All right, everybody, welcome. Good afternoon. Thank you for coming late on Saturday. We're going to talk about what you're getting into. So whether you are still in training early in your career or thinking about transitioning, it's going to be perspectives from academic, private, and hybrid practice physiatrists. I have nothing to disclose, per usual. Please help me out. I'd appreciate it. We've got wonderful faculty here, very beautiful, good-looking guys, and a woman. Objectives, number one. So these are overall objectives that we're going to cover today. We want to compare and contrast challenges and responsibilities in these different practice settings, be able to describe the process of academic promotion, such as from assistant professor to associate, describe expectations of maintaining an academic portfolio, even in a non-academic setting, and be able to differentiate between the advantages and disadvantages of various options in managing private practice considerations. So our first speaker is an outstanding individual, board-certified in physical medicine and sports medicine, a former athlete who no longer possesses the sheer strength or unyielding endurance of his youth, now managing patients and athletes of all ages and abilities. From the University of Miami, Timothy Tew. All right, so what setting is right for you? Academic, private practice, hybrid, other things to consider working for the VA, and also non-clinical. Just because you go to medical school doesn't mean you have to do a residency. If you want to practice medicine, yes, but you could do a non-clinical position. And just because you complete a residency doesn't mean that you have to practice medicine. We're going to talk about the first three today. So there's a lot of things that we don't learn in training. FTEs, RVUs, templates, they're not what you're thinking of. They're not the dot phrases in Epic. What is taxonomy? And billing. But these are important things that we have to know and we're expected to know. So why the face? What is an FTE? I don't know if anyone gets it from Modern Family, but FTE is a full-time equivalent. You got no laughs, though. No, I don't get any laughs, but it's fine. So if you work five days a week, AM and PM, you are 1.0 FTEs. If you have a half day of admin time, you are now 0.9 FTEs. And that's important because it may affect your target RVUs if you're employed and potentially your benefits. So if you have an employed position, for whatever reason you want to work part time, whether it's family or you have other professional obligations, there may be a minimum number of FTEs that you need to satisfy in order to qualify for your employer's benefits. So for example, if you work three days a week, you might get benefits. But if you work two and a half days a week, you don't. So it's important that if there is that stipulation, that you're aware of it and you can match your schedule as needed. An RVU is a relative value unit. So the powers that be have determined how much our work is worth. 1.0, I don't know what CPT code is a 1.0, but everything is relative to each other. And then on top of that, we get a certain number of dollars per RVU. And that can vary based on geography and specialty. So I put standard in quotes, which is, we're going to use level three as an example. I put it in quotes because actually with the new CMS guidelines, it's quite easy to bill level four, whether it's a new patient or a follow-up. That's a whole other talk. A standard new patient visit is 1.6 RVUs, level three. Level three follow-up is 1.3 RVUs. So you say to yourself, oh, that's 20% less. I'm just going to see new patients all the time. But you have to consider how much time it takes. You can see two at the minimum follow-ups in the time it takes to see one new patient. If they're straightforward follow-ups, you can even see more than that. So if you're talking about RVUs per minute, follow-up visits are much more high yield than new patient visits. And now let's talk about procedures. So a knee injection, landmark based, 0.79 RVUs. So that's half of a follow-up visit or half of a standard new patient. If you throw on the ultrasound, it's 40% more at 1.1. So you might think, let's do ultrasound on everybody. But depending on your skill level, depending on your setup, it may take an excessive amount of time to do ultrasound guided procedures. And it may or may not be worthwhile for you. Clinically, you should do it. I'm just saying. I'm just saying. And just for reference, a fluoroguided SI joint injection is 1.48 RVUs. So maybe not so much more. But there are the facility fees that you can collect or the hospital collects. So these are the E&M RVUs, just so you can reference yourself. We have new patients in the middle column, follow-ups on the right. As I said, it's quite easy to build level 4s now. So a new patient level 4 is 2.6. And a follow-up is 1.92. Depending on your subspecialty or your patient population, you may be able to build some level 5s. I'd say I'm probably at least 66% level 4s. Maybe less than 5% of my patients are level 5s. Actually, maybe more, because I spend time with them teaching as well with the residents. You only build for your time, though. WRVUs are work relative value units. So that's how much the physician gets. The health system, employer, whoever will determine some conversion factor of how many dollars you get, what I mentioned before. And potentially, 2023, this number might go down. So not enough of us in politics. But we got something to be aware of and hopefully resist. Calculating the targets, there's many ways to do it. Most basically, just for example, $100,000 as a salary, the employer might divide that by that conversion factor. And then the target would be the RVUs that you get. Other factors that may affect the target RVUs may be benefits, admin time, and research funding. So just because you do research doesn't mean you don't have to meet your RVUs. Dr. Gorb is going to talk about it getting promoted. But if you don't have the funding for it, you're still expected to do some research. You're just doing it in your spare time. Spare time, no one has that. All right, so how to find these numbers? I didn't pull them out my badonk. But you go to CMS.gov or you just Google CMS RVU search. This little thing comes up here. You type in the CPT code. The MAC is the geographic location. Just hit search and then it'll show how much each CPT code gives back in terms of RVUs and various fees. So template, as I said, is not the dot phrases in Epic. It's how your schedule is set up. So things to consider are the visit type, duration, and the order that you're going to put these visits in. So this is just a sample template, okay? And I put four columns. Each one shows a different setup. We're using 1530, so 15 minutes for follow-up, 30 minutes for new patient, and we'll say 15 minutes for a procedure. So you can set it up however you want. Well, you know, within the confines of what you're allowed to. So in this first column, we have a new patient visit followed by two follow-ups, new patient, two follow-ups, new patient, two follow-ups. Some people don't want to be bothered by seeing new patients at the end of a session, so they may front load all the new patients and then finish strong with a bunch of follow-ups. So it's easier to catch up on work. You can schedule a day of just procedures or you can have procedures mixed into your day. I personally find it much more efficient to have procedures on a separate day from my clinic time so that I can just go room to room to room, and then when it's procedure day, it's just, I don't have to worry about, you know, writing prescriptions or printing things out for patients, et cetera. Taxonomy is very important. So basically, it means it's a code for what your specialty is. It's available at this website. Each specialty and subspecialty has its own taxonomy. So I use pain as an example. If you're pain management from PNR, you have a different taxonomy from pain management anesthesia. It doesn't matter