I have pursued the SBA PPP because I am a physician small business that is organized as a PC, and I am part of the legion of American small businesses that have been impacted by the COVID-19 crisis.
Aren’t Physician’s Making Money In A Pandemic?
The average citizen assumes that a medical pandemic has resulted in an income boost for physicians because healthcare is in the news all the time.
Of course, they are wrong because the majority of us are not located in surge regions, nor are we in service lines connected to COVID-19. Thus, most of us have seen significant reductions in our income the past few months, including 1 in 5 having our employer reduce our pay.
For private practice physicians, this has led to a host of short-term interventions in their struggle to keep their business afloat. The SBA PPP is a helpful bridge for many to help their business to survive. Not only does it help the physician owner get paid, but it helps them pay the staff. This is a critical piece connected to retaining staff, who can easily find other jobs in a very competitive environment for healthcare workers. Staff retention is a huge challenge in physician practices.
For example, my primary nurse has chosen to take a furlough from the practice to work at an extended care facility that has offered her a large financial incentive. This includes leading the development of their COVID-19 unit for nearly $10,000/month. It’s hard to compete with that, and I suspect I may never get her back.
For employed or specialty contracted physicians, the PPP is of no help to them, as those funds go to their employer, the company that generates their paycheck. Even with this government support, many physician employers are slashing salaries and compensation due to massive corporate losses from the moratorium on elective, non-emergency healthcare.
PC’s Are Unique Small Businesses
For me, as I outlined in my last post, I have an employment lite agreement with my PC that has insulated me from most of the challenges that private practice and employed physicians face in regard to the business of medicine during the pandemic.
Due to my unique structure as a small corporation under the pseudonym “Country Doc MD, PC”, I am eligible for PPP funds. This is because my own company writes my paycheck each month. It employs me, and my wife who serves as our bookkeeper. Like most PCs, it is a lean company. This mirrors most small businesses whose employees often originate from within their personal households.
Do I Want A Bailout?
My initial response to this government bailout program was one of passivity for three reasons:
Because I am a small business with less than a million dollars in revenue annually, I wasn’t sure of the amount of money involved would be worth the process.
Speaking of process, I figured the process of gathering data and information for proof of the need for a government program would be too cumbersome
Personally and corporately, I was financially secure enough really not need the loan.
But, as I saw reports of large corporations around the country going after these funds that were framed as forgivable loans, I realized that it would be foolish to turn my back on it.
Civic Duty
After all it seemed like my civic duty to acquire the money that our government wanted to rapidly re-infuse into the economy. So I decided to check into it further.
SimpliMD Team
[the_ad id=”471″]Fortunately, my corporate accounting and legal team called SimpliMD was already working on it behind the scenes, and in essence said “sign here” and they would get the SBA PPP loan documents to the bank for funding. Wow, now that is worth every dime of my fixed fee structure for this dynamic team at KDU who leads my business and fiduciary operations. I didn’t even look at the application that closely, I just did what my team told me to do, and trusted their wisdom. I love that about having a trusted professional team to guide my enterprise month after month.
It kind of reminded me of how I operate with my primary care office team, I depend on them to round up and complete the various forms needed for DME, Home Health, Transitional Care, etc..and I just “sign here”. Beautiful! I trust them to do the work, especially the busy work, and simply sign where needed.
The Traffic Jam At the Bank
As some of you know, the banks and lending institutions ended up being thrust into the drama. They were unprepared and overwhelmed by the loan application process from so many small businesses.
The banks sorted themselves out into 4 categories in regards to helping small businesses:
For a minority of banks, the bank as a whole AND their commercial banking staff went above and beyond working with clients, started early, stayed late, and nailed it. Everyone in, everyone good.
Others decided it was too hard, and too much work, so they had their IT department create a web-portal and effectively said, “Do it yourself, and best of luck”
Yet others had applications come in, and elected to cherry-pick which of those clients (all who had long-standing relationships with them) they would put in first. Not who got their clean application in first, but who they “decided” they should put in first.
The large banks like CHASE and BofA all did portals, and the process for the masses was slow as expected.
With my application pending, I heard reports that the SBA PPP loan fund had dried up, especially as numerous large corporations took huge chunks of it. Now that’s pretty frustrating when Ruth’s Chris was able to steal funds intended for me!
Denied
I was notified the next day in an email from my bank that my application was not processed in time, and therefore was not funded.
It left me wondering whether I was a victim of large corporate raiders of the fund, or if my bank someone viewed me with less value, thus putting at the bottom of their stack.
Funded
But the good news is that congress rallied, and appropriated more money, and my application got processed and funded.
Although I have been honest, it didn’t happen until I emailed the bank and asked them to check on the status of my application. After getting an immediate “let me check on that” response, I then got an email to say that it was being it was funded. Surprisingly, that same day they sent me the closing documents to sign.
It leaves me wondering what would have happened if I had not called?
The Loan
So I am taking the $22,500 PPP loan for my PC. It is a modest amount that I know I can easily pay back, but I plan to comply with whatever pathway is necessary to make it forgivable.
My team also warned me that these forgivable loans will likely get taxed as the IRS seeks to recoup more revenue through the process. This makes it feel like laundered money will be used to refill the treasury. Congress is seeking to over-ride this Treasury interlude and hopefully will succeed.
