noncompete Archives - NonClinical Physicians https://nonclinicalphysicians.com/tag/noncompete/ Helping Hospital and Medical Group Executives Lead and Manage With Confidence Fri, 21 Jun 2024 10:58:17 +0000 en-US hourly 1 https://wordpress.org/?v=6.6.2 https://nonclinicalphysicians.com/wp-content/uploads/2016/06/cropped-1-32x32.jpg noncompete Archives - NonClinical Physicians https://nonclinicalphysicians.com/tag/noncompete/ 32 32 112612397 How to Set Up Your Medical Writing Business https://nonclinicalphysicians.com/set-up-your-medical-writing-business/ https://nonclinicalphysicians.com/set-up-your-medical-writing-business/#respond Fri, 21 Jun 2024 10:45:58 +0000 https://nonclinicalphysicians.com/?p=22198 How to Start Your Own Medical Writing Business: A Practical Guide Starting your own medical writing business can be both exciting and challenging. Whether you're an experienced medical writer or a healthcare professional looking to transition into writing, setting up your business involves several important steps. Here’s a straightforward guide to help you get started. [...]

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How to Start Your Own Medical Writing Business: A Practical Guide

Starting your own medical writing business can be both exciting and challenging. Whether you're an experienced medical writer or a healthcare professional looking to transition into writing, setting up your business involves several important steps. Here’s a straightforward guide to help you get started.

  1. Identify Your Niche
    First, define the kind of medical writing you want to specialize in. The field includes technical writing for pharmaceutical companies, journalistic writing for physicians and patients, and writing continuing medical education (CME) manuscripts. Knowing your niche will help you target clients and tailor your marketing efforts.
  2. Create a Business Plan
    A business plan is your roadmap to success. Outline your goals, target audience, pricing strategy, and marketing plan. Here’s what to include:

    • Mission Statement: Define why the organization exists, what its overall goal is, the kind of product or service it provides, and its primary customers or market.
    • Market Analysis: Research your target market and competitors.
    • Services Offered: List the types of writing you plan to provide.
    • Pricing Strategy: Set your rates based on industry standards and your experience.
    • Marketing Plan: Plan how you will reach potential clients, including creating a website, leveraging social media, and networking.
  3. Choose Your Business Structure
    Decide on the legal structure for your business—sole proprietorship, LLC, or corporation. Each has its own legal and tax implications. It might be worth consulting a business attorney or accountant. Also, don't forget to register your business name and get any necessary licenses or permits.
  4. Build an Online Presence
    In today's world, having a professional online presence is crucial. Create a website that showcases your services, portfolio, and contact information. Consider including:

    • About: Share your background and qualifications.
    • Services: Detail the writing services you offer.
    • Portfolio: Provide samples of your work.
    • Testimonials: Include feedback from past clients.
    • Blog: Post industry insights and writing tips to demonstrate your expertise.
  5. Network and Market Yourself
    Networking is key in the medical writing industry. Join professional organizations like the American Medical Writers Association (AMWA) or the International Society for Medical Publication Professionals (ISMPP). Attend conferences, webinars, and workshops to connect with potential clients and stay updated on industry trends. Use social media, especially LinkedIn, to build your professional network and highlight your expertise.
  6. Get Your First Clients
    Getting your first clients can be tough but rewarding. Start by reaching out to your existing network and offering your services. You might consider doing some work for free or at a discount to build your portfolio and get testimonials. Freelance platforms like Upwork, Freelancer, and specialized medical writing job boards can also help you find opportunities.
  7. Manage Your Business Operations
    Effective business management is crucial for long-term success. Set up systems for tracking income and expenses, invoicing clients, and managing deadlines. Tools like QuickBooks for accounting and Trello or Asana for project management can help keep you organized.

More on using LinkedIn

Many publishing, continuing education, and medical communication companies look to LinkedIn to find prospective new writers. It is an excellent platform to showcase your work and list the companies for which you've written. And by publishing your work on the site, you can attract followers who might refer or hire you.

Summary

Starting a medical writing business requires careful planning, networking, and dedication. By following these steps, you can build a successful business that leverages your expertise and meets your clients' needs. Stay adaptable and continuously look for opportunities to grow and develop professionally.


