All right, so good morning, good afternoon, good evening, whatever it might be, wherever you are watching this. Really excited to present this section or this session, pardon me, on decision making in practice settings, specifically in the spine pain space, but I think that the decision points that we're going to talk about during this conversation are pertinent to a variety of practice settings, subspecialty or specialty types, and a variety of sort of decision points. We want to make this as informal as possible, obviously that's a little bit challenging with a prerecorded webinar format, but we're going to try our best to make this more of a conversation and less of a lecture, therefore we don't really have any slides for this section, but we really are going to have more of a Q&A sort of feel. So with that said, I'm going to just take a couple of minutes and introduce myself and then give each person a chance to introduce themselves as well. So my name is Mehul Desai, I'm a physiatrist who's board certified in physical medicine rehab and also pain medicine. I practice in Washington, DC. And one of the perspectives I hopefully bring to this discussion is that I've sort of been in various different practice settings. So I started, I finished fellowship in 2007 and joined academic practice at George Washington University Hospital in Washington, DC, where I was in the division of pain medicine, but in a department of anesthesia. So that provided some sort of unique, both advantages and challenges. I left GW in 2013 and went into private practice, first joining a large orthopedic group and subsequently joining an anesthesia run pain medicine group. And then started my own practice in 2016 back in Washington, DC. And now we have a group with physiatrists, anesthesia trained pain medicine physicians, and also physical therapists. So we have sort of a interdisciplinary multidisciplinary group that we work with. And I think that, boy, some of the challenges and decision points that we face have certainly evolved and changed over the last 13 or whatever years I've been in practice. I think that sort of the key features and factors remain somewhat similar. And I work with lots of different people who are looking for jobs. I get lots of calls about people looking for jobs with us, and a lot of the same questions come up. And I think while those questions probably remain the same, we have some really interesting and unique challenges right now, specifically to COVID-19 and how that may change the way people look for jobs, the kinds of jobs that people look for. And so we'll talk a little bit about that as well. The objective here is to really sort of, you know, not necessarily get into the key features of the differences between work RVUs and contract negotiation, but really sort of, to some extent, 30,000 viewpoint of what people look for, what important points might be for them. And that's sort of part of what's unique about this. And what's important to me might not be important to one of my colleagues here up on this panel. And vice versa. And I think that provides for some novel insight into the things that, into the way people think. And I think additionally, I think that as people look for jobs even more these days, virtually, maybe more so than in person, asking some of these questions, both of your potential future employer, but also of yourself going into the conversations will be really important. So with that, I'm going to introduce, or at least pass the baton on to Dr. Purcell. And she'll hopefully give us a little bit of about her background, about her practice, and go from there. Dr. Purcell. So my name is Annie Purcell, and I live in Redding, California, which I'm representing the Boondocks in this talk. I live in a small town that is where I grew up. And we have about 90,000 people who live here, a little airport with one gate, one terminal. And we serve a medical community of about 200,000 people with the outlying areas, but it's definitely rural. So I am a physiatrist in private practice, outpatient musculoskeletal. I did an interventional spine fellowship, and then went straight from fellowship to opening this practice. I had wanted to return to my hometown. So I had a few options to maybe try to join with ortho group, or just start out straight on my own. And I went back and forth with that, but ended up just going for it with literally, like, no business knowledge, you know, just getting the loan, figuring it all out as I go. So that was 10 years ago, 2009, we opened the practice called Redding Spine and Sports Medicine. I didn't do a lot of, I didn't interview or look for anything else. I just decided to throw all the eggs in this basket and go for it. So the environment has certainly changed a lot in the past 11 years since I opened this practice. A lot of people want to consider opening their own practice and ask me a lot of questions about it. You know, I think it's always possible, but one of the key factors in my transition in my career was, if it's something you're considering, going straight through, I think is actually a huge blessing because you're coming out of debt. And a lot of people think, let me get a job and make money for a few years first, and then I'll feel more secure to do it. But it's actually very hard for a lot of my colleagues to go back and leave that salary behind and borrow money and start a practice. So that's sort of one pearl about my path that might interest people. So the practice that I have, it's a single specialty, so two physiatrists. We do a lot of office procedures, musculoskeletal ultrasound, we do interventional spine procedures and EMGs. I also took a recent interest in doing some lifestyle medicine that's sort of shifting with how I'm practicing. Over the 10 years, I've had three separate advanced practice providers that I've worked with. So I've learned a lot about that on the good and bad side of things. Unfortunately, right now, I'm not working with one. And we have a staff of seven or two doctors. We have our billing in-house, which I wasn't confident to start out the practice that way. I started with a billing company, while I took the time to sort of learn how to be the boss of a biller. So that's a little scary area. So something else to add about that is just whatever practice setting a physician finds themselves in, I think one of the most important things is to be able to look into your billing and collections and understand what's going on back there. A lot of physicians, it's more of just, oh, the money's not coming in. Once the money's not coming in, it's kind of too late. So I encourage across all practice settings to know where and how the money's coming from, how to check on it. I think that's going to lead to success in any setting. But I personally had a long journey of learning all that myself, several things the hard way. But overall, it's been worth it. And the autonomy was the main factor for me on going this route. And I'm going to jump in for a second just to sort of comment on some of the things Dr. Purcell said. I think that Dr. Purcell and I have joked in the past