So, I survived the whole winter without getting sick. I evaded seasonal flu, H1N1, RSV and even a bocavirus or two. I religously wash and sanitize my hands, at work and at home. In fact, I drive my husband crazy nagging him to wash his hands right when he gets home from work because A) he takes the bus B) he works with Pseudomonas (that's not a person, but a nasty bacteria) and C) I have a strong aversion to smells on hands, even those that aren't my own.
Despite all of that....I came down with a raging cold that bloomed into a sinus infection just in time for my annual "March Madness" vacation. On antibiotics and breathing freely, I am back at work 2 weeks later. And back to blogging. Now just in time for the historic health care reform passage. Atul Gawande, of whom i've spoken before, writes a thought-provoking editorial for The New Yorker calling on physicians and communities to take responsibility for the success of the reform and the repair of our damaged health care system. The battle has just begun.
Wednesday, March 31, 2010
Thursday, March 11, 2010
The Top Five
My husband and I, when we were first dating, used to play the "top five" game. You know, when you ask each other for your top five books, movies, teams, songs, bands, etc. It was a great way to get to know each other and the game served to ease us through the awkward "chatting with you over dinner before this bottle of wine kicks in" phase. (so glad that's over!) In fact, we just played this game and listed our respective top five Stephen King novels (over a bottle of wine coincidentally). I happen to be a huge fan of the author and my husband, well, was more of a fan in junior high than now. But we can't all be highbrow with our literary leanings.
There was recently a fascinating editorial published in the New England Journal of Medicine regarding "top five" lists. The premise is this:
The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit.
Working in a neonatal intensive care unit, where we routinely keep babies alive artificially and often for great lengths of time, I witness firsthand the miracles of medical technology. And the failures. And the ethical dilemmas. And the extraordinary costs of doing things because we can. I also witness my friends in general pediatrics working long hours and fighting everyday to spend enough time with their patients and families under the constraints of billing and 'moving them through'. It's no secret that the 'doing' specialties are reimbursed far more than the 'talking' specialties. Technology pays. An interesting spin on the healthcare reform debate...
There was recently a fascinating editorial published in the New England Journal of Medicine regarding "top five" lists. The premise is this:
The Top Five list would consist of five diagnostic tests or treatments that are very commonly ordered by members of that specialty, that are among the most expensive services provided, and that have been shown by the currently available evidence not to provide any meaningful benefit to at least some major categories of patients for whom they are commonly ordered. In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit.
Working in a neonatal intensive care unit, where we routinely keep babies alive artificially and often for great lengths of time, I witness firsthand the miracles of medical technology. And the failures. And the ethical dilemmas. And the extraordinary costs of doing things because we can. I also witness my friends in general pediatrics working long hours and fighting everyday to spend enough time with their patients and families under the constraints of billing and 'moving them through'. It's no secret that the 'doing' specialties are reimbursed far more than the 'talking' specialties. Technology pays. An interesting spin on the healthcare reform debate...
Tuesday, March 2, 2010
Thank God for Unanswered Prayers. Because I Said So.
Let's be honest here. There was once a time when I naively believed that as professionals we would look out for each other and treat each other with respect and kindness. That was until I was offered my first real employment contract. This was about two years ago, after I had decided to leave my fellowship and was floundering about trying to figure out what the heck I was supposed to do with my life. In the process, I had interviewed with a private practice in an affluent community, a community health center in an underserved community, a private practice in a middle class community, a pseudo-academic peds hospitalist group, a community peds hospitalist group, a neonatal hospitalist group and an ethics fellowship. Oh, and I tried to submit an application at Borders but my husband wouldn't let me. I was clearly a bit directionless. That being the case, when I was offered a position with a private practice, I jumped at the chance to settle into a life polar opposite to what I was living as a fellow. After getting the contract (a 20 page monstrosity) I decided to have it looked over by a lawyer simply as a formality. That flip decision ranks as one of the most important in my life to date. Who knew? This blog, my friends, is dedicated to the road not taken and I hope that a little tidbit from here makes a difference to at least one little starfish...
Lessons I Learned About Contract Negotiation, Part 1:
1. Don't treat yourself to a celebratory dinner and bottle of wine until the ink is long dried on the contract that you successfully negotiated to your liking.
2. Spend whatever you have to on a lawyer experienced in physician contracts to look over yours. Just do it. Please.
3. Don't be so enamored with your base salary that you ignore how your raises and bonuses will be determined. "Physician's base salary will be reviewed and adjusted if necessary" does not cut it. If it's not in the contract, it doesn't exist.
