We Need More Customer Service In Medicine

Customer service in medicine is important. I know many people don’t want to hear that, but it’s not going away. Patients are talking to each other more than ever. They’re leaving comments on Facebook, Twitter, and numerous physician review websites. Get a few bad reviews, and watch your patient volume drop. Your revenue won’t be far behind.

However, I believe the current focus on customer service is actually too narrow. Yep, that’s right. I think medicine needs more customer service, not less.

While much of the physician lounge discussion and staff meeting arguments stem from external customer service, medicine actually needs a larger focus on internal customer service.

The business world is already well versed in both internal and external customer service. Talk with any businessperson and you will hear them talk about their internal and external customers. It’s considered standard practice to extend the same level of customer service to your internal customers as your external customers.

The reason for this is simple. To best achieve your organization’s mission, everyone in your organization has to work together. Team work makes the dream work as we like to say.

Unfortunately, I have witnessed a lot of colleague interactions that were downright scary. Many times, they look something like this:

(video courtesy of Youtube and ZdoggMD.com)

While that video might be hilarious (this one is even better), these types of negative interactions not only throw a wet blanket on a everyone’s day, but they hamper patient care.

In my mind, there are three reasons that medicine, and physicians in particular, should focus on improving our collective internal customer service skills. Allow me to explain.

The Patient Is Still Sick

 

I use this phrase all the time when embroiled in some type of specialty turf war or argument. While we’re sitting here arguing about “whose problem” this should be, the patient is still sick. Think about the poor patient in the middle of this confrontation:

(video courtesy of Youtube)

I don’t know what the mission of each of your organizations is, but I’m willing to bet that taking care of patients is an integral part of it. As a profession that generally prides itself on caring for others, arguing and negative interactions takes the focus off the patient and onto ourselves. We should view this as countercultural and unacceptable.

I fully recognize that legitimate conflicts arise that need to be solved. However, my rule in my personal practice and those whom I supervise is to take care of the patient first, period. We will deal with the system issue, but step one is always to care for the patient in front of you.

By flexing our internal customer service skills, we can make these occurrences few and far between. I was involved in a great conversation on Twitter discussing the role of radiology and pathology in patient care, and specifically how both specialties desire to be more directly involved in the care of the patient. Here is one quote I think is poignant:

“Cannot tell you how many times I’ve gotten “I’m just covering” when calling back to ask more questions about a study.”

Good internal customer service recognizes that these types of conversations cannot happen and our relationships with our colleagues are essential to achieving our overall mission of caring for the patient. “I’m just covering” turns into “how can I help our patient today,” and the patients benefit at the end of the day.

Conflict Increases Your Workload

 

Can you afford to add more tasks to your day? Do you really want that routine case to take double the amount of time it should? No, right? Your day is already slammed.

Negative interactions with your colleagues not only hamper patient care, but they waste your time. First, there is the obvious. If you’re like me and you have an argument with a colleague, then its going to take you a few minutes to cool down. Are you going to do much productive during that time? Nope. Time wasted.

Second, are you going to work with that colleague in the near future if you need to? You might hesitate if you have a poor interaction with a radiologist and then need a quick chest x-ray interpretation. Might just wait for the report, right?

My previously mentioned Twitter conversation had someone that probably has lived out this reality. Check out this quote:

“Surgeons at my old institution referred to radiologists as “possums”. They lived in the dark and would bite if approached/provoked.”

Pretty sure you’re just going to wait for the report if you think the radiologists you work with are “possums.” Waiting for that report is probably going to cost you some time in the care of that patient. Instead of having the information you need and moving on, you’re going waste time because no one is practicing good internal customer service.

physician call

Frustration Leads To Mistakes

 

Now its time for the rubber to meet the road. It’s one thing to have your schedule inconvenienced or to feel upset. It’s quite another to put patient safety at risk. Unfortunately, practicing poor internal customer service does just that.

Remember that example I just gave, where a physician and radiologist don’t want to talk because of a poor interaction? That lack of communication endangers patient safety. The patient safety literature already supports the idea that lack of communication amongst teams leads to medical errors.

As a community, are we OK with that? As a patient yourself, do you want your medical team to avoid communicating with each other? No! You want your medical team working together to provide care for you because you know that anything less is going to result in substandard care. If your medical team doesn’t communicate, then your care might look like this:

(video courtesy of Youtube)

So the next time you are frustrated at that specialist who is giving you a hard time about a consult or you’re nervous that the pathologist is going to bite your head off on the phone, remember we need more customer service in medicine, not less. Even Mr. Bean can figure it out.

Hopefully, I have convinced you that customer service inside of healthcare is actually the most important form of customer service. At the very least, I hope you got a few laughs watching the videos.

Just like we have resolved to provide excellent service to our external customers, patients, in our efforts to provide the best care possible, we must equally resolve to provide excellent service to our internal customers, our colleagues, so we can all provide excellent care to our patients. As professionals, we should demand no less from ourselves.

What do you think? Is customer service a bad word or do you agree we need more? Have you ever been assaulted by a colleague dressed as Darth Vader? Leave a comment and let’s talk about it.

Four Ways to Improve Physician Meetings

I often see physicians on my Twitter account bemoaning sitting through staff meetings. Some of the tales they tell are pretty harrowing. I silently grieved for one group as I read about how their meeting was three hours over time. I don’t like sitting through unnecessary meetings any more than the next guy, even when I’m running the meetings.

Based on my experience with colleagues in the business world and the medicine world, medical meetings typically lack in structure and organization. This meeting dysfunction makes many physicians staff meetings either ineffective or worse, unnecessary.

Physicians already have schedules that are highly compressed throughout the day. Calling meetings that accomplish nothing not only waste everyone’s time, but they erode trust between administration and doctors. Given our current climate of distrust in healthcare, I do not think this is something we can continue to do.

With this in mind, here are four tips that can help you run a better meeting with your colleagues. Feel free to use them at the next meeting you run, or print this out and anonymously leave it on the desk of your boss!

physician meetingNegotiate the agenda before the meeting

 

Staff meetings should not be mystery events where you show up to find out what the next bomb is going to be that will drop. No one trusts a leader that holds back all the information until they absolutely have to give it to you. Meetings are an excellent way to be transparent in this regard.