about setting up a sort of a practice management or how to start your own private practice from scratch, sort of talk for the annual assembly. Because I think it can be daunting. I mean, I think you mentioned some of the things that rise to the top in terms of how daunting it can be. But sort of every day while you're becoming facile at being a doctor, you're also becoming facile at being a employer, an owner, a boss. Those are all things that take practice. And so I think I've always felt a great deal of admiration for what you've accomplished. And so I think that takes organization at the very least, right? So you have to be really organized because some of those resources exist, some of them don't. And I think the other key point that I wanted to sort of talk about in terms of what Dr. Purcell said is that when you're looking, if you run across a practice that's unwilling or unable to show you what the cash flow looks like, what their books look like in general at least, that's probably a red flag. If there's that level or that much lack of transparency before you even signed on, that's probably not a great sign that there's going to be any further transparency once you've signed on. Because if you think about jobs, the best someone is is when they're dating you. Once they've sort of gotten you to sign up, you often get the real person. So these are just little things that come up that you want to keep an eye on. I mean, I was just, I had a conversation with, I've had the pleasure of sort of working with lots of future physiatrists as medical students and as residents. We work with Georgetown residents and GW medical students, and I still get calls from people asking questions about things like this. And I was just on the phone with a colleague who talked about their contract and it was astounding in some ways how bad their contract was. And I was sort of shocked to hear about the details of that contract. So there's two sides to contracts. If it's too good to be true, it's probably too good to be true. And if it's really, really that bad, you probably shouldn't sign it and you should think about it before you sign on. So I want to, with that, I'll pass it on to Dr. Sarno to give us an introduction about herself and we'll go from there. Dr. Sarno. Thank you. I personally want to thank Dr. Desai for including me in this panel. I'm one of those medical students who Dr. Desai has mentored when I was a medical student thinking about physiatry as well as pain medicine. I had such valuable advice from you, so thank you, and continue to learn. And also I'm really impressed with Dr. Purcell and what you've accomplished as well. It is complicated, so I'm just really glad you mentioned those points. I did my physical medicine and rehabilitation residency at New York Presbyterian, Columbia and Cornell, and then went to Boston for a pain medicine fellowship through the anesthesiology department at Mass General Hospital. And then I stayed in the Boston area. At the time of my fellowship, the opportunity arose in the Department of Neurosurgery at Brigham and Women's, and I would still be considered faculty in the PM&R department, but I would be the first physiatrist in the Department of Neurosurgery there. And I had often heard about orthopedic surgery hiring physiatrists, so this was new for Brigham and Women's, at least for the Department of Neurosurgery, to have a physiatrist in their spine service. And so I thought it was a great opportunity, and I mostly considered academic practices as adventurous as I am with travel and food. When it came to feeling comfortable in my career, academics was something I was very familiar with throughout medical school, residency, and so I didn't consider outside of academics at least to start. I had heard from different people that sometimes it's easier to start off in academics and then go to private practice, but everyone has their own perspective, and that was something I felt that I could at least start off in. And now I'm very happy in this particular area. I really enjoy teaching medical students and residents, as well as pain medicine fellows, and I've taken a very active role as teaching faculty for the anesthesia pain fellows at Brigham and Women's. And so I found a lot of value in the collaboration with my anesthesia pain colleagues, as well as with my fellow physiatrists. So being part of the Spalding PM&R department, I am also part of the spine and pain division for the Department of PM&R. So I really appreciate and value the support that I get from the PM&R group and my colleagues there. And so it does mean a lot of faculty meetings, a lot of division meetings in all these different departments, but I have my different roles with each department, which I'm grateful for. So within the Department of Neurosurgery, I serve as their non-operative spine specialist. So coming in, I already knew that there'd be a referral source. I'm seeing a lot of the patients that the neurosurgeons really don't want to see at first, people who haven't had imaging yet, haven't done any physical therapy, haven't tried interventions. And so when I first came on, that was a role that I was able to provide and continue to expand upon, and I've really enjoyed that aspect. And then teaching the PM&R residents, especially mentoring ones going into pain, I have really enjoyed showing the PM&R residents some of the interventions, getting them involved in research. So I'm mainly involved with simulation-based education research, so developing a curriculum for pain medicine fellows, learning how to practice and perform these interventional pain procedures on a cadaveric spine model with a thermoplastic material and developing a curriculum around that to teach the fellows in a safe and allow them to practice in a safe way. And then the PM&R residents get involved by actually learning how to manipulate the C-arm and collecting the data and getting involved in research in that way too. So just to sort of, I think one of the things that you mentioned that I think is a huge advantage of what you're describing. So if we were to strip away some of the other things that are great to have, like it's an incredible luxury to be a part of academic organizations where you have academic appointments and you're part of the PM&R department and neurosurgery and involved with pain, which is, I mean, you've been able to carve out a really sort of magnificent niche for yourself, which is amazing. So that sounds lovely. One of the things I'm sort of curious about and to get your take on is, and you talked about this, the jumpstart you got for your practice, if you just look at this purely practically in terms of patients coming in the door, how would you weigh that for yourself as important versus not important? How meaningful was that for you? I thought it was pretty meaningful to be able to start a practice and not have to do any marketing. So in the beginning we had a marketing person meet with me, but then that wasn't even, we didn't actually do the marketing, the clinic was filled pretty fast with the patients that were calling a spine surgeon thinking that