Hi, everyone. My name is Isabel Huang, and I've been asked to do a little discussion about negotiations for jobs. So my title is a little tongue in cheek how to find the right one you want to swipe left or swipe right, and feel free to put down any questions in the chat box I'll answer it. As I go along with my presentation I kind of like interactive approach for the presentation. Okay, so, um. So, the first thing about getting a job is knowing yourself first, you need to know what your goals are for your job. What gets you jazz what gets you down and prioritize what's important to you. Do you care most about salary do you care most about location flexibility the hours do you want full time or part time. What kind of setting do you want academics or private. It's really important to get to know you yourself first because if you don't know what you want. And you go into a situation that's just not the right fit maybe it's the esteem very amazing sounding job that everybody is gunning for. But if that's really not what makes you excited like if you really don't want to be writing research papers but you got an amazing offer at a top academic institution. Is that really going to make you happy. So really knowing what makes you happy. What really is like a non negotiable you just don't want to do it is important when you're looking for jobs. So the next thing is meeting your candidates. So you want to get to know all your servers. If you're going for location, look in a specific area look at all the different places that you could be working at. And you want to meet up all those places make contacts with them. And really the first meeting is get a gut feeling about this place. Do the people seem happy or maybe you don't want to be super happy at your job and you just want to be like a really really hard worker do all the people there seem really really hard working like maybe that's the environment you want to go for. Be yourself, but be the best version of yourself. I know that sounds silly to say that but sometimes we'll go in there and we just want to be like a pick me boy or pick me girl like you want to say everything that this person wants to hear that may not be the best. Best situation for yourself. You really want to show yourself so that the person that's hiring you really understands what kind of person that they're hiring. And don't show your cards immediately so don't commit to quickly don't tell them like this is unless unless that is truly the place you want to be at, but if you don't know yet. Don't commit to quickly just say yes I'm interested in this job and keep it very very simple interview and multiple places, it's easier for you to be in the negotiation seat to have the upper hand. If you are integrating multiple people just as if you were dating you could date multiple people, and then may the best one win at the end, you know, the cream of the crop will rise to the top and you'll know that's the right situation for you to be in and be realistic we all love to work like, you know, eight hours a week, and make 300,000 a year, like that's not realistic so we need to be realistic about what kind of job work environment is a good fit for you, and there is no perfect fit. flexibility that's needed on both ends. So it's nice to, I'm sorry my, my kitty. It's nice to be able to understand that you know the person that you're working for is a little bit flexible on things and you may be a little flexible on things because, you know, when you actually get there and get the job, it's, it could be a little bit different than what you expected. Ask questions, ask the people that work there as people interviewed there. Okay, so when you're getting ready to commit like this is the negotiations part. So this might be like a second or third visit on the first visit really like I said it's just a gut reaction gut feeling about the place do you want to proceed to a second or third visit Yes or no. So now on your second and third date, you're maybe a little bit more committed, and you want to get everything in writing. So when you're discussing things about your job, and you're taking notes with whoever's hiring you. You could ask for a copy of the notes that you're discussing that way, everything you've talked about, there's a paper trail. So topics that are really important to be discussing salary. So I, I didn't realize this, and I'm. This is my second job second academic job my first was in UT Houston. I moved because my partner at that time moved for his work. So, then my second job, you know, I didn't understand the difference between supplemental versus base salary. So base salaries and salaries that you're going to be receiving year after year, hopefully without any, we haven't had any cuts lately but year after year supplemental is an additional amount that they may give you. Maybe first year, second year third year depends on your contract like how much they want to add on to your base, but understand that that that supplemental may not be what you're going to be seeing next year. So, they may give you a dollar amount they may say you know 250,000, but you need to know the breakdown what if your base is only 150,000 of that supplemental is like, you know, oh my gosh I can't do the math $10,000. You're, you're going to be sorely disappointed next year if you're realizing that the base is a little bit different than what you're expecting. So understand that breakdown. And in terms of salary it's it's mostly location dependent in terms of like what human or can be commanding and it's also, you know, situational dependent academics versus private practice. It can vary quite a bit. It's good to be asking people questions in that area, you know, maybe you have a good friend who, who you can ask questions about somebody who's worked there already. And then retirement plans. Is there matching things to be aware