Monthly Archives: May 2007

There Is No Team In Medicine

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Teams pull together. They’ve got your back. They work together towards a common goal. The term “team” is used very loosely in the medical world. The fact is there is no team in medicine — it’s just a term used to foster some semblance of cohesiveness within dysfunctional rotations. Don’t let them try and tell you otherwise.

Medical school rotations are typically made up of an attending, one or more residents, and one or more medical students. This is what is collectively called the “team” on ward medicine. If you look deeper you’ll soon realize that an accumulation of more than one body isn’t adequate to truly define a team.

The common goal on ward medicine is typically to care for patients. This is really where the teamwork both begins and ends. Unlike a football or basketball team, there is a lot going on behind the scenes in medicine to ensure that teamwork does not truly exist.

  • Other students will go behind your back and attempt to show you up. This can include answering questions about your patients or bringing in journal articles when other students aren’t prepared.
  • Some residents will not tell you where you need to be and then fault you for not being wherever it is that they (supposedly) wanted you to be.
  • Attendings are malignant about “pimping” and some verbally abuse students and/or residents for not knowing the answers.
  • You are overworked and very rarely will another person put in some extra effort to make sure you’re out on time.
  • Attendings waste tremendous amounts of time. They’ll tell you that they want to round at 5 PM and then not show up until 6:30 PM. No phone calls are made to let the residents know that he is going to be late. You sit around for an hour and a half with your thumb up your ass.
  • Nurses, who are sometimes considered part of the “team,” are incredibly slow about getting things done.
  • As a student, you are made to complete meaningless extraneous tasks such as coming up with a presentation about some topic you’ll never use ever again. This time could be spent studying for your shelf exam.
  • Most residents and attendings don’t care that you have an exam at the end of the rotation to study for. Instead, they’d rather you follow them around and waste 4 hours every day.

With just a few examples, you can see that there really is no teamwork in academic ward medicine. Here is what you actually have:

  • The attending is getting paid a monthly bonus on top of his regular clinical (or academic) duties and salary to participate on the wards. Thus by nature of the situation his ward duties come second.
  • The residents are there to please the attending and to do the daily “scut” work. They just want to make sure that everything is in order before rounds.
  • The students are there because they were told to do so. At best they want to learn something useful to apply to their career. At worst they just want to pass the rotation and could care less if they remember anything 1 day after the shelf exam.
  • In order to impress the attending, cut-throat measures on the part of students and residents will sometimes be employed. After all, they want good letters for that competitive fellowship or residency.

So in reality, you have three different individuals: Attending, resident, and student. Each wants something different. This in itself defeats the “team” in medicine.

Contrast this with a football or basketball team. The coach wants to win. The players want to win. They pull together to make it happen.

There is no team in medicine. What once might have been a team has transformed into a cut-throat competitive atmosphere where each participant has their own individual goals. Without well-defined universal objectives that apply to each participant as a whole, teamwork cannot and will not exist.

When Did I Realize Medicine Wasn’t For Me?

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First and second year was pretty decent. I got to make my own schedules and really only went to class for exams. I had my daily studying completed by the time my classmates got out of class by not attending classes each day.

At some point during the beginning of second year, we had to begin doing H&Ps on real patients in the hospital. We were assigned a preceptor, and we met with him or her once per week for a few hours while we saw our patients, wrote up an H&P, and then presented.

If I had to mark one single point during my medical school career that I started having second thoughts, it was during this time. From the first day I stepped into a “real” patient room and starting asking questions to get more information, and then finally going into the physical exam, I started to realize this wasn’t what I had signed up for.

But, most of my time was spent studying with my own schedule so life was pretty good. The fake H&Ps eventually ended and then we all moved to third year.

This is basically where my initial thoughts during second year were solidified. I started third year on pediatrics in the outpatient clinic. The hours were good, but I didn’t particularly care about dealing with lots of kids or the parents. Still, looking back pediatrics was probably the lesser of the evils in terms of clinical rotations.

After pediatrics was OB/GYN. Now, this is where it really got shitty. I hated OB/GYN. I mean I really, really hated it. It was at this point that I had second thoughts about quitting.

