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Negotiating Pitfalls for the young doctor

Posted on January 14, 2019January 30, 2021 by SmartMoneyMD

In an ideal world, we should all be compensated fairly for our services and skills. The reality, as we all experience, is an amalgam of mistakes and victories. One hopes that with time our skills will translate to a greater number of victories. Most greenhorns entering the workforce are unfortunately poorly equipped to assess their worth. I certainly was.

Greenhorn doctors stand to lose a financial lot from mistakes simply because doctors tend to experience a significant jump in income after they finish their formal training. Seemingly inconsequential mistakes can end up costing us a lot of green and sleep over time.

The significant jump in salary signals a well-deserved reward at the end of the rainbow, but what doctors frequently fail to recognize is how big or small that pot of gold ought to be. In some ways it is difficult to believe that relatively intelligent, hard-working people who become doctors can have so little clue about our worth. When I was in my training, business sense certainly wasn’t in the medical school or residency curriculum. I doubt that much has changed over time either.

The last time I interviewed a high school student from New Jersey for college, I asked her if she knew how to pump gas. The response was an overwhelmed deer in the headlights look. (New Jersey law still doesn’t permit people to pump their own gas) It really isn’t that difficult to find voids in one’s fund of knowledge, no matter how intelligent anyone is.

When I was a fledging greenhorn coming out of my training, I made plenty of mistakes in looking for a job. Some of factors I overlooked were so egregious that I probably deserved to fumble. Live and learn, as they say. January and February are the typical months of year that graduating trainees start looking for jobs. This is also the time I start getting questions about job hunting.

I figured it was time to distill some of my impressions about rookie mistakes into a post.

Underestimating your worth

Medical trainees provide way too many services pro bono. In my training, I moved gurneys, waited for up to an hour over the phone for health insurance companies, cleaned up excrement, and performed many duties that didn’t require busting my ass. When trainees enter the workforce, life suddenly becomes easier in most respects.

What do you say when you’re offered this to take call on Christmas eve?

Sometimes if life becomes easier no matter how you spin it, we may be more willing to take anything we are given. Maybe your potential employer intends to give you a signing bonus of $5,000. Great! Would you think any differently if they gave your coworker an $8,000 signing bonus instead? That’s where doing your research will pay off. Most medical graduates do a good job in their sleuthing skills, because that’s what medicine is all about.
The key is actually going to the right sources. Your friends who are several years into practice can give you pointers. But relying solely on their experience can only give you a certain picture into the situation. Your friends might share similar views that you do, or even think like you do. They are likely to provide the information that you want to hear, but there is also a possibility that their mindset leads them to overlook certain aspects of the job world that you’d miss too.

Pro tip: Ask doctors who may be in a different generation as well as other maybe even in another specialty about their wisdom. Get the advice of others who have worked for the employer that you’re considering, or those who have paved a career similar to what you envision your career to be.

Overestimating your worth

Not understanding your skill level can lead doctors to ask for too much as well. There are statistics out there that include median starting salaries along with median mid-career salaries of all the specialties. The problem is that these are median numbers, and you have to be able to extrapolate the statistics.

For instance, if you plan to join a bustling medical practice that is drowning with patients you will be busy very quickly. However, most new doctors fail to recognize that they still need time to ramp up their practice patterns. Just because the retiring doctor who touch-typed was seeing 100 patients a day doesn’t mean that you could see 120. In fact, as someone learning the ropes you might only be capable of doing a fraction of the work and maybe even at a fraction of the quality! There may be reasons why the employer would consider starting you at a much lower salary as someone else with a decade of practice under their belts.

Pro tip: Go into your negotiations with the facts, and make your potential employer give you good reasons why they think that you’re worth what they’re offering you. If you can prove them wrong, you can command a better arrangement. Just be aware of your own limitations too. Gray hair does come with some benefits.

Overestimating what the employer can afford

This is a touchy subject. Financially and business savvy new doctors can make very informed decisions about their qualifications and practice goals to potential employers. The problem arises when everything is a great fit except that the potential employer isn’t actually able to financially afford what you’re asking. Sometimes this happens.

Pro tip: You cannot earn more than your boss. If you do, then they are in either a horribly desperate situation to bring you on board or a situation to make you work like a dog. Neither situation is sustainable long-term.

