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REAL ESTATE ADVISOR Tips & Tools from the world of today’s Realtor

So, you are a physician looking to buy your first house. But like many young physicians you are still recovering from your medical education debt and forced poverty during that education process. Your free cash flow has allowed you to accumulate only about $18,000 for a down payment. On the plus side you have a guaranteed employment contract with a base of $170,000 and are on a fast track to partner. To buy or not to buy…and if the decision is “to buy” how much house can you afford and what price range should you be considering. Those are all good questions. Here are some things to consider.

1. If you have not yet forged a relationship with a trusted financial advisor with whom you have crafted a detailed

financial plan, you should hold off on your decision until you can incorporate any home purchase with your short

and long term financial goals.

2. If you want to know what you can afford, the best person to talk with is a mortgage broker. He or she will often

have an online calculator that can do the math. Look for someone that works with other doctors and has a lending

product crafted specifically for medical professionals.

3. Determining what you can afford is not the same thing as determining what you need. The tendency in today’s

depressed market is to grab for as much house as you can afford. You may well qualify for a mortgage with a small

down payment that will leave you with a $6500 monthly payment. But that is probably not the best route for a

young physician to go.

4. Determine how long you plan to stay in your first house. In all likelihood your compensation and net worth are

going to grow dramatically as your career advances. If you plan to stay in your first home for less than five years

(about average) you can kill two birds with one stone by looking at this first purchase as an investment. Buy smaller

with a 20% minimum down payment and plan on paying off the mortgage in five years.

5. Turn your first home into an investment property and keep moving upscale every five years until you arrive at that

dream home. Until you are certain that you will be staying in your present position and in the present location for

the foreseeable future, view each purchase as an investment.

6. Keep in mind that residential investment property can work for you in more than one way. You don’t have to

become a landlord by renting out a property. You can keep moving up the housing ladder by selling your current

property with owner financing and get a very nice return on your capital.

Final thought: Many young physicians are anxious to reward their family with a beautiful home in recognition of the

sacrifices they have made to their medical education. But in the absence of a solid financial plan, that move often

comes too soon. Before anything else, make sure you have built your six month emergency fund. In your case that

should be in the neighborhood of $50,000. And that is the first neighborhood you should be considering come home

buying season.

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Case law and frozen pre-embryos

Those of you who follow the paparazzi are probably aware of the

ongoing legal battle between the actress Sofia Vergara and her ex-

fiancé Nick Loeb. But their celebrity has little to do with the import of

the fight going on in court. What’s at stake here is the fate of the

couple’s frozen pre-embryos. For the record, case law now refers to a

fertilized egg that has been frozen as a pre-embryo, pre-gamete or

pre-zygote. The key is the prefix or “pre.” It does not achieve embryo

status until it has been implanted in a woman’s womb.

A quick look at case law finds that the determination of disposition of

frozen pre-embryos after a marital or even a non-marital breakup of the progenitors has evolved since Davis v. Davis a

Tennessee Supreme Court ruling in 1992. In Davis, the couple participated in a frozen embryo program and were later

divorced while frozen pre-embryos remained. There was no written agreement between the couple or with the clinic.

The wife wanted to donate the pre-embryos to another couple and the husband wanted the pre-embryos destroyed.

The lower court held that the pre-embryos were essentially children and awarded them to the wife. But the Tennessee

Supreme Court reversed the ruling noting that the frozen pre-embryos were neither children nor property but

something in between. They noted that frozen pre-embryos held the “potential for human life” which removed them

from the traditional property category. The court first looked to any written agreement that detailed disposition in the

event of divorce. There was none. The court was comfortable with the concept that the progenitors do in fact have the

right to determine disposition but in the absence of an agreement they turned to the constitutional right to privacy.

They ultimately gave more weight to the husband’s right not to have children than the wife’s right to donate the frozen

pre-embryos. Although the case established some precedent, the fact that the wife wanted to donate the pre-embryos

rather than have them implanted in her probably affected the outcome of the case.

From Davis v. Davis we move to Kass v. Kass, a New York case from 1998. Clinics were urging couples to sign an

agreement in advance of any freezing of fertilized eggs, both between themselves and with the clinic. In this case the

couple did in fact have an agreement in place which stated that in the event of divorce the pre-zygotes could only be

removed from storage with the consent of both parties. The agreement made passing reference that ownership would

be part of a property settlement as directed by order of a court of competent jurisdiction. The court ruled that the

passing reference to a court directive was not intended to transfer the disposition decision out of the hands of both

partners. They ruled in favor of the husband who did not wish to have children and was unwilling to agree to release of

the pre-embryos.

The case law became more ambiguous in 2000 when a Massachusetts court flat out ruled that even with the presence of

an unambiguous agreement to release pre-embryos to the wife in the event of divorce, the court would not, as a matter

of public policy ever enforce an agreement that would compel one donor to become a parent against his or her will. So

Davis v. Davis called for the courts to follow the instructions of a properly drafted written agreement while another

court from another state refused under any circumstances to enforce a properly drafted written agreement that forced

a parent to become an unwilling parent.

If things were not complicated enough a case from New Jersey in 2001 threw another monkey wrench into the case law.

