In today's podcast, internist Dr. Anjani Mahabashya describes her efforts to overcome adversity following a disabling injury sustained early in her medical career.

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Career Transition to Overcome Adversity

In 2019, she had a terrible fall.  Anjani's healthcare insurance and visa qualification were jeopardized in the summer of 2020 when she could not return to her clinical position due to her injury. This is when her career transition started.

She decided to seek a utilization management physician advisor role. However, she struggled to find her first position. After becoming UM certified and speaking directly with the program director, she was hired by Geisinger Medical Center as a full-time physician advisor.

Dr. Mahabashya's Advice

…build a network, build connections, and be curious to learn new things.

Summary

Dr. Mahabashya left clinical work because of an injury. And she faced even more challenges than other physicians who decide to move to a new career. But by networking, finding a supportive sponsor in the new field, and obtaining additional certification she was able to find a fulfilling job that build on her clinical training and background.

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

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Links for Today's Episode:

• Dr. Anjani MahaBashya's LinkedIn Page
• Partnership for a Healthy Community in Central Pennsylvania
• Why Utilization Management Physician Advisor Is a Great Hospital Job – 230
• How to Go from UM Physician Advisor to Revenue Cycle CMO with Dr. Ralph Wuebker – 069
• The Journey From Career Loss to Physician Advocate with Dr. Stephanie Pearson – 023
• Meet the Modern Physician Advisor – Interview with Dr. Timothy Owolabi – 012
• NewScr!pt

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Today's PNC Podcast Transcript

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Transcription PNC Podcast Episode 253

How to Overcome Adversity and Find Success in a Nontraditional Career

John: I love having guests on here who have had a unique experience in transitioning to a nonclinical career. And it's not always about burnout. There are other reasons why people either choose or have to leave medicine. So, I'm really excited to have today's guests here with me. Welcome Dr. Anjani Mahabashya.

Anjani Mahabashya: Hello everyone. Thank you, Dr. Jurica for having me on today.

John: This is going to be really fun. We had a chance to talk before a little bit. Your story is very interesting and you have a lot of good insights and advice for our listeners, which is what we're all about here on the podcast.

Anjani Mahabashya: Yes, that is true.

John: All right. Let's see. Well, as usual we get right into it pretty quickly. What I would like you to tell me about a little bit is just your education, pretty much everybody on my show is a physician. So, tell us a little bit how you became a physician and about your residency, and then maybe segment at the end of that. Maybe go into a little bit about why you ended up switching out of clinical medicine.

Anjani Mahabashya: Sure. I wanted to become a doctor because I lost my father really young at age 12. And that was my only dream. I wanted to be a doctor and that's it. Because of the pain I experienced, I didn't want anybody else to lose a loved one. And I went to medical school in India and during my final year of my medical school, I also came to the US. I did my clerkships for about six months there. The fourth-year medical student rotations here. I went back, graduated in India and came back and did my residency in internal medicine in Michigan. I graduated in 2015 after which I had to work as a hospitalist in Iowa as an underserved area. It was on a JN visa waiver program at that time. And after I finished those three years, I moved to Harrisburg, Pennsylvania, again, as a hospitalist in 2018.

And the transition of my career happened just in one incident. And I would say that was a hallway that changed my life. It was 2019 of November, just a regular day as a hospitalist. I was walking through the hallway of an emergency room to admit one of my patients and I had a terrible fall. It was a rapid response and I was taken to the ER immediately. And the only way I walked out of the hospital that evening was on crutches. I went home on crutches and I couldn't sit, I couldn't stand, I couldn't use the restroom and I couldn't even get onto the bed. I didn't know getting onto the bed was so difficult. And I was by myself. I had nobody to help. I was a hospitalist who could do 20 shifts straight and not get tired. And I couldn't walk those 20 steps in my apartment.

I'm a chatterbox. You could ask anybody. But I lived inside my apartment for almost a year, all by myself, and that silence that I experienced was deafening. I kept worsening with my injury. I didn't know what was going on. Every time something new was getting added as a diagnosis, I ended up having a consequential injury in my good leg. And after that in summer of 2020, I was told that I had to be let go as a hospitalist and I couldn't return to the position. That was probably the most difficult situation for me because I had exhausted my FMLA. I had exhausted my short-term disability.

So, I had to trade my paid time off to be on the payroll and continue my healthcare insurance. That was very important because of the number of tests I was having, and the number of doctors' visits. And that was when I realized that, "Oh my God, all my years of training, this is all I know, being a doctor." I just don't know anything else and I didn't know what to do. And it did not immediately strike me to go into utilization management or physician advisor, but I had to think, I had to think something out of the box. I started looking for these kinds of roles, but again, I didn't have much success. I had some difficulties, but eventually I was hired by Geisinger Medical Center as a full-time physician advisor. And that's the reason that this transition happened.

John: Well, that is a very instructive story. I've only had maybe one or two other guests in almost 200 that I've interviewed that really had to leave because of an injury, or it could be an illness too but it's some type of disability. And we don't think about that. We never think about that when we're young and we're thinking about our future and all of this time and money and energy we've invested. And it can be taken away in a moment with something like this. The other guest that I talked to, where she was actually an obstetrician, was delivering a baby and she had an injury while she was delivering a baby, because the patient kicked her.

Anjani Mahabashya: Oh my God.

John: And she was unable to practice after that. And so, like you, then all of a sudden, you're faced with this catastrophe, like, "Okay, now what do I do?" Wow, it must have been hard at that time. Did you have some support in terms of just emotional support, friends, family, that were at least encouraging during this time?

Anjani Mahabashya: Definitely a couple of friends, but I think I was so tired of answering questions. And honestly, all my friends, nobody was in a situation like this, so nobody could guide me. I had the injury. I was dealing with worker's compensation. I was dealing with doctor's appointments. I was on a visa. I had the combination of the worst. So, I'm like, "Where am I going? Where am I heading?"

I think not that people couldn't be there, it was just too much for anybody. I had so much on my plate. And also, I'm a little bit of a private person. I'm like "Don't ask me the same story 1000 times, it's not changing." I was trying to work on more "How do I get out of this now? What is in my hand, what is not in my hand?" So, I started working towards that.

John: And the other thing you obviously have mentioned, and it just adds that other level of stress is the visa situation, because you had to find a job and do something that meant the qualifications to continue on that work visa. Correct?

Anjani Mahabashya: That is very true. That is very true.

John: Now how did you happen to choose becoming a physician advisor and working in utilization management? Did you know somebody? Did you just do some research? How did that come about?

Anjani Mahabashya: The hospital that I was working in had physician advisors, so I knew what it was. But again, that didn't strike me because I had advisors about taking up nocturnist physician or a primary care physician. But everything was very tasking. I had a boot in my leg and I had an injury in the other leg. So, I'm like, no, I cannot do justice to something that I can't really deteriorate further and I was trying to balance out something.

And when this struck me, I started looking for jobs as a physician advisor. And I wasn't having a lot of success mostly because I had absolutely no experience. I was just four and a half years out of residency. So, people were like, "You're too young. Why do you want to get out of medicine?" I couldn't convince people that, "No, I need this job. I don't care about money. I need to have a job. I need to have health insurance. I need to stay in the country."

And then I think in all honesty, it's God's timing that a physician advisor full-time role opened up in the Geisinger health system, but at a different location. And I actually took the initiative of writing to the medical director directly because he was still within the system and saying, "Hey, can we have a call?" I don't know him. And he was very kind Dr. Lesinski, he's my medical director, my boss. He was very kind to call me. And I told him very honestly, "Listen, I don't know anything about utilization management, but I will work very hard if you give me this job."

He actually set up a formal meeting with the leadership of utilization management. And I was also preparing for my UM board. So, I had the theory knowledge of UM and how it works. And I was able to answer every single question. I knew I could sense that I smashed the interview but I was just waiting to hear back from them. I did not hear back from them. And I'm like, I was preparing for the worst day, like the end of world kind of day for me alone. But then, I finished my board, I got the result. I passed my board. So, I informed my medical director "Hey, listen, I'm also board certified now." And I still did not get any confirmation. And finally, one day I was driving back from Hershey medical center after a doctor's appointment. And he called me and my heart was pounding. I'm like, "Oh my God, what is he going to say?" And he said, "Hey, I'm going on a vacation." And in my mind, I'm like, "Do I care?"

John: Yeah. Right.

Anjani Mahabashya: "But I wanted to tell you this before I leave. You got the position." I'm like, "Did you really just say that?" And that was actually my last day of trading a PTO to be on the payroll. And it was that close.

John: Wow. It worked out.

Anjani Mahabashya: It worked out. Yeah.

John: Probably from his perspective, even though you had told him that story now, he probably didn't really understand the severity or the intensity of the anxiety that you were having, the worry.

Anjani Mahabashya: Right.

John: Maybe the way I look at it too, and probably you wouldn't look at it this way, applying for the job, it's really hard to find someone that's a good physician advisor really.

Anjani Mahabashya: Yes.

John: There are a lot of jobs out there and a lot of physicians look at it as something they don't really want to do. But the reality is you know all the medical part of it, that's what UM is. You are trying to figure out what's indicated and whether this justifies something being done or not done, or admission or observation, and you have taken care of those patients. But physicians don't realize that when they're switching gears, like you did in this big way, they're like, "Well, this is brand new to me", but you have to be a physician. And you already had those years of experience. You can count what was in residency because you were taking care of patients. So, it's great. It worked out.

Anjani Mahabashya: Yes. I would like to add to that, he was aware of what was going on, but I think what was happening was the hospital that I was working in was bought by a different system. So, the contract said they couldn't take me. They had to work out those legal issues and I didn't know about it. And I'm like literally dying here of all kinds of anxiety. Once I knew why I had to wait, I was like, "Okay, now I feel better."

John: Yeah. Well, especially if you have a restrictive covenant, although technically that I think would refer to your clinical activities. It doesn't even refer to the nonclinical, but sounds like it was great that it worked out. So now, how did you happen to decide to go for the certification? I've heard of this certification through this board before. There might be others. Did you find others or is this just the one that stood out? And it was really the one that most people do.

Anjani Mahabashya: This was the one most people do. And like the physician advisor that was in the hospital where that I was working in, took these boards. So, I started inquiring about it. I had this growth mindset and I also felt that taking the boards would at least show some seriousness that I'm a stronger applicant and I'm serious about this. I started looking into it. I called the boards. I got some information from them and I started looking at Facebook forums and all these things.

And I fortunately found another physician who was planning to give this exam. So, I reached out and I said, "Hey, can we discuss topics? Can we study together?" And that was very important for me at that time, because I had injuries in both my legs. I had a procedure that I had to get done during my preparation. I was dealing with so many things, workers compensation. I needed a letter to extend my medical leave every 15 days, everything was just so stressful.

But having a study partner helped me stay motivated and be accountable and study every single day and not lose time. I got the material from the board and I literally studied every single line. I knew at the back of my head I could point out which line is there and which part of the material. And I did the questions over and over again. And before I went to the exam, I told one of my friends I will come out double board certified and I did.

John: Nice. Now, let me just ask a question about this particular board. Are there any required courses you have to take or is it basically based on an examination?

Anjani Mahabashya: It's just based on an examination. I think having a little bit of experience does help because I still found the exam very tough in spite of my vigorous preparation. But I think if you are very thorough with the material and you do the questions over and over again, and if you are a hospitalist, you do also understand how the system works. So, I think that is quite enough, for somebody like me in that timeline, I think this is enough, the material you get from the boards and the questions. Yeah.

John: And you made that point earlier, and I think it's true, we've talked about this before that if you are in the process, if you've taken the exam or if you're attending courses for a certification or you're doing something like that, that really can help psychologically to the recruiter, to the person that's looking for someone, "Okay, they're not just doing this on a whim. They are committed to this. They want to do this. It's not something where the person's going to leave in six months and do something else." And so, I should do a plug for the board. It's the American Board of Quality Assurance & Utilization Review Physicians. Right?

Anjani Mahabashya: That is correct. That is correct.

John: They're not a sponsor, but we got to plug them because they do help a lot of us physicians to get this information, that education and those jobs.

Anjani Mahabashya: And they're very approachable. I must have written a zillion emails to them at that time. And they responded appropriately and were very helpful on what to study.

John: And it has the word "physician" in it. So, it really is geared to physicians. There are other types, I've seen certifications where it's sort of any clinician can do it, a nurse, a physician, but this one is specifically for the physician reviewers.

Anjani Mahabashya: That is correct.

John: All right. Tell me what you like about this position now, or do you not like it?

Anjani Mahabashya: There is no not liking it because when I look back, I don't think I want to be anywhere else in my life other than being here. I absolutely love my role. I really enjoy my role and whatever I know today, I owe it to Dr. Lesinski, my medical director. I learned everything on the job.

John: Awesome. Tell me a little bit, maybe about what is a typical day for you doing this kind of work?

Anjani Mahabashya: I shuffled between the Geisinger Medical Center, the main hospital, which is almost a 600 bed hospital, and the five-satellite hospital, two weeks here, two weeks there. That actually gives me a lot of experience in a variety of cases. We have an inbuilt work queue system, already plugged into the epic. Based on the number of hours with different insurances, whether it is Medicare or the commercial insurances, the cases get pulled into the work queue automatically. And depending on which physician is assigned to which campus, they are just working through their work queue, the team flowing through the day. And we keep working through the work queue.