they needed to call the Department of Neurosurgery because they're having low back pain. And I think the call center was always relieved and the neurosurgeons were relieved to just know that they had now someone they could say within their department, keeping the business within the department. Typically they would refer out and then having the neurosurgeons or mostly see patients who are actually surgical. So it was helpful to know that I was coming into a place that I wouldn't have to worry about volume. Some other areas I thought maybe I would have to put more effort in, which I'd be willing to do, but it was nice to actually just know that the clinic would be filled and I would just expand and grow. But the problem was is actually, and we'll talk about some cons too, but there are a lot of politics that are involved within departments getting actually fluoro time. So I actually, although I had many patients to see in clinic, when it was time to actually do a procedure, I didn't actually have enough procedure opportunities, so enough procedure space and enough fluoro time at first. And I was told in the beginning, we're going to expand, actually I did get to expand, but I actually ended up referring patients to the pain medicine folks because they actually could get them in within a reasonable amount of time. But I think I'm sort of curious for you to extrapolate or expand upon that a little bit at least. What were the political ramifications with that sort of role? So one of the things that's interesting about what you're describing is that you've sort of got PM&R and they're doing some of this. You've got anesthesia-based pain. They're clearly doing some of this. Then you start having people who are like orthopedic spine hiring their own folks and neurosurgery hiring their own folks. And what ends up happening is you're cannibalizing, whether it's, you want to use that term or not from the organization and you get this divvying up of patients. So have you felt that? Have you seen that? Have you had people comment upon that? Yes. Yes. I knew that me coming in in this role when all the neurosurgeons already had a pathway to anesthesia pain, I already had in my mind how I might be perceived that I'm coming in and taking away patients and perhaps there might be more of a competition feel. With that, I just, I did already know I had my goals of teaching and I wanted to be collaborative with my anesthesia pain colleagues because I knew there are procedures that I don't do or I didn't want to necessarily do. I was focusing more on spine care. And so I know I can expand as I grow in my practice with the procedures I do. But if there are any things that I feel like I want to refer, I wanted to establish a nice relationship with anesthesia pain colleagues. And they refer patients as well to me, especially knowing our diagnostic capabilities as musculoskeletal experts. And I found that that helped ease any of the, that perhaps potential competitive vibes. I'm making sure to, when I had at first starting my practice doing spinal cord stimulation, connecting with some of my anesthesia pain colleagues and working in the OR together and then developing this curriculum for the pain fellows helped to actually establish more of a bond and less of a competition. I had heard about previous politics with previous leadership through the anesthesia department with physiatry. And so I was already aware of some of that between departments. So the good thing is that there are enough patients to go around these days. I mean, unfortunately for chronic pain, but that they're in chronic pain, but there are enough patients that we don't have to look at it as much as a competition from the ortho side. There's another physiatrist who is our division chief actually. And so he was actually a mentor. And so if patients couldn't get them to see him and I had opening, I could see them too. And at first I wondered, is that, is that okay? You know, the patient saw you first and now they want to see me and we all, we all share. And so I've seen that over the time that we can all actually collaborate in the care of each of these patients. Yeah. so I think the only comment I would make, I think, just to kind of balance out what you're saying is, you know, in some ways, what you're describing is sort of a relatively ideal state situation, right? So where people are willing to, to create those collaborative relationships or to have conversations to are open to sharing and open to collaborating. And I think that occurs oftentimes at large organizations. Also, you had the opportunity and ability to gauge the temperature of the organization before you started, because you already, you're a fellow there. So you kind of had, you knew the ropes, right? So I think one of the things, my, one of the pieces of advice I would give people who are maybe listening to this, who are going in blind, right? Like they've, they've trained at organization X, but they've accepted a job at organization Y in the Department of Neurosurgery. Spend some time trying to learn the politics, build as many bridges up front as you can, as opposed to trying to sort of maybe go at it alone completely and sort of destroy any potential bridges that you might be able to build, because nothing can sort of tank a career faster than sort of, you know, that sort of process where people close ranks. And although I agree with you a hundred percent, and I've experienced this many, many times that we, there's plenty of patients to go around. It's always shocking to me how many people close ranks and get upset at the concept of, sorry, of that. With that, I did want Dr. Purcell to maybe comment on how she found getting patients up front, like when she was, when she started a brand new practice from, from scratch, because we talked about how it happened for Dr. Sarno. Yeah. We, I took an old school marketing strategy because it was a small town and I basically felt like people were probably not going to send me their patients until they met me and had a sense of me in person. So I did develop a lot of materials to let everyone know about what we do. But it's not as simple as just, you know, sending everything out, faxing things out, sending letters. So I actually started with a party. We, I knew a few physicians in town, only a couple, because I'd been gone for like 15 And I just asked them, we hadn't just invited anyone. And we had like about a hundred people come to this party where we could just mingle and meet people and tell them what we do. They were invited by other doctors. And so that was huge because that only took one night of my time. And that really got the ball rolling. And then like, honestly, my main strategy and I did this 10 years ago and I thought I'd do it again every few years, but I've just never had to do it again, is that I just scheduled either lunches or a drop in coffee, you know, have my staff schedule it with their office. You buy food for the whole office so they won't let you in. And you just ask for five minutes of the doctor's time, whoever you're targeting. I targeted primary care and spine surgeons. And