Lori Rogers-Stokes

Think back to the day you finished your residency. Were you prepared for the realities of falling reimbursement, reams of paperwork, and rising malpractice costs? Were you prepared to work until you were in your 70s?

How you answer that question depends on what year you finished that residency. And it lies at the heart of an emerging generation gap among younger and older physicians.

Ask anyone about the major source of differences -- and potential hard feelings -- between older and younger doctors, and the same issues come up repeatedly: there are fewer doctors willing to work 24/7, take call, or face the heavy workloads of full-time internal medicine or pediatrics. More doctors are choosing to work part-time, or to enter specialties that give them more free time. 

Corporate America's move toward work-life balance has caught up with the medical profession.

For the new generation, skimping on their personal lives is no longer a given when they see that most older doctors aren't reaping the rewards of giving up everything for their profession. 

"I don't see what I'd call a divide in my practice. But there are some generational differences," says Jennifer Shu, MD, chair of the AMA Young Physicians Section, which was founded in 1986 to help doctors make the transition from residency to daily practice. Shu, who is entering her seventh year of practice as a pediatrician at the Sharp Rees-Stealy Medical Group in San Diego, says, "Younger doctors have made work-life balance more of a priority. They've seen other physicians -- often their own parents -- burn out before retirement, and they go into the profession with more awareness of the burdens on practicing physicians. A lot of us make it a priority not to be brought down by that so we can do good practice over a long career."

"I think there are a fair number of longer-tenured providers who perceive that younger providers are much more focused on life balance," says Jayne Oliva, a principal with Croes-Oliva Group, a consultancy in Burlington, Mass. "They're approaching retirement, they want to scale back, maybe drop call. But they can't, because younger physicians are much less willing to take on more work. ... When you get down to best practice issues -- call, rounds, new patients, delivering babies -- when doors are closed in the practice boardroom and the younger doctors aren't saying, 'I'll do it, I'll do it,' that's an area of tension. Younger doctors are much more protective of their time."

Merritt, Hawkins & Associates, a physician search and consulting firm in Irving, Texas, recently published its 2004 Survey of Physicians 50 to 65 Years Old; the survey results verify that older physicians are indeed disillusioned. Its 436 respondents overwhelmingly cited a "general dissatisfaction with today's medical practice environment." 

Embedded in that survey was a two-part question about young doctors: Do you think they are as dedicated and hard-working as physicians aged 50 to 65? Sixty-four percent of the survey's 436 respondents said no. When asked if young doctors were more dedicated and hard-working than their older counterparts, a full 100 percent of respondents said no.

"We wondered if some of them must have checked the wrong box," says Kurt Mosley, vice president of business development at Merritt, Hawkins. "The purpose of the question was not to create a rift between older and younger doctors. It was to highlight the fact that 38 percent of doctors in practice today are over 50. We wanted to say, 'We're going to need the bulk of older doctors to continue to practice for five to 10 years until the new doctors grow into their roles.' But those older doctors have issues with the young doctors they should be mentoring. Their view of younger doctors is just one part of the substantial frustration and dissatisfaction of older doctors."

While one survey doesn't represent the entire medical profession, it seems clear that if more doctors are finding themselves on different sides of the work-life issue, conflict is bound to follow. And that conflict will be expressed in terms of how hard-working and dedicated doctors are, regardless of whether that's accurate. So let's examine some of the issues that can come up and ways practices can work toward a common resolution.

"Flex-time is a big issue," says Shu. "A lot of doctors coming out today want to be able to work part-time in a clinical practice and spend the rest of their time doing research, writing for Web sites, or working for pharmaceutical [companies]. Older doctors weren't usually in group practices so they didn't have the option to not be there when the phone rang."


It's not flex-time itself that causes problems, but a lack of organized, formal response to the demand for it, says Oliva. "If you work on a team, you cover for each other and it's informal and personal, so decisions about going to part-time are treated as personal agreements made between collegial partners. But these agreements come under stress when legitimate operational ramifications like coordinating care and taking call come up. When it seems like it's always the younger doctors who expect to go part-time, this can cause age-based resentment."

To avoid problems, Oliva suggests that groups devise a compensation formula "that [encourages] the behavior the group wants. If some people don't want to take call, those who do should be [more] highly compensated. Be very clear about expectations and contributions on both sides."

A case in point is West Ashley Family Medicine in Charleston, S.C., founded in 2000 by John Gastright, an internal medicine specialist. The practice has three doctors in their 30s and two in their 60s, including Gastright. "We have two younger doctors working three days a week," says Gastright. "They were part-time from day one. One of the reasons it works out well is that we all take call equally, and that prevents any problems between doctors concerning workload."

Gastright admits that he and his younger colleagues have different priorities when it comes to work. "We keep tension from building up about this by addressing it. Sometimes we'll say to the younger doctors, 'This is something you have to do.' And then they'll do it, if you put it like that. But it disrupts their activities outside the office.

 "That's what's really different about younger doctors: their life outside the practice is extremely important to them. We older doctors love our families and our outside lives, too, but we always put the practice first, life second. Our primary identity in life is doctor. I respect young doctors and their commitments, but I wouldn't change places with them. I get a lot of pleasure out of being a traditional doctor."

Improvements in technology and the overall quality of healthcare help drive the move to part-time work and more time for family and other interests. "Conditions that were life-threatening and required time-consuming care 30 years ago can be cured with a prescription or minor surgery today," says Mosley. "And younger doctors can do more in less time with technology. It allows them to maintain continuity of care without the huge time commitment."