about is that part time versus full time the retirement plans may differ for myself I'm part time so I cannot engage in the certain types of retirement plans that does have matching so I don't because I'm choosing to be part time. You can also negotiate relocation costs now make sure you understand all the details that go into the relocation costs in terms of like how exactly is it going to be reimbursed. Does it have to have to submit your receipts at a certain time do you have to use their moving companies, there might be a lot of different details in terms of getting that recouped administrative time is very key people often forget to ask about this when they're negotiating. If you're asked to have an administrative role, yet you're seeing patients, you know, five days a week, it's, it means that that ministry of time is going to be coming out on other times, not your Monday through Friday. So having administrative time negotiated in is important to consider. So, vacation days and sick days are important as well to be able to compare and contrast different types of jobs. I know one of my jobs was a locum type of job, not a locum job, it was a, it was a job that paid hourly. So when you're getting paid hourly you don't really have any vacation days, so that also factors in exactly how much you're actually making conference CME textbook money you can negotiate all of that. Even if you're part time or full time you can still negotiate maybe you want to negotiate full time pays payment reimbursement for conference fees, you can consider doing that. Other things to consider just to check into the place that you're going to be working for other human resource benefits, do they offer wills advanced directives. These are all, you know, it still costs money advanced directives may cost $600 that will offer, but maybe this academic institution does it for free for their employees. Asking about my practice insurance is a really big one is it covered where you're working or are you paying out of pocket for this, and whether or not it's claims versus occurrence, the one with the tail coverage is the one that's more expensive. And usually what's offered with more academic type works jobs, and then the do not compete clauses, that's a big one because oftentimes your first job may not be your only job. So let's say that your spouse lives in a certain city and you know that that their job is not going anywhere, but you are going to apply for your first job so hopefully your first job works out but if it doesn't and you have a do not compete clause, let's say it's a year of. You cannot work 15 mile radius of any of the satellite clinics. Let's say it's a big hospital with tons of satellite clinics, then you may not be able to be working in the entire city of whatever city you're living in. That could be a whole year's worth of not being able to work, no salary if you're going to be changing jobs. So if you can negotiate do not compete clauses into something more reasonable, maybe like, you know, three months of do not compete or the location, the radius of we're not competing can be adjusted. That might be helpful for you to consider before you commit to your jobs. Before you commit. I would recommend trying to get a win win situation. I'm trying to see a balanced approach on things. Maybe your whole goal is to get like the highest salary but I don't know maybe the job is really suffering to have to pay you a high salary. I think it's better to have a win win situation for both parties, I think long term, it's just a better situation. And again, talking about email and paper trail. Anytime you're emailing about the various things you have been discussing, do it through email or paper trail so you have you have data in terms of what you've talked about asking about start date and what you need to do on your end to start your job on timely manner. And again, like I said, the first job. Most people do not stay at the first job for a variety of reasons, not just not just they don't like the job but you know they may move or what have you and making sure you're aware about what your conclusions are for the do not compete clauses very important. Okay, so any questions for anything that I discussed. Yeah, I'm 11 minutes now. And I'm in an academic institution at UT Southwestern and this is my second academic job that I engaged in. So, I will tell you when I first was looking for jobs initially when I was in residency I thought I would only do private practice. I really like academics, a variety of reasons I like the social aspect. I liked the it kind of encourages me to publish and be part of that research community, which is important for me I don't know if I didn't get the push. I probably would not be publishing papers myself but that's why I kind of like the academics I like the social reasons I like teaching I like being a part of the residence days, so that's why I chose my academic job, instead of going practice which is what I initially thought it would be doing. Okay, if there's no questions I'll pass it on to, I believe, Dr. Monica Gutierrez. All right, I'm going to share screen and a little bit more about reimbursement models and how we get paid and I think that, you know, I first think well this is really important for people to know who are starting off but I also realized that sometimes people reach out to me when they start looking for other jobs, especially if they might be changing jobs from academia to private or private academia, that it's really important that you understand how you're going to be able to get paid. So I'm going to go through some of those examples with you. So again, I am talking about the models of payment, talk about barriers and challenges and then basically how you get paid but then again, it's all about what do you want in the end, and always pay doesn't have to be money yes money is very important