Interview with Dr. Lawrence Huntoon – 341

In today's episode, Dr. Lawrence Huntoon offers insights into sham peer review, an all-to-common abuse of the peer review process.

Dr. Huntoon is editor-in-chief of the Journal of American Physicians and Surgeons and an expert on this topic. During our discussion, he highlights the importance of early recognition, prompt legal representation, and aggressive defense in response to sham peer review to safeguard your career. 

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Understanding Sham Peer Review

Dr. Lawrence Huntoon defines sham peer review as an abuse of the peer review process, emphasizing actions taken in bad faith for motives other than improving quality care or patient safety. He delves into the various tactics and underlying motives hospitals employ. And he emphasizes the importance of recognizing early signs of sham peer review.

Protecting Against Adverse Actions

Exploring the consequences of sham peer review, Larry describes the devastating impact on physicians' careers, such as adverse action reports to the National Practitioner Data Bank. He provides insights into the fraudulent tactics employed by some hospitals. He urges physicians to be vigilant during informal meetings, emphasizing the value of legal representation to navigate these complex situations.

Dr. Lawrence Huntoon's Advice on Preventing Sham Peer Review

Be aware of underlying motives: Sham peer review often occurs due to personal animus, retaliation against whistleblowers, anti-competitive purposes, racial discrimination, or other improper motives. Recognizing these motives early on can be crucial.

Summary

For further information or assistance, Dr. Huntoon suggests contacting the Association of American Physicians and Surgeons (AAPS). AAPS provides resources, including a sham peer review hotline and limited legal consultation services. You can visit the AAPS website for more information or call their hotline for assistance.

NOTE: Look below for a transcript of today's episode. 

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Links for Today's Episode:

• Association of American Physicians and Surgeons website
• AAPS Sham Peer Review Resources
• AAPS Sham Peer Review Hotline: 1-800-635-1196
• Why You Must Wake Up Before Bad Behavior Ruins Your Career – 296
• The Interesting Life of the Professional Development Coach with Dr. Ryan Bayley – 064
• Dr. Debra Blaine's Coaching Services

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Today's PNC Podcast Transcript

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Transcription PNC Podcast Episode 341

The Ultimate Swindle Known As Sham Peer Review

- Interview with Dr. Lawrence Huntoon

John: Several years ago, I was at a conference in Chicago and I was there to learn about nonclinical careers, and there were a bunch of doctors there that were seeking to leave medicine. Most of them were because of burnout or just didn't like the lifestyle, but there were several that left because they were forced out of medicine for a variety of reasons, most of which involve being reported to the National Practitioner Data Bank. And since that time, I've learned more about this, and I was reading an article in the Journal of the American Physicians and Surgeons about Sham Peer review. I thought I'd better find out more about that. And I think it's something you'll want to learn about too so maybe you can avoid this particular reason for leaving medicine. With that, I'd like to welcome Dr. Lawrence Huntoon to the show. Hello, Dr. Huntoon. How you doing?

Dr. Lawrence Huntoon: I'm very well, thank you. Thank you for having me on the podcast today.

John: Yeah. I'm really happy to have you here because I have several questions. I will say for the listeners that there is a lot that Dr. Huntoon has written about this topic, so we'll be just scratching the surface. But before we get into that, just tell us a little bit about your background, Larry, and how you got into this.

Dr. Lawrence Huntoon: First of all, I'm a physician. I'm a board certified neurologist. I also have been trained as a medical scientist. I have a PhD in physiology with specialization in neurophysiology. And back in 2003, an award-winning journalist by the name of Steve Twedt, did a series of articles for the Pittsburgh Post-Gazette called The Cost of Courage, where he discussed a lot of instances where physicians were whistleblowers, were retaliated against by hospitals, and in some cases that involved sham peer review. Hospitals don't always like to hear what's wrong as far as in their facilities. Maybe they haven't got equipment that works, maybe there's problems with the staff, but sometimes they don't like to hear about that. And so, instead they go to kill the messenger. And that's what that series of articles was about. He's no longer with the Pittsburgh Post-Gazette, but at that time the AAPS board of directors said, "Look, we're starting to get a lot of calls from physicians that this is affecting throughout the nation. We need to do something to investigate this and see how we can help these victims of sham peer review. Early in 2004, the AAPS Board of Directors formed the AAPS committee to combat sham peer review, and I became chairman of that committee, and I have done that ever since.

John: Okay. You've seen a lot of examples of sham peer review and have been involved heavily in that. Can you tell us maybe a little more specifically what you define as sham peer review? And we'll go from there.

Dr. Lawrence Huntoon: Well, I'll go over the concise definition, then I'll go over the legal definition. Basically sham peer review is abuse of the peer review process for some purpose other than quality care and patient safety. The definition that I have published is sham peer review is an adverse action taken in bad faith by a professional review body for some purpose other than the furtherance of quality care or patient safety, and that is disguised to look like legitimate peer review. The hospitals have found lots of ways to abuse the peer review process, make it look like they're doing legitimate peer review, when the purpose that they're doing it for has nothing to do with patient quality or patient safety.

John: Now, I'm assuming, and I think from reading the journal that you believe and as I believe that a good peer review is appropriate and makes sense and it can help protect patients. The distinction is in the sham peer reviews, they're using a process that was designed to help the patients, but it really isn't being used for that purpose at this point.

Dr. Lawrence Huntoon: Right. And I want to make clear that I support, as does the AAPS, we support a good faith peer review. We support that. The only type we oppose is that type that's done in bad faith, again, for some underlying motive that has nothing to do with quality care or patient safety. We support a good faith peer review.

John: Now, in my recollection, medicine has evolved hugely in the last 30 or 40 years. There's always been some type of so-called quality improvement, and in fact, peer review was probably the main way that we did quality improvement, let's say 30 years ago. But now we can measure performance in different ways. And then the Medicare or CMS started saying we need to do specific types, what was it the acronym FPP? Did you see an increase in sham peer review when they started pushing all of this other type of more formalized peer review that was mandated?

Dr. Lawrence Huntoon: Not really. It's sort of just kept studying even increased over time. That what you're talking about is something that the Joint Commission came up with. It must have been about 2008. They defined OPPE as Ongoing Professional Practice Evaluation. And this is the type of peer review that occurs, and every physician in the hospital is subject to that. They will pull charts based on certain criteria, a patient that readmitted to the hospital within 24 hours after discharge, or died within 24 hours as a complication of surgery. And they have various criteria. All doctors are subject to that. It's kind of a screening type of peer review. And then the joint commission also defined FPPE - Focused Professional Practice Evaluation. And as that name implies, that's a type that is focused on a specific physician and would otherwise be characterized generally as a physician peer review.

John: Okay. But the big distinction here is if someone was having a subject as FPPE for legitimate reasons, fine, it's just something a joint commission requires, and you're going to go through that process. But really the sham peer review is when it just starts from the wrong place for the wrong reasons. And maybe you can explain some of the reasons that the hospitals or other members of the medical staff or other interested parties might start to invoke some type of sham peer review.

Dr. Lawrence Huntoon: And I've written an article on this, "Risk Factors for Sham Peer Review." I've given presentations on this. But there are many underlying motives that we've encountered for sham peer review. It might be retaliation against a physician whistleblower, and I don't particularly like the term "physician whistleblower." These are basically strong patient advocates who speak out in favor of things for the patient. And that's what gets characterized as physician whistleblower. Also sham peer review is often used in cases of personal animus. Maybe the people get in power and they don't like this particular doctor and they're going to get him. It will be done for anti-competitive purposes if there's maybe two or three of that type of doctor in that specialty at the hospital. If one of them gets in power, they may look to eliminate some of the competition. I've seen racial discrimination under underlying sham peer review. There's just a ton of improper motives that we've encountered that underline sham peer review.

John: Can you give us some examples? I know you've been involved with many cases, and I think you actually testify in some of these cases that make it their way to court. But what do they look like at the beginning? How might we recognize that "Wait a second, this doesn't sound like the kind of peer review I'm used to?" And we'll go from there.

Dr. Lawrence Huntoon: Yes. I'm a court qualified expert in sham peer review in federal court as well as a number of state courts. And you asked how do you recognize it early on? And I would say if it smells bad, it probably is bad. But what you're looking for there is you begin to encounter things that just don't seem fair at all. And of course, I've written articles on tactics that are characteristic of sham peer review. I've given talks on that.

But you start seeing things like the ambush tactic. And the ambush tactic is a tactic that's characteristic of sham peer review. That's where they invite the doctor into maybe the administrator's office, and they don't tell the doctor what it's about ahead of time. And they tell the doctor, "Look, this is just an informal friendly meeting. We want you to come." And the doctor may ask, "Well, what's it about so I can prepare?" And they don't tell him. And then the doctor gets into this so-called friendly informal collegial meeting, and he finds himself sitting across the table from the CEO of the hospital, the chief of staff, and probably the attorney for the hospital. And every one of those individuals knows exactly what it's about. The only one in the room who doesn't is the doctor that's been called in for the ambush. There's a lot of tactics like that. And the thing they have in common is they violate due process and fundamental fairness.

