4 Physicians Who Are Fighting to Save Medicine

Last week’s interview with Mark Cuban generated a huge response — thank you to everyone who listened, commented on, or shared the episode.

New guests will debut next week, but this week, we’ve rounded up some of the show’s most inspiring and thought-provoking moments to date, to help new listeners get acquainted with How I Doctor and with Offcall’s mission. The four physicians featured in this episode are examples of MD leaders who are using their voices to improve the healthcare system. Their insights will push you to think about medicine differently:

• Dr. Will Flanary, an ophthalmologist and comedian who’s become better known by his online persona Dr. Glaucomflecken.
• Dr. Eric Bricker, an internal medicine physician-slash-entrepreneur who explains the finer points of healthcare finance in his signature whiteboard videos.
• Dr. Elisabeth Potter, a reconstructive breast surgeon who went viral on social media for exposing how insurance companies bully doctors and compromise patient interests.
• Dr. Jim Dahle, an emergency medicine physician who founded the White Coat Investor to teach doctors about personal finance and money management.

Dr. Will Flanary

Will explains what he’s trying to achieve as a content creator, namely: He’s educating other doctors about the nuances of healthcare, pointing a finger at corporate entities that he feels play a big role in creating and perpetuating systemic failures, and, perhaps most importantly, doing his part to humanize doctors.

“It's a weird job, what we have. It's very strange, what we do. To be able to look at it through a comedic lens at times, it helps bolster our humanity I think, in our own eyes. But also in the eyes of the public, they see us enjoying a little bit of comedic ribbing toward ourselves, toward each other. That shows people, ‘Oh, this doctor, he's just a normal person that just happens to do this very strange and important job.’ It just humanizes us.”’

Listen to the full episode with Dr. Glaucomflecken and learn more here.

Dr. Eric Bricker

Eric talks about his efforts to clear the fog around complex topics that doctors need to understand better, such as pharmacy benefits,. He also shares practical tips to help doctors gain more financial leverage and push back against employers who take advantage of them.

“Job switchers make more money, and it's like 30% more. Because people are always looking for docs. … And people are so scared to leave. Dude, just leave. You'll be okay. ‘I got my student loans to pay back.’ Just leave. ‘ I got my kids' college savings to take care of." Just leave. You will find a job. You will be okay. It's really the fear, false evidence appearing real. You just got to have the courage to just get over that, and you just got to walk.”’

Listen to the full episode with Eric and learn more here.

Dr. Elisabeth Potter

Elisabeth talks about how doctors are reaching their breaking point with insurance companies because increasingly absurd approval requirements have made it harder and harder to advocate for patients. As a practice owner, Elisabeth can speak more freely than doctors who are employed by health systems, so she’s using social media to hold powerful insurers to account.

“I'll do anything that you tell me will help my patient. I will jump through hoops. … I'll do all the work, and I'll look to my mentors, to see the best way to treat this problem, and what new skill-set do I need to obtain? And with this issue, navigating insurance, nobody has the answer. There's nobody out there who's done this successfully, right? There's nobody who's telling doctors, ‘Oh, this is the way that you can have a viable practice and deal with insurance.’ I'm like, ‘We have to do something different.’ And I just felt like being honest has always been a good policy. You can build from there. And I felt like, Let me just be honest about this thing that's going on. And it resonated in a way that I truly did not anticipate, but I am so very grateful for.”’

Listen to the full episode with Elisabeth and learn more here.

Dr. Jim Dahle

Jim discusses common money mistakes that physicians make, especially early on in their careers. He also issues a warning about predatory behavior from financial advisors and firms.

“The financial services industry is actually out there hunting you. It's Captain Ahab, and you are the whale. They're coming after you. They actually use this term in the industry, “whales.” We want these high-net-worth people that we can churn their accounts and generate all these commissions from them. There are actually people out there who, it's not that they don't want you to succeed, they just want to make money off of you. They're not always looking out for your best interests. Sometimes they're pretty ignorant actually. They hold themselves out as a financial advisor, and mostly they're just selling products to you. Sometimes it's a firm that wants to make you scared about getting sued and losing everything. They sell you these super-expensive and complex asset protection plans that involve overseas trusts and family limited LLCs in Wyoming or Alaska or New Hampshire or whatever. They just take advantage of your fears, and you end up with these weird things in your financial life.”

