All right, so my name is Warren Silverman. I started out my career back in the late 70s in internal medicine, and then I got smart and got into occupational medicine, which I've practiced pretty much since the early 80s. And in the course of doing that, I've reinvented myself in what I do a dozen times. So what I'd like to do today is give you an idea of some of the alternatives that can make being an occupational medicine doctor the most fun, exciting branch of medicine that's out there, because it really, I've had the most amazing career and done so many different things. So we're going to talk about that. But the first thing I want to emphasize to you is how you're different than other clinical specialties. When I deal with other doctors and testimony or anything like that, the idea of who is your customer comes up. If you're in clinical medicine, your customer is 99% the patient, okay? But when you're in the field of occupational medicine or all of its different ramifications, you have to deal with multiple stakeholders. You have to deal with the patient who you don't always establish a doctor-patient relationship with unless you're going to be treating. You've got to deal with case managers, employers, safety officers. You've got to deal with insurance companies. You've got to please all of these people in the middle. That gives you a skill as a go-between, a negotiator that opens up areas of medicine that other people are not good at as we are, okay? So we don't typically, if you're doing workers' comp, injury management or something like that, you do develop a doctor-patient relationship. But if you're doing pre-employment exams, whatever, you're an agent for the employer. Or if you're doing testimony, you're a neutral party, okay? So it's important to understand who you are and what you're doing. So there's a certain other aspect, cross-specialty expertise. None of the branch of medicine other than, say, like ER or something like that allows you to have an expertise in orthopedics, OBGYN, pediatrics, every specialty. And I can tell you, I've had the opportunity to go against chairs of departments of pulmonology and cardiology and ortho. And as long as I'm prepared, you know, I think I can do a shoulder exam as good as any orthopedist. You know? In fact, most of the time the patients come in to me and they say, wow, he didn't even examine my shoulder, you know, but you did. So it's great. And there are all these external players. There are all kinds of areas that we get into that other people don't. So when I was on the environmental, chair of the environmental section, we're talking about urbanization, that the population of the big cities are going to increase double by 2050 and triple by 2070. We had one guy who has an undergrad degree in urban planning. We talked about him going in as a consultant for municipalities and helping to avoid people jumping out of high-rises like they did in Shanghai during COVID as we rapidly grow cities. So that's a career path that's unique. Anyway, we deal with government agencies. I've worked for federal agencies, I've been in the U.S. Public Health Service. I've been, I actually was in uniform at one point. And we work with private industry and safety. So let's look at some of the options. Okay, so litigation. Controverted means that the person that's paying the bill doesn't agree with the claim. And typically that's workers' compress, but it can be no fault, it can be all kinds of different stuff. Usually when you're doing IMEs, you're getting the case because somebody, typically in a carrier or something like that, thinks they can win. There's something odd about the case. I don't, you know, if somebody falls down in an elevator shaft and gets killed and that's part of their work job, I never see that. Because everybody agrees that that was a work injury, okay? So when people say, oh, you're for the carrier or something like that, well, 90% of the cases I get are people, insurance company people or whatever, that say something's odd about this case. Right? Okay. Come on. There we go. All right, so what is an independent medical exam? I'll talk about that first, because frankly that's quite lucrative. At this point in my career, I do a lot of international stuff all over the world. I pay for it out of my pocket. I can pay for all of that stuff by seeing four or five patients a month, okay? That's all I need. So it's a tool that the carrier, the lawyer, or the employer, and it can be both sides It can be the plaintiff's lawyer, too, they use to try to get the idea across. It can be a second opinion. Sometimes the claims adjusters can't figure out what the hell's going on in the file and they'll ask for an IME so somebody can explain it to them. Is it really independent? I think if you're going to be able to charge good money and if you're going to get a good reputation, you have to tell the truth. You have to say what you really believe, okay? Who orders them? Lawyers hire them, carriers, insurance companies order them. I've done cases for workers comp, no fault, police brutality, toxic torts, wrongful death, and human trafficking. So once you get out there and you're giving a real medical opinion and you get a reputation, you may get all kinds of weird cases. I can tell you I had one case where a guy was bulldozing a field to try to level it and he had somebody over there with a surveyor's rod and he's working away, working away. Somebody looks around and doesn't see her. Gets off the tractor and they're under the tread, she's crushed. Why would they contact me? The question that I was given was, how long did she suffer? Because there was some monetary issue involved. In order to figure that out, I had to look up the mic and model of the tractor. I had to find out the specs, how fast it could go in reverse. I had to look at the autopsy report, see where it first impacted her body. I had to go ahead and see the track of the tractor tread and then I had to figure out how long it would take to hit her vital organ when she would no longer have consciousness. It's an odd question, but these are kind of interesting things that challenges your intellect. So who supplies them? A lot of times people say, how do I get into this business? There are actually IME vendors out there and IME companies in New York State. The IME vendors have to register with the workers' comp board. You can get a list of them. You just call them up and say, I do occupational medicine. Maybe I've got some experience in internal medicine, surgery or something and I'd like to do cases like this. The other way to get into this is that there are vendors that do large numbers of lesser