but again like Dr. Wong said it's also about how what you want in your life and what's priority for you and if you want to have a job where you do lots of research, and you go looking for jobs but you don't ever tell the people that you're looking at jobs for that you want to research job then they're going to try to probably put you in a clinical job so again you have to align it with what you want to do. So for the different types of incentives there's basically three different way that people get paid so first it's just salary and this is probably the most common one seen in academia where it's like okay you're going to come in this is what our faculty make usually. There's an opportunity for incentive and bonus but it is usually you're just like this is a salary sometimes there is an income guarantee type as well and that is usually where they just say okay, that might be a private setting but some academic may do this we're like, you're going to come in. In the first two years we're going to pay you $300,000 or whatever it may be. And that's what you'll get for sure, while you're building the program while you're building your business. And then after that two years, you're going to get paid by, you know, XYZ whatever they decide that to be. So, probably somewhere in the middle and one of the more common models is the salary and production, so you may get a base salary, and then get paid more based on our views, and there's different models for that it may be ones where, like for your first 1000 RVUs you get paid a certain amount per RVU, and then the next 3500 RVUs you get paid a little bit more, and then every next 1500 RVUs you'd get paid more for those. So you might just be like we'll give you just, you know, $100,000 and, or let's just say something where math can be easy $120,000 a year plus production so that might be, you know, at least $10,000 a month but then production basis on what you make. This is from actually organization that looks at recruiting and looks at how physicians and other medical professionals are are paid and so for the most part, most are going to be salary with bonus, like I said salary and some type of incentive pay is the And it seems like it really hasn't changed too much through the years at least in the last five or six years that you can say, see here for the most part it's okay you're going to make a salary and then you're going to be able to get incentive pay based on if you hit your RVU target or whatever it might be. And then the next common one is salary and then income guarantee and then other whatever other maybe. So, when they had that salary plus production, what were those production bonuses based on. So the vast majority is RVU based. Some of these were, you know, and or it wasn't just because obviously those all together do not add up to be 100%, but then some places look for quality remember this Merritt Hawkins look it's at all specialties it's doesn't just look at PM&R. And so in some places they're really judged on their quality net collections is another thing. And the difference between those two things is can be a big deal and this also happened in my first job in academia, was that bonuses were based on actual money that were collected but then I realized that I was working more at the level one trauma center doing consults and guess who gets seen there versus the freestanding rehab hospital where you have to have insurance to go there. So, I was not getting paid as much just doing consults because again that was at the trauma center that had to see anyone. And so even though my RVUs might have been great. My collections were not great because there was a lot more underserved patients there was a lot of self pay which really means no non insured I'm in Texas, some of the lowest insurance rates and the whole insurance percentages in the whole entire country, or Medicaid. And so once where the collections would be very low. So again, RVU based is somewhat better. Patient encounters is another way okay are you seeing the amount of patients they want you to see are you hitting your targets for patients that they want you to see gross billing so again it's just, you know, percentage of what you completely bill for which is not at all what you get so that's probably why that is not a very popular model, and then others not as common. So, RVU based is usually what it is. People will ask that what are the RVU targets for PM&R? So I will at least let you know what they are for academic. PM&R is the benchmark for PM&R per the AAMC is about 5,300 RVUs is the average. So that's 50th percentile. Of course, they have all sorts of percentiles so you can see what it goes up to. And then for pain management and spine and pain, it is a little over 6,000 RVUs. And you know, the pay is sometimes very different between someone just doing general physiatry and pain, but they know how much someone's RVUs for pain might bring in versus just someone who's doing a general outpatient visit without a procedure. So just something to consider. Also what your RVU target might be when you're getting paid, because if they're saying, okay, well, we're gonna pay you based on RVUs. And if you're hitting the 90th percentile RVUs, but maybe only getting paid in the 25th percentile, then you know, that might be something that you have to bring up when you talk or when you're negotiating for either to continue to stay at a job or at a job, or when you're going into a job as part of your negotiations, what's my RVU target? Is my pay gonna be aligned with what my RVU target is? And then if patients, for ones that had quality as being their metric, then only 11% of their total compensation was determined by that metric. So specifically for physiatrists, most of them, 66%, you can see have the type of model where it's a base salary plus a variable. And then 18% have a flat salary, 13% had a 