Small Business Support
I do think that this stimulus package will prove to be a wise investment in the small businesses of America as long as both the IRS and the large corporate raiders can keep their hands out of it.
For my fellow physician-owned small businesses, I hope you are able to gain access to this program as well.
Most physician employees receive W-2’s from their employer and have NO PROTECTION OF THEIR PAYCHECK under the congressional CARES Act. These funds were created for small businesses, with some controversy on size requirements, to keep their employees working and paid.
The majority of employed physicians have either seen their pay reduced, or have been asked to voluntarily reduce it as a good corporate citizen. In my physician network it was a simple email request to employed physicians:
However, I am a W-2 employee, and the SBA Paycheck Protection Program has been helpful. You might ask, how can that be???
Let’s start with the understanding that I own my healthcare company under the pseudonym of “Country Doc MD, PC”.
Employment Lite
“Country Doc MD, PC” is contracted with our local physician network to provide family practice with obstetrics medical care to our community and receives an annual 1099 for the Professional Services Agreement (PSA) otherwise known as an “employment lite” agreement.
This “employment lite” agreement allows the physician network to maintain control and alignment of my professional services, and in exchange, I gain control of my income flow, tax strategies, and benefit plans just to name a few.
Like most PSA’s, “Country Doc MD, PC” is paid based upon the fair market value RVUs that are generated by my workload on a monthly basis. It’s that simple in my PSA, I have no other responsibilities for the practice, employees, billings, collections, etc.
I am paid a fair market W-2 annual salary by “Country Doc MD, PC” for the medical work provided.
This is a diagram of “Employment Lite” or a PSA
My wife and I are the only two employees of the PC, as she provides the book-keeping for “Country Doc MD, PC.” The PC structure allows for income flow control that adds levels of tax strategies and retirement benefits for our household that are not available in the typical employed physician W-2 arrangement, nor in the typical contracted physician 1099 arrangement.
The Secret Sauce
There is a secret sauce involved in organizing this business structure that leads to significant retained income and significant increases in retirement savings. Of course, it’s all within the boundaries of the tax code.
The PC-PSA structure has provided a level of insulation for me from the economic undulations associated with COVID-19
Unlike my private practice friends, who have several employees (including themself) depending on the business to stay afloat, I have no pressures like this to manage.
Unlike my physician network employer, who is managing the tension of reduced revenue in connection with complex staffing decisions associated with running a primary care clinic, I don’t have to worry about coming up with the solutions.
While my employer looks to voluntarily, or involuntarily cut physician pay, I am out of this loop.
Protection From Productivity Losses
For better or worse, my PC is paid for the work I do, and it’s just that simple. The translation is that my company will likely see a 25% dip in the “Country Doc MD, PC” income over the next few months as the RVU’s go down. But my employee salary has been set at a much lower number than the corporation earns, thus most reductions in corporate income will not negatively impact my monthly pay.
Note here, although it is counterintuitive, the lower W-2 salary in this secret sauce actually leads to greater retained income than standard employment contracts.
Let me say that again, due to my business structure, my productivity losses due to COVID-19 will not negatively affect my employment salary.
No Hand Wringing
This is why am I not wringing my hands over the healthcare economic downturn from COVID-19?
I have chosen “employment lite” for the very reason that I don’t want to worry about all elements of practice management associated with running a primary care clinic, including the profits and losses associated. √
The only employees to manage are myself and my wife, and we have organized our professional and personal financial structure to weather this storm. √
Here Are Some Other Reasons Not To Wring My Hands
I Am Financially Independent
I have no pressure to earn a certain amount of money per month in order to pay my bills. The biggest element that propelled me to Financial Independence, was switching from standard physician employment to a PC-PSA model. This transition was worth a million dollars, or more, to my net worth. Modest living, some financial literacy, and having a great financial advisor-planner have also helped my family get to this wonderful place of freedom.
Passive Income
My wife and I knew that we would want to have passive income to supplement our retirement income that was limited to ERISA caps as an employed physician. Many physicians falsely believe maxing out their employer-sponsored retirement programs will lead to enough to retire on. Since most physicians are used to living on a higher monthly income than ERISA accounts for, employer-sponsored programs will typically leave the physician well short of their goal.
We began to build passive income channels through real estate and construction business ownership as a strategy to augment my employer-sponsored programs. I made my share of mistakes in this realm, especially with angel investments, but I have managed to organize it into an integrated portfolio that has led to building our long-term net worth. Net worth is the most important number to keep in mind.
The two most valuable decisions that I made to help increase net worth and retirement funds were both linked to my transition to a PC-PSA
I purchased a medical office building, negotiated to move my practice to that location, and began leasing to my employer. Currently the building is paid off, and this provides nearly $10,000 per month in income. With multiple providers in the building and a thriving practice, it is likely to continue as a leased medical office building even after I retire. The monthly revenue from the building and the value of the asset makes it a double win.
By forming a professional corporation with my wife and me as the sole employees, we are able to significantly broaden and deepen the benefit plans that are individualized to our needs, and this is especially the case with retirement funding. We are now putting away 4x more in retirement the amount than we could with a traditional physician employment contract.
