Classic post

Throwback Thursday Classic Post – Moonlighting in the Navy

Posted on Updated on

It’s August and a whole new crop of recent residency graduates can now moonlight for the first time in their Naval careers, so here is a video and blog post that discusses some of the basics of moonlighting.

Should You Moonlight?

I think the answer to this question depends on a lot of things. First, do you envision yourself working clinically when you leave the Navy? For most physicians, the answer to this question is yes, and depending on your specialty you may need to moonlight to maintain your clinical skills. We don’t always get exposed to the full scope of our specialty in the Navy. My wife is a pediatrician, and when she was on active duty I thought she had a full scope pediatric practice and did not need to moonlight to maintain her skills. As an emergency physician, though, it is rare to get exposed to the full breadth of emergency medicine in a Navy emergency department. You have to make an honest assessment of your specialty, the breadth of your Naval practice, and whether you need to moonlight to maintain your skills.

In addition, you need to figure out your motivation for moonlighting. A common motivation is to earn extra money, and that is a fine motivation, but you never want to make decisions that make you dependent on the money. You may deploy, your CO could take away your moonlighting privileges, or you could PCS somewhere where you can’t moonlight. You don’t want to be the bankrupt doctor because you bought a house you can’t afford without moonlighting.

The Navy’s Moonlighting Rules

In order to moonlight you have to get permission from your command. It is a privilege, not a right, and you can lose this privilege if you fail a PFA, don’t stay up-to-date on your training/readiness requirements, or don’t produce academically when required.

If you are going to moonlight somewhere outside of a 2 hour drive, you need to take leave. If you are flying anywhere, no matter the distance, you need to take leave. You can’t moonlight more than 16 hours/week and you need to have 6 hours of time off between clinical periods for your moonlighting job and your Naval duties. You’ll need to complete an annual attestation that says you are aware of these policies and compliant with them. If your specialty makes complying with these guidelines hard, you can ask for a waiver from your command.

Where Should You Moonlight?

If you moonlight locally you don’t need to take leave. If you can find a clinical setting you think you’d like after your time in the Navy is complete, you can even start working toward partnership.

If you work locum tenens, you can travel and sometimes chase “the big money.” If you work enough, the locum companies will cover all of your expenses, DEA, state licenses, travel, hotel, expenses, and malpractice insurance. Because you are likely traveling to a location more than a 2 hour drive away, you’ll need to take leave.

Basic Financial Planning for Moonlighters

Moonlighting allows you to put more money in tax advantaged retirement accounts. If you’re a non-moonlighter, you’d be limited to putting $19,000/year in the TSP and $6,000/year in your IRA (based on 2019 limits). If you moonlight and get paid on a 1099 as an independent contractor, you can fund a SEP IRA or solo 401k up to $56,000/year. It is rare that you’ll hit this maximum because you can’t moonlight enough to earn the amount required to do it, but you will be able to put more away than a non-moonlighter. A SEP IRA is easier to set up than a solo 401k, but a Solo 401k allows more money to be contributed at an equivalent salary. Plus, a SEP IRA messes up your backdoor Roth IRA contribution. For a great discussion on these two options, go to this article, but the bottom line is you’ll likely want to set up a Solo 401k and not use a SEP IRA:

http://whitecoatinvestor.com/sep-ira-vs-solo-401k/

Finally, moonlighters often want to incorporate because they think it provides malpractice protection, but that is a myth. Although there may be some tax advantages to incorporating, it doesn’t protect you from professional liability or malpractice.

Contract Pitfalls

If you are going to sign a contract, you are going to need to get some professional help. You should hire a healthcare or contract attorney to review any contract you are considering. You could also consider using a company that specializes in reviewing physician contracts like Contract Diagnostics. There are many issues you need to understand, including:

  • Due process or termination clauses – For what reasons can they terminate you? Are you entitled to a hearing with the medical staff before your privileges are removed or restricted?
  • Tail coverage – Does your malpractice insurance require tail coverage? If so, who is paying for it? Tail coverage is malpractice insurance that covers you after you stop working for that employer, and it can be VERY EXPENSIVE so you will want to know who is paying for it.
  • TRICARE or VA eligible patients – You can’t bill these patients as they are already entitled to your services.  This is spelled out very well in the moonlighting paperwork you will file with your command, but make sure your employer understands this.