100% variable plan, 2% have temporary guaranteed salary, and then 1% have other. And so this came from, they, PNR had a compensation report that they did in 2017. And this is just from the answers that they got when physiatrists did the compensation report. So again, a salary plus a variable plan. Mm-hmm, mm-hmm, mm-hmm, mm-hmm. And then the fixed versus the variable was also similar as far as almost 50-50-ish. So for the ones that are variable compensation plans, what else did they look at? And this was specifically in physiatry. So for the most part, they were looking at work RVUs. In some, it was the revenues less your expenses. So, okay, this is how much you brought in. Your overhead is, you know, $50,000 because you have to pay your MA and your billing company and whoever answers your pagers after hours. And then that's what your revenue might be. Again, even in PNR, sometimes it's quality, whether they want to link it with your outcomes for your back pain, your patient satisfaction. So those are different things as well. Your summits type, it's based on the net professional collections. Again, so what you're actually bringing in. Some, it's non-production based. In some academic settings, they have eRVUs. So not work RVUs, but something that they develop a metric for academic RVUs. So perhaps you, you know, maybe just hit your RVU target, but you also did three papers and brought in a small grant, then those would be academic RVUs. Some looked at total RVUs. Some may offer you a APP stipend to either supervise an APP or sometimes it's like, if you want an APP, it's going to come out of your salary. Then it just depends also on provider profitability because in some cases, especially in academic setting, you might hit all your RVUs and more, but if the whole department's losing money, then no one's getting a bonus. Even if you had twice as many RVUs than everyone else and I've learned that the hard way in my initial jobs. And then again, less likely gross professional charges. So what specifically happened with COVID-19? So it went from, and it's changed a little bit more, but it went from a seller's market to a buyer's market. So basically what it's trying to say is that initially when COVID started, and remember there was that period where a lot of clinics were shut down and there was a lot of uncertainty about what was happening. And so it was actually people, companies, organizations, physicians' offices, academic centers were losing money. And so they actually had to put hiring on hold. So it was really hard for some of even last year's graduates to get that perfect job that they wanted. It's starting to come around now. Academic centers, other places now have done better now that it's been over a year. And so now jobs are becoming open again. So definitely COVID affected it, but now there's some more job opportunities, but definitely was closed for a while there. So tips that I have for this is educate yourself. So again, you wanna go in anytime you're doing this with as much information as possible, as well as knowing, educating yourself about what you want and what you expect. You have to know your worth. So again, you can know what you want to do, what kind of expectations you're gonna have, what do other people in the field that you practice make, what look at all the data related to gender pay gap. And we have at least three papers in the PM&R literature, and then there's tons more in the general literature about gender pay gap where there's consistently less that women get paid less than men in medicine, including they just had a Medscape also had a women's burnout type of survey results that came out. And then yes, okay, they may have burnout. They also are continuing to be paid less throughout their career. So you wanna ensure you're being paid equitably. And so one thing, it's hard because a lot of times people who are hiring, they hold their cards here. And so I may be very much now about transparency and say, okay, people come in, then we're hiring at this percentile and this is what your RVU should be. And this is what we'll pay that goes along with the AAMC for that RVU target. And then there will be opportunity to get a bonus if you're above and beyond that target. The other thing to know is, okay, we expect 0.9% or, and then you get 0.1 administrative time, at least some many departments do it that way. But also remember that you can negotiate more administrative time, especially if it's paid administrative time. So if they want you to develop a program and you're in a rehab hospital, then see, can that be covered by the rehab hospital so that you have more administrative time? Do they want you to be a medical director and the hospital pays for a certain part of your medical directorship? Then that can be time, that can be something that decreases your RVU target because an outside entity, whether that be the hospital, the inpatient rehab unit, whoever's paying the medical directorship is funding that part of your salary. So your RVU target should actually be less. The same thing, if you're going to be expected, if you're doing research and you know that they're going to expect a certain percentage for your research efforts and make sure that those effort percentage is taken away from the total RVU goals that you have. So you're not doing 110% of the work for 100% of the pay. And there's data for AAMC, there's data for MGMA, AAMC is, that data is very costly, but it is around and a lot of people may have it, especially even including your program director, especially if your institute belongs to one of the AAM, is one of the AAMC affiliated institutes, which many are. And then also other data gets around with what is the MGA data, which is probably more aligned to what private practice is paying and not as much aligned to what academic is paying. So again, think about what you want that is