as 2012 2013 I reviewed a case from 2013 the same six day hospitalization had fourteen thousand pages from the EMR. I can't even tell you how overwhelming that was to see that in one decade 20 times as much information is produced. And so you know that case I actually took some time and looked at it and you know ninety nine percent of it is duplicated. So it it will say the same thing over and over and over and over again and I can see doctors filling out three filled out notes just hitting return return return return return return and they don't realize that it's generating this massive massive amount of material that is it's it's impossible to navigate after the fact. I can't imagine what it's like to navigate trying to practice medicine. So there's all those challenges that are going on right now with technology and in the administration and practice of medicine. And at the same time we've removed this kind of doctor to doctor mentoring about your own life. : And I think that I think that that's why I have found I think that's why I'm I'm moved to do what I do and to work with the doctors the way I do is because it it's a huge deficit. I have experience and and expertise and I love to teach. I love to teach medicine. I love the teaching Anastasia residents that those were that was the highlight of my career was when I got to teach both the SRO and A's and and medical students and residents. I just absolutely love teaching. And so now I found a new thing to teach for and and I'm I find that I'm just as just as emboldened with trying to get everybody to learn everything as I used to be. : Great. We know Chris and I don't see this this medical system getting any better. I'm sure the manner of bureaucracy will even increase in physicians frustrations will continue to evolve. So I really I really loved your message of financial protection and and you know there's two I think we have two audiences here right now. I think we have an audience of young people who we can give them fair warning on on what steps they need to take to protect themselves for the duration of their career and also bear in mind their career may not be 35 years it might be just 10 years or 15 years. And so you really want to take the steps to make sure that you're protected and then the second thing I want to talk about is you know you're you have a couple of mid career people like myself for example you just reviewed my group policy and what I've done is I've done the reverse stacking so I have my group policy and then I have a private policy stacked on top of it right. So what advice would you. And that's that's pretty much the majority of people that I know who have the situation. So what advice would you get. Advice for physicians under 40. : So let's let's let's break those into two groups. Let's break it into the the under 40 crowd which will be your young attendings and residents right now you know if you're in residency get yourself to an independent insurance broker and get yourself individual disability insurance from a quality carrier get a quality product make sure that it has all the future increase options on it so that it will cover a majority of your career. So you get that in place. The if you're an attending and you're within a system and you're only under a group product then you need to do a couple of things you need to one find out if it's possible that you can get an individual policy for the people who are under your contract who are making less than two hundred fifty thousand dollars. They would be basically boxed out from getting anything but there are other policies out there that only go up to five thousand if that's the case then they can qualify for five or six thousand dollars. Now they can put future increase options on it and they can they can get that gap sealed. Over 40 advice. : Once you hit 40 you start to acquire medical conditions. Maybe you've been burnt out in the system. Maybe you've gone to therapy all the sudden getting insurance and I don't know in your particular case whether that was a problem you're you're pretty healthy from what I know of you. So for you it was just simply Hey I make this much money I've got this coverage. How much more can I get. And hopefully when you got your individual disability insurance product you had some future increase options on there because if you were ever to leave your current job and I don't know your family decides to move to Florida you go get a job down there.What happens if you change jobs. "Well when you change jobs before you're under the new group policy you would exercise all of your future increase so that you're covered on your individual policy maximally. And then the new group policy would stack on top of that." : Well when you change jobs before you're under the new group policy you would exercise all of your future increase so that you're covered on your individual policy maximally. And then the new group policy would stack on top of that. So what's really important for midlife doctors those that are 40 to 50 three is if you you're going to change jobs if that's part of the plan in the next couple of years. Then you need to look at positioning yourself even if you just buy a very small policy like fifteen hundred dollars a month but you have the future increase options so that during the transition from one job to the other job you can exercise those those options. That is that is kind of the only way to get that in that midlife which is you know it's a little bit more of a difficult especially if you're like a career