Meeting agendas should be posted prior to the meeting. Ideally, the meeting leader will request all attendees to send any items they wish to add to the agenda. The meeting leader will individually negotiate any items proposed that are outside the scope of the meeting.

Physicians can then actively participate in the structure of the meeting and not just have the meeting “happen to them.” Hopefully, physician participation leads to greater enthusiasm and a more productive meeting for everyone.

An added bonus of this process is that you will often find that some agenda items can be removed. This has happened for me many times. There may be an item that I think requires group discussion, but the barrage of emails that I get after sending out the agenda indicate that everyone already agrees on the solution. If everyone already agrees about an item, then don’t discuss it further and waste everyone’s time.

Apply time limits

 

Meeting agendas should not only delineate what items to discuss, but they should state exactly how long to discuss each item. This practice will allow your staff to know what to expect during the meeting and get a general sense of the depth of each agenda item.

Using time limits will also shape how much discussion occurs about a topic. How many times have you been a part of a meeting where a minor point on the agenda railroaded the entire meeting because you talked about it for too long? This is much easier to avoid if the agenda already has the time listed next to each item. If something is only slated to be talked about for two minutes, then cut off the conversation at two minutes and move on.

Agenda time limits can take some adjustment for some groups. I recommend giving warnings at one minute or two minutes so everyone knows where you stand. You may have to even cut off a few conversations without making decisions at first. However, once your staff gets the hang of it, then they will be able to tell when it is time to make quick decisions and when it is time to discuss at length.

small meetingLimit meeting size

 

As meeting sizes increases, the productivity of the meeting goes down. This is true across all industries. Medicine is no exception.

I don’t like strong arm tactics, but this is an area where you should be militant. Do not invite people to meetings that don’t need to be there. If people are at a meeting unnecessarily, then ask them to leave.

There is no need to be rude about this. When I have to explain this to people that I am kicking out of a meeting, I explain it in terms of their personal productivity. What is the best way for them to use their time today? Sitting in a meeting where they are not going to participate or providing clinical care?

Most physicians will appreciate this gesture. I have never met a doctor that does not have some type of work to do. If it is a better use of their time to see patients or attend to clinical duties rather than being in the meeting, then that is what they should be doing.

Steve Jobs was famous for using this practice at Apple. There are some pretty entertaining stories of people being removed from meetings who had no idea it was coming.
His explanation, however, was directly in line with my thinking. I hired you to do a certain type of work. It is best if I do not distract you from doing it as much as possible.

Build in flex time

 

As good as you are as a leader and as well as you apply the above principles, unplanned things always happen in meetings. So…plan for that. I never run a meeting where the time limits on the agenda add up to the entire length of the meeting. For example, a 60 minute meeting always has 50 minutes worth of agenda items and 10 minutes of flex time.

You can use this flex time for any number of things. I typically use it for questions at the end of the meeting. This is a great way to give staff access to administration for any pressing matters. This will also give you time to discuss something that may have come up in the meeting, but it was not already on the agenda. If the questions that come up more of a personal nature, and don’t forget to cut the other staff members loose so they don’t have to listen to someone else’s personal questions.

The most popular use of flex time is to end the meeting early. Remember that ending a meeting early is never a bad thing. You will likely increase your popularity as a leader if you do this often.

Sometimes, it is even necessary to end a meeting early before all the agenda items are discussed, especially if you determine that you do not have the people or resources needed to make decisions about the agenda items. Never be scared to do this. As a leader, you need to respect both your time and the time of your colleagues. They will appreciate you for it.

I’m hopeful that following these tips will lead to fewer horror stories from my colleagues and honestly, less meetings doctors have to attend. Doctors really do tend to be happier when they focus on clinical care. That’s what they signed up to do. Let’s make staff meetings help them in this mission, not hurt them!

Let me know some of your best meeting stories below. Have you been a part of a particularly painful meeting? Do you have any funny stories about your staff meetings? Share in the comments!


Four Financial Tips for New Attending Physicians

So, you’re a new attending now, huh? The big money is rolling in. Your pager doesn’t go off as much at ridiculous hours of the night. Life is good. Life is going to be even better when we take our newfound riches and buy a Mercedes, right? Wrong.

Like other professionals that come into big paydays very quickly (professional athletes, lawyers, etc), physicians are highly prone to making very rash decisions with their money right out of the gate.

Nothing will set you up for misery more than tieing up your hard earned cash in petty things. New attendings tend to think they are invincible now that their paychecks have changed.

Your dream job you have now is perfect, right? No way it will go south and become awful. What if your job is actually terrible? What if you are ready to jump off a bridge six months in? It happens a lot, and the person that was smart with their money and can afford to make a change is in a much better position than the person driving the Benz.

So with that, I’d like to offer some free advice to the new attending crowd. Some of these tips I followed personally. Some I didn’t, and I have learned from the school of hard knocks. Heed my warnings so you can be in the best position possible.

Like any good boss, I don’t do all of the work myself, especially in the personal finance arena. There are a myriad of excellent blogs devoted to physician personal finance. Where applicable, I have linked to them so you can benefit from their wisdom.

Don’t Spend Differently

 

On the day you get your first attending paycheck, you should celebrate by eating out…at Subway. My first tip is don’t change your spending habits at all. If you bring your lunch to work every day, then keep bringing it. If you have a push mower to cut your lawn, then keep pushing (OK, maybe you can go self propelled here).

My point is don’t let your expenses grow with your new paycheck. When your expenses change with your paycheck, I call that living paycheck to paycheck. When your expenses are low and your paycheck is big, you are headed towards financial independence.

The temptation is so great in this arena that I propose literally hiding your money from yourself. Figure out how much you need to continue living your residency lifestyle. Keep that much in your checking account. Take the rest and put it in a separate account. Savings account, checking account, whatever. If your HR department lets you deposit your paycheck in multiple accounts, then do it that way. There is a bunch of free budgeting software out there that can help you keep track of your money across all your accounts. Pick one and use it. I use Personal Capital.