And the other thing is the utilization management nurses, who by the way, are the rock stars of our team. They're just excellent. And honestly, we couldn't do without them. They plug in some cases too, based on their reviews. And if there's something that doesn't get pulled in, or needs a manual input of what needs to be done. So, that's how the typical day is like. Depending on the campus, we see anywhere between 25 something cases in the tertiary hospital and about 20 in the satellite, because we have five satellite hospitals. That's how the typical day is. Plus, or minus five can get really busy, and can be like a lighter day. Every time after the long weekend, I'm like, "Okay, be prepared."

John: Oh yeah, yeah. On a long weekend. And then you got to catch up on all those cases that came in the last few days.

Anjani Mahabashya: Yeah, yeah.

John: It would seem to me that part of this could be done remotely because you're working on an EMR. But are you doing anything remotely or are you physically at the site usually?

Anjani Mahabashya: This is like an onsite role and I just live like one mile from the hospital, but when we are in the satellite hospitals, obviously I can't go there. I'm like an hour and a half away and stuff. So, if it's in the main campus, yeah. It's going to be onsite just to have that interaction with the physicians and it's better that way. Yeah.

John: Do you sometimes interact with physicians in an educational way? Not on an individual case, but do you occasionally get involved in doing education for the medical staff?

Anjani Mahabashya: Right. Actually, when I took up this role, it was quite challenging for me because I was a new face here and nobody knew me. My main focus was building that relationship and helping these physicians and myself know why. Why is this happening? I took up the initiative of presenting to the big guns off the hospital, the internal medicine, trauma surgery, and pediatrics, and telling them the why. Why do we need to do this? What does utilization management do? And how does it affect? Why should we stick with the Medicare guidelines and how it affects the revenue? And once the department saw the numbers, like what we lose, they were on high alert mode.

Then the third aspect was why is status important when we admit the patients? Because when they get discharged in an incorrect status, it leads to that dissatisfaction and the patient's satisfaction scores go down when they're like, "Oh, now you're going to get a bigger bill." I worked through that by going and presenting and talking to the physicians, initially my texts were super long trying to explain. And I always appreciated whenever I got their help. I was actively listening to the physicians and the medical directors of the insurance companies just to see where they're coming from. Because I was a physician and I was a hospitalist I know how cranky we can be until noon. So, I don't usually text or bug. I empathize with their busy days. I'm thinking about them before I shoot a text. Is it the right time? Can it wait? There are some charts that can wait, there's some charts that cannot wait. It depends on when we should get that done. It is always chart based, like a patient-based case. So, it's something like that.

John: Very nice. And it sounds like you're really getting good at it, getting efficient at it. You're getting to learn what the physicians prefer in terms of communication style. Do you want to call? Do you want to text? So, that sounds great. Anything new coming up with this job that you know of? I don't know if there's certain levels of things that people in that department do, physician advisors over time as they get better.

Anjani Mahabashya: As we get better, again, we focus on innovation. For example, last year, we started something called an alternate level of care, and this is to start tracking all these avoidable days when patients are waiting for replacements or their social issues. Just to see what is the dialogue we can have with the insurance companies in terms of payments instead of a complete nonpayment.

So, those are the things we kind of see. We see the trends, we see the revenues, we see where we are going. And I think these are the things usually. We take up one thing in a year, for example. And this year we wanted to look more into the Medicare short stays. We are very particular about "How do we build that? Are we going to self-deny or are we going to explain why the patient left within two midnights?"

I'm only one year, nine months into this role. This is the year that it's the short day year. Last year was the ALOC. When something like this is introduced, it comes down to, again, educating the physicians. So, we educate the physicians, we educate ourselves, it's always learning. And then we get into cruise control mode for some time, and then we have July and then all the new residents come in.

John: Oh yeah. You probably have to teach them quite a bit. Okay. So, things seem to be going really well at this point. Where do you see things going for yourself over the next few years?

Anjani Mahabashya: I struggled a few years back to answer that question. And I would also come up with these goofy answers that I would be like if I'm five years older, what would I be? But now I have a better idea. And as a physician advisor, when I talk to the medical directors, what we are all looking for is value-based care and providing care in the appropriate settings.

And added to that, my experience with partners for a healthy community, where I volunteer with senior citizens, has helped me understand what happens at a community level and the social determinants of health. And our senior citizens are very lonely. They don't have help. They don't have social support and I could immediately relate to that. I was able to spend time with them without having time constraints. And that eliminated those barriers too.

So, I see myself wanting to be a part of this changing landscape of healthcare, where I can form that connection between the health insurance companies and healthcare systems investing in the communities, because when we build a healthier community, the healthcare costs will automatically come down. Finally, I have the maturity to answer this question with all my experiences in life. So, I can answer this question with confidence now.

John: Yeah. It's good to see that there are other aspects that are related to what you're doing with your job that kind of definitely affect it and affect the care of patients. And I think you're right, we're going to have to really help the community and help keep people well, rather than waiting for them to come into the hospital. And so, this sounds like a great thing. Is this a voluntary activity? How much time do you spend doing this kind of thing?

Anjani Mahabashya: I'm actually in the leadership of the volunteer program too. I spend anywhere between 30 to 40 hours a month. Sometimes it's very busy, sometimes it's okay. But it takes a lot of behind the scenes work to get that ball rolling.

John: That is a significant commitment. And the thing is when you're doing that kind of thing, that's another thing that demonstrates your management and leadership skills and creates taking on new responsibilities, which can also help professionally. So, that is just awesome.

Anjani Mahabashya: Thank you.

John: Now let's swing back to the original thing that brought you to this job and some of the things that you had to overcome. What advice would you have for physicians, whether they're burnt out, whether they've had some issue like this? Sometimes people leave medicine because they have a sick family member they have to take care of. And then they just know they get flustered and they're not sure what to do. It sounded like you took some pretty logical steps. So, what kind of advice would you have for physicians in that position?

Anjani Mahabashya: I agree I was logical, but I was also very emotional and that's very human. And I think with COVID and how healthcare providers across the globe have stretched too far, I think it's important to take care of yourself. There are many people who go through many issues, whether it is an injury like me or you have a sick child. How can you provide care to somebody when your heart is aching? I just don't know. I couldn't imagine that.

I would say build a network, build connections and be curious to learn new things. And also add something to that new role you're thinking you're picking up because then you will feel that you are valued there. And also, you will like it, you love the role.

I think preparing for something like this has become very important at this time. And how healthcare is changing I think most importantly, all of us are trying to put the patients outside the hospital. So that is opening up new roles in terms of innovation or health coaching and many other fields. I would say if you're experiencing anything where you feel you are not able to perform at your best level, because nobody stays in the hospital. We go into the hospital, nobody is happy. You get so drained. And when you come home, you are either alone or you have more responsibilities. There is nobody to say "Are you okay?" I think it's important to take care of yourself. And if somebody has to switch to a nonclinical career, temporarily or permanently to take care of yourself, I would really say go for it please.

John: Yeah. And some of the coaches I've talked to, they said, first of all, just take a deep breath and pause. And if you have to take a few days, weeks off to really start to think about what you need. But the thing I wanted to get back that you mentioned just a second ago, and at the beginning you talked about networking, make sure you have a network of connections and friends.

But the thing is you reached out to somebody that somehow you had identified. And I talked to a lot of physicians who may be looking for a UM job or a CDI job or something for months and months and years and years. Well, they're just putting an electronic resume into a job site or something. They don't have that connection with a single person.

So, you did that. You reached out to a single person. It doesn't mean that person was going to solve your problem, but in your case, it worked out. And in other cases, it does. If you have somebody you can identify, they may or may not be the decision maker, but they can be your sponsor. They can be your supporters. They can be your connection. So, I don't want that point to be missed either.

Anjani Mahabashya: Yes. You only have a one-person chance, but that one-person chance is enough for your life. And I took that chance.

John: Yeah. And it worked out great. So, this has been a really good story. Luckily, it seems to have had a happy ending. We'll have to circle back sometime in the future and see what else you've been up to after you get a really complete pro at this job. There are usually opportunities in the hospital for leadership and management positions for physicians in this situation, if they're doing a good job and then they can help build that team and so forth. I think things are going to continue to do really well for you. And I think some of our listeners might want to get a hold of you and ask you a couple of questions. What do you think? Is LinkedIn probably the best way to do that?

Anjani Mahabashya: Yes. LinkedIn is the best way to do that. My message option is open for everybody. So, you could just shoot me a message, anything you need. If you want to even cry out to me, you are welcome.

John: Yeah. If you look for Anjani Mahabashya, you will find her, it comes right up. There aren't that many Anjani Mahabashya out there. I don't think so.

Anjani Mahabashya: Yes.

John: So, I'll put the link in, or at least make sure they have the spelling of your name and all that in case they have questions. I know this has been fun. It is a great story and I congratulate you. Yeah, I think it's a good example for others to have faith, even when there's so many things that have possibly gone wrong, that there is a way out and be hopeful and positive.

Anjani Mahabashya: That is very true. Yeah. I think the underlying message is that of hope and make sure you take care of yourself and when your cup is full, give back something to the community.

John: All right. Anjani, I really appreciate you coming on today. I think with that, I'll just have to say goodbye.

Anjani Mahabashya: All right, goodbye. Thank you everyone.

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The post How to Overcome Adversity and Find Success in a Nontraditional Career – 253 appeared first on NonClinical Physicians.

This week's episode is a replay of the second most popular episode since the podcast was launched discussing a great hospital job: utilization management physician advisor. It was first posted in January of 2022 and featured Dr. Robert Craven. 

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.

He serves on the executive council of the physician advisor special interest group (SIG) for the Society of Hospital Medicine. He still works clinically as a hospitalist two to three shifts a month and also does medicolegal consulting. Rob currently resides in Murrells Inlet, South Carolina, with his wife and two daughters.

Unexpected Opportunity

He had no intention of working as a physician advisor. However, a previous employer contacted him unexpectedly and offered him the position when it decided to expand its UM Program. 

Today he tells us what his job entails, why he thinks this a great hospital job, and how you can land a similar position.

A Great Hospital Job: Utilization Management Physician Advisor

Rob explained the details of his job as a physician advisor. It is somewhat unique that he is working remotely for a large system, with occasional opportunities to go on-site if needed.

The job is more flexible than a full-time hospitalist position, and it accommodates his efforts to spend more time with his family. It is intellectually stimulating. And in this job, he provides value to his employer, its physicians, and patients.

Summary

After working nine years as a full-time hospitalist, Dr. Robert Craven finds that his role as utilization management physician advisor is intellectually stimulating and fulfilling. He works remotely from home on most days. And he still works a few clinical shifts each month, which enables him to maintain clinical skills and relate better to his physician colleagues.

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

Links for Today's Episode:

• Connect with Dr. Rob Craven on LinkedIn
• Dr. Robert Craven's email address: cravenmedical@email.com
• American College of Physicians Advisors
• Society of Hospital Medicine
• How to Go from UM Physician Advisor to Revenue Cycle CMO with Dr. Ralph Wuebker – 069
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Transcription PNC Podcast Episode 230

Why Utilization Management Physician Advisor Is a Great Hospital Job

John: Hello, Dr. Robert Craven.

Dr. Robert Craven: Hi, thanks for having me.

John: I'm just glad to talk to physicians but number one, I've wanted to talk to more hospitalists. I came from a background in family medicine, but I was a hospital administrator. And so, I worked with lots of hospitalists, particularly in those last 10 years or so after that whole specialty became a thing. I like to see what hospitalists are up to and how they transition into leadership positions and management positions. So, that's why I'm really excited to talk to you today, Rob.

Dr. Robert Craven: Excellent.

John: We'd like to hear a little background at the beginning, so you can give us a nutshell description of where you went to school and why you chose being a hospitalist and how that career went, and then just finish up with what you're actually doing today.

Dr. Robert Craven: Excellent. Well, I grew up in Tennessee and grew up really outside of Chattanooga. I went to undergrad at UT Chattanooga and then medical school at the University of Tennessee, in Memphis. I finished there in 2008 and then matched and did my residency in internal medicine in Charlotte, North Carolina, with what is now called Atrium Health. Back then we called it Carolina's Medical Center. I felt like I got excellent training there.

Initially, my plan was to go into pulmonary and critical care, but while I was there, that was right around the time that hospital medicine was becoming a big thing. And the temptation just to come on out and practice and have a week on - week off lifestyle was great. And I got offered an excellent job right out of training in Charlotte. I really liked the inpatient side of medicine. I liked the acuity of it. I liked the flexibility of it. I liked the schedule, the week on - week off schedule. At that point in time, I was still single. I didn't have any children. So, it was really a great lifestyle for me coming out of training in Charlotte.

I worked for about five years for a system in Charlotte and really enjoyed that, and really loved hospital medicine. Got married, settled down, started having children. And that's when my wife and I wanted to get a little bit closer to family because neither of us was from that area. And her parents live in Murrells Inlet, South Carolina, which is where we live now. Around early 2016, we started migrating closer to the coast of South Carolina. And I took a hospitalist position, with the system I currently work for and worked there for about four years.

This was in a small town and while I loved working for that employer, we just didn't really like the town. We wanted to be closer to my wife's parents and didn't really fully adapt to the small-town life in South Carolina. So, about 2019, we decided to move further to the beach. I made the decision to join another group, out this way and that was right before the COVID pandemic hit. And things didn't really pan out that well in that group, as we might talk about more later. But while I was there, the system I had previously worked for reached out to me and said, "We have this opening available as a physician advisor and we know you and you know us and the team you'd be working with, you're very familiar with."

