Pigs Gets Slaughtered

pigs_get_slaughteredThe recent gyrations of the stock market had me remembering an old expression about Wall Street investing: “Bulls make money, bears make money, but pigs get slaughtered.”

This expression is supposed to be a reminder that investing rewards patience and long term thinking, not impatience and greed.  So, what have I done over the past week with reference to the stock market?

401KNothing at all really, other than buying equities through my maximum 401k contributions this week and two weeks ago.  Why am I so cool, calm and collected about the stock market, you ask?

First of all, having been investing since the early 1980s, I have seen multiple ups and downs in the markets.  Not panicking and continuing to stay the course of periodic contributions whether the markets were high or low has treated me very well.  The economic principle of dollar cost averaging truly works, as it has over the last 4 decades.

Secondly, having a long range horizon also helps a great deal to help with the short term panics or crises.  If I know I will not need this money for at least the next 5 to 10 (if not more) years, I can stand pat and continue to watch and wait.

Bull-and-BearMy best advice is to stay with the plan that has already been worked out by the greatest financial minds. Use the power of dollar cost averaging, compounding, diversification of your portfolio, and long range focus.

Years from now, when someone asks you about the stock market turbulence of the summer of 2015, you will barely remember it.  Turn off the financial news and read a good summer thriller on the beach.

My Solution to the Primary Care Shortage

disappearing-primary-care-doctorI have been seeing a number of articles recently about the primary care physician shortage, or “crisis” depending on whom is writing the article and where it is being published.  If someone is just now recognizing that there is a PCP shortage, he or she must have been living with his or her head in the sand for the past 20 years, or is a modern version of Rip Van Winkle.

As a primary care representative on a number of statewide and local committees, I have discussed this issue several times in the past.  In doing so, I have felt like the living manifestation of the motto of my alma mater Dartmouth College, “Vox clamantis in deserto”: A voice crying in the wilderness.  Despite being the PCP of record in these venues, I truly felt that no one was listening to me.

At one point in time, I tried to make the other specialists and the hospital and insurance administrators aware that many of their programs actually made the existing PCP’s life and practice worse and less inviting to young doctors coming through the pipeline of medical school and residency.  The constant nickel-and-diming of prior authorizations for studies and medications drains the energy of the PCP.

electronic_medical_records_problemElectronic records, which were initially seen by others as a panacea, have frustrated providers and reduced their productivity & their ability to communicate with their patients.  Rather than making primary care medicine more attractive to the younger professional, most of the initiatives to improve medical care have been built on the backs of the primary care providers.  PCPs do most of the grunt work and share very little of the reward, if there is any.

In these committee meetings, you could hear a pin drop when I brought up the next topic: Money.  It is no surprise to anyone that most medical school graduates are carrying over $200,000 worth of loans into their residency and practice years.

If they are a married medical couple, and there are more of those lately, the loan portfolio load can reach over a half million dollars.  This weight affects decisions these doctors will make.

These are very smart people.  Despite what is said about doctors and their ability to handle money or not, this is actually relatively simple math.

Should I leave my internal medicine, family practice or pediatric residency and practice primary care in an office setting because there is a need, or should I extend my education by a few more years to become a specialist and make twice as much money for the rest of my life?  Hmmm . . . Let me think!

doctor_brokeAnother option that has become very popular for those who don’t want to do the extra time in fellowship is to become a hospitalist or ER doctor.  The salary is not double, but it is a lot higher than the office practice compensation.

Also, PCPs can practice in what they are well trained, which is hospital based medicine.  They also don’t have to deal with the hassles of modern medicine like call schedules, nursing home coverage, and paperwork, even in the age of EHRs.

A cardiologist at one meeting was lamenting about the fact that he and his family hadn’t seen their designated PCP in years in the office because that PCP is always assigned to the nurse practitioner.  I leaned across the table and asked him, “Are you serious about attracting more PCPs not only to Maine but to the profession and the country?”.

“Yes,” he replied with a resounding nod.

“Good,” I said, “I have an easy solution that would be very effective: Pay PCPs like cardiologists.”

doctors_meetingFor the most part, we are way over-doctored in cardiology compared to all primary care areas.  I know that many cardiologists go into that field because they love the study of the heart.