You have to set realistic expectations in any situation. I have known plenty of doctors who calculate how much they should be earning based on professional charges, negotiate based on expected overheads, and anger many potential employers. The reason? Many of these doctors don’t realize that there is give or take. They may have underestimated the costs of running a business.

Pro Tip 2: Do your homework. Go into your negotiations with reasoning. But don’t forget that you could be wrong too.

What other tips do you have for new doctors?

The daily life of a pediatrician

Posted on December 30, 2018February 2, 2021 by SmartMoneyMD

Most doctors well into their tenure of medical already have a general idea about how other specialists spend their days (except for radiation oncologists, where NO ONE else knows what they do). However, as a medical student I had incredibly limited insight on the variety of means to practice medicine. Even as an attending physician, I am still discovering how creative some medical specialties allow one to be. For instance, how many of you guys knew that you could be a cash-only neuromuscular neurologist?

Fortunately all medical school rotations will include some exposure to pediatrics, but this doesn’t mean that one or two months of rotation is actually adequate to inform students on the merits of pediatrics. This article will serve as an overview for those students considering a career in medicine or those medical students who are in their MS3 rotations considering what specialty to choose.

The medical aspects of pediatrics

Pediatricians take care of children, who are not small adults! This ranges from well visits to intensive care hospitalizations. One can also opt to take of children as sub specialists who train in a separate fellowship, like pediatric cardiology. There are too many pathways to take care of kids than I can keep track of. A rough diagram can be summed up as such:

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Pediatrics residency spans three years, with some programs adding a year of research if you choose. Fellowships can also span anywhere from one year to as long as one desires, although at some point you have to realize that the only way to truly master your profession is to get out and practice medicine. After training, there are a few common venues to practice pediatrics.

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The daily grind

Outpatient pediatric medicine is the more common approach to practice, and it is exactly what you think it is. Patients are scheduled perhaps every twenty minutes throughout the day, along with space for add-on emergencies. Some are well visits. Others are sick visits. Kids also get sick during winter months, so pediatricians are typically busier during those months. A pediatrician’s clinic schedule may range from twenty to thirty patients a day. It’s also common for most doctors to spend at least an hour after clinic tidying up notes or calling patients/parents about lab or test results. With the mandate of electronic health systems, we can all expect to spend some time after clinic to finish charting.

Years ago, most outpatient doctors also took care of their own patients while hospitalized. It’s more common that there are some pediatricians who work strictly on the inpatient services to take care of hospitalized kids. What that means is that you could become a pediatrics hospitalist. All newborns need to have a physicians in order to be discharged from the hospital.

Income

Unfortunately as important as our next generation is, society has decided to reimburse “pediatrics” anything at only insulting to mediocre levels. We all have to realize that none of us should ever consider going into medicine for the sake of money, but many medical students that have rotated with me have boldly commented on physician salaries. The bottom line is that you’re not going to starve if you become a doctor who takes care of kids. Don’t expect to own any McMansions.

Special venues

There are also options to go against the grain. Concierge medicine is becoming more popular in affluent areas, where the patients pay a certain retainer to obtain better “access” to the doctor. It is more common for internists to become a concierge practice, although the same can theoretically be done in pediatrics.

Other possibilities simply include working outside of clinical practice: consulting, health insurance reviewer, or even medical officer within a corporate health system. The sky is the limit.

What other aspects of pediatrics should medical students understand before choosing to enter the field?

Gratitude, stock market gains, and GOMERs

Posted on December 25, 2018January 30, 2021 by SmartMoneyMD

It’s that time of year again. Holiday gatherings, work parties, and thankfulness fills up the calendar. This also means that it’s time to reflect on the year’s accomplishments and failures. Perhaps we can learn from our mistakes and strive to be a better form of ourselves the following year.
It’s time to run through the three G’s, Finance-Edition:

Gratitude

We are lucky to have great hospital support staff, an electronic health record that only crashes intermittently, and a nice parking spot at the office. This time of year also translates to gifting. For the finance-minded folks, here is a list of reminders to keep track:

Gift tax – Suppose that you’ve hit the jackpot with your medical practice and are sitting on a cool $20 million in your estate. Maybe you decided to forego that living trust option and just want to spend down your stash. The annual gift exclusion amount for 2018 is $15,000 per person. You and your husband can each gift $15,000 per person without getting hit with a gift tax. This means that you can gift out quite a few $15,000 increments without having to pay a gift tax. Get your checkbook ready, or mail them online checks if you’re computer savvy.