cases like things like social security disability exams or veteran determinations or whatever. They don't pay as much, but it gives you some business. I worked for MetLife doing disability file review for a while and I got a lot of experience in the disability world. They were trying to determine if the person was really disabled and what I found was one person that was totally disabled with a back injury. When I did an internet search, found them in an equestrian competition in Texas, having won the competition. Another one that I searched around and it's totally disabled. There was an article about how she was welcoming the Mexican delegation to the city that she was mayor of. I love forensics. It's like being a real voyeur. You're going to learn all about people. What are the qualifications? You've got them. You've got them. I would say the more utility you have is based upon the more experience you have in clinical medicine. My internal medicine background and working in the ER and all that stuff added. If you're just starting out, it may take a while to build up that reputation, but you can do it. When I write a report, how do I do it? Well, first of all, I have to realize I'm not writing it to the other doctor. I'm writing it to a judge. Judge may not know or a hearing officer or a jury. They may not know medical terms, whatever, so if I've got a strange disease, the beginning of my assessment is to talk about the disease, what it is, who gets it, statistics, everything like that. The claims adjusters, you assume that they're medical people. Some of the insurance carriers hire people right out of high school to adjust claims. They may know very little about medicine, so you have to educate. You have to explain your line of reasoning, so if I say, I believe it's this, you have to take them through why one step at a time so that at the end of it, they don't have a choice but to agree with you because it all makes sense, it's logical. Don't ever say anything you don't believe because you'll get in a deposition. That'll be the question that they'll ask you, doctor, how can you say that? Well, I mean, I was getting paid to say something, so I said that. And then testimony, your utility in the IME field depends upon your ability to testify effectively, and we'll talk about that. So how do I do my typical lake workers comp IME? I hear about IME companies, they'll fly a doctor in, they'll give them seven people to see in one day, I don't do that. I start out with a real internal medicine history and physical, the way we learned it in the old days. I take about 40 minutes with a complete history and about 20 minutes for a physical typically, and I've gone as long as two or three hours if I need to. So the other thing is, this is not your patient, this is a claimant. You don't have a doctor-patient relationship, and by all means, don't establish one, because if you say something wrong, you can get sued for malpractice if you give medical advice and it turns out to be the wrong advice. So you give them an opinion, but don't tell them how to treat the patient. I typically, the first question people come in and they're already, he's going to ask me, the first thing he's going to say is, you know, how did the accident happen? And they've got, they're all tense and all nervous, because they want to, you know, win their case, whatever. Some bring lawyers, some bring videographers, some bring their spouse, I don't care who they bring, because they're just telling me their story. So the first question they always ask is, where were you born? That takes them off guard. And then we find out about their whole life history. So the fact that they had a football injury when they were in high school and they wound up with an elbow dislocation might just have something to do with the arm problem that they have now. And if you don't ask complete history, you'll miss it. So I use different headings that get, I'll go quickly through a typical internal medicine history and physical categories that you'll see. So, but the educational history, I'll go through their whole education, whether they've been in the military. If you don't ask if they've been in the military, you won't find out that they have a service-connected disability. Oh yeah, I do happen to have a 20% service-connected disability I got when I was a paratrooper. I got a back problem. So you have to ask everything. And these, I'm not going to, I'll just show you, these are the typical headings that I use in my report. I don't care if they're coming in for a bad toe, I'll ask them about allergies. I'll ask them about older medicines and I typically ask if they've had non-work-related accidents in prior workers' comp, hospitalization, surgeries, all that kind of stuff. Substance abuse. You'd be amazed. Each one of these questions has at some point in an IME that I've done given me the answer. Review of systems, a complete review of systems. I won't go over it all with you. I don't typically ask gynecological questions of the guys. Anyway, but I do ask all the other stuff and we make sure we go through it all because every once in a while something will come up that will really surprise you. Now doing the history of present illness, since you're talking to a judge and you're not talking to another medical person, I try to write a novel. I try to write a narrative. This is what happened. But within there, and I'll tell you, I typically see the patient before I review medical records. I do that because I don't want to be biased. I want to hear their story first. I want to hear it the way they tell other doctors. Oftentimes I find that the one note in the medical record or the series of notes that are most important are those that correlate with the time of injury, the first ER record. Because it's amazing how a week later the story changes. It evolves. Or they find out that they're going to need something and they want to be able to get paid while they're out of work, you know, on worker's comp. So it just changes. So the other thing is the mechanism of injury. You know, if you land forward on an outstretched arm, you're more likely to have a labral tear than if your arm goes the other way because you're pushing up in that glenoid and you're going to push that humeral head right up into that labrum. Sometimes the mechanism of injury, when you really talk to the person, doesn't correlate with their physical complaints, and it turns out it's because of something else that they have the physical complaints. So try to imagine the body as a piece of mass moving and having some energy applied to it in some form. And does that correlate with the actual medical complaints? Then