Well thank you again for joining us and thank you for AAP for having this mid-year symposium again. I'm Kim Barker. I am at UT Southwestern and Dr. Dita Mananagalu will be joining us in a little bit. She's the co-director for this course. I didn't mention this yesterday but there were a lot of people that actually did help in preparing this mid-year symposium. Dr. Leslie Shirley Ryan and Dr. Jennifer Paul at University of Rochester. So just wanted to thank everybody that helped out and this morning we're going to have Dr. Nathan Bartford who's at the University of Rochester as well talk about financial well-being. So thank you. You're welcome. Thanks for having me. I'm going to share my screen here. Hopefully everyone can see that. Can everyone see that? I'm seeing it looks like I'm sharing you. It doesn't make any sense. Hang on. I see it. We see it. Okay good. Okay. So you know I wanted to give this talk because I didn't really get a lot of financial education when I was a resident and what I got was really from people with major conflicts of interest. And so you know I think it's important that residents understand how finances work and what to do to not you know kind of mess up because it's really easy to mess up especially when you don't have a lot of background in it and when you when it's really easy to find information that comes from unreliable sources. So let me just make sure my there we go I've got some disclaimers because I'm a physiatrist. I'm not a financial professional. I'm not an attorney. So I don't know everything about all this stuff and this does not constitute any personalized financial advice. It's just sort of some general overview and there's way too much to cover for one lecture. So consider this an introduction and each of these pretty much every one of these slides is something you can do an entire lecture on. So I'm trying not to go into too much depth but consider it a starting point for doing some you know education on your own. So you know why do we care about finances? Obviously you know none of us went into medicine because we you know because we wanted to you know be rich because if we just wanted to be rich there's a lot of other jobs which pay a lot more with a lot less trading pipeline. But you know it's important that we know something about finances because you know we're all going to want to retire someday. Maybe not all but pretty much all of us at some point are going to want to stop working or at least cut back a lot. And in order to do this you know pensions are very rare these days and so in order to pay for your living when you retire you have to have some sort of savings. And it turns out you have to have kind of a lot of savings if you want to be able to stop working and still live the kind of lifestyle that you live when you you know earn a decent paycheck. So and you know unfortunately a lot of doctors still live paycheck to paycheck. There's some good surveys around that you know it's not the same percentage as the general population but it's still way higher than it needs to be. And so you know the other thing about it is that when your financial ducks in a row are in a row you can really be a better physician in a lot of ways because you know if you're not kind of a slave to you know earning more money and and you know having to work more or having to you know do other things that really may not be you know in the best interest of your patients or or in the best interest of yourself because of you know money being an issue. And so if you kind of have everything at least have a plan and know what you're doing with your money you can have that be less of a driver of your day-to-day decisions. The other reason you really should learn about finance on your own is that there are many many financial salespeople out there who style themselves financial planners or financial advisors and they you know specialize in you know helping physicians achieve their goals etc etc. And really what a lot of these people are are salespeople and not really they don't really have like a fiduciary duty necessarily and even if they do that you know that definition of sort of having your best interests at heart is very gray when you compare that to like the Hippocratic Oath for example. And you know we're used to to dealing with people you know in the medical field who sort of have that sort of higher ethical standard and in the financial world it's really not like that. And so it's it's very easy to to find someone who's a very nice person and seems to be giving you lots of good advice and really it's not necessarily what's best for you. So you need to have some knowledge on your own so you can recognize good advice and recognize when somebody's really not giving you good advice. And it's really not that hard but it does take time to learn all this stuff and to understand at least enough to know when somebody's trying to take advantage of you. So to start off with you know one of the major problems is you know you're attending salary obviously it's higher than when you're a resident but it's not as high as you think. And there's a lot of reasons for that you know the numbers themselves don't don't tell the whole story. So you know one of the main things is your and I'm going to talk about each of these points but one of the main things is there's a late start to your career. So you know if you if you had friends who are like chemical engineers you know in college or some other you know similar bio major but they went out straight into the workforce after they graduated and you had another you know four years of med school four years of residency maybe another year fellowship and now you're finally starting to work and earn that paycheck. Now you know you've lost nine years of your early savings and those early savings are really important which I'll talk about. And so that shorter timeline between starting to work and retirement it really makes it makes a huge difference a bigger difference than it might seem of just nine years you know eight years whatever it is. Debt is a big problem for physicians obviously medical school debt is a is a big thing. If you're going into private practice and you want you know we want to take out a big loan to help buy into a practice that's a lot of debt mortgages you know other things a lot of people rack up credit card debt during residency because they're just trying to you know trying to get by on on less than they're expecting to earn in the future and so that's that's a big cuts into your earnings when you have to pay off that debt. Insurance is is a big part of sorry it's a big expense that you end up needing and we'll talk about some of the insurances you need when you're in attending. And then taxes so I don't have a problem with taxes but you need to know how they work because you end up the more you earn the more you pay and and so you need to understand kind of how that works in order to understand how much money you're taking home at the end of the day. And then the other big thing is really societal expectations. You know especially from from family members but also from society at large you know they kind of expect you to have a nice house and a nice car and you know wear nice clothes etc. And you know I think it's really easy to kind of buy into that like oh you know I make money now I should be able to you know I should be able to drive that nice car etc. And that can really make it harder to save when you're spending all this money on these things that that you think you deserve. So to start with the first of those points you know doctors start their career late. So this is looking at what happens with compound interest. If you were to save you know three hundred dollars a month toward retirement every month and assume you get a pretty decent return on your money you know five percent on average something like that. If you were to start at 25 you know age 25 by the time you hit 65 you're at you know like the forty five hundred dollar or forty five hundred thousand range you know something like that. When you start at 35 which is more like what I did and you double your your savings so say you put 600 a month and get a five percent return you know you're only at 250,000. And if you wait till 40 and do the same you know I'm sorry I said that wrong 35 with the with the same amount three hundred dollars a month you end up only at 25 250,000. If you were to start at 40 and double how much you put down so now you've got you know you're you're theoretically over time you put the same amount in you still don't quite reach up to what you would if you started early because of the power of compound interest that early money that you put in ends up earning so much more because of how compound interest works than when you start later. And so that's one of the problems when we start late. And so this is another graph where it shows you basically how if you were to save a certain percentage of your income how long would it take you to to get to what they call financial freedom which essentially means once your your money is earning enough money it's what the financial people like to say that you can take money out to pay for your expenses and not run out of money and when and you're taking out the same amount that you have been spending all your career but now you're not having to work because that money is coming from your investments. And so you can see if you're only saving five percent it'll take you over 50 years just to get to you know financial independence where you can stop working as opposed to you know when you get up to say 20 now it's only going to take you a little less than 30 years and that's kind of more reasonable when you start at 35 so you don't retire at 65 which is like a normal retirement age you know you have to save like 30 percent it's you know 20 25 27 percent to get up to that if you only save 20 it's going to take you more like 30 years. So this just gives you sort of an idea of why you really have to save more and generally the recommendation is like 20 to 25 percent of your gross income should be going towards saving for retirement and investing toward retirement and that's a big chunk. So the other big issue is that doctors start the career with more debt than again your friends from college who went into chemical engineering or something like that. This was a survey done back in 2017 and they surveyed people you know the number of people with these you know thousands of dollars in retirement savings, student loans, and mortgages and you can see the frequency of respondents you know the vast majority of people had like less than 49,000 in retirement savings which you know that's kind of normal that's what I was and then as you go up the as far as the amount of student debt you know it's like a it's up the the higher numbers are more common and then a mortgage you know it's kind of in the middle. So this was you know 71 percent of the residents and fellows surveyed had some sort of student loans 48 percent of those their loans were over 200,000 and so you know when you're looking at debt you know first of all you want to be careful with how much debt you take if you have a lot of student loans and you're eligible for public service loan forgiveness you should really consider it and look into all the details of what's required. It is still happening you know there's a lot of sort of talk out there about how PSLF is going away but I'm sorry oh it is really happening it happened you know my sister was able to get it and you know people are getting public service loan forgiveness it's you just have to dot all your i's and cross all your t's and so if that's something you're considering you should really look into all the details. And then if you're not eligible for public service loan forgiveness consider refinancing and just get those loans out of the way you know whatever whatever it takes whatever you need to do to to get that to pay off you really don't want your student debt hanging over you your whole career you don't want to be you know in your 60s getting ready to retire and still paying off your education. So the other problem I mentioned you know doctors are targets for financial sales people. Everyone knows that we earn a decent paycheck and the the financial industry knows that we're not typically good with money you know we're very smart and we think we're very smart and so something like money you know it's all just numbers that should be easy but you know we're not that smart when it comes to money on average. And so you know we may be embarrassed to admit that and you know when someone approaches us with hey you should really do this you know it's it's it's hard for us to sort of contradict them and be confident with you know knowing that they may not be giving us the right advice. So especially you know they call themselves financial advisors financial planners and they're saying you know they're going to really you know help you get your house in order. They often offer free advice which you know sounds great and they often target residency programs that's what happened to to me at you know during my internship during my residency during my fellowship you know they would come to our didactics and tell us all about you know why you should do this this and that and it all sounds very reasonable but then in the end it ends up being a sales pitch you know buy insurance through me I'm going to get a commission you know I really want to get you into this retirement vehicle which is going to be so much better than whatever else you might be looking at and you know it ends up being you know major conflict of interest sometimes and it's not that all financial advisors are disreputable it's just that there's very little regulation and so there's so many people out there who are really commissioned sales people who get away with masquerading as advisors and you know there's nothing saying they can't call themselves that and so especially those higher products with our products with higher commissions and higher fees you would think you know you get what you pay for but in in the vast majority of cases you really get what you don't pay for the things that are more expensive for you to buy end up being end up being worse for you in the long run as far as you know how it's going to perform how it's going to serve you in the long run one of the other issues is that doctors need expensive insurance so you know we all know about malpractice insurance it's usually paid by your employer but not always that's very expensive disability insurance is also very expensive but you know the idea of this is if you do become disabled you know social security disability is basically you get that if you can't perform any job at all but you know if you can you know sit and work at a call center or something like that you know you're not going to be able to have that income that you've sort of counted on and built your financial plan for and so you know personal disability insurance ends up protecting saying that if you get disabled and can't do your job with the job that you do they'll you know compensate you for that if you know if the claim is approved and all that stuff and it's more common than you might realize for people to get disabled for doctors and even residents to get disabled you know spinal cord injury that sort of thing we all we all see patients with disability and you know so really ideally you should be getting disability insurance before you graduate residency but you just have to be really careful about what you're buying and know what it's really covering and how it works because there's a lot of variability in how it works so you have to be just really cautious about what you're what you're getting life insurance so if anybody depends on you for your income the idea is that if you die they get basically a lump sum that sort of compensates for the amount of money that they're expecting you're going to be earning you know in the next 30 years and it's not that they'd get you know you're not adding up all that amount but some sort of amount that that will sort of take care of them and provide the kind of life that they're expecting from being married to a physiatrist and this is relatively cheap if you have people depending on your income you should buy it now it's not based on you know how much they expect you to earn it's just you know you're a certain age you have certain health comorbidities and and they you know you can buy it on the open market there's no like there's nothing special about it there's many companies that offer it and you really want to get term insurance now there's also you know they call it like permanent life insurance or universal life insurance cash value life insurance this idea that you know rather than a term policy which which expires at a certain point which you know should be around the time you're expected to retire or at least have enough money that when you die it's not a big financial burden for your for your family the idea of like this cash value life insurance is that whenever you die even if you're 105 then your family gets some sort of cash benefit for that and that's generally speaking not what you need there's a lot of arguments for it which are made by financial advisors again but typically it's not really what you want and so if you if you're thinking about buying some sort of permanent life insurance really be very cautious run it by a lot of different sources and and make sure you know what you're buying because the vast majority of these policies are not appropriate for physicians for a number of reasons you also want some sort of personal liability insurance so you know malpractice insurance will cover you with malpractice but the other thing that happens is you know say you you know hit somebody with your car or get in a car accident or or you know somebody visits you at their house and they fall at your house and they fall down the stairs or something like that you know people know that you're a physician and you know that you have money and you know more they're more likely to sue you even if you don't have money and so umbrella insurance or personal liability insurance covers you for those sorts of lawsuits that aren't malpractice you know it's relatively cheap to buy it's it's probably worth it you probably don't need it as a resident but probably as soon as you graduate you should have umbrella insurance health insurance obviously usually it's paid by the employer but um if you're in in private practice or if you're in um if you're like in a contractor type of position you're going to need health insurance and then obviously auto home and renters all you know basically for your stuff and then they have basic liability coverage but not it's