4. Tail insurance coverage = big deal. Typically, the tail is about twice the cost of the annual premium. So, if the 1st year premium for you is $6000, the tail is $12000 for that first year. In many practices, until you become partner/shareholder (more on this later) you are responsible for the cost of your tail (or a portion) if you leave for any reason. This is why some say that joining a private practice is like getting married. You better be damn sure that's what you want or else it will come back to bite you in the tail (I couldn't resist). This could potentially be thousands of dollars you will owe the practice when you leave. Ouch!
5. Restrictive covenants are standard nowadays. They are otherwise known as 'non-compete clauses'. Make sure that they don't prohibit you from practicing anywhere else in a reasonable drive from where you live. E.g. a radius of 7.5 miles in Chicago is pretty rough. In Phoenix? Not so bad. Get out a map and use it.
6. Termination. It could happen to you. The following sentence is a red flag "Employer may terminate this agreement immediately if...Physician engages in conduct that, in the sole discretion of Employer, is detrimental to patient care or to the reputation or operations of Employer." Wow. That basically says that they can make up a reason not to like you and fire you immediately. Here's another one, "... the other party shall have no rights to cure or contest the termination of this Agreement." I can't even contest it?? This clause smacks of the "Because I said so" mantra of my mother when I was young.
7. Here's another one of my favorites. "Physician agrees...not to make any disparaging remarks to any third party concerning Employer or any of its officers or directors...throughout the term and at all times thereafter." Really? You mean I can't say anything nasty about the unreasonable and freakishly controlling contract you offered me? I can if I didn't sign it. ;)
8. Clarify your vacation time/CME time/sick leave. Especially if you see a rule like this one. "Excused time for illness extending more than two days requires a consultation with your primary care physician." Ignoring the obvious fact that you are a primary care physician, when was the last time you needed a note from your doctor to prove you were ill? Wait, am I actually reading that application for Borders? Sadly, no.
That wraps up Part 1 of contract negotiation, otherwise known as "Learning from my Almost-Mistakes". The statements quoted above may or may not have a basis in fact. They may or may not have come from a contract I was once offered and still have if only to remind me of how close I came to misery. That lawyer charged me $800 to review my employment contract. Pricey? Sure. Priceless? Absolutely.
Lessons I Learned About Contract Negotiation, Part 1:
1. Don't treat yourself to a celebratory dinner and bottle of wine until the ink is long dried on the contract that you successfully negotiated to your liking.
2. Spend whatever you have to on a lawyer experienced in physician contracts to look over yours. Just do it. Please.
3. Don't be so enamored with your base salary that you ignore how your raises and bonuses will be determined. "Physician's base salary will be reviewed and adjusted if necessary" does not cut it. If it's not in the contract, it doesn't exist.
4. Tail insurance coverage = big deal. Typically, the tail is about twice the cost of the annual premium. So, if the 1st year premium for you is $6000, the tail is $12000 for that first year. In many practices, until you become partner/shareholder (more on this later) you are responsible for the cost of your tail (or a portion) if you leave for any reason. This is why some say that joining a private practice is like getting married. You better be damn sure that's what you want or else it will come back to bite you in the tail (I couldn't resist). This could potentially be thousands of dollars you will owe the practice when you leave. Ouch!
5. Restrictive covenants are standard nowadays. They are otherwise known as 'non-compete clauses'. Make sure that they don't prohibit you from practicing anywhere else in a reasonable drive from where you live. E.g. a radius of 7.5 miles in Chicago is pretty rough. In Phoenix? Not so bad. Get out a map and use it.
6. Termination. It could happen to you. The following sentence is a red flag "Employer may terminate this agreement immediately if...Physician engages in conduct that, in the sole discretion of Employer, is detrimental to patient care or to the reputation or operations of Employer." Wow. That basically says that they can make up a reason not to like you and fire you immediately. Here's another one, "... the other party shall have no rights to cure or contest the termination of this Agreement." I can't even contest it?? This clause smacks of the "Because I said so" mantra of my mother when I was young.
7. Here's another one of my favorites. "Physician agrees...not to make any disparaging remarks to any third party concerning Employer or any of its officers or directors...throughout the term and at all times thereafter." Really? You mean I can't say anything nasty about the unreasonable and freakishly controlling contract you offered me? I can if I didn't sign it. ;)
8. Clarify your vacation time/CME time/sick leave. Especially if you see a rule like this one. "Excused time for illness extending more than two days requires a consultation with your primary care physician." Ignoring the obvious fact that you are a primary care physician, when was the last time you needed a note from your doctor to prove you were ill? Wait, am I actually reading that application for Borders? Sadly, no.
That wraps up Part 1 of contract negotiation, otherwise known as "Learning from my Almost-Mistakes". The statements quoted above may or may not have a basis in fact. They may or may not have come from a contract I was once offered and still have if only to remind me of how close I came to misery. That lawyer charged me $800 to review my employment contract. Pricey? Sure. Priceless? Absolutely.
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