Listen to the full episode with Jim and learn more here.

To make sure you don’t miss an episode of How I Doctor, subscribe to the show wherever you listen to podcasts. You can also read the full transcript of the episode below.

Offcall exists to help restore balance in medicine and improve the wealth and wellbeing of physicians. Sign up for Offcall here to bring about more physician compensation transparency and join our physician movement.

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Transcript

Highlights from Graham’s Interview With Dr. Will Flanary

Will, you've made such rich tapestry of recurring characters, the Glaucomflecken Cinematic Universe. What's the unifying theory or the message you're trying to convey in your videos do you think?

WF:

I just want people to laugh at themselves.

GW:

Not take life so seriously?

WF:

Yeah. Ultimately, I think that's the biggest thing. It's a weird job, what we have. It's very strange, what we do. To be able to look at it through a comedic lens at times, it helps bolster our humanity I think, in our own eyes. But also in the eyes of the public, they see us enjoying a little bit of comedic ribbing toward ourselves, toward each other. That shows people, "Oh, this doctor, he's just a normal person that just happens to do this very strange and important job." It just humanizes us.

GW:

Will, that's actually my favorite part of what you do. Even more than the comedy, it's just showing that we're just humans. You really often have a message about self-expression and having to balance that with our professionalism. But we're well-trained humans is the way I put it. We're not robots, we're not gods. Why do you think that's so important to you, that you want to get that message across?

WF:

I have had so many experiences as a patient, I know what I like to see in a doctor from the patient standpoint. That's someone that actually has a personality. I know what it feels like to have to feel like you need to suppress that, because we've all done it at some point in our careers. We just keep that side of you a secret because it's not professional to want to tell a joke, or to want to cry, or whatever it is. Show any kind of emotion. I know that I appreciate that in my doctors, so I want to emulate that.

GW:

That we're flawed, imperfect creatures, but we're trying our best. Yeah, yeah.

WF:

Exactly.

GW:

Yeah. What do you think the state of medicine is like today? And what do you think has changed since maybe you were in med school?

WF:

It's certainly is hard to be a doctor. What's changed is I think the public perception of medicine in general has been a big thing, with social media in particular. There's some good things about it, that patients have more autonomy now, which is a good thing. Through social media, and interacting with healthcare professionals on social media. There's less of a patriarchic al type of situation where the doctor's word is final. People are taking ownership over their health, which is I think a great thing. That's so important. Have the agency to ask questions, and challenge physicians, challenge healthcare professionals.

But on the flip side, it's also brought distrust to an extreme degree. To where now, we don't actually have the expertise to tell people, recommend treatment, or what they should do, or whether it's vaccines, or whatever it is. That's dangerous.

I feel like we're trying to fight these two things. We want patients to have autonomy, but we also need them to respect our expertise, and sometimes listen to us. Hopefully listen to us all the time, just like we need to listen to patients. It needs to be a back-and-forth. I think it's getting harder and harder to find that balance.

GW:

Yeah. It does feel like there's an erosion of expertise, or that doing our grueling training isn't sufficient or is equal to somebody else reading something online, or something.

WF:

Yeah, the misinformation.

GW:

Yeah.

WF:

There's so much of it now. People are designed to you want to believe somebody saying something. Especially if they're a very charismatic, engaging person, like you see often on social media. Because that's what people who are engaging and charismatic do, they go on social media and they become influencers. They may not be correct at all in what they're saying. But they say it confidently enough, you're going to have people that just say, "Oh, this person just looks like they know what they're talking about."

You have to tell people, "No, actually you don't need to sun your perineum. That's not going to treat your rectal cancer." We have to debunk the nonsense. No, you don't need to use aged urine eyedrops, that's not going to do anything for your eyes.

GW:

I saw castor oil recently on TikTok as well.

WF:

Castor oil, yeah. That's another one. We have to tell people, "Don't do this thing that's obviously nonsense." But then also, the actual things that they should be doing. It feels really challenging. It's hard enough just to try to get the quality medical information out there without having to deal with all this other nonsense that really shouldn't be out there in the first place.

GW:

Totally agree. Yeah, it's exasperating.

Will, you've got a lot of resident and med student fans. What would you say you've learned that you only learned once you were an attending, once you were done with training?