where you work. The taxonomy is very important in terms of determining whether a patient's new or a follow-up and potentially our views that you get back. So other things that you're expected to know. Documentation, right? Why bother? Why do we have to write anything? If you look at the new guidelines, the documentation, the requirements are history as appropriate, physical as appropriate, and then medical decision-making has all these tables, right? So you should document because you need to know what's going on when you read the chart. Other people have to know what's going on. You need to defend your assessment and plan. You need to justify the level that you're billing. You need to get certain procedures or diagnostic workup approved unless you love doing peer to peers like I did while I was here. I don't love it. It's just, you know, soft. Or if you just want to remember, you know, the patient's kid, start going to this college and you want to talk to them about it next time. Billing and coding. So it works both ways, right? Like I said earlier, this is an entire, billing coding can be an entire two-hour lecture by itself, but whether you want to bill appropriately, right? Of course you want to get compensated for the work that you do, but not only is it wrong to overbill, it's also wrong to underbill. So getting compensated is the right thing to do. As far as disability and restrictions, I don't know about you guys, but in my training, I didn't learn how to come up with work restrictions such as, oh, yeah, this person, they can walk for five minutes. He can lift five pounds overhead. That person can do this. I don't know. It's kind of just making things up as I go. So if you're ever in a situation where you have to present this information and you can't get out of it, what I've learned is that you can just refer them to a functional capacity evaluation. You can write a physical therapy prescription, write FCE in it, spell it out, and then it's actually quite an intensive exam. It's a couple of hours long. They have the patient do all these various activities, and then they will objectively write what their restrictions are, what they can tolerate for each activity, lifting overhead, lifting at the waist, bending, stairs, everything. This way, you wash your hands. The employer knows what the restrictions are. The patient can't question. They did the evaluation. This is what was found. All right, this is the money. Seriously. We have the AAMC data 2021 public schools, AAMC 2021 private schools, and the MGAMA data 2021. So this information can be found potentially at your academic library if you have access to it. If not, maybe they can order it. Otherwise, you probably have to pay thousands of dollars to find this, or you have to be kind of an internet detective, kind of being a little creepster with Google searches and stuff. But let's see the median numbers. So if you're working for a public school at the, let's say most people would enter at assistant professor level, the median is 228,000. At a private school, 237,000. MGMA is going to include private practice. The median is 313,000. And your boss is making easy half a mil. So the takeaway is to be your own advocate, okay? At the end of the day, no one is going to fight for you. No one's going to do what's in your best interest except yourself. So just like everything else in life, you can take lessons from sports. The great Rocky Balboa has a nice quote in this movie, Rocky, where he comes out of retirement. Fantastic movie, per usual. Thank you very much. So the next speaker is going to be Dr. Jocelyn Gober. She is an assistant professor at the University of Miami. She's the director of pediatric rehabilitation medicine. I asked her for a one-liner on what's cool about her. She said, she can't think of one, therefore we can conclude that she is not cool. It's true, not cool. So like you said, I'm Jocelyn Gober. I am the pediatric rehab physician at University of Miami, so I work with Dr. Tu. I'm going to give you a little bit of insight of what we do in academics. Mine is a little bit more complicated because I was hired on to kind of do a lot of program development to build a pediatric program, but I'm not going to focus on that at all. And I was told to start off by explaining a little bit of what my typical day looks like. So typically, I come in early in the morning. I do both inpatient and outpatient, and that includes a unit and consults, and then my clinic and procedures. So I'll mix into one. I'm the only pediatric rehab physician there. But I typically come in early in the morning. I round up my patients, and then I will go to clinic. That typically starts at 8 o'clock. We're not always the most efficient, so typically I have a little bit of time to spare before the 8 o'clock patient is ready to see me. So I round up my inpatient kids, and then I'll go to clinic for the rest of the morning, trying to deal with other phone calls in between patients if I can. And then in the afternoon is typically when I go to see my other consults. I do both adult and pediatric consults throughout the hospital, and then the rest during that time is also meetings, documentation, all the other administrative stuff that has to be done, which doesn't sound like a lot when you say it like this, but it's actually when you're doing it. So that's my typical day. So when you're talking about academic medicine, what do you need to know? What are the responsibilities and expectations? So when you're in academics, you have more than just clinical and patient care, right? So obviously that's one thing. That's a big part, a big chunk of what you're doing. But then there's a lot of educational requirements that you're doing, a lot of teaching, both the medical students, residents, fellows. Obviously, you're all pretty much in that shoe, so you know exactly what they're doing for you. You have a lot of administrative responsibilities, some more than others, depending on your role and your obligations that you have. And then depending on what your requirements are and your expectations for that, you might have different time allotted for the administrative duties. And then research. Now, this is not necessarily something that everybody likes to do or wants to do, but it is required for promotion, which becomes a little bit complicated, which you'll see in a little bit because we don't really get the time allotted for it without being a researcher. But you need to show some proof of it to really get promoted. So like you said, you're doing it on what we call your own time, which we don't have much of. So I just like this little diagram that I found online. I did not make it myself. But it just shows everything that's included, right, in academic medicine. You have, again, a lot of the patient care, a lot of research, and a lot of medical education that all kind of combines, coalesces into one and gets you busy but enjoyable. Okay. So promotion, everybody wants to know about. To talk about promotion, we're first going to talk about what are the different ranks and appointments that you might have, what are the different tracks you might be on, what is the process of a promotion, and then the requirements as well. So starting with the ranks, typically these are the four that you'll see. You usually go in as either an instructor or some don't have that, and you go straight into it as an assistant professor. But an instructor, an assistant professor, from there, you can become an associate professor and then a professor. And usually they tell you a certain amount of time that they want to see you get promoted from one to another, especially if you're trying to ultimately go for tenure, if you don't get it within that certain time frame, then you typically cannot get tenure. And if you have a good department that kind of walks you through this, they are trying to help you get there. They want to see you succeed because it looks also better on the department. And then what are the different tracks? So this is what we have at University of