»» Welcome to our 1.30 session. Hopefully you're all excited after lunch. My name is Dr. Danielle Hairston. I am part of the Scientific Program Committee here. And the session that you're about to enjoy is called Physician Contract Negotiations, Considerations and Strategies for Professional Attainment by Dr. Napoleon Higgins. It's my pleasure to introduce Dr. Higgins who, like me, is a former president of the Black Caucus, former president of Black Psychiatrists of America, currently the CEO of the Black Psychiatrists of America. And I can say this is my friend who also helped me with negotiating my contract. So I know that he knows what he's talking about. So I will allow him to come up here and help you all as well. Welcome Dr. Higgins. »» Yes, it is great to be here today. I did want to go ahead and give my disclosures, Otsuka, Lonbeck, Acadia, and Janssen. And I think that's about it. So what we're going to talk about today is, you know, first thing, I wish I could walk with a mic. But I would say the first thing we want to talk about in contract negotiations is knowing who you are. So giving a bit of a background on how I got to, you know, doing this talk. When I was coming out of residency at UTMB, you know, I did all the training and all the work and things of that sort. And no one had taught me about what do I do after residency, all right? And the understanding of, you know, how life is going to be, how work life is going to be. And at the time, you know, I was a previous minority fellow here at APA. So was Danielle as well. And I want to thank her for giving me such a warm welcome, old friend from a long time. She's not as old as me though. I shouldn't have said old friend, any time you're dealing with people. But I came through the fellowship about 10, 15 years before she did. And so as I was finishing up residency, I was reading a book called The Miseducation of the Negro by Carter G. Woodson, which is the creator of Black History Week, which later became Black History Month. But as I was reading that book, you know, as I was ending residency and going into the practice world, I said, you know, there needs to be a book on the miseducation of the American medical student. Because the important part about practicing had been left out of the conversation in training. Now we did have a few lectures on, you know, transition to practice is what the name of the lecture was called. And we had a few lectures on it, but it, to me, left me grossly inadequate to understand what I would be facing as a medical physician. And then that, so I had a talk called The Miseducation of the American Medical Student, which a lot of questions would always arise about contract negotiations and, you know, looking for work and the job search. And so from then on, I was able to develop this particular talk here. So I will say that I am a medical professional. I'm not a contract. I'm not a lawyer. I'm not a contract negotiator. So if that was what you all are looking for, that's the wrong room, all right? I'm a medical doctor, just like many of you all here or persons out here practicing in the healthcare field, who just walked the landmines and made, you know, multiple mistakes. And so what I wanted to do is be able to educate individuals about what's going on and what we should notice and things we should look for in our practice. So I'll start this by saying in my hotel, the first, considered to be the first physician and the builder of many pyramids, wrote on every pyramid that he built was, know thyself, all right? And I tell individuals, it is very difficult to actually negotiate a contract if you don't know what your needs are, all right? So you've got to know where you are in life, what are you looking to do, and your needs will change throughout your entire lifespan, all right? Things change on the dime, you know, marriages happen, kids happen, divorces happen, I don't know, natural disasters happen, and your needs will continue to change. So one is know thyself, all right? Physician, know thyself, and being true to yourself and doing that introspection before you ever look for a particular job that you're going to look for there. And so you should always go into the job negotiating what you want. Now people think a negotiation is dollars, vacation, but we all negotiate contracts in our work situation unconsciously, all right? So if normally you end up training somewhere near, you normally work somewhere near where you train, all right? So when you looked at your training and going into residency, you should have been looking also at looking at where do you want to work. Some people will say that I want to move back home, all right, or I may have elderly parents, or I want a good place to raise my children around. All relationships, where is the person that, realizing because we've been in school forever, a lot of us have developed partners that have been around forever and have their own particular needs, and you have to pay attention to not just yourself, but other individuals who are impacted by where you work and where you live. So just like in negotiating which way you go to work, I mean, I'm assuming everybody works here, everybody drives, everybody grabs a subway or something of that sort, and you negotiate your route to work, and you negotiate your route home. So you're constantly negotiating, but you also want to make sure that you're paying particular attention to all those negotiations that are both conscious and unconscious, because the first negotiation actually starts with yourself, all right? I think well too often we end up picking jobs and picking careers based upon what our training said was good work and what was good careers, and not paying attention to what is good work and good careers to us. And most individuals, a lot of people in residency want to work in academia. And why is that? Because you've been in school your entire life, you feel very comfortable working in a place where you've always been, realizing only about 7% of doctors will actually work in academia, 93% will be working somewhere else. So I know in my own self, I enjoy residency, I did well, I was chief resident or chief fellow, but I knew coming out that I didn't want to work for anybody. I have a pretty bad attitude, all right? And residency got the most of me that I could do, and it wasn't a bad place, UTMB-Galveston was a good place and really good people. But I knew that I did not want to work with anyone, I wanted to work for myself. And I would say my start of working for myself was when I was 12 years old, cutting yards, best job I had before I became a physician. Paid the most money, set my own hours, all right? 15, I was 12 years old, making $15, $20 a yard cut, cutting about 8 yards a week, had a contract cutting for a whole street for the development. I made a lot of money, spent it all on GI Joe's, skateboards, BMX bikes, that was before I was interested in girls. And but then somebody told me I needed to get a job, all right, and I worked at Popeye's for $3.35 an hour, and that was a job. But I was making, I cut 2 yards an hour when I was 12, 13 years old, and I was making a lot more money then. But I based on having a good job based upon people saying what a job was, versus the job I had and I wasn't paying attention until later that I was like, I really gave up some good money. Maybe if I'd have kept with it, I may not have become a doctor, cutting yards pays a lot of money. So before you negotiate, you have to introspect on yourself. So, of course, when we work, we want to have money, power, and respect, all right? We want money, we want power, we want respect. Anybody know where that comes from? What was that? Scarface. Not Scarface. Well, did he say it as well? He did, okay. I took, you know, I actually wrote a book on this and I quoted the Locke's, Lil' Kim and the Locke's. So, but Scarface, but money, power, and respect is what we want. Now, a lot of doctors get confused when you say that you want to get paid. This is not the lecture that's going to talk about why it's not important to be paid and why we should work for free as doctors. Realizing that medicine, behind the federal government and oil and gas, the next biggest industry in this country is medicine. Less than 1% of that money goes towards paying doctors. So if you're in the room saying that I don't want to get paid because making money is a bad thing as a doctor, this is not the lecture for you. Because they're keeping 99 plus percent of all the money that comes into medicine. The cost is not you. Even though, on politics, you know, the reason we need to save money with Medicare, we need to decrease spending on doctors. The spending is not on us. Every patient that you see, you write out, they walk away with about, you send about $2,000 worth of prescriptions out for each patient that we see. And you just got paid $200, not to mention labs and all, I tell people, being a doctor is like the matrix. You're a battery plugged into the system. All right. And I say, the next thing is that you have to look at UDoc Incorporated. Your business in medicine should be about you. It should not be about the hospital. It should not be about the corporation. It should be about you, yourself, and what are your desires and needs. Because the happier you are doing practice, the better you will practice. To me, the two are directly correlated. You need to be happy with the work that you're doing and find it to be very satisfying. And you need to be at the center of you. Trust me. They know how much, everybody knows how much money a doctor generates. Except for the doctor. All right. Now, let me ask a question before I keep saying doctor. How many MDs and DOs are in the house? Okay. All right. Any nurse practitioners, physician's assistants, PhDs, people who work for folk, headhunters? Who did I miss? Who's in the room that I missed? That's everybody? Okay. Students. Medical students? Any residents? Great. All right. Cool. So, UDoctor Incorporated, in that wherever you go, you take your doctor with you. Your doctor goes with you. So, I can be a psychiatrist in Houston, but I can be a psychiatrist in San Francisco. I take my doctor with me wherever I walk, wherever I go, and I can pick up my bag and go to the next place. And I always tell people, if you're not happy where you