Interview with Dr. David Feig – Episode 332
In today's episode, John interviews a podcast listener who describes his search for fulfillment and flexibility in a nontraditional job.
Dr. Feig completed his medical degree and his Master’s Degree in Public Health at Emory University. Then he completed a Family Medicine Residency at the University of Michigan and a Sports Medicine Fellowship at Rush University Medical Center.
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Find Fulfillment and Flexibility
He worked for 4 years before branching out into chart reviews, and part-time medical director roles in various settings. He also tried locums and telemedicine along the way. David also explains why he decided to move away from full-time clinical practice to find fulfillment and flexibility in his work.
David has faced the challenges that many listeners face. He described how his attitudes and feelings about each new job can shift from enthusiasm to burnout or indifference. We heard the rationale behind the choices he made as he moved from traditional clinical practice to locums and telemedicine to his current nonclinical job.
Fully Nonclinical Position
In his most recent job, he reviews claims as a Medicare contractor. During our conversation, he describes his thoughts on the different jobs he has tried since leaving clinical medicine. And he explains how working as a Medicare claims reviewer is different from the usual utilization management positions.
Summary
If you have any follow-up questions about any part of his journey, you can reach out to Dr. Feig on LinkedIn by searching for David Feig, MD. A link to his LinkedIn profile and other related content can be found in the show notes below.
NOTE: Look below for a transcript of today's episode.
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Links for Today's Episode:
- Dr. David Feig's LinkedIn Profile
- What Is It Like to Be CMO for a MAC? – 165
- Revisiting Why Utilization Management Physician Advisor Is a Great Hospital Job – 305
- The 5 Most Popular Home Based and Remote Careers – 291
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Transcription PNC Podcast Episode 332
How to Find Fulfillment and Flexibility in Your Nontraditional Job
- Interview with Dr. David Fieg
John: I invited today's guest because I think he represents many of you. He practiced medicine for a while, decided to try some other things part-time and full-time. And he tried locums, he tried telemedicine, and recently he's been performing claim reviews for Medicare. I'm really interested in hearing what he has learned from all these jobs he's done and what advice he has to share with me and with you. So, welcome and hello, Dr. David Fieg.
Dr. David Fieg: Hello, John. Thank you for having me today.
John: I'm really glad you agreed to do this because, again, so many of us reached a point where we thought, "Well, maybe I should do something else", or for whatever reason, we maybe get into your reasons today. And then we just look around and try different things. Sometimes part-time, sometimes full-time. And so, I think it's just going to be really interesting to hear what motivated you and what you learned along the way. So thanks for being here.
Dr. David Fieg: Oh, again, my pleasure. I was a listener before I became a guest.
John: Yes. And that's a good way to go for me because then it's so relevant to the other listeners to hear your perspective. But tell us a little bit about your early education and your clinical career before you started thinking about making a change.
Dr. David Fieg: I had a little bit of an atypical path to medicine in the sense that I went to college. I was pre-med. I thought, "Oh, I'm always going to be a doctor." Growing up I had a very gifted pediatrician who took very good care of me and my brothers. And he was definitely an inspiration. Just as an aside, I guess he was trained clinically as a neurosurgeon but apparently, he had some issue operating. Back in the day, I guess the way they did lighting and the ORs, it gave him sneezing attacks. And obviously during brain surgery, that's a big problem. And he had to retrain essentially in pediatrics because he couldn't operate. But that level of skill translated into his pediatrics because he was quite brilliant. And he always had a moment to answer my questions. And he was very much a great role model for me.
I went off to college, and was in the pre-med track. And I tried to distinguish myself by trying not to be as cutthroat as the stereotypical pre-med students. And I had some moments. I already had notions of taking a year off. I was going to take a year off. My mistake was looking back on it was, what was I going to do in that year off? Because if you're looking for a job, a lot of places are like, you're going to go in a year and start school, and not a lot of places are excited to hire you in those scenarios. So I was able to get some work and I did apply to medicine.
And I think for my first application cycle, I was very ill prepared in terms of where I applied. I applied to a bunch of very selective schools. Maybe I was a little over confident, who knows? I think I got two interviews and one wait list and it didn't work out. And then I'm like, "Oh, this is terrible. I didn't get in. What am I going to do?" And I applied one more time. This time I was a lot more broad in where I applied. I'm remembering, but I'm pretty sure I was on seven wait lists. And I thought "Seven wait lists?" This has got to be made and I'll get in somewhere. And seven became six and five and four and three, then two. And then I was like, "Oh dear."
I went back and got a master's in public health with the notion that either I was going to get a job in healthcare if I couldn't be a doctor or it would be enough to hopefully get me over the hump and an acceptance somewhere. I did that and I applied one last time. And after some trials and tribulations with two more wait lists, I got offers in both places and everything started. And it was quite the shock when I finally got accepted.
John: Well, we have more in common than I knew about even from talking to you before. I was not accepted. I was out for two years. What I did was I took a micro course because I think that was the area I was weakest in. And lo and behold, when I applied two or three years later, I got in. But who knew? And we both have master's in public health. So, keep going. Tell us more now. You've made it through med school. You went into family medicine, but then you did a fellowship after that, from what I know.
Dr. David Fieg: Yeah. Medical school was definitely really hard for me. And I think it's hard for a lot of people. Coming from probably very academically talented and most people that go on to medical school have great academic credentials that they wouldn't have gotten in. The one footnote maybe to this story that I do get a kick out of later on was at times, I think I caught the ire of some of my professors because of my yawning. I would yawn a lot on rounds, and it got enough that it was noticed and I really couldn't put my finger on it. But it definitely didn't make things simple, I guess what I would say. But I persevered, get to Michigan, get a fellowship, and then sort of go on from there. That was sort of everything. That's sort of why I gravitated a bit towards family because of the connection to sports.