Miami, so I just put this on here. It might be a little bit different at other places, but typically you will have a clinical educator tract, and that could be split into two different ones because, again, you're not just a clinician, you're also an educator when you're at an academic center. So how we split it up is there's FTEs more or less than 70 percent, clinical FTEs more or less than 70 percent. We use the, again, 70 percent. I think other places use that number might be a little bit different. But basically how much time are you doing clinical care versus education? And then your requirements for promotion are going to be different depending on this track. So, again, we have the clinical educator, less than 70 percent. Clinical educator with clinical FTEs, more than 70 percent, which I think is the majority of us. Then you have the purely educator tract, and then the purely research tract, which a lot of our PhDs and all of them who are doing the funds and getting the grants, that's what they do. So what are the requirements? So it's kind of a busy slide, but I think you can read it. So there's multiple parts. The first is the obvious, right, the clinical impact. So Dr. Tu mentioned your productivity or your RVUs. So you'll come in and you'll know your idea or they'll tell you how much your, how many, what your goal is for your RVUs, how many, what that number is that you're going to need to reach in order to make your salary, and then what you're going to need above it to maybe get a little bonus. But also what goes into this is also your evaluations. So this is both from your supervisor evaluations, your peer evaluations, and even your patient satisfactory scores. All of that kind of goes into what type of clinical impact you have. The next part, obviously, is the education, the teaching. So they're going to ask you to keep track of the number of students or residents or fellows that you're teaching or you're seeing or you're educating on a daily basis. How about the number of courses or lectures that you've written, that you've taught, workshops that you've established? All of that is gonna go into it. And then if you've had any other positions, program director position, assistant program director, all of that is going to account for education and teaching requirements. Followed by that, you have the scholarship. So this is if you're writing manuscripts, books, chapters, books, textbooks, book chapters, review papers, if you're getting any grants. Just a little caveat to this, these are all then kind of given a certain amount of points that go towards your expected amount of points you need for promotion. And depending on where you're located in that authorship, what is the impact factor of that journal, all those things are gonna play a role into how many points you get for that manuscript or book chapter or whatever else that you did. Did that make sense? Okay. Next is the reputation. So this is how you're being recognized outside of the university, whether it be for your clinical contributions, your research, your advocacy, or other professional things that you're doing. And this goes both regionally, nationally, or internationally. Obviously, the more you're doing, the more that's getting the university recognized, the better they look, the more points you get. Next is the service. So this is any additional service that you're doing to the university outside of clinical impact. It could be to the university, to your region, national again, or international. So this could be things like, again, you're gonna be in an academic center, so you're gonna have a residency program. So from a university standpoint, are you getting involved in the PEC or the Program Evaluation Committee? Are you doing interviews? Are you doing the CCC or Clinical Competency Committee? A regional or international, right? Are you doing these type of courses and assemblies? And then obviously international ones if you go to ISPRM or all of that. And then the last is the citizenship. So this, basically you have to be in good standing, right? So you're eligible for promotion. In order to be eligible for promotion, you have to basically be a role model. They wanna be able to say, yeah, she's one of ours or he's one of ours. So I just put this up because I mentioned, depending on the track that you do is how much percentage you need to show for promotion. Now again, this might be different, a little bit different on each one, but this is what we have at our institution. So I'm just gonna kind of point out. Oh, there you go, okay. So for example, when you are a researcher, right, you obviously have no clinical impact. And the majority of what you're gonna be doing is funding and scholarships. So that's what you have to focus on. Versus if you're a true clinical educator, you get absolutely nothing. You're not really expected to get any funding, right? So you don't have to get any of that. And the majority of what you're doing is education and clinical impact. So depending on, again, your track, you have to make a certain percentage of each of these different requirements. So what is the process like for promotion? It kind of starts small and then goes more external. So it starts within you. You wanna become promoted, right? You have to have that desire. You wanna be considered for promotion. You then take that to your chief or department chair, whichever you might have. And then some departments have their own internal committee review. Ours, I don't believe, does. But some of them do if they're large enough. From there, if everybody's on the same page, you then get taken to the next level. So you go to the School of Medicine. So typically, they will have an APT committee or Appointment, Promotion, and Tenure committee that kind of reviews. You put together this whole application, which is quite extensive. So they review your whole application and they will ultimately vote. Depending on what their vote is, if they give you a no or a split vote, your chair actually has the opportunity to appeal it. From there, it goes to the dean, which ultimately takes their recommendations and makes a decision from their standpoint. And then from there, it goes to the university. So they have another committee. Ours is the University Academic Personnel Board that reviews and votes. And then they make the final decision. Now, if you're up for tenure, then you also go to the Board of Trustees who reviews everything and makes that decision. Okay, so that's a lot. So one of the biggest things we kind of wanna just briefly talk about is your CV. So maintaining your CV is gonna be really important, right? And you're not gonna remember this all the time, what you're doing all the time. You're actually, you get very busy very quickly. So my biggest recommendation I have is update and review it regularly. Don't wait no more than six to 12 months before you're gonna go back and review it. Or if you're a little OCD like I am, you do the activity, you go back and you change it right away. And just keep it updated because you are going to forget. I mean, you do it because you wanna do it, but you also wanna get credit for it because it does take a lot of time and energy to do a lot of things that you're doing. The typical sections that you're doing, that you're seeing are usual, I think, that you're used to, right? Starting with personal information, going into your educational experience, going into your publications, your teaching experience, your community activities, all of that stuff. I will say remove outdated information by the time you're, as an attending, you don't necessarily need to be putting on there that you, what you were so amazing at doing in high school and college. It's not necessarily as important at this point. Again, I'm a little OCD, but formatting is gonna be important. And I've been told that multiple times. If you have this font on one side and italicized over there, but not over there, it's a little bit just unappealing to the eye. And I have been told by numerous people who have been