CME: Get the credits for FREE

I’m here to tell you that all CME is not created equal, especially as it relates to the cost.  It seems that we associate CME with having to spend money on a seminar, online training course or some other educational opportunity with a price tag.  I encourage you to think about CME credit accumulation and resources as connected but not mutually exclusive to one another.  You can accumulate the required number of credits, often at the cost of $0, freeing up your money and time allotment for CME activities that you are actually interested in, such as this Everest Base Camp Trek.

The easiest way I know how to accumulate free Category 1 CME credits is to continue doing what most of us are already doing: daily use of UpToDate.  Many employers, especially larger organizations, will provide free access to this resource.  All you need to do is to make sure that you have a login username and password, and make sure at the beginning of each shift that you log in.  You will accumulate 0.5 Category 1 CME credits for each search that you do within this account, and these will add up VERY quickly, well past the required 100 necessary for each 2 year cycle.  As an example, I don’t think my account has dipped below 500+ CME credits in the last 2 years due to the frequency of my usage through my free account.  (PRO TIP:  If your employer doesn’t cover the cost of a subscription to UpToDate, negotiate for this at some point…this is the equivalent of nearly $1000 and frees you up to make CME your “fun money”)

If you work for a larger organization, especially a teaching hospital system, there are likely a plethora of free CME activities available to you.  I’m willing to bet that there is actually a CME tab on your intranet website that can lay the opportunities out for you.  (Not sure?  Go ahead and look…I’ll wait)  Keep your eyes and ears open for opportunities that can be baked into your current schedule, but only pursue those things that you are interested in learning about.  One example is taking part in electronic medical record (EMR) proficiency classes, of which you will earn you some CME credits and also decrease time spent within the EMR…a “Win-Win”.  (PRO TIP:  Always look for CME opportunities that do more than just get you some required credits…dual purpose or “Win-Win”)

And if you’re still looking for Free CME opportunities, there’s this aptly-named website called…of course there is, right?!  #internet

DISCLAIMERS: 1) The views expressed here are my own and do not necessarily represent the views of my employer. 2) There are no conflicts of interest to report. 3) I don’t know what I don’t know, so feel free to message me if you don’t agree with something that you read.

KEYWORDS: #free #CME #burnout #medicine #physicianassistant #nursepractitioner #doctor #physician #barriers #wellness #efficiency #proficiency #control #worklifebalance #happinessatwork #carpediem #clinician #stress #covid #covid19 #pandemic #lifehacks #leverage #tools #charting #physician #MDM #worklife #worklifebalance


Many are probably already using, but just in case, I wanted to draw attention to and recommend it. I find this to be an incredibly helpful tool, one that I use just about every day in Primary Care, and very frequently used in Urgent Care medicine also. Whether outpatient or inpatient, you should be aware of this tool, and should sign up for a free account.

“What is MDCalcMDCalc is a site for medical professionals, to help us do calculations, process algorithms and scores, and assess risk—all using the latest and best evidence—to make patients better, faster.”

Whether you know it already or not, here are some Pros, Cons and Tips to understand get the most out of MDCalc:


  1. FREE to sign up for an account.
  2. Now offering AMA PRA Category 1 CME credits (caveat found in “Cons” list).
  3. Easy copy and paste functions to put into your documentation. (TIP: use it to build your case in your Medical Decision Making)
  4. Diverse array of choices, helpful for both inpatient and outpatient medicine.
  5. Favorites” tab to keep your most frequently referenced.
  6. Easy to use with multiple avenues to find what you need. I like the “Specialty” tab for discovering new tools to use in my practice.
  7. Log in once, and stayed logged in for your entire shift (the site doesn’t log you out due to inactivity).
  8. Easy to use website or phone App.
  9. In-depth discussion about each calculator, algorithm, score, risk assessment, etc. (“When to use”, “Pearls/Pitfalls”, “Why Use”, “Evidence“, “Creator Insights“) for better understanding.
  10. Guidelines” tab available to learn the most up-to-date recommendations about specific topics, such as Acute Venous Thromboembolic Disease.


  1. Must read about, and not just use, tools to earn CME credits.
  2. CME credits cost money to redeem, even if earned.
  3. It’s yet another phone app or website tab that you should just keep open during your shift.
  4. It’s yet another log-in and password to have.

I’m finding myself working hard to list the “Cons“, and I admit that could be that I am biased in favor of MDCalc. It’s a great resource with a lot of content to offer, applicable to most specialties. For now, I favor getting your CME credits elsewhere, such as UptoDate, as you may be able to accumulate Category 1 CME credits at no cost to you as an employee. But for clinical-decision making tools, I have yet to find anything nearly as good as MDCalc.