John: How was that program?
Dr. David Fieg: Oh, that was a breath of fresh air. In medical school, depending on the size of your class, it could be 50 people, it could be 100 people. I'm sure there are some schools that have even larger classes. But it was a breath of fresh air and a lot of struggles that I had in medical school, really I think were different in residency. And then the funny thing is, after getting some concern, that I was on call and I was snoring so loud on call, in the call rooms, people would pick me up physically and move me to the outside of the call room and kind of lay me by the door. Other people began to notice and then the thought was "You also kind of stopped breathing when you're sleeping. Maybe you should get that sleep study." And I was like, "Oh, get out of town. That can't possibly be. I've been doing this since I was in medical school." And it's like, "Oh, okay, go get it."
I got a sleep study and they did diagnose me with very bad sleep apnea. Very bad. And I was the resident that when I was on call, I would carry my CPAP machine with me to the hospital in case I got a chance to lay down for a while. I would put my CPAP on because that way if I slept, I actually could get restorative sleep for a change. It was definitely a wake up call. And then everything got a lot easier after that, shockingly. I was doing better. My in service exams got much better, my performance on rotations got better.
I did finish up with my family medicine training and I went off to do a sports medicine fellowship. And that was eye-opening just in the sense of the nature of the practice and how you want to maximize how much you're getting out of that one year to get the skills you need to sort of build forward.
And I think at times it was a struggle because it is one year, it's only really one year to acclimate in some cases to a new city or a new environment. But all the while you kind of have to be on your toes in terms of dealing with a new system in some cases, and then also your professors, the athletes you're taking care of. So, it was a very busy year, and it definitely was a long year as well.
And after finishing up, basically decided I had enough for the winter being in the Midwest for a few years. That's when I was looking for jobs on the West coast to get away from snow at least for a little while. And lo and behold, I did find something and I was off to the west coast to try to hopefully escape the Midwest winters that I had gotten used to over a couple of years.
John: What did you find? Was it something that was geared mostly in sports medicine or was it family medicine too or something else?
Dr. David Fieg: Oh, definitely family medicine. And that was maybe the strange thing as I was going through my fellowship. I had realized that I still enjoy the practice of all spectrums of medicine. Maybe not as much obstetrics, but certainly the primary care component was what I think called to me the most. But I still enjoyed the musculoskeletal part two. Instead of trying to do sports med only, I had gravitated to more traditional practice.
In that particular group, it was me who had the sports background and then we had an orthopedist who had decided to stop operating. He was really doing non-operative stuff. So we sort of had a nice relationship, a synergistic relationship that we would sometimes see each other's patients and I'd ask him questions and vice versa. Although mostly I asked him questions when I was starting out. And he had to go out and about and he had patients that needed say synvisc injections on their knees or something. I'd be happy to jump in and help out with that. So, that was a great initial experience as my first job out fellowship.
John: Nice. Well, how long did you continue doing that and what caused you to make a change?
Dr. David Fieg: It was about four years. And I think I come to the realization that they say your first job out of training is going to be the job where you figure out what you want your job to be. And as with everything, there are some always some really good stuff. And then there's stuff that's not so good. And ultimately working in a big system carries a lot of benefits in the sense that there's a billing department, there are other departments that can support you, there's a credentialing department. All these things that you can take advantage of. They are often CME that they'll pay for and other benefits that you get from working in a large system. But you also have to realize that you also work in a large system with your other doctors and your other coworkers, nurse practitioners, PAs. Everyone that kind of forms the team. You definitely have to be part of that system.
And if you say have an entrepreneurial spirit or you want to maybe spread your wings or if you're like me and you're also very technical and you get very frustrated by maybe the electronic medical records that you use, and most physicians have strong opinions about it obviously, you're not really in a position where you can get them to give you your own system, you're going to use what they have. And you can do the best you can within it but flexibility is not something you get necessarily in those environments. You get the security of working for a larger system. The large system is going to pay your salary, whereas if you have your own practice, you've got to get a bookkeeper and make sure you get your bills sent out to get paid usually from the insurance companies, otherwise you don't necessarily have an income.
Having a more explicit understanding of that kind of trade off, I think after four years it became a little more clear just in the sense that you have to find a niche, I guess. And I do very much say that when you're out of training, finding what you want to do can be tricky. Definitely I wanted to point out systems and technology and how we use it to be more efficient, but also realizing doing that in a large system, I think change is never easy. And I think change in a large hospital system or any healthcare system is challenging. If we look at how our hospital systems have changed over the years, or even how they changed from COVID, we can kind of realize that kind of change is atypical. Usually it takes a crisis like COVID to get things to change. And that was maybe a big thing we'll talk about in a bit is how much telemedicine changed in that timeframe out of necessity. That it hadn't really changed a lot before that until there was like, okay, people need this care and we have to find a way to do it, and these are the places that are set up to provide that.
At any rate, all those things go on my mind and I realized that I did want to make a change and I had pursued some other opportunities and I found a job working more partly clinical, partly as an area medical director for an urgent care system. It was based out of Portland that had opened up some places in Seattle. I guess you could say it was my first official administrative role.
The funny thing is, and it's the other thing I learned the hard way, when you're a physician working in a clinic, whether you want to be management or not, you are one of the doctors there, you are a provider, which means that other staff will definitely notice when you say or do things. You have to be careful what you say, and you also have to realize that you might not necessarily... You want to just show up and take care of patients and go home, but I think it's rarely ever that simple.