I would just go in and, you know, you only ask for five minutes. That's how you get in. Don't ask for their whole lunch hour, but just tell them what you do. Let them see what kind of person you are. Let them ask you questions. A lot of them would sit and talk and have lunch with us for an hour, but you know, then it's like we're friends. So they'll give me one patient. If I do a good job with it, they'll come, they'll keep coming. And so I never even got through the whole list of everyone I wanted to do that with because my schedule is full and I'm seeing patients. But I think that could work well for a lot of different settings. You know, they need to see what kind of person you are in person. I'm the same way. You know, therapists always drop all this stuff off. It's like, who is that? You know? So that was my main strategy. And then just, you know, just showing them the best service. And then another thing that comes up about the turf and all that stuff is that, you know, when we came to this town, we were taking some business from other people or there were overlaps, but there were plenty of patients for everyone. And the best way I think to approach it is to like meet your colleagues, see what you may not have in common. Like we really aligned with some anesthesia pain guys who do stims and pumps because we don't. And then, you know, they learn more about EMGs and send us their EMGs. We send them those and, you know, just try to see what you can do for each other and just have respect for the other people. It worked really well. It was pretty simple. Like I don't do marketing. I actually don't like having like being in the phone book or, you know, advertising like to the general public. I prefer the direct referrals to make sure they have a physician taking care of them. So marketing is, was pretty cheap, you know, by, I bought like a bunch of lunches and a dinner party like 10 years ago. Yeah. And the reason I asked that question is also that you're sort of, a couple of different points come to mind. One is you're talking about some of the differences between maybe a less urban practice and where the medical community is fairly tight knit and knows each other and wants to meet the new person, right? So the fact that you had a hundred people show up to an open house is amazing. That's great. You know, if I do an open house, we did two open houses in our DC office and our Arlington, Virginia office. And we literally had in the DC office, we had like 60 people show up, but 58 of them were physical therapists. And in Arlington, we had three people show up. Right. And because it's in the district, in Arlington, in urban centers, people are like, I got to get home. Like my commute's an hour and a half. I'm out of here. Right. But the other reason I asked that is because when people take jobs, oftentimes they're not aware of how much of their reputation, their reimbursement, the kinds of patients they get is based on developing referrals. And really nothing beats the old fashioned, like knocking on doors and making appointments, as you said. And people want to know who they're referring to. I mean, the more, the longer you're in practice, some of that changes and people start coming to you because their sister, their aunt, their cousin, whomever comes to you and they had a good experience. But in the beginning, it's a huge part of it. It's sort of, hey, I know that doctor. And if everyone got referred to the best doctor, there'd be, you know, a few people would have all the patients. It's really who you know, that makes a big, big difference in these settings. So with that, I wanted to emphasize, oh, sorry, go ahead. No, please. I just wanted to emphasize what I said is very specific to like a smaller town type area where there is a medically underserved community. So, you know, you go in like, New York, New Jersey, D.C., you know, this is not going to be easy to do or everyone else is trying to do it. It's an oversaturated by specialty. So, you know, I do caution people when they're looking to open a private practice. You can do like what I did if it's if the area is open to it. And so if you can find a town that doesn't have an interventional physiatrist, you're not going to have to do much to be successful. And then I have colleagues fighting it out, you know, in the tri-state area. And no one even wants to let you drop off a coffee and say, hi, like they're over it. You know, they're busy. So it's very regional. So I think that's a really good point. Yeah, and I'm always asking Dr. Purcell if she's going to hire me so that I can come work in Reading. With that, I, you know, I first and foremost, I really want to thank Dr. Sully, who's going to introduce herself next for making herself available at sort of a very late juncture. So I really appreciate your time. And I'm really excited, actually, because you bring such a different perspective than than the rest of the folks on this panel, including myself about your background. So love to hear about you. And I'll pass it over to you, Dr. Sully. Sure, thank you, Dr. Desai for inviting me to be a part of this panel. So I graduated physical medicine and rehabilitation residency from University of Pennsylvania. And I did a sports buying fellowship at a private practice with a year of academic work in between. So similar to Dr. Sarno, I was working in a surgical primary surgery department under the orthopedic surgery umbrella. And so that department was a little bit different from what I had experienced before, primarily being in PMR, but I really enjoyed it. I really liked the multidisciplinary setting, I thought it was probably the easiest way to coordinate high quality care and bounce ideas off of each other and learn from each other. But pretty much since my fellowship, I've been affiliated with the VA, the VHA. And, you know, I suppose I've been fortunate in that, you know, every department that I've worked for has already been well established and developed. And so I didn't have to do a lot of, you know, teaching to my colleagues about what we do. I didn't have to worry about finding patients or referrals. I did try to establish good connections with PCPs, with rheumatologists, with neurology. But primarily, I do EMGs, ultrasound guided interventions, some spine. I've worked in a couple different capacities at the VA. So I've been a full time employee. I've also had an employee status, which is called fee basis. So it's different from the full time in that you're almost like an independent contractor. So you kind of get to set your own schedule. And as long as there's a need for what you're doing, and you're consistent with that, then it usually works out pretty well. At least in my experience, it has. So if you don't want to work Fridays, you don't work Fridays. You just want to work three days a week, you can work three days a week. I mean, the there's some pros and cons. I mean, I guess the flexibility to the schedule is probably the biggest pro. The con is that you really are only paid for the work that you do. So if you have six patients scheduled, and it's a bad weather day, and only