I'm an associate professor at the University of Texas Health Science Center in Houston, where I also direct the fellowship program. I will introduce our speakers for this morning. So we have Dr. Elizabeth Hagelin. She's an endocrinologist at the Endocrinology Clinic in Minneapolis and Minnesota. Dr. Shant Parsegian is an endocrinologist and director of the Montville Endocrine and Diabetes Center in Massachusetts. And then Dr. Mary Mugo is an endocrinologist at Atrium Health Floyd Primary Care Center for diabetes in Georgia. And we'll have plenty of time for questions at the end. Good morning, everybody. I want to thank the Endocrine Society, Dr. Guttenberg, and all the organizers for giving us a chance to do this presentation again. This year, instead of a solo presentation, we have a panel of speakers with different experiences. And I believe you guys will really learn a lot from this morning. So for most of us who are here at the crossroads, graduating fellow looking at a new career opportunity, some of you may have decided to go into academia. Some of you may have decided to go into private practice. And some of you may have decided to go into government work environment. Can I have a quick show of hands as to how many of you here in the room are actively looking for your next phase, and your next contract, and your next job? Can I have a quick show of hands? Excellent. And how many of you have actually signed on the contract and you're ready to go? You know exactly where you're going. OK. So that's good. And how many of you are kind of mid-career endocrinologists who have been in the practice for about 10 years or so? Awesome. OK. So I'm Elizabeth Hagelund. I'm at Endocrinology Clinic of Minneapolis. And my email address is there. So please feel free to correspond. We will take questions at the end. And we're going to have a seamless presentation between myself and my colleagues here. My practice specifically is a group practice. So we are three endocrinologists. We have two mid-level providers. We have three diabetes educators, out of which two are also dieticians. We have a very robust pump and CGMS practice. We have an in-house lab. It has gone through some transitions, but we have an in-house lab. And then, of course, we have medical assistants and clinical assistants. We don't have any RNs or nurses in our practice. Our medical assistants take all the phone calls. And the clinical assistants are the ones who room the patients. And then we have a clinic manager as well. So that's kind of the setup of my current practice. I have no financial disclosures. And I do want to emphasize that this presentation is not a substitute for legal counsel. The learning objectives for this morning, the first thing I want to do is just to give you a quick statistics. What's the demand and supply for endocrinology as we stand today? And then I want to go into how to plan and develop your practice. And you will find that this is an important aspect of your entire career as you view it over the next few decades. What you do today is not what you may do five years from now. But what you do today is going to be foundational for what you will do five years from now. So I want you to have a practice plan that is running at the back of your mind so you know what it is, where you want to reach at the end of that time. The next two objectives are financial contracting, management, and profitability, and contracting for success. Those two objectives will be covered by Dr. Mugo. And finally, Dr. Parsegan will share his real world experience. So today, one in 10 Americans have type 2 diabetes, which is a population of about 37 million. And one in three have pre-diabetes, a population of 96 million. Over the last decade, the prevalence of obesity has increased from 32% to 42%. And that of severe obesity has doubled, gone from 4.7% to 9.2%. Now, in the face of this increasing demand, there was a publication not too long ago in JCAM that quoted, in the absence of any intervention, there will be a deficit of 2,700 endocrinologists in the United States by 2025. And it's no wonder that endocrinology is now within the top 10 specialties with the highest demand. Traditionally, the average annual turnover rate for a physician was about 6% to 7%. But the recent pandemic has made a big change in that scenario. 43% of physicians switched jobs during the pandemic, 8% retired, and 3% left medicine altogether for a non-clinical career. And whenever a physician leaves a practice or an institution, there is a huge price to pay. You have to recoup the cost of the recruitment and payment of the recruiter, the onboarding cost that is now lost, and then the revenue that is lost because you are in transition trying to find a new person to fill in that position. So it works really well for an employer to be engaged with their employees and to keep them to value professional satisfaction. The first question's first, right? All of you who are graduating or who have already signed on a contract, you want to know, what's the salary? What's the compensation? What am I going to get? And it's really exciting because it's a big jump from a fellow salary to a real life salary. So the sources here in the left-hand column, they are from health care staffing companies. So the first line, Merit Hockings, gives us some data on what is the usual starting salary for endocrinology. Now, there is a wide range. It can go anywhere from $200,000 to $250,000. And this is dependent on which geographical location you're going to practice. It also depends on whether you're going to work the four and a half days a week, which is the initial expectation, or whether you're going to go part time. So the median compensation is around $240,000. Medscape and MGMA gives us data on average annual compensation. And Medscape quotes $245,000. MGMA quotes $280,000. Again, the range is wide. When we talk about starting salary, there is usually added sign-on bonus, relocation expenses, perhaps some loan repayment included. Not included, but actually an add-on to the initial salary. And average annual compensation includes the oversight for advanced practitioners and a production bonus. So in the next few slides, I'm going to give you insight into what are the models that exist for private practice. This is a brief overview. There could be further manipulations or nuances to creating your own practice. But generally, there are four different models of private practice. Most models have the hospital-employed system, where you have a central HMO, teaching hospital, or community hospital. This is linked with outreach clinics. So you may be employed in the main hub and then have to travel to an outreach clinic, perhaps once or twice a week. Or it could be the other way around. You could be positioned in an outreach clinic with the opportunity to go to the hub, perhaps once a week. Now, this model is called as the integrated delivery model. The next model I'm going to talk about is if you're part of a solo practice or a group practice, but you really want to have a steady stream of referrals. And you can approach a community hospital or an HMO or a teaching hospital and say, hey, I'm here. I am willing to provide endocrine services to your patients. And so HMOs may be interested in the service you provide because there's such a demand for endocrinologists. They may ask you to enter into a contract that says, we will give you our population of patients who require endocrinology care, and we will pay you a certain amount of money for a patient that you take care of. The more complex the patient, the more reimbursement you get. And the less complex, the less reimbursement you get. So irrespective of whether you see that patient or not, you will get a lump sum, and the way you manage those patients then is up to you. This is called SP by capitation. You can also have another situation where you have a solo or group practice where you say, no, I don't want to enter into that capitation system. I will manage my own billing. I will manage my own revenue. However, I do want to be associated because you guys are a good source of referral for me. So I want a place, a real estate that I can rent from you. I want to share your staff. So I want your nursing staff or your clinical assistants or medical assistants. I want your scheduling system to be able to run my practice. So there is a provider service agreement where you can run your practice. You can do your billing. You can create your own revenue, but you have to pay a certain amount to the teaching hospital for the services that you're going to take from them. Now, if you are in a situation where you're going to a new place, perhaps your spouse has a job in a new place and you have to tag along and you have no idea. You don't know where you're going. You don't have any contacts. You don't have any family, and you really want to scout the area before you commit to any particular organization. And doing a locum job in that situation is entirely reasonable. It gives you leverage. It gives you an understanding of the system and how you need to leverage yourself for that geographical area. Okay, so some of the things that you have to start considering once you have decided what kind of practice model am I going to be working in? What is it that suits me the best? And the big question here is autonomy, and I'll talk more about autonomy. Because as physicians, we are autonomous people. We have taken a lot of autonomy in carving out a career, in deciding what fellowship to take, how to navigate life for ourselves. And so we walk into life with that autonomy built in within us, and suddenly we can find ourselves cocooned within a hospital environment, and the autonomy is not as much as you thought you would have, and you don't wanna be frustrated by walking into a practice situation that does not quite match your level of autonomy. So in the next few slides, I'm going to cover these different aspects. So personal factors that you will consider is very intuitive, right? You guys kind of know I don't wanna live in Minnesota. Who wants to spend six months of the year buried under the snow? I'd rather be in California or in Florida or Texas, and fair enough, that's perfectly fine. Some people may have family in a place, and they're like, no way, I've got little kids, I can't manage on my own. I'm gonna go where I have my parents close by or my siblings close by. So you guys will decide based on the climate and the family where you're going to go. Housing, the kind of houses you want. I think the new generation of kids, they just wanna want a one-bedroom little place, and they don't care for big homes, whereas we have our Texans who like that big homes in the palatial environment. So it depends on what kind of a home and housing you