Transcript Modified Elmslie Reconstruction of the Ankle Using a Free

Life Skills
SWOTA 2009
Thomas A. DeCoster, M.D.
University of New Mexico
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Acknowledgements
• Dr. Robert Schenck, MD
• Mr. James MacGillivray, CFP
• Mr. Brad Day, CFP
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What percentage of orthopedic surgeons
change jobs in the first 2 years of
practice?
A. 1%
B. 4.5%
C. 10%
D. 20%
E. 40%
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What is the most common reason for
orthopedic residents to be dismissed
from a program?
A. Low OITE scores
B. Poor surgical technique
C. Personality conflict with the chairman
D. Dishonesty
E. Depression
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Life skills
• Financial
–Orthopedic
–Non-medical
–Malpractice
• Personal/personnel
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• Many aspects
What are Life Skills?
– Family
– Ethics
• Partner, children, parents
• More successful, greater importance
• Who you are?
• What do you stand for?
– Practice
• Many new concepts
• Successful practice
– Financial
– Is not just good surgery
• Investments, Savings
– Are you going to work forever?
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Why Life Skills Talk?
Because residency does not teach it.
• Residency is adult education
» Much like the college athlete
• You will have many distractions and temptations
» In a long line of academic degrees
• We tend to dismiss life skills
• Residency focuses on the practice of orthopaedics
» Not the private practice
• Patient care and integrity issues are critical concepts
– That is why indigent care is so important in training
• Physicians clearly have problems
» Financial, work load, delayed gratification
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Personal
• BALANCE
• The non-orthopedic non-medical aspect of
your life
• TD “All of our friends were my medical
friends until I joined a country club
where I’m now known as Ginny’s
husband.” More balance
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Personal
• Individually defined
» Decide what is important
» Don’t let your job become you, unless you want that
• Priorities
» Family
• Relationships outside of work
» Lifestyle
• Ramifications
» Decisions are not isolate
• Successful people make decisions based on the “big picture”
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Ramifications
• Spouse selection
» Critical decision
» 30% of married PGY-4’s divorce by 6th year of practice
• Focus on relationships outside of work
» Throughout entire career
• Satisfaction is often related to family
• Divorce
» Huge personal costs despite necessity
• Will affect your entire life
• Divorced spouse will have a lower standard of living
• Will reduce the wage earner’s assets to zero
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Marriage
• TD
“I observed a 75% divorce rate
among orthopedic attendings. Most were
married early and divorced by the first
two years of practice.
• People changed (grew apart)
• No time to deal with little issues during
residency so they became big problems
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Ramifications
• Divorce is starting over
–Personally
–Financially
–Recognize the ramifications
–Choose wisely
–Make the effort to maintain the relationship
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Moving (changes houses or cities)
• Moving comes at a huge cost
–Job
–House
–But moving is cheaper than divorce!
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Professional Skills
• Integrity is critical
» mantra, “do the right thing”
• Focus on providing care
»Treat patients as family
• Money will follow
• Continued education
»Always learning
• learn from the people around you; residents
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Professional success
AAA
• Availability
• Affability
• Ability-
–Most important to you -Ability
–Most important to others - Availability
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Ethics
• What you do when no one else is around
• It is very easy to justify behavior
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Thoughts on Professional Behavior:
During and After Residency
• Become well-rounded and well known for:
–Conservative care
–Good surgical technique
–Good bedside manner, in and out of OR
–Knowing your limitations
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Humility
• “He who humbles himself will be exalted”
• “Let others admire your work.”
Seltzer
• “Nothing ruins results like long term
follow-up”
Brown
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Orthopaedic Residency
• Great Specialty
–Fun
–Effective
–Great future
–Flexibility
–Great peers
–Equivalent to 10 million dollars
–Welcome, you’re in the club
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Residency
• Think in 12 month blocks
• Suggested approach
• First 6 months
–Acquire the skill set required for that year
• Second 6 months
–Focus on the next year
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Skill set by PGY
• PGY1
• PGY2
• PGY3
• PGY4
• PGY5
learn to be a doctor
learn orthopedic basics
orthopedic skills and breadth
learn what you don’t
know
become a team leader
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Residency
Most common mistake to be fired
• DISHONESTY
–Avoid temptations
–Select good mentors
• NOT low OITE scores
–If problem-get help-you can do it
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OITE and Board Examination
• OITE
» Written by the AAOS
» A relatively good predictor of failing boards
• 10th percentile OITE, 90% chance of failing written boards
» Keep an OITE library
• Boards
– Last three years exams with answers
– OSAE examinations
– OKO review
» Written by the ABOS
» Part I (written) and Part II (practice based)
» A requirement for privileges, insurance panels
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ABOS=American Board of
Orthopaedic Surgeons
• Know the rules
–Example-practice start date September 1
NOT September 2!