The White Coat Investor has many excellent articles about maintaining your residency lifestyle to grow wealthy. I recommend you check them out. Personally, I fell into this trap and then cut back my lifestyle after discovering my mistake. Don’t copy my screw-ups. Do it right from the beginning.

Physician Finance Max Out Your Retirement Accounts

 

Do you want to retire one day? Do you want to become financially independent so you can just do the work you want to do? Both goals involve saving and investing money, so start doing it. The best way to save and grow your money in a tax deferred way is through your retirement accounts (401K, 403b, SEP-IRA etc).

If you’re making the average new attending salary in almost any specialty, then you can afford to max these out. The current maximum for those under age 55 in 2017 is $18,000 per year of employee contributions to a 401K. Divide that up by the number of paychecks you get per year and contribute that amount every paycheck.

There are multiple free resources available regarding the technicalities of retirement accounts and the different selections you need to make. For those already familiar with the numbers and terminology, I’ll say to set up your asset allocation with low cost index funds so you can reap the benefits of your contributions and your employer match. For those that have no idea what that sentence means, then read the following articles:

1. Index funds

2. Asset allocation

3. 401k basics

Clean Up Your Student Loans

 

If you’re like me, you came out of medical school with six figure student loans. You need to clean that mess up, pronto. You probably don’t have the free cash to pay all of those bad boys off immediately, so you need a plan.

This topic is very intricate, and there are a myriad of blogs and entire websites devoted solely to this topic. In a nutshell, here are the items you need to address:

1. Loan pay off vs. Loan forgiveness

2. Find any applicable loan assistance programs

3. Find the lowest interest rate

4. Variable vs. fixed interest rate

5. Identify the best loan term

For quick links that can give you great information on making these decisions, check out the following:

1. Student Loan Hero Guide for Doctors

2. Physician on FIRE Student Loan Resource Page

3. White Coat Investor

Public service loan forgiveness (PSLF) is the most popular loan forgiveness program. This applies to anyone working for a 501 (c) non profit or federal/state government. It is fantastic program that will allow your entire remaining loan balance to be forgiven tax free after 120 on-time, qualifying payments. This article gives you more in depth details regarding this.

Folks choosing PSLF should realize that your entire strategy changes if you are going this route. If you choose PSLF, then your entire focus should be on making your payments as low as possible. That way, you pay the smallest amount possible and maximize the amount that is forgiven. Pay close attention to what a qualifying payment is so you don’t wonder outside the bounds of the program in your search for the lowest payment.

Lastly, the subject of loan assistance programs is not well covered in the physician student loan world, in my opinion. You can negotiate with your new employer to write a check for your student loans for each year you’re employed with them. I have seen amounts ranging from $25,000/year to $50,000/year. You can also make sure they throw in enough to cover the taxes on that check.

Several government agencies also offer loan assistance above PSLF. The Department of Veterans Affairs will pay you up to $120,000 over five years through the Education Debt Reduction Program in some cases to work for them, just as an example. Don’t ignore these types of possibilities.

Physician Financial EducationEducate Yourself

 

There are enough resources available for physicians to be very successful with your finances without having to pay exorbitant fees to someone else. I have linked to several above, but here are links for the main sites of a few that will get you on your way.

1. White Coat Investor

2. Physician on Fire

3. Passive Income MD

4. Wall Street Physician

5. Rockstar Finance

If you follow my Twitter account as well, you will see me mentioning any new resources I find.

If you still want personal guidance after looking at these resources, then I recommend getting professional help in the form of a fee only financial planner. Fee only planners are financial professionals that will give you personal financial advice for a flat fee.

I mention this particular type of financial advisor specifically because they are the most likely to give you unbiased advice. Just like doctors that get paid by Pfizer are more likely to recommend drugs made by Pfizer, financial advisors paid by a certain services are more likely to recommend those services. You don’t want the services they get paid to recommend. You want the best ones. The National Association of Personal Financial Advisors is a great place to start looking for a fee only financial advisor.

So there you have it, my four financial tips for new attendings. Hopefully it prevents you from falling into some of the traps I fell into. I enjoy talking about money now that I’m starting to be responsible, and my life is always better when my financial ducks are in a row. I hope my tips help you do the same!

For those of you further down the line in attending world, leave a comment with your best advice for the younger crowd or maybe a personal story of something you did or did not do well financially. I’d love to share others’ experience in addition to my own. 

If any bloggers want to guest post on a physician personal finance topic, then shoot me an email or message me on Twitter.

Physicians Guide to Conquering Clinical Quality Metrics

I can think of no more well received topic amongst physicians than clinical quality metrics. Whenever I walk into a cafeteria or social event, quality metrics is one of my go to topics to lighten the mood and get everyone smiling.

OK, that’s a complete lie and all of you know it. However, that doesn’t diminish the importance of this topic. The number of metrics in healthcare has exploded over the past few years. They range from the essential to the absurd, and I’ve had a little fun on my Twitter account recently commenting on this.

The reality remains that metrics are not only increasing in our daily lives as clinicians, but they are starting to affect our wallets as well. I would venture to guess that a majority of you reading this now have some type of clinical quality metric that figures into your paycheck.

Once something starts affecting my paycheck, then you better believe it has my attention. As I’ve stated before, my goal is FIRN, so I cannot afford to have someone shaving pennies off my hard earned dollars.

My goal with this article is to give you some basic principles to apply whenever confronted with a clinical metric, not go through the ins and outs of all the different Medicare measures out there. I will readily admit that I am one of these weird physicians that enjoys this kind of stuff. Many of you are probably normal human beings that would be perfectly happy if this isn’t a part of your day. So, if you simply want to leave a snarky comment at the bottom as a means of taking out aggression, then please be my guest.

With that, let’s get started. I focus heavily on the mission whenever answering a question, so let’s start there.

Clinical Metrics

The Purpose of Quality Metrics

So, why are we doing this stuff? No, it is not as a means to pay doctors less money, despite what many may think. The reason we follow metrics is to improve the quality of care we provide. No improvement happens without first measuring what you want to improve. Clinical quality metrics are the first collective step in that process.