DISCLAIMERS: 1) The views expressed here are my own and do not necessarily represent the views of my employer. 2) There are no conflicts of interest to report. 3) I don’t know what I don’t know, so feel free to message me if you don’t agree with something that you read.

KEYWORDS: #MDCalc #burnout #medicine #physicianassistant #nursepractitioner #doctor #physician #barriers #wellness #efficiency #proficiency #control #worklifebalance #happinessatwork #carpediem #clinician #stress #covid #covid19 #pandemic #lifehacks #leverage #tools #charting #physician #MDM #worklife #worklifebalance


Clinicians that can get themselves to be in “The Good Place” are those that are firing on all cylinders. They have high patient satisfaction scores, have cultivated an optimal work/life balance, feel that they are compensated well, are valued by their employer and are seen as a productive and integral part of the team. But, is this even attainable, or in reality, is “The Good Place” a mythical state that no clinician can reach?

I say “attainable“, but with intention and attention. I think that in order to find yourself in “The Good Place“, you must first create boundaries that you are not willing to cross, and these will help define for you when you’ve reached the point where what you are doing to rejuvenate and recover are less than the efforts that you are putting in…this is a one-way ticket to burnout, and that is definitely not “The Good Place“.

Providers in “The Good Place” may make it all look easy, mostly because they have the knowledge, experience and systems in place to be productive, personable and happy. I think you know these people when you see them, but they are rare. All too often, trying to keep 3 parties (clinician, employer + patient) happy can feel burdensome, and can prove to be like multitasking, wherein all entities suffer from the lack of focus.

Nonetheless, if you don’t find yourself in “The Good Place” currently, you can get there within a few months, or even within a few weeks. What it takes is reflecting on where you are, where it is you are wanting to get to, formulating a plan, and taking baby steps in the right direction. I really think that James Clear’s book, Atomic Habits, is a critical read for anyone looking to make some positive change. So, over the course of the next few months, I’ll attempt to use that book as the basis to write some posts that give pragmatic advice on how to get to “The Good Place“, and stay there for a prosperous career. For now, here are some great quotes to meditate on from Mr. Clear:

“Every action you take is a vote for the type of person you wish to become. No single instance will transform your beliefs, but as the votes build up, so does the evidence of your new identity.”

“You do not rise to the level of your goals. You fall to the level of your systems.”

“You should be far more concerned with your current trajectory than with your current results.”

“When you fall in love with the process rather than the product, you don’t have to wait to give yourself permission to be happy. You can be satisfied anytime your system is running.”

“Goals are good for setting a direction, but systems are best for making progress.”

“Be the designer of your world and not merely the consumer of it.”

“You don’t have to be the victim of your environment. You can also be the architect of it.”

DISCLAIMERS: 1) The views expressed here are my own and do not necessarily represent the views of my employer. 2) There are no conflicts of interest to report. 3) I don’t know what I don’t know, so feel free to message me if you don’t agree with something that you read.

KEYWORDS: #burnout #medicine #physicianassistant #nursepractitioner #doctor #barriers #wellness #efficiency #proficiency #control #worklifebalance #happinessatwork #carpediem #clinician #stress #covid #covid19 #pandemic #lifehacks #leverage #RVUs #charting #physician #billing #coding #jamesclear #atomichabits #habits #worklife #worklifebalance

TIME IS 💰: 2021 E/M Changes for Outpatient Services


Photo by Negative Space on

Apparently there was a sudden interest in this topic, and people found their way to my Blog post to read up, as viewership had a tremendous spike on January 5th. I hope some folks found my post to be helpful. Given that we just finished the first workweek, I wanted to add to the post with the following observations and tips to increase understanding of these E/M changes, with the ultimate goal to leverage your knowledge to meet your goals for 2021.



  1. I feel an increased pressure to finish the charting on the day of the visit, given the new requirements within billing for time (only time spent on the date of the visit counts). My question is: Who is keeping track of this? If anyone knows the answer, please message me.
  2. I’m glad that billing based on Medical Decision Making (MDM) has not changed, as having to relearn two things would definitely require additional mental bandwidth, which I do not have right now.
  3. Being able to now bill for pre-charting, after-visit charting and other time spent around the encounter (such as phone calls to specialists) feels great. It’s about time that all of that additional time spent on the encounters is now counted and seen as valuable.
  4. The new time requirements for each level of visit look daunting on paper, but aren’t that challenging to meet if you get a loose tab of your total time spent. For example, the time requirement for a 99214 in an established patient is 30-39 minutes, but here’s how I’ve been getting there easily:
  5. I’m glad that codes 99201 and 99211 are now gone, as I don’t think I EVER used them anyways.
  6. Even though it doesn’t factor into the billing anymore, I still find a thoroughly performed and documented HPI to be a vital aspect of the visits. I don’t know if I’ll ever feel comfortable with letting some of this slide, as it gives me a sense of insecurity in my MDM, as well as makes me feel more vulnerable to potential litigation.


