• LecturehallWhat Am I Worth?
  • Lecture Transcript
  • Male Speaker: So there’s different types of work that you can do and it’s not only a primary work, that’s going to be whether you’re employed, whether an employee and I think [indecipherable] [00:17] employeed which I made that word up. You have to know the MGMA numbers who want to negotiate your insurance contracts so that you are – it’s hard to negotiate in insurance contract when you’re just one person. But if you have a group of people and you kind of corner the market in a certain area, you can go back to a payer and you can tell the payer, “Look, we’re the ones to see all these patients in this area with diabetic foot ulcers. And we do at the best outcomes or the best and we want to negotiate this insurance contracts, so that not only now are we getting a 105% Medicare, we want a 111% of Medicare.” And so that’s how you negotiate insurance contracts. But then you can also do consulting then you can do consulting by either lecturing for industry and that’s pretty lucrative but you have to set yourself as an expert. You can’t just be a normal podiatrist and not have any expertise in not be seen as an expert in one area or another and expect to get a contract lecturing for industries. So you have to be a good lecturer and then you also have to be seen as an expert and then that increases the amount of money that they’re willing to pay you to be a consultant and lecturer as well. So you lecture at meetings and now lecturing in meetings might be a little different, meetings like this where at CME meetings where you and your own state society or county society, they’ll ask you to talk on a certain topic. But they don’t pay you as much as you do if you’re lecturing at – for industry. Then you could do general consulting where if you’re seen as an expert in a certain area, they will – a company will come to you and say, “Hey, I’d like your opinion on a few products that we’re developing and maybe how to introduce them to the market or how to talk to podiatrist about them.” And so then you charge $500 an hour or something for consulting and then you would have them – they can come and either come and talk to you, bring you to an advisory board meeting. And they pay you to be in an advisory board, go over a lot of these things. You can also do expert witness work and there are a lot of podiatrist that do expert witness work, testifying in law suits. I do a lot of it as well. There’s just a few keys to that; one is never advertise those services. Because if you ever advertise them like I’m an expert witness, I’m going to put a note in a trial lawyer magazine. That’s always going to come back to bite you because they’ll bring that and they’ll show that ad to a jury. And they’ll tell the jury that you’re not a credible witness because you’re advertising for the service. So you don’t want to advertise those services and that’s a questioning always asked every time that I testify that go through the first five or six questions when they asked you these questions. And a lawyer is asking you these questions because one, they want to see how experienced you are as an expert witness. So some of the questions are like a really inexperience person would answer a certain way and an experience person would answer another way. One of those questions is, “Doctor, are you being paid for your testimonies today?” And an inexperienced person would say, “Of course, I’m being paid for my testimony. So you have me come here, I’m sitting here. Why would I not.” But that’s not the right answer because you – the words that they use because they’re lawyers and they’re tricky. Words they used are you being paid for your testimony? You’re never being paid for your testimony because you can’t be paid for your testimony. You’re being paid for your time away from your office and reviewing this case and for your expertise. So instead the correct way to answer a question like that is, “No, I can never be paid for my testimony but I’m being paid for my time away from my practice and for my expertise.” And they know that you’re more experience then – but another question they ask you is, “Did you advertise your services as an expert?” And then they’ll take that and you don’t even see it because you’re going to be doing the closure arguments with the jury but they’ll say, “This doctor admitted that he is being paid for his testimony, and he is being – he advertises his services,” then that looks bad. So you don’t want to do that. And then you want to take both plaintiff and defense cases. You may hear people say, “I’ll never take a plaintiff’s case because that’s just bad to testify against somebody.” But there are a lot of podiatrist who are doing the wrong thing. And some of them are really dangerous and it’s not bad to take plaintiff’s cases. But if you only take one or the other, if you only take only plaintiff’s cases or only defense cases, the attorneys are going to paint you as a shell for one side or the other. So it’s best to have a mix between them, so you can say when they asked you, “What percent of your cases are plaintiff’s cases and what percent for defense cases?” You can say it’s around 50-50 but I don’t care which side of the court I’m arguing on. I only care with what’s true and I’ll review any case and look at the case. And if there’s merit in the case, I will agree to testify in that case just like this one. In a jury – the jury’s always listening to that.