They approached me to see if I would be interested and with everything going on and with the COVID pandemic, it seemed like too good of an opportunity to pass up. Even though I previously would never have told you, I was interested in doing physician advisor work. I interviewed for the job and ended up getting the job. And it has allowed me to work for the system that I work for now, and previously had excellent experience with. But yet I still live where I do now with my family, close to my in-laws, and enjoy the coastal life of South Carolina. Now, I've been doing that for about a year now. I transitioned in December of 2020. A little over a year ago, I made the transition to the nonclinical world and it hasn't been perfect, but it's been great. And I have no regrets.

John: Well, let me see, let me jump in here. One question I have is, are you doing any clinical work currently, even if it's just once a week or a month or anything?

Dr. Robert Craven: I do. The job I'm in is technically 100% admin, which I'm trying to work out to where it's more like 80% admin, 20% clinical. But the way it stands right now, I'm doing an average of two to three shifts a month as a hospitalist. Just more so for my own benefit to make sure I continue to have a foot in the game and continue to have clinical relevance in what I do.

And typically, what I'll do is do a Friday, Saturday, Sunday stretch, and I work throughout the system. So, it's opened me up to get exposed to some of the smaller hospitals in the system I work for. And that's been refreshing and fun to meet new people and work in a bit of a different environment. But typically, I'll do a Friday, Saturday, Sunday stretch. And then back to my administrative role Monday morning.

John: Okay. As I was following that timeline, there was some relocation in there somewhere. The Friday, Saturday, Sunday, is that something that's at a distance? Is it fairly close to where you live? Do you just stay on-site when you're doing those weekends, how does that work?

Dr. Robert Craven: It varies. There are some weekends where I work locally and I just come home every night, and then there are some weekends where I might be two, two and a half hours away. In those situations, I'll stay in a hotel for the weekend.

John: Okay. Let me ask you this about the whole situation as a physician advisor. As a hospitalist, I'm assuming you had interaction with people that were doing that role or could be nursing they were doing the UM and case management. Was this something that you were very familiar with when they asked you? Was it something you had to get up to speed on? How did that work?

Dr. Robert Craven: I was familiar with the very basics of it. I was practicing there before they had a physician advisor and back then, if there was a denial that requires a peer to peer, the attending hospitalist would handle that peer to peer. And maybe I did a couple a month back then. It wasn't that frequent, but it was enough to understand the process. But I'll tell you what really led me to it was that the denial team that I work with, I probably knew 80% of them from my time as a hospitalist there. It largely is comprised of one nurse that is their denials coordinator, their chief physician advisor, who was there before me, who I knew and worked with because he was a former hospitalist and now myself. It's really the three of us. And then the administrative leadership over that, I also knew fairly well with my previous work.

Knowing them and them knowing me, I think led to a lot of that. They knew that I would fit well with the team. They knew my work ethic and they also wanted a bit more of a presence towards the beach because they had facilities out here, and I was able to fill that void as well. It worked out well for them and it's worked out great for me.

John: I want to get into what the day-to-day activities of your job entail. And you can tell us what you like, what you don't like. But one of the first parts of that, is this something that you do pretty much as a remote physician advisor? Do you do any on-site? How does that work out?

Dr. Robert Craven: Most of what I do is remote. I do have an office nearby. It's about 30 minutes from where I live. I might spend one or two afternoons in that office. The rest of the time I'm working from home. I typically commute to our main campus, which is about an hour and a half away, and usually spend a day there a week. Just to keep up to speed with everything that's going on, make sure that I'm seeing the other people in the department, make sure I'm seeing the other physician.

I do think there's value in being seen and having conversations at lunchtime in the doctor's lounge. You'll get different opinions about that. There are some physician advisors that work entirely remote and they'll tell you there's no value at all to being on campus, and then you'll meet others that say that you should never be remote. You should always be on campus. And I like having a bit of a balance. But my schedule is very loose and I get to dictate a lot of it, which I like. I can coordinate with my family if there are certain days that week where I really need to be home, then I'll adjust my schedules to accommodate that and make sure that I'm not working a clinical shift or planning on commuting to a different campus.

John: Now, when we talk about UM and physician advisors on the podcast, a lot of times we're talking to someone who's working for an insurance company or I guess I would say a middle man. Someone who's on the outside trying to get things authorized or that kind of thing. And I only bring it up because sometimes they tell me, "Well, any physician can do that work working for an insurance company. It's basically knowing the protocols, knowing the criteria takes about anywhere from six to 12 weeks to learn it." Okay. So that's cool. I mean, pretty much any physician can do that. I just want to know what your on-ramp was? What was your learning curve at the beginning, and what would you tell others to expect if they're going particularly into a full-time physician advisor role?

Dr. Robert Craven: Right. It is a bit of a learning curve. I think certain specialties adapt to it quicker than others. And I'll say that in this role, I've dealt with medical directors with different insurance companies from a whole host of backgrounds, from OB-GYN to surgery, to ophthalmology. It's possible for anyone of any background to do this. But I think if you're in a specialty that is not so inpatient centered, hospital-based, that sort of thing, I think it's going to be a bit more of a learning curve for you. The people that tend to make the transition easier, and are more common to make this transition, usually come from hospital mass and emergency mass and intensivists that sort of thing. But there's not a whole lot of educational resources out there for this type of work.

The American College of Physician Advisors exists and they're excellent. I don't represent them in our conversation today. I'll say that I'm a member, anyone can join. And they have a lot of video tutorials on their website that are excellent. A lot of explanations on their website, and resources.

There's a lot of self-learning that you can do if it's something you're interested in, but most systems will have some sort of process for bringing you up to speed, with either a third party or some sort of educational program that they have. The system I work for used a third party to educate both me and the physician advisor that I was joining. He went through the same education that I got a few years before. And then when I was onboarding, he went through it again, just to have that extra benefit.

But the training I went through, the actual online training that I went through with this third party was about two days. And then there was a lot of kind of apprenticeship type training with the chief physician advisor, just learning their workflow, which was a big part of it, just how my system in general handles denials.

But then also learning the ins and outs of the two-midnight rule and CMS rules and regulations and the various commercial insurers and how they operate, all those things. Like most things in medicine, you learn by doing. And so, the first peer to peer I would do, he would be in the room with me. He would review the case as well, and give me some pointers. I would make that phone call, put it on speakerphone so he can hear everything that's being said.

And the first ones often didn't go well. And then afterwards, he would be able to teach me and say, well, you really should have emphasized this point or that point. It was very much a learning-by-doing environment.

But I would say, after two or three months, I was pretty comfortable. The first month I spent a lot of time on-site, on our main campus just to have that constant resource of the other physician advisor, someone to bounce things off of. But as time has progressed, I've gotten more independent. Whereas now rarely do I bounce something off of him. Usually, if we're communicating about a case, it's because it's something highly unusual and not because I'm looking for his advice or feedback.

John: Excellent. Now that gives us a good picture of how to work into it. You know the environment. You know what it means to be in the hospital and the different types of admissions and observation and so forth and inpatient-outpatient. It's then learning the language, the jargon they use, and then the criteria that they use, I would imagine.

So, what is your day-to-day now? I know it's probably hard to put it in simple one, two, three, these are the three or four things I do. But what would you say if someone were to ask you that question? What is it you'd spend most of your time doing? Is it something that takes a lot of planning? Is it laid out for you? How does that work?

Dr. Robert Craven: Sure. The past two weeks have been a bit abnormal because my kids are out of school. And when you're working from home and your kids are out of school, it can be a bit challenging. But on an average day as a hospitalist, I was not that involved in my kid's day-to-day routine, but now I am because my day starts later.

So typically, my wife and I will get up around the same time, to help get the kids ready for school. We have a carpool with our neighborhood. Sometimes I drive, sometimes other people drive. But I'm very involved in getting them ready in the morning, getting them off to school. And then now I go to the gym in the morning or try to, after they're ready for school.

John: Nice.

Dr. Robert Craven: I do about 30 minutes of cardio or other exercises. And then I come home, get ready for work. And usually, I'm sitting at my desk, logged in to our system by about 9:00, 9:30 in the morning. I'll be on and off the computer until 4:00 or 5:00 PM, usually. Technically until 5:00, but some days things wrap up a little earlier, our denials coordinator will tell us, look, there's nothing else in the queue. And then, you know you can leave early.

And an interesting thing about physician advisors is it's such a new thing, every system uses them a little differently. My experience as a physician advisor could be very different from another physician advisor in a bigger system, a smaller system, a different area of the country.

But the way it works with our group, the bulk of what we do is review denials, it's what we call denial management. There are multiple cues that I'm following online in our computer system. And one of them is where any denial from an insurer that comes through our system, it will get reviewed by our denials coordinator. She will do a little brief summary as to why it got denied and any specifics about the case. And then it gets put in this queue.

And then myself and four of the other physician advisors, we just work through that as we can and sign up for these denials, claiming it as our own, labeling that we're going to be the one to review it. And when we review it, this is where you get a lot of deviation from one system to another. The way we do it is, we actually will write a report usually about half a page or a one-page report summarizing the case and also stating if we feel like it is really inpatient appropriate, or if we don't and why.

And then we file that report in a couple of different places, both in our electronic healthcare record and on our hospital's systems drive on their internet. So that way, if we were to get audited, if an insurer were to audit us and want to see our review process, we have it very well documented that we thoroughly reviewed it. And we felt like it was inpatient for the following reasons. And sometimes we'll reference CMS guidelines or other criteria like MCG or Interpol, but a lot of times we're re-reviewing it at a bit of a higher level than those things. That's one cue that we're managing.

There's another one full of what we call short stays. And those are discharges within the system that were put in as inpatient but discharged from the hospital before crossing the second midnight. And so, that queue fills up a little slower, but there's usually two or three of those a day that we review, and determine, is this something that was inpatient appropriate that we should release the inpatient bill? Or should we self-deny that and just bill it as observation to try to minimize the risk of us getting audited on the back end? And so, that's a process that we do as well. We also write a report. Usually, there's communication with the attending that we feel if they were placed in the wrong status, we will communicate with them, that they did so, and why we thought that was an error, that sort of thing.

And then there's the third queue and the final queue is secondary reviews or concurrent reviews where a case manager in a hospital is having trouble getting a patient to meet inpatient criteria that the physician put in inpatient. And they'll want us to review that and see if it needs to be downgraded to observation, or if we think inpatient is appropriate. And oftentimes that requires a conversation with that attending.

We're kind of managing these three different queues all at one time. And an average day between the two of us, we might generate 15 to 20 reports a piece. A busy day I'd say is 30 to 40 total between the two of us. But it's not uncommon for us to generate 15 reports a piece for that day.

John: Okay. Now, I probably know just enough to become a little bit dangerous, but I'm going to ask you some questions just because I hear these things come up and because my daughter is a social worker who did UM for a long time and was managing inpatient discharges. You don't have a whole lot of let's say mental health issue denials or admissions or behavioral health units. Those seem to be a little different from the typical medical I would think.

Dr. Robert Craven: They are, but they still, we do have behavioral health hospital. And so, we still deal with that. It is rare, but it does still come up.

John: Okay. And then when you were saying, and this is probably in the weeds, but in terms of inpatient, are you talking about the initial admission, like on day one that they are inpatient as opposed to out? Or let's say each additional day where the insurer might be saying, no, they should have a three-day length of stay and now they're on day four, we're going to deny it?

Dr. Robert Craven: It varies. Both. It's all based on the contractual agreement that your system has with the insurer. Some of them will give you a lump sum for a DRG for the whole hospital stay. And whether you have them there for two days or seven days, they don't really care. They're giving you the same amount and then others will have a per diem component.

And that's where having some negotiation skills can be a benefit because you might end up having a peer-to-peer discussion with that insurer. And they're saying we're not going to pay for the last five days and you're trying to negotiate. You'd like them to pay for all of it, but you end up compromising, and at the end of the conversation, they're not paying for the last two days. It ends up still being a win for the system.

It really goes down to what contractual agreement you have with the insurer, and that is another complexity of all of this because all of them vary and are different.

John: Is there a way that you have that information in front of you when you're having these conversations? Or is it something the nurse relays to you or do you have to look it up?

Dr. Robert Craven: Some systems that have been doing this a while often will have some sort of Excel sheet or Flowsheet where they can glance at it and see the specifics of each insurer and what their agreement is. We don't have that yet. We're working on that, but a lot of it I've learned just by trial and error. And you'll learn from talking with the different medical directors of these insurance companies, because sometimes they'll have the contract in front of them and they can say, "Yeah, we have a per diem component with you all." And then you just learn by repetition, which insurers have a per diem component and which do not. But ideally, I should have a spreadsheet with all that right on it so that I can glance at it for reference.

John: Interesting. Yeah. That makes sense. It's unfortunate that things are so complex that you actually have to create an entire system to deal with it, but that's the way it's been for quite a while.

Dr. Robert Craven: That's right.

John: Tell me more about the things that you like because I think I got the idea that you probably like being more involved with your kids. You like having the flexibility of starting a little later in the day. What are the things you like with what you're doing now?

Dr. Robert Craven: I think I was doing some case review before I made this transition. I was doing some medical malpractice reviews. I was doing and still do some standard of care review for the State Medical Board. I've done disability appeals before. I don't really care to go back to that, but it was something I dabbled in briefly.