I also try to get the complete idea of who's actually seeing you. And sometimes they won't tell me about a person, and later on it'll come out in the history, oh yeah, I do see pain management, or I do see that, whatever. So try to do that. And I'll go through a typical day right now, because that goes towards impairment and disability. You wake up in the morning, what do you do? Do you take a shower? Do you make breakfast? Do you vacuum the house? Do you take the kids to school? What do you do? Gives me an idea of what that person looks like, because when they walk in the office, they may be walking like that, but they're out there, you know, playing, you know, paddle ball or something. I typically do a complete exam, and I've had this, and I have a police officer that has got a finger in an injury which may disable him because he can't pull the trigger. But I still look in their ears, I look in their eyes, for two reasons. One, you may find something that affects their ability to do their job, but also you want that person to walk out of there and not go back to the lawyer and say, he didn't even look at me. I want to do the best exam they've had through this whole thing. I want them to, usually, even though sometimes I'm trying to take away their benefit, and they know that because the carrier sent them in to see me, I want them to walk out of there. A lot of times they'll say, that was the best exam I've ever had, and they appreciate it. They say, thank you, doctor. And that's a good relationship. Now why is it a good revenue stream, okay? Well, first of all, I would encourage you, every one of you got into the medical field by being maybe not top in your class, but high up in your class. And in college, you could do a good term paper, couldn't you? You didn't get the Ds and the Fs, maybe I did one or twice, but you can do a really good job looking up articles, getting references, things like that. Approach it that way, and then everybody will respect what you work. So treat it like it's a college term paper, and I particularly like the forensic side of it. I'll spend, sometimes if I think that there's some red flags there, I may look up what the claimant does on the side, their Facebook page, their everything like that. I may look up the doctor, oh, he's not actually licensed to practice in this state, oh, he's been censured a few times, because sometimes you get doctors saying all kinds of crazy things. I'll look up anybody that I think is questionable in the thing. I've got one website, publicdata.com, it allows me to look at all the prison records, it allows me to look at all, and I'll often find, you know, people have been arrested for assault or drugs or something, and that may affect the discussion we have about it. Testimony is important. You have to be good at testimony, because if you do a wonderful report, but you always lose at court, that won't really get you what you need. So first of all, I learned this a long time ago, you're not the one on trial, so don't get nervous, okay? You're an expert witness. Don't say anything in your report you can't defend. If you copy a physical sign that a chiropractor did, and you don't know what the name, what kind of maneuver it was, look it up before you testify, because you don't want to look like you don't know something. So make sure you go through your report before and prep before the deposition, spend time before it, charge for that time as well, and I'm going to talk about charges in a minute. And consider it like chess. It's you against the guy who's trying to discredit you, okay? Use your intellect, say, I'm going to win. Try to figure out what the lawyer is trying to get you to say. Because this is the lawyer's golden rule. Never ask a question you don't already know the answer for. Now, I know enough about law that I know that golden rule. So if he wants me to say, yes, I'll figure somehow to make my argument so he gets a no. I'll try to always give the opposite answer to what they want. And I can rationalize. There's enough file there. There's enough record there. I can figure out a way. Because with a lawyer, momentum is a lot of it. If you can get the witness to have to think fast and not have time to cogitate, you can get them to slip up and say the wrong thing. So slow it down. A lot of times what I'll do is they'll ask me a question. They'll say, and the doctor said this. And I'll say, oh, well, let me make sure exactly what he said. Let me look up the record. I've got 500 pages on my computer. I'll go page 1, 2, 3, 4. And about 20 minutes later, I'll find it. They're all, you know, I don't usually do that when the guy's on my side, but I do it when the guy's on the other side. Gets them frustrated. The only important person in the room is actually the person making the determination at the end. So hearing officer, judge, or jury, whatever it is. Depends upon what kind of case it is. Now, I love it when I get a lawyer on the other side that doesn't know how to pronounce a word, because I'll be sure to say, oh, you mean so and so, it's spelled like this. It's pronounced like this, because it makes them look dumb. They haven't prepped. Okay. So it's just strategies, but I'm giving you the secrets. Okay. I want you to know the secrets of how I do it so that you can think about that as well. It's not bad to learn some of the precedent. So, for example, in New York State, in the workers' comp law, if a guy has a heart attack while he's on the job, one of the criteria for making it comp is if there's something unusual about that activity. Extra heavy lifting, extra hot day, extra whatever, because people naturally have heart attacks. Like, for example, a head injury from a seizure. Okay. If a person is just standing there and has a seizure, falls down, it's not comp. If they have a seizure problem, it didn't cause it. However, if they're standing on a one-inch platform, have a seizure and fall down and hit their head, it very well could be comp, because something about the job made it worse. Okay. So, sometimes if you look up the case law, that'll make your reports a little bit more meaningful. What to charge by the hour? Well, of course, it's the market rate, but I, first of all, there are vendors out there that'll try to get you to do IVs. They'll say, we'll pay you $400 for an IME. I never work for those guys, because I'll get a file that'll be a quarter of an inch thick, and the next one I'll get will be a box full. Okay. So, I charge by the hour. And I've got, I don't usually get them on the travel fee too much. You know, if they want to fly me somewhere, that's great. Whatever. But, because I charge enough for what