Taking time

One of the things I truly forget about is... myself.  Taking care of myself, taking time for myself, and just taking time with family.  

I get so involved in the number of hours, case types, and thinking ahead to length of assignment/finances/bills/investments that I lose sight of self.  I forget the 70 hours of work and 40 hours of sleep is 110 hours in 5 days 5x24 120 doesn't leave a lot of time when you drive an hour a day.  Most weekends I am off which helps but notice I say most because I offer myself up to any days.   

So, as I mentioned I'm planning our family vacation to Hawaii to see my brother and sister-in-law.  This takes financial and self awareness.  You'll recall I'm 1099 which means paid vacation does not exist.  I have to make sure all standard bills will be paid while gone and that $$$ exist for hotel/AirBNB, tours, and the like.  

This week long vacay may only be a week but I've decided to do something that 50% of people say horrible things to me about and the other half... support.  I'm going to get my gastric sleeve.  Not because I can't just go on a diet and lose some weight.  It's because I can't get myself to completely change my habits.   Why?  When I diet I can rationalize that this workout or diet for three days means I can go with friends to X restaurant have drinks and dinner and enjoy... then the next day I just skip the workout because I'm tired and have a beer with dinner because man I worked so hard.  The wagon is broken.  I'm changing the ability to rationalize by saying my body has been altered and despite all things and what people say .. I'm limited in ability to fall.  Yes in 3 years if I want to screw things up... I can.  Have you changed everything for three years and decided to return to a life you didn't like?  My hope and goal is to do this drastic thing to myself to force a change in habit.  Right or wrong I'm doing this so I am around for this family.  I feel like if I don't I'll be that 40 year old in the ER with a heart attack.  I'm hoping at 37 this will allow me to physically change and reverse the negative effects on my health before they are permanent.   No it's not because I don't want to exercise.  In fact, I walked 6 miles today with elizabeth.  It's not because I hate healthy food.  I love it... too much.  It's portion re-training:  yup, I'll have to break the Diet Coke addiction too.  

That's two things I'm doing for me... but that's in November.  You can't just take a week every 3-6 months and feel fulfilled.  I think at least every couple weekends you need a little just for you or just for family time so you see the fruit of the labor.   

What do you do? 

Weekend

I am so happy it's the weekend!  I went for a four mile walk with Elizabeth.  Sent Francisco to the Urgent Care office for bronchitis and may send EE but she seems to be improving.  

I can always tell when I start getting paychecks again.... I start planning what it's going towards.  So, we are just planning our trip to go see family in Hawaii for Thanksgiving and I'm also thinking that just after I will be considering the Gastric Sleeve.  Lots of things would have to come together to make this possible but I can see the possibility. 

It's amazing how opinionated everyone is on the subject.  It's not an easy thing to come to the decision of "there is no way this will happen and be lasting if I continue to do the diets, exercise, and all the things I have done over and over again"  They have morally bashed me saying it's just you and you can do on your own, you have to be an example for your kid, and you need to just be a better you.  You don't think I know this... you know I walk a couple miles multiple times per week, you know that I know what I should eat, you know I know the portions and then what the stomach and brain say totally contradict the rest.  It doesn't matter how much I know... it's the habit and ability to truly change the body and mind.  Yes, I can totally screw this up... I can do everything and lose the weight and 4 years later over-eat so much that it stretches the stomach and I gain all back and more.  The idea is to completely overhaul the brain and break the habits that one goes to when a diet fails or missed exercise days become months.  

So, I'm still looking into options. 

Work is work and we are busy.  I love good days but I'm so not used to having multiple people in the room "helping".  I am not used to a hospital where the room nurse and CRNA don't go get the patient together.  I'm not used to the differences at this hospital than the ones I've been to in multiple states so I'm having a harder time not saying "this isn't right and needs to be fixed".  Generally, I try to stay out of politics and policy.  I have told several that this is going to cause errors and they have even said that it already has caused them.  In which case I don't understand why the process hasn't been changed?  

Maybe it's not my soapbox to get on.  Philadelphia is a very different city to me.  I know we'll be here for a while so I better start embracing it a bit more :)  time to work on the websites, plans, 401K and so much more.  

