Transcription PNC Podcast Episode 396

Pursue One of These Part Time Nonclinical Hospital Jobs

John: I want to provide a brief overview of two part-time hospital physician advisor jobs that you might want to consider if you've decided to expand your options and begin your transition away from direct primary care for whatever reason. I’m addressing these two because they overlap quite a bit. They're both based in the hospital setting, generally started part-time, and can later become full-time jobs. There aren't a lot of barriers to starting such a position, and if you're already working in the hospital environment, it's really not all that difficult to do.

So, these are the two positions I'm talking about today: the physician advisor for utilization management and the physician advisor for clinical documentation integrity. Just so we know, using this term "physician advisor," sometimes these are called medical directors. Now, if you're doing utilization management for a large insurance company or other healthcare payer, they're typically going to use "medical director" for that position as the title. In the hospital setting, it's typically called a physician advisor. It's a part-time job that could start out as little as one or two hours a day, but they might also use that medical director moniker as well.

If you're already working in the hospital in a variety of inpatient settings, you could easily start doing one of these jobs if your organization has a need for it. So, when I talk about this kind of topic and about transitioning, I do like to generally talk about some other things to prepare us to make this kind of transition.

So, the first thing I want to do is mention some of these items and talk about how to get into the right mindset. What happens typically if you've been working clinically full-time and now you're thinking of making this change? It can be difficult because of some limiting beliefs or even some myths that we have internalized that I want to talk about right now. I'm not going to address every one of these; I actually have addressed this in other presentations. As a reminder, let's just go through two or three of these.

So, the first thing is that this is going to be a difficult process because all I know is medicine and I don't have the necessary skills to begin a new career. Here’s what I have to say about that issue: especially for these jobs, having completed medical school and residency, maybe a fellowship, you really already have a lot of demonstrated valuable skills and abilities. Okay? So whether it's focus and concentration, lifelong learning commitment, organizational skills, teamwork, analyzing data, and formulating a plan, you have a lot of background in the necessary sciences, including biochemistry, physiology, anatomy, epidemiology, etc. You're good at writing, lecturing, and speaking, teaching, and mentoring. You've done leadership oftentimes in your roles. You're great at decision-making, and you have a lot of other qualities that make you an awesome employee in general. So those exist, and these two jobs don't really have a lot of requirements for additional skills. So they lend themselves to being learned on the job. You will learn some new skills for this new career, but they'll be learned on the job. And since you're already a lifelong learner, it's going to be quite straightforward for you to do that.

The second belief sometimes is that you're wasting your medical career if you pursue a nonclinical job. The thing is, once you become a clinician, you actually have reached a plateau, and there are dozens and dozens of other jobs that you can only do after becoming an experienced clinician. It's like saying that you're wasting your training as an attorney if you decide to pursue politics or to become a judge, or you're wasting your training as a nurse if you decide to become a nursing home administrator. An administrative job is a business position, but yet you have that background as a clinician, which is very helpful for many important, fulfilling careers. Having a medical degree and board certification is a prerequisite to even being considered for that new career. So it's not wasted training. Chances are you've already applied your training in that venue, and now you want to move on to something bigger and better. In some cases, oftentimes it even pays more and has more responsibility, particularly when you're taking a leadership role.

Number three that I want to talk about is: you know, my family, my friends, colleagues, and other people I know will be disappointed if I leave clinical medicine for a variety of reasons. You think that they might not really understand it, and maybe they'll say something that makes you think that. But the reality is, particularly if you're burned out or unfulfilled with this job, it's not really satisfying you doing this clinical work. You know, everybody in your life that loves you just wants you to be happy, fulfilled, and working in a career that brings you joy. That's really the ultimate goal. Many of us think that taking care of patients is the way to do that, but for whatever reason, sometimes it's just not true. So I don't think the people that are important in your life are going to sit you down and try to convince you not to remain in a job that's tedious, unfulfilling, or producing anxiety or is unhealthy.

I know the financial aspects will be a concern at times, but really, ultimately, that shouldn't be the thing that stops you because there are a lot of positions that will equal your current financial reimbursement or compensation, and yet with less stress and more joy in doing that very job. I think that shouldn't hold you back either, unless you can find there's something simple to change in what you're doing clinically to make it more palatable that I think you should continue to move forward.

Now, there are also some caveats that I want to mention to you. Some of these are pretty obvious, and don't be offended if it seems like I'm being too obvious, but let's see here: first, no matter what job you're doing, continue to do it with excellence. Okay? So just because you're burned out or you're feeling like you're going to have to change jobs or something like that, don't sort of quit while on the job. Don't become lazy or try not to become overwhelmed and just indifferent. Your current employer and colleagues will be asked to comment on your dedication, integrity, ability to work with others, accountability, etc. If you've already started to pull away and not keep up that high level of performance that you probably are used to doing, it can harm you because it may take you a while to get that first job. Particularly, even if you're going to stay with your current employer, hospital, or health system, then that might be something that puts the hold on it, particularly if you somehow have been becoming more vocal about how unhappy you are. So try to keep everything at that level of excellence and just move forward with trying to make the change.

The second caveat is you must try to gain some experience in your new career even before applying for the new job if you can. Notwithstanding what I said earlier that these jobs are open to you already, but every little bit of information and understanding of the role you're going to step into will be helpful. And so if that means volunteering somehow, you can do that. Two areas we're talking about are utilization management and clinical documentation integrity. They usually interface with the medical staff and clinics face-to-face when you're dealing with the topic and also in committees and subcommittees that deal with the results and try to come up with plans for improving things. You can usually volunteer for one of those committees and understand the lingo better. You can meet some of the people that are currently involved in that. Sometimes you can get a little bit of experience in a nonprofit board of some type, some steering committee. So think about that.

That's the second caveat. The third is that it's always great to use a mentor, find a mentor, engage a mentor, and interact with them. Now, when I tell you about mentors, I'm always talking about something that's pretty low-key, not a lot of time. I've had mentors in my life who didn't even know they were mentors—just someone I would meet with briefly or run through, you know, briefly for five or ten minutes, ask a question, get the answer, and then use that information to help me figure out my next steps. So it's helpful to have multiple mentors and just use them judiciously to help point you in the right direction. Obviously, this mentor should usually be someone who's doing the job that you're thinking about moving into.

And so, you know, that's just the third bit of advice. The fourth is that there's probably some book or course that can help you in the process. You know, on these topics, for these two exist, and I'll talk about resources where you can find those in a minute. Fifth, there are usually places, getting, you know, kind of building on the fourth one, there are usually specialty societies or associations, professional organizations that have more resources that I'm also going to mention later.

So that's given. And then the sixth thing is that sometimes when you're doing a nonclinical career, it's helpful to have some kind of a blog or a podcast or something. I mean, as an example, if you're becoming a medical writer, then, you know, if you can create a platform where you're writing regularly and you're sharing some of that for free, in addition to posting things that maybe you've sold that you've done as a medical writer, that could be awesome. In this situation for doing these two, I would say the main thing is to get a good LinkedIn profile. You probably could find your first job directly on LinkedIn without even engaging a headhunter or something like that. You know, particularly after you've already done the job at your current organization, if that's how you choose to move forward. But having a really completed LinkedIn profile, which is something I've talked about in the past, can really help people reach out to you and actually recruit you directly off of your LinkedIn profile as long as you put in there some of the experience that you've already gotten that applies to the job that you're looking for.

So, let’s start then with the first position, and that’s as physician advisor for utilization management. So, to summarize, in the hospital setting, again, you can do this kind of job for an insurance company, but in the hospital setting, it's a little different. It's quite direct with the providers; the physicians and NPs and PAs are taking care of patients in the hospital. So basically, the physicians who are leading the patient care will need help in determining the appropriate care status—outpatient versus inpatient, for example—and work with other team members to decide if continued stay is warranted. Warranted means meeting guidelines, specific guidelines that say that they should either go or stay. They need an intermediary like you, the physician advisor, to help educate on that and to actually answer questions directly on this patient that we're considering right now.

So, you can do teaching too, where you help clinicians understand CMS and other payer rules. And that's around the appropriateness of testing and invasive procedures. Like, you know, if somebody comes in for heart failure and you've got them 90% better, is it appropriate to do a colonoscopy? Well, that can be hard to justify. That's a pretty obvious example, but you don't want to be doing those things because you really want to try to keep that admission as short as possible while using the minimum resources so that the hospital actually has a bottom line.

There are full-time and part-time positions doing just what I've described. Most of those job descriptions will say that you need to be residency trained, board certified, with five or more years of clinical experience. Sometimes they have a preference for primary care, but not always. And they may even say that they want a current hospital staff member.

Now, I'm going to read you a typical job listing for this. They don't all look exactly like this, and this is a very shortened version of it, but just so we're clear, let me describe that: Candidates have a strong clinical background with excellent communication skills and leadership abilities. The role of the physician advisor of case management services requires the review of other physicians' cases, their plan of care, and resource utilization. Case study can be necessary for various reasons, including patient outliers, i.e., extended stays, utilization review issues, reimbursement issues, or quality concerns. The physician advisor will work with hospital administration on all campuses and clinical committees as requested to develop processes and guidelines to improve quality of care and value, or the outcomes divided by the cost.

So, that is a short version of a typical job description.

So, let's talk about some real practical things you can do other than being a good medical provider right now at your current institution. First thing, the first step is to see if you can get your hands on a copy of the "Hospital Guide to Contemporary Utilization Review" by Stephanie Daniels and Ronald Hirsch. This thing is probably at least five, maybe even as long as ten years ago, originally published. I think there are multiple editions. But this is a good guide. So, this is what I mentioned earlier. There may be a book that can be very helpful. I think it's relatively expensive. I looked it up recently, and it was like $170 for a new copy, but you might be able to find a used copy or you might go to your own hospital and say, "Hey, do you have a copy of this thing?" Because the utilization management department might have it. And it can be helpful to read through it; it gives some of the background behind doing utilization management and affecting things like length of stay and how to move people through the system. And also, you know, what needs to be documented.

If possible, here are some other steps you can take. Join your own hospital utilization or case management committee if one exists. Get involved with denials management, maybe even in appeals. You may not be able to appeal another physician's case, but if you have a case that becomes denied and you know, normally you hand that responsibility over to the UM department, you could try and at least be involved in the appeal in your case, particularly, you know, if you're talking about an online or telephone appeal, live appeal, and you can learn about what's important in the terminology.

Again, I'll reach back to what I said earlier about a mentor. So, look for a mentor that's currently working in utilization management, possibly the current medical director or physician advisor for your case management. Establish that relationship and just talk with them a little bit over time. Again, don't make them feel like you're trying to own your success. You want to just chat with them, get their advice on how they got into this and are they aware of any really good resources that they found to be helpful?

Here are some of the resources I think that are no-brainers that you can get into right away: You might look at the resources in the American College of Physician Advisors. You can find them at acpadvisors.org. It's the American College of Physician Advisors. You can just Google that if you want. And they have all kinds of research sources written. They've got lectures and conferences that they do every year. I think sometimes they might even have some kind of certification. When I last looked, I mean, there were at least six or seven tabs on their website for resources for their members. You can get involved directly, and there's probably publications that you can get from them as well. And I don't think the membership fees are all that high.

When I've talked to other people about this, they always bring up the Seek Annual Non-Clinical Careers Conference because usually they have at least one speaker talking about this one, utilization management for sure. Sometimes they also have somebody talking about the second topic for today, which is the CDI or clinical documentation improvement. If you want to get really into it a little bit and understand how people use guidelines, what the guidelines look like.

Oh, by the way, to find the Seek Annual Non-Clinical Careers Conference, it's usually in October, and you can find it at nonclinicalcareers.com/conference. That's a link that I created from my website. So if you go to nonclinicalcareers.com/conference, it should bring you to the Seek Annual Non-Clinical Careers Conference. It's spelled S-E-A-K. It doesn't stand for anything in particular, but it is in the Chicago area every October, and they've been doing that for about 15 or 16 years.

You can get a copy of the Milliman Clinical Guidelines. That's one set of guidelines that UM nurses and others who are doing reviews of charts for purposes of, you know, utilization management and continued stay and so forth. That's what they use. They use Milliman Clinical Guidelines. There's InterQual guidelines as well, I believe, but the Milliman seems to be more commonly used, and you can find that at mcg.com.

