Floating Doctors + Humanitarian Medicine

The Floating Doctors Mission is to reduce the present and future burden of disease in the developing world, and to promote improvements in health care delivery worldwide.

• Providing free acute and preventative health care services and delivering donated medical supplies to isolated areas.
• Reducing child and maternal mortality through food safety/prenatal education, nutritional counseling and clean water solutions.
• Studying and documenting local systems of health care delivery and identifying what progress have been made, what challenges remain, and what solutions exist to improve health care delivery worldwide.
• Using the latest communications technologies to bring specialist medical knowledge to the developing world, and to share our experiences with the global community and promote cooperation in resolving world health care issues.

Sound like something that you might be intrested in helping out? (Freelance MD is already making a small monthly payment to help foot some of the bills.)

You can help Floating Doctors with a donation of any size.

Volunteer medical providers?

Doctors, nurses, PAs, NPs, dentists, optometrists, physiotherapists, occupational therapists, medical students, public health researchers, educators, engineers, and anyone with a pair of willing hands and the desire to help out in this world are welcome to participate in our project.

Everyone has some special talent or characteristic that can be used in the service of others. We pride ourselves on maximizing the experience of our volunteers to express their particular talent in a way that brings the most help to our patients.

We have no minimum or maximum length of stay and a reputation for working hard and being easy to work with. It is impossible to know exactly what kinds of cases we will see, or what situations we will encounter. All we know is that it will be an adventure of the heart—at some point, there will be a moment where your presence can mean a tremendous change in a person’s life.

Here is a typical experience for a volunteer…a surgeon from Austria vacationing in Panama decides to joining Floating Doctors for a one-day mobile clinic to a remote island indigenous village.

“Life is not about seeing what you want and how to get it but rather is about seeing what you have and how to give it.” Frank Baxter

How Do You Diversify Your Skills As A Physician?

How Do You Move Into A Nonclinical Job Or Diversify Your Skill Set?

If you are trying to work towards diversifying your career or transition into a nonclinical career, you may wonder if you have the skills necessary for a job outside of direct patient care.

As a doctor, you can do just about anything you want to do.  But it’s not easy to be confident when you don’t know how to proceed and we aren’t taught to ask for help.

When I was trying to do it, I got caught up in how unsure I felt about what I wanted to do and how to actually do it.  As a result, I lost confidence in myself and that was a mistake.   Without confidence in myself, I didn’t have the positive thinking needed for translating my skills and seeing all the opportunities out there.

Many doctors wonder if they need to go back to school to take the next step in their careers.  While you can never go wrong getting an education, defaulting back to a full time alternate degree program is rarely the best way to go.  It isn’t the “next logical step” to spend more money and time back in school.   However, if you choose to pursue an MBA, MHA, MPH or some other degree, there are many excellent programs, some specifically tailored towards a physician.

But remember this; becoming a doctor gives you a unique skill set that can be translated to fit almost any industry.  Think about how often you’ve dealt with conflict and how often you’ve contributed to increased growth and revenue.  Why is that important?  Does that confuse you?  You’re not alone.  We aren’t trained to think that way in medical school, residency or beyond.   But these are the ways your skills are valued in a non-clinical career and your skills are translatable. 

Here are a few ideas on how to get started or how to move forward if you have already started considering diversification of your skill set and exploration into the non-clinical realm. 

1. Determine if there are associations or societies dedicated towards professionals in the fields you want to explore.  For example, if you are interested in healthcare information technology, make it a point to explore the resources on the Healthcare Information and Management Systems Society (HIMSS) website.  Since you are reading this post, you have already found Freelance MD and you should make it a goal to fully explore all the resources and people available here.
2. Look into certificate programs in the area(s) you find interesting and are the subject of current hiring trends.  Quality, process improvement, leadership and information technology are areas of opportunity right now.  Resources like the American College of Physician Executives are helpful for these opportunities but there are other resources for certificate programs. 
3. Consider the big picture.  I made several mistakes when I was transitioning and I try to help others avoid pitfalls by making sure they take everything into account.  Things like lifestyle, salary requirements, geographic location, etc. are equally important in this journey.  If you don’t consider them, even your perfect job may seem like the wrong thing.  It’s important to set yourself up for success as much as possible by looking at all aspects of your life.
4. Put together a Personal Development Plan (PDP).   Please see a previous post on why is this important and how to do this at http://freelancemd.com/blog/2011/7/5/mid-year-career-strategy.html.
5. Consider nonclinical options and network with other doctors who are also interested in other options.  Not sure where to start doing this?  In addition to Freelance MD, there are resources with information directed specifically at physicians and non-clinical careers.  For example, visit the Physician Renaissance Network at www.prnresource.com. 