I work. And basically, the exam time is an hour. Testimony and workers' comp is typically an hour. Testimony in, for example, we have police and fire injured in the line of duty that I do. I've done one for 36 hours. Okay. They can take a long time. Things that wind up in Supreme Court, things that were, state Supreme Court, not the big Supreme Court. You can, you know, they may last a lot longer. I'll give you my fee, so you get an idea of what it is. I haven't raised them in 15 years. I haven't raised my fee in 15 years. I get $7.50 an hour. So, if I do 10 hours on one patient, and plus travel, and then there's an hour of testimony, talking 10 grand, it's lucrative. All consulting work, if you get a reputation, can be lucrative. So, I, I'll come back from all my traveling around, and I'll see four or five patients, that's all I need for a month. Right? Okay. Now, I'm not saying you can all start out at $7.50, but you might start out at, you know, $400 or $500. When I had some docs that were working with me, that also had tox boards. They were also boarded in toxicology, and we gave them a tox case. We were charging a grand an hour for them. So, if you've got a particular expertise that's unusual, you can charge more, you know. So, it can be very lucrative. And, if they hand me a file, they say, how much is it going to cost me? I say, I don't know, because if I get a file that's from a hospital chart, and they've got all those pages of nurse's notes, I can do an inch in 10 minutes. But, if it's all clinical office notes, and I've got to read all of those, then it could be two or three hours for an inch. So, I can't tell them. I just say, that's what I charge per hour. It's whatever. I also include the time I research the medical literature. I include the time I prep for the file. I include everything I do, because my time is valuable. I charge for preparing and dictating a file. If they give you a file that big, it's typically not in chronological order. What I do is, the first time as I go through the file, all I do is look at the date on the note. I put it on an Excel spreadsheet, and I put the page. And, I put that all down. And then, at the end of that, I just sort the Excel spreadsheet, and it's in chronological order. But, I charge for all that time. Okay. Time to dictate and testimony time. Prep time, too. Okay. So, what are you trying to determine in a typical worker's comp? You're trying to separate the causally linked conditions from not causally linked, typically. Or, you may be asked to determine disability. Temporary, permanent, mild, whatever. All that kind of stuff. And, you can look up all these definitions. I want to get past the IME stuff, so we get into other things. These are typical course cases I've had. All kinds of things. I had one guy that was standing on the roof of one of those TV microwave vans. He was fixing the antenna, and they turned it on. Microwaved him. You know? I mean, there's all kinds of weird stuff that you could find. I got asked to do a case. They said, we'd like you to come to Kuala Lumpur. We're going to bring two people from Abu Ghraib prison from the Iraq war that are claiming that they were abused by the contractors that were working with the army there. Well, that's pretty fascinating, isn't it? You know, it's a challenge. And, you're not giving, you're giving your best opinion. You're hearing all the evidence, and you're giving your best opinion. Now, when you get to disability impairments and stuff, not every state does the AMA guidelines. New York State is not an AMA guideline state. They've got their own. So, you have to know what they use in your state. If you do want the AMA guidelines for disability, you can subscribe online. The last I checked, it was like $2.79 for the guidelines. So, I've had to use them occasionally for federal things, but not usually. Term of schedule loss of use. So, somebody's gotten injured, something bad happened to their arm. Based upon how many degrees of motion they've lost, and whatever, there's a price determined in how many weeks they're going to give them. So, if they've lost 20% of their elbow, so many dollars if they've lost, or 20 degrees, if they lost 40 degrees, it's more. So, you go in there with a goniometer. I think a physical therapist could actually do this job better. But they send them to doctors, and you just measure things. You write it down, then you calculate it on the tables that are in there. Non-scheduled impairments, different. That's where you look at the medical condition, and you determine how disabled they are. In New York State, we've got different scales, and it says by body part, and the AMA guidelines does it differently. So, I recommend charging by the hour. I mean, I think you'll like life a lot better. You know, when they hand you a big file, you won't say, oh, God. You'll say, yeah, okay. Now, here's another line that med docs never think about. Everybody says, if you're gonna be a school health doctor, director for a school district, you have to be a pediatrician. Not true. I don't treat any of those kids. But what you have to do is be in the middle of the principal, the athletic director, the teacher, the parent, the psychologist at the school, the treating doctor. You have to do something that a pediatrician doesn't have time to do. So, I like school health. I'm the director for five school districts. I don't know how many 10,000 kids, whatever. I don't know how many there, but I will tell you, took up a lot of time during COVID because we were setting a policy, health policy, and I had to work with all the school nurses, principals, superintendents, all that kind of stuff. So, there are all kinds of assessments, things like that. You have to, like I said, those are all the stakeholders that are typically in a school setting. Okay, and you can do it differently. Some school districts, some school district will put it out for an RFP, and you can bid on it. And it's an annual contract. Plus, you can do, you can say, if I come in and do sports physicals for kids or something, I'll send a PA or a nurse practitioner, or I'll go, and you can charge by the physical. So, I think we charge like 40 or 50 bucks per kid or something like that when we do that. So, plus I've got an annual contract with the school district. It takes time, though. I mean, they're always, you know, the doctor says this kid should be homeschooled. Well, for a school district, that means paying for a tutor, and it comes out of the public revenue. So, you have to use your judgment and give them good advice. Firefighter exams. I started these in 1994, the practice before I gave it away. It still is going, whatever. We