are, trust me, somebody else is hiring a psychiatrist today. All right? There's no need to stick to a place where people are not allowing you to grow and be who you would like to be. I understand that all things are negotiable, and too often we think about negotiating so far as a money issue. Money is only part of the equation, and it's a major part of the equation, but there are so many other variables and happiness in work, in the work that you do, that's well beyond money. You always want to negotiate the win, but I always tell people, everybody needs to win on a negotiation. All right? So, of course, you want to be paid well, but what happens to people who are overpaid? I can find somebody who got paid less, all right? But also, if I'm paying you to the point where I cannot keep my doors open, then essentially I've got to let you go. All right? So, you want to be paid well, but you want to be paid correctly. I had a friend of mine who had a resident coming out, this is Houston, different people pay different payments to different places, but he was like, yes, in order to work here, I need to get paid at a minimum $3.75 a year, and her response was, thank you, I'll get back in contact with you. I'm not about to bet the farm on somebody who's coming right out of school, and I know that that person would have to generate X amount of dollars for that to occur. So, we have to look at, everyone needs to win in negotiations, all right, and it makes for the best relationship. Now, sometimes a place may be desperate, and it may hire you for a higher price, but generally, you want to be paid within range, and you want to be paid well, but be careful of what you're looking for. The gunner attitude, that's a very big issue that we run into in medicine, where individuals, we act as if we know everything in medicine, all right. We are actually trained to believe that we know, when there are a ton of variables of what this can be and what we see, all right, so we have to do leaps in logic to actually believe that this is depression. It's leaps in logic to believe this is ADHD or bipolar disorder, realizing that, especially with psychiatry, there's a very big arc to what we do and a lot of variables, but understanding when it comes to business, there are a lot less variables. There is a what you create versus what they pay you, all right, and too often, we make these leaps in logic where we have to believe that we know in order to feel comfortable doing the work that we do, understanding that that can get you a lot of trouble in business. In business, most people know that doctors don't know. It's only the doctor who believes that they know, when most people believe that you probably don't, because we're not trained in that direction. Now also with that, I am a serial entrepreneur, so I have several businesses, and I always keep that in mind that myself, I never want to take advantage of anybody. I want everybody to be happy, all right, and I never want someone upset working in my office, because I like life too much, and I don't like angry people around me, all right, so you want to make sure that everybody has a clear understanding. Where you are in your career matters, all right. There's a difference between your needs when you're coming out of residency versus the middle of your career versus the end of your career, so you have your doctor false start. We come out of school, we're all fired up, ready to go, all right, but we haven't, may not have considered much of what we already talked about, so you go into a situation, and most people don't stay on a job over two years. Their first job, normally they're in and they're out. I call it Dr. Grant hustle, basically, where you just kind of go out and make as much money as possible, all right. A lot of us got needs, a lot of us have bills, a lot of us have daycares, a lot of us have, you know, medical school loans, trying to make it, trying to get started. Obviously, some people come out of school without any debts and things of that sort. I was not one of those people, and so you need to really make money. Sometimes in life, you become Dr. Ned job ASAP. Something happens, all right. Sometimes you get fired. I had a friend of mine, he has now three or four dental clinics, he got fired. He couldn't believe he got fired from the sheriff's office, like he was working at the county jail. He was like, I can't believe I got fired. But it opened up multiple more doors to him. But he was like, he's still upset that he got fired. He never told me what he got fired for. But you can end up needing a job very quickly, maybe there's an immediate move, there's a change that happens. I don't know, there's a, your spouse lost, you know, or your partner lost their job, now you're having to double up. These things happen. Dr. Easy Steady, where essentially if I keep doing what I'm doing, I'll be able to retire and live a comfortable life. And Dr. Ness Egg, there are certain things that are very different towards the end of your career. You need to be paying attention to different things about your finances, saving money, taking care of the next generation. One of the biggest things that breaks Dr. Ness Egg is having kids who fail to launch and continue to stay inside your home. That can move you back to Ned job ASAP quick. Benefit packages, realizing about 20, 30, 35% of your income can be in the benefit package. You know, so far as what is your health insurance like? Realizing that when you go to a place for health, and they have a health insurance plan, the health insurance plan is really more so about them and less so about you. It's the needs of the job. So is your health insurance adequate? What are co-pays, things of that sort? Vacation time. There's a difference between two weeks of vacation and three weeks of vacation. Versus four weeks of vacation. Sick leave, that counts. I say I hate to be sick on days when I'm taking sick leave, but that sometimes happens. Mental health days. Some places allow mental health days. All of these days add up. I call mental health days, I can't deal with y'all today, all right? It's better for both me and you all for me to stay at home, all right? These are your mental health days. Expense accounts and CMEs. So if they allow $4,000 in CMEs and $2,000 in expense accounts, you definitely want to spend all of that money. You want to take all of your days off. You want to use all of your sick days, because those are things for you, all right? And you don't want to, you know, there is no prize in saying I worked extra and received less of my benefits. You want to make sure you use all of those. Your salary versus independent contractor. And especially when people are coming out of residency, they may not understand, well, some of us don't understand the difference. A salary job is where you're working for someone, all right? You are being paid to do a job, and they tell you this is the job, this is when you work. Sometimes we have to make changes, essentially, I don't know, we're going to open up a Saturday clinic, you know, we're paying you good money, we're going to add a Saturday clinic, and you may not get paid extra for the Saturday clinic, all right? But also comes with that, the benefit packages also come with that, all right? Now a contractor, you know, when we're in residency, you know, they call it moonlighting. When you come out of residency, it's called a job, all right? So the independent contractor decides when they're going to work, how much they're going to work, what they're willing to do, and what they're not willing to do. Normally the independent contractor is probably being paid possibly for a job or by the hour. And normally they're paid more than a salary position, but the salary position typically comes with the benefit package that makes up the difference, all right? So essentially, if I'm an independent contractor, and I say you all open up a Saturday clinic, my thought is, well, I can get paid extra for the Saturday clinic, all right? Or you all are opening up a Saturday clinic, and I may say, I don't want to work on Saturdays, all right? And you all may say, well, we really need a Saturday doctor, and since you're not willing to work on Saturdays, you know, we really don't have a place for you here, all right? So these jobs kind of come and go, and I know people who are independent contractors for their entire careers. I've even seen where people negotiate as an independent contractor even having benefit packages inside of the independent contractors, inside the contract for the independent contractor. So you're looking at work duties, salary, they tell you how to work, independent contractor, they suggest how you should work, all right? Compensation, normally independent contractors are getting paid more, but not receiving these things here, versus a salary person is normally going to be receiving these things. Make sure that you understand that, you know, disability, you know, needs to be inside the benefit package. Life insurance, all right? If you are a contractor, you must have your own life insur- no, listen. You actually have life insurance, and people will say, well, what if I don't have kids? You've been in school your entire life. If you die, somebody should benefit from that, all right? It's only $100 a month, and so you went to school your entire life, you died, and nobody benefited, no. Everybody should have a life insurance policy, and then also a disability insurance policy, because there's a high chance that you'll be disabled, all right? That is a very pretty high chance, about $100 a month. But then also, when you look at your disability packages, you know, I would recommend having them 100%. So I may say, if you make $250,000 a year, you would want to have a disability package that pays $250,000 a year, in case you're disabled and not able to do the job. Accidents happen. People have weird things they love to do, like bungee jump, or jump out of planes, or go skiing, or riding bikes down a busy street. All these kind of things can happen to you. And then so you're looking at, also, tax rates. Normally on a salary job, they're going to be taking the taxes out. As an independent contractor, you have to make sure that you're paying your taxes. One of the quickest ways to go broke is to forget to pay your taxes. And those