No Debt
Literally right as COVID-19 hit the US, we made our last banknote payment of any type, it was on the medical office building. We owe no-one any amount of money. That feels really good, as all of our real estate and business ventures are fully paid for. This component especially creates a sense of peace and stability in regards to any physician income changes that could occur associated with COVID-19, or any other economic crisis. Regardless of how little or big my monthly paycheck is, it literally is the icing on our financial cake.
Personal Finances and A Support Team
We have always created and followed an annual budget, sought to live frugally, enjoyed the good life associated with a physician income, gave to charity with an increasing percentage every year, and worked with a fee-only financial planner-advisor who supported us every step of our professional and personal journey.
We really turned the corner though when we put together a financial-business team that included a financial planner-retirement-wealth manager along with an accountant and an attorney. When we all sat in a room together and worked as a team, the outcome was magical. It led to the formation of my PC, the PC-PSA agreement, and separate business development and marketing company that supports the PC.
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In fact, I became so convinced that my personal and professional journey is within the wheelhouse of thousands of physicians around the country, that I helped create a company to make it simple, yet individualized for each physician. You too, can have a physician-led team that provides a full accounting, legal, business, and benefit plan team that works together on your behalf, all at a fixed fee that has over a 300% ROI. Check out SimpliMD if you want to know more.
I Qualify For The SBA Paycheck Protection Program
So, even though I am a W-2 employee, my company “Country Doc MD, PC” does qualify for the SBA PPP. And under the direction of my support team, I applied for an SBA PPP loan.
Check-in with me later this week with my next blog post to walk through that experience together.
A little-known secret to the average citizen is that many physicians live paycheck to paycheck. Yep, and that risky personal financial strategy has gotten exposed during the economic hurricane called COVID-19.
In the midst of this crisis, the emergency fund that the dutiful doc had intended to put away, never happened, due to the tyranny of the urgent. Most of the time, it was put off due to some other consumptive purchase that was a result of unleashing all that pent-up delayed gratification associated with becoming a doctor.
The large monthly cash flow created the illusion of safety. That large check always seemed to keep the ship afloat, and hid the risks that lay under the surface. Some money in the checking account and regular funding of the corporate retirement plan created a sense of security that came with a predictable high income.
The classic 50-25-25 post tax spending plan sounds good in theory. You know 50% goes to fixed expenses, 25% to variable expenses, and 25% to savings. But that the 25% savings always gets pushed to the end of the line, as more pressing bills consume those funds. We assure ourselves, at least we were saving for retirement with a maxed-out corporate plan. Little do we realize that those plans were developed with caps that represent the projected needs of the average worker, not the high-income earner.
We knew that given the size of our student loans, buying the over-leveraged “Doctor’s House” was not the best move, but doggone it, we deserved being able to have something nice. Besides, isn’t a house an investment and not truly an expense? On top of that, the mortgage is tax-deductible, so putting both ideas together, the bigger the better, right?
The new car was affordable when that $90,000 tesla was broken down to the $1100 monthly payments. Why not, you reason, there is enough in the bank each month to cover this. Or even better, just lease the car of your dreams, for $800/month as that is even cheaper than buying. Now get one for both you and your spouse.
Childcare, private school, tutors, college tuition, and such are all part of the family responsibilities that must be kept up if our kids are gonna make it in life. After all, public education may be cheaper, but the best networking and job opportunities come from the top private institutions, right?
Isn’t medicine in America recession-proof? People will always need, want, and demand healthcare in this country, won’t they? Going the employee route or contractor route, all but seals the deal with guaranteed contract money. Most of the contracts have a basement and then are incentivized for productivity bonuses. The bonus money especially feels good, as it strokes our competitive nature.
But then the walls start to erode, as the COVID-19 crisis takes hold. Suddenly financial fragility hits financial turbulence.
Our savings and net worth start to ebb away as the stock market heads into a bear market.
Our productivity goes down due to elective and non-urgent medical care being furloughed for public health safety. There go our bonuses.
Our contract is restructured so that our employer does not go bankrupt, and we are asked to accept lower pay as part of being a good citizen. It feels like we don’t have a choice.
Even worse, we could get terminated in a bear market where physician hiring is being frozen, and delayed for who knows how long. So signing on somewhere else is not a bail-out option.
If we were diversified enough to have a side hustle, those likely have melted away in a broken economy. If you were fortunate to have passive income from real estate holdings, guess what, all those leasers can’t pay their leases due to losing their jobs too. Now you are holding a negative cash flow asset, and the bank still wants its monthly commercial loan paid. Guess who has to come up with that money?
If you are in private practice, you MIGHT have gotten in line early enough to get an SBA loan in order to keep our small business afloat, while you nervously play a game of survival with your staff-employees, and likely aren’t paying yourself.
Now that you are getting a paycheck for half the normal amount, and suddenly those fixed monthly expenditures are extremely tight, and your variable expenses, which your family deem as essential, are now a contentious conversation piece.
It’s tempting to pull out the credit cards, with their $30,000 limits, and the reason that this was just a bad month, next month will be better. So you use this “get out of jail free card” now and simply pay it off next month. Guess what, this pandemic and its economic impact are going to last a while.
