A Physician on Job Search, Practice and more

Hilarious TV ad shows that Lexus is growing up

2011-02-27T13:17:00.003-05:00

Have you noticed a recent ad on TV where a Lexus SUV is sitting on a huge copier? It is being copied and out at the bottom come 3 other brand SUVs, among them a Mercedes.
This is absolutely hilarious! Lexus is the company that introduced replica cars to the world, that elevated the concept of shameless imitation to a new art!
In the 70s groups of Japanese traveled the world, and particularly visited Germany, back then as well as today home to the best cars, most advanced technology, outstanding craftsmanship and original innovations. The visitors were known for their broad smile, extreme politeness and constantly clicking cameras. Soon the purpose of all these photos became clear. A company called Lexus started shipping "luxus" cars that almost looked like an original Mercedes, especially in dim light.
According to unconfirmed rumors, several Lexus designers and whole design teams were fired on the spot when it became clear that you could easily distinguish their designs from a Mercedes. Another joke was that it takes ten people to design a new Lexus - one designer and nine copyright lawyers. The designer woould start with the large photo of a Mercedes and modifiy the image ever so slightly while the lawyers were debating heatedly if the changes were enough to fend off copyright suits. We all have seen the results. How many Lexus models looked like last year's Mercedes? By far too many - or was it all of them?
Then, something unheard of happened in the upper management of Lexus - a dramatic, sudden shift in design! Unbelievable, a dramatic break with their tradition of copying Mercedes! About 4 years ago, they decided to drastically revamp their design guidelines! And so it is...now they are "interpreting".....BMW.
And whereever Lexus designers strayed from direct copying they seemed to adhere to the principle of "noncommittal undecisive blandness". Other cars have style and are recognizable by design elements - Cadillac is a great example. Agressive styling, modeled after a pyramid, representing sportiveness, grip to the road and strength. You know a Cadillac when you see one. The same goes for Audi and BMW.
Lexus has no such characteristic styling elements that run through their whole line of cars. No styling elements are recognizable as "pure Lexus". This is not surprising at all, considering their history of "interpretive" designs and their history of avoiding anything edgy, innovative and unusual with a paranoia-like obsession. When a design team is forced to very closely copy for over a decade they most definitely are unable to develop their own visual language.
So, what does it mean that Lexus now tries to pull the wool over people's eyes by pretending that they have innovative designs? And even better, that they would like us to believe that they are in fact the original? What a daring thought! What chuzpah!
Are we going to see more ads like this? Maybe Toyota invented the pickup truck? Are we going to be treated to an ad where the Toyota pickup truck - what was it's name again? - stands on the copier and out comes....the Ford F150? Hey, Al Gore invented the internet! Lexus might as well have invented the SUV and the pick up truck...
People with enough money to buy whatever they want and whatever is best drive - Mercedes. Which head of state, minister, billionaire or multimillionaire has ever been seen driving a Lexus? We are still searching for them. Mercedes on the other hand....There is one in every ultrasuccessful human's garage.
Lexus in Germany? Rare - people know how to compare and they are able to distinguish an original from an interpretation...
Lexus in the US was always the "value option", the choice for all those that wanted to look like they were driving a Mercedes, but that did not want to spend the money to get the real thing. Very much like wearing a replica Rolex watch...
Another, more gentle interpretation comes to us if we compare the growth and development of a car company to the growth of a human being. According to this viewpoint Lexus has now reached young adulthood and behaves like my son, who claims to be independent and completely different from me and has forgotten where he got most of his genes and his education from - his parents. And I leave him be. I simply like his confidence and know that he sooner or later he will realize where he came from.
So will Lexus. After all...one slogans remains true: "Lexus - the relentless pursuit of Mercedes!"

The "Munford Law Of Physician Job Search"

2011-02-21T11:16:00.002-05:00

The more attractive a position is, the less likely it will be presented to you by a physician recruiter.
The more drawbacks a position has, the more likely it will be presented to you by a recruiter.

Looking for a physician job? Run if you hear these trigger words

2011-02-21T10:39:00.005-05:00

Dear fellow physicians: If you are searching for a job, you are aware of the importance and power of words. Words can be powerful or devastating, the choice of words is often very revealing.
During your job search you may encounter certain words and expressions that should raise a flag and should trigger an immediate termination of a conversation about a position. These trigger words should also make you move on if you read them in a magazine or online ad.
What words are we talking about?

When you hear these words - run!

1. "opportunity", used to label positions or physician jobs. Typically used by salespeople that are neither potential employers nor colleagues. If you hear or read "opportunity" you are dealing with a middleman, and by nature of their training (if any) and experience they have not "walked in your shoes", they are not your colleagues, they do not feel for you. And this is an "opportunity" for THEM - an "opportunity" to make money off of - you. Physician recruiters are only hired when a job is hard to fill. The more drawbacks a job has, the more likely a salesperson will be needed to fill it! Have you ever seen recruiters advertising "Office in San Francisco/LA/Manhattan/Boston with harbor view and above average pay"? Why not? Those jobs are gone even before anybody ever places any ad in a magazine...Have you seen salespeople recruit for Harvard faculty position? When you hear "opportunity", a salesperson had to be hired at significant cost to sell you a left-over job! You know that recruiters receive 30,000 plus for a signed job contract. That is the "opportunity". Remember, employers have positions, salespeople hawk "opportunities". If you hear that word - Run!

2. "easy access to..." common sales euphemism that is slipped in to cover up a remote, unattractive location - usually 1-3 hours from where you want to be. An undesirable location is a common reason to have to hire help. Salespeople fudge over the fact that a location is unattractive by using vague, and positive sounding terms such as "easy access". This trigger word is usually accompanied by colorful description of supposedly available "culture" and "communities bursting with activity". Visiting just a few of these "easy access" communities will clarify the term and allow you to understand that "easy access" is a variation of "fly-over country". And remember, it is not the recruiter's fault that he or she has to sell this job, because those are the only jobs they get!

3. "low crime rate, affordable housing" "plenty of outdoor (sic!) recreational activities" are equally euphemisms for remote, unexciting locations. Ever heard of "affordable housing" on the shore in San Diego, Miami or Boston? I prefer to be in a more expensive housing area, and usually those areas just happen to come with low crime rates. In areas advertised by salespeople, sadly, the crime rate is usually low because there is nothing left to steal. And when everybody knows everybody else, the crime rate is naturally low...
Another often used term that should stop you in your tracks is "family oriented community". In those communities family is really the sole and exclusive focus of activity, since there is...really, really nothing else to do. You have 5 stores, 4 restaurants including all diners, 3 movie theaters and 2 hours of car travel along the 1 road that leads out of town to the city where you originally wanted to work. Should the ad mention "hunting and fishing", then the moose population is generally larger than the human population.

4. "This area is oversaturated" or "There are no jobs in this area". Immediately end contact to any person that utters these words! Seriously. "Oversaturated" means "nobody is willing to fork over $ 30,000 to have a job filled". A classic sign of an attractive area, where jobs are not advertised, but handed over without magazine ads, online ads and especially without involvement of recruiters. The more attractive a job is, the less likely it will come through a recruiter - the first law of job search. Of course there are jobs in those areas - actually there are a ton of people working in Boston, New York, Washington, San Francisco etc. And they change jobs as often as anywhere else!
You can easily find a position in any "oversaturated" - meaning attractive area by direct mail. You write your cover letter, CV, mailmerge the addresses of all physicians in your target area with the cover letter. For every 100 letters you send out you will receive 2 interested answers. Contact information of physcicians is readily available at infoUSA.com and similar websites that sell physician contact info. You can download the excel or CSV list within seconds after paying with your credit card.

THAT is the real way to find a job! Or you can click over to "The Doctor Job.com" and have them do all that for you - for a fee of course. Might be worth it.
And do not forget to check the website of practicematch.com, where you will find job ads by actual employers - real people that are willing to employ you and that post their actual correct and complete address and telephone number as well as an email address!

The end of the physician recruiter era

2011-02-19T08:46:00.006-05:00

The internet will soon make third party physician recruiters obsolete - and we are getting very close to that time.

Imagine internet services that have access to ALL email addresses of physicians in the US together with fairly complete contact information, data on education and professional experience as well as a few basics of personal preferences. Imagine the marketing possibilities.

At that point you can market any position as well as any job seeker in a most inexpensive way to any chosen target population. It will all come down to writing a good description of the job or a good presentation of the candidate. Then you can send this to any target group you wish, large or small - let's say, all physicians in one specialty in one state, all physicians that prefer to work in rural areas, all the ones that like warm climate or all who prefer cold climate or let's say skiing, that prefer to live on the water etc. You could market appealing to entertainment and hobby opportunities, to desired income etc.
And it all will cost close to nothing, and can be done from any keyboard.

We are almost there. The companies are still divided into those that look at job search from the perspective of the employer (the vast majority) and those that look at it from the perspective of the job seeker. On the employer side "Practicematch.com" fulfills all above criteria and on the side of the job seeker "TheDoctorJob.com" is the clear winner and outstanding business and service.
Both services do exactly the same thing, one services the employers, the other one the job seekers. The service they provide is the same. Could they unite or merge? Could each one do the job of the other one as well?

There are new and useful ancillary services as well. A new service called "Physician's Agency" is able to analyze any location for a reasonable fee for any physician looking to relocate and is able to help with salary and contract negotiations.

The basic need for employers is to get the description of a position in front of candidates
The basic need for job seekers is to get their cover letter and CV in front of employers.
All this can easily be done through the net. No need for any middleman. It is solely a matter of information, access to information. And that access is spreading like a wildfire, every day and every night.

We have come a long, long way way and we are almost there.
Easy, hassle free, straighforward job and candidate search without much manipulation and misleading and money making monkey business are within reach.
We are very close. And the days of the fast talking overpromising pull-the-wool-over-your-eyes telephone salesman (aka recruiter) are coming to an end. Another benefit of the internet.

Physician Recruiters - be afraid, be very afraid!

2011-02-16T23:26:00.004-05:00

After a few years of focussing on other issues I recently came back to my previous hobby , the issues of physician job search. And.....how the world has changed! Practicematch.com cought my attention. It has evolved from a seemingly small recruitment and data company to a very smart enterprise that basically provides absolutely everything in the field of job search an employer could wish for! If hospitals and employers only realized what Practiematch can do, third party recruiters / commission based recruiters would be out of a job! Seriously.
Practicematch collects data on physicians, on all physicians. And, clever as they are, they "catch them when they are young". They start collecting info about residents and actually interview (!!) them over the phone, either in planned, targeted fashion or should the resident contact them. They collect email adresses - very smart, very smart - email marketing is dirt cheap...And they collect preferences of the residents and physicians -where do you want to practice, what kind of practice do you prefer, what do you want to do, are you married, what does your wife do? Excellent details to know when it comes to recruiting...
Then they follow physicians along their way and keep collecting data.
Where they get their data from is not revealed exactly, understandably - AMA? USPS confirmation?
But they claim to have excellent, tested, confirmed addresses, telephone numbers and email addresses on most physicians in the US.

Just imagine what you can do with this information!
You can target physician groups by email, literally for free! using the stored preferences you can target your marketing even better! Wonderful...
All this specifically to serve hospitals and other employers. Practicematch looks at the world throught the lens of the employer. Not bad, but not complete.
Not to forget the physician, they offer a fabulous job board as well - jobs are actually advertised here with exact location and include the precise contact information of the actual employer! Great!
No vague wishi-washi of "this opportunity is located in a wonderful family oriented community with easy access to blabla city" - which later turns out to be a backwood or backwater village and they "easy access" turns out to be an excruciating three hour drive to the next acceptable metropolis...this is the typical recuiter opportunity description....
None of this at Practicematch.com. Practicematch delivers real positions, with photos, precise location and contact info. Bravo!
That is what physicians are looking for!
Now, if you could just include the salary range. Please break that stupid taboo of "oy, you never talk about money". I never understood why employers seem deadly afraid of even mentioning a salary. No, dear employer, you do NOT lose negotiating power by being the one "who quotes a number first". Not true, nonsense. You simply allow the physician to walk into an interview with more certainty, with the reassurance that the position pays what he expects and is willing to work for.
I still remember how I had to withold my anger when I heard an unacceptable low salary offer - AFTER I had traveled a whole day, and gone through the whole interview and seen the whole practice and and and....I could have strangled the guy! The nerve!
Please, Practicematch, do something about that. Openness about money is a good thing - trust me!
And please, ban that stupid "competitive salary". Are your clients paying YOU "competitive fees"? And the salary is "competitive" with what? Oh, sure, competitive with MGMA guidelines - you got to be kidding - absolutely no resident knows what exactly the MGMA guidelines say, so why refer to them? "Competitive"? How "competitive"? Competitive without a chance of winning? Competing to lose? What is it now?
If you thought only 3 seconds about this phrase you would discover that "competitive salary" contains no information at all. You might as well leave it out. Please ban it from any and all adverstisements!

So, having all contact info for all US physicians allows Practicematch to target pretty much as many or as few physicians as they need or want to.
Practicematch actually has absolutely everything an employer could dream of having! Contact Practicematch - recruitment done! Can't do better than that....Who needs recruiters?
Again - who needs recruiters in view of what Practicematch can do?
N-O-B-0-D-Y
Think about it, take a few minutes, let it sink it.
Third party recruiters are obsolete. Period.
Employers just have to figure it out.
And Practicematch works with in-house recruiters / the in-house recruiter network....and the hospitals are taking over more and more of medicine, so they reach of Practicematch is easily growing bigger and bigger.
Be afraid, third party recruiters, be very afraid.
The sign is on the wall, look at the bottom of the Practicematch.com website - I looked and laughed!
Here is what it says:
"Third party recruiters are prohibited from using this website"
WOW! Confident and strong. They clearly can do without the dollars of third party recruiters...
Good for you Practicematch.com!
I welcome the publication of more honest, clear, precise, straightforward information about job offers!

Kiyosaki - bad, Tim Ferris - good. The 4-Hour Workweek

2011-01-29T10:15:00.011-05:00

Self-help books, recently relabeled into the more euphemistic "self-development" category have been a secret vice of mine for quite a while. One book that stood out as particularly disappointing was Kiyosaki's "Rich Dad, Poor Dad". The basic concepts can be summarized on a single page - and yes, we know that it is better to hve your money work for your instead of working for your money - gosh, who would have thought so? I just wish I had the money to do this. And it was curious to have "asset" redefined as something that makes you money and "liability" as something that drains your account. And the "cash-flow quadrant" is certainly worth considering. And when you are done reading the book, you have the good feeeling that yes, you can be rich too. But then the trouble starts - how do I do it? Kiyosaki offers outstanding advice - after looking through the whole book, it seemed to be vital to form "your team" - consisting of a realtor, an attorney and a finacial advisor. Hm, and what I tell those poeple about what they are supposed to do? so "forming a team" is what is going to make me rich? Looking further on what to do to become wealthy, I find a single sentence, a single sentence - no kidding - in the middle of another Kiyosaki book, here it comes, watch this, are you ready? "turn your ideas into companies" - done, end of advice, finito. And then he immediately waffles on with the 5th, 6th and 7th repetition of the cash flow quadrant or another similar hot "economics 101 for 6 year olds" topic. Kiyosaki does not write "how to become rich", not at all, he simply writes motivational feel-good leaflets. Detailed advice that helps you in real life? None, zero, nada....
Yet, Kiyosaki mentiones an annoying amount of times how much he learned listenting to "Rich Dad" discuss business with his son during dinner - but, somehow he never gets around to sharing any of those pearls with us, the interested readers. What did he do with all that knowledge, with ll the accumulated wisdom of rich dad? Where is he hiding it? Why is Kiyosaki afraid of sharing it? Instead of sharing it, he repeats his basic concepts ad nauseam until you fall asleep or throw his books away or start writing bad reviews and bad blog posts about him. And here I am.
I did not fully realize just how pathetic Kiyosaki was until I read something that actually delivers the goods - the book by Tim Ferris titled "The 4-Hour Workweek".
Now here is a gem - fully packed with practical, usable information, and almost no fluff. Chock full of innovative ideas on how to come up with ideas, test ideas, create a product, how to test it, how to market it and how to outsource the whole manufacturing and advertising and administration and go traveling around the world with the money you make. Tremendous insights on how to work more efficiently and how to actually LIVE. An incredible amount of inspiration and information packed into one single book.
Ferris does not hold back, he does not ration his information nor his advice, because in the back of his mind, he is already planning to publish a whole series of similar books and does not want to share eveything at once - none of that. He freely tells you what he knows. Importantly - he mentions other books and people he learned from and gives you his sources. This is good, since you can read his sources and understand them better, learn more. I believe this to be the sign of a good author. You could almost call him charitable. He truly shares, he does not seem to sell. It is not one of those thin books with slightly larger print and wide margins that beats a single thought to death. He really lays it all out. Great! Great! Great!
Kiyosaki, you are a ...can't print this here...!
If you, dear reader actually had the patience of finishing a Kiyosaki book, now is the time to throw it out, donate it to a Pre-Kindergarden program or give it to someone you don't like (great waste of her time).
Then read the real deal: The Four Hour Work Week. This is one of the few books with the potential to be life changing. Tim Ferris delivers what others only promise.

Boy, you have the industry pegged!

2008-07-24T16:29:00.010-05:00

This is a comment on one of my past posts. It is so clear that it does not require any additions. Hear the opinion about physician recruiters from someone who has done it, who worked as a phyisian recruiter...! Emphasis added by me.

Start quote:
Boy, you have the industry pegged! It is funny, I have been a "Physician Recruiter" for over 15 years and started to work for myself at home because I hated the way the industry was run. I have given physicians the name and contact information to positions that do not pay me a fee (worked for free) because it was in their best interest. I was tired of working for people who played games with Physician's lives for the sake of the almighty dollar.

Now, I may not be rich doing business this way. I "loose" a placement or a fee by handing over information but I can look at myself in the mirror everyday and I also know, if they took a job that I could not get a fee for, then that was ok because it only means they would not have been happy if they accepted a job from one of the hospitals which would pay me a fee. I am happy to say, once I started "giving" jobs away, I could still pay my bills and I received more referrals from physicians I had helped and I stopped calling myself a "recruiter" and became a "Physician Career Consultant".
End quote

Post jobs and find jobs for FREE on Sermo - a 60,000 and growing online physician community

2008-05-03T20:00:00.003-05:00

I love Sermo, for many, many reasons. The community is physicians-only, it is free, you may even earn a bit of money by giving your opinion and it is a great community. Responses are many, diverse, friendly, supportive, interesting, funny. Sermo has a great humor section. What started in 2006 with just a few people is now a vibrant 60,000 physician community and continues to grow by about 1000 a month.

Here is one more reason to love Sermo: Recently they have started a job board - FOR FREE. And it will stay free. So, this is my new favorite in the physician job market. Please take look at Sermo.com, and if you are a physician, register for free and and look around. Go to the posts in your specialty, go to the "general interest section" and go to the job board.

The Founder and CEO introduced the job board with the below quoted post in Sermo. And, not to my surprise, I found that my opinions on the physician job market and in particular on physician recruiters are widely shared by my fellow physicians!

Quote start:

From the Founder: Return to Professional Courtesy - SermoJobs

Being the son of a physician I remember very vividly the role of professional courtesy. While I was always blessed with access to incredible physicians, dentists, and orthodontists, I can recall several occasions where professional courtesy became a topic of great discussion between my parents. To my father, and ultimately myself, it represented something much more meaningful; the willingness and desire of physicians to help one another in any way that they could.

Almost a year ago, when Sermo started to consider the features, services, and products that our community would find valuable, a Jobs Board quickly became a topic of great discussion. It has always been clear that a large physician community could benefit from a very powerful "network effect" if all physicians could use the medium for their collective interest. Then members of this community repeatedly posted jobs and contacted me about their strong interest in a jobs board. Then our Chief Medical Officer started talking about this in terms of a return to professional courtesy and it hit me. This community wants to cut out the third parties. Physicians want to connect to one another, network, discuss, and ideally resurrect the professional courtesy that was once so central to our profession. Sermo could do that As we researched the concept of a jobs board, the community was very consistent in the feedback:

• Demand for physicians is soaring, especially of late. The necessity to resort to recruiters is becoming all the more common.

• Physicians are frustrated by the intrinsic conflicts of interest that third parties (recruiters, head hunters, etc.) bring to the recruiting process.

• With so many financial pressures on physicians, the 10-33% of starting salary paid out to recruiters is increasingly unbearable.

• There is no single resource where physicians can present and discuss employment opportunities to and with one another.

Sermo Jobs is a free resource to all active physician members of the community and will not be accessible to any for-profit third parties. I can, however, foresee a model where physician employers such as hospitals, IPAs, and institutions could eventually participate, perhaps in a way similar to our client postings.

Job postings will benefit from the same community moderation and discussion that have made Sermo so successful. Should the author choose to engage in commentary around their posted job, they will not be identified as the author but their real Sermo user name will appear. This system allows the individual physician to independently choose if they would like to reveal their Sermo user name.

Sermo encourages the philosophy of physician professional courtesy and shared benefit between the job poster and applicant. It is our hope that when a candidate accepts a job position the two parties will share any financial resource that would have been spent as a recruiting fee thus keeping more money in the pockets of hard working physicians.

Daniel Palestrant, MD
Founder & CEO
Sermo, Inc

Quote End.

Thank you, Dr. Palestrant and thank you Sermo Team, for this great opportunity to pass on jobs directly from physician to physician. This is exactly what I wished for and predicted in the age of the Internet. No middlemen, no third parties that distract more than they help. Direct contact from physician / employer to physician.

Professional courtesy. Now we are talking!

Another grrrreat recruiter email! Have fun

2008-05-01T12:33:00.005-05:00

Hello Dr.

We have many new and Great opportunities available in ALL STATES which include, $alary increase, sign on bonus, relocation packages. Locums and Perm National Positions Available!!! Open ended Assignments!!! Great rates $$$ All expenses are covered including lodging, mileage, and malpractice for Locums. VERY FLEXIBLE HOURS!!! GREAT FOR THE FAMILY!!! Must have a State license for Locums and Client will wait for Perm. Recent grads are welcomed. Excellent support staff and coverage. Possibility to covert to a permanent position. Low Stress Environment!!! All Submissions are strictly confidential.

Thank You,

Besides the very personal approach so familiar from too many recruiter emails "Dear Dr.", this recruiter apparently had help from his children armed with their new crayons! And I love the specific details! Are all his jobs so great? I guess so...I suspect he put all the superlatives from many many ads in a blender and out came....
It was very, very hard to resist calling him!
What else can you say if you receive such a customized personal message? You truly believe that he is "going to customize a search for you".

Physician Recruiters and Divine Justice

2008-01-30T09:00:00.000-05:00

Deceased physician recruiters realize to their great dismay that they are stuck in hell! Why?

They were told "heaven is oversaturated", so they chose a place with "easy access to heaven".

A Physician's View of Job Search

2008-01-26T11:09:00.000-05:00

A colleague of mine wrote this comprehensive piece on job search, short and to the point. Wise. True. You will see why physicians always will give you more and better information than any recruiter.

The best jobs are with:

1. People you know
2. People recommended by the people you know
3. People who know the same people you know (listen carefully to the people you know)

You have to know what YOU want first:

academic versus private versus mixed
solo, small group, big group, employee of a large concern
small town versus metropolis
Coasts versus center
North versus south

Once you decide on the above, you have to do the market research. Get a directory from your society, count the number of society members in each state (this takes some time). Then take go to US census site and take population in that state for your target population (Pediatrics, young adults, middle aged, Medicare). Then figure out practitioners/100k target population. The places that have the lowest number are the places where you will likely do best in solo or small group practice. The places that have the higher numbers generally are the more desirable places to live, and you should consider joining a group. Another good resource is the Dartmouth survey of medicine which has a listing of specialists/population for almost every burg in the city. For example, in White Plains, NY, if you hit a pedestrian, you just hit a doctor. Also, do this for the major referring specialties for your practice - you need feeder fish.

So, if you are a shark, you need to know where the feeder fish are, and if there are already a bunch of sharks there.

Watch for signup bonuses - contract may say it is a "zero interest loan", or part of your buy-in, or other nonsense.

Watch for dictators - they are the majority partners and have the practice of burning through young people to keep costs low. Don't be a slave.

Get a handle on what is the MGMA average for your intended practice situation - your department should provide you with this. Negotiate starting above the mean.

Don't get enamored of the metropolis - you'll probably never afford housing. Better is if you work in a friendly, but out of the way place (much more doctor friendly) - then you can buy a pied-a-terre in San Francisco, Manhattan, or Aspen, or all three, if you invest in carwashes, gas stations, or become a slum lord in your small town.

If your spouse can't go where you must go, it's easier to divorce at your stage than at later when your net worth is higher (not from personal experience, but from watching a lot of car crashes).

Also, consider this: if you can find one or two other people to form a practice and commit to a three year business plan, and find a hospital willing to finance you (joint venture), you can start your own practice from scratch and make your own rules. You'll be hungry to start, but you won't beholden to a dictator and can become one yourself! (don't). If you find a partner, and you see an ad for more than one of your positions in Montana, go and stick up that hospital in Montana. If you don't have a partner going there with you, tell the hospital that you'll do the work of two and that you'll hire your own partner, and have them give you that other position's salary for all that extra work you're promising.

Actually, if you want to make money, go into hedge funds. You have no business in medicine.

In your specialty, you have billable services tied to revenue generating activities. Take the 10 most common activities and figure out ~how long it takes and ~how much it reimburses. From this, order these in terms of revenue density (reimbursement/average time). The priority from a purely financial viewpoint is to maximize the revenue dense items and minimize the revenue diffuse items. Things like GETTING TO KNOW YOUR PATIENT is probably why you went into medicine and is not billable, but necessary to generate the revenue dense items.

Rounding on inpatients and hanging out at the hospital and volunteering for committees are also revenue negative. In your figures, then budget a workweek and figure out how you wish to spend your time. For all the revenue negative or less dense times, figure out the opportunity cost compared to what would happen if all you did was the revenue densest activity. The difference between the balanced scheme and the fully revenue dense scheme is the money space that you should negotiate under.

You can then structure a business plan that includes using residents, physician extenders, and MLP's (slaves, slaves, and sharecroppers) to soak up some of the revenue less dense and negative activities and let you spend more time doing the revenue dense activities. Better yet, get the hospital to pay for these functionaries so that you are set free to sit in a windowless room and read EMG's day and night or whatever revenue densest activity it is you have.

Grim, but the hospitals and more knowledgeable practices crunch these numbers, and so should you. Radiology - pure revenue, no wasted motion of the jaw or ask me what - just neurons firing - is the extreme example. But again, money is not why you went into medicine, so let's step away a bit and get real and budget your ideal week of work. You have to know what it is that will keep you running on that wheel and how much it is worth.

If you find that the chairman - recommended jobs are not exactly what you want, you then have the recruiting industry. As long as you are mobile and not wed to absolutely having a metropolis with a Chinatown, and you realize that first jobs are like first wives, the recruiters are not so bad if you know what they're good for.

Matchmaker, matchmaker, make me a match! Typically, a practice makes a contract with a recruiter on contingency of a hire - typically this fee runs about $15-20k. If they hire you without a recruiter, the practice keeps that $15k - which is good negotiating room. Recruiters are then like a real estate agent and use their own ad language. But if you must, you should USE them. If you are a good candidate, their relationship just became worthwhile - to the tune of 15k. That's like a $300,000 house.

Don't be an easy mark. Let them know you are looking at other positions with other recruiters. Get them to pitch more than one position at you. That way, you can ask compare and contrast questions. They are your job-finding assistants and make them earn their keep. Get data - how many hip replacements at that hospital? How much trauma? How many orthopods? How many primary care physicians? Who else is practicing in your field there? The good recruiters will have this info.

Find out specific locations and do your homework. The web makes it very easy. Is that Lexus dealership in another state? Are there more WalMarts than Targets in that town? Is Applebee's haute cuisine in that burg? Get staff lists of that hospital and figure out where people trained and where they are from.

Check out the real estate in that town - you can get a baronial estate in North Dakota for what you pay for a studio in Manhattan. Know the school system if you have lil'uns. Is the place on Craigs list (or in really nowhere)? If so, what are these people buying and selling from each other? Woodcarvings of bears or antique Shaker dressers? Crossbows and used computers from the 90's or timeshares in Cozumel and slightly used Espresso machines? Unspeakable acts with fat strangers or skinny ones? Check out the symphony if they tout one - does it thrive (count number of different shows, less than 4 and you recognize all of the pieces and this is a symphony in trouble). Check out the Broadway shows they tout and see what the locals like (Mamma Mia or the Rockettes Christmas Extravaganzapalooza). Count the number of Starbucks, and you get a general count of New York City blocks this town is equivalent to.

At interview, look at the people you'll be working with. You'll spend most of your time with them rather than the people and activities that you love. Check out their teeth. Do they have a singing fish on the wall? Who is going to drive you crazy?

Negotiating - get a number and tell them you'll get back to them. Collect at least two offers.

Have a medical contract lawyer review - costs between 300-1000 bucks and is worth every penny if you have a good one. Make sure your malpractice is covered, including your tail and your next tail (cost of leaving - is it impossibly high?).

And finally, unless you're married to a woman (and then she decides), you decide by going eeniee meenie miney moe, and go with the place that gives you the most peace of mind.

More "Recruiter Speak"

2008-01-25T16:34:00.001-05:00

Another contribution to understanding what recruiter ads really mean...

"family-oriented community" = everyone in town is related.
(If I divorce my wife, is she still my sister?)

"good hunting and fishing" = moose population greater than human population.

"little managed care penetration" = Medicare/Medicaid heavy

"beautiful region" = isolated

"salary guarantee" = loan

"many recreational opportunities" = small town

"$400K income potential" = on call 24/7 without help.

Send me your translation tips!

Better Tools For The Physician Job Search

2008-01-12T18:23:00.002-05:00

Years ago I asked my chief resident how I could find a job. He answered: "Just ask all the attendings and if that doesn't work, call a scalper", and nowadays he would have added, "go on the internet".
Well, I googled the terms "Physician jobs" and "ObGyn jobs". The results were a disaster: Recruiter website after recruiter website, then the websites that post recruiter ads, then the recruiting companies, then the occult and hidden recruiter ads disguised as "advice" that sneak up on you on student and fellowship websites, and on general health websites, and so on. In short, recruiters dominate the internet. This is severly misleading and a gross distortion of reality.