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Disclaimers:

Some of the links that I refer you to are affiliate links. That means that I receive a payment from the seller if you purchase the affiliate item using my link. Doing so has no effect on the price you are charged. I only promote products and services that I believe are of high quality and will be useful to you. As an Amazon Associate, I earn from qualifying purchases.

The opinions expressed here are mine alone. 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. 

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The Ultimate Swindle Known As Sham Peer Review https://nonclinicalphysicians.com/sham-peer-review/ https://nonclinicalphysicians.com/sham-peer-review/#respond Tue, 27 Feb 2024 11:44:16 +0000 https://nonclinicalphysicians.com/?p=22475   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 [...]

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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. 


Our Show Sponsor

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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.


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Our Episode Sponsor

Dr. Debra Blaine is a physician like many of you, and her greatest challenge was fear. The whole concept of leaving clinical medicine was terrifying. But she is so much happier now as a professional writer and a coach. According to Debra, “It’s like someone turned the oxygen back on.”

If fear is part of your struggle, too, she would like to help you push through those emotional barriers to go after the life you really want. Click this link to schedule a free chat.

Or check out her website at allthingswriting.com/resilience-coaching.


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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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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Negotiate a Great Contract, Avoid Burnout, and Be Happy https://nonclinicalphysicians.com/negotiate-a-great-contract/ https://nonclinicalphysicians.com/negotiate-a-great-contract/#respond Tue, 13 Feb 2024 13:34:59 +0000 https://nonclinicalphysicians.com/?p=22193   Interview with Ethan Nkana - Episode 339 In today's episode, Ethan Nkana explains how to negotiate a great contract, avoid burnout, and protect yourself legally. Ethan's advice revolves around empowering physicians to advocate for their best interests, understand the nuances of their contracts, and seek professional assistance for optimal negotiations. Our Show [...]

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Interview with Ethan Nkana – Episode 339

In today's episode, Ethan Nkana explains how to negotiate a great contract, avoid burnout, and protect yourself legally.

Ethan's advice revolves around empowering physicians to advocate for their best interests, understand the nuances of their contracts, and seek professional assistance for optimal negotiations.


Our Show Sponsor

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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.


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Our Episode Sponsor

Dr. Debra Blaine is a physician like many of you, and her greatest challenge was fear. The whole concept of leaving clinical medicine was terrifying. But she is so much happier now as a professional writer and a coach. According to Debra, “It’s like someone turned the oxygen back on.”

If fear is part of your struggle, too, she would like to help you push through those emotional barriers to go after the life you really want. Click this link to schedule a free chat.

Or check out her website at allthingswriting.com/resilience-coaching.


A Crucial Step in Career Success

In this interview, Ethan Nkana, founder of the Rocky Mountain Physician Agency (RMPA), sheds light on the often-overlooked importance of negotiating your best employment contract. The conversation highlights the significant role contract negotiations play in a physician's career course. These negotiations have an enormous impact on overall job satisfaction, financial well-being, and work-life balance. Ethan's expertise, honed through years of working in hospitals, is presented as a valuable resource for physicians navigating this complex terrain.

Key Considerations in Physician Contract Negotiations

Ethan provides practical insights into the essential elements of physician contracts, guiding both new and experienced physicians. From compensation and restrictive covenants to job duties and support resources, the discussion offers a roadmap for physician employment agreements.

On this matter, we explore the top two or three critical elements that physicians should prioritize. These topics are demystified, with Ethan offering his valuable insights. Tail coverage for malpractice insurance and considerations for experienced physicians seeking contract renegotiation are also explored.

Ethan Nkana's Advice for New Graduates

It's a matter of asking, knowing how to ask, and what to ask for. For the first time attendings coming out, please do not feel as though you have to sign whatever is put in front of you… I want to encourage you, please advocate for yourselves, know what matters to you most, and ask for those things in your contract. 

Summary

Ethan shared valuable insights into why you must fight for your best employment contract, and what to prioritize. He also reminds us that there are professionals like him who will serve as your agent to get you the best contract possible.

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


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Transcription PNC Podcast Episode 339

Negotiate a Great Contract, Avoid Burnout, and Be Happy

- Interview with Ethan Nkana

John: Sometimes physicians can be their own worst enemies. We finish our training and agree to work for a large practice or a hospital system, and then two or three years later we're miserable. And we discover that our contract does not protect us from being mistreated or underpaid. My guest today is Ethan Nkana, and he's here today to help us avoid those issues. Welcome Ethan. I'm glad to have you here today.