Next month, we ask that is the minimum payment on that maxed out 19% interest credit card, and we go to the bank and ask for a personal loan to bail your family out. After all, given our lifetime earning potential, bankers really like to loan doctors money. Besides interest rates are low now, it’s almost like free money. But you discover with everything maxed out in your personal finance, even the banker finds it difficult to figure out what will be the collateral for the loan. He is willing to offer an unsecured loan, but the interest is pretty steep. You have no choice, but to sign and take the money.
And we kick the can down the road further. Saying to ourselves that after the pandemic you are going to look for a new job that will provide a hefty signing bonus that will pay off the private loan.
Then we’ll go back to our normal life, living paycheck to paycheck, but happy as a clam that we are living the good life as doctors.
Doctors, use this interlude to do some personal inventory and break the patterns that have put you in this predicament. You don’t have to go back, you can move forward.
Get some help from a physician agency today, from people who understand the physician’s world, and have resources to help you. Check out the resources at White Coat Investors, Physician Philosopher, and SimpliMD just to name a few.
We are creatures of habit, and predictable routine brings most of us rest and peace. We like knowing what to expect through rituals and patterns that mentally map predictably from unpredictable moments. That’s why physicians are known to “look at their schedule” for the day, or for the week. It provides us with a glimpse of what to expect, and thus frames our mind with some semblance of predictability. It is comforting to know what to expect for the day, and each doctor tends to create a schedule or routine for their clinical life that allows them to manage this tension. If you want to see a doctor look uncomfortable, change his schedule, his procedure day, his shift sequence, his staff support, or his workload.
Doctors are conditioned to be calm and logical during tense and unpredictable moments, but trust me, with the daily changes and challenges coming at them from COVID-19, they are feeling unsettled on the inside. Doctors ARE humans too, and the waves of change are disconcerting to them just like the rest of the planet.
The book by Spencer Johnson entitled “Who Moved My Cheese” nicely unpacks the idea that change is part of the human experience. The core message of the book is that things constantly change, so we must adapt. It provides a nice parable for us as we all experience our changing world.
Virtually every sector of our American culture is being forced to adapt to the menacing virus called COVID-19. Politics, Banking, Business (big and small), Healthcare, Education, Entertainment, Globalization, Food Industry-Farming, and Individual Liberty are just a few major categories that have had to radically adjust to this international pandemic that has especially impacted the US.
To be honest, it feels like the changes in my physician world are daily, and the persistent fluctuations wear me down. Although I tend to be an early adopter, and therefore embrace change more easily, the continuous waves of change empty my energy tank. I think that aptly explains my fatigue when I tend to be a high-energy guy. I am seeing fewer patients than I have in years but come home exhausted every night. Even this paradox creates tension for me because it defies my logical view of how patient volume-RVU and fatigue normally associate.
Looking to more deeply understand what is happening to me, I decided to create a diagnostic list of the changes, hoping maybe it would bring a deeper self-awareness of why I was feeling this way. So here it is, and perhaps it will resonate with you.
Professional and Personal Changes For Physicians From COVID-19
Patient Care-Staffing
I used to see my patients at one location within an integrated schedule that was a mixture of wellness, chronic disease, and acute care. I was surrounded by a team of healthcare professionals who all worked together to provide comprehensive medical care. It was efficient, effective, and energizing for me as I touched and talked to my patients one by one, and led my clinical staff.
Now, I only see and touch non-sick patients 2 days a week in person, I suit up in full PPE 1 day a week for sick patients, and a do a bunch of tele-visits the rest of the week. I miss touching my patients and connecting with their lives.
My physical location for the majority of my patient care is in someone’s else’s building (mine is now the FURI clinic) or my home. Being displaced reduces and disrupts many operational efficiencies, and is more unsettling than I expected.
We have cut back our staff with furloughs, moved some support staff off-site, and I am now working in some else’s building. Each of these alterations place unspoken pressures on me and my nurses. We have to handle every little detail that had previously been delegated to our team-mates while at the same time adjusting our clinical operations to the ever-morphing guidelines. We miss our medical home, we miss our nest, we miss our team, and we really miss our predictable routines.
Infection Prevention
Universal Precautions have always been part of our training and clinical experiences. Whether it be the more elaborate process in the OR, or the daily grind of the clinic, we are all used to being cautious. Doctors in primary care have long been known to have robust immune systems that compliment their infection prevention measures, and allow them to mostly evade infections. But this new COVID-19 is strong and elusive, requiring time consuming, and thoughtful cleaning, PPE, and hand location awareness all day long. You can’t let your guard down, while you breath through that uncomfortable mask that you have to tediously and carefully apply and remove. Then there is the constantly changing PPE protocols at the hospital that I attend. This seems to vacillate between PPE stewardship and rigid use to prevent infection spread.
Cleaning our personal tools like the stethoscope is critical, but the most important instrument, after our stethoscope, to remember is our pen. My habit has been to always have a pen with me, but mindfully breaking that habit, as well as repeatedly cleaning it after use has been challenging. They say it takes at least 30 days or more to form a new habit. I have not arrived there yet, so my brain is working overtime on these things numerous big and small things all day long.