And then there's an organization called the American Academy of Professional Coders. Now, when I talk to UM people and when I was doing this job as a physician advisor, I don't think I ever saw that organization or heard of that organization. But if you go to aapc.com for American Academy of Professional Coders, there are resources there that you can access, and it gives you again some of the basic nitty-gritty about becoming a physician advisor for utilization management, benefits management, and so forth.

All right. So now I want to move to the next one, which is this physician advisor for clinical documentation improvement. Well, now we call it clinical documentation integrity. And basically, if we want a short description of this, it is as follows: Physicians in this position will need to learn about appropriate coding and documentation guidelines, either in the hospital or outpatient setting, and help teach other physicians about coding and interact with them on specific cases to make appropriate changes to coding if necessary. Full-time or part-time positions are available.

Now, this one, you know, there's a big motivation to do well on this because the coding is what leads to the reimbursement. It also leads to the quality of care as observed by other people because a big part of coding is to capture pre-existing conditions, complications, and so forth. And if you find things that are present on admission and document those appropriately, then they won't be counted as a complication later on. So if somebody is admitted with some problem, let's say pneumonia, and then they develop diabetes or hyperglycemia and then they get a coding for diabetes during that stay. Now, we all know that it's probably pre-existing, but if it's not put in as a present on admission, then it's going to be counted as a complication. And that's a bad thing that can affect your reimbursement at the hospital.

They usually are going to be looking for someone who's residency trained, board certified, with five or more years of clinical experience. The typical job listing will sound something like this: As the CDI physician advisor, the PA will act as a liaison between the CDI professional, HIM (which is Health Information Management), and the hospital's medical staff to facilitate accurate and complete documentation for coding and abstracting of clinical data, capturing severity, acuity, and risk of mortality in addition to DRG assignment.

So, that's what you're going to see, and you're not going to see requirements for a lot of formal training. What they might look for is more experience. Now, another comment I want to make, kind of a caveat, at any time you're looking for a job and you're looking at job descriptions is that keep in mind that a job description is the new employer's attempt to get absolutely 100% of things they could get in the best possible circumstances. So, they almost never get a person that meets all those so-called requirements. And so you have to try and tease out whether the requirement they're listing is absolutely mandatory. Like, for example, they might say they want someone with five years of experience and at least two years doing a CDI. Well, what if you have four years of experience and you're only doing one year of CDI? These things are all flexible, and you have to learn how to tell the difference between something that's absolutely required as opposed to something that would be nice to have because most of this will be learned on the job.

Okay, so here are some advice for steps to take. Number one, you might get a copy of the CPT Professional 2025, which is the CPT manual that's put out by the AMA every year. Now, it's expensive, and you know what? Things don't change that much. So if you can get an old copy of the one from 2024 or 2023 or 2022, a lot of the rules will be in there; it'll be exactly the same. It's just the fine details change from year to year in terms of the definitions of the DRGs and the weighting and things like that. So just try and get a copy of that, and you can probably borrow the old one from your current CDI group and go from there.

If possible, these are some actions you can take now to position yourself: If there's a CDI team, see if you can join as a volunteer or go to some of their meetings. Spend time with the coding specialists in the Health Information Department. When you talk about coding and documentation, not only do you have yourself as a clinician doing the documentation part of that, but you have the nurse documentation specialists. And maybe some paramedical staff, you know, that aren't nurses or physicians. And then you have the billing departments, whether it's in a clinic or at the hospital, what you would call the Health Information Department. They have experts in coding and documentation. They're the ones that do the final coding on the charts.

They're usually not a nurse, but they usually work so closely with a nurse and the physician advisor to get things right. Sometimes they're in a big hurry and they don't want to take the time to do that. So you have to help set up systems where you can quickly respond when they have a question. Because again, the more accurate it is, the better off the hospital is and better paid the hospital is.

Okay, so you're going to try and just start mingling with those people. You're going to identify a mentor that's currently doing this kind of work, clinical documentation integrity, and maybe the medical director if there's a medical director in the hospital doing this, or there might be somebody who's over that in a large medical group. It's totally different coding in the outpatient and inpatient side, so you might want to end up specializing in one or the other, but most of the time, what I'm talking about are the physicians who are working for the hospital to do this job.

And then you're going to also complete your LinkedIn profile, just like I mentioned for the last position, and try and focus and list your experience and documentation and coding in the hospital setting. No question comes up on LinkedIn all the time is, "I don't want to scare away somebody, or I don't want to tip my hat, my hand, so to speak, that I'm thinking of leaving and looking for this job." So sometimes you can do a LinkedIn profile that's somewhat generic. That's focusing on your professional activities, and you know, you might put in there all the things you've done clinically, and then maybe a paragraph that talks about what you've done from the standpoint of documentation and coding and understanding how it works because all clinicians need to do this anyway. But if you focus on it a little bit more, then a recruiter is going to be more prone to notice and actually reach out to you on LinkedIn and say, "Do you want to talk about maybe looking for a job?" And it could be even a headhunter who maybe doesn't even have a job for you right now, but when they notice someone with that kind of profile, then they're going to reach out and position themselves to be ready to tap you when the time comes.

Some of the other resources which would be very helpful would be the American College of Physician Advisors, which can be found at acpadvisors.org. I think this is the same one that I said earlier. It's good for both utilization management and for clinical documentation improvement. So that's a repeat. The Seek Annual Non-Clinical Careers Conference is another repeat. Every October, you have a two-day event with a pre-conference and post-conference, so there's a lot of activities going on. You can look that up.

There is something new here: the Association of Clinical Documentation Integrity Specialists. It's a hard one to remember; it's kind of a tongue-twister. The Association of Clinical Documentation Integrity Specialists, known as ACDIS, can be found at acdis.org. Lots and lots of resources there. You can join even before thinking about doing this in a way, see if there's information in it that sounds interesting to you. And then when you do think about moving forward, then start accessing some of those. I think that one has training and even certificates, things like that.

The other big one is the American Health Information Management Association. Now, this is multi—actually, both of these are multi-professional, I guess. There are nurses, there are physicians, there are health information management workers, there are all kinds of people in both of these: ACDIS.org and the American Health Information Management Association, which is called AHIMA, A-H-I-M-A. A lot of people refer to it as AHIMA, and it's at ahima.org.

And then I've seen one mentioned several times in the past called the National Association of Physician Advisors. When I last tried to access it, it would not let me link up because of a fear of some kind of lack of security on the website. You know, some of these old websites are not really good at preventing, you know, issues with people trying to steal information and so forth. So if you can find the National Association of Physician Advisors, that might be useful. Otherwise, the other four places I talked about would be helpful for you.

But, so that's basically what I had to say about these two nonclinical positions. Again, they start part-time, they can eventually go full-time. There's a lot of jobs out there. There's lots of resources, and you can maybe find a job where you're doing 50% clinical, 50% one of these, or go 100%. There's a lot of flexibility. And if you're in a big metropolitan area, there's probably many jobs around that would be at other institutions within driving distance.

And so that's why I talk about these quite frequently. I've always had a lot of—not my most of my nonclinical jobs were in the hospital setting. These also can lead to getting a BPM or a CMO job because if you think about it, the Chief Medical Officer at a hospital is responsible for typical things that go that include these: utilization management and length of stay, quality improvement, clinical documentation integrity, which goes directly into quality improvement, and then informatics a lot of times. And so if you're involved with any of those four, it's a good starting point. And ultimately, if you end up looking for a job as a CMO, which usually pays more than a primary care clinical position with about 20% less commitment of time each week, that's an awesome job. Payments for CMOs are quite high. You're going to have to learn about all four of those plus a lot of other things.

And my usual advice for that is go to the AAPL, which is the American Association for Physician Leadership. And you can get a lot of those, which it wouldn't hurt to start that now while you're doing these other jobs or thinking about doing these other jobs. And they do have some specific courses, actually, at the AAPL, which are kind of introductions to the areas we're talking about today.

Transcription PNC Podcast Episode 394

It's Time to Start a Direct Primary Care Practice

- Never Bill Health Insurance Again

John: Let's get to today's topic of discussion. Recently, I've become more and more interested in DPC as a solution to the unfulfilling corporate employment and its lack of autonomy, the lower pay, the long hours, and the interference in the physician-patient relationship. I've been doing a lot of research on this and a lot of reading, and I want to explain today why I think you should really consider developing your own DPC practice.

Now, this is for those of you who have been employed with a large system or a large group and you're thinking, "Okay, I'm burned out. I need to go into something completely nonclinical or unconventional." And really, I'm starting to believe that DPC practice is one option for you to consider.

It has some barriers and some caveats that I'll explain in a moment, but it's really a way to recapture the joy of practicing medicine and seeing patients, if that's really what you want to do.

What is a DPC practice? Hopefully, most of you have heard of it, but a DPC is direct primary care practice, a model where patients pay a monthly, quarterly, or annual fee directly to their primary care physician, rather than relying on traditional insurance billing or really relying on insurance as a payment method at all.

If you think about when you get rid of the insurance involvement in care, you really enable a physician, yourself, to spend more time with your patients. You're getting paid at the beginning of each month or each quarter. There's no collections, there's no billing, there's no sending overdue bills to a collecting agency, and you don't have to hire the staff to focus on things like coding and documentation and billing and so forth.

It really takes away a lot of the headaches and frees up time to spend with patients and also reduces your documentation time and other things. So let me just give you a little background.

DPC model began showing up around the early 2000s, and over the years, it's begun to catch on and building up steam and growing. In 2010, the Affordable Care Act recognized direct primary care as a viable healthcare delivery model, allowing DPC practices to compete with other more traditional settings, traditional not insofar as like from 50 years ago, but traditional as of the last 20-30 years. And now there's, I think, about 2,500 known DPC practices in all 50 states across the country and in Washington, D.C. And so, it seems to be growing and there's much more interest in it.

One of the questions that people have when they first get involved with this and start thinking about it is, "Well, look, if I'm doing this, can we still use Medicare for DPC? And if not, well, then how's that going to work? Because so many people depend on Medicare, and it's hard to convince them to switch over to a DPC model."

Patients can continue to use Medicare when they're involved with a DPC, but it would be for anything not happening in the physician's office. In other words, you could still use it for hospital care, expensive testing, inpatient visits, imaging, prescriptions, things like that. It's just that when it comes to the day-to-day ongoing chronic care and treatment of acute illnesses in the office, everything can be put under this new type of model.

Most DPC physicians do opt out of Medicare because they really don't want to have to interact and meet all the requirements for any kind of a Medicare payment. So you're best to just opt out, although there are some exceptions. If someone has chosen Medicare Advantage, then there may be network restrictions and so on. There may be some challenges. And these are all things you have to figure out before you set up your first DPC practice.

Now, I'm going to pause here and say, what's the best way to approach this from the standpoint of, is this something I can go into right after residency or fellowship? And probably not, because it would take a lot of planning. You'd have to spend the last year of your residency or fellowship thinking about how you're going to do the DPC, learn about marketing, put aside some money or arrange to borrow some money to set up the practice. I think it has been done. But to me, it makes more sense, you're fresh out of residency as let's say, a primary care doctor, and you would go to work for a hospital system or a large group, get a guaranteed salary, have them help pay off some of your loans.

But you would have this idea that maybe in three or four years, you're going to go out on your own into this kind of a practice, which has more flexibility and a better lifestyle. And so, one of the things you want to do early on then as you're looking at those contracts is you want to think about, well, if I want to leave that practice and maybe pick up some of those patients in my new DPC practice in three or four years, what do I need to do to plan for that?

And that's where an attorney comes in and looking at your contract. Can you get rid of the non-compete that will prevent you from moving away from that practice to a new practice and take some of the patients with you? Even if you can't take away the patients, like there might be a limitation on marketing to those previous patients, you still want to have the ability to actually set up another practice without too much of a restriction.

If you have a six-month non-compete and then you can open your doors in six months, that's not too bad. If the geographic limitation is within driving distance, so you really want to have an attorney help you think through that when you're signing your first contract as an employee. So that's really all I'm going to say about that.

But to me, you start out when you're first on a residency or fellowship, it's good to have continued interaction with other physicians in your specialty in a controlled environment where you don't have to worry about all those things that we're talking about.

But then once you're out three or four years, you should feel confident to start your own practice if that's what you want to do. Now as an aside, I'll say right now there are DPC practices which are quite large where the physician is actually employed in a DPC practice, but I'll talk about that more in a minute.