beyond just money. So yes, it was like, show me the money, but also like Dr. Wong said, if you want to work part-time, then you know you're giving up some money and possibly some benefits. And then the other thing is look at the benefits that you're going to get and do they align with what you want as well. And so, yeah, that was the look beyond money. So yes, money is very important. I want everyone to get paid equitably for sure, but also you have to think about what else you want. If you want work-life balance, if you want time to do research, if you want time to develop programs, then make sure that is part of what you asked for and see how it can get paid. So that is my section and I will stop sharing. Thank you. Dr. Russell's next. Okay, thanks. Any questions for Dr. Gutierrez while I'm setting up my... Okay. You can chat at the end. Okay, yeah. And feel free to ask questions at the end. We'll have some time for that. And yeah, I'm just going to talk a little bit kind of along the lines of both of these and just kind of talk about kind of general overall business of healthcare. I will by no means call myself an expert, but has just been, you know, things that have been on the learning curve as I've gone along in my practice. So I am an assistant professor at University of Texas at Houston and assistant professor. I work primarily out of Memorial, Tier Memorial Hermann the Woodlands, and yeah, I have the academic appointment and have an interest kind of in healthcare finance and economics. And it certainly seems like, you know, that's there's definitely something that's, you know, always on the forefront. So annual healthcare expenditures have been steadily increasing over time in the last, you know, since 1980. There's been significant increase. I would say that this graph is probably not adjusted for inflation. It's probably a little bit more linear when adjusted for inflation, but this is a US federal spending on healthcare from 1960s to the projections for 2022. And as you can see, that was the spending and also kind of goes along, this is in billions of dollars. So, you know, over 2. Or $2,200 billion. So a significant portion of the budget. Medicare has changed over the years, was first instituted in 1960s because after workers were retiring, they hadn't had a way to have healthcare when they left their jobs. And so in the 1960s implemented a fee for service and cost-based reimbursement. The 1980s is when DRGs kind of came into play. 1990s is kind of the capitation and the global payments, which we'll kind of talk a little bit more about these as we go on. And in the 2000s is when the APCs and the P4P kind of came into play. So a little bit of differences on Medicare and Medicaid. Medicare is funded from federal tax on income. You'll notice, you know, you have Medicare wages that are deducted from each paycheck. It's for people who are over 65 or 65 and older. Some people who have disabilities that are under age 65 and people with end-stage renal disease. So there's been an increase over time in the number of covered beneficiaries as well as a change in the life expectancy. When it was instituted in 1960, the life expectancy was about the late 60s, maybe even like 67. And now the life expectancy, you know, is late 70s, early 80s. And so, you know, where is that funding coming from? Well, it's coming from federal tax. And so that's how that can kind of, you know, all of the comments you hear about the Medicare program running out of money, you know, it's multiple changes like that that have become part of the reason why there's a drain on that. And, you know, 28 and a half million people in 1980 to 50 million today, you know, now the boomers are the ones that are aging in that Medicare age. And so that's a significant portion of the population. And, you know, how much are the expenditures? Well, it was 36 billion in 1980, now in 2012, you know, 574 billion. So that cost has gone up a lot. Comparing that with Medicaid, it's a federal and state tax on income. The federal pays a larger share than the shares based on the state's per capita income. People that are covered are people with disabilities, people without financial means, usually just above the poverty line, needy women and children in terms of, you know, the CHIP programs and childless adults. In 1981, you know, there has, again, been an increase over time, it was 20.2 million individuals, in 2010 was 66 million. And there has been an increase in expenditures as well, from 1980, 24.7 billion, all the way up to almost 400 billion in 2010. And as you go, this is a very complicated equation, I'm not gonna go kind of over everything, but just how hospitals and healthcare systems get paid and where everything comes in as far as the case mix index, location, and everything. And so, you know, you'll get different payment rates in different parts of the country for different things. And so this is really just kind of an indication of just how complex the payment system can be. And Dr. Gutierrez and Dr. Wong had talked about, you know, a little bit about physician reimbursement and looking for a job. And so, you know, what the heck is an RVU? And, you know, it's one of those things that you hear RVUs, especially when you're coming out of training, you hear RVUs, you hear work RVUs, and, you know, what all does that entail? And so work RVU is kind of related specifically to the physician or clinician. It's adjusted for geographical differences as is practice expenses and professional liability RVUs. So all of that can go into computing physician payments, not only with this whole equation, but also with negotiation and payments and contracts and everything. And so way that payers have been working to kind of control costs, as we talked about, you know, the increase in healthcare has been going up over time. So, you know, in the 80s, they came up with the DRGs