want to live in and you're gonna be comfortable in. The culture of the area, the recreational opportunities, the transportation. I have some people who said, I wanna be in a place where I don't have to drive a car. I really wanna use public transportation, and that's important for me because I do not wanna have a car. And I have friends who have made some career choices based on that. Schooling, and where do you want your kids to go to school, the standard of schooling, and of course, cost of living. The professional factors. Now, it's not personal anymore. Now you're actually going to be evaluating the practice or the group that you're going to join. You really want to research the colleagues you're gonna work with. Look them up, find out where they have graduated and when you have a chance to meet them, ask them questions of why did they choose to be in the practice that they are now? What made them come there? What made them stay there? Ask them, what is their research interest? And what is their idea of career advancement for each one personally? So you get an idea of how ambitious your colleagues are. And is that something that you resonate with? Do you wanna be part of that group? Your salary, of course, we touched upon and Dr. Mugo will go into the financial aspects a little bit more. You wanna look at the office space, how comfortable that office space is, and whether you have all the equipment needed to make your practice run. You need to also understand what kind of supporting staff you will have. Now, if you have nurses working for you, remember that they are expensive. And so you're a part of the income you make will go to pay their salary. So do you really need an RN working with you? Or if you're looking at the RN to really make phone calls, do you have a smart enough medical assistant who can do that for you? And they would be cheaper but rarer to come by. And then there are also clinical assistants whose jobs are really not even to call patients, but just to help you with the rooming process and to keep your calendar on schedule. So think about what staffing is available and what you are going to use because you have to pay their salaries too. Electronic medical record. Boy, we talk about this on and on and on and on. I think there's going to be an adaptability needed with EMRs. It'll take time to adjust to a new EMR and that's okay. But you have to learn to become more and more efficient with that EMR. And if your hospital chooses to change the EMR or it becomes too expensive or you want to go to a better model, you really want to be ready to adapt to the new EMR as well. So don't be too hung up on any EMR. It's going to change and that's really the rule of the game. Career advancement. Are you interested in getting an ECNH certification? Will your institutions support you? Are you interested in getting a higher degree or maybe a sub-certifying in an endocrinology area and then starting a practice specifically in that sub-specialty area? So what are your opportunities for career advancement? Is there going to be competition? Is there going to be jealousy? You really want to be able to ask those questions upfront. And then hospital privileges, right? Do you want to be in an outpatient practice? Because many of the hospital employed systems would be happy to have endocrinology just as an outpatient and some do want inpatient coverage. Now, having inpatient coverage means you have to go to the hospital, you have to round on your patients, and then you have to rush to the clinic to get your first patient seen on time. And you may be paged in the middle of the day depending on how your hospital patient is doing. And if there is an urgent consult, your day doesn't end with your outpatient practice, you have to go back to the hospital to see that patient. So think about having a commitment to do hospital practice. It is a big commitment. And then your on-calls become that much more busier, and then your weekends also become that much more busier. However, it's a great idea to take on hospital employment and do that hybrid model, at least in the beginning. And that's my personal experience. I think the opportunity to just have that exposure to so many other providers that you're going to bump into in the hospital is going to be important as you move forward. Lastly, but not the least, is market factors. So we talked about personal factors, we talked about professional factors. Now we're actually stepping back and just trying to evaluate the market around that particular clinic. You want to have, I've kind of subdivided it into four categories, and my next slide will outline that a little better. So what is a practice reputation? So how easily do they get referrals? And a quick question to help evaluate that point is to say, hey, how many new patients do you guys see per year? How many new patients do you see per day, per week? So you can kind of get a sense of, within the practice, how robust is the referrals that come through? Maybe a good idea to also ask about new patient assortment policy, because you really don't want any biases in the way patients are being allocated to you. For example, if a patient has private pay versus Medicare, Medicaid, you don't want the private paying patients to be going to one provider and the other group going to a different provider. That's going to be, there's going to be a huge disparity in the take-home pay. And you want to be shrewd when you ask these questions so you're not being taken advantage of. I think one of the things that happen, you know, all our life, you're like, okay, medical school and then residency and then fellow, and there's always somebody telling us what to do. And when we walk into a new employment, the title of this topic is surviving the first year of medicine. Let me tell you, you are not surviving. You are in demand. You have a place, you have authority, you have knowledge, you have expertise, you have value, and it is time to step up and start recognizing that value. So do not be, do not be afraid to ask questions in an amicable manner. And ask about the new patient assortment policy so you're not going to be taken advantage of. Internal culture. So it's good to know whether the, whether you're going to be getting referrals from internal medicine doctors or from family medicine doctors because the level of complexity of the patients that end up in your basket could be different. Or perhaps you're going to see a lot of referrals from nurse practitioners and physician assistants. Their referral pattern is distinctly different. So it's good to know who's referring to you. Restrictions to diagnosis-based referral. I put that in there because in my previous employment, we had an internist who was very interested in osteoporosis. And she had an excellent osteoporosis practice. But when the management decided to bring on an endocrinology team, she was not very happy to share her osteoporosis patients with us. So there had to be some talking with the management, some negotiation to be able to dip into that pool and keep that practice going for endocrinology as well. Similarly, for thyroid FNA, as most of you know, you know, it's usually in the realm of radiology. Radiologists do the ultrasounds. Radiology does the FNA. And if you're interested in doing your own ultrasounds and doing your own FNA, you might want to bring that up front and then ask for it. Now, is it financially very profitable? I think traditionally, we tend to think, hey, any procedure is going to be revenue generating. I don't want to burst the bubble, but that is not true. And you will find many endocrinologists saying, I don't want to spend half an hour sitting and doing a biopsy. If I can see two follow-ups in that time, I'm going to make more money than do one biopsy or one ultrasound. So think about that too. Networking. I think I found it very, very energizing to go to the hospital and, you know, sit on that, sit behind that hospital desk and have a nephrologist sitting on this side and a cardiologist sitting on this side. And we're all seeing maybe the same patient has got multiple referrals. We have a chance to talk. We have chance to have colleagues. And that's important because suddenly, you know, from a group of medical school friends and fellowship friends, we are out there launched into real world. And it's good to have colleagues and it's good to have friends. And having that hospital environment was very invigorating for me. You connect with neurosurgeons. You connect with cardiac surgeons because you're managing their post-CABG glycemic control. You connect with the ENT surgeons who's going to do your cervical neck biopsies. So that's very valuable. And as you move forward in your career, these are the physicians who continue to be a referral base for you. They will send their endocrinology consults to you. So take the time to network with them. And lastly, you know, to be aware of community factors. So what is the need for endocrinology in that place? What is the demand? How many hospitals or clinics are there within a certain radius? Are they all hiring? What are they looking for? And then to know the competition. So how many endocrinologists are already there in that area and what is going to be the competition for you? The economic diversity of that place. Are you going to be interacting with blue-collar workers? Are you going to be interacting with more affluent who have done their own research on Google or immigrant population or those who need interpreters? It's good to know what you're going to walk into. And then waiting time for an appointment. Please do ask that question. How long does it take for a new patient to get an appointment? And if they say, well, the waiting list is long, new patients can't get in for about three months, you know that they have enough demand for a new endocrinologist. So that's a place that you're comfortable. Also, sometimes you may be walking into a practice where somebody is retiring and they want to replace that person. You might want to know what is a retirement date for that person and if they are going to actively be marketing you when it's time for transition. Because retiring providers start transitioning their patients about a year ahead. They may have been in that practice for 20, 30 years and they have a very strong relationship with their patients. You want that retiring physician to start telling their new patient, hey, we're going to have a new provider join our practice and he or she is excellent. And I think I would be very comfortable if you considered that person as your next endocrinologist. So don't hesitate to find out who you are replacing and have a conversation with them, maybe even take them out for a coffee, talk to them, and develop that relationship once