Most clinicians want to improve healthcare quality. On average, physicians are honorable professionals that want to do their best for their patients. They would gladly put in the work to improve their patients’ blood pressures or lower their patients’ collective risk of surgical site infections.

The disconnect occurs, however, in how the measurement process works and whether measuring things really leads directly to improving them. Many physicians feel that the steps required to collect and report clinical quality data are too onerous and take up inordinate amounts of their time (they’re right by the way and we’ll discuss how to spread the work around later).

Healthcare is still in the process of determining whether all of this measurement is beneficial to patients on a broad scale. From my vantage point, this depends heavily on what metric you pick and what resources are available to improve it. I think we are often guilty of trying to hit home runs in this arena when singles and doubles can score runs.

You can get tangible results by improving the colon cancer screening rate. A solid single. Cutting the thirty day readmission rate by fifty percent may be a home run but is a much tougher goal. This leads me to my next tip…

Picking the Right Metric

If you want to meet a metric, then pick one you can meet. It doesn’t get more obvious than that, but many fail to understand this. If you are already a physician administrator, then this is where you come in. You need to be able to explain to your non-clinical team that setting the goal of 100% of patients having a systolic blood pressure less than 130 is flat out impossible. Just like goal setting in any other realm of life, picking the right metrics to focus on should involve shooting for something that stretches you but won’t break you in half.

In addition, try to pick metrics that are actually meaningful. Picking some meaningless goal like “we will check blood pressures on ninety percent of our patients” is easy. Professionals want to be challenged, however, and will revolt against pointless work.

For those of you not directly involved in picking the quality metrics that your organization focuses on, you have two options to provide input. One is find the physician that does have direct input in the process so your voice can be heard. The other is to become the physician that gives input into the process. As I said before, your paycheck probably depends at least in part on this process. I prefer to be sitting at the table when the meal is served, and I suggest you do the same. I have done both of the above tactics in my career, depending on what my position in the organization was at the time.

Clinical MetricsKnow The Inputs

Once you have a metric picked, then you need to know exactly what the metric entails. Things seem very simple when sitting at a conference table, but they quickly become more complicated when you are back in the clinic seeing patients and trying to meet your goal.

Your electronic medical record (EMR) is intimately involved in this process, so plan to collaborate with your IT people or EMR vendor.

It’s probably easiest to use an example here so let’s suppose your clinic has decided to focus on your diabetic patients, and you want to get 80% of your diabetic patients to an A1c<9. Right off the bat, here are a few questions I would ask:

  1. Will ICD-10 codes identify diabetic patients or something else (i.e the EMR problem list)?
  2. If using ICD-10, which codes are we including (i.e what about the steroid induced diabetes folks etc)?
  3. Can patients be “cured” of diabetes? How will we figure that out?
  4. How do we track patients that have A1c’s done outside our healthcare system? Is someone going to manually enter these in the EMR or manually add them into the final calculations?
  5. Will both point of care A1c’s and serum A1c’s be included? Will the EMR capture both?
  6. Does the final A1c number of the year count or the average A1c?
  7. Will you be penalized if you go too long without measuring an A1c?
  8. Who are “your” patients? Is it the person that orders the A1c, the person that saw the patient last, or the person listed as the primary care?
  9. Do patients that move, change providers or get lost to follow up during the year still count?
  10. Do patients on hospice count?

A “simple metric” gets very complicated very fast, doesn’t it? Someone with a clinical background needs to be asking these questions, however, if you want to be successful. Knowing all of these details will allow you to take your next step in conquering a quality metric, building a systematic approach to success.

Using Systems to Meet Metrics

Physicians cannot meet quality metrics by themselves. This concept is so important that I’ll say it again. Physicians cannot meet quality metrics by themselves. Systems of care meet quality metrics. Quality metrics are a means to improving systems of care at the end of the day. Physicians are essential to this system but are not the entire system.

This systematized approach happens at both an organizational level and an individual practice level. Let’s return to our A1c example from earlier. If trying to tackle this from an institutional level, I would address several items:

  1. Easy availability of A1c testing (lab availability or point of care testing)
  2. Technology transfer between health systems to obtain A1c data
  3. Working with EMR vendor to run periodic reports and ensure appropriate data capture
  4. Ensure appropriate diabetic referral resources available

As a provider in my daily practice, I would focus on different aspects of my individual system of care:

  1. Establish nursing staff protocol for nursing to test patient’s A1c’s automatically when due
  2. Establish or improve relationship with Endocrinology or clinical pharmacy to ensure quick patient access when needed
  3. Ask administration to give periodic updates on our numbers. Request real time data access if possible. Send the data to your staff so they can schedule appointments or deploy more resources for individual patients.
  4. Have front desk staff ask all diabetic patients if they have had labs drawn at other facilities. Get release of information on the spot for anyone that says yes.

As you can see, the scope of each approach is different but the concept is the same. You have to modify the system of care, not rely on one person (i.e the physician) to collect, analyze, and act on the data. The organization that can best implement systems at multiple levels instead of simply relying on doctors to do all the work will always win, and these doctors will not feel the onerous burden of meeting metrics by themselves.

healthcare administratorThe Evil Administrator Myth

Lastly, I want to tackle one common misconception that I constantly hear from physicians in regards to clinical metrics. I enjoy hearing physicians say things like,”This metric is just a way to cut into my paycheck,” or “I guess we’re not meeting the budget so they put in a few more metrics.” While I can’t speak for Uncle Sam’s motivation when it comes to implementing clinical quality metrics, I can tell you that the administration in your organization wants you to meet your metrics.

It is worth a lot more money to provide measurable, high quality care than to use metrics to deny doctors part of their salary. Number one, it makes for excellent marketing. If every primary care doctor you had controlled 100% of their diabetics, would you put that on a billboard if you were the CEO? You bet you would. More patients then come to your clinic, and everyone makes more money.