fees at the IRS are extremely high. Trust me, I know. They know where to find you. So the fact is that you have to pay your own taxes. I always tell people, make sure you have a good accountant, especially if you're an independent contractor. You need to make sure you have a good accountant. And pay close attention to the salary benefit package. I remember the first time I received, I remember when I went to residency in there. First two or three days, benefit packages. I'm extremely bored in the room, hardly being able to stay away. But the older I get, the more I would be paying attention to that benefit package, and that you should be paying attention on day one. And then also, retirement accounts that some salary jobs will have versus independent contractors. Typically, there's not a retirement with that at all. So the question becomes, what about the money? We haven't talked really about money yet. So what are you worth? And that comes from making sure that you do your own research. Google, what does an adult psychiatrist with 10 years of practice make in private practice in San Francisco? Or in academic practice in Oakland? You can Google that information. Now, if you work for a public university, everybody's salary is listed. The base is listed. Now, that doesn't mean they're not receiving other compensation. But the base is going to be listed at a public university. So it's going to be important to make sure that you look in. Now, there are, I forget, there's a yearly thing that comes out and tells how much every doctor makes. You can subscribe to it. It's a few hundred dollars a year. But the fact is that you want to know what your worth is. Because if you tell me the job, more than likely, I can tell you what you're about to pay me. It should not be a surprise. You tell me the job, and I can tell you about what it should pay, depending upon the region, how big the need is. If it's Houston, where there's a lot of Houston major city, a lot of docks, sometimes the pay is not as high. If it's middle of nowhere, Texas, where the nearest airport is two hours away and excellent fly fishing during the summer, all those kind of things, normally they're going to pay a little bit more. So what are you worth? And what if the pay is lower than expected? You need to ask the question. Well, I noticed on Google, or I noticed that on your website, when I went to the public universities, the average doctor is being paid x. Why did I get offered less? I had a friend of mine who was about to sign a contract. I was looking over the contract form. And I was like, well, this looks a little bit low. She's like, it does look low. But I went to APA, and I remember I talked to these folk. Let me go and find the paper. She found the paper. And she saw that she has been offered $25,000 less than what the paper has stated just months ago. So I asked her, well, I told her, I said, go back to them. Showed them the paper, and asked them why you're being offered $25,000 less. And the person said, oh, it was a complete oversight that we offered you $25,000 less than what was listed on the paper at APA just months ago. We gave you an old contract. So we want to look at, if the pay is lower than expected, you want to come in and show actual numbers. This is what I would expect, and this where it says how much it should be. Why are you offering me less? And you put it on a number and a date issue. And that may have a good reason. They may say that, oh, well, realizing that this is four hours a day, 30 hours a week, this is not what was listed at 40 hours a week. So there may be a reason. What if you're being paid more than you would expect? Make sure that you understand what the job is, because sometimes they may have left that out. It's a clinic job. It's 8 to 5, yada, yada, yada. Good work. But you may have to cover, I was working at a place where you had to cover emergency admissions during the middle of the day, up to two. So you've got a full clinic, and then you had to go do a couple of emergency admissions in the middle of the day. That is a different kind of animal. Now the clinic is being pushed back, and the intensity has greatly picked up. Key factors other than money. How much time am I spending on this particular job? So it may seem easy enough, but how much time? What is the volume of patients? How sick are the patients? The intensity. The intensity, location, and support staff. Because a job may say you have to cover 20 patients a day. Patient clinic, that's moderate volume. All right? And then the question is, is there adequate people to check the people in? Are there adequate people to check the patient out? 20 patients on the inpatient is different than 20 patients on the outpatient. 20 patients on the inpatient without support staff and without a social worker, and you've got to make phone calls, is a whole lot of patients during the day. So I worked at a hospital. It was a very busy hospital. Extremely great support staff. So 20-something patients in a day went by before lunch. Because of all the setup, they would set them up, tell you what was going on, this, that, and the other. You would visit with the patient, interact with the patient, ask several questions, make a decision about the medication. You got to scribe. Orders went in, next patient, next patient, next patient. Paid really good money. The support staff had been there for years, worked with each other. Very appreciative place out in the rural area. Oddly enough, you would think the rural area, some people would think a rural area is slow. Not the case at all. Your catchment is so wide. It covers so many miles. And people are really out there really needing your help. So you have to pay attention to those other factors, because those other factors will make or break that job. And oddly enough, those factors are not written into the contract. They're not going to list how many support staff and all that we have. Are you all with me? You all OK? And so also understanding what are the employer's needs. Sometimes you're negotiating the contract. Maybe you don't think that it's enough. And you say, hey, well, since, do you all have a Saturday clinic? Like, oh, we've been waiting on somebody to work on a Saturday. So the fact is that you want to know what are the employer's needs, what is going in the place, what kind of need can you meet? I know I was working at the jail. And they had a big issue with this time to get people out of the, we call it the holding tank, to see the psychiatrist. Well, I'm like, I'll tell you what. Let me focus on that while other people focus on other things. And if that's your biggest issue and you're getting in trouble with the Department of Justice behind that, I could focus on that. And if I get a certain type of volume and I can help move the needs of the inmates, can you pay me more? And well, the issue was, this was a big issue for us. We appreciate it. We'll put $20,000 more if you can make sure you can solve this issue for us. And so I solved the issue, and it worked out well. Now, closing the deal, the interview, realizing that whenever I cut a deal with anybody, I'll look them up on Google. And I go at least five pages. The more money involved, the more pages I go in deep. I always put in the name versus, versus the name. Who's getting sued dealing with this person? I'll look up, and everybody's NPI number is up. I look them up on Texas Medical Board. And you'd be surprised what I found. I'm like, how is this person CEO of the next hospital? And at least five doctors who've dealt with this person have all gone to prison. But we pay well. It ain't worth going to prison for. Now, you know, I am a black man. I don't trust much in the world. But if I see that you've gotten sued multiple times and all the doctors go to prison and you don't, I think you're working for the federal government myself. All right? So I always research everyone, realizing that the deal starts at the conversation, at the point of contact. If it's inside the article, a job, X place, pays X amount doing such and such work, that is the start of the negotiation. That is the deal right there. And also, in this fast-moving world of Facebook and Twitter and cell phones and text messages, you're negotiating with that person at every time you have a contact. Now, I know for myself, I'm a person that doesn't like to answer the phone. If you call me and you're not in my phone, I'm not picking up. The reason that is, especially if I'm talking about negotiations, you call me and I wasn't expecting the call, puts you at an advantage. All right? So I always want to make sure that I'm very careful. Be careful of negotiating while busy. You're driving down the highway and you're talking about $250,000 a year, but you're going to negotiate that while driving down the highway? And where are you going to work and the type of work you're going to do? That is not the time to negotiate. If you're distracted looking at Facebook while texting back and forth with somebody, that is not the time to negotiate. Make sure that you're staying in mind on what you're doing and what you're thinking, because it's hard. Even though they say, oh, let's just talk numbers. And you're like, sure, what about, and then people start holding you to that. Even if they say they're not, not unless you have formed a relationship, like we're just going to talk numbers and these don't matter. But make sure that you're paying attention to that. When you close a deal on this deal, you're closing the deal on the next deal. How you dress, how you shake hands, how you communicate, how much do they like you, all of those things go in. Office politics, office gossip, all those things are involved in every job that you work. The media, as stated, be careful what you have on social media. I will look you up on Facebook. Now, realizing that my practice is mine. So I'm in private practice, and you're a reflection of me. And the question is, are you a good fit for the practice? Look out for your gut feelings. A lot of times we ignore things that go on unconsciously. Like I have a hesitation. I don't know why this job doesn't make sense to me. Anytime I'm going into a deal, I like to be excited about the deal. And if I'm not excited, then I need to find out what is actually going on. So make sure you get the facts of