do 15,000 firefighter physicals a year. And that's all over. We do New Jersey, New York, Vermont, Massachusetts. And what you do is you basically put together a team. They go to the firehouse. They bring the portable massage tables and the EKG machines and the PFT machine and an audiometer, and they'll do, you know, 20 to 40 guys in a night. The origin of the firefighter physicals is actually OSHA's respiratory standard. So, it's based upon that. However, some departments, particularly in the more affluent areas, they say, if a guy's gonna volunteer to be a firefighter, we're gonna give him some benefit. So, we'll do a prostate screening exam. We'll do a this. We'll do chest X-rays. We'll do whatever. Okay, you want that? We'll give it to you. Hepatitis B. There's all kinds of services that firefighter, it's a hazardous job. We also make a determination, actually, I sort of put this together back in the 90s, of ABCD classification. A is a firefighter that can go inside a burning building, internal structural firefighter. B is a firefighter that can go outside a burning building. Internal structural firefighter. A B firefighter is somebody who can fight the fire, but only outside. So, if he drops, he's not gonna be a hazard to his fellows or himself. Okay. C is fire police. They usually direct traffic down the road or they do something, but they're not actively fighting the fire. And a D category firefighter is basically somebody who loves being in the fire department maybe does administrative work, but is out of reason, M.I. or something. You don't really want them to be out there. Even a fire policeman is a risk for the fire chief at the scene. He doesn't wanna hear about the fire police guy two miles down the road that just collapsed when he's fighting the fire. So, everybody, you have to assess them for what they do at that work site. And there are all kinds of new issues, too, about toxins that they're exposed to, hazards. For a while there, there was a lot of papers that were coming out saying the epinephrine that firefighters experience when they're driving to the fire increased their risk of heart attack, all that kind of stuff, causing atherosclerotic disease. So, this was just one of the marketing pieces. If you're doing this kind of work, market it. Put it online, make advertisements, go out there. We hired, actually, salespeople to go to meet with fire commissioners at their meetings and explain what we do. So, we sent them out in the field and built up the business to quite a few firefighters. Every night, two or three fire departments, somewhere, a team was at. Becoming a specialist in municipal services, you do the same thing as an Ahmed, but in most states, municipal law for state workers has different guidelines. So, disability or whatever, different things. In New York State, if you've been out because of a disability for 365 days, you can be terminated. So, when they show up again at 363 days with a note to return to work, they'll send them to us, figure out if that's real or not. FMLA, determination of that, all that kind of stuff. Interesting sidelines. But you're dealing with different funding sources. These are municipal workers, it's public funds. So, you're dealing with different funding sources. Municipal workers, it's public funds. You're dealing with the safety of the general public. So, when I get a 911 operator and they're doing something funky, they're acting weird, I try to look at it from the standpoint as am I putting the general public at risk? Am I putting that responding policeman at risk? So, you have to look at it a little different. You've got railroad work injuries. There are different agencies other than the typical workers' comp, and you can become a specialist. If you're in an area with a lot of railroads, you can be the railroad guy. You know, I've worked with CSX in the past. I've worked a couple, you get to go up in the engines, get to look around, you get to do a lot of fun stuff. So, you can get into that industry. You can do a lot of federal workers because federal insurance is different than workers' comp insurance. Different rules, different testimony. If you get the reputation for an area like this, you'll get business. There are military work. There are companies that sort of fend that, but you can actually, sometimes I've seen actually, sometimes I've gotten calls, will you do this? You can actually also subcontract with Theo, Federal Employees Occupational Health, and then you're doing Secret Service, Federal Marshals, Park Service guys, and you do it at the federal building. And that's pretty interesting. I mean, I find that the absolute smartest of all the agencies, the guys that come in, are actually the Secret Service guys. They're really sharp. But there are all kinds of different jobs. You'd be amazed at how many federal workers carry firearms, like the IRS, when they've got people going out into the field. So, you know, it's really interesting. FAA, I've been an FAA medical examiner for almost 40 years. You do private pilots, you do commercial pilots, you do all kinds of different things. And it gets a little complex. You have to know the regs, you have to know the job, you have to know a lot of things. And if you do this, you can actually go to Oklahoma City, where the Medical Certification Division is, and use the simulators and do different things. You can have some fun. But doing pilot exams, particularly if you're near airports, is not bad. I mean, I don't know what we charge for class one, I think it's something like $260, something like that. And you do a hearing, you do a vision, you do a physical. If they're over a certain age, you do EKG. For class one is ATP pilots, airline pilots. Class two is commercial, class three private. So, but you have to apply to the FAA for that. They base the number of aviation medical examiners on the region, how many pilots are in the region. And they pick a number of providers, because they want each provider to see enough pilots to be current. Okay, and you have to get recertified every three years. You have to go through some training. You all know about DOT, railroad. Won't talk to you about those. All these are specialty agencies that have different rules. So, depending upon what your passion is, if you like being out on the water, you can do ferry pilots, you can do all kinds of stuff. There's work to be done in merchant marine with military, all that kind of stuff. Now here's a, I'm gonna talk about these. So, if you're getting into this, being a corporate medical director is, like I said at the beginning, you're uniquely trained because a corporate medical director has lots of