Why didn’t I just go ahead and bite the bullet then? I tended to always talk myself out of it. The thoughts in my head were something like “I’ve already done two years of medical school, what’s two years more?” Each rotation that I had completed (and hated) was only one step closer to finishing school — and one step farther away from me getting out.

But then I’ve always believed that sticking it out was the most ideal situation. Fall-back plans are great, as you never know what is going to happen in the future. The desire inside of me to always have a fall-back plan — all bases covered — is what kept me in for the long haul.

Knowing how things worked out, I am very satisfied with my decision and I feel that I made the best one for me. But making that decision with an unknown future was certainly scary. Now, the company is doing extremely well and I am completely happy. I could technically go back into medicine if I ever needed to. But, I don’t think this will ever be necessary.

Offering Incentives To Increase Your Bottom Line

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Incentives are everywhere. You see them from car dealerships, credit card companies and travel agencies. Why should medicine be any different? Let’s take a look at how you, the potential future private practice owner, can pad your bottom line by offering incentives to established and new patients alike.

Incentives Aren’t Just For New Cars
You’ve seen the $2,000 rebates or the 0% financing to entice buyers to purchase vehicles. Incentives work. The consumer thinks they are getting more than they would elsewhere, and in many cases they are. Just as incentives work for purchasing new vehicles, they’ll work for getting more patients into your private practice.

How do we do that? Let’s take a look at a few examples that I came up with in order to increase your patient volume and ROI.

Getting Creative With Incentives
Drug companies love to leave free samples lying around, particularly if it’s a family medicine practice or other primary care practice. One thing you could do is offer an incentive to new patients to give them one month of their medication for free. For many patients, this means saving anywhere from $10 to $60 or more in copay fees for drugs. Some patients will jump on this while others won’t bother. Those that do will probably convert into a regular patient and you’ve just increased your patient load.

Let’s take a look at another incentive that targets those patients who regularly miss appointments. Missed appointments for you mean a loss in revenue. You could offer a private shuttle service (or offer to pay for a taxi) if it means getting that patient into your office and giving you a net positive addition to your revenues. Obviously it wouldn’t make much business sense to pay out of pocket to get that patient into your office if it meant breaking even or going into the red on that particular transaction. For incentives such as these, you’ll need to roughly figure out what it’s going to do to your bottom line before you offer it.

Cutting Down Wait Times
A popular complaint with patients is the amount of time that they have to wait to see the physician. If your practice was known for incredibly short wait times, this is an indirect incentive for the patient to come to your practice versus other physicians in the area. This mostly applies to new patients, but you should still be able to acquire patients from another practice if you offer comparable service with much shorter wait times.

How you should cut down your wait times will certainly vary by practice. Just evaluate your triage procedure from office entry until the patient gets back into the exam room and find out what you can do to decrease that time period. Cutting down wait times also means that you’ll have to be efficient with seeing patients yourself. Making the patient wait shorter times in the waiting room, but transferring that wait time to the examination room won’t cut the mustard.

More Indirect Incentives
Indirect incentives are those that you don’t physically offer to the patient but are rather built into your practice to begin with. These incentives have a significant impact on patients, because you’re not really “advertising” anything. Instead, patients interpret the incentive as better service coming from your practice. These incentives perhaps have the largest impact on patient retention and your overall bottom line. Let’s take a look at a few more.

Office Appearance
Having a nice-looking office will do wonders for your practice. How many times have you been to see the doctor and find uncomfortable plastic chairs, cheap-looking art on the wall, and industrial-grade tile floors in the waiting room? It gives a bad impression to patients.

Go ahead and take the plunge to purchase a furnishings for a really stand-up waiting room. If you don’t know what I’m talking about, head over to a prominent cosmetic plastic surgery practice in a large city and take a look. These guys realize that appearances matter, and it does truly make a difference. Instead of plastic chairs, get leather (or pleather if you can’t afford it) couches and chairs. Buy some nice pictures that don’t look like prints from Wal-Mart. Put down some nice carpet or hardwood flooring. It costs more up front, but it will give your practice much more credibility. Appearances matter.

