2013 New Family Physician Toolkit by California Academy of Family Physicians

New Family Physician Toolkit The process of securing a job as a new family physician can be a challenge. With the passage of the landmark Patient Protection and Affordable Care Act (PPACA), many new opportunities have opened up for family physicians. The California Academy of Family Physicians (CAFP) has developed this toolkit to help you kick start your career in family medicine. We hope this guide will help as you navigate the path toward your first job offer. We wish you every success as a family physician.

About CAFP CAFP’s mission is to advance the personal and professional development of California’s family physicians. With more than 8,000 members, including active practicing family physicians, residents enrolled in family medicine programs and medical students interested in the specialty, CAFP is the largest primary care medical society in California, and the largest chapter of the American Academy of Family Physicians. For more information about the benefits of membership or details on how to obtain an application, go to Membership Application.

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CAFP champions family medicine for California and helps family physicians improve their everyday practice lives.

CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

Table of Contents

Introduction by Jay Won Lee, MD Welcome to the real world.

Patient Centered Medical Home (PCMH): The New Model of Care The economic picture looks bright for family physicians, since the new model of care requires less overhead, delivers higher quality service to patients and enhances provider satisfaction.

The Next Generation of Care: Determining the Medical-Homeness of a Practice Interested in PCMH? Here are some tips on determining how PCMH-friendly a practice is.

The Ideal Practice Setting for You Family medicine offers a wide array of practice settings. This guide will provide an overview of typical practice settings to help you determine the perfect opportunity for you.

The Interview Process This section provides an overview of the interview process and includes a checklist of questions to ask as you assess the health, stability and fit of a practice.

Questions to Ask a Prospective New Partner Practice management consultant Keith Borglum provides an overview of issues to examine when considering a practice opportunity.

Checklist for New Associate or Space Sharing Arrangement Use this checklist during interviews with practices at which you are considering partnership or a space sharing arrangement.

Physician Employment Contract Review Service Our service can help you protect yourself. For a modest fee of $525, CAFP will provide tools to assess your practice choices, including contract review by a qualified attorney.

Five Frequently Asked Questions Regarding Employment Contracts Can I be employed full-time at a medical group as an independent contractor? Can you explain the interplay between the term of the agreement and the no-cause termination clause? Find the answers to these questions and more here.

New to Practice Checklist CAFP developed a checklist of issues to address as you enter practice, such as applying for hospital privileges, obtaining your DEA number, finding professional liability insurance and setting up CME recordkeeping.

Resources for the New Family Physician We've created a quick sheet of resources you can access via the Web to help you stay up to date clinically, manage health information technology tools, connect you with peers and much more.

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

Basic Financial Management for New Physicians This checklist offers simplified rules and suggestions to help you start a “saving” lifestyle.

Malpractice Overview for New Family Physicians Barbara Hensleigh, consulting attorney for CAFP, provides the basics of malpractice insurance.

The Balancing Act Martha Molina Bernadett, MD offers practical advice on achieving life/work balance in this article from our quarterly magazine California Family Physician.

From Resident to Leader: How to Be the Best in the Business Tips on keeping your focus as you embark on a new career from the 2010 R-CAFP President Sharon Lin, DO, PGY-3, Santa Rosa Family Medicine Residency.

Making Your Voice Heard How do you make sure your voice, and the voices of your colleagues and patients are heard? Anthony Fatch Chong, MD, family physician leader in San Diego, describes opportunities available to you to “speak up for family medicine.”

Benefits of CAFP/AAFP Membership The California Academy of Family Physicians and American Academy of Family Physicians are great resources throughout your career as a family physician. Learn more about what CAFP can do for you.

Welcome to the Real World!! Dear California New Family Physician (or soon-to-be): Welcome to “life after residency,” aka what near-retirement medical school faculty refer to, with misty eyes, as the “real world”! Here you are at that precipice of no more night float, no more 80-hour workweeks and no more strategic napping. Yep, you are all grown up now, ready to live up to that personal statement you wrote long ago. Don’t you feel special? You should, you know. After all, we new physicians are so special that our academy recognizes us as a “special constituency.” That said, my job is to best prepare you to use this toolkit to help you maximize your potential (individual results may vary) so here we go . . . You may have heard that a health care reform law passed in early 2010 ... The wonkalicious family docs among us speak of PPACA or the Patient Protection and Affordable Care Act (PPACA). Regardless of where you sit on the political spectrum, this law will transform the way you and I deliver care in the 21st century. How it will do so, believe it or not, has not been entirely worked out since after a law passes, regulations that determine whether said law has real teeth or not need to be hammered out. Whether a hammer or a saw needs to be taken to the law depends somewhat, again, on where you sit on I guess, but as family docs, the (potential) benefits appear to far outweigh the risks.

Access: Are you the key master? The main thrust of PPACA is to extend coverage to many, many more Americans with the hope of closing the gaping ravine of un- and underinsurance. What does that mean? Patients will now have a card that may or may not give them “meaningful use” access to a primary care physician. As experienced in Massachusetts back in 2007 (MASS), primary care centers struggled to meet the increased demand for services as it became abundantly clear that the supply of docs was (and still is) low. The provisions in PPACA aim to boost the number of primary care docs and what that means for you, dear friend, is that the job market will be filled with tremendous opportunity. What you do with that opportunity is limited only by how hard you are willing to work and your imagination.

Quality: One man’s trash is another man’s treasure? “Quality” has always been slippery to grasp in medicine because it is difficult to define. That being said, you will be measured (even if you aren’t measured perfectly). This movement towards data-driven performance began with the health care provisions in ARRA aka the American Recovery and Reinvestment Act (Recovery) that boosted funding for CER or comparative The provisions in PPACA aim to boost the number effectiveness research. As you may know, to of primary care docs and what that means for you, date, many of these measures have been dear friend, is that the job market will be filled “process measures,” i.e., did you check the HgbA1C of your patient with with tremendous opportunity. diabetes at appropriate time intervals? In this brave new world, you will be measured on your clinical outcomes (as best can be measured) and patient satisfaction (however that may be defined). I am telling you this not so much as to suggest you simply roll over and accept that this will happen to you, but so you are aware and stay engaged in defining how we all are measured across the health system.

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With all this emphasis on data, there also will be a greater shift toward population management and integrated systems. What that means is not only will you be measured on your individual patients’ outcomes, but also on the clinical outcomes of your entire patient panel. It also means is that doctors and hospitals will, by necessity, 4

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

need to better align their clinical and financial strategies because the days of getting paid for “preventable” hospital re-admissions is behind us. None of these changes will come easily, but once achieved, theoretically, they should make patient care better.

Cost: you mean health care costs money?

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What about cost? Perhaps the nebulous Keep a copy of your personal statement close by. part of PPACA is how it controls cost. What better career compass than that which you Follow my logic here: medical insurance -> poured your heart and soul into ... to remind you of PCMH, aka patient-centered medical home why you got into medicine in the first place? -> more efficient, prevention-focused care > less severe disease (or even reduced prevalence of disease) -> healthier population -> less high cost utilization -> decreased costs? Sounds nice, but will it pan out that way? In North Carolina, the Medicaid system realized hundreds of millions of dollars in savings. The above logic algorithm is, well, logical. Many policy crossroads still must be addressed, i.e., how strong will PPACA regulations be? The strengths of regulations may determine whether or not the US helath care system realizes cost savings. Obviously, there is a lot (a LOT) of disagreement about how much will be saved (or wasted) with the scale and scope of health care reform. Electronic medical records cost money up front. Will the potential cost savings on the back end be sufficient to put most practices in the black? The answer? Maybe.

Parting words of possible wisdom So like I stated earlier: “Welcome to the brave new world.” Do not, I repeat, do NOT be afraid. What’s the first rule of a code? Check your own pulse, right? Here’s some advice going forward: 1. Keep a copy of your personal statement close by. What better career compass than that which you poured your heart and soul into. Who didn’t spend hours agonizing over every preposition, adjective, adverb, or punctuation mark? Seriously though, when you feel that your career may be straying from your stated vision, take a deep breath, brew a cup of your favorite tea and cuddle up with your personal statement. It will inspire you (when I read your applications, I get inspired!) and remind you of why you got into medicine in the first place (if it doesn’t, individual results may vary, as I stated above). 2. READ (isn’t that your least favorite feedback on a rotation evaluation?). Seriously, read but don’t limit your selection to JAMA (JAMA) or NEJM (NEJM). Read about health policy. Understand the world which lives upstream from us clinicians, polluting, I mean, affecting what we do and how we do it almost daily. These days, your options are nearly limitless: blogs (BLOGS), websites (familydocs) and (KFF), journals (Health Affairs), and even mainstream media (just Google news “health policy”). The more informed, the less ignorant and the less likely to be a chump in the brave new health care system. Simple as that. 3. Get engaged! No, I don’t mean put a ring on it. I mean, play to your strengths and get involved. An oftrepeated phrase at both state and national academy meetings is: “if you’re not at the table, you’re on the menu.” I don’t know about you but I would much prefer to eat, than be eaten. Here are some suggestions:

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The more informed, the less ignorant, and the less likely to be a chump in the brave new health care system. Simple as that!

CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

Tell your story (thereby telling family medicine’s story). Blog or if you are even more adventurous, vlog (VLOG). Write a letter to the editor or an op-ed. Do radio interviews or better yet, play a (real) doctor on TV. Speak with your legislators about what your day job is like. Get on facebook (FB) or Twitter and share articles, exchange ideas or tell the world what it is you ate for dinner and how good it was (replete with HQ close-ups).

Lead. Identify performance improvement projects in your office or better yet at your hospital. Don’t like data? Start a PCMH project. The point is that we family physicians are ideally suited to take the U.S. health care system to the next level and we each must lend our voice to the process of transformation. If we truly want to make our specialty the cornerstone of health care, we need to act the part.

Vote. Admittedly, this is a bit more nebulous but follow me here. How many times have you been frustrated with the care that you provide an obese patient? No simple solution, right? Well, it is almost certain that our obesity epidemic is the direct result of social determinants of health: a person’s socioeconomic status, neighborhood, stress, race, education and employment (or lack thereof), influencing personal choices that result in health outcomes, i.e. obesity. No way to write a Rx to fix those kinds of issues, right? That’s where voting comes in. My patient will not exercise if he perceives (accurately) that the statistical likelihood of being shot far outweighs the potential for him to derive long-term benefit from regular exercise. It’s simple economics. So dear family docs, VOTE!

It is my hope (and the CAFP’s hope) that this new physician toolkit serves you well in your planning for the brave new world. I wish each of you the best in your new careers as full-fledged family docs, and look forward to working with many of you as together, we make the practice of our family medicine specialty even more rewarding. Warmest regards, Jay W. Lee, MD, MPH CAFP Secretary Treasurer

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

Family Medicine is Leading the Redesign of Medical Care Joseph E. Scherger, MD, MPH Family physicians continue to provide an incredible variety of front line medical care, from preventive to acute and chronic care to people of all ages. A family physician can enter any community in the world and immediately care for everyone there. As health information technology (HIT) and new quality methods bring new models of care, family medicine remains on the cutting edge of patient care. The Patient Centered Medical Home (PCMH) is the unifying concept for primary care in the 21st Century, and family medicine is leading the way in its development and implementation. Since 2007, the American Academy of Family Physicians (AAFP), with the support of the California Academy of Family Physicians (CAFP), has partnered with other primary care organizations to develop the guiding principles of the PCMH (PCMH).1 Among the principles are:  Personal physician: Each patient has an ongoing relationship with a personal physician trained to provide

first contact, continuous, and comprehensive care.  Physician-directed medical practice: The personal physician leads a team of individuals at the practice level

who collectively take responsibility for the ongoing care of patients.  Whole person orientation: The personal physician is responsible for providing for all the patients’ health

care needs or taking responsibility for appropriately arranging care with other qualified professionals. This includes care for all stages of life ... acute care, chronic care, preventive services, and end of life care.  Care is coordinated and/or integrated across all elements of the complex health care system

(e.g., sub-specialty care, hospitals, home health agencies, nursing homes) and the patients’ communities (e.g., family, public, and private community based services). Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.  Quality and safety are hallmarks of the medical home. These include patient-centered outcomes defined by

a care planning process, evidence-based medicine, clinical decision support tools, and voluntary participation in performance measurement and improvement. Patients actively participate in decisionmaking, and feedback is sought to ensure patients’ expectations are met. HIT is This is such an exciting time to be starting a career in utilized appropriately to support optimal patient care, performance measurement, family medicine! We are on the cusp of a great patient education, and enhanced transition in how care is delivered both to communication.

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populations and individuals.

 Enhanced access to care is available through systems such as open scheduling, expanded hours, and new options for communication between patients, their personal physician, and practice staff.  Payment appropriately recognizes the added value provided to patients who have a patient centered

medical home.

CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

What is so exciting about this new concept for family medicine? The new tools and methods of the PCMH promise to make family physicians more effective than ever before. Previously, in the traditional model of care, family physicians evaluated and treated patients based on what they could personally find out about a patient. Call this “off the top of the head” medicine. Most family physicians are quite skilled at this, but patients may not reliably receive the best that medicine has to offer this way. As David Eddy has said, “the complexity of modern medicine exceeds the inherent limitations of an unaided human mind.”2 HIT provides the tools that combine all important patient The mission, vision, and values of family medicine information to guide the best treatment. will not change, but will be enhanced by the Family physicians in the 21st Century will emerging model of practice. Now is the time to continue to have meaningful personal become a 21st Century family physician. relationships while helping patients and families, but the readily available world of medical knowledge will be shared and harnessed with highly informed and activated patients playing a greater role in their own care.

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The practice of family medicine is in a period of rapid change. More patients are using web-based personal health records (PHRs) through vendors such as Google™ and Microsoft®. They expect their family physician to be able to download the PHR in the practice’s electronic health record (EHR). Leading EHR companies are developing these systems through secure patient portals so that there is one medical record shared between the patient and the PCMH. A secure online platform of communication and care is emerging that promises to be the new “front door” of a PCMH practice. Payment methods for the PCMH are emerging to pay physicians for non-visit care such as e-visits and scheduled telephone visits. The proposed care management fees paid to family physicians for patients with chronic illness will provide a much greater financial base for primary care than in the past. Relationship-centered care delivered by family physicians has an emerging care model that will make the traditional “make an appointment, come and get it” model of care obsolete. Patients will have advanced access to timely communication and care with their family physicians, and the outcomes will be far superior. This is such an exciting time to be starting a career in family medicine! We are on the cusp of a great transition in how care is delivered both to populations and individuals. The information age is a boon for family medicine. As personal physicians caring for entire families and communities, family physicians will benefit most from the new knowledge management tools. The economic picture looks bright for family physicians since the PCMH requires less overhead, delivers improved quality and service to patients, and enhances provider satisfaction.3 The mission, vision, and values of family medicine will not change, but will be enhanced by the emerging model of practice. Now is the time to become a 21st Century family physician. The communities of America and around the world need us, and serving them will be the best it has ever been. Joseph E. Scherger, MD, MPH is a Clinical Professor of Family Medicine at the University of California, San Diego. He is also a CAFP Past President and the 1989 recipient of AAFP and CAFP's Family Physician of the Year Award. References: 1. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Joint principles of the patient-centered medical home. 24 October 2007. www.medicalhome info.org/Joint%20Statement.pdf. 2. Millenson, M.L. Demanding Medical Excellence: Doctors and Accountability in the Information Age. Chicago: University of Chicago Press, 1997. p. 75. 3. Report on Financing the New Model of Family Medicine. Annals of Family Medicine. 2004 2: S1-S21. www.annfammed.org. 8

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

The Next Generation of Care: Determining the Medical-Homeness of a Practice The Patient-Centered Medical Home (PCMH) is the future of primary care in the United States. Through a personal physician, comprehensive care is coordinated and individualized to improve both the quality of care and access to cost-effective services. The following questions were designed to assist medical students who are interviewing with prospective residency programs to better understand the features of the PCMH and how individual programs have implemented the principles outlined. These questions are also relevant to family medicine residents who are seeking a practice that is built on the PCMH model. Access to Care

1. How does your practice provide patient-centered enhanced access (e.g., evening or weekend hours, open-access (same day) scheduling, e-visits)?

Electronic Health Records

1. What aspects of your medical home are electronic (e.g., medical records, order entry, e-prescriptions)? 2. Does your practice use a Personal Health Record that allows patients to communicate their medical history from home to the healthcare team?

Population Management

1. Do you use patient registries to track your patients with chronic diseases and monitor for preventive services that are due? 2. Does your practice use reminder systems to let patients know when they are due for periodic testing (e.g., screening colonoscopy, PAP smear, mammogram) or office visits (e.g., annual exam)?

Team-Based Care

1. Who comprises your medical home team and how do they work together to deliver comprehensive care to your patients? 2. What services can non-physician members of the team (nurse practitioners, medical assistants, social workers, etc.) provide for your patients (e.g., diabetic or asthma education)? How do you train them and ensure competency?

Continuous Quality Improvement

1. How do you monitor and work to improve the quality of care provided in your medical home? 2. How do you monitor your ability to meet patients' expectations (e.g., patient satisfaction surveys)? 3. Are residents involved in helping to enhance practice quality and improve systems innovations?

Care Coordination

1. How does your practice ensure care coordination with specialists and other providers? 2. How does your practice ensure seamless transitions between the hospital and outpatient environment?

Innovative Services

1. What procedural services are offered in your medical home (e.g., obstetrical ultrasound, treadmill stress testing, x-rays)? 2. Does your medical home provide group visits (e.g., prenatal group visit)?

Reproduced with permission from AAFP. CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

The Ideal Practice Setting For You Family medicine offers a wide array of practice settings. This guide provides an overview of the most common settings to help you determine the perfect practice opportunity for you. As a family physician, you will have the flexibility to shape your career to take advantage of your knowledge, skills and unique interests. In addition to direct patient care, many opportunities exist in academia, research, public health and administrative careers, to name just a few exciting possibilities.

Solo Practice  Control and autonomy  Ability to set own schedule  Significant administrative and

 Responsibility for start-up and overhead costs  Control over one’s health insurance

managerial responsibilities I choose to practice as a solo family physician in private practice because I like being in control of my level of service Christopher Flores, MD and medical quality. After finishing residency, I “tried out” (for 10+ years) various types of employment and hospitalPractice Palm Desert based practices, including academic medicine for five years, Medical School: UC, Irvine but I was continually frustrated because I was never fully in Residency: Kaiser Permanente, control of my schedule, duties, staff and office management. Los Angeles It seemed as if I was constantly being asked to see more patients, supervise more mid-level and ancillary staff and manage a larger panel. The absurd thing was that as the primary care provider and physician leader, I was held accountable for my productivity, medical quality, chart documentation and patient satisfaction. Now in my own small “micro-practice,” following the Ideal Medical Practice (IMP) low-overhead model, I am in full control of my practice and I have never been happier. I see the whole spectrum of family medicine, with hospital work and house calls, and consider myself a traditional, old-fashioned doctor. New physicians who want more information about this style of practice should review Gordon Moore’s articles in Family Practice Management.

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

Group Practice  Established patient base  Schedule/coverage flexibility  Partnership with other physicians

 Potential income division conflicts  Assistance from other physicians in the office  Potential ownership opportunities

Option 1: Small Group My wife and I did our residencies in our home town, so we were very familiar with the physician community and the local hospitals. Staying in our community allowed us to truly have a full spectrum family practice. Although hospitalist programs in our area have swallowed a large percentage of our admissions, we still do both inpatient and outpatient pediatric and adult medicine. I have had to relinquish my OB privileges due to lower Craig Endo, MD volume and increasing malpractice rates, but my wife still does about 50 deliveries a year and often has to turn away Practice Pomona OB patients not to exceed her delivery cap imposed by her Medical School: USC, Keck School of malpractice insurance carrier. To get us started, Pomona Medicine Valley Hospital provided financial support via an income Residency: Pomona Valley guarantee for the first two years.

Hospital

I think we enjoy the autonomy of having our own office the most. We are open Monday through Friday and are located about three miles from home. We knew we did not want to contend with Los Angeles traffic and commute to our jobs. We have more control over our schedules and the types of patients we see, and making changes in the office tends to be easier than wading through a whole bureaucracy. I also enjoy having a greater decision on whom we work with as a practice. After four years of practice, we formed a partnership with family members and were fortunate enough to purchase a medical office building. We have tried to recruit like-minded health care providers because we try to address both the physical and spiritual needs of our patients. Our office encompasses most of the first floor and we lease out the other suites. We saw this as our best bet to help contain office overhead expenses over the long term.

Option 2: Multi-Specialty Group After graduating in 2007, I chose to join a private/large Bradford Perkins, MD group multi-specialty practice. As a new physician, I found that having other physicians in the office helped ease the Practice San Jose transition from residency to private practice. I always have Medical School: Wake Forest someone I can ask questions and learn from. Also, by joining University, School a large practice, I can concentrate more on practicing of Medicine medicine and not worrying as much about the business side Residency: Gelndale Adventist of medicine. I think there still is a lot of learning to do without having to think about the business side. I also chose this practice because it allowed me to do outpatient only medicine. I work Monday through Friday, which gives me plenty of time for my family. I take phone advice call once a month. I see all ages: my youngest patient is around 18-months-old, and the oldest is 100.

CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

Community Clinic    

Work with underserved population Opportunity to give back to the community Ability to partner with other clinics/hospitals May depend on federal and/or public funding

Dr. Rubinstein and I started our practice in a small rural town because of our desire to serve in a community of need and to offer care to an identifiable community. In a private practice setting, we were able to care for people with any payer status and from all backgrounds and walks of life. We have been able to care for the breadth of the community from the mayor to the undocumented, across generations. As our practice matured and we looked ahead to the provision of care and recruitment of doctors in future decades, we partnered with Adventist Health as an organization with experience in rural health clinics and a commitment to access to care.

Joan Rubenstein, MD and Alexander “Sandy” Sherriffs, Jr. MD Practice Medical School: Residency:

Fowler UC, Davis UCSF-Fresno Family and Community Medicine

We most enjoy the gift of being family physicians ... the variety of medical problems we encounter, the opportunity to take care of all ages, and every organ system in the context of an individual whose multigenerational family we often are caring for in the context of a definable community. It is never dull; one is always learning and learning new skills. We also have been involved in the training of medical students and residents, which always brings us a renewed and fresh perspective on our work, reopening our eyes to the wonder of being in a helping profession.

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

International Health  Opportunity to travel  Insight into other medical communities  Serving underserved populations

 Unique experience  Contract-based and full-time positions  Exposure to different medical challenges

Location, working in a challenging environment, and collegiality with my co-workers, both medical and nursing, were very important to me in making a decision on my first job after residency. During my residency training I found out Practice Los Angeles what really excites me about being a family physician. I Medical School: UC, Davis wanted to work in an academic/community setting which Residency: USC/California was ethnically diverse, served underserved families in a Hospital large city and had some component of service internationally. The scope of practice had to be as diverse as the patient population I served. For me this meant working in a practice with an academic affiliation whose mission was to serve those most in need. My first job allowed me to grow professionally in every aspect of medicine except international health. The challenge of developing an international component to a small and very busy academic group practice forced me to really look at what was important to me and my professional growth as a family physician.

CondessaCurley, MD, MBA

One of my jobs as a community advocacy educator allowed me the flexibility to further develop my interests in international health and continue as active medical staff in the residency program. I worked 40-50 hours per week and was able to grow my international health experience via a non-profit, 100 percent volunteer organization called Project Africa Global, Inc. that I co-founded. The vision behind Project Africa Global, Inc. is to provide other health care providers (doctors, nurses, and ancillary health care), medical students, residents, college students, and high school students the opportunity to explore their interests in international health. Project Africa Global, Inc. volunteers provide direct patient care, obtain training as HIV peer educators, facilitate an annual youth summit on HIV/AIDS, participate in our orphans and vulnerable children’s programs, and serve as faculty in our annual University of Pittsburgh School of Medicine CME conference on “Primary Care and the Reproductive Health of HIV Patients.” The conference is a part of our 18-20 day annual mission to Swaziland. Currently, I use my vacation and CME time to provide these medical and humanitarian services in Africa. I recently moderated a panel discussion on global health. One of our presenters put forth the idea that the ideal job would not only provide the benefits of vacation and CME time, but would mandate a paid two-week period annually for community service. What a novel idea! Dr. Curley was named CAFP’s Family Physician of the Year in 2008.

CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

State and Government-Sponsored Practice     

Unique experience Broad scope of practice Security or administrative rules may infringe on autonomy Requirement to adhere to government policies and regulations Public service careers often qualify for loan repayment programs

Option 1: Prison Health Care Services Incarceration rates are increasing with a large impact on underserved populations, particularly among African Americans and Latinos. I found, working in an urban underserved primary care clinic, that all of my male patients Elena Tootell, MD had been incarcerated for some time in their lives. Now that I work in the prison health care system, I see that most of Practice San Quentin the patients are in and out from the community, back to Medical School: Case Western their families, struggling with poverty and back again. But Reserve University community practices often forget the patients while they Residency: UCSF-San Francisco are incarcerated. Inmates are the only population in the U.S. General Hospital with a constitutional right to health care, and the government has an obligation to provide this group medical services, at least while they are in prison. I have found prison care to be a true community practice. Inmates ask about their mothers’ recent diagnosis of diabetes, and how they can prevent it. They ask about how to stay off drugs on the “outside,” their healthy food choices, how much to exercise, their back pain, and they take care of each other. This encounter is often the first chance the person has had to sit down with a medical provider and really discuss his medical care. I have never felt so appreciated by my patients as I have in the prison system. I work close to 40 hours per week, including home calls. I have union representation and am paid well. I see everything from complicated AIDS and tertiary syphilis to minor back pain and skin biopsies. Even though I have had to give up work with women and children, other correctional settings are able to offer a broader spectrum of population.