two of them show up, you only get reimbursed for the two that you saw and whatever you whatever procedure you did for those two. So that's, that's one of the cons of it. And then there are no benefits like health care benefits or retirement. But with the increased flexibility in my schedule, I've been able to pursue some other initiatives that have been important to me that I haven't really had time to do before. And so I've been able to start with some policy work. So I'm working with the Florida Department of Health, as well. I am in the middle of my MBA. So I aspire to work more within leadership and healthcare and healthcare systems. So that's pretty much what I'm doing. Well, interestingly, I think I wonder if there'll be a rash of applications to the VA system now that you're here to give this talk. So I guess maybe at a high level, and maybe some specifics too, but sort of you'd mentioned two sort of models, right? So it's within the VA, one was like a full employment model, one is almost like a, like a contract employee, right? So what do you, so from a physiatry perspective, what do you think the benefits of one versus the other are? Or could you talk about the benefits and maybe the disadvantages briefly of one versus the other? And how did you choose? I mean, you kind of mentioned that you wanted the flexibility, but were there some other factors that went into that? Sure. So as a salaried employee, the full-time status, you know, I have to mention that I think veterans are the biggest pro to working at the VA. They're a really great patient population, and I'm just so honored to be able to serve them. So that's, you know, the pros for being a salaried. Also include that, you know, this is not a for-profit-based system. And so I think there is less focus on your work RVUs, and there's a little bit more time, in my experience, that's allotted for patient care. So your patient visits can range anywhere between 20 and 60 minutes, depending on, you know, the reason for the encounter. But that's certainly longer than most of the patient care visits that I've had, either in my private practice as a fellow or my one-year working in academics. So I really appreciated that, like, focus and time to provide high-quality care. Because the VA has its own system for healthcare, you don't have to, there's not as much red tape for getting medications approved or procedures approved. Another benefit for being a salaried employee is the healthcare benefits, the retirement benefits, there's a pension plus the equivalent of a 401k with matching, and parental leave that has just been approved. So mothers, fathers, even adoption counts all towards 12 weeks of paid parental leave, which is something that you don't really get to see in a lot of the other models in the private sector. Another benefit of being a salaried employee is that there is no restrictive covenant. So I've never seen a non-compete in a federal contract. The cons are that, you know, it's a pretty rigid schedule, you know, 40 hours a week. As in comparison to the fee-basis employee, your schedule, like I said before, is much more flexible. There is fewer politics to being a fee-basis because you don't have to go to, you know, all of the admin meetings, you're not really expected to participate in that way. I think another pro of being fee-basis is that there's an easier way to transition to a full-time employee if they know you, they see your face, they think that you're doing good work, and they don't have to go to the admin meetings, they think that you're doing good work, and a position becomes available, you know, that would be an opportunity for you to sort of get ahead for that consideration. Being an independent contractor, there's still no restrictive covenant. I mean, but the biggest con to being a fee-basis employee is the wages. So kind of like I mentioned before, like with COVID, for example, that really slowed down credentialing because I just transferred VAs. And, you know, that because I wasn't credentialed yet, and I wasn't doing any of the work yet, that was a major decrease in salary, because you're only really paid for the work that you do. So it's not, because of that, it's not a model for everybody, I think. If you're doing a private practice on the side, and you work in your private practice for three days, and you use two days as a fee-basis employee at the VA to supplement, that might be a good model for you to consider. Or if you have a spouse, you know, that has a pretty steady and reliable income source, and you're happy to be a fee-basis employee, knowing that your salary can really dip at any time, there's no contract for that. So that might be a good model for you, but it's certainly not a model for everybody in that respect. Also, there's no benefits. So all of the great benefits that I mentioned before, you don't get in fee-basis. Yeah, and I think, when you're talking about that, when you start using some of the more systems, like the VA or Kaiser, one of the things that are probably underrated, and if that's a system that appeals to you, is sort of the pension 401k portion of things. So I think one of the things with, and I don't know if the VA has it, but with Kaiser, there's a mandatory retirement age. There's usually like three different systems of retirement. There's 401k, there's sort of another profit-sharing model at Kaiser, I believe, and then there's also a pension. And the other thing that's interesting, when you are a sort of a contract employee, where there's no benefits, they're actually, if you, one of the models you described is if you have a prior practice where you're working three days a week, and then you work at the VA other days, you can actually take some of the money, you can take actually a larger sum of money and put it towards retirement through something called a SEP IRA. If people don't know about that, you should talk to your accountant. It's basically a self-employed plan IRA, and you can put like $80,000 a year towards your retirement, unlike an employment position where you're capped out at about, I think it's 16.5 these days. So there's a lot of nuances that you can sort of look at when you start getting into those kinds of things. This has been great so far, so I want to kind of dive into a couple of questions. I'll start with Dr. Sarno. When you were looking, and clearly, you know, you landed in what sounds like a terrific location and terrific department and a terrific position, but what were some of the models you encountered or you considered during your job search? So mostly I was looking to stay in academics, and so looking into different models, such as being in a department of PNR, working with other, and then working with the Department of Neurosurgery or Orthopedic Surgery, where some academic centers had physiatry opportunities in departments of neurosurgery, but without a home base of physiatry. And so I noticed that I was gravitating towards being within a department of PNR, I felt that would be very helpful, especially just getting out of fellowship and to have that home base. So although there were some