what's going on. Ask the questions. Sometimes it's good to talk to the people, good to talk to the staff. I said, there's the good, the bad, there's the ugly, and then there's the downright spooky. And there are some shady things that go on in medicine, especially when you're dealing with Medicaid and Medicare. If you make a mistake, that's a felony in time in prison. I've seen friends go. So make sure you pay close attention to that. And I love this thing called your BATNA, which is the Best Alternative to a Negotiated Agreement. Too often I think that we could put all of our eggs in one basket. This is what I must have. Not paying attention to what the other place may have. So essentially, I must work for University X because they're known for X, Y, and Z. They're always being quoted, yada, yada, yada. And the job pays $140,000 a year. Public university across the street pays $280,000. And people will dogfight to get that $140,000 job. I have zero understanding of that. I don't believe my family deserve half, so I can put your name on my stuff. Now, at the same time, working certain places opens up other opportunities. So if you're working at a place that pays less, then what are the other opportunities that compensate and make up for that? So if I work for this place and I write my book, that makes me an expert because I have X University behind my name and I have a book. So there are other things that can make money outside of the job. If you're going to do something like that, also pay attention to who owns the intellectual property. I don't believe anybody owns my intellectual property. But there are also benefits from working for a place that does own intellectual property because there are other opportunities that it may make, or there are other opportunities once you leave that place. So my friend of mine, I'm not going to say where he worked, he said it's better to be from here than to be here. So it makes a good name to say that I was at a certain particular place. So be careful of your intellectual property. When to walk, it's not you, it's me. And then the other part of that second thought, no, it is you. But when you sign a contract, you're signing into the contract, but you're also signing out of the contract. It's written in the same paperwork. So you always want to make sure you know exactly what the out clause is. Is it one month? Is it six months? You can sign a five year contract, but if they say that we can let you go in 30 days, you're on a 30 day contract. Now, you may have to give them six months, but they only have to give you 30 days. My thought is if you give me 30 days, I gotta have 30 days too. Also, just making sure there's a clean break that you're out of the door. So when to walk, know when it's time to walk. Too often we're trying to fit square pegs around holes. This is not a good place for me. Now, sometimes there's a need to take the job because you need a job ASAP. All right? And so you know that there's an end, but right now I need to go ahead and take this one. I don't know. Parent got sick, I gotta move back home. I don't like the job, but it fits a need for what I need at the time. And always walk away with a good understanding in that just because you don't like a place doesn't mean it's a bad place. It may not be the right place for you at this particular time. And you never know who knows who, and who will offer, you know, listen, somebody offer me 20, 30,000 more. They say, sorry, we can't do that. You know, Dr. Higgins, we appreciate you. And you say, I appreciate you all, but I'll take the other job. Now, you never know. Years down the road, somebody else is working over there, you may just need to switch over, but you never wanna leave away with a bad understanding. I like to have a good understanding on why I decided not to take this job or why they felt like they didn't need, they felt, didn't find the need to offer me that. And so on second thought, it's you. Non-compete clauses. Be very careful of that. Where people are saying, the issue becomes, you know, if you can't work within five miles of a place, if you quit that place, that becomes a problem, especially if they have multiple locations throughout the city. Now you gotta change towns. I recently made a mistake on a contract that I didn't realize it said that I cannot work with other people if I work with them on this particular job. I made the mistake myself. I don't know how I missed that one. And then they came back around and said, oh, three years in, hey, we need to switch something on the contract. And I saw they add another five years. No, sir. I'm out in two. And then we're gonna renegotiate the entire thing. But look out for these non-compete clauses. They can be very detrimental, depending upon the state that you're in, it depends on how enforceable it is. Realizing that if you're working for, if you're competing, you know, if you break a non-compete, you can be sued. And realizing that institutions have infinite amount of money. You have finite amounts of money. That can be very problematic when you're trying to fight somebody and they have a budget of 120 million a year. And you have a budget of 120,000 and you got house notes. All right, maybe it's 240. It could be even 700,000. But they got 20 million and a set of lawyers. Termination. That does happen. People get fired for different reasons. Maybe it's your fault, maybe it's not. Know what the termination out clause is. Realizing, as stated, when you sign in, you're also signing out. How am I doing on time here? Special populations. Women in networking and non-traditional settings. All right. That's something that I used to do that I don't do anymore. I used to, you know, like to negotiate, have a meal, have a dinner, have a negotiation about the job. Because food helps to break bread and helps people talk. That can be odd, me being a man, I'm taking a woman out for dinner and drinks, talking about a job. I just don't do that anymore. No men, no women. Do we talk about jobs? Working for me, out over drinks. All right. Single versus married. That can sometimes determine where you want to work at. Being, if you're single and you want to get married and you're out in the rural area, that your choices can not be as high as many times inside the city. Living in a certain place where you live. Living in a certain place where you grew up can be very different than living somewhere where you don't know anyone. Also, we'll cover disparities in pay, but academia, there are other things that can be beneficial to the work that you do versus academia versus private. And then we have the issue of COVID and post-COVID where the world's kind of switched upside down. Telemedicine options are a lot more available now. What does that mean? Come just a few weeks ago, we were all gonna have to go see patients face-to-face. Then it was pushed out to November. And what does that mean going forward with many of the contracts that we have? I've been telemedicine. I have, you know, it's six of us at our clinic. We've been telemedicine for the last five years. If we all have to come into the office, I don't have six spaces in the office. So I don't know how it's supposed to work out. All right, but we have to pay attention to the changes and things are changing very fast. Now I'm gonna go into disparities in pay. This is a study from 2016 that showed that the average white male physician makes $250,000 a year, all right, in 2016. And this is after adjustment for payer type, age, years of practice, and specialty. The average black male made $188,000 a year, $65,000, nearly $65,000 less than the average white male doing the same job. Average white female makes about $90,000 less than the average white male doing the same job. And the lowest paid is the black female at $100,000 less than the average white male doing the same job. Now, there may be a difference in, when people write prescriptions of Prozac, oh, fluoxetine, sorry, semi-tolerant, between one person and another. Different scalpels cut differently. But there is racial bias and gender bias in medicine and pay. That's why you want to know actual, real numbers. So if I look up and I see the average person is making $250,000 and you offered me $150,000, my question is why? And I'm gonna put it on the email. I'm gonna write it down. We're gonna time, date, stamp this thing. Waiting on that response on why was I offered X when it says on Google, on Job Search, or whoever else, or on the public university. I had a friend of mine, very odd. They worked for a public institution. They had been there for like 15, 20 years. And they were being paid at the time, this is about 15, 20 years ago, about $140,000 a year. But every doctor that hired on to this public institution as a psychiatrist was being paid. They started at $220,000, $240,000. Now, the 140s, who I can think of are two black females. They were over the large public grant for the institution. Very well thought of, very well liked in the community. They're the directors of the grant, but every new doctor that you're hiring, you're hiring for $80,000 to $100,000 more than the two people that have been there. That's the rock solid cornerstones of your institution. And of course, they both abruptly quit, even when they asked for raises. Now, they decided not to sue. One quit right before retirement, and the actual state contacted her and begged her to stay on at a different job at a different site making more money, just so you could get your retirement. You're like 18 months away from full retirement. The other one quit and went to industry. But you have to pay close attention to this and that these things still occur. I remember I did one of these talks, and a white male straight out of residency came to me and said, Doc, so I'm coming out of residency. I interviewed for this job, and he said the offer was ridiculously high. He's like, I can't believe what they offered me versus what I heard that other people there are making. Why did they offer me so much money? I was like, one, you want to investigate what are you doing. So too often, people are offering you a lot of money. Now, granted, they may be offering you twice what somebody else is making, but working you four times as hard. That's not necessarily a good thing. I was like, well, maybe you got the white male