Let me review again the key features of a DPC practice. There's no insurance billing, period. Patients are paying monthly, quarterly, or annually. Sometimes employers are the ones paying. If you have a large employer or medium-sized employer that would like to provide for the care of its employees and there's not a lot of good primary care nearby, you can sometimes get the employer to pay for some or all of this on a membership or subscription basis because it keeps the employees at work. And some companies are really facing problems with employees constantly being injured or sick and you can work with employers to address that issue.

But most DPCs, I think the majority are actually just taking care of patients, usually within either like a family medicine or internal medicine or pediatric type of practice where you might focus on just a certain age groups, pediatric age groups or some might focus on adults in the middle ages and then sometimes senior practices.

But the nice thing is you get the flat membership fee. You're not billing patients. You can usually have a panel of no more than six or eight hundred at the most, so you can spend more time with your patients. 30 to 60 minutes per visit is often quite doable. And a lot of the benefit too is the improved access in non-traditional ways. So phone calls, using email, telemedicine, just messaging them on your telephone and even sometimes home visits.

And that all enables you to reduce the expenses in the office and really help people more quickly. And most DPCs have openings pretty much within one to two days as opposed to a two or three week backlog of patients. And then in that situation, again, the patients are much more happy with the longer time you spend with them and the fact that they have improved access and they become very secure with that kind of arrangement, much like concierge medicine, but obviously done in to meet the needs of chronic conditions as opposed to concierge, which usually focuses on acute things or just some carve out a particular type of specialty. I could belabor that, but I think it's really a nice model. Income is usually pretty good, and I'll get into that in a minute.

What are some of the potential downsides? The main one is that you have to create your own business, your own new practice from scratch, and it takes a while to plan. You have to learn some new things, perhaps, in terms of how to run a business. If you're doing high paying procedures, that doesn't lend itself to any kind of prepaid monthly payment as opposed to fee for service. And you have to learn how to market yourself so you can build that panel. You want to get to two, three, four hundred as quickly as you can.

And so, the biggest barrier basically is that up front investment and need to do all this planning, find a place to work and hire at least one person maybe after. You can start with just yourself when you only have five or ten patients, but once you start to get more and more and you're doing some marketing and they're starting to sign up, then you'll probably need at least one staff. But it's really pretty limited, one or two, if you're doing that kind of DPC.

Now, you could do another thing, and that would be to look for a practice that already is employing physicians and you would be an employee, but it would still have some of the advantage of a DPC if it's set up that way, because you'd have your own panel and you'd have some coverage. And again, the lifestyle would be better and you wouldn't be filling out a lot of paperwork. And even the charting is easier because you're not doing charting just for the sake of billing.

All right, let's go in a little deeper about this DPC model. I've kind of described the basics, and if we're thinking about starting a practice like this, you have to think about different things. You're going to have to actually create a business plan. Now, a business plan is just a document. It can be relatively short. It says, what do you plan to do? Who's your intended audience or patients you're going to recruit? What are you proposing to charge? Do a pro forma and engage an accountant and say, okay, well, if this thing grows in a certain way, let's say we're picking up so many patients per month for the first year, how quickly can you get to 200 or 300 patients, let's say in a basic internal medicine DPC practice? What can we expect in terms of all the expenses that will be covered during that first year and then in an ongoing basis?

You have to estimate those things and try and work out a pro forma of how you're going to go from losing money at the beginning, which obviously, if you have no patients, you're going to have some expenses and no income. The income is going to ramp up over time. You're going to be doing a lot of marketing.

When's the break even point? When's the point when you can start taking a salary? When's the point where you have to hire one or maybe a second employee and so forth? You need to spend some time thinking about the location. You can get creative and share space and really try and minimize the cost of your lease and the overhead associated with the clinic location. You have to choose an electronic health record and patient management software, that kind of thing.

Again, you're going to have to work on your pricing model. From what I read, typically children, you're going to charge $25 to $50 per month. Adults, $75 to $100 per month. For young ages, let's say $18 to $39. For older adults, maybe $100 to $125. And then when you get above age 65, probably $125 to $150. If you're in an affluent area, you may be able to get up as high as $200 for the kind of special service that you're going to be providing as a direct primary care practice.

With the children, I had a guest on. He was really on my show to talk about a new product that he had developed that he was selling. It was a software to help run and market a DPC practice.

But he did note that the charges for children depend a lot on the vaccine. So if you're getting newborns and those up to 18 months, three years, and they're going to receive a lot of vaccines, you have to make sure that you include that, consider that in your fees. As they get older, of course, all they're getting is routine checkups with almost no lab tests and no vaccinations.

And so that's where that price can get quite low on a monthly basis just to see them once a year for their physical, assuming they don't have any chronic illnesses, which would be not that common in a pediatric practice.

You're going to have to build that panel. You're going to have to set up a website, learn a little bit, pick some social media sites that will help promote and market your practice. You want to do community outreach where you're doing things live at health fairs or visiting local businesses and networking and doing some education in the community, which will get your name and your face out there.

And then in some cases, you might partner with an employer, as I mentioned earlier, which would be a way to try and keep the workforce healthy, especially when there's a lack of primary care in the area.

Staffing can be an issue only because you just need to decide how many staff you need, what they're actually going to do. But again, the requirements are much less than in a traditional practice. You might have six staff supporting a single physician with the billing and the scheduling and so forth. But when you're in a DPC, you're probably going to get along with one or two at the most to begin.

You're also going to have to set up your finances. The payments are coming in regular, so you're kind of prepaid. When you're doing it monthly, you're actually getting paid at the beginning of the month for each patient. And so you can very quickly see what it's going to take to break even. And then as you continue to grow, start becoming profitable. Some of the startup costs, I'm just giving you gross numbers, but you could probably start it from $40,000 to $100,000 overhead for that first year if you include the lease, the medical equipment, all the supplies, malpractice insurance, EHR, billing software.

Again, it's really just making sure that the membership fees have been paid. Marketing website and office supplies. Most break-even practices occur or reach that level when they've got about 250 to 300 members. Actually, you can kind of keep in mind. Now, I'm sure there are multiple books and courses and things that you can take to help walk you through this process. And I will be putting some resources at the end of the show notes. I'll mention it right now by going to nonclinicalphysicians.com/direct-primary-care-practice.

I think I've given you enough to get some idea what we're talking about and really start thinking about this. The other question that comes up from time to time is, can physician specialists build a successful direct primary care practice? Well, obviously, it's not a direct primary care practice, but it's a DPC style practice. And sometimes, yes, it can be very successful. The model needs a little bit of modification depending on what you're doing, but the model can be used by specialists for high demand specialty services and sometimes for employer contracts.

Let me give you some examples for this. For example, cardiology. Well, hypertension, heart failure, arrhythmia, sometimes there's chronic ongoing disease management for that. And cardiologists could carve out part of their practice following that kind of model in which they're getting a membership type payment every month or quarter. Now you have to, again, revisit this issue of can you do that. You can't do that for Medicare patients, obviously, if you are still a Medicare provider.

Now, if you've decided to focus on just those under age 65, then you can just leave Medicare and just do that part. And again, as I mentioned earlier, the patients can still access their Medicare for the other parts of their care. But if you're going to do outpatient only and chronic disease management, you could do this model. And it might even be possible to mix both, but I think you really need to check with an attorney or do some more research on that. Obviously, endocrinology, you can do diabetes care, thyroid disorders, hormone therapy, dermatology, concierge type of practice, only prepaid rather than pay as you go.

It takes probably a little more research, a little more aggressiveness to figure out how this would work as a specialist, but it can be done. And I think the pediatric side wasn't one that grew a lot initially, but it seems to be catching up now because a pediatrician that I spoke with says they're trying to figure these out, these problems out and how to handle the injections and immunizations. And it can work out quite well.

The marketing is a little different for a specialist. You're probably going to market to your referral base rather than directly to patients, although you could do both. There are examples out there. There's a cardiology DPC that is charging $150 per month per patient for unlimited consultations and quick access to the doctor and stress tests and EKGs on a regular basis and being very successful. Dermatology, cash-based clinic with a $300 initial consult and $150 per follow-up. And it's mostly for cosmetic procedures like Botox and fillers and laser therapy.

I think there's a practice out West and one of my guests was doing in which she was seeing psychiatric patients on a DPC style of practice, prepaid membership type of care rather than the episodic and fee-for-service with insurers.

I think that that's all I have to say about the specialty side of things. It can be quite lucrative and it also, again, brings you closer to the patients and much higher satisfaction for both practitioner and patient.

Should a specialist consider this? Yes, if you specialize in a chronic disease management or cash pay procedures, should work okay. And you'll get less insurance hassle and more direct patient interaction and can be quite lucrative. Now, if your specialty requires hospital-based procedures, then it's probably not going to work out. And if you typically rely heavily on high insurance reimbursements for high cost treatments, then again, it probably won't.

I think this could be a solution for some of you to sum up here. If you've been in practice, if you're unhappy, if you have no objection to being involved in the business side, you can start your own DPC practice, I kind of like it because I think we know that in general, people who are the most successful financially in life are usually those that own a business.

You can get some high salaries and specialties and even becoming a nonclinical physician, a CMO at a hospital or something like that. But at the end of the day, when you retire, what you have is your retirement savings and whatever investments you've made with that money. But when you have a practice, you can grow that practice. You can hire other medical providers. You can leverage your own care with APNs and PAs. You can hire more physicians eventually if necessary to make it work. You could bring them in on as partners.

But at the end of the day, then you can sell that practice or sell it to your partners or get bought out. And in addition to the earnings that you've made, which are going to be quite positive. Again, I didn't say specifically, but it's very common for a DPC with a mature practice to be earning anywhere from $280,000 to $500,000 per year as a primary care. And specialists can do even better than that with a combination type of practice. That's why I encourage that if you have any inkling that that's something you think you can manage. You can hire an accountant and an attorney to set things up. Make sure you jump through all the proper hoops.

You can get someone to help you plan the business, but you need to be working and either having a lot of money saved up to start this thing or continue to work part-time and cut down on your traditional practice as you begin to accumulate patients. And then if you've got a hundred or so, you can cut those ties completely.

Most of the time, most DPC primary care doctors are going to have anywhere from 400 to 600 patients. And you can earn a lot more getting to 700 or 800, but then again, the lifestyle begins to suffer. If you want to learn more about starting a DPC, it will require planning, investment of time and money. But if you're successful, you'll find that you're much more satisfied, your patients are more satisfied, and you'll be able to make a very good income while enjoying a wonderful lifestyle.

Tell you right now that if you go to DPC Frontier at www.dpcfrontier.com, there's a lot of information there. There's been a lot published on this in the literature and there's a weekly podcast called My DPC Story with Dr. Maryal Concepcion. Since September of 2020, she's been doing a weekly podcast. There's lots and lots of success stories in that podcast. I will add more resources for you to look at, again, at www.nonclinicalphysicians.com/direct-primary-care-practice.

Transcription PNC Podcast Episode 393

Valuable Resources For Doctors Exploring New Job Possibilities

John: As I mentioned a minute ago, today I'm going to share some of the free and paid resources that you might find useful. Some are freebies that I created, others are paid courses that I or a colleague have created to help you on your career journey. They include a few written resources, other in video format, and one that's actually a recurring live event. I'll describe each one, explain if there's any cost involved, and I'll read off the link to where it can be found. And of course, to make it easy for you, I'll place all of these links in the show notes for today's episode. So let's just jump right in.

Here are some of the valuable resources for doctors exploring new job options. This is actually not everything I've ever promoted or shared with you, obviously, but these are some of the major ones. I'll start by telling you about my academy. It's called the Nonclinical Career Academy. It's found at nonclinicalphysicians.com/joinnca. It has about 30 courses and lessons. Some are single videos, some are multiple. And it has a pretty good cross section, especially if you're just getting started, overviews and introduction to certain topics that maybe you're not familiar with, certain careers, certain side jobs, and forth.

And then there's a fair number in there to talk about how to work in the hospital environment as a medical director and a VP and the CMO And forth. So there's a lot in there. And actually, if you're, if you join the NCA as a member, you get access to everything and you don't have to go through everything.

And when you sign up, there is a little bit of an instruction there about how to navigate the different courses that are available, depending on your interests. So you can look at that. You can do a one-time purchase where you get everything forever. And even as I add things like new courses, which I haven't added many in the past year, but I am still putting out weekly Q&A sessions, which could get added to that about once a month. Those are short 10, 15, 20 minute Q&A sessions where I address one particular aspect of one particular career or approach to pursuing a new job or things such as that.