you've decided that's where you want to go. Okay, this is a focus point. So I don't know where you guys are going to finally sign on that dotted line. If you're going into a hospital-employed situation, you certainly want to ask about outpatient versus hospital. You certainly want to ask how many hospitals. If the previous place that I worked in, there were four different hospitals. So when I was on call, depending on where the consult came from, you're driving from hospital A to B to C to D and you're spending a lot of time just driving around. So ask how many hospitals are going to be covered? How many outreach clinics do you have to cover? So have a good robust idea of what your day looks like. Do you have to supervise advanced practice providers? Are you liable when you do that supervision? Are you going to get reimbursed for that work? Do you have admin work to do? Are you going to be reimbursed for admin work? Are they expecting you to start a whole new service line for endocrinology? Are they asking you to be the chief of endocrinology? That's going to take a lot of work and you want to make sure that you're recognized and not taken as just a starting endocrinologist. Your frequency of on-call, right? Not only the frequency of on-call, but also the intensity of your call is going to differ depending on, you know, how many hospitals you're covering and so on. The financial aspect, Dr. Mugo will cover allocation of referrals, I already talked about it. Now, if you're going into a group practice, in addition to keeping all the points of hospital employment in mind, you're going to ask for some more focused questions. You're going to ask about partnership track, okay? How long am I going to be on a guaranteed salary? Do I have an opportunity to become a partner? Now, everyone thinks that, oh, becoming a partner is great because, you know what? I get to dip into the profits and the profits come from the lab and from the advanced practitioners. Those are the two places where you get the profits, but then you're also responsible for the losses. So, if you are not running your practice efficiently, if you have advanced nurse practitioners and physician assistants in your practice, but their calendar is not full, but you're paying them a fixed salary, now you're just generating a loss more than a profit. So, it's good to ask about partnership track, but it's also good to know what are the sources or sources of revenue or additional profit for that particular firm. You want to know the overheads because that's important because your profits come only after the overheads are met, and the overheads are kind of outlined right here at the bottom. It includes the staff wages, their benefits, their retirement, the rental you have to pay for the real estate place you're occupying, the lease for the electronic medical record, the lease for perhaps an ultrasound machine, the lab supplies, any miscellaneous equipment like laptops and phones, office supplies. And say, for example, you want to do Prolea injections, they are very expensive. So, if you are going to do that in your office, you have to first procure the Prolea at a very high price, stock it in your clinic, and then claim the reimbursement after you have given it to a patient, and you have to wait for that billing cycle to be over and for the revenue to come in. So, do you want, do you have that kind of capital to be put aside to just let this whole medication revenue run its cycle? So, think about those things as well. Marketing, we just, the previous session was about social media and how to market yourself. It is important to market yourself in a culture where social media is so aggressive. So, remember, you want to market yourself, you want to know how your group markets you. You want to make sure that you provide the best quality of care you can give at the end of the day, all said and done, that 15 minutes you get with the patient, the compassion you have, the quality of care you deliver, and the relationship you build with that patient is going to be the strongest advocate for your future practice. Make sure your patients are satisfied. We all have patients who can walk into the office very angry because they've had negative experiences before they have met you. I remember one of my professors at Mayo said, and I went to him almost in tears saying, I can't do this because, oh my gosh, these patients are so agitated and they expect me to fix their, all their problems of all their life in like one visit. And he looked at me very calmly and he said, Elizabeth, their lives are miserable. Don't let them make your life miserable. And I had to think on that, those two lines, and I realized that I have to put a wall, but a very gentle wall that does not alienate that person, but at least protects me. And so the language I use, for example, when someone's very angry, I say, I'm so sorry, you are going through this situation. I understand your pain. So using that word, you and your, in your sentences allows them to understand that it is their problem. And then you can say, I will do everything I can and try and find out what's going on. I cannot make promises, but I will do my best. And sometimes that's all that is needed. But make sure that you have that compassionate approach to your patients. Finally, if you choose to go solo, great, because, hey, you get to keep all the profits. You get to decide on making your practice as efficient as possible. And your eyes are keen on those overheads and make sure that your overheads are minimized. The level of autonomy certainly goes up as you go from hospital employment all the way to solo practice. I want to end with this slide that says, one of the ways in which most, if not all, of our medical schools have failed to do their duty is in graduating students into professional life without giving them the slightest idea of the economics of medicine. This is quoted from JAMA 1906. We are over a century away from this publication, but we still stand, you know, in this mire where we are still learning about the business of medicine and the economics of medicine. I'm going to hand over the podium to my colleague, Dr. Mugo, who will take us through the next two objectives. Thank you. Hold all questions towards the end. Okay. Good morning, everybody. Good morning. Thank you very much, Elizabeth, for that presentation. As you heard, my name is Marianne Mugo. I work in a hospital called Atrium Health in actually a small town outside Atlanta, Georgia. I'm very excited to be here, and I thank you for inviting us to do this presentation because there's a lot of things we wish we knew when we were just like you, and we're here to try and empower you because we know sometimes you're so focused on learning, caregiving, that you don't actually pay attention to how much it's going to pay you after this. My background is I've been a hospital-employed physician for the last 18 years, since 2005, so I have a lot of experience in that, and I can tell you later on when we do questions and answers how much it has changed over time. So I have no disclosures. So let's talk about compensation models. For most of my discussion today is going to be on hospital-employed physicians. I know some of you may be going into private practice, however, that also, the considerations you take for employed physicians are also going to be pertinent for people who are going to private practice. So the first one is straight salary. You can see it there. I don't think it shows up on that slide. Straight salary is what's used for most new hires, which many of you are going to go into. It's also known as a guarantee. What the guarantee is is a fixed salary for one to two years, and then after that, you're going to be switched to something else. Now it's important to understand what your guarantee is because first, it should be commensurate to what you're going to be earning after you finish your guarantee. So pay attention because sometimes you might be paid less than what you're actually earning and what you're capable of earning for the institution. It is beneficial if you're growing your practice, you need time to go meet people, as Dr. Hageland said. You need to network. Patients need to get comfortable with you. So it's helpful to have a guarantee if you can. Even if you know you're going to work very, very hard and see a lot of patients, it's a good idea to start with a guarantee. And then as you build your practice, you can start to see where your income potential settles. The downside is you can get comfortable with that. You just get a salary. Whether two patients come, 10 patients come, there's a paycheck at the end of it all. So even though you're on a guarantee, just make sure you keep track of all the numbers, the patients you see, and how to translate into a different model if you had to be switched. The second one on the top right-hand corner is productivity. We'll talk more in detail, we'll mostly talk about that today. Productivity is where you're paid based on the number you see. Now there are pros to this because if you put more effort, you make more money, right? So if you feel like you're the type of person who has a lot of energy, you want to see more patients up front, I'm still young, I have energy, I can see patients, that's very good. The downside is you don't always get compensated for the complexity of the patients because the translation of the work you do is a fixed amount. So we'll talk about that in more detail down the road. The third one is on the bottom left, which is revenue-based. Those of you who are going into solo and group practice, this is what you're mostly going to get compensated with. This is where it's basically eat what you kill. Some of you know it as that. It's all the collections minus the expense. So the lower you keep your expenses, the more money you take home. If you have other people in your group, the more you have to share. So do that calculation when you're deciding which compensation. A lot of employers will not give you that unless they are trying to, one of the models that Dr. Hageland spoke about where maybe you're sharing real estate and employees, they might allow you to keep some of the collections. But in most cases, if there's an employer involved, they want to keep most of the expenses. Just keep that in mind. When you're employed, they want to keep most of their revenue. The fourth and final one is base salary plus incentives. This is mostly used for APPs or advanced practice, advanced nurse, advanced APP, mid-levels. There are some physicians who are paid with base salary plus incentives. The pros of this is that it's something you can use it if, say for example, you know you're going to have upcoming maternity or you have time, you have to take time off. The