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When Good Enough is Fine
Issue #497A, November 22, 2017

Stocks vs Real Estate: Asset Allocation. Part I of II
Issue #497, November 20, 2017

The Saudi Arrests and the Perils of Foreign Investing
Issue #496, November 13, 2017

Gambling and Las Vegas
Issue #495, November 06, 2017

Some Tips on Auto Insurance
Issue #494, October 31, 2017

Bitcoin and the Digital (Crypto) Currencies
Issue #493, October 23, 2017

The Coming Bear Market: Part II How to Prepare
Issue #492, October 16, 2017

Some Observations on Cemeteries
Issue #Interim Bulletin #491A, October 12, 2017

The Coming Bear Market: Part I: The Myth of Buy and Hold Forever
Issue #491, October 09, 2017

The Market makes New Highs
Issue #490, October 02, 2017

The Importance of a New High
Issue #489, September 25, 2017

A Little Insurance: Wealth, War and Wisdom
Issue #488, September 18, 2017

Some Observations
Issue #487, September 11, 2017

How to be Successful in Your Career
Issue #486A, September 07, 2017

How NOT to Buy a Home
Issue #486, September 04, 2017

This Week in the Market
Issue #485, August 28, 2017

Is the “Trump Bump” Running Out of Gas?
Issue #484, August 21, 2017

Gold is on the Move
Issue #483, August 14, 2017

The Importance of Estimation
Issue #482, August 07, 2017

Buying Art and Collecting: Part II of II
Issue #481, July 31, 2017

Buying Art and Collecting in General, Part I of II
Issue #480, July 24, 2017

Physicians need to be More Forceful: Follow-up
Issue #479, July 17, 2017

Physicians need to be More Forceful
Issue #478, July 10, 2017

Your First “Real” Investment
Issue #477, July 03, 2017

Leasing a Watch: Don’t
Issue #476, June 26, 2017

The Importance of Your Children having a Job
Issue #475, June 16, 2017

The Problem with Medical Student Debt is—the Med Schools
Issue #474, June 12, 2017

Critters and Varmints in your Home and Yard
Issue #473A, June 07, 2017

Leveraged ETFs
Issue #472, May 29, 2017

Leasing a Vehicle: Don’t!
Issue #471, May 22, 2017

Issue #470, May 15, 2017

More on Buying Jewelry
Issue #469, May 08, 2017

Buying Jewelry: Gold, Diamonds and Pearls
Issue #468, April 30, 2017

Thomas Sowell: Part III of III
Issue #467, April 24, 2017

Thomas Sowell: Pat II of III
Issue #466, April 17, 2017

Live Close to Where You Work
Issue #465, April 10, 2017

Medtronic in Hospital Management
Issue #Interim Bulletin #464A, April 07, 2017

Thomas Sowell: Part I of II
Issue #464, April 03, 2017

A Political Contribution a an Investment: Part II of II
Issue #463, March 27, 2017

A Political Contribution as an Investment: Part I of II
Issue #462, March 20, 2017

Buffett Selling Vacation Home
Issue #461, March 13, 2017

Advanced Placement (AP) ourses
Issue #460, March 06, 2017

The Importance of a Credit History
Issue #459A, March 02, 2017

A Credit Card Scam
Issue #459, February 27, 2017

The Electronic Health Reord
Issue #458, February 20, 2017

Issue #457, February 13, 2017

Platinum and Palladium
Issue #456, February 06, 2017

Economic Outlook for 2017: Part II of II
Issue #455A, February 02, 2017

Economic Outlook for 2017: Part I of II
Issue #455, January 30, 2017

A Story From Vegas
Issue #454A, January 25, 2017

Land Donation Deals and the IRS
Issue #454, January 23, 2017

The Theory of Gambler’s Ruin
Issue #453, January 16, 2017

Student Loans: But Wait, There’s More!
Issue #452, January 13, 2017

A Second Home
Issue #Interim Bulletin #451A, January 04, 2017

The Consumer Confidence Index
Issue #451, January 02, 2017

Social Security
Issue #450, December 26, 2016

My Outlook for 2017: Part II of II
Issue #449, December 19, 2016

My Outlook for 2017: The Market
Issue #448, December 12, 2016

Medicine in 20 Years
Issue #447, December 05, 2016

Higher Interest Rates
Issue #446, November 28, 2016

Trump and the Markets: The Bad and Ugly
Issue #445A, November 23, 2016

Trump and the Markets: The Good
Issue #445, November 21, 2016

Negative Trends: The Suits aren’t Makin’ Steel
Issue #444, November 16, 2016

The New DOJ Fiduciary Rule
Issue #443, November 07, 2016

Barron’s Conference, Part IV of IV
Issue #442, October 31, 2016

Barron’s Conference, Part III of IV
Issue #Interim Bulletin #441A, October 26, 2016

