The Position Paper 8/23/17

Welcome to The Position Paper! The Position Paper is my series featuring my quick take on a particular topic to help you manage your position. I will often feature one outside article as well that will allow you to dig in deeper if you desire. Read this while you drink your coffee in the morning and start your day off right!

Today’s Position: Financial Position

Featured Article: The Golden Handcuffs For Doctors-Loan Forgiveness by InvestingDoc

My Take

In today’s Position Paper, InvestingDoc talks about loan forgiveness and the many factors you must consider if you are going to accept an employment contract with loan forgiveness. First, loan forgiveness comes in many flavors. Here are just a few examples:

I have been offered loan forgiveness via employment contract, and InvestingDoc correctly points out that these are often structured as loans. Either the full balance will be due if you don’t stay for the length of the service agreement, or a portion of it will be due depending on how long you stay. There is often interest attached to the balance you must repay.


Want to track your money for free? I use Personal Capital. Check it out!


I recommend actively negotiating that the balance be repaid if needed based on the portion of the service agreement you complete, avoiding interest altogether, or negotiating the lowest interest rate possible on the loan if interest must be included.

InvestingDoc also discusses PSLF, which can be great if you work for a federal agency or 501c(3) non-profit. He correctly states that you need to be prepared to fulfill the full 10 year commitment if you want the tax-free loan forgiveness at the end.

He also discussed the recent paranoia surrounding ending PSLF for physicians. Though it is definitely a possibility that physician access to the program could be limited, I highly doubt the government will end the program for physicians already out of training.

The government’s modus operandi for cost reduction is to limit anyone new from entering a program, not cutting off people already in it. As someone with federal employee experience, I can tell you this is always what happens. Not only is it the most fair thing to do, but it is also the most politically popular thing to do.

Remember docs, if you want that PSLF to stay, vote early and vote often!

Have a great day!

TheBossMD

Do you like The Position Paper format? Is this someone I should keep doing or trash it? Leave me a comment and let me know!

 

Extended Hours 8/19/17

Welcome to this week’s edition of Extended Hours! While the term “Extended Hours” may be an undesirable phrase in the lives of physicians, this series on the TheBossMD should prove to be a much better experience!

Extended Hours is the weekly roundup post published every Saturday here on TheBossMD. As with all of my content, the purpose of this series is to help physicians manage their positions, whether it be personalfinancial, or professional.

These posts are light on my thoughts and heavy on the best content I can find during my travels through social media and the internet. We might even have some fun along the way!

Win $50!

Before we get to this week’s picks, don’t miss your chance to win a $50 Amazon gift card. We will be having a contest here at TheBossMD for the next month. I am going to pick one of my email subscribers to be the lucky winner, and it will be announced on the Extended Hours for September 9th. Please sign up below and share this on Facebook, Twitter, Google+, Linkedin, Pinterest or wherever else you may go.


Boss For The Day

A big thank you to Tom at High Income Parents, who was this week’s Boss For The Day. Tom gave us some great knowledge regarding The Work Life Balance of Physicians. If you’re a physician, or any busy professional that matter, then please check out his tips for balancing your home and family life. Your family will thank you!

I was honored to guest post over at High Income Parents as well this week. Please head over and check out my post Three Tips for Negotiating Job Flexibility. I hope it can help anyone looking to bargain for some balance in their job.

If you are interested in submitting a guest post to be the Boss For The Day, then please shoot me an email. I’m always looking for great content!

Personal Position

Do you love Disney? Do you like to run? Well then, you’ll love Rebecca Darling‘s post over at R We There Yet Mom entitled 11 Tips to Run a Disney Race at Walt Disney World. This is a great look inside the RunDisney experience. Disney World is one of my favorite vacations for my family. Why not combine some racing with your vacation time? You probably don’t take enough vacation anyway. Go for it!

I dug up an article a few months back that EJ at Dads Dollars Debts wrote for Physician on Fire about taking a gap year. In A Gap Year Away From Medicine: One Physician’s Experience, EJ writes about arranging a research year in Argentina during residency and traveling South America. He also gives great tips for other ways to work in breaks to your training.

In light of recent events, I’m glad I can share What’s In A Name (And A Color)? from Working Optional. This post is a wonderful look at both the positive and negative parts of one person’s experience being a first generation immigrant in America. I hope this conversation continues as we try to remember America’s founding principles and how we should treat each other as people.



Financial Position

Chris Durheim over at Keep Thrifty shared a really interesting article that I think is applicable to many physicians I know. In Breaking Our Addiction to Home Updates, Chris talks about avoiding the constant temptation to update your home and even talks about their decision to ditch homeownership altogether to remove this temptation. Anyone going to join him?

Ever wondered if you should just work as an independent contractor or stick to your W-2 job. Rogue Dad, M.D. hosts a great guest post by Anjali Jariwali entitled Pay More, Save More-Being the Boss. He talks about W-2 versus 1099 income and the pluses and minuses associated with each. Highly recommended for anyone considering working on your own.

The Wall Street Physician explores how index funds are actively cutting costs even further. In Race To The Bottom: Will the Price War Between Vanguard and Fidelity Lead to A 0.00% Expense Ratio Index Fund, he discusses the current market forces leading financial services companies to cut index fund expense ratios. Sounds like an opportunity to me! Glad my money is benefiting from these cuts.


Want to track your money for free? I use Personal Capital. Check it out!


Professional Position

Dr. Mo over at Urgent Care Career discusses how he plans to earn a full time income as a physician while traveling wherever he wants to go. Location Independent Income Put Into Practice: A Guide For Earning An Income While Living Abroad is a great read for anyone looking to pick up a few physician side gigs that can be done from anywhere or even for folks looking to see the world while working as a full time physician just like Dr. Mo!