OK, I get that. But if you were to tell a med student or resident, “Hey, you can make the same money as a cardiologist if you choose primary care medicine and get a jump on paying off those loans”, it would turn some heads in the PCP direction.

If the primary care shortage is really a crisis, and I truly believe it is, action is needed and fast.  Each year more and more doctors are retiring from primary care and they are not being replaced.

They cannot all be replaced by the physician extenders of all the various stripes, no matter what hospital administrators think.  They must not only be paid better than they are now, they must be paid A LOT better.  Primary care medicine is becoming the choice of only the most altruistic of us.

I have seen the young doctors in our local Family Practice residency, who have espoused the principles of old fashioned family practice when they enter the program, become ER docs, hospitalists and administrators when the realities of economics and family life come crashing down on them.  I truly don’t blame them. I think that they are making a very rational decision.

lonely_dinosaurIt is just very uncomfortable to watch the area of medicine that I practiced for over three decades and loved become a relic.  Now, I know how the last dinosaurs felt.

Coding Is King

medical-codingIf I really want doctors I know to immediately go into a daze and start thinking about other things they need to do, I start to talk about medical coding.  However, as far as their compensation and pay are concerned, how they code is, and will continue to be, extremely important.

For the non-medical readers, I should briefly discuss what coding is.  Basically, everything a doctor does in terms of procedures, and even the office visit and what is discussed within the office visit itself, has a code.

health_insurance_moneyInsurance companies and the federal government in the form of Medicare and Medicaid use those codes to determine how much work was done.  Most importantly, they use the codes to calculate how much they should paid us doctors for that service.

Each code is associated with what is called a Relative Value Unit (RVU), which means how much work was done and how much it costs relative to other medical work.  Each insurance entity determines a conversion factor which is a unit of money that they will pay per RVU.  Conversion factor times RVU = amount of money paid for that code.

Whew! Writing that summary took a lot our of me, and that was just an overly simplified explanation!

wastepaper-bin Most doctors consider coding to be beneath them and not that important as it is something relegated to medical record and billing clerks.  This could not be further from the truth.

Bad or inaccurate coding can seriously their salaries whether they are in private practice or in a productivity based salary position.  In addition, if the coding is inaccurate, they the doctors are ultimately responsible to the insurance companies and more dangerously the government for those inaccuracies especially if it results in more money being dispensed than the documentation would allow.

doctor_with_clipboardIn this area, I have had several mantras. The first and most important is document, document, document.

It is no exaggeration to say that if you don’t document something in a medical setting, it is as if it did not happen both in legal and reimbursement senses especially.  Even if you think you have an iron trap memory, you cannot remember within the torrent of patients you see every day a particular conversation or procedure if it is not documented.  For example, if you talk about smoking cessation with that COPD patient because you do it every time you see that person, you need to document each time AND you need to code for it.

That leads into Mantra #2: Everything you do and document as a medical professional needs to be coded if there is a code for it.  In general, there is a code for all sorts of things, especially because the insurance companies and the feds want to follow such codes to see if you are doing them.

doctor_memoryTo follow the previous example, if you talk to your patient about stopping smoking but do not code for it even if you have documented it, they do not register you as performing that task.  Nowadays, that can affect reimbursement but also more importantly, going forward that lack of coding can affect your quality ratings, which will eventually affect reimbursement in the coming world of accountable care and value-based care.

Finally, despite what many think about doctors, most doctors undercode.  This means that they choose a code that under-reports what they did.

If this act reduces reimbursement, why do docs do this?  Frankly, one answer is laziness.

As noted previously, many docs do not think of coding as important and frequently pick a middle-of-the road “favorite” code.  One time I reviewed the documentation and coding of the doctors in my own group and found one doctor coded every visit the same.

He used the code 99213 which is the average evaluation and management code most primary care visits for EVERY visit.  When confronted, he had no defense other than convenience and that he did not want to think about how much more documentation he needed to justify the next higher code. Aargh!

