Ask yourself these 7 questions about money

0:00 Welcome to the Clinician Researcher podcast, where academic clinicians learn the skills to build their own research program, whether or not they have a mentor. As clinicians, we spend a decade or more as trainees learning to take care of patients. When we finally start our careers, we want to build research programs, but then we find that our years of clinical training did not adequately prepare us to lead our research program. Through no fault of our own, we struggle to find mentors, and when we can't, we quit. However, clinicians hold the keys to the greatest research breakthroughs.

0:40 For this reason, the Clinician Researcher podcast exists to give academic clinicians the tools to build their own research program, whether or not they have a mentor. Now introducing your host, Toyosi Onwuemene. Welcome to the Clinician Researcher podcast. I'm your host, Toyosi Onwuemene, and it is an absolute pleasure to be talking with you today. Today, I'm talking about money. Specifically, I'm talking about questions you should be asking about money. And the reason this topic is fresh on my mind is because I'm part of a coaching group, so I work with Dr. Latifat, who has a money school for women in medicine, for physicians specifically.

1:30 And so we meet once a week, and we talk about money. And we talk about strategies, and we talk about what people are doing, and what syndication deals people are looking at, what investments people are making. And it's just so phenomenal because I have to tell you, I've never been in circles where we just talk about money. And every time I'm in these meetings, my awareness has just expanded. I learned things that I'd never understood before, because there I am at today's meeting saying, but what is a syndication deal? And I don't think I'm ready to do one today, but what I am is informed, because now I have information that I didn't have before.

2:12 But yeah, so this particular conversation prompted me to decide to record today's episode. But before that, there was another story that prompted my thinking a little bit more about money than I usually do. Okay, so a couple of days ago, I was representing my society, the American Society of Human Technology on Capitol Hill. And I am a member of the committee and practice. And once a year, the committee and practice will go to their legislators on the hill and will present issues that the society has decided are pressing issues. Okay, so one of the issues that we had on our list is the issue of physician payments.

2:56 And so if you are aware, the system regarding physician payments is broken, and I'm talking about physician payments from Medicare, such that even though every year, inflation is increasing, physician payments are decreasing every year. And there have been some stopgap measures to try to decrease the amount by which it's decreasing. I will tell you that it's an interesting phenomenon that it's decreasing every year. I'm sure that there are some more economic strategies to share exactly what's going on and the specificities of that. I cannot tell you, but simply the money is going down every year.

3:38 And the strategies that they have to fix it right now are to decrease the amount by which it decreases every year. That's better than it decreasing by a more significant amount every year. But the issue is that while inflation is increasing, physician payments are decreasing. Okay, so that was one of the issues that we brought to Congress. And what's interesting is that, so we're a hematologist and we had one representative from Indiana, one representative from Illinois, and I was representing North Carolina. We were sitting waiting for our next appointment and we looked across the table beside us and there is a group of rheumatologists. And we're like, oh, what issues are you taking to your legislators? And they're talking about, guess what?

4:19 The Physician Payment Act. In fact, the graph that shows how physician payments are decreasing while all other things on a fee schedule are increasing is a ubiquitous graph. Everybody has this graph. In fact, the graph is so ubiquitous, all the legislators know the graph. It's like, oh yeah, yeah, we know about this problem. It is a problem everybody knows about. And so then the question in my mind is like, well, if the problem is known and has been known for so long, why hasn't it been fixed? And I know that there are some of you who are legislative wizards out there and you can tell me exactly what's happening, but from my very simple understanding, it's like if payments should be increasing over time, but instead they're decreasing while inflation is rising, which means they're significantly decreasing, why can't it be changed?

5:12 And what are the big barriers for change? Anyway, so I'm not here to answer that philosophical question because that's a huge question and not one that I believe I can answer. But the question I do want to answer is, well, if they're not going to fix it, what are you going to do about it? And I'm asking that question of me because if over time the reimbursement to physicians from Medicare, one of the largest payers in terms of the healthcare system, most of our patients are older and on Medicare, then what's going to be happening? So what's happening over time, and we're feeling the pinch of the need to do more clinical work just to make the same amount that used to be made.