Ethan Nkana: Thank you so much for having me, John. It is a delight to be here with you.

John: I don't know why I haven't talked to someone like you sooner. I've been doing this podcast for several years and I've always focused on nonclinical, but the reality is, for most physicians, they want to go clinical. And they may not want to do it forever, but heck, if they're going to work clinically, they shouldn't be subject to low salaries and being beat up and burned out after two years. I think some of what you're going to tell us today is going to help us avoid that. And I really do think, and I don't talk about this enough, but every physician that's going to be employed really has to have someone help them negotiate their contract. That's my opening for you. Take it from there. Tell us about your background and how you got into this.

Ethan Nkana: Yeah, spot on, John. And actually I want to touch on what you said a moment ago. So much of what I get to do in my job is education. And so, I think it's so important for doctors first to understand what is in your contract and the risks, the benefits and burdens, all of those things. During our conversation I don't want this to sound like a sales pitch for my business. I want to help doctors know how to do it for themselves so they don't need someone like me.

But I think you highlighted something that is extremely important about the relationship that doctors have with employers is often overestimated. And so, doctors have this fierce loyalty to employers, which they find out the hard way is not necessarily reciprocated. I'm glad that you and I get to talk today.

John: I'm going to say another prelude to this whole conversation for those that are listening, because I used to do negotiations on the hospital side for these physicians. I think when you're negotiating or you're having someone negotiate for you, you have to realize, the way you set this thing up and the document that you sign is going to be what you're going to live by for the next few years. And if it turns out there's big holes in it or there's things in there that just don't align with what you thought you were getting, you're going to be miserable. Again, that's just my admonition to those as we get going. Tell us how you got started and I did a little intro separate from this and I talked about how you go back to the legacy with your mom, but tell us about that and then how you got into this.

Ethan Nkana: Absolutely, and I think one of the cool things about what I get to do now is it's kind of the only thing I've ever done in my career. As you mentioned, my mom is an anesthesiologist. Coming out of college, she told me, you've got to get into healthcare, you're going to always have a job. What she didn't know is that I got laid off in 2019 and all of a sudden kind of found myself having this existential crisis.

And in the midst of that crisis, I had this question, "Why don't doctors have agents like professional athletes?" I started thinking about your training journeys as a physician, how that parallels with an athlete. Then you go pro and there's all of this money and athletes hire agents, but doctors tend to DIY it. And so, I founded RMPA - Rocky Mountain Physician Agency as an agency for physicians. And so, my job is similar to a talent agent, athletes, actors, you name it, my job is to negotiate and renegotiate physician contracts for the most money and best terms for my doctors.

John: Now that leads me to a question about that process. Do you usually get involved with their first contract or do you have a lot that are halfway through and now they're getting ready to re-up or renegotiate? Because I could figure that would be a whole different scenario.

Ethan Nkana: Yeah, we do actually quite a bit of both. We do first time attending, what we call rookie deals. Doctors who are coming out of residency and training. And we also negotiate deals for experienced doctors. As you mentioned, those are very different. The reason that for me, it's kind of like a fish in water is because the only thing I've done in my career is work in hospitals. From HR intern, which is my first job, supply chain, food and beverage, physician contracting, finance. If it's in a hospital, I've either done it or I know it.

And so, for me, it's really easy to kind of transition between, "Okay, I have a rookie doc who's going in their first contract. What are some of the things we want to prioritize?" But the cool thing about that though, John, is I get to see into the crystal ball of what attending doctors are concerned about. Then I get to say, "Hey, Dr. Jones, you might want to make sure that you lock in your call schedule, because that's the most common thing that experienced doctors call me about." It's kind of this cool dichotomy of getting to see doctors at the beginning of their career when it's all in front of you, and then I also get to work with doctors as they progress through their career, renegotiating their employment contracts.

John: And I think it's implied, but I have to ask you directly. Given your experience, even prior to doing this and then starting the agency and now doing this, would you agree that if you really pay attention and you get the right contract, life is going to go a whole lot better? Or on the other hand, maybe you walk away from something. If you can't get to that contract, it means there's something wrong. Is that your experience?

