Beyond Residency: The New Physician’s Guide to the Practice of Medicine

By William L. Doss, M.D., M.B.A., Clinton E. Faulk, M.D., Carrie A. McShane, M.D. and Matthew W. Wilson, M.D.

Beyond Residency offers practical, no-nonsense advice about the business and economics of being a medical doctor. Used as a textbook in the Business of Medicine Course at East Carolina University's Brody School of Medicine, this edition is designed to work more broadly for other institutions teaching business of medicine courses and for new physicians starting out in practice.

Recalling his days in medical school, Marc Lyles, senior director of health care affairs for the Association of American Medical Colleges said, "Whenever we asked a business question we were always told, 'Don't worry about that. You need to learn the medical side before you worry about the business side.'" He states that between 2003 and 2007, the majority of students were satisfied with their medical and clinical training. However, less than half felt that enough time was devoted to the practice of medicine, especially to medical economics.

The Brody School of Medicine addresses that discrepancy, offering its Business of Medicine Course as a fourth-year elective and as a postgraduate class for students in the Department of Physical Medicine and Rehabilitation. Topics addressed include time value of money, contracts, RVUs, disability and life insurance, and investment plans such as traditional IRAs and Roth IRAs.

In 2015, the Business of Medicine Course received a positive score of 4.68/5 (94%) for its value to medical students, and Beyond Residency received a score of 3.89/4 (97%) for its effectiveness in teaching students the business of medicine.

Beyond Residency helps students to understand important yet under-explored areas that will impact them as practicing physicians.

• Language: English
• Publisher: ECU Brody School of Medicine
• Release date: Dec 12, 2016
• ISBN: 9781469633992

William L. Doss, M.D., M.B.A.

William L. Doss, III, MD, MBA, is the lead author of Beyond Residency. He received his BS and MD degrees from the University of Michigan and Howard University College of Medicine, respectively, and his MBA from Auburn University. He completed his Physical Medicine and Rehabilitation (PM&R) residency at the Baylor College of Medicine. He currently serves as Clinical Associate Professor in the Department of PM&R at ECU's Brody School of Medicine and also serves as staff physiatrist at the Greenville Healthcare Center branch of the Durham VA Medical Center. He is board certified in Physiatry and Electrodiagnostic Medicine.

Book preview

Hustle ’n’ Flow: The Current Business Environment in Medicine

In 1974, my father, William L. Doss Jr. MD, a child psychiatrist, was the highest paid Medicaid provider in the City of Detroit with a salary of greater than $400,000 per year. This did not include the privately insured patients he saw. I was proud of my dad and also overjoyed that he made it into the paper . . . for making so much paper. However, my father was neither happy nor amused. In fact, he was quite angry because the article as it was presented did not include his overhead. My dad had a staff of about twenty at that time, including several psychologists, social workers, and an office manager.

By the westegg.com inflation calculator, that $400,000 would be equivalent to $1,663,050.83 in 2005. Now, this is comical because no physicians, especially psychiatrists, are receiving over one million dollars from Medicaid.

I bring up this point not to subject my father’s fiscal affairs to public scrutiny, but to illustrate the change in the financial landscape of medicine. My dad at the time this report was published in the Detroit News had approximately 1,500 patients in his practice, maintained two offices, and owned a methadone clinic on 18000 James Couzens Road in Detroit for heroin detoxification.

My father would be very fortunate to clear $50,000 for the same number of Medicaid patients in 2005.

The seventies were the last of the golden years for physicians in practice. Most physicians were in solo practice then. There were no CT scans, no MRIs. DRGs had not yet arrived, HMOs were in their infancy, and Managed Care was but a twinkle in the eye of the medical financial picture.

This was an era when physicians were able to practice medicine, direct patient care, and truly not worry about the financial picture. Many physicians just wanted to see patients and did not want to be involved in the business aspect of medicine. They felt—and rightfully so—that the financial rewards would take care of themselves. Many believed that to be concerned with the fiscal aspect of medicine would take away from their devotion to their patients, and therefore was unethical. Hence, the listing of one’s name in the yellow pages for reasons other than to offer directions to one’s office, was felt to be sleazy and was frowned upon.

This was a time when fee-for-service was king, and a physician would collect nearly 100% of what he billed, and where a patient could and was admitted for just a history and physical or routine blood work.

Clearly, these golden years were susceptible to fraudulent abuse by some physicians, but this was a time when physician self-worth was at an all-time high because physicians were in charge not only of their patients’ care, but also could directly influence a hospital as to whether that patient would be treated there or not.

Those days seem like the Middle Ages compared to today, but they illustrate a couple of points as to why physicians are so frustrated now and fewer and fewer undergraduates are applying to or attending medical school.

Remember, physicians had control over patient flow and were reimbursed for nearly 100% of their charges. Obviously, this is no longer the case, as insurance companies have gained the upper hand.