I certainly learned that you have to be mindful of that when you're in your job. Now, I was in this new job and I was actually officially management in my title at least. I got to see patients also help oversee some nurse practitioners and some physician assistants to run the clinics and kind of keep things running smooth. And I was doing a lot of chart review and just being available for clinical support for the team, and practicing in a different way. Seeing how they figure out the account I think was a valuable insight that I hadn't had a chance to really experience before.
John: Now, was it at that location that you started getting into the telemedicine, or did that come later?
Dr. David Fieg: That actually came later. As much as I enjoyed the opportunities working in urgent care, I had this thought in my brain that launched the having relationship with your patients and having that longitudinal care was actually a good thing. And it is a good thing. Although, looking back on it, I think there are caveats you have to be mindful of too.
I wanted to get into a situation where there was more of a panel of patients that I'd be taking care of. Maybe shift from the acute stuff to more of the continuity of care that I enjoyed. I made one more shift to a startup that was doing more work in that field, more based out of employer healthcare model in which employers actually can have their own clinics that are managed generally, contracted by this third party, so that the patients, the employees can go thinking that they are not necessarily going to the company doctor. It's the company that the company hired to help provide some extra care.
And there are creative ways you can manage the finances such that you can provide services, the company can cover it. If it helps with utilization of your primary insurance spending, then it can often pay for itself. There's some interesting ways around it. I think the market has changed a bit over the years, but that was what it was when I came into that profession.
John: What was that situation like? Was it one or two of you in a pod or was it a large group? Was it centralized where employees were coming from all over?
Dr. David Fieg: It started out pretty small with only two locations. And over time it expanded to multiple locations around the Pacific Northwest. And then it kept expanding from there. The growth of the company was pretty huge. And it did go on to do some big things from what I understand. I learned a lot again. And I was hired to work there, as one of the docs. And there were some changes. And then I had the opportunity to get more involved in leadership again, which was nice. And I did do a lot more on the technical side, kind of working with the EMR system, got to see the nuts and bolts of it, and that was sort of exciting and also overwhelming.
The more you dive into it, the more you realize that it's pretty complicated. And it's sort of why hospital systems have entire departments of people trying to wrangle this because it oftentimes has that level of detail because humans are complicated, medicine is complicated. And to translate some of that stuff to the non-physician, but to the developer that's writing the program, these are complicated things that we don't often think about. I learned a lot from the other perspective about that. That was definitely a great experience and also very much overwhelming in the grand scheme of things.
John: Then what? You were about to segue either into another move or thinking about something else. What was the next step for you?
Dr. David Fieg: I think it was at a professional low point in terms of my health that I think the stress of keeping up with medicine is something that all physicians have to deal with. And actually almost anyone in a professional setting, whether it's a nurse, a lawyer, a doctor, a nurse practitioner, a physician assistant, I think you all experienced some level of burnout. And I think over the course of my career, I certainly had burnout several times. I should give it a little shout out to Dike Drummond who I did connect with at different points over my career. That was really one of the first people to talk about burnout amongst physicians and then other health professions in a really solid and very focused way that really tried to define it.
I had left that particular job and that's when I sort of did more telemedicine. I also started to do a lot more locums in the area. More opportunities came up where I had never really done locums before. The opportunity to leverage some connections I had, I built up over the years to help cover some clinics, to help cover some maternity leave for some larger hospital systems, but also still going back and then sometimes then doing a couple hour shift in telemedicine was an experience. And it went well enough that I kept doing the telemedicine for a while. And that's when I got to experience both, you can say, doing coverage physically in a clinic, and then also doing telemedicine from home.
And I learned a lot. This was actually still pre pandemic. It was just before the pandemic and that was where things got really crazy, I guess you could say. Only in the sense that I was doing a little bit of both. I was still sort of looking, experimenting, do I want to open my own practice? Should I open up my own telemedicine practice? How can I manage this? And that's sort of when I just focused a lot on telemedicine for a period of time. And that's sort of when my locums assignments had run out and I decided not to sign up for anymore for a while so I could run more with the telemedicine component. And then I was doing that for a while.
The one thing I learned is that when you're in primary care and you have a patient coming in for a visit, the first few minutes of the visit can be incredibly nerve wracking because you don't know how sick the patient really is. And then when you see them on the camera, if you can, that's when you get an idea, "Do I feel good about this? Do I not feel good about this?" And maybe the major thing I learned was if you have concerns that the patient maybe is too sick for telemedicine, you have to be very explicit about that. And no, they'll never be happy to hear that. But if you're firm and you communicate your concerns, vast majority of patients that I explained my concerns to were willing to go into an emergency room and get care, which was good. And I think you have to be very cognizant of that if you're doing telemedicine because it's not the same as in-person care.
And maybe that's the biggest difference. At least in-person care, you can see the EMS take the patient to the hospital, but in telemedicine, you have to trust that they're going to follow through. And that was always a point of concern.
John: People I've talked to, they seem to indicate that's the skill you need to know to recognize when they're sick, and then to be able to quickly and effectively communicate, okay, this is not a telemedicine visit. You need to see somebody and whether it's emergent or in the next six hours or what have you.
We're going to run out of time pretty soon. So I really want to hear about what you're doing now and how you feel that fits in with your long-term plans and do you enjoy it? I'd like to see what you think about it. I don't know that many people are doing the job that you're doing now.
Dr. David Fieg: Right. I'd say I'm from New York, so we talk a lot. It goes with the territory. As I was doing telemedicine, I did have some friends that were involved in doing more utilization management work. I was able to pick up some extra work on the side. I cut to halftime telemedicine, halftime doing utilization management. This is more the traditional nonclinical job in which you're usually reviewing advanced imaging and trying to make decisions about whether the MRI or the CAT scan should be approved. I did that for a while.