opportunities with higher base salary and some other locations and other non-PM&R based departments, I just, I did feel that it would be worth it to be in the Department of PM&R and to have colleagues that I can grow and learn, since I just felt after a fellowship, I'm still learning so much and I'm continuing to learn. Four years in, I'm always learning and having that support structure I felt would be very important for PM&R. And I noticed that it also varies, I'm just talking to some of my colleagues who also had applied around the country, the compensation structure is very different depending on where in the country you are, city versus rural, and also taking into account just what kind of other things can you negotiate. So when I was looking into opportunities, not just looking at the base salary, but what are the incentive opportunities based on your productivity, and as Dr. Purcell was mentioning, the financial piece of it can be very complicated, and so I wish I did have better understanding of billings and collections, and I'm still learning. So at that point it was more about what is the daily life looking like in these different models, and am I expected to take over a practice that have a lot of patients on opioids, and could I have the support of a department to have more of a non-opioid based practice, looking at other strategies, and what would the administrative support look like, what would the potential opportunities for having, working with a physician assistant or a nurse practitioner to help support clinically the workload. So when I was learning about this particular opportunity, and knowing that there was opportunity for potential growth, not just for a salary or incentive opportunities, it would be more of a potential to have support from a physician assistant to help with administrative and clinical tasks while you continue to focus on your clinical volume as well as research and education and teaching. Great. No, that's really helpful. Dr. Purcell, I know you didn't necessarily interview in a lot of places, and you sort of, as you said, went all in on private practice, but what were some of your considerations when you started thinking about your practice and what made you sort of gravitate towards private practice rather than academic medicine or an employment situation? Yeah, the main thing was in fellowship, learning the interventions and, you know, knowing that they're the highest value reimbursement of what I do, talking to people that were a few years ahead of me in different settings for interventional, I just felt like I could not be happy or be authentic and practice patient care that I wanted being someone's employee because there was always going to be those incentives. How many blocks did you order? How many blocks did we do? Like feeling that pressure. I just felt like I could hate my job and it just seemed like a common feature of every setting, you know, not just your salary being determined by how much procedures you perform, but like it being a requirement. So I just felt like I can't be happy unless I just, a patient, I think they need it. That's what I'm going to do. If they don't, I don't and I'll make less money, but I can go to sleep at the end of the day. And so I actually just got a lot of anxiety talking to people in some of these interventional pain settings and I just knew I wouldn't make it. So that's what just made me willing to take the risk. I didn't even interview in those settings at all. So it's just more of a personal choice. And then also just wanting to control when I work and when I don't, you know, you know, I just couldn't, I just couldn't see myself doing it. So I think a big part of that was being willing to take the risk and also being okay with making less than people in those settings. And, you know, sometimes I found some ways maybe to make more, but I didn't know that at the time. So it was just more about just feeling right about what I'm doing and not feeling like hospital systems were offering that and not feeling like large interventional groups were offering that. Sure. Dr. Sully, can you comment on that at all? I know you were saying this, but. Sure. You know, I actually didn't focus very much on the WorkRVU component very, very much. I probably should have. I really was just focused on, you know, would I be able to hone my skills? There are some departments that, you know, if they were hiring you in PMR, they really didn't have room in the fluoro suite for anyone in PMR because that was already being taken by pain or they didn't have an ultrasound machine yet, but they promised they're going to buy one, you know, in a year or two years. And that was, those were red flags to me. I really wanted, you know, a practice that I was able to utilize all of my skills. I didn't really want to give up anything that I had learned already in my fellowship. And I wanted to be able to focus on quality and in spending time with patients. And so I really didn't want to join the high pressure, high volume sort of practice setting. And then finally, I was also looking for the multidisciplinary groups because I really did enjoy that time in academics when I was able to, you know, speak with the neurologist, speak with the surgeon and pull up the MRI and show it to them and, you know, do lifelong learning like Dr. Sarma said. Yeah, so I think you've got academic medicine, you've got professional employment, you've got system-based employment, you've got private solo practice, private practice within a multi-specialty group, private practice within a neurosurgical group, private practice within an orthopedics group. And I think there's no, there's no better or right or wrong. It's really about how you value your time and how you value what you do, right? And what things you need in return for the things that you value. So I think some of the points that were made here, I mean, clearly they're incredibly important. And rather than saying one is right or wrong, I think it requires someone to do some self-reflection on what is most important to them. Because otherwise you'll just find a job that you think you want, but you won't actually like it as Dr. Purcell said, because you'll do a job or you will be compelled to do a job that you don't really want to do. So there are clearly huge advantages and disadvantages to every single one of the models that we've talked about. Because if you, for example, work with a large orthopedic group in South Carolina, you may, if they treat you as an equal, you might get partnership in a very large group eventually. You may get partnership in a bunch of ancillary services, ambulatory surgery center, durable medical equipment, et cetera, et cetera. And your direct reimbursement, while maybe somewhat limited, may be augmented handsomely by a lot of indirect revenue from other things that you have ownership in. Whereas on the other end of the spectrum, working in a large hospital group or a large university-based practice, you may have a great base salary in some of those cases, but your ability to augment any of that may be limited. Now that's important for someone