Barron’s Conference, Part II of IV
Issue #441, October 24, 2016

Barron’s Conference, Part I of IV
Issue #440, October 20, 2016

This Newsletter
Issue #439A, October 12, 2016

Memoirs of US Grant: Vol II
Issue #439, October 10, 2016

More Points on Collecting, Investing and the Economy
Issue #Interim Bulletin #438A, October 05, 2016

Personal Memoirs of US Grant
Issue #438, October 03, 2016

Ideas for a High School Part-Time Job
Issue #Interim Bulletin #437A, September 29, 2016

Collecting, Investing, and the Economy
Issue #437, September 26, 2016

Free College
Issue #436A, September 22, 2016

A Military Commitment to Pay for Med School
Issue #436, September 19, 2016

When a CD isn’t a CD
Issue #435, September 12, 2016

I Made a Mistake
Issue #Interim Bulletin #434A, September 07, 2016

What is Your Spare Time Worth?
Issue #434, September 05, 2016

Credit Cards and Bonus/Loyalty Points
Issue #433, August 29, 2016

The Write-off of Student Loans
Issue #Interim Bulletin #432A, August 25, 2016

412 Retirement Plans
Issue #432, August 22, 2016

Join the Club
Issue #Interim Bulletin #431A, August 18, 2016

The Case for Precious Metals and Hard Assets
Issue #431, August 15, 2016

When the US went off the Silver Standard
Issue #430, August 08, 2016

Why NOT to Open a Restaurant
Issue #429, August 01, 2016

Some Tips on Life Insurance
Issue #428, July 25, 2016

More Observations on Negative Interest Rates
Issue #427, July 18, 2016

Issue #426, July 11, 2016

Is a PhD Worth It? Part II of II
Issue #425, July 04, 2016

Is a PhD Worth It? Part I of II
Issue #424, June 27, 2016

Avoid Part-time real Estate Agents
Issue #423, June 20, 2016

Issue #422, June 13, 2016

The Problem with Auction Reserves
Issue #421, June 06, 2016

Make Full Use of Your Capital Investments
Issue #420, May 30, 2016

The Fed’s Announcement
Issue #419, May 23, 2016

Quit While You’re Ahead: A True Story
Issue #418, May 16, 2016

The Precious Metals
Issue #417, May 09, 2016

Negative Secular Trends: Part Ii of II
Issue #416, May 02, 2016

Negative Secular Trends: Part I of II
Issue #415, April 25, 2016


By Robert M. Doroghazi, M.D., F.A.C.C.