Recruiters only seem to be important when you look on the internet. In reality, they aren't. Accoring to my personal impression recruiters handle between 10-15% of jobs. A telephone survey of 1000 practices, unplublished, done by "Thedoctorjob.com" was consistent with this. A recruitment company researched the issue and arrived at an estimate of 33% of jobs, something that I believe it to be too optimistic.

So how do we find jobs? Print and direect internet advertising by employers may be responsible for filling 20-40% of jobs - in my estimate.

The remaining roughly 50% of jobs are filled by word of mouth, by direct personal contacts.

This has serious implications on how a physician should look for a job.

Networking should be effort number one, because most of the jobs are filled through personal contacts. This includes talking to anybody who is willing to listen and presenting them your "elevator pitch". The elevator pitch is a short presentation that includes who you are, what you are looking for, what makes you special and what makes you different than the rest. Handing out a business card with your contact info and maybe the elevator pitch is a good idea.
Networking includes contacting hospitals in the area where you want to work, I have discussed this in previous posts.

Networking includes sending a letter to every single physician in the area where you want to work and introducing yourself with a letter that essentially says the same as the elevator pitch. You may or may not include your CV in this letter. You will find the addresses and all other contact information of any physician anywhere at InfoUSA.com, where you can buy them for 50$ each. I have described this elsewhere in this blog.

Mailing a letter to each physician in your target area is especially useful, since you find all the physicians that have not advertised yet, that are just thinking about maybe hiring someone. This is great, since it gets you in before the competition. You automatically find all the physicians that have already advertised. They will simply think you are responding to their ad, even if you have never seen the ad. You will also reach all the physicians that have contacted recruiters, and you will be especially welcome, since your application does not have a 20K price tag attached (the fee the recruiter charges for brokering a candidate).

So, with one single activity, sending a letter to every physician in your target area, you reach absolutely everyone.
You tap the "hidden job market" as well as all other "markets". You cannot do better than that.
You can do this yourself, or you can have a company such as "thedoctorjob.com" do it for a fee.
Compared to networking and direct mail, all other methods of searching for a physician job pale. By looking only at print ads and internet ads you are limiting yourself at 30-40% of the job market, and by searching through recruiters, you limit yourself to about 15% of the job market.

Why is the Internet and why are the print media dominated by recruiters? Because they pay. Follow the money! Recruiters pay websites to post their ads and the websites do not mind giving them a little "editorial space" - and, voila, you have a nice editorial touting the "advantages" of recruiters. Print media need advertising, and they need recruiter ads. They survive because of these ads. And they do not mind publishing a few nice articles presenting the "advantages of working with a recruiter".

And so you have a completely slanted view of the "physician job search" on the net.

It does not help the balance of published material that physicians have no interest whatsoever in writing about the almost embarassing topic of "job search". They just get it done and go to work. Write about it? Please...I have better things to do with my time!

And that is the reason why every new generation of graduating residents and fellows do not use the best tools to find a physician job. They simply do not know. And they fall for one of the thousands of slanted and partial websites prepared by recruiters. And the older, exeprienced physicians do not bother telling them how to find a job. We need to raise awareness of what physicians can do to find the jobs they want.

A physician job seach is a straightforward thing: contact all potential employers by mail. And Network. Done.

If you are interested in detailed info about techniques, in tips, in experiences, in books about physician job search, in new ways of using email alerts and websearch techniques, if you want to find more helpful weblinks, good websites, help in writing cover letters, CVs and more, please browse through my blog.

You will find it all. And it will be from a physician - for physicians. No financial interest, no pushing recruiters nor recruiter agendas, just good, straightforward, helpful info. How it should be.

Physician Friendly States - Consider Them in Your Job Search

2008-01-10T18:35:00.000-05:00

Where are you going to practice? States actually are quite different when it comes to being "Physician Friendly". Massachusetts for example deters physicians with high cost of living and one of the lowest reimbursements in addition to unusually restrictive state rules, such as being forced to carry malpractice insurance as a condition to licensing, prohibition of balance billing and other unsavory goodies, which for my own good I cannot mention here. But then of corse, everybody just cannot explain why, oh why there is a primary care physician shortage in Massachusetts! I don't know either, can't figure it out.
This article by an editor of "Physician Practice" is worth reading. I am quoting an abreviated version with gracious permission from the author - Thank you!

Begin quote:

The Best States to Practice: America's Physician-Friendliest States
By Bob Keaveney, executive editor of "Physicians Practice"

Kansas, South Dakota, Oklahoma, Indiana and Texas are the most physician-friendly in the country, according to Physicians Practice's biannual analysis. We examined factors that affect a doctor's ability to work relatively hassle-free while still making a nice living, and found that the big flat, open spaces of America's Midwest outshine the glitzier coastal states as attractive places to practice medicine.

We emphasized factors such as malpractice climate, reimbursement, and cost-of-living — not so-called "quality-of-life" issues, we find that the simple-life states tend to fare best. Places like Hawaii, New York, and California may be terrific places to live, but the cost of living is just too high. Also, densely populated states tend to be similarly thick with physicians.

Our methodology
We didn't consider the subjective, so-called "lifestyle factors", the main ingredients of the "best places to live" rankings, Since there is no particular "lifestyle" that most physicians would agree is ideal. For those rankings, see Money magazine's, found at www.money.cnn.com/best/bplive, and Sperling's BestPlaces, www.bestplaces.net. As for Physicians Practice, we sought to identify the best places for a physician to work.

We considered the following:

Malpractice climate — We disqualified any state considered "in crisis" by the American Medical Association.
Physician-patient ratios — In our analysis, a lower ratio is better. Using an examination conducted last year by the New York Center for Health Workforce Studies (based on 2004 data by the U.S. Census Bureau, the AMA, and the American Osteopathic Association), physician-patient ratios affect a range of factors, from physician salaries to contract flexibility. The consolidation of commercial payers is putting a squeeze on practices. Having fewer physicians in your area increases your leverage.
Cost of living — Using data from the second quarter of 2006, the U.S. Bureau of Economic Analysis indexes the states against one another, with a median score of 100; the higher a state's score, the higher its cost of living. Thus, a lower score is better. For example, Hawaii scored 161.3; Oklahoma, 88.5.
Reimbursement — Medicare uses a similar indexing system for its Geographic Adjustment Factor. Hawaii's adjustment factor in 2006 was 1.044; Oklahoma's, 0.913. Commercial payers often tie their reimbursement rates to Medicare. For our analysis, the higher the score, the better.
Cost of living/reimbursement margin — These measures are closely linked; neither can be examined in a vacuum. Some states have costs of living that are relatively high or low in comparison to reimbursement rates. We evaluated and contrasted both of these indices to gain a sense of which states actually fared best.

Selecting America's most physician-friendly states is a subjective task. We recognize that factors affecting your particular quality of practice and life will include many additional variables.

Texas: A new law, passed with the assistance of the Texas Medical Association (TMA), established caps on noneconomic damages — money for pain and suffering — that plaintiffs can win in a malpractice suit. "I think the liability climate is one of the best, especially for physicians," says Ledon W. Homer, the TMA's president.

"We've found that a lot of doctors who relocate and never go back have gone from California to Texas," says Mosley. He made this exact move himself 15 years ago, and he found the stories of a unique Texas culture to be accurate. "One of the first things I saw was a bumper sticker that said, 'I'm from Texas. What country are you from?' And it really is like its own country."

Indiana is one of only two states to appear on our list all three times we've conducted this analysis. Its malpractice climate is "currently OK,", its cost of living is the 12th-lowest in the nation, and for every 100,000 residents, it has 180-200 physicians. "One thing that's kind of unique about Indiana that a lot of people don't really know about is that it really has a lot of great universities," he says. "Notre Dame, Purdue, Indiana University, Valparaiso, Ball State. People don't really think of Indiana as an academic university kind of place, but it is."

Oklahoma offers rock-bottom cost of living and comparatively low physician density (150 physicians per 100,000 residents)- combined with good reimbursements and generally higher incomes.

Kansas has the seventh-lowest cost-of-living, low physician density, and good reimbursement. were the deciding factors. Several physicians report that the biggest advantage is the people. Heartland folks just seem nicer. There's more respect for physicians. There's a greater willingness to trust."
Good economics make Kansas a great place to be a doctor. You can get a really nice home for a lot less than you'd pay in California. Kansas does have a $250,000 cap on noneconomic damages.

South Dakota has a friendly malpractice climate, they have the [noneconomic damages] cap. But it's also supply and demand, the supply of physicians is fairly low. The Plains state remains one of America's least-dense with doctors per capita. It also has the ninth-lowest cost of living.

Consider what matters - Don't get us wrong. We're not suggesting you pack your bags and move to Topeka or South Bend. We do suggest, however, that if you're ready to move — and more of you than ever, it seems, are — start your search by asking yourself what you're looking for in a practice setting and lifestyle, and then look for areas that meet those needs. Many physicians start with a place in mind, and then hope for the best, which is exactly the wrong way to proceed.

You may have familial or some other personal connection to a particular area; that's fine. But if you're just trying to indulge a fantasy by, say, insisting on practicing in Hawaii, then you're possibly setting yourself up for disappointment.

Consider the practice's size, compensation model, call-coverage policies, opportunities for partnership, and culture. Think also about how well-run the practice seems. For example, ask about average patient wait times (more efficient practices tend to have shorter waits) and about its use of information technology.

Bob Keaveney is the executive editor of Physicians Practice . He can be reached at bkeaveney@physicianspractice.com.

End quote

"Competitive salary" a useless term

2008-01-06T18:08:00.000-05:00

One of my pet peeves in job ads is the term "competitive salary". This term means nothing and therefore deserves translation and explanation. Below is what "competitive salary" can mean, and, to make it more tiresome, it can mean any one and all of these.

1. "Competitive salary" can mean that the employer's offer is in the range of the average salary according to the MGMA (Medical Group Management Association) lists.
This is the explanation I heard from a recruiter: "The MGMA does a tremendous job tracking each specialty, how much revenue a particular physician brings in, how large the population draw must be for a specialty to make sense to either expand or create. The industry of health care has many cut and dried business formulas. The RVU production model is one prime example of one of those formulas. An average OBG generates $1,413,436 in revenue annually for in/out combined and has a total RVU of 13,166 with each RVU valued at $43.49. For example the median salary for OBG physicians is $271,425 and if I had a really, really good opportunity I would refer to the percentile to indicate the range of salary. For example the 75th percentile for OBG is $350,000. So since my opportunity is "competitive" you can assume it's average and not over-the-top fantastic because I didn't refer to the percentile." - End of quote.
Well, NOW you know, right? You, like every job seeker, have nothing else to do but to pay the MGMA $520 for this info as soon as you start looking! And now of course you have this $520 list of averages sitting right on your desk.
This particular recruiter considered herself quite smart while in reality she is lost in her own world and has forgotten that the MGMA info is not readily available to everyone. SHE may know the averages, but YOU do not. If you read her comment closely, she says "competitive means average". Now that is great information...

By the way, here are two links to find out an approximate information of this kind, at least as national averages, even if this does not say much:NAPR
and Merritt and Hawkins

Another big problem that this recruiter chose to overlook is that this "average" varies. The average varies by experience, and it can vary from 180K in the first year to 270K after 5 or 6 years, this average varies by location, meaning in the South and in the Mid West it usually is higher and in New England it is lower, the average varies tremendously by HMO "penetration", it varies tremendously when you compare rural with urban areas and finally it varies by employer. Recruiters are not very concerned with urban jobs since they do not get them anyway.

And, how competitive is it? Very or hardly? Even if you knew the "average salary", is this particular salary competing in the 30%, 40%, 50%, 60% or 70%? You see, "competitve" spans probably more than 100K...

Turns out that "competitive" means NOTHING.

Do the following: When the recruiter asks for your CV, say that your CV is "competitive" and therefore you do not need to send it to him or her. Then may he or she will get the message.

2. "Competitive salary" is an evasive phrase used by employers that have not yet decided what they want to pay. They prefer to see what the candidates expect and then negotiate down from there.

3. "Competitive salary" is used by employers who want to take advantage of you. They are hiding the fact that their salary is below average. Sure it competes, but on the loosing end. They will only tell you after long talks, and after they feel that they have you on the hook, how little they really want to pay.

So, in summary, "competitive salary" is a completely useless term, and one that in the majority of situations works against you! Refuse to accept it and demand a clear statement about anticipated salary, such as "150-180K depending on experience". Statements like these should be the norm. Expect them, ask for them. Should an employer (or a recruiter if you really need one) not be upfront about the salary range, this may be a red flag.

Reading recruiter ads

2008-01-04T14:30:00.000-05:00

Funny and sad at the same time, but very true. You need a dictionary to read recruiter ads. Since the funtion of recruiters is to sell the leftover jobs to unsuspecting and inexperienced physicians, to fill the less desirable jobs, the jobs that everybody else has looked at and declined, well, because of this physician recruiters have to be very, how should we say this, "creative" in their wording.

The colleagues of "Ace Medical" in Gardenia, California, who have created the blog "careermedicine", have published their own tips about how to decipher recruiter lingo. Careermedicine is a good blog. Their idea is to share the experiences made during job search as well as during the opening and running of a medical practice. Publishing these experiences for the benefit of your colleagues is not done often enough. We all have valuable experience to share and we should share them. It will help us survive the avalanche of insurance abuse and government overregulation, the two main problems for physicians today.

But here is the quote from the careermedicine website about recruiter language:

Reading the Physician Recruiters Ads

Well, on a lighter note , here is the code for understanding those mailers sent to you by the Physician recruiters:

1) Located in the heart of paradise = a very very rural area.

2) Charm of a small town life = Here fine-dining is Apple Bees

3) easy access to all amenities = If you drive couple of hours looking for it!

4) 15 minutes inland from the ocean = Be careful! lots of hurricanes!!

5) For those who love outdoor activities = It is deep in the jungle.

6) Enjoy year long skiing = You got it! Very very cold!!

7) Opportunity of a lifetime = We are having tough time finding applicants.

8) Opportunity to do it all = No specialists available around...you will be on your own.

9) Low cost of living = If you buy that house in the Ghettos.

10) Option of Partnership track = Just kidding!!

Thank you careermedicine!

What Physicians Think of Recruiters

2007-09-23T21:25:00.000-05:00

A quote posted by "PsychMD" in one of the forums of studentdoctor.net, which I am adding to the other quotes from physicians who somehow have arrived at the same view of physician recruiters as I have. I have described this very extensively in my past blogposts.

Just a general comment re. recruiters mailing you. Everyone starts getting junk mail recruiting around the time when they start to appear listed in several databases (available free for anyone who looks), such as medical licensing boards, the Specialty Board Certification site, hospital privileges staff lists, even final year resident rosters which are available on many programs' websites.

I wouldn't encourage anyone to pick a job pitched by a recruiter who has your name from a database and has no clue who you are and what you want. Plus, of course, they will all tell you that the "market" is pretty tight in the major cities, because most major hospitals in most major cities do not even go through these recruiters; they have their own in house recruiters, or recruit staff through internal networking; they have where to pick from. Look for a job based on where YOU want to live and where YOU are familiar with the local medical scene. Do your homework well. Lots of jobs picked through recruiters are jobs that are not already filled locally for a variety of reasons, not all of them good, in many cases.

All that aside, there are some rural area jobs that are GREAT, and the only reason they don't get filled is their more remote location. For someone who doesn't have a lot of pre-existent family obligations (such as a spouse who also needs to find work in a non-medical field), or are just starting their families, and do not mind being 1-2 h. away from a major airport or other larger city amenities (nowadays a lot of stuff can be available on line anyway!), some of these jobs are true gems.

(This pertains to all specialties, not just cardiology.)

Recruiters Have the Less Desirable Positions

2007-09-23T13:53:00.000-05:00

A colleague whom I know from emails, but with whom I have never spoken about recruitment or recruiters, sent me an email today which I am quoting literally after having removed his name on request.

I am amazed how closely his experience mirrors my experience with recruiters.
May I point out that he finds that positions coming through recruiters are in "...less desirable practice locations...a candidate must keep in mind that these recruiters work FOR the hospitals, and not the candidate...these recruiters usually will not heed the candidates' needs...since stopping my search, I continue to receive recruitment flyers and e-mails (as I am sure many of you do)...those who would take these job opportunities may lack the insight into the economic realities of private practice..."
Recruiters may argue as much as they want, this is how they come across to a majority of physicians. And, please, do not tell me "it's a few bad apples", those few bad apples seem to incredibly busy and seem to just pop up everywhere!

"As a relatively recent recruit to (2003), and subsequent recruiter (2005-6) for my former practice, here are my observations.

When I was searching for a position, I looked at these incredible and unbelievable offers. I too, looked at Merritt, Hawkins, and Associates' findings over the last 6 years. I then observed a trend when I actually called these opportunities / offers. Although not universal, most of these positions offered by "recruiters" such as Merritt, Hawkins & Associates are in less desirable practice locations. Not necessarily rural, but nonetheless less desirable. Factors including geographical location, payer mix, competition, etc., may all come into play.

One must ask why a hospital needs to utilize these search firms and pay them tens of thousands to recruit a urologist. A candidate must keep in mind that these recruiters work FOR the hospitals, and not the candidate. Even if a candidate specifically mentions he/she does not want to join a multispecialty practice nor want to be on the east coast, these recruiters usually will not heed the candidates' needs and will contact the candidate anyway when they have any job offer remotely resembling (or NOT!) what the candidates want.

Since stopping my search, I continue to receive recruitment flyers and e-mails (as I am sure many of you do) advertising $500,000 starting salaries almost on a weekly basis. I know of one such offer and its exact location if anyone wishes to move to a rural Arizona town. Contact me directly and I won't even charge you a finder's fee!

Now the question: How do all these practices afford to pay these huge salaries with all these benefits? I will bet the practices are not paying these costs. These incentives are subsidized by the hospitals.

I can not imagine offering these incentives and having the recruit be "let down" in year 2 when the hospital subsidy ends and reality hits. The short term gains may be great for the candidate, but one must evaluate the long term consequences of taking such a job position.

Those who would take these job opportunities may lack the insight into the economic realities of private practice, and may not be ideal candidates whom I would want to eventually call "partner". Experienced managers know the emotional, production, and financial costs of having to replace an employee. Imagine the headache of having to replace a urologist... It's true that this recruitment process is like choosing a life partner (for both the practice and the candidate); one must chose very, very carefully."

Great books for Physician Job Search

2007-09-17T16:47:00.002-05:00

Two useful publications for physician job seekers:

The first is the surprisingly good "The Ultimate Guide to Finding the Right Job after Residency" by Koushik Shaw, published in late 2005. This is probably the most useful book for the physician job search that I have come across so far. It is short, concise, to the point (sometimes a bit too short), but it covers absolutely everything that is relevant from getting to know your personal preferences in your work life to determining where exactly you want to live and work, how to find a job, how to interview, and - kudos for this section - how to analyze a practice you are looking at, what questions to ask a potential employer to uncover risks and possible mismatches early. The author goes into details of analyzing benefits offered by an employer and negotiating a contract. He even goes into the basics of opening your own practice.

Overall very well written, in good style, very easy and quick to read and extremely informative. One smart book everybody should read at least once and at least one year before graduation. It fits the motto of my blog perfectly "What I wish I had known as a resident". I highly recommend it.

Here is a review by Paul Gill on Amazon.com:
"This book is an absolute must have for any graduating resident. The author has put an enormous amount of research into a concise and organized fashion, allowing even the time restricted resident to conquer this book in a few short sittings. I have discussed this book with several junior attendings and private physicians, and they are all amazed at how much accurate and insightful information is hidden in this short concise book. It will save you weeks or even months of research and grant you an amazing head start into identifying and obtaining the right career. I truly believe this book will substantially increase your chances of a successful and happy career choice plus teach you to avoid many of the common pitfalls."

Published by McGraw Hill it costs $21 at Amazon or at your local book store. If you are a physician searching for a job and only want one resource, read this book. If you have a bit more time, read my blog "The Summary on Physician Job Search" too, where I have summarized my experience and my knowledge about this topic.

While we all would love one single access point to the job search, it does not exist yet. It is doubtful it will ever exist, because there are so many different people and so many different ways of going about finding a job. New interesting websites for job seekers are added all the time, recently it was Jobfox.com, a site worth visiting, exploring and watching.

A free publication is also worth mentioning: The recruiting firm Comphealth's "Best Friend's guide to find a job", which you can download for free here. It is a remake of Weatherby's booklet with the same title. Caution, you get what you pay for. It is free, because is a marketing tool for Comphealth and on every other page you stumble across sentences like "If you have any questions about xxx, call your Comphealth representative, who is well trained and very experienced, especially in xxx". And so on...

The information is good though and you can't complain about the price. As you would expect, the information is severely restricted to anything that will help to make you a client of Comphealth and make you more sell-able to Comphealth. A better CV, a better cover letter etc will ultimately make you more sell-able and therefore will benefit Comphealth. Any information that would lead you away from Comphealth and make you an independent job seeker such as tips for networking and for approaching hospitals directly and for direct mail are absent. But that's what you can find on my blog. Comphealth's "Best Friend's guide to finding a job" is an excellent complement to my blog.

As a side note - I would demote anybody from the rank of "Best friend" who would try to recommend that I use recruiters as my main way to find a job. After all recruiters know about maybe 50% of all jobs, not more. And here I am overly optimistic in my estimate, since a maximum of 30% of jobs are handed out through recruiters, according to a recruiting companies research. The real percentage of jobs brokered by recruiters might be lower, since nobody can accurately estimate the size of the "hidden job market" and the number of jobs filled without any participation of the public. The only way to approach the hidden job market, and that means all those jobs that either are not advertised yet and all those jobs that might be filled before they are ever advertised (because they are so attractive), all those jobs are off-limits to recruiters. But YOU can easily find them by networking, by sending your cover letter and CV to EVERY doctor in your target area and by using "TheDoctorjob.com", who can do the legwork of direct mail for you for a fee.

There is another book available on the topic of physician job search. It is called:
"The Physician's Job-Search Rx: Marketing Yourself for the Position You Want" J. Kashani, W. Allan and K. Kelly. I DO NOT recommend it. It was published in 1998, it feels outdated and actually is outdated. The internet and its possibilities are not discussed as you would expect, and overall it just pales compared to the excellent style, balanced handling of topics and thorough research of Dr. Koushik Shaw's book.

Physician Recruiters Love Direct Mail, But Will Never Recommend It To You

2007-09-08T15:25:00.000-05:00

Recruiters are hired by an employer and they are the agents of that employer. The recruiter is NOT working for you, the searching candidate, simply because you are not paying for the recruiter. When you contact a recruiter, you are dealing with someone who is looking to fill a position in order to get paid, not to help YOU FIND a position. You are NOT dealing with someone whose job it is to help YOU, the candidate. A recruiter is NOT YOUR AGENT. Recruiters are called recruiters because they recruit. The recruiter is pursuing YOU, he is a "headhunter or "doctor-hunter" or "doc-hunter". Rumor has it that in a far far away and remote corner of the web there even a recruiter website called "dochunterdiary.com".

Do not expect a recruiter to behave or function as a "candidate search agent", "search advisor", a "career advisor", a "career consultant". They do NOT get paid for any of that, so why should they do it?

Nevertheless, sometimes recruiters work in the job seekers interest, when it happens to coincide with their goal of filling a position. Such a match or coincidence is possible. Recruiters will support you, the job seeker, as long as it is in their main interest. Their main interest is closing the deal.

Let's assume for a moment that a recruiter is really, truly on your side, on the job seekers side. In that case, your recruiter would tell you how to find a job independent of his listed jobs, he would tell you, teach you, instruct you how to network, in that case the recruiter would point you to the most informative and most helpful websites for job seekers, the best job boards with the most job postings, the journals with the best ads. A recruiter that was truly on your side, on the job seekers side would advise you to call hospitals and their physician liaison departments (yes, some actually do that!), and finally he certainly would advise you to mail a letter to every physician in your specialty in the area where you want to work (NO recruiter will do that).

A recruiter that is on your side would give you pretty much the advice I am giving in my blog. Right? Take a close look at it. I have summarized most of my tips and tricks on the blog "A Physician on Job Search". My blog is not a "logging of current events", no, it is a publication of experience and recommendations. Please look at them and compare that with your typical recruiter information.

Reality check:
Now, compare what information recruiters offer you with what I am offering on my blog. Recruiters offer you tremendously helpful tips such as "how to answer a recruiter call", "how to get along with your recruiter", "what information to have ready when a recruiter calls" "why the countryside is worth taking a look at", "Disadvantages of city jobs" (we know where that comes from) and they of course help you with truly grave decisions such as "should I contact one or more than one recruiter during my job search?". You get the picture!
Oh, sorry, yes, they may give you a few hints about how to improve your CV and how to behave during the interview, after all, that makes you more marketable....

Too many graduating residents are not aware of these rules. Too many graduating physicians still believe that using recruiters is a mainstream way to find a job. Too many graduating physicians are not aware that they do not need recruiters at all. It is the employers who needs recruiters, not the job seekers. Employers need to fill positions.

Recruiters need physicians, "candidates". On their blogs they muse about the ideal candidate - someone who is happily employed and doing a great job, and not even thinking about switching jobs. They have names for good candidates, they call them "MPC" - most placeable candidates. They think about the tip of the iceberg - the candidates that are actively seeking and think there must be a large number of candidates below the surface, just like the iceberg has most of its mass below the surface. Recruiters look for ways to find those candidates, to tap that untapped mass of candidates...If they just could find a great approach to all those hidden candidates!

This is of absolutely no concern whatsoever to a job seeker. Job Seekers need jobs. They do not care about the hidden iceberg of silent candidates. They are the candidates.
Job seekers assume correctly that advertised jobs, and especially jobs coming through recruiters, are only the tip of the iceberg. The larger number of jobs is hidden under the surface, often never advertised. Jobs constantly change hands in big cities and only the insiders know about it. This is called the "churn of the job market", the hidden constant movement. Physicians change jobs all the time, from one hospital to the next, sometimes within one community, sometimes they switch to the neighboring hospital or health care system. These jobs are not posted, they are talked about over coffee, over lunch, in the locker room, on local CMEs, on informal department meetings, on the golf course and so on.

Recruiters hardly ever have access to the hidden job market - and here I am just trying not to be too radical by saying "no access at all". The churn of the job market is like the "gray" or the "black market" - a semi-underground affair.

Yet, you the job seeker can easily break into that hidden job market! Not just by networking, but even more easily by direct mail. Job seekers can find easy access to this hidden job market by sending their cover letter and CV to every physician in their area of interest. I have frequently described how in the smallest detail. Please go to my blog "A Physician on Job Search" and check the posts "Active Job Search" among others. You can also have others do the leg work for you by going to "TheDoctorJob.com". This company will optimize your cover letter and CV, merge the cover letter with a list of doctors in your area of interest, send you all the letters. You sign them, put them in envelopes and stick a stamp on the envelopes.
It works.

And because this method is a threat to recruiters, they will never recommend it. It makes you, the job seekers completely independent, self-sufficient. You do not need anybody's help and yet, you can reach every single doctor in your area of interest.
Recruiters are extremely familiar with direct mail, they use it. They appreciate it, they love it. The NAPR routinely send out massive amounts of mail to all physicians looking for positions and for candidates. Yet, you, the lowly job seeker will never hear about this from any recruiter.

Direct mail is the most basic thing. I want a job. I send a cover letter and CV to a doctor who might have a job. Repeat a thousand times. It is so simple.

Direct mail is the job seekers ticket into the hidden job market! You have to know about it if you want to find the best possible job for you!

14 Must Know Facts about Physician Recruiters

2007-07-30T10:17:00.000-05:00

Physicians are not well informed about job search methods and about recruiters, about how they really work and about their limitations. Residents in particular lack awareness of the disadvantages of working with recruiters. Graduating residents are just stepping out of an educational, basically helpful environment. They are naive in business matters and rarely understand the economical pressures that shape recruiter behavior.

The fact sheet below was developed after years of personal experience with physician recruiters, based on being a candidate looking for a new job as well as an employer looking to hire a new associate for my practice. I am writing specifically about contingency recruiters, and that these facts and rules do not refer to retained recruiters, in-house recruiters or locum tenens recruiters.

Recruiters will deny all of these facts or at least try to gloss them over. Many actually will claim to be proud of avoiding one of the drawbacks below, which is ...just marketing. I leave it up to you whom to believe: a physician without any financial interest that reports out of personal experience and research, or recruiters who defend the living they make based on marketing slogans.

Also consider that there are always the "exceptions that confirm the rule". There are those recruiters that market less "aggressively", that really care about you, that do visit the practices they represent, that are straightforward about what they are able to accomplish and what they cannot, but that does not change the big picture I am describing.

As much as recruiters may try, as nice or good hearted or ethical or hard working or well-meaning they might be, some facts will never change:
a. recruiters are hired and paid by the employer
b. they charge a $ 20,000 fee for their services and
c. they only get paid after closing the deal.
These facts lead to all the consequences and problems described here. I am not trying to indict recruiters, I am describing the basic framework they practice in.

1. Physician Recruiters are hired and paid by employers to fill a vacancy. They are not hired nor paid by the candidate. This is much more important than candidates think! Their loyalty therefore is to the paying party, the employer, not to the searching candidate. They do not get paid to consider the desires, careers or preferences of the candidates. The candidate is useful as far as he or she fills the job the recruiter gets paid to fill. A recruiter for example will never "negotiate a salary" for you, as some claim. You really think they will go against the employer who pays them and create higher costs for them? When it comes down to it, recruiters are not on the side of the job seekers. They are on their own side: closing the deal and getting paid.