Described only as J.B v. M.B the court had a divorced couple with a written agreement that spelled out disposition of

the frozen pre-embryos in the event of divorce. In the agreement the pre-embryos would revert to the IVF Program

unless a court specified otherwise. In this case the husband wanted to donate the pre-embryos to another couple and

the wife wanted them destroyed. The court was not amused with the agreement’s willingness to dump the decision

into the court’s lap. They ruled that the agreement was too ambiguous. But then the justices ruled further that

ambiguity was irrelevant because a contract to implant frozen embryos violated New Jersey public policy and the best

rule of law is to enforce agreements entered into at the time in vitro fertilization is begun, subject to the right of either

party to change his or her mind right up to the point of use or destruction.

So far we have case law that generally was willing to follow the instructions of a written agreement; case law that would

not force either party to become an unwilling parent no matter what the agreement said; and case law that said that

even if both parties agreed to specific rules for the disposition of pre-embryos in the event of divorce, either party could

change their mind at any time. How could the case law be any more confusing you ask?

Take the case of Litowitz v. Litowitz, a Washington state case from 2002. Now pay attention because this one gets a bit

complicated.

The parties wanted to have a child.

The wife was unable to produce an egg or give birth to a child.

They acquired eggs from a third party.

They fertilized the eggs with the husband’s sperm.

They had the resulting pre-embryos frozen.

One of the pre-embryos was implanted in a surrogate mother (a fourth party) who gave birth to a normal child.

The remaining pre-embryos were still in frozen storage when the couple divorced.

A contract with the egg donor had been signed that prohibited the Litowitz couple from allowing any other party

to use the eggs without the written permission of the egg donor.

A contract with the medical clinic called for the frozen pre-embryos be thawed after five years in storage and

not be allowed to undergo further development.

You got all that? A lower court considered the best interests of the frozen pre-embryos and ordered the father to use

his best efforts to donate the embryos to a married couple. The state Supreme Court reversed and following the

wording of the clinic agreement, five years having passed, ordered that the pre-embryos not be implanted. The court

further ruled that the agreement with the egg donor ceased to apply when the eggs were fertilized and became

embryos. I have no idea what conclusions to draw from this one.

So, it would seem that evolving state case law actually follows the US Supreme Court’s established precedents regarding

abortion. The mother’s rights overcome any rights possessed by a nonviable fetus. The frozen embryo cases appear to

hold that no one may be forced to procreate and that right overcomes any contrary right possessed by an objecting

parent or by the frozen pre-embryo which the US Supreme Court seems to feel has no rights at all.

Back to Ms Vergara and Mr. Loeb. It would seem that Mr. Loeb’s stated wish not to become a parent in the case of the

frozen pre-embryos that he and Ms. Vegara created would have the weight of the law on his side. Ms. Vegara on the

other hand has referenced two other cases currently on appeal that would overrule the objections of the husband in the

event that the female partner had undergone chemo therapy that made it impossible for her to have children. In these

cases, the only way the woman could become a genetic parent would be to implant the frozen pre-embryos. The only

problem is that Ms. Vergara does not have that problem. So, as most things in Hollywood are, their case will be

sensational, illogical, and emotional and in the end settled to the financial interests of the warring parties. So much for

case law.

Growing momentum for off label promotion of medications by drug manufactures

Primary care physicians are having a hard time staying current on

new “off label” uses of pharmaceuticals that are both safe and

effective but which have not been approved by the FDA. The

problem here is that although a physician can prescribe any safe

treatment regimen including the use of pharmaceuticals not cleared

by FDA regulators for that particular illness or disease,

pharmaceutical reps cannot not recommend or discuss such use.

There is growing pressure from the Congress to expedite the release

of new drugs to market. A bill known as 21st Century Cures is

working its way through the legislative branch and parts of the bill would appear to make it necessary for the FDA to

relax its strictures against “off label promotion.” And now the Second Circuit Court of Appeals has thrown another

monkey wrench into the FDA’s attempt to keep a tight hand on the regulation of medications.

In 2012 the court reversed a lower court conviction of a pharmaceutical rep for talking about off label use of the

narcolepsy drug Xyrem (Alfred Caronia a sales rep for Orphan Medical). The court cited the First Amendment right to

free speech saying that the amendment protected “truthful and non-misleading off label speech.” Now a coalition of

drug manufacturer heavy hitters including Pfizer, Johnson & Johnson and GlaxoSmithKline calling themselves the

Medical Information Working Group is using the Caronia decision to pressure the FDA to relax its regulations. In the

tradition of government regulators, the FDA opposed to anything that might weaken its regulatory authority. But with

billions of dollars in potential pharmaceutical sales in play, the FDA is being out spent and out lobbied.

In a concession to growing pressure on all fronts, the FDA has announced plans to hold a public meeting later this

summer to hear drug company concerns about the harsh restrictions to “off label free speech.” It’s hard to see any

losers in a compromise that allows the FDA to require uniform rules on the promotion of pharmaceuticals and

pharmaceutical manufactures to promote effective uses of their drugs while the often complex and time consuming

regulatory process inches forward. Stay tuned for developments.