    But take both cases, I wouldn’t take plaintiff cases in your hometown. It’s not a good idea because other people are going to refer to you. You never testify against somebody that refer to you and you don’t take cases in the geography of whether they’re going to refer to you. But you take cases in – I do a lot of cases in Chicago for some reason. But I don’t live in Chicago so it’s okay. And then they get training, you never want to – and this works with lecturing too. You’re going to be trained how to do it because you can always get better. And as an expert witness, there are things that you can do to be a better expert witness, a lot of that being an expert witness is acting. The attorneys are literally acting but these two attorneys are friends and they know each other. They’re on either side of cases all the time. They go out drinking together and their wives probably meet up and the kids go to the same school and their friends. But you would never know that in a court case because they’re arguing and yelling at one another. And they’re acting because that’s what the jury expects to see and they’re doing that. But you as an expert should also be acting. You should act like a very trustworthy doctor that the jury would want to see you as a doctor. And if the jury can see you as their doctor, then you won that case. And so there are things you can do to just act better as an expert that will help you to win more cases. So look at MGMA, Medical Group Management Association publishes the average reimbursement or – I mean they publish in different ways. They publish both salaries. They publish the take home pay, net income, et cetera for multiple specialties. But one of them is podiatry and they break up podiatry and the general and foot and ankle surgery. And you can see that these are the MGMA, and you can get this book. So all you have to do is look up on line MGMA physician compensation book and it’s a really expensive book. It’s about thousand dollars to get this book. So what I would do is I would just get it as a residency program, for your whole program. It’ll be good for a few years get the numbers don’t have – you can see they change a bit but not sufficiently to warrant spending a thousand dollars every year. But you split it among a bunch of people, you get this book and now everybody in the residency has access to it. So when they’re going out looking for a job, they all know what the real numbers are. So this is for podiatry for general or foot and ankle surgery. And you can see the trend changes between 2013 and 2015. And this is better than any podiatry management survey or any APMA survey or any of this. Because this is actually what medical groups are paying for podiatrist. So the MGMA, this what it would looks like whenever you see in the book. But you can see that here we have podiatry, foot and ankle surgery and orthopedic foot and ankle surgery. And this makes you mad that that somebody’s doing the same work as you and look at the median column which is that median column which is in the – kind of over towards the right a bit. And you can see that a median orthopedic surgeons is making $566,000 and the median foot and ankle surgeons is making about $280,000. It is a little bit different with the RVUs and these are the relative value units. It’s the amount worth that they’re doing, they’re generally doing – you can see 8,000 RVUs and the median versus 5,500 RVUs in the foot and ankle surgery. And some hospitals will gauge amount of work especially if you’re employed based on the RVUs for that. And so you gotta know those numbers as well. You can get all these stuff from the MGMA book. So looking at the – podiatry actually is in a pretty good position. This is on the 10 best paying jobs of 2014, podiatrist were number 9 in that case. And this is all podiatrist – this is a bureau of labor statistics survey. That’s why I say trust the MGMA survey better because the MGMA’s what these medical groups are actually reporting. That they actually did pay and these surveys are a little bit different. US News and World Report rank podiatry number 12 in best paying jobs for salary, job market, future growth. And then you can also look at the highest paying markets for podiatrist. And you can see some areas like Fort Myers where I think they have an older population. It’s more lucrative to be in those areas than some of the other areas. Michael Jordan said that some people want it to happen. Some people wish it would happen and others make it happen. And I think that’s what you have to think about here. You can think about stuff happening but it’ll never happen unless you do it for yourself.