The Ethics of Concierge Medicine

I just finished reading Concierge Medicine: A New System to Get the Best Healthcare by Dr. Steven Knope.  

Steve spoke at our 2010 Medical Fusion Conference, but before that event we had never met.  I had seen his book and read excerpts and believed he would be a good person to plug into what we're doing with Medical Fusion, but I really didn't know much about Concierge Medicine and I didn't know any Concierge Medicine physicians personally.

For those who aren't familiar with the terminology, "Concierge Medicine" refers to the medical practice design where patients pay a retainer fee in exchange for exceptional access to their personal physicians.  Physicians agree to limit their practice size to a few hundred patients and give their patients their cell phones, pagers, email addresses, and often make house calls in addition to yearly executive physicals and preventative medicine counseling.  Concierge Medicine is sometimes called "Retainer Medicine" or "Direct Medicine."

Concierge Medicine has been growing over the last few years due to the frustrations associated with primary care-- for both patients and clinicians-- and the development of franchise models like MDVIP.  However, whenever Concierge Medicine is discussed, critics are quick to point out it's weaknesses and cast Concierge Medicine physicians as unethical extortionists.  As an example, in Steve's Concierge Medicine office in Tucson, Arizona, one of the newspaper clips hung on his wall is an article describing his medical practice, and a quote from a local academic physician describing Concierge Medicine as "medicine at its mercenary worst."

Interesting.

So is Concierge Medicine "mercenary" as its critics suggest or a new practice model that is saving primary-care medicine?  Let's look at some of the major issues regarding Concierge Medicine and go from there...

1. Is it ethical for a patient to pay extra money for extra time with their physician?

Most discussions on Concierge Medicine are framed by asking whether it is ethical for physicians to charge "exorbitant" fees in order for their patients to see them.  This is the political equivalent of those squirley political poll questions like, "Do you, as a voter, believe it would be good to have a tax-evading, draft-dodging, ignorant, narcissist as your next governor?"  When the voter answers "no," the polling company reports that voters overwhelmingly are against the candidacy of politician X.  The question frames the debate.

The problem when the discussion of Concierge Medicine begins this way is that physicians are automatically cast as villains.  The "greedy" doctors are simply too money-obsessed to take care of anyone not willing or able to pay these incredibly high fees.

Bu what if the debate is turned around?  What if it's not a "greedy doctor" who is demanding the fee?  What if it's a patient with multiple chronic medical conditions that cannot be solved in the typical 10 minute primary-care visit who is pushing for the change?  What if it's the patient requesting extra time with their physician and to ensure this extra time is willing to pay for the equivalent of 2-3 regular visits a month?

The fact is that Concierge Medicine is a market response to a very broken primary-care system in this country. Patients are driving this change as much as burned-out physicians.  These patients are frustrated and dissatisfied with the current model, and are making their health a priority by investing money and time into their patient-physician relationship.  Many of these patients have multiple medical issues and they need more time with their physician.  They also need someone to help them coordinate their medical care, and have found Concierge Medicine to be a reasonable way to help them improve the healthcare system for themselves.

What's fascinating about this aspect of the debate is that the resource these patients are requesting-- time with their physician-- is the very resource that so many ethicists, consulting groups, and administrators stress is so important to patient satisfaction scores, proper diagnostics, reduced malpractice risk, reduced unnecessary testing, and overall improved clinical medicine.  It's as if the patients read the research and simply got tired of waiting for the system to fix itself.  The patients that gravitate to a Concierge Medicine practice are simply willing to put their money where there mouth is and pay for the extra time they know they need with their physician.  The Concierge Medicine model is actually correcting one of-- if not the-- most glaring problem with modern medicine in the United States: a lack of significant time between patient and physician.