typically not going to be enough for what you know what you might need as a as a doctor and then taxes i mentioned taxes you know we have a progressive tax system in this country where you know the more you earn the more taxes you pay and that's generally a good thing because then the people who don't earn anything at all or don't earn much at all are are sort of protected and then uh the more you earn you end up kind of paying more more share and you know this again it's a good thing but you you want to make sure you understand how that works um because uh to make decisions from your for your money so for example if you're going to say i'm going to work an extra shift or something um you know and get earn whatever however much more money um just understand that that extra money you earn is what ends up getting taxed more so not the whole thing but you know say you're at you know 200,000 here and then you earn another 50,000 well that 50,000 is taxed at 24 percent not 22 percent um and so you know the more the higher you go the more the more chunks of money get taken out so for example here uh resident salary you know a payment r says it's between 40 and 72k that's outdated data but let's say 60 60,000 um so your first 200 you know 25,000 or so is taxed at uh zero percent so that's your standard deduction when you do your federal taxes um so zero percent of that money is taxed the next step above that from 25,000 to roughly let's say 47,000 it's taxed at 10 so 10 of that gets taken off and then above that it's taxed around 12 and then as you go up you know those those brackets get higher that's what the tax brackets are so functionally what that comes out to you with a 60,000 paycheck is you get overall 6.5 of that is taxed and then the after-tax income is around 56,000 um so that's when you when you combine all those different taxes tax chunks that are taken out so let's say you graduate and you go on and get a job uh you know payment are attending salary again a human r says it's between 200,000 and 275 uh 75,000 roughly so let's say it's 240,000 just to quadruple the residents and kind of make our math easy so now you got your you know 0 10 12 like the resident and then once you get above 100,000 you start getting to jump from 12 to 22 and then above 200,000 you start jumping to 24 and so what that ends up looking like is here this one has no tax taken out this part has this little sliver taken out here and then this one has more and this one has more and then this one has you know 24 in that top bar and so what you end up with is overall your tax rate is 19 and your after-tax income is is 81 now obviously 200,000 left over is still much better than uh you know 56,000 left over um but just understand that you know every time you go a little bit higher and a little bit higher you know 24 of that money is going to the federal government which again is fine it's just that what you're taking home you're you're paying for your buck so to speak on that margin is is what you're really looking for you know for example you're married filing joint and this is all married filing jointly just to make it easy because that's what's what I am but um you know does your spouse work your spouse has a lower paying job you know they want to work that's great but just understand that you know say they're earning you know 40,000 you know they're getting taxed at your marginal tax rate if you're if you're filing jointly so that you know they are add 40,000 24 of that is getting taken off right away um so just understand kind of how that works so what do you do um you know this all sounds like very doom and gloom um it's not uh it's just you know the the key thing 100 you know the first thing is just spend a lot less than you earn you know when you go to from a salary of 60,000 to 240,000 don't go spending 240,000 of your money as you know especially to start with so that you know the the um advice is to live like a resident this is white coat investors you know mantra um he's he's a very good resource for all this you know all this information I don't agree with everything he says but he's very good a very good financial advice, relatively unbiased financial advice resource. So he says, two to five years after your residency, as you're paying off your student loans, essentially, earn whatever you're going to earn, but only spend a portion of it. And then the rest goes to paying off your student loans, getting rid of your consumer debt, getting a jumpstart on your retirement savings, really trying to build up. Because the earlier money that you put into retirement is going to serve you more. As you get closer to retirement, it's not going to have the time to earn as much. So that early savings is really the important part. And then save up a down payment for a house that you want to be in. You don't want to stretch yourself to try to buy that house first thing, which I'm going to talk about here. So almost no one manages to actually do this. You get a job, you want that house, you want that car. So this is really an aspiration. You want to make decisions so that you can grow into your income slowly, and not jump up to that lifestyle, because it's much, much harder to scale back. If you're spending paycheck to paycheck, again, you're spending all that money that's coming in, it's really hard to cut out a piece of that and send it off to savings. Much harder than when you first start out, that you cut out that chunk at the top, and you're used to living at that level that you have. So in order to do all this, you plan your spending. And the first thing is to automate retirement contributions. So 20% to 25% of your gross income. That means if we're saying this $240,000 roughly, so your monthly income is $20,000, $240 divided by 12, $20,000. That means that $4,000 to $5,000 a month is going to go into retirement. And as your income goes up with inflation, or you get a promotion, or you start seeing more patients, or whatever it is, you need to bump up that retirement savings, because otherwise, you start spending more, and you're still saving the same amount. And when you get to retirement, you're used to spending that amount. Now you're not going to have that amount coming out from retirement. So you really want, again, that's 20% to 25% to retire at like 65%. And so you really want to keep fixed expenses low. So fixed versus variable expenses, the fixed expenses are the same every month. And they're things that you can't change. Your mortgage, you got a car loan, you got your insurance, child care, phone bills. Anything that's on a payment plan, you can't just say, oh, I'm going to cut back on my mortgage, or oh, I'm going to cut back on my car payments. Your variable expenses are things like eating out, going to museums, going on trips, that kind of stuff. That stuff you can cut back on and cut out, clothes, food, whatever else. And so those are the variable expenses that you can make changes to. But these fixed expenses, once you sign that mortgage, you need to pay that amount every month. And if things start getting tight, and you start, for whatever reason, you start having trouble, that's really hard to change those payments. And so the key point is don't buy too much house, especially early on. Buy a house that you think doesn't deserve a doctor living in it. Don't lease and finance expensive cars. So pay cash when you can. Don't buy a fancy car right away until you know you can afford it. I remember when I was a resident here, and one of my chief residents calling, she got that job. And she was calling the car company and getting her custom, whatever fancy car that she was going to get when she started. And she hadn't even graduated yet. Just be really careful. And then other things like consumer purchases, your phone. You don't have to have an expensive phone or expensive computer. Don't pay cash for it when you can and save up for it. Don't buy a boat and have it on a payment plan. That's ridiculous. And just generally don't buy expensive things you don't need. What you really want to do is try to get out of the payment mindset. Oh, that's only $500 a month. Oh, that's only $50 a month. Whatever it is, those things add up. And again, you're locked into them. You can't change those. If anything happens, a little bump in the road, you can't get out of those payments. So just be really, really careful. And then keep a healthy cushion. You never know when something happens. You got to change your job. You got to move across country to help your parents or something happens where your job significantly changes and you have no control over it. And you need to either cut back or find a new job. You need a cushion to be able to get you through that transition. So you're not going to rack up debt. And so just really keep a healthy emergency fund. Make sure your retirement savings are all locked in. You don't want to be living on the edge if you can help it. And the last thing is, if you have a significant other, if you have a spouse or a long-term partner that you live with, include them in the financial planning. Because the last thing you want is to have all this plan set up and have your significant other not be on board with you. And money is one of the big things couples fight about and one of the big reasons for divorces. Divorce is very expensive too, besides the human cost. Divorce can be financially very difficult for a physician and for anybody. And so you really want to be on the same page with your spouse and make time for them and have everyone on the same page so that you're not creating conflict. But again, going back to this, if you've got your plan laid out and you've put that money toward retirement, you've got those fixed expenses so that they're not too crazy. And then whatever's left is yours to spend. You go out to dinner, get nice stuff, send your kids to private school, whatever you want to do. As long as you have those major things, you get the big stuff right and the rest is going to be easy. And you want to plan things before your first paycheck. If you look up paycheck simulator, there's calculators there that will give you your annual salary. And then they'll look at how much you're expecting to pay for your insurance, how much you're going to put into retirement, what state you're living in, what your local taxes are. You put all that stuff in and it spits out, OK, your $20,000 paycheck. Now after you spit all that stuff out, now you're left with whatever, $10,000 because of taxes and insurance and retirement contributions and all that stuff. And so understand what you're really taking home, not just your gross salary. So one other thing just to talk about investing real quick is that you really want to invest passively. If you look at trying to save for retirement, you would think that the more somebody works for you, the better return you're going to get on your money. But the way that the stock market works in general, it's very efficient. And so what you really want to do is just get the overall market return, how the overall market is doing. And over time, you're going to end up beating the people who are trying to get an edge and try to, because they may beat and get an edge for a while. And then when they crash, they crash hard. And so take the time to learn how to do all this yourself or hire a reputable planner who's really going to make a plan with you. You typically pay them hourly or maybe by the year and make sure they know what they're doing and not just trying to sell you something. If you have retirement accounts at work, you can start with just a target date fund. And you say, OK, right now it's what, 2022. I want to retire in 35 years. So that's going to be, I can't do math, it's going to be 2059, right? So let's say 2060. There's this target dates that are like 2055, 2060. And they automatically have a, based on index funds, they change your investments to make them more aggressive early on because you can afford to be more aggressive. And then as you get closer to retirement age, they scale back the aggressiveness so that when you retire, you don't have big changes in the amount of money you have because it evens out. And so target date funds are great for especially when you're starting out. And then keep expenses low. So if you are buying index funds, you should not be paying significant percentages per year in fees. You want to look for passive as opposed to active funds. And those, look for expense ratios. Those should be very, very low. And they shouldn't have commissions. You shouldn't have to pay somebody a commission to buy a mutual fund. Those are more expensive. That money comes out of how much return you get on it. And again, on average, over time, you're not going to beat just the regular market return, which is what you would get with an index fund. And then automate as much as possible. Have your retirement savings go out before you see the money in your account. Because the more it's automated, the less you have to think about it. And the less tempting it is to sort of, oh, well, maybe this year I won't contribute to that retirement account because I want to build a new deck on my house or whatever. So just when you automate it, you don't have to think about it as much. So here are some resources. The White Coat Investor I mentioned, he's an emergency physician from Utah. And he's got a whole blog. He's got a podcast. He's got books. He's got online courses. He's got lists of trusted financial professionals, what he considers trusted. And these are people who you pay who will pay by the hour. And they'll set up a plan for you. And pretty much any question you have about any financial topic, if you Google White Coat and that topic, they'll find multiple posts on his blog because he's been doing this for 12 years or so. The Millionaire Next Door is a great book about being wealthy by not acting wealthy. So when you're not spending money on all these things that make you look wealthy, you can actually build wealth because you're saving that money. Planet Money is a great podcast just about the overall economy. But they had this summer school last year where they talked all about investing and how the stock market works and how bonds work and all this other stuff. And it's like eight episodes. You can listen to it in your car, great information. And there's another podcast called How to Money, which is not really doctor specific, but they talk about saving and being frugal and not spending all your money. They're dealing with different numbers than doctors, but the overall concepts are really helpful. Especially the very early episodes, they talk about the basics. Okay, so I actually did pretty well. I know that was a whirlwind and we didn't really, didn't have time for questions throughout it, but I really wanted to get through it so that we weren't rushing at the end. But let's see, let me stop sharing for a second and let's see how many participants we have. Okay, we got some here. I see a question in the chat concerned about inflation. Yeah, good question. So yeah, that's a big topic right now. Obviously inflation has been very low for a long time and most of us have not lived or at least been, cause I'm young too, I haven't been out very long and most of us haven't seen high inflation before. The bottom line is it's not something you should worry about too much. It's obviously a concern and it's something that is, it's gonna play out whether you do something about it or not, but when you look long-term, if you're looking at like your long-term savings, the things that beat inflation in the long-term are basically stocks. So if you look at the overall stock market and the sort of graph of it over time, it has big dips in it, those are called bear markets. That's what we're in right now. We're kind of in a little dip, got major financial crashes, but it ultimately recovers and comes back and it always goes up higher than inflation for a number of reasons. And so when you're thinking about long-term investing for retirement, which is again, 30, 35 years, however long you wanna work, you really should be in things that beat inflation, which is typically stocks and real estate is another thing, but that's a whole other topic. I don't really like talking about it. But the bottom line with any of these questions like that is that the bottom line is when inflation is high, you should spend less. And that goes for the economy as a whole, but it also goes for individuals because as prices go up, the more you save, the less you spend. And that less that you spend is accentuated by the inflation. What else? I wanted to leave time for questions because I know I went through that really quickly. Or is there any particular topic on that that you wanted to go back to or that you wanted to hear more about? Don't be shy. I know you guys got, we've got, let's see. We've only got two of you. So please, please, please talk to us. For the malpractice, if someone's an independent contractor, do you need to carry your own current malpractice, head and tail, or how does that, what are all the types of malpractice insurances we should be carrying? So that's a good question. I don't have all the details on malpractice because I work for a university and I don't really care that much because they pay for it for me. So I haven't spent the time to go into all the details, but the basics are typically, yeah, you want occurrence coverage, which is where you're covered during the time that you're working at a particular institution. And so if somebody sues you 10 years down the road for something you did during that time, that insurance covers you. The other type is claim-based where it's whenever the claim is made, that's when it covers you, even if you didn't have that policy at that time. And then tail coverage essentially is a type of claim policy where it covers you for what you might've done at a certain institution or while you were covered by a certain policy, even if you're no longer at that institution or covered by that policy. And so basically you want to be covered wherever you are. And so if you're an independent contractor, sometimes the institution will also pay for your insurance. So if you look at like locum tenens, a lot of locum tenens jobs will end up also covering your malpractice. You just have to really know all the details. Are they really covering you for the occurrence while you're working there? Are you going to get stuck with it later? And again, if you Google white coat investor malpractice, you'll have lots of information. Sorry, that's my dog. Oh, hang on a second. He did pretty well throughout the presentation. Thank you. I didn't have any more questions if anyone else does. I'm sitting here and thinking it's too late for me. This is one of those, I