Ethan Nkana: That is spot on, John. I think that often gets overlooked because psychologically we are so averse to change. And so, when doctors think about what it takes in order for them to advocate for their best interest, there's this big barrier, this big wall of change that they have to go through, or they have to think about scaling. And so, a big part of my job is the psychological part of helping doctors understand, "Yes, there's going to be change and it's going to be worth it." You're going to be happier, you're going to have less stress, you're going to have more support in your practice, you're going to be more fulfilled with your work, and then obviously make a bunch more money to do that.

John: Awesome. All right, obviously you're not going to be able to walk through like a typical 15 page contract or something and cover all, but all the bases. But tell us in your experience what are the top two or three issues and what are some of the pitfalls and maybe the things where you really have to step in and say, "This isn't worded right, or we really have to pay attention to this?" Just take it away and we'll learn as much as we can from you.

Ethan Nkana: Yeah, great question. I have what I call the big five, which are the five provisions that if I had 15 minutes, here's where my eyes would go. First and foremost, the compensation. We're all looking for that big sexy six figure number to see what's my annual salary. But don't forget about your bonuses. Your production bonuses, volume bonuses, signing bonus.

The second thing that I'm looking at is education loan debt assistance. I can count on one hand how many doctors I've talked to who do not come out of training with some type of debt, usually in the six figure range. And so, my responsibility is also to help make sure doctors can pay that down as quick as possible. Going back to what you mentioned a moment ago, which you teed up is doctors being happier. And one way doctors are happier is when they have less student loan debt hanging over their head and then they can use that money to fund the lifestyle they've worked so hard for. And so, I always will encourage doctors to ask for education loan debt assistance. Those can be big dollars anywhere from $25,000 to $50,000, and sometimes above that a year in addition to whatever you're putting into that.

The third is non-competes. You've probably heard of those. They're also called restrictive covenants. The primary difference in this between sports and doctors is that in sports, once your contract ends, you can go play for any team who's going to hire you. But for doctors, it's so much more restrictive. And I don't think people appreciate that. When a doctor finishes their contract, that's when the restriction ends. Let's say you do five years with an employer and then they say, "Nope, you got to get out of town because you can't practice within 20 miles." So, who's going to move 20 miles away and they can change your school district for your kids and your church and social network? I don't have to go into all that, but the non-compete can be really burdensome.

I'll give you a quick cheat code. The non-compete penalty should be paid by your new employer. I often hear doctors say, "Well, I can't go anywhere because of my non-compete." Don't worry about that, negotiate that into your new contract so that way you don't have to worry about that. They'll give it to you upfront as a bonus. They're going to forgive it over the period of your contract. And that way if your employer comes knocking on your door saying, "Hey, you owe us X thousands of dollars", cool, I have a check for my new employer to pay you. So you don't have to worry about getting sued.

The other thing I want to look at is your job duties and schedule. This is huge. This is the thing I often say if doctors got the resources and support they needed from employers, I would be out of a job. But the fact of the matter is, medicine is a business and doctors are a very important cog in a very large wheel. And so, understanding what your clinical contact hours, your patient contact hours are each week, what are your call expectations. And then I just had this issue last week, what happens to call when a doctor leaves? Do they have a support pool to cover that for you? Or do other remaining doctors have to take more call and now impinge upon your lifestyle?

And then lastly, it's your resources and support. You want to make sure you have adequate administrative, clinical, financial support in your contract so that way you can perform at the highest level. It's stressful enough the work that doctors do. Make sure that the hospital provides you with the resources to play at the highest level or to care for patients at the highest level.

John: Those cover a lot of areas. Let me ask you a question or two, maybe about two or three of those. The salary. What drives it? Is it surveys? Is it, "Look, I'm just going to get as high salary as I can. If they're really hurting, then they're going to pay a lot of money." What do you find works the best? And do you usually find that you can get more dollars than the physician actually anticipated?

Ethan Nkana: Absolutely. Every time we go into negotiation, we make our doctors more money. I was asked by a physician group last week, "Well, what happens when that doesn't happen?" The way I get paid is a percentage of my doctor's pay. So, if I don't make them more money, I don't get paid. Our batting average has to be a thousand in order for us to even stay alive. So, we always make our doctors more money.