Dora Akuetteh-Saforo, MD Practice Medical School:

Residency:

Camp Pendelton Univeristy of Ghana School of Medicine In His Image Family Medicine

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

Option 2: Military Health System I chose this practice because it is outpatient only. In a branch clinic of the Naval Hospital at Camp Pendleton, I am involved in international medical missions; this practice gives me the flexibility to travel abroad to developing nations to make a difference. Taking care of our active duty service men and women, their family members, and retirees is a joy. I have been here since September, 1998.

HMO/Permanente Medical Group  Established patient base  In network/internal physician referrals  Limited administrative responsibilities

 No overhead costs  Coverage and schedule flexibility

I chose Kaiser Permanente because it is a fully integrated health care model that allows me to deliver the best care possible to my patients. At Kaiser, we can do this by emphasizing evidence-based medicine, the ability to refer to Jay Iinuma, MD, MBA practically any specialty with the assurance that they will be seen in a timely manner, and care management assistance Practice Pasadena that helps patients with chronic diseases manage their Medical School: UC, Los Angeles conditions. We can also do it with an electronic health Residency: White Memorial record that seamlessly allows the provider the ability to see Medical Center what everyone on the health care team has done for the patient. There is ample opportunity to explore the administration end of medicine as well as research via the ability to take a sabbatical to explore a particular area of medicine. We also have our own Institutional Review Board to help facilitate and channel our research processes. I currently work two miles from my home, so I often ride my bike to the office. I have made strong friendships here at Kaiser Permanente and feel the respect of my peers. I feel the administration is truly hard at work trying to assist the physicians with any and all needs that we may have. I enjoy working at Kaiser Permanente because it helps me do what I do best, primarily helping people with their medical conditions and to thrive!

Academia/Resideny Program  Opportunities to teach and/or mentor  Flexible clinical responsibilities  Innovative research and clinical work

 Opportunity to mold new generation of family physicians  Opportunities to be involved in various projects

Working in an academic residency-based practice has allowed me the flexibility to be the kind of family physician Jay W. Lee, MD, MPH that I had envisioned. First and foremost, I serve as primary care physician for a panel of patients and families. Second, I Practice Long Beach teach residents and medical students. Third, as the Director Medical School: USC, Keck School of Health Policy in our program, I serve on the CAFP of Medicine Legislative Affairs Committee, have given lectures on various Residency: Long Beach health policy topics, and have had the privilege of working Memorial on RxVote (now RxDemocracy), a non-partisan national voter registration campaign aimed at the civic engagement of and partnership between patients and their physicians toward a better health care system for all. What I enjoy most is that my days are dynamic and the satisfaction in knowing that I am making a real difference every day for my patients.

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The Interview Process Interviewing for your first post-residency job is a delicate process. You should begin by assessing a practice’s general characteristics. Don’t worry about the details until an offer is made. Save contract negotiation for later interviews, closer to when an offer might be made. The following questions may be helpful as you assess a practice’s health and viability to determine if you want to join the team.

About interviewing Interviewing is a two-way street. Just as employers are trying to determine if you are a good match for the practice, you must determine whether the practice is a good fit for you. The potential partner(s)/employer will be trying to assess your clinical skills and whether or not your personality and work style meet their expectations of the ideal candidate. In turn, you should be assessing their personalities, work style, and expectations to determine if they will work well for your lifestyle. One physician manager recently discussed the hiring process with CAFP. He asks himself three questions about the physicians he interviews:  Do they know their stuff?  Can they get along with staff and physicians?  Will patients like them? This is your opportunity to “sell” yourself. Be yourself; be confident, but not cocky; and, remember to breathe!

Before the first interview Decide where you want to practice, the type of practice you are looking for, and key features (sort of like house-hunting!). Identify the ideal practice characteristics before you send out your résumé so you don’t waste anyone’s time. Your cover letter should be concise, engaging, and persuasive. Communicate why your background and interests have led you to apply for the position and why you would be a good fit. Limit the cover letter to one page and have at least two people you trust proofread it for spelling and grammatical errors. Your resume or CV should highlight your accomplishments and skills. Consult online sources, such as the National Institutes of Health, for examples of résumés and CVs and follow the templates.

At the interview Schedule the interview on a day you will be rested; never interview post-call. Always be prompt for a job interview. Leave plenty of time for transportation and plan for the unexpected: getting lost, having trouble finding parking, etc. If you are unfamiliar with the area, it may be worthwhile to do a practice run. Dress professionally; it is always better to be overdressed than underdressed. Try to relax and enjoy yourself as much as possible. Be natural, but professional, and try to establish rapport with your interviewers. A quality family physician has good people skills, so show your friendly side. Make eye contact and smile as much as possible. The person interviewing you is likely thinking, “What are our patients going to think of this person? Will they like him/her?” Try to demonstrate attention to detail, inquisitiveness and follow-through ... all essential attributes for physicians. Listen carefully to the questions you are asked and always assess what the interviewer is trying to discover about you through his or her questions. Take a moment to gather your thoughts before answering. Be as responsive as possible in your answers. Give concise examples from your work or life to back up what you say.

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

Questions you might be asked:            

Why do you think you are a good fit for this practice? What are your strengths? What are your weaknesses? What steps have you taken to improve? Describe a few difficult patient interactions and how you dealt with those situations. Describe how you respond to work pressures. Tell us about your experiences working with non-physician personnel; how do you see their roles in providing care to patients? Pretend you joined our group, and it is a year from now. You are happy. Why is that? Where do you see yourself in five years? In 10 years? How does working in our practice fit with your professional goals? What do you like most about your specialty? If you could turn back the clock, what would you do differently? What are your interests outside of practicing medicine? Tell me something about yourself that is not on your résumé /CV.

Demonstrating stability, maturity and commitment is critical, and this involves looking beyond the day-to-day elements of practice. You will be joining not only a practice, but a community, as well. What can you contribute to the community? Your “fit” with other personnel can be crucial, so be friendly, open and establish eye contact. Smile!

Additional Factors to Consider

Many other factors should be considered when you make your decision about which practice to join:

Community  Does the location meet your family’s needs/desires?  What are the community's demographics? Are there other singles, young couples or families with young children you can relate to?  Is it a growing or underserved community?  What is the cost of living? How will this affect your ability to meet your financial obligations (e.g., loan repayment)?

Practice characteristics  What is the working relationship between doctors? Is there collegiality among physician peers? Do interactions between personnel seem friendly?  What is the scope of practice? Do you want to do OB? Gastro? Are there local obstacles to expanded scope, such as restrictive hospital medical staff rules?  Do physicians in the practice have the option to care for their hospitalized patients?  Are there been barriers to privileging at the local hospital?  Is there support and cooperation between medical specialties in the area?

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Quality of care  How is quality measured by the practice, and is the culture conducive to improvement efforts?  How does the practice encourage improved patient outcomes?  How are consultations and referrals handled? Any restrictions?  Are complete and accurate medical records kept in the practice, and are they available for review?  What preventive tools are used in the practice?  To what extent are evidence-based, peer-reviewed guidelines used?  Will you have a voice in determining clinical policies?  What are the current and future goals for the adoption of technology tools?  Is there senior leader support for participation on quality improvement projects?

Office management How efficient is patient scheduling? How far in advance are physicians in the practice booked? How long, on average, does a patient sit in the waiting room? How frequently does the office measure patient cycle time and flow? How is patient satisfaction and/or patient experience measured? How is provider satisfaction measured? What is the billing/collection ratio? Days in accounts receivable? Does the office staff like working there? How often are staff meetings held? Do all staff participate or just clinical and practice leaders? Is the staff committed to patient care? How is staff commitment encouraged and reinforced? Is there space for all-staff meetings? What is the staff turnover rate? Is the equipment adequate for the scope of medicine you wish to practice? If not, would the practice buy or lease needed equipment?  Is the facility comfortable? Could you work there efficiently?  What type of information and technology systems are in place and are they suitable to meet the practice’s long-term needs? What are the short- and long-term costs of the practice's information systems?  Will you have a voice in office policies? Who has ultimate responsibility for office management?              

Practice stability When was strategic planning last conducted and what type of plan is in effect? What kind of reserves or financial backing does the practice have? What is the ownership agreement? What is the turnover rate of physicians; Who has left within the past five years and why? Can you talk with former employees/physicians?  Will there be opportunities for "buy in"? At what price? Is there a non-compete clause if you leave the practice and wish to stay in the community?    

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

Work expectations  How many patients will you see each day?  How large would your patient panel be?  Are productivity requirements flexible enough to ensure that patients needing extra care and attention receive it?  How are work-ins and emergency visits handled? Is there open-access scheduling?  Is the call schedule fair? Is it weighed according to seniority?  Does the practice know the patient population's language access needs? Do they use or access professional interpretation services? If you speak another language, would you be expected to provide services using another language?  How many days per week do you work?  Do you receive paid vacations? CME time and/or financial support for professional education?

Practice economics  How are practice finances monitored and by whom?  Is the practice busy enough? Too busy?  How many patients leave the practice each month? Why do they leave?  What is the percentage of capitated patients?  How many HMO contracts are there? What would be, or has been, the effect of losing one?  Are health plans/IPAs/medical groups in the area accepting new physicians?  What type of billing system is used? Have there been billing issues, such as a recent switch to move billing in or out of house?  Is the practice participating in Pay for Performance (P4P)? If so, how many different programs? How are performance bonuses calculated and which staff receives them? Who is responsible for submitting and reviewing data submitted for P4P?

Practice costs  What is the total overhead and how is it divided among the physicians?  How does the practice fund capital expenditures?  What is the ratio of full-time employed support staff per full-time employed provider?  Will current revenues be used for retirement of any partners? If yes, when?

Access to risk pools Are you at risk for utilization of outpatient services? Is efficient management of care rewarded? If so, how? Does the medical group accept pharmacy risk?

  

Compensation  What is the salary guarantee and how long does it last?  What are your anticipated earnings in the first, third and fifth years of practice?  How are bonuses administered? Are there internal quality incentives?  How are administrative, vacation, CME, and holidays calculated?  What is the retirement plan?  What are the health, dental, and disability benefits?

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Signing the Contract and Other Legal Matters

This may seem obvious: read the contract and make sure you understand everything contained within. It is always smart, and STRONGLY recommended, that you have it reviewed by an attorney or practice management consultant. We suggest you take advantage of CAFP’s Employment Contract Review Service. An attorney who specializes in physician matters will review your contract for a small fee. Information is included in this New Family Physician Toolkit on page 26. It’s always best to ensure you fully understand your contract before signing so there are no surprises down the road. A written employment agreement should cover:  The work expected of you  Exclusivity requirements (i.e., can you moonlight?)  Compensation (i.e., amount and when paid)  Malpractice insurance including tail coverage (i.e., coverage required if/when you leave a professional liability company or leave practice)  Employment termination clause (i.e., does the clause have “for cause” and “without cause” termination policies?)  Non-compete clause: if there is one, how restrictive is it?

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

Questions to Ask a Prospective New Partner Keith Borglum Most new physicians join a practice without first giving it a thorough history and physical. Here is a checklist of questions to ask about any new partnership or office sharing prospect. How many newly trained physicians eagerly join a seemingly thriving practice only to find after a year that it is not at all they expected? In my experience, plenty. On top of that, what if the new physician tries to leave and finds out that she still is expected to pay “her share” of a large new piece of office equipment? By asking pertinent questions up front, before you join the practice, you can save yourself a lot of aggravation. First, it will help you avoid joining the wrong practice. Secondly, knowing your rights in the practice ahead of time will help you or your partners avoid dragging one another to court several years down the road. The checklist (at the end of this article on page 25) is a good starting point and can be adapted to fit almost any partnership or space sharing situation.

Compatibility First, and absolutely foremost, is compatibility between you and the practice itself ... the physicians, the staff and the systems. If you even mildly dislike the partners now, chances are you won’t be able to stand them a year from now. I strongly encourage all new physicians to visit a practice for at least a half-day or full day to give people a chance to show their true selves, rather than their interview personalities. Even the most successful business will not overcome an incompatibility problem.

Check References Another step that many new physicians skip and later regret: Call or visit the medical director or chief of staff of the hospital at which the partner or partners have privileges; say that you are considering joining the practice. If the feedback is positive, you will know it. If it is lukewarm or guarded, you can read Carefully assess the financial health of the practice. between the lines. Will the physician be Ask the partners for a copy of their recent financial offended that you are “checking him out?” Not if he has nothing to hide. You asked statement. If the partners won’t share the him for his references; he should expect statement, don’t join. you to contact them.