Pamela Wible MD guest posted on KevinMD and shared a wonderful piece entitled Doctors:Are You Employees, Business Owners or Entrepreneurs? Dr. Wible eloquently talks about how individual doctors need to do a better job evaluating exactly what role they want to play in the healthcare system based on their personal characteristics. You will only enjoy your work if you do what fits you best!

Is medicine something you enjoy? Do you wake up in the morning excited about it? Passive Income M.D. writes that the secret to enjoying medicine is to make it your hobby in For A Long Happy Career, Make Medicine Your Hobby. He argues that uncoupling your income from your medical career can allow you to truly enjoy medicine. Sounds like a good plan!

Just For Fun

Now that school has started in TheBossMD house, I look forward to some great post work hugs when I walk through the door. Definitely the highlight of my day a lot of the time. My oldest is almost five now, so I don’t get quite the same reaction as I used to. This video below though will make you smile if you’ve ever had your kid run up to you and hug you when you come home. Try to watch it without smiling. The cuteness cannot be resisted.

 

You may remember from my previous Extended Hours post that I love World War II movies. I have successfully made my way through The Pacific mini-series about the Pacific theater of World War II. I’m now re-watching Band of Brothers, the mini-series documenting the European theater of World War II.

I take care of several World War II veterans, as I’ve mentioned before. The majority were in Europe, and I love to hear their stories. I selfishly try to carve out as much time as possible during appointments just to let them talk. It may have nothing to do with medicine, but I’ll gladly run behind just to hear their take on history. Truly fascinating.

Not Fun

My late night TV viewing took on a whole new meaning with the events in Charlottesville this week. I try to keep this post focused on fun and positive things as much as possible, but I’d be remiss to not to say something about this.

I was horrified to see the Nazi flag and hear such venom spewed in a protest march in the United States in 2017. My patients that fought against this and watched their friends die are probably even more sick to their stomach. My wife’s grandmother grew up in Germany during World War II as well, and I sat with her and listened to some of her experiences before she passed. She was horrified then and would be horrified now to hear these hateful ideas publicly lauded.

There is no place for any kind of intolerance, bigotry, and hatred in America. We cannot stand for it, and I am confident that we won’t.

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How To Disagree With A Patient

There has been a lot of talk about physician safety after the recent tragic news of a physician getting killed for refusing to prescribe opioids. The sad reality is that these types of situations are not new. Though many don’t end as tragically, physicians are bullied and pressured every day to provide care that is medically unnecessary.

How should we respond in these tense situations? What should we do when we anticipate that a confrontation might occur? These are questions every clinic and physician should be asking. Though the temptation may be to give in at times to avoid potentially catastrophic consequences, we must not do this. As the professionals tasked with caring for the public, our duty is to provide safe, high quality healthcare.

All of these situations, however, start out as a basic disagreement. It is there that I would like to focus our attention today. How can physicians best manage situations when patients ask for something we are not going to give? Do we yell and scream? Do we immediately assert our authority and shut down the conversation? Do we go silent and simply let the patient talk?

While no “strategy” is going to change a patient’s mind or prevent all situations from escalating, we owe it to ourselves, our families, and even our patients to manage these situations as best we can. I would like to propose seven strategies below to help us safely and effectively disagree with our patients. To be clear as well, many physicians have used all of these strategies I list below and still had bad outcomes. We are not going to prevent every bad situation, but we have to take action to reduce them.

Communicate Expectations Up Front

Every new patient that comes through my clinic spends the majority of their first appointment discussing office procedures and expectations. My nursing staff does the majority of this work, and it is essential. In essence, we tell each patient that we promise to communicate professionally with them, and in turn, they need to communicate professionally with us.

Professional communication entails communicating in a timely and civil way, and it goes both ways. We promise to communicate with you in a clear, calm, and courteous way and you must do the same. During moments of disagreement, I can call on this deal we made and remind them that I have held up my end of that bargain. It has been very helpful at times.


Tell Them You Care

As soon as I feel a disagreement is happening, I am going to work how much I care about the patient and their health within the next two sentences that I say. The reasoning for this is simple. First, I really do care about my patients. It’s not an act or a line I’m feeding them. My treatment of them prior to that moment can speak to that.

Second, discussing how I care for them reframes the conversation. The patient is approaching the situation as confrontational. I am approaching it in a cooperative manner. This is not the patient vs the physician. This is the patient and the physician against your chronic pain, or the patient and the physician against your viral URI that is making you miserable.

No matter what the patient says, I will always reiterate that we are on the same team and I am there to help them. It is much harder to escalate the situation when framed this way, and I can often steer us back towards something productive.

Let The Patient Talk

As someone who personally fields many patient complaints and reviews patient/physician disagreements, I can tell you that the vast majority of patients will tell you that they escalated the situation because they didn’t feel heard.

Yes, they disagreed with the doctor’s decision, but the part that really ticked them off was when the physician shut down the conversation. No one likes to be told they’re wrong and then be told to shut up, even if you know the other person is much more knowledgeable. There is a basic human response to lash out in that situation.

So, I tell my providers all the time to let the patients talk. Give them the courtesy of being heard. Sure, it may put you behind schedule. It may produce no change whatsoever in the decision you make. But, if it can save your relationship with your patient and help prevent something disastrous, then we must do it.

Tell Them Everything

Once you let your patient say everything they want to say, then tell them everything you possibly can. Explain in detail why you’re making the decision that you’re making, and explain it in a way that they understand. Define what certain terms mean if you have to, but you need to show your patient that this is not just a “cookie-cutter” decision. You have looked at their specific situation and applied your medical knowledge to them.

This way, patients know that you are not just lightly or blinding making decisions about aspects of their lives that affect them so much. You have taken your extensive medical knowledge and applied it specifically to their situation to formulate the best treatment plan. I will often say this exact phrase to make sure they understand this. I’m making the best choice for them, not just the best choice in general.