5:56 And so if you're an academic medical center, you may not feel the pinch as much, but if you are in private practice, for example, if you have a small practice, you're going to feel the pinch because this is money that helps you pay yourself. And so I think it made me stop and say, hey, who's in charge of the finances? Who's asking the questions about whether I'm able to be independent financially ultimately or not? So it got me thinking. And that's why having this meeting that I just stepped away from where we're really talking about taking ownership of our finances was huge, right? Stepping out of this meeting where we're all talking about taking ownership of our finances is a big deal.

6:40 That's why I wanted to come talk to you about it today because I want you thinking about it too. I think one of the challenges for us, especially as academic physicians, is that we are so focused on all the stuff, seeing patients, writing our manuscripts and submitting grants and just doing all the things that are associated with being an academic physician. But here's the thing about being an academic physician, it will end. A day is coming when you're going to retire. You're going to walk away from the hallowed halls of the academic institution. And then what are you going to do? And will you be financially prepared for that moment? Some of us will not wait until retirement before we leave the hallowed halls with the academic institution for better or for worse.

7:24 And are we prepared for that moment when it comes? Okay. So that's what I wanted to share. But I want to talk about seven questions you should be asking. Okay. About money specifically. This is about money and it matters because although really I'm really big on you being kind of the academician, the scholar, the clinician scientist, the clinician researcher that you need to be, I also recognize that if you cannot afford your life, that's a problem. And so I'm not here to talk to you about budgeting, not even really here to talk to you about investment. I just want to ask seven questions that I'd like you to consider asking yourself. Okay.

8:04 So number one, how do I make money? How do I make money? Why is this question important? This question is important because whether you know it or not, how you make money drives your experience in the academic medical center. For example, when I first started, I was fully clinical, which meant it was 80%, but I was seeing patients five days a week. But how I made money actually is seeing the patient and writing the note, closing the chart. Until the chart is closed, money is not made. Or at least there's no bill generated so that money can be made. And so every time I was not very good at closing charts, every time I got the notification that, hey, you didn't close your charts, that was the sign that someone was like, hey, you're seeing patients, but we're not making money.

8:54 Can we fix that? And it was a source of stress to me. I just thought that there was this principle they had and charts needed to be closed. What I didn't realize is that charts being closed means the institution makes money or at least can generate a bill so that money comes in. And so when I didn't close charts, I was playing with somebody else's money. Mine too, but mostly somebody else's money because they get more of it than I do. Right? But if I understood that, then it makes sense that I'm being badgered, I'm being bugged and people are like, you haven't closed your charts. You haven't closed your charts. You haven't closed your charts. Because what I realized is that that's how I make money. The moment I close a chart, money is made and it goes somewhere and there's some credit that comes to me, but that is the final denominator.

9:40 But what goes into closing a chart? Well, first of all, you got to see a patient. Right? So prepping my notes before clinic doesn't earn me money. Seeing the patient is part of earning money, but it doesn't earn me money. I can see patient, charts not closed or money is not earned. Or I can see the patient, write the note, close the chart and then money is earned. Okay. Why is this important? This is important because you will live a happy life and no one will ask you questions as long as the math equation works between where all your funding comes from and your clinical revenue such that your salary is covered.

10:21 Okay? The moment something happens and your salary is not being covered, let's say you haven't seen the requisite number of patients, you will hear about it. You absolutely will. Somebody will let you know. In academics, we talk about money indirectly. And so people will talk about charts being closed and your professional responsibility and it's not okay that you saw 50 patients and you've only closed three. They will talk about all that and you'll feel guilty because you're very good at feeling guilty. But the bottom line is that, hey, CES, if you did not close charts, that means bills were not generated and you are not making your salary. Okay. So I just wanted to talk about that in the context of the clinical picture because I think we understand it a little bit better in the context of writing grants.

11:05 No funding means no protected time. It's very simple. But understand how you make money in terms of funding. So what gets you funding? Well, you have an idea and then you write a grant and you submit the grant. Great idea, grant not submitted, no money can come. Great idea, grant submitted, opportunities for money can come. But it's important for you to understand how do you make money? What part of your salary is covered by grants or part of your salary is covered by clinical effort and what aspects of those things actually bring you money? Okay. So if I have 300 meetings and some of them may be related to research, some of them may not, but if any of them, of any of those meetings don't move my research forward, don't increase my ability to write the next funded grant to write for more money, it's not helping me make money.