Second, meeting quality metrics produces improvements in staff morale.. There is a palpable improvement in the esprit de corps of a group when they meet a goal. Recognition for achievement will compound this effect even more in a group passionate about the cause. Healthcare professionals fit very well into this mold. Do these motivated groups then produce more? They do indeed. Every administrator on earth wants to improve the productivity of their people, so I promise, any administrator with sense is pulling for you (I hear you laughing back there!).

So, what do you think? Are you ready to conquer the clinical metric world? Do you still not care about this stuff at all? Does your boss need to read this article? Let me know what you think in the comments below. Remember that, at the end of the day, its still a great job to be able to take care of patients. Don’t let numbers on a page change that. But, if some numbers on a page can help you do a better job, then let’s do it!

Three Keys to Physician Negotiation

One of the most important career skills in any industry is the art of negotiation. There have been many books and articles written on this topic, and it is not my intention to cover negotiation in its entirety. 

Based on my experience negotiating things from service line agreements to compensation packages, there are three aspects of physician negotiation that I’d like to cover today. These apply to physician negotiations in any setting from private practice to military medicine (or negotiating with any other professional for that matter). Use them and you too can write a best selling negotiating book and become President (the reference was too good to pass up). Ignore them, and, as our esteemed President says, you’re fired!

Good Faith

The fine folks over at Harvard Law School define good faith negotiation as “to deal honestly and fairly with one another so that each party will receive the benefits of your negotiated contract.” In short, negotiating in good faith means that both parties negotiate honestly with one another with the intention of reaching a mutually acceptable agreement.

You will find many instances of career blogs or journals suggesting that job candidates of all stripes, including physicians, should negotiate a job offer with an employer solely for the purpose of learning about the job market or using the offer as leverage in another negotiation. As the guy often sitting on the other side of the table during that negotiation, I can tell you that is bad idea. 

I’m not suggesting that you have to talk to one potential employer at a time or that you can’t use another offer you’ve received when sincerely negotiating with someone else. I can absolutely tell you, though, that it is not that difficult to spot someone who is going through the motions with no real intent of considering the position.

Not only is it flat out rude to waste everyone’s time and energy negotiating an agreement that you have no intention of considering, it is also detrimental to your professional reputation. Physicians managers absolutely talk to each other, especially in our local community. I have seen it happen where a physician has been found out trying to do this. Even if you are not found out during the negotiations, your reputation will follow you in the future.

This becomes even more true if you are negotiating with private practices about joining their group. As someone who hires for a larger organization, I may be annoyed with you but I will usually move on to the next candidate that my HR department has found for me. A private practice, however, who has spent considerable time, money, and effort recruiting you and getting you to the negotiating table, will likely be much more vindictive if you go all the way through the process to the end just to sign with the rival group in town.

Negotiation

Know What You Want

There is nothing more frustrating then trying to pick a restaurant for dinner with someone who has no clue what they want. Well, I take that back. The only thing more frustrating is someone who constantly changes their mind after supposedly making a decision.

Negotiation is no different. A good negotiation is contingent on both sides coming to the table knowing what you want. Not only does this make the process faster, but it also helps both sides get what they want out of the deal.

I’ve been a part of negotiations with physicians that have left me wondering if they had thought about what we were discussing at all before the conversation began. While negotiating with a new hire, I have had a physician literally try to figure out if they wanted to work part time or full time while negotiating salary. After providing two separate packages for part time for full time work, the physician began to negotiate each one separately, bouncing back and forth depending on which was the flavor of the minute.

Needless to say, I have no intention of negotiating two compensation packages for the price of one, and I halted the process until they could definitively tell me what they were after. I never hired that person, and have not heard from them again.

Even if I had remember them, however, it is very unlikely that they would have gotten the best deal out of me. I had already spent so much of my time and energy, that I was not inclined to haggle with them much more. There is only so much capital you have to spend in each negotiation. Know what you want and you can spend wisely to get what you want. Walk in clueless, and prepare to hear that a lot of things have suddenly become non-negotiable.

negotiation

Show Your Ethos

While my first two keys can be used by anyone when negotiating, this last one is specific to physicians and handful of other professions. As a physician myself, there is a certain ethos or characteristic spirit I expect to see in other physicians. A negotiation with a physician should be palpably different from a negotiation with a CEO, accountant or any other person.

I see physicians all the time that try to mimic some of the negotiation tactics they see other professionals use. I always tell anyone that will listen that your best tactic as a physician is to insist from the beginning that you are different from all of these other people. No one else has signed up to do the job you do. No one else will gladly be stopped in the grocery store for medical advice for free. No one else will sit at a patient’s bedside for as long as needed until they are cared for.

The way you conduct yourself at the negotiation table should reflect this inherently honorable aspect of being a physician. This should not only manifest itself in how you treat your negotiating partner, but it should also affect the subject matter that you discuss.

Everyone wants to discuss compensation when negotiating a new job, and physicians should absolutely strive to be paid what they are worth. No one expects less. The best hires I have ever made, however, never started with compensation. The best physician negotiators always started with something that displayed their ethos first.

I have seen one physician start out by negotiating how much free care he could provide if he had patients in need. He suggested a reasonable amount and then asked for a percentage of his own salary that he could throw in to help patients if needed. I hired him.

I had a physician ask if he could take a certain amount of his salary and pay it out to his staff as bonuses for excellent patient care. I hired him.

I had another physician negotiate a set amount of time where he could provide free lectures at events to benefit the local community. I hired him.

In many of those cases, these physicians asked me for more money above my initial offer. In each case, I gave it to them with minimal discussion. They were so impressive in how they conducted themselves and displayed their professional ethos that I had no doubt the extra money would be worth it to retain them. And so far, that has held true.

I’m interested to hear your stories about your negotiation experiences. What are your best negotiation tactics? What are your most awkward or strange experiences? Leave a comment below so we can talk further. Many become unnerved when the time to negotiate comes but if you keep a keep a clear head and represent what you stand for, then you will be just fine. Now, go out and get what you want!

I Love To Tell the Story

For those aspiring to be leaders in medicine or even have some influence over the operations of your clinic, you will have to know more than when to increase someone’s insulin. You will need to tell the story.

