Good morning, everyone. My name is Soojin Lee. As I introduced, I'm a voluntary assistant clinical professor at UC Irvine, Department of Physical Medicine and Rehab. Actually, Dr. Kroll and Dr. Street and I myself pulled this presentation together because we have seen some need in our specialty and our actually medical community education about the finance and also different options of careers and negotiation skills. So we pulled this presentation together. I really appreciate the opportunity to APM and R2 hosting us as the guest speakers. The first slide is disclosure. I am a physiatrist. I'm also spinal cord injury medicine specialist and also certified by coach. I'm not a certified financial planner nor CPA. I have some knowledge, but those are not professional advice. It's education purpose or some people's kind of feels these are entertaining. So education and entertaining purpose, not a professional advice. If you have any further questions, making decisions, I highly encourage you guys to discuss with a CPA certified financial planner or family members and significant others to make good decisions. And this is just the beginning of the education. I highly recommend and encourage continued learning process to learn about the finance and having a fulfilling career as a physician. I think that's the whole purpose of our talk. So why do we need financial education for physicians? We spend so much time as undergrad and medical school learning about the medicine. We are experts in our field, but when we finish our training going into the real world, there's more than just practicing medicine. We have our own personal life, financial life, and we are missing sometimes enjoying those lives or thinking about the plans of those lives. So there's a study published in 2017. It was a web-based survey, 422 residents and fellows. They asked the questions about the 48 questions about personal finance and investment knowledge. The results show that 71% students have student loans and about more than about half of the students have more than $200,000 of a student loan. That's a very large amount. And also 20% have a credit card debt. We just briefly talked about, you know, some of the students used to take some personal loans or a credit card to interviewing multiple places for the medical school and fellowship and residents that all adds up. When we finish our training, we ended up having huge amount of a gap. Even we make a higher salary compared to a general population. That's a huge burden. About 52% have less than $25,000 in retirement saving. By the time we finish our training, most of our residents fellows are in their late 20s, maybe early 30s compared to people who starts their career right after college around age 24. It's about 10 years later on, we only have $25,000 in the retirement saving. The time loss for 10 years, it's difficult to catch up. So these are all significant findings. An interesting factor is the satisfaction of the personal finance condition of those 42, 422 residents and fellows, their satisfaction about the education knowledge they have their satisfaction was 4.8. So 10 is they're very happy about their understanding of finances. Zero is no, they're not very happy. They're very miserable. And we're not even halfway through the understanding or having knowledge or or having personal financial conditions. We're not very happy about that. The other interesting data that we follow sometimes is the medscape. So medscape every year as part of their big survey, they publish the data about the lifestyle, happiness and burnout. burnout became very focused during the pandemic. It's known fact that physicians are having a lot of burnout issues. And during the pandemic, this issue became more focused. And then we're a lot of physicians experience more burnout. So this data specifically shows on our specialty physical medicine, we have our lifestyle happiness and burnout report came out this year. In terms of a different specialties, our ranking is actually pretty good. We're above average, we're kind of going towards more satisfied sub specialists. But even we are not the worst in all the medical specialty, about 44% of our physicians feels burned out, depressed or both. So look at the data 30% our specialty fields were burned out 3% feels depressed and 11% feels both burned out or depressed. So the other survey data that interesting to me was what contributes most of a physician burnout, a lot of complaint about the bureaucratic tasks, so administrations and having not having controls, but you can actually see that spending too many hours at work, it's about 35% things that's contribute their burnout, and not having enough compensation or reimbursement about 26% feels that's a part of the burnout. This is why the finance is understanding and having clear pictures and goals. In finance is important to having a satisfying professional life, and also preventing burnout so that we can practice medicine in our own term and a very longer it's a longevity of our career. I think very closely tied into having solid financial understanding and foundation. So I'm doing like overview about personal finance one on one and Dr. Vargas-Full and Dr. Street will focus on the more narrowed down topics about non clinical career options and negotiation skills, but my talk is going to be basic ideas about the finance education. The resources I use is the three books actually the book actually I used is not exactly this book The White Coat Investor, but it's by this author. The other book is A Simple Pathway to Wealth and the other book is Rich Dad Poor Dad. These are very popular, good entry level books for all the physicians and patient communities. So I will talk about money mindset, spending plans, student loan payment options, and what about creating additional incomes other than clinical practice and retirement plan and investment strategy and protecting ourselves financially and personally and professionally too. So money mindset is interesting concept because I don't think many of us don't talk about money in our culture. It's kind of taboo talking about either we don't have money or we have so much money. I see often that many people actually when we have a lot of money we don't want to talk about because we feel like people's going to think they're greedy or we're making money not a good ways or something like that. And also we're so used to going through the medical school and undergrad we always been poor. So we take a lot of depth and then we don't think about money. So our basic idea thinking about the money is like I don't know anything about money or I don't have enough money. So when we are thinking into that mindset I don't know anything about money it kind of scares us and we it puts us backwards in terms of instead of being proactive and learning we just shut down. So many of my colleague female physicians they don't they don't know anything about finance they just leave it to their spouses they leave it to somebody else until they really have to think about those ones. But instead of having that approach it's very helpful to just acknowledge that we didn't have a time to know about the money but now it's the time to learn and invest and have a good education and have a good planning so that we can have a fulfilling life. I think that's an important mindset to have a switch. The other mindset is scarcity versus abundance. I used to think that way too if I make more money my colleagues may make less money. If I take too much if I take more money from my patient they may not afford the money to have a care from me which are all not really that true. Instead of coming from the scarcity mindset I think it really helps us coming from the abundance mindset. Money is something that we can create and also it doesn't have to be all time tied too. So that concept is in my fourth item time money relationship. We often I think we are trained our times we the only way to make money is more working more. So the way that how we generate money is either we see more patients or we work more hours which can actually burn going into the putting us the situation that we ended up having burnout because we worked too many hours or we ended up being too busy. The other mindset I would like to transition out is having debt is normal. There's a good depth and bad depth but because we were so used to taking student loans and not making money so we are thinking like we always have a debt so we feel like having debt is natural. So sometimes we end up spending a lot of credit card and just leave the balance in there having like 25 interest rate. We just kind of don't look at it but just because we don't look at it doesn't mean that it's going to go away. It's something that we have to take care of and also getting out of the mindset of having some good debt is good but if there's a high interest rate that probably it's a better idea to switch or pay off as soon as possible. The other money mindset is some people talk about like a budget but some people don't like the idea about budget. I'm one of those ones I don't like the idea of a budget like calculating every single dollars and cents how much I say, how much I spend and calculate everything and then you know cutting out the you know items and stuff. That's not what I meant by budgeting. My concept of spending is spending with intentions. So instead of thinking about like every penny and cents to save having some ideas what are the accepted items and what are the okay to spend. What are the money is you know something something you can have a flexible budget and change because in the expenses there is the fixed expenses and flexible expenses. Fixed expenses something like a house mortgage payment something that you have to use all the time those are not part of a negotiation but when you go into flexible spending those are the one where the intentions either you can spend less or if you can spend more even you spend less if you come from the intentional mindset you don't feel like you're deprived. When we go into mindset with deprived then it kind of rolling down the negative mindset of the all the scare about the money so I kind of don't encourage about those going into that mindset. So the most important thing well I guess the basic first idea is having some spending plan. Many attendings in many books and many website and podcasts or the blog they talk about live like a resident. So this concept of a live like a resident because most of our reason is because we have a high student loan until we are able to pay off those loans it's reasonable to live like a resident. Just we make a higher income doesn't mean that we have to spend all those monies. Those are actually good opportunity to have a very good solid financial foundation because we missed some of the period that other people were started ahead of us in terms of their age but we starting late but we have an advantage of we can actually learn anything. I mean if you went through the medical school and residency being a doctor probably that's the most hard thing to do so I feel we have the capacity to learn everything. So the first you know five years or whatever the years it's going to take to until we pay off the student loan or having the plan solid plan for the student loan it makes sense to live like the resident. Also it's recommended having the weekend spending plans and I think I mentioned briefly about fixed expenses and flexible expenses. In order to have the healthy retirement amount of money saved we recommend about 20% of your income including retirement saving is ideal number. I will go over the detail why 20%. It ties into the amount how much you save and also it ties into the length of a duration how many years you have before you need to retire or you decide actually when you want to retire that will change the amount how much you want to save for the retirement so that you can reach certain you can reach the retirement at certain age. And as I mentioned that pay off credit card every month the main reason is because their interest rate is very high. It's made mostly I think it's more than 20% any kind of investment you make it's very difficult to have a 20% return of investment. So you're thinking about leaving that money over there on the credit card and paying that interest even you make a lot of money there's nothing that you're there is very rare to have that kind of return for investment. So probably it's most wise to pay off credit card every month. Using the credit card is not a bad idea as long as you can pay it off every single month. The other recommendation is saving emergency fund. Emergency fund some people save it for a year worth of the living expenses. So emergency fund is usually to cover your living expenses three to six months just in case something happens you're not able to make money or you're not able to generate income you don't want to pull other private loans or credit cards so having three to six month emergency fund is recommended. There's some thoughts about how much should we have and how where to save it. The amount is actually tied into your disability insurance or some other fundings you can pull out. So for example something happens to me and then I'm not able to work if I can qualify for my disability insurance my disability insurance kicks in 90 days so as long as I have a three month of emergency fund it can cover my essential living expenses for three months and then my disability can kick in then it will be covered or three months give me some time pull other resources either I can sell my funding or I can pull out something like something like that and having money so that gives a little cushion without pulling too much of a higher interest of a money to cover those three months. So it's usually recommend three to six months but those are very personal decision some people feel more comfortable having longer period of time some people feels more comfortable having shorter period of time depending on your personal finance situation. Okay student loans um I kind of looked through what are the options about student loans and you know that's uh not so great answers so there's the maybe it's a good thing that we don't have so many different answers. If you started paying off as a your intern or doing residency the public service loan forgiveness is actually a good option. So the criteria or qualification is you make 120 on time qualifying payment which is 10 years. It's kind of interesting to know what is the qualifying payment because even you make 120 payments on time if the government decided that was not a qualifying payment then you may not be forgive at the end of 10 years. So in order to be qualified for this plan you have to be employed full-time by a non-profit 501 entity so internship and residency and fellowship that all qualifies. I didn't know about this program and then I ended up not staying in the full-time employed position so I don't qualify for this one but I didn't know when I was interned that you can start having a little payment like a minimum payments from the internship and by the time you finish your residence and fellow that's about already five years or if you go into longer fellowship that could be six years and seven years. After that you just need to stay another four or five years in a full-time employee as a physician in non-profit 501. Most of the academic hospitals are qualified for non-profit organization. Some of the health care organizations in Kaiser in Southern California that qualify as a non-profit 501. VA has their own loan forgiveness program so I'm not sure if it's there qualifies non-profit 501 but if you work for the VA system they have a different loan forgiveness program that might be beneficial to take those. So now I ask my residents like oh are you paying off your loans and I try to make sure if that's the option for them if they plan to work for the full-time for some type of hired physician I highly recommend those ones but it only applies for the federal loans if you took out the private loans during your residency or medical school that doesn't apply and I hear a lot of physicians complain that doesn't work it's just a you know gimmick it doesn't really work the reason why it's this criteria is very strict to meet all these requirements. So once you are in that program it's make sure some people recommend every year you make sure that you meet the criteria you certify or make sure that you have all the payments qualified and I highly recommend starting early so that you don't have you can get to get out of the loan as soon as possible then you will have a freedom in terms of choosing your employers and having different practices that could be an option. I have a chat let me just check really oh I see Q&A oh somebody asked me about do you recommend saving 20% gross or net income it is actually gross income of 20% and that includes the saving for the retirement. I can kind of show you a little bit there's a chart that I kind of pull out what how that works but it's usually gross income 20% it depends what kind of expense you have because if you're W-2 then your gross income there's no changing the gross incomes and you know you just get the money if you're 1099 you can change that income a little bit depending on your expenses. So the general rule is just 20% of a gross income that can give you the good timeline that what you want to retire but it kind of goes back to how long you want to work in the full time as a clinician or how long do you want to when do you want to retire that changes the duration of the working and also the return of investment. Okay the other two options of the student loan payment option is consolidation and refinancing. Those are two different things consolidation means you just put everything in one account so when we take this student loan for my my example I have a couple different accounts for my student loan from university and some other federal entity so they have a different names if you keep those ones you have to keep making payments in a different ones it's a little bit difficult to keep track of. So you can actually consolidate if you consolidate you are still eligible for the PSL app it doesn't mean that your loan cannot be qualified anymore when they consolidate they take all different interest rates and then they kind of average out and then they put everything in one account so that you can make one payment to the same account over and over again but you can still be qualified for PSL app. Refinancing is completely different from the consolidation refinancing is through the private um lenders uh so far is one of the most popular one I know first republic bank has a very good interest rate I think right now it's about two percent but it's a little bit more difficult to be qualified but once you refinance you don't qualify for PSL app. So you have to make a decision. Do I wanna go to route of a public service loan forgiveness, or I know I'm not gonna be qualified this one, or I decide not go to that route, then definitely you should refinance. I think my student loan rate was like 6.8. It wasn't too bad, but that's still much higher than 3% you can get these days. So if you haven't refinanced your student loan and you're not in the PSLF yet, then probably you should refinance as soon as possible. The interest rates are still very good. Okay, so there's a different ways to save for retirement. You can save more, or you can make more money so that your saving rate goes higher. Sometimes it is easier to make more money than to save more, especially our specialty, our physicians are highly skilled people. Our skillset is not just about seeing the patient, actually running the clinic, able to manage the clinic flow, teaching residents, counseling the patient, keeping up with all this new informations and recommendations. There are so many skillsets that we have that we're not aware of. Probably Dr. Berges-Kroll may kind of mention about it. That's why we're so well situated to have a different work outside of a clinical care because we're still having skillsets, just we are not aware of it. So if you think you are not making enough money or my lifestyle needs to be this way, and