2. Recruiters charge $ 20,000 to fill a position. This is the biggest handicap for recruiters, something that no recruiter can overcome. This creates a barrier to hire them. This places recruiters at a severe disadvantage compared to you, the physician, when you are looking for a job and applying for a position. You come without the price tag and instantly are more attractive.
Obviously you could argue about the significance of those 20K. Maybe the hiring hospital is flush in money and can afford to spend it, maybe they consider physicians valuable enough to spend that kind of money on recruitment, maybe the loss of revenue with an open position is even more expensive, but 20,000 are still 20,000. Maybe the yearly collections of the physician (neurosurgeon) dwarfs those 20K, but to me as an ObGyn it means about 8 complete "9 months of prenatal care plus delivery" and to a family physicians it means seeing a whole lot of patients!

3. 80-90 percent of private practices refuse to work with physician recruiters, since they are very expensive. The usefulness of recruiters in medicine is reduced dramatically by the fact that they cannot reach that 80-90% of the job market - which is most of the private physician job market and pretty much the whole job market in desirable areas.
Keep in mind that 50-60% of physician jobs are filled through networking, 10-30% through advertising by employers on Job Boards and 15-25% by recruiters. What kind of help can you expect from someone who can only reach 20% of possible jobs?
What do recruiters do in response to this? They tell you that those areas are "oversaturated" and try to lure you to under served areas, where recruiters do get jobs.

4. What does a day in the life of a recruiter look like? Recruiters are salespeople and spend their days on the phone. Recruiters spend part of their day cold-calling practices, groups and hospitals to see if they are interested in their services. Then they pay large fees to NTNJobs, eHealthCareers and numerous other Internet boards to post job descriptions. Then they spend a few hours each day cold calling physicians, sending fliers, postcards or e-mails to program directors, specific departments and numerous physicians fishing for applicants.
Candidates will usually respond to recruiters by e-mail, submit their CVs and recruiters then forward these CVs with names blacked out to the potential employers.

Recruiters love to give you the impression that they have resources or skills that you don't possess, yet, once you see what they actually do, you realize that you can do it perfectly well on your own. No, they don't have secret sources in high positions; they just want you to think that. Unlike what they sometimes claim, most recruiters do not visit practices and they do not get face to face with physicians. Usually they work nationally and seeing offices and physicians means travel and would be very time consuming and expensive.

5. Most recruiters subscribe to a background database, usually the NAPR "Job Bank". Paying subscribers store short profiles of jobs and candidates in these confidential, recruiter-only databases. Since thousands contribute to these databases recruitment becomes more efficient due to sharing of resources and combining efforts. "Maybe my candidate fits your job". Fees are usually split between the recruiter who has the candidate and the one who has the job. This is the same model that Realtors use. When a recruiter says "we personalize a search for you", (I love that slick line) he means that he enters your name in the recruiter background database and checks if there is a matching job for you. The only problem is: the whole database is filled with left-over and hard-to-fill jobs.

6. Occasionally recruiters market themselves as "screening candidates and practices carefully" to give themselves an air of quality. Based on my personal experience I doubt this. Screening does not fill positions and only filling vacant positions gets them paid.

7. Recruiters are first and foremost salespeople, not helpers. Given the fact that recruiters only get paid their $20,000 if they close the deal, they are highly motivated to sell.
This explains their behavior:
They contact as many physicians as possible per day, hoping to find the one that can fill the job. They try to convince you that the jobs in "Desirable city" are not so desirable and that the countryside jobs they have actually might be better for you.
Recruiters loose interest in you immediately if you insist on a job in very desirable area or if you are looking for part time jobs. Their chances of getting paid in all these scenarios are very low and therefore the interest in you vanishes.
Because of the pressure to sell and the strong competition, all too often the candidate becomes just a number, a meal ticket, a means to fill the job, to close the deal and get paid.

8. Physicians can easily find 2-5 times more jobs than the best recruiter. Doctors have been the target of marketers for a long time. They are all listed in multiple databases. List of doctor contact info can be easily bought from a large number of sources, some of them in a few minutes online. Check out InfoUSA.com! Since physicians are so easy to reach, candidates do not need any help from recruiters. Medicine actually does not appear to be an appropriate field for recruiters.
Please refer to my blog for excellent information how you personally can find more jobs than any recruiter.
Physicians applying to an employer without a recruiter do not have a 20,000 price tag attached and they immediately become a preferred candidate. Recruiters vehemently deny this in public, but admit it privately. In the end recruiters are more of a distraction and burden to a job seeker rather than a benefit.

9. Recruiters are not "free for the candidate". This is a common marketing myth. Yes, the employer formally pays the fee. This fee is "recruitment cost" and therefore part of the overhead, the expense, caused by the candidate. The employer will recover this cost from the employed candidate in one way or another. Getting a job through a recruiter usually means a lower salary or fewer benefits, at least in the frist year.
Although, the true price of working with a recruiter is less visible and much higher: you get a less desirable job!

10. Recruiters may have many jobs, but they do NOT HAVE GREAT JOBS. Here I have to declare my own bias. I consider jobs in attractive, large cities "great jobs", an opinion that not everybody shares.
No matter if we talk about city or countryside though, the recruiters tend not to get the best jobs. The most attractive jobs are never advertised and are filled by word of mouth or direct mail. The moderately attractive jobs are advertised in print and on the Internet. Only those jobs that employers just cannot fill, even though many physicians look at them and decline, are handed over to recruiters to fill.
Recruiter told me" We get jobs in areas where there are more jobs than applicants" and "The function of recruiters in medicine is to fill the less desirable jobs", and Pam Pohly, another recruiter writes "Recruiters get the hard to fill jobs". Do you really want one of those jobs?
Ask yourself before talking to any recruiter: Do I really want a less desirable job?
After all, why would any employer pay 20,000 to a recruiter if a job can be filled by word of mouth of with $400-800 of advertising in a few journals?

11. Physician recruiters advertise using their own language: "easy access to", "a short drive to" means the locations is 1 to 2 hours from an attractive city. "Easy access to city A and B" is even worse, this job is in the dead middle between 2 separate suburban areas. "A great place to raise a family" means there is absolutely nothing to do in that town. If you are single, you are dead!
Much more important is what recruiters do NOT mention, such as high turnover of associates, low salary, high-buy-in and other hidden drawbacks.
But how can a recruiter find out in a 10 minute phone conversation what goes really on in a practice or hospital? They can't and the candidate is the one who suffers the consequences.
Recruiters sometimes "forget" to mention drawbacks of jobs, since that disclosure would hurt the sale.

12. Recruiters advertise insidiously by masquerading as "job search experts" and "advisers". This kind of marketing is much more dangerous, since it is often not recognized as the advertisement it is. This misleading marketing includes posing questions such as "How do you choose the recruiter that is right for you?” The implication of this question is that there is actually a recruiter that is right for you. Posing this question is similar to "Should I shoot myself in the left or right foot?" NO, you should not shoot yourself at all, and NO, you should not use a recruiter at all!
Often recruiters post tidbits of helpful info on their websites, such as links to licensing boards, short "5 points to improve your CV", but that is all marketing fluff to attract you or to make your CV more marketable. They will never give you advise how to best find a job - outside of recruitment. That would be bad for business and would threaten the basis of their existence. Therefore this info is never complete nor truly useful. In the end is only a means to get you as a client. Nothing wrong with that, you just have to be aware.
Anytime you read - anywhere - that someone recommends recruiters or even considers them a good alternative to networking, you are dealing with either a recruiter or someone who just has no clue about how the job market works.

13. Recruiters are NOT advisers, helpers, career counselors, CV writers or job market experts. They are usually neither qualified nor versed in any of these matters. They may read a lot of CVs, but that does not make them experts at writing or editing them. They will not take the time to go over your CV and advise you. They check your CV mostly for one single question: Can I sell this candidate?
They are not experts in the job market, even though they spend their time trying to fill job vacancies. Recruiters know only a small segment of the job market, the segment that is available to them. Do not trust their opinions in that matter, their opinions are shaped by the marginal 10-20% of jobs they are aware of.

14. Worst of all: recruiters do not disclose their limitations. They will not tell you that they cannot get jobs in desirable cities and locations. They will not tell you that they cannot get jobs with desirable practices. They will not tell you about alternative ways of finding jobs. This is a serious ethical issue - imagine a physician not treating a patient, just because he personally is unable to perform a certain surgical procedure! We send our patients to someone else who can help them. Recruiters never do that. Physician recruiters simply tell you that the great areas where you are looking for a job are " oversaturated". In reality this is a code for "unreachable for recruiters who charge 20K to fill a job". They will never tell you: "Just mail a letter to every doctor in Desirable City and you will get a job", because this might threaten the foundation of their existence. Imagine all physicians just mailing letters to eployers and getting jobs! Instead recruiters tell you "Call back in a few weeks, maybe I have something then". The obvious idea is to keep you as a client and maybe get that commission later, in blatant disregard of what you want and need! I consider this a lack of responsibility towards clients.

Summary: AVOID physician recruiters!

The better way to find a job is a simple and very successful method: mail a letter containing your CV with a cover letter to every physician of your specialty in the area where you want to work. You buy the list of contact info online from e.g. InfoUSA.com, then load it onto your computer and mail-merge it with your cover letter in Word. Voila - hundreds of personalized letters addressed to every single physician in your area of interest. Most successful!!
See my previous blog post for a detailed description.

How can all this come up after recruiters have been serving the physician community for 20 years?
Personal computers and then the Internet have changed our lives. Contact information for physicians, once hard to find and expensive, can now easily selected and downloaded on the web within a few minutes. A PC can easily produce hundreds of customized, personalized letters and the new Internet fax services allow us to fax a letter to thousands of doctors with a few clicks.

That, together with Internet job boards that are becoming easier to navigate and with physicians and hospitals becoming more computer savvy, leads to a future of job searching directly without middlemen. More and more candidates will contact employers directly and
viceversa.

So, what keeps recruiters in business?
It is those employers who sadly do not know how to find candidates and those employers who do not have the personnel to recruit themselves. It is those colleagues who pay recruiter fees, who allow recruiters to pay for their advertising avalanche on the web. It is all paid by us, the physicians! This can change! I have described in detail the know-how that employers need to recruit successfully. Please check past posts in my blog for this.

Short and Sweet Summary of What Physician Recruiters Do

2007-07-27T21:31:00.003-05:00

I found a nice comment on one of the discussion forums of the "Student Doctor Network" about what recruiters do, from yet another physician (LAdoc) who agrees with me:

"Never use a recruiter. Their job is to fill crappy jobs with YOU, and take a decent chunk of your salary to do so. You get doubly screwed."

This pretty much sums it up. Truly short and sweet. To me, it replaces the previous motto: "The function of recruiters in medicine is to fill the less desirable jobs". I love this new quote.

A Former Recruiter Supports My Judgement

2007-07-26T23:19:00.000-05:00

Comments about my blog come in two flavors.

One is "yes, that is just what I have experienced" and "excellent post", "residents need to know this", "Why do they not tell us this in residency" or something along those lines. This opinion usually comes from fellow physicians, who ran into similar problems and experienced similar frustrations with recruiters.

The other flavor is "You have no idea what you are talking about" "Of course there are a few bad apples among the recruiters, you just have not spoken to enough of them". That view would be, you guessed it, from active recruiters themselves.

I have plenty of experience, ooohhh, yes, do I have experience with recruiters. Too much for my liking. That is exactly what turned me against recruiters. But in the last few posts I have happily demonstrated that my views are actually shared by recruiters themselves, or by former recruiters. Of course they know what they are doing, they are not blind....And here is another one of these statements from a former recruiter. It could have come from my keyboard, I love it...

By Rahulazcom, "Senior member", SDN student doctor network

Start quote...

I used to be a recruiter before I went to medical school...

...I would advise you to not use recruiters at all. Recruiters are like Real Estate Agents. They provide the impression that they have certain resources or skills that you don't possess until you see what they actually do and realize you can do that on your own. This is what they do. They cold call groups and hospitals to see if they are interested in their services. Then these recruiters pay a large fee to Monsterboard or some other major search engine to post job descriptions. No, they don't have secret sources in high positions like you think. That's what they want you to think. Candidates will usually respond through e-mail and then they forward their resumes (with their names blacked out) to the hiring person. Recruiters will also send flyers or e-mails to program directors or specific departments "fishing" for applicants.

Be aware that the best companies are not actively looking for people. The companies that are willing to shell out 30-60K in recruiting fees are those that are desperate to find someone or are really struggling to find someone. This is not alway true but it's true most of the time.So if a recruiter is discussing a job opportunity, please keep that in mind. Ask yourself why is that job open and why have they contracted a recruiter?

Also, see if you can assess the experience of the recruiter. The bad leads are dumped on the new guys to see if they can close them; the senior guys will not want to work those bad leads. Also, if a recruiter calls you and starts rehashing information from a database, that's usually the newbie that is calling old leads that is stored in a database which is an ominous sign.

Back to my original point...., by applying directly to hospitals and groups, you will actually increase your chances of landing a job because the group/hospital doesn't have to pay a larger recruiting fee (30K to 50K) to hire you.

Okay, so here is what I would advise all of you to do if you are in the job hunting stage.

1. Have an idea where you want to settle down. Narrow your search to one or two cities

2. Create a portfolio by having your CV, photo and LORs photocopied and placed inside a large envelope.

3 Mail the packages directly to groups and hospitals and make certain to let them know you are not being represented by a recruiter and that you are representing yourself. Make sure to address your portfolio to one of the physicians. Don't address it to the title of the practice or the hospital department because it could end up in the HR/Office manager's hands and they could just dump it in the trash.

4. Follow up with them to see if they received your portfolio.

5. Be aware that the best groups are not actively looking to hire someone, but if the right candidate lands on on their desk and they don't have to pay a large recruiting fee to hire him or her, they will strongly consider hiring that individual.

6. AVOID the HR! That's a recruiter basic! Talk to the decision-maker or one of the partners. You can talk to the HR later in regards to benefits etc. but the physicians/partners are much easier to deal with.

End of quote....

He has it almost right. Just mail a letter to every single doctor in your area of interest, not just to the groups and hospitals! And I should mention that "thedoctorjob.com" could do it for you for a modest fee...

What happens when you register at the recruiter job bank

2007-07-25T22:30:00.000-05:00

The following quote is from the "dochunterdiary.com" blog, written by Jim Stone and Bob Collins, two competent and smart recruiters from the search company Medicus Partners, who work in committees of the NAPR as well. It lists in great detail what happens when you, the candidate, registers at the recruiter tool "World Job Bank". Extremely enlightening!

Here is the blog post. I do not like to quote that much, almost a complete post, but this quote is so full of data that it cannot be shortened without loosing impact.

Start quote:

"A World Job Bank Physician Registrant’s Experience

Ever thought about the kinds of contacts our physicians receive when they register on the World Job Bank?

This will give you an insight into one physician registrant’s experience: Dr. X, a female, board certified internist, registered on the World Job Bank. She wanted a traditional, permanent internal medicine position and limited her geographic preference exclusively to New England.

Within hours she received numerous voice mails and e-mails. Over the course of six and one-half months, she received 189 e-mails from recruiters at 35 search firms and 72 voice mails from recruiters at 20 search firms.

The following is a breakdown of the e-mails Dr. X received: She received 66 e-mails with brief practice descriptions from one recruiter. Of the 66 e-mails, three positions were for geriatricians, one was for emergency medicine, one was for a hospitalist position and 60 were for general internal medicine. Sixty-five of the 66 e-mails were for geographic areas in which Dr. X was not interested. Only one of this recruiter’s e-mails was for a position in New England. Dr. X also received 33 generic e-mails containing no practice information (e.g., “Are you still looking for a position?”). Of those 33 e-mails, six had nothing in the subject line and one recruiter sent a questionnaire for the doctor to fill out (requesting her geographic preferences which Dr. X had just listed on the World Job Bank). Another 32 e-mails were from one recruiter. One of his e-mails described a practice opportunity in Dr. X’s desired geographic area, the remainder (31) gave brief practice descriptions for geographic areas in which she was not interested. Fifteen e-mails were received from a second recruiter at the same firm, none were for the geographic area in which Dr. X was interested. Dr. X received another 43 e-mails from other recruiters which contained brief practice descriptions. Seventeen of the 43 e-mails gave brief practice descriptions for geographic areas in which Dr. X was interested, the remaining 26 were of no interest to her.

The following is a breakdown of the 71 voice mails she received: One recruiter left 14 messages asking if Dr. X was “entertaining practice opportunities,” but did not mention any opportunity. Another recruiter from the same search firm left three voice mails which were identical in wording to the first recruiter’s messages. A recruiter from another firm left 14 messages stating he had a practice opportunity but gave no details and stated he would “take her off his list” if she indicated she was not interested. A recruiter from a different firm left three messages about Dr. X’s supposed preference for jobs in the Chicago area (she only wanted New England.). One recruiter gave brief information about a practice opportunity but didn’t provide a state or even a general geographic area where the practice was located. Another recruiter apparently dialed the phone and forgot, or didn’t realize the doctor’s voice mail was recording. No actual message was left but Dr. X got to hear a recording of the person chewing and crunching on what sounded like a carrot! Thirty-three voice mails contained nothing more than the recruiters’ names, phone numbers and infrequently their companies’ names. Only three voice mails gave some information about practices in Dr. X’s desired geographic location.

To summarize: Dr. X received 260 contacts (both e-mail and voice mail). Of the 260 contacts, only 20 contacts provided information about practice opportunities in her specified geographic location that were potentially of interest to her."

End quote.

I am speechless from the shock that a recruiter would actually publish this. I have nothing to add, except that it matches my personal experience exactly! Dr. X, I feel for you! Since I have this representative story, I can postpone counting and examining the statistics of the response that I have received. You may have read it in my previous posts, I have been looking in one particular Desirable City, where recruiters typically just cannot find jobs. We all know why. Who in their right mind would be sitting in a practice or hospital in a fabulous location and pay a recruiter $$$$ to have a position filled, when a simple ad in a few journals, at NTNJobs and eHealthcareers would bring in dozens of applicants?

The other remarkable point is: Recruiters are in such a marketing and selling frenzy that they simply do not pay attention to what candidates want. Right from the start I found this rude and careless. I always wondered why on earth recruiters did not read my profile and kept on sending me positions that were as far away from my desired city as could be.
Now I know that they are just too busy emailing and cold calling and mailing anybody that leaves their contact info within their reach that they cannot think. It is a selling frenzy.
And by the way, no wonder recruiters have "to work so hard" if they waste their time in this fashion. They spin their wheels for nothing, or worse, they get a backlash. I am part of that backlash, by the way.

My humble opinion: I you do not want to be the next victim of time-wasting spam called recruiter advertising, don't bother using recruiter job banks!

Instead, read my blog for better ways to find the great job you want!

7 Reasons why I Admire Physician Recruiters

2007-07-23T11:16:00.000-05:00

1. They have a "positive mental attitude" (as written by Jim Stone of dochunterdiary.com). They are able to see a "great place to raise a family" and a "great place to build a practice", where I see just, well, Desert Gulch, a place where I would neither want to exile my family nor would want to build a practice. And where in general I would not want to be caught dead after sundown.

2. They have magical, mystical, truly superior means of transportation, very much like Harry Potter's broom. A town they see as "only a short drive from LA" to me is 75 miles away and it takes me an excruciating 3 hours on a good day to get to the city.

3. While they can "enjoy all Boston has to offer" from a small town on the New Hampshire border, I get frustrated with all the woods and rocks. And for me the hour plus drive to Boston pretty much takes the fun out of it. I believe one-hour commutes are overrated.

4. They know much better than I what to do on the Internet. They know that you best use Google to "find physician recruiters where you want to go to" (Healthcarerecruiter blog), while I merely have been able to find employers that offered me jobs.

5. They know that the "best practices" are located far outside the city, while I sheepishly was looking INSIDE the city for a practice.

6. They know that a good job search starts by contacting a recruiter, one single recruiter, preferably in a small firm (recommended by recruiter Rebecca Gresham on a product-placement article on the otherwise very respectable MomMD), while I erroneously thought that starting your search by contacting recruiters is the equivalent of shooting yourself in the foot.

7. They know that it is much more ethical and professional NOT to tell your clients about your limitations. They know that it is absolutely wrong to refer your clients to someone that might be able to better help them. Meanwhile I am still making the horrible mistake of sending my patients to a specialist or a more appropriately talented or equipped colleague as soon as I cannot solve a specific problem myself.

We have a Physician Oversupply, not a shortage

2007-07-19T21:50:00.000-05:00

How will health care look and feel like in the year 2020 when we have the "physician shortage" that Dr. Cooper predicted in his shaky and dubious study? When we supposedly will be short 200,000 physicians?
Will people die in the streets? Lines in the ER around the block? People traveling hundreds of miles for cancer treatment? Mortality at an all time high? Women delivering babies in buses?

I believe those will be everyday scenarios - or not?

Well, this kind of future is very easy to foresee. It actually is already here. In Oklahoma. Just fly there and look around, go to the offices and hospitals, get treated at modern and pleasant ERs, have attentive doctors and nurses take care of you.

Oklahoma has numbers that Dr.Cooper foresees as catastrophic. The physician density is 1.6 for 1000 Americans. The US average is 2.6. The Massachusetts average is 4.3!!! And that is why you hear the whining of "shortage of primary care physicians" the loudest in Massachusetts.
Strangely, you do not hear "help, we are sinking into a health care crisis" screams from Oklahoma.

Does that make you a little skeptical of the "looming disaster"? It sure should.

Dr.Cooper is very wrong in important points, as I have laid out in a previous blogpost. I can only suspect who supports him and why...

It is time that the AMA, ACOG and other professional societies take a better look at his numbers and consider modern developments such as the exploding "Minute Clinics", growing telemedicine and the progress in genetics. And for the notion that the "coming generation of physicians is not willing to work hard", that is the old stuff that parents have ben saying about their children's generation for ages. Ahhh the good old times. Everything was better back then, right?

The "looming physician shortage" is blatant nonsense. In fact, we have an oversupply of physicians since the mid eighties. The proof is simple and does not require any fancy studies: Our incomes have gone down continuously since that time.

Do EMRs make a Difference in the Quality of Care we provide?

2007-07-19T14:55:00.000-05:00

A new study released by Brigham and Women's Hospital in Boston discerned no difference in performance outcomes in terms of whether or not physicians use EMRs. The researchers reviewed office visits to non-federally funded, community, walk-in physician practices across the country, using 17 ambulatory quality measures. The lead researcher, associate physician Jeffrey Linder, claims that other studies have revealed that many electronic health records aren't much more than an electronic replacement for paper charts, which suggests a mass underutilization of an EMR's true capabilities.

For more details, read the article in The Washington Post or review the study in the Archives of Internal Medicine (abstract only, unless registered).

Very interesting.

Jeffrey Linder interprets this as "mass underutilization of an EMR's true capabilities". I hope he was not referring to the physicians underutilizing the EMRs. This is certainly not true. The present day EMRs simply fall short, massively short, of what a good EMR could be.

I have no doubt that EMRs have great potential. Sadly, nowadays it is mainly mere potential. My hospital bought Centricity, the former Logician and now the EMR of GE. I was very disappointed by the striking difference between what an EMR could do and what it really is able to do in daily life. It only fulfills a fraction of the dream and it creates a whole lot of unnecessary work. The difference between your dream and reality is just too large.

Let's see: Does your EMR print out instruction leaflets personalized to the patient and her problem after the visit? Does it automatically fax a good looking, well worded, well formatted letter to the PCP after each visit? (My EMR does not even know the PCP of a patient, and even if it knew, it would not know the PCP's fax number and even if it knew, it could not fax it).

Does your EMR tie in and cooperate seamlessly with your website? Can patients book their appointments on your website and they show up in the EMR? Does your EMR send appointment reminders to your patients? Does your EMR produce automated lists of outstanding test results and missed appointments?

Does it generate lists for marketing such as patients and PCP birthdays; does it allow you to record the personal preferences of your patients, starting with how they would like to be addressed and numerous others?

Does it allow your patients to enter their medical histories online? Does it allow the patients to check in online or electronically in the reception area? Does your EMR interview the patient after arrival in your office - about her complaints, her symptoms, her concerns, her compliance with the usual screening tests?

Does your EMR send automated emails to your patients with follow up recommendations, more information on the topic at hand?

and on and on and on...

So, your EMR does that? No? Why am I not surprised?

So, why do you think your EMR should have any more abilities than just a paper chart converted into software?

Once EMR companies start asking for the needs of physicians and actually building programs that really help and really take over some work instead of causing more work, then we will see an increase in productivity!

And that will not happen anytime soon! Now all our poor colleagues feel under pressure to adopt some kind, any kind of EMR and are just wrapped up in choosing among the bad, the somewhat bad and the very bad EMRs that are commercially available.

Someone please come up with a smart EMR

Disorder in the Court

2007-07-18T11:27:00.000-05:00

These are from a book called Disorder in the American courts, and are things people actually said in court, word for word, taken down and now published by court reporters, that had the torment of staying calm while these exchanges were taking place.

Q; Are you sexually active?

A: No, I just lie there.

Q: What is your date of birth?

A: July 15.

Q: What year?

A: Every year.

Q: What gear were you in at the moment of the impact?

A: Gucci sweats and Reeboks.

Q: This myasthenia gravis, does it affect your memory at all?

A: Yes.

Q: And in what ways does it affect your memory?

A: I forget.

Q: You forget? Can you give us an example of something that you've

forgotten?

Q: How old is your son, the one living with you?

A: Thirty-eight or thirty-five, I can't remember which.

Q: How long has he lived with you?

A: Forty-five years.

Q: What was the first thing your husband said to you when he woke up hat morning?

A: He said, "Where am I, Cathy"

Q: And why did that upset you?

A: My name is Susan.

Q: Do you know if your daughter has ever been involved in voodoo or the occult?

A: We both do.

Q: Voodoo?

A: We do.

Q: You do?

A: Yes, voodoo.

Q: Now doctor, isn't it true that when a person dies in his sleep, he doesn't know about it until the next morning?

A: Did you actually pass the bar exam?

Q: The youngest son, the twenty-year-old, how old is he?

Q: Were you present when your picture was taken?

Q: So the date of conception (of the baby) was August 8th?

A: Yes.

Q: And what were you doing at that time?

Q: She had three children, right?

A: Yes.

Q: How many were boys?

A: None.

Q: Were there any girls?

Q: How was your first marriage terminated?

A: By death,

Q: And by whose death was it terminated?

Q: Can you describe the individual?

A; He was about medium height and had a beard.

Q: Was this a male, or a female?

Q: Is your appearance here this morning pursuant to a deposition notice which I sent to your attorney?

A: No, this is how I dress when I go to work.

Q: Doctor, how many autopsies have you performed on dead people?

A: All my autopsies are performed on dead people.

Q: ALL your responses MUST be oral, OK? What school did you go to?

A: Oral.

Q: Do you recall the time that you examined the body?

A: The autopsy started around 8:30 p.m.

Q: And Mr. Dennington was dead at the time?

A: No, he was sitting on the table wondering why I was doing an autopsy.

Q: Are you qualified to give a urine sample?

Q: Doctor, before you performed the autopsy, did you check for a pulse?

A: No.

Q: Did you check for blood pressure?

A: No.

Q: Did you check for breathing?

A: No.

Q: So, then it is possible that the patient was alive when you began the autopsy?

A: No.

Q: How can you be so sure, Doctor?

A: Because his brain was sitting on my desk in a jar.

Q: But could the patient have still been alive, nevertheless?

A: Yes, it is possible that he could have been alive and practicing law somewhere.

Natural Cures "They" Don't Want You To Know About

2007-07-18T09:51:00.000-05:00

A short note about a book by Kevin Trudeau called... Natural Cures "They" Don't Want You To Know About

The author, who is mainly a marketer and salesperson and who has minimal or no medical training, tries to conjur a kind of conspiracy theory: medicine is driven by the commercial interests of big pharma, who ruthlessly abuse Americans. Government institutions such as the FDA, medical universities and physicians in general are in on this ruthless for-profit game.
What suprises me is the success of this book, which supposedly sold hundreds of thousands of copies.

The first upsetting issue is that the title insults your intelligence. Who really believes that absolutely everybody is in on a conspiracy, that nobody would step out of the conspiracy and get really rich with medications that work? "They" do not exist.

One of the important points in this book is - what does the author recommend that you do after reading all this?
And this is not a joke, he actually recommends NOT to see any healthcare provider that
a) writes prescriptions and / or
b) does surgery!
You need to wrap your mind around this.

The ability to write prescriptions and to perform surgery happen to be the things that require a state license. And they require a state licence because they are powerful, high impact actions that demand training, experience, intelligence and accuracy to do them right and use them for the benefit of others. It demands the committment to go through a substantial, difficult training and qualification process. Those 12 years for pre-med, medical school and specialty training demand quite a bit from you.

And the author recommends NOT to see anybody who has and uses those abilites. What would you think of someone who told you NOT to send your child to a school with licensed teachers? Would you trust someone who told you NOT to have your house built by a licensed contractor? Would you trust someone who recommended that you take your legal affairs to someone who is NOT licensed by the state?
But that is just what the author recommends. He suggests that you put your health into the hand of dubiously, if at all, trained individuals practicing far away from science and from the mainstream.

This recommendation nevertheless may explain the success of his book. Every "health care practitioner" that populates the twilight of the medical underground will most strongly recommend this book to all his friends and "clients". For a very good reason: They need clients and cash, they need credibility. Since they do not have a license to show, maybe a conspiracy theory will do.

Insurances somehow failed to comprehend the author's wisdom and trust those people who write prescriptions and do surgery. But then, they are in on the conspiracy...
The underground practitioners live from the cash payments of misled people. And to them, this author's book is money in the coffers.

The book looks like a planned, slick compilation of strange stories and myths from the medical twilight and health underground. It feels as if the stories were compiled to specifically appeal to those who frequent the medical underground - maybe due to disappointment with scientific medicine or due to sheer lack of knowledge. This is a sufficiently large number of people to make a book successful.

One of the many reasons why I like practicing in the US is that there are less people who believe in the nonsense presented in this book. The general level of edcuation and overall trust in science is very high, at a very enjoyable level. After all, it took humanity thousands of years to rise to the level of today's science. Evidence based medicine is simply...better.

And for the weird stuff, go to www.quackwatch.org

Another book I do not recommend:
Asset Protection for Physicians and High-Risk Business Owners
by Robert J. Mintz, Paperback, from $10.85

This book is by far too general and does not offer truly usable advice.