guy and a system. You know I don't suggest quitting your job and going to another job for a year and then coming back. But there are docs who have taken sabbaticals to do locums work for six to 12 months and then they come back and they have their individual policy completely maxed out which then puts their group on top of it and they're good for the remainder of their career. Say from fifty three onto 65 to 70 which is when most of us spend down into retirement.Advice to over 60 year old doctors. "The a lot of them financially are fine but they spent so much of themselves in their career that they don't really have anything to look forward and retirement and sitting around for 70 hours a week not doing anything is unappealing." : And that brings us to that last group of doctors if you're listening and you're over 60 years old. One of the really and it's tragic because I you know I looked up to a lot of the doctors who are now in that 60 to 70 age group they were my mentors and they are not all retiring well. And it really has very little to do with finances. The a lot of them financially are fine but they spent so much of themselves in their career that they don't really have anything to look forward and retirement and sitting around for 70 hours a week not doing anything is unappealing. So one of the things that I've I've written about illicitly in small amounts is that if you're going to retire have a plan and and fade out of medicine don't just stop cold turkey reduce the amo

EP 03: Leverage in Negotiations with Financial Independence by Leif Dahleen | The Physician Negotiator http://traffic.libsyn.com/thephysiciannegotiator/Ep03_Physician_On_Fire.mp3 WHO’S ON THIS EPISODE ? POF Website ? Pof@physicianonfire.com ? POF on Facebook ? POF on Twitter ? POF on Pintrest EP 03: Leverage in Negotiations with Financial Independence Although there are many negotiation tools and strategies, the single most important lever is confidence from having a Best Alternative to a Negotiated Agreement (BATNA).   Which is the best of the best according to Physician On Fire?   Financial Independence of course.  Have financial security to not have to give into consensions during a contract negotiation will give you the most confidence over any other trick.    So what is financial independence and can it solve other problems plaguing healthcare?  This podcast is intended for new graduates who are just starting out and have questions about student loan debt, signing bonuses, how to keep a low tax burden and geographic arbitrage.  Having Financial Independence doesn’t mean you have to quit your job, it just means that your job needs you more than you need them. Tanya Foster This then gives negotiating room to ask for a part-time job or transition out of medicine entirely.  Some people call medicine a calling and even though he has been criticized for wanting to retire early, at the end of the day Medicine is a business and we as physicians have free will.  POF used to help only one patient at a time.  Now that he has a blog with thousands of page views amazing advice he can help many more than practicing medicine.   His final advice on the recent and ongoing stock market correction;  Stay the course, recognize that this will be a buying opportunity which will help you get ahead.       DOWNLOADS Show Notes   ? Previous Podcast Next Podcast ?

Ep. 02 Networking for busy physicians and job seekers by Docofalltradez | Dr. Michelle Mudge-Riley http://traffic.libsyn.com/thephysiciannegotiator/EP02_Michelle_Mudge-Riley.mp3 DOWNLOADS Show Notes Ep. 02: Networking for busy physicians and job seekers Dr. Michelle Mudge-Riley trained as a physician but realized early in her career that wanted to transition into non-clinical medicine.  In doing so learned lessons that are not usually taught to physicians.  In the process has become a successful serial entrepreneur her current company, Physicians Helping Physicians serves physicians who are interested in figuring out how to make their career work for them. The community is unique because it’s not a “cookie cutter” approach to career transition or strategy. Every doctor is different and is coming from a different place. Some are 1-2 years or more out of residency and others have been in private practice for 10 years or more before finding this community. It’s been our experience that 80-90% of the time, physicians who work with this community will have a clear focus and career direction within 6-8 months. Most doctors have been struggling with this on their own for years, if not decades. In this episode, Michelle teaches us the importance of networking for career advancement.    Also, We are announcing the Physicians Helping Physicians Celebration Conference.  From Michelle:  In April 2019, I will hold the first Physicians Helping Physicians celebration meeting.  I’ve been coaching for over 10 years and I have only met a fraction of the people I’ve worked with.  Most, if not all our work has been via phone or Skype.  For those of you I haven’t yet worked with, this is an opportunity to get your non-clinical career or side-gig started – or grow it.   On April 6-7th, 2019, I’m having a meeting/conference to celebrate you, meet you, and to talk about non-clinical careers and side gigs.  I’m springing for food and drinks (over $10K!) and have negotiated a block of discount hotel rooms with an airport shuttle in Austin, Texas.     In keeping with the theme of non-traditional careers, this will be a non-traditional meeting.  