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Personal Finance

Tips & Tools from the world of financial planning

You have completed your medical training and

have moved into the world of medicine. You

are justifiably proud of your new six figure

salary and guaranteed contract. The future is

bright and the mountain of medical education

debt though imposing is manageable with a

little bit of planning. And as a young physician

starting out you are one of the wise ones who

has partnered with an experienced financial

planner…no rookie mistakes for you.

So, it’s time to push the beater that has served as the family car off the nearest cliff and put yourself and perhaps your

spouse behind the wheels of two suitably luxurious vehicles in keeping with your new status. To buy or to lease…that is

the question. Well, perhaps not the only question.

The case for buying a car is all about equity. At the end of your finance contract or when you are ready to trade for a

newer model you have something to show for your monthly car payments. On the other hand the leased vehicle

generally comes with little or no down payment, a lower monthly tab and a new vehicle every three years. And

maintenance costs are often included.

There are a number of economic factors that drive the purchase/lease decision and in today’s economy the odds are

stacked very heavily on the lease side. These factors revolve around the used car market and the real verses projected

depreciation of a leased vehicle. Because space is limited for this column I’ll keep it simple. Although there are some

signs of a pulse, since 2008 the auto industry has been in a coma. For many years sales of new cars were deeply

depressed. The result is a shortage of late model used vehicles. And this shortage is expected to extend well into the

future. So, come the end of your lease in three years there is a very good chance that you will “beat the lease.” You

might even have some equity in the vehicle!

And as a physician looking at a luxury vehicle the numbers are even more in favor of the lease route. A luxury vehicle’s

value is going to dramatically depreciate in the first two years. If you look to trade in three years after a purchase you

may actually be underwater. So much for the pride of ownership! And of course there is always the consideration of

business use of your vehicle and the resulting write off. But the rules are not as generous as they once were and unless

you are a country doctor making house calls in your “company car” you may find it hard to dip in the tax man’s pocket.

For the time being, the numbers favor a leased vehicle for both the doctor’s vehicle and the family car.

Fun in the Sun

Spring is sprung…the grass is riz

I wonder where the sunscreen is

The Center for Disease Control and Prevention (CDC) is out with its

annual report on sunscreen use. Not surprisingly they report that a

very low percentage of citizens protect themselves from the

potentially harmful rays of the sun. According to their research only

14.3% of men and 29.9% of women use sunscreen regularly. And 33%

of those who use sunscreen haven’t a clue if their brand provides

broad-spectrum protection against both UVA and UVVB rays.

As a motorcycle enthusiast, your author spends a good amount of the time in the summer sun and I must admit, I wasn’t

even aware that there were two flavors of rays I needed to worry about. It would seem that UVB are high energy rays

that cause sunburn. While UVA are lower energy rays that are actually more dangerous because they are present year

round, can go through clouds and glass and are the linked to melanoma, the most deadly form of skin cancer.

Although skin cancer is the third most common cancer in adolescents and young adults, protecting oneself is relatively

easy. The CDC recommends that you stay out of the sun during the hottest times of the day, wear protective clothing

such as a wide-brimmed hat and sunglasses and apply a protective amount of sunscreen every two hours. Although this

may be a practical proscription for most, it doesn’t help an active biker. So I of course zeroed in on their advice

regarding sunscreen.

Consumer Reports is always a good place to search for product recommendations and they didn’t disappoint. They

tested 34 brands of sunscreen and published their 2015's best and worst picks. It was interesting to note that 15 of the

brands they tested did not deliver the sun protection factor (APF) that they advertised. Part of the problem seems to be

that spray on sunscreens, although convenient, may not be used in great enough quantity to deliver the SPF claimed.

One final note. ..the FDA limits the level of chemical ingredient in sunscreen that produces the SPF and that limit maxes

out at around 20 SPF. In fact the FDA is thinking of limiting sunscreen labeling to claims of no higher than SPF 50. Any

sunscreen with an SPF of more than 50 is probably a waste of money because it simply isn’t delivering a correspondingly

higher level of protection. So, enjoy the summer. Use common sense. And check out the old tube of sunscreen left

over from last summer. You may not be getting all of the protection you think.

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clients achieve the personal, professional and financial goals that drew them to a career in

medicine. She offers a bridge between the world of medicine and the world of business.

Skip a meal and you just might gain weight

Don’t you just love how some common sense approaches to some of

life’s little problems prove to be counter intuitive. As the old saying

goes, the best laid plans of mice and men often go awry. And speaking

of mice another batch of little furry creatures have been called upon to

aid human researchers in better understanding how fellow humans lose

and gain weight as they sit atop the food chain.

I don’t know about those of you who follow my blog, but this author is

resigned to the fact that I’ll never fit in those jeans that I used to wear

in college. To be completely honest, I never really had six pack abs. But at least I was able to see my toes and when

necessary touch them. Today it is a constant battle to just hold the line. And now I find that my favorite dietary strategy

may be causing more harm than good.

Whenever I get bored I like to pick up some lively reading like the Journal of Nutritional Biochemistry. And as I was

absorbing all kinds of useful knowledge I found the results of a new study published by researchers from The Ohio State

University and Yale. And it would appear that these knowledgeable gals and guys are bent on debunking one of my

trusted common sense approaches to fighting the battle of the bulge. Namely, skip meals, shed pounds and inches.

