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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

Not Winning is not the same as not Losing
Issue #414, April 19, 2016

Behavioral Economics: Part II: Weaknesses
Issue #413, April 11, 2016

Behavioral Economics: Part I: Valid Points
Issue #412, April 04, 2016

The Most Important Books I’ve Read
Issue #411, March 28, 2016

Secret to Success: Take Risks and do Things Differently
Issue #410, March 21, 2016

The Over-Priced Food Presentation Hustle
Issue #409, March 14, 2016


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

The Electronic Health Reord

Issue #458, February 20, 2017

    There was a recent article in The Annals of Internal Medicine (2016;165:753-760) on the Electronic Health Record (EHR) entitled “Allocation of Physician Time in Ambulatory Practice”. The basic conclusions are “For every hour physicians provide direct clinical face time to patients, nearly 2 hours is spent on the EHR and desk work within the clinic day. Outside clinic hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work.
    Effects (of the EHR) on ambulatory care are still unknown, and unintended consequences are gradually gaining recognition, including additional time spent documenting care and performance metrics, impaired communication with patients, and increased career dissatisfaction and burnout among physicians”.
    Many people have told me that I am the most efficient person they ever saw, so I am constantly thinking about (admittedly almost obsessed with) how I can save time. One point I routinely make is that a physician is an executive, making dozens of important decisions every day. An executive must relentlessly push work and decisions (see below) down the line as far as possible. Physicians bill $200-250 per hour. An RN makes about $40 per hour. It is a complete waste of time and talent and makes absolutely no financial sense for a physician to spend one second on something their nurse can do. A secretary makes about $15 per hour. It makes absolutely no sense for an RN to spend one second of their time on what a secretary can do. One of the absurdities of the EHR is that it forces physicians to spend their valuable time performing clerical work.
    Why was the EHR instituted? 1) It was supposed to make physicians more efficient. I had been retired 1-2 years when the EHR came along. I received a tour at the U. of Chicago and a cardiologist told me the EHR added about 45 min. to their day, but when everyone got the hang of it, it would save time. In my experience, the improved efficiency of a new way to do things should be obvious from the beginning. Next question. 2) It is superior to storing and leafing through hundreds of pages of paper. Agreed. 3) It can be accessed from elsewhere, facilitating the transfer of information. Agreed.
    4) But the main reason the EHR was instituted was to facilitate the mining of data by payers, and especially the government. In the April, 2016 issue of The American Journal of Medicine, I had the Commentary “The American Board of Internal Medicine: Maintenance of Certification and Over-Reaching Bureaucracy”. I noted that in the beginning there always must be a few basic, common sense rules to define how to play the game. Ex: the approximate 354 words of the Hippocratic Oath adequately governed the practice of Medicine for 2300 years.
    But bureaucrats must justify their existence, and to do that they need more rules. Then after these guidelines are met, they need more rules. The EHR is a bureaucrats dream. The result of bureaucracy is always the same: to discourage the use of judgment and common sense. It makes no difference if things could be done better 99 times out of 100. If they can prevent 1 problem from slipping by, the bureaucrat feels justified in their onerous guideline. A patient comes in with an extensive anterior MI (heart attack) and you bust your chops to pull them through. But you didn’t look in their ears and you didn’t note in the family history that Jimmy (Cooter) Jones, their 4th cousin, once removed, died in an auto wreck in 1926 trying to outrun the revenuers outside Flea Hop, Alabama (now called Santuck, AL).
    Here is the mentality: if you are to receive some particular level of reimbursement, you must have every blank, no matter how inconsequential and unrelated, filled in. Let’s face it: when the payer says you have to do something or you won’t get paid, you do it.
    My routine work day was 12 hours, 6 AM to 6 PM, and average week about 65-68 hours. At present, the average physician work week is about 50 hours, 10 hours per day. If they are wasting 1 hr. per day on clerical work, that is 10% of their time. BUT: considering the average physician has about 50% overhead, one hour of lost time cuts their net by 20%. A local, hard-working primary care doc did all of his own entries on the EHR. He finally broke down and hired a scribe. Even counting the salary of the scribe, his production went up $39K (a lot for a primary care physician).
    RMD final comment: add the EHR to prolonged training periods, student debt and a variety of other factors that decrease the desirability of Medicine as a career for the smartest kids in the class. Why enter a profession that requires 12 or more years of training post-high school, generates $178K of student debt, where you know you will be wasting at least 10% of your day on clerical work?
    If Mr. Trump wishes to help Medicine, he can streamline the FDA and the EHR.         
    “Cooter” is slang for a snapping turtle. They are aggressive, mean, and dangerous. The big ones hiss at you. A large snapper can easily bite off a finger.
    One of the most important factors in job satisfaction is allowing people to make decisions: they feel important. Hire good people, train them well, give them all the responsibility they can handle, and they will provide years of loyal, competent service.
    Warren Buffett added to his positions in 4 airlines.
    RMD comment: this allows me to make a point I’ve not had a chance to before: if you like an industry, invest in at least two companies in that sector. That way you will still profit from the move even if one company has a problem specific to them.
    The Philadelphia Fed Index, formally known as the Business Outlook Survey, questions manufacturers on general business conditions. Any reading above zero indicates improved business conditions. The latest number surged to 43.3, the highest reading since 1984, and up from 23.6 in January.
    RMD comment: Whoa. Animal spirits. The business community likes what they see so far from Trump and the Republicans.
    I asked a subscriber who is getting a PhD in Business at Stanford to critique this newsletter. “One thing I really like is your fluency and your brevity. Each newsletter is short, to the point, and absent superfluous words. I’ve also find your topic choices to be extremely relevant and important”.
    RMD comment: From the beginning, my strategy has been that you won’t learn anything if you don’t read the newsletter, so it must be A) short, and B) interesting. If you remember just one point from every newsletter: ex: from last week—never sign anything you haven’t read—I have succeeded, and you will get your money’s worth.
    The choice of topics is easy. If I see or read something I find interesting, or something I believe is important for you to know, I talk about it. Some newsletters discuss current topics of importance, such as the market, interest rates, or the US Dollar. Others are to provide background information, such as the Luhn Algorithm, the Gordian Knot, Pascal’s Wager, and the Pareto Principle.     
    Unilever (UN, the world’s 3rd largest consumer products company after Proctor and Gamble (PG) and Nestle), recently issued a 10-year bond with a coupon of 1.03%.
    RMD comment: There’s something wrong with this picture. That interest rate is below the 10-year French note, and more than 1% lower than the US 10-year Treasury. The market seems to be saying that UN is more credit-worthy than the French and US government.
    Last Monday I had surgery on my left eye for a near retinal detachment. The doc put in bubbles of nitrous oxide to help keep the retina tacked up. I must keep my head flat, with no activity as much as picking up a gallon of milk, for the next week.
    RMD comment: I can bench press my weight, do 7-8 chin-ups. I pride myself on self-reliance. Last week Diane had to drive me around and help me through the grocery store. It is really quite humbling. 

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