You can get that for one price, or you can do a monthly membership. That monthly membership currently is at $57 a month. And that's there so that you can get in there and just spend two or three months, four months really intently going through it and then just dropping off. Or you've got the one-time purchase so that those fees don't continue forever if you're taking your time.

Now you can use for the monthly membership a code FIRSTMONTHFIVE. That indicates that you can get your first month membership for only $5. And you can look around and make sure it's right for you before continuing your membership. You can always leave, if you're on the monthly membership, you can leave at any time. That's the first thing I wanted to mention. It's been there for several years and I am still adding some content to that, and there can always be more in the future.

The next one is my free Five Career Guide. Now that's a 19 page, I think. Yeah, I think it's kind of like an eBook, 19 pages or so long, and it's free. And you can get that at nonclinicalphysicians.com/freeguide. You see a pattern here, right? All these are going to be nonclinicalphysicians.com/ some keyword. This one's nonclinicalphysicians.com/freeguide. It's all one word. It's a 19 page eBook.

It's one of the first things I put together. It provides advice for pursuing a career as a physician advisor for utilization management, as a physician advisor for clinical documentation integrity, which most hospitals have these days, as a medical informaticist, as the VP for medical affairs, which definitely is a step up. Those are all obviously in the hospital setting. And then I also added one which is very commonly pursued and is very popular, and that's how to pursue being a medical writer.

On each of these topics, there are some multiple resources, really. I'll look through the first one here and kind of tell you, this is kind of what how I've broken it down. I'm talking about the supporting circumstances, which might help you get into one of these, the typical job listings, the steps to take, and then some useful resources for each of those five. And that's a good starting point if you're interested in one of those jobs. Now, if you're not interested in that, and you're talking about something in pharma or in health insurance or life insurance, or who knows, then this would not be all that helpful.

Then let's step to the next one. Again, this is one I produced several years ago, and I keep adding to it. It's called 70 Nonclinical Careers Checklist. It's the 70 Nonclinical Careers Checklist. It actually has 73 specific unconventional and nonclinical jobs for physicians on it. So it's growing. I think I've caught all the major ones. And it can be found at nonclinicalphysicians.com/70jobs. You have to give your email address to pick this one up and the previous one as well.

But in this one, it's a list. It's about three or four pages long. It's got 73 specific unconventional and nonclinical jobs for physicians. And most of them, the vast majority of them have some kind of a resource listed that goes along with trying to get this that would support your ability to learn more about it, and maybe to even find some resources to pursue that particular job.

Most of those resources are either a professional organization, or some other useful website that will provide support for you as you narrow that list down to one or two or three, and start working on how you might pursue that job.

All right. The next one is actually a course. It's one single course within the Nonclinical Career academy that I mentioned earlier. And it's very popular because it's a type of job that's very popular because pretty much any physician can pursue it. And it is a segue into the pharma industry. If you don't have any other way in, you don't have a background in research or anything like that. It's a course called Build a Rewarding Lucrative Career as a Medical Science Liaison. And you can find that at nonclinicalphysicians.com/MSLcourse. That's all one word.

This one does have a price tag. I think this is probably the most expensive on this list. It's a little bit under $400 unless sometimes I do specials. But as I said, it's a popular job. And by going through this course, you'll learn the proper lingo, you'll learn where to look, you'll learn about all the resources that I've identified for helping anybody become a medical science liaison.

You could be in an unhappy, unfulfilling job that you're starting to really burn out from. And by going through this course and implementing the things in there within six to eight months, you'll be ready to apply for your first job as an MSL. That's something that's been out there for several years.

And then speaking of courses, here's a course by someone other than myself. And it's one I've been promoting recently. It's closed right now for membership. However, this one is reopened at least twice a year. And this is called Expert Witness Startup School. It's at nonclinicalphysicians.com/ewcourse for expert witness. This is Dr. Gretchen Green's very popular course for becoming an expert witness consultant.

I'm not going to go into great detail here. But if you're in clinical practice, and if you're not averse to working with attorneys, it could be very fun for those that are in the right frame of mind. The course is excellent. It's extremely popular. It consists of four weeks with content for each week and then live sessions with Gretchen, a lot of supporting materials. And if you are thinking, "Okay, I'm a little burned out here", what you can do sometimes is start to do witness, expert witness consulting. And it generates enough revenue that you can cut back on your clinical time to the point where you might be doing I'd say 10 or 20 hours a week of expert witness startup, expert witness work, and then cut your clinical down by at least 20 hours, you'll still end up making a lot more money because the expert witness work is much more lucrative.

I throw that out there because it's been around for over five years. Several of my followers have taken the course and I know that hundreds of other physicians have taken it and successfully started their own expert witness consulting business.

All right, the next two actually are resources that have been created by Dr. Heather Fork. The first one is LinkedIn for Physicians. For many, many careers that you might pursue, whether clinical or non-clinical, a LinkedIn profile is important to create and to maintain. And you can try and struggle through setting up your LinkedIn profile by yourself. And LinkedIn does a fairly good job of walking through it.

But this course by Heather Fork is really a comprehensive LinkedIn course specifically for physicians. It tells you in there how to build your LinkedIn profile so that you'll be attractive to people out there looking for physicians with certain skills and physicians interested in certain types of side gigs and or moving into a nonclinical or unconventional clinical job. If you don't do this right, you can be lost in the mix. But if you have a good LinkedIn profile, as Dr. Fork recommends, it's very useful and very effective for finding those jobs.

Now, the link for this is nonclinicalphysicians.com/linkedIn. That's actually one of the affiliate links that I have on this list. That means that I get a small commission for sending you to her. The same is true for the Expert Witness Startup School and for Dr. Heather Fork's other course, which I'm going to describe in a minute. It doesn't affect the course cost, whatever it is, at whatever level that Heather's asking. It's exactly the same. It's just that because I can send her someone perhaps that she couldn't reach by herself, I get a small commission for that.

It's definitely the best course for learning how to use LinkedIn for physicians. There are other courses out there for the general public, but she even gets into how to network using LinkedIn and specifically as it relates to physicians networking for nonclinical careers. So, it's extremely helpful.

The next one, again, is Dr. Heather Fork's Carpe Diem Resume Kit. This is really an awesome course for creating a really excellent resume. When you're looking for an unconventional or nonclinical job, you usually don't use a CV. You use a resume. It's structured differently and it does take some skill in putting a resume together. And her course walks you through the process and it consists of digital guides and video tutorials, templates, skills builder exercise, because there's certain types of words that you should use. And she goes through and kind of explains the types of words to use, keywords and so forth.

She has actual samples of resumes and a whole lot more in that. That's called the Carpe Diem Resume Kit. And this one can be found at nonclinicalphysicians.com/resumekit. And again, very reasonably priced and will really help you to get that resume in a position where it's going to clearly meet the needs of the company that's recruiting you and the headhunters that are looking at your resume and including all the keywords and other things that make a resume stand out from everybody else's.

All right. The next one is another course called the Medical Affairs Associates Program. It's found at nonclinicalphysicians.com/mantra because it is produced by Dr. Paul Hercock at Mantra Systems. And that's in the UK. This one is rather unique. It's a medical affairs training course suited to physicians and other medical and scientifically trained professionals looking to explore certain jobs in the medical device regulation industry in the UK and then the EU.

Paul Hercock has been on the podcast two or three times. Several years ago, there were some new requirements put in first in the UK and then the rest of the EU where there are medical device regulations. I think that was in 2002. Paul created this short course to teach you how to understand the regulations and how to help to support that. And partly because he hires people to do that. Even if you're in the US, you can do this for Mantra Systems. And for a small price, you can take the course. And then once you've taken the course and demonstrated that you understand the MDR and associated regulations, you can then apply for a job at Mantra or elsewhere for that matter. Again, that one is not an affiliate. There is a price, it's a very small price for what you get out of it. I would recommend you check it out at nonclinicalphysicians.com/mantra.

Well, those are the main ones. But the last one I want to mention before I go, and I do usually promote this on my website and in my podcast episodes, but we're still doing a weekly Nonclinical Physician Q&A. Those currently are being held every Thursday at 02:30 P.M. Eastern, 11:30 A.M. Pacific. I'm in central time. I'm basically logging on at 01:30 in the afternoon on Thursdays, my time. And we hit almost every single week unless I'm traveling or something.

You can access that going back to that nonclinicalphysicians.com/joinnca and looking for the Q&A sessions themselves, which you can sign up for only $5 a month and you'll get three to five posts a month with particular Q&A related to nonclinical and unconventional clinical careers. In fact, another way to access that directly would be go to nonclinicalcareeracademy.com/p/weekly-qa. I'll put that link again in the show notes, but nonclinicalcareeracademy.com. You go there and just scroll down to through all the courses and you'll see the Weekly Q&A and you can sign up and then for very nominal fee, you'll have access to those. And then you can actually join us live for the Q&A.

Probably the easiest way to find out about those is to go to nonclinicalphysicians.com/dailyemail, and you'll be sent emails on a regular basis. They won't be daily, however. Again, that's nonclinicalphysicians.com/dailyemail.

That's it for the free and low cost resources. I wanted to mention today, I'll probably do another episode like this a few months down the road with some of the other resources that I've come across over the years. But for all of today's links and a transcript of today's interview, go to nonclinicalphysicians.com/valuable-resources.

If you like these interviews, then please leave a five-star rating and a review on your favorite podcast app, such as Apple Podcasts or Spotify and also you can share it with a friend.

Transcription PNC Podcast Episode 392

Exploit Your Medical Knowledge In New Ways

- Interview with Dr. Robert Cooper - Part 2

John: Well, let's go back to another one then. I think that's one that you've been doing for the most amount of time and have spent the most cumulative hours on, and that's the disability file reviews. So how did you find that? Did someone point you to it? Were you just searching around the internet? I mean, how did you find that? What should we do if we're interested in it? Because I have looked into this a little bit myself. And I'll just say, as a family physician, they're usually looking for a specialist. I mean, there's a lot for neuro and physiatrists and that, but I know they're out there for primary care at times when they just need the general. So any tips on that? What's it like? How long does it take? We'll kind of do that first, and then we'll move on to the next one.

Dr. Robert Cooper: Sure. The first gig, I think, was through the New England Journal of Medicine. Like I said, I answered that in the New England Journal of Medicine. Small company, I went out and learned how to do it, and they trained you to some degree—not terrific. And I started doing it. I like it because it's almost like taking raw materials, right? Looking through a file like a detective and trying to figure out what's going on. What you're trying to do is determine the level of impairment of a claimant—we call them claimants. There's terminology involved, but you have to know what you're doing when you're going through this. It's a method for actually sorting out the file, figuring out where it is, where the pieces are, how to put it together, and the different components.

I have not found really good training in this, honestly speaking. I took a course in it, but it didn't help me—I had done it before. So I think really providing nuts and bolts is important. I worked for three companies, but there is another way to find it. I'm not gonna mention the specific companies, but I will say that NAIRO—N-A-I-R-O, the National Association of Independent Review Organizations—has companies on there. Now, here's the important thing. Here's the important point for viewers: don't be undersold, okay? A lot of these companies are paying rates that are ridiculous.

What's happened in the disability world, unfortunately, is that they're moving a lot of stuff in-house to do full-time physicians come on board, and they're taking it away from some of that. I found that that's happened over the last five years. I told you before, I worked 10 hours a week for a major insurance company as an independent contractor. So I was doing that in addition to the other vendor companies. It was just a lot of work—10 hours a weekend. But I learned a lot from doing it. Then they stopped that and moved it in-house. So you have to be careful.

There are companies out there who ghostwrite reports. I'll just tell you that what they do basically is—they write the whole report up, and you just sign it. And they pay you very little money to do it. They're trying to save money. That is something you want to avoid. Okay, I won't mention any specific companies except to say that you don't want to do that. You want to really be legitimate about this. This is important. If you're doing this kind of work, it's important to be fair and impartial and to look at the work and come up with a conclusion that's reasonable. And that's what they want, actually—insurance companies want. Unfortunately, they're constrained like everybody else financially, so they're looking to cut corners. Unfortunately, that doesn't work too well when it happens.

So you have to be careful what you're getting yourself into. It's very important to pick and choose who you're working for carefully—not just in terms of what they're paying but also if they're ethical and so forth.