John: Now, I'm going to get to the meat of some other cases. But just to kind of jump ahead a little bit, what is the devastating outcome if this doesn't go as we plan as physicians, but as the way the administrator or the other physician wants it to go? What does that usually result in if we don't know how to defend ourselves?

Dr. Lawrence Huntoon: Well, it results in an adverse action report to the National Practitioner Data Bank. And the National Practitioner Data Bank was created as a result of a law passed in 1986 called the Healthcare Quality Improvement Act. And the Data Bank actually went into effect in 1990. And so, what the Data Bank is, it's a national repository for adverse actions that have been taken against physician hospital privileges or medical licensure actions, that sort of thing.

And there's other types of Data Bank reports. The one I'm talking about here are the adverse action reports. And what it does, it basically transforms a local action at a local hospital to a devastating national action. Because here's what happens. Every hospital is required to query the Data Bank before they admit someone on staff. They're also required to query that Data Bank every two years for renewal of medical staff privileges. If you're applying to a hospital and you have one of these adverse action reports in the Data Bank, the hospital basically considers you to be damaged goods and they don't want to put you on staff. You will have trouble getting on medical staff, you'll have trouble getting the medical license. You'll have trouble staying on insurance panels if that's what you're doing, renewing staff privileges or renewing licensure. It creates an incredible number of domino effects that are very bad for the physician.

John: It might result in you getting kicked off the staff that you're on now or being somehow penalized, which has to be reported. Basically it can destroy your career overnight.

Dr. Lawrence Huntoon: Yes, it can totally ruin it or end it.

John: Exactly. It's like one of those things where you spent whatever number of years of your life with your education, your training and experience, and it's pretty much gone if there's an adverse listing in the Data Bank. Now we get reported, of course, for lawsuits. I don't think a single or a couple lawsuits on the Data Bank means that much depending on the size and the frequency and so forth. But this is a different situation where there's definitely an adverse result that's reported that usually indicates a negative. It is supposed to be evidence that you're at some level a poor physician, I guess is the way I would say it.

Dr. Lawrence Huntoon: There are five different types of Data Bank reports, and I've found that hospital attorneys just love to confuse the Data Bank reports when you get into trial in front of a jury. And they bring up this idea of these Data Bank reports having to do with malpractice actions and malpractice settlements. And they say, "Well, it didn't seem to hurt the doctor that much. He's got two of these malpractice reports or settlements in the national practitioner Data Bank. What's the big deal?"

And so, I explained to the jury, that the types of reports involving malpractice settlements and whatnot, that's maybe like getting shot in the foot. You can continue to limp along, whereas one of these Data Bank reports having to do with removal of hospital privileges, it's like getting shot in the head. It ends your career and ends your world as you know it.

John: All right. Well, let's get back into how we can try and avoid some of this. I read something you wrote, I believe, or maybe it was in a video, that there are certain physicians who seem to be at risk. It doesn't have anything to do with, let's say, the quality of their practice, but because of adverse relationship with the hospital or financial situations. So, what are some of those that if you fall into this category, you might be a little bit more aware that this could come up?

Dr. Lawrence Huntoon: Well, of course, any disputes with the hospital administration is likely going to put a target on your back. But we've been able to identify certain specialties that get attacked more than others. And I think that those specialties that are at the top of that list tend to be those that receive very high compensation. These might be neurosurgeons that involve spine surgery, maybe anesthesiologists, and I've listed the whole list down there as far as risk fact, the article I wrote on risk factors. A lot of that has to do with money. Again, you're looking at anticompetitive type actions in some cases where you can get rid of a competitor, that leaves a bigger pie for the person who did the sham peer review.

John: Yes. Now I think you also mentioned sometimes, maybe a solo practitioner, just for whatever reason, they are a little more independent, a little more autonomous, they want to do things their own way, and all of a sudden we find that the hospital thinks, "Well, we've got to get them off the staff."

Dr. Lawrence Huntoon: Yes. The main reason solo physicians tend to get attacked is not because they necessarily like to do things their own way. It's because they don't have any support structure in the hospital. If you're a member of some big group, you've got that big group kind of supporting you and protecting you in the hospital. Solo physicians or those who are new on staff may not have that, and therefore they're vulnerable. Foreign physicians, the same thing. They tend to be vulnerable to these types of attacks. And sometimes the attacks are based on discrimination, blatant discrimination.

John: Now, I would think, "Well, let's see if a physician is actually employed by a hospital or a health system, they have a contract, they can always cancel a contract if they don't like this particular person." But that doesn't necessarily prevent you from this sham peer review.

Dr. Lawrence Huntoon: There's two different issues there. There's an employment issue and a medical staff privilege issue. And a lot of these employment contracts, almost all of them are going to have a no cause clause in it whereby they give a certain number of days notice, maybe 90 days notice, and they can terminate your employment contract without giving a reason. That's a no cause clause. And they often do that. They may have a non-compete clause as well.

When they terminate your employment, you're not allowed to work within a certain number of miles of that particular hospital. Having your employment terminated does not get reported to the Data Bank. But if they decide that they want to take a privileging action against you, that is one way they look to terminate the contract and harm you at the same time. These contracts require, of course, that you maintain medical staff privileges at the hospital where you have the contract. And if they can get rid of those privileges, that ends the contract and they get to harm you as well.

And so, in one particular case I saw, the hospital had recruited a specialty surgeon in to start sort of a new area of specialty in that hospital. And after about a year, the hospital determined, "Well, this doctor is not bringing in as much revenue to the hospital as we thought, so we need to get rid of that doctor." And so, rather than just terminating the contract and letting the doctor move on, they did a sham peer review. They brought false charges against the doctor, fabricated charges, and they got rid of the doctor's privileges. And of course, that got rid of the contract as well.

John: One of the things I remember when I was a CMO of a hospital was that we would sometimes face an issue like we thought the quality could be bad but because we didn't do this very often, it didn't really seem like we knew what we were doing in terms of trying to just go through this process, keeping it up and up. But at the same time, the CEOs talking to the COO and the CFO have their input and he's a finance guy, he is not really a quality guy. And then all of a sudden, "Well, we got to bring our attorney in." And so, now, the whole hospital has started to amass this whole thing involving multiple parties and not even necessarily the medical staff yet at that point. And then here you are, the physician come in for this informal meeting, as you mentioned earlier. Can you expound on how some of the cases have gone when they get to that point?

Dr. Lawrence Huntoon: It's been my experience. I've encountered a lot of people in the hospital administrations who don't know what they're doing at all. That includes the hospital leadership, maybe the chief of staff and whatnot. They don't know what they're doing at all. Maybe they haven't done it before or have not done it that much. And the problem is they tend to look to find an outcome that they desire and they don't really care about following the medical staff bylaws. Well, the medical staff bylaws are there to provide some due process and fundamental fairness to the accused physician. And if they've got some outcome in mind, well, it doesn't really matter, and they don't follow the bylaws. I encounter that I would say fairly frequently. And it does happen in places where they don't do many of these or have never done them before.

John: Yeah. And if the idea is maybe they have some kind of inkling or they just don't like the person, like you said, and so everything is jumbled together, the emotions. Maybe the doctor irritated someone by something that they said or could be anything I can imagine. And now they have this little ball rolling, this snowball, and it's like, "Okay, let's figure out how we can use all, whether it's our contract, whether it's our bylaws or a combination of those to get our end result, which is we just maybe decide we don't want this person here." They don't really seem to be too concerned about "What is the final consequence for the doctor?" All they want is for the doctor to be gone.

Dr. Lawrence Huntoon: Right, right. And the other thing I'd point out is sometimes you'll hear these peer reviews go forward and people will testify, "Well, I would've done that surgery differently. I don't take that approach. I take a different approach." But that shouldn't be part of taking an action against a physician. There's always room for improvement in our care. But what the important thing is, did the care provided, did that fall below the standard of care? Not "If you didn't do it my way, then you're not doing it right." No. That's not the standard of care. And sometimes they will portray it wrongfully as that. I see that a lot.

John: One of the things that was mentioned in one of the articles you wrote that I read, and I've heard this before, but if you're in the middle of this process, at whatever level, you're the physician and one of the things you hear is this comment. "Well, maybe if you just withdraw now, either this privilege or withdraw from the hospital, we won't do a report to the Data Bank." And so, why is that a huge red flag?

Dr. Lawrence Huntoon: Well, number one, that's fraud. And I just wrote an article about that in the December, 2023 issue of the journal. I see that a lot. A lot of the hospital administrations and leadership, including the chief of staff will tell the doctor, "Look, this will go better for you and you won't have to engage in all this messy peer review if you just resigned now and we won't report you to the Data Bank." That's fraud. And it's totally false. What happens is they get the doctor, the naive doctor who doesn't know any better. "Oh yeah, that sounds good to me. I'm getting out of here. I don't want to be here anyway, I'm resigning right now." After that, what we see is the hospital reports the doctor to the Data Bank the very next day. And the report that is made has standardized language, which says, "Doctor resigned while under or to avoid investigation." That makes the doctor look like he pled guilty. He just wanted out of there or didn't want to face the music or whatever.