I hope your journey is amazing!  

To Sep or Solo

A big question asked often is weather to Sep IRA or Solo 401k.  Of course, I must make the statement that I am not a tax or financial advisor of any kind.  Now, I talked to Vanguard about starting a Sep IRA or a Solo401k.  

I talked to a business advisor and not just the personal finance advisor.  I had them and said I'm a 37 year old 1099 earner with my own Llc S-corp with flow through Gross X amount and taxable net income amount of X.   

He said, ok so for a Sep IRA you can do up to 25% (up to 52-54k) business contribution in basically any investment vehicle through a brokerage account.  A Solo401K you can do 25% (up to 52-54k) business contribution plus $18000 personal addition to your 401k.  They will only allow vangaurd funds for the Solo 401K.   These are also different if over 50 years of age.   There are eligible catch-up contributions as well depending on the IRS regulations.  (This is where a tax/financial broker will help.)

I said ok, if I have others in ownership of my company do I have to pay out the same amount or percentage to them?   

Yes, if they are paid owners from your corporation then they will require the same amount as a percentage of their income in retirement for either the Sep or Solo but personal contributions don't have to match. 

No, if they are unpaid. 

So, I clarified again that both are pre-tax IRA investments and should decrease the overall taxable earnings in the future with the understanding that taxable income in the future would likely be less in retirement than right now.  They agreed.   

I have asked for the information on the accounts and will include them as attachments to the Blog if possible.  I will also add the supporting IRS fact sheets for both the Sep and Solok.   

The phone number for Vangaurd Business Solutions is: 800-992-7188

I chose Vanguard based on the discussions on the Dough Roller Money Podcast based on the simplified minimal basis point costs and overall low fee structure.  Low fees and good management history points toward a possible growth in the future despite my negativity on the overall stock market.   

I also have questions on rights of survivorship so will review the forms for potential to rollover on death to other family as a paying IRA in the future.

SOLO 401K IRS PAGE

 SEP IRA IRS PAGE

Individual 401(k) New Plan Kit Vanguard

Fun plan

Today I was at a third hospital and people say things like I can't believe you remember from place to place what you need to do.  The good news is anesthesia is anesthesia.  Knowing where everything is even at a place you've worked for a year has a bit of a relativity factor.  Meaning you get used to a place fairly quickly and if you get a halfway decent OR crew, anesthesia tech and are surrounded by decent people... it's probably going to be ok.  

Now, Fun.  Seriously, you have to go to work having fun!  Plan each day to be exciting and happy.  If you drag people down everyday and you are around people stressed and unhappy. Where will your job satisfaction be?   

You have to have fun on the weekends, after work, and plan vacay!!! Life isn't just work.  What you do outside of work leads to your whole self health.  When I get off work I'm going to.... 

If your friend said when I get off work I'm going to take my daughter out for a walk along the river, see the urban culture of a melting pot of people at a skatepark to skulling for their college crew teams, then shower and have a relaxing corona by the pool.  Would you think they were negative about the city or bored?  If you are on an assignment you have to be the person that makes your afterwork and weekend plans.  You have to be the friend that says hey let's go to Atlantic City.    

Every place is what you make of it and it's important to keep yourself and others excited about what you do.  That first plan was my night tonight.  It cost 2$ for the beer and otherwise it was a free nights entertainment.  Your colleagues, nurses, techs don't need to know when you spend $1000 on a trip but they should hear how excited you are about what's happening in their backyard.  It also leads to your overall satisfaction by not becoming TV bound or complacent.  

Best of luck and add some fun to your plan!   

New hospital day

Today I will go to another new hospital.  I'm meeting them at 6:30 in the lobby and I'm pretty sure it's a 7:30 start.  I've been up for 20 minutes and have a 45 minute drive... so here are my ten minute notes on today.   

I have an 8 hour day today so it's not so long and I know I'll make it through.   

When I drive into the parking lot I'll note the main entrance as that's where I'll meet another CRNA to give me the quick run-down.  Hospital systems are a little harder to just go in and 30 minutes later be in a room.  The "red-tape" isn't just paperwork and long credentialing.  These places require smart ID's to let you in and out, and sign-ins for multiple computers/programs/machines.  Even cases will typically be a couple starter cases to get used to equipment, paperwork, and get to know staff.  