And that experience, particularly working with different insurances and how to interpret rules and regulations, did give me the skills to connect with where I'm working now, which is more about reviewing Medicare claims as a qualified independent contractor. Working from one of the companies that reviews claims, it's quite complicated, much more complicated than I ever realized.
But what it boils down to is that Medicare rules and regulations are quite complicated. And even though I've worked in big hospital systems, even though I've worked in small startups, even though I've worked in many places, I did take quite a few Medicare paying patients. The physician's knowledge of the intricacies of some of the regulations is maybe not what we thought. And then you kind of realize, well, everything's on the website, so if you really have a question about how to bill for X, Y, Z, you can go to their website and look up rules and regulations. And maybe that's sort of the takeaway for me was I learned a lot through practice, although I did mainly outpatient, so I was probably more in part B than inpatient part A.
But you learn a lot by practice, and since we have separate billers and coders, maybe you don't get into the same level of detail that you do when you're actually reviewing the cases. And you see how it was coded, you see how the documentation was, and then you compare what you have to, what the regulations for Medicare are, and you try to make sense of why it was denied, what the rationale is. You do an independent review. You basically start from scratch to sort of see what your concerns are. But it certainly makes you realize just that obviously billing and coding for medical care is very complicated. And know physicians really focus for obvious reasons on the clinical side.
But looking back on how Medicare does their guidelines, how they do national coverage determinations, how they do local coverage determinations, all that information is out there. And if you do have patients you're taking care of, it's really important to be aware of how you do your documentation. That's probably why clinical documentation improvement specialist or clinical documentation review is also becoming a hot field because if we all had time, we could probably document better. If our computer system was better, we would document better. But you have to be the most efficient and the tools you have at hand.
John: Now I have a question. The review of Medicare, was there much of an orientation or training? They just throw you some manuals? How did that work out?
Dr. David Fieg: Oh, no, I got some great doctors to work with. We actually did it virtually because I had started the job right when COVID hit for real in March of 2020. That was when Seattle had its first few cases right before. People finally realized that it finally had reached to the states. And certainly things changed a lot after that fact, changes in telemedicine and then changes with remote work. This was always a remote position interestingly enough. I was able to virtually sit, and of course, now we have the technology to do this. Sit and talk by phone, by video, by real time sharing screens, going over cases, going over the information, trying to read through the major case types, understanding the types of cases you'll see in different parts of Medicare, whether it's part A or part B. Understanding one's more inpatient, one's more outpatient. Certain drugs are considered the B of A, so they fall under more of the part A side. Getting a lot of minutiae of detail, and just understanding how the cases go.
But a lot of really good doctors that have been doing this for a while and have a lot of experience, were really helpful in getting me trained to pick up all these details. And then a lot of it, honestly, is also reading a lot of cases, reading the decisions and going back to the case and just looking through it back and forth and understanding seeing the patterns arise. Why was this denied? Well, they didn't document X, Y, Z. Well, why was this approved? Well, they did document X, Y, Z. Sometimes it can come down to that, sometimes it can be more of a judgment call. But document, document, document is what they say.
You want to be careful on what you put in the chart in the sense of just for certain conditions, you just need to be very explicit as to what you saw and document it. It also comes back maybe strangely to the systems that we use. And if your EMR, as you said, whether it's due to time, energy and money is more out of the box, maybe it's not as customized as it could be for your particular style or your clinic. And that could affect your reimbursement if it's not configured correctly to capture all the key things that you need.
It's funny how that's kind of a strange circle and that we don't have time so we run through with our computer systems to document what we need, but maybe we don't spend enough time making sure it's documenting enough of the things we need, whether it's private insurance or commercial insurance or is it Medicaid, Medicare. Because they do have requirements that are available for review. And we do want to be mindful of them because getting paid is important and not getting paid for even the large health system can be quite onerous.
John: Yeah. It catches up with you if there's too much of that going on. Well, we are going to be out of time here in about a minute. So, just looking back, maybe advice you have for other people that are at the beginning of the journey that you've made so far where you're trying to find the right clinical thing to do, or maybe they want to do two different things or maybe they don't want to do clinical. What advice would you have for people that just find themselves early in that process?
Dr. David Fieg: I think you do want to get at least some clinical basis. And when you're out of training, you want to practice for at least a few years. A lot of the best nonclinical work does often require anywhere from three to five years of actual practice experience. For a lot of people you might close some doors if you don't finish your residency, if you don't do some clinical practice for a few years.
But once you get through that point, that's a great time to reassess. And as I said, there's more and more opportunities, whether it's telemedicine, whether it's utilization management, whether it's clinical documentation improvement, whether it is doing case or claim review, whether it's legal consulting. There's a tremendous variety of things available. One of the struggles I think is just connecting to figure out what's out there because it seems to change all the time. A lot of people didn't know about the work I'm doing now in terms of review for Medicare claims. More were familiar with utilization management. I think more are getting familiar with certainly the legal consulting component, and also getting more familiar with the clinical documentation improvement.
That's maybe the flip side to what I do, is that they're working with the docs to make sure they understand if they're seeing case X all day long, that they know what the requirements are for documentation, if they're billing a lot of Medicare claims. So that everything is set up to set them up for success rather than confusion in a lot of physician queries. I see that they send a query to the physician, the coder sends a query to the physician. What was this? And I remember getting them when I was practicing more in a traditional practice and it's like, "What is this? Why am I filling this out?" It's like, no, fill it out and try to actually think about what you're going to write because it's really important and it may actually affect whether you get paid or not.
John: Yeah, absolutely. I think some people might have lingering questions, you've covered a lot of material here today. It's okay I assume maybe if they can just find you on LinkedIn?