But even practices suffering from a generation gap can level the technology playing field. "Physician leadership is crucial when it comes to technology adoption," says Pamela Moore, senior editor, practice management, for Physicians Practice. "Nontechnical physicians will get on board if they see other physicians achieving real time and cost savings. The hurdle usually isn't lack of ability or technophobia, it's that it can be hard to see the advantages of change." 

Gastright is one who does. "When I started this practice, I wanted it to be technically advanced," he says. "In fact, we're paperless. I think the age-difference problem has been overplayed; while it can be challenging, it's equally challenging for young and old. In our practice, all the doctors use their PCs to check patient charts from home, for example, and that kind of technology use helps us all get out of the office on time." 

When the subject of working part-time comes up, the fact that more and more women are becoming doctors inevitably follows. It seems logical to assume women will be more likely to go to part-time because of child-rearing responsibilities. But part-time is not a clear-cut gender issue.

"It's true that we can assume this was originally a female-driven trend," says Oliva. "But women don't dominate all specialties. [Over] 48 percent of pediatricians are women; that's the specialty with the highest percentage of female practitioners, and only 28 percent of those women work part-time. So if part-timers are an issue in medicine generally, then we have to look beyond gender."

 "In part, it's women in the workforce who want to have a little time off with their children, but I think it's more a question of working couples where both people are doctors," adds Shu. "In the past, most doctors were male and their wives stayed home with the children. Now you have a lot of male doctors who are married to female doctors and they both choose to be more flexible so they can share in household and family responsibilities. I know of a lot of dual physician couples, including my husband and myself." 

There are clearly differences between younger and older doctors. But that difference doesn't have to drive a wedge between them. It can unite doctors by giving them all a chance to change the way they work and achieve a measure of work-life balance.


"We're saying it's OK for anyone, of any age, to practice medicine successfully while also having a successful personal life," says Shu. "No one's saying, 'Oh, those old doctors were so crazy.' It was a different world, there weren't many options. Now there are, and they're open to everybody."  

This article originally appeared in the June 2004 issue of 

Articles

An update on generational differences among physicians

My Generation

Your patient has been feeling extremely tired, with aching joints, loss of appetite, nausea, and yellow skin. The patient goes online to a medical information site and learns the symptoms could mean Hepatitis C. What does he do next?

For more and more people, the answer is no longer to reach for the phone to schedule an appointment with you. Instead, they're grabbing the phone to order home healthcare tests. Just as online do-it-yourself medical diagnosis sites have proliferated in recent years, sites that offer home tests for a wide range of diseases, conditions, and other risks are finding a receptive audience among people who feel that, as informed adults, they are capable of playing an active role in diagnosing and treating their illnesses.

Type "home health test" into an Internet search engine and you'll find thousands of links to sites that sell hundreds of tests: date-rape drink tests, hazardous chemical detection strips, male and female infertility tests, a range of allergy and cancer tests, menopause monitors, cholesterol tests, urinary drug tests, HIV tests, and many more. 

What's behind the boom in this industry? The factors cited most often are privacy, convenience, cost, and control. Home health testing is anonymous, can be done at will without a long wait for an appointment, is cheaper than lab tests done through a physician's office, and puts decision-making about what is wrong, what should be done, and when -- or whether -- to consult a doctor into the patient's hands. Americans who consider themselves better informed about health issues feel that home testing levels the playing field when they do see their doctor.

The success of the home pregnancy test, which came out in the late 1970s, spurred the development of other tests and led to oversight by the FDA, which evaluates home tests and certifies those that can be trusted to provide accurate results when administered correctly. The FDA maintains a list of approved home test kits sold online and over the counter at drugstores and pharmacies at 

There are basically two types of home test: diagnostic tests used to discover existing conditions, and monitoring kits used to manage a known condition. But despite the growing popularity of both types, home testing is not on the radar for many physicians. 

Often patients don't tell their doctor that they've scheduled an appointment on the basis of home test results. They may want to avoid appearing as if they've gone behind their doctor's back. And while some physicians disregard home test results, there are many doctors who approve of and encourage home testing, for the same reasons of privacy and convenience.

Frannie Kronenberg, MD, a primary-care and internal medicine physician and medical director of Brigham and Women's Physicians Group at Brigham and Women's Hospital in Boston, is one of them.
"I see home testing as a helpful way to facilitate a partnership between patients and physicians," says Kronenberg. "As people get more access to information they want to have a more active role in managing their care. I see home testing as facilitating self-care, and enhancing the patient's role in healthcare overall. For example, take what glucose monitoring has done for diabetes patients: they can change their dosing and have tighter control of blood sugar to prevent complications." 

Medical associations, including the American Academy of Family Physicians (AAFP), have also endorsed home health testing; the AAFP states that it "recognizes the proliferation of home diagnostic test kits for a variety of diseases and conditions ... [and] encourages patients to consult with their physicians regarding selection, use, and interpretation of these tests."

But can laypeople be trusted to conduct and interpret home tests correctly? And does home testing challenge the importance of the doctor-patient relationship?

"People have a responsibility to do their own research and learn about the condition they're testing for," says Ken Adams, president of Home Health Testing in Melbourne, Fla., a retail company that sells home health tests online. "Many tests are simple, and so long as the instructions are clear, the FDA has said there's no reason not to do them at home."

If a test is not administered correctly and turns up positive for a condition, it's a mistake that's easy to correct -- and it's very likely to be corrected. "You take a test, then you go to the doctor and say, 'This test indicates that I may have this problem,'" Adams says. "The doctor may give you the same test again since he may not know if you did it correctly. But that's OK, because the whole point is to get you in to see the doctor. Better to self-test and then be re-tested than never to find out that you have a condition. 

"Do you really think that if someone takes a test and gets a positive result that they're not going to see their doctor? If you get a positive test result, you go to your doctor to see why."