then I still wanna save more, then there are different options of having additional clinical income, additional incomes. So right now, if the job is not paying you well, you're not very happy about that, then you can definitely look for another job. If you love your job, but my pay is a little bit low, you can negotiate. You can review your contract. You can ask your attorney to review your contract. You can get a coach, about the negotiation coach, and you have ability to know your values and able to negotiate. There's books that you can read to bring up your negotiation skills. You can also improve your practice, change your pattern of your practice. If you have a private practice, you can change your payer mixes, which means, let's say I'm only taking certain insurance, then they only pay maybe less than Medicare CMS guideline. Then you can say, okay, I wanna take more private insurance, pays more PPO, so you can change your payer mix that will increase the pay to yourself. You can hire a staff. Let's say I do, I see sometimes that physicians starting their own private practice, they check in patient, they call the insurance company to get authorized, everything, but that's not really best use of our time. We have a very skill that can pay in a very higher rate. So even though in the beginning, it looks like it's spending money, but it's an actually investment hiring staff, either hiring the mid-level so that you can see more patients. Those are the possible options that you can have additional incomes. You can add new procedures. You can change your practice pattern or changing into concierge medicine. I know some of my colleagues, they changed their practice to concierge medicine and actually they have a better control. They don't have to worry about all the insurance authorizations and they're very happy about it. If you're thinking about doing something outside of the medicine, there's different options of a side gig. Actually, local tenants are still part of a clinical medicine and moonlighting too, but you can pick up some administration work. If you work for the bigger healthcare system, you can do consulting, you can do medical legal work. There are many options. I'm sure Dr. Vargas-Cruz is gonna go over the details about all these options. And also you can create multiple streams of incomes. If you have a hobby that you are enjoying to do, it can become a second work that you are passionate outside of medicine. It's okay to have some passions outside of medicine. I think we kind of buried that under our mind because we were so focused to become a physician. But once you feel comfortable in terms of having good clinical skills, I see it's actually very fulfilling for our personal life. I see some of my colleagues do some music. So she's a radiologist, but she set up a music studio in her home because her passion is music. Now she creates some music that went out to spaces. So she creates a little bit of a extra income. So those are the options that you can consider. Let me pace a little bit. So I am talking about the retirement plan. So there's a retirement money, retirement accounts. The money that you put in your retirement is the biggest tax break we can get because we're higher income workers. The less tax we pay, then we'll have a more net income towards us. Some people don't have a really good understanding about how our incomes are taxed. The income tax is rated as a marginal tax rate, which means let's say I make $200,000. It doesn't mean that entire 24% of my $200,000 is gonna taken out as a tax. That's not how they tax it. How they tax it is they tax you 10% from $0 to $19,000. The next money, this is a married single and there's the joint. So there's a different tax bracket. So from $0 to $9900 is 10%, they take it out. Between $9,900 to $40,000, they take it out 12%. The other bracket, it goes up. So those are how our money is taxed in reality. So those are marginal tax rate. It's a little bit complicating to know how much I paid my tax. So there's effective tax rate. How you calculate is you divide tax paid last year, divide by the close income last year. That kind of gives you the number, how much tax you take. It gives you the effective tax rate. So for example, I put an example here. Let's say I make $100,000 last year and I filed as let's say this person filed as unmarried individual. Then the way how they calculate tax is marginal tax rate. So I kind of put little numbers up here. This individual ended up paying $18,000. So if you just look at it straightforward, you may think if the person made $100,000 as a single, then you may think, oh, maybe he paid 24% of $100,000. That's not how it is. Actually, they ended up paying 18%. That's the effective tax rate. So there are many different kinds of retirement accounts. If you're an employee physician, then the employer gives you the different tax retirement accounts. Most of them is like a 401, 403. Some employer has a 457. So that's a separate account between 401, 403. 401 and 403, they combined as a 401k. So that contribution limit for this year is $19,500. It's a pre-tax money. So you pay this money up into your account and this money is not going to get taxed. So many different types. Usually we say IRA and 401k. There's a traditional IRA. As many of you know, Roth is always post-tax money. So that's the money that you put after tax and grow tax-free. And when you take it out, you know, actually it's the growth you pay tax and then you take it out. It's a tax-free withdrawal. There's a Roth 401k too. You can contribute, but 401k all combines together. You can only put $19,500. HSA is health saving account. That only qualifies for the people who has a high deductible health plan. Sometimes employee positions don't have option to do HSA. If you're self-employed, then you can decide for your health insurance to be a high deductible health plan then you can qualify for HSA. This one saves the most tax. You put the money before tax. It grows tax-free. When you take out, it's tax-free too. So you don't pay any tax if you put money in here and use this one, but it has to be used health related items. It doesn't have to be on the same year that you put the money in. So you can put money this year and then you can use it later. So a lot of people put, maximize the money in this account and let it grow and use it later. Also, it doesn't have to be the same year when you take the money with the money that you spent. So let's say I have a medical expense this year. You don't have to use HSA money this year. You can claim like five years later, six years later. So I know some people save all the receipts for medical bill and they're planning to use it or take it out when the money grows in a bigger amount and they plan to take it out. So some people plan to have that time. There's IRA, SEP IRA and simple IRA. Those are contribution limits and those are tax treatment. One of the reason for the self-employed people, people recommend 401k. The reason is because you can do backdoor IRA if you have a 401k. If you put your money in the IRA, either SEP IRA is another one, a lot of the self-employed physicians have. If you have money left in IRA, you cannot do backdoor IRA. So if you're thinking about doing backdoor, put your money in the 401k and not having any money in IRA is the way to do backdoor IRA. Okay. So those are the different types of retirement account and how to determine how much to save. There are many different factors to calculate this one. And the first thing is like, okay, when I retire, how much am I gonna spend? Usually we recommend about 80% of our current expense will be spent. Maybe we don't have to fund a five to nine anymore. Maybe we will pay off our house mortgage. Maybe we, hopefully we don't have any student mortgage anymore. So most of the people anticipate about 80% of our current spending is gonna be the money that you will need during retirement. And also multiply that number by 25 to 30 because we anticipate we usually retire around age 65 and then we expect we're gonna leave up to 80s or 90s. So the way, one of the way to calculate the money amount needed is either the yearly expense multiply 25 or 30, usually 25. The most expenses when people retire is the medical care. Average couples spend about in their retire age, they spend about $295,000 for medical expenses. And a lot of people when they retire, they travel more. So those are gonna be a higher expense. So the expense doesn't drastically reduce when we retire. And also depends on how much will you earn on your savings. So the saving means your retirement account. The average return rate, the growth, actually we anticipate it's gonna be about 8%, 8, 7% if you have a 60% stock and 40% bond. Past 20, 30 years, the stock market has been grown about 10% in average, bond is about 4%. So if you have a portfolio of a 60% stock and 40% bond, then you're gonna have about 8% of a return. And then also how long will you live as I discussed earlier and how much can you withdraw from the saving each year? So I kind of put numbers. How did I do this one? I think I put my age. Oh, I kind of create a scenario. They're four years old. Right now they have about 20,000 in their retirement account and then put like 20% of the income for about 15 years. I guess it's 25 years. It shows that how the retirement account grows and then how much the money is gonna run out around the age of 84, 86 age. So this is the website. I'm not gonna go into this website right now. I guess I'm kind of running behind, but if you can go to this website and you can plug in number, then you can play around the number a little bit. This is an interesting chart, the retirement plan. So this one actually explains how long it's gonna take, how much you save for your retirement. So as I said, average retire fund rules is a 7%, 8% growth in your retirement account. And when you withdraw, we kind of say, I think it's a statistical calculation that if you do 4% withdrawal, that will last about 30 years. So for example, I think I have the case in the next one. So this chart is actually shows that, let's say I want to save $3 million for my retirement and I make $250,000 a year. Then this one shows if you save 5% of $250,000 to, and then this one shows the different rates of a return of investment. So if it's a 2% return investment, then it's gonna take 89 years to reach $3 million. So let's say if you only save 10% of $250,000, return of investment, if you leave it in the CD or something, it will take 62 years. That's what it means. So let's say average growth, you leave it in the 60%, 40% of the stock and bond, and then average like a mutual fund, whatever, expecting that it grows 7% or 8%. If you only save 10% to $25,000, it will take 30 years. So if you're early career, let's say you're 30 and you're working until 60, then you just need to put 10% every year, leave it in the mutual fund or retirement account, it's gonna take 30 years. If you wanna retire earlier, let's say I wanna retire in 14 years. And I'm gonna stay with my mutual fund 8%, then you will have to save 50%. So the rate of saving and return of investment will change the duration, how long it's gonna take. So how to catch up or how do I change the timeline? The way is either increase return of investment ratio, either some people do real estate investment because some of the things that you have more control over, how much of a return of investment you can have. You can definitely put extra money. If you have more income, you can put extra money. And also you can create a passive income, which has more than 4% return of a passive income. Let's say you have a rental property generate $2,000 every month. You pay off all the mortgage in 20 years whatnot, then you're gonna have $2,000 every year. Then that can be your part of the retirement plan. So it's kind of a helpful to have a written retirement plan. So for example, my retirement goal is I would like to have $120,000 income in 15 years. And in order to have that income, based on the 4% rule, you need a $3 million. So if you have a $3 million, if you take 4% every year, it will last about 25 to 30 years. And that will give you $120,000 a year. So this is pre-tax. So you have to think about after paying tax, how much you're gonna have. You're gonna have a little bit less than $10,000 a month. You can save all this in 401k or backdoor Roth IRA. You can have all $3 million in that account and then you will have that money. Or you can have alternative options. Let's say I have, I'm gonna only save $100,000 and let me save $1.5 million and I will have $60,000 income, $5,000 a month from retirement account. As I said, you can have a rental income or you can have some other passive income. Let's say you wrote a book. So your book pays you $1,000 every month. Then your amount to save for your retirement account kind of goes down. So this one shows, let me see. This one shows how much you need to save. This is the link. If you go, I looked up a couple of different links. If you go with this link and then you put numbers like how much retirement you have right now and what's your goal, then it will show you how much you need to save for every year. So the example I put was right now I have $170,000 in my retirement and I wanna retire in 15 years. Then it tells me I have to save $52,000 every year with an 8% annual growth, which is like a conventional retirement plan. Maybe a little bit higher than that. Okay, so now we kind of know how much do I wanna save or how much do I need for retirement? How do we get there? So there's different ways of investment strategies. So most common one is retirement account and brokerage account. If you max out your retirement account, then you can have money in the brokerage account and buy stocks and bonds and funds, whatnot. The other popular thing these days is cryptocurrency. There's many Bitcoin, Ethereum and Dogecoin, so many different options. I'm not familiar with those, but I hear from the people who are in that finance community they recommend about 10% of your retirement plan can be in the cryptocurrency. That shouldn't be a primary retirement plan unless you are really in that space. But I know some people have everything in there, but they're very involved and they're actually managing very actively. As a physician, I tends to recommend with a given situation and knowledge and experience and skills that we have, the easiest way to make more money is actually utilizing our own skill until you have other pathway you wanna explore. So the type of saving for investment, some people buy some gold instead of silver because these ones all behave very separately from the stock market. So the downside of having everything in stock market is, let's say you have 100% retirement in stock market, if they crash, then everything's gonna go down. But if you're diverse, that's the term of a diversification. For example, the cryptocurrency may be impacted by the stock market a little bit, but they behave a little bit separately. The real estate behave very differently from the stock market. So some people put some retirement plan in the real estate and have some money in the stock market. They tends to go a little bit opposite way. So if you wanna shelter those downfalls from the stock market, then when it goes up, when it goes down, the real estate market can stay there steady or go up. So you're not gonna have all your in retirement accounts are following directly from the stock market. So that's one of the idea of having different retirement strategies in different market can actually help you that your money doesn't go into, follow in just one direction. And it very depending on how the market goes, which we have no control over. Real estate, if you, let's say you have, a couple of duplex, whatnot, multifamily space, you have total control over. If you don't like that market, you wanna get a different one, you can sell it and get a new one. You definitely have a lot more control than having a money in your stock market. So a lot of people ask about, what's the best way to invest in the stock market? Some people buy some new company IPO, some people buy individual stocks and try to figure out what's gonna be the good one next two months, three months. Some people do well in that space, but it takes up a lot of time and it's kind of risky. Unless you are really committed in those space, I don't recommend putting monies in individual stuff unless you are, you know the company really well and hold it for a very long time, like a very solid company like Apple, Amazon, Tesla has been the most successful ones those days. Even Warren Buffett, he's the most successful investor recommend large and small investor should stick with low cost index funds. So he's still recommending having most of the investment in index funds. So this one shows like, how do we put our monies away when you have money or what's the best way to save taxes and having most efficient way of investing. So as a high income owner, it's highly recommended putting all the money, well, not all the money, the most of the money to the bucket that you can save the most of a tax. So the first bucket, when you have money, money comes in, the first bucket you fill it in is 401k, that amount that matches the employer matches your amount because when employer matches the amount that you put it in, that's a free money. So why not using that money so that you can get the most, most money out of it. So most of the time, this one has a limitation and pretty tends to be a little bit smaller amount. So the first bucket you should fill it is the 401k match because those are free money. The next bucket is pay down high interest debt. This one can go up and down. I would recommend actually, if you have a high interest rate debt, refinance it to a lower interest rate. That's probably the best way to do it initially. But if you cannot refinance it, recommending paying off the high interest debt because when you pay interest more than 10%, whatever investment you do, unless you have more than 10% return of investment, you're gonna lose money. So it's very critical to knowing that nuances about interest, how much you pay. If you're gonna make more than 10% return of investment, then I would recommend go ahead and invest that one instead of paying off the stat. But if you have a debt, it's more interest rate is more than 10%, either refinance or pay that off as soon as possible. The next one is HSA. I kind of go back and forth between 401k max or HSA. HSA limits are pretty small. For the family, I think it's a $7,600. So because this is a triple tax benefit, you put money before tax, you grow tax-free, you can take the money tax-free. So if you qualify and if you have a HSA account, then you fill this bucket first. The next one is 401k max. You max out your 401k because those are all tax sheltered. And the next bucket is doing the Roth IRA. If you qualify, if you have any other IRA account, you cannot have a backdoor. The next one is taxable accounts. So it's like a brokerage account or other investment. And then the last bucket is pay down low interest debt, which is less than 5%. So these are like a recommendation. As I said, these are just my way of how I do it. It all depends on your personal financial situation. If you're gonna make a decision, you may wanna talk to your CPA or significant others, make a decision accordingly to your situation. Okay, next couple of slides, I'm gonna talk briefly about asset allocation, which means once I put the money in the account, where do I put those accounts? Where do I invest those monies? I kind of use the concept from this book, A Simple Pathway to Wealth. Many people tried many different ways, having individual stock, different funds, but not. But the best way, or if you don't wanna think too much about it, it totally makes sense putting money in the target day fund portfolio. For example, Vanguard has, okay, I wanna have this amount of money this much by 2060. You can select that fund. It will automatically adjust the investment types depending on the market changes. So you can do that, or you can have a very simple two fund portfolio. You put, it's a split between stock and bond. Bond