stakeholders. Okay, you've gotta get between the administration, the worker, the whatever. You may have to go to different, if you're doing a global country, you may have to go to that country's government. You have to maybe be familiar with them. You may have to find who the providers are. I've had IMEs on guys that were working in China or something like that and they got some strange fungus. And I had to research it. Did it come from there? So, you'll get really interesting challenges in your career if you do all kinds of these weird things. But corporate medical director, we've talked in some of the residency training programs about a specific course on how to be a corporate medical director. But if you don't have access to that, try to get together. There's a lot of corporate medical directors here. Learn from them. And you may wanna network with them. And if you go into indeed.com or one of those things and you look for occupational medicine, there are even remote jobs you can take as medical directors of health plans, corporate medical. So right now, I'm a corporate medical director. I've been for Regeneron in the past. I've been for what? I'm a corporate medical director for a Canadian paper company. And I get a monthly salary. I probably do about five or six hours a month. Pay me a good amount of money for that. But like they asked me the other two months ago, they said, tell us the future of our employee population. So I have like 250 paper plants. Each one's got like 200 employees. I said, within 20 years, each of those plants is only gonna have about five workers because all of that's gonna be automated. I said, but the continent of Africa has no paper companies. They import all their paper. And it's the truth. I looked it up before I wrote that. I didn't just say it, I don't know if I, I said, you've got all this machinery that's going to be outdated. Put it on ships. Bring it to Africa. They've got lots of trees. They've got lots of forest. You get 20 more years out of it. Okay. Now, that's the medical director making them think about the future of employee utilization. You can do stuff like that. It's fun. You can get involved with policy. You sit there at the table. I've been a medical director at an HMO. Sit there and you talk about policy. You talk about all that stuff. Like, it's fun. Workers' comp PBOs. Some states have PBOs or HMOs that are workers' comp only. I've been medical director for a couple of those. New York toyed with it for a while. And, you know, you have to call up doctors, do peer reviews, things like that. That's a job you can do. Again, you get paid a salary. I've been in some that paid me money just to be able to use my signature. Make a few, you know, you get five grand a month just to write your name a few times. That's not bad. So try to like, you know, find jobs like that. Insurance file review. In my past, I worked for a while as a contractor with MetLife Disability, scanning these disability claims that the adjusters were not sure about. And I learned a lot about that. You get experience doing all these different jobs. So that was fun. Or you could be medical director for different insurance carriers. You know, the guys that are the head of the chub workers' comp division are docs. I mean, the medical people. You know, so you could get a job as a medical guy at an insurance company. That's not a bad gig. You could go into academics, teach at the medical school. I've done a little of that at Albany Med. That's fun. Residency director. Do we have any residency directors here? Yeah. Well, that's why you're here. But one of the great things about ACOM is say you have an interest in doing that, they've got a section. And you can go there and meet them and talk to them, find out about it. They've got a section on corporate medicine. You can go to those meetings, maybe network, maybe there's somebody that's looking for somebody. You say, I want to get into global medicine. Well, if you go to a place where there's a lot of global medical directors, you might be able to walk in the door right there. So there's a lot of options. International consultant, that's a growing field. The world is beginning to really need medical people to help them sort out occupational medicine and environmental medicine. I was recently, last was April, at the American College of Preventative Medicine meeting in Washington. And it was filled with residents and medical students. They have the same problem getting residents too. But, and the one question they'd come up to me and ask is, how do I get into global? How do I get into global? Young people really want to do global work. Okay. So, and there's stuff out there now because I don't know if you just saw Kenji's talk, but it's growing. Everybody's trying to catch up. And if you go to a small country, like I spend a lot of time in Cambodia, Vietnam, whatever, they say, we would love to have safety people that know OSHA standards and stuff. But here in Cambodia, even if we had those standards and we adopted them, we're not ready to comply with them yet. We can't get the levels down to that. We can't do this. We can't do that yet. But they want to get to the level of the developed countries. So, you might not make a ton of money there unless you're doing specialty consulting work, like I said, urbanization or transportation or something. You know, one of the major causes of death in Thailand, one of the highest motor vehicle death rates. You know, you wouldn't think, but that's, you know, the thing about Thailand, for example, is the number one revenue generating industry in Thailand besides tourism. What do you think it might be? Oil. The biggest company is PTT, which is an oil producing company. So, if you train people in the Middle East to do occupational medicine, oil specialty, or you give a certification course on the occupational medicine of the petroleum industry, they can get jobs all around the world. You know. So, that's really interesting. And the international educator, I think that's a great way to enjoy your life, okay, because everybody. I go, I teach in Northern Thailand. I've taught in Hanoi. I've taught in Singapore. I've taught in whatever. It's fun. I'm treated like royalty. Anybody that's from Europe or U.S. or whatever. I've told a few people here. One time I gave a lecture on heavy metals coming from China down to the Pearl River in Vietnam, and how it was affecting the swordfish that was being shipped to America, and pregnant women were being told not to eat. But in order to give that lecture, I had to fly in. When I got to the airport, somebody had one of those little placards, Dr. Silverman. So, I follow