Kronenberg agrees. "Home testing is only harmful when tests are unreliable and falsely alarm people," she says. "But overall, that's not as common as you'd think."

Susan J. Kalota, MD, of Arizona Urologic Specialists in Tucson, Ariz., says home testing is a part of her practice.

"As a urologist, I see basically two types of patients: older patients with complicated urinary tract infections; and young, sexually active women with frequent, simple infections. The latter are ideal self-test candidates. Established patients who take a home UTI test and get a positive result can drop off a urine sample any time, and if it comes back from our lab positive, I'll have a prescription on hand for them so they can just get their antibiotic. They don't have to come in to get a prescription. If their symptoms persist after three days, then they can come in for an exam."

People who resist coming in for testing or treatment often misuse home testing. "I've had patients call up and say, 'I know what I've got, just treat me,'" says Kalota. "I say, ethically, I can't do that. I have to see a urine sample so I can see that it was a clean catch and that it's a viable sample. We added a [physician assistant] so these people can come right in and get a full evaluation as soon as possible, without waiting for an appointment with me."

Kronenberg agrees that home testing must be verified by a doctor. "While I would use home test results as a starting point for evaluating what's going on with a patient, I would want to verify them, and as a matter of course I'd ask the patient all the relevant questions about history and symptoms. I wouldn't rely on test results and just medicate them. I would repeat the test and do other tests."

Clearly, physicians who have not already would do well to become more aware of the role home testing may be playing in their patients' care decisions.

The first step is the simplest: when it seems appropriate, ask your patients if they are basing an appointment on the results of a home test, and, importantly, whether they have already self-medicated on the basis of that test. If patients balk at re-testing, remind them that to ethically treat them, you must personally verify that their test results are accurate. Then, see if there is a viable way to incorporate home testing or monitoring into the patient's healthcare plan. 

Physicians can also follow Kalota's example and alter their practice to allow for home test verification outside normal appointments. Finally, letting patients know the risks of relying on home tests in place of an active relationship with their doctor will cut down on incorrect self-diagnoses and self-medications.

In short, the more you know about your patients' home testing and the reasons behind it, the better off you and your patients will be. It's clear home testing is a factor to reckon with in the ever-evolving doctor-patient relationship.

This article originally appeared in the April 2004 issue of 

Suggestions for managing patients taking advantage of home lab tests

Home Health Testing

What would you do if you drove to your office one morning and found the building was a smoking ruin? Or discovered that burglars had made off with your computers or medical equipment? Would you be able to recover from the losses quickly and continue seeing patients?

When doctors think of insurance, malpractice coverage is often what first comes to mind. But insurance industry and loss prevention experts warn that damage to a facility or its equipment -- even minor water damage from a flood, sprinkler system, or broken water pipe -- can force you to relocate for days or weeks while your office is dried out, rewired, and refurnished. If you share a building, one tenant's fire can result in smoke or water damage, even if the fire doesn't reach your space. 

Insurance coverage can help your practice to get up and running quickly after a disaster. It also can provide the funds to rent a new space while your building is repaired, buy or rent new equipment, and possibly arrange transportation for your staff and patients. 

Basic insurance does not typically cover floods and certain other catastrophes, and it may not cover the cost of relocating and replacing expensive medical equipment. That's why coverage for business interruptions, replacement of special equipment, and loss of critical information should be part of your practice's insurance portfolio.

Still, too many medical practices have inadequate office insurance or none at all, says Thomas H. Stearns, vice president of medical practice services for State Volunteer Mutual Insurance Company, a physician-owned malpractice company in Brentwood, Tenn. "We find doctors focus most of their risk assessments on patient safety and quality patient care and trying to stay in compliance with all the regulations they have to deal with. They don't spend a lot of time looking at other types of risk," Stearns says.

So where do you begin to protect yourself? "Start by looking at your office contents," suggests Larry Hansard, senior vice president of healthcare practice at McQueary Henry Bowles Troy LLP, a Dallas-based insurance broker. "The replacement cost of computers, phones, [and office] machines is a good starting point. If you're a specialist  --  say, a cardiologist -- remember to get coverage for more expensive machines, like EKG and stress test equipment. There are practices that don't even have this bare minimum of replacement coverage, but it's a must."

Protecting your office against theft means more than replacing lost or damaged equipment, drugs, and medical supplies. Think about your patient records, both paper and electronic (see sidebar, below). Do you have coverage to meet your legal liability if any files containing patient credit cards, insurance accounts, or Social Security numbers are used in an identity theft scheme? Adding a fidelity bond to your insurance coverage will protect you from theft committed by your own employees. 

Next, says Hansard, think about coverage for losses to the premises. "If you're pushed out [because of physical damage], you need the coverage to pay for moving," Hansard says. "It's a good idea to start by talking to the owner of your building and find out if they cover anything for you. Owners are primarily concerned about general liability, and probably won't cover any of their tenants' relocation or equipment replacement costs. They insure the building, not the tenant or the tenant's belongings."

The front line of defense to deter break-ins is an alarm system. Ask your building's owner about the facility's alarm systems, but don't stop there. Your offices should have a separate security system to detect any intruders who evade the main building's security system. Keypad systems, photo IDs, and "smart cards" with unique identifiers for each holder are common solutions. Some insurers offer premium discounts to businesses that use security systems.

How you use or -- misuse -- the security system is important, too. "Err on the side of caution and always remain vigilant," says Christine Mary Maggio, publisher and editor-in-chief of PrepareRespondRecover.com, an Albany, N.Y., company that provides safety planning and disaster response and recovery support to small to midsize businesses. "For example, you might have office doors that require an ID card to be scanned before they open; however, this safeguard is completely bypassed when people 'helpfully' hold open the door for others," says Maggio. "A thief posing as a delivery person -- or even as a patient -- can easily slip into a building this way. Simple but regularly reinforced practice policies can go a long way toward reducing the likelihood and consequences of theft."