Gifts to employees — There are certain rules to how you can rewards your employees. Be sure to reference the IRS’s de minimis guidelines to make sure what you do falls under the rules. In general, throwing an occasional holiday party to your staff will be perfectly fine. Giving them cash equivalent gifts will not.

Gatherings — It’s not uncommon for doctors to throw holiday gatherings for their staff in their homes. That’s very nice, but make sure you have an adequate amount of umbrella insurance. You’ll never know when someone has a little too much to drink and ends up hurting himself in your swimming pool or trampoline. Be sure to consider buying a rider for libel or slander as well, if that applies to you.

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Stock Market Gains

My last weekly e-mail from Personal Capital appeared like this:

Across the board, the stock market has performed poorly in 2018. The gains from 2017 have quickly vanished, and these are times that I feel fortunate that I have a stable income to fall back upon. Do I wish that I had alternative income stream from real estate or side gig? Sure. But it still isn’t necessary. The beauty of being a highly-compensated professional allows you to have more options to control your lifestyle, expenses, and ultimately, your net worth. Set your savings rate on autopilot, and make it a goal never to lower your savings rate unless some catastrophic life events occur.

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Bear market? Healthcare is here to stay, whether or not we like the direction of it. Some calculations project a physician shortage of up to 100,000 doctors by 2030! Even including doctors who trained outside of the U.S., it is inconceivable that we’d be able to sustain the physician shortage dilemma. We’ve seen automation, physician extenders, flowchart medicine, and all of the strategies to find ways to care for illness with minimal direct physician input. What this means for you, the doctor, is that you have job security. Use that to your advantage. Work hard and keep up with the bear market. You don’t have to do any more to win the game.

GOMERs

Anyone who has read Samuel Shem’s The House of God will understand the reference. We all have GOMERs in our medical practice, whether we work in inpatient or in ambulatory medicine. That one patient who we can never discharge because some snafu prevents us from doing so. Or the patient who keeps coming back unhappy about the seventh cosmetic surgery revision he’s had, and wants another one.

For free.

On a Saturday afternoon.

GOMERs are the one constant in the medical field that sometimes puts me at the edge of dislike for my profession. But whenever this irritating experiences occurs, I remind myself that we are still lucky to be in a well-paying profession that allows us significant freedom to heal. No matter how negative our workplace can be or how annoying certain hospital regulations are, don’t forget that we are still healers. We have a skill that allows us to provide services that even to this day I am still amazed that we are able to bring people back from the dead.

Happy Holidays!

How to wind down your medical practice

Posted on December 15, 2018January 30, 2021 by SmartMoneyMD

A retirement plan isn’t usually a top priority for fresh doctors looking for their first jobs, whether that final date is in five years or thirty. Perhaps knowing when to hang up your hat is immaterial so early in your career since most doctors will end up leaving their first job within the first five years anyway. However I do wish that I had some inkling about the career paths at some point as during my medical school rotations. Knowing how medicine is really practiced and how practice patterns affect retirement would have probably influenced my career choices.
Interestingly, the specialty that you choose determines the means that you can even wind down. This is because different specialties lend themselves to different work situations.

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If you are a thoracic surgeon, you could work for yourself and contract with a local hospital. If the hospital decides to employ its own thoracic surgeons, you might have no choice but to join the party or pack for the hills. No matter how you intend to practice medicine, it is worthwhile to have some inkling how to wind down your job.
You might decide to hang up your hat completely and leave the medical world completely. Or you might want gradually wind down your hours. Here is the list of options to wind down your practice:

Cut down your hours
If you are a shift worker, then you have it made. Many hospitalists, nocturnists, and emergency room physicians have the ability to ramp down their schedules by taking fewer shifts. If you belong to a large medical group, it actually isn’t that difficult finding someone who will be willing to take extra shifts for the money. Pare down your shifts, and you can downshift your clinical practice as you wind down.
One of the emergency room doctors I know who is slowly transitioning to administration fills in roughly four shifts a month. I suspect that this number will eventually become zero as he renews his board certification through a non-clinical tract.