WF:

Oh, how the healthcare system works.

GW:

Yeah.

WF:

It's outrageous. It's wild to me that we still don't just inform students, med students about the way the healthcare system works. That's a huge blank spot in our education.

Going into private practice, it was a really large uphill climb trying to figure out how billing works, and what is a prior authorization. What about peer-to-peer reviews? Why do I have to do this? What about this carrier versus this carrier? A PBM, I don't even know ... I hadn't even heard of the term pharmacy benefit manager until I was out of training, in practice.

Our healthcare system is so complex, and we do a terrible job of preparing physicians, new physicians to practice in that complex healthcare system. Some of this wasn't until I was a patient until I actually felt it. I felt the weight of all these moving parts that are bearing down and weighing down patients, and forcing patients to navigate those complex systems.

GW:

You're done with residency or fellowship and you're like, "Oh, God, thank God I'm finally done." Then it's like nope, there's actually a whole third more chunk of stuff you have to figure out. Quality metrics, and billing.

WF:

Oh, yeah.

GW:

And all that.

WF:

Congrats, you learned the medicine. Great. By the way, you're still going to learn just as much medicine out of training than you are in training. But then you also get a PhD in health policy just because you have to.

Highlights from Graham’s Interview With Dr. Eric Bricker

Eric, if all physicians or many more of us had a better understanding of the money, what would we do with that information? Would we be advocates or lobbying or just play the game, play the game better?

EB:

So one would be around like prior authorization. And at the end of the day, guess what? If you want something prior auth-ed, you will get it approved. So A number one for prior auth is that the vast majority of the time, if you want the stress test or if you want blah, whatever, guess what? You can get it.

And so it's a matter of understanding that and then understanding that, okay, yeah, maybe you're going to have to delegate that to maybe an MA or a nurse or whatever, and you're going to have to go through... So you've got to be persistent and blah, blah, blah, but at the end of the day, you can totally do it.

And so, that's the little secret that insurance companies don't tell you. Because, of course, the protocol is, I mean, they've literally taught them this. They're like, "They're going to deny everything."

Two, okay, what else? This whole non-compete thing is a bunch of garbage. At the end of the day, you as a doctor, you can and you should leave your job, and you should go across the street to the competing hospital system. Just do it and be like, "What are you going to do?"

GW:

Because the hospital's not going to actually do it.

EB:

Right, and guess what? Maybe you got to get a lawyer. Getting sued is not the end of the day. You get a lawyer, they'll drop it. Vote with your feet and just do it. And they'll try to intimidate you to not do it, but just freaking do it.

And so, this is true. So one of the topics is what can physicians do to just make more money? You switch jobs. I mean, this is true across any job across the economy.

GW:

Any industry, I think. Yeah, yeah.

EB:

Any industry.

GW:

Right.

EB:

Job switchers make more money, and it's like 30% more.

GW:

Wow.

EB:

Because people are always looking for docs, I mean people are always looking for docs.

GW:

Especially now.

EB:

Yeah.

GW:

Yeah.

EB:

And people are so scared to leave. Dude, just leave. You'll be okay. "I got my student loans to pay back." Just leave. "I got my kids' college savings to take care of." Just leave. You will find a job. You will be okay. It's really the fear, false evidence appearing real. You just got to have the courage to just get over that, and you just got to walk.

Physicians are basically lied to by insurance companies. They're lied to by administrators. If you don't want to use the word lied to, they're manipulated. So the point is is that if you actually understood how the money works, then a physician would be much less easily manipulated.

GW:

How does that make you feel, Eric, when you come to these realizations? Do you feel we've been taken advantage of all along or have things changed over time?

EB:

Oh, yeah. We've totally been taken advantage of. We kind of get used to not pushing back, and then in residency we don't push back. And so, we've been trained to not push back. I've even had hospital administrators admit this to me that whenever they need the physician to work more hours or see more patients, they essentially intentionally guilt trip them into being like, "But this is for the patient." They literally told me, "Yeah, that's a strategy we use to manipulate physicians."

GW:

I think Danielle Ofri had a piece in the New York Times that I always think about where she essentially said the Hippocratic Oath is abused in that doctors and nurses have decided to go into medicine for these hopefully somewhat altruistic reasons. We take this oath that says we're going to put our patients above us, and then the system uses that oath that we said we were going to put patients first to get free labor, work extra hours-

EB:

Oh, yeah.