I’ve already had 15 people who have successfully transitioned to a non-clinical career commit to coming to help mentor you.  There will be sessions, workshops, networking, and plenty of fun!  I will personally guarantee you an updated resume, elevator pitch, and action plan.  I’m hoping for media training, expert witness training and companies with actual jobs who will be available to talk with you.   The best part?  The registration fee is up to you!  Yep, I’m keeping with the non-traditional theme.  I only ask that you consider a donation of $200-$500 to help with the costs.  IF there is money left over, it will go towards next year’s celebration to make it even bigger and better! Learn more about the conference! . WHO’S ON THIS EPISODE ? Physicians Helping Physicians ? Dr. Michelle Mudge-Riley ? Dr. Michelle Mudge-Riley ? Dr. Michelle Mudge-Riley Ep. 02: Networking for busy physicians and job seeker [3:49]  Dr. Mudge-Riley Discusses transitioning out of medicine early in her career. [5:12] Networking is not a skill learned by doctors.  It helped her transition out of medicine.   [7;21] – Recommend working while in school to learn skills about the world and people.  Networking is not about selling, it is about adding value to people’s lives.  And in turn, that motivates them to want to help you. [10:05] – as doctors, we are always fearful of selling and being sold to, and just that mindset, and that’s what a lot of people think about when they think about networking [12:19] – And you may not even get another conversation with this person, because they’re going to not want to talk to you. And they’ll think that you’re going to be asking them for a job. So by really focusing on what’s the other person interested in?  [14:19] – And you may not even get another conversation with this person, because they’re going to not want to talk to you. And they’ll think that you’re going to be asking them for a job. So by really focusing on what’s the other person interested in?  [16;32]  So networking is a little bit harder. It’s not just an easy, call a recruiter, have them feed you jobs, take the job, they give you boom, you’re done. [23;11] –  networking was probably twice as hard for me, because I’m an introvert, and it’s scary for me to reach out to other people. [24;49] – But if you think about a big room, most of those people are either afraid or introverted or don’t want to be there or just are unsure [26;03 – Today, social media is an interesting beast, it is very overwhelming… But the great part about social media is that it can introduce you to people that you never would have otherwise met. [29;08] – First, I would do a little bit of research is easy for us doctors… So once you identify what your options are, then you can start to see if there’s anyone there at any of those clinics or hospitals or organizations that you may know…find someone that is an alumnus of your medical school, or your residency or college or that your brother’s sister knows, or somehow you have a connection with this person…reach out to them and and just let them know that you’re considering moving to that area? And do they have any advice? Or how do they like it, you would not ask for a job at that point. [31;32] – Here’s the really beautiful part about it, you may find out something that you would never have found out about. [32:31] – So if you don’t have those coaching, those mentors that help that upward trajectory, all of those things, then all of the the burnout, the exhaustion, the extra administrative stuff, that extra hours, all that is just going to become intolerable, and you’re going to end up leaving. [33;51] – (about coaching and Dr. Atul Gawande’s acceptance of coaching) But I think it kind of goes back to the culture of medicine and the inability to ask for help, or to be seen as weak or to be seen as not knowing it all. [36:32] – Physician Helping Physicians Celebration Conference… we’re going to be mentoring like crazy. There are going to be some workshops and sessions because I want people to get value out of this. And I will personally guarantee that everyone who comes has an updated resume an elevator pitch when they leave.  Now the really cool thing about this is the way that I am structuring the registration for it’s going to be a donation.   RESOURCES & LINKS Fireside Podcast Episode Docs outside the Box Podcast Never Eat Alone- Keith Ferrazzi Atul Gawande Ted Talk PHP Celebration and Networking Conference  ? Previous Podcast Next Podcast ? YOU MAY ALSO LIKE No Results Found The page you requested could not be found. Try refining your search, or use the navigation above to locate the post.

EP 01: Location, Money or Lifestyle. The Rule of Three. by Cory Fawceit | The Physician Negotiator http://traffic.libsyn.com/thephysiciannegotiator/EP0120Cory20Fawcett.mp3 DOWNLOADS Show Notes EP 01: Location, Money or Lifestyle. The Rule of Three Dr. Fawcett is a man on a mission; to teach doctors how they can live healthy, happy, and debt-free lives–to regain control of their practice, their time, and their finances. He is making an effort to improve the lives of his colleagues. This episode explores the physician job market and looks at strategies to start your career on the right foot. Dr. Fawcett is an award-winning author, speaker, entrepreneur, personal coach, and repurposed general surgeon. He completed his bachelor’s degree in biology at Stanford University, his doctor of medicine at Oregon Health Sciences University and his general surgery residency at Kern Medical Center. After completing his training, he returned to southern Oregon to practice for twenty years in a single specialty, private practice group in Grants Pass. Since 1988 he has shared his home with his lovely bride Carolyn. They have two boys: Brian, who graduated from the University of Oregon with a degree in economics, and Keith, who graduated from Full Sail University with a degree in mobile development. In this podcast, we explore the “rule of three” for finding a job as a physician.  