The main message is: As a wealthy person, e.g a doctor, you are a target for lawsuits. Lawyers go after the deep pockets, meaning you. Asset protection is possible and provides a good shield, but the details are complicated.
Ok, and now you know what the book says.

Mintz writes a lot in vague terms about filing the "appropriate" documents, but never bothers to explain what "appropriate" really means. He implies that you should leave this whole complicated matter to an experienced attorney. An experienced attorney such as, you guessed correctly, the author himself.

The book is mostly a sales pitch for his legal practice. I consequently contacted him with a request to provide me with a structure for my few assets, in preparation for the future. I had very few assets at the time. He did not even bother to answer my email. I assume his fee depends on the assets under management and I assume he is fishing just for wealthy clients...

Stay Up To Date With The Best CME

2007-07-09T19:28:00.000-05:00

I like the Harvard courses in Boston called "Annual Update in ObGyn" that are held in spring and fall. I attend one of these courses every one to two years. The courses in Spring and Fall are not the same in terms of faculty and content. Check for alternatives at Yale, Duke, Cornell, UCSF, etc - these alternatives may exist, although I am not aware of them. A further advantage is that you have the chance to get in touch on a personal basis with the outstanding and very approachable faculty of Brigham and Women's. You also receive excellent print materials. You may purchase excellent Video CDs of surgical techniques for a reduced price.

Audio-Digest CDs, "the spoken medical journal" is the best CME program I have found.
After you subscribe they send you a CD (or MP3) every two weeks with selected lectures of very good, renowned, expert speakers, many of them nationally known, on topics that really matter. Lectures are easy to understand. I listen to the CDs in my car on the way to work and back, over and over again - until I am bored. This is a very effortless way of learning. The material kind of diffuses in.
They send you a printed summary of each CD, you can get short abstracts of their website, you can download a list of these lectures from their website. This is something I include in my recertification / relicensing papers. Of course you have the ability to collect CME points.
Has proven to be incredibly effective, I would not want to miss it. The best bang for the buck in terms of CME.

The other best CME is the ABOG list of publications and the corresponding questionnaires they send out four times a year. Our hospital librarian finds the publications and copies them for all the ObGyns that participate. You can't beat this - a. you keep your board certification up to date, b. someone does the legwork of selecting interesting and relevant publications for you and c. you get CME credits

Consider a subscription to “UpToDate”, my favorite medical database and, yes, textbook. It is written mostly by Harvard faculty, very easy to read, very uptodate (as the name implies), very thoroughly researched. Easy to search.
Uptodate also has another very nice feature: the section on "what is new in..." and the section on ObGyn then reports about "10 important developments in the last year". Very nice, easy tool to keep up and make sure you have not missed anything during the last year!!

I also like two of the Throw-away journals:
1. "OBGmanagment" since Robert Barbieri is the editor. Barbieri, the chief of the ObGyn department at Brigham and Women's, happens to be incredibly smart, talented and also is a brilliant teacher. He and his editorial staff have an uncanny ability to find out which topics are relevant at the moment. The journal is presented very well, with hints how to read it fast, with hints as to what is important. And on top of everything he is nice if you meet him in person.
2.Contemporary ObGyn, which is Yale-powered. Similar praises as for 1.

Not so good and not recommended:
1. ObGyn Survey: somehow the selection of topics is off, I subscribed, ended up not reading it and cancelled.
2. Practical Reviews, ObGyn and Women's Health by Oakstone Publishing: they select articles, review them and comment them. The selection was just OK, the abstracts were good, the comments were just slightly changed abstracts without many new insights. Overall - not worth the time and money. Cannot hold the water to AudioDigest.

Deciphering A Recruiter Ad

2007-07-07T10:38:00.001-05:00

Looking for "Gynecology Jobs" in "Florida" in a larger recruiter database, I found two ads. These two ads seemed to represent two different jobs, but only at first glance. Recruiters do not tell you the locations of their "opportunities", but with just a few minutes of searching, you can sometimes find out.
Here are copies of the two ads, and here are the steps I took to find the name and phone number of the doctor in under 5 minutes.
And remember, recruiters fill the less desirable jobs. You may not want or need those jobs. The best way to find a physician job is direct mail!

Begin quote of ad one:

“A 129-bed full service hospital, located in Coastal Florida, is seeking a board certified Gynecologist to join an existing Gynecologist. This opportunity provides a competitive first year income guarantee, relocation, and marketing assistance.. The Medical Center is a progressive, community hospital providing personalized, quality health care for Indian River County and south Brevard County residents. The counties’ population total 250,000 with a catchment area of 80,000, and rapidly growing. The facility offers an array of inpatient and outpatient services including a new emergency services department, wound care with hyperbaric therapy, sleep disorders center, and an outpatient diagnostic center. This Medical Center has been recognized as a “Top 100 Hospital”, “Best Places to Work” for 2004 and 2005, Company of the Year for 2004 by the Indian River Chamber of Commerce and “Best Medical Center” by the Press Journal Reader’s Choice Award. Location Description Nestled in a surrounding of natural beauty and one of Florida’s authentic Treasure Coast communities on the Indian River Lagoon, this community is the famous home of America’s first National Wildlife Refuge, Pelican Island. You will discover beautiful beaches, attractive inland/oceanfront parks, plentiful shopping, libraries, live theater, and fine dining. Sebastian offers plenty of sites for fishing, marinas harboring boats of all sizes, fishing piers, a championship golf course, tennis courts, airport, and sports complex, including a newly renovated playground and skating facility. A sunny and warm climate lends itself to a variety of outdoor activities including various bike, jogging and walking paths throughout the area. This Community is an ideal location to live due to affordable housing, excellent public and private schools, as well as, several community colleges and universities nearby.”

End of quote of ad number one.

begin of quote of ad number two:

“Currently seeking a BC/BE Gynecologist to join an existing Gynecologist. This opportunity provides a competitive first year income guarantee, relocation, and marketing assistance. Medium-sized acute care facility that provides general medical and surgical services, a full service emergency room, an outpatient diagnostic center, wound care center, and home health services. This facility has earned reputation for providing quality healthcare for its patients with unmatched courtesy, competence, and compassion. Since its opening this hospital has maintained excellent survey scores by the JCAHO. Florida/No State Taxes!! Living and working is easy in this area, and the sleepy fishing village communities have come into the 21st century with a boom. Raising a family, seeking higher education, fulfilling employment, or just enjoying your retirement years, this is the perfect place to do it all. Located east of the famous surfing capital of the east coast of Florida, the inlet and barrier islands provide miles of oceanfront. Surrounded by water, whether you choice is the salty breezes of the Atlantic Ocean, the briny waters of the Indian River lagoon and the St. Sebastian river, or the fresh water bass fishing capital of the state, Fellsmere, we have it all.”

End of quote of ad number two.

I extracted the likely useful information from each ad:

Extracted from the first ad:
Join one other gynecologist (not a group)
129-bed full service hospital
Indian River County and south Brevard County
Medical Center has been recognized as a “Top 100 Hospital”, “Best Places to Work” for 2004 and 2005,
Company of the Year for 2004 by the Indian River Chamber of Commerce and “Best Medical Center” by the Press Journal Reader’s Choice Award.
community is the famous home of America’s first National Wildlife Refuge, Pelican Island
Sebastian

Extracted from second ad:
East of the famous surfing capital of the east coast of Florida, the inlet and barrier islands provide miles of oceanfront
Indian River lagoon and the St. Sebastian river, or the fresh water bass fishing capital of the state, Fellsmere

Here is what I searched based on the first ad:
“Pelican Island” turns out to be very close to the “Indian river lagoon”.
The website of Pelican Island” tells you that “the nearest community” is Sebastian, FL. Now I google “Sebastian, FL”, and check the Wikipedia entry on Sebastian.
The wikipedia article confirms all the data in both ads and now I am sure that it is actually only one position that both ads are presenting.

A look at the website of the hospital immediately confirms the “laurels” mentioned in the ad. The very informative hospital website further says everything you want to know about the hospital including the humble beginnings. It also confirms that it is a “129 bed hospital”. It turns out that the second ad is a pretty much an exact replica of the hospital ad, just with some of the identifying information removed.

What I searched based on the second ad:
I googled “Indian River Lagoon” and “Sebastian river” and “Fellsmere” in one line and this web search yields a little Google map with a town called “Sebastian” in the center. The rest of the steps are exactly the same as above.

The hospital website mentions exactly one solo physician in the specialty of gynecology: Dr. Jennifer XXX, with photo, address and telephone number. Pick up the phone and call her. What else do you need?

"Looming Physician Shortage" is Nonsense

2007-07-07T10:07:00.000-05:00

You may have heard the rumors an "impending physician shortage". Dr. Richard Cooper from Wisconsin calculated that we will need 80-100.000 physicians more in 15 years, and is spreading alarming news about a "looming physician shortage". He recommends that we should enroll more students in medical schools, found new medical schools and expand existing residency programs and create new programs.

I disagree with the notion of physician shortage that resulted from Dr. Richard Cooper's study. I suspect the numbers and basic assumptions are wrong.

There is no shortage now. While we had 1.6 physicians per thousand Americans in 1970 (500.000 physicians total), in 2000 we had 2.4 physicians per thousand (over 800,000 physicians) and presently we have an average of 2.6 physicians per thousand Americans. Despite population growth, the ratio of physicians to patients has grown, has improved. Our present system of education is actually increasing the number of physicians per 1000 Americans.

In addition, in my opinion we have an oversupply of physicians since the 1980s. Here is why: I repeat: The cost of any service is determined by supply and demand.This is so simple that most people forget it, although the sudden rise of gas prices after hurricane Katrina should have reminded everybody. Physician earning power has dropped to about 1/3 of what it was in the mid eighties.

One example from my area: 20 years ago an ObGyn in Boston earned about 400 K and a very nice home in the best area of Boston cost about 400K. Nowadays the very same house costs 1.6-2 million and the same ObGyn (working a lot harder and seeing about twice the number of patients) earns 200K. Physician income has dropped dramatically. And that means that we have an oversupply of physicians. And we have an oversupply since the 80's. No study required. You have been reading about continuous and seemingly unstoppable decreases in reimbursements for physicians. Is that a sign of a balance between supply and demand? No, It is a sign of oversupply.

This means that Dr. Cooper is wrong in assuming that the present situation is "balanced" or "neutral". The present situation is not the "normal level", it is a level of oversupply.

There is no good way of planning physician supply. Who knows what will happen tomorrow and how it will impact physician supply and demand? Maybe we will find the gene for motivation to exercise or the gene for weight and obesity and the manipulation of that gene will make all the heart diseases shrink to 5% of what they are now?

When considering prediction for the future, do you remember what 60's thought the cars of the future were going to look like? There were pictures of large ship like cars with fins, rotating seats, driving fully automatically... which is just what we have now - right? That is how well predictions about the near future work, even if they are made by qualified people.

Dr. Cooper, the author of the unfortunate study, who now is making a living off the buzz around "physician shortage", did not foresee ...

1. The "minute clinics" that are sprouting like mushrooms in CVS stores, Walmarts etc all over the country. The numbers of patients seen in these clinics are rising rapidly and the number of visits are already reaching millions. These clinics, operating under the slogan "you are sick, we are quick", are rapidly gaining in acceptance, and not only the number of visits to these clinics are growing, but also the average payment per visit. The customer satisfaction is on par with the satisfaction in physician offices. These clinics will be a tremendous competition to physicians, or, in the eyes of Dr. Cooper, a "relief" of the "shortage ". The development and growth of these clinics alone may prove Dr. Cooper wrong.

2. Dr. Cooper did not foresee or consider telemedicine. Indian physicians are already reading numerous x-rays, CTs and ultrasounds at night, due to the fact that our nighttime is daytime in India. This trend will expand, since Indian labor is cheaper, and soon we will have a decreasing need for radiologists.

3. There are large numbers of very well trained and very competent physicians in Central Europe (Germany, United Kingdom, France, Spain and Italy) that could transition to the US. These physicians would only need residency training. They would not need medical school. The cost savings for the US would be dramatic and these physicians would be available much faster than physicians newly schooled and then trained in the US.

4. If, yes, if there really, really, truly more demand for health care providers it would be much more economical to train more nurse practitioners and physician assistants, who are very well suited to take care of routine cases. Physicians would diagnose and treat the more unusual and difficult cases.

And, training more physicians is very expensive. Physicians create their own demand, even if Dr. Cooper denies it. Every physician works to fill his or her practice, even if it is with minor issues. Young, unexperienced physicians are more expensive than experienced physicians, since they order more tests, since they need more diagnostic procedures to reach the same diagnostic goal than experienced physicians. American taxpayers would be punished with the extra expense of additional unneccessary medical schools and training programs and Medicaid contributions. The strain on Medicaid and Medicare would accelerate.

Overall, I seriously doubt we can reliably foresee the demand for physicians in 15-25 years and prefer to go with Yogi Berra's statement "predictions always are difficult, especially about the future". I do not see a shortage now and I see easy relief for any kind of "shortage" that may (or may not) present itself in the future.

Dr. Cooper's statements are extremely damaging for physicians and should be re-evaluated. This should be done before the present oversupply of physicians is worsened and perpetuated by creating more unnecessary and very expensive and costly medical schools and residency programs.

Who benefits from this alarming rumor? Who makes money from it? Guess who - the HMOs.HMOs make money by withholding payments, delaying payments and by lowering reimbursements. This is only possible because they can rely on a large number of physicians that have to put up with these shenanigans, because they do not have alternatives to the current HMO contracts and payment methods (or better witholding-payment methods). The HMOs exist only because of physicians need to contract with them. Physicians only need to contract with HMOs under the present conditions because there is an oversupply of physicians.

A very good example of this, and proof of my opinion is the comparison between Massachusetts and Oklahoma.
Massachusetts has the highest density of physicians per 1000 Americans - 4.3 and Oklahoma has the lowest density, 1.6 (only Louisiana is lower at 1.5).
The income of a primary care physician after residency in MA is arouond 120K, the income of a primary care physician in OK is 250K. No difference in training, no difference in work, just a difference in HMO contracts. Suprisingly, I have never heard news of a physician shortage in Oklahoma, but I hear complaints about "primary physician shortage" in Massachusetts. Even sophisticated colleagues wonder in public how we can have a shortage while reimbursemnents are going down. Dear colleagues - you are right to wonder, we just don't have a shortage as long as reimbursements go down, wake up, it's rumors and whining, not true shortage.

So, what does that tell you. We supposedly have a shortage in Massachusetts,in a state with the highest density of physicians, but not in Oklahoma, where we have the lowest density.

What I conclude from this is: Demand for physician services has a subjective component.

What would happen if we actually would even have a balance of physician supply or even a mild undersupply? Physicians would be busy enough to "fire" their most abusive, payment-delaying, under-reimbursing HMO and simply stick with the HMOs that pay a little more realistically.
Good for us, bad for the abusive, greedy, bottomline oriented HMOs.

Oh, you say this is "hyperbole"? Well, read the lawsuits that were decided in favor of physicians that clearly find that HMOs routinely underpay and try to cheat physicians out of their money using multiple tricks. It is a fact, not hyperbole.

It would be a disaster for HMOs if physicians could demand better payments. The future of HMOs depends on the ability to have a large supply of physicians, an oversupply of physicians, willing to work for less and less. Actually, the future of HMOs is at stake here. What do YOU want to do about it?

Letter to a recruiter - Why I am disappointed

2007-07-06T06:56:00.002-05:00

Here is a letter that I wrote to a recruiter with whom I had worked in the past. He came across my blog and was very upset. We exchanged a few emails. Here is the last of them that summarizes what I think about recruiters and why I promote other ways of finding job for physicians.

Beginning of letter:

You are right, I may have generalized my personal experience to "all recruiters". Nevertheless, I have been searching for jobs since 1999, in excess of 7 years. I therefore have been in touch with recruiters for about 7 years. I have spoken on the phone to dozens, maybe a hundred recruiters, seen countless recruiter websites, aggregator websites that publish ads from multiple recruiters, and read innumerable newspaper and magazine ads. I may not be the "national expert", but I think I am most certainly knowledgeable enough to voice an opinion. I am definitely more knowledgeable than your one time job seeker.
In case you were wondering, I have been searching for that long due to quirky personal circumstances that have nothing to do with my training, my performance at work or with any kind of legal issue. It's just personal.

I have stopped job searching in March 2007 and at the same time started a blog about my experiences with my search, because other physicians need to know what I experienced. Other physicians should not have to go through the same thing.

The fact that made me search for so long is in part due to insisting on very select locations, such as inside Boston and inside Miami. Due to this the same sequence of events kept repeating over and over and over and over and over again: Recruiter: "Contact us, we have lots of great jobs" Me: "Well, do you have something in Miami?" Recruiter:"No, but ...30-50 miles away". And after the hundredth or so phone call and email that goes exactly the same way, you start to get frustrated, then you get aggravated and then you get cynical. I did become cynical when I read "great jobs everywhere, the best jobs, the best practices" etc etc.

For me, the preferred place to work is in a large city. Since it is my preferred place, I call it the "best place" and the jobs in the large cities the "best jobs". That may not be everyone's opinion. But, like it or not, the majority of physicians prefer larger cities. And therefore, the jobs in large cities are filled without any help. Job is large cities are filled because physicians network their way to those jobs.

My mistake was that I mainly searched passively and not actively, meaning I kept on looking at print ads, internet ads, recruiter emails etc.
Since I could not find a job that I liked, I even started to believe that good jobs (good according to my definition, meaning in large cities that are attractive to live in) were just not available to me, that somehow I could not get them! That was painful and made me feel helpless.

My beef with recruiters is actually that they do not have jobs inside cities such as Boston and Miami (you are literally the exception that confirms the rule) and that nobody, but really nobody told me that recruiters are just unlikely to get them. I would have been ok if recruiters told me "Hey if you are looking inside Boston and Miami, you have to approach your search differently! Do this or that and you will find a job". Only one recruiter ever told me, and it was an older, seasoned recruiter. And he added before telling med: "I believe that I will be rewarded for this some day somehow".

It is my firm opinion that recruiters should tell physicians about their limitations, about the areas where they either do not find jobs or are very unlikely to find jobs. It would dramatically cut down on criticism. Disclose your limitations and drawbacks. Even home sellers have to disclose what is wrong with the home they are selling.

Now I know that recruiters do not get the desirable jobs in the big cities. Now I simply do not ask anymore. But now I know how to find jobs in highly desirable locations myself without any outside help. I am not helpless anymore.

After a while I started asking the recruiters head on: Why do you not have jobs in Miami? One of the answer was: "we usually get positions in areas where there are more jobs than applicants. In Miami there are more applicants than jobs and therefore we tend not to get them".

That is the kind of answer I had hoped to get several years ago.

But recruiters all act as if there "simply are no jobs", the term is "that area is oversaturated". What they convey between the lines is "If I don't get jobs there, then there simply are no jobs there". I sometimes think they even believe that nonsense themselves.

And then of course there is that other cute sales answer that I received 6 or 7 times: "I will call my clients in Miami and see what I can do" - meaning he or she actually has "clients" in Miami, meaning he or she is in regular contact, has good business connections to them etc. Sounds impressive at first. But the being impressed faded away, when, not surprisingly, I never ever heard back from any of those people.

So, I think I write from experience. I know that recruiters are human, I know that there are a lot of good people among them. I mentioned that I like the two owners of Medicus Partners that write the blog "Dochunterdiaries". I like their blog, I like their opinions, I like what speaks through the blog, I like what I perceive as the people behind the blog. They are great guys and I agree with most of what they write. But there are also a lot of people that just sell. And nobody, not the good ones and especially not the bad ones tell you how to find a job in the desirable cities.

And, no matter what, for recruiters it is exceedingly hard to overcome the 20K handicap. And, of course, you get called to fill the positions that are difficult to fill for many reasons.

Your.....

End of letter

Physicians Slow in Adopting Expensive and Inefficient EMRs

2007-07-01T09:36:00.000-05:00

It seems to be fashionable to complain about doctors and present them as old fashioned and technophobic. Here we have Scott MacStravic wondering why on earth physicians seem to have difficulties transitioning to electronic medical records. Wise and heavy words are being used, concerns are expressed, motives speculated. Academic reasons are considered. Oh, my, oh my. We physicians are the same as everybody else. We are just a little more independent and demanding. We want things to be done quickly and easily. If you present us something that is easy, we'll do it. Scott MacStravic writes about "The hidden reasons"... Scott, you know what, do us all a favor, use those things for a few days and the reasons will no longer be "hidden".

Why are we not running to adopt EMRs? We all have seen the websites where doctors ask for help in deciding which EMR will be the least damaging to their practice and their pocket book! We are not rushing to buy them, because most EMRs today are clumsy, klutzy, slow and expensive systems. None of these software people has had the smarts to start with the consumer. Nobody has studied what physicians do in everyday practice, how exactly they do it, studied it down to the smallest detail, studied the exact work and documentation process. That is what they should do, and then, please take that process and take all, but all the routine work out of it, leave only the "presidential decider" part in, throw in a little help in the deciding department too, give the system some AI, make it adaptable, so that we can have it "our way" - like Burger King. Then make it smart, build in "favorites" everywhere, make the system able to learn our specific style, our specific preferences in diagnoses, billing codes etc. Make it able to link to literally everything and put it on a graphical surface, maybe one that you can also click on with your finger or your regular pen or with one of those fancy computer pens. And you will have a system would sell like the proverbial hot cakes.

Look at what we have in reality? We have overpriced systems that look more like Windows 3.1! Programmers, have you ever heard of MAC or have you seen Vista? Have you ever been to Yahoo.com? Have you thought about "ease of navigation"? I doubt it.

The system my health care system has presented me is a prime example of a clunker. The core was programmed 20 years ago, and you see it and feel it. History and tradition are a good thing, but not in software. It is so old fashioned, you see the Windows 3.1 still peeking through the creaks. It is crystal clear that it is a patchwork of not very well integrated components. It is embarrassing. Amount of work that has gone into investigating consumer needs and making it easier to use: Minimal. Price: Maximal.

And, talking about money. The clumsy Centricity that I am using has a completely separate billing component. The billing component knows nothing about what goes on in the EMR. This is the biggest stupidity I have ever seen. Billing should be done fully by the software based on the documentation. And should you fail to immediately understand this, you do not belong here in this discussion. We document what we do and we bill according towhat we do. Billing is 100% dependent on what we do, straightforward. So simple, a caveman could do it. And the famous software package Centricity of the famous American company GE should be able to do it too. It should be designed to do it in the first place. It should not even be separate from the documentation part, it should be a completely integrated part of documentation.

With all due respect, Scott is not a physician and has never used an EMR in daily life. I just finished implementing an EMR in my practice. As a hospital employed physician I did not have to buy the system, I just received the hardware and software and started using it.I am a computer enthusiast. And I was very, very disappointed by the EMR (Centricity from GE). It slows me down, it drains my productivity, it makes simple tasks complicated, every little thing takes clicks and click and clicks and more clicks and then some more clicks. It does not provide good access to data, it does not give me the same quick overview of a patient that I had in my paper chart. upon opening my paper chart I had the "summary", a kind of history of the patient with some personalizing remarks and notes and reminders - all on the left side. one glance and I remembered the patient and knew what was going on. My EMR does not allow that, it only gives me the stupid ICD 9 codes, uncoded comments, notes and remarks are "forbidden". When I protested about the lack in functionality I heard the sadistic comment "We try to keep the system standardized". Hey, that works in big corporations, not in private practice. Another one is "We have to do this for patient safety" of "it is a HIPPA requirement". Patient safety is such a fabulously chic buzzword at the moment. But it is a very bad excuse for a clumsy, klutzy system that makes you confirm and confirm and confirm again the most simple steps!

I drive a Volvo for security and it drives as well or better as any other car. Security happens behind the scene. My Volvo does not force me to stop every 100 feet to look around and it does not limit my speed to 25 mph in the name of safety, my car does not force me to stop before making a right turn and confirm that I really plan to make a right turn and so on.

Everybody out there, please understand. The sole idea of software is efficiency and ease of use.
The idea is the Three Click Visit. First click to confirm the history entered by the patient or the nurse, second confirming the template that the system chooses for you and third confirming the prescriptions that will be faxed to the pharmacy, the education leaflet printed for the patient and the automatic letter being faxed to the PCP.That would be a system everybody runs to adopt. Please do not try to find contorted far fetched theoretical reasons for "lack of adoption".
IT IS THE EASE OF USE AND THE COST.

And that, my dear concerned observers, is the reason that physicians are slow in adopting EMRs! EMRs on the market today are complicated, user unfriendly, inflexible and expensive. What a winning combination! We can't wait to buy one of those systems. Did I mention that they drain productivity, but we get paid less instead of more? Physicians are just a tougher clientele. We are not employees in a big corporation where you can simply slap a computer on each desk and say: put up with it or leave. We actually (still) have the freedom to choose (still). We would love to have EMRs, but we are not going to put up with crappy ones. So, make some good ones, and keep the price down. Is that so hard to understand? If Yahoo was as difficult and clumsy to use as my EMR, it would already have vanished from the net.

Can someone please design a systems with a surface like Vista or Mac OS, a system that is built after careful user studies and user analysis, after studying what physicians do all the time, systems that physicians can adapt and mold exactly to the way they want.

And then make those systems cheaper. Forget the abusive purchase prices and the high maintenance costs. Doctors are not rich anymore!

How to find more physician jobs than any recruiter

2007-06-30T14:33:00.002-05:00

Physician Job Search

The best, most powerful, most successful and least advertised way of finding a job

1. Decide where you want to work and live. Consider the climate, the landscape, the economical situation and future outlook, the culture, your ability to pursue your hobbies, the cost of living and of real estate, the cost of malpractice, the possibility of working without paying malpractice, and financial issues such as being able to balance-bill.

2. Buy a list of all addresses, phone number and fax number of all physicians in your specialty in the desired area. This is much easier and cheaper than you may think.

List providers are InfoUSA.com, WebMD or MMSlists, the marketing arm of the AMA.

I prefer InfoUSA.com. First, you can easily select just the right group of physicians you want. Second, you can purchase your list online, without having to call anyone. Third, there are no restrictions on the list you receive such as number of times you can use it (The AMA just loves to restrict you...). The cost per physician contact info is about 75 cents. For this you get address, telephone and fax number. InfoUSA also gives you year of graduation, name of office manager and a number of other useful little data. You will receive the list via email in CSV or Excel format. Either format is fine for your purposes.

3. Write your CV and cover letter. Have them reviewed, rewritten or may be written anew by an expert, such as a friend who is a marketer or publicist, an English major, or a professional writer, e.g. the people at Quintcareers.com. I have personal experiences with Quintcareers.com and was happy with them.

4. Have your CV photocopied on quality paper at Staples, Office Max, Kinko, etc.

5. Use Microsoft Word to Mail-Merge your cover letter with the address list from InfoUSA and print the 100-500 personally addressed letters on the same paper as your CV. Your office store can do that as well for you. Sign all letters, fold and put them in envelops. Address the envelops with clear plastic labels, e.g. Avery, that you buy at your office store. You can print the addresses and your own home address on these labels using Word.

6. Mail your cover letter and CV to all doctors in your target area. Mail them so that they arrive on a Tuesday or Wednesday. This increases the chance of being read.

7. You may also fax your cover letter and CV (or maybe just your cover letter) to all physicians in your target area. You can fax all letters individually or you can use an Internet fax service such as JBlast.com. This is my preferred fax broadcast system because it allows you to Mail-Merge your letter with your list of addresses with the same ease as MS Word. You can literally fax your letter to hundreds of physicians with a single click. This costs about 6-10 cents per fax. Please consider the laws about unsolicited faxes that apply in most states! You may be considered to send unsolicited faxes, which may be illegal! You are doing this at your own risk!

The response rate will be 1-2%, meaning if you mail or fax 800 letters, you will receive about 8-16 interviews. The more physicians you contact, the more interviews you will get. This is the least expensive and most effective, most successful way to find a job as a physician - and you can find it exactly where you want it. Obviously, you may repeat this after three to four months if it does not work the first time.

Sounds like too much work for you? You do not know how you can fit this into the schedule? there is a company that does all the legwork for you. It is called TheDoctorJob.com. They will charge about 1.50 to 2.00 for each letter they write, print and mail. It is slightly more expensive then doing it yourself, but it saves you time. They have been doing it since 2003 and are very, very good at it. Since 2006 Doccafe.com also offers this service, but they do not seem very enthusiastic about it. After all, they seem to live on recruiter ads and recruiters despise the direct mail method. It makes them obsolete.

8. Follow up, follow up, follow up. That means sending another letter, another fax or calling one or two weeks after sending the letter. Be persistent.

9. Parallel to all this, use the methods that I call "Passive search". Click here to find out more.

10. You do not need recruiters. With the above method you will find 2-5 times more jobs than the best recruiter will ever be able to find. Your application does not have a 20K price tag
attached and therefore your letter is much more welcome than a mailing from any recruiter.

Teaching medicine to residents and students

2007-06-30T08:18:00.000-05:00

After truly enjoying teaching students, nurses and now residents as long as I have been training and practicing medicine I found that a few thoughts, preferences and priorities seem to be important to me and do not seem to change.

Physicians, and family physicians in particular, have to be competent in a large number of areas and therefore it is vital that the information presented is simple, easy to understand, and memorable. Out of a 40 minute lecture, residents, like everybody else, will likely remember only 2 or 3 facts or sentences. It is necessary that those 3 sentences are the right sentences and the most relevant and most important ones and that they are those that I really want to communicate. These 3 sentences have to be the skeleton or the outline of the topic and should be practical, usable knowledge. Lectures are meant to stimulate, to open the mind for a topic, to make students receptive for a topic, to give students a basic structure, a basic skeleton of a topic. later on they can put the flesh on the skeleton and the guts and the skin. The first thing has to be a clear overview that makes the big idea immediately understandable. A lecture or power point is not meant to provide exhaustive information!

I often start a lecture with “and here is the summary for the post-call-resident” and then say for example: "Dysfunctional uterine bleeding is treated with OCPs. And if the patient is over 35, you also give them OCPs, but you do an EMB first and ask if they smoke”. I summarize the basic message in one sentence, so that everybody remembers this single sentence message.