I've always enjoyed case reviews. And I think that's critical for this kind of work because it's the bulk of what you do. You're just reviewing it for different details. Instead of reviewing a case to look for a deviation of standard of care or causation of harm, that sort of thing, you're reviewing a case to see can I make an argument for inpatient status with this particular insurer?

But the principles of reviewing a case and how to do it efficiently, I think carry over from one aspect of that to another. That I enjoy. I enjoy the flexibility as we had touched on earlier. I did some traveling over the summer and didn't take any PTO because mostly what I was traveling for was occurring in the evening. So, I would just work in my hotel room during the day. I had excellent internet and cell service and I didn't even have to take PTO. With this kind of work, as long as your employer's okay with it, you can be extremely mobile and even go on vacation, let your family enjoy it, while you're working out of the hotel room.

John: Anything you don't like about it?

Dr. Robert Craven: I think there's a bit of a lack of connection sometimes. On the campus I used to work at full time, I know most of those people. So, if I have an issue and I call one of those physicians, more than likely they remember me, we had a good relationship. But if I'm having to deal with a physician at a campus that I haven't worked at, I feel like there's a disconnect there.

And especially as a physician advisor, which is a fairly new thing, the doctors that don't know me are a bit uncertain of what it is I'm doing. Am I really on their side or am I not? You get a little bit of hesitation from some doctors when they hear what you do. Some of them view this as selling out and becoming a suit, becoming an administrator. But I still very much feel every day that I'm really fighting for the patient, advocating for the patient, and trying to get their insurer to pay for the care that they needed.

John: Yeah. I hear that from some physicians that are thinking about doing it and not sure they want to be seen as an adversary in some ways. But to me, the most successful UM physician advisors have been more looking at it as "I'm just trying to educate the physician so they can document what needs to be documented and put the patient in the right setting in the first place rather than have to go and fight the insurance company later." That's definitely a trend.

Dr. Robert Craven: Right. And it's so much easier if you can get the patient in the right status on the front end, in a controlled environment, in the hospital where you can explain things to them, what it means to be an observation. It's so much easier on the front end than on the back end where maybe they're already home and now they're getting a letter saying, "By the way, your copay is going to be higher and you've got to pay for all these meds that you got in the hospital that you initially thought your insurance was going to pay for, but the doctor puts you in the wrong status. And therefore, now this all comes back to you." That can be a huge dissatisfier for the patient. Hospitals have a lot more control over it and the optics of it, if you're doing it in real-time while the patient is there.

John: Right. Yeah. That makes sense. If somebody you knew came to you and said, "I've been practicing for a few years and it's okay, but it's not as fulfilling as I thought it was going to be. I need to get a little more freedom, a little more flexibility in my life. And I think I'd like to do what you're doing." But as far as you can tell that person has not done anything to really learn about it or get the necessary skills. What would be the things you might advise that mentee to try or to do, to get some of the skills that would position them to potentially move into a part-time or full-time position?

Dr. Robert Craven: Right. That's an excellent question. And I get asked that a lot on different social media forums where people are talking about this kind of work. What I usually tell people is every hospital has to have a process of some sort for this kind of work. And usually, they're overburdened and they would like more help.

I usually tell people to figure out what the process is at your hospital. Do they have a physician advisor? Do they outsource that? Do they have a committee of docs who take turns? There's a number of different ways that a hospital or a system can do this. And try to see if you can participate. Even if it's half a day, every other week. That's still some experience that you previously wouldn't have had. And a lot of times I think systems would be open to that.

Another thing is, like I mentioned, the American College of Physician Advisors. They're an excellent resource. You could become a member there and they have some excellent online content and resources, including several books that they or other people have written that are very well written and informative about this kind of work.

I will say as I read one of these books prior to taking the job. Reading these types of texts before you've actually done the work is kind of like reading Harrison's Internal Medicine before doing an internal medicine residency. The context of it and how it all applies to real-world scenarios is a bit lost on you when you're just reading the book cold.

However, I do think it was helpful for me, but having those books as a reference afterwards to go back and look up certain chapters, certain things have been invaluable. And there's going to be growing content, educational content online for people interested in this kind of work.

I know the Society of Hospital Medicine. I'm a member of the Society of Hospital Medicine but I don't speak for them. They have a special interest group in physician advisors, which I'm a member of, and they are working to develop some educational curriculum, not just for hospitalists, but really for anyone that is interested in learning about the physician advisor world, maybe to get them more interested in it and eventually, to train them into how to become a full-time physician advisor. They already have excellent educational content, but they're talking about adding more specifically for those interested in the physician advisor world.

John: That's very useful. I hadn't heard that. So that would be good to know. And it would seem like you said, you mentioned hospitalists and ER docs in there, but hospitalists probably make up a decent percentage of physician advisors. Something you mentioned earlier really struck the chord with me as an awesome way to get your feet wet in a way is to do other types of chart reviews.

Dr. Robert Craven: Correct.

John: If you're doing peer reviews and you're doing let's say quality reviews in the hospital setting, or like you said, for State Medical Society or something like that, or medical, I guess it would be the licensing board more than a medical society. Those are great ways to say, "Okay, not only do I know how to look through a chart, discern what I need to discern, but I like doing it." If you sit down and do that and look at that page and go, "This is boring as hell. I can't do it" that would weed you out.

Dr. Robert Craven: Right. Yeah. And that's an excellent point. Because if you can't sit in front of a computer all day, you're probably not going to be happy doing this. Just like I would make a horrible radiologist because I wouldn't want to sit in a dark room and look at pictures all day. That's part of it too.

But the other thing too is if sometimes I get bored in my home office, I get my laptop and I go out on the porch or the deck or I go somewhere remote where I'm not going to violate HIPAA, but I know I'm going to have nicer scenery and solid Wi-Fi. There are ways that you can mix it up a bit, but at the end of the day, the majority of your day is reviewing cases.

I should probably point out, there are some misconceptions out there that even I had about what it's like to be a physician advisor. I had thought that, and I hear this from a lot of people who are considering it as well, that there's a lot of arguing. People will say, "Well, I would probably enjoy it, but I just don't like arguing with people." I really don't argue that much at all.

The other common misconception is that the physicians who are working for the insurance company have completely sold their soul and they have gone to the dark side and they are evil people that we should have nothing to do with. And that's not true either, because what I've found, we deal with the same medical directors over and over again, you end up developing a relationship with them.

There are a couple of them that I talk with almost on a daily basis. And you learn about your children. You learn about families. You learn about where they live. It becomes very collegial and really there's not much arguing. You build a case for why you feel the patient should be inpatient. You present that case and usually, they'll agree with you. And if they don't, they'll give you a reason why they don't. And often it's "Look, I'm sorry, but per our protocol, we have to have X, Y, and Z, and you don't have, Y. You just have X and Z." Even they are often apologetic about it. But they're just doing their job. And then instead of arguing, you just kick it to the next level of appeal. Getting all fired up about it and yelling and stomping your feet, I have found doesn't bring any benefit. And developing more of a collegial relationship with these physicians on the other side, I think has a lot more benefit in the long run.

To go back to the two misconceptions, you don't argue a lot at all. I think maybe I've had two argumentative conversations with a physician in a peer-to-peer over the last year. And as a hospitalist full-time I feel like I was having argumentative conversations all the time just to get various consultants to help you out or whatever.

I feel like in that regard, it's a lot less stressful. You realize that the docs on the other side of the phone are much like yourself who maybe didn't have the opportunity to work for a non-profit healthcare system, but the only opportunity they had was for a large national commercial insurance company. I've learned to appreciate the people on the other side of the phone as well in this whole process. Some of them are probably listening to this podcast.

John: No, it's true. And it's true in life in general, even just working on a medical staff. Some people just like to be oppositional, it's part of their personality. But most people want to just get along, help the patients, move people through the system and move on to the next case.

Dr. Robert Craven: Right.

John: All right. I think we're about out of time, really, probably going over a little bit, but that's okay. The last question I have for you is what advice you have for physicians, my listeners in particular, who many of them are burned out or they're frustrated, COVID has had an impact on their lives and they're just getting a little frustrated and looking for different options. Any general advice for people that are getting a little burned out and don't know what to do?

Dr. Robert Craven: A couple of things. First and foremost, I would tell people to keep an open mind, because sometimes the way a job is described can sound really boring and unfulfilling. And then when you actually do it, you actually really enjoy it.

I would've said that about physician advisor work. If you had asked me two or three years ago, would I ever see myself doing that? I would've told you "Absolutely not. It sounds completely boring." So, keep an open mind. I would tell people to try to dabble in different things. Healthcare informatics is a really big thing and there's a lot of people that are transitioning over to become consultants for EHR companies or chief medical informatics officers.

So, dabbling in that can be a benefit. I dabbled some in that and realized it's okay, but it's not something I would want to make my career out of. I ended up not going down that road. Dabbling in administration and asking to become an assistant director of your group or in charge of scheduling or whatever, and see if you like more of the administrative side. I've done some of that and felt like the more I was responsible for other physicians' behavior, the more frustrated I became. So, I felt like that was not really good for me. And there are all sorts of side gigs out there. People starting up concierge practices, medical spas, doing expert witness work. You're not really going to know what you like, what you're good at, unless you try some of it, and talk to people who are doing it. I would definitely tell people to keep an open mind.

Another thing, especially if you're looking at making the jump into more of an administrative role within your system or another system is to always remember, people are always looking at you as a physician and critiquing how you handle stress and how you interact with nurses, how you interact with case managers.

I probably would not have been selected for this job if the case managers that I'd worked with had a bad opinion of me, if I had been volatile or temperamental. Same with the nursing staff. If a physician came to me that I know is temperamental or blows up at medical staff meetings, and they're thinking about transitioning into administration, I'd probably tell them they need to either reconsider that or admit that they might need to have some anger management counseling and work on their demeanor.

Especially if you've worked there for a while, people have already felt you out and decided if you're someone that would be able to fit into the culture there as an administrator or not. That's one of the benefits of working in a system before transitioning to administration. And it's one of the negatives. If you've been there for a number of years and haven't made a good impression on people then trying to get into a position like that is going to be more challenging.

John: Yeah. I think you can try and transfer, let's say, the way an OR works with the surgeon at the head of that team to management and administration, but usually, it's a little different. We usually look at it more as a servant leader when we're talking about actual management and leadership in a more corporate setting as opposed to more of a militaristic approach sometimes in the OR, or surgical center. But it's not that big of a transition if you look at it differently. Those are good bits of advice.

I want to thank you for going into so much detail here in what it means to be a physician advisor in a hospital setting, but in a remote position primarily. I don't think it's unique, but it's a little different. We either think of them and like you said, in a single hospital, they're going to be on site. And if they're working for an insurance company, it's a whole different thing. So, this has been very interesting.

Dr. Robert Craven: Excellent. Well, thank you so much. And I should just clarify that everything that I've mentioned in the podcast are my own thoughts and opinions, and don't reflect my current or previous employers or Society of Hospital Medicine or the American College of Physician Advisors.

John: All right. We appreciate that. But I think it's been very insightful and useful. With that, Rob, I will say goodbye, and I hope to talk to you again down the road sometime.

Dr. Robert Craven: Absolutely. Thank you so much.

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Dr. Nkeiruka Duze achieved balance in her professional life by balancing her roles as medical director and concierge physician.

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Medical Director and Concierge Medicine

Dr. Duze splits her time equally between clinical and non-clinical work. She is a physician advisor to the revenue cycle team and the medical director of value-based arrangements and risk adjustment coding at a large medical center.

Her primary responsibilities include coding education, liaison to payer teams who oversee value-based arrangements, appealing outpatient denials, and physician coder consultant. 

In her clinical practice, she recently transitioned from traditional outpatient practice to concierge medicine. As a result, instead of managing over 1500 patients, she is now responsible for 180.

Here visits are now twice as long, and it is much easier to get to know each patient very well. She is beginning to share patient coverage with another part-time concierge physician in her group.

Satisfying Balance

Dr. Duze enjoys her work as a medical director and concierge physician. She is helping her practice run more efficiently, document care better, and bill more accurately. She also continues to provide high-quality medical care to her panel of patients.

Summary

Nkeiruka was beginning to feel the effects of a high-volume practice. However, by replacing some of her clinical duties with nonclinical management work, and the remainder of her practice to the concierge model, she is much more fulfilled in her job. The feelings of burnout have resolved. And she is caring for patients in more rewarding ways.

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

Links for Today's Episode:

• Dr. Duze's LinkedIn Profile
• American Academy of Professional Coders
• Dr. Duze's Email Address:ncnwoko@gmail.com
• NewScr!pt

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Today's PNC Podcast Transcript

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Transcription PNC Podcast Episode 234

Achieve Beautiful Balance as Medical Director and Concierge Physician

John: Like others before her, today's guest sought to overcome burnout and find more balance by splitting her time between nonclinical work and her outpatient practice. But what I find so fascinating is her practice itself transformed from traditional to concierge medicine at the same time. I think that's super unique. Hello, Dr. Nkeiruka Duze.

Dr. Nkeiruka Duze: Hi, John. Thank you so much for having me on today.

John: I'm glad you're here because I think your story on the one side, it's like a lot of other people's stories in terms of trying to fight burnout and move forward in your career, but there are just some parts to it that I think are quite unique. Listeners, you're going to learn a lot today.