and the CRGs as well, you know, that's prospective reimbursement. When they came into the hospital, you know, they got assigned this diagnosis, this diagnosis cost this much or, you know, paid out this much, and that was kind of what you were getting. Capitation is if you have a thousand individuals that are in the community under this healthcare plan, you know, they're gonna pay out so much per capita. Global payments is a single price for several providers. So a good example of that is going to be kind of like your hip, like hip replacements or, you know, knee replacements, things like that, where they have kind of a global payment. And if you have a complication from surgery, you go in and it's still covered under that global payment. And it can also, you know, be several providers that also are taking kind of out of that bucket. Then there's retrospective reviews, the audits, concurrent reviews, prior authorizations, pre-admission certifications. You know, they've also instituted, you know, second opinions, gatekeepers, as well as, you know, hospital systems. Texas is not one, but I'm sure some of y'all are in a state where that is a certificate of need. So before increasing hospital beds, you know, they have to petition the state and give a business plan, you know, as to why they need those increased hospital beds. And the way that providers have been able to help control cost is to shift to outpatient outpatient services when possible. You know, I was talking with an orthopedic surgeon not too, in the last week or two, and they were talking about how, you know, when they were training, there was no way they ever thought that, you know, hip replacement was going to be an outpatient procedure. And now, you know, it's kind of a bedded outpatient and try and get up and going and on their way. Implement more sophisticated cost accounting systems, information service technologies, mergers and acquisitions. So, you know, hospital systems that are being part of larger hospital systems, and physician groups that are kind of the multi-specialty groups, and then kind of re-engineering and redesigning. So then there's, as far as reimbursement for services, there's kind of two broad categories. There's the fee for service, which payment is tied to the number of services provided. So this can be based on charges, it can be based on cost, and it can be based on the prospective payment or like the DRGs. And then there's the capitation where the payment is tied to the number of covered populations. So, you know, say, we're University of Texas. So University of Texas, you know, has, to make it easy, a thousand physicians. And so, you know, they're going to have this number of physicians that are going to cost this much for health coverage for whatnot. That would be an example of capitation. So the fee for service is a fixed payment that's determined beforehand, negotiations with, you know, hospital systems, physicians, providers, and the insurance companies, as well as Medicare, Medicaid. It can be on a per procedure basis. So the charges can be on the diagnosis, can be on a per diem, as well as the global pricing. And then there's the capitation, which is entirely different. It's usually payments made to physicians in like an outpatient setting on a per members per month basis. And it's used primarily by the managed care plans. And so this is just something, because, you know, I've been in meetings where I've, you know, they're saying, well, you know, we want to be able to offer this service, but we need, don't want it to be a losing endeavor. And so we just at least want it to be a breakeven. And so this is just a little bit of information on, you know, the concept of breakeven in order to develop the equation. And so say you were, you made a hundred dollars a visit, the variable cost for visit was maybe about $25. So you had a contribution margin of $75 a visit, and you started this clinic and it costs $200,000 to start this clinic. So using that fixed cost, the 200,000 and you know, the $75. So to break even, you would have to have this many visits and this many visits over this time span is what you would kind of work on to, to look at the, you know, if it's a worthy investment. So kind of looking at that kind of upfront money that people will be putting into, just wanted to touch briefly on the time value of money. And so, you know, the saying a bird in the hand is worth two in the bush. It's kind of the same way with, you know, the bird in the hand being money now is better than money later, the two in the bush. So I'm getting money now is going to be better than getting, you know, twice as much later. And so in Excel, they have this, these equations that you can kind of play around with your own stuff own numbers, but they have FV is the future value. PV is the present value. I is the interest rate. So historically the stock market has had a 10% yield and N is the number of years. And so the future value can increase that by increasing the number of years of compounding. So keeping the money in longer and, or increasing the interest or discount rate. So if you want, you know, that's, I think part of the reason why in, you know, financial talks, they talk about, you know, conservative growth versus aggressive growth. So increasing that interest rate and aggressive growth where you have more, maybe like stocks, that type of things, or the bonds and kind of the more conservative growth can, can affect that. And so this is just then how to calculate from the future value, how to calculate the, the present value, which again, is it's an Excel if you ever wanted to look at that. And so kind of talking a little bit in the end is, you know, you won the lottery. So this is kind of going on that time value concept of money. And so if you hit a mega millions jackpot, you could get the lump sum option which is 48.4 million now, or