Lower Your Voice

Ok, this move is straight out of parenthood but there are multiple psychology studies to back this up. When someone is confronting you, the natural reaction is to raise your voice. Don’t do it. Consciously lower your voice. It is very difficult to yell at someone speaking softly back to you. Most people will naturally lower their voice if their verbal fire is not returned.

Interestingly, speaking softly can also be a very effective method of communicating confidence. Any of you that had a parent or boss use this style with you can attest to this. A person that quietly outlines their position and does not yell often appears much more authoritative and sure of themselves. A person that yells appears to be covering up their insecurity with volume.

Don’t Fire The Patient

Some of you are going to disagree with me on this point, but that’s OK. I very rarely “fire” patients. I’m not saying it never happens, but it’s rare. Part of this does have to do with my sense of duty towards the patient. The other part though is that you would be shocked how effective it is when you tell the patient that you want to see them again.

We all have cared for patients that have been fired from a previous practice. I have forged some pretty good relationships with some of these folks when I refuse to prescribe something and then immediately ask to follow up with them closely so we can see how things are going.

This reinforces the fact that I really do care about them; it’s not just an act. I’m also reinforcing that I really believe the treatment plan that I have proposed, and I’m willing to see them through it.

Many physicians will make a one time recommendation and ask the patient to never come back if they disagree. Right or wrong, this looks like you simply said something for the sake of saying it and then got rid of them. Consciously telling the patient that you want to keep seeing them communicates confidence and a desire to have an ongoing relationship with them.

Have A Safety Plan

At the end of the day, you’re still going to run into situations where patients inappropriately escalate a situation. Be ready. Have a written policy of how to handle these situations. Make sure everyone on your staff knows the policy and better yet, practice it regularly!

What do you do when a patient yells and won’t stop? What do you do when a patient threatens you or even becomes physically violent? Have everything planned down to how you communicate with your staff that you need help to who is responsible for calling 911.

As with all emergency situations, you will always revert to what is most ingrained. If you and your staff know your policy cold and have practiced it, then you will be much more likely to safely handle the situation. Heaven forbid that something were to happen and a patient would accuse you of wrongdoing, a written policy with documented staff education and routine practice will also help you prove that you had a well thought out plan that you followed.

Remember Your Value

At the end of the day, if no one else says its to you, let me tell you that you do hard work and you are valued. Healthcare is a tough environment right now, and doctors’ well-being is often lost in the shuffle. I hope the seven tips above can help prevent a at least a few situations from getting out of hand. We need more doctors engaging with their patients and honestly caring for them, not fearing for their safety.

I’m curious to hear from all of you about your experiences and what you think might help doctor safety. Leave a comment below so we can discuss more. This conversation needs to continue as we aim to make the exam room a caring environment for everyone, even the doctor.

Boss For The Day: The Work Life Balance of Physicians

This guest post is the first of our Boss For The Day guest posts. In these posts, I aim to bring you the best content possible to help you manage your position, straight from the desktop of those that know best. If you’re interested in being the Boss For the Day, then shoot me an email. Today’s post comes from Tom, who runs a great site over at High Income Parents. Tom doles out great advice on parenting for high income earners and has dropped some knowledge for us here today. Thank you Tom, and enjoy!

The work life balance of a physician or physician-in-training who is also a mother or father is a difficult thing to master. On one hand, you have a family you love. On the other, there’s never a lack of things to do to further your medical career.

I was once told the whole point of residency is to learn ten years worth of medicine in three or four years. There is some truth to the statement. That’s why we have the long hours and the endless amounts of material to cover. What we learn in that short time will contribute to the health and lives of our patients.

Before attending medical school, I sought a job in the local hospital for exposure to the medical field. The goal was to see if I really wanted to get myself into this business. It was a valuable experience but I met some doctors that were for lack of a better word, douchebags. As a naïve college student, I didn’t understand why a human being could treat another person like some of those doctors did every day.

It was a real eye-opener that a profession I thought embodied the ideals of caring for humanity and compassion would treat coworkers and subordinates with such malice and disrespect.

I vowed to never become like one of those doctors. I think I’ve upheld that vow, but after going through the process, I understand how the doctors for whom I worked reached that malignant attitude I saw then and still see today with some of my colleagues.

We’re taught to be aggressive and take charge. Often times a patient’s life is in our hands and we need to get things done precisely and accurately to save a life. You can’t be timid about those decisions. That training often spills over into our family lives and how we handle our spouse and kids.

The problem is often our spouse and children don’t respond very well when we tell them to jump. The nurse or technician at work may say, “How high?” and trust our decision making. That’s the chain of command, but when we tell our kids to jump, they say, “Why?”



Communication

Like most things in life, communication was and still is the key to a harmonious relationship with our families. There are several main things I discuss with my kids and spouse to help them realize what we as doctors go through on a routine basis. Even though they can’t experience our daily lives, we need to convey to them what we experience.

I’m pretty good at compartmentalizing when it comes to difficult patient situations but even for me, I think it is good to share what I see when I go through a difficult situation. Those patients that have bad outcomes can weigh on you. Even if you did everything you could and made the right decisions, we can’t control everything. Sharing that experience with my family has helped them understand what I did during training and even today with my regular day-to-day job. I think it helps them grow closer to me because they get a glimpse of the hard decisions that we as doctors make every day.

Pressures

When you’re under pressure, it’s difficult to deal with these alone. Sometimes our natural tendency is to hold these in and not bother our loved ones with the troubles we face. This is a mistake.

Likely, the pressure we feel to learn the medical knowledge, practice good medicine that helps our patients and acing the never ending string of tests we take throughout our careers will boil over into misdirected frustration and anger. We should share this with our families.