And the other thing hospitals like about that, number one, they get to harm the doctor. They like that. Number two, once you resign, you don't have any due process rights like a peer review hearing or appeals process because you are no longer a member of the medical staff. So, it's a big win-win for the hospital when they can convince a doctor to resign while under or to avoid an investigation. And of course, we're beginning to see lawsuits where the hospital attorney, the hospital CEO and others that have been involved in that fraud are sued for fraud. And there is no immunity for fraud.

John: Interesting. Have there been some successes in that realm where they were found guilty of fraud?

Dr. Lawrence Huntoon: What happens is, when you sue a hospital attorney, he doesn't particularly like being accused of fraud. And that may not go too well in terms of his reputation. What you see is, all of a sudden, the hospital may have been dragging its feet and saying, "No, we're not going to settle this case. We're not going to avoid that report in the Data Bank because we're legally obligated to report you." You sue the hospital attorney, CEO and maybe the chief of staff for fraud because they committed fraud. And all of a sudden, things change. And so, what I've seen recently is, for example, a settlement where the hospital agrees to void the Data Bank report and put the doctor back on staff without restrictions. And of course, provide the doctor with some compensation for what they've done. They don't want to go to trial on that at all.

John: Yeah, that makes sense. Well, to give you a lot more leverage than it sounds like there has been in the past. So, that's good to know.

Dr. Lawrence Huntoon: And I'll say that it's very important to know that once you get a Data Bank report, it's impossible, nearly impossible to get that out of there. And the hospitals will always claim, "Well, we can't void a Data Bank report. We're required by law to report it." And they'll whine and whine but they can, and they do when you've applied the right leverage to get it done on.

John: Okay. Well, we've learned a lot so far. I want to ask one more specific question, and then I want you to tell us about the AAPS and the journal and that sort of thing. And you probably addressed this earlier, but let's say I'm brought into one of those meetings, all of a sudden I'm looking at the CEO and the chief of the medical staff and an attorney. They're saying they're going to have a conversation. Should I just run out of the room immediately and call my lawyer? Should I just listen? I think in one of the articles you gave us advice on how to go into that meeting, what you could do, at least if your spider sense is going off a little bit. What are your suggestions for that if we find ourselves in that situation?

Dr. Lawrence Huntoon: Well, it's hard to avoid the meeting. Because if you avoid the meeting, they'll say, "Well, the doctor's not being cooperative. We're just trying to help him by tying him to the post in front of the firing squad. We're just trying to help him." And so, you can't really avoid it without them portraying it that way. You can listen. And again, the ambush tactic is done for one purpose and one purpose only. It makes the doctor look guilty. Because if they're talking about maybe three or four patients that they feel you provided poor quality care to, well, you didn't know about that ahead of time and you're busy trying to remember while you're sitting in this stressful meeting, "What? These patients? I don't recall exactly what I did at that time." And so, when you flounder around and you're trying to remember to defend yourself, and you do a poor job of defending yourself for that reason, you look guilty. And again, that's the purpose. They want you to look guilty in front of the assembled members at such a meeting like that.

John: Oh boy. Yeah. Maybe you should bring someone with you to any meeting, so at least you have... And who would know what kind of meeting it's going to be if it's not got a label or a purpose?

Dr. Lawrence Huntoon: Here's the thing. The medical staff bylaws often forbid the physician to bring anyone with him, most certainly not an attorney, to one of these informal, friendly, collegial meeting. We're just a bunch of friendly doctors getting to gather to discuss things. They also often won't allow the doctor to bring an attorney to a meeting before the investigative committee to explain his side of the story. And oftentimes, most times, they will not allow a doctor to bring an attorney to a meeting before the MEC, the Medical Executive Committee to explain his care.

Now, they've gone even further than that in some cases. Going to peer review, once they've proposed an adverse action, you have the right to peer review and appeals in the hospital. Guess what? Some hospitals tell the doctor, "Yes, you can bring your attorney to the peer review hearing, but no, the doctor can't talk." The doctor can't raise objections. The doctor can't cross examine witnesses and doctors are not well prepared to do that. Doctors who don't have a JD degree aren't attorneys and they've function poorly as attorneys. They've done that in some cases. And to me, you have a right to representation under the Healthcare Quality Improvement Act. But to me, that's not representation when you put a piece of duct tape over your attorney's mouth and he sits there in the peer review hearing and can't say anything.

John: Wow. It doesn't sound like it's very hopeful that you're going to come out successful in these, unless you do everything right along the way. And then once the process gets going, of course, you want to have a good attorney, as you mentioned earlier, that knows how to deal with these kinds of situations.

I'm going to have another question to ask that's related, but first, tell us about the association and why listeners might want to get the journal, why they might want to join the association, that sort of thing.

Dr. Lawrence Huntoon: The Association of American Physicians and Surgeons was established in 1943, and we have been the voice for private physicians ever since. Our motto is "omnia pro aegroto" which in Latin means "all for the patient." And that's where we stand basically. And we believe in protecting the sacrosanct patient physician relationship. We believe that physicians are the ones that should be practicing medicine as opposed to insurance bureaucrats and government bureaucrats, often who are not physicians at all, not licensed to practice medicine, yet they tend to direct the way medicine is practiced.

One of the three benefits you get as an AAPS member is that you get access to the AAPS sham peer review hotline. And I have run that hotline on a pro bono basis for 20 years now. And so, that gives you, as soon as you join, you have access to the AAPS sham peer review hotline. You also have access to the nation's top attorney in sham peer review matters. We call it our AAPS Free Limited Legal Consultation Service. And you can discuss these things with a very knowledgeable attorney. Know that I'm not an attorney, I don't give legal advice or legal opinions, but we have an attorney who is very experienced at that. Those are some of the things you get as benefits as an AAPS member.

John: What is the website? Is it aaps.com?

Dr. Lawrence Huntoon: No, it's aapsonline.org. The best way to join probably is the 800 number. 1-800-635-1196. And as soon as you join, like I said, you have access to those free benefits.

John: Actually, I joined today. I thought I was a member already because I get the journal.

Dr. Lawrence Huntoon: No, you were a member back in February.

John: Oh, was I? Oh gosh. Okay. Well, I just renewed it. They get the journal automatically if they're a member, correct?

Dr. Lawrence Huntoon: Yes. Yes.

John: What's usually in the journal?

Dr. Lawrence Huntoon: It's the Journal of American Physicians and Surgeons, and we're a member of the Directory of Open Access Journals. And what that means is we don't charge people to download our articles. Our articles are downloadable free of charge, the full article. We don't require any usernames or passwords. You just go on the website. If you find an article you want to read, you download it and read it. That's what the journal is about. And it's been in existence since 2003 and I've been the editor and chief since 2003.

John: Okay. Let's see. Other things I wanted to mention or have you even tell us about. Supporting this relationship between the physicians and patients and the original way that medicine was to be practiced. One thing is insurance out or no interference. There is a big interest in direct primary care and cash-based businesses and other iterations. And so, I think you were telling me that you do or the association does presentations to physicians who are interested in learning more about how to make the transition. And that would include being off of Medicare or CMS.

Dr. Lawrence Huntoon: Right. AAPS has run "Thrive, Not Just Survive" workshops for many, many years. And those talks and presentations are all available on the AAPS website. I myself ran a third party free opted out of Medicare practice, and I was in solo neurology practice for 34 years until the government put us out of business in 2020 by these harsh, unwarranted and totally ineffective lockdowns that were done. And that put us out of business. It put a lot of small businesses out of business, and we were a small business.

John: Yeah. That was really harmful to a lot of businesses, a lot of physicians, small groups and so forth. And in retrospect really to pretty much almost totally unnecessary I would say. That's my belief. It's a little bit political, but whatever, we won't get into that right now. But another resource for listeners, if they're thinking, "Wow, I'd like to opt out of Medicare, I'd like to opt out of all insurance companies." There's some resources there at the association.

All right. Anything else I'm not asking you about that is important for us to know about the association or about the journal at this point?

Dr. Lawrence Huntoon: No, but I think you asked the question "Is there any way that we can avoid this at my hospital, for example, sham peer review?" And the answer to that unfortunately is no. Sham peer review does not occur in a vacuum. It occurs in an environment of turf battles and personal jealousy, personal animus, and a whole lot of things like that. It really isn't possible to find a way to prevent it at any particular hospital. And the trouble we have is trying to get support from a number of physicians, particularly in the hospital where they know sham peer review is going on against one of their colleagues. These are the so-called bystanders, who know what's going on, turn their head away and don't do anything to help stop it. And this is like bullying. Sometimes all it takes is one of these bystanders to stand up and say "We don't think this is right what you're doing, and you ought to stop it" to derail the thing. But many of these bystanders think "This'll never happen to me because I'm a good physician. I practice very good medicine. This won't happen to me." So, they don't want to get involved.

John: Yeah. I suppose there's some risk in doing that. Looking at it though from the other side as a physician, there are surgeon centers. Some surgeons can work there and not have to rely on the hospital, and if that's owned and run by physicians, hopefully they won't be pursuing sham peer review in that setting and avoiding the insurers. At the end of the day, maybe the only way for some of us to have traditional good relationships with our patients and practice medicine is to opt out of some of those onerous systems.