Here are the Powerpoint slides for the video podcast below:

Moonlighting

Throwback Thursday Classic Post – Basic Anatomy of a FITREP

Posted on Updated on

There is a HUGE knowledge deficit in the Medical Corps about FITREPs, which is sad when you consider that they are probably the most important document in our Naval careers.  To address this deficit I created this video podcast.  In 43 minutes you’ll know just about everything that you need to know about FITREPs.  This material is based on about 10 lectures I collected over the years and is consistent with the 2015 update of the FITREP instruction.

Grab a FITREP to look at or start up NAVFIT98a and write your FITREP as you watch the video because it will be much easier to follow along this way.  In addition, here are the slides to download and view and the page with all my FITREP resources:

Basic Anatomy of a FITREP

Joel Schofer’s FITREP Prep Page

Throwback Thursday Classic Post – Could a Master’s Degree Get You Promoted?

Posted on Updated on

When discussing why they failed to promote, one of the more common reasons that officers give is that they were unable to get a leadership position. When I ask them how they prepared themselves for these positions and what they did to improve their chances of getting one, they often don’t have much to say. Frankly, they didn’t do anything “extra” or above and beyond their normal duties to prepare for and get a leadership position.

Don’t be one of those officers.

The recipe for promotion is fairly simple. Superior performance in leadership positions leads to early promote (EP) fitreps, which leads to promotion. As promotion gets more difficult, the competition for leadership positions is likely to increase, and officers need to find a way to differentiate themselves from the crowd, increasing the chance they’ll get leadership positions. Obtaining a master’s degree can be one of the things that will distinguish you from other physicians and can dramatically increase the chances that you are competitive for career advancing positions.

What Kind of Degree Should You Consider Getting?

This depends on your career goals. If you want to become a leader in research or global health engagement, an area of increased focus in the Navy, you probably want to get a Master in Public Health (MPH) or similar degree. If you want to become a residency or fellowship director, a master’s degree in adult or medical education would fit the bill. If you want to become an operational leader, attending a war college would make sense. And if you want to become a clinical administrator or pursue executive medicine, obtaining a management degree, such as a Master in Business Administration (MBA), Master in Medical Management (MMM), or Master in Healthcare Administration (MHA), would make sense to me.

How Can You Get a Master’s Degree While on Active Duty?

There are many ways you can do this, but the most common include:

  1. Complete a fellowship that includes a master’s degree. Some fellowships either include or have the option of obtaining a MPH, such as the Global Emergency Preparedness and Disaster Response Fellowship. I also know of multiple officers who asked the Graduate Medical Education Selection Board for an additional year of fellowship to obtain a degree or simply for permission to obtain a degree alone. What are the chances this will be granted? Well I’m sure the chances change from year to year, but they are zero if you don’t ask.
  2. Complete the distance learning Executive MBA from the Naval Postgraduate School. This is how I got my MBA for the cost of books alone, and I think the program is excellent. You have to go to Monterey for 1 week at the beginning of the 2-year program, but after that all classes are held on-line.
  3. Apply for the Navy Career Intermission Program and take time off to get a degree.
  4. Attend a war college. Intermediate colleges are for officers who are O4 or below, while senior college is for O5 and above. If you’re interested, contact your Detailer.
  5. USUHS offers a Master in Health Professions Education.
  6. Pay for it yourself and do it in your free time on-line or in person. One program to look into is offered by the American Association for Physician Leadership (https://www.physicianleaders.org/education/physicians/masters). By taking some CME you can then enroll in various patient safety and management degrees that are all physician focused. The on-line University of Massachusetts healthcare focused MBA that they offer is the most reasonably priced MBA that I could find that is accredited by the top business school accreditation body. If you want a fast MBA (but pricey), look into the University of Tennessee Physician Executive MBA program (http://pemba.utk.edu).