I’ve been guilty of being short tempered with my kids for minimal things. It might be because of the weight of an upcoming presentation or dealing with a difficult patient. Our loved ones shouldn’t suffer the consequences.

Thankfully we frequently talk about the challenges doctors face and my family is forgiving. Being upfront about the pressures and not letting it get to the frustration level has always worked the best.

Leadership/Expertise

Leadership and a take charge attitude are a fundamental aspect of practicing as a medical doctor. When the stuff hits the fan, the hospital personnel look to us to lead them to the best decisions. This helps accomplish our common goal, helping the patient.

Leadership opportunities are a vital part of being a spouse and a parent, but it usually doesn’t manifest itself in the same way. If I started barking orders to my kids without guidance because I expect them to “know their job” it’s rarely effective. Getting down and working with them on their level is much more productive.

Like the BossMD says, we need to know our position.

I’ve also found it helpful to tell my kids and spouse the way things usually work in the medical setting. Since I’m in the OR and things get hairy from time to time, we expect everyone to know their job and perform.

With my older children, I’ve discussed how a code sequence played out or how taking life-saving measures quickly and decisively has rescued a patient from death.

They appreciate the honesty and getting to walk a mile in my shoes. They love that I can share my day with them as they also share how their guitar lesson went, or how the youngest learned to jump off the diving board.


Want to track your money for free? I use Personal Capital. Check it out!


Patience

When we are tired and stressed, patience isn’t very abundant. Working long hours, taking care of stressful patient situations and dealing with administrators tries our patience.

Then we come home and have another set of challenges to overcome. Maybe teaching your 15-year-old to drive or sitting down with your four-year-old to practice phonics are your next duties at home. Discussing how you would teach a nurse to assist with a procedure isn’t going to prepare you for dealing with your kids. Take a step back and remember the way to success.

If I don’t have the capacity to be patient right at that moment because of an especially difficult day at work, I ask the kids or my spouse for a 15 or 30-minute break. I gather my thoughts and tell them I’ll be back to tackle any challenges.

They care about me and understand. Often they even ask if they can help me. We both exercise patience for each other.

Double Lives

Sometimes I think of doctors as superheroes. At work, we are doing things that would be considered assault if we didn’t have permission. We commit these actions because we know they should lead to good.

At home, we are usually mild mannered and don’t always take the leadership role. Our kids and spouses have expertise that we don’t and we should let them demonstrate that knowledge.

It’s kinda nice in a way to not always need to lead the way. It gives us the opportunity to think about the way we treat those who we lead and how we would react to the leadership styles of our coworkers.

Finding the balance between work and family takes requires thought and intentionality. It’s not easy but like all good relationships, it takes both sides working their hardest to help and serve the other. This is especially true with our families. If we want a good balance we should commit to both and give both career and family our all.

How do you cope with the two lives of being a doctor? Do you find it hard to separate them? Is it hard to transition into family life? How do you share your work with your loved ones?

Tom is the creator of HighIncomeParents.com. Tom is a doctor, husband and father of five with a passion for parenting and finance. When he isn’t skateboarding, riding BMX, or jumping on the trampoline with his kids, he is reading and writing about personal finance. He helps high income parents educate and mentor their kids to become financially, emotionally, and intellectually self sufficient.

Extended Hours 8/12/17

Welcome to this week’s edition of Extended Hours! While the term “Extended Hours” may be an undesirable phrase in the lives of physicians, this series on the TheBossMD should prove to be a much better experience!

Extended Hours is the weekly roundup post published every Saturday here on TheBossMD. As with all of my content, the purpose of this series is to help physicians manage their positions, whether it be personalfinancial, or professional.

These posts are light on my thoughts and heavy on the best content I can find during my travels through social media and the internet. We might even have some fun along the way!

Win $50!

Before we get to this week’s picks, don’t miss your chance to win a $50 Amazon gift card. We will be having a contest here at TheBossMD for the next month. I am going to pick one of my email subscribers to be the lucky winner, and it will be announced on the Extended Hours for September 9th. Please sign up below and share this on Facebook, Twitter, Google+, Linkedin, Pinterest or wherever else you may go.



Personal Position

KevinMD shares a good word from MusedWithMary regarding having other interests outside of medicine in Love Something Other Than Medicine? Its OK. Great reminder to be a complete person, not just a doctor.

Dr. Val of GetBetterHealth shared a story from Outside that I thought was applicable to physicians entitled Why Do Rich People Love Endurance Sports? Anecdotally, the endurance sport pull does seem to fit as I have several friends that participate in these types of things. Does the ambiguity of our everyday workplace environment make achievement so ambiguous that we pursue self punishment just to accomplish something? Read and find out!

Physician on Fire deviates from his financial advice to talk about personal fitness (Do you think you’re a doctor or something?). I believe this is one of his older posts but I wanted to share it anyway. His article Stay Fit for a Longer & Better Retirement is ostensibly about staying fit to enjoy retirement, but it actually contains great advice for staying fit right now. My patients are well aware of my focus on a daily exercise regimen to stay health and reduce stress, and it looks like he agrees with me.



Financial Position

Colin over at Building Income had me rolling while reading his article The King of My Castle. I think everyone can relate to having a moment where you blow your budget or when you try to tell your spouse “I don’t need permission to do this.” It never ends well for me, and it doesn’t look like it fared any better for you, my friend!

Ever do something stupid that costs you money? I know I have (I swear that sign said 55 MPH). Financial Panther writes that you should plan for this in his article Create A Stupid Mistakes Fund For Your Stupid Mistakes. Seems smart to me!

Sometimes we physicians need to be reminded of the advantages we have in many aspects of life, and there are other people that have achieved far more while starting with less. Tim Kim over at Tub of Cash shared his post recently entitled Did You Hear About The Millionaire Janitor? Think about this next time you complain about your money!