I think the important thing for doctors to understand, I'm going to bookend this. The most important things that I think would be how busy you are as a physician. Let's take your specialty out. Your specialty is going to of course drive. Like a neurosurgeon, generally speaking, is never going to make less than a nephrologist. That's just never going to happen realistically. We'll leave that out of the conversation. Let's just talk about within your specialty how salaries might change a little bit.

The doctors who generally make the most money are going to be the busiest doctors. My job when I worked in hospitals was to quantify for my CEO how much money we're going to make off of Dr. Jurica based on how busy you are, the type of procedures you do, and then the other counterbalancing expenses, how much do you cost us as a hospital? And then the balance between that is what's called the ROI or return on investment. Doctors are seen literally as line items on financial statements, and I could quantify down to the dollar how valuable doctors were to our hospital. And so, that rule sets the bar as like the busiest doctors generally tend to make the most money.

The other major consideration is where you're practicing. Even if you're looking at two high cost areas, say New York and California, you cannot compare those. Because there's just so many nuances. Now, I'm not an expert in finance, but there's just so much nuance. You must look in similar geographic regions, but then even within that, the care setting you're in matters. Some doctors are in private practice, some doctors in academics, some are in safety nets, like county hospitals.

The general rule of thumb that the data shows is that the fewer layers between the insurance carrier and the patient, the higher pay for the doctor. Private practice, highest pay. Insurance pays the doctor, who pays the practice, and then the expenses get paid for the practice from there. Then as you get to the world that I was in, which is, and I only worked in nonprofit, so I never worked for a for-profit hospital. But those hospitals are looking at "Well, how can we bring on the most doctors of a particular specialty within a geographic area?" They call them service areas.

And so, the chess game that I get to play is how can I help shift doctors among health systems in a way that they have to pay doctors the most money to either acquire or retain them. And so, my job is to help doctors maximize the value of that compensation with your employer. We're looking at "I'm going to pull your stats. I'm going to pull how busy you are." In sports, how many touchdowns did you throw? How many points did you score? How many rebounds did you grab? I want to know how many procedures did you do? How busy are you? Because those are the things that are going to impact your compensation. I can tell you from experience if you come in with the latest and greatest MGMA report, your hospital or employer will find 18 different ways to invalidate that data. "Well, this is looking at private practice. This is looking at left-handed doctors." Just save yourself the time, save yourself the money.

You should get a ballpark of what your salary should be. Doximity, Medscape, Merritt Hawkins, Physician Thrive. They all publish national and annual surveys on physician compensation. So you should have a ballpark of what you should be making. But if you think that that's going to help you in negotiation, you're just going to get laughed out of the room, unfortunately.

John: Now, one of the things that I remember that really drove physicians crazy in this process is the actual way that they're paid. And I'm sure it's changed since I was involved with this, which is more than 10 years ago. Well, they are going to be paid based on RVUs, number of patients seen, just a flat salary, some other goofy formula. Is that becoming any less complicated or do you still see all these different methods of trying to figure out how much you're going to actually take home?

Ethan Nkana: I'm convinced that the industry of law is made up so that people intentionally cannot understand it unless you go through this rigorous three year training program. Yes, it's extremely complex. Could a doctor understand it? Absolutely. But the time that it would take you, I was looking at a family medicine doctor's RVU bonus structure, and it was the wonkiest thing I'd ever seen. And I'll spare you the gore of how bad it is. But the point being, it's unlike anything else I've seen in the country. And so, this one organization has this bonus structure that's disadvantageous to the doctor and she has no recourse to change that. One, she didn't understand how it worked, which, how could you? It's so dense. And then secondarily, when I explained to her, "Hey, this is not in alignment with the industry standard and it's disadvantageous to you", how do you think she feels? It's miserable and it's unfortunate that we don't do a better job of making it plain.

I think what doctors appreciate about working with me, it's that I'm not a practicing attorney, I'm an agent. So, how I talk to you is different. How I interact with you is different. I'm not charging you when you call me. I get a bill from my attorney if I send him a text message or if I send him an email. Again, no disrespect, I have an attorney for my business, but it just seems like a really unsustainable way to add value for my doctors.