While committing to a master’s degree program will take major time and effort, that is the point. It is a well-recognized way to demonstrate to the Navy that you’ve made a serious commitment to your professional development and could go a long way toward giving your next interview for a leadership position.

Throwback Thursday Classic Post – What Should You Do If You Didn’t Promote?

Posted on Updated on

If you are particularly interested in this post, I’m sorry. You or someone you care about probably failed to promote. In reality, nowadays it is normal and expected to fail to promote to O5 and O6, so you have company. Here are my suggestions for those that fail to promote.

First, try to figure out why you didn’t promote. Because the promotion board members are not allowed to speak about your board, you’ll never actually find out why you failed to promote, but you can usually take a pretty educated guess if you talk to the right people (like me).

If any of these things happened to you, they are likely a main reason you didn’t promote:

  • Any PFA/BCA failures.
  • Legal issues, such as a DUI or any other legal trouble.
  • Failure to become board certified.

There are other things that could happen to you that make it difficult but not impossible to promote. They include:

  • Coming into zone while in you were in GME.
  • Having non-observed (NOB) fitreps before the board, such as those in full-time outservice training.
  • Spending too much time in the fleet as a GMO, Flight Surgeon, or UMO. This is mostly because it causes you to come into zone for O5 while you are still in GME, and is more of a problem if your residency is long.
  • Never getting a competitive early promote (EP) fitrep. Many officers who fail to select have never had a competitive EP fitrep in their current rank. This can be because they were stationed places without competitive groups and they get 1/1 fitreps, or it can be because they were in a competitive group and did not break out and get an EP. To me this is the #1 ingredient to promote…competitive EP fitreps. If you don’t have them, you are really up against it.
  • Receiving potentially adverse fitreps. This most commonly happens when you are at an operational command and your reporting senior is not someone who is used to ranking Medical Corps officers, although it could happen for other reasons (like your reporting senior felt you deserved this type of fitrep). The most common situation would be if there is a competitive group of 2 officers but both are given must promote (MP) fitreps instead of 1 getting an EP and the other the MP. When both get an MP, it reflects poorly on both officers unless the reason for this is CLEARLY explained in the fitrep narrative, which it often is not. The other thing that happens is that a reporting senior gives you a 1/1 MP instead of a 1/1 EP. If you are ever getting a 1/1 fitrep, make sure you get an EP. You should consider getting a 1/1 MP an adverse fitrep. If there is no way around this, often because the reporting senior has a policy that they don’t give newly promoted officers an EP, make sure that this policy is clear in the fitrep narrative.
  • Having a declining fitrep. Mostly this happens when you go from getting an EP to an MP on your fitrep under the same reporting senior. If it is because you changed competitive groups, like you went from being a resident to a staff physician, that is understandable and not a negative. If you didn’t change competitive groups, though, make sure the reason you declined is explained.
  • Making it obvious to the promotion board that you didn’t update your record. The most obvious ways a promotion board will know you didn’t update your record is if your Officer Summary Record (OSR) is missing degrees that you obviously have (like your MD or DO) or if many of the sections of your OSR are either completely blank or required updating by the board recorders. Remember that although promotion board recorders will correct your record for you, anything they do and any corrections they make are annotated to the board. While a few corrections are OK, you don’t want a blank record that the recorders had to fill in. It demonstrates that you didn’t update your record.

So who actually promotes to O5 and O6? In general, the officer who promotes is:

  • Board certified.
  • Has a demonstrated history of excellence as an officer. In other words, whenever they are in a competitive group, they successfully break out and get an EP fitrep. Being average is just not good enough anymore.
  • They have no PFA failures, legal problems, declining fitreps, or potentially adverse fitreps.
  • They have updated their record, and if they previously failed to select they reviewed their record with their Detailer and actively worked to improve it.