salary. Because on average, white men will be offered more money to do the same particular job. So your resources, you have your recruiting firms. If you all walk out to the exhibit hall, all kind of headhunters, all right? All kind of headhunters wanting to hire a whole lot of folk. So we want to make sure that, realizing that the recruiting firm is working for themselves. They're not in it for the doctor. They're not even in it for the institutions that they're representing. They have to get somebody signed up. And whatever you say that you want, they say they can get it for you. Whatever that institution wants, they're telling them that they do the same thing. Once they sign, and you stayed on for a certain period of time, they got their check, they're out. Unless you're looking for another job. And they'll recruit you to another job while you're working that job, all right? Medical lawyers, one thing about medical lawyers, about lawyers in general, their main job is to make sure that the contract is correct, all right? That it makes sense. Their job is not to figure out time, and money, and patient, and volume, and intensity. They're lawyers, that's not what they do. So be careful when dealing with a medical lawyer, because they make sure the contract is right. But past that, that's not really what they do. As much as we say, go make sure you get a lawyer to look over your contract. And they can help you walk into a bad situation. They're making sure that it's right. Medical office startups, that's where they put you in a medical office and you've got to promise them two or three years. Basically, you've got to promise to admit all your patients to their hospital, water through their labs, and things of that sort. Realizing that as a physician, you're a battery. This is the matrix. I was on one with Denzel Blade, where they're using people as the bodies for blood, as blood forms. So essentially, they know that you in that office, that you're going to generate all kinds of money for them. So they'll help you start up in a private practice. Now, the thing about those is that if you don't make the mark, you've got to pay them money. Even if you sent them inpatient, you bought their labs and all that. They'll offer you, say, $250,000 a year if you only generated $220,000. So you're $30,000 in the hole. Next year, you're going to generate $240,000. Now, you're $10,000 more in the hole. That's $40,000 in the hole. Your third year, you didn't make it all the way out the hole. Now, you owe them a check. Be careful of that. Private practice. I tell people private practice is entrepreneurship. Some people have a barbershop. Some people have a beauty shop. Some people have bike shops. Some people have a nail shop. I have a psych shop. And we help the people. But whether it's working or not depends on the first of 15. Did I make payroll, or did I not? So there is a financial need to make sure that you're making more money than you spend. The secret to business is making more money than you're spending. That is the complete secret to the whole thing. And it's very hard to do. And most businesses won't. Will not be able to do that. So making more money than you spend is complete entrepreneurship. And there's ways to make sure you follow and track your money. And too often, they're not teaching us anything about the business end of what we do. Realizing that the average physician is going to finish up with about 15,000 hours of education. 35 hours to make an MBA is something that, when we're in that learning mode in medical school, they could have done in about, oh, two months. Because we're in high volume, fast learning, picking up information, absorbing like a sponge when we're in that mode. But that is completely left out. And I doubt if it's by accident. They could teach us how to do this. My mother, God rest her soul, would always say that reading is fundamental. It's amazing how many people never read the contract. A lot of people don't read their contracts. They just sign them. Also, if you have a question about a contract, get it answered. If there's something that needs to be changed on the contract, make sure you initial it and date it. And that they also initial and date it before you sign on the bottom line. Because your initial and date doesn't mean anything without theirs. Also, another thing I've seen people do on contracts, when you want to change, they say, sure. They turn around and send you back the same contract. And you never read it the next time. Or checking to make sure that everything in there is the same, nothing's been changed. Make sure you're going to make the necessary changes according to what your needs are. And I'll just give some bonus time about physician and finances. How many of you, well, I ain't going to ask y'all. Raising our hands on how many of y'all have med school loans. But I'll just say this. Physician and finances, you make $200,000 a year, you make $100,000 net gross taxes, $16,000 before taxes, $10,000 after taxes. And look at all these things that you've got to pay throughout your life. A lot of times, people believe that as soon as I come out of residency, man, I'm about to hit the jackpot. I'm about to get paid. And I'm going to make a whole lot of money. And everybody knows that physicians, on average, know nothing about money. Oddly enough, you've been in school your entire life, you come out somewhere between 30 and 35, and you know what? You just had your first job. When everybody else started working at 16 because they weren't as smart as you, they started working at McDonald's, or your college friends finished out with degrees in engineering, make as much money as you, and had 10 more years of work. They had time to blow their money in their 20s, but we turn into our 30s, get our first jobs, and put ourselves in a whole lot of debt. And it becomes, until we actually are retiring, that we get underneath all those households and all that. And by that time, kid's going to college. And because you're a doctor, your kid has to go to this certain college that's paying $80,000 a year for your kid to go there. 20 years from now, it'll be $100,000 a year, and your kid wants to teach elementary school for $400,000 worth of debt, all right? So we have to be very careful about what we do with our money once we make our money. Everybody wants to separate physicians from their money because they know that we're financially immature. A lot of us don't know life, and we have not made those mistakes. It's one thing to make a mistake when you're making $12,000 a year working at Best Buy part-time as a college student. It's a different issue when you're making $400,000 a year in 30-some years of age. The sharks are way out there, and they're hungry, and they smell blood and water because of our immaturity. So understand that physicians and investments, I recommend paying off your loans, getting out of debt. And then, therefore, when you get out of debt, you decrease your risk so that if you're not, you know. So any time you're in debt, you're at high risk. When you're in no debt, you're at low risk, all right? Be careful about the decision making that you make as a physician. This is the book, Transition to Practice, 21 Things Every Doctor Must Know About Contract Negotiations and the Job Search. I wrote that about 10 years ago. I learned a whole lot more since then. But trying to keep people out of the mistakes that I made throughout my early career that I'm still trying to recover from. That website no longer works. I don't know. I get a check every few months for like $20 or something like that, yeah. Thank you all so much. I appreciate your time and attention. Thank you. All right, thank you to Dr. Higgins. You got a packed room. So if you have questions, I just ask that you come to the mic to ask any questions so that people can hear your questions. And I'll have the first question for you, Dr. Higgins, because I got your book when I first finished. Not 10 years ago, but almost. I know you highlighted it a little bit, but can you explain what can happen or if someone wants to leave their job? As we understand, usually when you're coming out of residency, you're not staying at that job over 18, 24 months. Can you explain to the trainees or people who are looking for jobs what you need to look at when you're going to leave a position? Because I know you talked about the time, but also just I want you to be clear, because this catches people owing your job. Sometimes you owe them if you haven't done a certain thing. Well, I think you can answer that one. But I would say that, well, one is read the contract. The out clause matters, day one. I'll sign up for a whole lot of things if I know I can make a clean break by Friday. So my thought is I want out. When I want out, I want it to be done. Now, I'm in private practice, but I work a lot of different contracts. So my thought is that I want to be out the door. Now, you want to make sure that you don't want to sign a contract where you're going to owe them money or owe them time or owe them volume, realizing that contracts are only as good as the people to sign them. And there are some dirty people out there. I've seen people get into some of the crazy. I saw where there's a black male who signed a contract, and they put him under this, what do you call it, where you have to improve yourself? Improvement clause or improvement plan? And in there, they fired him. But because he had signed the improvement plan, he needed to work there for free. Yeah, so he had to hire a lawyer. And he's going back and forth. His license is tied up and all this kind of stuff. Because of the side contract that he signed on the improvement plan. Now, this is a sub-sub-specialist who makes half a million dollars a year. And they were trying to hold him till you have to complete this improvement plan for no pay. So now, obviously, this is a dirty, ugly group of folk. Who would even think of doing something like that? But you have to be very clear on the out clause. And if they want you to sign yet another contract or another sheet of paper, if there's a question, at that point, you hire the lawyer. Now, you can hire one before, depending upon the complexity of the contract. And I'll tell people this. The longer the contract, the shadier the people to me. It's a 100-page