    So that means you’re going to have to go and make yourself worth more because you can’t just expect to walk in and get the best salary right at the beginning. So how do you make yourself worth more? Well you can do a fellowship and you may get different opinions on this but I did a fellowship and I did a fellowship with Armstrong. I did – I only made $75,000 for that year in my fellowship. So people will say, “Why would you do something like that? You make – you could be – you’re taking away one year of your top income for $75,000, when you look at your overall work life. And it doesn’t make any difference.” But I think it does make a big difference when you do a fellowship with somebody who is one, mentoring you and two, you’re going to be able to use that fellowship at always the rest of your life as a way to say that you’re providing better care than somebody else who doesn’t have a fellowship. And it really resulted in my case in a big change in my income from not doing a fellowship to doing a fellowship. And that change in income goes for every year afterwards. So I think that that makes a big difference. Doing a fellowship it’s – you’re not quite as busy as you are in practice and you’re not working so hard just to make ends meet. So you do have time to meet a lot of people. You have time to write papers which establishes you as an expert. So that when you do get out, you’re an expert in whatever category it is, whatever subspecialty in podiatry. And then you have to embody the – what an expert is if you want to be an expert. And you have to write papers, you give lectures. You know they say, dress for the job that you want not the job that you have. I know you’ve heard that before, but you want to. When I was in your shoes, every meeting I went to I always dress in a suit and tie. I wasn’t lecturing but I would dress as suit and tie because what I wanted them to see me just as the speakers, as an expert. And now, you can see the way I dress now. I never wear suit and tie but I am dressing for the job I want now which is like semi-retired. It’s the job I want. But you should dress for the job that you want not the job that you have. And then do things like press releases through the hospital, engaging social media. You can even hire a publicist. This is very common in LA practice where you hire a publicist to do all these things. You’re on the doctor show. You’re doing all these things so that then people really do think you’re an expert because you should really be an expert too but people can just think you’re an expert, and you get the same effect. So have better outcomes. If you keep track of your outcomes and you can prove that you do things and it results in a better outcome and especially a lower cost, than what the national leverage is then you’re going to be able to go to people and say – and payers and they’ll be willing to contract with you for that. So become a better speaker, you gotta go to speaker training, learn how to make a professional presentation. Some presentations are really bad. You gotta learn how to make a professional presentation that things like the type of background that you use. The type of font, how big the font should be, how many words should be on a slide whether or not to have more than one picture and animations. All these things are important and some lectures that you see are a really bad lecturers. And other lecturers are better lecturers because the speaker knows how to create a slide deck that looks well. And be generous so people will always come up afterwards and they’ll say, “Hey, can I get a copy of your presentation,” and then that really irritates speakers. It really does because speakers will they put a lot of time and effort into their presentations. And the first thing a speaker would normally think about is that, “This punk just want to rip off my presentation and just give it themselves.” Well, maybe that would happen sometimes but in a majority of the cases, if you’re generous with things and Armstrong does this as well a lot. If you’re generous with things, you mark it with your water mark with things with your name on it, I don’t care if somebody uses my presentation if they give you credit for it. That actually – if they’re giving you credit for using your presentation, that even makes you a bigger expert than you were before. Because somebody’s using your information and getting it out there, so just the same thing with writing papers. You write papers you want everybody else to cite your paper and use your paper. So anybody ask me for a copy of my paper, I’m happy to send it to them and I’ll send a PDF, et cetera. So you can be a wound care provider, you can work on a wound center. Wound center what we find, I’m the Medical Director for Restore itself which is a large group of wound centers. We have 200 centers in 30 states. And that’s why I spend so much traveling. But this is another reason why I don’t wear suits anymore because I’m on the road for 25 days and I can’t pack a suit for 25 days.