“

Carefully assess the financial health of the practice. Ask the partners for a copy of their recent financial statement. This report can be easily generated by a practice, in fact, it should regularly be generated by a practice. If the partners won’t share the statement, don’t join. If they can’t produce it, ask yourself whether you are walking into an antiquated practice with no interest in modernizing. Or, ask to speak with the practice’s accountant and have that individual go over the numbers with you. For an unbiased opinion, you can have an independent practice management consultant or CPA analyze the income and expense statement. Is the practice growing or declining? Is the partnership in need of a new associate because it is overwhelmed, or because it is slowing down and the incumbent physician is looking to retire and have you take it off his hands?

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Division of Income and Expenses This is rarely a straightforward issue. Are you going to be an employee for a time or a true partner? Most practices pay a base salary plus a percentage for productivity (for example: $90,000 base plus 30 percent of all gross receipts over $270,000). By offering incentives, the practice is asking you to demonstrate an ability to manage volume and build a practice. Are the incentives reasonable or set so unrealistically that no newcomer could reach them? Check out the turnover history of other associates in the practice to see if there is a revolving door after one year.

Basic Formula. Subsidies, Deferrals, Security: Will the practiceâ&#x20AC;&#x2122;s members share income equally? This is sometimes not a good idea, because it rewards lack of productivity. Some physicians include in their contracts a right to leave within the first year with 30-day notice, obligation-free. 1. How are expenses going to be divided? Will the practice subsidize your expenses, or waive your expenses for the first year? 2. What kind of security is there? 3. If you decide after a few months that the practice is not for you, can you walk away without obligations, or 4. Will you be expected to pay for some major overhead items?

Hospital Financial Assistance: Will the local hospital subsidize recruitment of new physicians? Many will offer an income guarantee for the first year and pay any difference between your actual income and the guarantee. Some hospitals will provide relocation expenses. If you accept the terms, what are your obligations to the hospital? Loan forgiveness is taxable income. Compensation to Doctors for Administration: Every hour of time spent in patient care requires at least six to 10 minutes of administration. Is compensation built in to cover administrative time? Shared Purchases in the Future: Would the officeâ&#x20AC;&#x2122;s equipment be better off in an antique shop? If so, what are the plans for major purchases in the future and to what degree are you expected to foot the costs for these purchases? Excluded Income: One of the partners spends a quarter of his time at a nursing home, another is compensated by the hospital for her role as medical director. Is this considered practice income? For the sake of fairness, many practices throw everything into the same pot, focusing on how physician time can best benefit the group. Paid/Reserve Deposit: When are expenses paid? Are there reserves in case the building needs new carpeting? Are there deposits or buy-outs on leased equipment that would go back to a particular partner upon the equipment's return? If so, would you get a portion of it if you made half the equipment payments? Disability/Death Obligations: An area in which your lawyer would obviously be involved is asking what happens to the practice in the event of one partner's death or disability? Whose property is it, and what does that property consist of? Does an insurance policy exist on key partners to help the practice get through a death or disability?

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

Other Financial Issues Equity Balancing and Documentation: How do you balance existing equity (i.e., when two practices merge)? Use the same appraiser; if the equity in Doctor A’s practice is judged to be worth $50,000 more than the other practice, Doctor B might compensate Doctor A with more stock or cash. Further, if equipment ownership is not totally shared, then “what’s mine and what’s yours” should be documented. Buy-In/Pay-Out Formula: Are you expected eventually to buy into this practice? Is one partner planning to retire and expects to be bought out by the other partners? If so, what kind of payout would be expected? Are the formulas updated annually, for example, for Medicare reductions? If you are expected to buy-in to the practice in the future, know the formula and qualifications before Don’t just accept the word of the partners that you starting day one of employment. will be accepted into the managed care plan, “Predatory” practices routinely get it in writing from the plan itself employ new physicians at reduced (phone confirmation is not usually safe). compensation with the opportunity to apply the discount to buy-in, only to fire the new physicians at buy-in time.

“

Transferability of HMO Contracts: A very important consideration that many overlook is the transferability of HMO or managed care contracts. What if a practice gets the majority of its patients from one or two health plans, but the plans are closed to accepting any new physicians? Don’t just accept the word of the partners that you will be accepted into the managed care plan, get it in writing from the plan itself (phone confirmation is not usually safe). Some plans have too many doctors and are waiting for retirement to thin the ranks. If you can’t confirm your acceptance, you may have to keep looking for another practice. Compensation for Call Coverage/Non-member Plans: If call is distributed unequally or between physicians in differing plans, how is fairness achieved? Retirement Plan: Do you know the answers to the following questions: 1. Does the practice have a retirement plan and do you qualify? If so, when? 2. If two or more groups of doctors join to form a partnership or corporation, can their retirement plans be linked? 3. How will existing equity in other retirement plans be affected? In these situations, most practices would consult a benefits administrator or benefits attorney to link the retirement plans. Sublet Full Services: If you are subletting office space, are you arranging to sublet the full services of the space, including staffing, instruments, paper and office supplies, electricity and other utilities? How is payment calculated to be at market rate?

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Governance and Decision-Making in the Practice Structure, Length, Duration, and Minority Rights Consider the following:  Who is in charge of the practice?  Is there a senior doctor or a president?  Are there elections to determine this individual?  How long does he/she retain this role? Many practices rotate senior leader positions at one-year intervals. What are the decision-making rights of the physicians who have seniority? As a minority shareholder, do you have any rights? Disagreement Arbitration: If there are disagreements in the way the practice is run, how are they handled? Is there a protocol for arbitration in writing? Reporting and Meetings: What is the frequency of staff meetings? I often recommend the key medical staff in a practice hold a status meeting every week, or at the least every two weeks. With fewer meetings than that, communication gets lax. Furthermore, all staff should try to get together in the same room at least once a month. Does the practice have access to a room that would accommodate a full staff meeting? Relative in the Practice: It is not uncommon to encounter a physician whose spouse has served as the office manager for the past 30 years. These arrangements work either very well, usually if the physician is solo, or very poorly. With more than one physician in the practice, it is simply not possible for a family member to be fair and unbiased toward all doctors. How does the practice fire a family member? If you are considering joining a practice with nepotistic tendencies as other than as a simple salaried employee, request the right to terminate the family member on a no-fault, no hard feelings, no repercussions basis, should it become necessary. Management Responsibilities: Speaking of firing employees, consider these questions: 1. What are your management responsibilities? Would they include hiring and firing of employees? Reading all contracts? 2. Who deals with the hospital? 3. Who is in charge of systems? 4. Who checks the financial statements? Restrictive Covenants: Some physicians leave a practice to stake out their own territory in the community, only to find that their contract had a restrictive covenant prohibiting them from practicing within a set radius of the old practice. Laws vary from state to state and may not be enforceable; check with your attorney.

Systems Access to Office and Hours: You are a night owl, but you find out that the lights in the building go off at 7 pm. Will you have access to the office any time, or is occupancy restricted to particular hours? Access to Personal Space: Is your personal space a private office, a cubbyhole, a bare spot on a desk? Some physicians function very well sharing a desk in a noisy environment; others need four walls and a door to get through the day. Make sure you have seen what your personal space will be. Personnel Issues: Do you know the answer to the following: 1. Is there a handbook for personnel? 2. Is the office understaffed, and is the addition of a new doctor expected to make up for some administrative deficiency? 23

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

3. Do employees have clear job descriptions? 4. Most importantly, do the supervisors handle the employees professionally, or are they at risk for a lawsuit? If you observe what appears to be sexual harassment, for example, bear in mind that you could be cited in a lawsuit even if you just joined the staff. Call and Hospital Privileges: How many nights will you be on call, and are you eligible for privileges at the area hospitals? Patient Distribution: How are patients allocated in the practice and how are new patients distributed? Do you alternate being assigned new patients? Will all the new patients be referred to the newest physician on staff? Phone Numbers: If the practice splits up, who gets to keep the office phone number? This may sound petty, but many practices have gotten into bitter disagreements over this very issue. Fee Schedules and Coding: How are practice fee schedules determined? Do you have a say in how they are set? Is the schedule consistent with the geographic location? Is the office coding legally and appropriately? A practice management consultant would be able to help you address some of these questions. Malpractice Insurance: Evaluate the adequacy of the group’s malpractice insurance coverage. Training Schedule for New Doctors: Simply put, who is going to show you the ropes? Are you expected to absorb things through osmosis? Practice Promotion: Last but not least, how does the practice plan to promote itself and you? Is there a plan for marketing or attracting new patients? What is the budget?

Summary Many or all of these questions will be applicable to you when you seek out a job, partnership, corporation, or even a space-sharing arrangement. Can you expect the practice to be able to address all these questions in one sitting? Probably not, but the list serves as a starting point and may inspire the partners to sit down and work out some necessary details. I have consulted with countless physicians, both employers and employees, who didn’t realize any of these issues could come back to haunt them. If the practice has a document that spells out everything on paper, wonderful! It is more likely that the practice has the bare bones of an employment or partnership contract, 95 percent of which is legalese and probably out of date. Work with your lawyer or practice management consultant to list everything on the document that could affect you in the future. If the partners balk at this kind of detail or say, “We’ll work out all of that later,” your response could be, “To be comfortable going ahead, I really need to know these answers.” If you are a detail-oriented person and they are not, the practice may not be a good fit for you. You could always start a new practice from scratch across the street if you insist on that town.

Keith Borglum consults on practice start-up, productivity, profitability, marketing, management, staffing, practice appraisal and sale, and mergers. Mr. Borglum is frequently quoted in medical business journals and authored The Medical Practice Forms Book for McGraw Hill. He was a Trustee of the CAFP Foundation and is a Director of the National Association of Healthcare Consultantsmand is on the AAFP FP-Assist consultant panel. He can be reached at (PM.COM) . CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

Checklist for New Associate or Space Sharing Arrangement Use this checklist during interviews with practices in which you are considering a partnership or space-sharing agreement. By covering all the bases up front, you will do much to avoid unnecessary conflict down the road, advises management consultant Keith Borglum. This checklist is adapted from his book, “Medical Practice Forms,” available from McGraw Hill at (877) 833-5524.

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Compatibility

Reference checks both ways

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Financial

Governance and decision-making 

Structure

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Length/duration

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Minority rights

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Division of expenses

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Disagreement/arbitration

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Basic formula

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Reporting/meetings

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Subsidies, deferrals, security

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Relatives in the practice

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Hospital financial assistance and forgiveness

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Management responsibilities

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Compensation to doctor for administration

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Restrictive covenants

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Formula for shared purchases in the future

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Excluded income or expenses

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Access to office and hours

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When paid, reserve, deposit

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Access to personal space

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Disability, death obligations, and practice purchase rights

Systems

Personnel

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Equity balancing

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Handbook

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Document equity contributions ongoing

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Needs

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Buy-in/payout formula

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Job descriptions

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Compensation for call coverage

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Supervisor behavior and risks

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Non-member plans

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Call/privileges

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Linked entity retirement plan issues

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Patient distribution

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Sublet full services

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Phone numbers

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Fee schedules

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Malpractice insurance

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Training schedule for new doctors in office systems

Article from: Life In Medicine, September 1995 adapted and reprinted with permission.

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

Physician Employment Contract Review Service Family physicians commonly begin life in practice as employees. Sometimes, this is a trial period prior to being invited to become a partner in a practice. Increasingly, however, physicians are serving as employees indefinitely. Either way, to protect yourself, you should seriously consider having your contract reviewed by a knowledgeable attorney familiar with health care law and medical practice issues. CAFP can help: For a modest fee of $525 (for CAFP members) or $700 (for non-members) (ECRS), we will lead you through the process, from basic education to legal review, with a qualified health care attorney. With your future at stake, you can’t afford not to take advantage of this service. Service includes:  Background reading on employment contract issues  A thorough review, of one contract, including written comments and follow-up phone consultation by a qualified attorney* Interested? Here’s how to get started: 1. Complete the form below and fax to California Academy of Family Physicians. 2. When you have received an employment contract from the prospective employer, fax it to CAFP. We will forward it for legal review. 3. The reviewing attorney will fax her written comments to you and place a follow-up phone call to discuss the contract and possible revisions. *Service does not include direct representation for contract negotiations.

Questions: Contact CAFP at (415) 345-8667.

CAFP’s Contract Review Service Name: Address: City: Phone:

AAFP/CAFP Member #: State: E-mail:

Fax:

Zip:

Amount Due: $525.00 for current CAFP members $700.00 for non-members. Payment method: Card #: 3-digit Security Code: Name on Card: Signature:

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Check (made payable to CAFP)

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Visa

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MasterCard

Exp. Date:

Return by fax to (415) 345-8668 or mail to: CAFP, 1520 Pacific Avenue, San Francisco, CA 94109

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Five FAQs Regarding Employment Contracts Barbara Hensleigh, Esq. Signing a contract always takes careful consideration. This is even truer when entering into a professional employment relationship. Having reviewed more than 100 physician employment agreements, I know the most frequently asked questions well.