2.  Isn't it more ethical for a physician to stay in the system instead of "opting out" with Concierge Medicine?

This question assumes that the basic primary-care model in the United States is working and those who choose Concierge Medicine practices are messing it all up for everyone else.

The unfortunate truth is that primary-care medicine as it is currently practiced in the United States is not working, not for those who opt out and choose Concierge Medicine or for anyone else.  Those physicians and patients who have chosen Concierge Medicine aren't the cause of this problem, they're a response to the brokenness of the typical primary-care practice model.  In fact, Concierge Medicine could not exist in a market where individuals were getting exceptional healthcare through third-party payers and the standard primary-care system.  The fact that Concierge Medicine has gotten traction is evidence that there are plenty of physicians and patients (ie- willing payers) who are dissatisfied with the status quo.

Here's a very interesting twist to the debate about Concierge Medicine:  if an individual wishes to condemn Concierge Medicine as unethical, does that same individual then defend the current primary-care system where patients are pushed through clinics like cattle and physicians are beholden to third-party payers?  What is more ethical, a patient and physician agreeing on a set fee or a physician who is compromised by the cost-curtailing focus of a third-party payer?  Which physician is the better advocate for the patient?  

3.  Isn't Concierge Medicine only for the rich?

The answer to this question really boils down to your definition of "rich."  

Of course, there are individuals who have zero disposable income and are truly destitute.  Concierge Medicine does not address this very real need.  However, for most people, the issue is not that they lack the funds to afford a Concierge Medicine physician, it simply is that their priority system places greater emphasis on things like cigarettes, alcohol, entertainment, fashion, and luxury than health, and they spend their income in a manner consistent with their priorities.

This discussion reminds me of a letter to the editor that I recently read online written by Emergency Medicine resident Dr. Roger Starner Jones:

Dear Sirs:

During my last night’s shift in the ER, I had the pleasure of evaluating a patient with a shiny new gold tooth, multiple elaborate tattoos, a very expensive brand of tennis shoes and a new cellular telephone equipped with her favorite R&B; tune for a ring tone.

Glancing over the chart, one could not help noticing her payer status: Medicaid.

She smokes more than one costly pack of cigarettes every day and, somehow, still has money to buy beer. And our President expects me to pay for this woman’s health care?

Our nation’s health care crisis is not a shortage of quality hospitals, doctors or nurses. It is a crisis of culture – a culture in which it is perfectly acceptable to spend money on vices while refusing to take care of one’s self or, heaven forbid, purchase health insurance.

A culture that thinks I can do whatever I want to because someone else will always take care of me.

Regardless of what you think of Dr. Jones' letter, the point is that individuals make choices regarding the use of their disposable income, and many in our culture choose to place other priorities above healthcare.

Let's break this down...

MDVIP is the dominant franchise model for Concierge Medicine.  Patients who are members of these practices pay $1500 per year for the privilege of being members of this practice model.  Here's the math:

• $1500 per year = $125 per month
• $125 per month = $4.17 per day
• $4.17 per day = current price of a Starbucks expresso or a pack of cigarettes

So for what most people spend a day on such extraneous things as a cup of premiere coffee or an unhealthy indulgence like cigarettes, these same individuals could have their own personal Concierge Medicine physician.

Yes, there are individuals who cannot afford even this amount per month, and Concierge Medicine does not address this issue (although some are experimenting with a retainer-type practice coupled with indigent care and many Concierge Medicine physicians, including Dr. Knope, spend significant time providing free care to non-paying patients), but no practice model is perfect.  Concierge Medicine could improve access to healthcare of a significant number of working people, if they would only choose to buy into the model.

Additionally, if a patient opens a Health Savings Account that is coupled with a high-deductible insurance plan, pre-tax dollars can be set aside to use towards the costs of a Concierge Medicine physician, making the retainer costs much less expensive for the average consumer.  

In sum, Concierge Medicine is a growing trend that some consumers are using to maximize their healthcare experience.  It is not a system that solves every problem, but I believe it is ethical and it is a solution for some patients.  Instead of criticizing the patients and physicians involved with Concierge Medicine, we should work together to continue to find additional ways to solve the problems with the current healthcare system.  