John: So does it seem like that's one of the things that's sort of changed since you've been doing this, right? I mean, heck, you started probably doing this before the pandemic, and then the pandemic hit, and everything's going online. Any other observations about what we should look for or not look for when looking for disability evaluation file reviews?

Dr. Robert Cooper: I mean, a reasonable rate is reasonable. I mean, I don't want to go into exactly what I mean. The ranges generally are, just to give you a range, I mean, $150 to $200 an hour is reasonable or over that. Some companies—I mean, I've not settled for $50 an hour or $25—I mean, it's ridiculous. Some companies that are actually coming into play, I would just walk away from them. Again, walk away. Instead of walking away, they get in trouble with that.

I will make a comment about something you said, John. There are a lot of family physicians doing this—general physicians. It's not actually—it’s just as much general physicians as there are actually specialists doing this because you need to have a holistic point of view of some of these patients. They look for this, and they want somebody to go through everything, all the problems, and come up with a conclusion. So, it's very much driven by primary care, family medicine, and internal medicine. In fact, the whole segment of that, in the company I worked in, was for that. So, you could do that.

You could also use this, by the way, any of these things, as a segue. I mean, mine is the expert network consultant, but a segue to get into full-time work. If it is what you choose to do and say, "Listen, I just don't wanna do clinical medicine anymore. I have to determine this is not for me." I mean, unfortunately, that's what happens sometimes. It's nothing—somebody's choice.

You could use this because many of these companies will ask you, "Have you had any work before? Have you done this before? Have you done disability file review? Have you done medical assessment review before?" Yes, I have. I've done, you know, X, Y, and Z, and this is what I've done. "Okay, great." And they'll interview you. This is why people have a problem getting in at the ground floor if they want to convert to full-time. If that's what they choose to do, it's because they don't have the experience. This is a way to get experience.

John: One of the things in my little research I've done on this topic is looking at Social Security disability file reviews. And that one seems to be a unique animal. Have you ever done those for Social Security? I think they have different companies specifically that only do SSDI-type reviews.

Dr. Robert Cooper: I have a friend that does that for endocrinology. But the problem is they don’t pay well. Private insurances, the vendors, the ones that deal with private insurance, pay much more. So it's not uncommon to get about a third or a half. She actually looks at me and says, "Oh my God, you're getting that kind of thing for doing it for the vendors? That's ridiculous, I'm getting nothing." And so I don’t, and I get those rates back, and they come back to me. And then, you know, people come to me and they'll approach me all the time. Today I had three of them approach me. "Would you like to do some work for us?" And I just look at it and say, "It's not worth it for me to do what I make." It’s not gonna do it. And I think once you get to the point where you're comfortable doing this, you’re gonna realize that and say, "You know, I’ve just not." It’s better to walk away.

John: Well, that’s good to know. I’ll just stop even trying because it’s been difficult to get any information on the SSDI ones, but they don’t pay well. What’s the point? Are there other types of chart reviews? This one, I get this question all the time. I know, for example, that state medical societies, you know, they have quality reviews. Those are pretty few and far between. But any other types of, you know, more or less paperwork, file review, based on your clinical knowledge that you've done or that you know of?

Dr. Robert Cooper: The medical necessity ones are good ones actually too, because they could be quick sometimes. Unfortunately, they don’t pay as much as the disability ones. But some of the private vendors will pay fairly well for a medical necessity review. The big thing about— I didn’t talk about this—but the peer-to-peer phone calls, those can be challenging. So you have to have a thick neck about you, particularly when you're doing a peer-to-peer for a medical necessity review. But I worked full-time for the insurance company. Every day was filled with these peer-to-peers. And eventually, after about two or three months, I said, "Uh-uh, no more." I went back to clinical medicine because I just didn’t want to. I was just... But doing it on a part-time basis, you know, and calling up, you can conduct these, and it's an act of doing this. You have to have a knack for doing this and calling up, but it’s a challenge sometimes. Because physicians are generally, you know, not going to be amenable. You know, they’re frustrated and upset. You’re calling them up and telling them that you're going to deny something or you don’t have the adequate information, and they're gonna come back at you. But there’s a way to handle yourself in both these things. And that includes disability file reviews too, because there’s peer-to-peer for that as well when you're calling up the attorney position. So you get that a lot too. So you have to be willing to do that. Some people are, some people aren’t. And just handle that. I mean, everything has its pros and cons. Every one of these things, okay? So you have to kind of take the good with the bad when you're doing it.

John: Well, yeah, I guess, you know, each person has to sort of assess what they’re good at, what they’re interested in. You know, I’m a meticulous person. Maybe that helps in certain situations. Maybe it doesn’t help in others. I was going to also ask your opinion, switching gears here, on some follow-up on—you've been, in the past, an expert witness, which, you know, as you mentioned earlier, in the field of endocrinology. But what advice would you have for physicians who maybe are still working, you know, part-time, thinking about entering that field?

Dr. Robert Cooper: It’s a good field. It’s very lucrative. I mean, it’s not uncommon for somebody to charge upwards of up to a thousand dollars an hour in some cases for some specialties. I mean, it sounds great, but it has its problems too. I mean, you have to have a thick neck. I mean, just sitting in the seat I'm in right now—I told you last week, I had a deposition. I was deposed actually on a case. I have another case that’s going on that I’m getting subpoenaed in. I might have to travel to a different state—it’s a criminal case that spun out of a civil case. I mean, I’ve never had that happen before in the years I’ve been doing it, but I mean, these things happen, and they can be disruptive to practice. They can be disruptive to doing it. You have to have a contract in place. I mean, all these things are important. They're not something that you just kind of throw yourself into. And you have to be able to carry yourself well to be able to do that.

I mean, writing an expert report is very important. I mean, SEEK has some courses on this, how to do it. There's a great book on that too, but I think also being coached—like, how do I write a report? How do I put one together that's going to make sense, that's going to flow? Because the better your report is, the less chance you're going to be deposed or put to court because it's going to settle most of these cases. So you have to learn that. It's the kind of thing that you learn as you go along.

So again, you need to enact this—kind of figuring out what is the best way to put a good report together, different stages, learning a little bit about law and how it works, and the evolution of a case. How do you get deposed? When you get deposed, how do you handle yourself during a deposition? How do you handle yourself during a trial? These are all things to consider because if you screw up a couple of times, you're not going to get asked again to do any cases.

So it's all about putting your hands into one thing. You know, I always step back and say, "You know what, I want to do a good job. I really do, as an expert witness." But if, for some reason, something out of my control happens—and it does sometimes—that I get looked upon or frowned upon negatively for whatever reason, I have something else to fall back on. I can do other work. I don't have to throw myself into one particular thing. That's how I always look at it. I still want to do a good job.

John: Let me ask you this, because this comes up, I think, in others I’ve spoken with who are looking to get more and more into expert witness consulting. I guess, marketing themselves—how do they find clients or attorneys? Do they just come to you when you've done this just because of your local notoriety? Or do you have a process for trying to get visibility for some of these attorneys who are looking for help?

Dr. Robert Cooper: First off, you have to be careful with that. If you start listing yourself all over the place, that's going to come up during deposition. It came up last week. "How many directories are you in, Dr. Cooper? How many times do you do this? What are you doing?" Because they're looking for people that are hired guns and trying to nail them on that. So actually, I don’t list myself in anything except SEEK. SEEK is the only directory I list. I’ll make a little plug because they’re a good company.

I just had somebody call me right before I got on the phone with you, saying, "You know, the spam call—it wasn't a spam call—it was somebody trying to get me into a directory." I just quickly got them out of there. "How much money is it going to cost me? What is it going to do?" I really don't have a need to list myself in 16 different directories. I've never really found it to be helpful.

I think the best thing is word of mouth. When you do a good job, the next thing that happens is the next attorney tells somebody else about it. Then they call you and say, "You know, you worked with my friend on a case, and I want to work with you too as well. I've heard that you are pretty good. You're responsive, you get back to me, and you're available."

I think calling people—like if an expert, if an attorney calls you—you need to get on the phone with that attorney the same day, within an hour or two. Get on the phone and respond to that attorney, saying, "What's the deal?" And also, you're interviewing them too. You don’t want to get involved with any type of attorney who’s not doing anything ethical. Everything has got to be ethical. It’s got to be impartial. You don’t want to come across as somebody who’s biased during a case.

These are all things you learn as you do it. There’s a way to conduct yourself. It’s very, very important. You don’t just jump into these things—you have to know what to do to provide a good product.

John: I think that particular one—the expert witness—it’s a good combination because you're acting as a physician, as an expert, as a professional, but at the same time, it’s a business if you decide to continue doing it on a regular basis. So you have to know about those resources, like the SEEK list of available consultants.

And again, there are places where you can learn—SEEK included—that, you know, maybe give you a little advice on how to prepare for these things. And if you're doing your first deposition, that kind of thing. So that's always been interesting to me.

Dr. Robert Cooper: Yeah, oh, sure. It's a very interesting thing. I mean, I've done probably over 100 cases in expert witness work over the last 10 years. And I would say that I've had everything from somebody having a terrorist attack and blowing up the pituitary gland in our country and having me testify in that to, you know, hypoglycemic episodes in jail and things like that. I've had cases like that. I mean, it's so fascinating. It really is. You find yourself like a detective. Many times, I've come back to an attorney and said, "You know what, you don't have a case here." They don't want to hear that, but you don't have a case. You have to be honest, very honest with your attorneys that are coming to you. Very ethical and very honest. This is very important, any of the work you do.

John: Well, they might not like to hear that, but better that than they waste tens of thousands of dollars and find out at the end that they don't have a worthwhile case at that point.

Dr. Robert Cooper: That's right.

John: All right, well, have there been any of these other side gigs, consulting types of things, and reviews that we haven't learned yet from you, any others, examples, or have we kind of covered the majority today?

Dr. Robert Cooper: Well, there is another thing I do—I love actually too. I teach actually, I teach at a, there's a company called MCE—I'll just be specific I guess about that. Cause I teach that once a year or twice a year, they have me fly out somewhere and teach primary care and I love it actually. I really enjoy it. We have about 150 people there sometimes and it's on it, usually it's on endocrinology review for primary care. And I've enjoyed that. I've had two stints in Disney world already.

John: Oh yeah?

Dr. Robert Cooper: Where I've gone out there and done that. And I love having people respond back and ask questions.

John: So that's just like a continuing education for physicians?

Dr. Robert Cooper: Yeah, that's right. That's right.

John: Okay.

Dr. Robert Cooper: Another part of this that we didn't talk about actually, too. Maybe we should at some point. Maybe we've done now. Locums. Locums are a way to freedom, actually, too. And I think I've done that. I've done a lot of locums work in the past. I don't now. I'm permanent. But it's some of the best freedom you can get. And if you're like in this position right now where you're kind of considering, like, I think I would just say to your viewers, if you're in a position where you say, "Oh my God, I can't go back to work," and you have that feeling in your stomach on Sunday night, like I've had a couple of times, think back for a second and say to yourself, "Hey, why do I feel that way?" That's the first thing—introspection. Why do I feel that way? Is it something that I could change in the environment I'm in first that could actually make things better? Or, if it's not, is it a different environment clinically that I could be in? Or do I need to figure out a way to integrate this other stuff maybe into place that I could do it so I could cut back on that? Because I don't think it's all or nothing.

I see people at SEEK when I taught this year. They come up to me at lunch and say to me, they sit down—we have like a group of, like, I have 50 people sitting next to me—and they say, "How do you kind of get away from this?" One physician came to me and said to me, "When I was pregnant, I was sitting on my bed. They were giving me an epidural, and the administrators were coming over to me, saying, 'Look at the computer at the CMR, at the letter on medical records, and go back to the records.'" And I said, "I can't believe that." She said to me, "How do you function in that environment? This is what I'm going through," she said. "I have to find some relief," she said, "because I don't have a break ever." I find that so difficult to deal with. I mean, you have to be able to practice. Medicine is a great field to be in. It's a great thing to be a physician, regardless of what specialty you're in. But I think you have to do it on your own terms. You can't have that plugging and deal dread and stuff. So that's the important point, actually, too.

John: Yeah, absolutely. And... You shouldn't put up with being burnt out and frustrated and unfulfilled for too long. You can do it for a little while, but you don't need to put up with that. Because really, as you said earlier, physicians, they have a lot of information, a lot of knowledge, skills, and it's all very valuable if you can leverage it to your advantage.