Enter our trusted white mice partners. After counting off by twos, group one was put on a steady diet of small meals all

day. They were allowed to nibble their way to health and happiness. And they did reasonably well. Group two on the

other hand were put on the fast & feast diet that I have used repeatedly with such spectacular absence of results.

Group two’s rodents were fed just once a day(apparently the same amount that the nibblers got over the course of the

same day) and, no big surprise they literally inhaled their chow. Sound familiar?

Group two participants became what Martha Belury, the senior author of the study, likes to call “gorgers.” And even

after they were released from the diet they continued to behave as gorgers. But what really captured my attention was

the fact that not only did the little fellows gain back all of the weight they lost, but they actually began to increase the

amount of fat around their bellies.

A vastly simplified summary of the researcher’s findings show that the gorgers’ livers developed insulin resistance. The

livers stopped listening to “insulin signals” telling them to stop producing glucose (evil sugar). And that overdose of

sugar traveling through the blood stream headed straight for the waist line and parked there as adipose tissue (belly

fat). Next time someone tells you that you are becoming a bit chubby tell them it is just an excess of adipose tissue and

you are working on the problem. In short, the mice were consuming the same number of calories but they were now

storing the calories differently.

And what is the lesson to be learned? Snacking all day long on nuts, berries and twigs is a better strategy for controlling

your weight than skipping breakfast, lunch and dinner and consuming a bed time snack of a two pound porterhouse

steak. And if you find the prospect of munching on celery and carrot sticks unappealing you can join 108 million of your

fellow citizens who spend over $20 billion on weight loss products every year. By the way, did you know that 85% of

U.S. customers who consume weight loss products and services are women? But that is a story for another day.

2,147,483,647

On Tuesday, June 4, 1996 the first flight of the Ariane 5 rocket,

designed and funded by the European Space Agency was launched. It

was a relatively brief flight. It lasted exactly 39 seconds at which point

it exploded and transformed four very expensive satellites it was

carrying into $370 million worth of confetti. Fortunately it was not a

manned flight.

On Thursday, April 28, 2015 the American FAA reported that the Boeing

787 aircraft may have a potentially catastrophic problem where the control unit managing the delivery of power to the

jet’s engines might automatically shut down the engines if it has been left on for over 248 days. This is more than just a

potential problem on a scale of Canadian white mice contracting stomach ulcers from drinking six gallons of green tea

each day for a month of Sundays. You see the control units are not normally shut down in between flights or even in

between scheduled maintenance.

What, you may ask, do these two events share in common? It would seem that they share the number 2,147,483,647.

Without going completely off the deep end with IT minutia, the above stated number is the maximum positive value

that can be stored by a “32-bit signed register”. In layman’s terms, many modern computer systems commonly use 32-

bit signed registers. Now 2 billion would seem to be a pretty big number. But for modern computers it is on a level of

2+2=4.

Here is the problem in an oversimplified analog nut shell. If the odometer on your car can only handle a number as large

as 99,999 and you travel beyond 102,000 miles, the odometer simply rolls over and starts over. It cannot recognize a

larger number, becomes confused and reboots. In the digital world of computers the register controlling the computer

that controls the gadget can become overwhelmed, confused and generally schizoid. The point at which it blows a fuse

is determined by the size of the register.

Take the Ariane 5 event. The rocket actually had a much older 16 bit register left over from the previous generation of

rockets. No one gave it a thought. A 16 bit register goes gaga at only 32,767. When the rocket censed lateral velocity in

the newer and faster rocket that exceeded its limited ability to comprehend, it went to fail safe and blew itself up.

Oops!

The Boeing 787 issue did not come to light until a number of amateur geeks pointed out that if you count time in 100ths

of a second (as apparently computers do) 2,147,483,647 100ths of a second works out to be…you guessed it…248 days.

As if I didn’t have enough flight worries with terrorists, deranged pilots and global warming.

So, why should doctors and hospitals and patients worry about this seemingly esoteric digital dilemma? Well, how many

of your hospitals cutting edge technology diagnostic, surgical, imaging, and monitoring devices are managed by micro

chips? And how many of them have a signed register tucked away in some corner of its brain? And what size is the

register. And what units of time does it spend its days counting? Do the devices ever get turned off? And what will

happen if it reaches fail safe and shuts itself off in the middle of a procedure? I may be tilting at windmills here but it is

certainly something worth worrying about. I know that it will be one of the last conscious thoughts I’ll have as my next

surgery is set to begin and the cute CRNA puts the gas mask over my face and instructs me to start counting backwards

from…2,147,483,647.

Mind controlled bionic limbs

Ossur, an Island based global leader in non-invasive orthopaedics, is

focused on improving people’s mobility through the delivery of

innovative technologies within the fields of Prosthetic,

Osteoarthritis and Injury Solutions. They recently announced

positive results in two tests of their mind-controlled bionic

prosthetic lower limbs.

According to the company, two amputees equipped with their new

technology are now able to control their bionic prosthetic legs with their thoughts, thanks to tiny implanted myoelectric

sensors (IMES) that have been surgically placed in their residual muscle tissue. The IMES instantaneously triggers the

desired movement, via a receiver located inside the prosthesis. This process occurs subconsciously, continuously and in

real-time. “Mind-controlled Bionic prosthetic legs are a remarkable clinical breakthrough in next-generation Bionic

technology,” said Jon Sigurdsson, President & CEO of Össur. “By adapting not only to the individual’s intentional

movements but to intuitive actions, we are closer than ever to creating prosthetics that are truly integrated with their

user.”