wish I knew this when I graduated. Yeah. But thank you, very much. Of course. Yeah, it was definitely something that, during residency, I definitely made some mistakes. I mean, I can tell you a couple of quick stories about what happened to me. Nothing terrible, fortunately. But when I was a fellow, I was moonlighting, which was great, great extra income, couple thousand dollars a month extra. And we were basically spending that as soon as I earned it. I was just, phew, phew, phew. And so I found out then when I, during fellowship, I started learning about all this stuff. And when I started my real job, I then was putting like maxing out my retirement accounts, putting all this money toward retirement. I was paying for disability insurance, paying for life insurance. I had a mortgage during residency, which is not really recommended, but I did. And I bought a house that was not expensive. It was less than my annual income. But because I had that extra money coming in for moonlighting, and I was spending it right away, when I actually got my real paycheck after going through all those other expenses, the money left over was not what I expected at all. Just because of these extra expenses, the extra taxes coming out. I live in New York state, that's notorious for higher state taxes as well. And I was kind of expecting, oh, my income's whatever, triple, quadruple. The money was not nearly as much as I thought. And so obviously there are jobs you can get, especially private practice, where you are earning kind of a ridiculous amount if you really want to. But obviously we're all in academics here, we've got other goals. And even when you earn more, you still have to pay attention to all these things, because there's just a lot of, it's very complicated. And on that note about saving, just as we still have some time, unless, was there anything else from the residence before I rant for a second? So, oh, go ahead, Carly. Oh no, I was just going to say, no, not from my end. Okay. So just briefly talking about retirement accounts. So the idea of a retirement account is that, the federal government wants you to save for retirement because they don't want to have to pay for your retirement or pay for you when you're retired. And so they've created basically tax breaks for people who are saving money toward retirement. And so something like a 401k, or if you're an academic institution, it's typically a 403b, but it's the same idea. You put in money into your retirement account, there's a certain amount per year, this year it's 20,500. And that money is taken out of your taxable income for the year. So I put in 20,000 of my money into a retirement account instead of spending it. And now I save, now I save whatever that marginal tax rate, depending on what bracket I'm in, say I'm in the 25% bracket, I'm saving $2,500 in taxes by putting, I'm sorry, I'm saving $5,000 in taxes by putting $20,000 into a retirement account. And it's not like that money is gone, it's in a retirement account, which then can be invested and grow so that when I'm retired and no longer working, I can use that money to spend and to do things. And so the 401k works like that, IRAs work like that, but it's a little more complicated because there's income limits. And so you have to do some special things to be able to contribute to an IRA. There's 457Bs, which is basically where you tell your employer, I want this much of my money to be taken out of my paycheck and you guys keep it until I decide that I want it later. And it's basically your institution's money until you decide, until you separate from the institution or retire. And that's a 457B, it works a little bit differently, but it's a similar idea. And you put that money, take that money out of your paycheck, now that's not taxable anymore. So again, you save on taxes then. As opposed to a Roth, you may have heard of people having like a Roth IRA or a Roth 401k. Roth is where you pay the taxes now and put that money into retirement and then it never gets taxed again. So as it grows, the growth isn't taxed and when you take it out at the end, that money isn't taxed. So it comes out tax-free. And so that's nice for when your current tax rate is relatively low. Cause you can put money in without being taxed very high on it. And then when you go into retirement, then you don't have to be taxed on it. And so Roth versus the traditional version, kind of depends on what you think your tax rate's gonna be now versus when you retire. And typically when you're in your kind of peak earnings years, early and middle of your career, your tax rate's gonna be higher than when you retire. Typically, if tax rates stay the same, which that's a lot of debate about, who knows in 30 years, taxes might be much higher. Who knows? So that's, and then HSAs are another account you should be aware of. Some people are eligible for a health savings account, which also can turn into a retirement account. It saves you on taxes and you can invest it just like a retirement account and it can be very beneficial. So if you have access to all those accounts, max them out and you still may need to put more money into a regular taxable brokerage account in order to get to that 10 to 20% of savings to get you to retirement. I'm sorry, 20 to 25%, I misspoke. And that's beneficial for federal income tax, but does it apply to state income tax? Yeah, yeah. So, well, every state's different, so I can't say for 100%, but typically your adjusted gross income, is what the state tax gets calculated by and those retirement contributions, if they're pre-tax retirement contributions, those reduce your adjusted gross income. So that when it comes to, on your tax forms, it comes to tax time, that money is like not in there in the calculation. It also affects your loan. So if you're in like a federal loan program that's based on your income, like an income driven repayment plan, your monthly payments, once they start again, if they ever start again, are based on your income, your adjusted gross income. So again, if you're putting 20,000 into your, if you're maxing out that 401k, that 20,000 is not calculated in your student loan payment. So if you're going for public service loan forgiveness, if you reduce that adjusted gross income, then you're also reducing the amount that you're paying toward your loan. So it can end up being very beneficial to max out your retirement accounts from a taxes and from a student loan standpoint, if you're going for public service loan forgiveness. We had somebody else hop on, did you have any questions about, you know, we kind of went over this whole presentation, but did you have any sort of financial wellness questions? This is Laura, he's actually our next speaker. He's our next speaker, I'm sorry. No, no, no, that's fine, he was on yesterday too, I think, so if he does, he's welcome to ask. Okay, welcome. All right, is there anything else from our participants before I sign off? I'll just end by saying, you know, really go and look at, again, I think the White Coat Investors are, you know, kind of the best out there. He's not perfect, he's definitely got some, there are some, there's always conflicts of interest, but I think as far as, you know, as far as these things go, he's probably the best one who tries to mitigate those conflicts of interest, and so he's a really good resource for if you're looking to educate yourself about any of these topics. And read his book. Thank you so much. Thank you for having me. Okay, perfect. And I, so first of all, thank you for having us. I'm really excited to be presenting with Dr. Siddiqui, who is a mentor of mine and was actually one of my attendings while I was a fellow, so it's always fun to be on a panel with someone that's a mentor. And then, obviously, thanks for having us at this mid-year meeting. This session was sort of billed as a bit of an interactive session, and so I know there aren't too many of us on the chat or on the Zoom here today, but I would invite those of you that are on to participate a little bit, either in the chat or speaking out, just so that we can get a little conversation going, because these are designed to be sort of case presentations and not necessarily a right or wrong way to approach every single case, as we know, and sort of a discussion of why things went the way they did. So, I have no disclosures. Again, the goals that we're going to discuss, three to four interesting cases today, sort of talk through the data gathering, the history, the physical, and then kind of focus on a physiatric approach. And then, again, wanting to be interactive here, so just a bit of background. I'm from Arizona originally, born and raised in Tucson. I went to medical school at U of A in Tucson. I had hair back then, and it seems to have left me recently. And then I did my PM&R residency at Carolina's Medical Center in Charlotte, North Carolina, and then I did my sports medicine fellowship at Columbia Presbyterian. My practice, I work actually in an orthopedics department, but I'm one of the non-operative primary care sports medicine doctors in the orthopedics department, so I see a lot of, obviously, sports medicine and musculoskeletal patients. I do a lot of exercise counseling, which I think is a really important piece to my practice. My sort of niche in the department is mostly musculoskeletal ultrasound-based, and so I do a lot of diagnostic ultrasound and injections, and then referrals for surgery when indicated. I also am faculty for either UCSF Sports Medicine Fellowship, as well as the Travis Air Force Base Sports Fellowship, and I do some ultrasound teaching at various conferences, and then I'm the team physician at Cal State East Bay, which is a Division II school out here. So just, again, hoping to get some sense of who might be on here. If you can just put in the chat your level of training. I know we have, obviously, some attendings on here, too, so perhaps I should have put a G on here for level of training, but it does seem like E. Okay, so we've got a couple of PGY-4s. Great. So obviously, you guys will have some pretty good knowledge base to discuss some of this stuff, and it looks like Carly and Gina, perhaps, are the two that I'm seeing there. Please feel free to speak out. Turn your mics on if you have questions. So this first case, this is a 39-year-old female with a sort of acute on chronic episodic left calf pain. There was no trauma or inciting event that brought on this discomfort. She states it kind of comes on two to three times a day, really couldn't really find a way to determine what brought it on. She says it sort of averages a five out of ten pain, but increases to eight out of ten periodically. She describes it as aching and sharp with periodic tingling, but she also says that she feels this in multiple extremities. She says the pain is so bad that it limits her ability to walk at times. So when I'm approaching a physical exam, I sort of think about it. This is my favorite mnemonic is the IRS pester students, and so I start with inspection, range of motion, strength, sensation, palpation, and special tests. So on inspection, there was no obvious deformities, swelling, or atrophy. She had symmetric ankle and knee range of motion, good strength throughout. The sensation did seem slightly diminished over the kind of distal posterior aspect of the lower leg, but reflexes were symmetric and there was no clonus. There was some mild tenderness to palpation in the kind of posterior lower leg near the distal aspect of the gastroc, and then she had a little bit of tenderness up at the sciatic notch as well, and straight leg raise did seem to reproduce her calf pain. So certainly interested to hear anybody either, again, typing or speaking out, things that you would be thinking about in a differential at this point. Like a chronic exercise-induced compartment syndrome. Awesome. Radiculopathy, potential muscular strain. Yeah, amazing. And then Gina, it looks like, said peroneal neuropathy as well, which is another good thought. Yeah, absolutely. So yeah, these are great differentials. This is kind of what I came up with. Certainly, there seemed to be some sort of component of chronicity to it. I thought about maybe some sort of calf strain. I agree, Lombo, lumbar radiculopathy, and I'm glad you brought up chronic exertional compartment syndrome. I typically see that more in patients where the pain comes on as they're exercising, and she didn't have that particular history, but those things are very uncommon in general and seem to present variably, and so I think thinking about that is a great point. And then I had popliteal artery entrapment syndrome, another really rare one of sort of posterior leg pain. Good. So what do we do next? What's our next steps here? I mean, since you have the ultrasound in the room, I would probably go ahead and just take a look at what you can see in there, especially since you can do it functionally since she's not really having a triggering physical exam maneuver that she's been able to identify, you might be able to identify in clinic. Yeah, great. And I think, was that Carly? That was you speaking up? Yeah, I'm biased, and I throw the ultrasound on all the time, and so I agree with you. The way that my clinic works is I typically am getting patients that have been referred from a primary care doctor, and so oftentimes they've had a bit of workup done already, and so in my case, they had been seen by their primary care doctor who thought maybe this was a DVT, and so they had ordered Doppler studies, which were negative. They had also ordered x-rays of their lower leg, which were negative as well, and then based on the fact that they had a positive straight leg raise for the primary care doctor as well, they had actually first been sent to my spine colleagues. I don't see a lot of low back pain in my particular clinic anymore, and so they were seen by my spine colleagues who did order an MRI of the lumbar spine, which showed this mild L5-S1 disc bulge without obvious nerve root impingement, and then they were actually sent to neurology due to her descriptions of paresthesias and her family history of multiple sclerosis, and they did an EMG that was also without abnormalities, and it was not felt to be a central nervous system etiology, and so then they were sent to me, and so now I've had this big extensive workup. Everything looks pretty normal so far. Why is she still having calf pain? Let's have you go see Dr. Bailowitz, and so that's when the patient was sent to me, and so I did end up. My next step was to do a diagnostic ultrasound. There are specific protocols for various joints, shoulders, knees, et cetera. The posterior leg doesn't have a specific protocol outlined by the AIUM or the AMSSM, but so this is my protocol. These are the things I take a look at, and so just as a quick review from a dermatomal and peripheral nerve distribution, we think about the nerves in the back of the leg. I know, and I'm sorry, I'm not remembering your name, Gina. You had mentioned the peroneal nerve, which is a good thought. The nerves that we look at back here are the sural nerve as well, the tibial nerve, and the saphenous nerve, and so from an anatomy standpoint, the sural nerve really did seem to fit best with the distribution of her symptoms. It typically gets branches from both the peroneal and tibial nerves, but there is quite a bit of variability in terms of the distribution of how that nerve is created. Sometimes it can come purely off the tibial. Sometimes there can be two that come down, and it's a purely sensory nerve, and it typically travels with the small saphenous vein, and so on ultrasound, it's relatively easy to distinguish. It's usually superficial to the fascia and sits just next to this short saphenous vein here, and there was one study that even looked at a normal cross-sectional area, and so in our patient, we were able to see that the sural nerve was very flattened here, and you can see it sort of almost looks entrapped within the fascia, and let's see if this video will play. Here we can see the sural nerve looking relatively normal, and then it gets kind of smushed and caught in the fascial layer there as we travel proximally, and so our diagnosis was a sural nerve entrapment in the area of the free gastrocnemius aponeurosis, and so the biggest question here for me was when I saw this patient was, why did the nerve conduction study miss this? Do you guys have any thoughts on why that would have happened? Assuming that you can find it on NCS bilaterally, you'd have to have a 50% drop to call it abnormal, but you might have an entrapment without the 50% drop seen yet. Yeah, absolutely, so if it's not severe enough to be a true sort of nerve injury, if it's just more nerve irritation or neuritis, sometimes you will miss it, absolutely. Any other thoughts? You can ignore D. It was, I don't mean to pick on my neurology colleagues. Yeah, so the other interesting thing in this case is that the entrapment, the location of the entrapment, typically measure the typical nerve conduction study is the 14 centimeters proximal, and the entrapment was a little bit too far up for that, and so I think it's a good, we have these sort of standard protocols of our nerve conduction studies, and while they serve us well, a lot of the times it's important to remember that the entrapment was a little bit and while they serve us well, a lot of the times it's important to remember that nerve entrapments can happen in other locations, not just in the places that we measure on our nerve conduction studies, and so in this case, the entrapment site was a little bit too far proximally, and so again, the setup may have been a limiting factor here in terms of our ability to detect this in addition to, yeah, that, are we not getting a big enough drop to really have this be a sensitive study, so great. Any thoughts on next steps, how you would potentially treat this patient? I'm still really bothered by the fact that she said she's experienced this in other limbs. Was that a persistent problem, or had there been a PCP workup done, or A1C, etc.? Yeah, I agree, and I wasn't able to give her a good explanation for why she was experiencing sensations in other limbs. I had been, I was a bit comforted by the fact that she had been seen by my neurology colleagues who had felt that there was not a more systemic etiology of this. I don't recall whether or not she had had an A1C evaluation, but I think that her primary care doctor had sent her to neurology because the initial workup had been done and been normal. And so I agree with you, and I think it can be challenging to explain one symptom with one limb or the rest of the body. But yeah, in this case, I wasn't necessarily able to offer her any significant explanation