Dr. Robert Cooper: I think the thing about locums, I was going to say before, just to get back to that for a second, we used to think of locums as being outsiders. But the truth of the matter is that locums are actually becoming sort of the norm, almost.

John: Right.

Dr. Robert Cooper: That's not a great... I mean, it's getting competitive, actually, to get a locum position or something like that. Because there's a shortage of positions, people are looking. But there are some great companies out there that do locums kinds of activity, a call, and they can really provide you with some great experiences to do it, too. I mean, it may not be for everybody, but it's a way to sort of break away.

John: Yeah, I think if you're feeling desperate, you might as well consider everything and narrow it down, maybe, to what fits best. But locums and part-time work and consulting and telemedicine, you know, is another option.

Dr. Robert Cooper: Yeah, right.

John: So, let's see. So, you told me that you like to help other physicians learn this stuff. You're teaching at SEEK and other places. So, let's see if someone would want to get a hold of you, learn more about what you've been doing, and get some help. I think you are on LinkedIn, is that correct?

Dr. Robert Cooper: That's right. I have a website. You have it there. RJCmedicalconsulting.com.

John: Okay. RJCmedicalconsulting.com. Okay, go ahead.

Dr. Robert Cooper: Correct, correct. I'm looking at some point maybe in... I actually developed a course already for leveraging medical. I haven't done it yet. I'm looking to see if there's any traction, if people want to take it. And when I get a critical volume of people together, I might do that, actually, too—online or in person at some point. And I, you know, all these topics, I think, as I mentioned before, preparation and learning how to do it is very important. So, you know, you could direct them there to that website, and certainly, they can.

John: Yep, I will put those links in the show notes, along with a transcript of our whole conversation. And yeah, maybe they should reach out and at least maybe follow you or connect with you on LinkedIn and then look at the website for more information.

Dr. Robert Cooper: The other thing I haven't done, but if anybody is interested, if they want me to come out and give a lecture at one of the meetings, either a keynote or something else on this particular topic, I'm happy to come out there too. So I'll just ask you that.

John: Yeah, absolutely. In fact, I'll mention this. I haven't talked about this in the podcast much, but when you talk about these opportunities and sort of the non-clinical side of things, most of the time, it still qualifies as CME. So, some of these organizations can actually give you CME credit for it because it's something that supplements your practice. And, as I think you have said in the past, you know, like when you're doing expert witness work, you actually become a better physician. To prepare for that, you have to. So, that's all good stuff for CME.

Dr. Robert Cooper: Absolutely right, absolutely right. And even expert network consulting stuff—you learn things. And things that you wouldn’t know are coming—ARE coming and are the wave of the future. And it really keeps you up to date on what’s happening. It makes it diversified. So it gives a different meaning to going in every day and seeing patients.

John: Exactly.

Dr. Robert Cooper: When you're doing it.

John: Exactly. All right, well, I think we're pretty much at our time now. So I want to say thank you very much for joining me today, Robert. This has been great. And I think the listeners will really appreciate all the wisdom you've shared with us today.

Dr. Robert Cooper: Thank you for having me on. I hope that reaches people and hopefully, we can help them.

John: I'm sure it will. All right. Bye now.

Dr. Robert Cooper: Thanks, John.

Transcription PNC Podcast Episode 391

How To Be A Stunning Success Doing Part-Time Consulting

- Interview with Dr. Robert Cooper - Part 1

John: Today's guest is a specialist as a practicing physician, but I bring that up because in the world of physician non-clinical careers, I consider him sort of a generalist because he's done different side gigs and actually some things that are clinical and unconventional clinical. And so he's worked so many numerous side jobs that they're very interesting. And I thought, well, this is going to be really good because doing this kind of helps you avoid burnout. It's interesting, keeps things interesting. You make a little extra income and there's lots of opportunities for physicians. With that, welcome to the podcast, Dr. Robert Cooper.

Dr. Robert Cooper: Thank you very much for having me. It's a pleasure being here, both an honor and a pleasure. I can tell you, I listen to your podcast all the time and it's my favorite thing to do on the treadmill when I'm listening. I've got some great segments there that I've listened to and learned from too as well. So I'm happy to be here contributing. Thank you so much for having me.

John: I love that. I love that. But I think you have a ton to share and maybe some of the things I don't know if you found all these things yourself, or maybe there was something mentioned by one of my guests. It doesn't really matter. This is all going to be helpful. And I'm really happy to have you here to tell us about some of these things. So let's start by just introduce yourself in terms of who you are, what you do, mainly your clinical background, maybe, and clinical work that you've done through your career.

Dr. Robert Cooper: I'm a regular doc. I'm an endocrinologist. I started my training in New York. I trained at Albert Einstein in the Bronx, went on to do a residency at Long Island Jewish, then went on to do a fellowship at Long Island. And I have an entrepreneur spirit about me. So when I finished my training, I was the first endocrinologist out in the Hamptons.

And I enjoyed that, but having your own practice is very difficult these days, even then. When I first started medical school, I had no idea of managed care. I came in because I wanted to be, I actually wanted to be a family doc and I wanted to have people come to my house and set up a shingle.

I went to a very expensive medical school as I said, and I am still paying back my loans, but anyway, but I enjoyed, I enjoyed medicine to this day. I know my son is a medical student. He's a fourth year medical student now, finishing up his rotations and actually going for the match. And he's asked me many times would you go into medicine again? I said, absolutely. I think this is a great time to be in medicine. I actually despite what people say and the naysayers, I love what I do. I love practicing. I love seeing patients, but I like doing it on my terms.

That's the key thing here, John. When I was out in practice, I then got recruited to Western Massachusetts to a place over in Western Massachusetts to run the fellowship there. And I did it the traditional way. And I was in academic medicine and so forth. And there was issues and things like that. And I've been in different places in Western Massachusetts. About 10 or 15 years ago, I looked at, well, I'm not going to go any further. I want you to ask some questions.

John: No, tell me what happened then. Something changed at that point. Practice was okay. It was good. It was fun, but what happened?

Dr. Robert Cooper: It's always been good. But I think I answered an ad actually to do disability file reviews in the New England Journal of Medicine for a company, a small company at that point, so small that my son actually went out to Maine actually. And we went to dinner with the CEO of the company actually. And he still remembers that this day he's 24 years old now. And I started doing disability file reviews at that point. I learned how to do it. You have to learn how to do this stuff. It's very important to learn and to produce a good product. You can't just get thrown in there.

I think there's something I had to learn on my own over years. And that was my first real stint towards nonclinical medicine. And then I learned other companies and I learned how to do it well. And at points in time, I've taken other nonclinical responsibilities as well. That was my first break in to nonclinical. But what I like about it is that I could do things, as you said, in combination. The key to this whole thing, I think, and this is a little words of wisdom if you're going for practicing 30 years, is not to put your hand into one thing. I always say, I taught at SEAK as you mentioned before at SEAK. And when I put my hand, you put your hand into one thing, I tell the audience, it gets chopped off your hand.

And that's true of clinical medicine. That's true of being all in full time sometimes. That's true of being an all in employed as an insurance person. That's true as being all in you do it in little bits of pieces of each thing, actually, too. It makes the best thing because nobody has complete control of you. You have control of yourself. It's on your own terms. We as physicians are very independent people. That's why we went into medicine to begin with. And then now what happens is that all of a sudden we're being controlled. And we don't like that. I don't blame anybody for doing that.

And the problem is as you pointed out, I said before about burnout. And I hate to see physicians burn out. We have a shortage of physicians right now, a shortage of primary care, a shortage of specialists. I would like to see people remain in medicine, quite frankly, but to a certain degree. it's not for everybody.

But I think at some point also in time, if somebody could combine the nonclinical and leverage that as well and stay in clinical medicine, we'd be all better off as well as the person, maybe if they wanted to be and the population at large.

John: Absolutely. That's actually one of the reasons why I wanted you to come on, because I've seen this before where still being in clinical, but maybe cutting back a little bit, doing other things to give you that feeling of autonomy, give you that sense that, okay, you're not if this company goes out of business, if this hospital closes, I'm not going to have a job. And it also helps prevent burnout because it's just the variety and the interest. And I think there's a lot of advantages to it. I'm interested in hearing more. Why don't you run down a list, maybe without going into any depth, just in some of the things you've done over the years, even some of those things, maybe that you're not doing any longer.

Dr. Robert Cooper: Yeah. I'll outline the four things I think I do the most of, and some of it fades in and out. It depends. The thing I do, I mentioned before, disability-followed consulting. I've done that both with the vendors, part-time basis. I've also worked as an independent contracting physician for a major insurance company, 10 hours a week. And that required a little stress. You have to understand something else. I just want to step back for a stressful situations because it can be just as stressful as clinical medicine.

You want to step back and look at this and how much you could take on and so forth. And so I did that, that medical necessity reviews is also part of file review. And that's also something that I've enjoyed doing through vendors. I also worked full-time for a short period of time for an insurance company doing that as well. I didn't care for it too much. I can tell you, it's my own personal thing, but I just say, it's not peaches and cream that people would say, come on sometimes.

That's another end of it, the whole thing. I've done all, the thing I really like doing, and I've done more recently is expert network consulting. That is a wonderful way to do it. People don't know about this. I've gotten into in terms of providing expertise to nonclinical people, Wall Street people, in a way that provides just public information to platforms, but not getting specific about the platforms, but I it is something that is very lucrative. It pays almost as much or as much as expert witness consulting, which I've done also, another one of my things.

I find it to be very fascinating and I love teaching. To me, teaching is teaching fellows and residents in the past. Here, I'm actually teaching people that are brokers or people that are actually doing, or they're sometimes scientific people trying to develop a drug and diabetes or something. I'm an endocrinologist, so I'm doing that. And you could teach people how to, but basically any specialty can do this really, as long as you're doing a little bit of practice most of the time, I think, and you could combine this.

And I can tell you, I will say to you this, that with the nonclinical stuff I did, I told you before, I have a son in medical school who has a huge tuition in Boston and a very good school. I doubled my salary clinically as an endocrinologist last year, last two years doing this, working four days a week, full time. And one day a week doing the nonclinical stuff. If that's your avenue is to get in and make more money and you don't necessarily want to cut back your clinical stuff, that's okay too so you can do that. And it's been really great that way too.

You have to know how to do these things. It doesn't come just with sitting down. We didn't go, we didn't just get put into an exam room and have to examine patients. We went through years of training and residency and so forth, the same thing here. You'd have to know how to do it. You have to know how to be coached, what to do, and kind of how to come up with a good product.

People want a good product like anything else. And when you have to produce that good product, they keep coming back over and over and over again, and they'll pay you what you want, quite frankly.

I think having that, I tell my son who's graduating. I said he's going to go on and do a residency. And I said even if you didn't have that residency, you should have, I'll finish it and do it. But just having that degree, the fact that we went through what we did is, you mentioned this many times on the podcast I've listened to before, being a physician and having that amount of knowledge and be able to pick up on things, we're in a perfect position to do all this type of consulting.

And so, the thing is that doctors don't realize is they're in demand, not just clinically, but nonclinically. They're in huge demand, but they undervalue themselves. This is an important point. And this is another Cooper point.

Number two, I'll just say, it's this, walk away from an opportunity that doesn't pay, that undervalues you. People gravitate to these opportunities that I find disgraceful, actually, in terms of what they do. And that can be any breadth of thing, of the things I'm talking about. Walk away. It's more important to walk away, actually, and not get the opportunity, but to take the opportunity and undersell yourself. Very important point that I've learned.

John: Yeah, I think there's nothing wrong with trying different things. But as you said, if it's not really going to be worth the time, because our time is probably our most valuable asset other than our medical knowledge, then you just should move on or take the time back and spend it with your family.

Dr. Robert Cooper: Exactly right.

John: So let's see, why don't you pick one of those? I'm interested in everything you've said so far, but the expert network consulting, how did you personally find this? Is there any ideas you can give us in terms of how to locate some of those? And then what is it you need to know to be able to do? What are they actually looking for based on what you've done so far with that?

Dr. Robert Cooper: They're looking for people who practice, who have some sort of basis, but actually could even do it without practicing. They had knowledge of the scientific basis behind it, some consults. You get these surveys sometimes that come to you through, I guess, a company called Sago or Schlesinger or other companies like that.