Examination Room Appearance
Along the same lines as the appearance of your office, take some time to make your examination rooms as comfy as possible. Put in some nice flatscreen TVs (they are really cheap these days), and put leather (or pleather) furniture for guests of the patient to sit on. Keep all medical equipment that’s not essential out of site in drawers or cabinets. I know you medical folks out there are used to seeing needles and syringes sitting all over the place, but your patients aren’t. It gives off a bad vibe, so don’t do it.

Stock each examination room with a mini fridge and keep diet soft drinks or juices for the patient and guests. Make sure magazines are neat and tidy, and up-to-date. Keep some snacks lying around as well. The patient knows whether or not he’s supposed to eat.

Free Advertising
Make the patient and the patient’s guest as comfortable as possible. Chances are they have never been to a doctor’s office that is so comforting and “professional” looking. Do what the other guys aren’t doing, and watch in amazement as word-of-mouth recommendations spread like wildfire about this new, incredible practice in town.

Even if you’re not the best physician in town, you’ll still win over patients with the direct and indirect incentives that you offer. Remember the key is to be different. Since many practices are doing the same thing right now, it shouldn’t be too hard to stand out.

Medical School Requirements

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So you’ve taken the plunge and have decided to attend medical school. Medical school requirements will certainly vary from school to school, but there are some generalities that we can make. These will help you in deciding which classes you need to take in order to get prepared for medical school.

General Class Information
For most medical schools, you will need at least one year of:

  • General Biology
  • General Chemistry with Laboratory
  • Physics
  • Organic Chemistry with Laboratory
  • English
  • Calculus

Now keep in mind that these classes will also help you immensely on the MCAT, which you will also need to take. These classes can be completed at nearly any four year college.

Grade Point Average
There is no secret universal GPA that you should have when applying to medical schools. However, each individual medical school will probably have their own internal cut-off GPA. If you browse around, you can find rumors and oftentimes official statements of what these cutoff values are. However, you should try and maintain your GPA as high as possible since getting into medical school is highly competitive to begin with.

A GPA of above 3.5 is ideal. Anything below a 3.3 and you’ll probably need to do some post-bac work to improve it. Your GPA will be broken down into a general GPA and a science GPA. Medical schools typically place more weight on your science GPA, so try to maintain it as high as possible.

Degree
A bachelors degree is required for most medical schools, but it does not have to be from a science major. In fact, there have been rumors that medical schools like applicants who aren’t science majors, as it shows diversity in the applicant. On another note, English majors typically do well in medical school since they have spent the last 4 years reading a lot of information. Thus, they have found ways to digest information more effectively, and oftentimes do incredibly well on the verbal portion of the MCAT.

If you do decide to complete a bachelors degree in a science major, it will not hurt you. Just keep in mind that you do not have to have a science major in order to be accepted into medical school.

Medical College Admissions Test
The Medical College Admissions Test (MCAT) is a requirement for all medical schools (except for the combined B.S. / M.D. programs). Just like GPA, there is no universal cutoff value in score. The exam tests your knowledge from college in the biological sciences, physical sciences, and verbal reasoning. Anything above 36 is a great score, but I have read about numerous applicants being accepted with scores as low as 28. If you go below 28, it’s probably a good idea to take the exam again and try to improve your score.

Taking the exam more then three times has been rumored to hurt your chances for admission. Although admission committees like to see persistence, a large number of attempts will show them that you might not be cut out for the rigors of medical school.

Most examinees will take an MCAT preparation course offered through Kaplan or the Princeton Review. Not doing so doesn’t guarantee that your score will be low, but you will be putting yourself an an automatic disadvantage versus other applicants. Take the course if you can afford it.

It has also been rumored that an even scoring distribution is ideal. So, for a score of 36 having three 12s is better than two 14s and an 8.

Volunteer Work
Volunteer work, although technically optional, is something that most applicants to medical school will complete at some point during their college career. Look for anything that will give you some exposure to working in medicine, and try to do as much as you can. Typically a year or more of consistent volunteer work will be sufficient to pad your application enough for the admissions committee.

Undergraduate Research
While not required, this is a great way to pad your application. I did research as an undergraduate and talked about this research at each of my medical school interviews. It shows that you’re interested in the sciences in general and certainly doesn’t hurt your application at all.

Keep in mind that doing volunteer work as well as research presents an awesome opportunity for letters of recommendation. You will need anywhere from 3-5 depending on the schools that you are applying to.