Dr. Lawrence Huntoon: One thing I'd like to point out is some people say, "Oh, the doctors are doing that for greed." And that generally from my experience is not true, certainly in the AAPS. What they're doing is they get tired of these bureaucrats interfering with the way they practice medicine and they kick these bureaucrats out of their exam room. And that's the real benefit. And you can set your own prices at reasonable levels that patients can afford.

John: Yeah. And we've talked to physicians here on the podcast who can spend more time with their patients. The patients are happier, the physicians are happier, and it doesn't cost the patients any more if it's set up properly and they get better care really. All right. This has been very inspirational. It's scary, but the fact that there are resources there to help us. Did we talk about the hotline for sham peer review? Is that the same 800 number?

Dr. Lawrence Huntoon: Yeah, they call the 800 number and they join and then they just ask the business manager who's going to be answering the phone, "How can I get access to the AAPS sham peer review hotline?" And he'll put them in contact with it. I'm always happy to talk with members about their individual situations and offer helpful information, particularly early on. Don't wait until the matter has been going on for four or five years and you've gone through a massive litigation and then "Can you help me?" Early on is best.

John: Yeah. I can see how that'd be a fantastic resource and just help point them in the right direction and some of the articles and the videos and giving advice and talk about maybe how to find an attorney. That can all be very helpful early on, obviously, than waiting into the second or third year or longer. This has been really great, Larry, thanks a lot for coming on the podcast and sharing this with us today. I think it's an important message.

Dr. Lawrence Huntoon: It's been my privilege. Thank you for having me on the podcast today.

John: All right. With that, I'll say bye-bye till next time.

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The post The Ultimate Swindle Known As Sham Peer Review appeared first on NonClinical Physicians.

In today's episode, John describes how to address 3 big issues when leaving your current employer for a nontraditional career.

The whole process can be less disruptive and stressful by taking steps to address them proactively.

Our Sponsor

We're proud to have the University of Tennessee Physician Executive MBA Program, offered by the Haslam College of Business, as the sponsor of this podcast.

The UT PEMBA is the longest-running, and most highly respected physician-only MBA in the country. It has over 700 graduates. And, the program only takes one year to complete. 

By joining the UT Physician Executive MBA, you will develop the business and management skills you need to find a career that you love. To find out more, contact Dr. Kate Atchley’s office at (865) 974-6526 or go to nonclinicalphysicians.com/physicianmba.

Address 3 Big Issues

There are major financial, legal, and emotional issues that can complicate your transition.

And it is essential to take these matters into account early on in the process. If we consider and deal with things sooner rather than later, things will go better. 

Review Your Contract

Legal or contractual issues will come up during the transition. These contract-related matters should be discussed with your lawyer so that you can prepare for them. The most common concerns that arise include the following:

1. notification requirements,
2. tail coverage,
3. bonus eligibility or calculations,
4. effect on retirement plan vesting, and
5. non-compete provisions (restrictive covenants).

Consider Your Financial Situation

This is usually the most obvious area of concern. Questions to address include:

• Do I have alternative financial resources to cover expenses if I leave my current job?
• Can I ramp up a side job or passive income source to cover expenses?
• Do I have vacation time (paid time off or “PTO”) that I can accrue to maintain my salary for a few weeks or months?

Prepare for the Emotional Consequences

This is a significant one that we frequently overlook: the psychological effects your transition will have on you, your family, and others close to you.

1. Changing jobs results in potentially enormous stress on us, similar to that associated with getting married or having a child.
2. Your immediate family members will be affected and will have concerns about the potential consequences of your career change on them.
3. The workplace will be affected, especially if it depends heavily on you for patient care call coverage.  Dysfunctional medical groups in particular don't always conduct themselves professionally during this process. Some coworkers will display one or more Kübler-Ross' five stages of grief. 

John's Advice

1. Review these issues and plan for them as early in your transition process as possible.
2. Communicate openly and often with your immediate family.
3. Use an attorney to anticipate and plan for the legal and contractual issues.

Summary

It is imperative to address 3 big issues when approaching a career transition. Recognizing and preparing early for these issues will reduce the negative legal, financial, and emotional consequences that might arise.

NOTE: Look below for a transcript of today's episode. 

EXCLUSIVE: Get a daily dose of inspiration, information, news, training opportunities, and amusing stories by CLICKING HERE.

Links for Today's Episode:

• Get Ready for What Will Happen When You Quit Your Miserable Job – 213
• Avoid These Dumb Mistakes I Made in My Business – 097
• Why Demoralize Your Employed Physicians Over Tail Coverage?
• NewScr!pt

Download This Episode:

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Podcast Editing & Production Services are provided by Oscar Hamilton

Today's PNC Podcast Transcript

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Transcription PNC Podcast Episode 282

You Must Address 3 Big Issues Before Leaving Your Clinical Job

John: We have issues with financial problems, legal problems, and emotional problems. And these sometimes are not anticipated. As my colleagues and my friends and students and mentees and so forth, are in the process of transitioning from a clinical to a nonclinical job, these things come up and they're unexpected and they cause some serious problems sometimes. It can even derail the job transition. We want to think about these things early in the process. And in fact, the earlier we think about them and the earlier we investigate them and address them, the better off things will be. So, without any question, this kind of conversation, whether it's with advisors or with our spouse, should occur early.

What are the issues that come up? The first ones I want to talk about are contractual issues, or you might call them legal issues. They're things that are usually in your employment contract. This is obviously applicable to those who work for a large group or work for a hospital system. And there are several of these that can really throw a monkey wrench into the whole process. Now, some of the contractual issues also affect financial issues, and we'll kind of talk about that overlap in a minute. But let's just talk about some of those contractual issues.

The first thing, in no particular order, is the required notification. Sometimes we get all excited. We think, "Okay I'm really having a hard time. I'm going to take some vacation. I'm going to investigate moving into a nonclinical job. I'm going to apply to a nonclinical job." And then boom, lo and behold, they hire you. Now it usually takes longer than just a few weeks. Well, let's say they offer you a job, then you look at your contract and you find out that you actually have to give six months' notice. That's going to really cause a problem, obviously, if they're expecting you to show up in two or three weeks, even a month or two, which is pretty typical.

So, you need to look at your contract and see what your notification time is and if there are any exceptions to that. And if you are in a big hurry, are there some workarounds for that? One workaround might be, let's say you have a bunch of vacation, and let's say you really haven't taken any vacation in a couple of years and you've accrued six or eight weeks of vacation. Well, you can at least work every day until the time you want to leave. And then potentially you can actually get paid for six or eight weeks, even though you've moved on to the next job.

The second thing is tail coverage. A lot of us don't worry about that, and a lot of our contracts don't have that as a requirement, but there are still some places that want you to pay tail coverage if you leave your group or your hospital. And that could be a big expense. That can be $20,000, $30,000, $50,000, or $100,000, and you might be obligated in your contract and maybe even in a hospital medical staff rules and regs to pay that tail coverage at the time of your leaving. And that might just be a huge financial as well as a contractual issue.

Now, it's a big pet peeve of mine. If you're listening to this and you're in the middle of contracting, or you're re-contracting for a current job or looking at a new clinical job, you should really try and get any of your tail coverage removed from the contract. But it can't always be done. So, you need to minimize it during the contract negotiation. But now you're faced with this issue, you want to leave and you're going to have to pay tail. So, you got to check with your attorney. Is it enforceable? In some states it's illegal. So, if it's in that contract, it shouldn't be. Look at how long it is, what does it include, and is there time to change it?

Let's say you're coming up for a contract renewal. Maybe you're on a yearly basis, and you might be able to change a few things. So, you definitely want to look at that tail coverage early as you're thinking about this process of leaving your job. What about vacation and PTO? That's paid time off (vacation). Same thing. Do you have any accrued already? Are you continuing to accrue it while you're thinking about leaving and while you're getting ready to leave for another job? Can you save it up so that you can address some of the other issues we're going to talk about in terms of having some income later? Or do you have to use it up before you leave and you somehow lose some of that PTO time? Is it somewhat at risk? Again, look at the contract, and how it talks about vacation and PTO, and be prepared to deal with that before you give notice.

What about bonuses? A lot of us have been on bonuses in our job. Quality bonuses, utilization bonuses, whatever. There are all kinds of bonuses. There's a dollar amount. Are they paid only once per year? Maybe after the first of the year for the previous year's activity? What happens if you leave three months before the end of the year or mid-year or whenever? So, you might actually want to time your looking, finding and leaving for that next job towards November, or December so you could actually leave after the first of the year and get a hundred percent of any bonus that you are supposed to be receiving.

Another one is retirement plans. Most of us have something straightforward like an IRA, a 401(k), or 403(b), something that can be rolled over. But if you're a highly compensated physician, you might be in a deferred comp plan. A deferred comp plan is usually more of a positive way to encourage you to stay in your job as opposed to a negative penalizing you.

But with many of those kinds of programs, you'll vest over time. Some you'll lose part of the money that you've paid into it. It's actually not your money, it's the organization's money, that they've paid into it. So, see if you can capture the majority of that money based on the timing when you leave or you're going to lose the whole thing.