GW:

... in the name of the patient.

EB:

That's right. And also, I just want to add too, it's not just the "system". It is specific people in positions of power. So people are always like, "Well, we don't like to point fingers." No, there are people who are consciously sitting in rooms making these decisions.

GW:

I want to transition a little bit to what's happening with physicians now. I'm seeing more physicians wanting to leave medicine, begging to leave medicine, or just do something else, whether it's a side gig or cut back on their clinical hours. How did we get here?

EB:

So, one, the reimbursement complexity has really continued to get worse and worse to the point where just the denials and the non-payment and the delayed payment for the independent physician was overly onerous so that they essentially had to sell their practice because they couldn't bill and collect.

And then, the other reason why is because the professional fee reimbursement is just so low compared to the facility fee reimbursement because the big hospital systems have the negotiating power from a commercial insurance, so from like a employer sponsored insurance plan.

So this is the classic thing of the orthopedic surgeon is like, "Well, maybe I'm getting $750 for the professional fee for the arthroscopic knee surgery." But that hospital could be getting anywhere from 16 to $32,000, and the doctor's getting 750. The surgeon's getting 750, the anesthesiologist is getting 1100, and the hospital's getting 32 grand. And it's just because of the negotiating power that the hospital has for that.

And then what really added kerosene to the fire in the last five years was the explosion of Medicare Advantage. Because historically, physicians still had traditional Medicare where you didn't have prior authorizations, and if you didn't, you would get paid relatively quickly. You do it, you get paid. You do it, you get paid. And that kind of existed.

But that was when only 20 to 25% of people on Medicare were on Medicare Advantage, and now it's over 50%. And that trend, it's going to go up to at least 75% that are on Medicare Advantage. So all the problems with delayed and denied payment that used to not apply to your Medicare population, now it does apply to the majority of your Medicare population.

And so you definitely have proceduralist doctors, cardiologists, orthopedic surgeons, neurosurgeons doing spine, radiologists, I mean, those professions that I just mentioned, they're making money hand over fist. In this new environment, they're making more money than they ever have in the past. And then geographically, especially in the South and the Midwest, these folks are easily pulling in over a million dollars a year.

GW:

Because the facility fees are so high, and so then the hospital can give them a nice chunk of that?

EB:

That's right. These hospital systems sometimes are making $10 million per neurosurgeon. So they're like, "Yeah, we'll pay the neurosurgeon a million bucks because we're making 10 million off this guy or woman every year."

GW:

Eric, are there other practical things that doctors can do to respond to the changes we've seen over the past couple decades whether it's to improve their salary or just improve their quality of life of finding a better place to work?

EB:

Yeah. So you're either going to walk, or the other thing too is you have to actively ask for raises. Guess what happens? People who ask for raises get raises. People who don't ask for raises don't get raises. So you need to ask.

GW:

Yeah. That's great.

EB:

And you don't ask once a year. Shoot, ask twice a year, ask three or four times a year, ask multiple times a year and be like, "Look, I want a raise. And if you're not willing to give me a raise, I'm willing to leave." And so you can either leave, you can threaten to leave an ask for a raise, and then the third alternative is you unionize. Because there are some places where they're like, "Well, there's just not enough options here. And so, we just need to unionize."

And we see this with doctors and with nurses. With doctors, it's been primarily the residents that are starting to do it. And these residents are making a lot more money than they used to make. They're getting much better working conditions, and it's actually not that hard to unionize.

GW:

It's always felt to me that physicians, we tend to circle the wagons around our own specialty, but do you get a sense that physicians are becoming more open to that idea of we're stronger together?

EB:

Unfortunately, I think the answer is no. I think we are still heavily Balkanized by specialty. Because to a certain extent, while we're all doctors and we take care of patients, our practices and our patient population...

Like a dermatologist and an orthopedic surgeon actually have very little in common. I mean, they're both doctors, but kind of. I mean, they're super different. It's like one guy's a plumber and one guy's an electrician. That's really different. Yeah, they both work on houses and buildings and stuff. It's hugely different jobs that you have.