    So I can wear Lululemon pants and I can wear a polo and that works for me. But if you’re working in a wound center, what we find is that if you only work a half a day a week in a wound center, it increases the amount of money that you bring in to yourself by $50,000 in a year. By just half a day a week because these are all procedures that are being done. You’re booking surgeries out of this. If you’re supervising hyperbaric oxygen, you’re getting paid to do that as well. So you can make an extra $50,000 a year just with a half a day a week in a wound center. And those patients from the wound center after they healed, they never want you to take the patients out with a wound because you’re getting them in the wound center. But once they’ve healed they can’t stay in the wound center anymore. And they’re going to need to go to your office and you can provide longitudinal care and shoes, et cetera. And then become more involved in the professions. You gotta make connections and have opportunities be involved in the boards. I don’t get paid anything to be on ABPM. You know it say, it’s actually the big use of my time I spent countless hours bringing the other test and doing this thing. But it actually results in other things that are beneficial to me. When I’m an expert in a trial. There’s a board member from the certification board, that’s an expert in the trial. They’re going to pay you more to be an expert in the trial. They’re going to pay me more to speak or be a consultant that’s something even though I’m wasting a lot of usable time by being on the board. So people will look at that and they’ll say, “I don’t want to do that. That doesn’t pay any money. And I’m just wasting my time.” Well it’s not a waste when you look at the overall picture. I want to get to questions so I don’t want to go through all of this but these – I’ve only been out technically for 10 years. And I was able to build all of this just in 10 years but it was always because I was constantly looking for other things to do and moving through my life and being involved in one way or another. And then the other thing was just concentrating on academics. This is over the past 10 years. There’s a number of papers that I’ve written in a number of lectures that I’ve given. And you can see some years like 2011, I had a really good year. And that’s actually because your papers get – you write a paper and it doesn’t get published for a year and a half after you write because it goes through this whole process and everything. So in my fellowship, my fellowship year which was 2006 to 2007 with David Armstrong. I wrote 30 papers in that year. But they didn’t get published for a year and a half and so I’m already out working and people think you’re a rock star because you’re cranking a lot of these papers. But I wrote them a long time ago and they’re just getting published now. And so you have the time to do it in your residency and you have the time to do it in your fellowship that you may not find that time later on. So you should be concentrating on doing that now because finally when they do get published, you will be on practice. And so write on something that you’re interested in practicing, making your practice about. I think this is the last part which is you just come and contract mistakes. When you’re looking at getting a job anywhere whether it’s you created it yourself or anything, you have to negotiate a contract. The first thing I tell you is never negotiate your own contract. You can look at the contract, you can make points about it but always hire a lawyer to do it for you. A lawyer is going to cost you about $1,500 to negotiate a contract for you and review it. And that’s $1,500 that you probably don’t have. But it will mean so much more in the amount not only the amount of money that you might make like they’re going to help to negotiate your salary higher. They’re going to negotiate your benefits but they’re also going to work on things like your termination, because that’s what lawyers think about. When this relationship goes sour, because relationships in many cases unfortunately do go sour or there’s going to be a – you’re never going to work in that place the rest of your life. There’s going to be a point where there’s going to be termination. How is that termination going to affect you? And so they will focus on things like the non-compete. These are things you might not even think about but there might be a non-compete in your contract that says, “You cannot work in a 10-mile radius from this place.” Now if you’re in the west side of Chicago and you have a 10-mile radius that’s – you get to move your whole family out of that area to then work somewhere else. So that’s really disruptive to you so they’re going to focus on things like that. Some states non-competes are not even an enforceable like in California. You can write in all the non-competes you want but it’s not enforceable in the State of California. So they can’t enforce it. They can say, “You can’t practice in California.” Doesn’t matter. They won’t do it. But what’s going to happen to the account receivable after you leave, you did all this work and you know you don’t get paid for months sometimes after you did the work. But that’s worth that you did and you might just think, “Oh, I’m leaving this job.” Well you’ve got $150,000 and an outstanding account receivable, you should – that’s your money. You did the work for that. So those are things you might not think about but that’s what a lawyer is going to negotiate for you. Mutual non-disparagement clauses. These are things – so if the relationship does go sour and you leave, you would say, “The mutual non-disparagement clauses, you don’t say anything bad about me.