downside is they'll pay you less per month, but then in one quarter or in a semi-annually, you'll get your bonus. So the bonus can be quite hefty. So this is something you can negotiate with your employer. It may not be labeled as that, but you have to recognize it as such when you see the contract. Now let's talk about where the money comes from. Remember, you're the one doing the work. So each patient you see generates money. There's the direct money you generate from each patient you see. That patient you see will generate a collection. Once you finish your notes, sign it, send it to billing, there'll be a collection. That collection will then, they'll deduct the expenses for that practice or that clinic where you work, and then ultimately there'll be a net profit. Right below that you can see there's the indirect money that you generate. So keep in mind that the direct is usually a third to one half of what you generate for the institution. So this includes the money generated from the tests you order. If you send your patient to a surgeon and they get a thyroidectomy, the money that the hospital makes from that, all the imaging, all the tests that will be done, that's income generated from you. However, if you're an employed physician, you're not going to see any of that. Now, this is where we want you to be aware so that when you're discussing your compensation, you can at least know that you're really generating a lot more income. You actually have leverage to talk about all those other expenses. Now let's talk about the RVUs. So this is what most institutions will use to pay productivity. Total RVU is the basic unit used to quantify a service. Total RVU is a composite of three different things. Work RVU plus practice expense plus malpractice expense. For your purposes, if you're employed, the work you do is work RVU. Work RVU is your individual work. And as an employed physician, that is the only thing you need to care about. Because it's the only thing that generates compensation for you. If you're self-employed in solo practice, the other aspects will come in, will be important. However, we're not going to discuss that in detail because it varies from place to place. It varies from the type of institution or group you join. And it really has a lot of detail that can only be discussed for individual clinics and locations. But let's focus on productivity. So how does your patient visit turn into your compensation? So if you look at this diagram, you can see on the extreme left, it starts with how many patients you see. What's your schedule like on that day? So the number of patients per day. So I'm going to give an example of a physician who sees 2,880 patients in a year. Now, the number of patients you see is what's defined as your productivity. And you'll find institutions talking about, this is a highly productive physician, low productivity. That's generally the number of patient visits you can generate per year. It's important to understand where you lie in their eyes. In this example, I'm going to use 99214, which is a level four. It's a common CPT code that's used by endocrinologists. I chose not to include procedures like ultrasound, but we'll talk a little bit about more. We'll talk about that a little bit in detail. So in this example, CPT code 99214 translates to a work RVU of 1.92. This is something you cannot negotiate. It is determined by Medicare. It changes every three years or so. They review it regularly. And it has gone up over the last few years. About five years ago, it was 1.42, now it's 1.92, which is good for us because most of our work is clinical patients. We see office visits more than we do procedures. So it's really beneficial for this to go up. Once you translate to the work RVUs, in this particular case, this doctor saw 2,880. You multiply that by 1.92. It totals to 5,529.6 total work RVUs for that year. So total work RVUs, your institution will usually give you a breakdown of numbers every month, and they'll give you an annualized. They call it a physician dashboard. In that dashboard, they'll tell you how many each month, how many work RVUs you have earned. And then they try to annualize it. And the reason for that is because there's a threshold. Most employers will give you a contract and say, this is the minimum you have to make. This is a threshold for you to get a bonus. Now, if you take that total work RVUs for the year, you multiply that with an incentive rate. Now, the incentive, this is where you can negotiate. When you get the contract, they're going to tell you, oh, here, take 45. That number is negotiable. Most endocrinologists are between 45 and 55. This number also changes based on MGMA numbers, based on your own productivity for the institution. But they do look at national benchmarks to decide what it's going to be. So most endos will be between 45 and 55. So in this example, I used 50. And if you multiply 50 by the total number of work RVUs, this person earned $276,480 for that one year. Now, keep in mind, in this example, I just used 99214. There will be some codes for example, 99213s. There'll be some 99215s. If you do ultrasound, in-office ultrasound is actually a very low RVU, 0.56. And so you need to understand that for those of you are thinking of procedures, it might be a good idea to do the procedures when you have a visit, if you can. If you can't, you might have to reconsider how much time you're going to give for an ultrasound that could take 20 minutes versus a 99214. And so it's also about creating your own dashboard of what is the mix of patients that I have. And I'm not saying you should target certain patients or not, but you should keep in track. It ties in with what Dr. Hagland was saying where the assortment and the allocation of patients in the practice, that's what's going to help you kind of decide how many types of patients of this level and how many procedures I can afford to do. It actually boils down to, can you afford to do that many procedures? All right. Now, in order for you to actually achieve what you have set down as your goal for the number of RVUs, you need to improve your productivity. So what are the common factors that affect your productivity? So first, there's the schedule component. So like in my institution, they've moved to where new patients need to be 20 minutes because they want more patients seen. Now, you can fight that and say, I want 40 minutes for news, but then you'll probably be restricted to four or five per day. And you can negotiate that, but keep in mind how your schedule is structured will affect the number of patient visits, which in turn translates to your productivity. You need to think about your time management. How much time in that 20 minute slot is going to be spent in documentation? How much time is spent in actual face-to-face contact with the patient? Because if you don't manage your time properly, you're going to be behind in your documentation. And that in turn will affect when you can get your RVUs tallied. The number of patients per day and per month is something you should be looking at constantly. Now, there are some things which are out of your control, like billing accuracy. You need to audit your own billing department. Make sure you look at, keep track of your own RVUs. This you can do using Excel. You can just use written. I use a calendar and I just write my numbers and then I tally them once a week. You can choose to do whichever one works. There are apps for it, but to me, I found the apps were not as helpful. Once you finish your note, it has to, they call it dropping, the charge will drop into the billing department. And then the billing department will take about three to four days to process that charge. So for example, in my institution, if I see a patient on May 28th, by the time that RVUs are located to me, it will be June. So that will be counted in the June numbers. So just keep in mind that there'll always be a lag. Maybe the first month your numbers will be low because they didn't account, there was no delay, but the second month, all those, there was a delay in the billing, but the second month, all those numbers will catch up. So it's kind of like, there's always a slight delay. So as long as you make sure that the deficit from the previous month was accounted for in the next month, then you'll be, you'll keep up with it. Now, what are the non-scheduling things? So clinical and non-clinical support, you have to know what kind of nursing support you have. The training of your nurses, the availability. Some of them are assigned to other departments, other types of work. Some of them have to go and do clerical work. EMR, you need to create your preference list, make sure it works. It's very efficient for you. Administrative and executive, the vision that your CEOs and CMOs have. If you're not aligned with them, if say, for example, their biggest priority is numbers or revenue, which it should be to some extent, but if that's all they want from you, they don't want to see you develop into a fully-fledged endocrinologist who has a lot of training and who has a lot of experience and has a good reputation in the area, then it might be something you should consider because it can affect your productivity. And then when it comes to the culture of the organization, you need to understand how your peers view you in that organization. Keep in mind, you might be working with family med docs who also are on RVUs. So sometimes they'll hold on to patients, maybe not refer them to you as soon as they should have because they also need those RVUs. So maybe have a very collegial relationship with them. Help them understand that you're not going to hold on to all the patients. They'll go back to them. If you can see new patients, help them get better, you refer them back or send them back to them, then everybody gets the RVUs that they need. So if you can try and develop that networking that Dr. Hagelan talked about, it's really important. Your productivity is something you have control over. Now, switching gears, we've talked about compensation, but the other important aspects of your contract when you sign are how you're going to leave that organization. I know it sounds very negative, but you do need to know how you're going to leave that organization, what you call an exit strategy. In most contracts, they're going to include a termination clause. Now, it might sound like you're being chased out of that institution, but the reality is a day will come when you have to leave, whether it's for personal reasons or for institutional reasons. You need to understand what termination is because if it's with cause, it means you've done something bad. If it's without cause, it means the institution had to change their status. And why is this