In future posts we'll be looking more into Concierge Medicine and other non-traditional practice models and explaining how you can incorporate these models into your current practice.

Doctors in a Tail Spin - You Are What Your Record Says You Are

I’m a big football fan. However, my team, the San Francisco 49ers, aren’t doing so well this year.  They have a losing record, and it looks like that they will miss the NFL playoffs once again.  Growing up in Northern California as a kid, cheering the likes of Joe Montana and Jerry Rice during their championship seasons, It is frustrating to hear the players and coaches dole out their excuses after another disappointing loss. “We’re a lot better than our record shows”, they’re quick to point out.

I often reflect back to what famous football coach Bill Parcells used to say – No matter how rigorous the schedule, the oh-so close losses, and the bad breaks, he was unwilling to give any excuses for a loss.  He would say “You are what your record says you are”. You are exactly where you should be. Better run teams have winning records. Team in disarray with poor planning end up with losing records.

That same principle can apply  in life.

For unsatisfied doctors, a significant number point to external factors to their unhappiness – declining reimbursement, government intrusions, an overall lack of respect for physicians, from CEOS to patients. But when it comes down to it, if you are not happy in the position you are, you are ultimately responsible to where you should be. Coach Parcells would say again “You are what your record says you are.”   

I  have a relative who was involved in the burgeoning tech industry in the late 1970s. He was trained to learn a very specific computer programming technology in his corporation.  He spend years educating himself on the programming, as well as training others, and then only to find out just a short time later the technology would soon become obsolete, as was his employment, as dictated by corporate headquarters. Soon there after, he found he was out of a job, a casualty of mass layoffs. He had no choice but to reinvent himself, going back to school, with new training, and a hope not to be made “obsolete”.

As doctors many feel we lost our position as being the decision maker in healthcare. It  pains me to see an industry where over 50% want to get out of the industry, yet feel powerless, to do something about it. Yet many of us as physicians have assets and fund of knowledge that we can use and apply in different ventures besides clinical medicine, as evidenced by the numerous examples we have in Freelance MD.

Last weekend, I conducted a workshop to a group of physicians who were all at different stages of their career. I commended them for attending, and remarked that unlike many of their colleagues, because they were willing to start something new and out of their comfort zone. Many doctors aren’t willing to reinvent themselves, because what economists refer to as an “opportunity cost”. For example, many physicians feel because they have spent so much time and money in medicine anyway, that if they do something different there is an additional lost opportunity cost. That is by starting something new, it would make  the years missed and the money spent all for not, and  instead they feel forced to continue to work in their current vocation,  even to the detriment of their own happiness. There is also the feeling that they are “giving up” if they choose an avenue that the rest of their colleagues would not follow. Albert Einstein, said the definition of insanity is “doing the same thing over and over again and expecting different results". Does this quote apply to you?

If you are not happy where you are, it may be time to start taking control and reinvent yourself. If you wake up and dread going to work, it may be time to take a mini-vacation or consider a new endeavor. If you feel like you’re going through the motions in your career, and not making a difference in the world, it may be time for a new challenge. Just as a team with a losing record, it may be time for a new coach, a new offense, a new strategy.

As Coach Parcells would say, “You are what your record says you are.”

Nonclinical Jobs For Doctors?

Not sure if a cashier is what most doctors are thinking when they're looking for nonclinical physician careers and opportunities.

(via A Cartoon Guide to Becoming a Doctor)

How Doctors Can Double Their Income

As a physician, you're trading time for money.

Most physicians are no doubt very adept when it comes time to academics and being “book smart”. We all had to get great MCAT scores and high grades to get into medical school. However when it comes down to financial planning or building wealth, it’s not overstating the case that our preparation was a bit lacking. Medical school didn’t prepare me very well for finances,entrepreneurship, let alone running my own practice.

As physicians, when it comes down to it, we are exchanging time for money. The amount of money a physician can make is generally in proportion to how much patients we see or procedures we do. This is no different then the majority of the population who earn wages for a living.

The unfortunate aspect is that for us to double income, we generally have to see double the amount of patients. And as reimbursement continues to dwindle, we are now having to see more and more patients to get the same amount of income, in comparison to five to ten years ago.