According to Dr. Thorvaldur Ingvarsson, MD, PhD, the orthopaedic surgeon who leads Össur’s research and

development efforts and spearheaded the mind-controlled prosthetics project, movement in able-bodied individuals

generally begins subconsciously, which triggers electrical impulses inside the body that catalyze the appropriate muscles

into action. Össur’s new technology replicates that process in an amputee: that electronic impulse from the brain is

received by an IMES that was surgically placed into muscles in the amputee’s residual limb.

“The technology allows the user’s experience with their prosthesis to become more intuitive and integrative,” Dr.

Ingvarsson said. “The result is the instantaneous physical movement of the prosthesis however the amputee intended.

They no longer need to think about their movements because their unconscious reflexes are automatically converted

into myoelectric impulses that control their Bionic prosthesis.”

The implant surgery is relatively simple and is done under a local anesthetic. The implanted IMES are very small and

because the brain is signaling residual muscle tissue using the body’s own neural pathways, no brain electrodes or

surgery are required! Ossur hopes to move into aggressive clinical trials with the new technology and bring products to

market in three to five years. Science marches on…literally!

MD Preferred Services is the only comprehensive online resource center for doctors. Each year MD Preferred

identifies and promotes uniquely qualified, “doctor friendly”, community based, preferred professionals from a wide

range of disciplines including: Accountants, Attorneys, Bankers & Mortgage Lenders, Financial Advisors, Insurance

Agents and Realtors. Visit us at www.MDPreferredServices.com

Apple’s growing investment in healthcare In the poorest parts of Africa one of the most common health problems is blood parasites. And as is the case with many

health issues in 3rd world countries, accurate diagnosis is often more of a road block to cure than are available medicines

and treatment regimens. Seeing a hematologist can entail long trips and expenses that the average citizen can simply

not afford.

Enter a team of IT and healthcare researchers at UC Berkeley. They have produced software and hardware that can

identify blood parasites in the field in less than three minutes. The projects name, CellScope Loa, uses a 3D-printed box

(very low manufacturing cost) on which a smart phone (Apple only thus far) can sit. The device takes five-second videos

of blood samples which are analyzed by a companion app. When movement of microscopic worms is detected, a

diagnosis for river blindness and elephantiasis among other diseases caused by blood parasites can be made. And the

drugs needed to treat these parasites are readily available.

But there are challenges that remain. One of the challenges are the potentially devastating side effects that the drugs

can have. If a patient is also suffering from African eye worm, or Loa Loa, the drug that can successfully treat other

blood parasites can cause death or traumatic brain damage. Thus the name of the project, CellScope Loa. At present,

health campaigns in African countries have halted by the fact that a cure can sometimes do more harm than good.

With the low cost of the program’s components and their ability to screen out Loa Loa patients, it is hoped that

aggressive public health initiatives will once again be possible. A planned trial in Cameroon will further test the efficacy

of the system. Increasingly the I Phone and other smart phones are becoming sophisticated tools that dedicated

physicians can use to bring cutting edge healthcare to remote, third world communities.

The Mouse That Roared

Well here is another interesting research study that any Renaissance man will find fascinating…how about a Renaissance

mouse. It would seem that scientists with an excess of time on their hands have found a way to increase the size of a

mouse brain by injecting a strand of human DNA (called HARE5) into a mouse embryo. And as they postulated, it

resulted in larger brain sizes. And you will be happy to know that the increase in brain size was greater than when a

similar strand of Chimpanzee DNA was used. Another validation of the theory that we are smarter than monkeys.

There isn’t all that much difference between our genetic makeup and that of a Chimp. Our DNA is actually about 95%

identical. But it’s that other 5% that keeps us at the top of the food chain. And our bigger brain seems to be the

benefactor of that differential. I am told that the average human brain weighs in at 1,352 grams and that of a chimp a

mere 384. That would explain why chimps are such lousy poker players. By the way, did you hear that a super

computer recently out played the top human poker players? Perhaps we should stick some micro chips in a mouse’s

brain and see how that plays out.

Debra Silver, an assistant professor at Duke University Medical School, and a member of the research team believes we

have “just scratched the surface” in what we can gain from this line of study. Hmmm. I assume she is referencing

advances that will accrue to the benefit of humans and not just smarter mice. Actually, this research can be seen as a

small step toward finding ways to repair, replace or grow human brain cells. And such advances could benefit patients

with Alzheimer’s and other diseases affecting the brain. And that is the piece of cheese at the end of the maze that

makes it all worth.

Government Speak

Doctors and hospitals are reimbursed by Medicare and Medicaid for their services to elderly and poor patients. The

reimbursement is regulated by the CMS. This is the lead agency in the government’s daily battle to control the ruinous

rise in healthcare costs. Their primary regulatory weapons in this war are the formulas and principles that they set to

determine how much government money flows to healthcare providers. Because these regulations, once in place,

become the law of the land, annual proposed changes are closely watched and analyzed by the healthcare industry.