And I don't think we're going to overcome that. And actually, that's really been the reason why everyone's like, "Oh, the AMA is terrible." Listen, it's not the AMA's fault. I mean, each physician is so married to their individual specialty society, whereas the American Hospital Association is actually quite unified for all the hospital, and it's been all this uncoordinated effort from a political advocacy standpoint. Whereas from the hospital standpoint, it's been highly unified.

Which is why I actually, from a practical standpoint, I actually, I'm like, "Look, don't rely... " Healthcare improvement in your life as a physician is not going to come at the federal level. It's going to come at the level of your own practice, of your own hospital, of your own county, and maybe your own state. And that's it. So if you want to focus, start incredibly local because PBMs have very organized and effective federal lobbying. Doctors are not going to beat that.

GW:

Is there a way that a physician can get a sense for how much the hospital is billing under their NPI or their name? Is that something that a doctor can figure out?

EB:

So the short answer is yes. And you know which group of physicians that I feel like does the best job of this is radiologists. Because radiologists, they know their RVUs cold. And the key to making money as a radiologist is your RVUs. Because if you're churning and burning and reading, you're literally generating 22,000 to 24,000 RVUs per year. A primary care doc is generating 4,000 RVUs per year. So just the economics of the way that you read films, you're just cranking out RVUs like crazy.

And then, you talk to the finance people within the hospital. Again, you've got to be persistent. You got to know who to talk to. Yeah, you-

GW:

This is part of asking for a raise is explaining your value too.

EB:

Yeah, but believe me, all the radiology groups that contract with the hospitals, they know exactly what the hospitals getting reimbursed per RVU. And what I've really found is that the radiologists, they tend to be good business people because they're very rational and they tend to be dispassionate. They're good at numbers. They tend to be like engineers. And they're very good at just looking at this and just putting together the numbers on the spreadsheet.

I mean, shoot, there's a lot of doctors that don't know how to use a spreadsheet. What is something that you can do as a doctor? You need to know how to use a spreadsheet. And as an autodidact, you need to be able to figure out how to build your own spreadsheets and being able to figure out and track your own RVUs and how you're getting paid or whatever.

So in terms of individual agency and keeping track of stuff, you got to keep track of your own. If you want to make more as a physician and you're not doing your own spreadsheeting, then the first thing you need to do is do your own spreadsheeting. Because guess what?

GW:

Yeah. Get your own Yeah, yeah.

EB:

That's right. Because that's what other people in other industries do. That's what engineers do. That's what people who work in investment banking do. That's what people who run small businesses. Physicians used to be small business owners. Physicians used to run their own small practices, a small business. You need a spreadsheet.

Highlights from Graham’s Interview With Dr. Elisabeth Potter

GW:That made me think of your post. We didn't meet until I was just scrolling TikTok and then came across your post and I was like, "Who is this amazing plastic surgeon?" What made you decide to get out your phone and start recording?

EP:

That day... It wasn't a one-off, right?

GW:Yeah.

The Story Behind Elisabeth’s Viral Video

EP:

I posted after being called in the operating room by an insurance company and asked to basically justify why my breast cancer patient needed to stay overnight after her major surgery. And I just couldn't anymore. I try to be someone who's collaborative and I've actually really been a friend to insurance. I've advocated for access through insurance to breastfeeding instruction. I don't balance bill. I don't do the cash pay game. I'm a good actor.

And I think it was this... There were a couple of things. It was the fact that I realized they have no idea that I'm a good person. They're giving me zero credit for my decade plus of advocating for access and doing surgeries for less than I should be paid and all the things, right? And then also, just I felt this creep of being questioned as a physician over and over. And I'd say I was interrupted so many times in my clinical practice by insurance asking me for a peer-to-peer that this just felt like, "Are you kidding me? You're actually in the operating room? This is insane."

GW:It captured, I think, the quiet rage that many of us feel working in this system. It gets harder every year to do this thing that we love in the name of trying to help our patients. And, when does this end?

EP:

I'll do anything that you tell me will help my patient. I will jump through hoops. Give me that, what a doctor says I should do, right? I'll do all the work, and I'll look to my mentors and see like what's the best way to treat this problem and what new skillset do I need to obtain? And with this issue, navigating insurance, nobody has the answer. There's nobody out there who's done this successfully, right? There's nobody who's telling doctors, "Oh, this is the way that you can have a viable practice and deal with insurance."