  1. If you’re not pre-charting already, you NEED to start. If you have to, spend time digging out and catching up, then stay motivated to be proactive and in more control of your days.
  2. Do not feel bad if your billing may seem higher with the 2021 E/M changes, if you’re thinking that it may mean higher visit bills for patients. We, as clinicians, have been doing a massive amount of “extra” work that was deemed as worthless with respect to billing. Do not undervalue your time as a highly-trained medical practitioner. Think about this: When is the last time that you thought that a car mechanic, lawyer, financial advisor, politician, veterinarian or dentist allowed themselves to have their time and expertise undervalued? We are no different.
  3. Post the new time, and maybe the MDM requirements, near your computer where you document the most frequently. Don’t try to memorize any of this stuff, just make it be within sight, and eventually it’ll become second nature with some repetitions.
  4. Personalize your EMR to account for these E/M changes: Create speed buttons, add a “Time Statement” into your templates or whatever else it takes to make it so that you don’t have to think much about the billing. Here’s my personal “Level of Service” setup in Epic (please note the deletion of 99201 and 99211):

DISCLAIMERS: 1) The views expressed here are my own and do not necessarily represent the views of my employer. 2) There are no conflicts of interest to report. 3) I don’t know what I don’t know, so feel free to message me if you don’t agree with something that you read.

KEYWORDS: #burnout #medicine #physicianassistant #nursepractitioner #doctor #barriers #wellness #efficiency #proficiency #control #worklifebalance #happinessatwork #carpediem #clinician #stress #covid #pandemic #lifehacks #leverage #RVUs #charting #physician #billing #coding #notoriousBIG #worklife #worklifebalance


I spoke to a local beer brewer once and asked him what he prefers to make, and his answer was something like a Triple, Dopplebock or something else that usually doesn’t appeal to the masses. That’s where his passion was, but my next question to him was why he had 6 different IPAs on tap, and yet none of the style he wanted to brew: “Because that is what my customers want.” He also told me that, in his estimates, he makes 3 IPAs to every other style of beer he brews, because that is what sells best.

What the hell is this story doing on my blog, besides making some of you long for the days of sampling a flight at a microbrewery? For whatever reason, after writing my post about Memento Mori, I got to thinking about how that is my Dopplebock option, but I need to balance having those offerings with at least “3 IPAs”. For every philosophical or existential dive, anyone reading this also might like a few other palate-pleasers to sample first.

So, in 2021, I am promising more juicy, hoppy IPAs for my readers. I will pack this website with consistently crisp, high-ABV (alcohol by volume) flavor bombs that appeal to the masses, so that you are never without taking away a pearl or pragmatic tip with the possibility of immediate implementation. After all, many love IPAs so much because you get a lot of bang for your proverbial buck, from flavor to ABV. Hell, I love a good IPA myself, but also appreciate the craft behind a more obscure, but more complex offering as well.

For 2021, the complex offerings will continue to be lovingly crafted, but I will be ramping up production of “IPAs” as well. I’m looking forward to this new strategy, and I already have 50+ ideas in the queue, so stay tuned! Cheers to 2021! 🍻

DISCLAIMERS: 1) The views expressed here are my own and do not necessarily represent the views of my employer. 2) There are no conflicts of interest to report. 3) I don’t know what I don’t know, so feel free to message me if you don’t agree with something that you read.

KEYWORDS: #burnout #medicine #physicianassistant #nursepractitioner #doctor #barriers #wellness #efficiency #proficiency #control #worklifebalance #happinessatwork #carpediem #clinician #stress #covid #pandemic #lifehacks #physician #worklife #worklifebalance #beer #IPA #alcoholmetaphors #Iactuallydrinkhardkombuchanow #dontjudge #iwouldtakebeersponsorship #justsayin


I just read a wonderful article by Dr. BJ Miller, hospice and palliative medicine physician. As 2020 had been a very challenging year, with much of the stress related to the pandemic, it also is a year that has some really valuable lessons for us to learn from. It has demonstrated to us that nothing in life is guaranteed, with the exception of death, which the pandemic has forced us to confront, whether we were ready to or not.

There is a concept in stoicism called “Memento Mori“, which in Latin means “Remember that you must die“, and this article brought me back to this concept. It is commonly used as a beacon of humility via remembering that we are mere mortals. Although many feel uncomfortable thinking about and discussing death, especially our own or that of our closest loved ones, this exercise can, somewhat ironically, genuinely lead to better living. This year, especially given the pandemic, has served as opportunity to reevaluate our lives, reflect on our mortality and as Andy Dufresne said in Shawshank Redemption: “Get busy living, or get busy dying.”

“You could leave life right now. Let that determine what you do and say and think.”