12:02 Okay. So I'm not trying to be mercenary here. Why is this question important? This question is important because it helps you focus. It helps you align your focus. It helps you really think about the 20%. What are the things you do that create the highest value for you and the highest value for your employer? Because your employer needs you to generate money. It's the only reason you've been hired. You're a physician. Physicians are good generators of money and they leave you alone to the extent to which you're actually generating the money you're supposed to. You can generate excess money. They won't tell you too much about that, but if you generate too little, they want to know and they will let you know indirectly.

12:44 So what it allows you to do, understanding how you make money, it allows you to prioritize what is it about what I do that creates the most value and you focus on that. A lot of things might fall by the wayside, but the things that fall by the wayside will not be the highest priority things. Right? So to be honest, I didn't used to think that writing notes was an important priority, but once I understood that, oh, it's not about the notes, it's about generating bill, then I can clarify, okay, how do I increase my efficiency? So I can close charts and people don't bother me because this is a thing that creates value in this space. So question number one is ask the question, how do I make money?

13:25 And that gives you opportunity to maximize it so that you spend less time doing stuff. If you know that calling a prior authorization doesn't make you money, well, now you can negotiate who helps you call that prior authorization. And I'm glad that there are a lot of people working towards helping us so that we're not doing that kind of stuff all the time, but recognize that the more you understand how you make money, the more you can prioritize what is most important and see how you can delegate the things that are not important. Okay. I feel like I beat that one today. I've beat it enough. How do I make money? Okay. Question number two, where am I working for free versus where I'm working for pay?

14:11 Why is this important? In our lives, we will not always be paid for the work we do and that's okay. Like I'm a mom, nobody pays me for that work or my pay is kind of more in kind, you know, like the joy that I get from serving as a mom, but it's not something for which anybody writes me a check every month. Would be nice, but it's not something I get a check for. But whether I get a check or not for being a mom, I love being a mom. I'm good with doing that work for free because the benefits I get are intangible. I value that. Okay. What else do I do for free? Well, I'm giving a talk to students who are interested in medicine and they're in high school and all they know about medicine is that you can be a nurse or a doctor.

14:56 I'm going to come talk to them about being a hematologist. I found out I'm the only hematologist on the panel to talk to these students. I'm super excited because I need them to know about hematologists. Am I getting paid for this talk? No, but I'm choosing to do that because it is meaningful to me to pour into the next generation like that. Okay. Now, as a physician, I get paid for a certain amount of work that I do and I'm on a salary. So usually I think I probably work more than I get paid, which is fine. That's how salaries work. It also means on the months where I don't work as hard, I still get paid. So that's the benefit of the salary. But then there are parts of the extra stuff that I do, sometimes we'll talk about, is it a 40 hour work week or a 60 hour work week?

15:42 Because if we can make it a 60 hour work week, then we can allow you to work harder and it not count as extra. Anyway, I say all that to say that it's okay to work for free if that's what you want to do. But if for any reason there are parts of your life where you're like, no, unless I don't want my work for free, just make it explicit and clarify. So when somebody says, hey, I'd like you to please take a couple of three weeks of extra coal because you know, there is nobody to do it. You know, three people just quit. You can say, oh, I know the goodness of my heart. I want to do this. And how much is it going to be compensated? How is my time going to be compensated?

16:24 And I know that's almost like a math amount because in medicine we don't talk about that kind of stuff. But I just need you to know that you might say, I choose to work for free. I'm going to take these three weeks of coal and I'm doing it out of the goodness of my heart. I'm working for free. And if that's your choice, that's your choice. Or you might say, I don't want to work for free. How is this extra time investment going to be compensated? And then you get to negotiate that. And it could be that you're like, can I, I want to get paid financially for it. I want money for this. Or you could say, hey, if I'm doing three weeks this year, I'm not doing three weeks next year because these three weeks need to count. But that's an opportunity you have when you know where you work for free and when you don't work for free.

17:07 So you can be very clear who is paying for this time, who is paying for this time. And it could be that I'm paying for it. That's okay. Here I am up late recording this episode for you. I'm choosing, I'm paying for this time. So what question I want you to ask is where in my life am I working for free versus working for pay? Make the distinction. You don't have to do anything with the information, but be aware. Don't be in ignorance about how you're using and spending your time. All right. Number three, what do I want money to do for me tomorrow? I'm talking about retirement.