Schedules
The staccato of rescheduling patients every day, adjusting to who is available to do face to face visits, which provider is at home, if the patient needs a FURI appointment, working in non-sick acute problems, and funneling all of my OB, pediatrics, and needed face to face visits into two days is extremely challenging. It requires me to think “where am I” and “where will I be tomorrow” all the time. Prior to COVID-19 I knew every trick for squeezing and adding patients into my packed schedule, now I feel lost.
Printing scripts for controlled substances (we are not set up to e-scribe them yet), work notes for COVID-19, downloading faxes, signing all the home health, hospice, dme, mail order pharmacy, etc. are no longer centralized to my one location. These tasks have to be batched on the days I am in the non-sick clinic, roaming in some else’s clinical space. Not a huge deal, but this change prevents me from “being done at the end of each day”. I am one of those people who like to start each day with a clean slate, and right now that is just not possible. When I start my day off behind, because I am cleaning up yesterday’s tasks, it stresses me out.
Public Health
Who is charge of managing and leading in this COVID-19 crisis? Is it the White House, the CDC, WHO, Congress, the individual states, or someone else? As hard as I tried to identify a concrete chain of command within the US for pandemics, I couldn’t come up with one. There are just so many stakeholders within the federal, state, and local governments in addition to a slew of associations, businesses, and organizations who are speaking simultaneously.
Instinctively, physicians look for authoritarian voices within the public health chain for guidance. But there are so many voices that speak to us each day. They include television, social media, email, radio, and all manner of digital feeds which all communicate critical guidelines to the health and inter-related economic features of this pandemic. The voices are from the stakeholders in our circle of authority who all seek to interpret where we are, and where we are going. It can be hard to listen to each one every day, and then try to distill the information down to practical steps for our medical care and patients.
Sheltering in place, social distancing, quarantines, and such have all become normalized concepts that start to get fuzzier as we talk about local and national stats, surges, mitigation curves, supply challenges, and 3 phased recovery plans all simultaneously.
Most physicians are used to being at the top of the authority chain within their clinical space and within their patient population. But now we are displaced from this role as we are mandated social and clinical changes that are rolled onto us day by day. We are forced to adapt and deal with them in the same real time experience that the general public is fed the information. It’s a little nerve racking, and can place us in awkward positions with patients who might walk into an exam room with more up to date news than we have had time to absorb that day.
And don’t get me started on the fake news and social media banter that we have sort through as well. This includes questions about the latest “cure” for COVID-19 that has been discovered by some non-scientist who has out-smarted the world’s medical experts. Truth can be hard to find in this age.
Home
I have written about the numerous changes that occurred for physicians in their homes as part of the process of protecting their families form the virus.
For me, I have taken the aggressive step of moving into our guest house to safely separate from my family, due to the fact that I am working on the front lines.
It is the right move, but this is a massive change for me with some associated psycho-emotional hardships with it. I definitely don’t sleep as well without my wife, and I really miss interacting with my kids. The loss of physical touch with my inner circle, leaves my love tank on the empty side.
Income-Personal Finance
I’ll have to admit, I haven’t thought a lick about the stock market and it’s undulations. My financial planner has taught me to stay the course at our long term plan and ride out both the ups and downs. So I do it, and don’t even look at the numbers.
My accountant rapidly helped me get the CARE Act SBA loan application into our local bank for my medical business. I just got notification yesterday that all the government funds had already been used, so they hoped I would get in the next wave, if congress adds some more money to the pot. So much for small business support from the government as billions of dollars have been scarfed up.
I am financially independent, so the reduction in my productivity and income will be noticeable, but inconsequential. I have prepared for this season by having no debt, as well as having passive income that provides monthly checks. I will simply be thankful for what I earn during the pandemic, no matter the amount. I don’t expect anyone else to fix it. To me that is part of being a business owner in a free market economy.
But the hardest part is to see the negative effect on my staff in terms of hours reduction and needed furloughs. It is gut wrenching to experience this with me team-mates, especially knowing how marginal some of their personal finances are. We keep doing all that we can to allow as many staff to maximize their hours, and stretch them. As the weeks go by, and the losses mount, I expect more reductions will occur. sigh.
Healthcare used to be considered relatively insulated from recessions and economic downturns, but we have discovered that pandemics can break that glass.
As optimistic as I want to be, I think it will take as many 6-18 months for us begin a robust economic recover, which will likely run parallel to the development of a vaccine.
Entertainment
In Northern Indiana we tolerate the winter with the anticipation of Spring. Spring brings the opportunity to freely roam from our home to all sorts of date night spots in our vibrant little town. I have really missed being able to go out with my wife on dates to those entertainment options that range from music, art, dramas, and sports. Screen time does not fill my tank the way sensory arts do.
I do enjoy all types of American sports, and I have found that I miss a mindless and relaxing evening of watching a Cubs game or basketball game in the evenings and weekends. Cancelling football would make me gasp. But this is where my wife has the upper hand, because the Hallmark Channel is always available, regardless of a pandemic.
Faith Life
My faith life is deeply personal and I find it to be a source of hope, comfort, and an anchor during these crazy days. Knowing that God does NOT change provides rest for me as I let him lead me quietly in His shadow.