I could go on at length about the irresponsibility and unprofessional nature of undercoding in a future blog post.  Suffice it to say, coding for a doctor is very important and should not be relegated to a secretarial function.

keep-coding-and-make-moneyIn fact, I think that many of the reasons that physicians have lost prestige, financial power and control within the medical infrastructure is that they have ignored important issues of documentation that they thought were beneath them.  For the sake of not only your credibility as a medical professional, but also as a medical professional desiring to attain more wealth in the long term, you should not do the same.

Coding is not beneath you.  It gets results, and it ultimately creates wealth.

Income Versus Wealth

doctor_piggy_bankI had a conversation recently with a younger doctor that I have known for some time and whom I initially recruited to join our local hospitalist group.  He was asking my advice concerning an offer he had received from a competing hospital system for essentially the same job and benefits, but a higher salary.  The salary differential was about 5% of his current salary.

This doc, who we will call “Ben”, was tempted, as several other hospitalists in the area have been, to hop around various hospitals in the state in order to edge up their salaries.  Ben is an excellent physician, and I certainly wanted him to stay around locally as I might need his services acutely someday.

But I tried to be objective and business-like, and give advice appropriate to his situation.  I asked him, “Ben, do you want to chase income or do you want to become wealthy?”

He looked at me quizzically and said, “Aren’t they the same?”

“No, grasshopper, they are not the same.”

As my father used to say, it’s sometimes not how much you make; it’s how much you keep.  If you increase your salary, but then just increase your expenditures, you are no better off other than the fleeting improvement in your lifestyle.  In Ben’s case, his increased commuting costs and the aggravation of learning a new EMR system made this increase in salary a wash.

doctor_walletHowever, I saw this a teachable moment to discuss my financial philosophies to the next generation of physicians.  I told him that his current salary is a good base from which to start.  His emphasis going forward should actually be to develop more than one stream of income.

For physicians, “moonlighting” in off hours is a common mechanism for another stream of income.  Over the years, starting in residency and extending well into my practice years, I did extra work in ERs, covering various inpatient services and nursing homes on call to supplement income.

Budget-Clip-ArtIn my financial psychology, I used the extra income for a specific purpose, meaning that it did not just go into the general household budget.  Since it was extra income, I assigned it saving for a next vehicle (I haven’t had a car loan in 30+ years), paying off residual debt such as a student loan, paying down a mortgage, kids college loan fund, or more retirement savings to reach whatever was the maximum allowable contribution at the time.

True wealth, I told Ben, comes from financial freedom.  It comes from having the ability to pay for what you want to have or do without worry about the future.

As I said above, I haven’t had a car loan in over 30 years.  My wife and I paid her law school tuition and the college expenses of both of our sons in cash and without loans.  Any mortgage we have had on our properties has been, or will be, paid off early.

doctor-cashWe have always contributed the max to our IRAs and 401Ks as allowable by law at the time.  As a result, we have no non-deductible loan interest, rapidly decreasing mortgage balances which will be paid off well before we retire, and a very healthy and steadily increasing retirement fund thanks to continued contributions and the markets.

Ben was skeptical in that no one had ever talked to him in these terms before. Not his parents and not any medical mentors.

Time will certainly tell because in a financial plan, time can be a blessing or a curse depending on how much you have.  The power of compounding rewards those who make even small changes early on.

Otherwise, they are going to need to make painful changes later.  I personally never want to be one of those people who bemoans their retired years because they are “on a fixed income.”

Just 1% Better

one_moreI had promised previously in this blog that I would address some of the techniques that I have used over the years to accumulate my “medical millions”.  The principle I will discuss today is very simple actually, but I have found that many find it very difficult to implement.

This is a technique that I have used unconsciously and instinctively since a very early age.  Consequently, it has made me and my business highly productive.

A little background first, though, by way of explanation.  Although I was and still am a diehard Boston Celtics fan, I did read an autobiographical memoir written by Pat Riley about his days coaching and managing the LA Lakers during their heyday years (i.e. the 1980s) when they were trading championships with the Celtics year after year.