This is not an epiphany for any physician in practice; however, certain trends cannot be ignored. Note the following facts:

1. In 1980, 52.9% of registered nurses (RNs) were younger than forty years of age. In 2000, 68.3% of RNs are older than forty years of age.

2. Medicare reimbursement is roughly forty cents on the dollar at this time. This amount was cut by 5.4% in 2002. According to Justin George of the St. Petersburg Times, beginning in August 2005 Medicare would be cut by another 26% over the next six years.

These two facts illustrate significant points: (1) our workforce is getting older, and (2) physician reimbursement for medical care for this same workforce is being depleted. This forces physicians to hustle to make the same amount of money.

For example, physician collection for an in-office colonoscopy in 2002 was $500. Therefore, it would take ten colonoscopies for that physician to make $5,000 on a given day. Now, cut that reimbursement to $400 in 2005. Now that physician has to do 12.5 colonoscopies over that same period to make the same money.

Let’s expand that model to a five-day week. In 2002, that physician would need to do fifty colonoscopies to make $50K. In 2005, that number would be 62.5. Over a year, the 2002 physician would have to do 2,500 procedures, and the 2005 physician would have to perform 3,250 procedures to make the same salary. One reaches a point of diminishing returns and decreased quality of care in order to make the same salary, and a number of physicians either cannot or will not maintain that pace.

This model does not take into account cost of living increases for personnel or materials needed to perform such procedures.

This creates a frightening prospect for most current practitioners and has hastened either early retirements or career changes for many physicians.

Take into account that physicians are the only professionals who do not directly contract with the consumer. Lawyers charge you a retainer fee and bill you for their services. Accountants send invoices to their clients for services rendered and receive a fee for their services directly from these clients. Even plumbers have a base fee and charge a per hour dollar amount that is paid once services are rendered.

Physicians not only have to receive most of their income from insurance companies, but they also have a certain portion written off by those insurance companies. Adding salt to the wound is the fact that they have to wait anywhere from two to four weeks to receive payment. This creates a cash flow crisis and added stress to the already stretched-to-the-limit physician.

Despite these obvious unattractive aspects of today’s medical climate, I love the medical profession and would do it all over again.

However, for the young physician entering practice today, these sobering aspects of medicine need to be recognized, appreciated, understood, and addressed in all facets of the medical career—including contract negotiation, selection of a practice, and the mental toughness and patience needed to survive in today’s medical field.

One has to be willing to hustle, work hard, and be flexible because nothing will be handed to the physician, no matter how they distinguish themselves during their residency. Physicians already in the game have little tolerance for newcomers who want a high salary but are unwilling to hustle for it.

Education Section

A, B, C, D, E, F, G . . . LMNOP

This chapter addresses the educational obstacles that young physicians must navigate. These are not the Anatomy, Biochemistry or Physiology obstacles. These are additional obstacles that if not recognized and navigated will sink the young physician’s career like the Titanic.

As a child, knowing your ABC’s was important when learning to read. In medicine, having the alphabet (FAAPMR, FACP, FACOG, or FACS) after your name is not just important in establishing your reputation in medicine, it is also required for hospital privileges.

The first step in knowing your ABC’s is to excel in medical school. This may seem obvious but as more students move away from primary care and more toward specialties, the competition for residencies in these specialties becomes fierce.

While class standing has always been important, passage of boards, specifically the National Board of Medical Examiners-NBME (Part I), was emphasized by some medical schools, like Howard University College of Medicine (HUCM). While I was a student at HUCM (1987–91), passage of the NBME Part I was required to move on to the third-year clinical rotations. However, at Wayne State University School of Medicine in Detroit, board passage was not necessary to move on to the third year; moreover, it was not even required to graduate.

In fact, many Wayne State graduates did not have to worry about board passage until they completed their residency and had to get a medical license. At that time, those residents could take the Federal Licensing Examination (FLEX) that was required to obtain a medical license. As a resident, you practiced in the hospital under an Institutional Permit of the residency program. Therefore, the need for board passage could be postponed for several years.

This changed with the formation of the United States Medical Licensing Examination, which, with the combined efforts of NBME and FLEX, standardized a national exam that required all medical students to pass Part I to move on to their third year of medical school; Part II for graduation; and Part III to complete a residency program and obtain a medical license.

This change put emphasis on passage of exams as one measure of excellence. Medical residencies have

Reviews for Beyond Residency

[Mosa'ab Ammat · Rating: 2 out of 5 stars]

I wish you did not include whole life insurance as a good option. It is generally a bad option. Investment and insurance do not mix!! Please stay away from whole life insurance and better use the high premiums to invest in alternatives i.e. mutual funds. Insurance and investment DO NOT MIX! Bad deal.