So what do you do if you were passed over and failed to promote?

Realize that it is not the end of the world. Based on the recent promotion board statistics (which you can get in the Promo Prep), most officers were passed over for O5 or O6, but a large number of the officers selected were from the above zone group.

If you do nothing, you will continue to get looked at by promotion boards until you retire, resign, or are forced out of the Navy. There is no limit to the number of chances you get to promote and your record will be evaluated for promotion every year. That said…

You need to try to promote. Consider sending a letter to the promotion board. What do you say in this letter? First, briefly state that you want to be promoted and to continue your career in the Navy. Second, explain what a promotion would allow you to do that you can’t do at your current rank. Answer the question, “Why should they promote you?”

For example, if you want to be a Department Head at a large military treatment facility (MTF) or a Residency Director (or whatever you want to do), tell them that you need to be promoted to be competitive for these jobs. The Navy wants to promote leaders. Make it clear to them that you are a motivated future leader.

Try and get letters of support to attach to your letter. These letters should be from the most senior officers who can personally attest to your value to the Navy. In other words, it is probably better to get a letter from an O6 who knows you well than a 3 star who doesn’t. If you are not sure who to ask for letters, ask those more senior to you or your Detailer for advice. Your Specialty Leader is always someone to consider if he/she knows you well and can speak to your contributions to the specialty and Navy.

Have your record reviewed by your Detailer, Specialty Leader, other trusted senior advisor, or by me. Because of promotion board confidentiality, you will never know the reason(s) you did not promote, but most of the time experienced reviewers can come up with an educated guess. They’ll often find things that you were not even aware of, like potentially adverse fitreps, or information missing from your record. My promo prep document will help you as well.

Do everything you can to get “early promote” or “EP” fitreps. This is largely accomplished by continually striving for positions of increased leadership. You need to get a job that has historically led to a promotion.

As a LCDR who got passed over for CDR, try to get one of these jobs and excel at it (this list is not exhaustive and these positions are not the only path to CDR, but they are a good start):

  • Assistant/Associate Residency Director
  • Department Head at a small/medium sized MTF
  • Senior Medical Officer or Medical Director
  • Chair of a hospital committee
  • MEC member

If you are a CDR who got passed over for CAPT, try to get one of these jobs and excel at it:

  • Residency Director
  • Department Head in a large MTF
  • Associate Director or Director
  • Officer-in-Charge (OIC)
  • MEC President
  • Division, Group, or Wing Surgeon
  • CATF Surgeon
  • Specialty Leader
  • Chief Medical Officer (CMO)

Meet with your chain-of-command. After you’ve been passed over is not the time to be passive. You need to sit down with your leadership and get an honest assessment from them of how you’re doing and what they would recommend continuing to advance your career. You may not like what you hear, but it is better to find out early if they don’t think you’re doing a good job or that you are unlikely to break out on your fitreps. That way you can try and put yourself in a better situation by changing commands.

In addition to the above list of things you should do, there are a few things you should not do:

  • Do not lie in your letter to the board. In other words, don’t tell them you want to do Executive Medicine if you don’t really want to. Your record reads like a book, and if it tells a story that is contrary to what your letter says, this is unlikely to help you and may hurt you.
  • Do not send long correspondence. Promotion boards have to read everything sent to them, and a long letter may not be appreciated. Keep it brief and to the point.
  • Do not ask your current CO to write you a letter to the board if they’ve done an observed fitrep on you. His or her opinion about you should be reflected on that fitrep, so they don’t need to write you a letter. If they’ve never given you an observed fitrep or there is some new information not reflected on prior fitreps, they could either write you a letter or give you a special fitrep. Ultimately it is up to them whether they do either of these or none.
  • Do not discuss anything adverse unless you want the board to notice and discuss it. This issue comes up frequently and people will ask me for advice, but ultimately it is up to the individual officer. The one thing I can guarantee is that if you send a letter to the board and discuss something adverse, they will notice it because they will read your letter! If you think there is a chance the adverse matter will get overlooked, it is probably better not to mention it and keep your fingers crossed.