Dr. David Fieg: Oh yeah, absolutely. I'm kind of an open book. David B. Fieg. There aren't too many Fiegs on LinkedIn. So, if you see the doctor, that probably is me.
John: Well, I will put that link in the show notes too. If anyone is really struggling to find you, they can go to the show notes for this episode.
Dr. David Fieg: Yeah. And if you see the one that went to Michigan for a residency, that's probably me. So go Blue. Hopefully, we'll bring home the big one for the playoffs this year.
John: All right. All of you out there, I hope you are Michigan fans. All right, David, this has been really good. I appreciate it. We might have to have you come back in a few years and see if you're still doing this or have done something else, but we have a lot to think about. I really enjoyed hearing your story today.
Dr. David Fieg: Sure.
John: With that, I will say goodbye.
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Transcription PNC Podcast Episode 332
How to Find Fulfillment and Flexibility in Your Nontraditional Job
- Interview with Dr. David Fieg
John: I invited today's guest because I think he represents many of you. He practiced medicine for a while, decided to try some other things part-time and full-time. And he tried locums, he tried telemedicine, and recently he's been performing claim reviews for Medicare. I'm really interested in hearing what he has learned from all these jobs he's done and what advice he has to share with me and with you. So, welcome and hello, Dr. David Fieg.
Dr. David Fieg: Hello, John. Thank you for having me today.
John: I'm really glad you agreed to do this because, again, so many of us reached a point where we thought, "Well, maybe I should do something else", or for whatever reason, we maybe get into your reasons today. And then we just look around and try different things. Sometimes part-time, sometimes full-time. And so, I think it's just going to be really interesting to hear what motivated you and what you learned along the way. So thanks for being here.
Dr. David Fieg: Oh, again, my pleasure. I was a listener before I became a guest.
John: Yes. And that's a good way to go for me because then it's so relevant to the other listeners to hear your perspective. But tell us a little bit about your early education and your clinical career before you started thinking about making a change.
Dr. David Fieg: I had a little bit of an atypical path to medicine in the sense that I went to college. I was pre-med. I thought, "Oh, I'm always going to be a doctor." Growing up I had a very gifted pediatrician who took very good care of me and my brothers. And he was definitely an inspiration. Just as an aside, I guess he was trained clinically as a neurosurgeon but apparently, he had some issue operating. Back in the day, I guess the way they did lighting and the ORs, it gave him sneezing attacks. And obviously during brain surgery, that's a big problem. And he had to retrain essentially in pediatrics because he couldn't operate. But that level of skill translated into his pediatrics because he was quite brilliant. And he always had a moment to answer my questions. And he was very much a great role model for me.
I went off to college, and was in the pre-med track. And I tried to distinguish myself by trying not to be as cutthroat as the stereotypical pre-med students. And I had some moments. I already had notions of taking a year off. I was going to take a year off. My mistake was looking back on it was, what was I going to do in that year off? Because if you're looking for a job, a lot of places are like, you're going to go in a year and start school, and not a lot of places are excited to hire you in those scenarios. So I was able to get some work and I did apply to medicine.
And I think for my first application cycle, I was very ill prepared in terms of where I applied. I applied to a bunch of very selective schools. Maybe I was a little over confident, who knows? I think I got two interviews and one wait list and it didn't work out. And then I'm like, "Oh, this is terrible. I didn't get in. What am I going to do?" And I applied one more time. This time I was a lot more broad in where I applied. I'm remembering, but I'm pretty sure I was on seven wait lists. And I thought "Seven wait lists?" This has got to be made and I'll get in somewhere. And seven became six and five and four and three, then two. And then I was like, "Oh dear."
I went back and got a master's in public health with the notion that either I was going to get a job in healthcare if I couldn't be a doctor or it would be enough to hopefully get me over the hump and an acceptance somewhere. I did that and I applied one last time. And after some trials and tribulations with two more wait lists, I got offers in both places and everything started. And it was quite the shock when I finally got accepted.
John: Well, we have more in common than I knew about even from talking to you before. I was not accepted. I was out for two years. What I did was I took a micro course because I think that was the area I was weakest in. And lo and behold, when I applied two or three years later, I got in. But who knew? And we both have master's in public health. So, keep going. Tell us more now. You've made it through med school. You went into family medicine, but then you did a fellowship after that, from what I know.
Dr. David Fieg: Yeah. Medical school was definitely really hard for me. And I think it's hard for a lot of people. Coming from probably very academically talented and most people that go on to medical school have great academic credentials that they wouldn't have gotten in. The one footnote maybe to this story that I do get a kick out of later on was at times, I think I caught the ire of some of my professors because of my yawning. I would yawn a lot on rounds, and it got enough that it was noticed and I really couldn't put my finger on it. But it definitely didn't make things simple, I guess what I would say. But I persevered, get to Michigan, get a fellowship, and then sort of go on from there. That was sort of everything. That's sort of why I gravitated a bit towards family because of the connection to sports.
John: How was that program?
Dr. David Fieg: Oh, that was a breath of fresh air. In medical school, depending on the size of your class, it could be 50 people, it could be 100 people. I'm sure there are some schools that have even larger classes. But it was a breath of fresh air and a lot of struggles that I had in medical school, really I think were different in residency. And then the funny thing is, after getting some concern, that I was on call and I was snoring so loud on call, in the call rooms, people would pick me up physically and move me to the outside of the call room and kind of lay me by the door. Other people began to notice and then the thought was "You also kind of stopped breathing when you're sleeping. Maybe you should get that sleep study." And I was like, "Oh, get out of town. That can't possibly be. I've been doing this since I was in medical school." And it's like, "Oh, okay, go get it."