 


Want to track your money for free? I use Personal Capital. Check it out!


Professional Position

I thought this article was really cool for anyone that enjoys medical history. Dr. Richard Vaughan shared a piece from 99percentinvisible called The Stethoscope about the history of the stethoscope. Pretty cool to learn about the origins of that thing hanging around your neck!

A Good Life M.D. writes about medicine and the toll it can take on your life in Medicine Is A Wormhole. I know I have asked the same questions as him sometimes. Where exactly did my 20’s go? Excellent read to realize you’re not alone in asking that question.

Future Proof M.D. is now a Doximity fellow. Congratulations! His first post, Why Students Should Go To The Cheapest Medical School, over at Doximity is something that every potential medical student should read. I know I will be sharing this with all potential colleagues that contact me. Hopefully they can learn from my student loan problems!

Just For Fun

Well, we are almost halfway through August, which means that all of our new intern colleagues have successfully made it through one month as a doctor. Congratulations! The party has just begun for many of you, but I’m sure you already have some great stories to tell. I can certainly remember a few “firsts” during my intern year.

I actually remember my mother asking me if I had taken any pictures with my first patient. I tried to explain that I saw my first patient around 6AM, and they were none too happy to see me. Looks like somebody else had the same thought when they put together this little gem.

Speaking of intern year, one of my staples was grabbing a nice cup of coffee and a donut after rounds. This may have contributed to my weight gain but it certainly was a little slice of heaven.

Apparently some numbskull decided to sue Dunkin Donuts because their blueberry donuts don’t contain real blueberries. I read about this over at The Penny Hoarder, and my first reaction was disbelief. I figured this had to be fake, and someone was playing a joke on me.

Alas, it turns out its true, and I can only hope that a judge will realize how ridiculous this is and defend the honor of my beloved blueberry donuts. They’re lucky they didn’t go after Krispy Kreme because that would be a level of injustice that would move me to open warfare. Here in the South, insulting Krispy Kreme is like insulting someone’s mother. “Them’s fightin’ words” as we say.

For anyone that has read my About Me section, you’ll know its one of my goals to join the Senior PGA Tour one day. While that goal may not be realistic, I do love golf and will be glued to the PGA championship this weekend.

I’ve really enjoyed watching Jordan Spieth play as of late, and I’ll be pulling for him as he goes for the career grand slam. Though I may not play like him, I have been able to recreate some of his magic recently.

When my patient satisfaction scores came out last week, I had made a big jump after some concerted effort. My reaction was similar to Jordan’s reaction below, if you replace his golf club with my stethoscope and his caddy with my nurse (video courtesy of the PGA).

Well that’s it for this week’s edition of Extended Hours. I hope you enjoyed this week’s selections. Tune in next Saturday for another edition!

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The Good, Bad and Ugly of My First Rental Property

Note I am not a CPA, lawyer, or financial advisor. All information below is for informational purposes only. Please consult with a professional prior to making investment decisions.

Real estate is my weakness in the world of investments. My real estate experience started at a young age. My dad owned several units growing up, including a quadriplex and several rental houses. That was back in the day when you could get a 100% loan for a property just walking in off the street. How times have changed!

That experience growing up was invaluable for me. My dad let me ride along on any real estate related trip he took. By the time I reached high school, I had seen all sorts of things. I watched my dad collect rent from someone screaming profanities at him. I watched a tenant get evicted. I’ve even seen a tenant arrested for dealing drugs out of the house!

Most importantly, I watched what a down market and bad partnerships can do to a real estate portfolio. Fortunately, my dad had the means to get through this and has liquidated most of his portfolio now, but I learned invaluable lessons watching.

Many years later now, I have now owned and sold my first rental property. I am currently without any real estate investments as TheBossMD household focuses on student loans, but I plan to get back in the game.

My experience thus far has convinced me that real estate is an excellent asset class but it is just like any other investment or business. You need to understand it to profit. I have added to my real world education with other resources like BiggerPockets and numerous books.

For those of you wondering if this is something you can include in your portfolio as a working physician, I’d like to walk you through the story of my first rental property. I did some really smart things and really dumb things along the way. Hopefully, you can learn from my experience and apply it to your own portfolios.




A Physician Loan

My first renal property was actually my wife and I’s first home. We used a physician loan to buy it. We put nothing down and got a 30 year mortgage at 4.75% (obviously not today’s market). When you add in insurance, taxes, etc, our monthly payment came out around $1150.

After living in the house for 5 years, we decided to move a little closer to family. I had toyed with the idea of renting the house for a few years, but I didn’t realistically think it would work out. Most physician loans stipulate that the home has to be your primary residence.

I decided it couldn’t hurt to ask and called up the bank to see what they would say. My jaw about hit the floor when she said,”We don’t care if you rent your house.” I almost followed up with asking if there was a limit on the number of physician loans they would give me, but I figured that was too aggressive.

Armed with this knowledge, I went to my wife to pitch the idea to her. My idea was simple. The house was located in a good community with strong economic growth. If we could rent the house to good people at a good rate, then we could make a few bucks each month. After a few years, we could decide if we want to keep it long term or sell it, depending on how the market is doing.

Finding a Good Tenant

I then proceeded to make my best decision of this entire process. I determined my criteria for potential tenants and I stuck to them. Here were my criteria below:

  • Monthly income must be 3x monthly rent
  • Solid prior landlord references
  • No criminal history
  • No eviction/foreclosure history
  • Credit score>700
  • Must return communications promptly

I told every applicant up front that those were the criteria. I got a generic paper application and charged an application fee to cover the credit check. A lot of people didn’t make it past the first phone call! I had a few people beg me to bend the rules, but I didn’t budge.