him. There were four motorcycle cops there, and a van, and with the sirens going and everything, brought me to my hotel. And they, wow, you know, you really get treated nice, and you have a good quality of life, and people really love to hear about what you have to say. So, if you ever feel like you're not that important in what you're doing, go overseas. It's really fun. There are other little things you can do. You can be a contract MRO, transportation stuff. You can get into little niches. The more specialized you get, particularly in consulting work, the higher you can charge. And there are going to be some real big challenges. I became the section head of the environmental section. When I became the head, I didn't know anything about the environmental health. But I taught myself. And now, if you want to ask me about, you know, hydrogen, the transition from the carbon economy to the hydrogen economy, what impact, you know, I love this. I'm a member of the American Chemical Society for like 30, 40 years, but there was an article about a little unit this big, an electrolyzer that was capable of taking the moisture out of the air and using solar energy to break it down into hydrogen. And this unit, which would cost just a couple of hundred dollars to build, it was a research thing, could provide the electricity for a whole village, okay? Now, patrolling companies don't want to talk about that. But imagine the transformation that that would make in Africa or in Central America if you could. Because one of the things holding a lot of these countries back is the cost of energy. Patrolling is expensive. We burn a lot of it, but a lot of people can't afford to do that. So there are all kinds of environmental issues you can get into, you can get into carbon capture and how that you can eventually make food out of that. If you want to see something really interesting, I'll give you a website. It's called airprotein.com, where they make food out of air. You can get into space physiology. As I said, there are going to be like 30, between 30 and 50,000 people off planet by 2050 or thereabouts. The first Mars mission was tentatively scheduled, and they may have pushed it back, but for 2033. That means 100 days of travel between Earth and Mars, during which time nobody has any medical protocols. What if a guy has a heart attack? There's going to be a lot of jobs there, okay? There's going to be a lot of interesting stuff. I would say that off-planet environment is the most dangerous environment that a human will ever encounter. You know, if you're a 20-year-old woman and you go into outer space, you're going to have menopause before 40, if we don't do something about it. You're going to lose half your eggs. You're going to lose your liver. You're going to lose your vision. Your vision gets distorted within a couple of months permanently because the fluid going back up, fluid in your brain, pressure increases. It kinks your optic nerve, and it doesn't, there's permanent damage. So figuring out how to deal with all that stuff is going to be a real challenge, and I, you know, the guys, those of us that are older, we're never going to, you know, screen 40 or 50 people to work, you know, in agriculture on a platform, in geosynchronous orbit around the earth, or making pharmaceuticals in space. I can tell you there's lots of articles in the American Chemical Society of pharmaceutical companies prepping to manufacture drugs in outer space because solutions don't settle. It creates an environment where they can make drugs they can't make here. There's going to be a whole field of making food from proteins and things that don't exist yet that are going to be invented by AI. You're going to have a diet that's specific to your body. So particularly for the younger people, I think there are some really amazing fields of medicine that you can get involved with that you just have to be creative. I spent 40 years doing DOT physicals, respirator clearances, all that kind of stuff, and, you know, so I know what the clinical work is. At this point in my career, I love all the fascinating stuff. I joined asthma at the Aviation Medical Society because the last time I went to their meeting, I missed this one because I was overseas, but at the Aviation Medical Examiner's Conference in New Orleans last year, there were 50 commercial vendors there trying to figure out how to make money in outer space. Years ago, if you went to the meeting, you'd be talking about aircraft and airports and, you know, all flight control. But lectures now are all about outer space. There are two universities now that have combined six-year programs for MD engineer. Okay? So when I get a high school kid come and say, I want to go into aviation, say, well, if you go become a pilot, you might have a career for 10 years or so, but eventually, you're going to get replaced by automation. You know, I said, but if you get into some form of off-planet work, and you don't have to work off-planet, you can stay here and design, develop, test human physiology. There is a Space Physiology Association now. There's a Space Nurse Association, too. There's a lot of different things. If a young person gets involved with that now, they'll have a career the rest of their life. So anyway, I just wanted to put up a bunch of options out there. Mostly what I want you to do is think creatively about what your passion is, whatever you really love. If you love working in a very legal, rich environment, do that. If you like living with poor and underserved, do that. If you like living in exotic adventure place, do that. Don't feel like you're limited to doing DOT physicals and respirator physicals your entire life. I've had the chance to do all of those things. And it's been a wonderful career. And I can't tell you how happy I was that I got out of internal medicine. Yeah. All right. And any questions for me? And I've got the mic, so. Yeah. Thank you. I appreciate your presentation. So as a recent graduate, I'm still trying to learn how to navigate the field. When it comes to things like negotiating your contract and there's things like non-competition clauses and things like that, would you be willing to comment on how you've kind of, if at all, got around that kind of topic when it comes to alternative options? Well, first of all, isn't there legislation now, I know at least in New York State, that the non-competes are not legal anymore? I think they're getting rid of non-competes. So you won't even have to worry about that part. But, you know, when I look at what I could do out there, there's so many options. You know, I just look at the environmental health stuff. Medical