Dr. Nkeiruka Duze: I hope so. And thank you again for having me.

John: Oh, you are welcome. Like we usually do on the podcast here, tell us a little bit about your background, your education, the clinical background, and then I want you to end with what you're doing at this moment, but then we'll fill in the gaps later as I get into some more questions.

Dr. Nkeiruka Duze: Absolutely. In terms of my education and clinical background, I have a first degree in biology, which I got at Texas Southern University in Houston, Texas. And from then I moved on to Indiana University School of Medicine, where I got my medical degree, and subsequently to Virginia Mason Medical Center in Seattle, Washington, where I did my internal medicine residency.

In terms of what I'm doing now, post all my training, I really have two jobs. I have my clinical and my nonclinical roles. And my clinical role is as an outpatient primary care doctor. I still see patients in the clinic. And then my nonclinical role is as the physician advisor, as well as a medical director for value-based arrangements and risk adjustment coding at a large medical center in the Seattle area.

John: Very nice. Now, a couple of things, I'm going to just jump in here as we go through, because when I hear someone like yourself tell me what you're doing as an internist, then I automatically assume you're a hospitalist. Because just so many of the internists that I know they either do one or the other, of course, but your practice really has been mostly outpatient, right?

Dr. Nkeiruka Duze: Exclusively outpatient since finishing my residency training.

John: See, I could tell from the very beginning that you're always going in a slightly different direction than the majority of people.

Dr. Nkeiruka Duze: Well, I guess I don't like to follow the crowd.

John: Now you were doing just practice for a while, correct?

Dr. Nkeiruka Duze: That is correct. My transition into including the nonclinical job into my role or my practice started a few years ago, actually. As you mentioned, I was experiencing burnout and I started to explore what are some nonclinical opportunities out there that I could do while still practicing medicine, but then just kind of cut down my clinical practice. That is when I started to look into the possibility of becoming a physician advisor.

John: Yeah. It was very similar to what I did a long time ago. I thought, well if I can work an hour or two doing something else and use that to cover the cost of working less in the clinic that would be a good exchange. Because when you're doing the nonclinical, there's really no liability, there's no call. You're going to just put your hours in. It's a good way to segue and see if you like it.

Dr. Nkeiruka Duze: Absolutely. And I can tell you that comparing what my life was like when I was a 100% clinical practice compared to now, which is where I do 60% clinical practice, 40% nonclinical, the difference is night and day for me in terms of just overall wellness and quality of life.

John: Now, apparently, do you like doing the physician advisor work when you first started that? Was it enjoyable?

Dr. Nkeiruka Duze: Oh, absolutely. When I was exploring nonclinical positions to help combat burnout, the reason that I was drawn to the physician advisor role is that I've always had an interest and fascination with billing and coding. That was kind of what drew me to that particular nonclinical role.

John: Most of us think when we think of a physician advisor, or thinking like making sure that the procedure was done, was legitimate or it was a good indication for like utilization management, I guess I would call it. Sometimes you call it benefits management, but there are others. You mentioned the coding piece. Were you actually helping people with coding at the same time?

Dr. Nkeiruka Duze: Great question. Not until I actually got the role as a physician advisor. I think my journey has been somewhat unique in that when I was looking into the physician advisor role, certainly, I say it was mostly kind of a utilization review type position. But I learned though that the job of a physician advisor, it's actually more robust than that. There are so many things that you can do. Not only the utilization review but quality and performance improvement, appeals and denials management, and then suddenly with the coding and documentation support and education. I latched onto the coding support and education piece.

I think it was easy for me to do that because the medical center where I work already had an established physician advisor program. And I guess more accurately, I would define it as a clinician advisor program because it has physician advisors, but also has a pharmacist. And that particular program also had an outpatient physician advisor as well.

John: Now, when you were talking there about the way that these things overlap, it really is a good point because the core thing about that is for whatever reason, you're doing a review of a case.

Dr. Nkeiruka Duze: Correct.

John: And like you said, it could be a quality review. It could be just strictly a documentation and coding review, especially on the inside inpatient too, but the outputs the same thing, or it's utilization and they all overlap. And the coding effects, utilization because if you don't have the right documentation, you don't have the right code. Well, you're not going to order the right test, at least in the eyes of a reviewer. It's just interesting. And then you can kind of figure out which of those three and maybe there are other aspects that are the most interesting.

Dr. Nkeiruka Duze: Yeah. And even though I studied mostly with the coding support and education piece, I've been able to expand my responsibilities or roles since then. And that's the other beauty of a physician advisor role is that you can do as much as you want. And you can go as broad as you want. It just depends on what your vision is.

John: I suppose it depends on the organization and the size of it. And like you said, it had a well-established program already. So that helped.

Dr. Nkeiruka Duze: That helps a lot.

John: I've talked to physicians and I find this remarkable, someone recently said, "Yeah, I was the first physician advisor at this large hospital or this large system". I thought PAs have been around for 40 years. You're the first, it's kind of crazy.

Dr. Nkeiruka Duze: Absolutely. Well, in my case, I wasn't the first. Our institution was not.

John: Now, has that role evolved since you started? How long have you been doing that now?

Dr. Nkeiruka Duze: I've been doing the physician advisor role for two years. I actually started the role on January 1st, 2020. But prior to that, I already spent a lot of time looking up the coding certifications, preparing, just basically trying to get the knowledge to help myself in practice until a position opened up where I could actually be a physician advisor.

John: Now, at least in the past some systems have trouble finding part-time physician advisors, they usually look into their medical staff or the physicians that are already aligned with them, unless they're doing something where they're getting something that's a freelance or a third party to come in. But at the same time, it doesn't mean we shouldn't prepare for it. You did some things, I think to kind of say to you up for success. I know you got some additional certifications. Where did that come in?

Dr. Nkeiruka Duze: Great question. As I was looking into this nonclinical space and wanting and setting my sites on a physician advisor role, like most people, when you want to do something, you don't know where to start, you go to Google. So, I started off with Google and I basically came across through my search, and when I was thinking about coding and billing the American Academy of Professional Coders, AAPC. And it's from that organization that I earned my certified professional coder, which is the CPC certification. And then subsequently more recently my Certified Risk Adjustment Coder Certification.

John: Did you get the certifications after you had already started as a physician advisor or one before, one after? How did that timing go?

Dr. Nkeiruka Duze: Great question. With the CPC, I had already started preparing for it before I got the job. And then with the CRC, I did that while I already got the job.

John: I'm not sure I've ever heard of the AAPC. It would be odd that I hadn't, considering how many people I talked to that do revenue cycle and utilization management and so forth. I had talked to people from the ACDIS. Now that's more for coding. I'm sure the nurses that worked at my hospital were very familiar with the AAPC. Were there many physicians that have gotten that certification to your knowledge?

Dr. Nkeiruka Duze: Great question. I personally only know two-physician coders, but I suspect there are many more that I just don't know. And the two that I know were within our system. Even when I was already thinking about it, and at the time I got the job, I learned at the time that both of the outpatient physicians in the program also had a CPC certification.

John: Okay. It's funny because when we had consultants to our hospital to do utilization, that was mostly inpatient, but they were involved and they were certified whether by the AAPC or some other organization.

Dr. Nkeiruka Duze: Yeah. I do know, John, that the AAPC also has a CIC certification, which is a Certified Inpatient Coder certification.

John: That's probably what I had come across. All right. So you did that extra, you're working hard. Did that completely resolve everything you were looking to do as far as your burnout, your transition, your balance in life?

Dr. Nkeiruka Duze: Absolutely. I would say though that when I took on a nonclinical role it made a huge difference in terms of balance and quality of life. But then when I also made the transition from the traditional practice of medicine to concierge medicine, that took it again to another level where I really feel, and I'm fortunate to be at this sweet spot where I feel like this is really what I've been waiting for, for a long time to have this type of balance.

To give you, and your audience a little bit of a clearer picture of what I mean, when I was in the traditional practice of medicine, I had about 1,700 patients in my panel. And then with concierge medicine, which I'll expand on a little bit later in the show, I imagine, if I were still a 1.0 clinician, the maximum number of patients I could have would be 300, but I'm a 0.6 FTE. So the maximum number of patients I can have in the practice is 180 patients. It's a huge difference between 1,700 patients to 180 when you think about whether it be the MyChat messages or the phone calls or the lab results, or the notes you have to dictate, or the number of patients you have to see in a day to keep your practice healthy.

So, it's a very, very vast difference. Making the change to a nonclinical role, and then also making the change in the same year to concierge medicine, I think was really what made me get to this point where I can say, "You know what? This is what I've been hoping for and wanting for a long time."

John: I have a couple more questions about that whole thing, that whole transition. Now you said 1,700 in the basic panel before the concierge, right?

Dr. Nkeiruka Duze: Correct.

John: Now, was that the full time or the 0.6?

Dr. Nkeiruka Duze: 1.0 is 1,700. When I was in traditional practice, but if I had remained 1.0 when I made the switch to concierge medicine, then my maximum would've been 300 patients. But I'm a 0.6 so my maximum number of patients is 180 because 1.0 is 300 patients in our concierge world.

John: And I think you have, I don't know if it's completely unique, but when someone tells me, well, I'm going to do concierge medicine. I'm like, oh, wow, you're going to have a big transition because you're going to have to tell all your patients, and they're going to have to decide if they want to pay you that way. And you're going to have to start your own business. But you're talking about doing concierge medicine within a system that supports doing concierge medicine. You have to tell us how that works and why that even exists?

Dr. Nkeiruka Duze: Well, very great question. I would say it may be unusual now. Maybe then it was unusual. I don't know how unusual it is now, but I would say for sure that the medical center that I work for really pioneered concierge medicine in that kind of a setting, in that concierge medicine practice has been in existence for over 20 years. I believe it started in 1999.

But I do know that at least one other medical center in the area now does concierge medicine. I believe the Mayo clinic does concierge medicine. I suspect that it's not as unusual now, but it must have been then when the medical center that I work for began this journey into concierge medicine in 1999.

John: Now, I think that's very forward-looking. I'm not an expert on concierge medicine, but when I think of it, when I was in practice and I started reading about it, it was really something entrepreneurial. Individual physicians, small groups were doing it and saying, "Look, we're going to get outta the rat race. We're going to have a core group of patients. They're going to pay us as we go. And that's it. We're done with Medicare and all that".

Then there were these franchises that started too, where okay, well, you can sign up and we'll do this turnkey, but I had never actually heard of a system, although it made sense because I think even at the hospital I was at, they thought, well, should we consider doing concierge medicine within our physician group? Now, they only had like a hundred physicians. This wasn't a massive group, so I don't think they really seriously thought about it. But yeah, it sounds like where you've worked has really been on the cutting edge of that, especially for a large system.

Dr. Nkeiruka Duze: Absolutely. If any of your listeners are part of a large medical center that does not have a concierge practice, this might be your opportunity to suggest settling with their support, because I can tell you that there is a huge desire or need. A lot of patients are really seeking out this type of service.

Because we have currently in our concierge practice a waitlist at all our locations. I know that this is something that patients want. Patients want more time with their doctor, they want easy access. They really want to be able to have a doctor that can spend a lot more time with them, get to know them, and not really just be feeling like they're in a factory churning out patients. A lot of people will pay for that service. I believe that if you don't have it in your medical center, it's your opportunity to maybe suggest it and be someone at the forefront to help your organization kind of tap into this model of practice.

John: Yeah. That would be great. If our listeners could get that expanded into other organizations. Now I'm going to quiz you. You went down to your 180 patients. This is the thing that really amazed me about concierge practice. Now if one of your 180 patients pages you, texts you, contacts you, there's a pretty good chance you're going to actually remember who they are. Is that true?

Dr. Nkeiruka Duze: Oh, without question. Without question. Yeah. Because you only have 180 people that you're taking care of. You'll know not only who they are, but you're also going to know the husband or a wife's name, you're going to know the kids' names. You're going to know their pets' names. You're going to know them so intimately because you're going to have a lot of time to spend with them.

I'll give you an example that when I was in the traditional practice of medicine, for a long time, the appointment slots were 15 minutes or 30 minutes. 30 minutes for an annual check-up, et cetera, or multiple concerns. Otherwise, a routine visit would be 15 minutes, but over time in the desire to address burnout, the schedules became 30/30. You have 30 minutes per patient. I thought that was really great when the organization did that.

To the concierge model, in our practice a regular appointment is an hour, whereas your annual check-up is an hour and a half. You really get to know people intimately. You really get to support them in a more well-rounded way. Because if you're busy, you may not have time to hone in on something that they said about what it's happening at home or in their family, which ultimately, will impact their overall health.

I had a few patients follow me when I made the transition and of course, I did pick up new patients. For those that followed me from the traditional to the concierge practice, they also comment on the difference being night and day. And then I personally, in terms of on the other end, I feel like this is really what I had envisioned when I thought about becoming a doctor. It's to really be there for my patients and have time to take care of them.

John: Okay. The bit of advice that I'm going to garner from that whole thing is when you're looking for your first clinical job, work for someone that has the possibility of a concierge program in it, even if you're not going into the concierge.

Dr. Nkeiruka Duze: Right.

John: Oh man, that sounds so good. And the thing is traditional medicine, you mentioned it before that patients did have these long waits and everything, and a visit under traditional terms is usually pretty unfulfilling for the patient because they're in a hurry. They feel like they haven't even told you anything. And you're like, I got to go. We'll deal with one thing today.