A break-in, flood, fire, or other catastrophe can make your facility unusable. That's why business interruption insurance is a valuable addition to your coverage portfolio. "If a tornado comes through and destroys your building, business interruption insurance protects against lost revenue from not being able to practice for some period of time," says Hansard. "It covers the expense of setting up business elsewhere and replacing your equipment."


Business interruption insurance is usually included in a business owner's policy (BOP), according to Mike Kraus, an underwriter with Russell Bond & Co. in Buffalo, N.Y. "Normally the BOP includes business interruption along with property and liability coverage, but only for 12 months," says Kraus. "It covers the actual loss sustained -- there's basically no limit on coverage for that period."

Talk with your insurer about whether you should extend your business interruption coverage past the initial 12 months. "If you don't have a lot of specialized equipment, you might be covered well enough by the property insurance," says Kraus. 

Cash flow is another issue. Does the practice have enough cash on hand to keep employees on the payroll and pay vendors in the event of an extended interruption? "The practitioner should also discuss with their financial and legal advisers a plan for using (or not using) business credit cards and lines of credit that were opened for the purpose of addressing normal operating expenses," says Maggio. While it may be tempting to use these resources during a period of business interruption, doing so over an extended period when the practice is not generating income can cause some significant problems down the road, she says. 

When searching for the right insurance agency for your practice's needs, "It's very important to get input from trusted financial, legal, and asset management advisers," says Maggio. "That includes the practice's accountant or CPA, attorney, and others."

What are the costs involved? According to Hansard's firm, you can include business interruption insurance for roughly the same price as your property coverage. That means that if you pay 15 cents per $100 of replacement value property insurance, for example, you'll pay close to the same rate for the business interruption coverage.

"Business interruption coverage is a relatively small premium," agrees Kraus. "If you think that your loss due to fire or theft or whatever happens may run into tens or hundreds of thousands of dollars, business interruption coverage is pretty affordable in comparison."

"The overall cost of catastrophic coverage may be not too much more than basic coverage if the policy is well-crafted and customized to address the specific needs of the practice," says Maggio. "The key here is to shop well for insurance. The physician needs to do some homework on the insurance companies that are being considered. Look for evidence that the company has a reputation for offering well-designed policies and being fair and reasonable when evaluating and settling claims. They may not be found in the local phone directory and it may take some initiative to find them, but the Internet, practitioners' professional organizations, and referrals from colleagues can help in this phase of the process."

If you own your building, look for insurance that includes the replacement value of the building and automatically reimburses you for possible required building code upgrades when rebuilding. And remember to request coverage for specific features of the building if necessary -- for example, architecturally significant windows or doors. 

Once you've got adequate insurance coverage in place, it's wise to have a plan for dealing with possible future damage or loss.

Emergency preparedness plans should include how you will contact your staff to let them know the office has been damaged, where you will meet if you can't meet at the office itself, and how you will contact your patients. Each staff member should have a specific task or tasks to take care of, whether it's calling patients, retrieving files, or overseeing the move of salvageable material and equipment to storage or a new facility. Review the plan at least quarterly to make sure that the lists of staff assignments and telephone numbers remain up-to-date.

You should also have a plan in place to address paying salaries when your practice is losing income. This might include letting temporary staff go, temporarily laying off some of your regular staff, or instituting temporary pay cuts. Ideally, you will avoid these measures by getting insurance that covers employee compensation.

The take-away message is this: don't take your practice facility for granted. Prepare for disasters before they occur by beefing up insurance coverage, facility security, and emergency planning. It will be a lot easier to pick up the pieces after a catastrophe if you already have the money and the blueprint for getting back on your feet in place before trouble strikes. 

This article originally appeared in the January 2004 issue of 

Too many medical practices have inadequate office insurance or none at all

What Have You Got to Lose?

You've just finished eating lunch and are sitting near the back of a crowded, darkened room watching a slide presentation. You had hoped to pick up some pointers on the latest diabetes treatment. Instead, the presenter at the front is only halfway through his 200 illegible slides on cellular function. Is this worth three hours -- or two days -- away from my practice, you wonder?

Is this your vision of continuing medical education (CME)?

For too many physicians it may well be a familiar -- and disheartening -- scenario. But it isn't just a lack of scintillating offerings that can make getting your CME credits a burden. Just as so many presenters fail to come up with interesting approaches to their topics, many physician attendees fail to develop the good lifelong learning habits that can help them get the most out of CME.

When it comes to earning CME credits, the burden of success is on you, the physician. It's physicians who have to find the best offerings, make time to take advantage of them, and constantly evaluate their own aptitude for and receptivity to the process of lifelong learning itself.

For some, lifelong learning may be construed as a treadmill where you forever chase after the newest theories or procedures, regardless of their true relevance to your daily practice. But lifelong learning is not just about earning CME credits. It's about understanding the value of staying on a learning curve. It's about infusing formal education sessions with the knowledge you pick up on the fly every day in your practice, and bringing the learning curve to your practice. And it's about developing strategies for discerning real learning opportunities from among the thousands of invitations to seminars and conferences you receive each year.

Two facts of life hamper physicians' attempts to become good lifelong learners: the demands of their daily practice and their lack of exposure to good lifelong learning habits. The rigors of medical school are partly to blame. Many doctors become hardened crammers who feel that once medical school is over, they've earned a break from studying. 