is a lot stable, but their return of investment is much lower. Stock is not as stable, but they grow higher. So return of investment is about 10%, but they're more volatile. So you can have a two fund portfolio. If you want to have some economic impact outside of a United States, if you think United States economics are unstable, then you can add international stock, or you can have REIT. REIT is a real estate investment trust. So it's a part of a real estate. It's kind of pseudo real estate investment, but they behave a little bit differently from the stock market. So if you wanna have some more stability, you can add REIT index fund. The other things to consider is asset allocation. When you are early in the career, let's say I'm gonna retire in 20 years or 30 years, then you can be more aggressive. So you can have a wealth accumulation phase. You can put all the money to the stock and that will grow faster. If you're in the wealth preservation phase towards the close to the retirement, then you don't wanna have too much ups and downs, then you can put more money on the bond or cash and have less money on the stock. So financial advisors usually recommend adjusting your investment style every year, review and adjust it. Let me see. Okay, so there's some different financial strategies. I'm not gonna go into details this one. I'm already 47 minutes. Okay, financial protection. So I just talked about all the monies, how to think about money, how to spend money, how to pay off debt, retirement, investment strategy. Another one very important is having protections of the money that we have. For life insurance, if you have somebody in your family or if you have a little ones, if you have a partner, depending on your financial income, it's important to have a life insurance. So the time in case you are not able to producing any more incomes or you're dead, then the rest of the family needs to be taken care of, you can purchase term life insurance. I don't have a life insurance, I don't have a life insurance because my kids are already older. So I didn't look at the details, but I hear a lot about don't buy any other whole life insurance or the other similar ones like a whole life insurance, universal. They have a different names, but they say if you wanna buy an insurance, buy term life insurance. That's the recommendation I hear, but I didn't look at the details because I didn't have to buy life insurance. Disability insurance. Disability insurance. Even your employer covers insurance for you, it's important to have your own occupation disability. If you don't have an own occupation disability, they may not cover your disability if we get injured and not being able to perform the clinical skills that you perform. So surgeons have their own clinical skill sets or own occupation disability. If you have a just general one, it may not cover the things that you're doing. Let's say you do a lot of pain injection. I need a disability. If I lose my hand function, I need to be covered. If you don't have an own occupation disability, they may not cover you. They still say, oh, you can walk around, you can perform daily activity, you're not disabled, which is very different from I don't have my hand function. It's very critical in my clinical skills and clinical income. So you want to have an own occupation disability insurance. So this company is popular or frequently used by physician communities, Pattern Life, Pearson, Revit. Peter Pearson is actually, she was the OB-GYN. She got into some condition, medical condition. She became disabled and she was not able to cover by her disability insurance, I believe. So actually she started providing disability service to physicians. She's pretty popular in the physician community. The other insurance you consider is umbrella insurance. It's very cheap. It covers a lot. Many different insurance only cover a certain amount. It may not cover entire asset you have. So let's say my disability covers $100,000, whatever. And my car insurance only covers my car. My house insurance only covers my house and my malpractice covers up to 3 million. But let's say my asset is 5 million. So I have a 2 million is not covered. They can come after your personal asset if cases gets really, really bad. So the way to cover that is having the umbrella insurance. Umbrella insurance covers, you can have the plan that covers all the way up to entire your asset and they're much cheaper than compared to other insurances. I recommend getting the same insurance company that you have your car and house insurance. Usually they are bundled and they're giving you cheaper rate. So I have my umbrella car and house insurance in all with the same insurance agency. The other important thing is having a trust or will, especially if you have a minor child. If something happens to you or your spouse, then there's nobody to decide the decisions. Sometimes it can go to the legal system and goes to court. It may take months and months to decide who's gonna get the money, who's gonna handle the money and who's gonna take care of your children. If you have a minor child or you are single parents, having a will is very, very critical. So these are the ways to protect your financial assets and you're like having a protection. I mean, we work so hard to create all this money and financial foundation, but if we don't have the right protection, it can be a loss. It's a very small price we pay compared to what we can be protected. All right, I think we're almost done. So, as I mentioned that we went over a couple of a concept, money mindset, plan, loans, retirements, investment, protection. These are my resources. The other resources I use, these are the books that I read in the beginning. Right now, I use a lot of Facebook group. I'm part of many different Facebook groups in finance and some other non-clinical work too. And also I listen to podcasts very regularly. I used to listen to White Coast Investor a lot. Nowadays, I just pick and choose. His podcast is having a lot of information. And Bigger Pocket, if you're interested in real estate space, Bigger Pocket is the podcast you wanna listen. If you're interested in non-clinical career, career prescription, this is another good podcast. I think that's my end of my presentation. Any questions? I don't see any chat box or anything. I'm happy to get started if we wanna just go. And if anybody needs a break, you can just let us know in the chat, but I will go ahead and share my screen. Okay, well, hi everyone. I'm Lisa Verghese-Kroll. I'm a Senior Physician Advisor for Optum360, longtime member of AAP MNR. And as Dr. Lee said, we're all really excited to be here today to talk about these topics that are really important and sometimes undercovered in our medical training where we tend to focus on a very narrow path. So we're glad to kind of shed some light in these areas. And I'm happy to answer questions later. If they come up, feel free to email and obviously to ask in the chat as well. So today I'll just be touching on some non-clinical career opportunities that you may or may not have considered. Piggybacking off what Dr. Lee has been talking about, this is one way that we can, A, increase our income streams and B, decrease the chance of burnout. So this is really, you know, this is kind of an overview to keep in mind whether you are considering leaving clinical medicine altogether or whether you're looking for a side gig, something to kind of, you know, freshen up the day, make things more interesting, increase your savable income for the future, whatever your personal motivations may be. These are all, this is just kind of a taste of some of the things that are out there. By no means is it a comprehensive discussion of all the possible opportunities that are out there because it's important too to remember, Dr. Lee touched on this as well. The reason we want to talk about this is because the skillsets that we carry as physicians, those skillsets are vast. Sometimes we get so locked into clinical medicine and into what we've been taught during our very lengthy training periods that we think that all we have to offer the job market is our clinical skills. That's it. But that's actually not true at all. And that's, you know, my assertion that that's not true is borne out by the fact that major consulting firms like McKinsey are very excited to hire physicians. Why? When they're not medical companies. Because there are actually many, many skills that physicians learn subconsciously without even realizing it because of the nature of the work that we do. One of those things is communication skills. We talk all day. I mean, you know, even pathologists talk all day even though they don't see a lot of other human beings. I mean, you talk all day, you write all day. Relationship building. We interact with people across the entire economic, racial, gender, social spectrum. That's not true of every career. And the ability to connect with people and, you know, discuss very personal things with them, that's a skill. And that's a skill that can be monetized in areas outside of medicine. Also leadership. As physicians, we are leaders every day in what we need to do. There are many staff members that we have to lead, that we have to manage. Particularly as physiatrists, we're very used to the team structure and to leading a team, directing a team. And that skill is invaluable outside of medicine. So it's just important not to undersell ourselves, to realize that you have valuable skills, to realize that they can be directed in different ways. And sometimes being creative and determining how those are directed is the key to finding new opportunities. So all these expressed are my own, they're not my employers and I have no relevant financial disclosures. So really why, you know, why would we consider pursuing non-clinical opportunities? As I said, you know, in some ways we may be looking for a new income stream, but a lot of the time people are looking to use or acquire different skills. If you've been in your career for quite some time, you might feel like you're in a bit of a rut. There are definitely people that feel like in order to be able to keep working for 20 or 30 more years, they really need to be doing something more different or more fresh. And that's a reason sometimes that people look outside their traditional doctor job. Sometimes we have a desire for more control over our hours or our income, as we talked about passive income streams or active income streams, but also with the reality of American medicine, often we don't have control over the number of patients we see, the types of patients we see, where we see them, how long we see them. So that desire to have more control, especially after all these years of study and training, that's a real motivator. Challenges with many things, I'm sure I don't need to list them for everyone, but challenges with payers, with administration, with competitors, mid-level providers, all sorts of different things that may make the day-to-day more difficult. Burnout for those reasons, if we're looking to avoid or reverse some aspects of that. And also if you're looking to make a change, but other clinical opportunities aren't a possibility because of non-compete clauses, that also may make you start looking for non-clinical opportunities. So if any of these reasons resonate with you, you may be wondering, what are some options? And we're just gonna do a quick sort of bird's eye view of some of the options that are out there, just to kind of get people thinking, some of them you might not have thought about before. Again, it's not a comprehensive list, but the idea is just to kind of open our eyes to all the possibilities that are available with a medical degree. So the first opportunity is IME or disability file review. This is an incredibly broad niche. So it really can encompass almost whatever you want it to, but some examples of the types of file reviews you can do are reviews for workers' comp, for personal injury lawsuits, various facilities or people that are looking for impairment ratings, evaluating patients for life insurance, disability insurance, health insurance, functional capacity evals, pre and post. And the kind of overarching philosophy here is that the patient that you're examining is not your patient. You are an independent reviewer. So you're not caring for that patient. You're really providing a medical snapshot of that patient at that point in time. And you're also not working for the requester of the exam. So whether it's an attorney, an insurance company, whether it's the patient themselves, you're not their employee. You're an independent reviewer, and therefore your determination is expected to be objective. So typically you may be paid by the hour. You may be paid a flat fee for the complexity of the case. And in order to be considered for these reviews or to be contacted for them, you can be listed in national directories in order to increase referrals. And that's usually necessary for people before they've kind of built up a reputation and the work comes to them. You usually will start out in that manner. Medical informatics is another really vastly growing field, especially now with the pandemic when we've transitioned so quickly to doing so much online. It's become even more important. But essentially informatics, these are people in informatics are experts in the field of using health technology to collect data with the ultimate goal being to improve patient care and to improve medical knowledge for practitioners. So an important thing to remember in terms of why informatics is important is that EMRs who have physicians behind their development tend to be more user-friendly and they tend to use more of their potential as well. So I think we've all had experience with really clunky EMRs and studies have shown that the clunkiest tend to not have clinicians involved in their buildup. So if we can have doctors who know how we really use them on a day-to-day basis and how to make the EMRs work for us rather than us work for the EMR, then that tends to be something that a facility can stick with long-term and that can actually improve patient care. We know that there's tremendous frustration on the part of physicians and other practitioners when EMRs just end up using more time in our day and adding to our workload, but it doesn't actually have to be like that if we are using EMRs that are tapping into the potential of physicians who have informatics backgrounds and can translate that into a user-friendly software model. So people who are involved in medical informatics, physicians tend to be CIOs, Chief Information Officers or CMIOs, Chief Medical Informatic Officers and duties include basically being the representative for clinicians in health technology meetings. So making sure that those meetings aren't just populated by IT, who are great with computer stuff but may not really understand how seeing patients changes what you need out of an EMR. Typically, medical informatics officers are the ones that approved any changes to EMR templates or workflow. Ideally, a facility would require a physician or a clinician to approve those changes because they're the ones that would know how that would actually work day-to-day and how that would impact your workflow. And then they also are expected to use the data that they glean from EMR to optimize healthcare delivery in some way. So using those metrics. So are we changing, can we use those metrics to influence, to decrease AMA discharges, to decrease costs, to decrease lengths of stay, to decrease other things, to decrease staff turnover, burnout, that kind of thing. Additional training is typically required except at very, very small facilities. Generally, you are gonna need at a minimum a health IT certificate, usually a master's in medical informatics or an MBA or other degrees or training. Physician advising, this is what I do. So essentially, these are utilization and medical necessity compliance review consultants. So you have the option of either working for an individual hospital and being on staff just for that hospital or maybe their local network or working for a national company that has as clients hospital systems around the country. So what a physician advisor does is review cases in real time and retrospectively, so both to determine appropriate admission statuses for patients. You're also reviewing documentation for regulatory compliance. This is particularly relevant for PM&R where we have CFR guidelines that we have to follow for IRFs. It's also relevant for psychiatry. So there's certain specialties where there are more guidelines and requirements than there are for others. And so in those specialties, documentation is really more important than we may realize because this is what we live every day. But in other specialties, it's really not as important to kind of hit those benchmarks. So we would review documentation for those specialized facilities, discussing cases with the attending physicians providing care and also with medical directors from insurance company third-party payers and testifying as expert witnesses at administrative law judge hearings for appeals cases that have gone all the way through all levels of appeal and are now finally being heard by a judge. So really the goal is to ensure that patients are treated in the appropriate setting of care. So if this patient deserves inpatient care, that they are really classified as inpatients or as soon as possible after admission. And if they really didn't rise to the level of requiring inpatient care, that they're appropriately classified as observation or outpatient. And this can be across the board, across all specialties and subspecialties, or you can focus in one specialty, but generally it's much more common to be broad and to see patients across specialties, to see patient cases across specialties rather. Pharma is another really popular entry into non-clinical medicine. These are physicians that are actually employed by Pharma itself. And they generally are either conducting or participating in existing research projects to determine or improve efficacy of the products that are sold by that company. They are also as physicians developing relationships with health insurer decision-makers in order to position their products when they come to market. The idea being that physicians can better build relationships with other physicians or clinicians. Helping build patient access programs, particularly when cost-saving measures need to be in place or patient cards need to be developed in order to decrease co-pays, especially at the beginning of their treatment. They also educate the medical community on products. So this is where we see physicians leading Pharma dinners. They will act as spokespeople for the company. And obviously not everyone that's speaking at a dinner is a full-time employee of a Pharma company, but sometimes they can be. And they may also be traveling around providing medical education to other members of the community, not just actual prescribers. Also, they may be monitoring adverse events for pharmacovigilance. The federal government is another major source of non-clinical positions for physicians. And so these are really any of the major agencies in the federal government that involves health in any way. So whether this is HHS or the CDC, FDA, that kind of thing. Some of these will require relocation. So now with the pandemic, things are changing as so many people have pivoted so quickly to going online, but we don't know really how those trends will hold as the world kind of emerges from COVID-19. There's a lot of vacillation about whether those changes of being virtual will be permanent. We just don't know really. So I think it's good to realize, at least in the back of our minds, that this still may require relocation in the future as it did pre-COVID. Generally to the greater DC Baltimore area, to Atlanta, sometimes to other satellite offices. So the reality with the federal government, there are some great benefits because obviously you sometimes have access to pensions, to other benefits like health insurance, childcare credits, that kind of thing. There's some