contract. I mean, dude, I'm only doing psychiatry. This is not rocket science, all right? Why do we have a 100-page contract with very small writing? And people can switch stuff up on you. And so I had a contract where I was basically a house consultant. And then they switched CEOs. And they were like, well, you have to sign a contract where it's five out of seven days because you need two days off. I'm like, cool, not a problem. They cut my pay by those two days. And then they added on the cardiology hospital, pediatric emergency room, pediatric ICU. Hurricane hits, shuts down UTMB. They got rid of social work, all right? And now I'm like, and I can't be UTMB for the Gulf Coast. So quit, all right? I had to quit. So you have to make sure that even when they sign these new contracts, make sure you always have an out clause. And that's on day one. Once you're in a bad one, then oddly enough, you can decide to leave a place before you left, all right? It's u.inc. So if I'm in a bad situation where it's a funky out clause, well, I'm actually looking at my out and planning it out so it comes out the best for me. Just because you decide to leave a place doesn't mean you have to leave today. You can leave when it's convenient for you, all right? So just make sure you pay close attention to that. Question? Do you want to go? Thank you so much for the presentation. Really appreciate it. I'm a resident, and I'm very amateur. I don't know a lot about these things. But I was just wondering, where I currently work, we're in a rural area. And there's not a lot of support staff. We are often short-staffed social workers, medical assistants, nurses. So I end up doing a lot of that work myself. And I was just wondering, when it comes time to my contract, is that something I can write in where I don't want to be doing nursing work, medical assistant work, social work, that I have that support staff? Can that go into my contract, having support staff? Well, I've never seen that written into the contract. I mean, you can always ask. It doesn't hurt that you must be, even if you don't have this, then I get paid X amount more because I'm doing the job for them. I remember working with a doc at a pediatric ICU. And it was just him. No second pediatric ICU doctor. He had to live within so many miles of the hospital. And he was waiting on them to hire another pediatric ICU doctor, of which they would have a contractor maybe come out twice a month to cover a couple of days here and there. He couldn't take any vacation. And it was over a year later, and he was waiting for the next pediatric ICU doctor. I said, listen, they're not hiring another pediatric ICU doctor. What are you making? $275? Well, they're getting $550 out of you at $275. What would the need be to hire another person? So the thing is that in that contract, you've already negotiated that you're already doing that job. So literally what you're asking them is pay me more. Or you pay more to keep me here. And I would say it's worth definitely saying that and ask of that. And if they're unwilling, not unless you're willing to do the social work and the nursing and draw blood and things of that sort and run stuff back to the lab and be the gopher, if you're not willing to do it, I would look at moving on. I would say the best alternative to a negotiated agreement, looking at moving on, and be willing to know when it's time to walk. Because right now, you're in a situation where they're already having you do that. And more often than not, not unless it's just good people working at that hospital, more often than not, they plan on you continue to do that while you work there. Thank you. Thank you. Excellent talk. Chris Aiken from North Carolina. And I was intrigued where you put in expense accounts, which I guess would be a good way to save on taxes as well with that kind of money. Can you think of other creative incentives that you've seen put into contracts besides bottom line pay? So expense accounts, time off, vacation, CME time, books, all those things are cash value, things that save you money that you want to make sure you pay attention to. Dr. Ariston. Life of the board, all things are negotiable. I've never talked about that. All things are negotiable. So board, licensing, coming to APA, paying for your time here, paying for extra CME things, all things are negotiable, especially for those in academics. We've got a certain salary that's perfectly as for those other things. Thank you. Hi. My name is Shebi Abraham from New York. First of all, thank you for this excellent presentation. I truly enjoyed it. My question is that I've noticed when I go for interviews, and even in my hospital currently, when there are certain services that's not in my contract, but they keep adding on things, and then I did bring it up about giving me the additional pay for those things, it always comes around to, we need to speak to our legal team about fair market value. What is this? I mean, I don't have access to it. I don't know where they're getting those numbers. I don't know if that's something you can comment on this fair market value, if that's something I could look up so I can bring it back to them. But it kind of felt like they keep pushing it off, talking about fair market value. Fair market value is basically that there's this clause that you cannot pay a physician over what fair market value is, and that, say, for example, fair market value is $200,000, and we're paying you $600,000. That's well above fair market value. Me, personally, fair market value is what somebody else is willing to pay you. I'm not sold on anybody. So if you're going to put additional work, additional time, I can't make my kids 6 o'clock practice or football games on the weekend or see my daughter run track because I'm working with you all. You all need to pay for that because it's not fair to me. It's not fair to my family. And the more you allow them to do, the more they add on. They're not stopping. So my fair market value is you're paying me $200,000. Over there, they're willing to pay me $250,000. That's fair market value to me. So are you willing to up it, or are you willing to give me the support staff? But generally, when it comes to American business, the 1619 Project talks about this quite well, where they want to drive as much out of you as possible. And they want to squeeze you until you fall out, die, or leave. And then the next thought is to squeeze the next person. Now, some corporations are like that. Not all places and institutions are like that. But look at what's going on around you to the other physicians, and know when to walk. There are other people willing to pay you good money. And too often, people can put their value in where they work. And your value should be within yourself. And if you're not taking care of me, I mean, we had a saying in Texas where we say, that dog won't hunt, and that I'm feeding the dog, but the dog won't feed me. So then the dog has to go, but that's another story. So the point is, if you're not taking care of me, I don't want to take care of you. Not unless I have a reason to stay there. There may be other reasons and other tangibles of why you love that job and love the work that you're doing. So you shouldn't up and leave a place because maybe they put in another hour on the day. But you could. So just keep that in mind. And give the argument of the time. And I like to write stuff down and give actual numbers. This is extending my time and my day. I'm working at home trying to finish up charts because I couldn't get to it during the day. And there's a value to my time. How do we work this out? Or how do you hire somebody else on so that I don't have my time taken up? Because if not, sometimes they're really not considering it. But if you keep working there, why should they? Thank you. Hi, Dr. Higgins. Thank you so much for your talk. My name is Megan. I'm from New York as well. So I had a question regarding basically role flexibility as kind of integrated into a contract. So right now, I'm in the middle of contract negotiations. And they have kind of outlined a schedule for me to be in a hybrid role covering two areas of the hospital. My concern is that in a few months or down the line, if there was a situation where there was a need in another area of the hospital, what could I add to the contract to protect me within my role to kind of stay in the area that I had agreed to work in? I don't know if that makes sense. Yeah, I would say that most salary positions are going to be this is the work plus other duties. So generally, it's expected that things will change during the contract. And they'll expect you to cover those things. And when you've written a sign of salary contract, that is just what it is. Now, some of these things, they can let you know upfront that we're planning on doing x, y, and z. And other things pop up. CEO change, board makes a decision. And they've added something on to the work that you're doing that really the person who you signed in with just did not know that this was going to occur. Really, you don't have a whole lot of fight about it other than to have a lot of discussions and talking about what additional work this is and how this impacts you. Also, now, there is one thing I kind of left out of here is another thing is about women negotiating versus men. And there's fact, there's science and numbers behind. Women are less likely to ask for additional things because the perception of how people will think about me as a sadly, from the standpoint of as a woman, asking for more things like I'm not appreciative or I should not. So women are less likely to ask. But also it's true that when women ask, people do judge them differently on the job than if a man asks, all right? So both men and women do judge women differently, all right? Not only enough, the best negotiator for a male is actually a woman. Women look out for other people more so than they look out for themselves. But I would say the important thing to do is stand up, say what the thought is, see what the issues are, and make sure you have a good open dialogue with the place that you work at to let them know what those issues are. Now, one strategy to do that is to say what all that you could do for them if they compensated or they gave you the correct support staff or the