I'm like, "We have to do something different." And I just felt like being honest has always been a good policy. You can build from there. And I felt like, "Let me just be honest about this thing that's going on." And it resonated in a way that I truly did not anticipate, but I am so very grateful for.

GW:Well, it feels like you're doing your end of the bargain of trying to keep up with the literature and come up with new techniques and find ways of saving time and being efficient and doing all the right stuff. You're doing the doctor part, and then the insurance people are supposed to do their part, too.

I remember I had this chief resident and he just said, "Graham, you got to do your job. That's all you got to do. It's not hard. Medicine's not hard. Just do your job and that's all you got to do."

EP:

I love it.

GW:It feels like the insurance people aren't holding up their side of the bargain, you know?

Why Doctors Are In an Abusive Relationship With Insurance Companies

EP:

It does. I mean, it does. I say this, and I'm not joking when I say it, the relationship between doctors and insurance companies has become an abusive one. And you know, we are underappreciated, and we're gaslit, and we're made to justify what we're doing all the time. And then questioned as though we're doing the wrong thing. Yeah, this is broken, and we do just want to do our job. I'm here for that. But you have to have boundaries in place, and you have to have actors involved that have similar goals. And our goals just don't seem to be aligned.

GW:I remember doing, you know, I think a care coordinator or somebody telling me, "If you don't do this," and not in a threatening way, but I took it that way. "If you don't do this 12 page form, your patient can't get discharged to where they need to go. And so, they're just going to sit here in the ER."

I had that same feeling. I will do anything for my patients. And it's the same thing I feel if I'm asking my resident or my med student to do something or a nurse, I am not above doing anything to help my patient. The concept of scut work, if you need to call the patient's family, you call the patient's family. But it feels like there's just... Every year there's more and more to this that makes it more and more challenging to, like I said, just do your job.

EP:

It's so, so true. I completely agree. And I feel like it makes me just look closely at what's actually happening to say, "I'm a physician. I have a patient who has a need and I can meet it."

GW:Yeah, "I can do this."

EP:

"I can do this."

And honestly, do we need insurance involved? So, here's your patient in the emergency room, and needs to be discharged. And someone's handing you 12 pages of paperwork to fill out before they can be discharged. In my gut, as you're saying that, I'm just thinking, "Let me show you how I can discharge this patient without that paperwork," and then just roll them out the door. It can happen. This absurdity, this theater, we've accepted it, and we all have to just end the show and get real.

GW:I love it. It is theater. It does feel like theater a lot of the time.

EP:

Yeah.

GW:Elizabeth, did you start to worry when the video went viral after the surgery? Were you like, "Oh, this is starting to do something?"

EP:

You know, that's so funny. I would say I pride myself on being, you know, pretty intelligent and aware, and I have a lot of common sense, but I wasn't worried. I wasn't worried. And I think I assumed that... I know that I'm a good person and that I've been a really good doctor, and that I always do the hard right thing, always. So if somebody like really looks at me and picks it apart, I do surgeries for free, I take TriCare, Medicaid, like I do all the things. I'm the safety net for women around the country. I wasn't worried. I just thought, "Oh, look, we're getting a voice."

And then as I'm coming into the hospital, there are people patting me on the back, like doctors, saying, "Thank you so much for saying what I couldn't say."

GW:Yes.

EP:

So I felt really good until I got a letter from United and that was like, "Whoa, okay."

GW:You did reveal this stuff that doctors have been doing for decades now that we've never shown, that we have never told anybody, is what we do. And I'm starting to see more and more physicians do this. There are physicians that read prior auths, theatrically. I've seen some medical practices that just record themselves on hold with the insurance company, and then they'll record like a 45-minute video and speed it up and just to show that it took 45 minutes of this person's time to get approved for some stupid thing like Zofran or amoxi... something that is not worth anyone's time for a generic drug that costs pennies. So I think we are starting to see more physicians like yourself, pull back the veil, show behind the curtain of what it's taking on the doctor's side or the doctor's staff's side to operate in this broken system.

EP:

I'm glad that we're doing that and I'm here for it and I support it. And I think you can do it with a sense of decorum.

GW:It would seem like a tremendous opportunity for United to say, "Hey, wow, we could really learn from this experience. And wow, this physician is someone that we work with, that we contract with, that we pay."