Physicians need to be More Forceful

Issue #478, July 10, 2017

    I was going to entitle this “Are Today’s Physicians Docile”? but that’s pejorative and un-necessarily provocative. It might turn you off so much that you don’t read the newsletter, which would be unfortunate, because I think this is an important discussion. You might not agree with what I say, but at least consider my opinion.
    I gave a presentation last month to the Boone County Medical Society on “Trends in Medicine”, based on the series of 6 Commentaries I had last year in The American Journal of Medicine (reprints available on request). The emphasis of my talk was on bureaucracy, especially as it relates to the controversy involving the American Board of Internal Medicine (ABIM) and the Maintenance of Certification (MOC) requirements proposed in 2014. They were so outlandish that physicians had what I call a “Popeye moment”, finally saying “this is all we can stands, we can’t stands no more”.
    There was a lot of whooping and hollering. A study showed that the new requirements would cost the average Internist $23,607 over the course of 10 years (since this is the average, it would cost many physicians much more).There was an Internet petition of protest signed by 25,000 physicians, and an alternate organization, the National Board of Physicians and Surgeons, was formed to act as an accrediting body.
    But the rank and file physicians, and their leaders, never carried through, they never broke out the spinach. The ABIM initially made a few changes, and just recently made a few more, but, in my opinion, they are totally cosmetic, and border on pandering. And in spite of accusations of financial impropriety, those in power at the ABIM, with their obscene 6 and 7-figure salaries, remain in power.  In the opinion of someone like me, who has been retired for more than 11 years, on the outside looking in, it appears that physicians just rolled over, grabbed their ankles, and took it. 
    Now for the subject of this newsletter. Why aren’t physicians more forceful in standing up for themselves? I hesitate to use the word aggressive. Military commanders and professional boxers are aggressive. All that counts is to win, to demolish your opponent at all costs. We are physicians, taught to be caring and compassionate, to trust people. This must not change. Rather, physicians must realize that when they are dealing with business issues, they need to turn this attitude off, and become just as hard-nosed as their opponent in defending their interests, in sticking up for themselves.
    I believe this trend toward “non-aggressiveness” (I hesitate to say “docility”) has in recent years become part of the medical curriculum. First are the restrictions on resident work hours. When I trained and was in practice, you worked until you were done. You never handed over a problem to someone else, you took care of it yourself.  Now there are time limits on how long the House Staff can work. When I read about these mandatory “rest periods” it reminded me of when I was in Kindergarten in 1956-57. We would have Kool-Aid, cookies, and everyone would lay on their red-green mats on the floor for a nap.
    It’s like physicians are taught not to be decisive, to avoid taking the initiative. I heard a case presentation several years ago. To me, it was obvious what to do. But when it came time to act, the House Staff had to convene a Committee to make the decision.
    In today’s medical schools, political (in)correctness has reached the point that even an honest disagreement is considered an inappropriate confrontation. True story: an attending physician asked a student a question. They did not know the answer. He said “You knew we would be talking about this. You should have read up on it and known the answer”. The student felt “shamed”, went to a Dean, and the attending was reprimanded!
    “Life-style” is at the top of the list of many of the current generation of physicians. Several local docs, who are now the senior people in their groups, lamented to me that they can’t find people who are willing to work as hard as they do. Many physicians now become hospital employees. As more physicians just “punch the clock”, they will be less forceful in defending their interests, because of both the “docile” mindset, and the lack of any leverage.
    I recommend.
    1) The “touchy-feely” mindset instilled in physicians during training must change. RMD comment: unfortunately, it won’t. This is the same Medical Establishment that has so prolonged training that physicians have become professional students, and that continues to raise tuition far faster than the rate of inflation.
    2) Someone who has been in industry and private equity for years told me that if they were starting a career in Medicine today they would also get an MBA. These are the exact kinds of people who should hold leadership positions in Medicine.
    3) Are you sitting down? Physicians need to unionize, or form some type of large organization with real clout. Look what unions have done for professional athletes. In fact, to take this analogy further, physicians being told they are professionals and they should not focus on money is the same as the players being told it was “for the good of the game”, while the owners raked in all the bucks.
    Single physicians or small groups are facing off against the multi-billion dollar insurance and hospital behemoths, and the government. They have zero leverage. Nada, nothing, no chance. The AMA and the various colleges and societies are NOT the answer. They have their own interests to protect, and all of this has happened on their watch.
    The point of my 6-piece series in The American Journal of Medicine is that trends such as long training periods and student debt are making a career in Medicine less desirable for the smartest kids in the class. Add physicians not standing up for their own interests to the list.     
    What is the most popular beer in my neighborhood? Answer below.
    I watch CNBC from the time I get up until 4 PM, when I turn the channel to Jeopardy. Sometimes the talking heads get on my nerves, so I will often have the sound off and just look at the ticker. Some guests, such as Jim Grant of the Interest Rate Observer (and author of The Forgotten Depression, reviewed in Issues #373, 7/6/15, and #374, 7/13/15), and Nobel Winner Prof. Robert Shiller of Yale (author of Irrational Exuberance, Phishing for Phools) catch my interest.
    But my absolute favorite is Rick Santelli. As I often note, both fundamentals and technical are important, the former in determining what to buy and sell, the latter when to pull the trigger. Santelli notes that since the financial crisis of 2008/9, the central banks have had such a pervasive influence in the markets that fundamentals have become less important. In a reference to putting your thumb on the scale, he calls this central bank interference “thumbdamentals”.
    His point: technicals are becoming more important as a signal. Ex: since the election, the rate on the 10-year US Treasury has been in a range of 2.15-2.6%. In the past, things that you would expect to push interest rates one way or the other, such as the US Dollar, the economy, unemployment, productivity, seem to have little influence. Forget what you “think” should happen, wait until it happens, then go with the flow. “The trend is your friend”.
    The precious metals have been noticeably weak lately. Gold could break below $1,200, but more likely, this is the bottom. A Commitment of Traders (COT) report is put out every week, which details the futures positions held by the Commercials (the miners and the big bullion houses, the smart money), and the large Speculators (the dumb money). At market tops, the Speculators have all the long positions, and the Commercials are short. It is the opposite at bottoms: the Speculators have few long positions and the Commercials have covered all of their shorts for a nice profit. The latest COT report shows the Commercials with the fewest short positions in the last year.
    RMD comment: the COT report is not a precise timing tool. Gold could go lower. But the Commercials are always right in the end, and their small short position suggests we are at or near a bottom.   
    A long-time subscriber sent this quote.
    “When you are dead, you do not know that you are dead. All of the pain is felt by others. The same thing happens when you are stupid”.
    This year the Grasslands neighborhood 4th of July party was held at my home. The neighborhood is middle class to almost upper middle class. There is a high level of education, with about a dozen physicians, and many University professors and employees. I bought 48 Bud Light, 48 Budweiser, 24 Miller Light and 24 Coors Light.
Left over: 1 Bud Light, 6 Budweiser, 10 Miller Light and 16 Coors Light
    In the Grasslands, people prefer the King of Beers.
    Also note that hosting this kind of event gives you significant exposure, it’s a great practice builder. Say it costs you $500. Just one cardiac cath and you’re ahead.       
    I just started Art Collecting Today: Market Insights for Everyone Passionate about Art (Woodham, Allworth Press). This book is great, and will be the subject of a newsletter in the near future.



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