He discussed how difficult it was to motivate superstar athletes when they had achieved so much success.  Despite the fact that these stars, including Magic Johnson most notably, were obviously very motivated to get to that peak level in their careers,  achieving their ultimate goal of a championship made them less hungry and harder to motivate to go for that goal again.

pat_rileyPat Riley’s solution was simple yet brilliant.  He would go to each player and review their statistics (in terms of points, assists, free throws, etc.) for the previous year.

Then he would ask them one simple question: “Can you give me just 1% more?”  Unanimously, they would shrug their shoulders and say, “Sure, Coach. That’s easy.”

What Riley found was that psychologically his players could give him more effort because he was only asking for a small improvement.  He also knew that if he could get each of his players to improve even by only 1% (they almost all improved significantly more than 1% over the season), the compound effect on the whole team would be exponential.

Back to medical practice.  In my office, I always kept track of my patient load.  I could tell day to day, week to week, and month to month how many patients I saw.

Then, I would approach my staff and look at my schedule and see how and where I could see one more patient per day. Even the most recalcitrant staffers who tried to manipulate the schedules of our various providers so they would be out of the office exactly at 5 P.M. could not argue with the small request.

But I knew the numbers.  Remember, this was private practice and I could only “eat what I killed”, or profit only by the patients that came into the office, not by just having the office.

doctor_&_patientSo to simplify, let’s say I only cleared an average of only $50 per patient, considering payer mix and coding variables.  That one extra patient per day would mean $250 per week extra, $1000 per month extra and approximately $12,000 per year more to my bottom line.

Not too bad for a seemingly small effort!  This amount would obviously compound further over the following years.

After a period of time and once everyone was used to that extra patient, I would repeat the process again and again and again.  I and my nurse got more and more efficient.

We constantly tweaked our flow and interactions to improve patient care and efficiency.  In my practice group, I was always the most productive doctor by a country mile.  Also, when I looked at others in my medical community in my role in our local physician-hospital organization, I saw only one or two other primary care docs even in my ballpark.

Small changes compounded over time can make big differences down the line. I know everyone knows that intellectually, but very few are willing to make the changes necessary to accomplish the task.

They would look at my patient load and say “I could never see as many patients as you do”.  My response was always “Yes, you can! It’s really not that hard.”

In a near-future blog post, I will talk more about how to enhance reimbursement and income within the patient load you already see on the road to your “medical millions”!

Gronk vs. Wedding Loans?

gronkTwo different, separate information items inspired my blog writing for this week. Both are related to money, and how we treat and use money in our lives.

The first was a small note in a sports section of my local newspaper. The article was related to Rob Gronkowski, nicknamed Gronk, who is a well-known tight end for my favorite team, the reigning Super Bowl champ New England Patriots!

This article specifically highlighted Gronk‘s finances. It noted that over the course of his career so far, he has received over $10 million in signing bonuses and pay from his work as a pro football player.

What I found most interesting is that he has not spent a single penny of that $10 million yet. It is all saved and invested.

gronk-flakesInstead, he lives on the money that he has obtained from endorsements stemming from his celebrity as football player. He had had multiple endorsement deals including Dunkin’ Donuts.

When asked to comment on the strategy, Gronk said that he knows that his football career will be short-lived, and he will need money to support himself for the remainder of his life.

wedding-loanMy second money-related thought was stimulated by driving by a local bank the other day which had a sign out front advertising wedding loans at a low 4.99%. As I was looking at the sign, I was also saying to myself “Wedding loans? Wedding loans!?!”

I know that I am frugal (and I don’t have any daughters).  However, as far as I’m concerned, if you have to get a loan to finance your wedding, you either shouldn’t get married or you should have a much cheaper wedding.

wedding-piggybankI know that some will tell me that the average wedding in the United States now cost $35,000. Basically, though, you’re spending a lot of money for one party on one day.  That money could actually be used for a down payment on a house,  to furnish an apartment, or to pay down other debt.

I was heartened to hear that a professional athlete, and an enormously popular one at that, was being financially responsible and planning for his future. I was also disheartened that some people are seriously willing to go into debt for a one-time party.

wedding-savingsAs befitting the theme of this blog, I feel that doctors and other medical professionals should be more like Rob Gronkowski (even if they are not Patriots fans like I am) and save for a financial future for which they will be responsible.  I also definitely feel they should not be like the wedding couple or family that goes into debt for a short-term, and quickly depreciating, event.