But I do miss assembling with others in my faith community. I long for their relational support associated with being life on life as we all navigate these changes. My faith is strong, but it’s missing an important human touch each week.
Isolation
Due to sheltering in place and carefully trying to protect my family, isolation has become normative. My work family has dramatically changed, my biological family is now across the street, my faith family is no longer meeting (beyond the Pastor on a screen), and my patients only see me behind a mask. For a relational guy like myself, isolation is a necessary change, but it tends to stop the flow of energy from others that fill my tank each day.
Change is inevitable for each of us. The scope of changes due to COVID-19 is unique to each person, but also common to many.
We must anticipate the changes, adapt to them, and learn to embrace and enjoy them. Do so and you won’t just suffer less stress and unhappiness, rather you’ll enjoy more success and fulfillment in every part of your life.
Change often represents the end of something, but more importantly, it also represents a beginning as well. COVID-19 has created this dynamic in all of our lives. Although, we all long to “go back to normal”, the intra-COVID season, as well as the post-COVID days, will probably be forever different.
Each one of us is equipped with a symbolic energy tank. Week by week our tanks get filled and then get emptied by a whole host of events and experiences.
Physicians are especially prone to have our tanks emptied by patients, phone calls, texts, emails, instant messages, reports, documents, and other clinical demands. Our home life can have the same effect, filling or emptying our tank. How we view ourselves, and our deeper sense of purpose even impacts our tank. For many, change tends to be a tank emptier, although some are energized by it. In an odd paradox, many physicians around the country are seeing fewer patients due to the pandemic, but they feel more exhausted at the end of each day. If you haven’t figured this out yet, it’s due to the undercurrent of change.
The COVID-19 Pandemic, and its associated day-to-day changes in our life, have brought about a host of challenges for every American. However, it has especially assaulted the well-being of physicians, who prior to this pandemic, had already begun to feel the ugly shadow of burnout cast upon them.
Right now, we just need a roadmap to help us see some daylight and hope. I want you to take a deep breath, and follow these steps for self-care. This will help ensure you don’t become a casualty of our profession, even if you are fortunate enough to avoid becoming a casualty of the virus.
I have broken this down into a day-to-day process that will lead to deposits being made in your energy tank, rather than withdrawals.
Monday: Look For The Purpose
Mondays have a way of setting the tone for the week. No matter the challenges of last week, or how hard the weekend was, Monday affords the opportunity to start fresh. For most physicians, our greatest driving force remains to help a patient with a broken area of their life.
When we can walk away from a patient encounter knowing that we did something that made a difference for them, it fills our tank.
Start the week off by filling your tank with some self-awareness that you are bettering the lives of people with your medical touch. There are so many signals from patients that demonstrate this including a look, hug, handshake, smile, card, a thank you, and even tears. Look for the signals and choose to joyfully savor those moments on this day.
If you really get enthusiastic about it, tell a HIPPA compliant story about one of these patient encounters to your family when you get home. They will enjoy seeing you light up over the deeper purpose of why you work so hard in medicine.
Tuesday: Count Your Blessings
Regardless of the circumstantial hardships that we find ourselves in, there is always something to be thankful for in life. On your way into work today, identify something you are grateful for.
Write it down, and share this with someone today, anyone. Pausing to reflect on gratitude is one step, sharing it with another human in your world existentially takes it to a whole other level in your soul. It tends to fill the tank even further.
Only you know the answer, but something fills your tank personally, and today you need to do that thing. Physicians are taught self-denial and delayed gratification as part of our code of honor. So it’s really hard to do something purely for yourself. But today is that one day of the week, that I want you to think about YOU.
It could be a simple choice to start your work shift an hour late or cut out an hour early. Physicians know how to maximize time, so an extra hour of self-time is a treasure.
The reality is that from here the spectrum of what fills the tank is as broad as our personality spectrum. Alone time or a small gathering, quiet meditation or a game of cards, going for a walk, run, bike, or boat trip.
Simply reading a book in a secluded place. Watch a movie, paint a picture, write in your diary. For me, having a date with my wife really does the job.
You have to know yourself and love yourself enough to do what is needed to fill that tank.
Thursday: Connect with Others
Small gatherings with friends or families that still respect social distancing rules can be enriching. We have a nice front porch on our home that faces main street. We can all sit on the porch, separated safely, yet talk and relax together as a family.
Technology can keep you from feeling isolated and lonely. Text a friend, call a family member or try a video chat. Checking in can make both of you feel better.
If you are used to being connected with a community of faith, make sure to tap into their online connection options. There are many sources that can be richly accessed on your digital device.
The love of others, especially family and close friends, has a way of filling our tanks like nothing else.
Friday: Relax and Reflect
The end of the week allows one to take a deep breath and look back at what has transpired during the week.
There are often lessons learned, painful moments shared, therapeutic triumphs, and human experiences that touch us deeply. Either write down, or verbally express these moments with your partner. Remember to do this after you have been able to put yourself in a place of relaxation. Whether it’s taking a breath using aromatherapy, listening to calming music, or sipping a cup of tea, or even taking a dip in the hot tub – take a moment to pause and fill your senses with something that soothes you!