Government speak has raised the use of clever acronyms to an art form. The names of agencies, programs and

initiatives are often determined by how cute their acronym will be. Here is just a sampling of the alphabet soup that

permeates medical journals and government entities:

HHS - United States Department of Health and Human Services – the cabinet level department of the U.S.

government that is charged with protecting the health of Americans and providing essential human services.

HCFA – Health Care Financing Administration – the former name of the government agency within HHS that

manages Medicare and Medicaid now known as CMS

CMS – The Centers for Medicare & Medicaid Services – the federal agency with HHS that administers the

Medicare program and works with state governments to manage Medicaid which provides subsidized

healthcare services for the poor and also administers SCHIP and HIPAA

HQSRR – Hospital Quality and Safety Reporting Requirements – part of Medicare’s reimbursement formula that

is designed to move physician and hospital reimbursement toward a payment model that rewards quality over

quantity

PQRS – Physician Quality Reporting System - a CMS program initiated in 2006 described as a “pay-for-reporting”

incentive that pays physicians a bonus for reporting quality data

EPIP – Electronic Prescribing Incentive Program – another CMS initiative designed to move doctors toward

electronic prescription technology and devices that minimize miscommunications and adverse drug interactions

SCHIP – State Children’s Health Insurance Program – a program that provides matching funds to states for

health insurance for uninsured children in families of modest incomes that are too high to qualify for

Medicaid…now more commonly known as CHIP.

HIPAA – Health Insurance Portability and Accountability Act of 1996 – The Act has two primary parts…Title I of

the act lays out regulations that protect the health insurance coverage for workers and their families who have

lost their jobs or are changing jobs. Title II of the act establishes national standards for electronic health care

transactions and governs very strict privacy rules for the handling of personal healthcare records and

information.

EHRs – Electronic Health Records – government mandated digital records that will replace paper records of our

health history including doctor visits, test results, medications, diseases and disabilities. There are still many

issues to address including privacy concerns and hardware and software standards that allow the transfer and

sharing of records from one healthcare entity to another.

NCHIT – National Coordinator for Health Information Technology – The government Czar charged with making

EHRs happen.

APIs – application programming interfaces – pieces of software code that give patients access to their medical

information on their smart phones and other mobile devices

Common sense trumps religious freedom

One of the founding principles of this country was religious freedom. “Congress shall make no law respecting an

establishment of religion, or prohibiting the free exercise thereof...” And along with other guaranteed freedoms, it has

weathered the test of time. But in the healthcare arena, religion and medical research and technology have increasingly

been at odds.

When one considers that many of the founding texts of the major religions date back thousands of years it should not be

surprising that literal adherence to religious dogma can lead to undesirable consequences. And immunization for

childhood diseases is one of the most hotly contested examples. Religious fundamentalists (not just Christian, Jewish or

Muslim) often turn their backs on modern science (with the obvious exception of bullets and bombs). Their version of

the creator is all powerful and if their lord wants a child to be healthy and to live a long life, then who is man to stand in

the way of divine guidance. If illness threatens, they turn to prayer rather than medicine; faith healing rather than

pharmaceuticals, divine intervention rather than preventive medicine.

And it is in the area of childhood immunizations that even diehard conservatives and liberals alike are having some

problems defending the rights of some parents. Personally I am willing to stand aside when a parent genuinely believes

that they know what is best for their own children. I cringe when I read stories of young children who ultimately perish

after their parents withhold potentially lifesaving modern medical care. And shake my head when they staunchly say

their loss was God’s will.

But I do have a problem and am prepared to push back when their decisions threaten the health and well being of my

children. If a fundamentalist is prepared to stand by and watch a loved one suffer and die, well, that is their choice and I

can’t change the world. But if their decision leads to suffering and possible death to my own, that is a line that they

cannot cross. And such is the case with a refusal to have their children immunized against highly contagious childhood

diseases like measles and polio.

If a parent, citing religious beliefs refuses to have their children immunized, than it is this author’s studied opinion that

they forfeit the right to have their children mingle with the general population. And that includes public places such as

schools, shopping malls and other places where card carrying members of the 21st century gather. But even enforced

isolation is not a practical solution. It is simply not possible to enforce such restrictions and sooner or later their kids will

slip into Disney World and sicken their fellow citizens.

Thus I find myself doing something I would have thought impossible. I am agreeing with legislation put forward by two

California liberals, Democratic Sen. Richard Pan, of Sacramento and Ben Allen, of Santa Monica, dubbed Senate Bill 277.

The legislation which passed the state Senate on Friday would not allow personal or religious exemptions to infant

immunization. It would require every child to be vaccinated for such diseases as measles and polio, before entering

kindergarten. If it makes it through the state assembly and if Governor Jerry Brown signs it into law, as he has signaled

he will, California would join Mississippi and West Virginia as the only states in the union where common sense has

finally trumped religious myopia.

“Trust in the Lord with all your heart, and do not lean on your own understanding”

Words to live by…22 centuries ago.

Riding Life’s Arc

By: Anthony J. Ogorek, Ed.D., CFP, Ogorek Wealth Management LLC,

www.ogorek.com

Most physicians would like to view their lives, or at least their life expectancy, as a

continuum projecting out to infinity. The unfortunate truth is that our lives can more

practically be viewed as being on an arc comprised of a beginning, middle and an end.