I don't want to go into specific companies, as I said before, but I could certainly talk about that individually with the guests that want to do that. But I think that you get these companies that will approach you sometimes and ask you for your expertise, spend an hour or so. In fact, before I got on the line with you today, I spent three hours downstairs working on three different consultations, three different ones today, because I'm "off" on Fridays.

I was working on that, but really, it's just phenomenal in terms of that. So how did I come into this? All of this is really, things just come to me, I think, somehow. When you put yourself out there, that's the key. I have a LinkedIn page and I'd like myself open to opportunities. People will come to you and they see your profile, but the most important thing is when they come to you is being receptive, A. B, providing a good product. When you're on the phone with an hour with somebody coming on that's asking you about a diabetic product or something, or asking you about the sensors or something for how you feel about this different sensors, you want to provide insight into what you do.

We all know this already. I don't have anything non-public. The key thing you have to worry about with this is that you don't want to provide anything that's non-public. That could be construed as you get arrested for doing something like that or have really a problem. So you want to provide all public information that you're not from clinical trials or anything, but I don't know anything non-public. Most of us don't. We're not involved in clinical trials. We just do what we do each day, but that's what they want to know about.

These platforms, expert network platforms are looking for people. They keep asking me, can you refer somebody an endocrinologist, another endocrinologist? I get things that sometimes are outside my field of expertise. I never take anything that's outside my field of expertise. I will not feel uncomfortable with that. I will not do it. I will pass up on it. That's important actually not to do that, but I will go on and I will refer people sometimes to it. I've never actually gotten a commission for doing it.

If you refer people and they actually do consults, you can actually get a commission for it, but I've never actually seen anything like that, but that's okay. But anyway, I think you could get, there's multiple different platforms that are out there that you could look up and research, expert network platforms and do it. It's not perfect.

There are downsides to it. I taught a course at SEAK last year on this, and I think they're making that, they're a good organization, SEAK, and they're making it available too. I think they recorded me part of it, but I think they're making it available as well. But I also have my own course that I've taught already at SEAK.

John: Well, let me ask you this thing just to dig into it a little bit. When I'm online, I've had a LinkedIn profile for a while. And then again, the email addresses get out there, but are you saying that of the expert network consulting platforms, most of those coming through LinkedIn? Do you ever get just blind emails coming in?

Dr. Robert Cooper: Yeah, I do get blind emails coming in from different companies I even heard about before asking me, I've heard that you do this kind of work. Are you interested in joining our platform? Are you interested in doing a one-off consult? The nice things about these one-off is that you don't have to really, but I do prepare for it. There is a way to prepare for it. I wouldn't say I didn't prepare for it. And I could certainly go into elaboration about that in terms of looking at investor conferences. I find myself sometimes looking at that more than I do scientific conferences on different drugs and things like that. So I do prepare for it.

I want to provide a good product when I get online for an hour. Because if you spend an hour and you don't provide anything, I don't think anybody's going to want to come back to you again. It's like anything else. Even the expert witness work, you want to provide a good product when you're going through that. Disability file reviews, anything.

I think that it's important to prepare and to be ready for it. You also have to have a certain mindset when you do these consults. You have to be relaxed. I think the best investment you can make is to buy a headphone, a head jack, just to put it on because it frees you up and you can look at the computer at the same time. You want to get information. That sounds like a simple thing. I think it was a few dollars to buy the headphone investment for me.

But that was a very important thing. I'm not fumbling with the phone when I'm doing it. These are little tricks that you learn as you go along that you wouldn't know about. How do you conduct yourself? How do you continue to keep the conversation flowing? That's an important asset to have that. If you just stay still and don't elaborate or know something and don't talk about it, you're not going to get that across and you're not going to get the best outcome. So I think that there's a way to train people how to do this, I think, to some extent, to make them more effective.

John: Let me ask one more question about this and then we'll move on. I've never participated in that kind of thing, but I always kind of get the sense that from the invitation, sometimes it sounds like it's a one-on-one conversation. Other times it sounds like it's kind of a panel. For the ones that you've experienced, what is it like? Is it just getting on a Zoom call with somebody? Is it more of a multi-person call?

Dr. Robert Cooper: It's all the above. The ones that are multiple ones. Sometimes I'm actually listed as, I do a lecture actually, where I'm lecturing to a group of investors actually. For that, I charge more money for that. I actually have rates that I charge. And that's another thing. I'm not going to go into that now, but I would tell you that I do that and I charge more and I charge a minimum of 60 minutes. That's another important point. I don't prorate it because I don't want to be on a line for 15 minutes and waste my time when it's an hour I could be getting from somebody.

There's a whole series of things I've learned, how to maximize your time and your profitability when you're doing this. But it can be, I actually had times when I've actually had to travel New York City or Boston, I live in Western Massachusetts, to do something.

I always tell the story at SEAK when I'm there, that they had me, it's a funny story actually. They had me actually go to Boston to do, I think it was Sago or one of those companies, to go to Boston to insert into a dummy, a device for diabetes. They had me come there and they were actually paying $1,500 to do this plus travel for an hour's worth of work. Think about that for a second. That's not uncommon, by the way, to have that happen. I got this thing and I went and traveled into Boston. I'm sitting there, there's a one-way mirror actually on this place that I'm working on. I'm trying to put this thing and I was a cardiology fellow before I became an endocrine fellow for a couple of months. A little bit manual, not that disastrous. I'm trying to put this device into the dummy and I can't do it. I'm putting it in the wrong place. They must've been laughing at me behind the mirror. I can guarantee you.

And then they came out and I said, oh my God, they're not going to pay me because I didn't do anything right. They came back and they handed me a check and they said to me, that's exactly what we wanted to know, Dr. Cooper. We wanted to know how to put it in. We wanted to figure out whether endocrinologists were capable of doing this. That was the whole point of this. Thank you so much for your help. And they handed me a check.

John: Interesting. They learned they have to change it if they're going to involve an endocrinologists I guess.

Dr. Robert Cooper: That's right. But they're looking to learn. Exactly.

Transcription PNC Podcast Episode 389

Have Faith in Your New Life Insurance Medicine Career

- Interview with Dr. Megan Leivant

John: Over the years, I've had the occasion to meet physicians who work in the life insurance industry, not health insurance not doing UM, but actual life insurance. And I've been sort of very interested in that topic. Those that I have spoken with informally, not necessarily on the podcast have said they really like those jobs. I've been interested in finding someone who's doing life insurance medicine. And so that is today's guest. I'm very happy to have the opportunity to talk to her. Hello, and welcome to the podcast, Dr. Megan Leivant.

Dr. Megan Leivant: Thank you so much for having me.

John: I think this is going to be fun. I wanted to learn more about this for years. And it's not as common a full time or even part time position as let's say, someone working in health insurance. I don't know about disability. Anyway, tell us a little bit about yourself, your mainly your education and clinical background that will get into what you do professionally now.

Dr. Megan Leivant: Sure. Well, thank you so much for having me on the podcast today. I'm really excited to be able to talk about life insurance medicine. It all started for me. I went to DePaul University for my undergrad, and I majored in biology and did a minor in French and then went to IU School of Medicine, Indiana University School of Medicine, and followed that up with my residency in internal medicine at Northwestern in Chicago. And then actually practiced outpatient internal medicine for 10 years.

And I did that in a variety of settings. I started out in a traditional private practice, and then I moved to the VA, and I worked at the VA for about five years. And then I was in more of a hospital based community practice before I made my transition. And then I did have a lot of teaching appointments throughout that period of time as well. And that was something that was really important to me.

John: Very nice. Well, then the obvious question that comes up is when a physician transitions from clinical to nonclinical, what led to that decision?

Dr. Megan Leivant: I would say several years before I transitioned out of clinical practice I realized that I was having an increasingly difficult time coping with the demands of outpatient clinical practice, which I know that many people are feeling that way. And present day. And so I actually started working with a physician career coach, Dr. Heather Fork, through Doctors Crossing, just to see what I could do to help my situation. Because at that point, I wasn't sure if I wanted to leave clinical medicine. I just wanted to try to figure out could I could I do better? Were there changes that I could make to try to make the day to day a little bit more manageable?

And we worked together for a good while. And I ultimately realized that transitioning to a nonclinical career was the path that I needed and wanted to follow. So through coaching, I learned a lot about my interests and my dislikes. We did the Enneagram and talked about marketable skills and personality traits. And it was really just a great growth experience to learn all that stuff and then help leverage those findings to apply them to different nonclinical career options. So part of that process, I attended the SEEK nonclinical careers conference to help jumpstart my research and look into other career options and reached out to former colleagues to kind of explore what they've done in the nonclinical realm.

I made new contacts on LinkedIn. it was a very kind of vulnerable, exposed experience putting myself out there to try to just figure out what was next. And I even tried some telemedicine during that transition. I did a little utilization management just to see what else is out there. But I kept hearing about this life insurance medicine career. And the more I heard about it, the more I thought it would be a really good fit. And so that's ultimately how I got from point A to point B.

John: Well, what you described is really, it could be considered like a model in some ways. These are things we always talk about in the podcast. Okay, getting a coach, using a coach. Heather Fork's been a guest here at least three or four times, and I've been on her podcast several times as well. And so she's kind of an icon from the standpoint of coaching physicians. There's many out there now. But while you've hit on a lot of the points we've talked about Seek here before. Many of the people I've interviewed have actually been alumni from Seek as speakers. So you can add your name to that list now. I guess you've been a mentor there, I believe?

Dr. Megan Leivant: Heather. Yes, I was actually a mentor just this past October, and that was a great experience.

John: I guess I'll go off a little longer on Seek. It's only like 45 minutes from where I live. It's held near Chicago, and I live south of Chicago. I've driven up there and attended a couple of times to meet some of the mentors and the speakers. So that is good. I mean, I think that'll inspire some people to get off the dime because I get asked a lot about what about coaching. And in the old days, Heather and a couple others were like the only ones. I don't know when you started.

Dr. Megan Leivant: Yes, yes, there are a lot of physician coaches out there.

John: It's always something to say, oh to try if that's if you're kind of stuck. All right. You kind of looked at your skills and your interests and what's out there. And then the lifestyle, I think, is always part of that decision. So why don't you start by next telling us what are the duties of a medical director? That's the really the entry point for most if they're going to do life insurance medicine. What does that look like?

Dr. Megan Leivant: Exactly. Yeah. And it is a bit of a of a frame shift, but at the core, I like to think of the primary duties of a life insurance medical director as three pillars. Case consultations are definitely the biggest pillar. And I'll talk about that a little bit more. Teaching is certainly part of that.

And then research. At a very basic level, you're assessing the morbidity and mortality risk of insurance applicants. And so they can be applying for many different types of life insurance products, but really at the core it's mortality and morbidity. And as a physician, really, that responsibility lies in understanding disease processes, their associated risk factors, and how that's going to impact morbidity and mortality. So that's where that frame shift comes in a little bit. as physicians, we are thinking certainly more in the moment, treating what is in front of us.

I think that's probably one of the biggest pivots that has to happen. But there's a number of areas of risk selection. So there's that life mortality risk, there's disability, there's critical illness, and then there's long term care, which is more that morbidity component.

Really a day in the life, the bulk of it is those case consultations. So an underwriter will send over a consultation. And I almost liken that to presentations on rounds. They ideally are sending over, this is a 58 year old male with X, Y, and Z medical conditions. Here's my question. And so, as a medical director, you were there as a consultant to give your opinion. And you provide your opinion back to the underwriter. You're also fielding messages from them and calls and that kind of stuff. But that's, that's, I'd say the bulk of the day to day.

But then you're teaching the underwriters are there to learn from you as well. So that's what I really enjoy about this career is I still get to teach. And it's formal, it's informal you could be giving an external presentation to a room of underwriters, or you're just teaching over over the phone or through one of your consults.

I like that piece of it as well. And then research we're always needing to research these medical conditions that we're encountering. I feel like I've learned so much more in this career, I could probably go back and be a much better clinician. I think from my experiences, but you're doing projects, you're helping update the manual, the manual is what you use to help rate the impairments that the applicants have. That's at the core, I think what the primary duties look like for a medical director.

John: The scary part of that might be if I'm imagining that I'm thinking about taking a job like this, it's well, how I have an understanding of how different illnesses impact one another and why having hypertension might be a risk factor for something involving cardiac problems and so on and so forth. But I'm thinking that people might be like, but I don't know how to quantify that. Where does the quantification come in? Does that come from the underwriter or is that working together or is there a book that has numbers in it? There's some training involved on the job, right?