There are even some plans where the whole thing is at risk unless you retire from the organization, let's say at age 63 or 65 or something. You could be looking at losing $200,000, $300,000, $400,000 because you're changing to another job. You can at least take that into consideration in terms of a bonus for the person or the company that's hiring you or do something else to mitigate it. But you at least want to know that because it will affect the second big issue, which is financial, which we'll talk about in a minute.

And then you've got your non-compete, or what we call restrictive covenants in your agreements. Do you have to understand how long do they stay in effect? How far is it addressing your employment? How far from your current location? Is it from the place you actually provided care? Is it from any site in the system you might be in? You might be working 30 miles from another site and then end up finding out that you can't do any clinical and you might want to do clinical part-time and you might want to do clinical like a switch to locums or telemedicine, something that's not as intense.

But if you have a non-compete and you can't do some of that, that's going to, again, impact more the financial side, which is the next part where we're going to talk about. But it is a contractual issue. So, it has to be dealt with.

I'll say right here, after talking about these contract-related issues that you should have your attorney go through these with you. Look at each one, tell the attorney your plans and see how these things might affect me. Are some of them no longer enforceable either because of changes to the law or maybe because you're already in breach of contract? Not from your standpoint, but the organization you work for might be in breach of contract.

Now usually there are provisions to say, "Well, if they breach one part, that doesn't mean the whole contract is void." But let's say that you were told that you were going to have every four-day call, every fourth week, however, it's laid out. And it turned out they lost a couple of people. They failed to use locums. And now you've been on every other night or every other week call for a year or two, and that's actually why you're leaving. It may be possible to say, "Look, you breached your responsibility so now I'm not going to listen to this non-compete, or I'm not going to abide by this non-compete, or for that manner, I'm not going to pay the tail coverage" going back to that issue from earlier.

But if you're going to do that, that has to be planned also. You probably can't claim breach of contract unless you give your employer some notice like, "I don't plan to re-up my contract because for the last year, you've been violating your contract in this way." And then there's a process, and you went through the notification process. So, on your end, you're doing everything properly. Those are some of the contractual issues you should deal with.

Next is the financial issues. I already talked about the loss of the deferred comp plan. So, we're not going to go into that again. But if you're going to be moving and there's going to be a gap between the time you finish your current job and start your next job, maybe you're going to be looking during that time, maybe you want to have that time to really focus on it and do the interviews and so forth. But do you have the savings to cover your expenses? Maybe you have a spouse who's employed and or a partner, and that's fine. You can get some support from that person. And maybe the two of you put a huge amount of your income aside generally for retirement and so forth, 20%, 25%.

Well, the other thing you can do during that period is to stop making those contributions. But you should plan it. That's the whole point. Do you have a nonclinical side gig right now that you can ramp up? Maybe it won't cover all of your income, but it'll cover enough that it becomes a non-issue.

And then as I said earlier, the converse of using the PTO, let's say up, because you don't want to lose it if you have the ability to accrue it and if you've gone a couple of years without taking any vacation, and now you can go let's say 4, 6, 8 weeks where you're still receiving your pay. Because technically, even though you're looking for that next job, you're actually still getting your check every two weeks because you are on a salary and you have that many weeks of paid time off, then that can help.

Again, look at the income, look at what you need to do to prepare, and make sure you've got enough money set aside if that's what you're going to depend on, or that you have other sources of income. And don't let that become a big shock halfway through your career transition and something falls through, or you find out you're going to be unemployed for longer than you thought you were.

Finally, the emotional consequences. This is a big one and we also forget about quite a lot. I mean the emotional consequences on you, on your family, and relative to the workplace where you are now. I guess the way I would look at this one is to look at it from the perspective of where the stress on you is coming from. So, the first big thing is you, how anxious are you? What does it feel like to you to let's say go several weeks without some income or several months without income, or go through a series of interviews and being evaluated and assessed and questioned? You might not be used to that. Do you feel like you're in control of the process or do you feel quite anxious and fearful because it's unknown?

Each of us is a little different on that. Now, most of us physicians are very decisive. We're very calm. We usually can do very good research and we can plan things out pretty well. But transitioning from clinical to nonclinical is not quite the same kind of linear approach. It can be broken down into steps absolutely as I help people do. But it's not quite as straightforward as going to undergrad, getting into med school, getting in residency, and then getting into fellowship, if you do that, and knowing the steps well in advance as to what has to happen, and it's all pretty regimented.

But then there's your family's response. Your spouse clearly needs to be included in these conversations, spouse, partner, whoever you're living with. And the thing about children. I had someone tell me recently that he was concerned that his children would be afraid if he's looking and switching to a new job. Would they have to move, would they have to change schools? If you have a six-month hold at home and that's it, it's not a big deal. If you have a couple of kids in grammar school and high school, it can become a big deal for them, and then they can act out, they can have emotional problems, and stress related to even thinking about it, even if it's not going to happen. So, you have to figure out how to have those conversations.

The other thing is what is the employer's response? You go through the contract, you give your notice appropriately, and it sounds like it should be fairly straightforward. But when I've talked to physicians that have gone through this process, especially in large medical groups, especially large poorly run or dysfunctional medical groups, how are they going to act?

And they don't always act professionally during this process. In fact, many are extremely dysfunctional and some seem to be going through the Kubler-Ross five stages of grief or death and dying. The denial, the anger, the bargaining, depression, and acceptance. Acceptance doesn't come right away. And people might ignore you. They might shun you. They might try to dump on you all the work. They get angry, they don't want to talk to you, and they don't want to cooperate with you. They might start giving you more call than they should. And maybe that's something you should address with them early on.

So, think about the emotional and mental health-related issues that could occur in the process of making a big change. Maybe even working 10, or 20 years in a stable clinical job. You're burned out, you've had it, and you're already stressed out. Of course, with burnout, you have symptoms very similar sometimes to depression or anxiety. And now you're going through a major life change that can affect not only you but your family.

And so, again, mentally prepare yourself for that. You can do things. I could give you a long list of things you could do that would help like learning how to meditate and how to maintain some exercise and fitness while you're going through this process to burn off some of that anxiety. The things you normally would probably use to help fight burnout or depression or anxiety you would also use when going through this process.

The other big things that I would say related to these potential issues that you should address is the following. Number one, start early. The earlier you start thinking about it, talking about it, investigating it, researching it, and engaging who you need to engage, the better. So, start early on that part, on the legal part, on the financial, all of it.

Number two, communicate extensively with your family especially. Talk to your partner about this and plan it out together. And make sure that your partner, your spouse, and your kids have some understanding of what's happening. Try not to overwhelm them, try not to scare them unnecessarily. Just communicating constantly helps. Over-communicating is also something we tell leaders to do but it's important. People don't really always get the message the first time you give it.

So, start early, and communicate extensively with your family. And then the last is to get the expert advice that you need. As I say, from the legal financial side, you need an attorney. Maybe it's the same attorney that helped you negotiate your contract, but somebody that knows healthcare, somebody that knows employment contracts, looks through all those issues that I've mentioned. There are probably others that should be addressed proactively, should be prepared for, or should at least be understood so that you are not shocked when something crazy happens like you get a bill for tail coverage or you find out you can't do that part-time clinical job a mile down the road.

But also, others. Maybe you should see a counselor or a therapist if you have to, to help work through some of these things, at least the emotional side, especially. Maybe a coach. That can be very helpful. And possibly even a financial advisor, or an accountant wouldn't hurt. If you're seeing an account anyway for your income taxes, well, why not just do an extra one-hour visit? Explain what you're planning to do and see if they can sign off on it from the standpoint of the financial consequences of your plan.

I think that's it. I just wanted you to be aware of those issues. If you're getting a little burned out, if you're really in the pre-contemplative moving into the contemplative stage of "I might actually want to move to a nonclinical job", then you should start thinking about these issues and including these issues in your whole planning process.

All right, that's it for today's episode. I hope you found that helpful.

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The opinions expressed here are mine and my guest’s. While the information provided on the podcast is true and accurate to the best of my knowledge, there is no express or implied guarantee that using the methods discussed here will lead to success in your career, life, or business.

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The post You Must Address 3 Big Issues Before Leaving Your Clinical Job – 282 appeared first on NonClinical Physicians.

In this interview, Dr. Armin Feldman explains how to use a new kind of medical legal consulting as a lucrative side gig.

Our Sponsor

We're proud to have the University of Tennessee Physician Executive MBA Program, offered by the Haslam College of Business, as the sponsor of this podcast.

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A New Form of Medical Legal Consulting

Armin describes how he developed a unique kind of medical legal consulting during that time. He sold his clinic network about 14 years ago. And he devoted himself to providing those services full time. After a few years of perfecting his approach, he began teaching other physicians how to adopt what he was doing.

Over the past 12 years, he has trained over 1,600 other physicians through his Medical/Legal Consulting Coaching Program.

Active Medical Practice Not Required

Dr. Feldman’s consulting is pre-litigation and pre-trial in nature. He helps attorneys manage the medical aspects of cases, increasing case value and saving attorney time. He enables them to better negotiate and settle cases and get the appropriate medical care for their clients. And he does not participate in medical malpractice cases.