Those are my tips for those who find themselves above zone. Most importantly, if you want to promote, NEVER STOP TRYING. You can usually stay in as a LCDR for 20 years, and I personally know of people who got promoted their 9th look!

Throwback Thursday Classic Post – Is Commander the New Terminal Rank? (And Other O6 Promotion Board Takeaways)

Posted on Updated on

(2019 Note – This is one of the most popular posts on the blog and helped put it on the map. Since the FY16 O6 promotion opportunity of 50% when it was published in 2015, we’ve seen an uptrend:

  • FY17 – 70% promotion opportunity – 34% in zone selection rate
  • FY18 – 80% – 37%
  • FY19 – 90% – 41%
  • FY20 – 81% – 51%

That said, much of what I said in 2015 is still very true. Enjoy!)

In case you haven’t figured it out yet, it is getting harder to promote to Captain. Here are the historical promotion opportunities for O6. You don’t have to be a mathematician to notice the trend:

  FY08 FY09 FY10 FY11 FY12 FY13 FY14 FY15 FY16
CAPT 80% 80% 80% 80% 80% 60% 60% 60% 50%

There are a lot of physicians who came into the Navy when it was relatively easy for a physician to promote to Captain. If you could fog a mirror, you could likely promote. Well…things seem to have changed.

This has frustrated some physicians who failed to promote and is likely to frustrate more in the future. Aside from getting frustrated, though, it would benefit all involved if they could learn from this trend and try to adjust while there is still time. Here are my O6 promotion board takeaways:

  • It is now normal when you fail to select for Captain the first time. In the FY16 board only 39% of Commanders who were in zone were promoted, leaving 61%, a clear majority, who did not. Physicians should expect to fail to select or “get passed over” the first time they are up for O6. (Only FY20 got over 50%, and barely at 51%.)
  • Commander is the new terminal rank for full-time clinicians, and there’s nothing wrong with that. If the thought of taking on a significant collateral duty makes you want to cringe because you want to remain a full-time clinician during your time as an O5, you have likely reached your terminal rank. Physicians get very frustrated when they fail to promote to O6, thinking that the Navy doesn’t value clinical productivity, and this is just not true. The Navy does value clinical productivity, it just doesn’t think that they need to be Captains! The Captain rank has moved from being a reward obtained by most physicians who hang around long enough to a reward for those with senior leadership potential.
  • The overwhelming majority of Commanders who promote to O6 take on a significant collateral duty. Whether they were a department head at a large MTF, a specialty leader, a residency director, a director, president of ECOMS, or in a senior operational role, they all had to pay their dues in these roles in order to score the EPs on their fitreps that allowed them to promote. These roles almost always necessitate a reduction in clinical activity, which is why you are less likely to promote to O6 as a full-time clinician.
  • Having only one competitive EP fitrep before the promotion board is often not enough. At some of the larger MTFs it can take quite a while to “break out” from the pack of Commanders and get an EP on your fitrep. If you are lucky enough to get an EP but you only slide one in before you are in zone, it may not be enough. As the competition heats up, it is the people with multiple competitive EPs that will be in the best position to promote.
  • You need to demonstrate career diversity while not hurting your chances to promote. The best time to mix it up is right after you are selected for Commander. You are finally senior enough to get a decent position at an operational command, BUMED, PERS, or some other alternative command. If instead of mixing it up you stay where you are, you will be the new, small fish in the largest pond in the Navy, the Commander fitrep competitive group. No matter what you do you are probably going to get promotable fitreps for a few years. You might as well use those years to break things up, PCS (even locally to an operational command – I’m not saying you have to move), and demonstrate that you are willing to flex for the needs of the Navy. You may get 1/1 EP fitreps but while you are a junior commander this is unlikely to hurt you. Then once you are done with that tour, you can return to a larger competitive group and compete for one of the aforementioned jobs if you have making O6 on your radar.