"I think I learned more about lifelong learning when I was an MBA student than when I was in medical school," says John DeMaio, a part-time neonatologist and president of Cadence, LLC, a healthcare consulting firm in King of Prussia, Pa. "One of the things we need to do to improve the education of healthcare professionals is to teach good habits of lifelong learning. During the residency years, you don't hear about it because your existence is education. But the moment you've finished your formal training, that goes away and you're left to your own devices. We don't teach habits that will endure beyond that context."

Once they're past cramming, doctors may do the bare minimum to earn the necessary CME credits, or apply the same frenetic approach to study that can creep in during medical school. But lifelong learning takes time, planning, and dedication -- three things most doctors apply to their daily practices already.

So how can a busy physician become a dedicated, engaged learner?

"Making it a habit is the most important thing," says Brian Goldstein, who practices internal medicine at the University of North Carolina School of Medicine in Chapel Hill. "That might be as simple as carving out 20 minutes a day to review journals, or going to a grand rounds once a week, or making time for uninterrupted online or video CME. It has to be part of the fabric of your professional schedule."

DeMaio agrees that discipline is key. "You have to have a mindset in which you are constantly looking at your clinical practice to identify your own educational needs and then meeting them. There's an oversupply of educational programming. The challenge for physicians is knowing what their educational needs really are. How do I know what I don't know? That's the question you need to learn to ask and answer for yourself. I don't think we do a good enough job helping people figure out how to do that."

The good news is you are expanding your knowledge every day as you go from patient to patient.

"It's harder and harder for me to separate CME for credit from the learning we all do every day on the fly," says Goldstein. "Whenever I download information or references on my PDA because I've seen a patient and I need to get data to help them, that's a similar skill to doing lifelong learning through traditional CME activities. It's a time-sensitive version of CME."


DeMaio calls this concept "inline learning." He says an example of this kind of educational opportunity in his own clinical practice as a neonatologist is "when I'm confronted with a patient with dysmorphic features. I go on the Web and I've got the patient in front of me and an educational resource right at my fingertips. I can do my learning and fill the void in my knowledge in that one moment. I think that's the future of education."

"I'd like to see physicians receiving credit for learning what they feel they need to know based on their professional experience, as opposed to learning what someone else thinks they need to know," adds Michael Golub, an emergency room physician and director of CME for Medical Broadcasting Company in Philadelphia.

Some states are taking Golub up on that. "When I went to renew my state medical license recently, the medical board had a category called something like 'reviewing clinical information specifically related to a patient case,'" says Goldstein. "You could tabulate the hours you'd spent doing that and apply it to your credits. I was pleased to see that. I think we need that kind of a broad and progressive definition of CME requirements."

Once you've dedicated yourself to being a lifelong learner and you've begun to see your daily practice as an integral part of CME, you have just one hurdle left -- choosing which formal CME offerings to participate in.

You want to choose events that complement the learning you do in your daily work and that focus on your specific needs. It should be easy to find a half-dozen events that meet these two simple goals out of the hundreds of invitations you receive each month, but that's not always the case.

"Too much CME focuses heavily on the basic science and pathophysiology," says Golub. "The best CME is devoted to practical learning and decision making. If the audience is surgeons, for example, the best CME on a particular procedure might include the fine points that only an experienced surgeon would recognize, like where to stand, how to position yourself, optimal lighting technique, best instruments, etc. Instead, you get courses devoted to the molecular, cellular, anatomic, and pharmacological aspects of medicine, while paying short shrift to the actual behaviors and cognitions involved in being a clinician."

Christopher Crow, a physician at Family Medical Specialists of Texas in Plano, agrees that "CME courses need to be more practical. I've been to some that have been painful because they have nothing to do with my practice. Even though the drug may, they skip over everything that makes sense and go straight to cellular issues. I don't need to listen to someone going over biochemistry and cellular function for two hours." 

Presentation skills can matter as much as content. "I got an executive MBA last year and one thing I learned is you have to be a good presenter," says Crow. "Don't speak in a monotone. Interact with the audience. And don't have a million busy slides you just stand there reading aloud."

A great way to get CME credits without leaving home or your practice is to use the Internet. According to 

, the number of sites offering online CME credit hours jumped from 96 in February 2000 to 250 in July 2003; credit hours offered leapt from 3,000 to 20,300. The site is operated by Bernard Sklar, MD, who also has a graduate degree in Medical Information Science.

But online technology can test the mettle of most would-be e-learners. Participating in an online discussion or seminar means finding time to be in your office on your computer without interruption: no pages, knocks on the door, or phone calls to pull you away.

That's tough, says Goldstein, who has not yet accessed CME online. "It's harder for me to carve out the time to just focus on an Internet course, though in theory it should be more convenient," he says. "The chances of getting interrupted are just too good."

Another hurdle for online CME offerings is living up to the potential of the medium. "With few exceptions, most online CME providers don't really use its unique attributes," says DeMaio. "One of the beauties of this medium is its interactive potential. But when you look at most of what's on the Web now, it's just repurposing of monographs or slide presentations. One reason for that is it gets expensive when you develop interactive programs. And until everyone has broadband capabilities or DSL, it can be a very unsatisfactory experience."

Price does come into the online CME equation, according to Trace Urdan, a principal at ThinkEquity Partners, an institutional investment bank and industry research group in San Francisco. "You need a big investment of people, time, and money to create advanced, interactive technology, so for CME it comes back to the question of who's going to make that investment."


There are many companies that create online CME, but the big player that's missing is the pharmaceutical companies that sponsor most traditional CME events. "Drug manufacturers have high attendance levels at those events," says Urdan. "The events also provide a level of product support for them. So why should they invest a lot of money and effort in creating online technology?"