The top five questions are: 1. 2. 3. 4. 5.

Do I need an outside review of the contract? Can I be employed full-time at a medical group as an independent contractor? Who pays for professional liability insurance tail coverage if I leave my employment? What are the differences between non-competition clauses and non-solicitation clauses? Can you explain the interplay between the term of the agreement and the no-cause termination clause?

Do I Need an Outside Review of My Employment Contract?

Let’s face it: Many physicians sign contracts without reading them, much less having outside counsel review the agreement. You are just too busy. Moreover, the contracts may be “take it or leave it.” The employer may be unwilling to change the terms and lose uniformity in contractual language among its employee physicians. But there are plenty of reasons to spend the time and money for an outside review. First, it is good to know your obligations up front. For example, many employers incorporate into their contracts their general policies and procedures and contracts between the employer and managed care plans. By incorporating these documents into the agreement, the employer has made their terms, which you probably have yet to see, legally binding on you. Knowing the policies and procedures and managed care agreements are contractual commitments by you, so I encourage you to read and understand the policies and procedures and other agreements so you know what is expected of you. Second, many contracts contain illegal terms. These terms would not be enforceable in a court of law and thus are not legally binding on you regardless of your signature on the contract. One common example is a term permitting your employer to assess monetary penalties against you for violating policies or procedures of the employer or taking too much time off (even uncompensated time). It is good for you to know, and good for your employer to know you know, that these clauses are illegal and unenforceable. Third, you may be surprised by the negotiating power you do have. I have seen employers change language to:  Pay for tail coverage upon contract termination;  Include language making call schedules equitable; and  Add a termination provision requiring written notification of any breach of the agreement and an opportunity for the physician to “cure” any breach before termination of the agreement. Finally, as you develop your practice and business skills, you may be called upon to sign contracts. Understanding the importance of reviewing them yourself and having counsel review them can avoid pitfalls seen in litigation over contract interpretation.

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

Can I Be Employed Full-Time at a Medical Group as an Independent Contractor? Designating an employee as an independent contractor is a charade and also is not in the best interests of the physician. I recommend that physicians reject independent contracting designation clauses.

The law treats employees and independent contractors differently for tax, liability, and worker's compensation obligations, among other things. Here are the major differences between being employed and serving as an independent contractor:  As an employee, your employer is responsible for some of your taxes. As an independent contractor, you are responsible for all tax payments.  Under California law, an employer is legally responsible for the work of an employee (and thus likely to purchase professional liability insurance). As an independent contractor, you alone are legally responsible for your conduct.  An employer is responsible for obtaining coverage for any harm that befalls workers on the job. As an independent contractor, you are on your own. Because of the advantages, some employers attempt to recast employees as independent contractors. Using the label alone, however, does not change an employee's status. Courts usually see through the charade. If you are working full-time at hours set by the medical group, under the supervision of the medical group, you are likely an employee, regardless of the terminology used to describe your status.

Who is Responsible for Paying Professional Liability Insurance Tail Coverage Upon Termination of the Employment?

Tail coverage provides professional liability insurance for those cases arising out of work you performed for a medical group, but where the claim is made after you leave the group. Probably the hottest negotiation point is whether the employer or employee should pay for tail coverage. The answer is not clear and the costs may be significant, particularly if you have provided obstetrical care. I contend that under California law the employer is responsible for the acts of the employees, regardless of when the claim was made. Accordingly, it is up to the employer to mitigate against the risk of liability by purchasing malpractice insurance, including tail coverage. Due to the significant expense, many employers attempt to shift the burden of the cost of tail coverage onto the departing employee.

What are the Differences Between Non-Competition Clauses and Non-Solicitation Clauses?

Employment contracts often contain non-competition clauses or non-solicitation clauses, and sometimes both. Non-competition clauses attempt to prohibit the employee from practicing in the geographic area of the medical group within a certain time period at the end of the employment relationship. These clauses are illegal and unenforceable in California. Employers sometimes include the clauses in the contracts because they guess (often correctly) that a physician will not obtain legal advice and presume that the clause is valid and enforceable through legal means. Non-solicitation clauses attempt to prohibit you from recruiting patients or employees of the medical group to your new practice. Clauses strictly prohibiting solicitation are legal. However, many solicitation clauses purport to prohibit the physician from contacting patients regarding the physician’s departure from the medical group. This provision is unethical and illegal. Patients have an absolute right to know the whereabouts of their treating physician. An announcement card sent by the physician to former patients simply identifying the new practice location is not solicitation: it is information legally protected.

CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

Can You Explain the Interplay between the Term of the Agreement and the No-Cause Termination Provision?

Typically, physician employment contracts are for the term of one or two years; however they routinely contain a provision permitting either side to terminate the agreement with a 60- or a 90-day notice for “no-cause.” This clause effectively negates the term of the agreement by permitting either side to unilaterally change the term by terminating the agreement for any reason or no reason. Nonetheless, the term has a purpose. It generally sets the date for the parties to reassess their relationship to one another after the term period. For example, following the initial term many medical groups will consider the physician for shareholder status or reassess the compensation package. Some employers agree to pay for tail coverage if the physician completes the term of the agreement. Thus despite this seeming inconsistency, the term language and “no-cause” termination provision reside in harmony in the physician employment agreement.

Now that you have answers to the common questions, the issues related to reviewing physician employment agreements and the negotiations surrounding them are not that complicated. Nevertheless, there are many good reasons to have an attorney review your contract before you sign. If you do retain counsel to review the contract for you, be sure to familiarize yourself with the attorney’s qualifications and obtain an estimate of the cost of the review.

Barbara Hensleigh, Esq. is a partner at Andrews and Hensleigh, Los Angeles, CA. She specializes in health care law and is frequent contributor to California Family Physician magazine and Practice Management News e-newsletter.

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

New to Practice Checklist The California Academy of Family Physicians has developed this checklist of action items and issues to consider as you enter practice in California, whether you have just completed residency or have moved here from another state.



Obtain your license

If you are an MD: The Medical Board of California's Division of Licensing (LICENSE) develops and administers the physicians’ and surgeons’ examinations and also renews licenses to practice, which is required every two years. Allow at least four to six months to have your initial application processed; the Medical Board recommends starting the processing six to nine months before you need your license. For information on licensure, call (800) 633-2322 or go to (MBC). If you are a DO: Osteopathic physicians must be licensed by the Osteopathic Medical Board of California; renewal is required every two years. For information on osteopathic licensing, call (916) 928-8390 or go to (DO).

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Register with the DEA To legally prescribe controlled substances, you must register with the Drug Enforcement Agency (DEA). For more information, go to (DIVERSION) or call (800) 882-9539.

 You must obtain a DEA number, issued by the US Department of Justice. It must appear on all

prescriptions. If you move, a new number is required.  Drug thefts or patients seeking restricted drugs under false pretenses must be reported to the DEA.  Prescription pads for controlled substances may be ordered from any one of many approved printers.

As of January 1, 2005, written prescriptions for controlled substances must be on tamper-resistant security prescription forms that have been preprinted by a Board-approved printer and must contain specific elements. For a list of approved security prescription vendors, go to the California State Board of Pharmacy Web site at (SECURITY). You must first have your DEA number. It can take several months to obtain a provider number.  Physicians may prescribe drugs only in the regular practice of their profession and may not furnish controlled substances to persons not under their care. To reach your local DEA office, please call: Northern California: (888) 304-3251 Southern California: (888) 415-9822 San Diego/Imperial: (800) 284-1152

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Contact Medi-Cal and Medicare California’s Medicaid program is known as Medi-Cal (MEDI-CAL). For provider numbers and billing problems or concerns, call the Medi-Cal office at (800) 541-5555. If you are calling about a specific case, make sure to have your patient's claim number ready.

Medicare, the primary source of insurance for older Americans, is administered by Palmetto GBA. Contact Palmetto GBA at (PALMETTO) or at (866) 931-3901 for all claims, participation information, guidelines, and general information.

CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

 

Enroll in HMOs, IPAs, and PPOs

For information regarding HMO, IPA, and PPO listings in California, contact the California Department of Managed Health Care at (HMO) or at (877) 525-1295. Your local CAFP chapter or local medical society can also serve as a resource. The Council for Affordable Quality Healthcare has a new credentialing system recommended by the AAFP. For more information, go to (CAQH) and click on Universal Provider Datasource.

Know Disease Reporting Requirements Physicians are required to report a wide variety of diseases and conditions, including births and deaths, in California. Protecting public health, advancing scientific knowledge and guarding the safety of individuals at risk of violence are some of the reasons reporting is imperative.

Reporting births and deaths is done through county departments of public health. Reporting information is not available online; to request a booklet outlining reporting instructions, contact your county department of public health (use the link at the end of this section). The California Department of Public Health has made available a list of reportable diseases and conditions that can be accessed at: (REPORTABLE) Information on California's cancer reporting guidelines is available at: (CANCER). Because your local area may also have additional reporting requirements, you should contact your local department of public health for further information. Links to your city or county department of public health can be found at: (CDPH).



Obtain Hospital Privileges

Before making any final decisions about where you might practice, you should have a realistic sense of the typical scope of practice for family physicians in communities of interest, especially if you want to practice obstetrics or do procedures. Once you have settled on a practice location, you will need to apply to the medical staff office at the local hospital or hospitals before you will be allowed to admit or treat patients. Remember to keep all written documentation from your residency training regarding any and all procedures you have performed, especially gastrointestinal and obstetrical procedures. Resources are available from CAFP to help with privileging questions or difficulties encountered when trying to obtain desired privileges. Visit the Practice Resources section of CAFP's website (FAMILYDOCS) or contact CAFP at (415) 345-8667 for more information.

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Set Up Your Practice If you are thinking about starting a new practice in California, start planning early. This process should begin with a careful evaluation of potential practice locations and managed care or other health insurance income streams. Allow ample lead time to become credentialed with Medicare, Medi-Cal, and commercial health plans.

Starting a new practice, or buying an existing practice, is a significant undertaking. For a step-by-step guide, CAFP recommends AAFP’s On Your Own: Starting a Medical Practice From the Ground Up, available online at (AAFP) or from the AAFP’s Orders Department, (800) 944-0000 (item #749). Other resources are available at (FAMILYDOCS).

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE



Learn to Manage Your Practice Read Family Practice Management. Published by the AAFP on a monthly basis, this magazine offers peer-reviewed advice on how to succeed as a family physician in the evolving health care system. It offers practical how-to articles and analyses of current issues. Full text copies of FPM are available online at (AAFP).

Visit CAFP’s website FAMILYDOCS. The Practice Resources section (RESOURCES) has numerous resources to help you in your practice including information on coding and billing, working with consultants and attorneys, a forms directory, and the latest in practice management news. Check it out today!



Protect Yourself Legally

A malpractice crisis in the mid-1970s led to the passage of the Medical Injury Compensation Reform Act (MICRA), which placed a cap on non-economic damages (pain and suffering) in malpractice settlements. MICRA has been instrumental in maintaining affordable malpractice insurance in California. More information about MICRA can be found online at (CD ). Another by-product of the 1970s malpractice struggle was the emergence of physician-owned malpractice insurance companies, including: The Doctors Company NORCAL Mutual Insurance Medical Insurance Exchange of California

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(800) 421-2368 (800) 652-1051 (800) 227-4527

www.thedoctors.com www.norcalmutual.com www.miec.com

Published Legal Resources

An ounce of prevention is worth a pound of cure, or so the saying goes. The single best resource for the ins and outs of the many aspects of California health law is the California Physician’s Legal Handbook, published by the California Medical Association. This CD-ROM series is a comprehensive reference for practicing physicians and covers both state and federal laws. To order, call the CMA at (800) 882-1262 or visit: (CMANET). The cost is $480 for non-members and $398 for members, plus sales tax. This handbook comes highly recommended; every practice should have it. For more information, visit (CMA).

For California codes relating to the practice of medicine and the Medical Practice Act, go to (LEGIS). Medical practice regulations governed by the Medical Board of California may also be found by visiting the State of California Office of Administration and Law Web site at (OAL).

 

Attorneys You should have an attorney you know and trust to help with legal issues that may arise in the course of practice. Establish a relationship with an attorney before you need one in an emergency situation. For references, go to (LAWYER), or (AAFP).

CAFP’s Physician Employment Contract Review Service

Family physicians these days commonly begin life in practice as employees. Sometimes this is a trial period prior to being invited to become a partner in a practice. To make sure your rights are protected, you should seriously consider having your contract reviewed by a knowledgeable attorney familiar with health care law and medical practice issues. CAFP can help! For a modest fee of $525 for members and $700 for non-members, we will lead you through the process, from basic education to legal review forone contract with an experienced health care attorney. See the form included in this toolkit on page 26 or contact CAFP at (415) 345-8667.