17:48 What do I want money to do for me tomorrow? Talking about retirement. And to be honest, for most of us, we start, actually I shouldn't say most of us because I don't know where you are, but for me, I'll speak about me. I started, they told me I had to put money in retirement. I'm like, sure. They put it for me in target date funds. I was like, great. Okay. What am I supposed to do with that? Over time as I began to listen and learn, I was like, okay, let's look at the expense ratios. Is this how I want to invest my money? Let's look at the performance. Is this how I want to invest my money? And I've changed my investments. I no longer invest in target date funds. I'm not here to say that target date funds are problematic. They're not. It's just making active choices because I'm thinking about what do I want money to do for me tomorrow?

18:31 I'm thinking about tomorrow. I'm thinking about retirement. And I'm like, what are my plans? What is my goal? And now I'm making choices that affect what tomorrow looks like. Do I control tomorrow? Absolutely not. But I'm making the choice I can make because I recognize that tomorrow, the day of retirement, or leaving this place, is coming. And it's an opportunity for me to really think about what does tomorrow look like? When is tomorrow? Like, when is that day of retirement? When is it coming? When do I want it to come? Am I just going to accept that I'm going to be here until 90 or 100? All things working well? Or do I want to be done with this at age 62?

19:12 We get to decide. But part of thinking about what do I want my money to do for me tomorrow affects what you do with the money today. Okay. Question before is what do I want money to do for me right now? Now you can look at that in two ways. One you can say, well, if I want money to do this for me tomorrow, what do I need to be doing with money today? So that tomorrow it does this for me. Right? What do I need to do with my money today so that in retirement it gives me the returns that I want? Right? No guarantees. But how do I prepare today for tomorrow? That's one aspect of what I want money to do for me today. But the other aspect is how do I want to live today? I mean, you could totally like lock up all your money and just put it into the future.

19:54 Actually you couldn't because there are limits on how much you can invest, but there are opportunities to invest in different things. So it's not just your retirement accounts. You can invest in a syndication deal. You can invest like an active real estate. There's so many options for investment. So it's not as if your retirement account is the only place for an investment. So you could invest all your money. You just put it all in savings, investments. You do all that stuff and then you don't have enough money for yourself or you're paying off your student loan debt and you live like a pauper or maybe not a pauper. You live frugally. How about that? That feels a little bit better. Frugally. But is that a choice you're making? Are you actively making that choice or are you just kind of letting life carry you?

20:37 It's like, oh, this is the amount people pay on their student loans. Therefore, I guess I do this. Or when you are overwhelmed or feeling like, I don't like the way I'm living. I can't go on vacation. But it's just, what do you want money to do for you right now? And how do you free up money to do that for you right now? What do you need to let go of so that money can do what you want money to do for you right now? What do you want money to do for you right now? An important question so that you can make sure that you are achieving your goals and living the life you want while also building your legacy in your research, in your scholarship, your academic work, and also in your future. So you're taking care of all those things, making sure that also you're living the life you want to live today.

21:23 Okay? Question number five, how can I reach my financial goal sooner? Okay. You know you love this positioning. You love this positioning thing. You're going to do it forever and ever. Even then a day is coming where you're not. It's not possible that you want to wait until 90 to retire. I mean, once you get to age, I believe it's like 73 and some change, you start to make these, you know, like required distributions from your retirement accounts. But is that the age at which you want to retire? Would you want to retire sooner? Would you want to retire while you still have the great health to do the retirement thing? Or do you really want to wait until like your old, older, and maybe suffering challenges that are associated with aging?

22:07 You get to decide. But the question is, if you want to, how can you reach these goals sooner? Maybe you've resigned yourself to the fact that it's like, nope, I already have $300,000 worth of debt. I have another couple of hundred thousand in this home that I bought. I'm going to be in debt forever. I'm going to be okay. I've just resigned my life to this. And I've heard some say that to me, but I'm saying, hey, what if, what if, let's just imagine for a moment, what if it were possible? For you to have a different outcome, what if it were possible for you to achieve your financial goals sooner? How might that change the way you show up? Just a thought, just a thought experiment. Don't get too excited. But what if you could reach your financial goals sooner?