Still, Urdan points to many technologically rich online offerings -- especially simulations. "Simulations stem from the philosophy that trial and error is the best way for someone to learn," Urdan says. "The common element of simulations is that they require some level of interaction on the part of the learner, and you get different outcomes with different choices. If doctors are actually diagnosing fictional patients, for instance, it makes the whole exercise more engaging." 

Rather than reading the results of someone else's efforts, doctors in online simulations can come to their own conclusions by learning from their mistakes without running the risk of harming an actual patient.

Whichever venue you choose for CME, you will get more out of your experience if you develop good learning skills -- which may mean unlearning often-frantic medical school study habits -- and analyze prospective offerings for their relevance and interactivity. In Golub's words, when it comes to CME, "relevant, practical, and timely equal excellent." 

This article originally appeared in the October 2003 issue of 

Learning for Life

That's not a question you should wait to ask yourself when your hair is gray and your shingle weathered. According to financial planners, business consultants, and even experienced practice administrators, physicians should take concrete steps toward a viable retirement from the moment they start their practice. This is because physicians face a retirement double-whammy: they start making money later in life, yet they tend to retire earlier.

"Doctors don't get their first real jobs until their 30s, and then they have a lot of debt," says Marc Singer, a principal at Singer Xenos Wealth Management in Coral Gables, Fla. "They're finally getting up to zero net worth at age 40. But at that point, they may not be far from retirement, since many specialties, like neurosurgery, require top physical skills. What if you feel yourself coming off that peak at 55? Most doctors retire much younger than age 65. You could well have a working life expectancy of 20 years, not 40."

Indeed, financial planners and consultants notice a trend of doctors retiring younger. A 2000 survey in 

 showed that 38 percent of doctors age 50 or older planned to retire within one to three years. While financial security is a top concern, there are also operational factors to work out with your practice or partners in advance. And many physicians tend to make one of two mistakes: putting off planning for retirement, and investing too aggressively in an attempt to make the most of their money.

To gauge your retirement readiness, ask yourself the following questions:

This is the first question most physicians ask themselves, and the answer is almost always no. It's not just their late start and relatively short working life that convince many physicians they're financially unprepared for retirement. With insurance premiums high and reimbursements low, even successful doctors believe they will never have enough money to retire.

"It's not uncommon to hear doctors say they will never retire, no matter what, because they can't save money in today's practice environment," says Singer. "They say, 'I'll just work until I die and then my wife will get the life insurance.'"
 


You can't know if you have enough money to retire until you know how much money you'll need over the span of your retirement. Physicians, like most people, tend to underestimate this amount.
"Most people spend more when they retire -- more on recreation and more on their own medical care," says Sidney A. Blum, president of Successful Financial Solutions in Northbrook, Ill. 

"Credit card debt becomes more of a liability. You can't say, 'I'll spend less once I retire,' because you're fooling yourself. Before you retire, you've got to realistically figure how much you'll need per month."

"People don't want to come down in their lifestyle once they retire," agrees Marilyn M. Gunther, a certified financial planner and senior partner at the Center for Financial Planning in Southfield, Mich. "To avoid this, you have to look at all income sources: Social Security, fixed pensions, and investable assets available for retirement only (as opposed to assets set aside for children's education, for example). Then add a 3 percent inflationary factor for income (income should go up 3 percent per year) and a 5 percent to 6 percent investable return on assets. Once you look at all these factors, you can figure out whether you can meet your objectives by the age or year you've chosen to retire."

Sometimes basic expenses are overlooked. "Make sure you have long-term care insurance -- that's very important," says Blum. "You'd think doctors would be particularly aware of this, but often they aren't."

Once you come up with a realistic figure for your retirement income, how do you ensure that you meet that goal? This is the part that makes many doctors nervous. How can they generate two million dollars in just 20 years? Saving and seemingly staid methods of investing, like mutual funds or money market accounts, don't seem aggressive enough, and doctors are often led to invest in more risky schemes.

"Doctors tend to invest too aggressively," says Singer. "We call it the catch-up syndrome --  you're 35 and just starting out while your friends are on their second house and a nice 401(k). Doctors feel like they have to take excessive risks just to catch up. So they invest in programs with promises of unrealistically high rates of return.


"A rule of thumb is the 5 percent rule: assume the best you'll do on your money is 5 percent a year --  that's the most you can live on. If you have $2 million in assets, you should only plan on spending $100,000 a year after taxes. That should anticipate reasonable taxes, inflation, and rates of return. And even in rough times, like the past few years, this formula works at 4 percent." 

Creating a conservative portfolio and paying off debt top the list of recommended planning strategies. "Retirement planning is mostly about controlling spending and making good investment decisions," says Blum. "The magic of compound interest works in your favor, so start a savings program early on."

When it comes to investing, think safety first. "The absolutely foolproof thing you can do that no one does, because it's boring, is to take your monthly savings and invest it in a mutual fund," says Singer. "Put $500 a month into a money market account and you're virtually guaranteed a good return. Five hundred dollars per month for 25 years with the market earning 10 percent overall comes to $663,000. And a well-compensated doctor should have more than $500 to put in each month."

It's also important to make sure your investment assets will be liquid when you need them. "The typical physician, one week before retirement, has zero total investment income," says Singer. "If you stopped working tomorrow, how much money would come in from your investment income? The answer is almost always zero. That's because your assets --  a house, pension plan, brokerage accounts, IRAs --  don't produce income."

The fix is simple: "Set up a cash-flow stream where money comes in on a monthly basis," says Singer. "For example, if you need $6,000 per month, set up $18,000 in a money market, and that will provide income for the first three months. Then look at all your investments and decide what to sell to replenish that money market account at $18,000. It's a planned liquidation of certain assets that acts as income."