CALIFORNIA ACADEMY OF FAMILY PHYSICIANS



Set Up Your CME Record Keeping

CAFP works with AAFP to maintain your CME records, automatically re-electing you to membership in both organizations if you have sufficient CME, verifying your CME hours to the American Board of Family Medicine, hospital staffs and other societies, and responding to Medical Board of California audits for you. You need to earn and report 150 (75 must be AAFP Prescribed credits; 75 may be elective credits) CME credits each three-year election cycle. Start a record keeping system and stay current! If you have questions, call the AAFP CME line at (800) 274-2237 or CAFP at (415) 345-8667. You may report your CME directly to AAFP online at (CME).



Maintain Your Membership with CAFP/AAFP

If you have just completed residency and are currently a member of the CAFP/AAFP, your membership will be automatically upgraded from resident membership to Active membership. To maintain this status, you must report your license and contact information to the AAFP. AAFP will send you a reporting form, and you will be billed automatically for your dues. If you are already an Active member and are moving to another state, you should complete the “Relocation Application for Continuing Membership” form at www.aafp.org/relocation. You may also obtain this form from AAFP, CAFP, or your previous Academy state chapter.

Online Resources for the New FP New family physicians have said they are most concerned about practice management, staying current with medicine, medico-legal issues, technology management, reimbursement and coding, career management and connecting with fellow family physicians. CAFP has compiled a list of websites on each of these topics to help you better manage your practice and career. Staying Current with Medicine: American Family Physician www.aafp.org/afp Journal of Family Practice www.jfponline.com ACP Journal Club www.acpjc.org/?hp Up-to-Date www.uptodate.com

Family Practice Management www.aafp.org/fpm National Guideline Clearinghouse www.guideline.gov Physicians Practice www.physicianspractice.com Medical Professional Management and Marketing www.practicemgmt.com Medico-Legal Resources:

Essential Evidence PLUS www.essentialevidenceplus.com/ Practice Management and Managed Care: CAFP’s Practice Resources www.familydocs.org/practiceresources.php

CMA On-Call Legal Resource Center www.cmanet.org/bookstore/cmaoncall.cfm AMA’s Legal Issues for Physicians www.amaassn.org/ama/pub/category/4541.html

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

Cooperative of American Physicians www.capmpt.com/risk_management/r isk_management_library/articles_and _forms Harvard University Risk Management Foundation www.rmf.harvard.edu Payment and Compensation Information: Medical Group Management Association www.mgma.com Family Practice Management www.aafp.org/fpm Physicians Practice www.physicianspractice.comCAFP Coding & Billing Monograph (updated annually)www.familydocs.org/monographs.php

Technology Resources:

Family Medicine Specialty Resources:

AAFP’s Center for Health Information Technology www.centerforhit.org

California Academy of Family Physicians www.familydocs.org

AAFP Partners for Patients EHR Program www.centerforhit.org/x25.xml

American Academy of Family Physicians www.aafp.org

Family Practice Management www.aafp.org/fpm

American Board of Family Medicine www.theabfm.org

iHealthBeat.org www.ihealthbeat.org

AAFP CME Courses www.aafp.org/cme

Employment Opportunities and Career Planning:

AAFP Discounts for New FPs www.aafp.org/experience.xml

FP Jobs Online www.fpjobsonline.org

CAFP’s Vaccine Discount Program www.familydocs.org/news-media/didyou-sign-your-vccine-discounts.php

AAFP Physician Placement Services and Career Opportunities Online www.aafp.org/careers American College of Physicians Career Opportunities www.acponline.org/jobs

Healthcare Workforce Development Division National Health Service Corps (NHSC)/State Loan Repayment Program www.oshpd.ca.gov/HWDD/SLRP.html AAFP Funding Resources for Practicing in Underserved Areas www.aafp.org/online/en/home/clinical/ publichealth/culturalprof/underserved. html AAMC Educational Debt Management Services for Residents www.aamc.org/programs/first/residents/start.htm

Loan Repayment and Debt Management: Many changes to loan repayment programs have been made in recent years. For more information on options available, visit the CAFP website.

Health Professions Education Foundation Steven M. Thompson Physician Corps Loan Repayment Program www.oshpd.ca.gov/HPEF/STLRP.html

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CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

Basic Financial Management for New Physicians ... 17 Simple Rules Keith Borglum After being a student, your income as a new physician will seem like a lot, but you will be surprised how fast you will spend it and how little you will keep. Now is the time to start a “saving” lifestyle, in which you spend conservatively, rather than becoming dependant on a “spending” lifestyle. I have numerous specialist clients who earn more than $500,000 per year and can’t make ends meet, having become used to big houses, fancy cars and expensive vacations. You can spend an infinite amount of time investigating financial strategies. At your age and stage of profession, and for the next three to five years, you should devote your energies and thoughts to your profession rather than sophisticated outside investment strategies.

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Given the income tax breaks, and the deferred income tax until retirement, with the ability tocompound returns tax-deferred, funding your retirement plan is more important than paying off your student loan or buying your first house.

The following list presents simplified rules and suggestions for new (and old) physicians:

1. 2.

3. 4.

Remember, it is not how much you make, but how much you keep that counts! Consider consolidating your student loans under the Federal Direct Consolidation Loan program. One strategy is to consolidate loans into the longest period possible at the lowest interest rate possible, resulting in the lowest current monthly payment. This will increase your current borrowing power to purchase a home or obtain other business loans, and increase the money available to fund retirement plans. Be aware that this will also significantly increase the amount of interest you pay, but you can always pay the loan off faster if you want. For more information: (LOAN). If you work for a non-profit or in public service positions, your Federal loans may be eligible for Income-Based Repayment or the Public Service Loan Forgiveness Program both of which will forgive the balance of your Federal loans at the end of a reduced period of payment. Visit: (REPAY). Other reasons to consolidate:  If it offers you a lower rate than your current loans; and  If you have trouble meeting your monthly payments, have exhausted your deferment and forbearance options and/or want to avoid default. Note: keep in mind that if you are close to paying off your student loans, it may not be worth the effort.

5. 6. 7. 8.

Learn to live on 75 percent or less of your income. About 25 percent of new physicians will leave their first job within 18 months. Rent housing for the first year or two until you are sure of your job, like the area and know the good school districts for your kids. Take professional ICD/CPT coding training, which has a very high return on investment.

At a minimum, buy catastrophic-care medical insurance with a high deductible and low premium or start a Health Savings Account. 9. Eliminate or avoid carrying revolving (credit card) debt. Have a couple of credit cards with which to build your FICO score, but pay off all credit cards monthly. 10. Pay as many bills as possible with a credit card that offers frequent-flier miles and use online bill-paying to do it.

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

11. Hire a bookkeeper to do your office and home accounting and bill paying. 12. Fund retirement plans to the maximum possible. Given the income tax breaks, and the deferred income tax until retirement, with the ability to compound returns tax-deferred, I suggest that funding your retirement plan is more important than paying off your student loan or buying your first house. The earliest years of retirement plan funding are the most important because they have the longest time to grow. Have your retirement contribution deducted from your paycheck directly into your retirement plan every pay period, so you never see it, even if you are in solo practice and paying yourself. 13. In the stock market, approximately 85 percent of financial planners and stock brokers don’t do as well as the No-Load S&P Index 500 Mutual Funds (NLI500s). Consider investing 75 percent in NLI500s and 25 percent in money market funds. Leading sources of NLI500s are at Fidelity.com and Vanguard.com. 14. Buy disability insurance first, and only buy term life insurance if/when you have dependants. Do you even need life insurance? It depends. As a young physician, if you are single, with no dependants and no co-signers on your loans or debts that would burden others upon your death, what purpose would life insurance serve for you? I advise never buying whole life policies; you are better off investing that money into your retirement funds. 15. If you are a practice owner, make tax-deductible investments in your practice (i.e., marketing, revenue-producing skills, and instrumentation). If you are employed, have a small side-business for the tax benefits (or have your spouse do it). Don’t pay unnecessary taxes. Read the book Small Time Operator, and consult your CPA.

Disclaimer: Keith Borglum is not a licensed financial planner and all information contained herein is personal opinion, though supported by references. All investment involves risk, and readers are cautioned to obtain independent qualified investment advice fromresources of their choice. © PMM 2005 www.PracticeMgmt.com. Reprinted with permission.

Recommended Reading



Small Time Operator: How to Start Your Own Business, Keep Your Books, Pay Your Taxes, and Stay Out of Trouble, by Bernard B. Kamoroff (good for employees, too) The Millionaire Next Door: The Surprising Secrets of America’s Wealthy, by Thomas J. Stanley

The Intelligent Investor: A Book of Practical Counsel, by Benjamin Graham More good, basic financial planning information is available free online from many sources such as (READING).

CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

Malpractice Overview for New Family Physicians Barbara Hensleigh, Esq. Worried about how the malpractice market in California might affect your livelihood as a family physician? Here are some basics to get you thinking about malpractice insurance so that you can sleep easier at night. The vast majority of policies written in California are written on a “claims-made” basis. This means that you are only covered for malpractice incidents that take place during the period that your policy is in force. This is a less expensive option at the outset, since premiums typically grow in steps over four to six years, as your list of patients (and possible lawsuits) grows. Some companies offer policy discounts for attending risk management CME courses. The other important aspect of claims-made malpractice policies is that your coverage ends when you stop paying your premiums. When you terminate a claims-made policy, the coverage for all care given during the time of that policy ends. For example, if you work as an employed physician from 2002 to 2005, but then leave that practice, you will not have malpractice coverage for that time period unless you or your employer purchase “prior acts” coverage either from the former insurer (tail coverage) or your new insurer (nose coverage). Tail coverage rates are a factor of the last year’s annual premium, generally around 175 to 200 percent and can be a significant expense. All employment agreements should spell out who is responsible for purchasing tail coverage, preferably the employer. I need to buy malpractice insurance. What should I look for in a company and coverage? Malpractice insurance is supposed to protect you from the legal and financial risks inherent in the practice of medicine. The two most important qualities in an insurance company are that it be financially sound and that the company be responsive to the needs and concerns of the insured. A.M. Best (www.ambest.com) or Weiss Ratings (www.weissratings.com) can provide you with information about malpractice company ratings. You want to work with a company rated “A” or better.

Here are some of the questions to ask when evaluating malpractice carriers and their policies:  What are the available policy limits, and how much does coverage for someone in my specialty cost?  Are there premium discounts for good claims experience and/or attendance at risk management seminars?  What types of coverage are available, such as peer review or Medical Board defense?  How is defense counsel assigned to a malpractice case? Do I have any say in the process?  What role would I play in determining whether to accept any settlement offer made in my case?  What are the company's routine policy exclusions?  How many are insured with your company in California and nationwide? What is the breakdown by specialty? How long has the company been in existence? For an exhaustive list of questions to evaluate malpractice policies, visit: (MALPRACTICE).

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

Where should I go to buy malpractice insurance? CAFP recommends California-based, physician-owned malpractice companies to its members. These include: Doctor’s Insurance Company Medical Insurance Exchange of California (MIEC) NORCAL Mutual Insurance Company

(800) 421-2368 (800) 227-4527 (800) 652-1051

www.thedoctors.com www.miec.com www.norcalmutual.com

An experienced insurance broker may also be a good way to shop for your coverage. Contact your local medical society for suggested brokers in your community. How important is tail coverage? What should I know about it? It is very important that you maintain continuous malpractice coverage throughout your career in family medicine. California has a claims-made insurance market. You can be sued, but not be covered for your defense if you receive notice of a lawsuit for something that happened while you were insured, but have already terminated your policy. Tail insurance is supplemental coverage to a claims-made policy for incidents that happened under an old malpractice policy. When switching insurance companies, be sure to obtain tail coverage from your old company or nose coverage (for prior acts) from the new company. Tail coverage can either last for a certain amount of time or be unlimited. You may need to have been with the insurance company for a certain amount of time before you can purchase it. Tail insurance usually costs between 175 and 200 percent of your last annual premium and is typically only available for a short period of time after a policy expires, generally 60 to 90 days. Many companies have provisions for “forgiving the tail” in situations of death, permanent disability, or retirement. Be sure to investigate these provisions carefully for vesting requirements, age limits, etc.

Barbara Hensleigh, Esq. practices law in Los Angeles, California, focusing on physician representation in litigation and employment-related issues.

CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

The Balancing Act: Assessing Where You Are On Your Own Personal “Balance” Scale Martha Bernadett, MD, MBA Balance between family and work, scheduled and unscheduled time, plagues every busy professional today. With the advent of the electronic age, there seems to be no more “down” time. Connection to your practice used to make life easier, but now it seems confining. Why? Because the rules have changed. Patients expect to be able to reach you at all times, and patient loads are heavier than ever. If you don’t plan time for yourself, you won’t have any. Doctors are not known for being the world’s best adapters, and most of us find adaptation painful. We long for simpler times: times with less paperwork and fewer required forms and reports; times when we referred patients to colleagues with a phone call, not a faxed authorization form approved by a third party; times when we took an afternoon off to relax. The romance of the past can lead to bitterness in our daily lives unless we are able to find balance between our ideal day and the realities we face in today's practice models. My goal is to provide you with a framework for assessing where you are on your own personal “balance” scale and give you some ideas on how to achieve greater balance that leads to greater personal life satisfaction. Balance is a very personal thing: it means different things to different people. What is important is that you do what feels right for you. You may be able to make some changes on your own, but some may need help. Investing in yourself now will add time to your life now, when you can enjoy it, as well as time after retirement.