After listening to a lot of rambling phone calls and getting stood up for showings several times, I finally struck gold with a young professional moving to the area. She had a great job, solid references, and returned any email or call immediately.

Undercharging Rent

I celebrated finding my excellent tenant by promptly doing something stupid. The home commanded a rent of $1500-$1550 easily. I was so excited that I had found a trustworthy tenant that I got talked into undercharging her. We settled on a lease for $1350 a month. Yep, you read that right. I left at least $200 per month on the table. Like I said, stupid.

I also compounded my mistake by not raising the rent after the initial one year lease expired. I actually renewed at the same rate and did an eighteen month lease the second time! The only upside was that I minimized my vacancy and turnover costs.

Managing the Property

Given that I only had one property, I elected to manage it myself. This decision also got a lot easier when I left too much money on the table with my lease to pay for property management! I think it’s excellent experience for anyone that wants to really get involved in real estate to manage a rental yourself. No one cares more than you about your property, and experience is the best teacher for what good property management looks like.

Due to my excellent tenant choice, I received minimal phone calls for the entire time my tenant occupied the property. She even asked if she could do some things herself, like paint a few rooms to better match her furniture. Sure, no problem!

Another mistake I made, however, was trusting too much and not doing periodic inspections. I was lucky because my tenant never caused any major damage to my property, but in retrospect, I would have done inspections every six months to make sure everything was on the up and up.

If I had, then I would have noticed that the carpet was wearing out. I could have avoided rushing to replace it right when I was trying to sell the house later. In the future, I’ll be checking in more.




Deciding To Sell

As we passed the two year mark of being a landlord, I began to ponder what my end game was. Interest rates had dropped by then, and I had a decision to make. Do I try to see if someone will refinance at a lower rate to keep the property long term, or do I sell the property? I ultimately chose to sell for two reasons.

First, Mrs. BossMD and I decided to focus on paying off our student loans. It might have been the better financial move to keep the property, but we wanted the student loans off our plates and out of our lives.

Second, by selling before the three year rental mark, we could avoid some of the associated capital gains via the section 121 exclusion. Section 121 of the IRS code states that you can exclude capital gains from the sale of any primary residence as long as you resided in it for two out of the past five years. Single folks can exclude up to $250,000 of gains while married couples can exclude up to $500,000. Not a bad deal. There is some fine print associated with exactly how much capital gains you can avoid, so your tax professional will be helpful here.

Note, the section 121 exclusion does not prevent you from depreciation recapture, which you will still have to pay. For those that don’t know, depreciation is this wonderful real estate tax perk, where you can write off a portion of the purchase price of the asset every year for a certain amount of years (27.5 years for homes). This a large part of what makes real estate income tax advantaged. Depreciation often wipes out a large chunk of the income on your taxes.

Depreciation recapture is the process where the IRS “recaptures” some of that benefit when you sell the home at a gain (i.e sell it for anything higher than the current adjusted cost basis). In general, the depreciation is recaptured at your marginal tax rate, i.e if you’re in the 33% bracket, then it will be taxed at 33%. This is probably where you need a tax professional to assist you again. Best to figure out exactly what you will be paying Uncle Sam before you decide to sell.

Missing A Tax Opportunity

One opportunity that I missed was to do a 1031 exchange. A 1031 exchange is named for Section 1031 of the IRS code which allows for property owners to do a “like-kind” exchange of their property for another of equal or greater value. There are a few other rules surrounding this, but in general, you can avoid taxes on the sale of your property through this mechanism if you stay within the parameters of the code.

I could have potentially traded up from my house to a quadriplex with higher value, while avoiding the tax man for now. Stupid! I didn’t consider this at all when making my hold vs. sell decision. I had several tax friends later say I should have considered it, but it was too late by then.

This is something I’ll definitely consider in the future and also why I’ll involve my accountant much earlier in my sell vs. hold decision process.

Takeaways

Given the whole experience, I have to say I was pleased with my first rental property. I made a nice chunk of change, had minimal stress, and learned some good lessons. I plan to dip my toes in the water again once Mrs. BossMD and I reach our student loan goals and agree to diversify our portfolio a bit more.

Here are my takeaways from the experience:

Good

  • Quality tenants reduce headaches
  • Desirable properties in good locations attract good tenants
  • Tax advantaged income
  • Average physician should have multiple financing options

Bad

  • Long term leases can be good…until they’re bad
  • Don’t forget about trading up
  • Consult professionals when needed so you don’t miss opportunities

Ugly

  • Don’t cheat yourself out of rent!

Overall, I think maintaining a real estate portfolio is a great way to build wealth as a physician, and it’s definitely possible for a working physician. If I scale to more properties in the future, then I’ll definitely expand my team so I can remove myself from the day to day. Here’s hoping I can convince Mrs. BossMD to get started soon!

Do you have a good real estate story? What was your first rental property like? Tell me about it in the comments!

Extended Hours 8/5/17

Welcome to this week’s edition of Extended Hours! While the term “Extended Hours” may be an undesirable phrase in the lives of physicians, this series on the TheBossMD should prove to be a much better experience!

Extended Hours is the weekly roundup post published every Saturday here on TheBossMD. As with all of my content, the purpose of this series is to help physicians manage their positions, whether it be personalfinancial, or professional.

These posts are light on my thoughts and heavy on the best content I can find during my travels through social media and the internet. We might even have some fun along the way!

So sit back, relax, and enjoy this week’s Extended Hours!



Personal Position

I am putting this article first for a reason. Rick over at NoahsDad has an excellent blog where he details the life of his son, Noah, who has Down Syndrome. If you click on no other link in this post, please read How A Chic-Fil-A Employee Changed My Idea of “Meaningful” Work. Thank you Rick, Abbie, and Noah for  your perspective.