–Marcus Aurelius

I encourage all of you to read that article by Dr. Miller, and to spend some time reflecting on 2020 and the lessons that are available, should you just push aside the endless “doom and gloom” that overshadowed all else. My feeling is that many of us were caught in a state of entitlement, ungratefulness and complacency, and 2020 has served to slap us out of these mindsets and into a state of awareness and appreciation. I think many, including myself, were overdue for such a harsh reality check, and my plan is to never forget what I have learned in 2020.

“Let us prepare our minds as if we’d come to the very end of life. Let us postpone nothing. Let us balance life’s books each day. … The one who puts the finishing touches on their life each day is never short of time.”


My wife and I were talking last night, and I brought up that I would like us to consider using this years’ lessons to keep us grounded in the future. Simply put, I would like “2020” and “pandemic” to be reminders of how nothing is guaranteed, how we need to be grateful for what we have, and how nothing is more important than living our lives consistent with our values. “2020” and “pandemic” will also be available as trump cards to throw, should one of us find the other using superficial excuses, allowing fear to hold us back, not following our passions, becoming too comfortable, or just needing a break from the routine.

“Meditating on your mortality is only depressing if you miss the point. It is in fact a tool to create priority and meaning. It’s a tool that generations have used to create real perspective and urgency. To treat our time as a gift and not waste it on the trivial and vain. Death doesn’t make life pointless but rather purposeful. And fortunately, we don’t have to nearly die to tap into this. A simple reminder can bring us closer to living the life we want.”

Memento Mori: A simple reminder that can bring us closer to living the life we want. Assuming that this pandemic comes to a close at some point, we want to remember that time has a way of altering our perception of powerful events, and try to keep our lessons learned from 2020 fresh, so that they continue to motivate us to be humble, grateful and live our lives with a sense of urgency. This year, we’ve had to confront death on a scale that many of us have never experienced, but I encourage you to continue to spend some time thinking about it, reflecting and meditating on your mortality, along with the mortality of others, so that you can approach the rest of your life as if tomorrow is not guaranteed.

“To practice death is to practice freedom. A man who has learned how to die has unlearned how to be a slave.”

–Michel de Montaigne

DISCLAIMERS: 1) The views expressed here are my own and do not necessarily represent the views of my employer. 2) There are no conflicts of interest to report. 3) I don’t know what I don’t know, so feel free to message me if you don’t agree with something that you read.

KEYWORDS: #burnout #medicine #physicianassistant #nursepractitioner #doctor #barriers #wellness #efficiency #proficiency #control #worklifebalance #happinessatwork #carpediem #clinician #stress #covid #pandemic #lifehacks #physician #worklife #worklifebalance #stoicism #stoic #mementomori #YOLO

TIME IS 💰: 2021 E/M Changes for Outpatient Services

Medical Decision Making (MDM) and Time: these are what you need to focus on for Evaluation Management (E/M) coding as of January 1st, 2021. History and physical exam are no longer relevant for determining level of service.

BACKGROUND (brief): Healthcare professionals currently request reimbursement for services using specific CPT codes (eg 99212-99215). Current E/M code selection is based on a complex counting system focused on history, exam, MDM or time, all of which are based on 1995 and 1997 guidelines from the Center for Medicare & Medicaid Services (CMS). CMS and the American Medical Association (AMA) have worked together to update these guidelines, in an effort to make billing and coding more intuitive and to make unnecessary documentation tasks go away.

Blah, blah, blah…right? If you care to understand the history of how we arrived at these changes, or even retrospectively learn more about our current guidelines, then I’m going to let you go down that rabbit hole on your own (click here). I’m assuming that if you are in practice now, you have some idea on billing and coding, so let’s just look forward at the 2021 changes, in order to learn more about those and start to think on how we can leverage that information for better billing. I know this is really dry stuff, but if you look at it through the lens of basic mastery that can improve your work performance and decrease the chances of fraudulent documentation, it becomes only semi-dry:


The potential with these 2021 E/M changes is for a lighter documentation burden and more face-to-face time with patients: Out with the compulsory history taking and physical exam components (# of HPI elements (ie onset, palliative/provoking factors, quality, radiation, severity, timing, associated symptoms) and # of body systems examined), and in with better MDM documentation and inclusion of day-of-visit, total time spent on the encounter. Let’s take a deep(ish) dive, but start here:

(Ok, I need you now to focus, Young Skywalker. If you’re not in the headspace to digest this, walk away now and come back to it. Better yet, go do some kettlebell swings or pushups, or even yoga, and come back at another time)


Great news! The requirements for MDM have not changed, so if you understand them already, please feel free to skip ahead to the changes about coding by total time spent. But, who couldn’t use a brief refresher, right?