Know your personal limits. Everyone will come to the end of themself, and relaxing and reflecting has a way of refueling us. Take a moment to fill your tank via tranquility.
Put down your “to do” and task lists. Let the grass grow another day, and give those weeds a few extra moments. Today you need to do all you can to make sure your tank is able to naturally fill by resting. Our creator built rest into the cycle of life, including days and nights as well as a rhythmic calendar of days. Humans were not created to endlessly work. Meaningful work and meaningful rest are necessary companions for sustainability and balance. You must know your limits, and know the power of resting. Practicing how to empty our minds through prayer, meditation, yoga and other relaxation techniques are powerful methods to bring us rest.
If you will practice this tank filler, most will find rest actually leads to more productivity the other 6 days of the week.
Some of you need a deeper rest, and you should consider a sabbatical. With the economic downturn spilling into healthcare, many employers are offering a range of reduced workload and sabbatical options for their employees. This might be a good time to really get away from the pressures, and heal before returning to the healthcare battlefield.
Sunday: Hold Tightly to What is Important to You
Savor the things that tend to breathe life into you. Practice your faith, connect with your maker, love your partner and family. Today choose to be present exactly where you find your tank getting filled to the greatest degree. Treasure those people and items that make you smile with deep pleasure. That dopamine surge will go a long way towards preparing you for the next week’s raiders of your tank. Reassure yourself that this safe and pleasurable space will be a rock for you week after week.
Now rinse and repeat as Monday draws near. Reassure yourself, you’ve got this, because you do!
COVID-19 has collided with American physicians in many ways, but I have several observations that stick out from a physician’s perspective on the business of medicine.
1.We have personal risks including death due to the pandemic. This higher risk status affects those who live under our roof as well, as we become their greatest risk for them contracting the virus while they shelter in place. With this in mind, while I come in direct contact with patients who have COVID-19, I have chosen to separate myself from my family and I am now living in a separate dwelling from them. As a husband and father, I feel it is my obligation to protect them as much as I can. The truth is that worldwide thousands of healthcare workers have contracted the virus and many physicians have died while taking care of the COVID-19 patients. Make sure your life insurance plan and disability insurance are up to date and in place. If you haven’t started or updated your will and estate plan recently, get it out and take a look at it. If you need help with any of this, I have worked with an experienced team of professionals who can help you with this – Ben Hughes at Lattice Legal and Jeff Umbaugh at KDU. Reach out to them if you need help.
2. Our value to the safety and health of all America has never been more apparent. Physicians are the critical resource, although we all know it is a team game that includes nurses, pharmacists, therapists, and even administrators. The loving support from the general public for physicians and healthcare workers is unparalleled in my career. Prayers, cards, food, social media posts, texts, and phone calls all continue to pour in. As a community-based physician who still does traditional rural medicine (inpatient, outpatient, OB care, and nursing home care) I am keenly aware that my community is looking to me as their rock during this crisis. With the community beneficence in mind, our medical community has collaborated and converted my medical office to an exclusive FURI (fever and upper respiratory illness) clinic that is manned in a rotating fashion by physicians and NPs in the community. I am seeing face-to-face visits (OB, well children who need vaccines, hospital f/u’s, etc..) at another group’s clinic. This displacement for me is projected to be 8 weeks or longer, and it isn’t easy. But trying to separate the well from the ill in our community is critical to the mitigation efforts, and is a small inconvenience for each of us in our physician tribe to do. The altruism of physicians is expected by the community, and our modeling of necessary changes to social and essential services is critical to helping reduce COVID-19’s impact. Professional value to a community can be monetized, and a pandemic provides an opportunity for your unique skills and training to shine. When this pandemic passes, never forget your value at the negotiation table.
3.Your Hospital’s and Government’s assumption is that physicians are machines, and replaceable parts in the crisis, much like a ventilator. For all the doctors who are employees, you are increasingly aware of this during the crisis while you are herded around new plans and strategies developed by people above you. You may be asked for input, but mostly that is a feigned feedback process that ultimately results in a top-down directive. Mostly this is good, as we all do need a coxswain communicating to us as we grow in the same direction. My hospital system has already begun recruiting volunteers who are able and willing to manage vents (but normally don’t do it) in anticipation of the surge that likely will come. I did volunteer because it’s the right thing to do, but I must admit it does create a pang of anxiety due to the higher risk exposure, and due to the 25-year gap since I managed a vent. I will have to admit I was a little amused recently when my hospital system in a 125,000-250,000 people metro area asked for employed physician “volunteers” to man their 4 FURI clinics, and only got 5 volunteers. Our tight-knit rural medical community has no problems manning our singular FURI clinic but we are frankly used to working together eye to eye. In larger metro areas, I think it’s easier for a physician to think someone else will do it. After this pandemic starts to ebb, one might begin to reflect on how being a healthcare employee could negatively affect your well-being. Some have called this a moral injury to physicians, and COVID-19 has only accelerated this injury. The physician burnout crisis of the past few years has already exposed this issue, but this crisis may have added some additional illumination to the challenges of being an employee. If you are looking to make an adjustment after the crisis, due to your sense that you are simply a cog in someone else’s wheel, then consider a transition to an “employment lite” contract that provides you much more robust benefits as a professional.