Me in my naive way, clearly, is thinking, "Gosh, what an opportunity to help provide better service to the doctors who are delivering care for the patients that we cover, that we insure."

United Could Have Responded Differently to Elisabeth’s Video

EP:

As a business owner, if I had someone bring to me a concern about a service that I was delivering, I would really analyze that. And I do, like, "Okay, where was the breakdown and how can I make that better? Why does this person feel this way?"

And, I think for me, I perform, gosh, I think when I did a back of the napkin calculation, about 1% of the mastectomies for United yearly. That's a lot.

GW:What?

EP:

I did 500 breast cancer surgeries last year.

GW:Wow.

EP:

I do a ton of surgeries. So I just think, yeah, they have no concept of what I have offered to their members. Now, their members have a really high concept of what that is. My patients are like, they're so appreciative, but they just don't get it. And you know, they chose one path, and I think it played out the way it did.

GW:In the same way that, I think, patients often feel like a number, and that I think you try to make your patients not feel that way, I think United probably thinks of you as a number as well. You're just another line on a spreadsheet of plastic surgeons who do mastectomies for them.

EP:

Of course. And I'm just over that. I'm over it. I'm really valuable, and every surgeon and every doctor is really valuable. It comes down to what is the product that they're selling, right? They're selling a product to their members and they're saying, "Here's insurance and it's great."

And the truth is that that's just words. It's just words. It's all about the network that they have. It's about the physicians, and it's about the access that they can deliver to care. And when I see in a major metropolitan area that an insurance company will sell a product, someone will be insured, employed, and be diagnosed with breast cancer here in Austin, and then not be able to find, number one, a radiology facility that's in network to cover their mammogram. Number two, a breast surgeon who's in network to perform their surgery. And number three, a plastic surgeon that's in network to perform their reconstruction. I'm like, "I think you guys are selling goods that are flawed." Yeah, there's something amiss and the curtain needs to be pulled back.

Highlights from Graham’s Interview With Dr. Jim Dahle

Broadly speaking, why do you think physicians have such a hard time with money management, especially in those early years, say, right after fellowship or as a new attending, for that first five years?

JD:

Well, the main problem is doctors are people.

GW:

If we just got rid of that, we'd be so much better.

JD:

Yeah, that's exactly it. We make the same mistakes everybody else makes. We just tend to do it with larger sums of money. We borrow more, and then we earn more, and we pay more in taxes and we have to save more for retirement. So when we make a mistake, it's a bigger mistake usually.

Doctors are in a unique place in that they sta rt their career late, and particularly for emergency doctors, we have this step where we go from a resident income to an attending income. That might be the highest income we ever see, that first income we get coming out of residency, just because we're willing to work more shifts, and we're willing to work more night shifts and that sort of a thing. And then the income trends down throughout our careers.

Well, that's not the way most careers look like. If you get outside of medicine, most careers, you start earning something in your twenties, and you don't start with a mountain of debt hanging over your head. You progressively make more and make more and become more financially literate as you go. Whereas doctors just get thrown right into the fire, right from the beginning. We've got big practice loans and student loans. We don't have anything saved for retirement, and we have all these great uses for money and not enough money to do them all, whether that's maxing out a Roth IRA or upgrading that beater we've been driving since we were a med student or saving up an emergency fund. We have all these good things to do with money right when we come out, and it's really hard to prioritize them.

GW:

Well, I'd be making less money because of inflation. I'm not seeing as many raises, or I'm just not working as many hours usually.

JD:

It's usually because you're not working as many hours. Now, this is fairly specific to the shift-based specialties. A lot of other specialties are building a practice, and their income actually goes up with time. Yes, there's probably inflation raises if you're an employed emergency physician.

But most of us are not interested in working as much at 55 as we were at 35.

GW:

What?

JD:

We're not as willing to work the undesirable shifts and take as much call. The truth is lots of us don't make more money 20 years into our careers than we're making toward the beginning. And you need to manage your finances that way. You can't just say, "I'm going to spend it now, and I'll save later." Well, later you might have even less income, and I tell you what, it's pretty hard to cut back your lifestyle. Not that hard to increase it at all, but it's hard to cut it back.

GW:

I certainly remember hitting, I don't know, 35 or 40, and just being like, "I could not do 5 in a row, 5 nights in a row." Shout-out to our nocturnalists that do that because it's challenging.