important? So for with cause is if you're licensed, you no longer have a valid license. Maybe you can't get licensed because of something you did in your state. Maybe you have some criminal background or felony charges that don't allow you to get renewed on your application if you have alcohol or drug abuse history. And then it's non-compliance with institutional governance. They have all these compliance requirements that you must meet. If you don't meet those, you can be terminated with cause. Now, the good news is in most cases when they terminate, they do allow at least 90 days. So you will be allowed 90 days before you have to leave. And it's important in your contract to specify that you want to be paid. Whether it's with cause or without cause, you should be paid in those 90 days. If it's without cause automatic, you should be paid. And in a fair situation where your employer is being fair, you will actually not have a non-compete, which is the next thing we're going to talk about. Now, what exactly is a non-compete? Non-compete is also known as restrictive covenant. Remember, your institution will not want you to work and compete against them once you leave. So they also know that you can leave and be very successful. So there are really four main parts to the non-compete or restrictive covenant. First is geographical area. With a geographic area, they can restrict based on the distance from the main institution. And so that's mostly what happens to a lot of institutions, especially if you're in a town, a bigger city, they'll usually use distance. In some rural areas like where I work, it's by county. And so I have six counties that I cannot work in once I leave that institution. So pay attention to your contract because if it's counties, it might be 40, 50 miles before you can find an institution that you can work at. And if you have roots in that community, it can be very devastating to have to move. Also, the satellite clinics are really what makes or broadens that area to counties. The second one is duration. Now, a fair non-compete should not be more than two years. The better ones are one year. This is fair to both parties because they also developed you. They did some, you know, they helped you build your practice. So it's fair to have one. If they go beyond two, you need to be negotiating that. Practice restriction. Keep in mind that even though you're an endocrinologist, you might think, oh, maybe I'll just go and be a hospitalist in my area. Your non-compete will probably restrict you from doing that as well. And some non-competes actually restrict you from doing locums while you're employed. So pay attention to that aspect. And the locum could even be in another state next door. Pay attention to that as well. And then, of course, soliciting. No one wants you to take their patients. So really with patients, you don't always have control. And they understand that. Patients will follow you if they like you. But what they don't want is for you to bring your colleagues with you to your new job. So pay attention to that on the contract. What are the consequences if your colleagues follow you? Because it might be hidden in legal language that you will actually have to pay some money or they can sue you if you take any of the employees. So why do I say that? I'll bring up that topic again. But it's really important to have a lawyer when you're looking at your contract. Because they will pick up some of these details that you will not be able to understand, even though they look like common English language. Now, malpractice and insurance and tail coverage. These are also very important in your exit strategy. The long and short of it is that malpractice just covers you for any cases of negligence. We're not going to the details of what qualifies for that. However, in general, if you have malpractice insurance, it's negotiated by your employer. If you're in a group, they have a group insurance for most employees. In some institutions, they'll give you that, but they also, sorry, they'll pay the malpractice and you really don't have any say in who administers the insurance. But you can actually ask for clarification on what type of malpractice you have. Now, some institutions give occurrence policy. That's the best one. Occurrence policy is where they'll pay for any claim that comes while you're employed and also after you're employed up to a certain point. So it kind of has a built-in tail. The claims made policy is very specific. It only covers you while you're employed. So the next day after you leave, if a claim comes, even though the patient event happened while you're employed, you're no longer covered. So that's where the tail coverage comes in. This is what covers you after you leave the institution. And you need to pay attention to that. Some institutions will clearly state that in the contract. If they don't, ask about it. Some of them will say, we'll cover you for five years, but we're only paying 100% for the first year. And then every year we drop it by a fraction. And then after say five, six, seven years, their part is done. So it's best to make sure it goes as long as possible and the part you have to pay is zero if possible. Now, the reason I put this slide in here is just to show this is my contract, okay? So the parts in red, that's what the lawyer absolutely said are absolutely deal breakers. The blue parts were the parts where she said, you can actually negotiate this. You don't have to worry about what the details are, but I wanted to show you when you get the contract, it just looks like a document. But when they look at it, this is what they see. So it might sound repetitive, but please hire a lawyer. Legal terminology is complex. And finally, this is most of, some of you have already done it because you already have jobs, but it's important to think about how you're going to negotiate your experience. I know you may be coming out of training. You're thinking, I don't have a lot of experience. You do, you've probably worked with complex patients. You have done it for several years. You have experience. Don't let anyone tell you, I don't have experience. You can use leverage. If you're going to a rural area, you can use leverage for that because they need you and you're going to be busy. So accept that upfront and use it as leverage. They might also be really desperate. Like if someone is retiring in the next few years, they need you. So they'll give you what you ask for. If you have special skills, for example, you've done procedures, you've dealt with rare conditions, you've done med peds, you use that as leverage if you can. Some people have a background in analytics, MBA, bring that on because eventually all these organizations, they do want you to be a director. They have committees, they have measures. Anyone with that background, you have a higher chance of rising up to leadership if you're so interested. Remember, you bring a network. So if you have a network of colleagues, network of patients, bring that in with you. And if you have patients that want to follow you, don't say no, it's okay. Let them follow you. And then your strategy. This is something you probably should have learned by now. We're all constantly developing our negotiation skills. Your strategy should include a lot of background research on the institution. Hire a lawyer. I'm sorry, I feel bad because I didn't hire a lawyer on my first job. But I'm going to tell you, please do it. Please, if you can. If you haven't done it, do it now. What you want, you should be really clear in your mind. What you want in terms of money, in terms of the whole contract compensation. Because if you go in there and you're not really sure, they will try to give you the lower end of the sort of negotiation range. Remember what is your absolute deal breaker, also known as best alternative to the negotiated agreement. You need to know what are the things you absolutely will not take. Because that will allow you to not linger on a contract that you don't even want anyway. And then in the end, you do want a win-win. Both they want you, you want them. Try to make it work. And if there's something you can sacrifice, sure. But just remember that you really need to get what you want. And with that, I'll end over there. Thank you very much. All right, good afternoon, my name is Shant Parsegan, I'm an endocrinologist. It's kind of interesting, I've been in practice for 17 years, and after the things I heard, I got depressed, to be honest with you, so I mean, I feel sorry for you guys, but, you know, let's make it fun. So I've been, my recent job, my practice for about 13 years, I interview actively, so I'm going to bring some examples from my past, and examples from the new fellows that they come to meet me, and the examples may be a little bit extreme, just to make my point very clear, but, you know, you'll be surprised what I hear during the process. Okay. All right. Okay, fantastic. All right. So I'm a director of Monsanto Endocrine Diabetes Center. We're gonna talk about that later on, my disclosures. So, I don't have anything written on the slides or just pictures. So I'm Armenian. I was born in Damascus, which is 7,000 year old capital. I speak five languages. When I finished my training, I wanted to start a new job. So, if anyone from Missouri or that red dot area over here, I'm gonna say, you know, apologize for my next statement. That's what's called middle of nowhere. So I decided to go there and start to practice with Dr. Mugo, who was my first partner ever, only because I saw potential. They said there's no endocrinologist within 100 or 120 mile radius. I said, that's fantastic. So I can collect all the patients. So we decided to practice. I got good salary, two-star salary, and I hired an attorney, not like Dr. Mugo. My contract was good. I knew about all the exit strategy when I signed my contract. So when you get in a room, you should know where your exit is. You don't go in a room that has no windows like this, for example, or no emergency exit. That's right. So you have to secure your exit strategy when you get in in any project to see how much damage you can control in the end. So I went to Missouri and I took the job. It was a nice practice, brand new building. We designed it, me and Marianne. We started getting patients, but one of my patients I got over there, I remember, the guy who built my house over there, like just cheap houses over there. So he told me, can you see my wife for a consultation? Because her hormones completely messed up. Well, I'm a new endocrinologist. I'm looking for a business. I said, sure, why not? Have her come to my office next day. So she came to my office and suddenly I faced a bipolar patient who was completely untreated with no endocrine problem for me