involved in these reviews that it's kind of a red flag. And then obviously, proofread, you wanna make sure you're spelling everything correctly. And the other thing I will say, if you are posting or listing when you've been involved in talks or papers, wherever your name is, bold your name every time so they see that it's you. So even if you're a long list of four different people or more on a paper, bold yours. And then just to know, we all have our own CVs that during this time when you're applying for residencies, fellowships, and the job, we have our own little version or the way we template it, which is very different. You'll take somebody's example and kind of use that. Once you get to an academic center, they will have a template that then you'll use, you'll just kind of shift everything over. My advice there is just shift everything over right away and then keep on top of it. Okay, so how do you know if you wanna go into academic medicine? Teach your zone, right? There's pros and cons to everything. Some days I love it and sometimes I'm like, what am I doing? But just listing a few, this is definitely not an all-inclusive list. But some of the pros is it is a consistent salary, right? So you take vacation, you're not worried about you're not making any money during that week. You're expected to take vacation and you're still getting paid. You do have more variety in your role, right? You are wearing those many hats that we kind of listed in the beginning, for better or for worse. I kind of like it. You get to do more things than just like sit down and sit in a chair constantly talking to patients. It is easier to stay up to date, right? You're talking to medical students and residents and hopefully they're motivated to be learning. And then you're having journal clubs and grand rounds coming to all these conferences. So it's a little easier to stay up to date on things. You do get more exposure to unusual and challenging cases, right? Outside, I think more private practices is maybe a little bit more limited. So you're able to see more of a diverse group of conditions and some of them might be really rare and you'll be able to see that. Obviously, if you love to teach, academics is more for you. You do get other benefits, right? When you do an academic, in an academic setting, you do get healthcare, disability insurance and the malpractice insurance, that all gets included. It's nice, you don't need to market yourself. Typically, or I have to kind of market on building a program. But typically, when you come join an academic setting, you don't necessarily have to go sell yourself. You're part of a department. It is nice to build relationships with other people and you're impacting the future of medicine. Just remember, they're gonna be taking care of you one day. There is the availability of other specialists, whether it's a formal consult or a referral or just like a curbside, hey, I need some help. It's much easier in an academic setting. Paid for time off, I guess I kind of mentioned that beforehand. And then the public service loan forgiveness, if you're at an academic center, those get approved for those. And then some of the cons. So often, you do get paid a little bit less compared to private settings. You are an employee, right? You're not quite in charge as much as we try. Good or bad, like I mentioned, you do have a lot of expectations. Whether you have the time for it or not, you are expected to do the research and everything else. Here, it's a little bit less flexibility on what you wanna see, right? As an outpatient or as a private, maybe you say, I never wanna see, I'm just gonna put this out there, but I never wanna see back pain. Doesn't quite fall that well as an academic. You do have the competing demands for your time, which kind of overlaps with the other things I mentioned. There are a lot of bureaucratic challenges in red tape when you are trying to do certain things. It takes a long time to make some things happen, depending on where you are and what you're trying to do. It can be a little bit frustrating. You don't have that much control if you don't let your staff figure it out, because unless something really goes wrong, you have no say whether or not they can be there. You will have deadlines for the publications and grants. It is the convoluted promotional process, like I mentioned. Again, you have the time-consuming preparations for lectures, teaching, and to do all the evaluations. But one size does not fit all. I just wanna say, this is the end of it, but there are pros and cons to academic, private, and probably hybrid. Just know that all of ours, too, it's not all the same either, right? Our academic setting is gonna be different than another one, so there's some things that are gonna be the same, more or less the same amongst them all, but they're all gonna be very different, and there's gonna be pros and cons, and you're just gonna decide what you're looking for and which of the cons you're most able to accept, if that makes sense. All right, thank you. Thank you. Thank you, Dr. Gober. I just wanna add before I forget that when you're doing your CV, it's helpful to have the month and the year. Certain state licensures or jobs may require month and year, and it can be difficult to figure that out later on. So our next speaker, Dr. Nikhil Verma. He's an interventional spine and musculoskeletal physician. He has an independent practice in Columbus and Marion, Ohio called Essential Sports and Spine Solutions. He provides comprehensive physical medicine and rehabilitation care, and interventional pain care. He completed his residency at Kingsbrook Jewish Rehab in Brooklyn, New York, then did a NAS recognized program at Alabama Orthopedics, Spine and Sports in Birmingham. Please give it up for Dr. Verma. Thank you. He's cool. I wouldn't say that, but no, I thank everyone for showing up today, and the panelists here as well. I think it's a great topic. So get into it. The first thing I wanna talk about is, I kind of, I have a YouTube channel called Things I Didn't Learn in Med School, and I kind of talk about the business side of medicine and things that we don't really learn and how to kind of grow your practice and that kind of stuff. Usually it's weekly. I've taken a couple of weeks off because I've been really busy, but it's been, I get a lot of feedback from students and residents, and then they end up reaching out to me and ask me, and I'm donating some time to like talk to them. So if anyone out there wants to connect, connect with me, and I'm happy to help out any way I can. So I did want to talk about my pathway to get where I am. As you see, I went to St. George's Medical School. I did my core rotations in Brooklyn, New York, which I was exposed to three, four, five different hospital systems when I was there. My intern year was in Wayne State. I was exposed to two different hospital systems there. Different outpatient practices as well. Residency and Brooklyn, as we talked about. We had two main hospitals, but we had a lot of elective time, so we did a lot of outside hospitals as well. So the whole purpose of this is I've been exposed to so many different private practice, hospital settings, academics, strictly private. So that's where the whole point of this slide is. So I think this is an important slide. I think actually Dr. Tu and I, when I was doing my rotation in New York, he was attending, and he said, you can pick two of these three. Money, compensation, lifestyle, or location. It's really hard to get all three in. I added this peace of mind because I think that's what was most important to me. And I'll get into what that means in a little bit. So kind of earmark that and kind of look into that, what's most important to you. The pro-con list that I made, is it a pro, is it a con? I don't know. I think that's for you to decide. There's an unlimited ceiling. I could work 100 hours a week and make some millions of dollars, but that's up for me. I don't have the staffing and stuff. Every decision comes through me, for