Dr. Nkeiruka Duze: Another patient is waiting.

John: And then, of course, the physician isn't willing to treat something on the phone or telemedicine because they're not getting paid.

Dr. Nkeiruka Duze: Correct.

John: Now you just flip the whole thing around. I'm assuming you take care of a lot of patients just by email and texting.

Dr. Nkeiruka Duze: Well, we certainly have the ability to do that, to just have the patient call on your cell phone and have a conversation but I really believe in the value of actually having people come into the clinic. So that way you can naturally just have the focus time to talk about things and then also examine them. I always encourage my patients that if something's going on, let's make an appointment, and then suddenly if you're not certain, we'll talk through what the right thing is to do.

But suddenly there's some mild symptoms, people might express over the phone that it doesn't really warrant them coming in, but I still try to encourage people to come in. Not that it is required, but that is just what I found as the way that I find medicine fulfilling is to have that either face-to-face or virtual connection time set aside on my schedule for me to focus solely on you and any concerns that you have.

John: Now, that makes good sense. I'm just thinking of the one that calls in and says, well, I have athlete's foot, can you call something in for it? Or I have conjunctivitis. Well, I need to have you come into the office for that because otherwise I can't get paid.

Dr. Nkeiruka Duze: Correct. Yes. Basically, as you already alluded to, with the concierge practice the members pay a fee monthly, so regardless of whether or not you call me or see me, every month you're paying a membership fee. And when I do see you in the clinic, I'm still billing your insurance for any services that I provide. That membership fee truly is for the access that you just described, where you can call me on the phone and say, "Hey, I have athletes' foot can you send me an anti-fungal medication?" I'm like, "Sure. Yeah." So, when it's other things or multiple things and I tend to just have people come in. That's just my style.

John: There are a couple of other little background things we need to know about how this happened. First of all, it wasn't the type of thing where you were getting burned out, you just turned to the owners of the system and said, "I would like to do concierge medicine. Is that okay? Can I switch it over tomorrow?" There are some constraints on it. I think from what we were talking about before, in terms of who can do that, when they can do that, all that.

Dr. Nkeiruka Duze: Absolutely. Yeah. In order to make the transition, first, there has to be availability. There's got to be a spot that is opened up either because maybe someone is retiring or because they're expanding the program. And then in being able to be part of the concierge program, you have to have a certain number of years of practice. You have to have high patient satisfaction scores, et cetera. They're looking for a particular quality of physicians to join the practice.

John: And then the other piece, which I thought maybe you're going to go into since you're doing it part-time, that presents a little bit of an issue, doesn't it?

Dr. Nkeiruka Duze: Great question. Temporarily yes. To give a picture of what my schedule is like, usually, I'm typically in the clinic Monday, Tuesday, and Friday, and then my nonclinical days are Wednesday and Thursday. In the meantime, if a patient needs something on a Wednesday or Thursday, they can suddenly call my cell phone or send me a message to the patient portal. And then I respond during my admin days or my nonclinical days. But that is slated to change in the future because we're going to have a practice partner join me and we will both be then the first two real part-time concierge medicine docs. And on my nonclinical days, she'll cover me and vice versa.

But I must tell you, John, even on my nonclinical days I probably like on a busy day maybe get three or four emails or between emails and calls, maybe four, because again, we're talking about 180 patients. It's a small pool of patients. I'm not really getting a lot of people reaching out on the days that I'm not in the clinic. And if my patients do have to be seen on the day I'm not in the clinic, one of the other concierge medicine doctors is able to see them.

John: Well, it sounds like it's almost like a job sharing, but then again, if you're available, even when you're not officially on, it's not that big of a deal to respond.

Dr. Nkeiruka Duze: Correct.

John: All right. Well, where are things going? Where are things going? Are you going to do this for a while? Are you looking at expanding your nonclinical or do you want to hold things as it is for a while?

Dr. Nkeiruka Duze: I'm looking to expand my nonclinical role. As I mentioned earlier with the physician advisor role, you can do as much or as little as you want. And I've been focused a lot primarily on the outpatient, whether I be with education or outpatient denials and things like that, but I'm now hoping to expand to do more in the inpatient setting. When I think about where I'm going, I'm really going to be expanding my nonclinical role. And because it's concierge medicine as opposed to traditional medicine, I actually see myself being able to keep my 180 patients, and then just expanding my nonclinical role without having to cut back any further on my clinical role.

John: Yeah. Nice. It'll be nice if that works out. I remind people they ask me, "Well, should I quit doing clinical completely or not?" You could do a lot of executive positions without doing any clinical, but I remind people that the CEO of the Cleveland Clinic was doing clinical, the CEO of Mayo, the CEO of a lot of massive, huge organizations still do an occasional clinic day, just to keep that going. And this is even a different version of that. We'll have to wait and see. I want to right circle back with you in a few years and see what's going on.

Dr. Nkeiruka Duze: Absolutely.

John: What advice do you have if someone that was in the position that you were in where you are kind of getting burned to out and just kind of frustrated. Any specific words of advice you'd have for my listeners?

Dr. Nkeiruka Duze: Absolutely. And thank you for asking. I think three things that I would encourage you to consider. The first is whether you are a hospitalist or an outpatient doc, I encourage you to explore nonclinical roles. And the reason for that encouragement is that the nonclinical roles not only add variety to your career and your life but also, I think it's the quickest way to actually get that work-life balance that most of us desire. Because with clinical practice, as you know, when you see a patient, whether it be for 15 minutes or 30 minutes, there's a lot of work that has to be done just for that one visit, whether it be the messages you're going to get from the patient about that, or the lab results that you're going to have to respond to.

Essentially, I feel like full-time clinical practice is challenging and it's hard to have work-life balance if you're in full-time clinical practice in my humble opinion. My first encouragement is that no matter what you're doing, inpatient, outpatient definitely explore nonclinical roles, even if you're going to do that as a 0.1 or 0.2. Just to kind of give you a little bit of a break. So that way you can have more work-life balance. Life is too short.

The second piece of advice I would give is to be flexible. What I mean by that is two things. Be ready to pivot if you need to, when opportunities arise. And then the second is if you already have an opportunity, be ready and flexible to expand if needed because when opportunities come up if you don't tap into them, guess what? Somebody else will. Even if you've set your sites on something, then you see something else that looks interesting, that becomes available, consider it. You just never know. You might like it. My second piece of advice is to be flexible.

And my final advice would be to seek out mentors that are doing either what you hope to do or something similar to what you hope to do. Because I think that we can really learn a lot from each other. I've learned a lot from people along the way, like reaching out cold calls to people and saying, "Hey, can I just have 30 minutes of your time just to ask questions about what you're doing or how you got there?" I encourage people to at least seek out somebody, at least a person that can hopefully mentor you, as you make that transition of hopefully adding a nonclinical role to your career. And I'm suddenly happy to support or answer questions to anyone that needs that support. And I'm certainly happy for any of your listeners, John, to email me if they had questions. And my address is ncnwoko@gmail.com.

John: I got that written down. I'll put that in the show notes. And you are on LinkedIn and they can just go to LinkedIn and look up your name and they should find you. That's how I found you on LinkedIn. I had already been referred to you, but I did find you there.

Dr. Nkeiruka Duze: Yes, I am on LinkedIn.

John: All right. Well, this has been very interesting. I could go on asking you more questions, but I think we're going to have to go here because we're running out of time. I thought there are many unique things about your story, the certifications are not totally unique, but you proactively pursued that. And I think we sometimes forget that there are those kinds of things out there and the opportunity to switch to concierge and how much that helped. And if anyone can emulate that in some fashion either to get it established or expand it at your organization, that's another great way to balance the two.

Dr. Nkeiruka Duze: Absolutely.

John: All right. Dr. Duze, thank you so much.

Dr. Nkeiruka Duze: Thank you so much for having me, John.

John: It's been my pleasure. And I hope to catch up with you again down the road. With that, I'll say bye-bye.

Dr. Nkeiruka Duze: Thank you, John. Thank you so much.

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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 Achieve Beautiful Balance as Medical Director and Concierge Physician – 234 appeared first on NonClinical Physicians.

Nonclinical Nation, it has been a long time since we have heard about clinical documentation improvement as a nonclinical career. And I thought it was time to revisit this topic.

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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.

Clinical Documentation Improvement

Today I am revisiting my wonderful conversation with Dr. Cesar Limjoco, a nationally recognized expert on Clinical Documentation Improvement. This conversation is from Episode #5.

Cesar has a massive following on LinkedIn because of his reputation in the CDI industry. When I was CMO, our CDI program was essential for getting paid properly and demonstrating our quality of care.

It's not just about parameters; it's not just about protocols; it's not about coding. But it's really about the clinical truth. – Dr. Cesar Limjoco

If you have any interest in this area, it is a great entry into hospital management. And it provides opportunities for employment by a hospital or a consulting firm. It also makes for a nice consulting business once you’ve mastered the basics.

Getting Your First CDI Job

I enjoyed revisiting my conversation with Dr. Limjoco. He is very passionate about what he does. We really got into the core principles of CDI. And Cesar outlined the basic steps for pursuing such a career. Here they are:

1. Get involved at your hospital on a voluntary basis with the appropriate committees and offer to help with CDI projects
2. Join professional organizations such as the Association of Clinical Documentation Improvement Specialists, the American Health Information Management Association, and the National Association of Physician Advisors.
3. Take on a paid part-time position as CDI Physician Advisor as you continue your learning process.
4. Expand your responsibilities to full-time if that’s your goal.

Summary

Working as a physician advisor or medical director in CDI is a challenging and rewarding job. And it can lead to advancement in the hospital to chief medical officer or chief quality officer.

You can contact Dr. Limjoco by email at dr_cesar_limjoco@me.com. His LinkedIn profile is very complete and includes resources such as articles he has written. He is also on Twitter: @cesarlimjocomd.

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

Links for Today's Episode:

• Dr. Cesar Limjoco's LinkedIn Page
• ACDIS Website
• AHIMA Website
• National Association of Physician Advisors Website
• Dr. Limjoco's email address: dr_cesar_limjoco@me.com
• Top Reasons to Become a CDI Expert with Dr. Christian Zouain – 077
• Nonclinical Careers That Will Save Discouraged Doctors – 095

Download This Episode:

Right Click Here and “Save As” to download this podcast episode to your computer.

Podcast Editing & Production Services are provided by Oscar Hamilton

Today's PNC Podcast Transcript

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Transcription PNC Episode 206

Blast from the Past: Clinical Documentation Improvement

Interview with Dr. Cesar Limjoco

John: Hello, Dr. Limjoco. It's great to have you here.

Dr. Cesar Limjoco: Thank you. Thank you, John. It's so nice to be here.

John: I guess my first question for you is how did you get into doing this work with clinical documentation and coding?

Dr. Cesar Limjoco: Well, I guess I'm a little bit ahead of my time. We're talking about a lot of burnouts and physicians nowadays. Well, way back when more than 25, 30 years ago, I kind of saw it coming already. And I thought, you know what? This is something that maybe isn't for me. Direct patient care. And I was looking for something out there that would still utilize my knowledge and be able to contribute to bettering health care out there.

So, I just stumbled upon this thing. And it was all about coding at that point back in the eighties. I just started asking questions from the coding department at the hospital and learned to be cognizant of the issues between coding and documentation. That turned out and it evolved into sort of a working relationship as a liaison to the medical staff. And I did that willingly. And at that point, of course, I wasn't being paid for it, but I was just interested and I was able to help up both camps, both the coding department and also the medical staff to kind of be the go-between the two areas.

Coding is about portraying what is documented clinically in the chart. But also at the same time, these two areas are talking different languages, which is weird because it's supposed to be a mirror, a representation of the actual clinical reality. But that really gave me some good viewpoints, perspectives as to how to tackle issues.

John: Interesting. Now I might have my history wrong, but correct me if I'm wrong. Back before the mid-eighties and the adoption of DRGs, there really wasn't probably a big need for this. But once we got into the DRGs, it started getting more and more complicated and we were trying to use billing information or codes to not only get paid, but as time went on, it affected quality and measurement and so forth. So, I'm assuming over the last 20 years or so, it's changed a little bit.

Dr. Cesar Limjoco: Which is interesting. I would like to bring up a point. When you speak to providers, most of the time when the subject of coding comes into mind, still their perspective is more that coding is about the pro fee billing, E&M codes and all of that. That's really their main concern because that is what's nearest and closest to them but it really goes beyond that. It's about capturing severity of illness, the diagnosis is going to have a major impact on clinical coding, inpatient hospital coding.

By the way, it also impacts back on through the ENM levels because it impacts the medical decision-making part of the E&M code. It's actually a very important part of figuring out the E&M levels, because depending on the severity of illness, your medical decision-making will be impacted. And also, therefore the way you take your history and physical examination, what sorts of information you're getting from the patient? What kind of examination you're going to do and what kind of workup you're going to go into, it's going to be really directed and led by the medical decision making. And that's one thing that I think many physicians do not really realize.

So, a lot of times, it's a matter of checking the boxes. Yes, I did this H&P, I did this physical examination, I did this review of systems, this history, blah, blah, blah. But it's not just about collecting points. You have to justify it by why is it needed? Why do you need to get social history? Why do you need to get this family history? Does it have anything to do with your medical decision making?

John: Absolutely. And it's interesting because I think it takes a very certain type of person to be interested in this. I remember at my hospital and we should let the listeners know that we know each other, because when I was chief medical officer for the local hospital, you would come and you would be our consultant, talk to our medical staff, train our nursing staff, there were documentation specialists.