Dr. Megan Leivant: Oh, yes, absolutely. And I would say it probably takes a good six to 12 months just to really feel comfortable with that. So yes, to your point, when an applicant comes in and presents with, let's say diabetes or heart disease we all have 100% mortality that's a given, right? We all know that. But in the life insurance industry, we use what are called table ratings. And so they go up by 25 increments. 125%, 150%. And that corresponds to a person's mortality. So the higher that number gets the more medical impairments they have.

And every company uses a manual. And that manual includes those conditions like diabetes, heart disease, cancer and there's ratings that are associated with those disease processes. And that can vary. And it does vary per company. But that is where that risk is then assigned to the condition. And then as a medical director, where we come in is, well, what if you've got someone who's had diabetes and heart disease and prostate cancer? Is that a risk that we can consider that the company wants to consider? And from a medical standpoint, can we put all that together to determine if that applicant is suitable for a policy? Jennifer That's a great question.

John: Dr. Justin Marchegiani. But just like anything that you're doing, when you're going from clinical to non-clinical, there's obviously something you're doing in that new job that, well, it uses those skills and that background. It's different because it's a different industry. And I think that's what stops some people. And the thing is, all of these things have been figured out. whether you're going to health insurance or life insurance or pharma, these are not mysteries to the people that are on the other side. And usually they are well-prepared to train you. Now, there isn't really any certification that a physician would typically pursue or do other education before maybe applying for their first job as a medical director in the insurance industry.

Dr. Megan Leivant: That's correct. there are definitely a number of things a person can do to build their knowledge base. But there are a number of directors, myself included, where I walked into this industry very green. I'd had no experience in life insurance medicine, and I was trained on the job. And I've done a lot of those additional classes and certifications now as a director within the industry.

John: I want to hear more about what your career has done since you've been there. But why don't we go first into the obvious question? Maybe they've talked to people that have started doing this, they really love their job, their lifestyle is good. How would I start to look for those jobs and or prepare for the job?

Dr. Megan Leivant: Yeah, that's a great question. So I think there's a number of ways to start looking into this career. And I think there's not just one pathway, probably one of the most useful tools would be to consider joining AIM.

And through that organization, this is kind of like our governing body, if you will, of within insurance medicine. So it's a group of insurance medicine directors, but there are also underwriters and that are members as well. And when you become a member of AIM, you actually can get paired up with a mentor. And the mentor is usually a director who is already in the industry. And I have really found that that's been a great way for individuals who are interested in getting into the industry. they now have a point of contact.

And that really can be a great nurturing relationship to help jumpstart that interest within insurance medicine. But then I think it's a lot of the other things that individuals do to look for new jobs, right? Look for job postings on LinkedIn, get your LinkedIn profile spruced up, try to reach out to if you happen to know anybody that's in the life insurance industry, certainly that's always really, really helpful.

Let others know that you are looking for a new career or that you're interested in this. Connect with an industry recruiter. they are definitely out there. Depending on where you live most of our positions are remote. There are some that are hybrid, but research life insurance companies that are in your hometown that could always potentially provide an opportunity, whether it's a bigger name or a smaller name. And attending a meeting.

That's an absolutely wonderful way to get to network and meet other industry directors, industry professionals. And there's a number of those. So, AIM has its own meeting every fall. And then there are several others that also could provide really good opportunities to try to help kind of jumpstart that career.

John: That sounds logical. Yeah. And I, one thing that I ask about, because we, for some of the big industries, there are these things like LinkedIn groups and Facebook groups. Do are there any such entities that you're aware of for life insurance medicine?

Dr. Megan Leivant: AIM does have a presence on LinkedIn, and I would say that would be a great place to start. I am not aware of any specific life insurance medicine, Facebook groups or anything, but, but AIM again has so many great resources. And so, that's where we end up directing a lot of our individuals that are interested.

John: Okay. So, I'll be sure to put a link to AIM in the show notes.

Dr. Megan Leivant: Yes.

John: So, now let's talk more about you. A couple of things. Maybe you can tell us a little bit about what you like about it and, and, and then what you've done because you're, I think you're no longer an entry-level medical director. We'll just kind of talk about both of those issues.

Dr. Megan Leivant: Sure. I'd say what, what keeps me coming back every day is that this is a really mentally stimulating job. I've really enjoyed, and I continue to enjoy the, the challenge that comes from reviewing these cases that come through every day. This is why I went into internal medicine. I love to solve problems. So, it really gives me the chance to still continue to do that on a day-to-day basis.

There's a ton of variety. I'm seeing diseases that to this day, I still had never seen before. So, I'm still getting to use my medical, medical degree. I'm growing my knowledge base, and, and that was really important to me as I was considering the, the pivot. But it's also a small industry, so there's a lot of great networking opportunities. I've really been able to kind of expand a different part of my marketable skills, if you will.

I miss seeing patients, but I'm still able to create relationships. It's just done in a different way now. And so I'd say that those are probably the big things that kind of keep me coming back every day. It's critical thinking, it's teaching, it's teamwork and collaboration. So, I'm getting to still use a lot of those skills that I used when I was a practicing physician. Yeah, as far as my kind of course throughout my career so far, I've been in the industry over six years, and I started out at what's called a direct life insurance company.

So, a direct life insurance company would be the company where you apply for your life insurance policy. So, they directly, they do that underwriting, and I worked there as a medical director for just under two years, and I got that experience. And then I've, since then, have been working for reinsurance companies.

There are a lot more direct life insurance companies than there are reinsurance companies. So, reinsurance companies help to insure the direct insurance companies. That's probably a very high-level way to kind of describe it, but, but so our clients are the direct insurance companies.

We still, as a medical director, are doing very much the same thing on a day-to-day basis, whether you're at a reinsurance company or a direct insurance company. But in a reinsurance company, we're probably seeing cases that might be a little bit more medically complex. There are certainly some differences there. But at the core, like I said, this is ultimately, it's still the case consults, but there's more teaching, there's more research, and that's kind of helps keep it really interesting and a lot of variety.

John: I wonder I was a CMO for a hospital for a while, and our hospital insured itself from liability. We're talking a little different than life insurance. But they had a consortium, they were so, quote, self-insured. But they did have a reinsurance company, I think, on top of that. Like, there's things that happen that they can't really predict or plan for. So, it's kind of the same idea.

Dr. Megan Leivant: Exactly. if I had a whiteboard, I could draw a diagram the direct companies would be in the middle, and then the reinsurance would kind of be a bubble around it. So, here's an extra layer of protection. We might take on the full risk that a direct company doesn't want to take, or maybe we share that risk because it's a really high net worth case. There's just so many different permutations. But that is a great way to describe it.

John: All right. Now, let me ask you this. Do most of medical directors for a reinsurance company come from a direct insurance company, or are they just out there trying to grab anybody that comes along?

Dr. Megan Leivant: No, that is a really, really great question. I would say, on the majority, physicians that are within reinsurance companies usually are coming to those companies with some direct experience. Now, I'm going to say that's not an absolute, because I do know of some directors that started out in reinsurance. And you're going to get that on-the-job training, no matter where you are. But I would say, on the majority, that's probably the path that you normally see is a direct to a reinsurer.

John: Now, in other industries that are similar, in my mind, to this, they have this whole hierarchy of medical directors and senior medical directors and executive medical directors, and then they get into the VP level. And again, kind of mirrors even the hospital setting. medical director is still involved in the clinical stuff a lot.

The VP or the chief medical officer is really an executive position. So how does that work? The physicians, because I did know one VP of a life insurance company. I haven't talked to him in many years, but I didn't know exactly what he did as a VP, which was different from what he maybe had done prior in previous roles.

Dr. Megan Leivant: Yeah, that's a great question. I think it really, at least what I've seen, is that it really varies per company. I know a number of medical directors, whether they're in a direct company or a reinsurance company in that core role, they have a VP title associated with what they're doing. And I can't speak to the full industry as far as how many are VPs, but I think generally you're going to see that title or you will have that title as a medical director coming into a role, but it's very company specific.

The step up after that, though, is that, yes, depending on how big the company is, then some of them do have a chief medical director, and that's where you start to see some of that delineation as far as the administrative duties etc. Usually the chiefs are probably doing less casework and they're more involved with maybe research or product development or kind of higher level higher level concepts.

John: Yeah, that makes sense. And we see that in a lot of other industries where they just they just have a cascade of titles just to recognize the skill, the experience, and so forth. And then in some cases, it really means you're part of the senior executive team, which does a lot of the strategic planning and creating new service lines and things like that. So each industry, I think, has its own specific ways of doing things.

Dr. Megan Leivant: Definitely.

John: All right. Well, have I forgotten any important questions to ask you? I'm going to let you go in a minute. I definitely shed a lot of light. So any last comments or other things maybe that we've missed in this last 20 minutes or so?

Dr. Megan Leivant: Sure. Well, I think one thing you asked earlier was about prerequisites in a way of getting into the industry. And while there isn't anything that you need to specifically do to get into the industry, there are definitely once you are in, like, we actually, insurance medicine is a boarded specialty.

After you've been in the industry for several years, and there are definitely other courses you have to take and criteria you have to meet, but you can be boarded in insurance medicine. I'm actually working towards that myself. So I did want to kind of add that. And we do what's called a basic morbidity and mortality course that is part of that board preparation. So there are definitely all these opportunities to get that teaching that is needed as just part of the core function of our roles as medical directors.

John: Yeah, I would bet 99.9% of physicians coming out of the training would have no idea that there's such a thing as board certification in life insurance medicine.

Dr. Megan Leivant: Oh, sure. And it's both a written exam and an oral exam. So it's a process that can take up to a year really to kind of go through both of those.

John: And I saw that there's some certifications. Again, I'm assuming that those kind of things are sought after you're in the industry, but I noticed that there are certain things maybe you can explain a little bit about that.

Dr. Megan Leivant: Absolutely. There's a lot of, like I said, a lot of different initials, you can get after your name, a lot of certifications. And these are the courses that the underwriters take. There's LOMA courses, which is Life Office Management Association. And then there's ALU, which is the Association of Life Underwriting. And there are a myriad of different courses within each of those groups.

And those you take those and they're great courses. They really help teach you about the life insurance industry, especially the LOMA courses. Those are definitely more geared towards life insurance, just basic knowledge financial underwriting, risk management all of that. So yes, you can take a number of those courses and then ultimately get different designations depending on what combination of those courses you've taken.

John: Very good. Appreciate that. Yeah, I don't know. I'm a little too old to apply for a life insurance medicine job, but it sounds like the course might just be interesting.

Dr. Megan Leivant: Maybe not. And it depends on the company not everybody needs to be boarded. I think that's very company specific. There are definitely companies that might lay that down as an expectation. But I know there are directors out there that might do this part time and that's not an ask for them. So it's not I think there's definitely a spectrum.

John: Okay. Well, that's really good to know. Maybe they could create a career where they're doing half clinical and half something like this whether it's in this industry or even UM, whatever, that sometimes can be very positive from a lifestyle standpoint.

Dr. Megan Leivant: Sure. And I know of directors that are still doing that very thing. I do know of some that are still practicing clinical medicine, and then they do their life insurance job as well.

John: Excellent. Well, you did mention earlier, this whole thing about networking, tracking down your colleagues and former co-residents and so forth. But one of the things that I'm sure that our listeners might want to do is reach out to you. Hopefully that would be okay to do on LinkedIn. At least you can control that somewhat.

Dr. Megan Leivant: Yes, I'm happy to certainly connect with anybody that would like to do that through LinkedIn.

John: Okay. I'll put your LinkedIn, a link to your LinkedIn profile in the show notes as well, although if they just input your name, they're going to find you. So, all right, Megan, I think we've learned a lot today. I know I have, and I've appreciated this. I really encourage people who are listening to consider this because again, it's a small number, but the people I've talked to, some of them, they just love their jobs, you know? And so there's just something about applying your medical knowledge in this way that just so lines up so well with a lot of our intellectual stimulation, what we love and challenges. And so, I really appreciate you for describing all this and sharing this with us today.

Dr. Megan Leivant: Thank you so much for having me. Yes. Medical directors in this industry are very happy.

John: Nice. All right, Megan, you take care.

Dr. Megan Leivant: Thanks, John. Appreciate it. Bye.

John: Bye-bye.