Ok, well I hope your day is awesome... mine will start with a bit of a drive.  Thanks to podcasts at least I have the opportunity to learn a little as I go! :).  

a bit of my flexible plan in progress

My plan:
Regional Anesthesia Services LLC.
Fundamental delivery of anesthesia that is sound in practice and based on widely accepted care.
Provide care as a locum anesthetist in order to allow for an income stream that is higher than average W2 and allow for better than average tax savings.
Utilize a portion of the company to inform & educate CRNAs regarding locum anesthesia and allow them to support the site by referrals, site support tab for T-shirts or someday have enough traffic to the site for advertising revenue.
Personal finance:
I want to mention this as many of us are well paid but debt being what it is, it is easy to stay in-debt.  I have a spreadsheet that shows all debts and a planned pay-off date for getting out of debt.  Strategic use of debt for assets can be good but long-term high interest debt can be a real struggle.  Set a system in place that will keep the overall monthly debt decreasing and either increase income or decrease spending in order to decrease the overall debt burden monthly.
Retirement: despite debt and the fact that it's there many are more interested in retirement savings and depending on the rates of interest on debt ... retirement planning is very important and may be more beneficial than the quick pay-down of debt.  You really need a good financial planner and CPA to discuss this with.  This year will be my first year venturing into the dilemma of solo 401k v sep IRA.  My net taxable income was pretty low compared with gross income and therefor it appears that the solo401k may be a better option.  I also now have to think of our child and my husband.  Tax, financial, & retirement planning are a family ordeal and now they have to be taken into account.  Being able to save with the least post tax income, in most instances, is the goal.
Insurance:
Usually a necessary evil in the world. How much is enough?  How do you protect yourself without being taken advantage of and what is too much protection?
Health insurance... most agree you have to have this.  Some plan for if something catastrophic happens at the minimum.
But what else? This depends on where in life you are?  Are you fresh out of school and can't afford a week without a paycheck?  Do you have a cushion of expenses socked away in a semi liquid investment?
Short term and long term disability?  Do you need it?  Do you have to work to pay the bills?  If so, at least long term disability might be beneficial for you.  Can you take 3 months off and be ok?  If not, short term disability might be important.  Why am I not definitively stating?? I don't know your position.  I have other investments in real estate that are acting as my disability insurance and retirement savings.  They are not liquid and for a couple years it's been a big risk not having extra insurance. But the funds that would have been paid to insurance went into property that now keep me from the stress of what if someday.  It's still not even at bill paying level so I should technically have insurance for disability but if I had to cut back and sell things... I could live off the rentals.  Sooo, it's a start.  Things to think about concerning disability insurance.  Is it an "own profession" policy if not the insurance will say you can work as a Walmart greeter and you are not disabled.  This is a clause though that means the insurance will be more costly.  Also, please look at the overall payment amount should you have to use it.  Ask your CPA, but I think this amount is taxed as income.... sooo, is it really enough?  Many say it 30-40% of income but enough to pay the bills if I get injured (speaking about short term recoverable injury), what happens with permanent disability?  How long will it cover you and at what rate?  Does it change for inflation?
Life insurance:
So when I advise financial, tax and estate planning, I tend to tell people to be very acutely aware of those that try to place them in a whole life policy or an annuity.  These are insurance products that are high commission for the agent and have a lot of loopholes for the insurance company and some questionable benefit for the average individual.  Most advisors, planners, CPA and tax individuals that are not insurance sales people have recommended term life insurance.  Term allows lower premiums during the period of life where you are least likely to pass away.  This allows you to invest more for retirement, put dollars to work so that you may have your own estate plan that covers your final expenses when you die at 150 years of age and life insurance isn't needed.
Malpractice insurance:
First know your carrier and type.  Claims made V occurrence.  Do you have your own insurance?  Do you have a policy covered by your employer and have no idea?  If you have no idea... did you know that you could have been named in a malpractice suit and it settled without your knowledge or consent? This is one expense I don't go without.  This is very state specific and hospital/credentialing requirement specific.  Independent, 1099, county, state, and length/type of practice are generally taken into account when setting up a policy.  Any move or change requires a call to your insurance provider.