better or for worse. And sometimes the decisions, they weigh hard on you. At the beginning, it's very easy to take on new business opportunities, investments and that kind of stuff, because you have the time to do it, but you also have a challenge because it's really hard to get a loan. So that's something you have to think about. You get to structure your day-to-day life, how you do it. I did locums for a while to help fund my practice, and I kind of stepped away from that because I want to focus more on my own practice. Billing, again, it could be a two-hour conversation, but I have to learn it in and out and have to make sure I know what's doing right. I do outsource my billing now, but I still need to be on top of it. I talk to my billing people every day. Contracting, every insurance payer, you have to get a contract. When you're at an academic setting, you have those contracts built in already. But as an independent physician, you have to go get those contracts. And UHC, Aetna, and some of the other ones, they don't have open contracts for some specialties in some locations. So you won't be able to see those patients. What I did, and I got lucky in this, is I got a contract in-network with a hospital system in my area. So at least I have all those contracts. But if I was ever to leave that contract in-network, then I would lose all those payers. You have to assemble a team. Not only your staff, but you need to have a good lawyer, you need to have a good billing company, you have to have a good financial guy, girl, whatever. So there's a lot of things. In constant conversation with these people, I'm spending most of my time in meetings, really, than I am actually seeing patients right now. Medical record system is a hassle. They all suck. And it can cost you a lot of money. So the one I have right now has cost me nearly $10,000. I'm like, well, I gotta change, but that's not worth it, that's not worth it. You work your own hours, is that good or is that bad? Some people like the structure, same routine. What can go wrong will go wrong, and then you have to deal with it. Did a kyphoplasty on a lady last week, or a couple weeks ago, and unfortunately things went wrong. And I'm trying to talk to the neurosurgeon, like, hey, what's going on, how can I help? You don't have that setting in the hospital where you can maybe see that physician and see how they're doing. All the compensation goes to you. Setting up a business and a structure at LLC and S-Corp, and how you pay yourself is very important. You have to understand how that works. Taxes, it gets really confusing with personal and the business taxes. So that's why you need to have good CPA. Home ownership, I can't get a loan for a home, so I'm renting an apartment right now. I'm very happy, my girlfriend hates it. She wants a house more than anything in the world, she says, so. You get the benefit of business write-offs, you know. If I'm getting scrubs, you know, I just write it off as a business. Conferences, that kind of stuff, but. There's a lot of things that benefit from there. Conferences, societies, just talked about that. Networking, meeting people. If you're an extrovert like I am, you constantly have to be meeting new people and engaging them, et cetera, et cetera. Advertising, you have to market yourself. I think Jocelyn just talked about how she doesn't have to do that, and I do. And I'm constantly doing it. Buying into surgery centers, more specific for pain medicine, but you need to show your worth, but you're actually losing money when you're doing that versus doing procedures in the office. Research, if you want to do it, you can. If you don't want to do it, you don't have to. Office maintenance, I'm constantly cleaning my own office. I clean my own rooms after my patients. I'm doing all that stuff. Renting versus buying, do you want to take a big loan to buy your office, or do you want to rent it? Loans, we kind of talked about. HR, payroll, state bylaws, you have to understand how it goes. I do outsource my HR company, but you still have to be the final decision maker. Paying yourself, what's a fair value compensation for yourself, you could put a zero on the tax forms, but the IRS wouldn't like that, so you have to be at least, I think when Dr. Tu was showing the median, you have to be somewhere in that range to pay yourself. You can't just say, I make $10,000 a year. Social media presence is important as well, and that goes back into advertising. Profit and loss statements, you have to be on top of those. Constantly updating it, especially if you're looking for loans, working holidays and weekends. Every day I'm not working, I'm losing money. So I was here at this conference, so I lost everything on Friday, so I didn't see any patients. But I also can take, hey, I'm just gonna take this day off because I wanna go to the conference. Small fish, big pond, bigger hospital systems, especially in Ohio, Ohio State, Ohio Health, they really crowd me out, they don't wanna play nice with me so it can be a challenge to get patients in your door. We talked about business investments already. Just real quickly, so this is kind of my typical work week, and you can see, I'm working way more than eight hours a week. I'm constantly, I wake up, I do my routine, I'm going to my office, I'm doing administrative stuff, I'm seeing patients, catching up on notes. And I'm really, at night, too, I'm going back to the grind. So you work your day so you wanna work, but that's kind of how I have my day structured right now. People don't talk about that part, right? Typical work week, I'm in my Columbus office three days a week, I'm in my Marion office, there's an hour commute each way. And you just think, that hour, I'm losing so much revenue, I could be seeing patients, I could be doing procedures. Thursdays right now are my procedure days. I'm doing about eight to 15 every Thursday. The remainder of Thursdays, I'm in meetings and stuff. This isn't sustainable, the nine to three where I'm seeing patients, that's gonna have to change. It's gonna have to be closer to eight to four if I wanna continue to grow and expand my practice. I'm essentially alone, I have an MA, I have one office person, some other things I do, outsource. I would do work on the weekends as well. I was working before I came here. And I just kind of talk about that. So you should go into private practice, I don't know, that's for you to decide at the end of the day. I don't wanna be negative when I'm saying this, I actually encourage private practice, I have a big disdain for academic, not academic medicine, but the corporate overlords of, just for you, the corporate overlords, I hate the corporatization of medicine and that's kind of why I started my YouTube channel. And for me, I can offer the care to the patient that I wanna do and not have to step on any toes or feel like I'm stepping on the toes of a referring physician or something. If you wanna do a private practice, you need about $250,000 free cash, whether that's a loan or not. So I just say, you know, $500,000, be safe to get that. I am not profitable right now as a entity. It's sustainable, it's paying its rent, but I'm not, you know, it's not gonna be like that forever. The contracting will destroy you because you have no leverage. They'll actually give you the worst contracts that you can get with the insurance companies. And you'll work harder, you know, I'm not only am I working hard on the practice, but I'm still trying to keep up with the up-to-date recommendations and billing and the coding and all that stuff. And this is what I say, it's like, it's the most fun I never wanna have again. I enjoy it, I love it, but it's like, eh. But with that being said, I'm like, you know what? Since I've gone through this, maybe I do wanna go start another business. So I have the background, so, for what it's worth. And I have this slide again. Let's connect. Thank you. All right, Dr. Jesse Charnoff is an assistant attending physiatrist at Hospital for Special Surgery. He's also an assistant professor