measure of job security that sometimes isn't there with private employers. But the drawback is that the bureaucracy is part of the job. So you just have to be comfortable with that, with red tape and not get too frustrated with it. But some of the duties depending on your agency would include reviewing clinical trial data, working on approvals for new drugs, new vaccines. Like COVID, they've been working over time. Safety surveillance, after the product does go to market. Helping influence policy development. So again, the COVID vaccine is a great example where we had to really manage legislation in triple time. Things that take 10 years to be approved, we were doing in a matter of weeks or months. So helping the legislative branch manage the realities of what a new product or new FDA regulation means for the public. Overseeing federally qualified health centers and training other professionals. As a physician employed by the federal government that may also often fall under your scope of duty. So an MSL, a medical science liaison, this is another option. And these physicians are employed in CROs and contract researchers organizations, but also are sometimes directly employed by pharma or biotech. And a CRO is pretty much what it sounds like. So this is an organization that does research under contract. So a pharmaceutical company that may not have the time or resources to do extensive research on its own, may contract out to a CRO to do the research necessary for whatever product they're bringing to market. So an MSL will be employed by that CRO and is typically expected to be an expert in a specific disease or specific therapeutic area. So this is where your specialty will be more relevant and probably more required for whatever the position happens to be. So essentially here, your goal, your duty really is to maintain relationships with KOLs, with key opinion leaders at major clinical institutions. The goal being that if you have a longstanding relationship that you then have an end to kind of describe to them, whatever it is, that whatever the new breakthrough or new product is. You'll be communicating data. When information requests come in from the public or from other prescribers or clinicians, it will be you responding to them, training and education of the Salesforce who may not be clinicians, who typically aren't clinicians. So that'll be part of your duties. So the ability to communicate fairly complex scientific and medical data to a group that is not necessarily trained in that area, that will be important. That's an important skillset. And then the ability to analyze current markets and determine where the needs are. So if several years have been spent on developing a certain medication or certain product, and then the need or the market demand for that has changed slightly, then the ability to pivot will really rest on the quality of the MSL. So a major factor in that is you must remain up to date on scientific knowledge, both in your field and in surrounding fields that may have impact on whatever the product or device is. Medical writing is another popular sub-path because many people who enter medicine have had some experience with writing, whether that was in your years in a lab, in undergrad, writing scientific publications, which many of us did at some point in training or afterwards, especially in academics, we have plenty of experience doing that. And even people who have had a lot of experience in non-medical writing. I've spoken to medical admissions officers who said it's really surprising actually how many people have an interest in fiction writing, in playwriting, screenwriting. So this does tend to be popular. So in terms of using that interest and skill in writing in a medical sense, this is writing for publication, usually freelance, and it includes things like medical textbook chapters, online articles for a lay audience, blog posts, medical association newsletters, creating CME, but it can also include advertising, medical marketing, medical journalism, which typically involves breaking news. So obviously, this last year and a half with COVID was a massive source of this. It's very tempting. I think this is often a very popular way to kind of start branching into non-clinical medicine because the overhead is so low. I mean, you can do this from your laptop at night, but it is difficult to raise up to the level of making a livable income. So this is where really many people advise taking a specialized writing course. The American Medical Writers Association offers some, and there are others, but it's something to consider making an investment in if you want this to really start replacing some of your income or generating significant additional income. Medical finance is another area that many of us really hadn't heard a lot about, and Dr. Lee's talk was a great introduction into it, but it's another step if you wanna try making an income out of advising other physicians on managing their wealth. So there are many different aspects of wealth management that you might want to become an expert in, taxes, estate planning, retirement planning, insurance decisions about which insurance to buy, what types, how to change your mix of insurance holdings. If you wanted to become a certified financial planner, you do need to take an exam for certification. There are a number of other possible certifications. There's the CMP, which is a certified medical planner, AIF, I'm blanking now on that. I think it's an adjudicated investment fiduciary, CFA, which is a financial analyst, and there are tons more because many people don't come into this after obtaining an MD. So this is really a pretty significant educational path beforehand. So if you wanna be really serious about this and make this either a replacement for your medical career or a significant adjunct, then usually another certification is necessary in order to attract clients. And your compensation may be a commission or fee-based. Okay, I'm just checking. Okay. Yes, I'm just seeing the chat. Yes, exactly. EMR definitely does contribute to burnout. Depending on the EMR that you have, there's no question. And yes, exactly. Working as an investment advisor, particularly with real estate, which is very popular with physicians because of the ability to be somewhat hands-off, there's no question that there is potential in this area for additional income generation. Okay. So then other possibilities being a medical director for an insurance company. We all have some experience with this, no matter which side we've been on. Typically, as practicing physicians, we've certainly encountered them. So essentially what this is is you're working for a third-party payer, you're approving and denying claims, you're case managing on a patient level and at a systems level. So as we all know, their goals are to limit lengths of stay, to lower payer costs, to monitor the quality of care. So essentially your day-to-day duties would include reviewing appeals and upholding or overturning denials. And of course, issuing those denials in the first place before they're appealed. And then holding peer-to-peer discussions with either treating physicians or their physician or other clinician representatives. Medical admin is another path to consider. And so these are hospital leaders. This can be anything from leaders of units or programs, section chiefs or department chairs. You could consider being a VP of medical affairs, chief medical officer, being involved in informatics. Informatics is often very tightly connected to medical admin or being involved in business development. So the goals of medical admin are to optimize the use of available resources and to get more. So fundraising is a major aspect of this because resources are always limited and always being crunched it feels like every year. So essentially your duties here as an informatics where your duty is to kind of represent clinicians to IT, here your duty really is to represent clinicians to administration, to act as the liaison between both. And you're also representing administration to clinicians and to physicians. You're overseeing quality management. So often if there's an audit, a financial audit, you'll be involved. If there's an insurance audit, you'll be involved. But also if there's any kind of, obviously any kind of infectious outbreak, any kind of security issue, baby switching, that kind of thing, that will be where medical admin is involved. Credentialing, obviously when new physicians need to get privileges and new leader development because leaders need to be replaced as they move on. And so as we all know, when you're new in something, you need a mentor. And so that's often part of the duty here. So typically an MHA or MBA is required. Although again, at certain facilities there may be physician development depending on need. So that may be something that they would pay for or block off time for you to obtain once you're already in the position. Let's check the chat. Okay, yes. So how is a physician advisor different from an insurance company medical director? So typically physician advisors are representing the hospitals. So they are interacting with the insurance company medical directors. So the insurance company medical director is employed by the insurance company. Physician advisors are employed by the hospital or by a company representing the hospital. So you're typically on different sides. I mean, the terms might be a little bit different, but typically you're on different sides. The terms might be a little bit different. Sometimes you can still be called a medical director though you're employed by either the hospital or the representative of the hospital. But as a physician advisor, you're usually working with the hospital to improve utilization review on their end so that the insurance company doesn't deny it in the first place. Or if they do deny it, that you're helping them manage their appeals process. And then there's medical coaching. So this is very relevant to those of us who are considering even just thinking about nonclinical medicine. Because what medical coaches do is they're physicians who have become certified coaches and work with other physicians on customizing their career paths or just transitioning out of clinical medicine or any medicine completely, depending on what their goals are. So as a coach, their job is to evaluate the client's situation, their strengths, their needs, the options available to them, any weaknesses that need to be addressed. And we can all understand that it's much easier to develop that close relationship if the coach is another position who understands the level of training that you've been through and the social obstacles to leaving, the financial obstacles to leaving, all the kind of unique issues that contribute to physicians wanting to make a change. And part of the coaching process is assisting clients with exploring the opportunities available to them and their unique training and their unique skillsets and helping them to apply for new positions, practicing interviews with them, going over their resumes, recommending them to their contacts, that kind of thing. So in order to market yourself as a coach, you do need specific training and certification. There are multiple out there. I've listed a couple. The International Coaching Federation is one, College of Executive Coaching. You can get a certificate in leadership coaching, but there are others out there. Yes, I'm seeing in the chat, it is interesting. So coaching, I feel like it's very true. Other industries have been very used to this, and this is not new. For us as physicians, it's not something we've heard about. And I think this is true for most aspects of non-clinical medicine. We are not given a holistic view of this through medical school or residency training. And I don't place blame for that because I think there is so much to learn during those minimum seven years, could be 10 or 12 years, depending on your specialty. There's so much to learn and there's so much at stake because we're holding patients' lives in our hands that I can't see where the time would have been in the day, really, to add all of this. But I think it's important now as an academy to let our members know about this because this is a great point. Many of us are not aware that medical coaches exist, let alone that they're taking new clients and are happy to help us. But it is just kind of an accepted way of being in finance, in law, in all sorts of other high-level positions. So I think it's really good for us to know that these resources are there and good for us to start thinking about using them should we need them. And then there's the medical device industry. So there are a couple of ways to approach this. One is if you yourself have an idea for a product that would help in some way in your specialty. If that's the case, then you may be looking to start your own company and get a patent, or you may want to serve as a medical director for an existing device company. And essentially what they're doing is identifying a problem in healthcare and then creating a solution. And presumably if you're joining an existing device company, then that problem has already been identified and they're already working on creating the solution. But the caveat is that it must work with the current market. So you may have a great idea, but if nobody else perceives the need, then there won't be any income potential there. So that's kind of the thing to keep in mind, but your job would involve assessing the competition on a regular basis. And then also being aware of regulatory requirements. So Congress passes legislation that can change things overnight for your company. And legislation can come really at any time. So being really on top of that is an important part of this position. And then fundraising. I mean, capital acquisition, gaining investors, looking for grants, looking for government assistance, those kinds of things. A physician representative is usually used for any and all of those duties. You'll also be involved with literature review. You're usually involved with the design phase, grant writing, risk management, safety monitoring, especially after the product comes to market. So before I talk about the things to consider, I also wanted to say, because Dr. Lee touched on this as well, it's also important to think of non-medical opportunities. If you, there's no shame in having other passions outside of medicine, just as she said. And if you're someone who has a gift in music or art, or athletics, there's nothing wrong with using those gifts too. So whether that is giving music lessons, whether that's opening an Etsy shop for whatever form of art is your passion, whether it's buying and selling real estate, whether it's tutoring students for the MCAT or SATs, these are all other things that, especially because often those overhead costs are really low as well. They're a great sort of entree because it really doesn't take much to set that up over a weekend, and then you can kind of do it and keep your regular job and see how it goes. See if you like it, see if there are unforeseen obstacles that maybe make it not as enjoyable or as productive as you thought it would be, because it can also go the other way. Maybe there are fewer obstacles than you thought. Maybe there's potential that you didn't know. Maybe an investor sees what you have to offer and comes and offers a new idea or a new opportunity. In general, I feel like we are so focused on medicine that we sometimes need to be reminded, I think, that it is okay to have other interests, to do other things. It doesn't mean you're not a physician. Like that can't be taken away from you. Even if you stop practicing, it can't be taken away from you. Your education is always there. There's always an option to go back in some form or another, even if there are requirements that you have to do. So the fear, I think, of making a change is something that we really can gain the courage to kind of get over, even if that change is very non-traditional and completely non-medical. So things to consider when making the change, obviously, your salary. So this depends on whether you're considering just sort of starting a side gig or whether you're really looking to replace your clinical career. How much salary do you need to replace? And what is the potential in whatever path you're considering? Part of salary is benefits, for sure. If your family's on your health insurance, if your employer does a 401k match, if your employer offers stock options, all these things, can you replace them or can you afford to go without them? Non-compete clauses. This is key because if you have one, does it cover non-clinical work? Typically, they shouldn't, but important to make sure of that before you start anything. Maintaining your licensure and your board certification. Oops, sorry. If you are considering a side gig and you wanna continue your clinical work, then obviously you're gonna need to maintain your license and your board certification. If you're considering a career replacement that still requires licensure and board certification, physician advising is one of them, then you'll need to be aware of how you can do that. What steps are you gonna take to make sure that that won't be a problem? If you're still gonna continue some clinical work, and will you still need malpractice insurance, that won't be covered. So if you're going to plan to do your nine to five to be non-clinical, but you still wanna work in a free clinic on the weekends, will you still need malpractice and how will that be covered? So these are things to kind of be aware of. And there was a question in the chat about social media and med influencer paths, which is like very legitimate. I mean, we see so many of those. If you're on social media at all, there are plenty of them and more every week, it feels like. And I think I would never discount the potential in anything. I think there's definitely potential there. I would just advise that I think there are legal pitfalls because you can be construed to be giving medical advice simply by having an MD or a DO. So making sure that you have a very clear disclaimer, making sure that you try to avoid words like advice, try to repetitively say that this is for information only, make sure you are stating that you are not your follower's doctor. I host a podcast and we do wanna make very clear that this is not intended to be a substitute for actual medical care. So I think that there's nothing wrong with exploring those paths. I think that they can be really, not only personally fulfilling just because it's great to be able to use your medical knowledge and create a community and it's wonderful. And I think that there is monetization potential, but I think it's just really important to be careful upfront because in many ways, physicians have a target on their backs. Like it's not fair, but it's true. So I think just being clear about that upfront, getting legal advice upfront and being sure about what it is that you wanna achieve. Do you wanna replace your income with being an influencer? If so, that is going to require a very significant time commitment. So it's something that you may need to consider. Like, are you gonna take out a loan to cover your income until that can happen? Because it's not really, to generate a significant six-figure income through Instagram is something that's going to take tens, you know, dozens of hours a week. So probably not something that you could really do and maintain a full-time other career, but not something that I would say is impossible. So if you're interested in kind of exploring what's out there, what's possible. So a few things that I would recommend, I would say, first of all, that just the simple act of writing out or typing out your tentative plans, and this can change, but just having a roadmap has been proven psychologically to make it much more likely that you will take some of those steps, much more likely that you'll make a change, even a small one, and change begets change. So if you take the first step, it makes it much more likely that you'll take the second step, and then even that much more likely