there. But the majority of her symptoms were sort of isolated to that calf. She only experienced the kind of all-four-limbs sensation every once in a while. But yeah, good thought on the A1c. In the chat, we have an answer of D as well for this question. Okay. Okay. Yeah, and I mean, again, I have a bit of a bias. This is sort of my role in my department is to do these sort of ultrasound-guided procedures. But I don't think that any of these things are necessarily incorrect. And it's always challenging with some of our board examinations that we feel like there's only one right answer. And really, this is a discussion for me with the patient. So here are our options. We could start with physical therapy, and nerve-gliding exercises may help to free up some sort of entrapped nerve. Topical diclofenac oftentimes can help with especially superficial inflammation. And if the patient is averse to some sort of needle, or they don't want to play around with letting me poke them, these are all viable things. I probably would defer surgical referral at least until we've tried other things. But every patient is different. And so I think my takeaway from this slide is more that these discussions with patients and sort of shared decision-making becomes really valuable here. So in this case, I did perform an ultrasound-guided hydrodissection. This is a paper that came out from Stanley Lamb and his colleagues. I think Kentaro Onishi was on this paper and talked about some of the rationales and the pathophysiology behind nerve compression, nerve irritation, and then why these hydrodissections may work for it. And this was just a small study that looked at hydrodissection for carpal tunnel syndrome, as well as for ulnar neuritis. So there's a couple of papers for it. But in this case, we did perform an ultrasound-guided hydrodissection. So here you can see the needle coming in, the entrapped nerve is just above it. And then here's the completed hydrodissection now with fluid surrounding the nerve. And the patient got great relief from this. It was relatively temporary. And we repeated it one more time. And again, she got great, but temporary relief. And so she did actually end up getting this released from one of our peripheral neurosurgeons. So that was the outcome of the case. So I think takeaways for me, she did describe a little bit of tingling, but she also described this sort of achy, sharp pain. And I see this more and more where nerve pain isn't always just classic numbness and tingling. And so being aware that nerves can still be affected, even if it's not that classic distribution. Being aware that the nerve conduction studies can miss some things from time to time. And then obviously, hydrodissection is a viable treatment option for modern neuropathy. So good. Yeah. Thank you both for your participation in that case. Gina, Carly, any questions on that one? Do we know if the straight leg-raise positivity persisted as a physical exam finding? Do you mean after the hydrodissection? Correct. Like, I'm wondering if she had an intelligent gait that was causing an eventual compensation that led to that neural tension sign, or if it was something else. Yeah. So I've found really remarkable changes in neural tension testing following hydrodissections. And I think Dr. Siddiqui may speak to this a bit in his case, but it's pretty remarkable how just putting some anesthetic and fluid around a nerve can change the way that people feel with neural tension testing. I see this a lot in patients, even with like piriformis injections or injections more proximally in the deep gluteal space where they get a lot of buttock and strain with hamstring stretch kind of maneuvers. And then we do a sciatic nerve injection and hydrodissection, and they have a significant reduction in that neural tension testing. So in her particular case, she had an improvement in her symptoms immediately leaving the office. So yeah, good question. I'll add that if you go back to that carpal tunnel study, Zach, that study is interesting because it's a cadaver study where they were really looking to see what are the mechanical effects of the hydrodissection on nerve glide. And so... Oh, okay. That was a different one, actually. So there is a study, I think it's a Jason study, it's a cadaver study out of Mayo where they basically were looking at what is the actual mechanical impact of hydrodissecting the median nerve in the carpal tunnel. And they did it on cadavers and they were able to actually demonstrate freer movement of the nerve within that sort of fixed space. So as much as the anesthetic is somewhat desensitizing the nerve and alleviating some chemical irritation, it also, we think to a certain extent, some degree of mechanical relief that's occurring, particularly if you can get that full, as Dr. Bailoit so beautifully demonstrated with his video, if you can get that full halo effect where you can actually see fluid all the way around the nerve, you can feel pretty good that you will likely have affected the tension across the length of the nerve. And of course I chose my very best picture for this particular presentation. It's not always possible to get that full halo effect, especially in some of the deeper nerves. But yeah, there's been a couple of studies exactly to your point, Dr. Siddiqui, about just looking at in carpal tunnel syndrome, looking at median nerve mobility when fingers are moved. And we see that in patients with carpal tunnel syndrome, the median nerve is much more sort of stationary despite finger and wrist movements. And so we think that nerve pathology is potentially related to the ability of the nerve to move or not. And so in this case, I think a lot of the reason that the symptoms improve is because we're able to allow more movement into the nerve. So yeah, great question, Carly. Gina, any thoughts before we move on? No, thank you. Great information. Okay, cool. So we'll move on to case two. This is a 22-year-old college baseball player with two months of right posterior shoulder pain. There was no trauma or inciting event that he can recall. It came on sort of early in baseball season. It has progressively worsened. He describes it as kind of two out of 10, but it gets worse with throwing, especially in that late cocking phase. The pain is described as aching and deep. And the reason he comes in is not so much pain. I think college baseball players are used to dealing with discomfort. But of course, the thing that he cares about is that his velocity has decreased. And he's been working out with his college trainer, doing some rehab, and his symptoms have unfortunately not improved. So on inspection, no obvious deformity, swelling, or atrophy of the shoulder. He did have some slightly atypical range of motion in that his external rotation was greater than 90 and internal rotation was less than 90. But as we see with a lot of baseball pitchers, this sort of preference to external rotation is fairly typical and due to their adaptations from throwing. He did have a slight strength deficit, four out of five strength with external rotation, but otherwise his strength was five out of five throughout. And then sensation was intact and by a lot of upper extremities. Reflexes were good as well. He did have some tenderness in the upper trap, kind of posterior glenohumeral joint area. And then on special testing, his O'Briens was kind of equivocal, nothing too impressive about it, but he did have a positive jerk test during the exam. So any thoughts on a differential here for this particular patient? Some ligamentous laxity. Okay, yep. Some thoughts on some ligamentous laxity. Was that the range of motion that was pushing you in that direction? No, it's more of the positive jerk test. And then also the decrease in velocity, it seems like in that late cocking stage, he's actually having an interruption of his motion. So I'm wondering if there's something that's minorly subluxing or kind of subclinically subluxing that's causing the disruption of the motion. Great. That's awesome. Yeah. Great thought. He could have a compression, mononeuropathy, or he could have focal injury to muscular tissue, one of the SITS muscles. Yeah, absolutely. So I think, you know, common things being common, that was sort of the first thing I thought of, which was some sort of muscular strain is, you know, he's tender posteriorly. So there's some sort of infraspinatus involvement, less likely, but we always think about rotator cuff tears. So radiculopathy, you know, labral tearing is fairly common in our pictures. And so that was something I was thinking about. And then we'll talk briefly about posterior shoulder impingement, and then sort of less common things, brachial plexopathy and suprascapular neuropathy. So what do we do next? Got a lot of options here again. You know, nothing is necessarily a perfect answer here. Just sort of curious how you would think about it. Jean, I'm going to pick on you just to write something in the chat if you're around, just so that we can get multiple opinions here. Carly's been very generous in sharing. Thank you, Carly. Yeah, it sounds like you love ultrasound. So one thing you could consider is doing that shoulder diagnostic ultrasound. You can look at the nerves and obviously the tendons and the muscles. Don't fall into my bias. Well, I love ultrasound too. And if you know how to do it, and you can do it in the office, it would be, you could do it efficiently. Otherwise, maybe consider more of like a shoulder MRI and start them in therapy in the meantime. Yeah. Yeah. Great. I love it. Carly, any thoughts? Yeah, I would probably grab shoulder radiographs first, just so that we have that information. But I completely agree with quickly moving into a diagnostic ultrasound and some physical therapy, depending on what we find. Great. Yeah, perfect. I'm fortunate in my clinic that patients that get sent to me are required to have radiographs prior to seeing me. And so I had the radiographs already and they were normal. I did have this patient, actually, I think they were already starting with physical therapy when I saw them. One of the things I asked them specifically to focus on was their internal rotation deficiency, and then some scapular stabilizers and rotator cuff strengthening. And I think for baseball players, especially pitchers, that internal rotation deficiency and external rotation, increased range of motion, it can be a bit pathologic. And so if we can focus on that a bit, that can sometimes take care of the issue in and of itself. And then because there was that slight weakness, I was a bit concerned for either a nerve injury or a tendon injury. And so that did push me in the direction of wanting some advanced imaging. And again, diagnostic ultrasound doesn't have to be the answer. You can certainly get information with an MRI as well, but in my clinic, that was my next step. And so unlike the posterior leg, the AMSSM and the AIUM do have recommendations for a complete diagnostic ultrasound. And I would imagine as PVGUI-4s, you have both been exposed to this. So the goal of this is not to go through the complete shoulder examination, that's sort of a separate issue. But suffice it to say that in our patients, when I looked at the posterior shoulder, here's sort of a typical view in a patient, excuse me, this is, if you were to do a glenocumeral joint injection, that's what the white line means. But excuse me, in our patients, during that posterior view, you can see that there's this sort of anechoic circular mass sitting here in this location. So any thoughts on what that might be? I'm not sure if it could be some sort of evulsion that's now sitting in that space. I'm not sure. Yeah, I mean, it sort of takes a little bit of practice to kind of get to know what these things look like. One of the clues here is that it's really completely anechoic. And so usually when it's anechoic, that indicates that this is some kind of fluid. Like a cyst? Yeah. So this looks mostly like a cyst, exactly. And so this cyst is sitting in a specific location. This is the spinal glenoid notch. And so this patient ended up having a labral tear with a paralabral cyst. And that paralabral cyst was sitting in the spinal glenoid notch. And when it sits in the spinal glenoid notch, what it does is it impinges on the suprascapular nerve. And so this patient ended up having a suprascapular neuropathy due to that spinal glenoid notch cyst from his labral tear. And so that external rotation weakness ended up being because there was compression of that suprascapular nerve. This was not the patient's MRI. This is from something I stole from the internet. But you can see that the cyst is coming from where this kind of signal is in the superior posterior aspect of the labrum. And so we were able to make that diagnosis of the paralabral cyst in the clinic with the ultrasound. And that sort of lets us think a little bit more about potential ways that we might treat this. And so any thoughts on what you would try to do here for this patient? Well, you could drain the cyst just because it seems like you have active compression with muscle. Assuming he was five out of five strength as a college athlete before, I think we'd want to at least temporize the effect by draining it in clinic that day if possible. Yeah, great, great. Any other thoughts, Gina? I haven't actually ever seen if this aspiration is possible, but I'm assuming it is since it's an option. But would you consider after you aspirate it, putting steroid there too? Yeah, it's a great thought. And there's a lot of discussion and I'm also curious to hear your thoughts. Do you aspirate it and put steroid in the cyst? Do you aspirate it and then put steroid in the glenohumeral joint? Because that's where the presumable irritation is coming from with the labrum. So what I ended up doing was aspirating the cyst without putting any steroid in. Here you can see the needle coming in. We typically approach this from a medial to lateral direction. I usually have the patient prone and the needle comes in and you can aspirate. The challenging part is that it's an 18 gauge in order to aspirate this usually thick cyst. It's a deep spinal needle, 18 gauge, which can be a little uncomfortable for the patient. I usually use some local anesthetic first. But some of the discussion is do you put steroid right around the nerve? Maybe that actually helps the nerve calm down. Do you put steroid in the glenohumeral joints? In my case, I didn't either. My hope was that the paralabel cyst was a one-time thing and that by draining it, it would not recur. But I don't know that there's a right or wrong answer to that question. I don't know that there's any specific data discussing that answer. Yeah, from my perspective, I would say that because the cyst is typically communicating with the joint space, injecting the cyst technically is injecting the joint space to a certain extent. That may be a one-way valve, which may have accounted for why it accumulated the way that it did. So it may not actually reach the joint if you inject into the cyst. But the synovial outpouching that constitutes the cyst may calm down and may not reaccumulate as much. I do like the idea of possibly doing the suprascapular nerve block, possibly with a very small amount of steroid to see if that calms it down. Typically, in treating these, I'm usually, just like Dr. Bailo, just aspirating. I'm usually just aspirating and seeing how they do initially, particularly in a college athlete would probably want some EMG information to kind of track functional progress of the nerve and for getting a return. And then deal with recurrences sort of on more of a surveillance basis. I think, Gina, you were going to say something, or maybe Carly, sorry, one of you. I was just going to ask, since you were thinking it was like an isolated incident, low risk of the cyst reoccurring, I totally understand why, like maybe with the steroid, if it had been someone with a lot of arthritis, would you consider doing like a shoulder joint steroid injection? Yeah, that's a great question. I think, first of all, I think, and perhaps I misspoke, I think it's difficult to know if it's a low rate of recurrence because as Dr. Siddiqui was saying, you can have these sort of one-way valves and the same is true for like a Baker's cyst where it's sort of this one-way valve. So sometimes you drain it and your Baker's cyst patients send you a message three days later that the cyst has reaccumulated. And so that's always a potential risk for these patients. And in that case, then I might consider aspirating again and putting steroid in the joint at the same time to try to calm things down. But in a patient with osteoarthritis, although these paralabral cysts are less common, yes, I would definitely consider injecting the joint as well, just because, as you said, the irritation may be a more sort of constant process rather than just potentially a one-time thing. And to the point of reaccumulations, similar to these Baker's cysts, oftentimes when you are aspirating them, I try to fenestrate the sac as well to try and create some release, so that it doesn't actually accumulate to the point of actually being compressive. When you're deciding on those steroid injections, is your decision whether or not to inject sometimes influenced by the wait time on surgery if you do? In other words, have you found that your orthopedic surgeons are delaying time to the OR by three months if you do a steroid injection? That's absolutely one of the factors, yeah, for sure, especially in a patient who's a college baseball player who potentially has an upcoming season that he's starting. So yes, definitely the timing of surgery comes into play. I think for me, other things I'm thinking about are the potential risks of putting corticosteroid into a young shoulder. And so that maybe pushed me away from trying it right away, which is one of the reasons that in this particular patient, I just did the aspiration and then had him continue with physical therapy to see how he progressed. And I think one of the things is just sort of frequent monitoring. So checking in in a couple of weeks, okay, how is your external rotation strength? If that changed and you're feeling your strength has improved, terrific. If your strength is still weak and you're still having posterior shoulder pain, looking to see if the cyst has reaccumulated. And so sort of frequent monitoring because these things can kind of choose your own adventure. They can go in multiple directions. But yeah, absolutely. I think wait times from surgery are a real burden. It's a real healthcare issue right now as wait times are for everything. And so yeah, considering that is definitely something that I take into consideration for these. And