22:51 Would you want to? And what would you do if you did? It's a question to ask so that you can take charge and change the way you behave today to achieve the outcome that you want tomorrow. Okay. Sixth question is what's my current salary relative to my position and level of experience? Okay. Another one that's a little bit tense. I like, I can feel the tension building up in my belly even as I talk about it, because it's like an academic talking about salary. Oh, no, we don't talk about that. And I want to say it's time to talk about it. It is time to talk about it. For many of us who are underrepresented in the academy in any way, whether we're women or whether we're a gender or sexual or ethnic minority or racial minority, it is possible and quite likely that there may be some inequities in our pay.

23:44 I'm not saying definite. I'm saying possible, maybe likely. You don't know. You don't know until you start asking questions. And you may not want to do anything about it. You may be like, oh, I know there's inequities, but how much is the inequity? Or you may be like, oh, no, I'm fine. Yeah, to what extent are you fine? And I'm not asking you to say, well, what is that person earning? And am I earning something relative to that person, which, you know, it always starts its own kind of controversy. The question is not compared to others as much as it's like, well, for me today, as an associate professor who has been in this role for the last four to five years, how much should I be earning?

24:27 Ask that question. And maybe it's not a question that you ask yourself. As much as it's a question you can ask your division chief, like, oh, I want to make sure that I am benchmarked correctly. What are the benchmarks of someone who is at my position and has been in this role for the past couple of years? Ask the question and see what answer you get. It'll be interesting. It'll definitely be interesting. But if you don't ask, you don't know. I want to invite you not to be afraid to ask because information helps you make decisions. So ask, ask that of yourself. To what extent can you answer the question? But then ask that of the people who actually know. Now see to what extent they can answer the question for you.

25:10 Again, you don't need to do anything. You don't need to put up a fight. You don't need to be angry. Just get the information, just the information. All right. Number seven, what will it take to get the financial information that sets me free? This is a question that I actually I'm asking for myself. I'm already kind of in the process of getting information that sets me free. That helps me think differently about my finances. What I find about many of us academics, and I will speak for myself, is I'm so busy going from one manuscript to the other manuscript, one grant to the next grant, that to be honest, there isn't really time to stop and think about, wait a minute, what do I want to do with my financial future? Because it just doesn't feel normal, right?

25:52 In medicine, that's not something we really talk about. But it is time to start talking about it. It's time to start thinking about it. And what will it take to get the information you need? And I hear some of you say, but I'm so busy. It's like, yes, you are busy. And I'm so excited for you that you're busy. And you can never be too busy to take charge of your financial future. You can never be too busy to sit and think about, well, what are the financial goals that I have? How do I reach them? How do I reach them sooner? What will it take to live the kind of life I want to live today and the kind of future I want to have tomorrow? What will it take to accomplish that? These are questions I'm still asking myself.

26:33 I'm going to summarize in just a little bit. Number one, how do I make money? Number two, where am I working for free versus working for pay? Number three, what do I want money to do for me tomorrow? Number four, what do I want money to do for me right now? Number five, how can I reach my financial goals sooner? Number six, what is my current salary relative to my position and level of experience? And number seven, what will it take to get the financial information that sets me free? I tell you that this journey of academia or scholarship is about your whole life. It's not about just grants and manuscripts. And we would be remiss if all we focused on were the things that may not take us the distance that we need to get to.

27:16 I know it's important to focus. And I'm always a big person on telling you to focus. It's a thing. You should focus. And you should make sure that you do not focus on your career to the detriment of your financial future. Both should go hand in hand so that you can work your career to give you the financial future that you desire. All right. I'm going to have more thoughts on it in the future. But today, thank you for listening to what I do have to share. As always, if you are looking for a coach, definitely reach out to me. You can find me on Instagram, find me on LinkedIn, and on Facebook as well. I look forward to hearing from you.

27:57 And I am so thankful that you will, I ask, share this with somebody else who would benefit from thinking and talking about money. All right. Have a great rest of your day. And I'll see you next time on the Clinician Researcher Podcast. Thanks for listening to this episode of the Clinician Researcher Podcast, where academic clinicians learn the skills to build their own research program, whether or not they have a mentor. If you found the information in this episode to be helpful, don't keep it all to yourself.

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