Sell your shares
Many partner physicians working in a large group can opt to sell their shares back to the company or to a junior associate ready to become a partner. Depending on the practice, the physician can then continue working on a part-time basis as an employee as a means to transition the patients over to junior physicians.
Sell your practice
If you are the sole owner of your medical practice, you have several options to transition into retirement:

Sell to another fellow physician — Be awarded by allowing the tradition of medicine to continue. You put in the hard work over the decades to build up a viable brand. Allow it to continue in the hands of another fellow doctor.
Sell to a medical investment/management group — Perhaps you will receive a healthy buy-out. Two million? Five million? Ironically, these groups may have very deep pockets so you may get more for your practice. Who knows what the long-term viability of this type of model will last, but it’s not like you’re going to care. That’s right, you’re going to be sipping a pina colada somewhere in the South Pacific.
Sell your equipment, end your lease, and pack up – This might be one easy solution—just quit. Liquidate your equipment and office goods, fire your office staff, and call it a day. The one downside of closing up is that you need to find a successor to continue care for your long-term patients.

Retire from your existing job and sign up for locum tenens work

If you end up selling your practice, you’ve basically closed the door on returning to work. Fortunately there are plenty of part-time opportunities floating around in the world. New Zealand? Sure! There are plenty of hospital systems or groups that need temporary coverage—that’s where you come in. You might be able to see a new part of the country as well. The downside is that if you intend to get rich from temporary work, you might be out of luck. Some temporary jobs aren’t really going to be wildly lucrative unless the hiring practice is going to be incredibly desperate with deep pockets. You have realize what you’re getting out of working part-time and what the hiring practice intends to get out of it.
Your retirement may be decades away, but it’s worthwhile to at least have a few thoughts on how your medical practice might look like at the end of the rainbow.

Choosing how to practice medicine 101 for new doctors

Posted on December 12, 2018January 30, 2021 by SmartMoneyMD

When I finished my training, I wish that I had known all of the options I could practice medicine. Most of us categorized our options as either “academic” practice or “private practice”, but in reality these two options only cover the tip of iceberg. Was my limited understanding a shortcoming of my medical training? Perhaps. I doubt that many medical schools back then actually had seminars on practicing medicine. Since nearly all of my attendings belonged on faculty or clinical faculty, it would have been nearly impossible for them to round up a bevy of doctors from all walks of the medical scene.

The following is a compilation of some of the more common ways that doctors can practice medicine. There are nuances in every category of medical practice that one would only truly understand after practicing in that venue, but here is a good introduction (along with my personal opinions):

Solo Practice
Solo practice medicine is unfortunately not as popular for a number of reasons, but it is still a viable form of medical practice. Generally speaking, one could either purchase a practice from a retiring physician or start from scratch. That means buying your own building or finding a lease, signing up for insurance plans, and going at it. There is always a learning curve to starting your own practice straight out of residency, but it could be done. Obviously some specialties in medicine may be more conducive to solo practice than others.

Pros:

You can call your own shots. That means taking all of the vacation you want. Or you can work 365 days a year if you’d like.

Cons:

Likely to require more involvement into the practice, including the business aspects of medicine.
May require many years of long hours before business will flourish.
Insurance company in certain markets may not allow individual doctors to enroll onto their plans if there are larger medical practices that are willing to take care of more medicine for less reimbursement.

Some work situations are more conducive to cross-country trips in the winter!

Group Private Practice
Most of my classmates who decided to go into the private sector ended up joining a medical group. These medical groups may be small, several-doctor organizations, or multi specialty behemoths. One of the perceived advantages of joining a large group is that they may better systems in place for benefits and that the patient volumes are more mature. Having multiple coworkers also means that you will have more opportunities to collaborate and dissent. Group practices may be able to allow doctors to achieve higher than average salaries for their field, given that there is likely some capitalistic motivation among the group’s members.

Academic Practice
Academic medicine is synonymous with working for a university with teaching or research opportunities. This may be the most “conservative” approach to many doctors’ first jobs since most of us trained at academic institutions (there are some training programs that are spin-offs of private practices). Many of my classmates simply opted to remain on faculty at the institutions that they trained at after finishing fellowship. There is familiarity with remaining at the institution that you spent the previous few years at.

Pros:

Familiarity with an institution that you’re already working at.
Good intellectual support system.
Likely cutting edge medicine.
Research support if you opt to conduct clinical/laboratory research.