I'll say that your question really does get to the heart of kind of what we mean by the physiatric approach to these cases is that, you know, we're not just looking at the pathology and because, you know, the pathology is not pathology and that's it, right? The pathology exists within the context of a person who has, you know, a life schedule, goals. And the treatment really is dictated as much by how that patient is interacting with their environment and what their expectations are for management as they are by the pathology itself. Right. So, so, you know, not just tying to surgery if you inject some steroid, but also considering, I mean, in a college baseball player, you know, is this something that, you know, is he a baseball player at a junior college and, you know, kind of does this more recreationally? Is he someone who has the potential to make a career out of this? What are the implications of surgery? What are the implications of non-surgical treatment? What would happen if he loses the season to a, you know, to a season ending surgery? All that stuff kind of goes into the into the mix the same way, you know, when you're discharging a patient from an inpatient rehab unit, you need to know, are you sending them to a wheelchair accessible elevator building or are you sending them to a six floor walk in New York City? So, you know, all of these things really get to the heart, like I said, of, you know, how we think as physiatrists. I have a quick question on the radiologic aspect of musculoskeletal. So I know that increasingly ultrasound is being used to help look at the pathophysiology as well as the prognosis of carpal tunnel syndrome. But where are we at in terms of gathering standardized data and a reference population for other compressive or inflammatory mononeuropathies such as this one? Yeah, from the suprascapular nerve specifically, I think it's pretty challenging because even in the thinnest patient, it's the nerve is so small in this location that it's difficult to measure the cross-sectional area. But Dan Cushman's group just put out a paper, I think last year, with some standardized reference values for a lot of other mononeuropathies. And so I believe I can find the reference for you, Carly, but that was the first paper that I had seen that really had, you know, sort of standardized cross-sectional areas for other nerves besides the median nerve. And I think there's a couple for the ulnar nerve at the elbow. But aside from that, I think, you know, as you point out, you know, that data is pretty slim. Fortunately, a lot of times we're able to compare to the contralateral limb, which provides us with some good data in a patient who otherwise it's hard to know. So, yeah, I don't know. Asad, do you have any thoughts on that? Yeah, I would agree with everything you said that, you know, for the data gathering process or something like that, where, you know, because of the limitations of ultrasound with respect to, you know, being very highly operator dependent and being very dependent on body habitus, being favorable for visualization, you know, lack of standardization across machines and image processing, you know, I imagine we're a long way off from actually being able to have reliable measurements for some of these deeper nerves. That's why it's kind of why I think the median nerve is the nerve of choice to study because it's so readily accessible. We're joking. We're talking about ultrasound demos. And what's the first thing you look at when you get your hands on a new ultrasound probe? For me, literally the first thing I'm doing is I'm putting it on my wrist because I'm looking at tendons, I'm looking at nerves, I'm looking at all kinds of stuff, I'm looking at bones. So it's just readily accessible. But, you know, to to that point and to kind of speak to some of what Dr. Bailowich was talking about with the rationale behind hydrodissection, you know, some of that literature suggests that. You know, actual mechanical entrapment is maybe not I mean, certainly plays a role in the symptomatology, but it's not the be all end all. And you can have functional nerve entrapments, not to give away too much of the next case. You can have functional nerve entrapments that produce symptoms but don't necessarily produce structural changes in the nerve that would be visible on any imaging modality. And so, you know, what are the other ways that we can kind of correlate what we see to what we think is going on? Yeah, and I find that so often that there's and the way I sort of distinguish it in my documentation is that there's a neuritis versus a neuropathy, where a neuritis is a patient with nerve related symptoms, but the nerve is normal in appearance and normal in function. It's just irritated for some reason. And so, yeah, I think that's that's a really important point that that even in these patients where the nerve looks normal, that doesn't rule out a potential nerve issue. I think that's all I got. I'm going to I'm going to stop sharing, Asit, and I'll let you take over. Great discussions, Carly and Gina, thank you very much for being here. I really appreciate this. This is this is exactly what we were hoping for. Yeah, thank you. Thank you. All right, can you guys see that? Yes, I can. Yeah. OK, perfect. So I'm going to keep this party going. I have one more case and then we'll kind of wrap things up. But so I am Asit Siddiqui, I'm a faculty at Columbia Cornell residency program. My primary appointment is at Cornell, where I'm an assistant professor of clinical rehab medicine. I'm also the chief of rehabilitation medicine at New York Presbyterian's Brooklyn Methodist Campus and kind of went through a similar path as Dr. Bailowitz. My residency was at NYU. My fellowship was in a was actually in a family medicine, a true primary care sports fellowship in South Carolina at the Steadman Clinic there. And my practice is fairly similar in the sense that I'm kind of a head to toe, musculoskeletal and sports medicine physician, have worked with and continue to work with a number of teams, high school team physician for City College of New York, which is a D3 school here in Manhattan. And yeah, so, you know, we jump right into the case. You know, sort of similar set up, it's a 27 year old female, she was the chief complaint of right worst and left shoulder and arm pain, no inciting event, no trauma, it started five years prior. This is a young woman who works as a graphic designer. She is right hand dominant. And started to notice that she was having, you know, sensations of pain going into the arm, numbness, tingling and the sensation of fatigue in the in the arms, right worst and left. And the sensation of knots in her neck, got, you know, pretty constants, seven out of 10. But, you know, symptoms were less when the arms were by her side, symptoms were worse when she was typing, reaching, particularly out or overhead, and when she was trying to write for longer periods of times. She has a personal past medical history of epilepsy, which is controlled with an anti-epileptics. And might have had some kind of a seizure or something like that, but she has a history of anti-epileptics and migraines, which were somewhat controlled. She was still kind of working with her neurologist on a maintenance regimen. No previous surgery, family history of diabetes, prostate cancer, and a sister also with epilepsy. Married, half pack per day smoker, one drink nightly, no reported history of illicit drug use. So what are your initial thoughts? I kind of like to think, you know, as I'm working through these cases, I, you know, I feel like I kind of make my differential, you know, based off of the chief complaint and then continue to just kind of shuffle it as I get more information. So so before even a physical exam or prior workup, any thoughts? With it being bilateral symptoms, I'm concerned about like a cervical stenosis with like, you know, bilateral radiculopathy could be seen on EMG, the overhead movements making it worse, myopathy comes on my differential as well. Great thoughts, great thoughts. So as I mentioned, you know, five years prior or five years of symptoms. So she has actually, you know, had a fairly significant workup in the sense that she's already had an MRI of the brain, which showed nonspecific, you know, minimal scattered hyperintensities of the white matter. She did have an MRI of the C-spine. This was probably two years prior to presenting in my office with mild disc bulging of C5-6 and C6-7, no nerve root impingement centrally or foramenally, there's no facet arthropathy, none of the typical things that we see that sort of cause compressive neuropathies of those nerve roots. And she had had an EMG and nerve conduction study, which was read as normal. No, you know, myopathic or motor neuron disease concerns, no slowing of conduction velocities. So now what do you think, what, what, what gets crossed off your differential now? The cervical stenosis causing bilateral symptoms and then obviously the myopathy. Cervical stenosis causing bilateral symptoms and then obviously the myopathy. Yeah, yeah. So any other thoughts as to where this could be coming from? So this is what I was thinking. I was like, okay, so, you know, again, we talked about the difference between structural symptoms and functional symptoms. So, you know, in thinking about where these symptoms coming from, you're thinking about the brain, you're thinking about the neck, thinking about the shoulder locally, thinking it could be vascular, thinking it could be metabolic, and thinking, you know, possibly somewhat systemic. I would say the brain, neck, and systemic, you know, and metabolic, at least from her PCP notes, which I have included here, seem to be kind of lower on the differential. So I'm thinking somewhere between the neck, the shoulder, and it being somewhat nerve or vascular related. So that, you know, plays a role in how I sort of approach my physical exam, because now I'm trying to think, you know, if we put this a different way, is this a structural problem? Is it a functional problem? Is it a psychosomatic problem? Or is it not a problem? Is it something that, you know, are these are symptoms, you know, what are they actually interfering with? And I think that, you know, particularly when we speak about sort of the physiatric approach, knowing what a patient is not able to do and what they are trying to do and trying to match those up and seeing how the symptoms that they're reporting or coming to you for, to seeing how those symptoms actually interfere with them from getting to from point A to point B, it really does help guide kind of not just how I approach the aggressiveness with which I work it up, but also how I counsel them on moving forward. Because a lot of times, you know, patients end up in my clinic asking about, you know, back pain and things like that. But when you get to the bottom of it, the pain isn't all that bad. They're just more concerned about what it actually means. And if you can give them the reassurance that it, you know, doesn't necessarily mean anything bad or concerning or that, you know, that they're at risk for some kind of bad outcome, then that's kind of enough for them to feel confident in moving forward through a treatment program. So, you know, having that ability to connect with your patients and create that rapport is certainly important. This is her physical examination, vital signs, basically normal. She's, you know, very well, well nourished, well-developed female, nothing really jumping out on general physical examination. Her neurologic exam, fully intact sensation, strength, no upper tract signs, gait, she's, and coordination are normal. So in a focused musculoskeletal exam, she has full range of motion of cervical spine, no pain. She does have some tenderness over the right paraspinals, traps, levator scapula, but a Sperling's test is negative. Direct compression kind of on the side of the neck and the strap muscle region is somewhat, you know, a discomfort ting and does reproduce some mild sensation down the arm, pushing right over the sub-pectoral recess just kind of here in the chest actually, you know, significantly reproduces the symptoms that she's describing. Going to her shoulder exam, she has intact peripheral strength. I didn't mention it here. There's no muscle atrophy or anything like that at the shoulder girdle. Her near, her impingement signs are negative. In terms of her positioning, if you put her in this abducted external rotation position, that reaching position that she describes, she is within a few, probably about 30 seconds, she's able to reproduce the symptoms that she's describing. And then some of these tests, I don't know how familiar you guys are with these tests, but we'll go through them. Her Roux's test was negative. Her Adson's tests were negative and her Wright test was negative. So Roux's test is, all of these are tests for brachial plexus compression outside of the spine. So Tonell was negative over the carpal tunnel, the cubital tunnel and the superficial radial nerve. So now what are you thinking? Thoracic outlet. Good thought, good thought. And the, you know, what's interesting about this picture is that, you know, the thoracic outlet is one of those conditions that is somewhat, I wouldn't say amorphous, but it's kind of an umbrella term for a lot of different compression neuropathies of the brachial plexus outside of the cervical spine. And what's interesting is that these, you know, this Roux's test, this Adson's test and this Wright test, these are all tests, you know, physical exam findings for thoracic outlet. And they were actually, you know, they were negative. But when you have this mixed appearance, on physical exam, you know, the value of the physical exam maneuver is only as good as your pretest probability, right? So, you know, putting these in the clinical context is very important. So, you know, do you need any additional information? My thoughts are that you have, there's a very high likelihood that it's thoracic outlet on your physical exam, but you could consider more imaging to like an MRI of the area to see if you can see like exactly where, or like what kind of thoracic outlet the patient has. Very good thought, very good thought. So she had an MRI of the brachial plexus, which was largely unremarkable, at least in terms of sort of looking at the, you know, the fascicles, there was no structural entrapment of the brachial plexus or structural abnormality of the brachial plexus as seen on MRI. So surprise, surprise, we went to a musculoskeletal ultrasound so that like we talked about before, you know, there are advantages and disadvantages, the advantages being that, you know, point of care, being able to do it in the office and really making it an extension of your physical exam. It's dynamic and there's good visualization and differentiation of tissue and structure so long as you get your probe over the structure that you're trying to look at. And again, you know, that limited field of view is definitely a drawback. It's highly operator dependent. And, you know, how your familiarity with the anatomy and sort of expectation of what you're seeing is very important to your ability to interpret the images. So here is an example of the interscalene region where you have your middle scalene and your anterior scalene, and you can actually see the brachial plexus sitting in between in this sort of stoplight configuration. So working diagnosis, neurogenic thoracic outlet syndrome. Again, like we said, compression entrapment of the brachial plexus. And at this point, I'm thinking this is more of a functional rather than anatomic etiology. You know, she's had negative imaging studies. The fact that the EMG, which, you know, this is definitely, you know, within the bounds of a lower motor neuron condition or entrapment, the fact that the EMG was read as normal does give me some reassurance that this is not sort of a structural or, yeah, a structural entrapment of the nerve. That said, being able to actually sort of specify when you order your own EMG, if you're expecting that this is something that is compressive, kind of more up by the brachial plexus, you may have to, if you're performing it yourself, you know, where you're actually stimulating and recording from, you may have to do areas that are outside of your typical standard protocols for some of these EMG studies. Common points of entrapment for neurogenic thoracic outlet syndrome are your ribs. Typically, there's a cervical rib, which can be a structural entrapment point. Sometimes it can be compressed just above the first rib. The interscaling interval, subclavicular, and in the case of this young lady, it seemed like this was primarily subpectoral. So what was likely happening, and some folks have taken the call on this pec minor syndrome, but essentially that, you know, neurovascular bundle that travels underneath the pec minor and just medial to the coracoid process, when the arm goes in that abducted external rotation position, you get transient compression of the neurovascular bundle, which, you know, as we know, may not be sufficient to actually induce the physiologic changes that would be apparent on an EMG. So because it's so positional, that's one of the reasons why you may not actually see those changes. But we can see it on the ultrasound. So, you know, here is just an example. I wasn't able to get access to the ultrasound that had these images in time for this presentation. So I apologize for not having her images, but essentially you can see that you see the pec major, the pec minor, and then the neurovascular bundle sitting underneath. And with those dynamic maneuvers, you can actually see flattening or compression of the neurovascular bundle against the ribcage by the pec minor. So injections at this point, what do we think the value of an injection is at this point? Hopefully therapeutic for her, since it seems like we've already had like the diagnostic workup. Yeah, yeah. So certainly with these folks who, you know, I did initially send her to a physical therapy to kind of try to work on, you know, anterior shoulder girdle mobilization and stretching and posture and all that kind of stuff. With persistent symptoms, I kind of look at these injections as hopefully being both diagnostic and therapeutic. The injection that we start off with in this case is a pec minor trigger point injection. Occasionally I'll attempt to, if I feel like I can do it safely with the approach and the body habitus, occasionally I'll try to do it with the body habitus. Occasionally I'll try to hydro dissect the brachial plexus underneath the pec minor. But typically I'll do the pec minor trigger point with just some local anesthetic to see if paralyzing