to fix. Because that person believed, you know, that hormones does that, like, you know, give you psych problems. Yet the person just needed a psychiatrist. Which was okay. So then we started interacting with the providers in the area. So they were all family practitioners. There were no internal medicine doctors because usually internal medicine doctors, they don't go to this type of areas. So we'll fight every day about diabetes consultations, about osteoporosis. Nobody will know nothing about adrenals. Pituitary, forget it. You know, we hardly see hyperprolactin. I don't remember seeing prolactin patient maybe in Branson, Missouri for two years. So that tells you one thing. Nobody looked for the prolactin with the amenorrheic patients, for example, to see what's going on. So what I learned from that experience, and again, none of this negative, by the way. Everything you face in your life should teach you to get, you know, better outcome. Like even COVID. COVID was negative, was bad. But there are lots of, you know, good things changed in our life because of COVID. You know, I can tell different examples. But what I'm trying to say, your job as a person first, not a physician, is to find the good in bad. And you learn from the good in the bad, and you ignore the bad, and you move on. So the practice grew. We started seeing some patients, but then, you know, small hospitals started failing because they have no money and bigger systems, they were purchasing the smaller hospitals. So we ended up getting a pay cut, me and Dr. Mugo. But at that time, I decided, like, you know, I'm going to be out of here, and I don't want to stay in this small town that doesn't give me anything. I mean, my ambitions are completely, you know, crushed over there. I want to be like, you know, I have some entrepreneurship in me, and I saw, like, this is a dead place. Forget it, you know, just move out. So because there was high demand on endocrinology at that time, this is our old hospital, I said, you know, I'm going to move on. And my dream was to go to San Diego, because I hate snow, I hate cold, I love sun, I love the water. So I didn't get any job. I remember at that time, you know, when endocrinology was paid 270, 250, this is in 2009, they were paying $110,000 in San Diego. I got a job offer from Yale for $120,000, which is fine. It's Yale, not a big deal. But I got a letter from the department chief, who was not an endocrinologist. He called himself a diabetologist. That tells you one thing, he does not have endocrine training. And he said, do you have any problem with working with certain group of people or provider of certain background? I don't want to give more detail. That by itself was a lawsuit. If I took that letter, went to my attorney, I could have sued Yale for a few million dollars at that time, because he discriminated me from the letter. I mean, that tells you, you know, what type of environment you're getting in. So when you look for a job, don't look at just like, you know, easy life. Look at the patient demographic. See if people are educated enough to understand what endocrinologist is. You know, like I live in Boston, every patient in Boston likes to see an endocrinologist for the osteoporosis. Endocrine for diabetes. Because we have like more than 600 endocrinologists in Boston area. And people, they know what we do. Versus brands in Missouri, they had no clue what endocrinologist does. So try to learn your population and your providers. So I got a nice job offer from Boston, which is exactly the opposite corner where I want to go, where it's cold and super expensive. I'll give you a small example, like the town where I live, you know, the cheapest house is a million hundred thousand dollars. I bought it when I bought my house at $500,000. But my point is, you know, you may be like discouraged or it's a very expensive town to live in. You know, that house is 1 million, 100. You have to put another $300,000 to make it livable because it's a very old house because there's no adventure. But again, what are you getting in that return? You're living in a nice part of the country. I mean, for me, Boston is the epic for American culture. You know, you know, me coming from a 7,000 year old city and, you know, not for anything, you know, I love to be in place with this culture, like, you know, so politics, museums, everything, you know, so and plus the people I'm rubbing with, like for my kids, for example, their parents, one of my kids' friend's parents is the kayak CEO. So my kid goes there to their house. He hangs out with the kids and he learns tons of stuff. So that expensive town is teaching my kid lessons that I cannot give to them for hundreds of thousands of dollars anywhere else in the country, maybe. So you get more from what you what you pay for. So try to focus on the good in any experience or any negative experience. So I started my first job with a large employer in the Massachusetts, like, you know, big and women, which used to be called partners. And why I went to Massachusetts, by the way, you may ask me, for the same reason Dr. Mugo mentioned, which is no compete. So usually, you know, it's really, you know, discouraging if you live in Branson, Missouri, for example, and you have no compete, you have to shift your practice 60 miles away. You end up in another middle of nowhere area that there's no patients. So you cannot make a living. Imagine it's not about you only. It's about your kids and your family. So you can take your kids from their school to different school. You have to make new set of friends. So everything will change. So it's not like only you are screwing your life. You're screwing also your kids and your family's life. So think about like, you know, again, exit strategy. Boston, maybe it's difficult to live in. It's expensive. It's cold. But yes, if you have certain things, they'll protect your back when you take the job versus when you go to Atlanta or they go to like, you know, to Texas. I was told like, you know, if I go to Houston, I have to work third of what I work to make same income, which is right. Yes, but again, you know, certain places in the country or in the world, they offer you lots of things that you cannot, you know, put a price on them. So I took my job over there and I was the youngest, third youngest endocrinologist in the group until Dr. Nila Singh joined us as the fourth partner. And I was paid in the beginning on the model of compensation of expense, collection minus expenses. That's your salary. So you see 10 patients, you take 10 patients' money home. You do 20 patients, you do 20 patients' money home. We had a chief at that time, he came to me and he said, Shant, if you have a patient you don't like to see, give it to Nila. She's a new doctor. Immediately, that person became my enemy. Immediately, because that's the most unprofessional thing you can do to a colleague. Usually you see a young doctor next to you, you try to hold their hand and to try to make their life better, teach them. That's your job as a senior physician. That's your job as an attendant, to make you better, to make your life better. So when the chief tells you like, you know, if you have a bad patient you don't want to see, give it to your younger colleague, that is unprofessional, you know, and I never forgot that for him and I got him back to that and did that after a couple years. So I became very busy because I love to work very hard. I had crazy hours and I became to a level, I was at the diabetes council sitting with David Nathan, who I admired. I mean like number one in regards to my in my female country. I was sitting with him on the table for diabetes council with Ann Kalbansky, you know, who was the MGB CEO. We did very good things, but one day they decided to change to our view model. So I said I'll wait because I was going up the rank and I said one day I invited the CFO to meet me. I said bring me your numbers based on RVU and based on the old compensation model. So Scott was an Irish guy with red hair, super wet skin, blue eyes. When he was sitting in the corner, he gave me the numbers. He turned red, as red as the wall over there. And I knew they screwed up. They took $150,000 away from me based on their new model. So do not believe, I'm going to be only two minutes. So don't believe another employer will change a model for you only because they want to give you more money. That's what they told me first. Oh, we're going to give you more money. I said, well, I don't believe that, you know, but I'm going to go with you for one year. So I went one year. I said I want my money back. Whatever. Then I said, forget it. I'm going to move out. So I moved to my next practice. I moved out, you know, from having like, you know, reviewing so many contracts to a couple of works. I built my new practice which is called Mountfield Endocrine Diabetes Center. I was planning to go independent. Then because the system got purchased by different organizations, I became part of BILA, which is the second largest employer in the area. So I started with one medical assistant with 1,000 square foot office. Now my office is 4,500 square foot. I have two endocrinologists, educator, nutritionist, all what you want. So I built something very nice, I believe, based on my prior experience. In the area, I didn't want to live in it. I didn't like Boston's weather at all. But again, I succeeded. I did something good and I believed in myself and my family. So it went fine. All from learning from my prior experiences. So I'm going to give you a couple, there's two more slides here. So how to interview. Study the area, the patients, the providers. Think about your family. Remember the value you bring to the organization. Don't tell me, you know, you know, the worst thing I can say, like if a patient physician tells me, like, I work for this large organization before they give me their name. I don't care for the organization. The organization is run by business people, not by you. You are who you are. You know, if doctor so-and-so, you'll move from organization A to B, your reputation will follow you. That organizational reputation will not follow you. Remember that. Ask what they can do for me. You know, there's such a big shortage of endocrinologists. I mean, this thing like you are the least paid physician is total nonsense. You know, anytime you go in negotiation, if you don't go with the strong, you know, morale, you'll lose. That's right. So you have to believe in yourself first. And second, you know, believe to get what you want. Find the potential in any offers. I went to middle of nowhere because I saw potential. I came to Boston because I found the potential. So don't look at the negatives only, look at the positives in the contract. And do not get hung up