Or: “birth control pills are all the same. The only difference is that individual patients will react differently. Therefore you should know 3 or 4 basic, generic OCPs and prescribe them. Discourage brand names. Should the patient not tolerate the first OCP, switch to any other generic with a different estrogen dose or with a progestin from a different group – no secret algorithm to it.”

Or “for induction of labor you give 25 mcg of misoprostol until you can fit a finger into a soft cervix, then you switch to pitocin”

Or for introduction of fetal heart rate tracings: “The baseline should be 120-160 or exactly double the adult rate, the jitteriness of the baseline should be 5-25 and corresponds to the blood supply to the fetal brain, accelerations are good (and I give a thumb up) and decelerations are bad (thumb down sign)” And then I go into the details.

I try to teach MTV style meaning a bang or splash here and there is good – and I try to place the bang exactly at one of the three points that I hope they remember forever. I try to make the 3 points memorable with…

a. a joke,

b. an act ….I once had an imaginary interview with Chlamydia, who had a mean voice, was swearing frequently – which I replaced with beeeps. Chlamydia complained about his buddy gonorrhea who causes so many symptoms (fever, pus, pain), and who would get all the good Chlamydia killed because of drawing attention to the infection. Chlamydia called gonorrhea an old fashioned brute and cowboy, who is on his way out and proudly talked about receiving the award for “No 1 Cause of infertility”, then went on to say “it’s because I have stealth” – at this point I suddenly dropped under the table, so that I became invisible, and continued talking….Chlamydia also complained bitterly about the doctor’s who test and treat on suspicion, but was very appreciative of those docs that swabbed the vagina and not the cervical canal! And so on…it was big success….and a lot of fun

c. a video, such as the “dancing baby”

d. a song – if it is bad, it is even more memorable

e. sometimes I try short stories during slide shows, such as the introduction of PCOS as "a special gift from God to family practice", because it is important to recognize the condition early to prevent formation of too much terminal hair, to prevent obesity early oon instead of treating it later, and to be prepared for the treatment of infertility, for the prevention of diabetes, early recognition of HTN and so on. PCOS won’t kill you, but you need long term observation and help, " a gift to family practice". And I mentioned that God was sitting at the laptop running the creation software and creating this as a special goodie for FPs, and when he was done he went to South Beach for a few mojitos…and I had the photo of Ocean drive with the arrow pointing to a dark area "God is there!" and adding that “God is notoriously difficult to catch on camera”. That was the intro for the PCOS talk

I refuse to introduce topics with “this disease is veeery important because it is veeery expensive and xxx billions are spent annually on blablabla….” This is such a horrible introduction. Boring. Xxx billions means nothing to me, absolutely nothing. I can't even imagine a billion dollars, I stop thinking after 20 million, since I would retire and sail around the Caribbean if I had them. And what do the billions matter to your practice? Nothing, nada, zilch, zero. It might matter to federal policy makers. Are those people seeing your power points?

What matters to me is “what percentage of patients that walk through my office door have this” because that determines if I am going to do something about it, how seriously I am going to take it and what I am going to do…

And finally, topics should be taught in a clinically relevant way and not in a pathologically / systematic way. It is depressing when students or residents are shown long lists of differential diagnoses with weighing them according to clinical importance. It is absolutely impossible to remember the 22 causes of amenorrhea when they are presented as a long systematic list. It is an insult to the learner! Presenting a list without weighing the differential diagnoses by frequency of occurrence means that the teacher really does not care about the student and just slaps something on the slide in who-cares-what-you-can-learn-from-it style. Next time you as the student get presented such a list, either booo or make a frown and walk out.

The differential diagnosis of amenorrhea for example should be presented like this (taken from Kistner, Gynecology):

Option 1 – the right way

start quote

Pregnancy, and otherwise:

Hypothalamus / pituitary /stress 50-55%

PCOS 10-15%

Prolactinoma 7-10%

Asherman’s 5-6%

Hypothyroidism 1%

Ovarian failure 1%

end quote

You know immediately what is common and what is rare, you know immediately what to ask for in your history and what to look for in the physical exam.

Option 2 - the wrong way, too much to remember. All that remains after reading that is the impression that the topic is complicated and that you may have to consult a textbook or a specialist whenever a patient presents with that symptom.

It presents far too much information in a very badly structured fashion and confuses much more than it educates. Especially the long version at the bottom is a prime example of not well thought out presentation. Students and residents, do not put up with this kind of thoughtless teaching!

start quote

Causes of amenorrhea

Generalized pubertal delay
- Constitutional delay
- Hypergonadotropic hypogonadism
  - Turner syndrome
  - Gonadal dysgenesis with mosaic karyotype
  - Pure gonadal dysgenesis (Perrault syndrome, Swyer syndrome)
  - Gonadotropin-resistant ovary syndrome
  - Acquired causes (eg, high-dose alkylating chemotherapy, pelvic radiation, autoimmune oophoritis)
- Hypogonadotropic hypogonadism
  - Chronic conditions (eg, starvation, excessive exercise, depression, psychological stress, marijuana use, Crohn disease, cystic fibrosis, sickle cell disease, thalassemia major, HIV infection, renal disease, thyroid disease, diabetes mellitus, anorexia nervosa)
  - Slow-growing CNS tumors (eg, adenomas, craniopharyngiomas, meningiomas, pituitary microadenomas)
  - Abnormal hypothalamic development (eg, Kallmann syndrome, Prader-Willi syndrome, and Laurence-Moon-Biedl syndrome)
  - Acquired miscellaneous disorders (eg, infiltration disorders [sarcoidosis, Langerhans cell histiocytosis, syphilis, tuberculomas], ischemia disorders [caused by trauma, aneurysm, obstruction of the aqueduct of Sylvius] and destruction [concentrated, high-dose exposure to radiation])
Normal puberty
- Associated with hyperandrogenicity (eg, PCO syndrome, late-onset 21-hydroxylase deficiency [nonclassic congenital adrenal hyperplasia], immaturity of the hypothalamic-pituitary-ovarian axis, Cushing disease, androgen-producing ovarian or adrenal tumors, ovarian stromal hypertrophy)
- Associated with absence of hirsutism or virilization (eg, immaturity of the hypothalamic-pituitary-ovarian axis, pregnancy)
- Hypergonadotropic hypogonadism (eg, ovarian failure, high-dose alkylating chemotherapy, pelvic radiation, autoimmune oophoritis)
Anomalies of the genital tract
- Müllerian agenesis (eg, Mayer-Rokitansky-Kuster-Hauser syndrome) breast present
- Congenital or acquired anatomic obstruction (eg, imperforate hymen, transverse vaginal septum, Asherman syndrome, endometrial destruction due to severe infection or surgery)
- Androgen insensitive syndrome-absent uterus with normal breast development

end quote

Now you know, now you have a good overview of the issue, now it is all clear, this is what you are going to remember, right? Although this is pretty good if you know about the topic already and it is a very good summary. but not appropriate for a power point lecture.

Option 3 - better, but not good yet. The following list is shorter and a little better, but there still is no order and no frequency of occurrence etc.

start quote

Differential Diagnoses:

Pregnancy
Breastfeeding related
Menopause
Norplant related.
Hypothalamic.Suppression of the hypothalamic-pituitary-ovarian axis.

Exercise induced.
Eating disorder such as anorexia nervosa

Endocrine such as hypothyroidism.
Polycystic ovarian disease
Pituitary or ovarian tumor.
Rarely, Mullerian duct agenesis or other chromosomal or developmental defect.

A young woman who has is Tanners Stage 1 at age 14 or who has had no period by age 16 needs to be referred to an OB-GYN for work up.

end quote

Comment: Mentioning Breastfeeding and Norplant is probably useless, since they areboth pretty obvious to the patient. Why put it in the list? A list is supposed to guide me in a situation where I do not know right away what is going on and where I am trying to find a solution, solve a problem. I know if a patient is breastfeeding or has a Norplant (or nowadays a Mirena), or I find out at the time of the physical exam.

Option 4 - the disaster: Systematic, in a pathophysiological / pathological order that is nice for pre-med, when you think and consider and ruminate about the basic mechanisms of disease, but which is a plain disaster in clinical teaching. If someone shows a slide of such a list, you should walk out of the room. it is a waste of time to show such things and it is an embarrassment for a teacher to be caught overloading students with things they will never be able to remember! The idea of a lecture is to provide a useful take home message. The take home message of slides like this is "Wow, this is so complicated, I will never be able to learn it".

I am muddling the point a bit by comparing the first list, which does not contain the DD of primary amenorrhea with the other ones that contain primary and secondary amenorrhea, but I hope to make a point. You need to show the relevant ones first, and place the DDs in order or frequency, in order of clinical importance. You cannot get lost with chasing the rare and improbable, you need to know the two, three or four most probable causes, and you need to know them by heart.

Start quote and feel free to very quickly scroll down once you get the idea

CAUSES OF AMENORRHEA

Primary amenorrhea:

(1) No period by age 14 in the absence of growth or development of

secondary sexual characteristics.

(2) No period by age 16 regardless of the presence of normal growth

And development with the appearance of secondary sexual characteristics.

Secondary amenorrhea

Can be a transient, intermittent or a permanent condition.

The result of dysfunction of the hypothalamus, pituitary, ovaries, uterus, or

vagina.

GESTATIONAL CAUSES

Pregnancy

ANATOMIC CAUSES

CONGENITAL ABNORMALITIES –

Imperforate hymen

Abnormal Mullerian development – Rokitansky-Kuster-Hauser syndrome

Testicular feminization syndrome

5-alpha-reductase deficiency

Early failure prior to testicular development

Late failure

vanishing testes syndrome

Testis Determine Factor Gene deletion.

ACQUIRED ANATOMIC LESIONS

Asherman's syndrome:

ENDOCRINE

OVARIAN DISORDERS – The major ovarian causes of amenorrhea are

hyperandrogenism, from internal or external sources, and ovarian failure due to

normal or early menopause.

Hyperandrogenism

PCOS

Premature Ovarian Failure

Idiopathic

autoimmune

poly-glandular autoimmune syndrome (type 1 and 2)

anti-thyroid antibodies

anti-adrenal antibodies

karyotypic abnormalities

radiation or chemotherapy

Turner's syndrome – 45X,O karyotype

HYPOTHALAMIC AND PITUITARY DISEASE –

Functional hypothalamic amenorrhea due to Exercise, Nonspecific stresses (emotional, illness)

GnRH deficiency - idiopathic hypogonadotropic hypogonadism -

Other hypothalamic and pituitary lesions

Infiltrative diseases: result in diminished GnRH release, low or

normal serum gonadotropin levels

i. Histiocytosis X

ii. Gumma

b. Hemochromatosis: hemosiderin toxicity for the gonadotrope

c. Tumors:

i. Craniopharyngioma

ii. Meningiomas

iii. Gliomas

iv. Metastatic tumors

v. Chordomas

d. Sheehan's Syndrome

end of looong quote

Please note: this is actually a good and appropriate textbook section, but unfortunately I see these things in lectures! This is not meant as any kind of criticism towards the author, this is only meant as an illustration of how not to teach! Back to imagining that this was a lecture....

Wow, I am so impressed by this presentation! The author must be a genius! I bow in reverence! What a great teacher!

You know what? I regularly either fell asleep during these lectures or wrote down a lot of things that I never look at later or I picked up one or two tidbits that I could never use later on because they were out of context.

If you really succeed in memorizing the last list, then what are you going to do? Are you going to test for histiocytosis X each time a patient presents with amenorrhea? How many Histiocytosis patients have you seen in your life? And you test for Hemochromatosis? And for Chordomas – wait, I have to look up to remember what that even is….

Lectures are not supposed to exhaust or to overload your listeners and YOU are not supposed to show off pretending that you are a genius and know infinitely much more than your audience. Be down to earth, be normal, be a friend, lecture like you would teach a good friend!

Here is a book that might be worth reading:

"Made to Stick": Why Some Ideas Survive and Others Die, By Chip Heath and Dan Heath, Random House, 289 pp., $29.95.

Coauthors (and brothers) Chip and Dan Heath – a Stanford Business School professor and an education entrepreneur respectively – spent a decade disassembling and trying to understand the inner workings of memorable, persuasive ideas, no matter what kind of packages they came in. They studied political speeches, urban legends, news reports, management directives, and marketing messages like Subway's – not to mention culture-crossing proverbs, the various fables of Aesop, and the many soups of chicken (for the soul). It didn't matter whether the ideas themselves were good or bad, just that they'd "stuck." Each of these ideas could be described using one or more of just these six attributes: simple, unexpected, concrete, credible, emotional, and story-containing. We can't always pack all that into a lecture, but some or most of it.

Keeping this is mind it will go a long way to being a great and successful teacher.

Drugs for less for your patients

2007-06-29T22:42:00.000-05:00

Sometimes patients need to find medications for less. Here are a few tips. Please let me know if you have more advice on this topic!

1. Three companies that send medications by mail order. They do this in cooperation with most HMOS and also sell directly. Call the 800 customer service number of your HMO and check if they participate in one of these programs! These companies usually send you three months of medications, but charge only two copays. You save one third of the cost.

Caremark

www.caremark.com or

1800-378-5697

Express scripts

www.Express-scripts.com

1800-369-0675

Medco

www.Medco.com

1888-327-9791

2. The “Partnership for Prescription Assistance” is an initiative that helps physicians and low-income patients find low cost and free medications. The program is accessible online at http://www.pparx.org or by phone at 888-4PPA-NOW. It provides a single point of access to more than 475 patient assistance programs and connects to more than 150 assistance programs offered by drug makers themselves. It offers discounts on more than 1200 brand name and some generic medications.

3. Try www.needymeds.com

4. A company that orders drugs for you from a reliable Canadian pharmacy is “US Canadian Discount Drugs” in Hollywood, Fl. Tel: 888 989 0222. I nkow about them because relatives of mine live in the area. The company is run by Bernard Fox and Mel Stuart, two retired executives. They found a solution to high drugs prices that burden many seniors. They started as a service for the many not too wealthy retirees in South Florida, but offer their services to everybody. Call them and let them know what you need. They will tell you the exact price of the drug and will give you clear instructions. They have the medicines shipped right to your home and charge your credit card. They do not do birth control pills.

5. CanadaRx.com is a reputable Canadian pharmacy that ships to the US. AS you know the US pharma lobby has a very strong influence in the government and they succeeded in blocking some of the drug shipments from Canada to the US. All this "in the name of safety" - safety is such a great excuse!

6. Planned Parenthood in Boston on Commonwealth Ave has the least expensive oral contraceptives. Call them about their prices: tel 617-616-1600.

7. A great place to save money are prenatal vitamins. I recommend to my patients to take multivitamins (Centrum, One-a-day, Women’s daily, etc) instead of prenatal vitamins. Multivitamins have usually the same amount of folic acid, which is the only substance proven to make a difference in pregnancy. I also recommend store brand prenatal vitamins, e.g. Walgreen’s prenatal, CVS Prenatal, Brooks Prenatal, Wal-Mart prenatal, Prenatal Rx etc. My preferred over-the-counter prenatal vitamins are CVS Prenatal or Brooks Prenatal, since they contain 800 micrograms of folic acid, double the usual amount. On call I occasionally get phonecalls from patients asking for a "refill for my prescription prenatal vitamins". The last patient was paying $ 27 a month for prenatal vitamins. What a rip-off! You can buy CVS prenatal for the whole pregnancy for $25 .

If a patient is insured by an HMO it is less expensive to buy these vitamins over the counter rather than buying them with prescription. If you buy vitamins with a prescription you will be charged a $5 to 10 or even 15 and more in copay each month, which is higher than the cost of the over-the-counter vitamins. Only patients that are insured through Medcaid / Mass Health are better off with a prescription.

Recommendations for Graduating Residents

2007-06-29T12:46:00.000-05:00

Yesterday we celebrated the graduation of the third year residents where I teach occasionally. Some recommendations for their years ahead:

1. Stay in close contact with you colleagues, talk to your colleagues, don't keep to yourself, exchange thoughts and experiences. Maybe even get together from time to time and present each other new research results or interesting articles.

2. Assemble a group of specialists that are easy to talk to, whom you can call at any time and just get an opinion, or a curbside consult, and who do not mind teaching you a trick or two. Don't go for the "just send me your patient" specialists.

3. Consider AudioDigest for your CME, they have excellent recorded talks that help you in every day practice.

4. Use new technology and new procedures wisely. Don't be the first to adopt them and not the last one. Be critical, consider the value for the patient and balance it against the cost to society

5. Find a financial consultant that is "fee-only". Don't fall for the insurance salespeople masquerading as financial advisers. You want impartial advice, not sales chatter. Create a 5 or 10 year financial plan and stick to it.

6. Buy a house. We are in a buyers market, it is a good time to buy. I always heard from my parents "we wish we had bought the house back then". Real estate always appears to be high at the present time, but in 10 years you will be happy to have bought it for the present price. Use Zillow to get crucial information and to research comparable homes. You can even buy and sell your home on Zillow.

7. If you need a new job, send a letter to every physician in your target area (direct mail). This is even better than networking. This way you will find three times more jobs and better jobs than the best recruiter will ever find.

8. Plan to go into your own practice. It is more fun, more good responsibility and good stress, you learn a tremendous amount, it is a life experience that you cannot miss (see this blog). Physicians are independent and are not meant to be herded into big corporations. The Walmartisation of medicine is overvalued.

9. Defend your patients, but also defend your profession. Speak out against more pay cuts, especially if they hide behind such funny names as "pay for performance".
Be especially sceptical of the so called "physician shortage". I will not believe this speculation until I see my income going up significantly. The price of any good or service is determined by supply and demand. We are still loosing income, so there is no shortage! Speak out against opening new medical schools and new residency programs. We do not need more physicians, but we may need more nurses, physician assistants, nurse practitioners and midwives.

I wish you all the best and a very bright future!

Legal disclaimer for my blog

2007-06-28T13:04:00.000-05:00

I read Kevin, MD's blog with interest. He has a legal disclaimer, several pages long. Very impressive, very legal, very proactive, very careful. I thought I should have a legal disclaimer for my blog as well. Here it is:

I have no assets.
I do have a European license, which does not need to be renewed.

End of legal disclaimer. Short and to the point. In a language every lawyer truly and immediately understands. I am sure you understand too.

List of Websites for my patients

2007-06-28T12:54:00.000-05:00

These are the websites that I recommend to my patients. I tell them that they are thoroughly researched, no-nonsense websites, where nobody tries to sell them anything and that do contain "weird" information. I have this list printed and photocopied in each examining room and I often undeline a website or make an "x" in front of a particular website when I recommend a specific topic to a patient.

Here is my list, feel free to copy it and to send me new ideas:

http://medlineplus.gov/ …MedLinePlus is the consumer health portal of the National Library of Medicine (NLM) and the National Institutes of Health (NIH). Very extensive, very good.

www.Noah-health.org. NOAH is the “New York Online Access to Health” database, which is big and bold, like so many “New York” things.

http://patients.uptodate.com/index.asp Uptodate patient information is an outstanding and very informative website published by doctors of Harvard Medical School.

www.ACOG.org, the official website of the American College of Obstetricians and Gynecologists. They have excellent “patient information leaflets” on all topics in Women’s Health.

www.4woman.gov, the government’s website for women’s health, surprisingly good, considering that it is presented by the government.

www.mayoclinic.com, the website of the famous and excellent Mayo Clinic

www.CDC.gov. The website of the Center for Disease Control has great information about infections such as human papilloma virus (HPV), Herpes, HIV, travel medicine and much more

www.Familydoctor.org, the website of the Association of Family Doctors, covers all areas of medicine and explains issues in plain English, easy to understand

Special topics:

www.Menopause.org, The website of the North American Menopause society

www.NOF.org The website of the National Osteoporosis Foundation - fighting osteoporosis and promoting bone health. News, resources and information on advocacy and prevention.

www.Managingcontraception.com. this is the website that offers the best and most accurate information on contraception. You can even download a booklet "Managing Contraception" for free. They also have a very good book on perimenopause: "The Midlife Bible" by Dr. Goodman

http://nccam.nih.gov/health/ NCCAM is the National Center for Complimentary and Alternative Medicine of the National Institutes for Health, a great starting point for alternative medicine questions and information

www.resolve.org The national infertility association website – for education and support

www.MarchofDimes.com Good information about pregnancy

http://www.ucsf.edu/wcc/AboutBladderProbs_resources.html. This is a page on the website of the Continence Center of the University of California San Francisco
that has links to other excellent websites that inform about incontinence

www.quackwatch.org/ the site that keeps tabs on medical websites. They report all kinds of unscientific quackery on the Internet. Should a diagnostic method or treatment sound unfamiliar, very strange or too good to be true, look it up on this website.

"We personalize a search for you"

2007-06-22T22:15:00.000-05:00

While physicians and HR people usually comment on my blog in words like "you are so right", "you point very well out what is wrong with recruiters" etc, recruiters are very upset at my blog and usually claims that I do "not have enough experience with recruiters".
Ooohh, yes, believe me, I do. I have been searching for a job for over 7 years and I have been in contact with recruiters for about 7 years. I have spoken on the phone to dozens, maybe a hundred recruiters, seen countless recruiter websites, aggregator websites that publish ads from multiple recruiters, and read innumerable newspaper and magazine ads. I may not be the ultimate expert, but I am most certainly knowledgeable enough to voice an opinion. And I most certainly write pretty much everything in this blog based on my own blood, sweat and tears.

And, before I continue, I have found a way to find more jobs than any recruiter, click here to read it
But, to support that I am not alone, here is another experience with recruiters that mirrors my own.

It is from a pediatrician in North Carolina who had serious legal disputes with a hospital at which she was practicing, who consequently lost her practice and is now recieving recruiter emails offering her employment in her own former practice! It does not get much better than that! It is the perfect example for the claim of many recruiters: "We personalize a search for you", "We taylor a search to your needs". Thank you, Dr. Johnson, for this contribution!

Here is a quote from Dr. Johnson's blog:

I know I'm supposed to be on a break, but the following e-mail (from a physician head-hunter) was in my In-Box today:

Dear Doctor Johnson

Our firm is representing an excellent opportunity for a pediatrician to join two others in a beautiful community in central NC.

This employed position offers a strong income and benefits package with shared call of 1:4. The physicians have their own autonomy in clinical practice and management decisions are made by the practice administration in consult with the physicians. Physicians do attend C-sections as required.

This position is supported by a private, not-for-profit, 145-bed community hospital and is the only hospital in the county serving a population of over 130,000. The facility had 800 deliveries last year. Located in the beautiful, rolling hills of central NC, the community offers all the charm and quality of life expected in a small town. Residents enjoy all the advantages of living in a small town while enjoying quick access to the Research Triangle. Greensboro, North Carolina’s third largest city is just 25 minutes away, while Charlotte, the largest City is only 1.25 hours south.

If you would be interested in learning more about this outstanding opportunity, please forward a copy of your CV for review or respond to this email. I will not send your CV to anyone without your prior approval.

Regards,

X

Mr. X obviously didn't know that I am more-than-familiar with this "opportunity". Over the years, I've gotten dozens of these . . . as more Pediatricians came and went from the practice whose doors I opened in 1995.

Makes it kinda hard to just "forgive and forget".

......some material left out.........

Anyway, this is the umpteenth e-mail I've gotten about this job "opportunity" from headhunters who, if they had done the smallest amount of research, might've thought twice about sending me this particular "invite". And you'd think the geniuses running this practice would say to the recruiter, "If there's a Mary Johnson in your recruitment files, it's probably best not to send her this one."
Sometimes, I reply. Sometimes I shrug it off. Today I replied:

Mr. X, you are talking about Asheboro, North Carolina. It is my hometown. And a long time ago, I bought the sell. It is the worst professional mistake I ever made.

www.drjshousecalls.blogspot.com
www.asheboropediatrics.com

"The physicians have their own autonomy in clinical practice and management decisions are made by the practice administration in consult with the physicians."

That was not the case ten years ago. When this "practice administration" (still in power after all of the nasty & illegal things they've done) fired me after I intervened to save a newborn baby's life . . . a baby being mismanaged by another physician whose neonatology skills they falsely marketed to the public. Then they pulled every dirty trick in the book to ensure I could not stay and compete.

This "non-profit" has pounded me into the dirt for years and laughed as they pounded. But this story is getting out and around.

Respectfully, you (and every other locums company that has contacted me about this job in the last several months) should do a little more research on the situations you represent.

Mary Johnson, M.D., FAAP

And no. I don't feel any better for sending it. This guy has money to make and will blow me off.

No comments are necessary. Click here to read my instructions for searching the right way and finding more jobs than any recruiter can - click here.

What is bad, the recruiter or the job they represent?

2007-06-22T21:35:00.000-05:00

Kevin,MD, quoted part of my post "avoid recruiters" (Thank you!) and received very good comments that are worth repeating here:

First his quote:
AM"Physician recruiters - An OB waxes negative on the experience:
I now believe that most contingency recruiters just do not care. They sell, sell, sell and sell some more. They go for volume, they go for the numbers. The more emails they send out, the more people they contact, the more chances they may have to get an answer and sell one of their jobs. That is why they remind me of used car salesmen and telemarketers. Their ads are just the nice marketing face, and you have to read them with utmost suspicion." End of quote.

And here are three of the four comments:

1. One problem with recruiters is not with them but the jobs that they are recruiting for. From 20 years of observation in my own specialty, I have found that in general, the good people to work for have no trouble filling the positions by old-fashioned networking. Usually the ones who hire recruiters have to do so because something is wrong with the position. Perhaps it is a very poor payer mix, or the institution's management has a reputation of treating doctors poorly. Sometimes they want a physician compliant with their demands for unethical behavior but the local docs will not go along--and the local program directors knowing their reputation for sleaze will not steer graduating residents to them.

In short, most jobs with a recruiter attached aren't worth having in the first place.
# posted by Anonymous : 12:04 PM

This brings out an excellent and very important point. It's not the recruiter, it's the jobs they represent! Due to my blog I have received emails from very upset recruiters that resent what I say about them. One recruiter emphasized that he believes that recruiters are honest, hardworking, good people, that definitely earn their money. He went so far as to say that they are like a band of brothers. I felt he had a point. Personally I usually was treated well by recruiters, but they still never had the job I wanted. And that turned me off in the end.
And the comment is the perfect explanation: it is often not the recruiter, not the person, but the jobs they represent. Recruiter good, job bad...

Nevertheless, I have a beef with recruiters. None of them told me how to get a job in the area I wanted - in Boston and in Miami proper (NO, not "near", not "easy access to", no, actually IN those cities). None of them did as much as hinted at how to find a job there, nobody said "Hey, just mail all the docs in your chosen city a letter and you will reach all of them". That is my problem with recruiters!

2. Yes, the good jobs and positions don't need to rely on a recruiter. You need to be at the right place at the right time and/or know the right person.

I have always thought about returning to Oregon where I grew up so I scan the recruiting jobs out of curiosity. The exact same jobs have been advertised for the last 10 years. That tells me not to touch those with a ten foot pole
# posted by Anonymous : 1:13 PM

Yes, I have been saying them since post#1, good jobs and positions almost fill by themselves! Recruiters do not get them! But you can get them if you mail a letter to everybody in the area where you want to work....

3. Recruiters cost real money, and those practices willing to spend substantially usually have obstacles to overcome in attracting candidates. Sometimes it is nothing more than a remote location where a generalist or specialist would likely have to practice without much support while taking lots of referrals. Sometimes the location has an undesirable climate or a poor socioeconomic atmosphere.

And sometimes recruiters are the agents of serial abusers or are the pitchmen for institutions that promise much but habitually dishonor those promises and just turn to new hires when their old hires get fed up and leave.

It always pays to call the last doctor who left to get the story.
I have chased some doctors across the country when doing due diligence on practices. I am convinced that there is a lot of valuable information that can be had no other way.
# posted by Anonymous : 2:27 PMMonday, June 18, 2007

Recruiters cost real money. that is handicap number one for recruiters. 20K for filling a position? Employers are willing to do a lot, to try a lot of things before they pay 20K...And only those employers that have a problem may be willing to pay it. This is THE recruiter handicap. How are they going to overcome that? How could they? I have not found a satisfactory answer. Somebody explain it to me! An employer has a choice:
Candidate A is qualified and has mailed his CV in himself. No price tag attached.
Candidate B is equally qualified and comes through a recruiter. 20K price tag attached.
Employer decides for... you get three guesses!

That is the basic, basic, basic problem of recruiters. A problem they cannot over come. They have worked around it by massive advertising on one side and by the naivity and ignorance and lack of knowledge of physicians on the other side. Few physician know how easy it is to reach every and all physicians and employers in any given area, be inside a city or be it out in the country. You mail everybody your cover letter and CV, done. No other help needed! Maximum success.

With direct mail you reach 100% of all physicians in any given, any chosen area. Recruiters can reach a maximum of 20%. You, the single, lonely physician is able to reach 5 times more employers than the best recruiters. How do you like that????
Dear colleagues, you can do it, this blog can help! Click here for details!
And if you want someone to help you with the details, click over to "Thedoctorjob.com", they will write and print the cover letter and CV for you. You sign it and drop it in the mailbox. Done

Better Tools for Physician Job Search

2007-06-21T12:51:00.002-05:00

Years ago, when I asked my chief resident how I could find a job in the last year, he answered: "Aaahh, just ask all the attendings and if that does'nt work, call a scalper"
Today, he would add, "go on the internet". So, I googled "physician jobs" and "ObGyn jobs". The results were severely misleading. Recruiter website after recruiter website, then the websites that post recruiter ads, then the recruiting companies, then the occult and hidden recruiter ads disguised as "advice" that sneak up on you on student and fellowship websites, and on general health websites, and so on. In short, recruiters dominate the internet.

They seem to be number one when it comes to the physician job search. Not so.
In reality, recruiters handle between 10-15% of jobs according to a survey of 1000 practices (unplublished, by Thedoctorjob.com), which is consistent with my personal impression. The highest estimate I have ever seen was 1/3 or 33% of jobs. This estimate was published by a recruitment company and I believe it to be overly optimistic.