The Balance Table The Balance Table is a quick way to look at your current state of balance. Compare the corresponding terms in each column, then circle the term from the column that best describes how you actually spend your overall time. Telling, isn’t it? Professional Planned

Professional Unplanned

Administrative time Outpatient/office Time spent interacting with patients Charting pertaining to patient care Telephone follow-up with patients Completion of forms that don't duplicate other info

Clinical time Inpatient/hospital Paperwork Required paperwork (duplicate/regulatory) Telephone follow-up on authorization requests Form completion requiring excess of necessary medical info or requiring duplication Junk or excessive email Writing or calling in prescriptions Pharmacy phone calls (authorizing change because of formulary requirements) Time spent looking up drugs in a formulary

Email that is useful Pharmacy phone calls (refill requests) Free time Time spent looking up drugs on a pocket-card or commonly used drugs formulary acceptable by all formularies Scheduled time at the office

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

Unscheduled time at the office

Defining “work” Think about what you consider “work.” Most family doctors consider any time they spend away from home dealing directly or indirectly with patients or administrative practice concerns “work.” This ranges from coffee in the doctors’ lounge at the hospital at the beginning of the day to bedside examination, to charting, to seeing patients in the office, to phone calls. In addition, any time spent at home that involves direct or indirect patient care is also considered work, whether it’s talking to a pharmacy or patient on the phone or discussing a case with a colleague. With all that time spent working, when is there time for anything else? Defining “balance” The first step to achieving balance is to define what is out of balance. The “work” side of the equation is usually easy to define and populate, so save that for last. To find out what is missing in your personal balance equation, work through the exercises that follow. The ultimate goal is to generate a plan on how to achieve balance according to your own personal equation. In the case studies that follow, you will see some hypothetical examples of steps taken to achieve balance. Nobody said that achieving balance is easy. For most of us, it takes weeks to months to complete all of the exercises and achieve personal balance. The game plan The most difficult element of change is to take that first step. Change takes commitment, just as we tell our patients. This change is no different. Most steps you can take yourself, but others may require a professional consultant to assist you. If there are too many things in your daily life that distract you from keeping a focus on finding balance, do what the business people do: hire a personal coach. Have that coach keep you on track in completing the exercises

Personal: Self, family and friends

Professional: Above and beyond

Family and friends Family meetings Meals with family Weekend days with family or friends Free time with family or friends Dinner with friends outside of work Free time outside of work Outside community activities Time making new friends or maintaining already established relationships Leisure reading Time enjoying exercise Developing a hobby Vacation Dinner alone with spouse, partner or friend Reading to your child or having an unhurried conversation with an older child Doing things for yourself Class that you took at a community college just because it sounded interesting or fun

Work Staff meetings Meals outside the home Weekend days at work Any time at the office Dinners with colleagues Hospital committee meetings Providening free care to the community Time meeting new colleagues Reading medical journals Time working Keeping up with the latest medical information Trip for CME CME. committee or hospital dinner Reading an article on a new drug Doing things for others CME to meeting requirements

CALIFORNIA ACADEMY OF FAMILY PHYSICIANS

and achieving balance. It is a short-term cost that will pay for itself. You might ask business colleagues for recommendations or get recommendations from CAFP. Are you ready to be in balance in a year? Getting started with a Ƌuick-start plan If you are in need of freeing up some time at the office, but not yet ready to create a longer-term plan, the quickest way to achieve that is to use the Balance Table on the previous pages and plan to make changes within the next three months. You will need someone else to help you with this, because if you have been living this way every day for the past number of years, it is unlikely that you will change in the next three months. Hire a practice efficiency expert to help you make some office changes that free up a specific amount of time (for example, a goal of two hours a day). If you are willing to undergo a broad practice assessment with suggestions, you may find that even more time can be saved. The cost of this generally ranges from $5,000 to $20,000 depending upon the level of expertise of the consultant and scope of changes considered. Spend the money, save the time. You should include specific requirements in the contract with the consultant that they demonstrate that the savings from the changes they identify for you will cover their cost.

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Longer-term plan Conclusion: Each of us is unique. “Longer-term planning” is shorter than There are many ways to achieve balance; long-term planning (20-plus years). The what is most important is defining what"balance" purpose of longer-term planning is to glimpse ahead as far as you can, but plan means to you and then taking steps to achieve it. for two years and for five years. By that time, you will be ready to repeat the process, because life has happened and you have evolved. There is nothing wrong with 20- or 30-year plans, but shorter planning allows for greater flexibility. When to consider longer-term planning The longer-term plan includes introspection and life planning. I know many people who completed the exercises then noted that the process prevented a mid-life crisis. People strive for balance at all stages of their life, but we label the crisis at mid-life because it is such a common time to look for balance or change. How to approach longer-term planning If possible, plan some time away to concentrate on working through the balance exercises on pages 43-44. The time to complete these exercises should be time outside of work. Most of these exercises require quiet time to complete. They are best completed without the hustle and bustle of the practice. Do not do this on vacation; it is hard work. After you decide to start, plan to complete the exercises over the course of 60 days. Some of the exercises require others, like your accountant or business manager, to gather data for you or meet with you, so plan ahead. Set aside a long weekend, perhaps a four-day retreat, to complete the exercise. If you are on this journey of life alone, complete the exercises alone. If not, complete these exercises with your spouse or life partner. You can also complete them with a small group of friends with the same goal. They are completed individually and generally not shared with others, but discussions of related topics enhance the support group approach. Knowing others in the same stage of life results in benefits including the support and camaraderie of participating in such a group. The support group approach increases the chances for success in actually making and sustaining the changes you want to achieve. This group may be friends or colleagues, but all should have the same goal of achieving balance in mind. If using a concurrent support group approach, you should consider hiring a facilitator or personal coach to lead the group through the exercises. Each exercise is accompanied by the time you will likely need to spend completing it. They do not need to be completed in any particular order. Keep them in a folder as you complete them, for you will want to take them with you to a retreat where you pull them all together and create your plan to achieve balance.

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

Case Studies in Balance: What would you recommend? Time, time, time

Job-Sharing

Dr. Jones has been working 70+ hours per week and has no time to spend with his kids. He would like to be there when they get home from school one afternoon each week and would like another afternoon per week to develop a hobby. He broached this with his practice partners and they are willing to accommodate him, but this will result in a decrease in his wages (no benefits decrease). He discussed this with his spouse and found she has had an interest in taking up a part-time job for personal fulfillment.

Two doctors working full-time in a medical group lamented about wanting to spend time volunteering in their children’s schools. And, while dedicated to their patients, they each longed for better balance between their family and professional time. At the same time, their group was experiencing financial pressure, as the practice had not grown as fast over the past two years as expected. Still, it was a steady practice and the two physicians had a proven track record of loyalty to the group and their patients.

Dr. Smith is overwhelmed with paperwork but does not feel her practice is ready for an EHR yet. The constant reworking and duplication needed to fill out referral authorization forms is what is causing her the most grief. She keeps a file of all the forms for each IPA and health plan. Medical assistants fill out what they can, but she still spends almost two hours charting each day, arriving home exhausted to her vigorous young children and equally tired husband.

Job-sharing is one solution that may provide balance for the physicians and support the group’s needs. Successful job-sharing takes planning and buy-in from the whole group. Some colleagues may resent the freedom and balance that job-sharing allows others. However, if all are agreed, it can be a great asset to the group and individuals. Transition to a shared position generally takes three to four months. During that time, the individuals sharing the practice notify their patients, start seeing each other’s patients while both are in the office, and build their partnership.

While well on their way to reaching their retirement savings goals, neither physician seems to have time to live life right now. Suggestions: Dr. Smith should invest in electronic conversion of her office forms and standardized letters. Even if the forms are not transmitted electronically, the time-savings in duplicate writing by her and her staff will lead to a more efficient office. If tied into a logging system, the referral log will be generated automatically as the forms are prepared, so follow-up can be accomplished without duplication of log entry. Standard off-the-shelf computer programs can be used for this purpose. For the cost of a single computer terminal and printer, placed in a private location, patients can complete initial history forms in a similar manner. These can be placed in the patient chart and reviewed by the physician, decreasing charting. This is a small cost compared to the extra hours spent charting. Martha Molina Bernadett, MD, MBA, is a family physician and a VP/General Manager of Molina Healthcare of California, a health care company serving Medi-Cal and Healthy Families program patients. She strives to maintain a balanced life with her husband and three daughters andbelieves that the secrets to life are patience and a good sense of humor.

Taking time to educate patients and colleagues on new expectations is key. Several schedules may have to be tried before the optimum schedule works. Some people use the five half-days per week approach, one physician works the morning half-day and the other the afternoon, while others work two and a half-days each, or variations of these. Find the one that works best. Job-sharing takes discipline, cooperation, and flexibility. One of the most common reasons for failure of the job-sharing arrangement is the drift that occurs over time. Before a physician knows it, what started out as being a team player and pitching in to help get through “crunch time” ends up being a return to full-time work with part-time pay. Drift must be monitored and not become a source of resentment. At the same time, those who share a job must still be able to pitch in as team players with each other and with the group. It is a delicate balance, but the rewards can be great if managed well.

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Balance Exercises EXERCISE 1: Who am I, who was I? Write your epitaph. Write your own obituary. How do you want to be remembered? Write it, put it away, look at it tomorrow, and again next week with revisions as necessary. Total time: 2 hours. EXERCISE 2: Where am I? Draw a line on a blank piece of paper. This represents your life. Place an “X” on the line that represents where you are on that line today. Think about it. Total time: 5 minutes. EXERCISE 3: Paid work. Make a list of everything you have ever been paid to do, childhood to present. Total time: 30 minutes. 15 minutes to write, plus time to recollect and discuss at the dinner table. EXERCISE 4: People who influenced me. Make a list of people who have influenced you in your life. State in one or two sentences what you learned most from each of them. This can be done little by little over the course of several days or a couple of weekends. Total time: 2 to 4 hours. EXERCISE 5: Strengths. Write 10 strengths you possess. No, do not make a list of weaknesses. Total time: 10 to 30 minutes. EXERCISE 6: Personal values. List your values. Write, put away, revisit, repeat until satisfied. Total time: 1 to 3 hours. EXERCISE 7: What I still want to do? List everything that you want to do for the rest of your life. Be specific, and where possible, be concrete. For example, where do you want to live? If it is not where you are living now, be specific and describe the location as well as the house in as much detail as you can. Another example is travel. Where do you want to travel? How do you want to travel? What do you want to see when you get there? Have you been everywhere, met everyone, and done everything you wanted to do in your lifetime already? Don't forget time with children and grandchildren if that is important to you. When it comes to time, be specific. “Spend more time with…” will ultimately be followed by having to answer the question of how much time. Do what you can; this is your first step. This is where to write down your dreams. Sit down and do this at the same time as your spouse or life partner, but not together. Create separate lists. Give yourself 30 minutes, and do not share the results until after 30 minutes have elapsed. You may find that there are long pauses while you create your lists, but do not break concentration and talk. Dream quietly and other thoughts will come from within. Keep the list and add to it over time. Dreams written down become goals. Total time: 30 minutes. EXERCISE 8: The perfect day. Describe your perfect day. From the moment you awaken, to the moment you fall asleep again, describe in detail, your perfect day. This should be a workday, not a weekend. If you also work on the weekends, then you should complete this exercise twice , once for the regular workday and once for the weekend. If your “on call” days are different from regular or weekend days, then you have a third exercise within this one; repeat as before. Total time: 1 to 2 hours. EXERCISE 9: Personal vision. Create your personal vision statement. How do you see the world and your place in it? Write as much as you want, then condense it into a few sentences, short paragraph, or bullet points. Total time: 30 minutes to 1 hour.