correct work. So another way to work around that is how can I take care of you? Really, we all have a mom kind of thing going on, when, you know, both men and women. And that's a strategy to work on, which is I could do better for you all if you all helped me with X, Y, and Z. And oddly enough, that could be better received many times on the job. Thank you. Kind of as a quick follow-up, I don't want to take up too much time, but because you mentioned it as a woman and as a woman of color, are there specific things that in your work or in your discussions with other people on this topic you have found to be kind of good strategies that we can employ to make sure that our colleagues and those around us are appropriately compensated for our work? As Dr. Hairston was letting me know, on both Medscape and Doximity, they have compensation in what doctors may, you know, in that particular area. Now, that's going to be an average. You don't want to get paid below, but realize somebody else still could be making a whole lot way above average as well. So to me, when I see that baseline, that is the baseline, but everything else is actually above that, all right? So, you know, make sure you do your homework and you collect that information. And generally, I should pretty much know what this job's going to pay me within 5, 10K, or within a few dollars per hour, before they told me exactly what it was going to be. Thank you. Thank you. Okay. All right, so I'm Jonathan Lowe. I'm from the Lake Tahoe area here in California. I work for a rural healthcare hospital, and we are testing out AI scribes and looking to the not-too-distant future where AI replaces a lot of our employees' scheduling. And the hospital's really excited because this is going to mean that they are hiring less employees and we get more work. So I'm kind of looking ahead here to where maybe a 15, 20-patient day turns into a 25, 30-patient day, where we're expected as providers to see more, the hospital's spending less and maybe not paying us anymore. In renegotiating contracts, is there, do you sit down and say, how much am I pulling in for this hospital? Is there, I mean, I know they keep- Do I? Yeah, or is that something that we need to think about doing with renegotiations to say, how much are you making off of the work that I do here? How much are you billing out insurance? How much am I pulling in? You can basically, looking at Medicare data, you can see what the RVU is, and you can pretty much calculate about what, in addition, that's paying, but realizing that you're billing for physician services, but they're billing for hospital services. So aspirin for you at Walmart is X amount versus buying it at the hospital is X more amount. So if you want to see that, you could pretty much kind of calculate what you would do, and then you could also look at, calculate what the hospital is doing, but it's going to be very upsetting and disturbing. Right. If you ever got a hospital bill versus the doctor bill, the doctor bill was $200, the hospital bill was, you know, $2,800. All right, so realizing that it's probably about, you're receiving about 10% of what they're actually billing out, and I'll give you more like about, you're probably getting about seven of what they're billing out. So you're generating them money constantly. So whatever you, and so also, generally if you're getting paid by the hour, the person is probably making twice that off the billing. So you have to look at what is the doctor bill versus what you're getting paid, and then they got ancillary services on top of that. So if they're paying you $200 an hour, I can guarantee they're probably clocking four. If they're on a grant, they may be getting $600, and they're paying you two. All right, so they're probably paying you on about half of what you're actually generating off the doctor bill, but then the ancillary services, you're getting none of that, and that's being made just for them. Thank you. Whose turn is it? Okay, all right. Well, first of all, thank you for such a comprehensive review. I think, you know, this is some of the most important things. You know, we spend all of our time training a skill, and then we get thrust into business, and most of us really aren't prepared for that, and I'm about 100 years in practice at this point, so I've had my share of runs and run-ins with contracts, and the one thing that did come to mind that happened, I think is worth, you may want to comment on, is you mentioned the contract and the out of the contract. Oftentimes when things aren't going well, but I had a scenario when things, well, I thought they were going well, and so I've got a private practice group, and this was a seven-figure contract, and no complaints, everything's going well, and come time to renew the contract, and the CEO had gone and hired in a bunch of people less than us, didn't mention that he wasn't going to renew the contract, and so I had 30 days to figure out what I was gonna do with all these people that had been working in this hospital, and so one of the things that I've started to do in the contract is to set a renewal date that's prior to the expiration of that contract, so you don't get caught that way, because there wasn't an issue, the only issue was that he was able to save money by hiring a bunch of people, been nice if he'd have told me, because then we could have planned for it, but we ended up figuring it out, but we had 30 days to come up with a new contract to cover a bunch of people, so that's another incident that happened with contracts. Yeah, yeah, I left that out, but no, that's important to think about, especially if you have a private business where you're hiring other people, and that's the hard thing about working, owning a business is that other people's lives are impacted by your decision making, your confidence, or your incompetence, where essentially things that happen in the market that we cannot foresee, and generally most good folk will know that if you got all these people hired, that we need to let you know ahead of time, but that tells you a little bit about who you're working with, or sometimes something happened that they did not see happening, where they thought it would have renewed and it didn't, but that's a very scary situation. I appreciate you there for that, thanks. Hello, my name is Rebecca, I am a resident. I am in a program, or I guess I should say a hospital right now that is going through unionization for the residents, and one of the talking points that we've heard from the institution sort of trying to convince residents not to approve the union is that it may have an impact on sort of our hireability once we're done with the residency. So I just wanted to hear kind of your comments. And if you were in a union as a resident that people won't want to hire you once you leave residency? They may not hire you there, but trust me, somebody's gonna hire you. Just be like, you know, I got a line, people, I'll hire you. Johnny, you got a job over there? I'll hire you right now. No, so no, that is a lie. I do know, that is a lie. People will hire you now, the next job may not have a union, you know, but no, no, they're lying. You know, the thing about residency, people put a lot of employees in residencies. Just finish, I mean, just, it's fine. Oh, my bad, damn, you know. Just get out. I mean, life is not all about residency. It becomes so far in the rear view mirror in like two months. Once you're out of there, it's out of there. You know, so yeah, so no, you can definitely get on the job. I wouldn't be ugly about it or anything like that, but thank you so much for that information. I appreciate you, I'll be working somewhere else. Thank you. Hello, my name's Rava. Thank you so much for the presentation. I had a question about, you mentioned, you know, most of this talk is about contracts and having a boss and all of those things, but you talked about working for yourself. What are the reasons one wouldn't wanna work for themselves in like if you wanna do an outpatient practice and that's your goal? Well, I mean, the reason to not is you don't wanna have to run a business. So this is, you know, when you're working for yourself, it's a business. Now, you can do contract work, you know, where somebody else is making the shots and you're getting paid by the hour, you're getting paid by the job, things of that sort, but there is the need, you know, payroll and the taxes and employees and benefits. You work harder for yourself than you will work for somebody else. And you take the business with you wherever you go, you know, you think about it, what's the plan? I mean, payroll is Monday, all right? So I had to make sure that all these things are taken care of before I leave out of town. And so you're in the job of the business owner and a lot of people are depending upon you to make good decisions. So it never leaves you, you're constantly, it's a constant work thing. You know, there are benefits of it, but there are benefits of working for other people as well, where you kind of see the people, make the money, you let it go and you're out the door and everybody else takes care of something else. So there are both benefits, you know, positive and negatives from both ends. And when you're starting up a business, we're not really trained to do it, that's what makes it harder, but it doesn't have to be hard. And some of it just walking out there, you know, and you don't have to, you know, I tell people when you start a private practice, you don't have to just be all out day one, I'm starting my shingle, open up the doors and who's gonna come and see me? My first week I saw one patient, all right? The second week I saw about a patient a day, the third week was about two or three patients a day and about, you know, two, three months out, you know, I'm full, six months out, there's a wait list. But having to get your processes and procedures in place while doing that, because it's one thing if you got one patient a week coming in or one patient a day versus a hundred patients a day and you find out there's been a mistake going on for three months or why y'all not about to be paid, you know, so that is now a tragic issue. So, you know, it does take a level of understanding of information that they haven't taught us, but it is doable and, you