So what are our options? For physicians who want to maintain their current nest egg, they need to start building passive or residual income to work for them. Indeed, many physicians have resorted to passive income (in the form of investing, real estates, buying bonds, etc), or started “side careers” or investments (In fact, many of my ER doc friends have run anything from owning their own tavern, to daytrading, even starting your own winery! There’s a reason why Business Pitch section of the AMA news, a series that highlights physician side careers,  seems to be one of the most popular columns.

One great way to build residual income, is entering the domain of online health consulting and medical publishing.  No matter what you decided to do, building residual income to work for you will be more imperative for physicians in the near future. Starting early is the key.

3 Thoughts On Physicians & Career Modification

Non-clinical and non-traditional medical careers are a common theme on Freelance MD.

If you peruse the posts on Freelance MD you'll find articles on a variety of topics—writing and publishing, real estate investing, concierge medicine, medical device development, business skills, leadership, journalism, and many more.

The common theme of all these posts is the idea of career change, or as I like to call it, career modification. It's the idea that as a physician, you aren't forced to accept the status quo; you have options, and there are a variety of ways in which you can harness your skills and personality traits.

Having said this, however, I must say that it is very difficult for the typical physician to make any kind of career change.  It's been a long time since I've met a physician who wasn't significantly frustrated with their career, but I'd say maybe only one out of fifty, or even one out of a hundred, of these frustrated physicians are actively taking steps to modify their career in some meaningful way.  It's a strange phenomenon, but it does seem to be a cultural trait in our profession.

Look, I'm not a professional career counselor.  If you want professional guidance, I'd suggest Ashley Wendel, whose entire career is focused on helping physicians transition into more satisfying careers.  However, for those of you who can tolerate my amateurish anecdotes, here are my top three reasons why I believe physicians have a difficult time modifying their careers...

(drum roll please)

1. Physicians are Narrowly Trained

A typical physician is overall a very narrowly trained individual.  

The majority of us were science majors in college and then spent a minimum of seven years being crammed full of medical minutia.  When we finished our medical training, we had a fairly firm grasp of our area of clinical expertise, but not much else.  Few physicians have had any significant exposure to personal finance, the legal system, business transactions, popular writing, art, negotiations, investing, or anything of the like.  Many of the physicians who I know who do have a special area of expertise outside of medicine sort of fell into it, or were raised in it by their family upbringing, not necessarily because they sought it out.  

When you compare a physician to an attorney, for instance, and the diverse professional experience of the typical person in law or business, it's easy to see why attorneys and business-types seem to transition in and out of careers with a lot more ease than physicians.  We know the Krebs Cycle; they know contracts, and corporate structure, and business appropriateness.  It's not that we physicians are any more or less as professionals than our peers in other professions because of our narrow training, it's simply that what works in our narrowly defined world doesn't necessarily work elsewhere.  

Physicians who have decided to launch into business, or anything else for that matter, without sufficient prep time usually find just how lacking in knowledge they really are.  Our narrow training puts a premium on our clinical knowledge and skills-- it takes a high investment of time and resources to obtain a medical degree and become a licensed physician-- but it also condemns us to a narrow career path unless we actively seek out further training.  

The good news is that with further training, career transition is much easier.  Here at Freelance MD we're committed to exposing physicians to training in a multitude of diverse niches.   We don't want the "narrow training" issue to be an excuse anymore for any physician considering a career move.

2. Physicians have Difficulty with Ambiguity

This reason takes a little more to explain.

Think about your medical training and your current medical career.  How did you get where you are today?  

Few careers are more systematized for more years than a career in medicine.  Most physicians began thinking about medical school before college and worked towards medical school as a goal from the beginning of their undergrad education.

Take and excel at my core science classes...check.  Take MCAT...check.  Get letters of recommendation...check.  Send in applications and pray...check.

Once in medical school our lives are completely structured to the point of exhaustion.  We are routed into our various specialty tracks and move along the medical assembly-line like widgets, getting the final stamp of approval and then shipped to a place of employment where we dig into our clinical careers, join a medical society, buy a house, begin paying off our school loans, and well, not much else, really.  

When we finally take a look around-- years into our clinical careers-- we have no professional experience other than medicine from which to draw and no practical experience in how to transition into something that doesn't have a structure or system to it.  