Remember that MDM algorithm thingy, sometimes referred to as the “table of risk”? Well, that aesthetically-displeasing monster is still in play and how we are to determine our complexity related to the MDM of the visits. Instead of painfully dissecting this algorithm, here is a link with the revisions for 2021 for you to review and print for yourself, and I will focus on examples for optimal understanding of MDM.

LOW MDM: One stable established problem requiring minimal interventions (e.g., OTC drugs, PT/OT, skin biopsy)

MODERATE MDM: Uncontrolled problem that requires intervention with identified risk factors (e.g., prescription drug management, elective major surgery, diagnostic endoscopy)

HIGH MDM: An acute or chronic illness posing a threat to the patient’s life which may require intensive drug therapy monitoring, emergency surgery or decision to not resuscitate or provide comfort care due to poor prognosis

Documentation in your assessment and plan should include the following, when pertinent, as these 3 elements are what determine the MDM:

  1. Number and complexity of problem
  2. Amount and/or complexity of data to be reviewed and analyzed
  3. Risk of complications, morbidity, and/or mortality of patient management decisions made at the visit

There was previously a distinction between “New” and “Established” patients in how many of these elements were used to determine MDM level (straightforward, low, moderate, high), but the playing field has been leveled: 2 of 3 elements are reviewed to determine MDM. So much simpler to remember.

I went back and forth on whether to lay out the specifics of the 3 individual elements listed above, but am opting out of boring you with this, and instead going to offer some ways, via the Notorious B.I.G. (links contain profanities — it was 90s rap, after all), to remember what contributes most to the complexity of MDM:

  • Mo’ Money, Mo’ Problems. (do yourself a favor and click that link to hear some B.I.G.) If you are working through multiple problems within a visit, complexity is higher. Additional weight is given to problems that are new or established and worsening.
  • Order Up. If you order a prescription medication, lab or diagnostic tests, then complexity increases. If you have to obtain results, history or old records, or consult with someone these things, then bonus points. And if you really wanna be a Big Poppa, then review the imaging or specimen yourself.
  • Acuity is King. The more acutely ill the patient is, the higher the complexity. Whether it is a new or established problem, including something like a juicy abscess with evidence of lymphangitis, bump that MDM up.

Again, if you wanna read more of the specifics, then click this link. Good luck and god speed if you attempt to memorize that, but the rest of us will move on to E/M changes when billing for TIME.


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Again, if you are in practice, then you probably have a general idea about what amount of face-to-face time spent constitutes a 99203, 99214, 99204, etc., should you be billing for time. So, let’s just focus on the changes for 2021:

  • TOTAL TIME SPENT. This only counts if it is on the same day as the encounter, but the numbers of minutes does include the prep work (including Pre-charting), face-to-face time, test ordering, post-visit documentation, care coordination, education/counseling and communicating with other medical professionals (Yup, that phone consult with the vascular surgeon counts!). So, you finally get credit for your time documenting in the EHR, as long as it is relevant to the case you are billing for. This is a HUGE and WELCOME change!
  • NEWBIES NEED MORE TIME. As you can see, the time requirements for higher coding are more for new patients, as opposed to established patients. For example, a 99203 requires 30-44 minutes, as opposed to a 99213 requiring 20-29 minutes.
  • RANGES. As you can see from the charts above, the time for each level of visit is in a range, so pay attention to the minimum and maximum number of minutes of each range.


  1. THESE CHANGES DON’T MEAN YOU SHOULD SLACK ON DOING A PERTINENT HISTORY + EXAM! Ask yourself: Would you benefit more, in a malpractice case, from having or not having some history or physical exam findings to strengthen your MDM? Also, many patients expect some form of physical exam, so they may feel that you were not thorough should you decide to skip it.
  2. EFFICIENCY IS KEY. If you can keep up with the workload, then you won’t be spending hours and hours outside of clinical time trying to catch up and ensure that your same-day documentation is commensurate with the CPT code you chose. Plus, if you have the time, most of your days’ preparations count towards your visits. If you’ve taken 20 minutes to read Up To Date about the diagnosis of Polymyalgia Rheumatica and done some pre-charting to set yourself up for success, it won’t matter as much that the visit runs smoothly and only lasted for 10 face-to-face minutes.
  3. BIG BROTHER IS WATCHING? I don’t know who is going to be checking the stopwatch on how much total time we spend on each visit, but you’re probably safest assuming that your billing and coding team, and possibly your IT team, can somehow verify the amount of time that you spent in the EHR on each visit. These systems, such as Epic, are data-collecting machines, so it is best practice to only bill for the amount of total time that you spent on the visits.
  4. DOCUMENT THE AMOUNT OF TOTAL TIME SPENT. Create a smart phrase in your EHR with which you just have to enter the amount of minutes spent. Copy and paste this, if you like: “I spent a total of *** minutes on the date of this encounter meeting with the patient and reviewing documentation/coordinating care as described in the above note.”