that you'll take the third. And it also makes it more likely that, or less likely rather, that you'll get stuck at an obstacle, because if you've written out your steps, then you know what specifically the problem is that you need help with, rather than the problem being some unapproachable thing, like I don't even know where to start. So really, it can kind of be a template for your future that helps you even years on. You can go back and look at what your original plan was and tweak it. I always recommend considering joining relevant associations. So if you have a certain path that you're kind of interested in, if it's medical finance or medical coaching or medical writing, to look into what the associations are in that niche and join them. Most of them have entry-level membership tiers available for people who are just looking to explore. The American Medical Writers Association, the American College of Physician Advisors, there's really an association for everything. Also consider hiring a physician coach. I have a couple of sites here in my resource list. Those are coaching sites, Doctors Crossing and PH Physicians, Physician Helping Physicians. Those are both physician coaches that I personally know and would recommend. And it may be worth the investment because they've done this before. They've seen it, they've done it themselves. And so they have access to resources and contacts that can really, really be helpful and really help you kind of tease out where you want to go and how to get there. You can consider attending a non-clinical careers conference. This is something that I did and it was huge for me just because it kind of opened my eyes in the way that I'm hoping this talk will open eyes because I just had absolutely no idea. I had no idea how people were using their medical degrees in very creative ways. I mean, I met someone who has an almond company. Like I, and it's like marketed as doctor, you know, I forget his name, but doctor, whatever. And he sells almonds and like, it's just, you know, I don't have a passion for almonds, but I was really moved by his passion. So it's just nice to know that there are people who are making it work and in all sorts of different ways. And that to me was very encouraging and inspiring. And I would also really recommend devoting time to your resume and to LinkedIn. As physicians, we typically were not taught how to write a good resume, particularly if you went straight through from college to medical school to residency and didn't need a resume for another career, you have a CV and it's not the same. And LinkedIn, you know, I mean, depending on, depending on how old we were, you know, we might not have had that much experience with LinkedIn. So this is something where, and also if you've only had one or two jobs since you started, since you left residency, you may not have had any need for LinkedIn. So this is something where investing in a resume service may be very worth it, because if you're applying to a job where the primary employee is not a physician, they're not necessarily going to understand how to interpret your CV or how to interpret a very skimpy LinkedIn. So it's good to have those things speak for you ahead of time, rather than you needing to kind of backpedal and explain why they're not up to speed. And then these are just some resources. As I said, Nonclinical Careers is a site with a great conference. Doctors Crossing and PH Physicians are two medical coaches. And the other sites are sites that offer nonclinical, nonclinical job boards. So they're great to kind of see what's out there, but also blog posts about how to position yourself, blog posts that do deep dives into different types of jobs, networking opportunities, and that kind of thing. So hopefully some or all of them will be good resources for you. So thanks so much. Are there any more, any other questions that I didn't address? Yes, Dr. Lee. Hey, thank you so much. It was very helpful. I don't see any other questions from the panel, but I have a question. Can you share your experience, how you transitioned out and how the career has evolved since you took the position? I'm in the process of actually interviewing. I finished my interviewing and waiting for the result for a physician advisor for my hospital. So I'm kind of curious what's going on after if I get to take the position, yeah. Absolutely, yeah. So for me, I never, it really was not on my radar at all. I never really intended to be nonclinical. I kind of just thought I would do what I saw all my attendings do in residency. I never really realized what else was out there. But what happened for me was, I have a degree in broadcast journalism. And after leaving residency, I was feeling more and more that I wanted to kind of use some of those skills and that I wasn't doing as much speaking and writing as I really would like to. I kind of wanted to scratch that itch some more. And I also knew that I was geographically confined. My husband was still in residency. So I knew I couldn't leave my city for another three years. So that's kind of, it was kind of those two things that started making me think about nonclinical medicine. And I had no idea what was out there and just like doing some Google searches and, you know. And that was where I stumbled across this nonclinical careers. I actually, it's the first link I have on the resources page that's run by a company called SEEK, S-E-A-K. And they had been doing it for several years. And I, you know, I'd never heard of it. I didn't know anybody that had gone to this conference. I kind of thought it was a scam. And I was like, I don't know about this. But it happened to be that year, it happened to be offered on the same weekend and in the same city as a relative's wedding. So I thought, okay, I'll go to this wedding. And then during the day, I'll go, I'll just stop by this conference. But it was, it was fantastic. Like I've actually recommended that conference to so many people since then, because as I said, it was very eyeopening. And that was where I first learned about physician advising and kind of the whole thing, just kind of like one step led to another. I just, I thought I'd apply. I didn't really think anything of it. Thought I'd go to the interview. I didn't really think anything of it. And then, you know, it was just offered the position and decided to try it for six months. And I've been there almost 10 years. So it really, it was, it's been an awesome experience. I've really enjoyed it because I do get to talk to people, to physicians around the country every day. And I love that. It's really, it's fun to kind of build relationships with them to see what people are seeing. Like, especially during COVID, we've been able to see kind of where trends are differing. Like, oh, flu seems to be much worse in the Northwest this month. And, you know, why is it that we're seeing rickets in Georgia? Like, it's just, it's fascinating. And then also, I've also felt as a rehab physician, I've also been specializing in our rehab facilities. So we speak directly with them. We help them with their CFR compliance and that kind of thing. And I feel like it's great to be able to assist our colleagues in this way, in a way that's lesser known. It's really necessary. I feel that what I do kind of takes that one thing off the plates of my colleagues who can then focus on patient care. And I'm happy to do it. You know, we require, it requires a physician. And when I'm working with IRFs, it requires a physiatrist. So if I can be the physiatrist to do that, I'm happy to do that so that my fellow physiatrists can focus on getting their patients home. And I think, you know, how the job has changed, it's changed, you know, legislation changes so much. So when the two midnight rule came in, I think in 2013, things just changed overnight because all of a sudden, you know, for anyone who doesn't know, the two midnight rule came in, and that was the idea that an inpatient stay required two midnights. So really overnight, a bunch of hospitals dropped their physician advisors because they figured, you know what? If the stay's two midnights, it counts as inpatient. If not, it's observation. And it's really not that simple, but it didn't matter. People did drop their physician advisors, even though that belief wasn't actually true. So things like that, that really opened my eyes to the fact that laws matter. I mean, they really change your day to day. And especially people's interpretation of laws. So in terms of testifying before administrative law judges, it's very interesting because some of them have significant medical knowledge and some of them don't. And even though we all technically have the same laws, some of them interpret them one way and some of them interpret them another way. That was very eyeopening to me too, since I have colleagues who are MDJDs, but I don't have a JD. So it was very interesting and how you kind of approach as a physician, managing that context and that environment in order to get the best outcomes for your clients and their patients. So I think that's kind of been my journey. I think during my almost 10 years there, I've worked in various departments, working on cases concurrently, working on them retrospectively, working on peer to peers, on letters, on legal testifying. So all sorts of different things. I've really enjoyed the ability to collect those different skillsets, but it's changing. Things are changing. And I think it will be interesting to see, over the next 10 years, how people do this, whether hospitals are gonna go more to an in-house physician advisor or whether they're gonna go more to national companies that kind of represent networks around the nation. So those are kind of some of the changes that I can't predict yet, but we'll kind of see how they go. I have one more question, Dr. Cole. Do you work only with the physiatrists or do you work with the other specialists too? No, I work with all specialties. So although I do specialize in rehab, that's only a small portion of the day. So I talk to physicians across all specialties. And so that is something about being a physician advisor that you do have to gain some comfort with because obviously, once you enter residency, you're very specialized. So some of these things are things that you will be studying again for the first time since medical school, but we're so used to learning. Like that's what we've done for decades, right? So it's not that hard. It sounds a little bit daunting, but it's not that hard to study it and refresh your memory and learn again. And for me, it's kind of fun. I would never have seen some of these cases otherwise. And yeah, like I enjoy, you know, like relearning Apgar scores and things like that. So that's been a fun thing. Sorry, it's good to hear because the position I applied is actually for pediatrics and OB-GYN. I'm like, I do P's rehab. I'm like, I'm not sure what I'm going into, but I just applied because my boss recommended. And then, you know, I bring up those skill sets. I lead team all the time and I, yeah, I monitor hospital stay and we negotiate the length of stay all the time. So I think I'm gonna be the position. That's how I sell myself. Yes. Yeah. I agree with you. You're gonna be great. And yes, exactly. Right. Like OB, you know, yeah, of course, we probably haven't seen that since medical school, but I think that it's a good thing to exercise our brains and, you know, to remind ourselves that we had, you know, we had a huge, massive amount of knowledge, right? That we crammed in in medical school and it's not the same as specializing, but certainly we have the ability to relearn, you know, at least to the level that we knew then. So I think you're gonna be great. Thank you. Thank you. All right. So I'm going to go ahead and get started and hopefully y'all are trickling back. And I'm gonna introduce myself. I'm Linda Street. I am the obstetrician of the group. So when you're talking about FGAR scores, I'm like, oh, those are easy. And then you say rehab and I shudder a little. I'm like, ooh, when my people need rehab, it's a bad day. But I'm gonna introduce myself. I'm Linda Street. I'm the obstetrician of the group. So when you're talking about FGAR scores, I'm like, ooh, those are easy. But. I want to talk a little bit about negotiations here today, because really negotiation is something we do all day, every day. So we're fooling ourselves when we pretend that this is a big bad wolf school, like skillset that we don't have. This is something you're doing day in, day out as a physician. When you get a diabetic to take insulin, that's a negotiation. When you get a patient to follow the care plan, that's a negotiation. When you go home, most of my life with my spouse is a negotiation. So this is something that you're doing all the time, but for some reason, when it comes to a negotiation for our career, when we're talking salary, oftentimes with someone who's non-clinical and has had actual specialized training in this, we totally freeze up and we undervalue ourselves. And my goal is for you all to walk out of here and have the tools you need, or at least the framework to jump off from, so that you can be paid what you're worth. So starting with Dr. Lee's talk, the part of the equation that can change is the input. So if you're putting more in because you were able to advocate for yourself effectively, maybe without doing any more work, you're going to end out in a better place for yourself financially. So I think this is a non-negotiable skillset, and we're going to talk about it a little. Goals and objectives are really to tell you in more detail why I think this is so important. And really look at some of the limiting beliefs. So I'm going to circle back to some of the mindset work Dr. Lee talked about with money and talk about that in the context of a negotiation, because there are a lot of beliefs that get in between our way of being where we're at now and where we want to be in a career that really serves us. Because our goal is for us to choose when we leave medicine, for us to choose when we want a non-clinical career, for us to choose when we want to retire, instead of that choice being made for us, either because someone chooses it for us directly, or because we're so exhausted that we can't move on any further. When I left my first job, I actually left feeling like I could be a barista, I don't care, but I cannot do this, and quit without a backup plan. And I don't want you all to get into that space. And then really looking at three simple steps, because I don't want to make this difficult. I want this to be digestible and usable, just from this talk, so that you can go out there and negotiate more effectively for yourselves as well. Do you have a disclosure? I run a company where I coach negotiations for physicians. So who am I? Why should I talk to you about this? I am a board certified OBGYN and maternal fetal medicine specialist. I am also a certified life coach, and I'm currently pursuing extra certification in conversation intelligence, which is really fascinating, and I'll add a couple tidbits as we go. And I really, really love negotiations. So I'm that weirdo who gets really excited when I have an opportunity to negotiate. It's not something I dread. I think it's a lot of fun. And because of that, I've been able to really design my second job out of fellowship. My first one was a hot mess. But my second one, I was able to negotiate effectively for myself, so that it's a career that pays me well, and treats me like a human, and has the things I need for career longevity. And I want you to be able to do that too. And then I have a picture of my mini-me's. They're my reason for caring about negotiation. So why should you care about this? The easiest way to earn more money is to get paid more for what you're already doing. You don't have to learn a new skill set. You don't have to go invest in anything. You just have to do what you're doing anyway, but get a higher value for that. It is a no-brainer. This is a low-hanging fruit. Negotiating a job that fits you is another thing that I think is really important. It's not just salary. So if you're in a job that fits you well, instead of you fitting yourself into a job that doesn't fit well, you're going to last a lot longer in that job. And some examples of this are if you apply for a job, and you were really hoping to work, say, three days a week in clinic, and do one day of research, and do one day of surgery, or whatever, and then you find yourself working with patients five days a week. You're not teaching. You're not doing the research. You're not doing the surgical care. You're not going to be as happy as if that job you designed from the get-go is what you're working every day. And so if you have something that would be a really good match for you, and you know what that is, or you have some ideas as to what that may be, you want to advocate for those things and negotiate them into your contract so that the job you show up to is the job you wanted instead of making yourself conform to the constraints of the job because you're going to last in it a lot longer. And again, to circle back with how I started, we do this all of the time anyway. This is not something that is strictly limited to your career. This is part of your personal life. It's part of your interactions with your patients, with your family, with yourself. I mean, we negotiate with ourselves all the time. Those are the hardest ones for me because I'm pretty hard at shutting myself down sometimes, but being able to navigate all of these different negotiations are going to serve you. So this is something you should be able to do. So what matters to you? And this is where I like to begin. And people are like, okay, yeah, yeah, yeah. Enough with that woo-woo stuff. Let's move on to the things that give me more money. But you can't effectively negotiate for yourself unless you ask yourself what you want. And I'm going to do this from a career standpoint, but certainly for a lot of y'all, there are going to be other things that factor into this as well. But you want to look at what are the different facets of my job and what do I want from them so that you can really advocate for yourself effectively because you know what you're wanting. It's really difficult to negotiate when you don't know what you're negotiating for. That's kind of wandering around and hoping you land on something wonderful versus if you really take inventory of what you need into these different arenas that are common to your job, you're going to be able to effectively ask for them. And I like to divide this into a couple different places with position jobs. The first one is going to be salary. You have to be paid for the value you provide. This is something that we need to live so that we can pay off all those loans so that we can save for retirement. You have to be paid. So I always look at this as a dashboard, kind of like your gauge and your gas and your car. Am I full or empty? Like am I the one who's, and I do this all the time, I'm a naughty example, but am I like sitting there with the light on saying like please get gas or you're going to be on fumes soon? I do that in my car. I don't do that in my job. Or are you like absolutely filled up? Like you just filled up, everything's great, life is dandy. Where are you at with your salary? And schedule. That's the other thing. A lot of us feel like we have to take the job as it's advertised. Like it's an eight to five clinic. That's what I'm supposed to do. There's a Q7 call every other weekend or every other holiday. This is what I'm supposed to do. And that's how the job is. Well that's not true. That's how they're advertising the job. That's what they'd like you to take. But there's a lot of room for negotiation here. And it's not a zero-sum game. It's not like oh but if I don't do my fair share somebody else has to do it. Not necessarily. You could have locums come in and cover. You could have extra payment for those shifts so that somebody who may want to be saving up for something would be glad to take those extra shifts. Like there are a lot of different ways to do this other than if I don't do it