on minor detail. I remember I had this young fellow came to me, said, unless I do thyroid ultrasounds, I'm not going to work for you. I said, perfectly fine. I said, if you can justify the $80,000 expense for your ultrasound machine, I'm a chief of endocrine. I will fight with 20 radiologists to get you the right to do it. And $25 collection per biopsy. If you can justify all that, I will get you the machine and you'll do it. I'll fight for you for the end to get the rights to do it. Another fellow came to me, said, who does your PAs? Well, listen, we did not go to school to do PAs. So that's not the question you ask anyone because that tells you like the maturity in the the interview experience. So certain things, you know, you don't do, you don't fight for it, you know. So or who downloads the CGM? I had this senior physician came to me. She wanted to hire an RN to download her CGMs. I mean, it takes me two seconds to download the CGM. I just log in, put my password, done. CGM is downloaded. Do I need to hire an $80,000 employee to do that for me? Yes, if I have extra $80,000, why not? I'll do it. But otherwise remember one thing, you are bringing the money. There's no free staff in the office. If you have one staff or 20 staff, you are paying for them. You may not see it, but you are paying for them. The less staff you hire, the more efficient you are, less work you have to do and more money you make. And again, don't, I'm saying money so many times, but we are physicians first. But again, you know, it's your family money. Whatever you're not taking home, it's your kids' education money. Remember that. That's very important. Don't worry about existing office structure. You can always change, okay? You can bring your ideas. It will work fine. And highly unlikely your first job will be your last job. So don't worry about your first job. Screw it up. Learn. So how to succeed in your job now, after the job? So learn from your prior experience, you know, at different jobs. Remember, you represent yourself, as I said. Build a support team. Connect with other doctors. Your capital is your knowledge. And the best referral is word of mouth. I love when I see father, mother, daughter in my office. I have families, they had gastric bypass. They're all successful. You know that? How satisfying that for a physician that you are truly the family physician. Challenge yourself. Be creative. I mean, listen, academia is always nice and interesting, but clinical is not boring. I mean, I do research in my office. I do, you know, gestational diabetes research on my own questionnaire. I have two groups. I have diabetes prevention group visits that I designed, you know. It keeps me very entertaining. I love it. You know, it's fun. Two hours of, you know, every other week in my office. And the other things, you know, so there's lots of potential for you to grow. Don't think like if you're in a clinical setting, you can do nothing. No, you can do a lot. And one thing like, you know, is love your patients. I have like every patient I see, I learn something from them. I mean, I have a 92 year old guy, Harvard, you know, professor who works on flying cars. We talk about diabetes five minutes and 10 minutes, we talk about his work. So you learn from your patients. I mean, don't be like just a robot, you know. I mean, endocrine is very easy. It's not a difficult field to be honest with you. It doesn't take a, you have to answer a board exam in 70 seconds, meaning in 70 seconds you can fix a patient. That's how smart you are. But the idea is you connect with your patients, you learn from them, and they will feel better when you leave your office. Remember that. And that senior partner in the office sitting there annoying you, don't worry about them. Eventually you get them. You know, when your time comes, you'll get that person. So don't feel small. Don't feel like you're young, whatever, you know. Listen, I'm Armenian, you know, me and Dr. Mugo in Branson, Missouri, she was the darkest person. I was the second darkest, you know, so and we had fun. We had fun big time, you know, it was good practice. So try to like, you know, don't focus on negatives, focus on the positive, believe in yourself, and think you are a big shot, you know. But connect with us as well. And thank you very much. All right, so we have a few minutes for questions. So we'll have you come up to the microphone and introduce yourself and ask your question, but I will start. So Dr. Mugo, I know that you've been in practice for over 15 years. Can you tell us a little bit about what your experience is like now compared to when you first started? All right, thank you so much for excellent presentations. I am a second year fellow from University of Miami, graduating. I have two questions. So first one of them is, you know like we went to the medicine for mostly altruistic reasons and went to residency, fellowship, always work hard. We don't know, I am just talking for the majority about the business part. And you are right, our first job probably won't be our like forever job. If we sign the contract already, my question is like that I feel like personally we don't know how to ask actually more. More work, yes we can ask definitely, but how to ask more for compensation? Would you recommend any idea without being a troublemaker? And it's just like you know the things going on, like we don't burn out. And second question is, if we are in the hospital practice or even the private practice with the group, is there any like the idea we developed ourselves like for the business practice for the future if you want to go for the solo practice? How we can learn about the business strategies? Yeah, great, great questions. Great questions. I think to answer your first question, if you have already signed on the contract, it's a little too late. I think so it's good to good to do your negotiation before you sign on the dotted line. It's hard for us as positions, especially straight out of fellowship, to be there at the negotiating table. It's good to go through the recruiter and do not make any commitments when you are sitting at a meeting with your employer. Listen to what they have to say, end your discussion by saying, thank you for this information, give me time to review it, and then I'll come back to you. So you go back, you do your research, you call your colleagues, you call your professors, get your friends on board, come up with the strategy, the best strategy you can, because you want to know what are you going to really fight for and what are you going to say, you know, I'm okay, I'm I'm going to let this point go. And then go through the recruiter who will do that negotiation for you. And you can be a little bit more open with the recruiter as to what is your deal breaker, and this is not, this is really what you want. As far as, so the recruiter is going to be a really good advocate. Your lawyer will not do the negotiation for you. The lawyer will review your contract and mark everything in red, white, and blue, and give you a check or give you a bill that you have to write a check for, but it's your recruiter who will help you do the negotiation. The second part is, if you are going to join in a solo, into a group practice, to be part of all the discussions that's going on in the group, and usually groups meet once a month to discuss their financials. Sit in the financial meeting, go through every line in the printed document that the clinic manager brings out, understand what the subheadings are about, and ask questions. And that will give you a strategy to develop if you want to then branch off and going to solo practice, making sure that you're no compete and all that is not going to come in the way. My name is Noir. I'm one of the senior fellows, graduating fellows at the University of Virginia. I have actually one clarification and two questions. One of them is, for the first few months of starting a job, what to ask for as far as scheduling, as far as probably learning a new EMR, what are reasonable requests to ask a hospital employer for the first few months? The second question I had is, we heard a lot about this Federal Trade Commission proposed rule to ban non-compete, and would that apply retrospectively to people who actually already signed a non-compete? And the last clarification I have, Dr. Mugo, like in your slides, I just did some calculations with the numbers. So seeing 2,880 patients a year and billing for a level 4 follow-up, like 1.92 RVU, with working 48 weeks a year for four days a week, that comes to 60 patients. So basically seeing 60, 6 is 0, so seeing 15 patients a day. So would seeing 16 patients a day, or 15 patients a day, generate this to 70,000? Is this a realistic number? Because I see people saying like 20 and 25. Let me clarify. So I'll start with what you said with their scheduling. So if you're going to start with a guarantee, your employer should give you a staggered schedule. So you can start with 25 or 50 percent of what your expected target is, and that varies. Like some endocrinologists who are employed will see as few as 14 patients a day, and some will see 20 to 22. So like on my schedule, I have 21 slots. If I fill that schedule, I may have some no-shows. So on a given day, I might have, on a given day, I might see 17. The average for the week might be anywhere between 16 to 18, even though I have 21 slots. Now in your first six months, you should not see more than half of that. So if we say 18 is your target, you should not see more than 9 to start, and then gradually build up. Usually you can go with your comfort level. In an ideal situation, they will come and speak to you every month or every quarter and say, hey, this is how your patient, this is how you're progressing. To answer the last part, the calculation I gave was based on 15 patients a day and also four days a week, because some employers will allow you to work four days. But keep in mind, I gave 99214. That wouldn't be hundred percent of your cases. I use that to simplify because that might be 70 percent of your numbers, and so the real compensation might be somewhere between 250 and 290. I mean, if you see a lot of level fives, you might actually see more. Also, if you decide you want to work five days a week. So one thing I didn't mention is that in some institutions they will cap your RVUs. So like in my institution, 85 percent. If you're hitting 85 percent of the MGMA percentile, they actually cap and then they review your cases. They want to see, are you providing quality care? Are you just running through people? And so these are some things you have to be careful about, that even though you really have the energy and the capability to see a lot of patients, is it going to be realistic? And will the institution allow