Throwback Thursday Classic Post – How to Manage Your PRD and Not Get Stuck with a “Hotfill”

Posted on Updated on

(I’m going to start re-posting some of the better and more popular blog posts on the site on Throwback Thursday. Much of the content is evergreen or requires minimal updates, and the blog has a much larger readership than when many of these posts first ran.)

There are many important dates in your Navy career. One of the most important and neglected dates, though, is your projected rotation date or PRD. Your PRD is the month and year that your current orders will expire and you are scheduled to rotate to a new command. If you don’t manage your PRD and pay close attention to it, you can find yourself with few career options and in a situation you never thought you’d be in. With that in mind, here are my tips for managing your PRD.

Know Your PRD

First, know when it is because many physicians don’t know their PRD. If you are in this crowd, the easiest way to find your PRD is to login to BUPERS On-Line and look at block 14 of your Officer Data Card:

https://www.bol.navy.mil/

The other way to find your PRD is to contact your Detailer because they can look it up in the detailing system. Many physicians don’t know their Detailer, so here is a link to a page with “Contact Us” in the middle.

Manage Your PRD

Once you know your PRD, the easiest way to manage it is with whatever calendar you use (an app, web calendar like Google Calendar, Outlook, a date book, etc.). Place reminders in your calendar to correspond with these time frames:

13-18 Months Before Your PRD – This is when you should start thinking about your next career move. Although the normal time period to request an extension (find a template here) at your current command is 9-12 months before your PRD, many physicians request an extension during this time period if they are sure they want to extend. This is also a great time to talk to the Operational Detailer about operational billets you might have interest in or the Senior Detailer about what I’ll call “alternative billets” like those at DHA/BUMED, BUPERS, global health engagement billets, NAVMEDWEST, NAVMEDEAST, etc. If you act on your PRD in this timeframe, you’ll be well ahead of the game.

9-12 Months Before Your PRD – This is the traditional detailing window where you contact your Detailer and Specialty Leader to negotiate your next career move. This is when physicians normally submit an extension request as well as explore potential billets for their next set of orders. The one caveat is that the availability of billets is often contingent on the results of the Graduate Medical Education Selection Board or GMESB. Since these results are not finalized until January, people with summer PRDs will find that they may have to wait beyond this time period to find out what billets are available and get orders.

6-8 Months Before Your PRD – This is when the list of billets that are actually available will solidify and most physicians will get orders. If you want to extend at your current command and you haven’t submitted an extension request yet, you should do that ASAP.

1-5 Months Before Your PRD – Many physicians will get into this period without orders. If it is because you were waiting on the results of the GMESB, you are probably fine. If you are in this period for another reason, you should get nervous. The truth is that unanticipated things always happen. Commanding Officers don’t endorse extension requests. Unanticipated openings cause a Detailer and Specialty Leader to have a “hotfill” billet. When things like this happen, a Detailer goes looking for officers close to their PRD to fill the need. If you are in this window without orders, you are low lying fruit for filling these needs. And just so you know, most of these “hotfills” are not in Rota or San Diego.

At Your PRD or Beyond – Physicians let their PRDs “expire” all the time. Sometimes it is because they submit an extension request that never gets approved because it gets lost somewhere in the process. Other times they don’t know when their PRD is. Realistically, there is often no consequence if your PRD expires, although some commands will pick up on this fact and get your attention by threatening to take away your computer access. The biggest threat, though, is the aforementioned “hotfills” that inevitably show up. If your PRD is expired, you are going to rise to the top of the list when the Detailer goes looking for people to fill that need. Have fun wherever that “hotfill” is.

The Bottom Line – Know when your PRD is and manage it according to the above timeline. This will give you the maximum chance of getting what you want and reduce the chance that you are selected for a “hotfill” you don’t want.