someone else is going to suffer. So I want you to release that out into the world is not true. Growth opportunities. We are smart people who like to learn. As Dr. Kroll was talking about, when you finish medical school and you finish training you spent your whole life learning up until that point. And then a lot of us get into our careers and you learn little nuances as new things come out. But I felt like after the first like couple years of attending hood where you've got a pretty vertical learning curve, everything kind of plateaus out. Like what I do is not hard. I do the same 10 things pretty much most days, day in and day out. With the exception of a couple cool zebra cases here and there. But for the most part, my job as far as a learning opportunity is fairly plateaued at this point. So if that's the case from a clinical standpoint, are there other areas you could grow? Could you do research and that could help you grow your knowledge on a specific area? Could you do leadership opportunities and learn how to grow in communication and running teams and some of the other hospital ongoings that are happening? Do you want a growth opportunity into something else? And therefore you want to make sure you're only working three days a week or four days a week so that you have time to explore those other hobbies. What growth opportunities are available for you? Because for the most part, most of us are fairly unhappy when our growth trajectory is fairly flat. Like we like to learn, we like to grow. We always want to be moving towards something. So consider that and consider are there specific things that you want that'll fulfill that need for you? And then the environment. So there are lots of different environments. There's academics, there's private practice, there's hospital employment, there's non-clinical jobs. There are a million different environments you could be in. When you pare down a level further, who are the people you're working with? Are you the only person who does what you do? Are you working in a multi-specialty team? Are you working with five other people who do the exact same skills that you do clinically? Like what do you want? What are you hoping to do? What's the general mood? Is there a lot of turnover? Are there a lot of people coming and going? Or is it a pretty stable group? And why? Right? So these are all things you want to consider when you're looking at what do you want to navigate in your negotiation towards? What do you want to ask for? And then we're going to make this really easy in three different steps. So mindset is the first step. And this is really a couple different facets, but one of the things is confidence in your value. And this is one that I have a lot of, I hear a lot of struggles and a lot of limiting beliefs, especially when people are starting their first job out of training. There's a lot of, oh, I had to accept that salary because I'm a brand new attending. I don't have anything to offer. Wrong. You have a clinical skill set that is very rare and very phenomenal, right? Like it feels not rare because we're in this little cocoon of other people who can do what we can do, but there aren't that many people in the country who can do what you do. And then when you go beyond that, none of them are you. None of them have the unique combination of your clinical skill set, plus whatever other skills you have, the way you fit into a team, how you approach things. Like you have a lot to offer even in addition to your clinical skill set. And sometimes that's an easier place to start, especially when you're starting off your career at the beginning of your career is what do I offer in addition to my clinical set? And then that can get kind of the juices flowing. But even within your clinical skill set, are you really superb at ultrasound guided something or another, or are you somebody who really excels in one facet of what you do? Those are things that you can develop and have like a micro niche to really sell yourself. And so be confident that you're providing value and stop with limiting beliefs. And what I mean by this, and this is kind of a very general statement is I can only take the job this way. There's so many different ways you can make this job look, even within the context of one exact job, you can take that one same job and make it three different ways. I'm recruiting for a partner, for example, and I live in Augusta, Georgia, which is not the most exciting place in the world to live. I live here because I'm married into it. And recruiting MFMs right now is hard. Anyway, you could live in San Diego and it's hard. So when you look at that, you have to be a little creative sometimes. Like my employer was like, okay, we need a five day a week MFM. Can we be flexible on telemed? Is this something where we can kind of alternate somebody coming in in person and somebody being on telemedicine? Is this something where we can do X, Y, Z, whatever, be creative, look at different ways you can fill the patient care need or whatever need your employer's looking for in a way that might be a little outside of the box, but might really serve you. So especially in these last few years with telemedicine really increasing in acceptance, that's something that might be a way to buy a little more time freedom because you can be in your basement, in your Zoom wallet, in your sweatpants, and life can be really great that way. You can avoid that hour long commute, maybe a couple of days a week. So how is it that you can change your job in a way that it serves you better while still accomplishing the things they're hiring you for? And so just refusing to believe that it is as it is and there are no other alternatives and kind of taking off those blinders and really opening up to the fact that there are tons of different possibilities, even in the exact job you're looking for, even if you're restricted in the community you're in, like Dr. Verghese-Knowles said earlier, like she had geographic constraints for three years, like she had to be there, but she was still able to find something to do that was really able to kind of satisfy some of her needs for growth anyway because she was willing to look outside of the blinders of this is what medicine should look like, this is what a job for an attending looks like, and so be willing to do that. And then how you view the negotiation process, and this is a tricky one. So mindset-wise a lot of us look at this as a very tug-of-war, like it's me versus them, if I win they lose, if they win I've lost, like there's this very antagonistic relationship that a lot of us kind of assume as part of negotiation, when really and truly the definition of negotiation is simply a discussion with the goal of making an agreement, that's all it is. You can have discussions, you can agree, agreement's easy, people like agreement, right? So just shift your mindset of this is a tug-of-war to this is a collaborative process, and we'll talk about some techniques that you can use to really help them with that as well, like if you go into a negotiation and it feels a little adversarial, they feel a little aggressive on some of those things, there are plenty of different ways to slightly kind of re-shift the conversation and kind of recalibrate it to a much more collaborative and partnership-oriented process, and so if they can't do it we'll teach you how to. The next step is going to be market, know your market, you have to know a broad idea of what you're worth, because while everything is in ranges and you should certainly strive to be at the top end of that range, there is always a ballpark that you're going to be expected to be within, so know what that is, because oftentimes they're going to start on the very low end, and if everyone you've talked to also took the job as it was offered and nobody fought for above that low end, you might think that's average, you may say, oh well that's what so-and-so was offered and that's what so-and-so x was offered, that must be average, no you all got low-balled and none of you negotiated, so that's actually the 10th percentile, and then you find yourself five years down the road with six figures left on the table, not to mention all the compounding interests and things Dr. Lee talked about that you've now missed out on, so making sure you know what the market you should be in, and we'll talk about that in detail here in a minute, but oops, so know your worth, I use MGMA when I'm working with my clients just because all these databases are very expensive, you have to pay for them, and so you pick one, and that MGMA is mostly like medium-sized hospital systems and things, and so it was a good one to pick, so I picked it, but this is for PM&R, so this is y'all, and this is the median for nationwide, this is going to vary for a lot of different reasons, so region varies, there are tons of regional differences, and for the most part, the east coast and the west coast are going to be the least paid, the most expensive cost of living, and the middle of the country in the south tend to be cheaper to live in, and they get paid more, so supply and demand dynamics just tend to pair out that way, but the median of total compensation for physiatry is 313,000. There's a wide range, I can't remember what the numbers were off the top of my head when I pulled this out, I was trying not to violate my contract, but I was like it's just a little average, we're okay, but there's a wide range, there's a six-figure range between the 10th percentile and the 90th percentile, probably multiple six figures, so just because this is the median does not mean this is what you have to be paid. One approach I used with my last negotiation is they offered me a very 50th percentile pay, and I was like I'll work four days a week for that, and that's where we landed, somewhere around there, and so be clever, be creative, think of other ways that you can make it work for you, and get what you need. I cared more about my time at that moment than I did about my salary, and so it was fine, but knowing kind of what you're making in comparison to your peers is good, and this is not an absolute, this is a jumping off point, so even if you get data very specific to your situation, so say you're an assistant professor in academics in the east coast, and you can get that data, that's just still a jumping off point. It is not a period, it's not the end of the sentence, it's a place to know I should be ballpark kind of around here. If you offer special skill sets, you should be paid more. If they have terrible turnover and can't keep people, well you should be paid more. There's a lot of supply and demand that goes into these conversations that they may be willing to pay for that you need to monopolize on, so just keep this as a jumping off point, that is an absolute, and then have a bottom line. So I want you to have two numbers when you go into any negotiation before you talk salaries. So one is the bottom line, and the bottom line is a number that anything less than this, you're going to walk away. You're done, I see the question, I'll pop that up in a minute. You're done, you don't want the job, you would rather take a different job, or be jobless for a little while, or stay in your current employment, whatever it is, it's a deal breaker for you. So you need to know what that is, because anything below that, if you can't get above it, it's just a no, and that's okay, no is a complete sentence. The next number I want you to have that's going to be more important is the high expectation goal. So there are actually studies in negotiation that show having a high expectation goal by itself gets you a higher pay, and if you take some of the more classic examples in academics, where they took two people who were negotiating against each other, and they set up various parameters, like one person has ten dollars, one person has zero dollars, you have to offer them something and meet in the middle, or meet somewhere where everybody's satisfied, and everybody gets no money if you can't agree. Oftentimes people who had a high expectation goal got more, so what they did with this is they'd give the person who had no money a target. They're like, okay, so this person's going to be given ten dollars, I want you to negotiate your socks off and try to get $6.50, and they found that those guys got on average like $8.50, so they overshot. They're like, okay, I got to get more than half, I'm going to show up with my A game, and they made it happen. They did the same thing and told the people with no money, try to get $3.50, which sounds pretty easy to do. You're like, yeah, it's less than half, most normal people are going to give you at least less than half of the free money that they just got handed, and they actually did poorly. They got right around $3.50 most of the time, but they certainly didn't overshoot it because they showed up expecting to land there and that it was a reasonable ask, so just having this stretch goal, and it should feel a little uncomfortable. By default, a stretch goal should feel a little bit uncomfortable, so if it's like, I can get this, this is easy, you probably need to shoot a little higher. I usually tell people if you can't find a visceral one, aim for the 75th percentile because, you know, why strive for average? Strive for a little bit above that and see where you go, but having that goal can help you, and I'm going to look through the Q&A. Oh, what does RVU stand for? So relative value unit, so RVUs are basically just a way that the hospital pays you for your effort, but regardless of the payer, so with a collections model, you get like a percentage of what the practice earns based on your billing, and it's going to be dependent on what insurance that patient has, so a patient who has a well-paying insurance, you're going to get, say, $100 for doing task A versus a patient with a poorer paying insurance, you might get $50 for doing the same effort. RVU normalizes that, so it says every single time you do task A, you're going to get $75, whether the insurance company reimburses $100 or $50 or $200, like it doesn't matter, your cut of this is blank, and there's actually a committee that decides on what RVU value each different code you bill has, and it has to be a balanced budget per se, so if they give extra RVUs to something, they have to take it away from somewhere else, so it's a committee of like 30, 40 people, and they basically hash this out every so often, so it is, yeah, they have the calculated RVUs, and part of how you're paid if you're on a production model that uses RVUs, there's going to be a dollar amount assigned per RVU, and this is going to vary based on specialty and region and where you work, but that's actually a great target for negotiation, so a lot of jobs will have it set up to where you have, let me see how we're doing on time, we're doing okay, a lot of jobs will have it set up to where you have like a guaranteed salary or a base salary plus production option, some jobs are production only after you've been there for a year or two, but if you have production as part of your salary and RVUs are how they calculate that production, that's a great target number two, so say they want to pay you $50 per RVU for what you do, well ask for $60 or ask for $75, I mean it depends on kind of where that is in that region of reasonableness, when we went back, here let me go back a little and see what PMNR's median one was, oops a little excited here, 69, so 69.73, that's that compensation to work RVU value, which is the physician component, so just to make things a little more complicated, RVUs have different components, your part is the work RVU, that is the physician interpretation fee, so you will get paid X amount for each RVU you earn, and that's a negotiable number, and the median for PMNR is almost $70. And then the next step is, oh let me look at the question, sorry, what about employers that say pay vacation time is not negotiable, all of our physicians get the same contract, we're going to talk about that, first off make sure it's true, because it's really easy to say that, it's not always true, I know for a fact at many places where they've said that's true, somebody knows somebody else who makes different, so first off make sure it's true, if it is a place where there truly is actual transparent pay equity, which is really ideally what we would all strive for, if that is truly the case, there are plenty of other things to negotiate, so if they won't negotiate vacation time and pay, maybe they'll negotiate like a stipend for something, like you can have a leadership stipend, so if you're going to be doing something above and beyond the clinical seeing of patients, like say you're going to start a program within your field, where you're the medical director of the rehab center, or something to that effect, how much effort are you going to put into that, ask for a stipend, it's something above and beyond just the patient care piece, so that's a way you can sometimes get around that, another way is asking for kind of flexibility in things, so you could say well if that's the case I'd like an admin day a month, or an admin day a week, and I'd like to be able to telecommute for that admin day, I want to do it from home, so be creative, first I would say be skeptical, make sure that's actually true, because I think it's very easy to say, and it's not oftentimes the case, second of all, ask for things to make your life better, look for creative ways to make things better, the other piece to this is one-time payments, so a nice way to get around these, like everybody makes say $250,000 for a .8 FTE job, then say okay, well there's been a lot of turnover, and I know it's really important for you to maintain employees at this point, other places are giving sign-on bonuses, would you give me a retention bonus for staying, like one-time fees come out of a different budget item oftentimes for hospitals than recurring things, and so sometimes you can negotiate that, and it doesn't feel as pay and equitable to them, and so sometimes they're willing to give that, so be creative is my short answer, but the long answer is all those different things, how would you go about knowing it's true, yeah that requires a little bit more detective work, so I mean I think some of it is asking around if you have a good relationship with your colleagues, asking like hey they're telling me this, is this what they told you, is this kind of similar to what you offer, because if truly everything is equitable as far as pay, there should be no problem that you're talking about it, so I always question pay equity when they have a confidentiality clause in my contract about talking about my pay, I'm like well if things are so equitable, why can't we talk about it and see what they say, right? Like that's something for sure to talk about and ask about. I think some of this you have to go off of a gut feel, like some of it you may not be able to validate, but I would try to actually validate it first. And then income guarantee. Now they're basically loans. So it depends on kind of how it's set up. So anytime you're starting a new job, it takes on average 18 months for a physician to build a practice. So you want to make sure your guarantee covers at least that timeframe. I usually tell people aim for two years to give yourself a little flexibility, especially with COVID, because there are a lot of things in and out of our control that have closed down clinics for a little while, or you're short on staffing. I know the clinic that's next to mine literally has closed clinics because they don't have an MA some days. And so they have just shut down the entire clinic because there's not somebody to help the physician, which blows my mind like 400 ways from Sunday. So I think that having the longer guarantee is helpful. As far as them being basically loans, you want it to be forgiven when you go onto a production model, if you haven't met it anyway. So I always like, my favorite kind of contract with this is to have a guarantee that's a floor, not a ceiling. And what I mean by that is it means you will always make at least this, but you can earn above that if you're really