A hallmark of a good leader is the ability to express a narrative. A leader will not just tell his people what to do, he will tell them why they are doing it and the broader context behind why they are doing it. And if he’s really good, then he will do it in the context of a narrative that inspires and points to a noble mission.

Preventing the Turtle Response

This skill is especially important for a leader looking to introduce change. Physicians, in particular, can be a very tough audience to change. Given the current dynamic environment in healthcare, many physicians have taken to turtle mentalities where they retreat into their shell and resist any change that comes their way, no matter what the potential benefit to them is.

A competent physician leader will be able to coax their staff out of their shells and explain how change benefits them and the organization as a whole. Connecting change to the greater purpose and direction of the organization will give you the best chance of eliciting buy-in for the change you are trying to implement.

I have too often seen leaders elicit directives to physicians with minimal effort to tell the relevant story around why a decision was made. These “edicts” are always met with resentment, and in the absence of any narrative, physicians will fill in their own narrative that often assumes the worst intentions.

The Angry Colleague

I can recall a particular example where it was necessary to change several physicians’ clinic grids. The clinic’s wait time for new patients had grown too long, and these particular physicians had not been seeing new patients recently. The situation was especially challenging because these were senior physicians in the group that had effectively pushed the responsibility to see new patients disproportionately onto the younger physicians in the group.

I made the mistake of sending an email with my decision first and then following up in person a day later (rookie move). By the time I was face to face with them 24 hours later, they had officially declared World War III. In their mind, I had switched from their colleague to a worthless bean counter with no regard for the many years of hard work they had put in. 

As I sat down, the most senior physician opened the conversation by angrily demanding why they were seeing new patients when the younger physicians needed to fill up their panels. He then started to rapid fire questions at me. Are the younger physicians lazy? Do we need to find better junior colleagues? It was not going well.

After he finished speaking, I paused for a moment to collect my thoughts and then asked a single question of him.

“Why have you worked so hard for so many years at this clinic?”

He was taken aback at this, but after a moment he answered.

“I became a physician to help my patients and community almost thirty years ago, and I expect others here to do the same.”

“Perfect, I said. I agree. Now, how are we going to achieve our common goal of helping the patients in our community if we can’t even get them in to be seen?”

There was much conversation that followed, but ultimately, the senior colleagues agreed to the schedule change. It could not have been done by forcing it on them and walking away. Tapping into our common mission and common narrative around that mission was the only way they would agree to get on board. If you are looking to lead in any realm at your clinic or hospital, then you can’t afford to do any less.

Financial Independence Retire Never (FIRN)

I follow a lot of the FIRE (Financial Independence Retire Early) crowd both on their blogs and on social media. I find a lot of good advice there and many of the things I have read have positively shaped my personal finances today. 

For those motivated to do so, I take no issue with physicians working hard to achieve early retirement. In my view, you put up the money to pay for your schooling so it is your life to manage as you wish. If that means retiring at thirty-five and living in Tahiti, then God bless you and post pictures when you’re on the beach.

I suspect, however, that there are many folks like me that have a really hard time with the idea of working hard for some specified amount of time and then walking away forever. I’m willing to bet that many physicians, in general, share my uneasiness with this idea.

I will readily admit that I have a borderline pathological obsession with being active. I like to have my hand in several different pies at once and wasted time is truly my enemy. This even spills over into my vacation time. I will never be the guy that is able to sit on a beach for five straight days and watch the tide go in and out. Trust me, I would drive my wife crazy.

I am also blessed to say that I enjoy what I do on a daily basis, and despite the satisfaction I get when I stick that wedge within 3 feet, I would truly have less fun in my life if I just played golf every day. 

So with that in my mind, I would like to officially dub my version of financial independence as FIRN or Financial Independence Retire Never. I have no intention of accumulating wealth for the purpose of not working. I have every intention to attain financial independence to attain maximal flexibility to do the work I want to do.

FIRN

It’s really hard to find a FIRN image

The Four Principles of FIRN

Practically, many of the principles employed by the FIRE crowd are the exact same ones I employ, mostly because the basic principles of FIRE or FIRN are time honored tenets of wealth creation.  Here are my four basic principles:

Minimize expenses-I am not part of the extreme frugality crowd, but if you can do this then more power to you. The basic math dictates that the less you spend, the more you keep. This is especially important for physicians that find themselves in the upper tax brackets. Working to earn more money at a 35% federal tax rate can be downright demoralizing at times. Cutting out your $1000/month shopping budget is a tax free way to give yourself a big raise without having to pony up to Uncle Sam.

Eliminate Debt-I shouldn’t have to tell any physicians about the weight of student loan debt. Carrying six figure student loan debt definitely decreases your financial and professional flexibility and locks you in to having to pursue jobs that pay large salaries, regardless of whether you enjoy it or not. Unloading that burden can really improve your FIRN opportunities.

Use Compound Interest-There is no greater magic than watching money compound year over year. If you are earning an average physician wage, then your retirement accounts should be maxed out (401k, 403b, IRA, whatever it is). You should also take advantage of any other compound interest opportunities you may have. I will discuss more of these opportunities in future posts and link you to some great resources for getting the compound interest ball rolling.

Diversify Your Income-You might earn a fantastic wage as a physician, but your nest egg is at risk if that is your only source of income. Hospitals and physician practices are not immune to closure. You should work to diversify your income streams so that losing one will never be the end of you. Some do this by additional medical work on the side like expert witness work, chart reviews, locus work, or telemedicine. Others do things totally outside of medicine that they are passionate about. Take stock of whatever skills you have and see if you can apply them to set up an additional income stream.

The Freedom of FIRN

In my mind, a key principle of physician FIRN is that you always intend to do something, not necessarily medicine. Personally, I very well may decide to move on from clinical medicine one day. I have no idea what my professional future holds in this regard. I might even decide to cut back my work schedule one day. However, I can fairly confidently say that I will always be doing something that likely brings in a paycheck of some kind as long as I am physically and mentally able. 

What this really comes down to at the end of the day is what you enjoy. To some people, work of any kind is simply a means to an end. For others, work is part of what makes life enjoyable. It’s all about what makes you tick and what your passion is. For me, a life solely based in leisure would be unfulfilling. As my About Me page says, I am the guy that would probably train to join the Senior PGA tour if I ever devoted my life solely to my hobbies.