But there was a certain type of physician on the medical staff who would look at this and say "This is not really a game, but it's a system. And if you don't know the rules, you're going to be in trouble". And like you said, not only from the coding for your own professional services, but then the hospital itself, of course, could suffer greatly depending either financially or even based on the quality or safety length of stay and so forth, because there's a lot of risk adjustment that depends on the coding, from what I recall.

Dr. Cesar Limjoco: That's very true.

John: Speaking of that, what are you up to now? What kind of hospitals are you working with currently?

Dr. Cesar Limjoco: I'm working with this hospital in Norfolk, Virginia. It's a medium sized hospital and I go there every month for a week and train the physicians, do in-service for the coders and also train their clinical documentation specialists. So, it's challenging. It's rewarding. It's about making a culture change and that's really what's most important. It's not something that you go into for a week or two weeks or even a month and everything will change just like that. No, it doesn't work like that.

Culture change is something that happens slowly. At the beginning, there's a lot of resistance and it slowly moves and finally it gains momentum. And that's when you know that it's working. So, it takes some time for this thing to grow. And it really gives me great satisfaction when I see that coming, when I see that "aha" moment. And it's not just individually, but as a group. It's amazing.

John: Yeah. I'm sure you see shifts in the way things are being recorded, documented, the coding improves and then some of the metrics improve. So, when you're working at the facility that you're at now, I'm thinking there's probably some local medical staff members who become more involved or do they take a formal role for the hospital in terms of the coding and documentation initiative?

Dr. Cesar Limjoco: It's interesting, but there've been others that have field plural in the past. And so, it's still evolving. Some have left the role. Some are filling in the role. And hopefully after I leave someone else would go in and do the full-time position. So that's where it's at.

John: Because I remember that we had physicians on staff who would serve as a resource if one of the nurses had a question about the documentation or needed some face-to-face time with the doctor to kind of get something changed in real time. And I don't know if you're available to do that for your clients, or again, if that's something that you teach maybe one or two interested physicians to deal with on a daily basis. But I recall that we had someone like that.

Dr. Cesar Limjoco: Yes. That's part of the process, training a physician advisor or a physician champion to be the go-to person when I'm not there or when I'm not there anymore. So yes, that definitely provides continuity and sustainability of the program.

John: Now, do you remain available after the fact for, let's say the physicians that are doing that locally to consult with you or do you do any kind of ongoing training for the people that serve in that role?

Dr. Cesar Limjoco: It depends on what the needs are. The people at the facility can also gauge that and they will sense that, "You know what? We need to get him back or we need to do our consult" or something like that. Otherwise, if it's working well, probably follow-up assessments quarterly or semi-annually or annually deal.

John: So now if you've got somebody that's maybe stepped into that role part time, and they probably initially got most of the training from you, are there other resources that someone who's interested in this could access?

Dr. Cesar Limjoco: Definitely. The biggest resource that they can tap into would be ACDIS, which is the Association for Clinical Documentation Improvement Specialists. They're a good resource. As part of the association, we have annual conferences. I actually speak, present at the conference. Before the main conference there's the two-day pre-conference, where there's actually kind of like a bootcamp for physician advisors. So, that's a great starting point right there. Plug in to that ACDIS boot camp for physician advisors.

John: Okay, good. I'll put some links in the show notes here so that if any of the listeners are interested, they can look up those things.

Dr. Cesar Limjoco: There's also one more association, the National Association for Physician Advisors. You can Google it and it will come up. That's another thing you can plug into.

John: So, if our listeners are interested, they will definitely be able to check that out. Again, I'll put all that in the show notes.

Dr. Cesar Limjoco: One thing I wanted to add is for any physician who's interested in, maybe looking into this area is maybe to follow the same trail that I left out there. And that is first of all, be interested, plug into the coding department, the CDI department, and offer your services to be a resource, a champion. And that's how you get to learn because they will refer cases to you and you discuss them and you understand all the intimate underpinnings of what's going on in the nuances of the case. And that's how you learn.

John: Well, absolutely. I remember some of the nursing staff, and I guess they were in the medical records department or health information department that were doing the actual coding. They were pretty well trained, but really looking at a chart, they didn't really understand completely what was going on, particularly with a complex patient. So, they definitely liked having one or two physicians that they could go to, to help clarify those issues. And it's vitally important to the hospital. The hospital, again, the quality ratings and the amount of payment they're going to get, it just completely depends on how accurate this coding is now and it reflects the actual severity of illness. I think it's still to this day.

Dr. Cesar Limjoco: One of the main things that I do when I enter a facility is I want to make sure that everyone is on a level playing field and everyone is doing the right thing. And the way to ensure that is to help the facility and all the players, and all the stakeholders understand what's the real objective for this program or the CDI thing? And it's very important because if it's all about the money, people do really, really bad things just because of that. Then you start to see people looking for loopholes or maybe we can slide and get away with this because of this and that, and that.

It's really important that all of those rules and regulations that you alluded to, all those coding guidelines, and even clinical parameters, protocols and practice guidelines are directed towards one big thing. And that's actually the clinical truth. If you will have that as your north star, that will guide you to do the right thing. If you don't have that as the north star, you'll do weird things. And just to justify whatever your goal is, if it's maximum reimbursement or what have you. And people get in trouble with that. They may get away at it in the front, but at the back end, it will come and bite you.

John: Absolutely. Let me put it this way. The CFO looks at a program like this and says, "This is great. We're going to try and optimize our payments and we're going to document all this stuff". And again, if the staff don't understand exactly what's going on with a patient, that might happen, but that's why I think it's extremely important to have that physician involved to say, "Look, we're going to optimize and we're going to be complete here, but at the same time, it has to link really to what happened with the patient". And that way that person can stand up and say "Clinically, no, it does not justify shifting into that DRG or that diagnosis". And so, I think it's a really good point that you got to keep that in mind. I think that's just an awesome role for a physician to be in because they're the ones that have really the most clinical expertise.

Dr. Cesar Limjoco: Can I share you a little story that I like to share for the folks out there? And it's about a story about sepsis. I remember as a rookie physician in training. As a first-year resident or a second year resident, when you do your H&P assessments, we used to write them back in the middle ages where I come from.

John: Yeah, me too.

Dr. Cesar Limjoco: And when the resident comes in and the attending comes in, they kind of like to write a scratch off what you wrote and put down, no, this is something else. And they amend things that you write down. And it's a great thing, but also it shows you that, "Oops, I made a mistake". Anyway, it becomes like a thing. The goal as a rookie is to make sure that you get everything done correctly so that nothing gets changed or amended.

So, there was this one patient I examined and I did the initial workup and I was on the ball. I really thought I did a great job getting the history, physical examination and assessment of the initial laboratory workup. And I said, "Oh, this patient, all the classical pictures of a patient with pneumonia, and blah, blah, blah. Oh, by the way, the patient also has a creeping creatinine. So, the patient has acute failure, blah, blah, blah. Or the patient was also hypotensive, blah, blah, blah. And all of this comorbid could they have.

But anyway, I was so happy that I wrote it really nicely. I said, I bet you they won't be able to do anything with this. So, anyway, that attending goes on and he was one of the revered attendings. He was smart as a tack. He was really, really a great diagnostician. When he came on, I asked the senior resident, so what did he say? And he said, "Oh, sepsis". I said what? I said, "What? How can he say sepsis? He doesn't even have a blood culture".

John: Yep. But you described all the symptoms and signs, correct?

Dr. Cesar Limjoco: Yes. Yes. And the seniors said to me, well when you get to that level of the practice, you will be able to sniff out diagnosis, and be fully dependent on the workup lab. And I was thinking to myself, when could I ever get to that point that I'll be able to diagnose sepsis without the possible blood culture? Actually, this patient actually died 48 hours after. And you know what was in my head? I was still looking for the blood culture that was so ingrained in me that I have to have septicemia in order to call it sepsis.

But anyway, it's a great story to tell because in 1992 when the first serious criteria came out and you have two out of four criteria on mixed sepsis, and blah, blah, blah, people got kind of distracted. They are kind of misdirected. And they started doing stuff and everybody is now having sepsis. Every patient that comes through the doors of the hospital with leukocytosis are now called sepsis. We're missing the point. The pendulum has gone and swung to the other side that now everybody has sepsis in contrast to before that we were so dependent on blood cultures to make sepsis.

But really, it's something in between. And it is really possible blood culture does not make sepsis. You will have possible blood clots and pyelonephritis and pneumonia and even other infections, but the patient may not be septic. So, this is a great story to tell about how you get to the clinical truth. And it's not just about parameters, it's not just about protocols, it's not about coding, but it's really about the clinical truth. What does the patient really have?

John: Right. And the devil is in the details, and it's easy to just lump things and go on your way. So, it takes a level of sophistication, absolutely. Let me ask you something that you did mention. You did mention residents, of course, when you were in training, but I was wondering if you see that the people that are coming out now, medical school, residency, fellowships, and so forth, do they seem to have a better handle on this whole issue of documentation and coding?

Dr. Cesar Limjoco: Yes and no. The yes part is because they are getting the message about this thing, about documentation, about getting the specific diagnosis is important because of coding and so forth. But they are also held back by the same things that many are held back for, which is on the two other four criteria about the definitions and failing to see the big picture. And some folks actually on the extreme side are coming out and say, "Well, if I can't call it sepsis based on two of the four criteria, which I was taught in med school and in residency, how am I going to call it sepsis?" I get that kind of response. And I said, "Wait a minute. I was just supposed to be a doctor".

John: What's interesting is we are taught certain clinical things in med school and residency, but I would advise the residents and fellows to pick up the regulations or the descriptions of a DRG. Most of them were at MD-DRGs, right? There are usually three categories for each illness. And you have to somehow marry that system to what we're trained clinically and make some sense out of it. And it's not easy.

Dr. Cesar Limjoco: I have something to share with you about the DRGs. The reason why clinicians, physicians in general don't understand DRGs is this thing about the selection of the principal diagnosis, which one is the principal diagnosis. It's a very important question to them. And it's really a way of the industry figuring out why the patient needs to be in the hospital. That's really what it comes down to. Why does this patient need to be in acute inpatient care? It's not that every patient needs to be in acute inpatient care. If the patient has abdominal pain, the patient can be seen in the office or in the emergency room, urgent care, and be sent home. Not every patient with pneumonia needs to be in acute inpatient care. So, you need to figure out what it is that needs inpatient care in this patient.

This patient with pneumonia may have other comorbid conditions that make you think I got to get this patient in or else this patient will have higher risk of sepsis or other organ failures and so forth and so on because of the patient's circumstances and the comorbid conditions that the patient bring to the table.

So, the patient may come into the emergency room and say, I'm having abdominal pain. And once the physician examines the patient and does the initial workup and finds out that it's not abdominal pain that the patient needs to be in the hospital for. That this patient needs to be in the hospital because the patient is septic from a source or what have you. That is what the principal diagnosis is. That is why the patient needs to be in the hospital. Not because of the abdominal pain, which may or may not be related to this thing that is important that needs hospitalization.

John: It's a very complex situation. It's good for someone who's very meticulous, who likes to sort through problems and solve mysteries to some extent.

Dr. Cesar Limjoco: It's very House-like. You remember that TV show. And it's investigative medicine. It's really being into diagnostics and being a good diagnostician and that's what it's about.

John: Do you see any changes coming in CDI in this whole field in the next few years?

Dr. Cesar Limjoco: Yes, definitely. When the CDI thing for scanning took play, it was the way that people were able to sell it to the C suite is, hey, you know what? If you're not capturing specificity in documentation, you're leaving a lot of money on the table. So, it was all about the money at that point.

But the industry has to evolve because it's all about the money, a lot of things that are being done are because of the money. Every patient with infection is not sepsis. So, now the industry is getting to learn that's not the way also because now the payers, Medicare, Medicaid, and all the commercial payers are going to bite back and say, "Well, that's not really sepsis. Prove to me that it is sepsis". So now you have a lot of things that have been over-documented probably, or that now the payers are wanting to get it back. And now the hospitals are getting inundated, overwhelmed by a lot of claims denials.

And hospitals are using a lot of resources to answer those denials. So, it's just inundation. It's overwhelming. It's really going to affect their finances. So, the idea is if you do it right in the first place, that is, if your north star is the clinical truth, then it will take care of itself. Yes, there will still be denials. I'm not going to say that there's not going to be denials because the payers are still going to try and get some money back. But if your documentation is based on clinical truth, it will withstand scrutiny. You can go all the way to the Supreme court and you will win. But if your basis is on shaky ground, no.

John: Let's go back before we close here and talk just again about the process that someone who is interested in this might want to follow. You mentioned about if you're interested, get involved at your hospital, maybe work with the coding and documentation department, if they have one. Now sometimes how are those usually structured? Are they usually separate or part of health information? What do you usually see?

Dr. Cesar Limjoco: Both. They can be with H&N or they can be with quality. When I see that it's working under H&N, they kind of work together better. They're more collaborative when they're together. Whereas if it's not, you know how hospitals operate in silos. And that's what I try to do is break down silos. And if you can have them work more collaboratively instead of being territorial about stuff, that's how you get the most bang.

John: So physicians are getting involved at a certain level, maybe on a volunteer basis, and then would seek out the organizations that you mentioned earlier and see what kind of courses they might be able to take or meetings they could attend. Does that make sense?