• Abide by them
• Part 1• Part 2-
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Board Examinations
• Part I (written, July of PGY 5)
–Study for the boards
–Study with other graduates
• Part II (2 years after Part I)
–6 month collection period
–Present cases, much like indications conference
–Dress conservatively (like going to your own funeral),
have cases prepped and documented
–A great experience once passed
–Good for 10 years
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Continuing Education
AFTER residency
• Critical for surgeons
» Yet most people practice what the learned in residency
• No such thing as a SLAP tear in 1989
• Participate in regular education
» Rounds, courses, weekly conference
• Find some structure experience after residency
• Think outside the box
» Spend time with another surgeon
» Mini-sabbatical
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Practice
• The business of medicine
» Learn about practice management
» Residency training improving, but can’t be the focus
• Choose your job wisely
» Find a fair partner, call, little turnover
• You can always quit, but costly
» Read your contract and get professional advice
» Try NOT to be the 60%
• That change jobs in the 1st two years
» Interview (negotiate) at several jobs
• You don’t get what you deserve but what you negotiate
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Example
First year of malpractice insurance
• Typically the job will pay yours
• They each pay $50,000/yr
• Perceived to be a $50,000 benefit
• Reality about $5,000 benefit
• Chances of suit being filed in the first six
months is virtually zero
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Understand the science of business
• Business is a science
• Learn the language
• Understand the choices
• Learn what works
• Know what to avoid
• Business is NOT evil
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$5 M or $20 M of income??
Your choice
• Your orthopedic franchise is worth between
$5 Million and $20 Million
• If you have no good business sense and just
muddle along you will still likely make $5
Million in your lifetime
• If you pay attention to the science of business
the exact same practice will produce $20 Million
of income to you
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$5 Million or $20M?
• $5 M for orthopedics – that’s a lot
• $15 M more, from your practice, if you
apply business principles- that’s a lot
more
• The business portion is worth three times
as much as the orthopedic portion
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Practice
• Operative Dictations
» Dictate immediately with CPT code terminology
• Dictation is part of the operation
• Name the bone
• Don’t leave the OR prior to dictating.
• Billings
» Learn about coding-it’s important and often not well done
• Phone Calls
» Never regretted
» RS “the only phone call I ever regretted is the one I did not
make”
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Personnel- the people you hire
• Critical to your success
• Give them Incentives
• Part of the science of business but not the
curriculum of medicine
• Praise in public, criticize in private
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Malpractice
• Huge Impact
»Psychological, physical, time, financial, family,
professional, data bank, privileges
»To you it is a disaster
• To your lawyer it is income
• Most claims are from unhappy patients
»Felt weren’t listened to
» You must demonstrate empathy to avoid suits
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Malpractice
• Can’t prevent entirely
• But a lot can be done to minimize
» Motto:
–
RS “Pay Malpractice premiums one day at a time or in one lump sum”
» Avoiding claims
• Conservative treatment
• Patient education (draw out on paper, include risks)
• Careful dictations, documentation, date and time
• Talk to family in waiting room
• Never lose your temper
» If a claim
• Don’t freak out, documentation and doing the right thing will carry you
• Don’t make a mistake: alter records, denial, inadequate representation
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Malpractice mistakes
• 1.
• 2.
Altering the medical record
Inadequate representation
–Early
»Notify insurance carrier
»Panel
–Late
»Your lawyer appointed by someone else
»Settling without your approval
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Personal finance
• Apart from your orthopedic franchise
• How you manage your financial affairs.
• TD “I never bounced a check until I
started making money. I was making
$125,000 instead of $19,000 so I thought I
didn’t have to balance my check book.”
WRONG!!!
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• Individually defined
» Decide what is important
» But just isn’t money and certainly not how much you earn
– And it is not being cheap or a miser
• Many facets
» Savings/Accounting 101
» Debt
» Delayed gratification
• House, car, fun
• Giving, charity
Personal Finance
» Retirement
» Investing
» Insurance
» Taxes
– Life, health, disability
– Affect what you keep
» Income
– Cash flow determines everything
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Savings
• The first thing when you start MAKING
money is to start SAVING money and
NOT to start SPENDING money.
• It’s easier to save when you are not as
used to spending
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Savings vs. Investing
• Savings is money you earn but do not
spend
• Investing is one of things you do with
savings
–40% of savings to very conservative
–50% to “investments”
–10” to “speculation”
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Investment
• An investment is buying an asset that is
expected to produce income or appreciation
• NOT gambling (that’s the 10%)
• “I’m more interested in the return OF my
money than the return ON my money” Twain
• A fool and his money are soon parted. Barnum
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Common mistakes
• Not enough savings
• Savings but investing way too
conservatively
• Savings but investing way too risky
• Assigning all responsibility to someone
else
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Suggestions
• Retirement account
• House (after somewhat settled)
– Generally protected from liability
– Generally with tax benefits
• Other-60% conservative
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Investment portfolio
• After house and retirement
• 60 % conservative investment
–Mutual funds
• 30% growth
–Individual stocks
–Real estate
• 10% speculative
–Gold
–Ostrich farms…
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Personal financial mistakes that I have
seen first hand
• Buying a huge house immediately upon taking a
job
– More later
• Whole life insurance
Don’t do it
–Buy term life and invest the rest
–Buy whatever other “benefit” associated with whole
life policy
• Pyramid schemes
• Nigerian email scam
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Assets
• Accounting Definition
–Something of value ($ realized from potential sale)
• Investment Definition
–Something that PRODUCES income
• Examples
–Car- not an investment asset
–House-only an asset if appreciation greater than
maintenance cost
–Dividend stock-dual asset
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House
• Don’t buy a big house immediately
»Wait at least the first year
• Rent and get to know your town/partners
» Minimum 20% downpayment (avoid PMI)
»Get liquid money BEFORE loan application
»Only buy 2X your salary
• House costs 10% a year
• Many will tell you otherwise
»Your lender, realtor, spouse,… delayed
gratification
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Problem I have seen
Home buying
• 1.