If you want to learn more, you can check out the home page for his coaching services and watch a short video at mdbizcon.com. And if you’d like to sign up for his biweekly email, just send him a note requesting it at armin@golegaldoc.com

Summary

That was an eye-opening interview. And it seems like a fairly compelling way to leverage your medical knowledge. Following Dr. Feldman's methods, you will be able to provide lucrative pre-trial medical legal consulting services on a part-time basis.

NOTE: Look below for a transcript of today's episode.

Links for Today's Episode:

• Medical Legal Consulting Coaching Program
• Sign up for Dr. Feldman's Email Newsletter at armin@golegaldoc.com
• NewScr!pt

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Today's PNC Podcast Transcript

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Transcription PNC Podcast Episode 227

How to Do a New Kind of Medical Legal Consulting as a Part-Time Gig

John: I'm excited to bring you today's interview with an expert on a new kind of medical legal consulting. I think you'll find it very appealing. Dr. Armin Feldman, welcome to the PNC podcast.

Dr. Armin Feldman: Hi John. It is a pleasure to be with you.

John: I've really been looking forward to this because I'll just say that I discovered you somehow doing something that I find very intriguing, very appealing. I've always been one to like, although I've never done it myself, medical expert witness sort of work because I think it fits in with physicians as a part-time gig. But I think you've found a way to even improve on that. First, why don't you just tell us a little bit about your background and bring us through your education and so forth and, and then to what you're doing today?

Dr. Armin Feldman: Sure. I grew up in Milwaukee and I went to college at University of Wisconsin. and then I also went there for medical school. After medical school, I did an internship in internal medicine at the University of Colorado. And then stayed at the University of Colorado for my residency in psychiatry.

After I finished my residency in psychiatry, by the way, for the next five years of Friday afternoons and Saturday mornings, I was also a student at the Denver Institute for Psychoanalysis and I am also a graduate of the Denver Institute. For about 20 years, I have practiced psychiatry and psychoanalysis. And an interesting thing happened along the way. When I was still a resident, I met a young personal injury attorney who was doing some work for a friend of mine. We've been friends now for over 30 years. But after I got into practice, he started sending me his injured clients who primarily have head injuries. And that led me into the field of mild traumatic brain injury.

My true specialty in psychiatry turned out to be mild traumatic brain injury. And I wound up owning an outpatient head injury rehabilitation clinic in Denver. I had a treatment program of my own design. I eventually had other psychiatrists, psychologists, neuropsychologists, psychotherapists, biofeedback therapists, and others working at the clinic. And that led me to eventually wind-up owning outpatient head injury rehab clinics all around the country. I was fortunate enough to eventually sell those clinics. And after I sold the clinics, I was thinking about, "Well, what do I want to do next?" I didn't want to retire. I love medicine.

As part of that work, I testified as an expert witness more times than I wanted to remember on behalf of my patients who are either being cut off their medical care or offered some pits of a settlement. And I was quite familiar with our legal system and I thought, "Well, maybe what I could do is just consult attorneys on any kind of medical question that came up in a case and work with them, pretrial pre-litigation".

In other words, in the areas of the law that I started working with attorneys, approximately 9 out of 10 cases settled. And so, that's where I came in. Well, one thing led to another, and I wound up developing what has turned into a whole new subspecialty of forensic medicine that deals with the pretrial pre and aspects of legal cases. And I developed a whole variety of fairly specific services to help the attorneys help their clients to better negotiate and settle cases.

And after doing that for a few years, I realized this probably could be a new field. I started training other physicians how to do this work through a training program and through conferences. And I guess as they say, the rest is history, it's now 14 years later. Through those means I've trained over 1,600 physicians around the country. And so, that brings us up to today.

John: Very interesting. And of course, you've touched on some of the factors that maybe make this a little bit more appealing than some other forms of consulting. But why don't I have you really spell those out for us? When we think of medical expert witnesses for legal reasons, of course, we're talking about reviewing charts, then a certain percentage of those will result in a deposition and then even a smaller percentage will potentially end up in court. It can get a little stressful, a lot of time involved. It sounds like you're doing something a little different that doesn't always involve those aspects. So, tell us about that.

Dr. Armin Feldman: Yeah, that's right. First of all, I should say I don't do any expert witness work and I don't work in medical malpractice cases. I am working in other kinds of legal cases. The work is primarily in personal injury cases and workers' compensation cases with regard to injuries. But I'll tell you any physician in any specialty can learn how to do this kind of consulting. What happens is, the attorney will call me with a case. We will discuss the case. They will send the medical records. After I review the medical records, I'll interview the client of the attorney in every case. Typically, it was by phone, but now it might be by Zoom meeting. Less than 3% of the time I may want to interview the client in the attorney's conference room.

Once I do my review of the records and interview the client, then I'm going to do any medical research that I need to do. And then in many cases, I'm writing a report. Many services don't require a report, but the thing to understand is that I answer and other physicians that do this, we answer any kind of medical question that comes up in a case. And so, the issue may be related to a specific medical question, a specific condition, a specific injury.

By the way, there are about 16, 17 different kinds of services that we offer to these attorneys to help them. And what that means is to better settle the case. It means settling the case for better value with less attorney time. Help the attorney get the appropriate medical care for their clients, and also help the attorney just to negotiate all the medical issues in the case.

I'll give you a couple of examples. The service that is most requested is to provide the attorney with comprehensive medical summary reports, by the way, it's just a term I invented. But comprehensive medical summary reports that they will include in settlement demand letters. Through the negotiation process, at some point, the attorney will file or submit to opposing counsel and to the insurance company a settlement demand letter. And in that letter one of the things that the attorney must put in there, these are fairly standardized state by state, but obviously, they have to put in a description of damages. There are all kinds of damages. Damage to a car, loss of work time, loss of enjoyment of life, which by the way isn't medical damage. Medical damages tend to be the biggest group.

We will give our medical opinions based on all the things that I just told you about regarding every injury in the case. And so, we will write a comprehensive report that includes our medical opinions. And one of the things that makes this viable is in our legal system, physicians are expected to, and are sanctioned to give medical opinions to medical questions.

Now, if it's that 1 out of 10 cases that's going to trial, well, then obviously the attorney is going to need medical experts in every area of injury. But for the purpose of negotiating and settling the case, what the attorney needs are medical opinions, reports, and other services, all backed up by evidence from the medical literature that they can use to settle the case. And this is a completely legitimate thing that any physician can do. These reports will cover everything in the case, every injury in the case, along with a number of other fairly specific things that need to be in this kind of report.

Now, another thing that we do is that we can actually physically sit in and observe independent medical exams that other physicians do, which puts us in a position to write IME rebuttal reports. Now we all know that they're very good doctors that do very good IME. We also know that in every community across the country, there are physicians that are specifically asked to do these by the insurance companies because they have a fairly good idea of what the opinions are going to be. I think I was probably the first physician in the country to actually physically sit in and observe IBS and write rebuttals.

Another thing that we do quite often is we'll answer specific medical questions in cases. And when we do that, what we're doing, for the most part, is we're helping what the attorneys call to prove a particular medical theory for the case. Now sometimes we'll do that and we'll tell the attorney, "This isn't going to fly, don't do this". But most of the time what we're doing is we're helping to prove a particular medical theory for the case.

Let me just digress for a sec and I'll tell you one other thing. When I started doing this, let's say there was some issue in the case related to a rotator cuff injury, and the attorney wanted a report and my opinion on that particular thing. I would write up the report in the manner in which I just told you. My report's going to go to opposing counsel. Our work is not behind the scenes. Our reports are seen by opposing counsel. They're almost always seen by insurance adjusters. They're often seen by judges, treating doctors, IME doctors, and others.

And the opposing counsel gets my report. Well, what's the first thing they're going to do? They're going to look me up. They look me up and they call the attorney that hired me and they say, "Well, I looked Dr. Feldman up. Why should I pay any attention to his report? He is not an expert in rotator cuff injuries". And of course, this doesn't happen to me anymore because people know who I am, but that's what happens with everyone.

But what my attorney's going to say is, "Well, Dr. Feldman acts as a medical consultant for me, by the way, as opposed to a medical expert, but works as a medical consultant for me in all my cases. And if we can't get this issue and negotiate it out in the settlement based on Dr. Feldman's opinions and boards, and I back it up with evidence from the literature so forth, and you forced me to take this case to trial. When I hired my retained orthopedic surgeon, they're going to say exactly what Dr. Feldman said in his report. In fact, they would be both relying on the same literature, so let's get this settled". And that's how it works.

John: Okay. Let me go back a couple of things just to make it crystal clear because these are some of the things I found so fascinating. Number one is you were talking about the IME Independent Medical Exams. And what you're doing when you do them is you're actually observing someone else's IME as a way to kind of keep the whole process valid for your side of the equation for the attorney you're working with. I just want to make that clear. I think you did, but just for the audience to understand. This is like another sort of perspective to the whole process.

Dr. Armin Feldman: Yeah, that's correct. Sometimes it's something as simple as an observation. I did a case. It was a woman that had a head injury. She had

symptoms, there were CNS questions. All the treating doctors were in agreement with this. One IME doctor said, "No, there's nothing wrong with her". So, I went to a different IME and the IME report came back and the report was that Babinski's were negative. Well, one was positive. And I saw it, I observed it. I tested that. I wasn't the only doctor that saw that. Many of the treating doctors saw that.