I got a sleep study and they did diagnose me with very bad sleep apnea. Very bad. And I was the resident that when I was on call, I would carry my CPAP machine with me to the hospital in case I got a chance to lay down for a while. I would put my CPAP on because that way if I slept, I actually could get restorative sleep for a change. It was definitely a wake up call. And then everything got a lot easier after that, shockingly. I was doing better. My in service exams got much better, my performance on rotations got better.
I did finish up with my family medicine training and I went off to do a sports medicine fellowship. And that was eye-opening just in the sense of the nature of the practice and how you want to maximize how much you're getting out of that one year to get the skills you need to sort of build forward.
And I think at times it was a struggle because it is one year, it's only really one year to acclimate in some cases to a new city or a new environment. But all the while you kind of have to be on your toes in terms of dealing with a new system in some cases, and then also your professors, the athletes you're taking care of. So, it was a very busy year, and it definitely was a long year as well.
And after finishing up, basically decided I had enough for the winter being in the Midwest for a few years. That's when I was looking for jobs on the West coast to get away from snow at least for a little while. And lo and behold, I did find something and I was off to the west coast to try to hopefully escape the Midwest winters that I had gotten used to over a couple of years.
John: What did you find? Was it something that was geared mostly in sports medicine or was it family medicine too or something else?
Dr. David Fieg: Oh, definitely family medicine. And that was maybe the strange thing as I was going through my fellowship. I had realized that I still enjoy the practice of all spectrums of medicine. Maybe not as much obstetrics, but certainly the primary care component was what I think called to me the most. But I still enjoyed the musculoskeletal part two. Instead of trying to do sports med only, I had gravitated to more traditional practice.
In that particular group, it was me who had the sports background and then we had an orthopedist who had decided to stop operating. He was really doing non-operative stuff. So we sort of had a nice relationship, a synergistic relationship that we would sometimes see each other's patients and I'd ask him questions and vice versa. Although mostly I asked him questions when I was starting out. And he had to go out and about and he had patients that needed say synvisc injections on their knees or something. I'd be happy to jump in and help out with that. So, that was a great initial experience as my first job out fellowship.
John: Nice. Well, how long did you continue doing that and what caused you to make a change?
Dr. David Fieg: It was about four years. And I think I come to the realization that they say your first job out of training is going to be the job where you figure out what you want your job to be. And as with everything, there are some always some really good stuff. And then there's stuff that's not so good. And ultimately working in a big system carries a lot of benefits in the sense that there's a billing department, there are other departments that can support you, there's a credentialing department. All these things that you can take advantage of. They are often CME that they'll pay for and other benefits that you get from working in a large system. But you also have to realize that you also work in a large system with your other doctors and your other coworkers, nurse practitioners, PAs. Everyone that kind of forms the team. You definitely have to be part of that system.
And if you say have an entrepreneurial spirit or you want to maybe spread your wings or if you're like me and you're also very technical and you get very frustrated by maybe the electronic medical records that you use, and most physicians have strong opinions about it obviously, you're not really in a position where you can get them to give you your own system, you're going to use what they have. And you can do the best you can within it but flexibility is not something you get necessarily in those environments. You get the security of working for a larger system. The large system is going to pay your salary, whereas if you have your own practice, you've got to get a bookkeeper and make sure you get your bills sent out to get paid usually from the insurance companies, otherwise you don't necessarily have an income.
Having a more explicit understanding of that kind of trade off, I think after four years it became a little more clear just in the sense that you have to find a niche, I guess. And I do very much say that when you're out of training, finding what you want to do can be tricky. Definitely I wanted to point out systems and technology and how we use it to be more efficient, but also realizing doing that in a large system, I think change is never easy. And I think change in a large hospital system or any healthcare system is challenging. If we look at how our hospital systems have changed over the years, or even how they changed from COVID, we can kind of realize that kind of change is atypical. Usually it takes a crisis like COVID to get things to change. And that was maybe a big thing we'll talk about in a bit is how much telemedicine changed in that timeframe out of necessity. That it hadn't really changed a lot before that until there was like, okay, people need this care and we have to find a way to do it, and these are the places that are set up to provide that.
At any rate, all those things go on my mind and I realized that I did want to make a change and I had pursued some other opportunities and I found a job working more partly clinical, partly as an area medical director for an urgent care system. It was based out of Portland that had opened up some places in Seattle. I guess you could say it was my first official administrative role.
The funny thing is, and it's the other thing I learned the hard way, when you're a physician working in a clinic, whether you want to be management or not, you are one of the doctors there, you are a provider, which means that other staff will definitely notice when you say or do things. You have to be careful what you say, and you also have to realize that you might not necessarily... You want to just show up and take care of patients and go home, but I think it's rarely ever that simple.
I certainly learned that you have to be mindful of that when you're in your job. Now, I was in this new job and I was actually officially management in my title at least. I got to see patients also help oversee some nurse practitioners and some physician assistants to run the clinics and kind of keep things running smooth. And I was doing a lot of chart review and just being available for clinical support for the team, and practicing in a different way. Seeing how they figure out the account I think was a valuable insight that I hadn't had a chance to really experience before.
John: Now, was it at that location that you started getting into the telemedicine, or did that come later?
Dr. David Fieg: That actually came later. As much as I enjoyed the opportunities working in urgent care, I had this thought in my brain that launched the having relationship with your patients and having that longitudinal care was actually a good thing. And it is a good thing. Although, looking back on it, I think there are caveats you have to be mindful of too.