And there we have it, folks: 2021 E/M Changes for Outpatient Services. Although it may seem like “not my job” because it relates to billing and coding, there stands the potential for leveraging the knowledge about this to meet your goals for 2021. Take the time to review this, as often as you need to get a grasp on it, and I highly encourage those thirsty for more to engage with your billing and coding team or review this website. And if your employer hasn’t even begun to talk to you about these changes, then WTF…2021 is right around the corner!!

DISCLAIMERS: 1) The views expressed here are my own and do not necessarily represent the views of my employer. 2) There are no conflicts of interest to report. 3) I don’t know what I don’t know, so feel free to message me if you don’t agree with something that you read.

KEYWORDS: #burnout #medicine #physicianassistant #nursepractitioner #doctor #barriers #wellness #efficiency #proficiency #control #worklifebalance #happinessatwork #carpediem #clinician #stress #covid #pandemic #lifehacks #leverage #RVUs #charting #physician #billing #coding #notoriousBIG #worklife #worklifebalance #IactuallywasaTupacguy


For those of you that are just starting out in your careers, or will be graduating in 2021 and getting into practice, or even for those in practice looking to make a move professionally (so basically everyone), I’ll offer an unsolicited suggestion:

Start a list of all of the actions you have taken that demonstrate how you have gone “Above and Beyond” the demands of your role.

If you need to, go back and read your job description to know what the written expectations are. If you’re a newbie or will be soon enough, make sure you read and reread your job descriptions and contract agreements. Also think about the unwritten rules, such as what being a solid team member looks and feels like. If you’re in practice, then think about the last year, and write down any examples that clearly demonstrate how you are doing more than is required, AKA going “Above and Beyond”.

Little known fact: Above and Beyond is a town in rural Iowa.

Here are some possible examples that could serve as actions to list:

  • Stayed late on 6/4/2020 to allow other provider to attend meeting.
  • Arrived 30 or more minutes early to each shift to ensure understanding of the day ahead, maximizing productivity of morning huddles.
  • Did home visit for elderly patient on 4/13/2020 due to lack of transportation.
  • Worked Christmas Eve, Black Friday, Memorial Day to allow others to take the time off.
  • Volunteered at COVID call center.
  • Created and presented “5 Solutions for Burnout” powerpoint to office members.
  • Came in on days off (5/13/2020, 10/13/2020) to cover for other provider.
  • Joined Strategic Planning committee June 2020.

The more specific you can be, the better, and try to include dates for a stronger argument. “An argument for what?” you ask. Well, for a promotion, raise, request to drop back to part-time, or maybe even to keep in your pocket for that upcoming job interview. This “Above and Beyond” list can serve as a tool to demonstrate some of your best attributes, and are specific enough examples to set you apart from the rest. These actions can potentially give you some leverage to negotiate for what you want, because you will potentially be seen as indispensable and invaluable.

Does this work? Well, yes. At least it did for me.

Back at my first job, I spent the first year trying to get my footing with the art and science of practicing medicine, while also appreciating that with being the rookie, I was low in the pecking order. So, I watched for opportunities to demonstrate my value, and jumped on these to go “Above and Beyond“, without making myself some sort of martyr. This included staying late, letting colleagues leave early due to weather conditions, covering for them while they were on vacation and even holding a few Q+A sessions for our patients about topics such as diabetes. My colleagues and patients thought I was ambitious and a team-player, which I am, but what they didn’t know was that I was writing all of this down, should I need to prove my value (keep in mind this could also be necessary in bad times, should your employer have to decide who to furlough or let go).

Fast forward to 1 year after my start date, to a meeting for my annual evaluation with the office manager: I received my feedback, asked some questions on how I could improve, and then presented my case for a 10% raise. Armed with data that included patient satisfaction scores, RVU productivity, self-created reviews from colleagues, and of course, my neatly typed “Above and Beyond” list, I argued my case for the raise and subsequently became one of the highest paid APPs in the organization. Within 1 year of work, I had done enough to prove my value and asked for what I thought I deserved, and was rewarded. (I’d also like to point out the fact that most organizations will ask you about your previous salary and base their offers on that, so all of my subsequent offers were influenced by the raise I got after my first year.) Even if I didn’t get the raise, that list was coming with me wherever I applied next, as it did a lot to demonstrate to the potential employer what they should expect by hiring me.

The things listed on your list may seem trivial or are actions you take because you “just like to be helpful“. If so, then you’re a good 🥚 and your colleagues are lucky to have you around, but you should still keep a running tab of these items. This doesn’t mean that you are disingenuous or are a manipulative psychopath, just think of it as character insurance that you just might have to cash in at some point.

Did you know that Above and Beyond is the name of a British band? Well, I didn’t either, prior to my Google search for stock photos of “Above and Beyond”. Are they any good?

