Starting a Business: What I've Learned Along the Way

So you're thinking about starting or getting into business? Let me share what I've learned about setting things up properly. Quick heads up, like most things on this blog, this is just my personal journey, not professional advice. Always chat with experts for your specific situation!
 
Ways to Structure Your Business
 
Let me break down the main options I've learned about:
1. Sole Proprietorship - The Simple Route [This is the most basic way to go]

• Instead of giving out your SSN, you get something called an EIN/employer identification number (think of it as a SSN for your business)
• You can get an EIN here - https://www.irs.gov/businesses/small-businesses-self-employed/apply-for-an-employer-identification-number-ein-online
  
• Don't worry - you won't need to file a separate tax return! The EIN is just linked to your SSN
• Tax folks call it a "disregarded entity" (fancy way of saying it doesn't exist separately from you)
• The catch? No liability protection. But if you're just doing low-risk stuff like medical surveys, consulting, or medical directorships, that might be totally fine!

 
2. Single Member LLC - A Step Up [Sole Proprietorship's cooler cousin]

• Gives you liability protection (always nice to have!)
• Super flexible - you can either keep it simple or turn it into an S-corp later
• Great for real estate stuff or if you're just starting out with locum work
• Perfect when you're not sure how big your business might get

 
3. S-Corporation - The Heavy Hitter [This is what people often use when they're making serious money]

• Can save you some serious cash on taxes (more on that in a sec)
• But here's the thing - you might not know if you'll make enough to justify it when you're just starting
• Pro tip from my tax person: Start with an SMLLC, then switch to S-corp later if it makes sense

 
Let's Talk About FICA Taxes (I Know, Sounds Boring, But Stay With Me!)
 
FICA taxes are basically:

1. Social Security (6.2%)
2. Medicare (1.45%)

Adds up to 7.65%
 
Here's the deal with FICA:
 
When you're a regular employee:
- You pay half (7.65%)
- Your employer pays half (7.65%)
 
When you're self-employed:
- Surprise! You're both employer AND employee
- So you're stuck paying both halves (15.3% total - ouch!)
 
Let me break it down with a simple example:
 
Say you make $100k:
1. As self-employed:

• You're paying $15,300 in FICA taxes (brutal!)
• Take home: $84,700

 
2. With an S-corp [people generally will say the break even point of S-corp is around 60-70k in profit]
You pay yourself a "reasonable" salary (usually around 40% of profits)

• So on $100k, maybe $40k is salary
• You only pay FICA on that $40k ($6,120)
• Take home: $93,880
• That's about $9k more in your pocket!

 
Quick Reality Check
- You'll still pay regular income taxes on everything
- Your tax bracket stays the same
- The savings are just on FICA taxes
- Definitely talk to a CPA about what salary makes sense for you
 
Want to learn more about FICA? Check out [NerdWallet's guide] (https://www.nerdwallet.com/article/taxes/fica-tax-withholding).

Getting a Letter of Qualification from the IMLCC

I'm posting this because there are no posts on the timeline for IMLCC approval from application to Letter of Qualification.

In general, to obtain full medical licenses in various states across the USA, there are two primary methods:

1. Direct Application: This involves applying directly to each state's medical board, which can be time-consuming.
2. Interstate Medical Licensure Compact (IMLCC): Also known as a compact license, this allows physicians to apply for expedited licensure if they hold a full, unrestricted medical license in a Compact member state that serves as their State of Principal License (SPL). You can learn more about IMLCC and its requirements at https://www.imlcc.org/.

Here's a timeline detailing my experience with the IMLCC application process:

1. May 20th, 2024: Applied for the IMLCC and paid the $700 application fee.
2. May 21st, 2024: The Wisconsin licensing team contacted me to:
• Conduct fingerprinting for a background check. Completed on 05/24/2024.
• Complete additional paperwork (procedures may vary by state). Completed 05/23/2024
• Transmit USMLE/FLEX exam scores to the Wisconsin Medical Examining Board. Completed 05/28/2024
3. July 7th, 2024: I received my Letter of Qualification (LOQ) from the IMLCC.