For some odd reason, perhaps self preservation, we tend to park ourselves

comfortably in the middle of the arc, regardless of our age.

This creates the impression that our lives are static, rather than continuously moving forward. Understanding this fact

can radically change not only long held habits, but how we perceive our place in the world.

For example, many of our consumption habits may have been developed when we had little or no money. As we

accumulate money over time, we can definitely afford to change our spending habits but don’t because we do not see

our lives moving on the arc; we see ourselves stuck in a moment of time. Therefore, a successful physician may still take

the Super Shuttle from the airport instead of a cab or limo not because he or she cannot afford the other choices, but

because they don’t realize their life has changed and they can afford more convenience. How about bothering a relative

to do drop off or pick up duty at the airport in order to save the cost of long term parking?

One can look at the cost of driving instead of flying, settling for the cheapest concert or play tickets rather than ones

that may offer a better vantage point as signs that we have stopped evolving. How about philanthropy? Do our giving

habits reflect our station in life, or are they based on where we were financially during medical school, residency or

fellowship?

An awareness of where we are in the “circle of life” is not something to be feared. Reassessing our position on the arc can help us to appreciate each phase of life as well as reduce anxiety. This awareness can also give us an interest as well as the courage to embrace different experiences, with different people as we ride life’s arc. Here’s wishing you the ride of a lifetime.

THE RECRUITER’S CORNER Tips and Tools from Today’s Physician Recruiter

Submitting a CV to a potential employer without a cover letter is

rather like omitting the opening chapter of a novel when submitting it

to an editor. I have spoken with practice managers who regularly

discard unsolicited CV’s that arrive without a cover letter with little or

no review. The cover letter is quite simply an introduction. It is the

first important step in forging a relationship.

While it’s true that credentials win jobs, the cover letter is often the

means by which a candidate secures an interview. No interview…no

job offer. There are rules of etiquette and strategy that guide the

construction of an effective cover letter. Let’s take a look at a few.

1. If you want to lose the race before the opening gun is fired, send a form cover letter.

It never fails to amaze when a physician, a technically skilled, highly educated professional submits a resume with a form

cover letter beginning with something like, “Dear Sirs”. If you are not going to take the time to find out who the

interviewer is, and cannot take the time to create an original cover letter that speaks directly to the recipient, don’t

bother applying.

2. Never lose sight of the purpose of the cover letter.

It is designed to gain you an interview. Practice managers and hospital interviewers will reference your CV to search for

key skill sets. They will review your cover letter to determine why you are interested in their opportunity. In fact, one

could accurately say that the cover letter and the CV serve no other purpose than to secure the interview.

3. Little things matter.

If you are applying for a career opportunity that is likely to change your life and the lives of your family forever, invest a

few bucks in first class stationary paper upon which to print both your cover letter and your CV. Don’t print your CV on

high-end cotton paper and send it with a cover letter printed on 20 # copy paper that you use in your laser printer.

4. Address your strengths in your cover letter and your weaknesses in the interview.

This one could go either way. You don’t want to waste your time and the time of an employer by applying for a position

for which you are clearly unqualified. At the same time if you meet the vast majority of the job requirements listed, and

believe that you can acquire the skill sets you are lacking, address what you bring to the table and state that you are

always improving your clinical skills.

5. Addressing your current employment…

Don’t be afraid to state clearly in your cover letter that you are currently successfully employed but believe that both

the opportunity and location would be a positive career step that is not available with your current practice. And by all

means, clearly state the confidential nature of your inquiry.

6. Don’t forget to whom you are writing.

A dissertation on your sterling qualities and accomplishments without a reference to the practice group or hospital to

which you are applying is both arrogant and foolish. You might just as well print out a couple dozen form letters like

those described in our first point and send them off with your CV. You are applying for a very specific opportunity at a

very specific facility. Bring their needs and your potential contributions into the message.

7. How long should the cover letter be?

Ideally one page…two pages at the most. Remember your goal. You want to introduce yourself, establish report, stress

the relevance of your candidacy and get an interview!

8. “In conclusion…

Once you have accomplished your objectives and have edited your draft (this is a critically important document that

deserves an investment of time and brain cells) wrap it up with a thank you and a call to action. “Thank you for your

time and consideration. I would welcome the opportunity to address any questions you may have and to discuss further

the contribution that I can make to your practice group.”

It always helps to put things into perspective. You spent four years in college, three years in medical school, three years

in residency and three years in fellowship. How much time are you willing to invest in a killer cover letter?

NEW HEALTHCARE OPPORTUNITIES

Provided by MedicalMatch.org

Emergency Medicine - Atlanta, GA - EmergiNet

You may know Atlanta as the unofficial capital of the South, but there’s more to this city than its southern

location. If you make your home in the Peach City, you’ll find an undeniable mix of Southern charm,

sophistication and traditions. Atlanta continues its reputation as a transportation hub with the world’s largest

airport and easy access to I-75 & I-85. When it comes to Atlanta’s reputation for growth and innovation, health

care tops the list as the city’s facilities expand and improve services across the metro area. Serving some of the

fastest growing hospitals is EmergiNet.