temporarily that pec minor allows us to take some of the pressure off of that neurovascular bundle and alleviate her symptoms in some of those positions. And this is sort of, you know, thinking that's kind of been taken from our spasticity colleagues within the field who can often use trigger points to help map out where Botox injections might be the most effective without, you know, kind of subjecting someone to three months of paralyzed muscle without having that information. So these injections serve two functions. And particularly in these cases where it's more of a functional pain and not a structural issue, these diagnostic value of these injections is almost more than their actual therapeutic result because a trigger point is gonna wear off oftentimes in a number of hours. But, you know, the knowledge that's acquired from that can lead to a more comprehensive treatment. And in this case, we, again, kind of borrowed from our spasticity colleagues and treated this with a Botox injection to the pec minor once we had a positive response to a trigger point. So with that, she had complete resolution of her symptoms and it's kind of back to full activity at this point. So, you know, this kind of brings me to just to kind of wrap things up. When we think about where physiatry exists within the continuum of medicine, we kind of think about it as this sort of adjunctive specialty that touches every specialty in a unique and particular way. And so it kind of, you know, as physiatrists, we're sort of the Swiss army knife of whatever institution we're in where we have this knowledge of a lot of disparate elements of medicine that we are able to kind of integrate and apply through a functional lens. So the way that I kind of view it is that, you know, because we then take that functional lens and then we, you know, we're the specialty that doesn't just look inwards, we look outwards. So taking all of this focus on the pathology that's happening within the patient and then connecting that with their functional demands of, you know, interacting with their environment, I feel like that kind of makes us more of an all-encompassing specialty. And so when it comes to what I, you know, to me, what the, you know, the physiatric approach to these cases, it's, you know, think functionally, have a good sense of what their complaint is, not just in terms of the characteristics of the complaint, but what it's actually impeding. Think interdisciplinarily, I don't know if that's a word, but if it isn't, I just coined it. You know, you want to think not just through, you know, through your lens, but you want to think about all the associated team members involved in caring for the patient, both, you know, within the medical side and both on the, and on the sort of community side. And as physiatrists, we're very well trained to do that. Think comprehensively, that kind of speaks for itself. Think deeply, you know, the knowledge that we have is often sort of the surface level of what's available. And so, you know, these problems, they have answers and your job is to kind of get to them. Think logically, but then remember that, you know, algorithms are only as good as the information you provide them. And so your ability to really connect with your patient and fully understand their complaint and what it's doing to them is going to have a direct impact on your ability to care for them and get them the best outcome possible. So I think I came in under time. With that, you know, I think we have like a minute for questions. So just on that point, in this case, I'd really like to reach out to the firm and see if they have any occupational medicine specialists, because I think that's probably worsening her posturing. But I did want to ask both of you, since you're in sports medicine and we had some discussions yesterday, some presentations on physiatrists advocacy for those in adaptive sports, just what would be your take on anything you'd like to add to that discussion? I'll say from my perspective, so I'm actually the medical director for the City University of New York system-wide adaptive sports program. And it's in its infancy, but I mean, I think it's one of the most important initiatives that, you know, physiatrists, particularly in sports medicine can engage in because we're so uniquely suited to take care of these folks and advocate for them and the value to, you know, these athletes is high. They're often very underserved on the, you know, not just the athletic front, but even just the general medical front and having someone who's there with them, not only in their worst moments of being in the office, but in their best moments of achieving on the court, I found that it really reshapes their perspective in their relationship with the medical team and can often, you know, garner better buy-in to a lot of the treatments that you're trying to get them to participate in. So I think it's invaluable. Yeah, I mean, I couldn't agree more. And I think, you know, in the system in which I work, the majority of our adaptive athletes are seen in the setting where we have our inpatient rehab, which is not in the same location that I work. And so I don't get to see a lot of these adaptive athletes anymore, but it's something where I've, as I've started, I've started to say, hey, you know, this is a place that we can really thrive. And let's start to make this something that we can do, you know, region-wide in our system, not just in this one location, because these athletes are everywhere. And I think a lot of times they don't get the care that they need really, unless they are seeing someone with a PMNR background. And so, yeah, I couldn't agree more. I think we're well-suited for this. I know Monica Rose spoke to this in depth yesterday and it was great hearing how she really kind of rose, rose through the ranks because of her kind of initial physiatric experience. And so, yeah, we're well-suited for it. And it's a great opportunity for us to make our name in sports medicine. So we'll go ahead and get started. We have Dr. McDevitt from Baylor College of Medicine and Dr. Wersowitz, who's at Mayo Clinic Jacksonville now, talking about understanding physician employment and agreements. Thank you very much for giving up part of your Saturday. Happy to be here. And again, it's a small group, so we can maybe make this more of a individual consultation than a lecture. But remind me, the residents are Claire and Gina, is that right? Carly and Gina. Carly and Gina, I'm sorry, excuse me. Yeah. So we're talking to you, I guess, Carly and Gina, and I would, first of all, can you hear me? Yes, we can. Yep. So I would start by saying, maybe ask you to do something, and I won't shame you publicly or ask you to share any of this, but I would ask you to pause and think a little bit. First of all, are either of you involved in a contract negotiation or contemplating having to sign a contract at some point in the next year or two? How important is this to you personally? In the next two years. So coming up. So I would ask you to pause for just a second, silently, and imagine you've got your employment contract in front of you, and you are reviewing the terms, and you're going through them with your significant other or family or mom or dad. I want you to think about the single most important term in that contract. If there's one thing you think you're going to focus on, and that obviously could be your base salary, it could be a lot of other things, but I'd ask you to pause for just a second, and something popped into your head just now, just sort of the first thing that popped into your head. What do you think the key term is? And I'm not going to ask you to divulge what that key term is. That's a little bit personal. But keep that in mind as we go through this presentation. Greg and I are going to sort of mix this up a little bit. These are the things we will cover. I'm not going to read these objectives to you. We're not going to cover so much, and although we're small enough, maybe we can get into it if you want to, the power dynamics of a negotiation and how to appropriately leverage your negotiation and think about how much wiggle room you have and how asynchronous the negotiation might be. We're going to focus for the purpose of this talk more on the mechanics of what an employment agreement is and things you ought to be looking out for. I put this in the chat. You can download it onto your computer. You can use it as a reference, and which is probably the most useful thing. And by way of introduction, I think the best thing I can tell you to do is get an attorney and have your current attorney look at your contract. We're going to tell you stuff. We know some stuff. We're not experts. You are in no way experts. And if you're taking a job that's going to pay $200,000 a year and you're going to be in that job for five years or more, you're making a million-dollar decision. So it is worth spending $200, $1,000 on an attorney that actually knows something about medical employment contract law to give you good advice. And I think that's more important now than it ever has been for a lot of reasons. I mean, medicine changes. When I came out in the 80s, I started working for a guy who I really liked and trusted. And I sort of didn't worry too much about my contract because I liked and trusted that guy. Well, things changed. And in my case, that guy left. And suddenly, I'm working for somebody else. And organizations merge and acquire other organizations. And the corporate structure changes. The corporate culture sometimes changes. You may start your career working for a saint and end up working for a sinner. So it's important to have things codified. I think now more than ever. And then I think the other thing I would leave you with as you're going through this quickly, and I think we'll maybe have more conversation, is thinking about the balance of where you are in this negotiation. Because a negotiation around a contract always balances out trust on the one hand. You don't want to be that guy. You don't want to be the troublemaker. You don't want to be the person that's asking for unreasonable stuff that leaves a bad taste in the mouth of your future employer. You don't want to appear petty. But on the other hand, you need to protect yourself. So you can't just lay down and say, yes, I trust the organization for the reasons I mentioned before. But these are things we'll run over. I'll run through about half these items. Greg will run through the other half. So starting again with some of the mechanics. And again, feel free to stop me because we've got lots of time here. One document you may see is something called a letter of intent, or sometimes it'll be referred to as an LOI. And generally, letters of intent are non-binding documents. The organization, you've been to interview, they've offered you a job verbally, and they give you a document that says, we intend to offer you a job starting this day, doing this job, which becomes a template then for creating an employment agreement. It's sort of a codification that we are all agreed that we're going to move forward with this. Letters of intent can be binding, and they're usually non-binding. They say it explicitly. It'll say sometimes in the title, binding letter of intent or non-binding letter of intent. If it is a binding letter of intent, there'll be a signature line for both parties at the end of the document because it essentially is a legal contract. So just be aware of what you're signing in terms of a letter of intent. Keep in mind that's not a contract. I don't think you necessarily have to run out and get your employee to look at the letter of intent. It's not a bad idea. But there will be a contract yet to come. So don't get confused by that. And then in addition to, there are other sort of side contracts you might be faced with depending on your situation. Not uncommon, a hospital that is trying to recruit you to that community, if you're joining a group, the hospital might have a relationship with you to offer you an income guarantee. And there might be a side contract between you and the hospital around an income guarantee. So just make sure you understand what you're signing. And an employment agreement is usually very clearly documented as this is your employment agreement. When you think about the employment agreement, and again, this is really the thrust of what we're going to talk about. So I won't cover each of these points because we're going to come to each of these points. But would highlight a couple of things. If something's important to you and somebody has given you an oral promise that this is going to happen, just trust me. If it's important to you, you really need to get in writing. It really should be in the contract. Now having said that, I came to the Baylor College of Medicine and met with Bob King. I came as chair of PM&R at Baylor and met with my boss, the president and CEO. And they were in the midst of a big business deal. And we had a conversation to say, you know, come do this. We're going to find some other things for you to do. I don't know exactly what this is just yet, but I promise that's going to happen. I shook his hand. I trusted him. It worked out. But I knew going into it, I had no guarantee that anything else was going to happen. I just had, if Paul had become a different person, if there was a different president and CEO, if he just changed his mind, if he didn't like me when I got there, there are many things that could have derailed that. I should have said in the introduction, and Greg will introduce himself. I was chair in Carolinas. I was chair at Baylor. I'm currently dean of clinical affairs at Baylor. And among the things I'm responsible for is 2,500 clinical faculty. So literally every day I sign employment agreements. There's not a day that goes by that I'm not signing some sort of legal agreement. So I do this every day of my life. So if it's important to you, don't rely on an oral agreement. Number two, make sure you know who you're signing a contract with. It could be a hospital. It could be a university. It could be a medical group. It could be a governmental organization. But it's important to know who's actually hiring you for a variety of reasons. And the rest of these in the agreement, we're going to sort of detail these out one by one as we go through the list. I'd highlight a couple of points. And again, you have this document to review at your leisure and come back to it when you actually come time to do your contract. This first set of bullets, define expectations and work hours and duties. There will be in your contract some written description of what you're being hired to do. Your contract will not say, we are hiring you to be a physician, full stop. It will be if we're hiring you to deliver medical services at this location for this many hours a week for this percent of an FTE. It will be described in different ways. But pay attention to the job as described in the contract and make sure it's the job that you think you're signing up for, which unfortunately occurs sometimes. People sign up for one thing and they show up and suddenly they're asked to do something else. Understand compensation in particular. And I think Greg might talk about this a little bit later on, but is compensation all in or is there opportunity for extra compensation? How is call covered? Are you just expected to call? Is there extra payment for a call? And I think we'll get into some other things. Well, if you look at outside activities, another example, when I was young and I was in Charlotte and I signed a contract, my contract essentially said the organization owned my intellectual activity and my professional activity. And I started doing a little bit of expert testimony, which I hate it and I don't do anymore. But my belief was that I'm doing professional work. I owe all that money back to my organization. So I dutifully did my expert testimony and reviewed records and got paid my hourly rate and turned all that money over to my employer as a rule follower and a good citizen. As I've talked to people over the years, people looked at me and said, what are you crazy? What are you talking about? You don't give that money back to your employer. Well, maybe you do, maybe you don't, but you should have those conversations on the front end, particularly if you think you have a significant potential income stream. Expert testimony is common. It is not uncommon to perhaps want to moonlight for a different organization. There are two rehab hospitals in the same city, for example, they need call coverage at the second rehab hospital. Are you allowed to go and work for a competitor, for another organization, for some additional compensation? You may get to your big wig, musculoskeletal injectionist doing advanced procedures. Will you be asked to be a expert for a pharmaceutical or device company or serve on a board and get some compensation for being on a board? That should all be clear in the contract about, are you allowed to do those things? And what happens to the income generated from those things? And then lastly, intellectual property can be important if you develop things, if you're going to invent something, if you hold a patent and the way that works at Baylor, we have policies for, we apply consistently. If you invent something at Baylor, again, like my belief in Charlotte, we own your intellectual life. If you're developing something in medicine, it is intellectual work that is related to your professional life at Baylor. The fact that you do it at two o'clock in the morning is not really pertinent. It is still the atmosphere, the environment at Baylor that contributes to your ability to produce intellectual property. So our policy, which industry-wise, I think is fairly generous, is that if there's IP, Baylor owns 40% of that IP. I'm sorry, the investigator, the inventor, the patent holder owns 40% of that IP. Baylor owns 60% and of that 60, 30 goes to the department, 30 stays with Baylor. We've got a very codified policy. If that's important to you, you should understand what that is. And I hadn't thought about this until recently, but I'm sure both of you probably have huge social media followings with millions of followers. Well, it's not unusual in medicine for people to have social media accounts with millions of followers. And lo and behold, I don't fully understand how and why this happens, but that can be monetized and turned into a revenue stream. Our contracts at Baylor don't call out social media. I think if that occurred, we would argue that that's intellectual property. As I thought about this, I'm not sure our contract shouldn't specify social media. But again, that's something else to think about. If you anticipate being the