Ironically, I think a lot of the FIRE crowd actually falls into FIRN if we are being strict about the definition. Most of the blogs I read and people I come across are still very much working and bringing in paychecks (sometimes really big ones), even though that have “retired” from their day job. Maybe they will prove me wrong one day and totally pull the plug on working, but many of them look like they have the same itch to keep moving that I do.

FIRN Investing

The choice of FIRN vs FIRE has real implications when it comes to applying the art of compound interest. For investors of all stripes, there is often distinction made between returns that come in the form of value you receive now versus value you receive later. For real estate, this is cash flow versus appreciation. For stocks, this is dividends versus equity.

For the individual pursuing true FIRE status, investment activities would most logically be geared towards the immediate income side of the equation. The FIRN investor, on the other hand, can gear activities more towards total return. Assuming that a FIRN investor has already undergone some basic income diversification, then he can afford to engage in activities that may pay out nothing now but will be the most profitable in the long run.

A practical example would be Berkshire Hathaway stock. Berkshire Hathaway has paid out a dividend exactly one time in its entire history. This stock is much less valuable to an individual pursuing FIRE, but could be much more attractive to an individual pursuing FIRN. No dividends are no problem for the FIRN person. They can afford to play the long game and just watch the equity grow as the company’s value goes up. In reality, most physicians probably should have their money in index funds and not be buying individual stocks, but we’ll leave that for another day

At the end of the day, I’m not making value judgements about either philosophy. Everyone needs to decide what their goals are and then act accordingly. If you really do want to live life from your beach hut, then I wish no tropical storms on your paradise.

Both philosophies will eventually lead to financial independence, which is really the core goal you should be striving for. If a person that has achieved FIRE sits down to dinner with a person that has achieved FIRN, then I’m pretty sure they’ll both be happy with their lot in life and have a lot more in common than different. The FIRE person may have to wait for the FIRN person to get off work, but hey, retirement is just a big waiting game for life’s last big event anyway, right?

My Burnout Story

It’s no secret that medicine has epidemic of burnout plaguing it. I’ve read a number of articles both in journals and blogs outlining the sometimes stunning statistics regarding physician burnout. White Coat Investor has a great article outlining some of the details about burnout.

Today, however, it is not my intention to discuss burnout in a dry, statistical sense. Today, I want to discuss a burnout story near and dear to my heart, my own.

The Beginning

I determined that I was going to be a physician roughly around the age of four. OK, a bit of an exaggeration, but I was pretty young. I don’t remember dreaming of being anything else. After studying hard in high school and college, I entered medical school with my intellectual and professional flame burning brightly.

Four years of medical school and three years of residency later, that flame was burning a bit, shall we say, dimmer. I was tired, just like everyone else that has gone through residency. I started studying personal finance pretty intently near the end of my intern year. This had two effects on me. One, I began to get my personal financial house in order, which was helpful. Unfortunately, it also allowed my massive student loan debt to weigh on my mind 24/7.

This can be problematic for someone entering the primary care field, where my paycheck will never touch those of some of my specialty colleagues. With that set up, I then proceeded to make a very large mistake.

Forgetting the Mission

I got into medicine because I loved it, pure and simple. I loved the intellectual curiosity and the personal connection with my patients. There was no money involved. I would still be a physician even if my paycheck was much lower than it is now.

As residency ended and I searched for my first job, I promptly forgot everything that made me choose medicine. With my personal financial situation squarely at the forefront of my mind, I promptly signed up to work for the place where I thought I could grow my practice, and consequently my paycheck, the fastest.

In short, it was a disaster. Sure, my practice grew. I enjoyed treating my patients, and they seemed to enjoy having me as their doctor. Every day though, I would drive home and wonder what my life had become. That kid that dreamed about being a doctor and helping people had turned into a money hungry young professional who would count the number of patients on his schedule and get frustrated if it was less than twenty-five.

I forgot everything about my personal position and what my mission was in my career and life, and that is the fastest route to burn out that I know.

Burn Out

The Change

It didn’t take long before I hit rock bottom and informed my employer that I was done. It was one of the lowest points of my professional life. I was a young physician with large debt, no real career path, and a rapidly diminishing sense of who I was.

There are many situations where this could end much worse than it did, but with the help of friends and family, I gradually found my way. I found a new job with a healthcare system that fits my ideals. The pay was lower, but the job satisfaction was much higher.

And sure enough, you tend to do well when you work in situation where you know exactly why you show up to work every day and enjoy that purpose. Eventually, I was given an administrative role in addition to my clinical duties, and TheBossMD was born.

So please don’t take it as fluff when I say that the personal element of your position is the most important part of who you are. I know firsthand the effect that losing yourself can have on your life.

I will be speaking on the blog more about how managing your finances responsibly can be instrumental to you accomplishing your goals. Don’t worry, however, my focus will always be on how to make your finances work for you, not the other way around. Trust me, you don’t want go there.

The Three Elements of Your Position

In my day job, I field many questions regarding career management and what factors play into your individual “position” everyday when you wake up. This is a foundational principle for this blog and for physicians. Let’s define someone’s position for our purposes.

Your position is the combination of principles and circumstances you bring with you to any situation.

Your position will play a large part in shaping how you respond in certain situations, and quite frankly, how successful you will be in many of your professional endeavors.

If there is anything I can impress upon you on this blog, it is to manage your position. Many doctors not only don’t manage their position, but they don’t even know what their position is.

That is an extremely dangerous from both a career and life perspective. If other people know more about you than you do, then they can easily manipulate you. Conversely, if you don’t know the basic elements of yourself and your situation, then you cannot leverage them to steer your ship in the direction you want to go.

The Three Elements

I define three major aspects as part of your position:

  • Personal
  • Financial
  • Professional

Knowing and appropriately leveraging these three aspects will give you the best chance of success in any situation, inside or outside of the hospital.

Let’s explore the three elements further so you, not someone else, can be in charge of your position.