EmergiNet has positions available for BC/BP, EM residency trained physicians for work in hospitals

surrounding the Atlanta metropolitan area. We work as a team emphasizing quality emergency care, dedicated

customer service, professional and personal growth. Highlights include: Fee-for-service model having most

MD’s starting at around $350k with no ceiling; Profit sharing plan after first year including tax-deferred

compensation to supplement 401k(100% vested immediately); Physician-centric practice owned and run by

physicians; All facilities located within 30 minute drive from downtown Atlanta.

EmergiNet provides a full range of clinical and administrative professional services to the facilities we serve.

Our mission is to maximize patient care and facility resources, as well as educate, facilitate and integrate the

delivery of health care within the community. We continually seek ways to enhance the level of excellence and

quality in the services we provide to our clients. To review this and other opportunities E-mail CV to Neil

Trabel, ntrabel@emerginet.com; fax 770-994-4747; or call 770-994-9326, ext. 319. Please

visit www.emerginet.com for more information.

Staff Physician Needed – Toledo, OH – The Pediatric Center

Staff Physician needed immediately to join an established Pediatric practice. You will be joining a medical

staff that includes 3 physicians, 6 mid-level providers, supported by 12 nurses. The practice is affiliated with 5

hospitals. Our physicians round on newborns only. We do not attend c-sections. We utilize pediatric

hospitalists and/or specialists for patient admissions. Mid-level providers are on call for parents/patients.

Diagnostic or Interventional Radiologist – Providence, RI

A great opportunity for Diagnostic or Interventional Radiologists to join a well-established Imaging Network in

Providence, Rhode Island. The group is open to a Diagnostic; Interventional or any other subspecialty you

possess. Excellent compensation offered along with generous benefits. In addition, there would be an

opportunity to teach and or do research, if desired. One year to partnership for an experienced Radiologist and

Two years for a new grad. There is no buy-in…! 1:6 call. Providence has a lot to offer and is just under 45

minutes to Boston.

OBGYN – Indiana

Exceptional opportunity to join a busy, vibrant team Call 1:6. State of the art Medical Center. Very

competitive compensation and comprehensive benefits including Educational Loan Assistance, Signing Bonus,

Paid Malpractice, Paid CME, Relocation, and much more. This city offers excellent public and private schools,

University/Colleges and airport. Enjoy an abundance of cultural and recreational activities including water

sports, low tax base, safe neighborhoods, low cost of living, and more. Enjoy an exceptional quality of life.

Indiana is among the top 3 places in the nation in which to practice medicine due to its favorable malpractice

climate. (Medical Economics)

Family Practice – Greenville, IL

Greenville Regional Hospital, a 42-bed full-service hospital located in Greenville, Illinois, is seeking a BC/BE

Family Medicine Physician to join their team. The ideal candidate will be interested in performing the full range

of Family Medicine, have the ability and desire to build long-lasting relationships with patients and be a part of

the community.

Greenville Regional Hospital is hospital employed, outpatient only; competitive salary with productivity

bonuses; relocation reimbursement and sign-on bonus offered; student loan repayment options; full benefits

package including malpractice and tail coverage; rural background or preference for rural medicine is a plus.

Greenville, Illinois is located approximately 45 minutes east of St. Louis, Missouri. The home

of Greenville College, Greenville is a modern small town that offers solid, Midwestern values and an

intellectual feel. The community is close to a major metropolitan area and access to cultural events, shopping,

sports and other amenities, yet its residents are able to embrace the advantages of a rural setting with a lack of

congestion, pollution and crime.

Family Practice – Illinois

Excellent opportunity to join a very busy practice adding to their team due to continued growth. State of the art,

award winning health system. Very competitive compensation and comprehensive benefits including flexible

insurance plan, generous vacation, flexible retirement plan, relocation, Academic appointment available, and

much more. Located in a vibrant city with excellent public and private schools and numerous cultural and

recreational activities. Easy access to Chicago.

Primary Care – Cincinnati, OH

Primary Care Cincinnati, Ohio One of the top integrated health systems in Greater Cincinnati is seeking

physicians trained in Family Practice, Internal Medicine, Emergency Medicine, Internal Medicine/Pediatrics or

Occupational Medicine to practice in one or more of their facilities. These physicians will staff a Priority Care

facility for internal primary care patients, as well as community urgent care illnesses. Employed opportunities

located in Cincinnati, Ohio Full-time and part-time positions are available No inpatient or call responsibilities

Flexible 2015 start dates New state of the art facilities with fully equipped lab and x-ray services Complete

benefit package with malpractice, long term disability, medical/dental coverage, relocation, retirement plan with

matching employer funding. Competitive guaranteed base with bonus incentives Weekend and holiday pay

differential. To learn more, contact Arleen Richardson arleen.richardson@rmmedicalsearch.com

Job #21463

Dermatology – Quincy, Illinois

Blessing Hospital is seeking a Dermatologist for a full-time employed position with Blessing Physician Services

in Quincy, IL. Must be Board Certified or Board Eligible in Dermatology. The candidate must have a solid

work ethic and dedication to providing comprehensive healthcare to patients and their families. The ideal

candidate will strive to become an active member of the community, as well as uphold the core values of the

hospital.