And so, that was something that came up in that particular IME. But most of the time, it's more of an opinion thing. The person doesn't need revision surgery for the rotator cuff, because there was no dial leakage on her arthrogram. Well, most orthopedic surgeons would say pain and range of motion, degree of functionality. These are the things that would be criteria with regard to whether that revision surgery would be needed or not. And that's what I might talk about in my revision and my rebuttal report.

John: Right. Again, just to point out something you've already said, the fact that you're a psychiatrist really doesn't make any difference. You don't have to be an internist, an orthopedist, or a neurologist. You need really a basic medical background and maybe a little experience and the ability to read the literature and then serve as sort of an interpreter there for your attorney, your attorney's client, that sort of thing.

Dr. Armin Feldman: In fact, John, it's one of the things that's so much fun about this work. Now, some physicians I talk with, they might be interested in doing this. I talk with them and they just want to stay in their lane. They are not interested in this. But if you went to medicine because you found out that you love medicine, and you enjoy learning about all aspects of medicine, then this is just tremendous, it's so much fun.

I'm not in any position to do any orthopedic or neurosurgery, but I put my knowledge base of spine injuries, rotator cuff injuries, complex regional pain syndrome, and other things up against anyone. And I'm such a more well-rounded and better doctor for all of the hundreds of hours of research that I've done over the years.

John: It's interesting. I interviewed someone who is a medical director or a CMO at a life insurance company. And she happened to be a cardiologist. It's like, well, what does a cardiologist know about life insurance? But it was exactly what you're saying. She was asked to interpret. She would do her research. Whether she had to do with pediatrics adult cardiac renal didn't matter. It was all based on the basic background of being a physician that's got a broad sort of training. That's another very interesting perspective. All right. Are there challenges in this thing? It sounds like it's Nirvana, it's fantastic. There's got to be some challenges and probably some pre-work you have to do.

Dr. Armin Feldman: Yeah. Again, I'm not sure this is entirely a challenge, but it's certainly a thing of interest. In my training program, I'm training physicians on two things. I'm training them on the medicine they need to know, but also, I'm training them on how to successfully start-up, but more importantly, how to run a long-term medical legal consulting business. If there's a challenge, it's the issues outside of medicine. How do you get from zero to up and running with your business? How do you market your business? How do you run your operations on a day-to-day basis? How do you do your billing? These kinds of things.

And so, maybe the challenge for physicians is on that side of the equation. Physicians are now just being employees of big corporations or hospital systems. So, what's the biggest trend? Everybody wants their own side gig, right? So many doctors want their own thing. Well, to have your own thing, you have to know something about business and how to run that business. It doesn't run itself. Now for me, of course, this has been part of the fun of it all. But if there's a challenge it's getting used to... And any physician can learn it, but it's getting used to that side.

John: The plus side there it sounds to me is that if someone is unhappy, unfulfilled and is looking for an alternative that if they can just squeeze out some time, they can actually start this on a part-time basis, learn about it, start working on how to get some clients. And then if it really resonates with them, then they can gradually either phase out or quit their other job or get another type of less stressful clinical job let's say.

Dr. Armin Feldman: Yeah, that's right. Now there are physicians that do it full time. There are physicians that do it instead of retiring, but you're right, the largest group are physicians that do this as a part-time side gig.

John: Okay. Now, how does someone get paid doing this? Do you just sort of have a retainer? Do you use an hourly rate? Do you do a case rate? All the above? I think people will have that question.

Dr. Armin Feldman: The way I train the physicians that are doing this is I charge by the hour for everything that I do. One hourly fee. I keep the billing log form along. Attorneys understand hourly billing. Now, of course, in the areas of the law, which I work primarily, it's done by contingency. But I charge by the hour for everything that I do. Just to quick aside. Now I'm not working on contingency. When I send my bill, I expect to be paid in the next 30 days. And in the real world, 90% of the time I'm paid within 30 to 60 days of sending my bill.

But the way that I've advised physicians over the years is to do an informal survey of their colleagues, determine what you think is the average fee per hour for doing medical expert work in your community. Now, obviously, there's a range, right? Not hard to figure the average. So once you get that average, then you want to come in somewhat below what the medical experts are charging doing this acting as a medical consultant, pretrial, pre-litigation.

John: Okay. That's pretty straightforward. And they can get some either from you, if they take your coaching course or elsewhere, they can figure that out. Tell us about your course exactly. What is it? What is it like now? Is it face to face? Is it live? Is it online? Is it recorded? What does it look like?

Dr. Armin Feldman: It's one year and the physician gets all of the business concepts, all the business tools they need, the medical tools, the training, the manual, the how-to on every aspect of the business. They get everything that I use in my business. They get a website, so forth. And it's both on the business side and on the medical side. But the big thing is they get a year of coaching with me. And I've been doing this full-time for 14 years. And so, it's not an absolute necessity. Occasionally somebody joins the coaching program, I don't hear from them much and they're successful. But far and away, far, far and away, the physicians that stay in close touch with me are the most successful. Whatever they need during the launch plan period, I help all of the physicians with some of their marketing. That's how they learn it in the beginning. I'll actually help them to get their first cases in the door. I read tons of drafts of reports before they go out to their attorneys, and really anything I can do from my end that's going to help them to be successful.

John: That sounds like it's fairly comprehensive for those that take advantage of it. Can you give me an example? I'm curious if everyone that learns this from you, do they do exactly what you do or do you see examples where someone might say, "Well, I want to focus on this aspect or that aspect?" Or maybe they just end up doing something slightly different, just because we're all different. Any examples like that?

Dr. Armin Feldman: There's kind of a tried and true way to do this. And not that I haven't learned from coaching members over the years and made adjustments to things, both on the business side and the medical side. But the fact is if you vary too far from the standard approach, it tends not to be as successful.

John: Well, when you've been doing something for 15 years it tends to be a pretty well-oiled machine at that point, I assume.

Dr. Armin Feldman: Yeah. Yeah. And not that I'm not open to hearing what physicians that are training or have trained are doing. But most of them come back around to doing it the way they were trained.

John: Got it. All right. Well, before we go any further, we're getting near the end here, but I want to make sure I mention your website. Actually, it's sort of a page that has this course on it. It's called mdbizcon.com. And I found a video there. It pretty much explains everything. It's again, pretty interesting. That's one of the things that got me interested in getting you on here in the podcast today. So, let's not forget about that. And then I'm also going to put a copy of your email address in the show notes for anyone that would like to get on your email list. Is that doable?

Dr. Armin Feldman: Yeah, that would be great. I do have a newsletter once a month for physicians that are interested in this topic. And then two weeks after the newsletter comes out, I send out a shorter plain text email with tips, advice on various topics as they come up in my day-to-day work. And then I'll talk about it.

John: If you were to be addressing some of my listeners here who are sometimes a little bit burned out or they're just frustrated with medicine in general, what advice might you have for them in terms of thinking about their careers?

Dr. Armin Feldman: I think as physicians, we all want to help people. That's a good portion of the reason we got into it. So, I would say, first and foremost, find something that you can use your medical knowledge to still help people. And this isn't anything profound, I'm sure you've heard it before. But if you're doing something that you really enjoy and find fun, it doesn't seem much like work. If you're going to do something on the side or look for something to cure that burnout, make sure it's something that you really enjoy, that you find fun doing every day. And if you can combine that with helping people, and by the way, making money, what's better than that?

John: Oh, that's absolutely right. Great advice. Yeah, I think if people don't know about these things, then they feel sort of frustrated or resigned that they can't break away from the corporate practice of medicine or something like that. But just in having conversations with people like you, we've seen just dozens and dozens of different opportunities and options for people if they just sort of open their eyes and look around. I appreciate those comments. Anything else you need us to know about this new kind of medical legal consulting?

Dr. Armin Feldman: If you enjoy medicine as a whole, and you got a kick out of being in med school and learning all the things that we know, and you want to put that medical knowledge to work in a nonclinical field that really helps people and is lucrative, this is something that you should look at.

John: Yeah, that's what I thought when I first heard about this. It's intellectually stimulating. It builds on your medical and actual understanding of the healthcare system itself. And you don't have to be in any particular specialty and you don't have to keep practicing to do this ultimately if you decide to do it full-time from what you've said.

Dr. Armin Feldman: Right.

John: All right. Well, thank you very much. This has been very fascinating, Armin. I really appreciate you for coming on today. And I hope a few of my listeners take you up on the email letter and maybe even enroll in your coaching course. With that, I'll have to say bye-bye.

Dr. Armin Feldman: Okay. Thank you, John. It's been my pleasure.

John: It's been great. Thanks. Bye-bye.

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The opinions expressed here are mine and my guest’s. While the information provided on the podcast is true and accurate to the best of my knowledge, there is no express or implied guarantee that using the methods discussed here will lead to success in your career, life, or business.

The information presented on this blog and related podcast is for entertainment and/or informational purposes only. I do not provide medical, legal, tax, or emotional advice. If you take action on the information provided on the blog or podcast, it is at your own risk. Always consult an attorney, accountant, career counselor, or other professional before making any major decisions about your career. 