This is a part of the plan but it's getting long

66 hours

It has been a long week and typically I love it.  Yesterday was Francisco's Birthday and we did get to go out to eat, but it was still a pretty long day at work.  Have you ever had one of those days where ... just about everything was a little off?  That was my day.  The first case I had three people telling me how I had to do a standard gastric sleeve.  I generally accept help and how people want to do cases but having three cooks on the kitchen at induction it stresses the patient, me, and then the surgeons have a diminished view as well. 

I was hoping that the day would improve from there but it seemed there were little stupid things that were just a little off the rest of the day.  

One of these days I say that all will be perfect but I have yet to see anyone do a perfect case in everyones eye.  I tend to self deprecate and I definitely need to work on that.  Otherwise, I'm still working on my flexibility and even wanting to do more work as the day goes into 11-12 hours.  

All that is true, but today I'm home :).  I like being home with Francisco and Elizabeth.  I work a little on the site and adding to the states, updating the jobs available, and work on Francisco's new site in spanish.  (www.Conmuchosabor.com).  

I then go to the rental houses and dealing with what needs to happen in the coming week.  You know, this week was a bummer of a week on that aspect.  We lost another HVAC and have to redo an entire roof tear-off and gutters.  

I talked to two of our colleagues. One regarding 1099 perm position and the financial components and the need to really ask CPA and financial advisors questions and ensure they are on the same page as you.  Ensure they understand the differences and how it effects the nature of your finances from the start all the way through retirement.  

Another person asked about a contract that he was working on with another company.  The sticky points were a somewhat low amount per hour, a long drive, and a non-specific non-compete that could be detrimental should the place lose their contract.  

OK... feel free to E-mail at LocumCRNAs@gmail.com anytime!  Have a great weekend!

Maintaining the contract.

I like to check in about this point.   We are at two weeks into the contract and I have to say it's always a bit rocky.  I wonder what people really think versus what is said behind closed doors.  Every permanent person is your critic.  From the janitor to the OR manager, permanent anesthesia staff and other individual locums.  One poor view of you from the wrong person and the OR tech who thinks she knows everything can affect your job, contract and if you are hired again by the anesthesia management group.  

I check in with the docs to see what can be done better.  I check in with the AMG to ask them if something can be done better.  I check in with the chief CRNA to find out how things are going and what I can do to help out.  I want to be taken as part of the team and not the one just here for money.  

I was with a locum MDA this past weekend and he was so very talkative.  I had to get him to focus, he would keep patting me on the back or chest to say things like "you know how it is, big guy"... so many things I despise about that but touching me is a big no.  I knew I only had a few hours and he would be at a different facility.  I bit my tongue and tried to focus on the patient throughout.  It's definitely a learning curve and despite my inherent self I have to be a people person.  I have to keep a smile and work to keep everyone happy even when boiling on the inside.  A tech in the room is criticizing the chief surgical resident for going to get the patient with me and the chart not coming down with the patient.  In all other hospitals I have been to the OR nurse meets the patient and goes through the chart prior to entering the OR.  All of this said the people pleasing is definitely part of the contract maintenance.  

I also think that self-reliance is very important.  The more you can figure out where things are without calling every two seconds for something to be brought, the better you are perceived.  Being able to search the stock room, store cabinets, OR carts, and anesthesia drawers/kits/carts will serve you 20 fold in how you are perceived.  I typically hate calling for things and feel horrible when they are right there in the room.  

Process, this is very difficult as most places have set process' in place.  What do you do when a process doesn't work or is obviously going to be a challenge?  I ran into a problem with a patient that was having a potentially large surgery in a hospital with little process for Arterial Lines, monitoring, ABG's and other lab work.  I sent them off and was unable to get my numbers back in a timely fashion and although stable I was hoping to be able to optimize the patient.  This case allowed me to understand some missing links in the chain and to find out who in the process was unwilling to help in a hospital process.  I'm still not sure how to go about solving this but as a new takeover.  I know that there is an administrative process that might make it easier in the future to get these items fixed.  I will be using the staff that are part of the facility to bring it to the management as a potential problem in doing similar cases in the future.  This type of case should be able to be done in just about any hospital in the country and had process issues but not detrimental to patient care issues at this point.  The last thing I should do is take something to administration or try to yell, complain and make trouble for the current staff.  I am here in place of permanent staff and not as admin or a person to make policy or even affect politics.  