Print and direect internet advertising by employers may be responsible for filling 20-40% of jobs - in my estimate.

The remaining roughly 50% of jobs are filled by word of mouth, by direct personal contacts.

This has serious implications on how a physician should look for a job.

Networking should be effort number one, because most of the jobs are filled through personal contacts. This includes talking to anybody who is willing to listen and presenting them your "elevator pitch". The elevator pitch is a short presentation that includes who you are, what you are looking for, what makes you special and what makes you different than the rest. Handing out a business card with your contact info and maybe the elevator pitch is a good idea.
Networking includes contacting hospitals in the area where you want to work, I have discussed this in previous posts.

Networking includes sending a letter to every single physician in the area where you want to work and introducing yourself with a letter that essentially says the same as the elevator pitch. You may or may not include your CV in this letter. You will find the addresses and all other contact information of any physician anywhere at InfoUSA.com, where you can buy them for 50$ each. I have described this here - click here

Mailing a letter to each physician in your target area is especially useful, since you find all the physicians that have not advertised yet, that are just thinking about maybe hiring someone. This is great, since it gets you in before the competition. You automatically find all the physicians that have already advertised. They will simply think you are responding to their ad, even if you have never seen the ad. You will also reach all the physicians that have contacted recruiters, and you will be especially welcome, since your application does not have a 20K price tag attached (the fee the recruiter charges for brokering a candidate).

So, with one single activity, sending a letter to every physician in your target area, you reach absolutely everyone.
You tap the "hidden job market" as well as all other "markets". You cannot do better than that.
You can do this yourself, or you can have a company such as "thedoctorjob.com" or "Doccafe.com" do it for a fee.

Compared to networking and direct mail, all other methods of searching for a physician job pale. By looking only at print ads and internet ads you are limiting yourself at 30-40% of the job market, and by searching through recruiters, you limit yourself to about 15% of the job market.

Why is the Internet and why are the print media dominated by recruiters? Because they pay. Follow the money!Recruiters pay websites to post their ads and the websites do not mind giving them a little "editorial space" - and, voila, you have a nice editorial touting the "advantages" of recruiters. Print media need advertising, and they need recruiter ads. They survive because of these ads. And they do not mind publishing a few nice articles presenting the "advantages of working with a recruiter".

And so you have a completely slanted view of the physician job search on the net.

It does not help the balance of published material that physicians have no interest whatsoever in writing about the almost embarassing topic of "job search". They just get it done and go to work. Write about it? Please...I have better and more lucrative things to do with my time!

And that is the reason why physicians, why every new generation of graduating residents and fellows do not use the best tools to find a physician job. They simply do not know. And the older physicians do not bother telling them. We need to raise awareness of what physicians can do to find the jobs they want.

A physician job seach is a straightforward thing: contact all potential employers by mail. And Network. Done

The drawbacks of physician recruiters and the best way to find a physician job

2007-06-19T17:12:00.003-05:00

EvilHRlady was kind enough to insert a quote of my post in her blog! It is important to tell the other side of the story of recruitment, the story of the disappointed and mislead candidate, the story of recruiters acting like mere salespeople, mostly interested in placement - nothing else. It is necessary to publish the the drawbacks, the downside of physician recruiters. Everybody should be aware of the criticism that is out there. Graduating residents and physicians in general looking for a job have to know how to best find a job, what techniques are available, how to network. They also should know what physicians recruiters can do and what they cannot do.

Nobody has published on the drawbacks of physician recruiters in an organized or systematic fashion. Some kind of balancing information has to show up if you google "physician job" and "physician job search". Information that comes from physicians, not from third parties. The view and the experiences of the job seeker has to be published. We need peer to peer information that cuts through the sales fluff on the Internet.

All you get if you Google your area of work and "find job" is hundreds and thousand of recruiter websites touting the same "advantages" of "fabulous" recruiters. If you look behind the curtain, you find that the "wizards of recruitment" are not quite what they claim.

They mostly turn out to be volume oriented sales people that add much less value to a job search than you expect.

Occasionally you read idealistic publications on what recruiters should be: the experts that know or sense or figure out just who is the right fit for a given job - and who know just how to find that particular person.

While that sounds very nice and reasonable - how can it be accomplished? How can a recruiter know the atmosphere, the intricacies, the issues of a particular job, practice or hospital? Even physicians that start working in a new job take 6 months to fully understand who has the power, who is nice and helpful, and who stabs you in the back. It takes months to find out what the personality of a practice or a hospital truly is.

Recruiters cannot, short of a miracle of clairvoyancy, find these things out with their usual tools. And their usual tools are: the 10-15 minute phone interview, a 10-15 point checklist and some common sense. As you well know, there is no defined professional training for recruiters, no exam, no degree. All you need is the ability to sell and the willingness to spend hours and hours on the phone.
Hey, that, and a $200-2000 off-the-shelf software package and you are ready to go. Blackdog software even comes with prepackaged canned answers to most arguments that "hiring authorities" and "candidates" might have.

That is all you need to become a recruiter. Should you go for the long-term success, for building relationships, for adding value etc, your business will grow slow. Should you go for the "quick placement", your business will grow faster. Quick placement means: a maximum number of phone calls a day, since this process follows statistics, the more phone calls you make, the more viable cadidates you get, the more placements you make, the more you earn. You also should immediately drop candidates that may not be marketeable, since they are a waste of time. I have experienced this when mentioning that I wanted a job in "Boston inside the I 95 ring" - you are usually not called back, you just get on the general email recipient list, and from this point on you receive job offers from all over the US.

And, on top of all this, medicine turns out to be an area where recruiters might be unnecessary. Why? Because it is not hard to find doctors. It is much easier to find a doctor than to find a certain manager in the hierarchy of a large corporation. Doctors advertise, their names are published in many lists that can be purchased with a few clicks on the Net (InfoUSA.com). Doctors do not hide, they are easy to find, they want to be found. You do not need any special knowledge or tools or help to find them

All a physician looking for a job has to do is get a list of doctors in their chosen area and send all of them a letter. Click here for a detailed description. Done. Response will be 1-2%. Send out 500 letters, you will get 5-10 phonecalls - very good ones usually. And with this method you uncover all the never advertised jobs, you tap the "hidden job market". You will find more positions than you thought possible.

Direct mail works extremely well! Why else would the NAPR, the National Association of Physician Recruiters, regularly do massive direct mail campaigns?

I highly recommend direct mail in addition to personal networking as a winning job search strategy for physicians. Direct mail and networking is all you will ever need!
Direct mail and networking is all a physician needs to find the best jobs!

Avoid physician recruiters

2007-06-16T22:01:00.000-05:00

I teach Obstetrics and Gynecology to the residents of a Family Medicine Program in Boston. This includes a lecture on "How to Find Your Ideal Job" that explains the dramatic advantages of the direct mail method for a job searching physician and outlines the drawbacks of working with physician recruiters.

A faculty members asked me why I was opposed to recruiters. Here is the answer: It was a long learning process over years, with many dozens of big and small bad experiences and big and small disappointments. In the end, I could count the good experiences on one hand and the bad experiences and disappointments were in the hundreds.

I started out with enthusiasm about recruiters, and with great hope. Here are these people that have "hundreds" or "thousands of jobs nationwide", that have "the best jobs", that "personalize a search for you", that routinely find "the perfect practice for you". Great! Call seversal recruiters, get a great job and start working!

It turned out quite different. I had graduated from one of the large Boston teaching hospitals and wanted to stay locally. And with "locally" I meant really Boston, specifically inside the I-95 ring. So I sent my CV to recruiter after recruiter, but strangely, such a job did not seem to exist. Even the recruiters that advertised jobs with "Enjoy all Boston has to offer" live and work in "the Boston suburbs" never had jobs within the I-95 ring. To my dismay, recruiters defined the "Boston suburbs" very creatively and differently than I did. The suburbs suddenly turned out to be Methuen, Lowell, Lawrence, Framingham, Worcester, Plymouth etc. Driving distances in ads were routinely understated; places advertised as "only 30 minutes from the city" always were an hour away.
Then, after a while, there actually was a job IN Boston, and I rushed to find out what it was. "Obstetrics only", and underpaid. At the time the usual starting salary was 150-160, this employer offered 120. A number of similar experiences later let me conclude that "within-city-limits" jobs coming through recruiters had serious flaws.

I realized in time that recruiter jobs were never "just great", there was always something off, the jobs always seemed to have a flaw, some drawback, concerning location or otherwise. My comfort zone in terms of location ended before the "recruiter area" started! And I grew more and more cynical when reading the oh-so-promising ads...

A few years later I went on another job search, and this time it lasted over 4 years. I wanted a position in Miami. Again, not outside of Miami, no, IN Miami.
On the internet I found Physicianwork.com, a website chockfull with recruiter ads, registered and up went my hopes again – over 75 jobs in Florida! There had to be something in Miami among them! For starters, the typical recruiter job descriptions are short, cryptic and vague. I understand the reasons for this very well, but it is still frustrating. I screen jobs by location and salary – and that is exactly what they never, ever tell you. I also was surprised to find that many jobs are listed multiple times by multiple recruiters. Great…

And the same frustrating game started all over again. “Oh, no I do not have anything in Miami”, "But what about Lakeland, Tampa, Orlando, Jacksonville, and the panhandle and, and, and". Lots of jobs, just never where I wanted one.

I adapted and listed myself on the Internet as looking “strictly in Miami, nowhere else”, "not Fort Lauderdale, not Naples, not Orlando, not Tampa". After all, I have family in Miami…

Do you think any of the recruiters cared about what I wrote in my profile? Not at all. I received literally countless emails advertising jobs in Florida – anywhere in Florida, except in Miami. It started to sound like Miami was the new Boston.

Sometimes I felt spammed by recruiters. I had just spoken to a recruiter in person and explained that I was looking really only in Miami, sorry, really nowhere else…and to my surprise next day I get an email about a remote California location, “home of the California puppy”, of course far away from the action, “a short drive” of 75 miles from LA. Did that recruiters not hear me? Did he not care? Or did he simply not take me seriously? Did he think I would change my mind that easily?

What would happen if I treated my patients that way – “Dear Mrs Jones, I don’t care if you just want the birth control pill, here, read this leaflet on hysterectomy, let's schedule it”

I adapted again and started answering my emails with: “Thank you for contacting me, but I am searching exclusively in Miami”.
Bam, now I got the “Miami AREA” emails and ads. The “Miami area” seemed to stretch from the Keys to West Palm Beach. What kind of map are these people looking at? What are their concepts of distance? Do they ever commute? One excited and eager recruiter told me that I could live in Miami, but "commute to work just slightly north of Fort Lauderdale". She obviously had never, never been on I-95 in rush hour…

Then I started to add one more sentence to my answer to all those recruiter emails:
“I am only interested in Miami, and only in a practice that has a phone number starting with the area code 305”. Now THAT usually worked. One recruiter audibly chuckled on the phone. He seemed to understand exactly why I was saying it. At least now the number of emails about Naples and Orlando dropped somewhat.

I loved the following answer “I do not have anything in Miami at this time, but I’ll call my clients I that area to see if they have something” Oh, yeah! I am still waiting today for those call-backs.
And now, here is the outstanding, rare, single, amazing experience with a recruiter – an actual, true and honest answer: “I don't have jobs there. If you want to find a job in Miami, you have to call the practices yourself, one by one. And if it does not work the first time, then try again in three months”. I was blown away, a recruiter that actually does not try to convince me that Backwater, FL is a great place to live and raise a family, but that instead gives me a tip how to land a job in the city I want.

This happened only once, one single time, on one lonely occasion, on one remarkable afternoon, in several YEARS of searching, after literally hundreds of emails and telephone conversations! The first honest and true tip from a recruiter, advice from one human being to another human being - no salesmanship. It happened only ONCE.

Do you begin to understand why I do not like recruiters?

You would not believe how many emails I received about jobs from West Virginia to North Carolina to Indiana and Idaho, even jobs in other fields of medicine like anesthesia and pediatrics! The recruiters who are sending me these emails seemingly could care less about my profile and my registration information.
Do you understand why I cringe when I read recruiters advertise “we personalize a job search for you”. Idaho instead of Miami, really personalized, great job!

I now believe that most contingency recruiters just do not care. They sell, sell, sell and sell some more. They go for volume, they go for the numbers. The more emails they send out, the more people they contact, the more chances they may have to get an answer and sell one of their jobs. That is why they remind me of used car salesmen and telemarketers. Their ads are just the nice marketing face, and you have to read them with upmost suspicion.

But then, when I was starting to believe that good jobs where I wanted them, were just not available, then I found “Thedoctorjob.com” They explained how direct mailing works and how it is superior to any other search method. After reading through their website, the behavior of recruiters suddenly made sense and it became completely clear why they did not have the jobs I wanted – and why they never will!

I tried the direct mail myself, and it worked like a charm. One mailing and I had seven interviews and three job offers. And that in a city that - according to recruiters - was “oversaturated”, where there were “no jobs”. Months later I tried mass faxing with the same success. And mailing is easy, the lists are readily available on the Internet, there are services that review and improve your cover letter and CV and ….of course there is “Thedoctorjob.com” that offers all this in one neat package for a very reasonable price.
And, no, I am not related to any of the folks at TheDoctorJob.com, I am not part of the company, they do not pay me, I am not on commission. I just love the idea, the method and above all - the results.

Physicians - Best Way to Find a Job

2007-06-10T12:12:00.000-05:00

This is how you will land a great job! Read the recommendations of a physician who has "been there and done that". This is advice from an insider!

Most important - forget recruiters. Recruiters get paid to lure you to suboptimal positions that could not be filled through word of mouth or print advertising. Don't be fooled by recruiter advertising.
You want the best jobs and recruiters do not have them and cannot get them. If you have the slightest doubt about that: Have you ever seen a recruiter ad for a Harvard position? Or for that well running practice in downtown Boston with an office overlooking the harbor, in downtown San Diego, in downtown San Francisco, Los Angeles? Have you noticed that recruiter jobs always are located "one hour drive to..." or described with euphemisms such as "Easy access to" or "Near...". Once you look closer, you find that most recruiter jobs are located in less attractive areas and /or have other drawbacks such as high turnover, unpleasant work atmosphere, low salary, high buy ins, etc. The function of recruiters is to fill the less desirable jobs! And those are the jobs YOU do not want!

All the following recommendations assume that you know where you want to live, where you want to work and that you have written a truly impressive CV and cover letter that bring out your abilities and highlight your potential. Please see my past blog posts about these topics.

So, here are the ways to find a job YOU want: For the "executive summary", click here.

1. Network, using your personal contacts and beyond

2. Directly approach the hospitals in your desired area.

3. Direct Mail to all physicians in your desired area (the best method of all!)

1. Network

Consider your job search a marketing project for yourself. Apply marketing principles, use marketing tools and you will achieve great results.

This is not the time to be shy, not the time to be disciplined and withdrawn, this is the time to make yourself heard, to be clear and loud, to be relentless, untiring, persistent, this is the time to be pushy! "Squeaky wheel gets the oil!"

Talk to anyone who will listen more than 2 seconds and give them your "elevator pitch".Write an "elevator speech", meaning a one-minute talk to introduce yourself. State who you are, why you are good, what you have to offer to an employer and what you are looking for.

Practice the elevator speech and use it whenever you can. It will become easier and easier.

Here is an example: "Experienced, Board-certified obstetrician-gynecologist with Yale training and multilingual skills – including fluent Spanish – seeking new practice opportunity in Boston to be closer to family. I have an active Massachusetts license and am available to start working in 3 months."

The elevator pitch is a short introduction to what you have to offer, what you can do for others. You say who who are, what you do, what you excel in and how you are different and better than others. You can end with a call to action, such as "and I can start in three months"

There are several website and even books that spell out how to write the elevator pitch.Print a business card (if you have Microsoft Publisher or something similar) with your phone number, fax number and your email address. Always carry it with you. Hand out this business card with your contact information as often as if possible. You could consider printing your elevator pitch on this card as well.

Start to network with your residency program director. It is part of his or her job to help you find a job. Then ask every single one of your attendings. Ask them if they know anybody who is looking or anybody with a practice you might like, or anybody wher you would fit in based on your personality and preferences.

Try to find out if there are any former alumni of your residency program in the area where you are searching. Having gone through the same residency makes you sympathetic to a doctor and gives you a psychological "foot in the door".

Ask your parents and grandparents and your in-laws to contact their primary care doctors, their cardiologists, their orthopedists etc. See if the doctors of your family know of a very busy attending that might need help, might need a new associate, that might have plans to expand his or her practice. Just following this recommendation I got two great referrals in no time exactly where I wanted it and with almost no effort. One of them of one of the best job offers I ever had.
Call your friends from medical school to see if they are in apposition to hire you or if their practices or departments are searching – you would have an automatic contact reference.

Ask distant relatives you have not talked to for 6 years to inquire at their doctors offices - and even speak to your present acquaintances.Tell them what you are looking for, where you want to be and what kind of practice you would like to join (you already have decided and formulated this after reading the first paragraph). Don’t make it too exclusive, or you will be left without a job and don’t be too flexible, because you will be abused by someone who just wants to earn money off your sweat.

You could also try to get contacts through social networking websites such as Friendster or other! There are no limits to how and where you market yourself. Think Guerrilla Marketing. If you do not know what guerrilla marketing is, read the classic book by Jay Levinson "Guerilla Marketing". He wrote and co-wrote a whole series of guerilla marketing books, including "Guerilla Marketiing for Job Seekers".

2. Actively contact the hospitals and their Ob/Gyn departments in your target area.

You can find all hospitals by going to MedLinePlus, then to "Directories", then to "American Hospital Association". There you can find hospitals by name, zip code and city. There are several other hospital directories you can search and you will find most of them at Pam Pohly's list of hospitals and directories.

Pam Pohly was a consultant before becoming a recruiter, which may explain why her website has so much useful information. By the way - recruiter websites usually do not have useful information. The only purpose of recruiter websites is to steer you to use their services.

The is a very inexpensive hospital directory for download for $97 at Doctorlistpro.com. If you plan to search hospital data a lot, it might be worth buying it.

Once you have the hospital contact data, call the hospital and ask for the Physician Relations person, Physician Liaison or the Network Development person. Ask for the phone, fax and email.
Obviously you can also check the hospital’s website. The following link is a fairly complete and reliable list of hospital websites:
http://neuro-www2.mgh.harvard.edu/hospitalwebusa.html

The usual providers of physician contact data lists (e.g. InfoUSA) all have lists of hospitals as well. The advantage of InfoUSA.com is their reasonable prices. And the fact that you can buy exactly as many or as few addresses as you need. You essentially only need the address of the administrative offices, and then address your inquiry letter to "Physician Liaison / Network Development".

While contacting hospitals and their departments you will encounter two opposite biases:

First bias: The doctors in your specialty will tell you: “There is no need here, we are all set here, we have too many doctors already, 10 years ago we were 5, now we are 13, it may look like a nice place to live, but believe me, it is a problematic place to practice! Why do you not look 100 miles further north or south, east or west, it’s much easier there, I happen to know someone there who is looking yadayadayada”. They obviously do not want more competition and are more or less openly trying to discourage you from coming. If they really wanted more physicians, they would already be hiring themselves!This is course does not mean that you do not have a chance. The local doctors maybe older, maybe all male, may not be that popular anymore, may have some political pressure against them and in reality you may have a pretty good chance of being successful in that particular community.

Second bias, quite opposite to the first bias: The hospital administration is always very enthusiastic and encouraging – they always need more people, there always seems to be room for one or even two or three more, “Yes, there clearly is a need, there is an opportunity, you will do well etc, etc, blah, blah. We can help you with this and that, with everything actually (except a salary of course, except with any money at all, the help usually stops at non-material things, and routinely the Stark rules are cited as a excuse). In fact they might be able to help you a lot with marketing, by providing information about the community, giving you lists of fellow doctors of other specialties, give you background info on the service area of the hospital etc. But the hospital does not care at all (!!) how much money you make, or if you make any money at all. Deep down they do not care if you are successful or not. They have in mind that every new doc means another warm body attracting more business to the hospital. Every new doc means more admissions to the hospital floors… and therefore much needed cash in their coffers.

The medical director often stands somewhere in between these two opposites, and it is often someone specially hired for that position (retired, semi-retired handicapped, working part time etc) and therefore frequently the best source of information. Medical directors usually are more neutral. So talk to the medical director and try to get crucial information:

How busy are the docs in your field, how is the population growing, which areas in town or in the county are growing and developing, which segment of the population is developing, are people moving in or out of the area, how is the industry doing? Are offices and factories closing or are companies flocking to town to open new ones? Real estate prices going up or down? That means people are coming into the area or are leaving the area…What does the future look like in the area?

Then get the names and addresses of the practices affiliated with the hospital and the names and addresses of the practices that are looking or might be looking and contact them directly by sending them you cover letter and CV.

3. And, finally, here is the most successful and least published method to find a job.
Loved by those who use it, despised by the recruiters that loose much of their attraction - if they ever had it. This is the very best way of getting any job anywhere, even in the very best, most attractive, most competitive locations.

Direct Mailing and / or Broadcast Faxing of your cover letter and CV!This is the most direct way of presenting your cover letter and CV to as many doctors as you want - in exactly the area where you want to be. You buy the names, addresses, phone and fax numbers of all the colleagues you might work for. Then you send them a letter, send them a fax or give them a call. Calling takes a lot of time, and therefore I recommend mailing or faxing.

The big difference that makes all this easy and feasible is the Internet with unparalleled access to physician contact information databases and the availability of Internet faxing. Something that was extremely time consuming 10 years ago, is now a snap. Applying to 400 physicians is now literally a project for one single weekend.

So, how do you do it? First you buy the physician addresses, the contact data. The sources for buying physician addresses and contact information, fax numbers, email addresses and numerous data about the practices are: InfoUSA.com, USdata.com, WebMD and MMS, the marketing arm of the American Medical Association. The AMA has been selling lists of their members for profit for a long time, and so far this service has mainly be used by pharmaceutical companies to help their reps.

Doctorlistpro.com is probably the most affordable list service. The drawback is that you have to buy in bulk, such as all doctors in one specialty for $297, all doctors in one state for $297, all doctors in all of the US $497, all hospitals in the US $97. Can't beat those prices, this is a lot cheaper then MMSlists.

Of all the data companies, I recommend InfoUSA.com, since you can buy all data directly online, with a very easy process. All other companies have a minimum number of data to buy, require a personal call, make you jump through hoops and restrict your use of the data. And Info USA offers the best prices.

Here is how to buy the addresses in detail.

Once you are on the website of InfoUSA.com, look in the center, go down and click on: "Doctors, Dentists and other medical lists". In the window that opens click on "Physicians and Surgeons Database" then check the specialties you are interested in, e.g "Obstetrics and Gynecology" and then, further down, check "office based". On the following page uncheck the specialties you are not interested in contacting, e.g. MFM, critical care obstetrics etc. On the next page, click on "select all members in office". Do not check the "fax number" box, since this will exclude doctors that have not listed a fax number. You want all the names and addresses and phone numbers! On the next page you can select the geographic area, whihc can be the whole country or just one zip code, or a radius of 500 miles around an address or just 10 miles. For example: you would like to join a practice within 15 miles of your parents home. Enter the address of your parents and select "20 miles". on the following page, leave everything unchecked, since it would only reduce your list. Then you get to review the list. Sould the list be too large, then choose a smaller geographic selection, or select by age or gender etc. Of course, you can also increase your list this wayOnce you are there, go to “physician lists”, and then follow the simple steps to select the doctors you want to contact. The price is 50 cents per address. Beats having to type it yourself. Info USA is the database which the other addresses and list providers get their data from. So, go to the source. InfoUSA will email you a list in CSV format, which you can import into Microsoft Outlook, Win Fax, Act, Excel or any “Contact Manager”. I would keep the original untouched in a safe place and import the data into your application of choice.

Here are a few additional tips:

You cold also buy or borrow the American Medical Association book or CD that contains all the addresses of doctors in the US. The CD costs about $1100 and does NOT allow downloading and exporting of the data into a database. Who knows, maybe you know someone, who knows someone who has the disk and would be willing to loan it to you for a weekend? The AMA is very big on restricting the use of their databases. They want to be sure to squeeze the maximum profit out of your good name.

WebMD sells booklets for $18 for each Metro area that contain ALL physician names, addresses and telephone numbers. You will have to buy a second booklet for the same area to obtain the fax numbers. The fax booklet will also cost you $18. Over all a lot cheaper than buying the electronic lists, but you will have to type in th addresses if you ant to use them on a large scale. I have used the booklets from WebMD only to confirm my database that I purchased from InfoUSA.

You should be familiar with a software program called “Address Grabber”. This is a very nifty tool to collect addresses, names, phone numbers from any electronic sources and insert them into your lists! It sells on the net as a download for $70. It allows you to “grab” and capture any address you see on your screen from any website, from any source with a single click. Very cool! If you can see it on your screen, you can transfer it to your database! Digest that fro a moment! You can produce your own lists!You highlight the address you want to grab on the Internet or in Word or in other software...and then transfer all that information into a contact manager such as Outlook or ACT! With a just a single click. The info will appear like magic in the correct place, address in address field, name in name field, fax in fax field etc. Very handy. It is well worth the money if you search for a job in a difficult metro area and have to harvest addresses from the yellow pages, from WebMD etc. Obviously it is good for many other things, such as building address databases for referrals, fund raising, other mailings etc. There is a more advanced version of this technology called “ListGrabber” which imports not only a single address, but a whole page of addresses, a "list", hence the name Listgrabber, all at once, with just one click. It costs over $250 and most likely it will not pay off if you are a single physician looking for a job. But it is good to know that it exists, you never know...If you are an employer with repeated need for recruitment data, this is the tool for you.

Then you write your cover letter in WinWord.
Go to the Mail Merge function. You find this under “Tools”, then “Letters and Mailings”, then Mail Merge. Follow the instructions WinWord gives you step by step. You write the master document, then insert the merge fields, then open the database and…merge. You can easily see and manage the merged letters with the “merge toolbar”, which you have to open.Then you print out all the 100 or 200 or 300 letters on white or off white or cream 24 lb paper. You get 100 or 200 or 300 copies of your CV done by you local Staples, Office Max etc.Then you choose white or clear Avery labels at Staples or Office Max for the address and for the “sender” information (that is your address). WinWord knows how to precisely deal with the size of these labels. You enter the number of the Avery label and Winword knows the size and formats the address information exactly for the label. Magic! Then you print the labels using the Mail merge function again. You then fold and stuff the letters in envelopes, have the envelope weighed at the post office, buy the correct stamps and stick them on. You drop all 300, 500 or 1000 letters off at the post office and Voila! Mass mailing. You almost have the job. Just don't ruin the interview!

There is a company that does all the hard work of the mass mailing for you: ‘TheDoctorJob.com”. Go to their website and read and browse. Here are some quotes: “We help more physicians find jobs than any recruiter or job board in the country, and the reason is simple: we work for you, not for the employer. Unlike a recruiter, we won't try to force you to work in a rural area. Most of our clients find jobs in their first geographic choice, and we can help you find a great job in any metropolitan area in the country. 99% of our clients find jobs, and we guarantee that you'll find a job or get your money back. Visit our website at http://www.thedoctorjob.com" or call us to talk about our services and get a price quote. You will find a job with The Doctor Job. We guarantee it.”
They charge about $1, 50 to $2, 00 for each letter sent, but this is not too much. For that amount they review your letter and CV, maybe improve it, they get the names, addresses etc, they merge the letters, print them and send them to you. You have to sign them, to stuff them into the envelops and to put stamps on them, which costs money at 39 -63 cents a stamp. The service provided by “The Doctor Job” is very reasonably priced at $ 2000 – $3500. If that is too expensive for you, do it yourself. I did the mass mailing and faxing myself, and it cost about $1000, but it was a lot of work. I did never regret it though.

There is another company that provides this service since late 2006: Doccafe.com, a website founded and run by a former in-house physician recruiter and a lawyer. Not bad overall, but they still live off recruiter ads...

Mass Faxing:Legal notice: Do Mass Faxing at your own risk and only after closely looking at the rules and regulations in the state you fax to! Unsolicited faxes are illegal in many states! I am not responsible for anything that happens to you as a result of mass faxing. You have been warned!
You buy the addresses from Info USA or WebMD, have your CV and cover letter (re)written by e.g. Quintessential, add a signature image at the bottom of the fax and then fax it to 10, 50, 100 or 1000 colleagues using JBlast.

Step by step: You get the fax numbers from the same list sources. You use the same cover letter and CV. You can either sit at home or at the office fax machine and manually fax the hundred or two hundred cover letters and CV copies.

You can mass fax using an Internet service provider called www.j2.com, who offers a fax broadcast service called Jblast. Jblast is great, since it is easy to operate and offers a Mail Merge function that works just like Mail Merge in MS Word. And is very reasonably priced. You can use your Word document and your CSV address and fax number list or your Excel address/fax number list.

I recommend using an Internet faxing service anyway, since you can get a personal fax number with an area code of your choice - yes an area code anywhere in the USA - and you can switch it at any time. Now you have a fax number that you can print on your CV. The advantage is that this fax number will follow you after you move and after you leave residency. This fax number is as portable as your yahoo, hotmail or Gmail email address. This is an advantage because employer can send you faxes even after you have moved away and still find you. Maybe this is the way you will hear about your dream job!

Important! Add a signature at the bottom of your fax. It makes it look a lot better, more realistic, more credible. I wrote my signature on a tablet computer, saved it as a file, emailed myself the file and pasted it into my word document between the "Sincerely" and my name at the bottom - voila!

Follow up!Believe it or not, your application is not that special! Yes, it may get lost, neglected, forgotten in the daily rush, put at the bottom of a pile, or it may just get thrown away for whatever reason. It therefore is a good idea to fax the same letter and CV or a slightly different, maybe shorter version - about 2 weeks later. Keep your cover letter and CV in front of your potential employers!

And of course, you could call the most interesting practices and ask to speak to the doctors. Always leave message that you called with your call back number. This is not the time to be shy! Squeaky wheel gets the oil.