Not all retirement hurdles are financial. Continuing down our retirement readiness checklist, we come to the legal (and sometimes emotional) issues that come into play when you leave your practice. 

Many physicians make two assumptions about leaving their practice: that they will be bought out, and that they don't need to write up a buy-sell agreement until retirement is just around the corner. Wrong on both counts. 

"Sometimes there's hostility when a doctor retires," says Singer. "It doesn't go as smoothly as some anticipate, with seniors gracefully exiting and juniors taking over. Many practices are no longer worth much more than a percentage of receivables. If you want to be bought out, plan it out as many years ahead as possible."

Norma Plante, senior administrative director at Scripps Clinic in La Jolla, Calif., agrees. "I worked in a small orthopedic practice that had a partnership agreement spelling out the terms of the buy-out, but it didn't go smoothly," she says. "The initial agreement was set up in the days before managed care, when physician incomes were much higher. The buy-out was actually a financial burden for the doctors left behind because they had to pay out more than they could really afford. The buy-sell was never updated because changes required a simple majority and the doctors at or near retirement did not want to change it. The senior doctor who wanted to retire is still working."

How to avoid pre-retirement stress and misunderstandings? Planning. "Transition planning should be in place from day one of your partnership," says Gunther. "As in most small businesses, the coming together is easy, the leaving is not. There's plenty of enthusiasm for building, but not for paying out people's share."

Blum concurs. "As you form the partnerships you should work these things out. Be creative in structuring compensation for your practice. Do you want cash up-front, payments over a period of years, or a percentage of future collections? Do you want a cut on any new clients that come in because of existing clients? If you're a sole practitioner, could you take your practice to a competitor and work out a merger?"


Battles between doctors can impact the very asset they're struggling over --  the practice itself. Staff take sides when doctors argue, and morale and performance are affected. "Some staff leave with a doctor if they've been together a long time and the staff feel like the doctor was cheated," says Susan Rockwood, administrator at Stillwater Medical Group PA, in Stillwater, Minn. And problems for staff lead to problems for patients.

"One of the main concerns is providing continuity for the patients," says Rockwood. "You have to notify patients well in advance of the retirement and suggest how they might go about establishing a new relationship with another doctor. It helps to have a letter go out from the retiring doctor thanking the patient and making the connection to another doctor."

"The best thing doctors can do," says Plante, "is to automatically revisit their retirement agreement every few years, so decisions don't become personal."
 


Last but not least, it's crucial to think positively about life after retirement. While no one looks forward to the stereotypical vision of lounging in rocking chairs and building ships in bottles, doctors can be especially depressed by what they perceive as a life of inactivity or lost identity.

"Even those with a lot of outside interests find their work makes up their identity," says Rockwood. "This can be especially true in a small town where they've been the doctor for 30 years and everyone has a professional relationship with them. They are 'the doctor,' and that's hard to walk away from."

However, Gunther sees more and more doctors who are not totally defined by their work. "Older doctors were mostly working in individual practices, while younger doctors are either in large partnerships or in HMOs or other large organizations. For them, being a doctor is not such a purely individual reflection of themselves."

Retirement need not be the unpleasant reality waiting at the end of the road. With thorough planning and the right mental preparation, the retirement years really can be golden. 

This article originally appeared in the September 2003 issue of 

Retirement Readiness

Can't grab 10 minutes to look at your practice's bigger financial picture? Maybe an accountant can help. Long accustomed to getting help filing their personal income tax statements or maybe handling payroll, more physicians are now tapping accountants for expanded services. They are an integral part of many groups, even small ones.

For Dr. Frank Ingrish, a solo dermatologist in Alexandria, La., an accountant is indispensable.

"In my practice, it's just routine," says Ingrish. "I can't imagine going without a CPA (certified public accountant). My accountant handles the basics, like taxes, monthly statements, and bookkeeping, but he also spots trends in my daily payroll operations."

"Bottom line, if you assume that a medical practice is a business, then a good relationship with a CPA brings a strong business discipline to your practice," agrees Ken Hertz, an independent healthcare consultant and former practice administrator in Alexandria, La. "I'm talking about controls for handling money, reporting financial performance, and evaluating the health of the practice, then using those financial tools to make informed decisions about leasing, renting, and purchasing. There's also encouraging the development of operating budgets so you have an ongoing guide and series of benchmarks to measure how you're doing."

That said, not all accountants are created equal. Knowing what to expect from yours and taking some time to identify and discuss your needs can turn a mediocre arrangement into a revenue-building, cooperative relationship.  

First thing: Know who you've hired or want to hire and what you want them to do. Accountants fall into two camps: public accountants and certified public accountants. Both are generally trained in accounting and business principles, but CPAs must pass a rigorous exam testing their grasp of accounting and tax principles, auditing standards, and business law. CPAs are also state-certified and must meet continuing education requirements. 

The services you need from an accountant also fall into two camps: basic financial services and healthcare-specific services, including revenue enhancement, practice valuation, mergers and acquisitions, practice restructuring, and physician compensation. Sit down with your administrative staff and partner physicians and make a comprehensive list of what data you want, how often you want to meet with the accountant, and which tasks you'll keep in-house. 

While it's tempting to save money by keeping most tasks in-house, make sure to do the math. It may seem cheaper to have your practice manager handle most accounting tasks than to pay an accountant's hourly rate, but if the manager makes unwitting errors or spends so much time on accounting issues she does nothing else, your practice may end up spending more money than it saves.  