OK... I should stop for now.  On to a 32 hour call shift in the morning.  Best of luck to all in the next week!

Let's talk skill set.

A recent question was posed about skills and the fact that some of us get rusty or haven't done XYZ in a ... while.  What do you say? How do you talk about them?  Let's use pediatrics as the skill in question.

First, have you just not done any kiddos 0-18 in years and you want to start doing them again?? Maybe the case is you want nothing to do with kids but over 12 is ok?  Where does your comfort level sit?  

When you talk to agencies you should know they want to be realistic with where you are and where you are willing to go.  Are you willing to do pediatric cases but want a hand in the room until you are comfortable??? The first 5 - 10 cases or maybe you say I'm not comfortable and don't want to go a place I'll have to do pediatric hearts or solo pediatric ER intubations.  

This is all ok.  But, you have to realize each case type you can't do or won't do may limit your opportunities.  It totally may have zero effect.  My current hospital will put you where you are comfortable.  No blocks, heads, hearts, cvl's, art lines, peds... it's ok.   

Important! Don't tell them you do and you can't do!  You should get a credentialing packet that will ask your comfort with procedures, cases, and numbers (estimated) per year.   

Please, let your agency know where you are and be optimistic about what you do and what your willing to learn.   

Continue to show your education, CEU's, ask questions, and when you are at your assignment take initiative.  Ask questions, act interested, & be ready for opportunities. 

1st weeks

The first days in a new place are the hardest as one doesn't know the Doctors, CRNAs, Surgeons, Techs or admin.  

I had a lot of fun getting to do a variety of cases.  I'm hopeful that in the coming weeks I will have even more fun with the group here.  I have gotten back into hearts after at least a year or two off from them.  The surgeon is pretty nice and relaxed.  I've had a good group of people to work with and I truly look forward to the days to come. 

 I'm supposed to be going to multiple hospitals so next week will start a whole new day 1 process and a getting used to the system at a new hospital.  I'm excited to see this group and how they work together.  

It's interesting dynamics hearing what people do and don't like and how they express themselves.  It's not difficult to read people and see that they have reservations or dislike or like what they do.  

I have not seen it all and done it all.  I had a new experience of a doc on group text stating their displeasure with a call schedule and they will resign next week if it isn't changed.  It's just a whole new experience.  

I get a little perspective into other facets of anesthesia and management as I continue to work with people through this site, these facilities, and continually keep in contact with others.  The interesting thing is that it boils down to .. "just business".  What we do on a daily basis is truly the personal touch and a true people profession.  Please don't let me detract from that but the where we do, how we do, and when we do ... those things come down to business.  Some politics in how much hands are tied and what has to be done and how.  The thing is that business drives those decisions.  

When a new anesthesia management group takes over.  It's not because one was liked more or less or even that a group did a sub-par job.  It comes down to the buck.  Places get comfortable and complacent and happen to think they won't be taken over by another but they also have to realize that the board for the hospital, anesthesia group, surgical center, or whatever company ... may not be in the same profession.  They may have an MD/MBA and have never practiced medicine.  They may not have either a MD or MBA title.  The owner of a company may still outvote a board of directors that is supposed to be running the company.  All this is said to remind you that a contract is a contract and all have a term to them.  When things change it is business.  It is not because of the individual or that something happened.  

So, one week down and the business of anesthesia shows as a new group has merged with these hospitals and it seems to be eggshells for some.   I try to be mindful of the stress and go in happy and excited to be here.  There are things that help and happy patients are very important as the surgeons, anesthesia, and all parts of the group are more easy going and perceive a positive experience.  So ... the 1st week has to be a good week :)

Journey forward with me as we go :)