of clinical rehab at Weill Cornell Medical College. He's board certified in PM&R, and he completed a subspecialty fellowship in spine and sports medicine at HSS. He specializes in the care of acute and chronic MSK sports and spine conditions. He's also cool. Three out of the four of us are cool. I'm the coolest, there's no words. Ah, all right, I see. All right, so good thoughts so far. I'm gonna try to add a perspective from, I guess, a hybrid practice. So I have no disclosures. So we're going to try to talk about the different challenges that you may or may not face, depending on your position. I'm not going to talk much about academic promotion, because Jocelyn really hammered that one home. But I'll tell you about my experience. And then starting a practice, kind of the challenges that I faced, and the benefits and the cons of being linked with a big institution. So in my model, it's essentially you're under the umbrella of a big institution. I have academic appointment. But my practice itself is essentially a private practice under that umbrella. So when I start, it's my responsibility to get patients. That being said, unlike Nikhil, I have a lot of resources at my disposal. So I have something called HSS Connect. Anyone who wants to be seen at my hospital calls the hotline, and they get routed amongst the physicians. So when you start, you meet with them, and you tell them what you want to see. Oh, you're willing to see patients over 90. OK, first week, I had 10 100-year-olds, because no one wants to see those patients. But you can get busy faster. Within a couple of months, I was pretty full. So there's definitely the benefit of that. You have a lot more in terms of support logistically. I'm not cleaning my own rooms. I'm not on administrative calls all night. I have that taken care of. There are people who specialize in that. I work in a collections-based model, so it's not RVUs. It's basically whatever money I collect from the insurance companies goes into a pot. And then me and the hospital split it accordingly. We have a certain percentage in earmarks. But instead of the RVU model, which I am familiar with from residency, where essentially you do things because you know you're going to make x RVU for doing this, even if the insurance company doesn't necessarily pay, you do a knee injection with hyaluronic acid, doesn't get improved, you lose $1,500, you're not happy, versus just, oh, someone takes care of that. Don't worry about it. So you definitely learn quick how billing works and how it can affect you in a negative way. So it's important to keep that stuff in mind as well as you're learning to try to figure out the best way to practice. So I have an eat what you kill model, sort of. I have a guaranteed salary, but I have compensation that starts at zero. So you're really motivated to see patients and do well because it has a direct impact on you, which I think is a healthy model because it keeps you hungry, and it keeps you definitely striving to grow your practice and do the best you can, as opposed to the opposite, where you're kind of getting frustrated when you get more consults and you're getting frustrated potentially by doing more. So me and the hospital, we're perfectly aligned. They want me to be busier. I want to be busier. So I like that. Like McKill, the time off, you're not producing. You're not making money. It kind of messes with you at first because you're starting to, you know, I had a son this past year, and you're thinking about how much time you're going to take off. And then you're like, I can't take too much time off. But at the end of the day, you need to take the time off to avoid burnout and being able to treat your patients well. And then you're more efficient when you come back well-rested. But it's a fine line, and you're going to have to learn that on your own, what works for you. Political challenges in regards to credentialing. So you want to really be clear when you first start somewhere what you're going to be credentialed for. So for me, I do interventional spine. So you want to know what you want to do and that they're OK with that. At my hospital, there's kind of a line in the sand where the physiatrists aren't doing things like sympathetic blocks and spinal cord stimulator placements, which I'm fine with. That wasn't something I wanted to do. But that's something you've got to be clear about. If that is your goal and your passion, you're not going to overturn a political kind of atmosphere when you get a job. So that's never a good strategy. You always want to kind of go in with the expectations that are what the department already kind of has set. If you think you're going to completely change the way that a department's been doing things for years, maybe decades, you're going to be very frustrated quickly. So I would really look at that when you're thinking about what job you want. The other thing I would say is I would ask for more when you start and not think, OK, maybe I'll get credential to do radiofrequency ablation in year two or three. Because once you're there, it's really hard to change things. So I basically got credential in anything I possibly could initially. I don't do everything, but I can. Because working backwards is really difficult. Even if you have all the proper fellowship training, this, that, it's just difficult. The pain department may say, well, only we should really be doing these. So you just want to get it all approved when you start, and then you have it going forward. So academic promotion, for me, I have an academic appointment at Cornell. Like Jocelyn said, there's several tracks. The one for me that I'm more interested in is the clinical-based track. But this isn't really something that motivates me personally. If I were to get promoted, I could get more funding from their department, and it could help me take maybe more admin time to do more teaching or research. But it's not something that's a goal of mine, per se. But that's something that you've got to think about for yourself and kind of where you want to go. In terms of my academic responsibilities, formally, I have none. But I still have all the opportunity in the world to do things. So because I'm in an academic institution, there's really no barrier to entry for me to do research, for me to work with fellows, work with residents. It's all at my disposal. But how much I want to do is really up to the individual provider. So right now, I'm doing procedures with fellows once a week, teaching medical students and residents that rotate with us at HSS from Cornell Medical School and residency, and giving the fellows lectures every once in a while. So they encourage us to be involved, and they encourage us to do things. But there's no formal meeting where you're going to get in trouble because you didn't write x amount of papers, or you didn't do this many speaking engagements. It's all kind of there for the taking if you want it. But at the end of the day, it's not a requirement. So for the job search, I would say identifying your goals and linking it with the goals of the department is the most important thing, as I already said. Location and what type of practice you want is also critical. You don't want to take a job with the understanding that in a year or two, you might be moving to a city 45 minutes away. And they may have a spot for you out there, but let's wait. We'll see when that comes because, again, you're setting yourself up to be very frustrated. I'd expect whatever they're telling you you're going to start with, you have to expect that that's it. And if anything else happens, it's kind of gravy, but you have to expect what they're telling you up front because there's no guarantees beyond that. Support staff, patience per day, OK. So as part of my job and the benefits of being in a big institution as a hybrid private is I have really good support staff. So I have a great billing department. I have an office manager. I just recently was given a second medical secretary. So the office manager, medical secretary, all