the annuity, which ends up being 87 million over 30 years. And so if you got 30 payments each year of 2.9 million, that adds up to a lot more money than the 48.4. But it isn't always necessarily going to be the better deal. I mean, if you take the 48 million and you spend it all right away, it probably would be better. But if you were to invest it all, then, you know, it would be more worthwhile to take the lump sum. And that's just kind of going on that time value. So if you had a conservative portfolio that returned just 6.5% where stocks are historically 10, you could take out $2.9 million indefinitely with that lump sum. And if you invested it 7.5% and you accounted for inflation of 2% each year, that would last 88 years. So versus taking the 2.9 each year, but as that 2% inflation hits, you know, in 30 years, that would need to be, you know, 5.2. So you'd probably have to adjust your spending and your lifestyle a little bit more at that point. And that's all I have. And so I just wanted to open it up to any questions that anyone has. It looks like there was one from Sarah. So looks like that might be directed a little bit more to Dr. Gutierrez or Dr. Wong. Right. So I'd say I think people know right now that there are physicians who had to leave the workforce during COVID. For sure that's happened to a lot of women in healthcare, physicians, nurses, everything. So I think that you would just explain it honestly, you know, this happened, this is what happened during COVID. This is what I had to do during this time. I continued my CME. I kept up with XYZ, you know, everything else you did to keep yourself fresh in the PM&R world, and then just go back and go for jobs. And I think there's some places that, you know, there's, like I said, we couldn't hire for a while, and now we can hire again. So, you know, there's going to be a place hopefully that needs you. Okay. How do you ensure there's no gender pay gap when signing? That's a really good question. And one thing is that you, it might be hard just to come out and say like, well, is there a gender pay gap? You can't really say that, but just say, you know, what kind of transparency is there in pay? Or just want, you know, even be honest. I know that a lot of times that, and I'll tell you, this probably happened in some of my first finding jobs because I am not from a family of physicians. I am first generation to be in medicine. So to me, when I was a resident, I already made more money than my family made. And so to become an attending and just to make attending money sounded like, wow, that sounds great. Like I'm making tons of money without even thinking about a pay gap or what other people are paid. So I think if, you know, it gets to that point and just say, I want to, is there a way in this department or here that we know that there is some equity in pay? Because we know that there are demonstrated pay gaps across physiatry and across all medicine. And I think someone that's doing the hiring would be very honest in, in answering and saying, yeah, you know, well, we do it based on this, or we do it based on that, or like, don't worry about it. Then you could maybe figure out if there's red flags on that or not. It looks like we had another one that was what advice would you give someone who is negotiating the salary portion of their position? I was talking to someone recently, and it was like, again, knowing the data, knowing what the different, what is the pay in your area, and there's different places to look, you know, their Medscape has something, AAPMNR has something, AAMC has something, MGMA has something, you know, you may have other people that you know in the area that are willing to talk about these things. And I think that we keep it very private, but not, I'm saying, I'm not saying like, just post it on your Twitter account or on social media, but you know, people should be talking and asking about this stuff a little bit more. And that, so if you come in armed with, this is how much I know I can work, or how much I've worked before, this is what I know for someone who brings in that many RVUs makes. So, you know, ask and probably even ask for a little bit more. Someone told me recently that you have to maybe almost be to the point where you're embarrassed, but what's the worst that they can say? They can say like, well, maybe we can't offer you that much more, but we'll offer you this instead. And then also remember that it's a negotiation. So, you can say, and then part of the negotiation is, again, what's important to you and BATNA. I don't know if anyone's ever heard of BATNA before, but it's one of the negotiation techniques or it's part of negotiation. It's a better alternative to a negotiated agreement. So, you almost have to think like, what is my plan B and what is their plan B? So, what would be, if they offered me, you know, X, Y, Z amount of money for this, my first job, but I had plan B is I have two other offers over here, then it's very easy for me to try to negotiate more aggressively if that's the job that you want the most, because, you know, you have something else in your back pocket. The same thing, even when I was going for a chair position, it was like, well, if it really wasn't worth my while, then, you know, I knew that I had another, you know, I was already a vice chair, I had another opportunity for other things versus what was their plan B kind of thing. So, yeah, is this company that they need or this institute that they need someone so much right now to fill that position that they're willing to pay you and pay you really well versus, oh, they have five offers for one, they have five people looking for one position, then you may not be able to negotiate because you may not have as good BATNA as they have. And make sure it's not like a loan. Sorry, Meribeth. Oh, go ahead. Make sure it's not a loan. There's been some