productive. And I think that benefits both of you. So you can usually persuade them to do this if you show them how it benefits them, right? So if you have a ceiling, there's no incentive for you to work beyond your floor. Like once you hit that ceiling, there's no reason for you to see extra patients. You might as well go home early, clock out, call it a day. Versus if there's not a ceiling, there's that incentive to make sure that you work in that extra patient who needs a favor. You work in that extra clinic when somebody's sick, because there's a financial incentive, not that there's not other incentives, but I think there needs to be a financial one as well. And beyond that, that benefits both of you because they're not giving you a hundred percent of the cut for what you earn. They're giving you a portion of it. So while you benefit when there's not a ceiling, so are they. Their clinic is busier. That volume is busier. A lot of us who work for hospital employers, they can also charge all these facility fees that are really creative ways for them to make more money than private practice stocks. And so they're making the money. You should too. And so that's kind of my thoughts on those models. So you want to look at the wording and you want to talk to a lawyer about it to make sure it's wording that benefits you. I always recommend everybody use a lawyer. I actually used three because I was testing out different services to see how they would respond when I did my last contract. But you always want an attorney to look at it to make sure it's not a one-sided contract, because a lot of times they'll say things like, you have to give X, Y, Z notice, but we can terminate you with 30 days. And you're like, whoa, whoa, whoa. If I have to give 90 days notice, if I decide to leave, you have to give me 90 days notice. And if you choose to terminate me before that 90 days, you have to pay me for that 90 days. Thank you. Bye-bye. You want to make sure that your contract is not one-sided. So it needs to benefit both of you. All right. And so making it happen, we've already started diving in. You guys are so great. The first place I like to start in this, making this a partnership, making this collaborative is mutual goals. And I have my clients do this with starting with event diagram. So on one side of the event diagram, you're simply going to write all of the things that you have to offer and all the things that you want. On the other side, you're going to look at what do they want? What are they looking for? Why are they hiring me? Are they moving into a period of growth? They're trying to buy out these tinier places and expand, and that's why they need more docs. Are they looking to stabilize a department that's had a lot of turnover? Are they looking to get different referral sources? Whatever it is, what are they trying to do that they're hiring you? Why did they hire you? And that's important to know so that you can position yourself as the perfect solution to their problems. You're going to want to position your strengths as advantageous to them. And in order to do that, you need to know what they want to do. And you can figure this out on an interview. So just asking, like, why are you hiring? Where do you see yourself over the next few years? Are there any changes you see happening? There are a lot of ways to do this other than, hmm, saw there was a lot of turnover. That's fishy. Why? Like, you don't want to ask it that way. You want to ask it from a place of curiosity. Like, where do you see yourself going? What have been some challenges? How do you see that changing, right? Like, ask really genuine questions when you're on your interview to kind of find these places and these pieces so that when you go to negotiate, you're like, oh, I know that it's really important for them to have a local presence because they currently have been using a lot of locums and they haven't had a lot of stability. They want somebody to really take over the position within the community to build those relationships with the referring docs and strengthen the program so that it can expand. Okay. How am I good at that? Oh, well, in my last job, I had really great relationships with my referring docs. I think that's something I could do again. Or I have a strong social media presence. That's something I can offer to attract more patients. Really present the things that you're awesome at beyond your clinical skill set as a solution to their problems. Because the more you can do that, the more you change leverage to favor you. Because all of a sudden, they don't want you just for your clinical skill set. I say just, but it's awesome too. But that's not the only thing they want. They want you as an individual because the things you offer in addition to that clinical skill set make you a perfect fit. And they're willing to pay for that perfect fit. But you have to present yourself as that perfect fit to kind of get them into that headspace. How would you negotiate for a stipend if you're not far enough into the job basically, or if you're already in the job? Yeah. I mean, I think I would just simply look at like, Hey, I've done all of these things. I would emphasize the accomplishments you've made. So, okay. I've been a medical director for a year and some change. I know this was previously not a stipend in position, but since taking on this position, we've XYZ all the things you've accomplished. Don't assume they've noticed. I think that's huge advice for these things. A lot of these administrators are moving and shaking a lot of different pieces, and they may not have noticed that you took the clinic out of the red and into the black. They may not have noticed that I'm sorry, like the dog's trying to kill things. They may not have noticed that you were able to accomplish XYZ things that you've been able to do that you've been able to protocol make some protocols so that quality is better. That quality is more standardized, whatever it is that you've done in that position, highlight that and say, look, this has been wonderful. We've accomplished all these things. This needs to be a paid position. It is above and beyond my clinical responsibilities. I enjoy doing it. I'm looking forward to the continued growth that we're going to achieve, but it needs to be paid because if you're not paid for this, you're paying to do it. And I think you need to look at it that way. Like if you're not being paid to do something, you're paying to do it. You're either paying with your time at home. So instead of spending time with your family, you're like doing all your medical director responsibilities. You're either, if you're in a production contract, you're not seeing patients during that timeframe. However it is, you need to be paid somehow. Now, whether that's salary or whether that's protected time is up to you. You can ask for both. It depends on your goals and depends on what you're doing, but you have to be paid somehow for everything you do. In addition to what you were hired for, because otherwise you're paying them and you shouldn't pay to work. That's just not right. Leverage. And I've touched on this a little. I'm going to make leverage really, really simple for you. Leverage is about making it seem worse if they don't get you as an individual and it's about having alternatives. So you increase your leverage by having other choices. So you increase your leverage by having another job opportunity that you could go to by having a non-clinical stream of income that you could do instead, by having a savings and an emergency fund that you could live off of for six months if they're not willing to make your work conditions more humane for you. Those things give you leverage because you have power to leave. And at the end of the day, your power to leave is your strongest leverage. Their leverage and how you shift leverage to your favor on their end is going to be, how do I make it so that they want me more than just my clinical skill set? So they can't say, well, it's okay. We're interviewing three other people who do what you do. Like, we'll just take one of them. How do you make yourself so irresistible as a solution to their problems that they don't want the other three people? Like they want you and they're willing to pay for that. So that's how you shift their leverage. And that's all it is, is making them, making them want you more because you stand out as more than your clinical skill set and making them less something you need by having alternatives. Like those are the only things you need to worry about when you're thinking about leverage to make it more in your favor. And then obstacles and strategies. Let me see how I'm doing on time. I'm still doing okay. I always like to think of all the ways they're going to say no ahead of time. And this sounds really morbid and kind of depressing, but when you're in the moment and somebody tells you no, your brain goes one of two ways. You're either going to get really defensive and feel attacked, or you're going to feel really defeated and kind of deflated. Like one of those two things is going to happen when someone says no, and it's going to happen. It's inevitable. Neither of those places are the place you want to come back with a response from. You don't want to come from a response from being defensive because you're probably not going to show your best self. You don't want a response from defeat because you're probably going to undersell yourself. So the way to fix this, because you're a human who's going to feel one of those things when they say no, is to be like, you know what? They're going to say no. How are all the different ways? They're going to say, no, it's not in our budget. No, we have pay equity. No, we've never done that here before. No COVID. No whatever. Any reason they're going to say no, brainstorm them ahead of time and then have a response. Because ahead of time, no one said no to you. Your brain doesn't feel that need to feel defensive or defeated. Your brain's not in that space. It's in a creative brainstorming way. So when you're not confined by those blinders, you can come up with really creative responses. So let's say they say, no, it's not in the budget. You could say, okay, well, how can we get it into the budget? Or you could say, are there other places where we could pull from until next year when it could be placed in the budget? Or how do we make it so that if I'm going to go within the constraints of the budget now, there's an automatic raise built in so that next year that can be built into the budget, whatever. There are a million different ways you can respond to that. But the right answer is not, okay, because then you're going to make less. The right answer is to challenge that no, but in a way that is respectful of the constraints they have. It may be that the budget is solid and they can't move it. Okay, how do we reward me next year? It may be a place where like those one-time fees aren't in the budget the same way. So, hey, can we do a retention bonus instead? Or, hey, could we get a stipend from the hospital system instead of the physician group because I'm providing XYZ service? Whatever it is, be creative and have a solution ahead of time because that way, when that no comes, you'll initially feel how you're going to feel and that's okay. You're allowed to. You take a big deep breath and you're like, you know, how could we do it this way? And you bring those creative responses that you've thought of ahead of time to the table so that you're not accepting that no is a no. And so really taking the time to do that before your negotiation is going to serve you really well. And so I want to end on this note. We all have this thought that if we negotiate, it's going to be really, really, really uncomfortable. And I want to challenge you that the discomfort of neg- I can't speak. Lord have mercy. The discomfort of negotiation is always, always, always, always less of the discomfort of being undervalued. There is nothing worse than being six months into your job and finding out your partner makes $150,000 more than you. Been there. There's nothing worse than feeling like what you pour your heart and soul into day in and day out is not appreciated. And while salary is not the complete picture for that, it's a part of it. And if you're being underpaid and you figure that out because six months down the road, you find out different pieces of information, you're going to feel undervalued. And that's a whole lot more uncomfortable than the discomfort of advocating for yourself on the front end. And the discomfort of having that crucial conversation on the front end so that you can ask for what you're worth. And I've had several clients that a year down the road have been offered a promotion or been offered a leadership position because of how they showed up in negotiation. They were told, you know, I was so impressed with how you negotiated your position here. Would you be interested in XYZ? So I always like to think of the negotiation as the fourth trimester because I'm an obstetrician. You can't take me anywhere. But it's like a piece of your interview. Like it doesn't stop as soon as they offer you that contract. How you conduct yourself within your negotiation says a lot about how you have difficult conversations. It says a lot of how you approach resource management issues. It really says a lot about how you interact with other people and how you communicate. So if you can show up in a way that advocates for yourself while respecting the position they're in, you're going to be light years ahead of your peers as far as how they perceive you. So I think it can help you moving forward. And then if you have any questions, this is where you can find me. I'm at simplystreetmd at gmail.com. So just shoot me an email. There's also a contact form on my website, which is the same. And I'm happy to answer those. So could you comment on when to negotiate or ask for compensation? Always. Whenever you feel like you need it. I don't think there's ever a bad time for negotiation. There are some natural times where it's a little simpler and so there's less barrier to entry. And so certainly like when you're doing an annual review, a lot of these contracts, they've gotten very sneaky. So a lot of these contracts auto renew so that there's just not attention to them. Like you don't feel the need to readdress it. You don't feel the need to look at it any further because it just magically renews. So I think that here and I can stop share screen. So I think that when your contract's about to auto renew, maybe like three months ahead of that, so you have some time for conversations to happen is a natural, nice place to do that. The easy one is when you're starting for a new job. Obviously once you're talking about the job, there's a place for negotiation or if there's a change in your responsibilities. So you could be say in a three-year cycle, like my contract auto renews every three years or whatever. Say you're year two and so you're pretty close to actually having renegotiated it. And all of a sudden two people quit. So you have different responsibilities. That's a great time to have a negotiation or all of a sudden you're asked to develop something or do something different or to go to a new satellite site that changes your commute. All of those are reasons to have the conversation. So I don't know that there's a right or a wrong time to negotiate, but I think those are some natural times that make it so there's less of a barrier for you starting the conversation. Any other questions? I've had some good ones. So despite tripping on my words, we spoke a little quickly and kept going. If a contract is overdue for renewal, is there a way to negotiate potential losses? Oh, you can try. There's not a lot of incentive to them since that time has already passed to give it to you. I think that if you're being retained is contingent upon that and they're invested in you and you can kind of show them why you're such a great person to have hired for this position, it's not impossible. But I think prior losses are harder to negotiate for certainly than losses that aren't realized yet. So things coming in the future, it's usually easier to negotiate for the future than it is to negotiate for what already has occurred. So it's worth trying, but it's a little bit harder because you just don't have as much leverage because they've already paid you that for that time. Now, that being said, the caveat is if they were in breach of contract. So if they're in breach of contract, then there is some incentive to pay you because then they don't have to avoid, or they can avoid kind of the possibility of litigation. Now, whether or not you choose to litigate for breach of contract is a whole separate lecture. Like that's a conversation to have with your attorney because sometimes it costs more than like the $10,000 you're fighting over. And so it may not be worth the time and emotion and energy if you can't kind of get it with just easy conversations. But yeah, it's always easier to negotiate prospectively than retrospectively. But it's worth asking for. I mean, worst case scenario, they say no. That's exactly where you're at today. So you're not losing anything. Hospital, health system's bad, hospital's doing well. Right. So if they're paying a fortune for locums, point that out. Locums are really expensive because they're paying the doc more usually, and they're paying a middleman almost what they're paying the doc. When I did locums, most of the time the agency I worked for paid 50%. I actually was able to negotiate just a PRN contract with a hospital system, and my pay was almost double because I cut out the middleman. So I think pointing out, look, I understand. And it's called tactical empathy. Chris Voss uses this in how to never split the difference. But saying, look, I understand that the health system is in trouble, but what costs a lot of money is turnover. What costs a lot of money are these locum physicians to come in and fill these gaps. We've been doing really great, and we shouldn't be penalized for poor financial issues that aren't within our own context of our group. So in order to stabilize the group and to be able to continue to be doing so well, we need to be paid fairly. And part of that is having humane RVU targets for us to reach. Part of what we're doing as a residency program is teaching. We can't teach well and have a residency program where strong applicants come if we're being penalized for not being 200% clinical. So I think kind of tying back to the mission, tying back to the goals they have for the position. And if your group and your hospital is doing well, saying, look, like we can't be relied upon to compensate for other people's concerns. Like we're going to continue having turnover. You're going to continue having to pay more for these stopgap people and the middlemen if you don't treat us well. So why would you do that? How do we solve this problem? And that brings me into wording. So part of why I'm doing certification and conversation intelligence as well is because the words we use have so much power. And the words you use can change the meaning of what you're saying so much. And it can change the entire kind of just salt of the conversation. So when I'm asking questions, I always like to use how. It is almost impossible to phrase a how question in a way that's offensive. So how are we going to solve that? How do we get this accomplished? Like how do we, it's very collaborative. It gets you into this kind of partnership, oxytocin rich neuro environment. And they're going to want to work with you. Like saying like, okay, how do we solve this? How can we look at this a different way so that we're not being penalized for the overall health systems concerns financially? Like how do we approach this topic versus what is kind of a middle, like you can use what it's fine. It's not as good as how, like, what are we going to do to fix this? Like what can we do to find a solution. It's just a little more direct and aggressive than how. And so it tends to just put you in a little more defensive headspace than how. Why is almost never your top choice? Why almost