Summary of Medical School Requirements:

  • General Class Information
    • General Biology
    • General Chemistry with Laboratory
    • Physics
    • Organic Chemistry with Laboratory
    • English
    • Calculus
  • Grade Point Average
    • Above 3.5 is ideal.
    • Try not to go below 3.3
  • Degree
    • Bachelors degree is required, but not necessarily in the sciences.
  • MCAT
    • Scores above 28 with an even scoring distribution are ideal.
  • Volunteer Work
    • Optional, but doesn’t hurt your application.
    • Gives opportunity for letter of recommendation.
  • Research
    • Optional, but improves your application a decent amount.
    • Gives opportunity for letter of recommendation.

What People With a Net Worth of $5M+ Do That Other People Don’t

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Some of you may consider this post to be somewhat off-topic, but I don’t. The reason I don’t think this post is off-topic is because money is universal. No matter what we do for a living, we all need it to survive. With that being said, let’s take a look at what “pentamillionaires” do that the general public with average income do not, and then let’s apply some of those ideas to medicine and what you can do to approach reaching that seven-figure mark.

Earlier I wrote about working smart in medicine for maximum income generation. The latest article in Smart Money magazine talks about what the millionaires these days are doing, and some of my ideas fall along the lines of those that were successful in generating seven figure net worths. Before we get into the nuts and bolts of the article, let’s take a look at some interesting statistics quoted from the article:

  • One million is yesterday’s news. In fact, to reach the top 1% of income earners in the nation, you’ll need to amass a net worth of $5 million.
  • The number of people worth $5 million or more has quadrupled since 1997 to more than 930,000.
  • 70% of these fortunes are less than 13 years old and the people that have earned them are by and large entrepreneurs. Many of these people accumulated wealth as a byproduct of their passion. This is very important.
  • Respondents reported that only 10% of their wealth came through passive investments and only 10% of pentamillionaires inherited their wealth.

OK, there are some interesting tidbits in the above statistics, but what’s most important is that the wealth was actually a byproduct of people doing what they love to begin with. Read that again — the wealth is a byproduct of people doing what they love to begin with.

Another thing to consider is that these people did not make their wealth working a 9-5 (or 6am-6pm for some of our medicine friends). Instead, they all did their own thing through business. Yes, we all know that medicine isn’t the most efficient way to make money but if you’re going to be working in medicine why not make as much money as possible?

But how do you do that? Unless you’re a practice owner you are technically the employee of somebody else. You have a salary, perhaps with bonuses for doing volume. If you choose to stay somebody else’s employee, you’ll have a steady paycheck but I’ll be the first to tell you that you’ll probably never make the top 1% of income earners in the United States.

Let’s take a look at what some of the people did that Smart Money interviewed for the story:

Once you’ve got food in your belly and a big-screen TV, the mere prospect of more Benjamins isn’t enough to get you leaping out of bed at 5 a.m. Rather, rich folks often make their fortunes after they make up their minds to solve a problem or do something better than it’s been done before. When Frank Darras graduated from law school, all he wanted in terms of material wealth was a middle-class life for his wife and kids. But while working as a doctor’s assistant to put himself through school, he developed a burning desire to help the folks he saw struggling with unpaid insurance claims. “It was the David and Goliath aspect that attracted me more than anything,” says the Ontario, Calif., attorney. Once he had his degree, Darras was like a cruise missile aimed at the insurance industry. By 1990 Darras had his first million-dollar year, and today he oversees one of the nation’s largest disability and long-term-care practices. “I never thought I’d make $5 million in two lifetimes,” he says. “I just loved the work.”

So here’s another possibility for all of you medicine people out there — keep your ear to the ground at all times. Find something during your normal day-to-day work routine that you can do better. A perfect example is a surgeon. If you’re doing a procedure with a particular instrument and you know a way it could be done in a safer, more efficient, and/or more cost effective way — start working on developing that. The same idea can be applied across all fields of medicine.

The honest-to-God truth is that you’re not going to want to work the insane hours that you are working now along with the stress when you’re 60 years old. Doing something like this could be your meal ticket out of the rigors of medicine and into something way more lucrative at an early age.

Remember, medicine is business and it’s not a sin to treat it as such.