When I started my first career a wise older attending told me that I could not have it all.   I was told that I had to choose two out of three major aspects of a job.  They are: Money Location Lifestyle This was back in early 2000s and the healthcare job market has changed considerably since then.  Likewise many of the choices to understand the job market did not exist.  Today many companies survey physicians to better understand the job market.  Salary, demographics, location, job type, length of each job, student loan debt burden, life-style choices and other data.  This data primarily helps serve the industry looking to hire physicians but since it is made public can also provide valuable insights to the job seeker.  What this data has started to unfold is a changing and dynamic medical employment picture which looks somewhat different from only just 10 years ago.   I have attached several of the documents that Dr. Fawcett and I used in our discussion.    Key Points: Take Lots of vacation Figure out what you want in very great detail before looking for a job Don’t get burned out but if you do make sure have options like a financial cushion Take time off in between residency and your first job You can have it all.  Money, Location and Lifestyle Don’t forget about the work environment including culture and conditions Changing jobs after only working for two years may not be the best strategy for long-term financial success and well-being Location still matters and consider the pros and cons of living a larger versus smaller community.   Don’t forget how time and money can be lost if living in a larger city. Beware of larger than average salaries and bonuses, it could be for a reason. Find a mentor as soon as you start your job to help understand the culture and roles that are expected from you.  Modern society has shifted from buying things that last to a “throw-away society.”   Don’t practice medicine like a throw-away society.  Find the right job, significant other, home the first time and try not look at these commitments on the way to the next best thing.       WHO’S ON THIS EPISODE ? Prescription for Financial Success   ? Dr. Cory Fawcett   ? Cory on Facebook   ? Cory On Twitter   ? Youtube Videos   EP 01: Location, Money or Lifestyle. The Rule of Three Dr. Cory : (02:11)  Yes, I did 3 years of locums work and it was a way for me to taper my practice. Dr. Cory : (03:06)  Yes, we took somewhere between 8 or 12 weeks of vacation every year throughout my career.  Dr. Cory : (04:48) Dr. Fawcett give tips for taking time off in between residency and post-residency. Dr. Cory : (08:03) He gives advice on planning out your entire life starting with residency. Dr. Cory : (10:12) Gives advice on burnout and options.  Dr. Cory : (12:00) Discusses that today’s doctor can really have it all. Dr. Cory : (13:03)  Work environment matters too.  Dr. Cory : (16:09) The first job and figuring out what you want is key. “Start your practice right” Dr. Cory : (18:09) Changing jobs has consequences for many and may not be a good thing.  Docofalltradez : (20:00) Don’t forget about significant others with making career decisions.  Dr. Cory : (21:05) Time off versus location.  Choosing the right location will impact the time spent on and off the job..   Dr. Cory : (24:55) Rural medicine life versus living in a big city.  Dr. Cory : (28:10) Outrages salaries and bonuses beware.  Dr. Cory : (30:13) Should you use a recruiter and how to use a recruiter. Dr. Cory : (34:29) Millennial doctors and what they bring to healthcare. Dr. Cory : (36:36) Advice for millennial doctors, do be part of the “throw away society.“ Dr. Cory : (39:25) How a Mentor changed his life. Dr. Cory : (43:14)  Negotiate a balance with your peers to divide the work. RESOURCES & LINKS 2017 MHA Resident Survey ? Previous Podcast Next Podcast ? YOU MAY ALSO LIKE No Results Found The page you requested could not be found. Try refining your search, or use the navigation above to locate the post.

EP 01: Introduction by Docofalltradez | The Physician Negotiator http://traffic.libsyn.com/thephysiciannegotiator/EP00ThePhysicianNegotiator.mp3 DOWNLOADS EP 01: Introduction  Introduction to the New Podcast! Do you understand the Business of Medicine?  WHY? Because taking care of patients and clinical knowledge isn’t enough. Medicine will always be a business, it doesn’t mean we place money before healing, it simply means maintaining the ability to heal others requires financial and legal knowledge, this requires knowing how to negotiate. And along those lines, the Physician Negotiator Podcast is about learning how to negotiate your career path, overcome the lack of business knowledge, and create a career you LOVE. WHO’S ON THIS EPISODE ? Docofalltradez   ? THE PHYSICIAN NEGOTIATOR   ? THE PHYSICIAN NEGOTIATOR   ? THE PHYSICIAN NEGOTIATOR   ? THE PHYSICIAN NEGOTIATOR   EP 01: Introducion [00:00] – No Show Notes for this episode RESOURCES & LINKS The Physician Negotiator Next Podcast ? YOU MAY ALSO LIKE No Results Found The page you requested could not be found. Try refining your search, or use the navigation above to locate the post.