In summary, be more like Gronk. Also, before you or your child meets the future spouse of your or their dreams, save (don’t borrow) for that wedding day!

Myth of the Medical Millionaire

blog_followersMy last blog post received a great deal of reaction.  I had at least 35 people registering at my blog site to subscribe to future posts.  I also had local medical community reaction to my thoughts on the meeting discussed in that post.

Several of the older docs who had started out in private practice, and were continuing to fight the fight, thought my comments were common sense.  Like a lot of service professionals, doctors in private practice “eat what they kill”.

They have to be productive to meet the payroll and pay the bills before they get their pay.  They are more realistic about money, business, and finances.

A subset of the doctors who have been practicing for some time did tell me that they thought that it was easier for me in that I “had always been entrepreneurial.”  These docs remind of Eeyore from the Winnie the Pooh stories, always complaining about their lot in life.

brokeThey lament not getting paid enough, although they generally do not act on fairly simple suggestions to enhance their income by working smarter.  They also do not seem to have much left over from their paychecks to save or invest, despite their income being much higher than their average patient.

Their comments about me having it easy because I have always been entrepreneurial is sort of like when my overweight patients would dismiss my recommendations about weight loss because “you don’t know what I’m going through, doc.  You don’t have a weight problem!”.  The person who does the recommending gets blamed because they have been successful; because they have walked the talk.  Like the recalcitrant obesity patient, some doctors will not listen to financial recommendations.

I have had several doctors I have known personally and professionally who have not set aside sufficient funds away in their 401K funds in order to fund their current lifestyle expenses.  These docs are unfortunately going to turn around someday (when they’re in their 60s) and finally figure out that they cannot afford to retire because that nest egg is not there.

cash_cageThen, I predict with a high degree of certainty, they will complain about their lot in life again and talk poor mouth about their situation.  All of this is predictable. It is not rocket science. It just takes a long-term perspective and some discipline.

What astounds me is that these individuals obviously had to think long term and have discipline for at least a portion of their lives in order to become doctors.  Somehow, once the medical degree was obtained and the residency finished, these individuals thought the finish line had been crossed and they had it made.

Psychologically, I think that many of the doctors who reach this point after residency feel that they deserve some payback.  Justifiably, they want a house, they want cars, they want a family, and they have student loans frequently to pay back.

They can do all those things and still have money to invest and save if they approach it the right way.  Maybe they didn’t receive the right advice at the right time.  Maybe they are just tired of delayed gratification.

Whatever the reason is, they are strangling themselves by their financial inertia.  They will also get no mercy from the general public who feel that doctors make lots of money and should have lots of money left over when they retire.

happy_retirementSo, basically, what I am saying is that the general public impression that all doctors are millionaires is a myth.  However, all doctors should be, by mid to late career, multimillionaires and they MUST be multimillionaires to afford a successful and comfortable retirement.

That mindset is the reason for the ultimate delayed gratification.  As a well-known financial guru says, you have to spend some years living like nobody else so later you can live like nobody else.

invest_wiselySo much for philosophy for now.  I will intermittently weave in financial philosophy into my comments, but I also hope to outline my programs in future posts:

  • How I enhanced revenue
  • How I set up savings mechanisms
  • How I invested wisely
  • How I invested for the future

Let me know what you think, and if these comments strike a chord with what you see indoor medical community.

Becoming a Millionaire: A Vital Goal

doctors_meetingI attended a meeting last night that emphasized to me why it is not only a nice goal to become a medical millionaire, but why it is a vital goal.

Some background first: I attended a meeting of family practitioners in my local area to share with them data collected from insurance companies, and to help them to use the data to improve their practices and patient care.  Insurance companies offered extra payments to the doctors and practices to reinforce this behavior if these doctors reached certain benchmarks.

I have been the medical director of a local physician hospital organization, or PHO, for the past 20 years.  This PHO was formed back when the advent of HMOs came into this area and exerted their financial power to reduce the amount they were paying for medical care.

I have learned over the years to be somewhat cynical about the field of health insurance.  Health insurance companies are basically financial and for-profit institutions whose main purpose is to collect premiums from patients and employers, and pay out as little as possible.