Become an entrepreneur?  

Where's the fellowship for entrepreneurial medicine?  

Develop a medical device?

Isn't there a masters degree in medical device development somewhere?

Write a book?  

I'd love to, but I don't have time to go back and get a college degree in English.

Does this seem familiar?

Physicians are so trained in a systematic educational experience of structure and hierarchy that it is very difficult to imagine how an ambiguous career move might work.  The idea of setting sail without a predetermined path and system to plug into leaves many physicians completely flummoxed. 

Instead of taking a machete and beginning to forge our own path through the career jungle, we wait for someone to build a superhighway that we can follow, complete with rest areas and gourmet coffee shops.  Of course, this rarely (read, never) happens so many physicians sit around saturating in the magical thinking that someone will come along with a foolproof plan to save us, and getting more desperate and frustrated when that person doesn't show up.

I could go on and on about this point, but I will use this as an easy transition to my final reason physicians have a difficult time modifying their careers...

3. Physicians are not Risk-Takers

Alright, everybody calm down.  

I know you're brave and calm in tense situations.  I know you can thread an angiocath, or intubate during a code, or your steady hands can find the pulsating bleeder with the best of them, even when everyone around you is losing control.  I know you're good under pressure, but this is not the same as being a person who is comfortable accepting calculated risk.

What I've found in conversations with physicians is that their risk profile is extremely low.  Yes, they're frustrated with their careers, but leave their jobs, start a company, move to a different part of the country, invest actual cash in an endeavor? Are you out of your mind?  Greg, those things are so risky...

Look folks, here's the facts...

You will never grow, transition to a better career, get from where you are to some better place, move beyond your current boundaries, or do anything of significance without assuming some measure of risk.  It's impossible and if you're waiting for that risk-free career move to show up, well my friend, I hope you've got a lot of time on your hands.

Many physicians have a difficult time with this aspect of career modification, even sadly, when the only risk is of the potential damage it might do to their professional standing.  I know a number of physicians, for instance, who deep down do not like academic medicine, but who persist in academics because they simply can't bear the thought of what people might say if they left or how it might affect their standing with their peers.  They're afraid they'll be dropped from this committee or not invited to speak at that conference.  They persist in their academic positions not for the love of teaching or the stimulation of their research; they persist because of the fear that they might lose something in the transition.  Their positions have become shackles that confine them, and their peers have become juries whose approval they must have.

When I speak to a physician who is hung up on this aspect of risk, I council them to of course make sure the transition they're considering makes sense-- talk to mentors, read up on the area they're considering jumping into, spend considerable time planning the transition.  However, in the end most of these career decisions come down to taking a jump off a cliff, and when I get to this point in the conversation I always discuss with them the risk of the status quo.

You see, career modifications are not a discussion of risk versus no risk.  They're a discussion of risk versus risk-- the risk of a career change versus the risk of staying in the same place.

I ask them, "What is the risk of staying in your current position for another year, or two, or three?"

If they're honest, they begin to see that staying in the status quo also carries significant risk, and when this is realized, a potential jump doesn't seem as frightening.

The point is that for most physicians, being able to tolerate risk is not something that comes naturally.  We like systems.  We like order. We like knowing our next step and we like having safety nets.  We work in a culture that demands perfection each and every day and the idea of stepping out without a finalized gameplan is terrifying to most of us.  We're creatures of habit with a significant dose of OCD in us-- medical school selects for these traits-- but we have to realize that we'll never begin to grow past where we are if we don't begin stepping out.  The idea of growth without risk is ridiculous, and we need to recognize this fallacy and move beyond it.  Embracing calculated risk-taking isn't optional, it's mandatory for career modification, and the sooner we accept this the sooner we'll begin moving towards a more fulfilling career.  It's that simple.

So there you have it.  My three reasons why physicians have a difficult time with career modification.  

In future posts I'm going to explain more about what I mean by career modification and some unique perspectives on what is available to physicians in today's modern, fully-wired, world.

Until then, check out Ashley's posts here at Freelance MD or her website.  Her advice is excellent for those of you considering a career change, much better than the musings of physician blogger, and almost risk-free.

Almost.