know, I'm appreciative of it. You know, if Johnny's been doing 101 years, I've been doing 100, you know, and so I learn something new every year. I never thought about that renewal thing, all right? I never ran into that problem, but I appreciate Johnny sharing that with me. But the fact is that I learned something brand spanking new 20 years out of different options. There are so many things that they don't tell us. There are levels to the game, there are levels to the game. One quick follow-up, how long would you wait kind of out of residency before thinking about starting a private practice? I started day one. Yeah, so now I had contract jobs as well that were helping pay me, but I started on day one. And you won't, they won't teach you. Like people say, just come out first and learn it first. No, they're not gonna teach you day one or day 2001. They're not about to teach you that. Michael Petetta, Portland, Oregon. What are some effective ways of asking for contract pay raises, compensation raises after you've already been with someone for a particular amount of time, whatever that time is, and what are good ways to ask? I'm wondering, because I'm pretty clueless. I'm also a people pleaser, and I think that complicates me asking for what I want and then figuring out how to go after it. I'm working for somebody that I like right now, and it pays well, but I was just working for like a soulless, large health system that was just trying to get as much RVUs out of people as they could, and I don't wanna be too forceful in asking either. I don't wanna push this person away. So I don't know what's reasonable to ask for. Yeah, well, in private business, I have no problems in asking people for money, none. So if you feel like you're not being compensated like you should be compensated, I would give the reasons why and the arguments with numbers, as in Medscape, Doxamity, Google Search, colleagues that you know. I'm making good money and whatnot. Then also, what are the needs of the place? There may be other places that they need you at that may actually bring in more money. So far as, I'm doing outpatient, but we also have an emergency room, things of that sort. I could work extra hours, or I could be in a place that actually brings in more money. But if you're feeling, now, if you're being already overpaid over average, realizing they're making a lot of money off of you in other ways. But the question becomes, all right, we're paying the average doc here 220,000, you want 300,000. Why should we pay you more than everybody else? Which can create an issue on the job when somebody is an outlier, we're doing the same work. People get wind of that, and people just start quitting. So, but if you're not being compensated correctly, ask for the money. To me, that's not a danger. I don't think I've ever fired anybody and told somebody, I don't want you to work in my office because you wanted 5% more. Either I was willing to pay you 5% more, but some people, I was looking for them to go anyway. So, you're gonna leave if I don't pay you 5% more? This sounds great, all right? No, but most often, if it's a little bit more, it's probably not gonna change the bottom line a whole lot, but be careful of being the outlier, because often the outlier gets cut. Okay, so it wouldn't be about asking for a particular percentage increase, because I've been here for a year. It's more just about researching and comparing myself to others, and then seeing what seems to be reasonable there. Yes, and I would say, and if you're being underpaid in comparison to others, you need to ask the question, why? And if they say that, well, that's all we got, we're a broke hospital, we're a non-profit, that's all a lie. I mean, if they're broke, it's not because the five more grand they pay you. It was a lot bigger issue than that. Thanks, yes. I know we must be, what, five minutes left? Seven minutes, okay, we got time for a few more questions. I wanted to get back into the metrics. So you mentioned, I wanna talk about RVUs, and I've actually tried looking for some of the data for reimbursement for RVUs. For psychiatry, it's hard. At least I haven't been able to find it. So I have two questions. First is, do you know off the top of your head what a psychiatrist should be? I guess, what is the worth of one RVU for a psychiatrist? I do not know off the top of my head, but you can look at the Medicare numbers. So essentially, say a 90792 is 1.82 RVUs, all right? But then a 99214 is 1.1 RVUs. You could kind of get a judgment that it's a little bit more than, you know, so if one is 200 and the other one is probably gonna be about 120 on average, but you could look up what the Medicare numbers are, and insurance companies base the payment to the doctor based off what that number is. Now, just because there's an RVU amount doesn't mean that that actually pays a thing at all. So like, there's an RVU for a patient consultation, non-clinician visit. Well, no insurance company pays for that actual thing, so even though it's an RVU, there is no payment connected to that, I'm guessing, for the majority of individuals. So you can get a guesstimation, but you won't know an exact number, but I would try to look at the actual Medicare reimbursement if it's reimbursed, and other insurance companies base theirs off of that. So as a corollary, like, oops, we're trying to negotiate a salary or an increase. Let's say you're saying you're not, all RVUs are reimbursable, so therefore you're basically making the premise that you can't really use your productivity as a measure for asking for a raise. Or an increase in your salary, that's... Well, it depends upon, now I'm talking about RVUs when dealing with Medicare. Now, your individual institution may have RVUs based upon a whole host of different things. So there are things like, I don't know, medical student lectures. There may be an RVU based on that. Well, there's not a billing for that, but that is additional work, and what does that actually mean to the institution, are they willing to pay more for that? Let's go with a different metric. So, so where I work, let's say I'm like 160% productivity. I'm trying to make sure I get the other questions in, so. So wait, I have a question about this. How do you argue, how do you use productivity for your, for any kind of negotiation? So let's say if you're 100% versus under 100% or over 100%. I would honestly talk that up to your individual institution on how they actually calculate that, and how to, if you're looking for an increase in pay, how they base the RVUs based upon it. I'm sorry, let's get to, I want to try to get the two individuals on. Go ahead. I'll tell you what, y'all get both questions at the same time. Well, not at the same time talking, but you know, you say yours, he says his. He was next. All right, you go, then you go, and then I answer both. Thank you. Hi, I'm Richard from Chicago. I have a private practice. I've been doing it for many years. My question is about negotiations with insurance companies, because I can't even get an insurance company to engage me in a negotiation. There's no one there to call. You try to leave a message, and so this is the negotiation that I get the most frustrated with. Would you suggest that you hire like a negotiator for that? I know there are people like consultants who do that, or do you have any other strategies for that? Okay, second question, and I'll answer that one as well. Yeah, I was just gonna comment. I've been hiring people, psychiatrists, for 15 plus years. I came from academia, and I think I'm a good example of I'm academic, but I also have a private gig. So you can do both. I have a private forensic practice on the side, even though I'm a state employee salaried with benefits, and I was just gonna make the push that you can start out working in a mental health center, or a VA, or jail, or prison, and that's your steady gig with benefits and whatnot, and then while you're working on your private practice. So I just wanted to make that point, but I thought it was a fantastic presentation. I agree everything he said. The only other thing I wanna say is I think of salary negotiating like dating. The first thing that turns me off is if they ask what's the salary? So I want it like wait, let's slow it down, and then I'll pitch it to them. I'll say, you know, I'll throw out what is your number, and then what I really like is they say something like, compensation is an important issue, but to me, value in my work, and you know, so you kind of kick the salary equation down the road. Don't go right first date. You're going for, you know, home run first date. That'd be my recommendation. And what I would say always about salary negotiation is how much you're gonna pay me is the last thing I wanna know. You know, really, because I wanna know what the job is. That tells me how much the pay is gonna be. When it comes to negotiating insurances, sometimes they'll answer, sometimes they don't. There should be regular increase in insurance pay, whatnot. Now, when I first started, I took every insurance around me. It was like over like 60, 70, 80 different insurances. I cut them down who paid the most, you know, and who was, who paid, and who paid regularly with the least amount of fight. So if you paid me on a regular basis, but you didn't pay me as much as everybody else, but I was gonna consistently get paid, well, that was okay insurance. So, you know, so the way I negotiated was, one, are you willing to pay more, and if not, and some went up, but others who did not, whoo, gone. Now, that did cause me to cut. I'm down to one plan. Yes, yeah, so, or you already did it then. That was the negotiation. Best alternative to negotiated agreement, and sometimes that is walk. Now, what it did was it increased my cash patience. You know, I went from about 5% cash to 40% cash, and then on high-end pay and insurances, I really cared about their population, and it made life a lot simpler. So even though I got smaller, we became more profitable. Thank you all so much for your time and attention. Thank you, Danielle. Thank you.

Physician Contract Negotiations

Dr. Danielle Hairston

Dr. Napoleon Higgins

self-awareness

salary negotiation

Medscape

Doximity

salary disparities

private practice

out clause

artificial intelligence

healthcare careers