If you look at health insurance that way, it explains a lot of their behavior.  I have nothing against profit or capitalism, but let’s at least be up-front about the economic model with which we are dealing, and not pretend that they are altruistic entities.

board_meetingBeing a group of hard working and dedicated doctors, the data on these doctors in this PHO were actually quite good in terms of multiple quality parameters such as rates of mammograms, pap smears, and colonoscopies.  We had discussions about office and PHO procedures that could help out and improve the rates of these necessary procedures.

All was well and good, until the very end when several members “let their hair down.”  It was then that frustrations boiled to the surface on several fronts.

big_billOne doctor railed against the high price points of many tests performed in the local hospital, such as MRIs and colonoscopies, compared to other locations in our state.  Many local patients who either have no insurance or high-deductible insurances were finding it hard to pay for necessary tests, and expressing their frustrations to their point people in the health care system, namely their PCP.

Another doctor talked about the disrespect he felt from others within the medical community, including hospitalists and specialists.  He complained about having to deal with unreturned phone calls and medical community members being unreceptive to information about his common patients that the PCP had from years of working closely with them.

Then the discussion turned to money, of course.  Specialists, including hospitalists in our area, earn 2-3 times the income of the primary care providers, while it is the PCPs who are under the most scrutiny from the insurance companies, hospitals and other rating agencies in terms of quality.

frustrated_doctorOne independent PCP, who is a 2-person practice, talked tearfully about how hard is to remain independent in a practice when the economic landscape is tilted away from the doctors who are doing the vital primary care work.  After all, everyone agrees that this work is the bedrock of health care.

Part of the reason I got involved in the local physician-hospital organization is to have some control over the economic process of medical care.  I saw the train coming down the tracks in terms of the power significantly shifting away from the doctors to the health insurance industry.

Yes, I was still the one on the line seeing the patients, prescribing the medications and the testing, and paying the employees, rent, & other expenses.  However, someone else was wresting away more of the control on my ability to have the income flow to pay those expenses and, eventually, my own income.

An older doctor, who was on the board of our PHO until he retired several years ago, said a very succinct comment on this situation that I still remember to this day.  He said, “The golden rule of business is not do unto others as they would do unto you, as it says in the Bible. Rather, it is he who has the gold who makes the rules.”

A doctor putting money in his pocketKnowing how to negotiate with these financial entities that were controlling the income flow was vital to my financial future.  I always realized that I had to have multiple ways to make income so that a pinch in one aspect of the flow would not strangle my income and life.

In later blog posts, I will go into more detail about how I accomplished that feat.  However, my most important accomplishment was the mental leap and the realization that I did not want to be controlled by a system that was skewed against me.

All these ideas were flowing through my mind as I was listening to these family practitioners lament their plight and venting their sense of powerlessness.  I always wanted to be in the position of having the entities that wanted my work need me more than I needed them.

Another older M.D. mentor of mine from the early days of my practice once counseled me to “structure your practice (business) such that even if the hospital were to implode, you could still make a living.”  You can certainly substitute insurance company or Medicare for the hospital in that counsel.

overworkedUnfortunately, I also realized that many of the hard-working doctors were not just railing at the injustice of this current reimbursement system, but also feeling like they are on a treadmill over which they have no control.  They still need to work in this system despite its unfairness because they have massive financial obligations including student loans, mortgages, and future college expenses for their children that require them to continue on this treadmill.

I don’t want this blog post to be a complete bummer.  I do think that there is hope.

In fact, I feel that I have managed to thread the needle by approaching the medical/financial system with a business perspective and handling personal finances as if I were a corporation.  This mindset has allowed me to build and manage multiple multimillion-dollar medical enterprises while also amassing large retirement funds, investment portfolios, and real estate holdings.

I wish I could have piped into the PCP discussion with that message of hope.  However, it was not an appropriate message for that particular meeting.

But for this blog, I still attest that there IS hope, and there are multiple ways to navigate the ever-changing medical and economic environment and still come out a winner at the end.  Stay tuned!

Why Start A Blog?

computer_guyWhy start a blog? Why start a blog with this particular name, “Medical Millionaire”?