I wanted to get into a situation where there was more of a panel of patients that I'd be taking care of. Maybe shift from the acute stuff to more of the continuity of care that I enjoyed. I made one more shift to a startup that was doing more work in that field, more based out of employer healthcare model in which employers actually can have their own clinics that are managed generally, contracted by this third party, so that the patients, the employees can go thinking that they are not necessarily going to the company doctor. It's the company that the company hired to help provide some extra care.
And there are creative ways you can manage the finances such that you can provide services, the company can cover it. If it helps with utilization of your primary insurance spending, then it can often pay for itself. There's some interesting ways around it. I think the market has changed a bit over the years, but that was what it was when I came into that profession.
John: What was that situation like? Was it one or two of you in a pod or was it a large group? Was it centralized where employees were coming from all over?
Dr. David Fieg: It started out pretty small with only two locations. And over time it expanded to multiple locations around the Pacific Northwest. And then it kept expanding from there. The growth of the company was pretty huge. And it did go on to do some big things from what I understand. I learned a lot again. And I was hired to work there, as one of the docs. And there were some changes. And then I had the opportunity to get more involved in leadership again, which was nice. And I did do a lot more on the technical side, kind of working with the EMR system, got to see the nuts and bolts of it, and that was sort of exciting and also overwhelming.
The more you dive into it, the more you realize that it's pretty complicated. And it's sort of why hospital systems have entire departments of people trying to wrangle this because it oftentimes has that level of detail because humans are complicated, medicine is complicated. And to translate some of that stuff to the non-physician, but to the developer that's writing the program, these are complicated things that we don't often think about. I learned a lot from the other perspective about that. That was definitely a great experience and also very much overwhelming in the grand scheme of things.
John: Then what? You were about to segue either into another move or thinking about something else. What was the next step for you?
Dr. David Fieg: I think it was at a professional low point in terms of my health that I think the stress of keeping up with medicine is something that all physicians have to deal with. And actually almost anyone in a professional setting, whether it's a nurse, a lawyer, a doctor, a nurse practitioner, a physician assistant, I think you all experienced some level of burnout. And I think over the course of my career, I certainly had burnout several times. I should give it a little shout out to Dike Drummond who I did connect with at different points over my career. That was really one of the first people to talk about burnout amongst physicians and then other health professions in a really solid and very focused way that really tried to define it.
I had left that particular job and that's when I sort of did more telemedicine. I also started to do a lot more locums in the area. More opportunities came up where I had never really done locums before. The opportunity to leverage some connections I had, I built up over the years to help cover some clinics, to help cover some maternity leave for some larger hospital systems, but also still going back and then sometimes then doing a couple hour shift in telemedicine was an experience. And it went well enough that I kept doing the telemedicine for a while. And that's when I got to experience both, you can say, doing coverage physically in a clinic, and then also doing telemedicine from home.
And I learned a lot. This was actually still pre pandemic. It was just before the pandemic and that was where things got really crazy, I guess you could say. Only in the sense that I was doing a little bit of both. I was still sort of looking, experimenting, do I want to open my own practice? Should I open up my own telemedicine practice? How can I manage this? And that's sort of when I just focused a lot on telemedicine for a period of time. And that's sort of when my locums assignments had run out and I decided not to sign up for anymore for a while so I could run more with the telemedicine component. And then I was doing that for a while.
The one thing I learned is that when you're in primary care and you have a patient coming in for a visit, the first few minutes of the visit can be incredibly nerve wracking because you don't know how sick the patient really is. And then when you see them on the camera, if you can, that's when you get an idea, "Do I feel good about this? Do I not feel good about this?" And maybe the major thing I learned was if you have concerns that the patient maybe is too sick for telemedicine, you have to be very explicit about that. And no, they'll never be happy to hear that. But if you're firm and you communicate your concerns, vast majority of patients that I explained my concerns to were willing to go into an emergency room and get care, which was good. And I think you have to be very cognizant of that if you're doing telemedicine because it's not the same as in-person care.
And maybe that's the biggest difference. At least in-person care, you can see the EMS take the patient to the hospital, but in telemedicine, you have to trust that they're going to follow through. And that was always a point of concern.
John: People I've talked to, they seem to indicate that's the skill you need to know to recognize when they're sick, and then to be able to quickly and effectively communicate, okay, this is not a telemedicine visit. You need to see somebody and whether it's emergent or in the next six hours or what have you.
We're going to run out of time pretty soon. So I really want to hear about what you're doing now and how you feel that fits in with your long-term plans and do you enjoy it? I'd like to see what you think about it. I don't know that many people are doing the job that you're doing now.
Dr. David Fieg: Right. I'd say I'm from New York, so we talk a lot. It goes with the territory. As I was doing telemedicine, I did have some friends that were involved in doing more utilization management work. I was able to pick up some extra work on the side. I cut to halftime telemedicine, halftime doing utilization management. This is more the traditional nonclinical job in which you're usually reviewing advanced imaging and trying to make decisions about whether the MRI or the CAT scan should be approved. I did that for a while.
And that experience, particularly working with different insurances and how to interpret rules and regulations, did give me the skills to connect with where I'm working now, which is more about reviewing Medicare claims as a qualified independent contractor. Working from one of the companies that reviews claims, it's quite complicated, much more complicated than I ever realized.
But what it boils down to is that Medicare rules and regulations are quite complicated. And even though I've worked in big hospital systems, even though I've worked in small startups, even though I've worked in many places, I did take quite a few Medicare paying patients. The physician's knowledge of the intricacies of some of the regulations is maybe not what we thought. And then you kind of realize, well, everything's on the website, so if you really have a question about how to bill for X, Y, Z, you can go to their website and look up rules and regulations. And maybe that's sort of the takeaway for me was I learned a lot through practice, although I did mainly outpatient, so I was probably more in part B than inpatient part A.