people don't know anything about it yet. And you can learn about it. You can learn about some of the research going on. You know, I'll tell you a little secret. For investments in the stock market, I invest, one of the things I invest in is hydrolyzers that convert water to hydrogen because that's where we're going. Batteries, they're not going to let, although this month they came out with articles about lithium is not a very good battery component. The future batteries they're working on right now and they've developed prototypes are going to be calcium-based. Calcium, which is very abundant, a lot safer for the environment. They even have wires, wires that generate the electricity along the wire with calcium. So it's fascinating. The environmental stuff, the research stuff is really fascinating. But anyway, to answer your question, just you're going to have a lot of variety of options. I think you're going to get more into trouble with non-competes if you're like in a medical practice that's competing with other medical practices. That's where you're going to get into that trouble. And you're not going to be in the management position. You're going to be one of the workers there. So the kinds of things I'm talking about really are not as much along that line. Because if you're an independent contractor on some environmental issue like recycling or something, whatever, you're not going to have anybody else competing with you out there. You're going to be unique. Yeah. Any other questions? Yeah. If you could shout. I got a lot of voice. Thank you for this awesome talk. I do a lot of the things that you do. But I bet the Navy state is doing it. Yeah, yeah, no. Some of it up in the North. But one of the things that you talked about were the FAA, like this. I recently just got certified to do those. But the issue I'm coming across here is that if you're new, they only allow you to do class two and class three. And then another issue is that just getting my name out there. So I guess I'll ask that question. How did you get your name out there as far as marketing? There's actually a couple of ways. One, the way I, back when I did it 40 years ago, whatever, a lot of it was word of mouth. But there were actually vendors out there that you could pay to send out information to all of the registered pilots because if you get a pilot's license, it's in a database that they can buy. And you can buy it too, all the registered pilots in an area. And you can market. You know, if you're a primary care doctor, clinical doctor, typically you're not in a position where you think about marketing. Somebody else does that for you. You're not out there marketing. But if you're in occupational medicine, particularly if you're just opening up, nobody knows about you, there was one point in which we had two full-time marketing people in the field. They went around from business to business, said, this is what we do, this is how we do it. When I first got into occupational medicine, and I said to people, I'm an occupational medicine doctor, they said, are you a therapist? Right? They had no idea what I did. So I said, hey, listen, here's the OSHA regs. You've got to, you know, screen people for asbestos. You've got to do, we do that. That's our specialty. You have a truck driver, we do that. You know, so you can make up marketing materials, get a web presence. You know, go on the web, have somebody develop a nice page for you. Because people, you know, say, here's a small company and you've got a truck driver. They'll go online and see who the registered medical examiner. There's a page on the FMSCA where they list all the registered DOT people. But they may not know that. So if you put down, if they Google it, you know, DOT, physical in Cincinnati, you want your name there. Okay? So same thing through FAA. Yeah? Malpractice insurance. Good question. Since we don't establish a doctor-patient relationship, and if you're going to do workers' comp, you have to have a little malpractice. And in fact, a lot of the IME companies will ask you for a malpractice insurance coverage policy that you cover. But the policy that OCPD docs that's unique is called errors and omissions. Okay? That's a different policy. That means that if you're doing a DOT physical and you miss the fact that their blood pressure was above a certain thing or something and they get into an accident and the lawyer comes after you because he had a stroke, that you've made an error by not omitting a factor that you were supposed to be aware of in the regulations. So you need errors and omissions policy. And you can just Google that and you can find out that. Malpractice, I get the minimum. I don't do very much injury. I do police. I'm the doctor for the city of Albany. So I do do some, but I actually contract with the city that my job is to determine return to work and fitness for duty, not to treat. If they come in, they've got a new injury, I say, yeah, I think you need to see the orthopedist. Go. Goodbye. We're a contractor. I'm not an employee of the city. So we sign a contract with the city. Same as school districts, everything like that. I don't work for any of these people. Errors and omissions, but I would recommend that you, you know, you never know how they're going to interpret your note. So you probably should have at least a minimum. I do, I get the insurance rate for malpractice of a general practitioner level because that's the lowest level. That's what I get. Anything else? If you want to ask any questions, they can come up and ask me. Yeah. I'll tell you one thing I've learned over 50 years of doing this. The more you charge, the more they take your advice. Absolutely true. I ain't a broker. I, you know. They'll take your advice and give you money, and then they'll say, hey, we don't like your advice, but we want more. Here's more money. Yeah, you know. So we're going to do that, but don't do it for limits. We do it for a lot. People know, for example, that people don't appreciate something you give them for free as much as if you charge them. Fortunately for me, I had a practice manager. I'd say, oh, I feel bad charging that much, and she said, don't. Don't feel bad. And so when I send an insurance company, I see a patient for an hour, and I send them a bill for $14,000. She said, don't feel bad about that. Okay. They pay it, and they don't question it. Yeah, I just put it in perspective. You might be saving them $400,000. Okay. So. Okay. Thank you all. Thank you.

Dr. Warren Silverman

occupational medicine

career paths

stakeholders

negotiator

alternative career opportunities

marketing

non-compete clauses

future trends

specialization