4.Loss, or reduction of income is likely to happen for a period of time and could have enormous negative impacts on a physician’s personal finances. Unfortunately, too many physicians still live paycheck to paycheck and the fixed monthly expenses associated with loans and large purchases don’t magically go away during an economic downturn. If you are an employed physician, the government CARES Act, which targets the vulnerable lower-income earners, and the corporations (both large and small) will be of little benefit to you. You are going to have to adjust your personal finances, speak to your lender, or take out a short-term loan to bridge the downturn that is likely to last several months.
2 Trillion Dollar CARES Act Graphic
5. Small and large healthcare corporations, much like most of America’s businesses, will take a big hit during this pandemic. The business of medicine is not insulated from global or national calamities that influence the flow of money and resources. I never expected healthcare economics to be disrupted as it has. Virtually every physician, regardless of the source of his/her income will be affected by COVID-19. Because corporate America has become a significant stakeholder in the business of medicine, the downstream ramifications to physicians are inevitable. Let’s take a look at a few areas of impact based on categories of physician income.
Physicians By Income Type
1.The physician employeeswho are salaried are a little more protected by the very nature of their contract, but don’t be surprised if you are asked to defer part of your salary, or even asked to be willing to get paid less. Worse yet, some employers are simply breaching contracts and unilaterally reducing pay. Healthcare employers are bleeding from many directions, and there will be a downstream to its more highly paid employees, especially if those employees are doing less work than normal. Some CEOs are doing this already. A general surgeon would be a good example of a physician whose livelihood is significantly impacted during this time of forgoing all elective procedures.
2. The physician employees that are paid on a productivity model are also very likely to see their income dip during the next many months as patients shelter in place, and all elective medical care is suspended. You will earn fewer RVU’s no matter how much telemedicine you convert to. Although E/M, RVUs are the same for an office-based 99213 and a 99213 telemedicine visit, reimbursement is less. It won’t take long for your employers to make some sort of RVU credit adjustment for telemedicine and down-shift your monthly RVU count. If it hasn’t happened yet, it is likely coming. Bottom line, your monthly paycheck is going to be less
3. Contracted physicians, especially those who aren’t directly linked to acute care with COVID-19 patients will likely see their hours, shifts, and income reduced. Pathologists, Anesthesiologist, and GI doctors for example are all feeling this pain. Most of these commonly contracted services are either hourly based or have a sort of productivity mechanism incorporated based upon seeing patients and generating income. ER physicians, Hospitalist, Locums, Intensivist, and other critical care hospital specialists are likely to see surges in their workload with extra shifts being added, and longer hours performed. It is notable some are trying negotiated “hazard pay” bonuses into their contracts in order to capitalize on their front-line workload. Lots of variabilities can be found with income expectations for contracted physicians.
4. Incorporated physicians such as PCs often have the most flexibility in a time like this. Their contracts for services can vary based on salary or productivity. So monthly income could change as well. Their overhead and employee structure are typically very lean, so the income change will not only affect their personal finances but affect their co-workers who are not employed by the PC. Some of their PC benefit plans like 401k’s or Cash Balance plans may have to flex a little if income really goes down. But the good news is that they can also borrow or take a distribution from these 401K or Cash Balance Plans without penalty due to the CARES Act. These physicians also have the flexibility to contract their services for a negotiated price to provide added relief and assistance to any surge area of medicine that they practice in. The COVID-19 pandemic could create new opportunities to diversify their business profile both short term and long term. This could balance out any losses from their primary professional services, and additional income from new channels as proverbial “side hustles”. It will be interesting to see if telemedicine emerges as a side hustle coming out of this pandemic. Unlike their employed brethren, doctors organized as PCs have really got the upper hand at times like this due to their business organization.
5. Private Practice physicians/LLP’s/LLC–depending on their specialty, will have to make adjustments as revenue will be reduced in the next few quarters. As small businesses, the CARES Act may provide some relief for you, especially if your overhead expenses are relatively fixed. Much of this comes in the form of business LOANS, not bailouts per se. Furloughing employees and reducing hours can help with this, but it’s tough to do this in a small business when you know your cuts affect real people that you are often connected closely to. In group private practices this can create uncomfortable physician conversations about who is working, who is not, and how it affects the corporate bottom line. Physicians tend to be such individualists that when things are going well, most can tolerate “group thinks”, but when things start to go south, the individualism comes to the surface more. Coming to consensus views on items, especially when it negatively affects their personal income, can be especially difficult in this model. This practice model has been declining over the past many years, and the COVID-19 crisis may hasten the demise of some in this category. If you fear falling in that category, I encourage you to check out the PC-PSA model prior to simply signing up as an employee as you transition. It will afford you many benefits that you are used to in private practice, but still, retain a host of the benefits associated with employment.
Physicians-hang in there, you’ve got this. You are highly valued and needed in our economy, and you will weather this storm. You may have to make some adjustments, but you have a lot of options to help you through these days. You will always have a job, and you will be able to put food on your table. In that context, you are way ahead of millions of Americans, who have lost their jobs. Regardless of the hardships that come your way due to COVID-19, you can adapt, weather the storm.
In my next post, I will take a deeper look at how COVID-19 is affecting the personal finances of physicians.