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

EXERCISE 10: Practice realities: time tracking. Track your time to see how it is actually spent during your workday. You may start this exercise anytime; do not let it create stress for you. Some people look at large blocks such as 3 or 4 hour blocks of time and then stop and list what they did the past several hours. Others pause hourly to create their time tracking list. Do whatever works for you. This is for you to view and use in the planning stages. Total time: 15 to 30 minutes to make notes throughout the day for two to seven days, depending on the variability of your days. If you are tracking on an atypical day, track another day or two and look at the results together. Upon completing your day, review your list and determine those things that you did that could be delegated. If they could be delegated to someone else or are actually someone else’s responsibility, be specific. If they could be delegated to personnel that are not currently staffing your practice, write it down anyway; you may have defined a practice need. Total time: 1 to 3 hours for analysis. Optional: Hire a practice efficiency consultant to observe how things operate in your office and to follow you around for a couple of days to make observations and suggestions on steps you can take to free up time in your practice. The cost of the time saved or savings due to suggested changes should cover the cost of the consultation and should be included in your discussion with the consultant before signing the consultant’s agreement. EXERCISE 11: Practice revenue and expense analysis. Review your revenue sources and expenses. Do you spend 40 percent of your time generating five percent of your income? Total time: 1 hour and 10 minutes. 10 minutes to assign the task of reporting these items to your office manager, business manager, billing company or accountant as appropriate. Analysis time: 1 hour to review with your accountant. EXERCISE 12: Financial Plan. If you have not already done so, meet with a financial planner to determine how much you need to save to achieve financial independence. Total time: 2 to 4 hours.

Retreat Exercises It is now time to tie it all together. Your four-day retreat is scheduled; you are packed and ready to go. Take all your completed exercises with you and complete the Retreat Exercises. EXERCISE 1: Trade Offs. Determine the tradeoffs you are willing to make. Balance sometimes requires exchanges, for example, money for time. If you know how you generate money and how you currently use your time, then you are ready to act like your own free agent with your life. This is the exercise that ties it together. It should usually be done with your spouse or life partner. Total time: 2 hours to 2 days. EXERCISE 2: Written Plans. Create a 30-day plan, a two-year plan, and a five-year plan. Refer to the exercises you have completed and schedule what you want to accomplish within timeframes. Make timelines with measurable goals. Write the major milestones first, and then fill in with the steps needed to achieve them. Get help if you don’t know how to complete this exercise or need help in figuring out how to accomplish the intermediate steps. Total time: 6 hours to 2 days.

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From Resident to Leader: How to Be The Best in the Business Sharon Lin DO, MPH (WĂƐƚ R-CAFP President) Congratulations! Another milestone is coming your way: life after residency. Now that you can almost breathe a sigh of relief after residency, it’s time to redefine who you are and what you want to accomplish as a new fully fledged family physician. Perhaps in addition to relief, you are also feeling nervous about your new role where the sky is the limit with the support of faculty, staff, and colleagues watching over and guiding you. Don’t fret, help is on the way! Here are 5 tips to getting you on your way to being the best in the business: 1. Define your mission statement 2. Improve health outcomes 3 Take a look at the Big Picture at least once a month 4. Invest in your everyday people 5. Cherish your inner nerd Define your mission statement This is easier said than done. After years of contemplation, a dozen personal statements for various applications, and years of grueling hard work, your mission may not feel as fresh as when you first decided the field of medicine was right for you. Can the idealism of your past catch up to the reality of your present experiences? Often times in residency there is limited time to reflect on a) why you wanted to be a physician, and b) how you are feeling now that you are one. More likely, you are too busy learning how to be an effective physician. If your answer to the “why?” question was “to help people” than take stock in what helping people has felt like in the past few years as a resident. What was good, what was bad, and does it match how you want to feel? Once you take note of your feelings again, you can more easily ask yourself what you want your mission to be at this new stage in your career. Reflect on those feelings and thoughts by talking to others, keeping a journal, and/or making reminder notes to yourself for instance, so that in developing your mission your idealism doesn't get stale or worse yet, get left behind. Finding new professional support systems will be crucial as you embark on life outside of residency. Meeting and talking to other physicians is one way to building your new support system. CAFP has local chapter meetings and state-wide conferences and events where you can find people who can become your new support system as well as maintaining your residency network. Improve Health Outcomes The latest movement for family physicians is heading toward the Patient-Centered Medical Home (PCMH) model. For most of us, residencies have been struggling toward this new model by incorporating practice elements that, in the long-run, will make a chaotic day run smoother and our patients healthier. If you are entering a new clinic practice that has not yet developed aspects of the PCMH model, than you can take on a leadership role to creating change. Though the task at hand may seem like an uphill battle, CAFP has tools that can guide you in that endeavor. There are workshops, magazine articles, and online resources that CAFP offers that can help make the transition to PCMH feel more supported. Change within an institution starts with the efforts of a leader with a vision. If you have a vision of how you want your clinic to run, than there are several outlets within the CAFP network that can keep you on track. You can also improve health outcomes on a

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

community or public health level as an advocate for primary care. Become a spokeperson for CAFP and learn how to navigate the media and the grasp the interest of our legislators. Take a Look at “The Big Picture” That's right, once a month is just about the right amount of time our medical circadian rhythm needs to pause for reflection. Ever since our medical school and residency days, we have been well programmed to work in monthly blocks, so why not take the monthly cycle to look at where we stand in terms of the Big Picture? How are we doing mentally, physically, and Inevitably, the life of a physician will feel like you are being pulled in several directions. There will be spiritually? How are we doing in work, life, and play? Do we remember our times, however, that in your heart’s desire you larger mission and can we actually feel want to hide out with a stack of journals, review what our mission should feel like? If books, etc. and just catch up on some reading. things are not going our way, what do we This is you inner nerd calling out. ... need to do or how can our attitude about When we don’t nurture our inner nerd, we can eas- it change so that we can become closer to ily feel lost, left behind, and out of touch. our vision of homeostasis next month? If things are going great, what am I doing right and what are the factors that keep the good feng shui going? There are several online blogs, bulletin boards, and books written about our experience as physicians. The CAFP website also has blogs and magazine articles that ask these Big Picture questions. See for yourself if you can relate and please do share your experiences with others too!

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Invest in Your Everyday People There are people we see on a daily basis, whether for an instant, a few minutes, or a few hours. These people make up our everyday people. Collectively, they make up the landscape of our lives, coloring our experience with joy, fear, wonder, anger, and awe. Everyday people can make your day good, bad, or neutral. And though you may find that there are more everyday people that you can possible handle, there are a few that can make your efforts worthwhile. Invest in them by caring about their small stories and you will be a more grateful person. Share a bit of yourself in these interactions as a reminder of your vision, your idealism, and your human struggles. Maybe you can even add these people to your Facebook friends list. Investing in your everyday people will lead to a foundation of relationships that you can call your support. Cherish Your Inner Nerd Inevitably, the life of a physician will feel like you are being pulled in several directions. There will be times, however, that in your heart’s desire you want to hide out with a stack of journals, review books, etc. and just catch up on some reading. This is you inner nerd calling out. We all have an inner (sometimes outer) nerd, he/she is the one that brought us to this field of medicine diligently and reliably. When we don’t nurture our inner nerd, we can easily feel lost, left behind, and out of touch. To cherish your inner nerd, stay organized by adding “Learning” to your To-Do list and making the time to immerse yourself in reading, discussing cases, and attending conferences. CAFP holds an Annual Scientific Assembly (usually in May, usually in San Francisco) and a Medical Student Fall Conference in October to recruit new students in family medicine. Plan ahead and mark you calender! I hope that these 5 tips will help you thrive as a new physician. Please feel free to send any type of correspondence to CAFP staff via (FAMILYDOCS), so that we can better represent or address you concerns.

Sharon Lin DO, MPH is a PGY-3 at the Santa Rosa Family Medicine Residency and R-CAFP’s 2010 President.

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Making Your Voice Heard Anthony Chong, MD You have finally made it, after all those long days and nights spent in medical school, internship, and then residency ... You are now a full-fledged family physician. Do you spend all your time seeing patients, or is there more to being a physician? Two years after residency, I was busy juggling a family and a full-time practice. I had always been involved in my community and different aspects of medicine. So I felt that something was missing. Then, I was invited to join organized medicine at that time. Now, I am the President of the San Diego Academy of Family Physicians (SDAFP) and am a member of the Board of Trustees for the California Academy of Family Physicians Foundation (CAFP-F). I also served as the chairperson for a SDAFP CME conference. But why should you get involved? What could one get out of being involved in CAFP or other local/national medical organizations? There is a range of benefits of involvement. First, the personal benefits. Being in organized medicine (like SDAFP or CAFP) provides you with an environment to network and get to know other family physicians. While this not only promotes collegiality, it gives you an avenue to interact and discuss issues with other physicians, as well. You will learn from both young and old colleagues. Physicians are perceived as leaders, whether we like it or not. Involvement helps you develop your leadership skills. You will also be exposed to new ideas and developments in family medicine and your community. These arenas are good outlets for your ideas and your voice on important medical issues. Plus, these interactions will leave you feeling inspired, enlightened, and energized to go back to your practice and improve your mission to help your patients. Second, organized medicine allows you to get involve with the legislative and political aspects of medicine. There is no doubt that after the 2008 Presidential Election and health care reform, “change” is a popular word. The question is what will it mean for our specialty and our patients. Who will represent our interests and promote family medicine? Even with a busy clinical practice, organized medicine allows you to add your voice during the development of legislation and policies that will affect you and your practice. Whether we like it or not, new legislation and policies will be crafted and forced on physicians. Thus, we all need to be involved so that we as family physicians can work to advance our specialty and be a part of these developments. Lastly, being in organized medicine will allow you to improve the care of our patients and our physician colleagues. We know that patients will get better care when their medical treatment is directed by family physicians. Your participation will enable you to inspire a new generation of family physicians, from pre-clinical students to residents. You will be involved in developing educational tools and conferences to improve full-time physicians. There are many great reasons to get involved in organized medicine. Hopefully, you are ready to get involved. Where and how do you start? I first got involved through my local chapter SDAFP. Contact your local chapter or the CAFP. We are always looking for new voices with new ideas and we want to encourage all family physicians to get involved. Anthony Fatch Chong, MD is a family physician at Scripps Coastal Medical Center in San Diego. He is the President of the San Diego Academy of Family Physicians and serves oŶ the Board of Trustees of the California Academy of Family Physicians Foundation. 47

NEW FAMILY PHYSICIAN TOOLKIT: TIPS FOR PRACTICE

Ten Member Benefits for New Family Physicians A New Family Physician (or family physician who is new to practice) is defined as an active family physician member of AAFP and CAFP who completed residency within the last seven years. Take advantage of your Academy membership benefits to ensure a smooth transition to practice from residency. Among CAFP’s benefits for members are resources and services of special value to young physicians, including: Professional Networking CAFP is the ideal networking community for family physicians and provides activities, programs and forums relevant to the physician just entering practice. Access CAFP’s Facebook page at or attend local and statewide events to meet others in family medicine, share knowledge about new treatment options and discuss practice management issues.

Career Development Are you starting your own practice? CAFP’s online practice resource center is dedicated to helping your practice survive and thrive, especially in light of new opportunities for family physicians resulting from health care reform.

Job Opportunities Need assistance with your employment search? CAFP has partnered with 12 state Academy chapters to offer an easy to use online job center. This is the preeminent employment site for family physicians looking for new jobs and for employers looking for family physicians.

3. Relocating to California Making the transition to practice in California can be challenging. CAFP has developed a checklist of items and issues to consider as you enter practice here. Contact the CAFP, (415) 345-8667 for personal assistance. 4.

Educational Resources CAFO offers the latest news for young physicians, resources on continuous quality improvement and care coordination and quality education designed by your peers, with your needs in mind. Whether you want more information on health care reform legislation, legal/malpractice issues or achieving meaningful use with electronic health records, CAFP has the resources to help you understand and navigate the health care system as a family physician new to practice.

Find Colleagues Online Join CAFP on Facebook or Twitter to stay connected with us and your family physician network online. Post information pertinent to family medicine and key health care issues on our Facebook wall or read and comment on CAFP blogs.

Board Certification and Maintenance of Certification Confused about Maintenance of Certification with the American Board of Family Medicine? Look no further. Visit our MC-FP pages for the latest re-certification material. CAFP offers Self Assessment Modules (SAMs) programming at its Annual Scientific Assembly as well.

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Track Your CME Credits Use our free, centralized CME tracking service 24/7 and start tracking your CME credits for multiple reporting requirements. (You will need your AAFP/CAFP member ID to use this service; please call (415) 345-8667 for login assistance or additional information).

8. Legislative Advocacy AAFP advocates for you on on the national level on key topics as Medicare physician payment, medical staff privileges and scope of practice. CAFP works in Sacramento to ensure you and your patients are represented at the state level. If you believe that family medicine is crucial to the health of the public, one of the most important actions you can take is to join our political action committee (FP-PAC) or become a key contact for a local legislator. 9. Leadership Opportunities There are many way to get involved at the CAFP ... from writing an article to running for local or state offic. Weâ&#x20AC;&#x2122;ve got a long list of opportunities to become active in the Academy. For more details, call (415)345-8667. 10. Assistance with Membership Dues If you are experiencing financial hardship and having trouble paying your membership dues, CAFP and AAFP can help! Please contact the CAFP Membership department; CAFP can work with you to reduce your dues or to set up a monthly payment plan. If you have an idea for a New Family Physician service or a suggestion for an article, please e-mail us at cafp@familydocs.org For more information on membership benefits, contact CAFP: (415) 345-8667 or go to (FAMILYDOCS)

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