it? I'm just gonna make a comment about the overhead. You have to forget the RVU situation, okay? You are a physician. You bring, for example, collect a million dollars a year, okay? That is by seeing 16-17 patients a day. You have overhead. Your employer will tell you your overhead is, for example, there's different models. There's a fixed rate for overhead. Like you have $5,000 rent a month versus I'm going to tell you your rent is 5% of your collection, which is total BS. Because your rent is fixed money. You don't pay for this room thousand bucks a month and next month two thousand. So you have to understand that the overhead should not be percent, alright? The telephone bill is fixed. The MA or the assistant salary is fixed. The only thing is variable per percent is your collection fee. So you build million dollar, you pay five percent, which is $50,000. You collect two million dollars, you pay $100,000. Because people, they're collecting more money for the people, more people working for you. So you have to understand that a collection minus overhead, that money you should know what it is. So your employee will give you maybe that collection, maybe half of it. The other half will be profit for the system. So your job is to take as much as you can from the profit. My idea is 100% you take home. You don't work for anyone, you work for yourself. So you pay your overhead and you should collect as much as you can from the remaining money. So the better negotiator will get 100% home. The poor negotiator will take zero home. So you choose where to be. But the key to remember is your overhead. Is it percent or fixed? If it's percent, drop the contract immediately. Because they are making money off you big-time and you don't see it. That's the key. For the FTC, yeah. So the FTC non-compete, that is going to take effect I think 2024, 2025. It is not going to completely eliminate non-compete. But they're going to make it a little bit more fair in that if you want to go and set up a practice, you can actually leave your current employer and set up a practice. But there will be some restrictions. For example, if let's say I own a practice, I sell it to you and then I go across the street and set up my own practice, that will still not be allowed. Now that's not an institution. It will be more physician to physician. But to the institution, they're also going to be restricted on how long and the distance of your non-compete. It hasn't been finalized. So that one, just stay tuned. It's something for all of us to look forward to. Hi, I'm Michael Marcos. I'm an endocrinologist at Indiana University. And it's really nice to get to learn about the business of medicine with the beauty of medicine that we are already practicing. So I just want to highlight and ask some questions requiring for rough numbers. So I agree with what you said, that usually the profit comes from the lab and EPPs. Now when we talk about a collection model versus our view model, usually our view model count for these labs and imaging studies, because what we take home is more than what you take home from just the collection minus the overhead. But from your experience, what is the rough average for the overhead? If we're going to say it is a rough percentage from the average for the past several years, what should we think about that if I'm going to have my own practice? Do you want me to say all the questions or one question at a time? The second is, having an in-house lab, I would like to have a rough idea of how much volume you need, how much do you pay for the lab director, right? And how much for the clear certification, all of that. It is a lot of headache and a lot of expenses going on. And for the EPPs, how much do you think you're going to make out of every EPP? Especially if they are out of training and you are teaching, you are like raising a kid, right? I mean they know nothing. So early on when they are getting out. And then the idea of the guaranteed salary. If you were working in a place and you were making a high productivity and you are seeing a lot of patients and then you move to another place, will the guaranteed salary match that or you just go to what you make? I mean how usually things go from that standpoint. So the guaranteed salary is just a number. It's all negotiable based on experience. When we hire a new grad, we offer them let's say 270. When you hire someone 10 years experience, we pay them 350 because that 10-year grad will see patients more efficiently and will know how to do better. So that's all number. And your guarantee will keep going up and up and up. It's the demand and supply. You go to a high demand area like San Diego, you don't get paid. You go middle of nowhere, you get paid more money. I mean I was offered once for a RVU value $65, which was unheard of. When endocrine RVU was $40 at the time, only because they had no one over there. No one was taking the job. So they gave me $65 per RVU, which I didn't take still. So it's all demand and supply. It's negotiable. The lab question, I'm a big believer in the Stark Law. You should not own a lab. You should not own a machine because I see that. I go to primary care office, they have lab. They order labs unnecessarily only because they have lab in the office. Or when you have an ultrasound machine, they do ultrasound unnecessarily only because it's not always in a bad intention, but you have it, you use it. So I believe in the Stark Law. You should not have a lab, stay out of that. The other question, the overhead. Usually, if you compare, it all depends on what you need in your office. You're an endocrinologist, all what you need is a stethoscope and a couple computers. That's right, nothing else. Versus ophthalmologists, they have each instrument is $200,000, $300,000. If you're primary care, you buy a million dollar worth of vaccines, for example. So all that brings your overhead up. So ophthalmologists, overhead, let's say, is 75% of the collection. Average primary care is about 65%, 70%. Endocrinology is in the low 50s or high 40s, and depend how efficient you are with your hiring and your spending. Yeah, I do want to mention about labs. So yes, the Stark Law is very important. And if you are going to violate that law, and if you're going to be ordering labs purely because you have an intention of making a profit, and you're ordering unnecessary labs, you will be audited, you will lose your certification. So yes, clear certification is important. It is a pain to get it done, but your lab can also be profitable. There are times when patients come and say, oh, by the way, I'm here. Can you do this, this, and this too? Can you do a reverse T3? And we clearly tell them we will not do that in our practice because we are cognizant of the Stark Law. We do document in our notes that patient requested A, B, and C labs, which were not ordered because they are not indicated or necessary for this visit. And sometimes they also say, well, our primary doctor asked us to get a vitamin D level, or get this, or get that. We say, we will do that as long as we have a diagnosis. And if it is not justifiable by endocrinology, I say, ask your primary provider to send us an order. So we scan that into the system, and then we can facilitate that lab draw for them. So I think it's a question of being aware and just documenting everything so that if an audit happens, you have everything documented, you're not ordering labs. The advantage of having an in-house lab is you get the results right away, and you are able to respond to the patients as soon as the results come in, and they appreciate that. A term that I learned not too long ago was the anxiety that comes with bureaucracy. So the patients think that we are holding on to their labs and not giving them their results for some vicarious pleasure, which is not true, right? But to understand that they have so much anxiety around their own lab results, that it is appreciated when they can see their lab results, and you release it to them, and you give a phone call whenever it is necessary. So I think it's important to keep the Stark Law in mind, but that should not dissuade you from having a lab. It is more headache. So once you start getting into solo practice and group practice, you're having to expand your business skills and do all the... Try to keep multiple balls in the air, and it is additional work. As far as the APPs are concerned, I think APPs are best utilized if they are not labeled as an endocrinologist, because they're not. And you give them a specific diagnosis to work with. So we have our APPs, one person is a type one diabetic himself, he wears a pump, he's excellent in managing diabetes. So we have no problem giving him diabetes with very little supervision. The other person is a physician assistant, she's brilliant, she's hard working, she's willing to learn, and we started by giving her gestational diabetes, which is a small group to manage and easy to learn, and she was young, she could relate with the pregnant moms. So use your APPs wisely and make them diagnosis specific. They're not gonna see your adrenal and pituitary patients, don't make that folly, because your patients will walk out of there clearly knowing that they were evaluated by somebody who does not have the knowledge to deal with their case. APPs, if they have to see you, you have to decide, they usually need about 30 minutes. They're not as efficient unless you're seeing straightforward cases. So if you divide their calendar, their schedule and say, okay, you got to see 12 patients a day, our 30 minute slots, five in the morning or six in the morning and six in the evening, you want to maximize the number of patients. Remember, whether it's an APP, if they are really being productive, even at 60% of their full capacity, you're gonna make a profit from them within six months. And if you, as a new fellow in a new job, in three months, even if you're making only 50% of your total capacity, you're only seeing eight patients and not 16 patients a day, your employer is already profiting from you. So do not underestimate, don't think they're doing you a big favor by giving you a guaranteed salary. No, they're already making a profit by month four to month six. So be confident, focus on your practice and keep getting better and better as the days go. Alright, we're out of time, actually, so you can come up and ask the... Come. Don't worry, don't worry. Afterwards, okay, but we're out of time. And then, if you could please complete the evaluations on the table that we'll be...

endocrinologists

career development

practice planning

compensation models

productivity factors

scheduling

time management

employment contracts

business aspect

malpractice insurance

overhead costs

legal advice

negotiating contracts