Jim, you said that we physicians tend to make the same mistakes, maybe just with larger sums of money. How do you think physicians get taken advantage of? And what do you think are the biggest offenders?

JD:

The financial services industry is actually out there hunting you. It's Captain Ahab, and you are the whale.

GW:

You are the whale, yeah.

JD:

They're coming after you. They actually use this term in the industry, whales. We want these high-net-worth people that we can churn their accounts and generate all these commissions from them.

There are actually people out there who, it's not that they don't want you to succeed, they just want to make money off of you. They're not always looking out for your best interests. Sometimes they're pretty ignorant actually. They hold themselves out as a financial advisor, and mostly they're just selling products to you.

Sometimes it's a firm that wants to make you scared about getting sued and losing everything. They sell you these super-expensive and complex asset protection plans that involve overseas trusts and family limited LLCs in Wyoming or Alaska or New Hampshire or whatever. They just take advantage of your fears, and you end up with these weird things in your financial life.

I was talking with a doc who's on the cusp of retirement, who has 40% of his nest egg in whole life insurance policies because there was no one around to warn him. He actually has a substantial chunk of his nest egg in something that probably should have had three times higher returns over the years.

Managing Student Loans: Strategies and Mistakes to Avoid

GW:

Wow. What mistakes do you see new doctors make when they're trying to manage their student loans?

JD:

It would help if this didn't change every month. For many years, I've told people, "Hey, don't borrow more than you have to, and if you have money going into med school, maybe you ought to use some of that money to pay for med school and invest in yourself."

Well, now something like 50% of doctors are in public service loan-forgiveness-qualifying jobs. The right financial answer, the right mathematical answer for that 50% is not to spend your own money. It's to spend the taxpayers money and have the taxpayer pay for your med school. I actually answer that question differently now than I did 10 years ago.

The mistakes people make, they borrow too much. They spend money they maybe shouldn't be spending. They don't pay attention to it and get a plan in place. They don't figure out early enough if they're going to be going for a job that qualifies for public service loan forgiveness, or if they're going to be taking a regular job that hopefully pays more and refinancing their loans and paying them off. Maybe they don't enroll into the right income driven repayment program.

We actually have a company, StudentLoanAdvice.com, to answer student loan questions because just the management of them has gotten so complicated over the last five years. There's some truisms. If you can borrow federal loans instead of private loans, you should do that. That's still true. If you can get somebody else to pay back your student loans instead of you, you probably ought to let them do it. That's going to be a truism. Pretty much every doc coming out of med school needs to be enrolling in an income-driven repayment program and not going into deferment or forbearance. That is almost always a mistake. If you're paying your student loans back yourself, you're sure you are, you're not going for a forgiveness program, you can go ahead and refinance your student loans and have more of your payments going toward principal instead of interest. All those things are still true.

GW:

Yeah. Jim, just for our medical student listeners, deferment or forbearance would be you finish medical school, you start residency, but you have decided to not start paying back your loans because you're a resident, and you're not making much income. You're saying that you should not do that, generally speaking.

JD:

Yeah, it's a terrible idea, terrible idea. You can basically do that anyway. All you do is you file a tax return your last year that says you have zero income. Now your income driven repayment program, whichever one it is that's still available, your income's zero, your payments are zero. And those $0 payments count toward public service loan forgiveness.

These people that go into deferment, they come out of residency five years later, they're halfway done to public service loan forgiveness, and they have no payments because they went into deferment. It's a tragedy. It costs hundreds of thousands of dollars to doctors to make this mistake.

GW:

Do you get a sense that the medical schools are giving this relatively accurate general idea of how they should be managing their student loans when they become a resident?

JD:

The answer is almost universally no. It's not to say that's the case for all med schools. There are a couple that have a financial planner on staff. There are a few that have an optional finance course that you take as an MS4, which I think is a great time to become financially literate.

GW:

Oh, interesting.

JD:

This is my mission in life, is to make sure no student comes out this school while being a financial idiot. For the most part, people aren't getting this. Or worse, they're getting misinformation. They're getting some whole life insurance salesman coming in, masquerading as a financial advisor and-

GW:

Yeah, offering free lunch or dinner or something.

JD:

Yeah. Telling them something, and then at the end it's like, "Come see me so I can sell you some whole life insurance" or whatever.