Cons:

Excessive familiarity with the institution that you’re already working at.
Possibly poorly organized clinical support staff.
Likely cap on earning potential.

Managed Care Practice
In recent years, there has been an uprising of managed care organizations, or those that have certain arrangements with health insurance to provide care. Some healthcare systems like Kaiser Permanente have an insurance wing and a physician wing that work to cut costs and optimize care.
Pros:

Optimized healthcare system. Robust benefits program.
Stable and likely job security.

Cons:

Physicians may be subjected to assembly line care.
May have high volume of patients
May have restrictions on how you can practice medicine.
Not necessarily conducive to elective procedures.

Governmental / VA
In some ways, working at a VA is sort of like working at a managed care organization except that the VA may even be more slow to adjust to anything. Many of us who have worked in VA systems may have felt that the clinics and operating theaters functioned incredibly inefficiently. That being said, to each his own. Working for the government does have its perks in set working hours and mostly easy pace of life, plus the fact that you are taking care of our country’s veterans.
What comments do you have for each of the models of practicing medicine?

How I became rich by doing my job

Posted on December 1, 2018January 30, 2021 by SmartMoneyMD

Put your head down and do the work. This is the motto that medical students should have learned. Get through medical school and residency with a similarly positive attitude, and you will be fine. Skimp on the details if you’re short on time, but in the end you are still short-changing yourself. The unspoken assumption in medicine, however, is that as long as you work hard and don’t cut corners good karma will come your way. Be nice to your patients, treat them as if they were your mother, and you will achieve greatness.

You don’t have to be nice to get rich

If the rest of the world were sanctioned by the Hippocratic oath, then doctors would rule. Years ago when I interviewed for a job in the tech startup world, the second question I was asked (after how I intended to change the world) was how I could harness certain technologies to capture greater market share and profits for the company. The goal in startups is to generate enough momentum to continue through several rounds of funding, with the eventual hope that the technology becomes acquired by a larger company. The financial world is even more brutal—extract the maximum amount of profit out of your customers, gain market share, and get an annual bonus that could be more than twice your base salary.

We have too many options

Knowing not to invest too much of your earnings into alternative means is worth discussing. Having too many options can be detrimental. If given options, it is normal for analytical folks (most doctors) to spend too much time getting lost in the forest. A little bit of knowledge can be dangerous.

Having a life sized die cast aluminum sculpture of Sparky would not be considered boring

One of the more common financial decisions that doctors end up making is choosing between two potentially inconsequential outcomes:

Repay loans vs save for mortgage down payment
Repay loans vs invest
Moving low-cost investments to other low-cost investments

Then there are bigger financial decisions that might turn out to make a larger impact on your financial future:

Deciding to buy a nice house in an “A” school district in hopes of getting better resale value in 15 years.
Contributing a decent chunk of potential retirement savings towards speculative real estate investments that might turn out to be amazing investments (or might not).
Spending your free time with “side hustles” that focus on building ancillary income. It may result in a wildly successful business that could supplant your medical practice (or fail miserably).

Any financial decisions that we make, whether trivial or potentially financially impacting, consumes our time and energy. Unless choosing between a multitude of options is your cup of tea, we all have to remember that we could all benefit from putting our energy towards

Doctors can focus on the basics

Fortunately the formula for wealth can be a lot simpler for doctors, since society still is able to afford us relatively high incomes for demanding professions. The key is to avoid making too many long term financial decisions that chip away your earning power. As a recap, doctors can build their wealth by taking note of the following:

Save a fixed amount of your earnings. Many people recommend saving 20% of your income, others more. I would like to save more than that, and gauge based on post-tax income if you can.
Maximize your retirement accounts.
Grow your expenses slowly as your net worth grows.
If you decide that you have to find alternative investment schemes, don’t put all your eggs in one basket.

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I live a boring life, and my bank account shows it

At this point, people are expecting net worth graphs and numbers. If you are the numbers type, then here is a graph with arbitrary numbers but a similar trajectory that most doctors should be able to achieve:

Don’t you love it when you’re retired and the stock market moves like this?