Should you not get the right practice during the first mailing campaign, then try to mail to a larger group, let's say a wider area. Include one or two or three more counties, or a few more zip codes. Check the following: Are you sure that your CV is optimized? Is it really written by a professional? Have you made sure that Your letter arrives on Tuesday or Wednesday, when it has the highest chances of getting read?Or just try the same list again, who knows. Maybe this time they will actually open the envelope, maybe the practice situation has changed. Sometimes partners or associates or their husband or wives leave, sometimes people die or suddenly have to retire. So, just try again, I would recommend to repeat this every 4 months. It will work!

So, this is how you find a job! And where do recruiters fit in? The people who seem to have more websites and more presence on the web than Google and Yahoo? Once you know what you just read, you do not need them anymore. Behind every recruiter job posting is an employer that is desperate enough to be ready to pay $ 20,000 just to find someone.

Take charge, search actively and you get the job YOU want, not the job someone wants to sell you! Recruiters are...unnecessary for job seekers!

The most important issue in medicine

2007-06-05T10:49:00.000-05:00

In my opinion the most important issue in medicine is the number of graduating medical students. Why? Because supply and demand determines the price of any good or service. Train too many doctors and reimbursements will decline. This has already been happening since the mid eighties! and it should NOT continue. The US are a better place to work for doctors than most European countries (and as a German I know this from my own personal experience), because someone was smart enough to freeze new medical schools.

Now we have a most unfortunate study trying to predict the future, which forsees a "physician shortage by 2020" and consequently university deans, eager fro the reputation, funds and power that come with a medical school, clamor to create new medical schools. In my humble opinion the author of this study resembles a "useful idiot" for the HMOs (remember that cold war term that so aptly described those people that supported communist ideas?)

THIS IS THE MOST DANGEROUS ISSUE IN MEDICINE TODAY.

Few people see it that way. Everybody seems busy with their everyday activities and misses the big picture. Any increase in the number of physicians is absolutley detrimental. Incomes will drop even faster than they have in the last twenty years. Did you enjoy that? Keep quiet about new medical schools! Did you like loosing income? Keep quiet about new medical schools!
Have trouble paying off your medical school debt? Just support new medical schools and more doctors! Have troble paying your mortgage? Just welcome new and more doctors!
Are you enjoying the power of HMOs? They will only get stronger the more doctors are around - they will always find someone who works for less!

We need less doctors, not more.

The latest issue of the American Medical News reports on the "burgeoning retail clinics". There is your competition that you did not see coming! There is your increase in health care providers and services that makes it unnecessary to train more doctors!

In Minnesota Blue Cross Blue Shield supported the opening of retail clinics and from 2004 to 2007 the number of visits increased from 9,800 to 33,800 and the charges per visit increased from 39.84 to 72.90! And you thought this was a minorthing and people would not go or would go only for insignificant issues!

Hey, those that went to a retail clinic seemed satisfied. In the same article a table shows that:
patients that were very / somewhat satisfied with quality of care - 90%, withhaving qualified staff - 85%, with convenience 83% and with cost 80%.

This is completely in line with physician practices! And you thought retail clinics were no competition?

Not only do we NOT have a physician shortage at this time, we have a physician oversupply. The oversupply will get much worse due to Internet medicine and retail clincs. HMOs will rejoice and their profits will grow, your income, my dear colleague, will shrink.
You have been warned.

Flea outed. Settles case

2007-06-03T21:15:00.000-05:00

A medical liability case against a Massachusetts pediatrician with outstanding training and a great practice was settled before going to trial in mid May. The pediatrician happened to be an extremely successful and much read blogger known as "Flea". Flea had kept his identity private and referred to himself only as "pediatrician in solo practice in the Northeastern US".
Flea gave us excellent thoughts and insights into issues of pediatrics, medicine in general, office practice and into the preparations of a malpractice trial. Insights that thousands of physicians, patients and observers loved. He had very high ratings on Technorati.

Early in his trial his identity as blogger was outed by the plaintiff's attorney. Likely as consequence as that, he settled the next day.

Excuse me for being so naive, but, if I may ask: what on earth does a blog have to do with the case? What does it matter what Flea blogs about the jury, the case, the plans for defense, the plaintiff or the plaintiff's lawyer? What does a blog and the posts in a blog change concerning the question: Did Flea act according to professional standards in the treatment of this particular patient or not? And I believe that that this question, the most important of all, was not answered and will never be answered, because our justice system is not set up to focus on it.

I assume that Flea's attorney settled, because he was concerned that the subjective perception of the defendant by the members of the jury would matter so much that it was not worth continuing with the trial!
I believe this should NOT matter in court. Is that not the reason why we have 12 jurors? To keep things a bit more objective? Have we not learned anything from death sentences in the past that later were determined to be based more on an impression of the character of the defendant than on facts?

I repeat, in my opinion, Flea's blog does not change one bit about his treatment of that particular patient. Call me naive, but a good justice system should dispense justice according to the facts. Right? Not according to things such as "Oh, but he said this and that on such and such date and that makes him bla bla bla". Facts should decide, not gossip, not opinion, not personal impressions.

Sadly, this development confirms exactly what Flea had written in his blog: The jury decides overwhelmingly based on their subjective impression about the defendant! The jury's verdict is to 97% based on personal gut feeling and 3% based on facts! Flea was shockingly right!

Do we have a great justice system or what?

By the way, I personally do not think he presented himself in a bad way at all, at no point. I have a lot of respect for him for opening his heart and mind. But, the old saying it true - and this is not meant in an arrogant way - outsider just do not have the experience to understand what goes on in a physicians heart and mind and should not judge him by what he says privately, by his opinions, by his jokes.

This is just one more reason why the malpractice system needs to be replaced.

I have in past proposed a system similar to "Workman's Comp". You are injured on the job, you fill out a form, you get treated. No lawyers, no courtroom theatrics, no "pain and suffering". Compensation according to an expert opinion and a set table.

What works for the manufacturing industry should work for medicine quite well too.
You are injured during the course of medical treatment. You fill out a claim form, the issue is examined by experts, you are treated. Period. No lawyer drama, no lawyer fees. Reduce it to a bureaucratic act. Fill out form, get treated. Get better.
It should be "Patient's Comp" or in Ob it should be "Mother's Comp". Better, more affordable justice. With our present malpractice / professional liability system, 8% of injured patients reportedly receive compensation. How many receive compensation through workman's comp? Certainly more. Patient's Comp would be a huge improvement.

It would increase reporting of mistakes, since the guilt and shame are gone. It would increase fixing of system errors, since we all would contribute to making systems better. Money spent on liability would actually end up in patients hands instead of lawyer pockets.
Lawyers will not like that. I can see a few bitter comments already...But our patients would be better off.

"Physician shortage"

2007-05-30T10:43:00.000-05:00

You are a physician and as such probably familiar with multiple choice questions.
Here are a few true and false questions for you.

1. The gas prices are raising because we have either an oversupply of gas - or a decreased demand.
True or false?

2. The prices for computers and computer parts and accessories are going down because we have a shortage of manufacturing facilities.
True or false?

3. Real estate prices increased over the last 30 years because we have an oversupply of land, especially water front.
True or false?

4. Physician reimbursements have decreased continuously for the last 25 years because we have a shortage of physicians.
True or false?

5. The HMOs want to keep the number of physicians to a minimum, so that they can continue to pay less and less.
True or false?

You get the picture. I still cannot understand how some of my colleagues can be so incomprehensively stupid that they read about "decreasing reimbursements" and "physician shortage" in the same journal or magazine without wondering if it makes sense. I know we are notoriously bad in business matters, but do we have to be THAT bad and ignorant?

Close a few medical schools, improve the quality of training.
We need less physicians, more nurse practitoners and physician assistants. Tell someone.

What an EMR should be !

2007-05-22T16:19:00.001-05:00

Electronic medical records should speed up documentation of the patient visits, make documentation more complete and extensive and include all the redundant things that we always say, but never document (because they are soooo obvious to us). Faster documentation means finishing earlier or seeing more patients and more complete documentation means more payment and higher coding levels! And the “redundant parts” may one day very well save your behind in court. With an EMR Patient charts are available wherever you are – office, hospital or home.

At least those are the benefits that the EMR companies keep on repeating. Those benefits nevertheless are by no means certain or even guaranteed!
To my big surprise I ended up being disappointed when my health care system bought and installed the GE product "Centricity" (it used to be sold as "Logician"). You get the feeling that it is an old system that has been updated over the years, but it is far from being as modern as what we are used to from working with Google or Yahoo.
GE is rather inflexible and is not too eager to individualize it to you (or they make it expensive). Using Centricity has drained my productivity rather than improving it. Visits take longer, I do not have an easy overview of my patients data as I had before, there is no space for personal notes on patients (!!). Personal notes on patients are very important to me. They make each patient unique and allow us to pick up a conversation where we left of the year before. A note could be "likes cold climate, considering moving to Maine", "loves teenageers, thinks that they are in the most interesting age", "has winter house in Florida, plans to move there in 5 years", "husband is in the national guard" and things like that. Those are all facts that not only make a patient unique and memorable, but also may serve as a basis for marketing to patients. Centricity offers absolutely no help in marketing. No field for the answer to "who referred you to us" at the first contact! No field for preferences of referring physicians. No thought of marketing has gone into that system. To market to patients based on patient information I would neede a separate database, and who wants to do that!

Yes, EMR software has the potential to do certain great things, but the real system you end up working with might not do nearly as much as it could. The dream is much better than reality!

So, find out about the systems that are out there, look at their websites and then have one or more demos in your office. I do not have a clear favorite yet; they all have their flaws. “Tops Suite” from “e-MDs” seems good and might be one of the lesser expensive solutions. It includes scheduling, billing and patient records.

I would only get a system that allows me to store all data in the office – I do not want to negotiate with someone who holds my data hostage. Information has to be accessible anywhere (home, hospital.) at any time, preferably over the net. The system should be VERY intuitive to use. Secretary and nurses should enter the demographics and history, and it should take you only a few clicks to finish the rest. The goal is the three click visit.

Patients should be able to request an appointment online or even book an appointment themselves. They should be able to fill out their patient history online, they should be able to fill out the complaint and history part of the visit / encounter form online before they come into the office.

As an alternative it would be nice to have patients fill out a questionnaire on a computer in the reception area or have your secretary fill it out for those patients who prefer not to deal with the computer. This questionnaire should be interactive, so that it asks only the questions that are relevant to the occasion, which could be an annual visit, postoperative visit, Ob visit, problem exam, follow up visit, etc. For each problem the software should ask tailored questions.
These data should be processed to give you a tentative diagnosis and algorithm to proceed, what points to focus on, what tests to do. These data should select (or offer to select) for you the template that you will document the visit on, and consequently also the billing codes etc. The system should offer templates categorized and accessible under diagnosis or treatment or SOAP notes from previous visits to be reused for faster documentation. The system should more or less automatically print prescriptions in the office - or fax them directly to the pharmacy, it should print patient instructions that correspond to the problem or diagnosis or time in pregnancy when the patient presents or age of the patient at the time of the annual visit - customized with name and issues, fill out any forms you may need (disability, booking for surgery, request to have a medication paid etc), fax prescriptions to the pharmacy and - very important for your practice marketing - fax letters to the referring doctor, so that they have the report the moment the patient leaves the office.
All this should be EASY, hear me, engineers, EASY.
The ideal is the “three click visit”. The system should offer alerts and reminders (pathological Pap, mammograms, overdue annuals etc.) and should offer the ability to email patients the results of tests and appointment reminders as well as monthly or three monthly practice newsletters.
The program should also send follow up emails where appropriate to increase compliance, such as more information on Kegel exercises, more information on how to stay health, how to continue to monitor the irregular, PMS, menopausal symptoms etc.
Administrator love to forget that an EMR should make life easier, oh, sorry, let me word it so they understand it, an EMR should make the physician faster and more efficient. An emphasis on safety is NOT an excuse for a cumbersome system that requires clicks and clicks and acknowledgments of pathetic detail after pathetic detail. Safety happens behind the scenes! I drive a Volvo for safety, but the car drives exactly the same as an unsafe car. I do not notice that it has extra airbags and a better suspension and electronic roll-over protection. "Safety" is a very important goal and the software has to accomplish it without annoying us! Software has to make us faster!
And essentially you should never ever have to enter any data twice. It should synchronize with the PDA you carry around and on which you capture billing data in the hospital. those billing data should be effortless be transmitted to the main system. Your PDA should receive your daily schedule including your operative schedule. In the office you should have a wireless network with tablet computers - make sure your EMR program actually can be handled with pen clicks alone!

When you consider buying, don’t fall for high monthly “maintenance” fees, which are just a way of charging you or for an outrageous purchase prices in the range of 100K. Forget the proprietary systems and the Unix systems. See what works and what did not work for colleagues in your area. Most systems are in the range of 5-10,000 per provider or even less and prices should go down in the future. Never buy without a 3 or 6-month money-back guarantee in case the system fails in everyday life. Make sure that you have it written in the contract that you can get your data back for a minimal fee if you do not want the system! Companies tend to abuse you with high fees for returning the data! They know that you desperately need them and take advantage of this.

Go to http://www.emrupdate.com/ or org and take a look at an objective website without marketing hype where you colleagues give feedback on emr systems.

Your favorite headache: EMR

2007-05-21T22:34:00.000-05:00

Choosing and buying an EMR is difficult, since an EMR always means a lot of work and turmoil in the office and a lot of expenses. EMR companies usually fill pages and pages with "benefits" of using their products instead of listing what specifically their software can do and, very importantly, what it cannot do! That essential piece of information is never mentioned in the glossy ads. EMR prices and functionality vary dramatically from zero to hundreds of thousands of dollars.

Therefore, the first thing to do is to get good info, objective and marketing-free by visiting the website "www.emrupdate.com". This is a neutral site published by a colleague that was and is looking for a good EMR. The site does not promote any particular product, but rather reviews most available ones and gives very helpful hints.

I am presently using GE Logician, now called "Centricity Physician Office" and I was disappointed. I had been waiting and hoping for an EMR for 14 years and when I finally started using it, it was not I had expected.

1. I need more time than before to finish my charts. Most actions require just too many clicks.

2. It was like having a whole new set of paper forms that you have to get used to.

3. Your EMR is not like your paperchart. It was designed by someone else that does not work and think like you do.

4. You often cannot adapt the EMR to the way you think and work adn you can olny adapt it a little. Your boss will tell you: "We try to keep it standardized", which is another way of saying "The programming or consulting time to adapt this program to your needs is too expensive. Suck it up already and get used to what we give you!" One of the advantages of corporate medicine, by the way - you have to adapt to what they give you instead of you adapting things to your likings as it happens in private practice

5. The advantages such as having "access to patient records everywhere including at home" turn out not to be as amazing as you thought. The added work everyday more than outweighs the advantages.

6. My most important issue as a specialist was that I wanted a super-easy way to send a letter or fax or email to the referring doctors. I want to have the report of the visit to be on the desk of the referring doctor as soon as the patient leaves the office. This happens to be very difficult in Centricity with multipe clicks. A consultant has to create the templates you request, every time a change is necessary, a consultant has to do it and so on. You cannot even enter a new pharmacy address because stupid you could mess up the sytem.

7. Centricity does not have a space for email address, for primary care doctor, for cell phone etc. The system was created 20 years ago and it shows.

If I was in private practice I probably would get "Amazing charts", a system that give you the ost value. It was developed by a family practitioner in Rhode Island to avoid being taken advantage of by the IT industry (just my line of thinking). Costs only $1000 for the first physician, $250 for each next one. And it does not matter how many staff members use the program.

Amazing Charts: You can download it and try it for free for three months, and the three months do not begin to count until you have 10 or more patients in the system. Meaning, you can play around with 9 patients as long as you want. Use it with a standard off-the-shelf wireless network, desktop and tablet computers. You can almost do all the installation yourself. Keeps the office frugal. Amazing charts also offers to do your billing for a very good price, which makes sense. Google it and see.

Marketing your medical practice

2007-05-20T09:37:00.000-05:00

This weekend I attended a 2-day seminar in a Manhattan hotel by "Healthcare Success Strategies". It was run by its two founding partners which separated from "Practice Builders" after that company was sold repeatedly.

The seminar had pretty much the exact same content of their 8 CD set from Advanstar, the publisher of Medical Economics. It was so much the same that the layout of the talks was identical, the wording of their talks was exactly identical, and I mean literally identical and even the illustrative examples were exactly identical. They told me that before the meeting, but I was surprised HOW identical it was. I had hoped that the "marketing plan" for my practice would be something substantial, but I am not sure about that yet. The marketing plan is a list of points selected from the numerous things they talk about. The selection itself might have some value, I think it is important what marketing tools to use and what not, but I would probably would have selected the same things on my own if I had made the list. But then, I might not have made that list. Being motivated to actually do it was one of the reasons I went to the seminar.

I had suspected that the CD set ($200) is a way of motivating you to do the seminar ($1000) and the seminar is a way of reeling you in as a client and I was right. My next step is a website for $7000 or a combination of website and brochure for $11,000. Sticker shock! Printing of the brochure, hosting, pay-per-click advertising is all extra of course. Their plan is to start you with at least $2000 a month for the first year. And it goes up from there.

During the CD set they made sure that "a list of ideas is not a marketing plan" and of course "not as effective". During the seminar they make sure you hear that "little details in wording and in graphics may make all the difference", meaning if you want to be really successful, you have to hire them as your marketers.

Overall, their ideas sound very good and feel very real. I have read Neil Baum's book on ethical and effective marketing and it is very similar. The Healthcare Success Strategies guys offer a little bit more. And I believe that they actually have the experience they claim to have and I like their "test, track and adapt" of marketing moves.

I am not sure yet if their claims are correct and if they can be as successful as they say, but I suspect they are right. I am willing to try and see what happens with my practice. I'll keep you updated.

The Secret Golden Rules of Radiology

2007-05-15T14:31:00.000-05:00

Last weekend while on call I got lost in the radiology department and suddenly found myself in a small, remote, dimly lit room that contained only one large beautifully ornamented bronze plaque:

On top of the plaque it read "The Three Golden Rules of Radiology"

and below:

1. Never let clinicians lock you into a diagnosis, always be vaguely descriptive and always end with the sentence "...has to be decided on clinical grounds"

2. Never exclude the dangerous diagnosis the clinician asks you to exclude. Never write: "No ectopic", "no cancer" etc. Always end with the sentence "(Enter diagnosis clinician wants to exclude here) cannot be excluded"

3. Always recommend another radiological study "for confirmation" or for "further clarification". If the patient has had an ultrasound, recommend a CT, if the patient has had a CT recommend an ultrasound and so on.

I always had suspected this.....

basics for a successful practice

2007-05-15T12:54:00.000-05:00

The big idea, the overall strategy for a financially successful ObGyn practice is:

1. Do as much in the office as possible, spend as much time in your office as possible, do as many diagnostic and therapeutic procedures in the office.
Reason: This way you get paid for the procedure plus you receive the "facility fee". You also save yourself the wasted time of patient change over in the OR. It is YOUR office, you are in command and you can streamline all procedures to maximum efficiency. I heard it again and again from successful colleagues: if you can work most of the time in the office and avoid going to the hospital, you earn more.

2. Top procedures to do in the office at this time (May 2007) are:
a. endometrial ablation by Novasure, balloon, free water ablation
b. hysteroscopy, possibly with ultrasound
c. Essure
d. sonography, e.g. saline infusion hysterogram

3. Should you have to go to the OR, then try not to have block time, but try to get the first slot in the OR in the morning for one procedure. This way you avoid the loss of time involved with changing patients, whihc usually takes longer than you need to talk to the relatives and dictate you op note.
Do your surgeries on your on-call weekends, where you can't do much else anyway or have to be at the hospital anyway. Many hospitals allow scheduled surgeries on Saturdays.

4. Learn ultrasound and get AIUM certified, many HMOs require that certification for being able to bill the interpretation of sono pictures. Besides that: the optimal information comes from doing the ultrasound yourself. No still picture can replace that.

5. Learn coding well to maximize your reimbursement, attend courses, listen to your colleagues, and remember - the HMOs are using sophisticated, expensive, highly specialized software to aggressively downgrade your reimbursements no matter what you do. Visit an ACOG coding and billing course (one of those courses that are always sold out)

6. Market your practice like crazy, it pays off tremendously. Read the book by Neil Baum "Marketing your Clinical Practice - Ethically, Effectively, Economically" and follow the advice. You might also consider hiring a professional marketer for developing a marketing plan and for carrying it out. Consider Healthcare Success Strategies. Try the CD set for 200, then the course for 1000. Then you'll know if it works for you.

&. As soon as financially feasible, fire the HMO with the lowest reimbursements and with the biggest hassles (it is usually the same HMO). Repeat as often as possible.

More recruiter comments

2007-05-14T14:12:00.000-05:00

CEO, Physician Recruitment and Retention said...

For all of you that read this, get ready as a candidate to pay thousands to the "new" search firm called thedoctorjob.com. Actually, the job sourcing they do was invented by and is utilized by EVERY firm that is out there, except that you do not have to pay for it with recruiting firms. Just ask any recruiter out there.

Also, just as he states, watch who you listen to and talk to...having placed thousands of physicians myself and with my colleagues I must admit, even physicians can be wrong.

Lastly most of recruiters are there to serve the following purpose: Do the work you do not have the time to, and do the work as your representative. If Dr. Muenzer is the expert on all recruiters, then I guess he has not talked to very many. The world is full enough of know it alls, and not enough of those that will do all it takes.

Dear CEO Physician Recruitment and Retention,

I am glad to hear a comment to my blog from an actual recruiter.

You are completely correct. The method of sending a professionally prepared CV and cover letter directly to all physicians in your area of interest is old. I started doing it 23 years ago back in Germany. It is being used by recruiters as one of many sourcing techniques, such as direct mail, mass mailing, mass faxing, mass emailing.
That of course raises the question: If you use it successfully why do you never mention it to your customers? Too good for them? Could it be that you are upset that someone is giving out the "secret recipe"?
The method of sending letters to potential employers is probably as old as letter writing itself. To claim it as an "invention" of recruiters seems just a bit short sighted. It reminds me of Al Gore inventing the internet.

I also agree that recruiters provide a service for physicians that do not want to do the recruiting themselves. That nevertheless requires a comment.
Recruiters help employers fill a position. Recruiters usually are called when positions cannot be filled easily through word of mouth or simple print advertising. Recruiters usually do not help physicians search for jobs. They may run a search in their databases to see if a job fits the requirement of a candidate. But recruiters are not hired and compensated by the job searching candidate. Therefore, they do not truly work for the candidate. They do not go out and do mailing specifically for that candidate. They do not help the candidate improve the CV or cover letter. Recruiters recruit for an employer. Otherwise they would be "search agents". Search agents do exist, but are not very popular.

This differentiation between working for an employer or for the candidate might sound like splitting hairs. Nevertheless it is a very important difference: "Whoever pays calls the shots".

I usually teach my residents that they can search actively or passively. With an active search they are in control. Active search includes networking methods such as calling every conceivable contact and talking to every person that is willing to listen to get in touch with a potential employer. Active search means: mailing out your CV and cover letter, faxing it or emailing it to potential employers. Click here to read more details.

Passive search means reacting, reading, listening. This includes reading advertisements, job postings, visiting websites, looking on the internet and also leaving your search in the hands of a recruiter. Once you do this, you are passive, you are responding, reacting, not acting and therefore you loose control and power.

You have to take what you are offered! You do not go out there and get it yourself.
Let me repeat that: You are limited to what is offered to you, you do not go out there and get exactly what you want. You do not create or uncover your own opportunities.

Recruiters love to claim that they "search for candidates". Recruiters usually only search recruiter databases. They search in a database of positions where employers have agreed to pay 20 K to have that position filled. This alone shows that they are not acting in the interest of the candidate. As a candidate I would never dream of approaching an employer with the condition that 20K has to be paid to a third party. That would be completely ridiculous. Imagine me applying to a Harvard hospital stating that hiring me required a payment of 20K. They would refer me to a psych clinic or to their social worker on call. You understand the point?

Mailings cost money. Nobody understand that better than a recruiter. For $1000-1500 I can do a mass mailing myself, for $1500-2500 I can have thedoctorjob.com do it. If I have thedoctorjob.com do it, I am still in command, I still search actively, since they just do the mailing for me. They do not search for me, they just write or improve the CV and cover letter and they have the list of doctors in my target area.
I determine where I search, I call the shots, and consequently, I pay.

And for a whopping $20,000 you can have a recruiter "do the search". Yes, I agree, the physician candidate "does not have to pay it". Formally it does not come out of the candidates pocket. Formally...but the candidate usually ends up paying it anyway. He pays by lowering his chances of getting the job - since he may be competing with candidates that do not come with a recruiter, he may pay by receiving less benefits, maybe even a lower salary. I have commented on that in a previous post. Recruiters do not want candidates to know that. An empployer once said: Sorry I cannot pay you more the first year, since I have to pay the recruiter. After I mentioned this to the recruiter, he answered: "she was not supposed to say that according to the contract". Literal quote!

Recruiters seem so intensly immersed in their recruiter world that they actually seem to believe this "at no cost to you" thing.

The big, huge, overwhelming cost to pay for a recruiter, is that recruiters do not get into the desirable areas. Wherever there are more candidates than jobs, jobs are filled without recruiters. And I have this quote from a recruiter, from one of hundreds I have spoken to. You know it, we both know it: recruiters get paid to fill the less desirable jobs. Period.

And who wants the less desirable jobs?

That is the true price you pay for using a recruiter: you get a less desirable job.

So, you have a choice: Search actively by networking and mass mailing (DIY or thedoctorjob.com) or search passively (e.g by answering recruiter calls) and accept a lesser job.

And, as the last point, I have been in touch with many, maybe too many recruiters by phone and email, nice ones and rushed ones, eager to sell recruiters and more relaxed ones, younger and older ones. In house recruiters, retained and commission driven ones. I think I have seen enough in the 6 or 7 years I have been in touch with them to be able to judge.

Maybe I am not a know-it-all, but when it comes to recruiters I definitely am a know-enough. I might even say I have had enough too.

Your Matthias Muenzer, MD

Practice Marketing

2007-05-11T22:21:00.000-05:00

You might have maxed out the cost saving measures in your practice. The next step is to grow the number of patients that you like and love working with. Marketing will get you there.

You must buy and or read this book: "Marketing Your Clinical Practice: Ethically, Effectively, Economically", 3rd edition, Hardcover, by Neil Baum and Gretchen Henkel, about $90.

Neil Baum is a practicing urologist from New Orleans. His book contains the sum of all other advice that I had heard before plus a surprising amount of new ideas. No wonder nobody recommended it to me. Every resident should receive it as a graduation gift from the program director. It is an absolute must for private practice. Consultants are not going to tell you much more than what you will read in this book, they just charge you more. Read this book first and then attend the $ 2000 weekend courses (where you will be broadly solicited for more "consultant services").

"Guerrilla Marketing", the now classic text by Jay Conrad Levinson. The standard on marketing creatively and on succeeding against the big guys. Interesting, easy to read, stimulating, you get a lot of ideas and inspiration while reading it. Paperback, around $ 15. He has written numerous books on the subject in all its facets: guerrilla marketing handbook, guerilla marketing for free, on the Internet, guerilla job search etc etc.

"Healthcare Success Strategies" is a marketing company that specializes on private physician practices. They claim to have a lot of experience and success. They sell a good 8 CD set on marketing your practice, which gives you many insights, and also serves as a tool to more or less subtly convince you that marketing is more than a list of ideas and that you should have professionals (meaning to the authors) handle it. They offer a reasonably priced (about $1000) two day seminar (with preparation and follow up home work) to come up with a comprehensive marketing plan tailored to your practice. Take a look at their website, if you like it, buy their CD set for $200 and then decide if you want to go further. I think they are good and worth the money.

Strange

2007-05-11T14:03:00.000-05:00

It's very strange. I started blogging to share my experiences gained during a job search. While searching I became increasingly fed up with physician recruiters until curiosity and respect had given way to dislike and lack of respect. When I found that it was actually very easy to find just the job you want by mailing your resume out to all doctors in your preferred area I wanted to share this. Nobody read, listened or reacted, except for the few people that do that kind of mailing for a living.
Now I have vented my frustration about recruiters and have moved to other topics. When I write about how to do something better, tips for everyday practice, nobody responds. Is nobody interested in tips to improve your practice? Does everybody just say "Aha, nice, I may be able to benefit from this, and I'll better keep this quiet"
My dream was a blog or website where people share what makes them successful, what makes their practice run smoothly, what makes more money, what doesn't. How can we succeed as doctors? Probably more the question to pose a consultant, not so much a fellow doctor. Doctors seem very very guarded about their success strategies...
But imagine (I could say "I have a dream") physicians sharing their ways to succeed - we wold be incredibly more efficient and powerful on all levels of practice and life.
That is my dream. We all have things that help us succeed, that work well, I am slowly sharing mine, maybe I get a reaction here and there...

When I post something that is "political buzz" then I suddenly get responses. Wow, it's certainly nice to talk, but my life will not be any different if I write or talk about medication politics, malpractice, new laws or guidelines etc etc. When did my opinion, my writing, my talking last change anything?

But if I learn how to run my practice more efficiently, my life will get better.
Actions matter, not talking.

Talk about politics and entertain the audience in the blogosphere, discuss until all Google servers go down, to me it would not make a difference.

Zillow ! Just in case you did not know about it

2007-05-10T17:50:00.000-05:00

Use Zillow.com when buying or selling a home. It’s the best thing that happened to buyers, sellers and in general to real estate in a very long time!
It is a free website with fabulous services, that so far were not available to the public and closely guarded by realtors in order to secure their territory and their income.
Now you are able to see almost ALL publicly available information on a house, an estimate of the current market value called "Zestimate", a list of comparable homes, a graph with the development of the value of the property over the last 10,5 or 1 year, a bird's eye view of the house, a view of the city or neighborhood with little price tags on each house. You are able to see which houses were recently sold ad the selling price, you are able to see which houses are for sale adn there is a feature called the "make me move price"! And the best of all this - no realtor involved! No pesky sales tactics....

Use it when buying to see the estimated value of a home that you are considering together with a list of 10 comparable properties, see what the development of the prices in that specific neighborhood was during the last 10 years and if it is going down, negotiate a little tougher.