Dr. Cesar Limjoco: Yes, definitely.

John: Okay. And then tell their CEO to hire Dr. Limjoco to come in and train them.

Dr. Cesar Limjoco: I think that's the message.

John: That's the way to go. At least to get started, right? And then once they've got that locked in, then maybe they can back off. Now, it would be conceivable that a medical adviser for coding and documentation could end up at just an average sized hospital spending maybe 25% of their time or more doing this, I would think.

Dr. Cesar Limjoco: It can zoom up after that because he or she can be dealing with a lot of denial appeals, a lot of issues that are coming up with the coders or the clinical documentation nurses. Being the liaison, with individual physicians or with groups of physicians or specialties, education, all of that stuff. So, it can wrap up quite a bit after that.

John: So, ultimately, especially for a larger hospital I suppose they could end up being in a full-time position.

Dr. Cesar Limjoco: Yes, yes. Just like their advisors for utilization management. Same thing. Or you can actually marry the two together. It depends on the facility.

John: Do you have any sense of what hospitals are paying physician advisors, whether it's part-time or full-time?

Dr. Cesar Limjoco: If you look at Glassdoor, they have their own data. It's something low, what they mentioned as the entry level of physician advisors. They're looking at about maybe 150, 160. It can go up. And actually, in reality, I know that it is up. We're looking at about maybe anywhere from 180 to 200.

John: You are talking about annual salary.

Dr. Cesar Limjoco: Yes, yes. And depending on how much time in the position. And then in a hospital you go from adviser to medical director to CMOs. So, you know that the salary levels that are involved from a medical director to a CMO would be different also.

John: It's definitely conserved as a stepping stone for physicians who are seeking more, let's say, advanced or executive level as opposed to just getting out of clinical medicine. But someone who's happy doing the clinical documentation could do that for a long time and probably easily at least replace their clinical payment unless they were a subspecialist or something, I would think.

Dr. Cesar Limjoco: And then if you're a consultant, then of course, you'll have a higher return on investment.

John: Once you become the expert to the people that are learning like yourself. Definitely, it's a whole different ball game. Well, I think we can wrap it up here, but I need to find out how our listeners can get a hold of you if you'd like them to, or their organizations could. That would be very useful.

Dr. Cesar Limjoco: I think the best way to contact me is through my email address. Plus, also you can connect with me on LinkedIn and I can get messages through LinkedIn. It's got a wonderful profile there with lots of information, articles, published articles and so forth.

John: Well, any last words of encouragement or thoughts that you'd like to leave us with today?

Dr. Cesar Limjoco: What I want to leave with you is the thing about the clinical truth. If only everyone had that foremost in their minds, the better things will be, the better information will feed into improving healthcare. And that's really what's important because patient care is what's really all about.

John: Absolutely. Excellent words of wisdom there from a very experienced physician and documentation specialist.

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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 PNC Podcast Blast from the Past: Clinical Documentation Improvement – 206 appeared first on NonClinical Physicians.

In this week's PNC Podcast episode, I have a wonderful conversation with Dr. Robert Adams as he provides highlights from his long military and clinical careers and offers advice for finding nonclinical opportunities in retirement.

Bob Adams may be the most accomplished guest I’ve ever met. Coming from a military family, he attended the U.S. Naval Academy. Then, he continued his naval career and after serving as Navigator and First Lieutenant on the USS Hamner, he followed his dream to become a Navy SEAL.

He served 14 years in the Navy and was a Navy Commander when he changed services. However, he did so to become a physician on an Army scholarship at Wake Forest University Medical School.

As an Army physician, he commanded various clinics providing full-service inpatient and outpatient obstetric, pediatric, medical, surgical, and gynecologic services to a diverse population. He served four years as the Command Surgeon for the US Army DELTA Force providing combat medical services worldwide, and he was deployed to Iraq with the 82nd Airborne Division.

Along the way, he obtained an MBA from James Madison University. After retiring from the Army Medical Corps as a Colonel, he founded and practiced in a full-service medical clinic, “Knightdale Family Medicine,” in Knightdale, NC. He ultimately left the practice but was able to find several nonclinical opportunities in retirement to keep him busy.

He is the author of two books that he released this year: Six Days of Impossible – Navy SEAL Hell Week: a Doctor Looks Back – and Swords and Saints: a Doctor’s Journey.

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. And, unlike other programs, which typically run 1 – 1/2 to 2 years, this program only takes a year to complete. Recently, Economist Magazine ranked the business school #1 in the world for the Most Relevant Executive MBA.

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

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 needed to find a career that you really love. To find out more, contact Dr. Kate Atchley’s office by calling (865) 974-6526 or go to nonclinicalphysicians.com/physicianmba.

Adventurous Journey To Retirement

Bob is a fifth-generation career military and became a Navy Seal. After getting his MBA he worked in Washington. But he hated it. So he decided to go to medical school.

“I don't want to be a businessman. There's no morals. There's no ethics. I want to go to medical school.”

Searching for scholarships through the military, he found that Army scholarships were the best. So he switched branches, attended medical school and residency, and spent 18 years in the military. During that time, he deployed to Iraq with the 82nd Airborne Division. And for four years he was command sergeant for the Army's Delta Force. Later, he retired as a Colonel from the Army Medical Corps.

After retiring he started a private practice. He went to a bank and asked for a $4 million loan. Fortunately, they liked his business plan, so he built a 14,000 square foot multi-specialty clinic. When corporate got unpleasant to deal with, he looked for the next adventure and entered “retirement.”

Publishing Two Books

The first of Bob's nonclinical opportunities in retirement was writing two books. His first book describes his experiences during Navy Seals Hell Week. The story is about a doctor trying to figure out why he and the 10 others in his group made it through that challenging process. The second book is called Swords and Saints: A Doctor's Journey. In it, Bob describes the experiences that led him to, and carried him through, his military and medical careers.

Bob looked for publishing options and found that traditional publishers required too much control over the contents of his books.  And that didn't appeal to him. So he self-published, using a corporate group in Canada called FriesenPress. They provided editors that taught him to grab the audience and keep their interest. He found a military-friendly publisher for his second book.

Other Nonclinical Opportunities In Retirement

Pharma Sentinel, a London-based company reached out to him. They are building a medical app that monitors and reports news alerts about medications to those prescribing and taking them. 

MedicorHealth is a company that discovered a money-making opportunity for primary care doctors treating Medicare patients. The company provides turn-key tools that enable physicians to generate income through remote monitoring of their patients.

Summary

In this episode, Dr. Robert Adams describes his long career, his book publishing, and the nonclinical opportunities in retirement that he discovered. And he believes there are many more such opportunities.

Links for Today's Episode:

• Swords and Seals Website
• Dr. Adams' LinkedIn Profile
• Bob's Email Address: buds81@aol.com
• Medicor Health
• Pharma Sentinel
• FriesenPress Publishing
• Heroes Media Group

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The post How to Find Nonclinical Opportunities in Retirement – 159 appeared first on NonClinical Physicians.

On this episode of the PNC podcast, Dr. Robert Applebaum joins me to discuss the transition into his nonclinical niche as a physician advisor after many years of clinical practice.

Rob’s training was in cardiovascular and thoracic surgery. He spent decades working in private practice, then as a hospital employed physician. He is the first guest I’ve had on the podcast that I have worked with in real life.

When we met, I was the chief medical officer. And he was the director of the open-heart program at our hospital. Now Rob is a physician advisor focusing on utilization management, quality improvement and clinical documentation.

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. And, unlike other programs, which typically run 1 – 1/2 to 2 years, this program only takes a year to complete. Recently, Economist Magazine ranked the business school #1 in the world for the Most Relevant Executive MBA.

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

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 needed 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.

Burnout and Fatigue

Cardiac surgeons spend much of their time in an operating room. The hours-long cases were beginning to take a physical toll on Rob. So, too, were the middle-of-the-night phone calls. Clinical practice was becoming less satisfying and more stressful. Even the complicated cases he used to enjoy were becoming a stressor that began to foster feelings of burnout.

The post How This Heart Surgeon Found a Rewarding Nonclinical Niche – 132 appeared first on NonClinical Physicians.

Dr. Ralph Wuebker is CMO at Optum 360, a revenue cycle company offering end to end solutions for hospitals and physician groups, and he hires and deploys UM physicians.

Ralph’s current responsibility is building Optum’s On Site Physician Advisor (OSPA) program, including: sales support, recruiting, training and oversight of physicians at over 70 hospitals.

Prior to that he worked as VP at Executive Health Resources, and was previously Medical Director at Great West Healthcare. He received his MD from the University of Missouri – Kansas City School of Medicine. He completed a pediatric residency at St Louis University. Several years later, he obtained an MBA from Washington University in St. Louis.

The University of Tennessee Physician Executive MBA Program

I'm very thankful to have the support of the University of Tennessee Physician Executive MBA Program offered by the Haslam College of Business. You’ll remember that I interviewed Dr. Kate Atchley, the Executive Director of the program, in Episode #25 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 most other ranked programs, which typically have a duration of 18 to 24 months, this program only takes a year to complete. And, it’s offered by the business school that was recently ranked #1 in the world for the Most Relevant Executive MBA program, by Economist magazine.

University of Tennessee PEMBA students bring exceptional value to their organizations by contributing at the highest level while earning their degree. The curriculum includes a number of major assignments and a company project, both of which are structured to immediately apply to each student’s organization.

Graduates have taken leadership positions at major healthcare organizations and have become entrepreneurs and business owners. If you want to acquire the business and management skills needed to advance your nonclinical career, contact Dr. Kate Atchley’s office by calling (865) 974-6526 or going to vitalpe.net/physicianmba.

Ralph Wuebker's Transformation

Ralph was always interested in economics. Hence, after practicing medicine for a while, he returned to school to earn his MBA. Now Ralph understands the concepts needed to discuss financial topics, which can be intimidating to physicians.

Completing the MBA created a network of resources for Ralph, and access to mentors who helped him tackle specific problems. However, an MBA is not for everybody. Ralph thinks it’s critical to define what you want to do with the MBA before making the major investment of time and money.

Click here to download the TRANSCRIPT

Ralph ended up taking a position as a UM physician advisor with a company in the medical necessity space to evaluate claims, review patient status, and appeal denials.

He sometimes wondered if he was in over his head, so he continued his medical practice on the side.

Surprisingly, he started to enjoy his medical practice more as it became his “side hobby” and not a full-time grind seeing patients. He found that combining part-time clinical and non-clinical jobs created a more satisfying balance.

Don’t be Afraid of a Steep Learning Curve

Ralph did a lot of learning on the job. His first year was just as challenging as his intern year after medical school.

As a UM physician advisor, Ralph thinks experience isn’t the most critical aspect.. Instead, attitude, culture fit, and approach are more important.

He found that when you're a vendor at a for-profit company, there’s a similarity to seeing patients, because it involves a lot of customer service. The clients must feel like they’re getting value from the services you're providing.

Eventually, the company Ralph worked for was acquired. The best advice he received about such a transition: “Get ready. You're about to see the best in people, and the worst in people.”

Employees took on different roles and responsibilities. But the company continued to grow and provide opportunities for an increasing number of UM physicians.

Time to Climb the Corporate Ladder

Ralph took on greater management and leadership roles. He ultimately became CMO at Optum. He advises us that if your goal is to be CMO or CEO:

• Don’t be afraid to get your hands dirty;
• Do the work that you expect every team member to do; and,
• Embrace change.

Companies that Ralph worked for have changed what they do and how they do it through the years. But they still focus on helping hospitals and health systems navigate changing billing and collection challenges.

They still strive to decrease denials, improve appeals, and reduce the hassle factors of complex revenue-cycle systems.

UM Physician Opportunities

There are ample opportunities for physicians interested in utilization management / utilization review. Hospitals are always looking for physicians to be on their UM/UR committees.

And Optum is almost always hiring somewhere in the U.S. If you're interested, us the links below to check out available positions.

The ideal candidates will have a good medical foundation and 5-15 years of clinical experience. Regulations and guidelines can be taught, but it’s a lot harder to teach someone good medical practice.

Links for Today's Episode:

Careers at UnitedHealth Group

Dr. Ralph Wuebker’s Email

Dr. Ralph Wuebker on LinkedIn

Pfizer

Optum360

What Color is My Parachute?

Pivot by Jenny Blake

Thanks to our sponsor…

We appreciate the UT Physician Executive MBA program for sponsoring the show. It’s an outstanding, highly rated, MBA program designed for working physicians. It might be just what you need to prepare for that joyful, well-paying career. You can find out more at vitalpe.net/physicianmba.

Thanks again for listening. I hope to see you next time on Physician NonClinical Careers.

As always, I welcome your comments and feedback.

If you enjoyed today’s episode, share it on Twitter and Facebook, and leave a review on iTunes.

Podcast Editing & Production Services are provided by Oscar Hamilton.

Disclaimers:

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. 

Many of the links that I refer you to, and that you’ll find in the show notes, 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. And I only promote products and services that I believe are of high quality and will be useful to you, that I have personally used or am very familiar with.

The information presented on this blog and related podcast is for entertainment and/or informational purposes only. It should not be construed as 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 counsellor, or other professional before making any major decisions about your career. 

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The post How to Go from UM Physician Advisor to Revenue Cycle CMO with Dr. Ralph Wuebker – 069 appeared first on NonClinical Physicians.