these things I don't pay for. That's all part of the relationship that we have. I don't pay for my room per day. I don't have to pay for my procedure room. This is all part of it because we're both benefiting, the hospital and me. So that's kind of the deal we have going forward. That being said, I'm kind of maxed out now. I'm seeing about 20 patients a day, 20 to 25. I want to get an athletic trainer to work with me. I may pay for part of that. But that's where it comes from, quality of life and making decisions that best serve you to be more efficient, more profitable, so on and so forth. My schedule, just to throw it out there, right now I see patients three days a week. I do fluoro like a half a day, maybe a little more. And then I have, wait, so three days. No, no, no. So I see patients four days a week. One of those days is only 3 4ths a day I see patients. And the last 1 4th, I do fluoro. And then on the fifth day, half day is fluoro and the other half is administrative time slash golf. But you could do whatever you want. If I wanted to make more money, I wouldn't have the administrative time. But then you have to call patients at 9 o'clock. And you have to, you know. So it all goes downhill at a certain point. You have to do all these things. There's no way around making calls and doing patient care. So it's nice to have a half day to do that. It's good for quality of life. You can do research and different opportunities with time. But time is the number one resource that we have in limited supply. So you've got to keep that in mind with what you do. All right, so some of the negatives of being with a big hospital system is you theoretically lose some autonomy in the sense that they may not approve you for a procedure. You may learn how to do the basal vertebral nerve block. And they say, we don't want you to do that. And you're stuck if that happens. Again, that's where being aligned with your department and having clear goals and expectations is helpful. If you're in a department where they know you're doing cutting edge stuff and you're going to be trained on whatever is new and they're going to fight for you for that, you won't have a problem. But it's when those expectations conflict is when there's problems. So you won't be gaining equity in your practice. Right now, he's working 1,000 hours a week, but he might retire in four years and I'm going to still be doing this. So that's the risk and the reward potentially. But for me, I can have a really busy practice that I have six week wait. Patients love it. But at the end of the day, it's not mine. I can't take you with me unless I could do something. But I can't really take you with me. I don't own it. Difficulty in growing it beyond your capabilities. So I'm going to max out at some point. Even if I hire an athletic trainer, I hire an NP, there's only so many patients you can see yourself. So he can hire more doctors. I can't. So there is a max, even though it's a higher max than maybe an academic physician. No offense. But there is a max. And you can only do what you can do before you burn out. So that's a negative, I would say. And then justifying your resources. I can't just make a unilateral decision and hire an athletic trainer. I have to show I'm making this much. I'm really busy. I need support. Let's go into this together. I basically have a partner. So I have to convince my partner to come in with me. They're reasonable, and that's why I'm happy with my job and things are good. But when you're doing something like this, you want to make sure your partner is reasonable and that you guys are on the same page, because that's going to make you really frustrated if you're not on the same page. The benefits, as I said, great logistical support, not having to worry about dotting the i's and crossing the t's. All that's done for me. I have really good contracts with insurance companies. They pay as good as anything. I have a great referral source, easy to get busy and create a niche, whatever type of patients you want to see, you can make for your own. The institutional name behind makes it easy to do things like talks and different organizations, seeing patients, getting patients to be excited and convinced that your treatment's going to work. So all that helps build towards patient experience and satisfaction for them and me. The freedom to be able to control my schedule. So if I want to, I can. For instance, when I started, I was like, I want to do hour visits, because I didn't know what I was doing. And I wanted to ultrasound everyone, and I wanted to learn and all this stuff. So I was seeing a new patient an hour, follow up in a half hour, and no one could tell me, no, you have to do 30 and 15, which is a lot of institutions. They have very fixed schedule. So I did that for about six months. And as I got more comfortable, I ramped up. And now I do like 20 and 15. But I can change it at any time. If I want to take off next Friday, I could take off next Friday. A lot of these institutions, you can't. So there's definitely more flexibility. But again, it comes at the expense of you'll make less. So you've got to practice how you see fit. So yeah, so no one's pressuring me to do certain procedures or write opiates. Or any patient who comes in with a meniscus here, you have to send it to me for a scope. You might see that in a private orthopedic group. You work for the orthopedic surgeon. They're going to look at your charts and say, wait, why aren't you sending these to me? So for me, I don't have any of that pressure. I can do as I see fit. And for me, that's good. Quality versus volume. So you can choose to maybe see less, but do a better job. Or not do a better job, but spend more time, give a little bit more TLC. But that's all up to you. And that's a freedom that a lot of people don't have. So for me, that's a good perk. That's it. That's all I have to say about that. It's the best. So a couple of takeaways I have from all the lectures combined. Number one is, whether you're an academic, private, or hybrid, you're going to work a lot and not have time to do much. And like Dr. Charnoff said, time is our most important commodity. With each minute that passes by, we're one minute closer to the end. So even though that's very depressing, that was very wonderful information from everybody. Thank you very much. So we have plenty of time for questions. Hi. I feel kind of silly being here because I'm 17 years into my practice. But I just wanted to bring up two points. So I started in a interventional spine initially. It's a long story. I started in a multidisciplinary private practice that then got bought by the hospital. It's happening now. All of a sudden, I became an employed physician and was introduced to RBUs. That gives me PTSD to even say that. In any case, and then I left and started my own practice in 2018. I'm in Austin, Texas. And so one of the points I want to make is probably a lot of residents here and med students is you don't have to put yourself in a box right at the start. I had loans to pay. I wanted to be with other people. I didn't want to be by myself. And so I did the thing. I became an employed physician. I tried to absorb as much as I could. I got my feet on the ground. I got a little more confidence. And that allowed me, I think, the timely transition into private practice. I don't think I could have done that right off the bat. So if that's what you did, I applaud you. Yeah, I did. I went straight from fellowship and started my own practice. Yeah, to your point, I would recommend probably that. Right. Go do it. I mean, I'm a crazy person. Well, what I'm saying is it allowed me to get a reputation. It allowed me to establish care with patients that then followed me. So when I opened up my practice, I immediately had at least, I didn't know a pandemic was going to happen, but at least I had my own challenges But at least I had primary cares that knew me, that liked me, they were loyal to me, and stuff like that. But like you, I get no support from my employer, from my previous