TheBossMD family really enjoys taking trips and vacations. For those still in the medical school/residency phase of life, Mike and Nicole over at TwoGreenDocs tells you how to stretch your travel budget as far as it can go in Traveling on a Student/Resident’s Budget. Got my sights set on Disney World later this year!

My son has been learning to swim recently, so I have been that dad cheering wildly from the side of the pool. Despite my crazy dad status, I really enjoyed the Learning to Swim article over at Mommy’s New Groove. Doctors tend to have the same anxieties about their kids as everyone else. We just have medical knowledge to up the paranoia level a little bit more.

Financial Position

The state of your marriage has nothing to do with money, right? Wrong! If you’re like me, then your money and your marriage go hand in hand. Michelle over at Making Sense of Cents has a fantastic article about how to handle a spouse with limited financial insight in What To Do When Your Partner is Horrible With Money. Fortunately, this does apply to me. Love you honey!

I really enjoy real estate as an asset class and as a fun business venture. Brandon Turner over at BiggerPockets is one of the best in the business, and he recently wrote an article entitled The Top 100 Ways to Make Money in Real Estate. Head over and check it out. He’s also active on Twitter and puts out a great podcast each week. Hit him and tell him I sent you!

Speaking of real estate, Amy over at LifeZemplified is doing some real estate investing of her own. She admits that it may not be the soundest financial move in the world in her article Accidental Landlording:How Not To Buy A Rental Property. We’ll see how it turns out!

 

Professional Position

Michael Kirsch over at MD Whistleblower writes about adjust patient expectations for after hours care on KevinMD in When it comes to after-hours care, expectations need to be adjusted. Interesting perspective for all of us that have ever answered a phone or seen a patient on nights and weekends.

I can’t tell you how many botched patient encounters I see that are completely about communication. Suneel over at DocThinx write about 5 Communication Mistakes Doctors Should Avoid. Go check it out if you want to improve your communications with your patients or staff.

I always recommend learning as much as possible about your colleagues, especially nursing staff. It’s amazing how much better teams function when everyone understands each other’s roles. Charlie over at LifeOfAMedStudent talks about transitioning from nursing to medical school and the different challenges associated with each in From Nurse to Medical Student-Lessons Learned From Changing Careers. Great read!

Just For Fun

There’s a lot of stuff that goes on in medicine that is frankly hilarious. How many times a day do you do stuff just to get your patients care, but when you really think about it, is just flat out crazy? Brad Nieder over at Healthy Humorist talks about the insanity of health insurance physicals in this clip. Watch and chuckle.

In other news, the first day of school is coming here at TheBossMD household. We are proudly moving up from 3K to 4K. This year is much different from the last. This year, my son is talking nonstop about seeing his friends and meeting his teacher. Last year looked a little more like this:

Here’s hoping there are no news cameras outside my son’s school this year!

I’m a big fan of war movies, especially World War II movies. I have had the privilege of caring for my share of World War II veterans, and I still have a few that I see. I tend to recycle what I watch and one of my favorite mini-series is The Pacific.

You can guarantee that anything involving Steven Spielberg is going to be a winner, and this mini-series is no exception. I’ve had several of my patients that fought in some of the depicted battles say it does as good of a job as you can do showing what it was like. Give it a look, and when you’re done, thank a veteran.

Last but not least, we are right on the cusp of football season. I prefer high school and college football myself. There is nothing like a Friday night under the lights watching your high school’s team play followed by a Saturday full of college action.

This football season is different for me, however, as my alma mater enters the season as the reigning national champions. That’s right, my Clemson Tigers are still the champs, and I’m not giving up the title until someone else wins it. For all my Alabama fans or anyone else that wants to talk some trash, leave a comment and we’ll talk some ball.

For any of you that don’t know, Clemson has one of the best entrances in the country dubbed “The Most Exciting 25 Seconds in College Football” by Brent Musburger. I think it only appropriate that I leave you with this great behind the scenes look at my beloved team’s entrance. Go Tigers!

Well that’s it for this week’s edition of Extended Hours. I hope you enjoyed this week’s selections. Tune in next Saturday for another edition!

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Its OK To Be A Doctor With A Real Life

physician lifeCan I tell you a secret? I enjoy when my patients call me “Doc.” I know some of my colleagues may not like this, but where I come from, this is a pretty significant term of endearment. When I get called this, I know I have progressed from being just a doctor to a significant part of their life.
 
I didn’t always feel this way. In my first job out of residency, I worked hard to separate my professional and personal life. I shared no details of my family with my patients. I would do everything possible to avoid talking about anything outside of medicine.
 
One significant episode of burnout later, I realized that I have to be me when I go to work. I cannot be this soul-less robot that I had set out to be. My patients are real people. Its OK for me to be one too.
 
This revelation led me to the vastly different approach I take today. My new outlook is a significant part of the reason I enjoy my work much more.
 
My patients know me. They know where I live. They know about my family. They know that my wife is much more responsible for my personal fashion than I am (yep, I’m incompetent in this area). The benefits are numerous but let me expound on a few.



My Patients Talk To Me

 
Because I am open with my patients, they are open with me. I learn all sorts of things in our conversations that allow me to take better care of them.
 
I learn that Aunt Jean has moved in and cooks fried foods every day. I learn that their nephew totaled their car, which is why they didn’t show up for their last appointment.
 
On an even more personal level, I learn about their relationships. They tell me they don’t get along with their kids, which makes them depressed. Then, they fix three cocktails every night, and I see their blood work start to look bad.
 
This openness and honesty allows me to be frank about needed changes (like not drinking three cocktails every night). I tell my patients that I cannot guarantee that I will know everything, but I can guarantee that I’ll be honest with them. That includes being honest about my own struggles when I have them.