Buy a big house right away
• 2.
Buy a house in the wrong part of town
–Saddled with debt
–Moved shortly thereafter
–Lost a lot of money
–Didn’t realize it (airport expansion)
–Practice location moved
–Moved and lost a lot of money
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Problems I have seen
Home buying
• 3.
Wait to borrow money for down payment
– Lender approval and review
– Get the money in an account in your name early (before loan
• 4.
application)
Discovery of bad credit
– $10 Texaco bill-TD
– Credit score
• 5.
Buy with low down payment expecting PMI to go
away
– Mortgage “Insurance” required if less than 20% down
– Lasts the life of the mortgage
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Problems
• 6.
Paying points
–Offered as an option to lower interest rate
–Almost never a good choice
–90% of loans are paid off early
»Refinance for home equity
»Refinance for lower interest rate
»Property sold (moving)
»You lose the benefit from paying points
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Avoid High risk Investments
• Commodities/Futures
» Remember:
risky investments are usually
through ignorance of the subject
• Limited Partnerships
» General/limited partners
• Tax Shelters
» Don’t make investments for tax reasons
• Precious Metals/Coins/Gemstones
• Annuities
– Don’t make investments for insurance
purposes
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Best Investments
• Home
Although remember the warnings
• Mutual Funds
» Instant diversification
• Associated Retirement Plans
» Matching funds are free money
» Not the only investment
• Government Securities
– Larry Burkett, Investing Through Your Building Years
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College Savings
• Public vs. Private
• $15,000 vs. $42,000 per
year
• Need to save/invest early
• 529 funds
–Tax deferred growth
–Tremendous flexibility
–Start in residency
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Getting Financial Advice
• Chose carefully
» Financial Planner/Accountant
• CFP, CLU, ChFC, PFS, CPA
» Ask for references, interview, meet regularly
» Team of advisors
– Kiyosaki, Stanley & Danko
• Be happy to pay
» Drive a Lexus, but cheap out on financial advice?*
» Fee only or commission based
• Make your own decisions******
» Listen to advice, but decide yourself
» Spouse has veto power
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TD: Monthly lunch
• Financial advisor
• Lawyer
• Neighbor
• Other walks of life
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Your own family
Financial Schemes
• 1.
Don’t do it
–Rarely profitable
–You are generally considered affluent
–They think you can afford the loss
–Cause friction and ruin relationships
–Guys who sue their son/daughter
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Family financial schemes
• If you do it
–Gift
–Example:
RIMAGO
»Risk Management for Golf
»Stock
»Gift to his kids
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Personal loans from you to a friend or
co-worker or employee
• 1.
• 2.
Don’t do it
If you do- consider return OF your
money not ON your money because
unlikely to make money
• 3. Written document
• 4. Start pay back immediately
• 5. Penalty for late or balloon (incentive to
repay)
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Personal experience
Loans
• I borrowed money from parents for new house
down payment.
–8% interest first year
–15% interest thereafter
–Repaid in 1 year-OK
• Sibling loans
–Complicated relationships
–?More harm than good-facilitate fiscal problems
• Loaned money to OR tech, business deals...
–Got back about half
–Considered a gift
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Final Financial Thoughts
• Remember you have income not wealth*
• Mistakes*
» A smart man learns from his mistakes.
» A wise man learns from the mistakes of others.
» Bad experience leads to good judgement
• House
» No greater than 2x of salary
• No offer can’t wait till tomorrow*
• Private Practice
» Approach and apply business principles
» Start saving immediately
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Thank You
• Suggested
readings/references
» The Richest Man in Babylon,
George Clason
» The Wealthy Barber, David
Chilton
» Millionaire Next Door, Stanley &
Danko
» Rich Dad Poor Dad, Robert
Kiyosaki
» You Can Negotiate Anything,
Herb Cohen
» How to Influence people, Dale
Carnegie
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SWOTA : 2010
Resident Course - Fundamentals of
Fracture Care
“LIFE PRINCIPLES BEYOND SCIENCE”
Helpfulness of Material
A)
Worst
B)
Bad
C)
OK
D)
Good
COMMENTS Please
E)
Best
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SWOTA : 2010
Resident Course - Fundamentals of Fracture Care
“LIFE PRINCIPLES BEYOND SCIENCE”
Quality of Presentation
A)
Worst
B)
Bad
C)
OK
D)
Good
COMMENTS Please
E)
Best
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