John: Well, let's take it one step further than what you described. Maybe you have someone who was in this job, they're unhappy and miserable, now you're helping them. They find out they can't understand the structure, they're never going to get a bonus because they don't really even know what to do to get the bonus. And the hospital is just not budging. To me, that's like, "I know it's tough, but maybe this is not the place you should be working. At the end of the day, we can find you a better job that's going to pay more and it's going to be more transparent." I would think physicians are in enough demand, that they would be able to within a reasonable distance, find a different job.

Ethan Nkana: Yeah. Where were you when I started this out, John? You are preaching exactly what I believe to be the reality for doctors is sometimes you need to go to grow. And I'm not saying that you should go into a contract negotiation, willing to cut ties. But the first question that I ask a doctor when we're getting ready to work together is let's say you present your employer with very reasonable requests and they say no to everything. What are you going to do? And if you say, "Well, Ethan, I'll just go back to work tomorrow and do what I got to do", cool, I'm not a good fit for you then. We work with doctors who say, "Ethan, I know that I'm worth more than that. I know that I deserve better. My patients deserve better, my family deserves better."

All right, here's what we're going to do for you. I'm not going to waste your time as a doctor or my time by talking to your employer until I have an offer for you from somewhere else for more money and better terms. And then I come back to your employer and say, "Hey, Dr. J is looking for a nice little salary bump, he needs an extra PA for his practice. We need you to make those changes for him going to this new contract." They're going to say what they always say, "Not interested. - Okay, cool. Just so you know, Dr. J has an offer across the street for more money and better support. If you're not willing to pay, he's going to walk. - Oh, hold on, hold on. We can have a conversation about this."

Because now they know the economics of Dr. J moving across the street. And what they count on is Dr. J doesn't know his economics, but I do. I know exactly what your work to this hospital and conversely I know how much it would mean at another hospital in your area if they had you working on their team.

John: Now you said something earlier about the non-compete and the fact that you know where you're going should be able to buy you out of that in some way. Now the contracts I've seen have actually never had a dollar amount attached to what that would be. They're just a threat. "We're going to take you to court. And it says here you can't work within 20 miles and you can't work for anyone under this other system." That makes me think, then your contract should always have a figure of how to buy that out. Is that kind of what you're saying?

Ethan Nkana: Exactly. Typically contracts will. I won't go off the deep end about the legality of non-competes and whether or not they're enforceable because there's lawyers who spend their entire careers researching and understanding that. And that's just not my world. For me, it's more a matter of practical implications. I want my doctors to be able to violate their non-compete with no penalty. That's my goal. I don't care about "Is this enforceable?" It doesn't matter. Well, I'm going to assume it is enforceable and get you a route around that. I think it's important for doctors to know that, exactly like you said, Dr. J, there should be a finite number in there. If there's not, it's not going to be harmful for you necessarily. But the point being, that's going to be the amount that you are going to need to cover if you violate your non-compete.

And then again, here's the cheat code. Tell your new employer, "Hey, I've got this tail that I need covered for me. Can you help?" They're going to say, "Cool, we'll pay you that bonus, but you have to work for us for three or four years" or something like that. So, you can get around it. And I've worked around non-competes with new employers. But it's just something that when I was a hospital exec, I used to scare doctors with non-competes. Well, you don't want to upset the CEO because they might come after you. You know that's in your non-compete area. And of course, it has a chilling effect and doctors won't try to. I had a general surgeon last week who didn't feel like she could make that move because of her non-compete, despite me explaining exactly how she can navigate that.

John: I could go on all day with questions about the contracts.

Ethan Nkana: Let's do it. I got all day.

John: Oh no, something else occurred to me. How hard should you push for a notice? I've seen notice from three months to six months to a year. And to me, if you're miserable and you're ready to go, I don't know, waiting a year, and maybe again that's another buyout, but where do those usually fall on your clients?

Ethan Nkana: My goal is usually 90 to 120 days. And the reason I say that is because that's your one runway to find a new job. Let's say if you want to leave, you give them 30 days or 90 days notice, there's no harm, no foul. You're able to go practice where you want. The more impactful situation for doctors or detrimental is when the employer says, "Hey Dr. J, we don't need you anymore." And then now what's my runway to making my next dollar? You don't have that stability. And God forbid, if you're a primary breadwinner for your home, that can be devastating for doctors.