next Lady Gaga PM&R on Twitter and TikTok, then you should probably make sure that you have allowed for IP in terms of social media in your contract. Partnership. I've always been an employee. I've never been a partner. I'm not an expert in any things related to partner. And frankly, the vast majority of people coming out now are entering employment relationships. So you're unlikely to be entering a partnership or organization, but you might. And in PM&R, it is somewhat fraught sometimes because you're on occasion joining an orthopedic group or a neurosurgery group or a group that their phenotype is not rehab. It's something else. And you feel like they bolded you on. So there's risk in that that you're treated differently than the surgical partner in the group. But again, I mentioned getting an attorney before. More important, if you're contemplating a partnership, find an attorney that actually has knowledge, skills, expertise in medical partnerships because it's a very specific field of knowledge, not your Uncle Joe who does personal injury stuff on the side. It should be somebody that actually knows what they're doing. And the terms to buy into a partnership will be spelled out. Sometimes that stay around for five years and you become partner. Often, usually you stay for a period of time, a couple of years, and then you have to provide capital back to the practice. You have to pay $100,000 or $300,000 to buy a piece of the practice and become an equity partner. Sometimes you have options to own more or less of the practice. You can choose to own a minimal stake or a more major stake and treat it as an investment. And if you're doing that, it's also important to understand as an equity partner, how do I get my money out of the partnership? Do I have to retire and die? Or can I choose to leave in five years? And if I choose, can I sell my stake? Will the practice buy it back under what circumstances? Because that has real value. It becomes a significant part of your compensation and you're investing in the health of the practice. More commonly, you're not going to be a partner. You're going to be employed and somebody is going to pay you for what you do. And this is not a talk about compensation methodologies. Greg and I do that talk. We can come back and do that again some other time. But there are only so many ways to get paid. You've seen one compensation system. You've seen one compensation system. They're all nuanced and a little bit different. But fundamentally, you're either going to get a base salary. That's a very common, particularly in PM&R, a common compensation methodology. Or you're going to be on some sort of productivity-based compensation plan. In the Baylor practice, after a ramp-up, you are paid a dollar-per-work-RVU fee that is completely dependent on your clinical productivity. That's outside of research time and education time. By the time you're actually seeing patients, it really is a dollar-per-work-RVU system. It's a productivity-based driven system. There are hybrids of that where you might get a base salary with the opportunity to earn additional incentive based on productivity. So that's a common group of schemes to get paid. Another group of schemes are to get either, if you're joining a socialist group, then they might look at the margin generated by the group, and you get a percentage of that margin from the work of the entire group. If you're joining a capitalist group, then there are sometimes payment models where they just look at the money you generate and give you a percentage of the cash that you personally bring into the practice, and that becomes your pay. But again, obviously important to understand how you're getting paid. And lastly, and increasingly important, many, maybe most organizations now, as we move towards paid performance, a component of your compensation is going to be based on your patient experience scores, on quality metrics, on quality performance of the group, on sort of the value-based aspects of the group. So really important you understand those things, and why is it important to give you an example. If I hire you to come into a plan that I've told you is largely, not exclusively, but largely productivity-driven, and you're going to make $40-per-work-RVU, well, you need to ask me questions like, how many patients can I see? Are your clinics efficient? Can I get my template full? What's your cancellation rate? Is this practice growing or shrinking? Where are my referrals going to come from? I mean, if you're in a productivity-based system, you should be concerned about the organization's ability to put you in an environment that is going to be a rigorous enough environment that you're going to be able to grow and be productive. If you are in more of a capitalist model where I'm looking at cash and taking the cash through the door, then worries would be in that system, well, you're pitting me now against my guy down the hall, and if there's a Medicaid patient that shows up that I know I'm going to get $0.70 on the dollar, well, I don't really want the Medicaid patient. I want the Blue Cross Blue Shield patient, and can I actively work to shuttle that other patient to my clinic? To my partner? Then you have to start thinking about equity issues in the practice. Why do some people get the insured patients and some people get the uninsured patients? How do they deal with that conflict in the group? So understanding your comp methodology is important to understanding. It raises a lot of other questions. The other point I'd make is, as you negotiate knowledge is power, and understanding what a physiatrist makes in your market is important. And there are great surveys out there. And I will say it is fair game to ask the organization, do you have a written compensation philosophy? We do at Baylor. I will tell you that nobody has ever asked me what it is and nobody's ever asked me to produce it. But if they did, I would give it to them. It's publicly available to our faculty. It's out there. It tells what our philosophy is. We benchmark to the AAMC 50th percentile for compensation. That's one of our philosophical principles. So you can ask what their compensation philosophy is. You can ask to see their compensation plan. That'll give you an idea of what they pay. But I would also see if you can get your hand on published benchmarks. And they typically are not available to you as an individual. And there are some rules around what people can share. They're subscription-based. But if you quietly whisper in the ear of your chair, your program director, do you have access to the AAMC survey? Can you tell me what an assistant professor of PM&R currently is benchmarked at? They'll frequently give you that information from AAMC, MGMA. There are a lot of salary surveys out there. You can Google it to a degree, but the Google results are not quite as reliable as some of the surveys, which are really, really very strong. So having that knowledge is important. And then I think it's important to recognize, well, this is great. I'm going to get X dollars a year for pay. How does that change? And particularly in a time of inflation, if inflation goes up five or seven percent a year and for every $100,000 you bring in, then every year you're taking a $7,000 pay cut if your salary is not increasing. So how do I make more money over time? How is the salary adjusted? At Baylor, we're benchmarked at AAMC. We change our benchmark based on the annual AAMC survey. So there's some automatic adjustment up in the case of Baylor. And then I just, I think this is my last slide. I'm going to turn things over to Greg. Think about when you sign your contract and they give you good stuff on the front end. And I think Greg is going to talk about some of this good stuff. I'm sorry. I got two more slides. They give you a signing bonus. They pay for your moving expenses. They forgive your student loans and pay off your student loans. That can be great, but pay attention because sometimes there are clawback provisions that if you leave during the first five years of the contract, that you have to pay that money back to the organization or pay it back in some prorata form based on how long you were there. So you might be entering a form of indentured servitude, which is not bad. It's probably a good thing in some ways, but just be aware that you might have those payback provisions. And then, lateral to Greg here, a couple of important comments around benefits. Let's say you're making, you're in a negotiation to work for a $300,000 a year base salary. And you negotiate up to 315. Well, you'd be pretty excited about that. I got another $15,000. Well, your benefits are probably probably $100,000, about $20,000 of your compensation is benefits. So your $300,000 package is actually probably closer to a $360,000 package. It's a huge piece of your compensation. And as residents, you probably never thought about it. It's probably hadn't been terribly important, but it becomes increasingly important, particularly when you look at a career, particularly as you look at your need to save retirement and fund retirement plans, it is a very significant part of your comp. So pay attention to what they cover in terms of retirement. Benefits like paid time off are critically important. And travel, again, I'm not so much concerned if I'm going to every now and then drive down the street to talk to somebody. But if travel is a major part of my job, if my job is seeing patients across a broad geography, and I'm getting my car all day, every day, driving all over the greater Houston metropolitan area, well, then I should get some part, I should get reimbursed for travel expenses. That becomes a significant expense. So think through those sorts of nuances too. I won't read all these. And with that, I will turn things over to Greg. Well, thanks, Jim. I hate following you, but that's all right. A couple of things you wanted us to introduce ourselves. My name is Greg Worsrich. I'm here at Mayo Clinic, Florida. Past experiences, I've worked in the community. First, what Jim said, think what's most important to you. Know the organization you're joining. I've worked for a community-based hospital system with a residency program, been in private practice. Then I went back to the community-based program. I moved to Missouri, where I was chair of the department, which was a straight university-run contract. I also ran the 600 physician practice plan, not as big as Jim's, but had its challenges there. And then about a year and a half ago, moved to Mayo Clinic, Florida, where I am a straight direct employee. So had a couple of different things. And again, if you know who you're working for, what type of system, it's going to dictate some of these things we've talked about. And I will go back just one slide, Jim, real quick, to the total compensation package, if you could. And as a resident, I remember as a resident asking, what are you getting? What are you getting? What are you getting? Well, everybody's contract's going to sound better, but these total compensation benefit packages, all going to be different. There you go. Next one forward, Jim. Sorry about that. Nine. No, perfect. A couple examples. Paid time off or leave. When I was in private practice, guess how much vacation I got? As much as I wanted. They said you could have all the vacation you want, as long as you're paying your staff, your overhead. And when I was on vacation, I was losing money because I wasn't getting compensation. When I was at University of Missouri, I had four weeks off. I moved to Mayo Clinic because of my age, the way they do it. I have seven weeks off. So now I may get a lesser pay, but I have more time off. So again, what is important to you at what time in your career? A couple other things. We'll talk about liability insurance and how much you need, and we'll go through some of the differences there. But in my private practice, I funded my retirement plan totally through different mechanisms. But working at the University of Missouri now to Mayo Clinic, I have a defined benefit retirement package. You're not going to see those much anymore. So when you do go, ask about these things. From this lecture, as Jim point, you're not going to know all the details. You could give a hour, two-hour lecture on any of these parts of total compensation package. Be aware of these issues. It's good to have this list, and ask about them. Ask about your stipends. I have a very healthy stipend package where I'm at now, and my CME credit time that I have, it's variable. At Missouri, it was seven days. Where I'm at now, it can be up to 18 days. So again, it adds to total compensation. Why don't we go ahead. Next slide, Jim. And if any of the two of you have questions as we go, just ask us. Beware of restrictions. Jim made this before. Hey, are all my fees generated? Go back to the practice. If I do expert witness, does it go back or not? At Missouri, when we built a program, if it was a patient you saw during your care for the university, it went to the department. If it was outside business you picked up, as long as you did it on your time, either weekend, night, or vacation, you kept the compensation for that. So again, who owns the fees? And payment retention. The kind of retention of fees, think about it. When you leave a practice, you still have dollars that are being collected after you leave in your AR. That's your accounts receivable. If that's a big pile, and it's 60 days out, and most of your compensation is there, do they keep it or do you get part of that? Again, it's just who's keeping the dollars. You're not going to know all these things, but nowadays you have the thing called the internet. You can look up these things. You take things. Back in when Dr. McDevitt was chipping things on stone tablets, it was much harder. Again, I'm going to reiterate, you're going to know and able to get familiar, but you got to hire an attorney. It's worth the investment. And hire an attorney that does this type of contracting and is familiar with your state's laws. Okay. Next slide, Jim. Professional liability insurance. Boy, I had to read this 15 times when I first started. What's the difference between occurrence and claims made? So think of occurrence is going to mean any claim that arises from patient care when you were employed or you had that occurrence coverage. It's going to follow you forever if you were covered with claims made with, oh gosh, that's occurrence. I'm sorry. So occurrence. Claims made is you have to be employed at that time when the claim is made for it to be covered. So if you saw someone when you first started, they're going to make a claim. You still have to be employed. What happens if they make a claim and you're not employed or covered by that? You're on the hook for it unless you have what we call tail coverage. Okay. I made this mistake when I first started in private practice. I had a claims made policy and I thought, hey, I'm going to go ahead and what if I leave practice? Well, the next year when my contract came up, I made this point to him. I said, you know, if I don't get a tail, I'm your employee. They're going to come after the big practice anyway, because who has the money? Some young doctor with no insurance or the practice. So my practice agreed at that time to put in my contract a tail. I was lucky that they put it in rather than me having to purchase it on my own. So again, think about it. And what are the limits of coverage? Anybody know? I would ask those two of you, but what's the right amount of insurance I need? Do I need a million? Do I need half a million? Do I need 1.5 million? Usually the one nice thing you can look at is most hospitals require you by specialty to have certain coverage. And why would the hospital require that? Just like my practice. If you don't have insurance up to an appropriate amount, who are they going to want to go after? You or the hospital. So again, you want to look at how much do I have on an annual basis and what's my aggregate amount? Hopefully I'm not looking at aggregate, because that means I'm getting a lot of claims put up against me. But that's why I switched jobs. Kidding. Next slide, please. All right. Jim mentioned some of this, duties and responsibilities, and that has an impact on the type of work you're going to do. Can it have a significant impact on your practice? Yes, it can. If I'm in a, Jim mentioned, capitalist society where cash coming in the door goes to each of the individual docs, not that it would ever happen to me, but when I was in practice, electrodiagnostic studies in private paid extremely well back in the early 90s. Well, I joined a practice and the partners get 60 EMGs a week, and I have a month, and I have 10. And then we looked at cash collections. Boy, whose collections were greater? Well, they said they had built the practice. Well, I agree with that after year one, but as year three came on, I knew several of the spine surgeons that came when I came, and they'd be saying, Greg, I sent you a bunch of EMGs and it keeps coming with Joe's name on it. You're not doing my EMGs. Well, there was no assignment and their slots were built for those 60 EMGs would fill them first, or so which second. They were great people, and they had the idea. You got to look at their opinion. We built this practice from scratch. And as you come and build in, you will get more electrodiagnostic studies. So that's kind of one of those things where you want to know at least what is written, what are your duties? But to Jim's point, if I get too petty to say, no, I am only going to see three patients on Thursday at one, two, and three, you can bust up a possible negotiation. So it's a negotiation, what's best. It should also list what are your work duties? How much call? Are you the primary call? Okay. And issues such as one-sided statements that are down there, work diligently and best efforts can have variable in meaning. So that's where it's worth maybe talking with your attorney if there's words like in there, how can that be interpreted? What is interpreted there? These are all things you deal with every day, right? You think, oh, those are, I'm going to work good and I'll do my best. Just make sure on that. It's defined on where you come from. Next slide, please. Okay. Here's one, a non-compete and restrictive covenants. I've sat on both ends of this. A, having to sign and be on it and B, having to try and enforce or not enforce when running a practice plan. A couple of things. Why would they have them? Well, the point is they don't want physicians taking patients with them if they leave practice. It costs money, time, and effort to build a practice. If you bring someone in and then they're going to, after three years, you've helped start them up, marketed