Over the course of several blog entries, I will try to answer those questions as well as going into some of my personal history that has gotten me to this point in time.

Over the course of the past 30+ years, I have practiced in a small town in rural Maine.  However, despite that modest beginning as a solo practitioner, I expanded over time to a multi-million dollar, group internal medicine practice with multiple lucrative ancillary services.

How I accomplished that and why I felt compelled eventually to accomplish that will be the subject matter of this blog.

in_the_moneyWhile I agree in general that physicians receive a much higher income than the average population, I do feel that the concept of “the rich doctor” is a misnomer.  Over the course of my career, I have met many highly-compensated physicians who were by no means rich in terms of net worth, and many who cannot tolerate missing a paycheck.

I certainly would not expect any sympathy from the general public for the fate of these doctors. In many ways, I agree that their fate is their own fault and clearly preventable.

kindly_doctorI plan on using this blog to initially outline my medical, business and financial history. I also plan to outline how I accomplished what I did, and use this as a guide for other physicians.

I am not writing this blog to impress anyone, but rather to impress upon them the relatively simple and reproducible aspects of my success. Basically, my attitude is that if I can do it in a small world town in Maine, any physician can accomplish the same anywhere in the United States, and perhaps the world.

I do realize that starting off a blog, I will be primarily writing to myself.  However, I hope to build an audience who will benefit from this information over time. Continue to read and follow this blog, and we will discover many things together.

The Move To Maine

maineDuring the time of my residency, I definitely did not particularly care much about monetary issues.  I attribute this to growing up in the 60s and 70s and being largely altruistic.

I also had spent much of life up to that point in a student lifestyle not requiring very much on which to live, and being responsible only for myself.  As long as tuition, room and board were covered by a combination of scholarships, loans and work-study jobs, I thought I was OK.

However, at the start of my residency, I was recently married and my wife was more acutely aware of the cost of living in the world outside of academe.  Halfway through my residency, our oldest son was born which obviously ratcheted up expenses much more than I would have ever dreamed.

So clueless was I about salaries that I thought my residency salary, which at that time was the 2nd lowest in the country, was a lot of money. It was $9-10,000 in 1979, which, when you factor in working intern hours, was about $2 per hour, approximately what minimum wage was at the time.

My meager residency pay and my wife’s nursing salary kept our heads above water in Atlanta, Georgia.  Never one to eschew hard work, I supplemented our income with multiple moonlighting jobs predominantly nights and weekends off from residency in suburban and rural ERs.

So, basically, moving to a relatively less lucrative location like Maine did not bother us necessarily.  The move brought us back closer to home in New England.

maine_townMaine was, and is, a great place to bring up children, not to mention that it is a beautiful state.  Since I owed the federal government 3 years of service in an underserved area, this rural Maine location seemed like a good fit.

I had friends from medical school who tried to get out of their Public Health Service, and ended up working in infirmaries in a federal prison.  That work environment was not my idea of a good time.

Prior to our leaving Atlanta, a married couple who have remained dear friends over the years, threw us a going-away party.  It was clear from the guests who had come to wish us farewell that we had developed many personal and professional connections in Atlanta.

I could have developed a very good and well-compensated practice in that area and had many offers, especially from docs with whom I worked in the suburban ERs.  In fact, the father of the couple throwing the party was a physician who had just retired from a practice in New Jersey and was living in Florida.

At the party, he put his arm around me and proceeded to give me his sage advice.  He said, ” Jack, do your time in Maine.  3 years, is it?  Then, hightail it out of there and come down to Florida.  A good, well-trained doc like you can set up near one of the well-off retirement communities and make a bundle.”

My friend Dan interjected at that point saying half-jokingly, “No, Dad, Jack wants to go to a place where he will love the people and the people will love him.”  The wise doctor replied, “That doesn’t mean he and his family have to starve.”

So it goes and the journey began. No more dependable and guaranteed salary of a big pocketed employer like a hospital.  Whether I realized it or not at the time, I was about to learn a lot more about money, running a business, and free enterprise than I ever imagined, while also still trying to keep up with ever-changing medical knowledge.