always puts you in defensive land? Think about a toddler. Why? Why, mom? Why are we doing this? Why just never makes you have this warm and fuzzy, oxytocin rich environment to want to collaborate with someone? So being mindful of how you're wording these requests and how you're wording these conversations can also be really important. So are there more favorable options for sign-on bonuses or student loan repayments? Especially if you're not sure how long you're going to be. So the sign-on bonuses and student loan repayments and most of these one-time things can be worded a lot of different ways in your contract. Sometimes they're prorated over the entire length of the contract. Sometimes you can get them prorated over a shorter part of the contract. So having a sign-on bonus that is forgiven if you stay there for a year is better than if you do it over the five-year length of the contract. Having one that's forgiven on a prorated basis is a whole lot better than one that is only forgiven if you stay the entirety of the contract. So being careful to look at those repayment terms is really important. And that's negotiable. So if you get, say, a $50,000 sign-on bonus for a five-year contract, let's say, if you get forgiven that entire amount, if you leave after a year, that's going to be better than if it's paid after five years and say you leave year two, you'd have to pay back $30,000. Not the whole $50,000, but you still have to pay back $30,000 of it. Versus if it's contingent on the entire contract being completed or you have to pay back all of it, say you leave year four because something changes in your life, you have to pony up $50,000 instead of $10,000 instead of $0,000. So being careful to pay attention to some of those terms in your contract and your lawyer can help you with these things is really going to be advantageous. And that's something important to look at. So I think just looking at the forgiveness parameters would be really important, especially if you don't know that you're going to be there for a long time. What is the usual raise? That is a wide range. There's not really. So physician contracts oftentimes don't have just standard cost of living increases like many other industries. It's pretty standard in many other industries to have a 2% to 3% cost of living adjustment built into the contract. It's actually interesting because at my hospital system, the non-physician staff have this, like the nurses and my front desk person and the MAs. All of those people have a built-in cost of living adjustment. But the physicians don't, interestingly. So this is pretty standard in every other industry except for ours. And so you can ask that that bill be built in. You can ask for a cost of living adjustment be built into your contract. As far as raises as just keeping up with market data, I think it's worth looking at the market data. For the most part, physician salaries have gone up over time. I don't see that changing a whole lot because supply and demand is about to get a whole lot uglier when I think a lot of people are gonna leave the workforce once the kind of acute trauma of COVID happens and kind of settles down. So supply and demand has been a problem. COVID is gonna make it worse. So I don't foresee physician salaries going down a whole lot. I suspect they'll continue to go up. And even with COVID, a lot of folks had pay cuts and things. A lot of folks didn't. I made more money the year of COVID than I've ever made my entire life as a physician. Part of that was because I was burning a non-compete. So I was doing locums for a little of that time and then doing a permanent job the rest. But part of it is because the supply and demand mismatch was made worse by COVID. So I was able to leverage that and negotiate better deals. So I think that paying attention to market data and noticing when you're below that. So the salary you signed three years ago that might've been really competitive may not be competitive today. So keeping up with kind of what's the market data, what should I be being paid? And a good free resource for this is like Medscape. Dr. Lee talked about those Medscape surveys. They ask salary data. It's not perfect because it's based on recall bias and it's asking the physicians directly. And so different people might include different pieces versus the paid data sets are gonna be specifically from W-2 and 1099 data. So they're a little more objective, but it's a good jumping off point. If you notice like, hey, pay in PM&R has gone up over the last couple of years. Maybe it's time for me to ask for a raise. And how much of a raise you get depends on how much you can ask for. How much value are you providing? What are you not being paid for? So I don't know that there's a usual raise, but I think that there's almost always room for one. Let's see. What do I say when they're putting on pressure on signing the contract and you're reviewing? Just refuse to buy that bunk is my short answer to that. I have all sorts of four letter opinions on this. So it benefits them to put pressure on you because you're not gonna consider it as in depth. You're not gonna get the advice you need from the people you need to review it. And that only benefits them, not you. Now, sometimes they have a very reasonable reason for this. Like, hey, we wanna extend it to a different person if you're not going to do it. And I think that having a real transparent conversation with them of, look, I'm interested. I'd really love to make this work. It is important for you as well as me to protect myself and to make sure that this is a long-term solid relationship. In order for that to be the case, I need an attorney to review this. I need extra time. And if they say, well, we're going to have to revoke the contract, that would be the most extreme example if you don't get it by XYZ date. Really consider seriously, do you wanna work for someone who's gonna give you ultimatums based on unreasonable requests, right? It is completely reasonable to want an attorney to review your contract. It is completely reasonable for it to take a month for you to get back to them. That is a very normal time window. If they say, sign this by Monday or else, maybe you don't wanna work there. How are they gonna approach things when you break your ankle and you need to be out of work for two weeks? How are they gonna approach things when life happens if they're so concrete against you taking the time you need to make sure your relationship with them is well-defined? So you have to take that as an individual circumstance certainly, but I consider it definitely a flag if they're really, really rigid and not willing to entertain very reasonable requests like I want an attorney to look at this contract. So it's a multifaceted answer to that, but I would be cautious to that. And most people in that circumstance are just trying to get you to sign it as is and not consider things. Most people are going to be really well-received if you say, look, my lawyer has it, it's gonna be another week, I'm sorry. Blame it on the lawyer, it's totally fine, like no problem. And any key pointers to negotiating locum contracts? Yes, everything's negotiable and don't let the recruiter tell you no. So when you're negotiating locum contracts, I think the key thing to know there is that the middleman is getting a cut. Most of the time there is a set price that the hospital is paying the locum's agent. And what you get paid is just a balance of how much they get and you get. So say the hospital is giving them $5,000 a day to put a PMNR physician in that spot. If you get $2,000 a day, all of a sudden the agent gets 3,000 a day, right? Or the agency. And the agent usually is a commission-based employee. So they benefit from you getting as little as possible. The cheaper they can get you in there, the better for them. But at the end of the day, you're the talent. They don't make any money if they can't place you. They don't make any money if they don't get that position filled. So it's a dance for them of how little can I pay and still get the spot filled. So call them on that. Like, I'm the talent. This is what I work for. This is what I need. They should be paying your licensing fees. They should be paying your DEA. They should pay your car, your flight, your home, your housing, whether that be a condo if it's a long-term gig or a hotel. I always liked it better to be hotels because I got so many hotel points that I will never again have to pay to stay in a Hilton for the year that I did Locums full-time, whatever. But like, pick it and they should pay for that. And if they say, oh, we only use Marriott brand and you're a Hilton member, ask for the Hilton. Fly the airline. Like, all these fringe benefits, like, ask for them. And for the most part, you can wiggle a lot of Locums gig, especially if they've had a hard time filling it. You should also always get paid time and a half for holidays is pretty standard in Locums. Thoughts on hourly fees for medical legal work. Dr. Verghese may have more input on this than me. You can set them. That's the beauty. Right, sure, yeah, exactly. It's very variable because it really depends not just on what your initial, how high you initially set your fee, but also your experience. So if you're just starting out, it's probably unrealistic to aim for the higher range, but also remember that you're working in an environment of attorneys who have no problem setting what might seem to us egregious hourly fees. So this is an extreme ballpark because I don't do this work. So this is just based on my colleagues that do, but it can range anywhere from one to $500 an hour up to $1,000 an hour. If you have a set base of previous reviews that you've done and happy clients that you can give names of. And I would say, if you have a lot of experience, there's no reason to consider $1,000 an hour a ceiling. As Dr. Street said, why set a ceiling? But I think that those numbers are probably realistic when you're kind of thinking about what your goals are. There's no reason you can't be hired. There's no reason that when you're starting out that you might be significantly lower, but I wouldn't plan to stay at a lower rate because you're setting the numbers yourself. And also there's some psychology to it too, because people tend to attribute value based on the price. So there is some research on people think that a more expensive handbag is better quality even though it isn't. So if you low ball yourself, you may actually limit the amount of business you get because people think that maybe you're not really that good. So certainly some experience does play into it. It's unrealistic to go in at the very top when you're just starting out, but also remember that there's probably more money in the pot than you realize. I do some medical legal work, so I can give you some ideas. So if you go to the website, Dr. Crow mentioned, seak.com, they have a data. What's the average fees for medical legal work? They have a courses too. Because we're a subspecialty, and if you have an additional board certificate in pain management, I'm a spinal cord injury specialist. So I get spinal cord injury related cases. My advice from my mentor was don't charge anything lower than what you can make in your clinic per hour. So for our specialty, if you do like a full limb EMG, you can make 400, 300, whatever, don't charge less than that. If you're beginning, I think the ballpark is around maybe 500, 600. If you're experienced, you can go up to 800 to $1,000. Also, those are hourly when you review cases, might be a little bit cheaper. So there's a separate rates for email communication, telephone communication by like 15 minutes, 20 minutes increments. You can do hourly rate for these kinds of cases, and then you have similar rate for the case review. When you have an in-person conversation, you can charge more. There's a separate fees for that position. If you're asked to go to testimony, you charge by half day, and then you charge by half day and full day. You wanna put in your contract or your fee schedule. They have to arrange all the traveling two weeks before, and the cancellation should happen before two days before because the day you go testify, you cancel all of your clinic. So think about how much money you make, and you charge at least even you don't get to go because you cancel your clinic, you wanna get compensated. And also the initial retainer, you charge about four to five hours of your base fee. That's an initial retainer. So you get to keep that money, and then you do the work. Once you're done, ran out of all the hours, you get have a retainer. Usually don't work any further because there might be some delay of pay. So you hold off your work until they pay you completely, and then you go by hours. So let me see. Okay, Dr. Crow, yeah, retainer. So those are the fee schedules. If you're thinking about doing medical legal work, look around a little bit. Let me put a website. They have a downloadable base, like an average fee schedules with other specialty use. You can kind of start from there. Yeah, oh, yes. I definitely had an attorney forget to pay, so make sure you get this. It was an act of Congress and eventually became not worth my time to pursue, which is annoying. Going up to the nondisclosure agreement to receive a proposal. It's unusual. I've heard of it once or twice. Like it happens. It's fairly unusual. I think for a routine clinical job, it's fairly unusual. Is whether or not it's a red flag, I think depends on the job a little bit. If you have like five jobs and they're asking you to sign that, I mean, I'm curious. So I'd be like, okay, I'll just sign it to figure out what it is. I mean, the nondisclosure agreement is just saying, I'm not gonna talk about this. It doesn't mean that I'm committed to the job. So you get to decide, but it's not common. It's not unheard of. So it's not by itself a total red flag, but it does make me start considering like how invested are they in pay transparency? How invested are they in equity? Because when you start having people sign nondisclosure agreements for their pay, that's like a whole step above just like having a confidentiality clause in your contract. And I think my concern is what inequities are present. So if you can negotiate something fantastic for yourself, it may not be a bad thing, but in the back of my mind is always, why do they feel the need to do this? Because it's not commonplace. So it's not the standard for sure. It's not egregious, but it's definitely not the standard. So why are they asking for it? Would be a question I'd have. And then I'd sign it because I'd be curious about what they didn't want me to talk to other people about. So that's just me, but you get to decide on that. What is a good source to find market value? MGMA doesn't have this data. Yeah, so I think when you have such specialization that these larger databanks don't capture that, your best market value is to get a couple options, get a couple of job offers, see what they're willing to pay for what you do. That's the easiest way for what you do specifically to be represented. Because at the end of the day, value is simply what somebody is gonna pay for what you offer. And there are a wide range of that. So get a couple offers, ask friends. I think those are good ways to get data on things that are so sub-specialized and so sub-niche that there may not be a lot of data actually out there on an objective scale for. Yes, locums work is gonna be a completely different policy unless you're doing like moonlighting at your institution in addition to your regular responsibilities. So when I did locums, first off, you wanna make sure it's occurrence-based or claims made with TAIL. So you wanna make sure that you're covered for the time you're there and afterwards. And you're gonna have a separate policy for each agency you work with at each job. So even within the same agencies, if I would work at a different site, I would get another certificate saying I was insured for that site for the next year or whatever. So you will have a separate malpractice policy for that. And they should cover that. If you are working through an agency, that is part of why they get a cut. They should provide malpractice for you. You should not be providing it on your own. And most of the time, my favorite way to do locums is to do a PRN contract with the hospital. That has served me really well. And I think it serves a lot of other folks I've talked to well. So if you can find a place where they need you, asking, hey, would you be interested in a PRN work? And they'll pay a travel stipend. They'll pay all the things locums agencies pay. And I found it's not a whole lot more work. So that's something as an option to kind of get rid of the middle man is to ask your peers, like what's available? Does anyone need help? Would your hospital be interested in a PRN person? Yes, oh yeah. And Dr. Lee brings out a great point. When you're negotiating your contract, there's an outside work part. Like mine is I think a whole page long because I put in a bunch of addendums, but there's a whole paragraph or page of your contract deciding what you can and cannot do outside of your work for them. So you wanna make sure that that is as protective as possible of you. You wanna have the most freedom and flexibility to use your skillset and your other skillsets in any way you want to. So for example, like I have several things bulleted out. I think mine is very generic where it says I just have to ask permission, but I wanted pre-permission for certain things that I knew were gonna be applicable. And I wasn't willing to sign the contract unless those were carved out. So it was very valid for me. And so we just addendumed that part of the contract saying with exception of blank, blank, blank, blank that I can do. And some of that's clinical. I was actually able to talk my current employer into letting me keep a PRN position with a hospital across the country that I really enjoyed when I was doing locums work. And I do telemed for them on Fridays, which is a day I don't work. So yeah, you wanna have that protecting you. You want that in the contract. Data on locums pay for PM&R. So I'm not super familiar with that specifically. Locums varies a lot more than some other things. So it's gonna vary based on how hard they've had a time placing that position. And it's gonna vary based on how many docs are available versus how many positions are being requested. I think the best way to get that data is just to talk to a couple of locums agents probably or talk to your peers. But I don't personally know off the top of my head what the pay is for that. I don't know if either of y'all do. All right. I can tell you MFM, it's not gonna help you very much. There's a Facebook group for female physiatrists. Dr. Crow is in that member, I'm the member. And then there's a whole bunch of people who does locum. So sometimes we ask those questions in our more kind of close relationship. It's something that some people don't feel comfortable sharing those information, whatnot, but you can always mesh the people. So if you're a female physiatrist, there's a Facebook group you can join. And we talk a lot about work-life balance because a lot of us are mom. And that's very unique situation compared to male physicians kind of stuff. So there's other support and resources too. And I would also add, if you're not able to join, if you're not female or for whatever reason, I'm not able to join the women physiatrists Facebook group, there's also the phys forum on AAPMNR where you could post a question. Cause I don't personally have that data on my end. I don't personally have that data on PMNR locums, but that kind of question is a great thing to pose to the general AAPMNR population. Yeah, some people just message you with a very valuable information. So it's a very supportive environment. So don't feel bad about reaching out and asking questions. There's a lot of people who wants to really help genuinely. Thanks for having us. Is there one more question or are we all done? No, I think we're done. Thank you very much, everyone. Thank you.

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