    And I wouldn’t say anything bad about you.” Now you have to stick to the agreement because you’ll get suit if you say, “That hospital was a mess. People – you get sick over there. I’m not working there anymore.” Instead you just say, “Oh, it didn’t work out in that hospital. I’m over this hospital now.” And but they also can’t say anything bad about you. If they do you can sue them. And I’ve done that before. I sued a hospital in California and I won $105,000 law suit against them for – when my lawyer put a mutual non-disparagement. And the doctors of the hospital said some bad things about me, and we wrote – first, we wrote them a cease and desist letter and then it didn’t stop. Then we sued them and they settled for $105,000. So these are things that I would have never thought about but a lawyer put it in my contract. So my lawyer is a good lawyer because her husband is a podiatrist. She’s in California and she knows – she’s like the lawyer to all the podiatrist in LA. So she knows how to do this stuff. Then how to do conflict resolution if you get in the conflict with them, how are you going to resolve that? So these – don’t negotiate your own contract. Then the other thing too is that you – if you negotiate your own contract, you might be – you might not feel comfortable with it. But two, if you do feel comfortable with it, they’re going to – you’re going to be kind of an asshole when you’re negotiating your own contract. Because the relationship might not start at the right – off on the right foot. And instead if your lawyer negotiates a contract for you, you can – they’ll say, “Wow, you’re a lawyer.” And you’re like, “Yeah, he’s an asshole, right?” But that’s a good job. So I’ll leave you with this quote. We just have a few minutes for questions but this is Will Rogers no relationship to me says, “Even you’re on the right track, you get run over if you just sit there.” And so you could be on the right track of life, but if you’re not moving, you get run over by the train. So it’s important to always be thinking about where you’re going ahead and keep moving. Any questions? So the questions is about ABPM versus ABPS certification for hospitals. There are some hospitals that do care and that’s because the people who helped to write those guidelines are the podiatrists because hospitals don’t know the guidelines, right? And so if you have some podiatrists that are there, they’re trying to keep other people off of stuff and you’ll see that. They make very restrictive guidelines so that it only fits certain groups of people that want to keep everybody else off steps so that you’re not competition with them. The no right very stringent criteria, that’s why you have to get the hospital bylaws which we’re happy to give you and that’ll describe what the criteria is for being on staff for the – for your medical staff. If you do see that it says specifically, ABPS then what you do is you call the ABPM board office and you tell them that I’m trying to get privilege at this hospital. And they say that they require only ABPS and then the ABPM office writes a letter and calls them and tells them about the board certification. And that it is – there’s only two boards in podiatry that are approved by CPME and that’s one of two boards. They oftentimes don’t know that because there’s somebody else, some other podiatrist that said that, “I’m only taking ABPS people.” Now your board certification does not dictate whether or not you can do surgery. That’s that thing about it. Everybody in here is doing the same residency. You’re all doing a three year APMS residency. So you’ll have the same experience when you get out of your residency. Then you take your board certification and that’s another box to get checked. But the way that you get surgical privileges at hospitals, so we’re talking about credentialing versus privileges. You get credentialed and then that’s with either board and then you need to get privileges. And those privileges are – let’s say, you want to do an ankle replacement or you want to do Charcot reconstruction or any of these things that are on the privileging list. Your privileges are based on your education, your training and your experience. So you have to show that you have the cases in order to get privileges to do that. They won’t even if you’re ABPS, they’re not going to say, “You can do ankle replacements because,” – but if you have zero cases, you’ve never done them before, it’s not the board that matters. It’s what your experiences that matters. So in your residency you keep logs already. But you’re going to want to keep these logs, if they’re podiatrist residency, where’s the PR, what’s the ARCH stands for, resource. Yeah, so you’re going to have those logs anyway. But even when you’re not in residency or going through board certification anymore, I still keep surgical logs. Because if I apply in a new hospital, I keep an Excel spreadsheet and I’m going to print it out and I’m going to give it to them so that I verify. Because I only operate within my scope of practice anyway, I never asked for privileges that are outside of my area.


    I don’t ask for arthroscopy or ankle replacements or anything. I do Charcot foot reconstruction. I do lots of split like a skin grafts. I do all types of partial foot amputations, some reconstructive surgery for diabetes. Those were all – I do a very, there’s probably 10 common surgeries that I do and that’s it. So that’s why I’m asking for and then a few other things that might come up. But I verify that with my experience and I’m only ABPM. I’m not ABPS at all. Because when I went through, I sat for ABPS but I couldn’t pass the case qualification because I only do limb salvage. I didn’t have any diversity. They told me that you need to have X number of different types of bunions and this and that and all this stuff. I said, “Look, I only – calcaneal fractures or whatever. So I don’t do any of that stuff. I do only Charcot foot reconstruction. I do ankle arthrodesis. I do – I am for ankle Charcot. And I do more surgery than a lot of them did.” But I didn’t qualify because I didn’t have any diversity. So that’s what really include me into all of this. But you can use other people to help you get that. But just know that it’s your case logs that determine your surgical privileges. Alright. Thank you.