individuals that negotiate a salary, but inside it says if you don't do not make enough money to pay your salary that you're going to be paying back that loan. It's like in the fine prints, so just make sure it's not a loan slash salary. Yeah, and Dr. Fleming asked a question, you know, about negotiating the salary. And so, I guess I would just add on to that along with the BATNA is, you know, in some negotiation classes that I've listened to, they've talked about never accept the first offer, you know, as part of the negotiation. If you do that, first off, it might be your BATNA, you know, especially when you're coming out of training and it sounds like it's a lot of money. But if you're accepting the offer, but if you're accepting that first initial offer too, that that's, you know, the people that are offering it think that they might be overpaying for what they're offering. And so then that can lead to some more harder negotiations down the line if you were to start wanting to negotiate more for, you know, some of those other things that Dr. Wong had mentioned. And don't show your cards. Don't tell them you're on a timeline like, oh, my husband's going to be moving here in three months. I need a job in three months. Like, don't show your cards. And then we had another one, Dr. Caldera, knowing if you have a malpractice tail, if you were to leave is also really important. You don't want to stay at your first job. I don't always want to stay at your first job. It's this is different by insurance state and specialty. So, yeah, good point. For sure. I always tell my residents, your first job doesn't have to be your last job. Unless you're working for me, then it should be. But but yeah, so definitely look at what kind of malpractice there is there. The other thing is, if you're someone that you have to consider all parts of your job and what you do. So let's say you're someone that does consulting work, like you consult with pharmaceutical companies or you do medical legal work. Where does that money go? Is it a carve out where you can get your own? You can keep that money. Are you going to have to give it all to your department? You know, make sure if you're going to do that kind of work that that that there's something in writing and clarified about that, too. Yeah, that's very important. Another thing to consider is if you're looking into wanting to be a mother, want to, you know, have time to pump. There are some more mother friendly work environments versus not mother friendly work environments. I just know a lot of private practice. They don't have that built into their system. So my friends were in GI. They actually were in the negative because they still had to pay for all the overhead while they're taking time off having children. And when they came back, they had a book and time to be pumping. And there was nothing to offset that amount of time that they weren't actually generating money. So looking into that, too, if that's something you want to do in your life. But they should have places for you to pump because that's part of ADA or, you know, accommodations for sure. But yeah, doesn't mean that you get paid during that time. Right. Or if they'll even allow you to adjust your schedule to have pumping time. There's been situations where they're the bosses don't approve that. The other thing is, speaking of schedules, is if you want to do something flexible, if you want to do something different, ask about that, too. You know, in business models, there's people in the business world that do 410. So their 40 hour week is that way. So maybe there's some way where you could be, you know, have an extra shift of clinic or two days a week where you work really late and then you could have a three day weekend or, you know. So if that's something that interests you, knowing that, OK, what can I do and still meet my RVUs? But maybe there's different types of practice plans that I can do. Okay, does anyone have any other last questions, comments, concerns, anything? So Dr. Russell, when you were talking about the lotto thing, my husband always says the same thing. We just take the big payout. He's a finance person, so. Okay, that's good. I did buy a negotiation book. I never read it. A couple, a few years ago at, during one of the women community sessions, we had a negotiation specialist come to talk to us, and she's the one that, she writes the book, Women Don't Ask. So that is, that's the book I'm looking forward to reading. I'm looking forward to reading it, too. She writes the book, Women Don't Ask. She writes the book, Women Don't Ask. So that is, Women Don't Ask. So that's one book that you can read about negotiating. And there's a lot of, you know, I'll look at Harvard Business Review, just because it's a nice, I don't have to read a whole book. It's just something that's nice and digestible. And then the other thing is, as you move up, you may not, like in coming to a chair role, it wasn't all about, oh, I'm just going to negotiate my salary, especially when they're very transparent about this is how much we pay chairs based on WMC averages. But to me, I was going to negotiate for being able to get more faculty, to recruit the number of faculty that I wanted, to be able to have funds for my faculty to do things, to be able to get funds for a researcher, for a study coordinator, so we can build an infrastructure for clinical trials in our department. And so it was a lot beyond pay at that point. And that's where you can reach out to your other chairs to see what else you can ask for. Okay, well, if there's no other questions, I think we'll wrap up about two minutes early. So thank you so much, everyone, for your time. And if you have any questions, feel free to email us. And happy to have you all here and hope that you have a great week.

Isabel Huang

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