The truth is that anyone with a solid six-figure income can build a stable net worth relatively quickly. Without any strategic tax wizardry, an average physician with a mediocre salary of $225,000 in Houston, TX may take home $181,000 in 2018 (effective tax rate of ~24%). Even after spending $100,000, she will have roughly $80,000 (36% savings rate with a post-tax numerator on a pretax denominator) to put away. With relatively conservative investment projections, she should be able to have at least $1 million after a decade of “boring investing”.

Not bad, right?

Most doctors ought to be able to build up at least a $1 million net worth after a decade of practice. If you haven’t reached that milestone already, consider making it one of your goals!

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Financial implications of contractor work for doctors

Posted on November 24, 2018January 30, 2021 by SmartMoneyMD

Most doctors coming out of training have only experienced work as an employee. As residents and fellows, doctors are employees of a hospital or university. You receive a paycheck every few weeks, and at the beginning of a new calendar year your employer sends you a W2 form delineating your income. We use the W2 form to help file our annual taxes. Easy peasy.

Contract work is a different ballgame. Some companies or hospitals will opt to hire out contract physicians to cover certain lines of services. It may be temporary or intermittent services for a set amount of time. For the hospital, it is an easier way to deal with finding help without actually having to hire someone. It also sounds great as a doctor, since you work for yourself as a contractor, not the hospital. Some of us might have even gotten a taste of this line of work through moonlighting during our training. I remember that one of my classmates moonlighted in the emergency room during residency. He was paid $60 a hour, and received a check for $600 after finishing a ten-hour shift. No withheld taxes. As a resident, it was essentially free money.

But there are financial implications of being an independent contractor when you are in full-time medical practice. Let’s look at some of the considerations:

Employer taxes

We all have to pay into Uncle Sam’s system. Employers have to contribute to Social Security and Medicare taxes. For 2018, that roughly amounts to 7.65% for incomes up to $200,000. The employee also pays an equivalent amount out of his paycheck as well.

Independent contractors work for themselves, so they have to pay the employer portion of Social Security and Medicare taxes as well. This amount does not get taken out of the independent contractor’s paystub, the physician will need to allocate out this amount to pay Uncle Sam directly.

Personal taxes

If you work for yourself you also have to estimate and allocate the amount to pay quarterly. Most doctors are likely to have a federal and state tax bill in the six-figure range—by not handling prepayments properly you can end up footing a huge penalty. You will have to pay more attention to your bookkeeping as an independent contractor.

Benefits

Most large employers offer retirement plans like 401k/403b’s as well as basically disability and life insurance for its employees. These benefits do not come for free. As employees, we might not be able to perceive that there is a cost to offering these benefits. Those of us who operate our own practices will understand that health insurance consumes a sizable chunk of our income especially if our families are under our plans. Remember those patients who signed up Silver, Bronze, or Platinum Health Exchange plans? Their deductibles where through the roof, and yet their plans basically didn’t cover a cent of their surgeries while forcing you (the physician) to send these patients to collections. Just remember that you just might be that person too when you have to foot the entire health bill for your family.

Malpractice insurance

Malpractice is often covered for employed doctors. Hospital systems and multi specialty groups have enough doctors to negotiate better premiums for its doctors. As an independent contractor, you alone are responsible for your coverage. Some specialties like obstetrics, neurosurgery, and vascular surgery that perform higher risk surgeries will incur a greater out of pocket cost than for internal medicine. If you perform contract work, be prepared to pay for your own coverage.

As an independent contractor, you might have to consider insuring all of your employees, including the guy behind the fence…

Variable compensation

As an independent contractor, your pay might be dependent upon volume or surgeries that you perform. That volume might vary from season to season. You income may not likely be stable. You will have situations where your income might far exceed that of what you could otherwise make as an employee. Be prepared to deal with the rollercoaster of income, however.

The perks of contract work

Despite the additional legwork that you have to be conscientious of with being an independent contractor, there are also financial perks, namely certain tax advantages. Commuting between two offices? Dedicating part of your home to your business? There are certain tax strategies in being your own boss to reduce your tax burden.

Are you a points collector? Given that many of the listed expenses are big ticket items, you might be able to leverage a few percentage points back or business class airline tickets.

Conclusion

This list only brushes up on some of the salient points of being an independent contractor. There are doctors who have made a career out of it. It is a viable career option if you are able to find the right fit—you might just come out ahead.

Do you work as an independent contractor? What specialty do you belong in?