them and his or her skill sets, and then she wants to go across town and take patients with you, that's going to hurt your practice. The other issue is, so oftentimes there's a geographic location and a specific time period. It might be 12 months, might be 24 months, and it might be a mile radius. Well, 10, 20, 30 miles, you dream up. I think Jim had one. He offered me a job once and said the United States of America, but that's okay. They're there. I will say this. I've heard of people signing them and getting out. I've also heard of, had one where it was felt to be so restrictive and so expensive that we negotiated it down rather than going to a court and trying to fight it. This is where you need your attorney. Hey, in this state, are they enforced? Can they be enforced? If yes, is it reasonable? What if I, at the University of Missouri, have a restricted covenant for Columbia, Missouri, small town, fine, but then they put a satellite in another city, Jefferson City, 30 miles away. Is it now 10 miles from that 30 miles? What happens in the future as systems grow? Baylor College of Medicine used to be a little piece of Houston. Now it engulfs Houston, and Jim said probably soon Dallas and off to the Western border. The question is, what again, medicine's changing, what will happen with that? Can you negotiate? I saw there was a question. Didem, did you have a question? No, I'm sorry. Okay. Next slide, please. Conflict resolution. Hopefully, you won't have to come to this because, boy, if you come to conflict resolution, there was a serious problem up front, but you want to know on the exit, are there any issues that say, hey, if we have a big dispute or issue, how are we going to settle it? Are we going to do facilitation or mediation? Mediation is where you come together and you have one person trying to help both parties agree on what are going to be the terms of maybe your split or resolving whatever conflict it is. Arbitration, on the other hand, is going to be where a person is appointed, and he or she is going to make a decision, and you're both going to be bound to it if you have binding arbitration. So, the problem there is you may or may not like the outcome, but you're stuck with it. Here's an example. I ran the practice plan in Missouri. We had an issue. The way the Missouri university policy was, it was an arbitration by other faculty members. So, now I have a medical payment model, and I go up to the university and a professor of French philosophy, a professor of English, and a professor of natural resources who were paid a straight salary from the university were trying to tease out and have me explain that, no, we don't get a straight, we earn our salary, there's incentive based on what we do, but they as arbitrators felt, no, we vote on the side of the faculty member, regardless of what your rules are. And so, but the arbitration was set, we had to follow that rule. So, just an example. These things can come up in different models in the future based on what you do. Next slide, please. Term and termination. Well, term, oftentimes your first contract may be signed for one year, and then if you stay a year and you like it, you can have a two-year contract in some places after so many years, and you can get a three-year contract. Again, that's something you want to know about. The other issue is, wow, if the contract, how can they get rid of me? Is it with cause? And usually cause means I've done something egregious. So, out of my four jobs, I've only been terminated with cause three times. No, I'm kidding. No, usually has to be pretty egregious, but you ask your attorney or who, if that's in there, what are some examples of this? And without cause, it's kind of a handshake deal that you're going to go. Usually, you're going to know in time, but you want to know how it is written in there. Without cause provision, you should include, if they're going to get rid of me on their own, how much time are they going to give me? And are they going to give me a severance package for how long? In other words, how long are you going to pay me for or not? And how much notice do you need to give me? That goes two ways. I'm at a job. I'm not really happy. I move because how many people have the first job they ever took when they first got out of college? What about now? A lot of physicians haven't had a job ever till they get out of their medical training. So, it's not uncommon to move, but I can't just leave people high and dry. You need to make sure that you give appropriate notice on what's written in there. The other issue is you need so many days that you're not abandoning your patients so that you can notify your patients and let them know that the practice will be taking over coverage of your patients and that you will be leaving or they can find somebody. So, again, I will give you a tip. Usually, 180 days, three months is more than enough. You stay much longer after that. Your mind is gone. You're out of their mind, too, and you're just treading water and it's almost miserable because you're ready to move on. They're ready to move you on. So, just a thought. Final points, I think. Next slide, please. Final points, know what you're getting into. Jim made the point, what's most important to you? To me, it's been really the work that I do. This last move was most important was my wife said, nope, you're going there. So, that was most important to keep my marriage together. But we all have different ones. Non-competes haven't been a big thing to me. I just had a daughter that's starting work in Wichita, family medicine doc, whose husband lives there and he's a minister. His dream is to stay at his church and take it over. Non-compete to her is a big deal because she wants to stay in that area. First job you want to. So, again, based on what's important to you in that time in life can be different and it may change. Ask questions. What about the business? What's your financial future? Jim mentioned, Dr. McDevitt mentioned, hey, the group was going to be bought or maybe they were making some acquisitions. They weren't quite sure what was happening. But usually most people you're going to work with, hopefully, are going to be honest because you've done your due diligence. You have a feel for them, but they can leave. They can go. So, don't make it off of just one person. I would recommend a choice. Make it off of the situation. How long to make a partner? Well, that came up for me after three years in private practice. I was off is either partnership or not. And to buy in and the financial windfall in the future, it would have been tough to make a lateral move back into an academic world because at that time there was a big pay discrepancy. I think those are coming closer and closer, not as much of a discrepancy. But at my point in time, it was a decision time for the buy-in. And Jim, I'm with you. I'm not sure how much buy-in situations there are anymore. Malpractice claims, pending litigation. Is there a lot going on at the present time? Read every word and make notes. And that way, when you just don't have your attorney look at it, have an idea and notes and questions before you have an attorney look at it. Because you want to make good use of your time because they're either going to charge you by the hour to look at it or a set fee. And don't have ambiguity. And don't be pressured into signing. You're very valuable. You guys are all coming from great programs. You're competent. They need you. You need them. Find the right fit. Remember, ask for what you want. If there's a big thing, everything's negotiable. But remember, if you push and get something, they're going to push back and want something else again. And if you get too nitpicky, I had a position I was looking at, and it probably wasn't the right position because I was getting too nitpicky. And you know what? It soured the deal for both of us and we both walked away. Now, it may not have been the right job, but I did make that mistake of trying to get everything in writing to the point of, they're like, you don't trust us? You know, there's got to be some trust involved. So, and know yourself. I've had contracts all out. My most recent job, I joined Mayo Clinic. You know what my contract was? A handshake. They have no contracts. I was told this would be the salary. I now work for, you know, my boss, who I know well, told me, hey, Greg, come here, do this, and we'll let you then go do this. He, just like Jim, I've been lucky, stayed true to his word. But I'm also at a point in my life that, wow, if it doesn't work out, you know, maybe it's not the right spot. So, again, every time in your life, you have different needs within your contract. One thing I'll say is make sure you, though, even though you're young and you want the cash flows very important, look at what retirement plans they offer and what vehicles they offer for that. I know I've missed something crucial. Hopefully, this talk is mainly to set up things to think about, things to learn about. No, I think that pretty much covers everything. I think it's everything there is to know about contract negotiation. I'm kidding. Yeah. It's hard. Yeah. It's hard. It's hard doing this via Zoom, especially based on We have a good 10 minutes, so if there are questions, we can flesh out some of the concepts. I would add to something you said, Greg, about term of contract. The term at Baylor is a one-year contract. We can terminate a physician with outcause with 90-day written notice. A physician can leave with 90-day written notice. It is possible to have a longer term. Let's say you're a R01 researcher with a lab and you're going to move a ton of people to a different organization, or you're a CV surgeon that is bringing a unique practice to the organization, a big investment. It's not unusual to have a three-year contract or a five-year contract. You can get a longer contract. Recognize there are two sides to that coin. If I have a five-year contract and after two years, the organization decides they don't want me anymore and I haven't committed a deadly sin that they can fire me for cause, they're obliged to pay out the term of that five-year contract. Sometimes organizations do. They will pay out the term of a long contract. That's great, but the flip side of that is I've committed to the organization to be there for five years. If I decide I want to leave, I'm contractually obligated to the organization and they could turn around and file a suit against me for damages for leaving them in the lurch and causing academic harm to their organization. A long-term contract can be positive. It can also be negative. Yeah. I think, Jim, the one point you also made that I would stress is go in educated. Usually, the biggest concern is salary because someone's saying, I made $500. Oh, I made $300. I mean, get involved. Someone had mentioned, I think Kim might have posted, certain metrics are available through certain libraries or, hey, whispered in the chairman's ear, I'm very interested in this. As part of my GME learning and education, how do I get involved with the practice plan and know where things are? Don't be afraid to ask, like you mentioned, what's the basis for your salaries? How did you decide on your dollar per RVU? What is your X, Y, or Z? Because that is very critical. When I first started in the business, boy, I was so green and naive and scared, just happy. Oh, hire me, please. But you bring a lot to the table and assets to the table. Don't hesitate to ask on these things. What you think is a lot may not be a lot because, like you mentioned, they're dealing with huge dollars. Are there any questions? I have a question. For residents who are looking for that first new job, but they want to do research and want to try to get protected time to do research, what would you recommend that they do? And pretend they don't have any grants right now, but they want to have grants. Yeah, that's a really good question. The answer is it sort of depends. And again, it gets back to the strength of your negotiating position. If you are the random average resident that has a vague notion that you'd like to do research one day, it is going to be difficult to get the organization to say, yes, we're going to commit, we'll protect 20% of your time to do research. If you have an established track record in the idea, let's say you've got a K award, and the K award requires that you have 75% of your time, other extreme. There are grants that you might bring with you that require that you had that protected time that they would have to provide that for you. And there's everything in between. So I think it would be unusual as a rank and file resident in a first job to get that protected time. You'd have to be able to mount a good case for why you deserve that investment from the organization. And that would have to be based more on what you had done, a demonstration that that is your career trajectory, that is a good investment. But nobody's going to make that investment just randomly. And keep in mind too, if I did it for you, then I have 50 other people right behind you that I'm going to have to do it too. Why does she get a full day a week to sit around and think deep thoughts when I'm seeing patients all day every day? Yep, I'd agree. The thing I, with negotiation, one of the things on my end always was someone would do a fellowship and say, well, I'm fellowship trained, I should be paid more. Well, it's really what are you bringing to the organization? Is it a need always? And then just because you're fellowship trained doesn't mean I pay you more. It's what are you bringing special that would warrant that? Yeah, getting back to Kim's, maybe I'll do my hour BATNA talk in 30 seconds. Yeah, yeah. Again, we were not talking about power dynamics in a negotiation, but you've heard the term BATNA, perhaps the best alternative to a negotiated agreement. If you Google it, you'll find a ton of references for BATNA. But best alternative to a negotiated agreement is your fallback position. If a negotiation doesn't work out, what's your plan B? What would you do? And when I give this talk, the silly example I give is that I'm running into a car dealership with $500 in my pocket to buy a used car. If I have a perfectly serviceable car that I'm sort of happy with, and I'm at the dealership kind of on a lark because I just have a vague notion that I would kind of like a new car. Then my BATNA in that case, my best alternative to a negotiated agreement is if I can't come to terms with the dealership, then I walk out, I get in the car that I'm already sort of happy with and drive away. And so I have a very, very strong BATNA in that example. On the other hand, if I've, if I robbed the bank down the street and I'm running down the sidewalk with a bag full of money and the police are at my heels, and I, if I don't close a deal for this car immediately, I'll be arrested and thrown into jail and convicted for grand theft. Then I have to do a deal. My BATNA is very, very low. So taking time to understand, again, silly example, but if you're a faculty member, a potential faculty member in a sea of applicants for a entry-level job that there are two or three or four other people that could do the same job, your BATNA is not particularly high. If you bring a unique skillset, you have a research background, you have a documented track record, then your BATNA gets a little bit higher. Understanding where the organization is too. If they're in the middle of, no offense to Iowa, if they're in the middle of Iowa someplace, they may be a little more desperate to hire people than in the middle of Houston, Texas. But think about what their position is too. And then in a negotiation, actively think about how your BATNA could be better. What can I do to strengthen my negotiating position? Well, maybe that's keeping another iron in the fire. I've got a secondary job that might not be my first choice, but I want to keep that iron in the fire just in case I have a fallback. But to think of ways that you can improve your position as well. I think that's the point about improving your position. It's hard when you first come out with the BATNA, but as you keep going on through your career, get involved with stuff, keep it. What's your equity? Being a partner, my equity was the bricks and mortars of a building. I was buying into building and that would repay, like Jim said, when I sold. My BATNA is, wow, have I built a reputation? Have I done other things? Do I bring experience to the table, knowledge that they needed? And oftentimes, later on is the time to look for a job is not when you're totally miserable, but if you're just kind of curious. I got a little too nitpicky with the organization. What was my BATNA? I stayed doing what I was doing. It was perfect. I could walk. I didn't feel bad. So again- Yeah, I would echo that. The best time to look for a job is when you're not desperate for a job. When you're employed, you sort of like what you're doing. You may have a little bit of an itch, but you're under no pressure because then you can take your time. You can look at things. Sometimes it makes you happier with where you are once you kind of see what's out there that can be useful. Yeah. Exciting times. Right. Good. And I will say that anybody, you can spread this across the AAP, if anybody has an employment contract that they have questions about, Dr. Worsowitz will be happy to read. No, but Jim, Dr. McDevitt, sir, makes a great point is you have access to people. You're going to have mentors at your own place. I would look at contracts from my residents all the time. And then say, you got to get an employment attorney to look at it. But what about this? Do you know about that? X, Y, or Z. Call your past residents. What did they find? What do they wish they had? Because every time I do a contract that arrived on something, I wish I had to ask for that. Oh, I should have. But they're little things, not the big. The big things have always been met. And far right. We've got 1600 residents. So there's a lot of people. But our chief legal counsel, as a courtesy, will look at potential contracts for residents and give them informal advice, making it clear, we're not representing you. This is a courtesy. And that's good. And you can ask, kind of look around for those sorts of resources. In my opinion, probably the biggest financial decision you're going to make in your entire life is going to be to look at the contract. It is worth spending $1,000 to have somebody look at your contract. And if you change jobs, have a contract looked at again by an attorney, just because you've signed one in the future. I would do it every time you move. All right. Very good. Thanks, everybody.

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