You can post your home for sale on Zillow and you can advertise it by posting photos and a commentary. So, sell your home on Zillow and save yourself the realtor fees, which can quickly run into the tens of thousands. For that kind of fee you can show the home yourself and can easily hold a few open houses...
No need to support that BMW driving kid with the motor mouth that is out for the quick cash and other realtor types that make as much as we do with a background of education that can be obtained in a weekend! Their education includes less study material than we needed to pass a single subject in any given year in medical school.
And most of what realtors do is uttering profound sentences like: “That view is georgeous” “Look at this wonderful kitchen”, “Yes, the bathroom has been updated” I very much hope that realtors will fade away like travel agents after Orbitz, Priceline & others came along.

Fee only financial advisors

2007-05-10T17:43:00.000-05:00

As soon as you get out of residency - or even before that - you will meet another predator that has his or her eyes trained on the new doctor with sudden increase in income. This predator is ready to take advantage of you.

They commmonly present as insurance salesperson and "financial advisor" wrapped in one. He or she offers insurance, many insurancesIt is completely up to you how much insurance you need, but, for example, you definitely do not need life insurance if you are single. You may need disability though.

Always comparison shop and never sign the first time you meet someone. Don't fall for the trick that life insurance, especially "whole life" is "a great investment". It is, but only for the insurance company and for the salesperson, not for you.

It is a great idea to get a financial consultant, but don’t fall prey to all the insurance scamsters and salespeople that pretend to be "financial counselors". Everybody seems to be a financial advisor, counselor or consultant these days.

I recommend to look for "fee only" financial advisers. They have their own professional organization. Fee-only consultants charge by the hour only. Therefore they are the only advisers that do not have a conflict of interest. Everybody else will tend to sell you something in order to benefit, silently or openly. Insurance people will sell you insurance, brokers will recommend to trade, trade, trade (and make commissions), investment advisers from big firms will recommend the stocks and investment vehicles of their own firms and so on.

Fee based advisers get paid the same no matter what you do, and that is a fee per hour. (At least in theory, who knows if they get kickbacks or not, I assume they do occasionally) But in theory they do not care what you do or do not do. Therefore their advise is more objective and less tainted by personal interest. And therefore more reliable.

I would not work with anybody else.

Recommended CME

2007-05-09T10:32:00.000-05:00

As an ObGyn working in Boston I like the Harvard courses held in the Four Seasons in Boston called "Annual Update in ObGyn". Presented in spring and fall by the most excellent faculty of Brigham and Women's Hospital and the MGH. I attend every one to two years. You might check for alternatives at Yale, Duke, Cornell, UC San Francisco, etc. These courses allow you to get in touch on a personal basis with the very approachable faculty and you also get excellent materials with the course.

My daily dose of CME comes from Audio-Digest CDs, "the spoken medical journal". I get a CD in the mail every two weeks (it also comes as MP3 or cassette if you are one of those people who drive a Volvo 240 wagon and live in Cambridge). It is the best CME program I have found. The recorded lectures are given by good, renowned, expert speakers, many of them nationally known, on topics that really matter. I listen to the lectures in my car on the way to work and back, over and over again until I am bored. It is a very effortless way of learning, the material kind of diffuses in.

And, yes, I have tried the ACOG audio program. I did not like it, too superficial, not as relevant as Audio Digest for daily practice.

I have also tried and stopped a subscription to the cassettes by Oakstone Publishing in Alabama. They advertise that they scan the literature and select the most important articles, summarize them and comment them. Well, not quite. The selection is by far not as good as the ABOG selection and the comments are mostly simple repetitions of the summaries.

The other best CME is the ABOG list of publications and the corresponding questionnaires. Can't beat it - you keep your board certification up to date plus you get a select list of relevant publications plus you get CME credits.

My favorite other source besides the Green Journal of course, is the throw-away journal "OBG management". The chief editor is Robert Barbieri, the close-to-genius director of ObGyn of Brigham and Women's Hospital, who has an uncanny sense for what is truly important and relevant at any given time.

The best medical database that I consult frequently is "uptodate", written almost exclusively by Harvard faculty. It is very, very readable, precise, evidence based and last not least, up to its name it is up to date. About 500 a year. Uptodate also has some of the best medical information for patients on their website! Direct your patients there to avoid them falling prey to weird internet rumors.

WHO list of essential medications

2007-05-08T12:44:00.000-05:00

Have you heard of the WHO list of essential medicines, and if so, have you bothered looking at it?

It is a list of truly necessary, not replaceable, basic ("essential") medicines. If you were about to be dropped of in Durfur to establish a general purpose clinic, that is what you would take with you.

Let's look at the birth control pills, which is something that I, as an ObGyn, can talk about: You will find just two, the combinations of EE and norethidrone, to us known as Necon and the combination of EE and levonorgestrel or Levora.

That's it. And let me tell you, it is enough, even for the US. With Necon you have an OCP with a progestin component that has little androgenic side effects, is very well tolerated, generic and dirt cheap. With Levora you have an OCP with a more androgenic profile with excellent bleeding control, which we use in Levora, Seasonale (just a re-packaged Levora, no misteries there), Plan B and Mirena. Also generic, also dirt cheap.

How come there are over 100 OCPs o the market? All "Me too" products, nothing revolutionary new, maybe, but only maybe, Jasmin. So why do the parmaceutical reps fill your ears with "information" about their fabulous new pill with oh-so-great bleeding pattern, side effect "profile" and other utter nonsense?
Plain profit making. Nothing else.

We do not need most of the medications that are not on the "essential list", or we need them only for extremely specialized purposes. We really do not need over 100 different oral contraceptives, since the only thing that makes a difference between them is the individual response of a woman's body to any given birth control pill. And that, dear pharma rep, was, is and will remain unpredictable. You just have to try. During my first residency, many years ago, I asked one of my attendings about what to do if a woman did not like her birth control pill. His answer was: "Just give her any, but really any, other pill". Back them I thought he was rude and maybe even stupid. Now I have experienced that it is in fact true.

Another example: I still prescribe good old Ibuprofen for pain. It is cheap and it works every time. And the fact that I never prescribed those fancy new cox-2 inhibitors saved me a few sleepless nights when some of them were withdrawn from the market.

My other rule about prescribing medications is:
If I see it on TV I don't prescribe it. My patients would just be paying for the TV ads. Also, if a phrama rep comes to my office and pitches a medication, I don't prescribe it. It has to be expensive, if not they would not pay for a rep to come over. And of course, most of the meds they pitch are "now tier 2, and only with such and such insurance tier 3, but we are working on that"...

So, take a look at the WHO list of essential medications and see which meds in your field are essential! And which ones you can do without.

what well paid lobbyists can do

2007-05-07T17:35:00.000-05:00

WASHINGTON (MarketWatch) -- A Senate vote on Monday likely assures that U.S. borders will remain shut to lower-priced prescription-drug imports, marking a major victory for pharmaceutical manufacturers.
The Senate voted 49-40 to approve an amendment to a bill dealing with the Food and Drug Administration, which would require the secretary of the Health and Human Services Department to certify that drug imports would pose no safety risk to American consumers before allowing pharmacies to import prescription drugs from Canada and other countries. Health officials have said they can't provide that level of assurance.

Thank god, the drugs from Canada cannot come into our great safe and well protected country! I must have missed those newsflashes about the rampant deaths among the elderly, the children and in general the frail in Canada following ingestion of Canadian drugs...
We all know that the difference between drugs in Canada and the US is just the price (and the profit for the manufacturer). The drug manufacturers are the same in Canada and here, the production standards are the same, the hygiene standards are the same, the pharmacies have the same quality standards! Hey, this is Canada - we are not talking Afghanistan here.
But, the profits are less in Canada, and we cannot let that happen! So, the pharmaceutical companies give a few millions to lobbyists, and voila, the billions of profit continue to go into pharma's pockets.
This is a point where the HMOs should flex their muscle. Where were they when we needed them? Why have they not paid their lobbyists enough? Where were their millions?
This kind of obvious corruption is sad. Laws are maid by the wealthy and for the wealthy. Realistic, but very sad.
You understand now why I do not see pharmaceutical representatives? they get paid by the very same people who pushed this law through. Not only do pharmaceutical reps waste my time, they consistently overcharge my patients. And that is harmful.

patient education leaflets

2007-05-07T17:15:00.000-05:00

The first choice for many are the ACOG leaflets – more expensive than other solutions, but they are “the standard” and therefore always defensible in court should an issue arise. They look nice, fit into most purses, can be conveniently kept in wall hangers - even in small examination rooms. They are just the best.

Significantly less expensive than ACOG leaflets: a subscription to “MD-Consult”, which is only $220 a year on the net. This service not only gives you a large amount of textbooks, journals and pharmaceutical and pharmacological information, but (and this is the great thing that alone makes it worth the annual subscription) it gives you access to about 3000 (!) patient instructions, very well written, a good number also in Spanish. Often they have a short and long version of the same topic. I print out the instructions leaflets, copy them and keep them organized in my drawer, so that I can hand them to patients as needed - without having to log on and print them out each time. Loggin on, selecting an printing is very tedious in mdconsult.com. I dropped the subscription due to this. Printouts can be personalized with your name and office address. Advantage: price. Drawback: plain black and white printouts, no graphics, no colors.

Easiest, cheapest solution, but it feels somewhat dated: Miller, McEvers, Griffith: “Instructions for obstetrical and gynecological patients”. Now in its third edition, $50-60. You are specifically allowed to copy all pages and hand them to your patients. The book comes with a CD that you can load onto your computer. It lets you easily print out all 200 plus patient instruction leaflets. The book also includes diets and illustrations. A steal. Has proven to be extremely cost effective.

Write your own leaflets and information material! This is probably the best way. You will have tailored and customized information from your practice. And, your patients will first hear it from you and then read the same information on a paper at home (hopefully). This achieves maximum retention and effect. This also eliminates mixed messages or confusion when you say one thing and some website recommends another thing.

I recommend not writing leaflets by a list or on demand, let's say, in response to the thought, "Well, what leaflets might I need?" and then sit down and write them...NO, do not do that. I recommend a different approach: as soon as you realize that you are explaining something several times, as soon as you find yourself talking about something repetitively, you simply write down exactly what you just said. You use spoken language, simple terms. Voila, your leaflet is done.

Then continue to correct and expand it with time, as the additional questions and ideas arise.

This is also the best way to write a practice newsletter. Write down the things you explain to your patients, or the things you would love to explain, but do not have the time and mail them out or email them out every so often. Nobody says that a practice newsletter has to come out every three months. Write them and mail them as the issues arise. For example in late 2006 it was HPV, and the answers to the questions " Do I need an HPV test? Do you recommend the HPV vaccine?"

Post this information on your website. A good place to keep the original files or master files is in "Google Docs and Spreadsheets"

I have used all the above in the past, and presently, based on my experience, I use a combination of my own leaflets and the ACOG leaflets.

basic financial information

2007-05-05T16:46:00.000-05:00

Get a financial education. Where do you start? Do you invest in stocks? How do you pick the right stock? Do you do the research? You are able to invest hours and hours into looking into companies? I constantly felt overwhelmed by the choices of stocks. I thought funds would be a good idea, more balanced, a bit more diverse, more stable, easier to research than individual companies. I invested into mutual funds that performed high the previous year, and shockingly, the performed below average the year I bought them. Then, by chance, I ran across the following book and absolutely loved it. It provided a completely new perspective on stocks and funds, it made a lot of sense and it seems to make investing very easy, more a place and forget thing:

"The Only Guide to a Winning Investment Strategy You'll Ever Need: The Way Smart Money Invests Today"
by Larry E. Swedroe

20 dollars that might save you thousands and make you much much more. Swedroe lays out, in a kind of evidence-based way, the "modern portfolio theory" and the "efficient market theory". The "efficient market theory" states that the stocks on present day markets are always efficiently priced, that there are no "hot secrets", no undervalued stocks that you can capitalize on. The reason is that thousands of full time analysts are constantly combing the market, examining and evaluating companies. It is close to impossible to beat the market by purchasing specific stocks. Stocks are priced right.
And, you cannot predict how the market will move in the future. Short term developments are literally random. You cannot know more than the market, especially in the long run.

The "modern portfolio theory" says that index funds perform better than individual stocks in the long run. Index funds are the best performers, better than any personally managed investement fund, better than "aggressive growth funds" in the long run. The index funds grow in the range of 9-11% on average, long term. Just for fun, check the performance of the Dow Jones against your personal performance. Did you beat it consistently over 15 years?

Why is trying to score with individual stocks in hopes of "beating the market" generally believed possible? The media and brokers make a very comfortable living using and spreading this misconception. Imagine if everybody just invested their money in index funds and let it grow - brokers and media types would have to look for new jobs...They have zero interest in telling you that index investing is better than what they offer...and cheaper.

Only rare, select managers beat the indexes over the long run, but chances of you personally investing their money with them are minimal. On the other hand, your chances of under-performing are vast. Index funds offer an investment vehicle that is incredibly and unbelievably easy. Almost no research required (after setting them up) and very rewarding. There are quit a few indexes, some of which are more heavily weighted to large stocks and others to smaller stocks. There also are international indexes. It seems important to maintain diversification among various asset classes, but the book explains that nicely. It also teaches how to build a portfolio.

It seems easier and better, why not check it out?

My favorite patients

2007-05-03T15:08:00.000-05:00

When I started with my new call group I was surprised to receive one or two calls almost regularly every Friday late afternoon about 1-2 hours after taking over that sounded like this: "I am / my daughter is in excruciating pain, we have called the office (of the doctors I am covering for) severla times today and nobody has called us back. The pain medicine Dr....has prescribed is not helping / doesn't touch it. Is there nothing you can do?" and somehow the conversation would always turn to the perception that a narcotic prescription really would be the only acceptable solution to the caller's "excruciating" pain.

Initially I was annoyed at the negligence of my colleagues and attributed it simply being very busy. Sometimes prescriptions are forgotten, or not picked up by the pharmacist etc.
Then I collected the names and phone numbers of the callers and asked the "forgetful" colleagues about these callers. It turned out that they in fact had returned all those calls, but simply had not seen a good reason to prescribe the desired narcotics. And, as we all know, "Ibuprofen just doesn't touch it". Not only had my colleagues answered all these phonecalls, they had also informed their patients about their policy of "no narcotics on call or outside of office hours" - a policy that I now happily quote to those callers.

As it turned out, one patient was particularly tenacious in her requests for the comforting Vicodin. Her request was denied by my colleagues during office hours and, sicne she lives hours away, she was told to go to a local ER. So the ER calls me about this patient. All I could do is to relate my experience: She has called me multiple times after hours, she always requests Vicodin, I have never seen her nor examined her in person, and she either tells me she is about to have surgery for pelvic pain or she just had surgery for pelvic pain.

My hopes that this would be it for the evening were disappointed. The patient herself called me after receiving a prescription for ibuprofen, furiously reprimaning me about "giving the wrong information to the ER" " that made them not give her the right pain medicine" and that she "had to wait in the ER for hours with three children" and on and on. The next time I spoke to my colleagues I asked them to consider releasing them from their practice. The next time she called, I reminded her that restricted substances are restricted for a reason, that she should go to the local ER and that I could not do anything for her long distance over the phone (she lives hours away, God knows why she is still in my colleagues' practice, I can only suspect the reasons why she has not been able to find a local doc). I am waiting for her next call, for now it has been quiet.

I also love those prescriptions that are forgotten far away in the next state, where the patient did spend the weekend (apparently the "excruciating pain" does not prevent them from traveling for hours and hours).

I love the stories where prescriptions are forgotten on the bus, in a pub or in other public places. I personally would stash away such a valuable prescription in a very safe, deep pocket that I would never had a chance of loosing it. Strangely, narcotics precriptions seem to be the only ones that are teated with such neglect that they disappear, since I have never heard that an Ibuprofen prescription has suffered such a fate...

The patients that request those prescriptions usually tell you that you are the "best doctor in the world" and frequently mention that their last doctor "was just not a good doctor" who did not take good care" of them. I simply do not understand that they abruptly leave and never come back to the "best doctor in the world" once I explain that I do not prescribe narcotics more than once...

I also am surprised that those patients seem to lack the most simple and basic ability of foresight. You know that you need narcotics, you see that the bottle is almost empty for days, and you do not call your doctor's office during the day, but call me after hours??? As if you didn't see that coming?

Art in your office

2007-05-02T16:35:00.000-05:00

What's on YOUR walls? Those Mediterranean motives painted in fake impressionistic style usually sold to mass tourists on side walks, now available at your trusted Wal-Mart? That style of "art" that seems obligatory in medical offices if you believe your local decorator? You know, those pictures of Portofino, Lago di Garda, Lago di Como...

Try the following low cost – high style alternatives:

Nicholas Nixon “The Brown Sisters”. Shows 4 Massachusetts sisters as photographed yearly by one of their husbands over a time frame of 27 or 28 years now, one photo each year. A wonderful series – very suitable for an Ob/Gyn office. Buy 2 books for $39, tear out the pages and frame them. Or pay 100 K for a signed original 25-image-series available in a NYC gallery.

Take a look at the following artist websites (and remember that taste is subjective):
Photographies by Emerson Matabele http://www.emersonimages.com/

One great photographer, whom I happen to know in person, and whose art I have bought without regretting it one second is Martin Berinstein. Take a look at his photographies at www.berinstein.com.

Dry pigment paintings by Diane French who has studios in La Crosse, WI and St. Augustine Beach, FL http://www.statestreetgallery.com/ and http://www.canvascompany.com/

Ansel Adams never hurts either.

Should you have an Ikea nearby, they have very affordable framed and unframed art…

For nature images of the Everglades and Florida look up Clyde Butcher, who for me comes close to Ansel Adams. He photographs South Florida and its beaches, the Everglades, and the Big Cypress Swamp. On his website http://www.clydebutcher.com/ take a look at the “posters” section - for $40 you get excellent images…

Also good is Debby Krim, a photographer in Boston, whose work can be seen at www.debbykrimphotography.com. She has excellent plant and nature photographs, she uses photographs in an innovative way by placing them on small rectangles and then combining many of those small rectangles to bigger pictures. This open almost unlimited possibilities for your office

I have the privilege to live in Boston (a privilege for which I pay dearly with lower income and higher malpractice rates) and we have a fabulous thing called "open studios". These are events, usually weekends, where many or most or all artists in one part of the city open their studios to the public. They even offer wine, mineral water, crackers, sometimes music and always conversation. Truly a wonderful thing, I love it. I consider it one of the best sides of Boston. If you are anywhere near the city look in the Boston Globe or on the Boston Globe website or google the term "Open Studios Boston" and visit...

Be different!

Oh

2007-05-02T11:27:00.000-05:00

I am by far too serious in this blog, no wonder nobody is reading it. I just wandered around from one blog to the next finding fascinating, funny posts from ambulance drivers, ED nurses, medical students, all soo true and funny. I still remember the situations they describe, the weird and funny patients, the thoughts that I thought should never be published, but hey, here they are, readable for everybody.
Maybe I should stop blogging. Or maybe I should continue since this blog was created less for entertainment - I am not that funny, I know - but to post "what I wish somebody had taught me before I made a mistake or wasted my time". I guess I'll continue. And now I'll go and have some lunch, it is 12.38 and I hear the nurses laughing in the lounge of the office.

Medical Malpractice 3

2007-05-02T09:33:00.000-05:00

Posted by Anonymous on Monday April 2nd 2007 as a comment on one of Flea's posts concerning medical malpractice:

"Human nature's a bitch, isn't it? Good doctors get sued, sometimes with little justification; sometimes the get away with an understandable error of judgement that teaches them to be a better doctor, but leaves some poor smuck with a life long problem; bad doctors sometimes get away with it because patients are ignorant of what really happened, or don't want to sue. A recent Harvard (I think) study showed that the "compensation culture" is a myth, as most people who were treated negligently either did not pursue claims, or were unsuccessful, and some people whose cases had no merit won. The system is a mess, but how can it be sorted out?"

This points out a problem of our system: Most people who suffer a "damage" are not compensated and on the other hand some that are treated correctly are compensated unnecessarily. The system "is a mess", and there is a way to sort this out.

Instead of a court system we need a administrative claim system. Should a patient feel treated incorrectly or damaged, he or she should be able to submit a claim for compensation - similar to Workman's Comp. Patient will be examined by one or two or more physicians, the report will be reviewed by one or more experts, who will award a compensation or not, according to documented lists.

This removes the "fault", the blame, the court, the heated emotions and the lawyer profits. It is shorter and more conducive to open communications between physicians and patients, and more conducive to data collections about complications.

More patients would be compensated, we would learn more about complications and how to avoid them.

This "mess" is actually not difficult to sort out, so ....Why do we not have such as system?

Because our lawyers do not want to give up the "golden goose". That's what is wrong, that's where the problem is. Lawyer greed prevents solving the mess. The lawyers working as politicians in Washington do not want to hurt their buddies by taking away the profitable medical malpractice system that has financed many a second and third villa, boat, luxury car etc

Also, physician do not have a lobby as well funded and powerful as the industry lobby that pushed through Workman's Comp!

Lawyers preserve a system that is inefficient, expensive and slow, not because it is just, fair and good, not because it is the right system, but because it makes them wealthy.
I am not just unhappy about the "lawsuit culture", I am unhappy about a flawed system that might benefit the lawyers more than the injured.

I want "Patient's Comp". Or let's say "Mother's Comp" for obstetrical complications.

Medical malpractice (2)

2007-05-01T17:01:00.000-05:00

I am following Flea's malpractice story and the many comments about his posts.

When doctors complain that lawsuits are often "about the money", we are very aware that we all work for money. That is fine. And that is not what we mean. What we mean is that the financial incentive, the possibility for a large financial gain sometimes is the primary incentive to start the lawsuit. It is a chance to cash in, nothing else. Sometimes it is not about truth, justice and all that. We are not saying that lawsuits should not happen at all, we are not saying that all lawsuits are unjust and unfair. But we are saying that too many are unfair. 75% are decided in favor of the defending physician. What does that tell you? Successful, experienced lawyers will tell you that they review 10 to 20 claims before they take on one single claim! And of the ones they take 75% are not successful. Does that explain why physicians feel threatened and overall treated unfairly? Any more questions?

Example: A patient of mine tried to sue me and spoke to her primary care doctor about the situation. She told him: "I like him, but we just need the money". It could not be clearer! It could not be more plain and blunt! "We just need the money". What a great reason to sue a doctor! And this actually happened to me.
This attempt, by the way, never went beyond a request for medical records. Unfortunately for her, my documentation of our talks before the surgery was extensive.

Physicians do not say that lawsuits always are about money only, but it is sometimes. And this is very upsetting to us.

I did a little statistic of 120 ObGyns in South Florida that belong to one large group. Some of them practice in Miami Dade and some practice in Broward and some in Palm Beach County. The colleagues in Miami Dade work without malpractice insurance and the others work with malpractice insurance. Six % of the colleagues WITHOUT malpractice insurance had paid money after a judgment during the last 10 years and 19% of the colleagues WITH malpractice insurance had paid money after a judgment. Coincidence? I do not think so. More research is definitely needed. This is difficult, since (unfortunately) there are not many areas where you can practice without liability insurance.

Here is some anecdotal evidence, gathered through conversations with several lawyers in South Florida. I came to realize that lawyers are very, very hesitant to sue someone who does not carry malpractice insurance. Can’t get the millions! Representative quote of those conversations: “I did it once and I could not collect, so I worked for months and months for nothing. I will never do that again.”
Lawyers will not try to sue if there is no chance of a big cashout. They will rather tell clients that they "do not have a case”.

Medical Malpractice (1)

2007-04-21T14:32:00.000-05:00

I was very sorry and upset to read that "Flea" a fellow blogging physician has to review old textbooks because he is facing a lawsuit. I do not know anything about the case, but it encouraged me to write down my opinion on the medical liability system.

While still living in Germany I had heard about the ridiculous outgrowths of the American product liability system:

Woman is stupid enough to dry her poodle in the microwave oven. Microwave oven cooks poodle's liver, poor poodle dies.

In Germany she would have been the target of giggles and open laughter, of reprimands for killing her poodle and of instructions about what a microwave oven does and what you can use it for.
Not so here in the US. Here she wins lawsuit and becomes rich. What is the moral? Stupidity and ignorance are nothing to be ashamed of, you actually are rewarded for it. If you act stupid, the legal system does not consider you stupid. It declares you a "victim" and compensates you handily.

The spilled coffee of a McDonald customer is another outstanding example. While the woman should have received a few bucks for her dry cleaning bill and a reminder that fresh coffee is indeed hot - which is how everybody wants it and why we buy it in the first place -a jury awards her a few millions. Clumsiness makes you rich!

And these awards are especially aggravating, since they are a crude and insensitive slap in the face of any working person! I cannot emphasize this enough! Why should the woman with the spilled coffee get an amount of money that I as a physician will have to work for - day and night - for about 20 years? Have you ever thought about that lack of balance? What on earth could be worth 20 years of physician work? Can you fathom the loss of proportion? Can you even begin to understand how ridiculous these awards are?
It discourages you from being a hardworking, honest person. Instead it makes you think about other possibilities to become instantly rich by acting stupid and pinning the responsibility on someone else. What message do these awards send???

Another recent example that infuriated me was a Boston globe article about an oh-so-poor-and-suffering family who had lost a dog to an electrical shock, caused by an insufficently insulated manhole cover. The family and especially the poor child now was supposedly miserable and depressed. The article personalized the dog by addressing it by name only, never as "dog". The article contained a photos of the child with sad face and downcast eyes - can it get more cheesy? And the lawyer actually demanded a "compensation" of a one year salary of the CEO of Nstar! Excuse me, would the dog have earned that salary if it had not died? What were they smoking? That family deserved a bouque of flowers, a new dog and a "we are sorry"letter from NStar with the promise to fix the insulation on those manholes. And the state should go after NStar to make sure they solve the problem. The shocking part was that the Globe actually became an accomplice of the greedy lawyer due to the understanding and supportive undertone of their reporting.

A very sinister example is the true story of a couple in NY who was under psychiatric treatment after repeatedly abusing and harming their own child. Finally they KILL THEIR CHILD! Consequently they sue their treating psychiatrist for not stopping them from killing their own child.... AND THEY WIN.

This is the ultimate absurdity. It also is a brutal message that you pretty much can do whatever you want. You are just not responsible for what you do. This is truly sinister and is my best example that the legal system has gone wrong.

I think patients should be compensated for faulty medicine, but without the theatrics of lawyers wildly dramatizing during a courtroom show and without the immeasurable "pain and suffering" component.

Patients should be compensated according to a table or list. You loose the left hand and you earn such and such a year, you get such and such amount of money. Period. No jumping up and down of a lawyer in front of a jury, no tear-jerker videos or any such nonsense. You loose the right hand, you get such amount, you loose hearing, you get such and such. Period. End of story. It is simple, fast and fair. And it would save the state a lot of money.

Now, we already have such a system and we all know it. And it works. It is called "Workers comp". What stops us from doing something similar in medicine? "Patient's Comp", and for the field of Obstetrics "Mother's comp". Pedetermined compensation. Streamlined process. No lawyer BS. No theatrics - hey, if you tell me, that I may become a millionaire if just complain a lot - then of course I will declare that I suffered a lot, a whole lot and I will be depressed and unable to work and I will have incureed all kinds of losses etc etc. And I will describe my suffering in multiple colors and I will look depressed and worn out when I show up in the courtroom. Nobody can prove me wrong, it's subjective and cannot be measured.

On the other hand "Patient's Comp" would be fair and fast.

There are other approaches of course. Lawyers could be prohibited from becoming partners of the plaintiff as they are now and could be forced to reimbursement by the hour instead of being paid with by contingency.

And, hey, what about reimbursing lawyers the same way we get reimbursed - with a global fee? That would solve 95% of all liability issues right away. And the lawyers would hurry up like you have never seen before. No endlessly drawn out pondering and discussing and describing and musing and debating and thinking about commas and single words and all the implications of tangential issues....

And, another approach is simply not having malpractice insurance. It is well known that lawyers go after the deep pockets, and our malpractice insurance contracts with 1/3 or 2/6 million coverage is an open invitation to sue. Greed drives the malpractice misery. Try getting a lawyer to sue a physician with no insurance - "sorry, you do not have a case". And I am not making this up. There are areas in the US where you can practice - very happily I may say - without carrying malpractice insurance. One of the consequences: colleagues in those areas get sued a lot less, and I mean a lot less! I have spoken to lawyers in those areas. They were very unhappy about their situation. Needless to say that I could hardly contain my happiness about their situation.

But not having insurance will ultimately damage the occasional truly mishandled patient. Therfore my preferred solution are special health courts, where decisions are made by judges who actually understand about medicine plus a compensation model that discourages courtroom theatrics and is based on predetermined tables and list. Something comparable to Workman's Comp.

What is so hard to understand about what I just wrote?
Nothing is hard to understand, and we all know who keeps us from having a rational system.

In the meantime I recommend the following:

1. Asset protection, to keep your personal assets out of reach of greedy lawyers. You essentially have to be pennyless on paper. Very possible. Dramatically decreases the incentive of a lawyer to sue you. The first thing they check, even before considering the merit of the suit, is the plain and simple money question "What are the defendant's assets? How much is he or she worth"

2. The lowest insurance amount allowed by law, taking away some of the incentive to be sued.

3. Medicaljustice.com, a company founded by a neurosurgeon fed up with sleazebag "experts" who will testify anything the plaintiff's lawyer wants. They send warning letters to the lawyer as soon as the process starts and also to the plaintiff's expert witnesses as soon as they are named. The expert witnesses are notified that they will be prosecuted in several ways if their testimony is less than evidence based. Professional complaints filed with their professional society, legal claims etc. Go to their website
And it is not expensive! Works best as a prophylactic tool.

4. Consider relocating your practice to a state that allows you to practice without professional liability insurance. Massachusetts does not! Practicing in a state that allows "self insurance" of physicians would save me personally 70,000 a year. Not pocket change. I certainly would know what to do with the money. And I certainly would prefer this amount to go towards the education of my child instead to the education of a greedy lawyer's child.

More to follow!