who values that collaboration, as you guys talked about, but also maybe security as opposed to someone who maybe wants to take more of a chance and is that, that's sort of their personality. I think Dr. Purcell talked about this sort of to some extent, pain medicine or spine medicine or interventional spine or whatever we want to call it for the purposes of this discussion has been commodified. And what I mean by that is the value that you bring to a practice is often perceived only as the volume of procedures you're capable of doing in a given day, a given week, a given year. And I think that's sort of, it's a challenge to fight that because ultimately from the perspective of the hospital, from the perspective of academic organization, from the perspective of a private practice, from a perspective of any of those groups that we talked about, more is more, right? Like, and less is less. And so everybody wants more. And I think that's an interesting thing to sort of ascertain upfront and to dive into and understand it as much as possible. And similar to that, and this sort of segues into the next question, and I want to throw that to Dr. Purcell, what are the sort of models you're seeing in terms of reimbursement? So, you know, when you hire people, although I don't know that you've hired any external docs just yet, what do you contemplate doing? Are you looking at billing, total billing, and paying someone a percentage of that, paying them based on collections, or are you looking at more like a work RVU type of setup? And what have you heard? That might not be the best question for me because I have not wanted to hire someone. I really wanted to keep the model that I have going. And although I think, you know, the practice could make more money, it's just not an extra layer of something that I want to deal with. But model-wise, I think one shift that we're seeing that I'm looking at myself is how do we shift away from being completely tied to insurance and having other ways to bring income to the practice or, you know, to myself in general? So that's something I think a lot of new grads will be looking for. Is there an opportunity with a cash pay practice where you don't have to call and do peer-to-peers? And, you know, are there ways to scale our knowledge as physicians more than requiring one-to-one patient care in my time, one-to-one? So I think that's like a trend that's coming up that I'm sort of leaning towards as opposed to just hiring more doctors to work for me. And I think a lot of physiatrists are leaning into the self-pay market with a variety of different things they do. Dr. Sully, with the VA, when you talked about the sort of contract type of option, right? How does that position reimbursed? Is it our views? Is it collections? If it's collections, how are those determined? Right. So with fee basis, it's actually a negotiated contract before you start working. And so I will say, you know, this is the procedure I do. And the reimbursement that the VA offers is based on Medicare reimbursement. So if Medicare offers X, the VA will probably give you slightly less than that. And so for every single thing that you do that you would bill them for, you pre-negotiate that. It is approved by administration. And that's what you're credentialed for. You don't have to give, obviously, about your own contract, but are you seeing more in the organization you're in more of a collections-based contract or RBU-based contract? Oh, I'm sorry. Was that for me? No, that was for Dr. Sully. Sorry. I can't go forward. But feel free, Dr. Sully, feel free to share. Oh, no, no. Go ahead. I'm talking with colleagues, too, because being in the Department of Neurosurgery, I'm under a base salary, and they are looking into work RVUs. And for the PM&R Department, we're based on work RVUs. But you can determine, so in some ways, like a prior practice, determining how much you want to work, how much you want to dedicate to clinical time and build your RVUs versus also spending time with teaching and with other research endeavors. And so there is room for negotiation for targets. And as you were mentioning, Dr. Desai, sometimes you might have a comfortable base, but it really would be hard to make over that if you're not reaching those productivity measures or targets. And so I've found that with... I'm sorry. Go ahead, please. I have done a lot of self-reflection and looking at what I value. And I think having the option to have some academic time, so negotiating for some time that I would be able to focus on my research interests and develop some clinical innovations for patients with pain, such as virtual functional restoration programs or other types of programs, that's something that's very meaningful to me. So not feeling like I may, in some private practices, if I was hired and it was mostly focused, or other academic practices where it's focused mostly on your productivity. So it depends on... I think each place probably has different values. And even if it's within different academic centers or different private practices, I just noticed that there are major differences. And so it's really helpful to do that self-reflection and think about what you really value, how you want to spend your days, what kind of support would you potentially have. And that makes it all worth it, even if it's a lower base salary than maybe some other places. Yeah. So I think if you were to look at a general rule of thumb, and Dr. Purcell, feel free to chime in and correct me if I'm wrong. What you tend to get is large academic institutions or large hospitals where you either get paid by work RVUs or by total billing. Because those hospitals are willing to tolerate a lower collection rate because they tend to have a bigger variety of insurances that they accept. In addition, because they almost all have non-for-profit status, they can write off almost everything that they don't collect. So they can pay a slightly higher proportion of things because it's not as important to them to collect all the money that they bill. The interesting thing about that is, to some extent, that is a utilization-based reimbursement. So you're paying someone more for the more work RVUs they generate, the more billings they generate, the more you pay them. In most private practices, my experience has been, you get paid based on collections. And the idea there is that you can go out and generate as much money as you want and see is bill, bill, bill, bill, bill. But if you have payers that are not going to pay you for the services that you bill for, you're only going to get paid based on what's actually brought in-house. And that's in some ways, at least, because... And I think the key here is, and don't forget this, because I think as people look for jobs, a not-for-profit status really does change the way your accounting gets done. And when someone shows you your books in an academic organization or a large hospital that's not-for-profit, there's a whole component there that's often inscrutable. So I think that value judgment, it just tends to be more like, this is what you cost, this is what you brought