So, it's super important to make sure that you have a nice little runway. Typically what you'll see is it'll say the hospital or employer will give the doctor 90 to 120 days notice, but we can tell you, you're done as of today. But they have to pay you that full runway amount. So, that's the other thing to think about is they can still let you go right away, but they still owe you that notice period amount of pay, which can be significant for you.

John: All right, one last quick one.

Ethan Nkana: Let's hear it.

John: Tail coverage was always something... I was on the other side, again, I was pushing that you have to pay as much as we could get you to pay, and then the contracts we'd shoot for, all of it or have a reducing amount based on how long you've been there. But do you get contracts where you just say, "Look, it's a cost of doing business, I can't work if I don't have insurance, I'm not going to pay it." Do some institutions accept that these days?

Ethan Nkana: What I tend to see across the country is kind of two primary approaches. The default I would say is the employer is going to pay for tail coverage in some of these large healthcare systems. The exception to that is when I see private practices, that's where I tend to see more of the doctor has to cover 100% or the large majority of the tail coverage. And by no means is that a rule or research. That's just kind of my anecdotal observations. What I shoot for, for my doctors in any setting is employer covers 100% of tail insurance. I won't get into the intricacies of occurrence based first claim space, but just know if you need tail coverage insurance, there's kind of the primary default, which is your employer should pay that.

The other approaches I see is, the other bookend is the doctor pays the whole thing. But in private practice, what I'll sometimes see is the employer will cover more tail the longer the doctor's there. So, let's say the employer will cover 50% tail, but after two years they'll cover 100% tail coverage. The sensitive, weird thing about that is you're talking about when you end the relationship, but it's super important to talk about that because it's not something you want to have to find out the hard way that is disadvantageous to you.

John: Yeah. And the thing that I remind physicians about it, particularly if they're looking at their first contract, the tail is very low when you've never seen a patient since you're training. It's only when you've been in practice for a while where it can skyrocket. Eventually if you're an ortho or OB or whatever, it's going to be enormous. We had one guy at our hospital, he just walked away. He didn't pay it and he wasn't going to pay it. And I think the hospital had to protect itself by paying it even though it wasn't in his contract. I wouldn't recommend that approach.

Ethan Nkana: Yeah, likewise, I would not tell you "Walk away and not pay." Yeah. But that is one way to take the most aggressive approach. It's like, "Man, I'm not going to do it. What are you going to do?"

John: Yeah. All right, we are going to run out of time here. I want you to spend a little time, again, talking to us about your company. It's RMPA. rmpa.co is the URL for Rocky Mountain Physician Agency. Tell us more about that.

Ethan Nkana: Yeah. I think the cool thing about what I get to do for doctors is I'm not a traditional law firm or attorney. While my background is I'm trained as a lawyer, I have an MBA, I spent my entire career working in hospitals. And so, what that's allowed me to do is create an industry where we represent doctors the same way agents negotiate talent deals like artists, musicians, movie actors, professional athletes are the common one for me. And so, the cool thing about my work is I get to see doctors at the beginning of their career and help them negotiate a really strong foundation. And at the same time, attendings come to me and say, "Hey, I don't want to get screwed on another contract. Can you help me make sure that I get the best deal in this next contract?"Or physician groups will come to me and say, "Ethan, there's four of us, 10 of us, 20 of us. We have crummy contracts, crummy conditions, but we don't know how to get the attention of our employer." And so, that's where I come in and say, "Look, you get back to doing what you do best, which is taking care of patients, and I'm going to represent your interests to make sure that we address all of your concerns."

And as you know. Dr. J, doctors are not a monolith. If you have 10 doctors in a group, it's not 10 doctors who are all prioritizing the same things. Some of you are going to be in different stages of your career, so you may value different components of your contract, your job, or your lifestyle. And my job is to help take those priorities and interpret them in a way that your employer can understand and make sure they're in your contract for you.

John: Now, you alluded to this earlier, but we didn't get into detail about it. But basically when you're engaged, your plan is to put the onus of the payment on the employer, which is most of us have not gone that route. That would tell me that maybe there's a timing issue here. We're not going to bring you in at the last minute. When would be the best time for either a new physician coming out of residency, fellowship or someone who sees their contract up for renewal in a year or six months? When would be the best time to talk to you?