The post How to Do a New Kind of Medical Legal Consulting as a Part Time Gig – 227 appeared first on NonClinical Physicians.

Get ready for the financial, legal, and psychosocial consequences of giving notice to your employer or partners.

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We're proud to have the University of Tennessee Physician Executive MBA Program, offered by the Haslam College of Business, as the sponsor of this podcast.

The UT PEMBA is the longest-running, and most highly respected physician-only MBA in the country. It has over 700 graduates. And, the program only takes one year to complete. 

By joining the UT Physician Executive MBA, you will develop the business and management skills you need to find a career that you love. To find out more, contact Dr. Kate Atchley’s office at (865) 974-6526 or go to nonclinicalphysicians.com/physicianmba.

Idealized Process for Leaving

You may envision the following scenario as your exit plan:

1. You will find something else to do, either clinical or nonclinical, or both.
2. Once that’s locked in, or you have a really sound plan, you will give separation notice to your employer.
3. You will leave in a few weeks to a few months from now, and that will be that! Problem solved.

Unfortunately, that is not how it usually goes. If not fully prepared, what follows are a series of unexpected financial, legal, and/or psychosocial consequences that can slow or complicate your departure. 

Get Ready for Financial Issues

Any pivot will have financial consequences. If there is a gap between jobs, you’ll need a nest egg to get you through the time when income temporarily stops. This is ameliorated if you have passive income from other sources, or if your spouse’s income can cover expenses while you’re in the process of transitioning.

Here are some questions to keep in mind before finalizing your decision to give notice:

• Am I forgoing any retirement funds or deferred compensation by leaving? For example, certain plans are forfeited if you leave employment before retirement age.
• What expenses might I incur, including malpractice tail coverage, which can be quite expensive?
• Are there performance or quality bonus dollars that I lose if I am not employed at the end of a calendar or fiscal year? A relatively short delay in leaving might bring thousands of dollars of income that would otherwise be forfeited.
• If I leave, will I need to pay back any sign-on bonuses I received when joining the current group or system?

Get Ready for Legal Issues

This leads us to the legal ramifications. An employment contract is typically a long and complicated document. Many provisions are forgotten until separation is imminent. And some of them will prevent, postpone or complicate your departure.

Questions to consider include:

• Will a restrictive covenant keep me from working in my new job?
• If I’m shifting to my own practice, am I prevented from bringing key employees from my previous employer with me?
• What happens with the remaining time off and other benefits outlined in my agreement?
• How do I handle the process if I don’t have an employment agreement? What are the Human Resources Department Procedures that I agreed to follow when I took the job?

Get Ready for Psychosocial Issues

You may observe a common behavioral pattern in colleagues and employers when leaving. That pattern is Kubler-Ross’s 5 Stages of Death and Dying.

You may go through the stages of denial, anger, bargaining, depression, and acceptance once you realize that you can no longer tolerate working in your current situation. But you may not be prepared for those very same steps occurring in your colleagues and employer. The denial and anger of those around you can be particularly disconcerting.

It is naïve to think that a business that is dysfunctional is going to respond to your departure in a functional way.

Your managers may avoid you, even though there are issues to take care of. They may try to involve you in matters that are no longer of your concern. And they may attempt to burden you with more than your share of on-call duties. They may treat you as if you are not leaving.

You may intend to be completely professional and deliberate as you wrap things up. But prepare yourself for others to be oppositional, upset, angry, or in denial. This may manifest as passive-aggressive or overtly hostile behavior. So, how do you get ready for these potentially disruptive problems?

How to Prepare

Here is how to get ready for your transition when leaving your current employer.

1. Take time to develop a plan BEFORE you put anything in motion. Make a list of all of the above factors and consider how to approach each one.
2. Do your due diligence before reaching out to your employer. Review your employment contract or partnership agreement. Write down any aspects that involve significant financial consequences or legal landmines.
3. Do your own financial analysis based on what you plan to do. And strongly consider involving your accountant. In addition to the direct monetary consequences of the move, there may be tax consequences. And you may need to adjust estimated income tax payments. It might be worthwhile to have your accountant create a pro forma, forecasting the 1-, 3- and 5-year consequences of taking the new job compared to staying in the old job.
4. Next, I would meet with your attorney to go over questions in your employment or partnership agreement before making any final decisions about leaving. Be sure you understand the requirements for giving notice, and what happens once it is given.
5. Once you feel secure in your decision and have an understanding of how the separation should be handled, give notice per your attorney’s instruction. Generally, that will include speaking directly with the appropriate person (delivering the notice in person), followed by certified mail if required.
6. Prepare yourself mentally for the response from your current employer and those around you (starting with denial, and anger, and moving to bargaining, depression, and acceptance over time). Realize that denial and anger may follow quite quickly.

Final Thoughts

Oftentimes, you’re leaving an employer because it is dysfunctional. It may not be run like a business, with no regular meetings, problems that are ignored, the chain of command is ambiguous, and nonexistent strategic planning. It is naïve to think that a business that is dysfunctional is going to respond to your departure in a functional way.

So, be prepared.

NOTE: Look below for a transcript of today's episode.

Links for Today's Episode:

• Why Demoralize Your Employed Physicians Over Tail Coverage?
• What You Need to Know About Physician Recruiting Incentives

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Today's PNC Podcast Transcript

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The opinions expressed here are mine and my guest’s. While the information provided on the podcast is true and accurate to the best of my knowledge, there is no express or implied guarantee that using the methods discussed here will lead to success in your career, life, or business.

The information presented on this blog and related podcast is for entertainment and/or informational purposes only. I do not provide medical, legal, tax, or emotional advice. If you take action on the information provided on the blog or podcast, it is at your own risk. Always consult an attorney, accountant, career counselor, or other professional before making any major decisions about your career. 

The post Get Ready for What Will Happen When You Quit Your Miserable Job – 213 appeared first on NonClinical Physicians.

On this week's episode of the PNC podcast, I had the pleasure of a return visit from Dr. Marjorie Stiegler. Marjorie shares her insights into the legal landmines that a physician encounters when starting a new business or side hustle, and offers some strategies for avoiding them.

As Marjorie is a returning guest, this episode is a little different. We don't go into Marjorie's own background or the specifics of her business. If you are interested in learning more about her, you should listen to Episode 84.

Our Sponsor

We're proud to have the University of Tennessee Physician Executive MBA Program, offered by the Haslam College of Business, as the sponsor of this podcast.

The UT PEMBA is the longest-running, and most highly respected physician-only MBA in the country, with over 650 graduates. Unlike other programs, which typically run 1 – 1/2 to 2 years, this program only takes a year to complete. And Economist Magazine recently ranked the business school #1 in the world for the Most Relevant Executive MBA.

University of Tennessee PEMBA students bring exceptional value to their organizations. While in the program, you'll participate in a company project, thereby contributing to your organization.

Graduates have taken leadership positions at major healthcare organizations. And they've become entrepreneurs and business owners.

By joining the University of Tennessee physician executive MBA, you will develop the business and management skills you need to advance your career. To find out more, contact Dr. Kate Atchley’s office by calling (865) 974-6526 or go to vitalpe.net/physicianmba.

Legal Landmines

While everyone who embarks on a new business venture opens themselves up to a certain level of legal liability, for physicians it is particularly complex. It is important for physicians to understand that our risk of encountering certain legal landmines is especially high.

More than just medical malpractice, there are a variety of considerations that have potential consequences.

Dr. Marjorie Stiegler

Marjorie notes that a lot of physicians aren't thinking about how being a member of the medical profession might add unique risks when establishing a new business. However, in the event that a complaint is filed or someone decides to sue, your background as a physician can absolutely come into play.

However, that does not mean that you should be discouraged from starting a business or side gig. It is just a question of ensuring that you go about it the right way, to protect you, your existing partners or employer, and your patients and clients. With that in mind, Marjorie offers a few key questions that need to be answered to ensure you are adequately protecting yourself.

1. Are you practicing medicine?

This is the most important question to ask. If the work you are doing is in any way related to practicing medicine or providing care, you need to ensure you are protected by your malpractice carrier, and are not violating any licensing regulations.

However, just because you do not think that what you are doing could be seen as practicing medicine, others may not see it that way. Your title of ‘doctor' may well affect how people view your recommendations.

Just saying ‘this is separate from my medical practice' may not cut it.

Dr. Marjorie Stiegler

Marjorie uses the example of skin care or nutritional products. While not medical in nature, your customers may be influenced in their purchase by your position. Marjorie reminds us, “Just saying ‘this is separate from my medical practice' may not cut it.” Which brings us to the next point.

2. Do all parties involved clearly understand the nature of your relationship with them?

It is essential that everyone involved knows exactly in capacity you are operating, including business partners and customers. If you are not practicing medicine, you need to explicitly state that you are not engaging in your new role as a physician in any way.

You still need to operate within the bounds of ethical guidelines, and ensuring clarity with all parties involved will go a long way to ensuring that you are protected should a complaint or lawsuit be filed.

The post Beware the Legal Landmines of Your New Business – 114 appeared first on NonClinical Physicians.