DISCLAIMERS: 1) The views expressed here are my own and do not necessarily represent the views of my employer. 2) There are no conflicts of interest to report. 3) I don’t know what I don’t know, so feel free to message me if you don’t agree with something that you read.

KEYWORDS: #burnout #medicine #physicianassistant #nursepractitioner #doctor #barriers #wellness #efficiency #proficiency #control #work #worklifebalance #happinessatwork #carpediem #clinician #stress #covid #pandemic #timeoff #lifehacks #leverage #aboveandbeyond #toomanystupidhashtags #ilikeketchuponmyhashtag #hashtagyoureit


UPDATE: No surprises, but my organization has said that they haven’t budgeted for this provision, and cannot participate. Given this financial-disaster of a year, I am not surprised whatsoever. But, I hope my post opened some of your eyes to this possibility and that you had the courage to take action to at least inquire about it. If you did and had some success, or even if you didn’t, let me know!


Holy cannoli! How did I not know of this loan reimbursement possibility until yesterday? The potential for this was too good to pass on, so here goes:

The CARES Act expires at the end of 2020. Apparently, as of my readings yesterday, there is a portion of that bill that allows employers to contribute up to $5,250 annually to their employees’ students loans. The provision “expands the definition of educational assistance” given to an employee from an employer. If your employer has funds earmarked for an existing education assistance or reimbursement plan, then those funds can be used to assist in paying towards the student loans of employees. In essence, the expanded definition of “educational assistance” now includes payments towards your student loans.


From the IRS: “The exclusion applies to the payment by an employer, whether paid to the employee or to a lender, of principal or interest on any qualified education loan incurred by the employee for the education of the employee.” So, my interpretation of this is that the education assistance funds, with this expanded definition, can be paid to you the employee, or directly to your lender. These funds can be used towards your principal or interest.

Fortunately, my employer already offers a loan reimbursement and tuition reimbursement plan, so I’m guessing that this provision will not have my employer rushing to redistribute the funds usually earmarked for tuition reimbursement. Given that my employer is contractually obligated to give the loan reimbursement annually, I am going to push for consideration of them also giving the $3,500 that they offer annually for tuition reimbursement. I’ve sent an email inquiring about this to HR, highlighting the benefits of this, and will update this post as I find out more. I mean, what do I have to lose? Oh yes, the possibility of $3,500 paid towards my student loans, tax-free.

With just a few weeks left in 2020 (“Thank Goodness” I can hear many thinking), you should consider digging a little deeper into this opportunity and seeing if it applies to you. If so, take action to see if it haas just been overlooked by your employer. Given the financial climate, I suggest you be cautiously optimistic, as I don’t see that many employers would jump at the opportunity to allocate out more money. But, you never know unless you try, and there is the potential for $3,500 tax-free dollars to reward your efforts.

DISCLAIMERS: 1) The views expressed here are my own and do not necessarily represent the views of my employer. 2) There are no conflicts of interest to report. 3) I don’t know what I don’t know, so feel free to message me if you don’t agree with something that you read.

KEYWORDS: #burnout #medicine #physicianassistant #nursepractitioner #doctor #barriers #wellness #efficiency #proficiency #control #worklifebalance #happinessatwork #carpediem #clinician #stress #covid #pandemic #timeoff #lifehacks #leverage #finances #studentloans #retirement #leverage #investments #FI #financialindependence


Disclaimer: I’m not a financial adviser, nor do I play one on the internet, so all contents within this post should be vetted by you to ensure accuracy. Also, remember that PA, in my case, stands for Physician Assistant, not Personal Accountant. Do your homework about your finances — it’ll change your life!

$35,000. This is all that is left of my student loan debt. For many, in these difficult times, that mountain of debt may look like Everest. I feel blessed and grateful that this amount appears to be within close reach of payoff, especially given that it was at $108,000 just 4 months ago. Yes, if you just did the math, we have put >$70,000 towards my student loan debt in 4 months, and are on the brink of being completely debt free in 2021.

I can hear the naysayers and nonbelievers already saying that because I’m a PA and have a good salary, of course this sort of financial jiu-jitsu is possible. But what if I told you that my wife paid off >$70,000 in less than 9 months as a school teacher? If one could be a fluke, then maybe two just might be a pattern that can be replicated? Maybe we have the right recipe, but I’m here to tell you that there is no secret sauce, as a little knowledge and discipline is all that you need. It also helps to have opportunity knocking, such as that hidden within this pandemic.

Here we are in December 2020, and as of the writing of this post, we are in month #9 of the CARES act. For federal student loans, there has been a forbearance placed on payments, with zero % interest accrual, now through January 31st, 2021 (recent extension from 12/31/20). We do not yet know what will happen come February 1st, 2021, in regards to student loan payments, and cross your fingers that action will be taken to ease the student loan burden for Americans. (I will admit that I am skeptical that a sweeping executive action or plan is going to wipe the student-loan slates clean.)