"We've taken back some tasks from our accountant, but there are some areas where we absolutely need an accountant's expertise," says Linda Minkel, practice administrator at the Pacifica Institute of Cosmetic Surgery in Camarillo, Calif. "The more you do in-house, the more you'll save on accounting bills, but it has to make sense. Sometimes the savings hides a waste of time and effort. For example, it's cheaper for me to do payroll, but it eats up my time, so we outsource that."

Outsourcing can also provide additional security. Most practices need more oversight of their quarterly or even monthly operations.
"In small offices you often find one person is in charge of a physician's money, life, and schedule," says Rick Blum, president of Kingsley Consulting Group Ltd. in New Orleans. "That one person is trusted immensely with everything. They open the mail, take the checks, make the deposits, keep the records. Even if this person doesn't deliberately commit fraud, which they're in a position to do, they can make honest mistakes no one's there to catch, and then the practice is in trouble, especially at tax time."

"I've heard horror stories about doctors who were duped by trusted managers," says Minkel. "For me, it's a confidence-builder to know that if I make a mistake there's an accountant who'll bring it to my attention. That way I don't have to worry about the data I turn in at tax time, and no one has to worry about whether I'm doing my job."

Whether you have an existing relationship or are looking to hire someone new, it's also important to have an open conversation with an accountant about his or her experience and expectations. Start by asking about healthcare experience.

"Ask them how many doctor clients they have -- what's their medical experience?" suggests Larry Lehman, a practice administrator and CPA with Specialty Clinics of Georgia in Atlanta. "The medical profession has multiple unique accounting problems you don't run into in other fields. If your CPA isn't familiar with those problems they can do you an injustice. And don't be afraid of lots of clients; our CPA has 40 to 50 other physician clients. The more clients an accounting firm has, the more experience they have."


Present your needs thoroughly. "You sit down and determine what the skill sets are in the practice and which functions need to be filled, and then decide whether these functions can be filled from within or by outsourcing," says Hertz. "Then you sit down with your CPA candidates and you present those needs very specifically. There shouldn't be any surprises."

A good accountant should be able to tell you if your expectations don't jibe with how much you are willing to spend on accounting services --  an important issue to sort out before beginning a relationship.

Some issues don't make it to the negotiating table at all, but can end up costing you and coloring your entire relationship with your accountant. What are their hours? How much time do they have for questions and consultation on basic issues that take only a little time?

For instance, "Ask whether you're going to be charged every time you make a call," suggests Minkel. "If you have a quick question and you call the accountant to check it, are you going to find that two-minute call on your next bill? And what about emergencies? If I get a call from our workers' comp carrier saying they want to audit our records by a certain date, I have to be able to get that information from the accountant in just a few days' time."

Whatever the specifics, be sure to make the accountant-practice relationship a substantive one. Often practice members see the accountant as an outsider who comes in to criticize or to blame, and this is especially true when you only see your accountant at tax time. Making an effort to involve your accountant in your practice on a more regular basis creates a more collegial atmosphere.

Face-to-face contact is especially important; if the accountant is just a voice on the phone, you'll never really feel connected. Many practices have monthly in-person meetings with their accountant; some include their accountant on their board of directors. Other accountants are invited to company retreats. Doctors too busy to give face time should receive written updates on a regular basis, tracking their individual performance as well as the business of the practice as a whole.

"At our practice, each doctor has an individual cost center," says Lehman. "The CPA reviews their costs and income at the end of each quarter and then does personalized financial planning for them."

How much you pay for accounting services varies according to the scope of those services and the size of your practice. Estimates run from .5 percent to 2 percent of monthly expenses, or .7 percent to 1 percent of yearly practice revenue. Put into dollars, that can mean $30,000 to $40,000 per year for large practices and $8,000 to $10,000 per year for small and midsize practices. Some one-person practices receiving minimal services may pay as little as $2,400 per year.

"A large cardiology practice might be billed $40,000 a year, and that's .5 or .6 percent of yearly practice revenue," says Greg Gates, a principal at Gates, Moore & Company in Atlanta. "A two-person practice might be billed $8,000 a year, and that's closer to 1 percent of their yearly revenue."

That annual fee can seem daunting once a practice figures out exactly what level of services it needs. But don't give in to the temptation to scrimp on accounting to save money.

"I can justify the cost of using an accountant on the basis of third-party payers alone," says James D. Knoepp, MD, a cardiovascular surgeon recently retired from private practice and now a critical care intensivist at St. Francis Cabrini Hospital in Alexandria, La.

 "Third-party payers require so much information --  I wouldn't have time to practice medicine if I tried to track it, provide it, and verify it myself," says Knoepp. "And with all the other legal requirements for practices today, from collections to revenue flow to billing processing and Medicare, you're in trouble without a certified accountant working on your team."

Also, a good accountant will more than make up for their fee in savings to you. "I always said if I didn't save my client at least the amount I was billing, that client didn't need me," says Lehman.

Bottom line, the most important thing you can do to make sure your investment in an accountant is efficient and cost-effective is to take responsibility for letting the accountant know what you want and when you feel you're not getting it.

"Most accountants get busy," says Gates. "It's hard for them to step back and say, what can I do for THIS client."

And when you do get reports from your accountant, don't let them gather dust. "You want to know doctors are reading your reports," says Lehman. "Sometimes smaller practices say, 'Oh, we don't have to worry about tracking all those factors, and we don't have the time or money to get in deep with an accountant,'" says Hertz. "But every practice of every size needs controls and alert mechanisms in place to monitor their financial health. Costs are rising, reimbursements are down, the rules are constantly changing, and you've got to be smarter and smarter about the financial side of your practice. Part of that is getting smart about your accounting." 

This article originally appeared in the July 2003 issue of

Physicians are now tapping accountants for expanded services