Ethan Nkana: Yeah, good question. I would start by saying if you are an experienced doctor, you should renegotiate now. Unless you've negotiated in the last six months, nine months, 12 months, you should renegotiate your contract now. Because the chances are you probably haven't had a salary raise in the last 2, 3, 5 years, which means you're taking a pay cut. So, experienced attendings, I would say call me first. And I only say that because as we were talking about, I think we're recording this Dr. J, but we're not a good fit for every doctor. I'll be the first one to say, "Hey, if you are a doctor who only wants to work in this specific hospital or setting and you're not willing to consider your options", I'll be the first to tell you we are not a good fit and we're not going to meet your expectations.

The doctors who are a good fit for us are the doctors who understand that they deserve better. And they call me and they say, "Ethan, I'm frustrated. I'm frustrated with my practice, with not having enough support, with not having enough resources. My staff is not supported." Those are the conversations we can help talk you through. You just want us to give you the answers to the test. We'll be happy to do that. And in fact, we do that. We'll be with University of Michigan next week doing a workshop for them on how to go from training to your first job and make the most out of it. My view of it is call us first. Send us a note first and we'll help you help lay out the roadmap for you.

But I say for experienced attendings, you should renegotiate now. And I know it's going to feel awkward. "Well, my contract is not up." Renegotiate now. If you wait until it's up, you're going to be too late and the hospital is going to slow play you, which they love to do. And then if you're a first time attending, I say that the appropriate time to start looking for your job is about nine to 12 months from when you're finishing training. Typically you'll finish training June, July timeframe. So, nine to 12 months before that is when you should really in earnest kind of get the job search started and then looking to sign a deal in the spring so that way you can do the onboarding, HR, drug tests, all of that. And then potentially you might relocate. So, you'll need to consider that as well.

John: The people I talk to are usually pretty miserable. And so, have you ever been involved with someone who says, "Look, I am in the middle of my contract. It may be a three year contract, or maybe I'm early, it's been a year. I need to renegotiate it now, as you said." But have you had it where they said, "I am going to invoke my need to give my notice. I'm going to give my 60, 90 whatever, 120 days notice and it's not because I want to leave, it's because I just want to talk to you about getting a better contract." The employers, do they respond okay to that?

Ethan Nkana: Yeah, that's a really interesting perspective. I haven't considered that before. I haven't seen that exact situation. I always tell my doctors, whether they work with me or not, get a safety net first. Before you go to your employer and invoke your notice or say, "Hey, I'm going to leave", get an offer first or get some interest first because that will allow you to have, one, some confidence because you can actually back up what you're saying. But secondarily, it gives you a soft landing spot. In case you need it, you really need out, you'd have a landing spot that would allow you to have an uninterrupted livelihood and an ability to make a living. So, if you do put in your notice, I would say go get an offer first.

John: Makes sense. All right, one more time, what's the website and maybe the phone number if you want to give us that too?

Ethan Nkana: Yeah. The phone number is (720) 471-0059. My email address is ethan@rmpa.co. And then we're on Instagram and LinkedIn. We're also starting our new business YouTube page, where we have given a bunch of free tips on how doctors can advocate for themselves in contract negotiations.

John: Very good. Any other last thoughts or advice for us before I let you go? I'd say let's talk about the new grads that are coming out. Just any other things you want to leave before we get out of here?

Ethan Nkana: I think one of the most common misconceptions about first time attendings is that they do not have the ability to negotiate. And I want to be the first one, hopefully, to break that myth. Every one of the doctors that we work with makes more money in their contracts. It's a matter of asking, knowing how to ask and what to ask for. For the first time attendings coming out, please do not feel as though you have to sign whatever is put in front of you. I said a thousand times as a healthcare executive, "It's a standard contract, you can't change anything." And guess what? Doctors didn't change anything. I want to encourage you, please advocate for yourselves, know what matters to you most and ask for those things in your contract.

John: Excellent advice. I really appreciate that. Well, I guess that's all we have time for today. Ethan, I'll have to have you come back someday but this has been fantastic. I've learned a lot. With that, I'll say goodbye.

Ethan Nkana: That's been a blast. Thanks Dr. J.

John: Bye-bye.

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