So, there has essentially been 9 months wherein no payments were required on these federally-held student loans, and one bright spot for those on the Public Service Loan Forgiveness (PSLF) track, these months have counted as qualifying payments on your way to being off the hook for the remainder of your loans. I was in that program myself up myself until around March 2020, and due to changes in my payment increases with the income-based plan, along with the circumstances with the CARES Act and disdain for FedLoan Servicing, my wife and I decided to take control and get this debt monkey off of our financial backs.


I hope you have also found ways to set yourself for financial success, as there have been many opportunities within this pandemic to do so. I appreciate that SO MANY were furloughed, fired, got sick or whatever, and many are still out of work and struggling. My wife and I have been blessed to be “essential” during the pandemic, with very little changing to our salaries and benefits. With that said, there have been many opportunities to get your finances, including paying down your student loan debts, in better shape for 2021 and beyond. I’m talking about relative changes and incremental wins, as I understand that most are not in a position to pay down large sums like we have.

If you fall into a high-income bracket, have kept your job throughout the pandemic and you haven’t made some serious headway on your student loans, then picture me face-palming. On the bright side, you have the rest of this month (and now January 2021) to get the ball rolling towards financial freedom, but the window of opportunity may be closing at any time. Whether paying down the principal of your loans within the setting of zero interest accrual, or just increasing your savings to be poised to make larger payments in 2021, or increasing your savings and investments while the number of PSLF qualifying payments ticks up, these are all wins. But, if you’ve been working this whole time and haven’t made some headway, maybe even spoiled yourself on a few big-ticket items, then you really missed a golden opportunity. You likely have cost yourself thousands, possibly hundreds of thousands or even millions, mostly to future interest accrual on your debt and missing the opportunity of compounding interest within the next few decades.

I want to offer this great Chinese proverb I read the other day, which really applies to investing and the power of time to grow: “The best time to plant a tree was 20 years ago. The second best time is now.”

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Not everyone has the time or mental bandwidth to do a deep dive into investments, financial independence, loan repayment strategies, etc., but the good news is that you really don’t need to be an expert. As clinicians, we routinely recommend our overweight and obese patients focus on lifestyle changes, specifically eating a healthy diet and getting some physical activity. It’s a simple formula that works. Well, the simple formula that works for paying off debt and becoming financially independent is spend less –> save more.

Another financial opportunity in this pandemic has been how travel and other restrictions have potentially decreased discretionary spending. My wife and I, given she is working remotely at times, are saving money on fuel, travel, car maintenance, etc. We were supposed to take a trip to Italy this past summer, which of course got cancelled, so we’ve taken the money we planned on spending and invested it…with compounding interest, that $5,000 will become $20,000 in 20 years. We know that given our relatively high savings rate, we will rebuild the travel fund for when we can safely take that trip, and much of that will come from the discretionary savings I listed above. Just a simple redistribution of the money will fund a half-year of retirement for us, or maybe some college funding for our future family.

Taking many incremental steps forward with your financial futures, including reducing student loan principle, redistributing money saved to investments, optimizing asset allocations in your retirement accounts and just simply spending less and saving more, are all opportunities that have been ripe for the pickings during the pandemic. There are enough of these golden opportunities that are ever-present, pandemic or not, and these can be leveraged to pay off your debts and increase your savings/investments…all on the path to becoming a financially-independent millionaire. (this is not hyperbole, just take a look at a compound interest calculator)

Big picture: The pandemic has been tragic, frustrating, anxiety-provoking, exhausting, heart-wrenching and long, and on it goes for an unknown length of time…all of this has been blatantly obvious. Less obvious have been the opportunities to take steps, and even leaps forward on various parts of our lives, including our state of financial well-being. Some of these opportunities will be unavailable after a period of time (CARES Act), but the majority are ever-present and can be leveraged at any time. Take it from me, who at my core is financial novice who likes to “Geek out” about this stuff…taking control of your finances is incredibly empowering and this feeling of being the Captain of our ship during some rough seas has been both valuable and invaluable.

DISCLAIMERS: 1) The views expressed here are my own and do not necessarily represent the views of my employer. 2) There are no conflicts of interest to report. 3) I don’t know what I don’t know, so feel free to message me if you don’t agree with something that you read.

KEYWORDS: #burnout #medicine #physicianassistant #nursepractitioner #doctor #barriers #wellness #efficiency #proficiency #control #worklifebalance #happinessatwork #carpediem #clinician #stress #covid #pandemic #timeoff #lifehacks #leverage #finances #studentloans #retirement #leverage #investments #FI #financialindependence