Personal

There is a reason that the first post I wrote on this blog was entitled “The Mission is the Answer.” The mission is always the answer, whether we are talking about an organization or a person. You have to know what it is that you do and why you do it.

Why do you get up in the morning? Why do you practice medicine? What are your fundamental life beliefs? What are your religious beliefs and how do they inform your daily life?

Your personal mission is the most important part of your overall position.

Don’t worry about anything else until you figure this out. Nothing. Do not engage in negotiations over your salary or any other aspect of your life or career until you know this answer.

In addition to your ideals, your personal circumstances are included in this category. Are you married? Have kids? What types of things do you enjoy? All of these circumstances are primary to your success and should be considered carefully. A good day at home can soften a bad day at work, but a good day at work is not going to have the same effect on a bad home situation.

Financial

Doctors are like every other person on the planet. They want to be paid.

Believe it or not, you current financial position is the largest driver of your future financial position.

Who do you think is best positioned to negotiate a better salary, a financially independent physician who could afford to never work again or a debt ridden physician who has bills due every month? I hope you can see how the financially independent physician has a much higher success rate.

Having financial flexibility will also give you the independence to pursue your personal mission and professional goals independent of financial considerations. I have met physicians that have decided to join the military, open free clinics, or cut back on their patient load because, quite simply, they can.

All of them were able to do this because their personal financial position allowed them to. If your personal position leads you to what you do each day, then your financial position enables you to enjoy maximum freedom in how you do it.

Financial Position

Professional

Finally, its time to address your professional position. While incorporating the personal and financial aspects of your position, what do you want your career to look like?

Do you want to own your own practice in your hometown? Do you want to become the world’s leading academic rheumatologist? How about working your way up the corporate ladder of a large healthcare organization or insurance company?

Once you know the general direction, then get even more specific with your professional position. Do you want to get involved in side businesses or just focus on medicine? Do you want to provide healthcare to the masses or only focus on providing elite level care to a smaller population?

Also, consider your professional circumstances. What situation are you currently in? What relevant experience do you have? As you look around and chart your course, you will be surprised how much you can use from your current situation to chart your course.

All of these paths require very different skill sets, and I would argue that it is very difficult to do all of them at once. That doesn’t mean that you can’t change course during you career. You just have to pick one direction at a time.

doctor professional

The Punchline

I apply these three elements every day both personally and as a physician manager. I can write down something for each of these elements for all the doctors I supervise. This helps tremendously for setting individual goals and allowing each team member to contribute to the best of their ability.

You should strive to not just have your manager think about these things for you, but to consider and carefully manage them yourself.

So start thinking and get moving! Your position can be leveraged by someone else for their purposes or by you for your own. The choice is yours!

The Mission is the Answer

Its not often that a single phrase can be used to answer almost any question in any scenario. Today, however, we are in luck! For my inaugural post on the blog, I am going to talk about the most important thing in any organization, the mission.

This is Not a Mission

We should start about by discussing what a mission is not. A mission is not an overly generic phrase like “to make money” or “to help patients.” Any healthcare organization is going to try to help patients and will likely try to make money in some way.

An organization’s mission also should not be to simply to do whatever another entity tells it to do. I have seen this particular mistake made in numerous hospital owned physician networks. Phrases like “we just exist to generate referrals” run rampant in these places, and these types of phrases are toxic to culture.

This is a Mission

A mission should inspire employees. It should speak to a noble cause. It should be specific enough to define structure and function while simultaneously being broad enough to encompass ideals and principles, not just rote functions like “make money” or “help people.”

In healthy organizations, the mission statement is the driving force behind every action. Anyone unfamiliar with the mission is woefully unequipped to have any meaningful conversation about the work being conducted.

Inspired by a Mission

Physicians Don’t Know the Mission

I have met many physicians who have not put in the necessary time thinking about the mission of their organization, and it reliably leads to frustration and burn out.

It is impossible to find passion or joy while working towards a mission that you don’t know about or don’t care about.

The process of acclimating to the mission should begin before a physician even interviews with a company.

You should know the mission statement before you walk into an interview, and your opening question should be for the interviewer to explain the mission statement and how it informs operations. If the interviewer cannot answer that question, then that is a serious red flag.

If you are already part of a hospital system or network, then you should be incorporating the mission into everyday decisions. Let me give you a few basic examples.

Putting the Mission to Work

The Mayo Clinic has a lengthy mission statement, but the first part reads “To inspire hope…” Do you think that an organization aiming to “inspire hope” is going to have an extensive research component to their operations? Mayo certainly appears to think so.

Let’s get even more into the weeds. The last part of Mayo’s mission statement reads “Mayo Clinic will provide an unparalleled experience as the most trusted partner for health care.” Now, I can see all of the eye rolls happening here. The customer service surveys are coming! It’s true. If you put patient experience in your mission statement, then it will probably be extensively measured and emphasized on a day to day basis.

There are ways for you, the physician, to use this mission statement when you are interacting with administrators. Perhaps you work for Mayo and they are considering opening a new urgent care down the street. You’re not excited about this because that means your patients are going to be receiving healthcare from someone else, and thus, you are losing out on potential revenue.

Doctor Thinking About Applying Mission

By knowing the mission, you can seek to have a substantive discussion with the decision makers in the process. You can make the case that your patients should be seeing you for Mayo to remain the “most trusted partner” for patients since you are already their trusted physician, not some random person in an urgent care they have never met before.

If they respond with a comment about how you don’t have enough access in your schedule and access affects trust, then point out any number of options that could open up your access. Maybe an additional medical assistant or even a scribe. Point out how these options are cheaper than an entirely new urgent care clinic and better help the organization achieve its mission.

Remember the Answer

Any physician that follows this model can actually have a seat at the table where decisions are made that affect every day clinical practice. Better yet, physicians that speak the language of the mission are viewed as people that truly “get it,” not just employees trying to protect their own interests. All of this happened because you remembered the BossMD mantra…the mission is the answer.

What do you think? Are you excited about your mission at your workplace? Do you even know what it is? Does the mission affect your every day actions? Let me know in the comments below. To hear about my mission with this blog, visit the About Me section.