hospital. Patients would call the place I worked to look for me. And they basically were like, I think she died. Like, literally, they would not. I mean, literally, things that my patients were coming to finally, once they finally found me and I reached out to them. By the way, if you do that, at least in Texas, your previous employer has an obligation to give you a list of two years of your patients with contact information and everything. So that's another plus of maybe getting hooked into an employed situation or hybrid situation and then switch over. And so yeah, the point is you don't have to leap in. You can dip your foot in and kind of keep it on your radar. I took forms from them. I learned how to do that stuff. I had a recredential and everything, so I feel you on that. The second thing I was going to say was, oh, shit. Where was I going to throw it? I was getting somewhere. I had another good point. Let me think about it. Thank you very much for that advice. Hi, I'm Kyla. I'm actually from Canada, but thought I'd come and see you guys and kind of learn a bit more about the system. I also started my own private practice right out of fellowship and echo your schedule and challenges I'm sure we'll talk after. But physicians are terrible at business, some of us better than others. And whether you're in academic practice or this hybrid or out in crazy town with us, you need some business training. So what are some of your favorite business resources? I follow Alex Formosy on YouTube. He puts out a lot of free business advice, and he has a book and stuff. But it's very to the point, like this is what you should do. Thankfully, my father has started multiple businesses, so I get a lot of advice from him. My brother's a consultant for businesses, so I get a lot of advice from him. So I kind of use those as my main resources. I think it's very important to get a really good mentor as well. I don't have that specific mentor right now, but I have enough mentors I can ask questions about individual things. Yeah, I think for anyone who does want to start your own business, you feel like that for a few years. I'm just starting my third year of operation and will probably break even this year. Yeah, that's usually people say about five years. But yeah, getting a business coach and putting that into your financial planning strategy around your business, I think, is really important. Yeah. Thank you. I have a little bit of a tidbit. Sorry, the other tidbit is this, and I cheated a little bit. So I'd been in Austin for a long time. I became very good close friends with a hand surgeon. He had left his practice to go open up his own private practice. And so when I told him that I was leaving, he said, let me help. And so he basically gave me an exam room and access to his staff. And I pay him a percentage of collections. If you want to know that number, come see me. But so whether I made $0 or $10,000 that month, I gave him 45%. I automatically had an office manager, a in-house billing person, a scheduler, space. I don't need a lot of equipment. And she helped me with all the credentialing. And so I didn't have to. I think I put in like $10,000 to start my practice. So eventually, I want to buy my own building and do my own thing. But it was a, I like baby steps. You obviously, you're like, go big or go home. I'm more risk averse. But so if you have a colleague or somebody that you can, these work share spaces that are happening, I think that is one way that us physicians can help each other get out of the shackles of employed medicine. I mean, that's how it felt like to me. And still kind of do your own thing and have that autonomy, but not have all the risk and financial debt that can happen from that initially. So I was profitable right away. Thank you. Everyone, I'm a fourth year going into payment fellowship next year. For academics, when you were talking about the salary and all that, so based on the rank that you have, does that change per specialty? Or is it fixed for all of them? Does it include RVUs? And if you're in academics, can you still be a consultant for companies like Sprint, Medtronic, or is that, like, do you have to go through red tape and stuff for that? Those numbers I showed were for physical medicine and rehab, specifically. Those were the median numbers. When you get promoted, at least at our institution, I think you get a little bit of a raise, but you also get an increase in the number of dollars you get per RVU. Therefore, your targets decrease. If you have relationships as a consultant, you just need to make sure everything is disclosed and work that out. You have to be careful if you develop something, like you make an invention or something. If you've done it while you were employed, there's a good chance they're going to say that they own you. Yeah, that's a big thing you're going to see. Even if you go join an orthopedic center or whatever, especially the intervention plan, like, they're going to put in their contract, whatever you go, if you go to a speaking gig, they're going to take a percentage of that. Any article you write while you're working for them, they own that as well. So that ownership is a big thing. You want to make sure you look at it closely. I'm going to be very short. So I'm always working in private practice, and then I recently joined orthopedic group. The point I want to make is, so when you join hospital or any group, large group, if you're thinking about, like, in couple years you're going to be practicing on your own, when you sign the contract, really watch, typically most of the contract will have two years non-compete. So they will exclude you from practicing in certain regions. They usually have miles. How many miles out of their office, hospital, clinic, and you can't practice typically within two years period of time. So when you negotiate, if you think about you ever going to leave them, possibly going into private, you want to watch these things because that will probably prohibit you. You had to kind of go far away for several years, maybe lose all your patient referrals, and so that's something you want to watch for. So that's a point I want to make. Another thing is really just, like, these days, it's the environmental for practicing on your own, it's kind of very different. I think the hybrid is really a nice, large model for a lot of people to start with. I think, you know, you have a lot of probably business ideas and the environment is very different. There are a lot of requirements, like EMRs, you need to hire a lot of staff, you need to do all the MIPS, so there are a lot of requirements for private to survive. So like, you know, I can see in a lot of state, you know, the small practice are joined into a group. Like, I recently just merged with orthopedics, and that's one point. And third point is very short. If you're interventional spying, if you negotiate, make sure you, it's salary is really only one person. Make sure you have ability to get involved with the surgical center, maybe become a partner. Also, the new people probably don't know the surgical center here. If they're profitable, they probably give you more than your salaries. Thank you. Thank you. Yeah, that's a good point about the non-compete. It's important to note that it may not necessarily be where you practice. It might be relative to all of the facilities. So if you work for a university, they have satellite clinics all over a geographic area, you might be out of luck. You might have to move out of state or a totally different city. Depending on how it's written, so you should look into that, yeah. And it might, there are services, lawyers who can review your contract. They can even negotiate on your behalf. It's expensive, but it may be more worthwhile for your money. Any other questions? Thank you very much. Thank you.

panel discussion

physiatry

practice settings

academic practice

private practice

hybrid practice

full-time equivalent

relative value units

scheduling templates

academic promotion

private practice management