I Can Take Time Off

 
Have you ever had your patients encourage you to take some time off? I experience it all the time, and it’s awesome! I am convinced doctors do not take enough time off, and this leads to burn out amongst our ranks.
 
When your patients know you as “Doc” and not “the doctor,” then they will want you to have a satisfying life. Not only will they accept you taking vacation, but they will even encourage it! A wonderful example for me is the birth of my second son.
 
I decided to take two weeks off with the birth of my second son, which I admit I was nervous about. I didn’t want my patients to see a doctor who knew nothing about them.
 
Not only did my patients accept my time off, they facilitated it! Upon my return, I wasn’t met with the usual “back from vacation” barrage of messages. Many told me later that they delayed scheduling appointments because they knew I would be tired with a newborn. You better believe I hugged every one of them!

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I Feel Human When I Drive Home

 
Ok, this point has no “data” that I can point to, but every physician reading this knows what I’m talking about. How many days do you drive home after hearing about quality metrics, patient experience, or clinic revenue and don’t feel human?
 
I admit there are days where I feel this way, especially days where I may be doing administrative tasks most of the day. It’s amazing, though, how one authentic interaction with a patient can change that.
 
The numbers may say that the quality improvement work I do has the largest impact on the health of my patients, and many times it does. But as a person, I still need to see my efforts at work in my patients’ lives. That data point needs to translate from my computer screen to a real person for me to feel really good about it.
 
On those days where I have real and authentic interactions with my patients, I am the kid that signed up to change the world. On days where I don’t have that, I feel like a bean counter. I didn’t sign up for that.
 
I wish I could say that I’m perfect in this area now, but I’m not. There’s a lot of forces in medicine working against the doctor-patient relationship. I can say, though, that I enjoy medicine much more when I am authentic with my patients. I also happen to provide better care too.
 
Don’t be afraid to be yourself with your patients. Your patients want to see you, not some robotic person going through the motions. Give the people what they want!
 
Are you scared to open up to your patients about your life? Do you fear the consequences? Leave a comment and let’s talk about it.

Extended Hours 7/29/17

Welcome to the inaugural edition of Extended Hours! While the term “Extended Hours” may be an undesirable phrase in the lives of physicians, this series on the TheBossMD should prove to be a much better experience!

Extended Hours will be the weekly roundup post published every Saturday here on TheBossMD. As with all of my content, the purpose of this series is to help physicians manage their positions, whether it be personalfinancial, or professional.

These posts will be light on my thoughts and heavy on the best content I can find during my travels through social media and the internet. We might even have some fun along the way!

So sit back, relax, and enjoy this week’s Extended Hours!



Personal Position

Dr. Sonia Henry writes an excellent piece on KevinMD entitled Doctors:Don’t Lose Your Humanity. Highly recommended for anyone drowning in the world of metrics, reimbursement, and generally needing to remember why you’re doing this medical thing.

Looking to take your family on a sweet Hawaii vacation while paying next to nothing? The Luxe Strategist is here for you. Check out her tips for traveling to Hawaii for $45 in Travel Hacking:How I Booked Four Flights to Hawaii for $45. Sign me up!

Passive Income M.D. provides great perspective on managing work life balance and how to make the most of the time you have here on this Earth in his piece How Many Summers Do You Have Left? Will make you think deeply about your priorities.

Financial Position

White Coat Investor hosted one our lawyer colleagues, Joshua Holt of The BigLawInvestor, on his blog this week with a post entitled How to Save A Million Bucks Before You Become A Law Firm Partner. Don’t worry physicians, this is one lawyer you can trust. There is timeless wisdom here that can apply to any high income professional.

Physician on Fire recently ran an article featuring a physician that has taken saving money to a whole different level. Check out the man who earns $1,800,000 per year and only spends $70,000 per year in the first installment of Holy Stealth Wealth!

This next article features some personal mixed with financial. Michelle over at The Holistic Wallet has a good word that spoke right to my sometimes obsessive tendencies in True Life:I Was a Personal Finance Addict. I don’t know about you, but it probably would be more healthy to not check my student loans daily!

 

Professional Position

John Jurica over at The VITAL Physician Executive details the Top 10 Reasons to Pursue a Business Degree for aspiring physician leaders. Great points to consider for anyone seeking any type of leadership role from private practice to large healthcare organizations. I still say business degrees are not required in our current environment, but they are definitely more in favor than they used to be.

Everyone remembers some of those dark days during residency, right? Natashia Seemann delivers a nice article on her site More Than Scalpels and Sutures about Terrible Things You Will Think During Residency and Why Its OK. A good reminder that those in medical training should have a little leeway at times.

Heard much about medical quality lately? I have. Kjell Benson over at The Consolation of Philosophy writes about How to Create Medical Quality While Hardly Trying. I think you’ll find yourself nodding as you read, just like I did!

Just For Fun

Need a little laugh? A good pick me up? This section is for you. It’s hard to be a physician. You deserve some fun. Check this out.

Our friends over at GomerBlog deliver a wonderful new diagnostic tool in their latest masterpiece New Cheetos Finger Decision Rule for Abdominal Pain. Hospital administrators everywhere are lauding the improved costs and patient satisfaction scores. Any article with Dilaudid and Cheetos is sure to be a winner in my book.

For all of you personal finance types, the mecca of personal finance is at it again, The Onion. In their latest must read piece, they discuss their latest financial research entitled Study Finds Americans Do Most Financial Planning When Figuring Out How to Get Money’s Worth at Buffett. Truly insightful stuff.

Last but not least, I love you with one of my favorites, Brian Regan, talking about the emergency room. The clip is a little long, but if you’ve got 8:24 to spare and need a good laugh, then this video is for you.

Well that’s it for the inaugural addition of Extended Hours. I hope you enjoyed this week’s selections. Tune in next Saturday for another edition!

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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.

 


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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.

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