in, here's what you get paid. But as Dr. Sarno said, and Dr. Sali said, those models where people made decisions about what they value, it's so important. And I think one of the key points of having this conversation with the four of us is to let people know that, do some reflection, figure out what you value, because that should drive what you do. If you do something because you feel like you should be doing something, it's rarely a pathway towards any kind of contentment. But if you do something because you've made those trade-offs and are content, there's a little offshoot there. There's a lot of studies that show that contentment is more important than happiness, because contentment opens you up to happiness, but the search for happiness opens you up to unhappiness oftentimes. But the idea is that, what are you willing to live with and what makes you, at the end of the day, feel like you did something of value? We have about five minutes left. So in the interest of time, I want to get from each person just a one sentence about the number one advantage of their position and the number one disadvantage. So just one sentence. And so Dr. Sali, I'll have you go first, please. What's the number one advantage of your position and the number one disadvantage? Well, with the fee basis model, it's certainly flexibility within my schedule, and that gives me the opportunity to pursue some other interests that are still healthcare related, but it's certainly outside of clinic. The major disadvantage, I suppose, would be the financial piece, especially in the times of COVID when elective procedures are not prioritized. Okay, that's great. The number one advantage and the number one disadvantage. My number one advantage is that I call the shots. I create my schedule, my days, what I want to do with my career by far. And then the number one disadvantage is, you're a business owner. You're kind of, even though I take vacation whenever I want, you're kind of always working, right? And you're also, what we discovered in COVID that you and I have talked a lot about, Dr. Desai, is you are the bank of the practice too. If there's a problem, you're the last one that's going to get paid. COVID taught us that we are not pandemic proof. I always thought we were recession proof. I didn't even think about this. So yeah, we made it through, but in the end, it's all on you. So you've got to be financially prepared to not get paid for periods of time here and there. If the pandemic comes up or whatever else happens, there's no one else that can back you up. True, true. Very true. Dr. Asarna, number one advantage and number one disadvantage. I think the major advantage is the opportunity for collaboration in an academic center with multiple specialties and that support we get from the academic environment in times like COVID and what we've all been going through. And then disadvantage would be the bureaucracy and trying to move forward with some initiatives, having administrative restrictions and limitations, sometimes due to the politics moving forward with these initiatives. Yeah, those are really, really great too. I mean, really helpful. I think, you know, I would echo what Dr. Purcell said for our practice. We have 22 employees now, and we started four years ago with three, including myself. So I realized that I work for 21 other people, right? I actually don't work for myself. I tell our COO now that she doesn't work for me, she works for the practice. I tell the doctors that they don't work for me, they work for the practice. And ultimately my job is to make sure that the practice survives every day, not any one person, right? So that's the big obligation. And as Dr. Purcell said, I get paid last and I'm the bank. So if something happens, everyone turns to me and expects me to have the answers. And oftentimes, even if you have the best answers possible, they're not the answers people want to hear. So, you know, there's an anonymity to large practice that people get frustrated at other things. But when it's just a few people, it's very clear who their frustration is often directed at. But I would also say, having been a part of almost all the models up here, except for the VA system, that I would probably personally never go back to being employed by anyone ever in my life again. But that's just, you know, again, a personal choice that's based on my value structure. In the last few minutes, any comments on how you see the things we've talked about today changing with COVID? Dr. Purcell, do you have any comments about what you think, how people's job searches, what they look for is going to change, be changed based on COVID? Yeah, I think just COVID being this huge piece of insecurity that we've never thought of, the point that you kind of alluded to, it's for private practice physicians getting paid on collections, eat what you kill. You have to be able to know if you're getting paid for what you did. So yeah, you're getting a percentage of what you brought in, but you could have been doing procedures and the billing in your office is not collecting appropriately. You know, that's just my big point to everyone. Learn how to spot check these things. Learn how to make sure that what you are doing is getting paid for, and then that percentage is going to you. Because most people don't even ask. And then if they ask, here's the login, they don't even know how to look. So I mean, it's a dangerous territory where physicians need to start understanding the financial side a lot more. Yeah, I think that we could all benefit from some business training in medical school and in residency, a lot more business training than we get. You know, in the last 30 seconds, I guess maybe I'll wrap us up with a couple of comments. One is even prior to this, even prior to COVID-19, the number of physicians who are in private practice 10 years ago were about 70 to 80% private practice, 20 to 30% employment. That ratio had flipped in the sort of ACA era, the Accountable Care Act era, and I suspect that that will continue to change in the direction of employment. I think people are looking for security, and I think that that is more easily achieved. I do think that employers are more in the driver's seat now because everyone wants a job when they finish training. We're continuing to pump out trainees, but we're not continuing to create more jobs in the healthcare sector, especially in this area. So it's going to be interesting to see kind of what kinds of models, creative models people come up with when it comes to employment in the future. I really want to take a moment to thank all three of you for being here. This is awesome. It's kind of exactly as I kind of had hoped and conceptualized. So thank you all for your time. And I think all of us are open to people reaching out to us and contacting us if they have any specific questions. Again, I really appreciate each and every one of you. Thank you so much. Thank you.

decision-making

spine pain space

private practice

academic medical center

fee-based contract

collaboration

autonomy

financial stability

COVID-19 impact

job considerations