But you learn a lot by practice, and since we have separate billers and coders, maybe you don't get into the same level of detail that you do when you're actually reviewing the cases. And you see how it was coded, you see how the documentation was, and then you compare what you have to, what the regulations for Medicare are, and you try to make sense of why it was denied, what the rationale is. You do an independent review. You basically start from scratch to sort of see what your concerns are. But it certainly makes you realize just that obviously billing and coding for medical care is very complicated. And know physicians really focus for obvious reasons on the clinical side.
But looking back on how Medicare does their guidelines, how they do national coverage determinations, how they do local coverage determinations, all that information is out there. And if you do have patients you're taking care of, it's really important to be aware of how you do your documentation. That's probably why clinical documentation improvement specialist or clinical documentation review is also becoming a hot field because if we all had time, we could probably document better. If our computer system was better, we would document better. But you have to be the most efficient and the tools you have at hand.
John: Now I have a question. The review of Medicare, was there much of an orientation or training? They just throw you some manuals? How did that work out?
Dr. David Fieg: Oh, no, I got some great doctors to work with. We actually did it virtually because I had started the job right when COVID hit for real in March of 2020. That was when Seattle had its first few cases right before. People finally realized that it finally had reached to the states. And certainly things changed a lot after that fact, changes in telemedicine and then changes with remote work. This was always a remote position interestingly enough. I was able to virtually sit, and of course, now we have the technology to do this. Sit and talk by phone, by video, by real time sharing screens, going over cases, going over the information, trying to read through the major case types, understanding the types of cases you'll see in different parts of Medicare, whether it's part A or part B. Understanding one's more inpatient, one's more outpatient. Certain drugs are considered the B of A, so they fall under more of the part A side. Getting a lot of minutiae of detail, and just understanding how the cases go.
But a lot of really good doctors that have been doing this for a while and have a lot of experience, were really helpful in getting me trained to pick up all these details. And then a lot of it, honestly, is also reading a lot of cases, reading the decisions and going back to the case and just looking through it back and forth and understanding seeing the patterns arise. Why was this denied? Well, they didn't document X, Y, Z. Well, why was this approved? Well, they did document X, Y, Z. Sometimes it can come down to that, sometimes it can be more of a judgment call. But document, document, document is what they say.
You want to be careful on what you put in the chart in the sense of just for certain conditions, you just need to be very explicit as to what you saw and document it. It also comes back maybe strangely to the systems that we use. And if your EMR, as you said, whether it's due to time, energy and money is more out of the box, maybe it's not as customized as it could be for your particular style or your clinic. And that could affect your reimbursement if it's not configured correctly to capture all the key things that you need.
It's funny how that's kind of a strange circle and that we don't have time so we run through with our computer systems to document what we need, but maybe we don't spend enough time making sure it's documenting enough of the things we need, whether it's private insurance or commercial insurance or is it Medicaid, Medicare. Because they do have requirements that are available for review. And we do want to be mindful of them because getting paid is important and not getting paid for even the large health system can be quite onerous.
John: Yeah. It catches up with you if there's too much of that going on. Well, we are going to be out of time here in about a minute. So, just looking back, maybe advice you have for other people that are at the beginning of the journey that you've made so far where you're trying to find the right clinical thing to do, or maybe they want to do two different things or maybe they don't want to do clinical. What advice would you have for people that just find themselves early in that process?
Dr. David Fieg: I think you do want to get at least some clinical basis. And when you're out of training, you want to practice for at least a few years. A lot of the best nonclinical work does often require anywhere from three to five years of actual practice experience. For a lot of people you might close some doors if you don't finish your residency, if you don't do some clinical practice for a few years.
But once you get through that point, that's a great time to reassess. And as I said, there's more and more opportunities, whether it's telemedicine, whether it's utilization management, whether it's clinical documentation improvement, whether it is doing case or claim review, whether it's legal consulting. There's a tremendous variety of things available. One of the struggles I think is just connecting to figure out what's out there because it seems to change all the time. A lot of people didn't know about the work I'm doing now in terms of review for Medicare claims. More were familiar with utilization management. I think more are getting familiar with certainly the legal consulting component, and also getting more familiar with the clinical documentation improvement.
That's maybe the flip side to what I do, is that they're working with the docs to make sure they understand if they're seeing case X all day long, that they know what the requirements are for documentation, if they're billing a lot of Medicare claims. So that everything is set up to set them up for success rather than confusion in a lot of physician queries. I see that they send a query to the physician, the coder sends a query to the physician. What was this? And I remember getting them when I was practicing more in a traditional practice and it's like, "What is this? Why am I filling this out?" It's like, no, fill it out and try to actually think about what you're going to write because it's really important and it may actually affect whether you get paid or not.
John: Yeah, absolutely. I think some people might have lingering questions, you've covered a lot of material here today. It's okay I assume maybe if they can just find you on LinkedIn?
Dr. David Fieg: Oh yeah, absolutely. I'm kind of an open book. David B. Fieg. There aren't too many Fiegs on LinkedIn. So, if you see the doctor, that probably is me.
John: Well, I will put that link in the show notes too. If anyone is really struggling to find you, they can go to the show notes for this episode.
Dr. David Fieg: Yeah. And if you see the one that went to Michigan for a residency, that's probably me. So go Blue. Hopefully, we'll bring home the big one for the playoffs this year.
John: All right. All of you out there, I hope you are Michigan fans. All right, David, this has been really good. I appreciate it. We might have to have you come back in a few years and see if you're still doing this or have done something else, but we have a lot to think about. I really enjoyed hearing your story today.
Dr. David Fieg: Sure.
John: With that, I will say goodbye.
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