Overall, the process took approximately 6-7 weeks from the initial application date.

For further details, please refer to the following links

• IMLCC FAQ section at https://www.imlcc.org/faqs/.
• Videos- Really helpful https://www.imlcc.org/videos/

How to use Mendeley when writing a paper/citing articles?

I am writing this post to help my residents/researchers in writing their papers for publication. When I started out, I did not have the best tools to succeed, but thanks to my colleagues, mentors, and a LOT of people, I learned a lot and now I have a small number of publications. 

To help everyone, I am going to break this post down into steps.

1. Create an account and install Mendeley- It is a free citation software that you can download here

2. Once installed log into your account. You can drag and drop the paper to your account and the beauty of Mendeley is that it GENERALLY auto-recognizes the paper and adds the name title to it. For example the pdf file on your desktop maybe this 

But Mendeley will rename it to this 

which is extremely helpful to realize what the paper is on rather than trying to rename every pdf file/article that you download off the internet. 

3. In Mendeley, go to Tools and install Mendeley Cite for Microsoft Word.

4. Start writing your paper in MS Word and once you want to cite something go to References, where you should see something called Mendeley Cite-> Click on it (it will ask you to log in again)-> Click the papers you want to cite and then click 'Insert citation'

It should look something like this 

5. Now you can keep it as noted above or you can change the citation style to something different like the AMA 11th edition, which is a numbers reference technique by doing the following steps

6. In the end, insert your bibliography by doing the following 

7. Voila-> You have just learned the art of writing a manuscript and citing articles.

Please note, that people also use EndNote, Zotero, and many other citation software. Some of them are paid and I am NOT very well-versed in them, hence I will not try explaining them either. Hopefully, this small tutorial will be helpful to the multitude of researchers and residents out there :) 

The video version of this can be found here.  

Pediatric critical care boards

 There is unfortunately no real study guide for the pediatric critical care boards and hence I decided to create this blog post. 

The content outline for the Pediatric critical care exam can be found here and/or here. I am sure they will update it with time passing each year. The exam itself is 200 questions long divided into 2 sections of 2h 15m each with a 30 min break in between. Approximately 4.5 hours long in total. Details can be found here. 

This is another image that the ABP will send you closer to the exam date

Stuff that I used

1. PediaLink/Prep ICU: Prep ICU has approximately 72 questions per year, each focusing on different topics/concepts. It is NOT as streamlined as the pediatric boards questions which is a bit frustrating since you cannot focus on different topics/concepts. In addition, my program director used to send the fellows a question a week with her weekly update email, which was really useful. I created a OneNote book and just started filing them into their respective section. For more details please watch this video which I created for the pediatric boards.

2. Pediatric Critical Care: Text and Study Guide [Lucking et al]: I personally loved the 1st edition as it was succinct and to the point. If you have access to it, then I would use it alone and NOT buy the 2nd edition. I bought the 2nd edition but I think it was too much like a textbook and I ended up NOT using it. I used it for concepts for a little bit but overall I personally liked the 1st edition way more.

3. Old prep questions: Like I mentioned in point 1, there are VERY few questions each year in PrepICU and hence if you get access to old question banks I would use them to study/revise. Please note that since guidelines change, the older the prep questions the more incorrect they can be. For example, the surviving sepsis guidelines have changed a lot since the 2013-2014 set of questions.

4. I bought the Multiprofessional critical care review course which can be found here. In hindsight, I am not sure if this was a great use of my CME money. The teaching videos that you get from the course are amazing and I think I would definitely do the online video section alone if possible since you get education from the leaders in the field. However, the in-person course was a bit lacking, and in their defense, as this was the first time a new hybrid method was being trialed and I think they will get better with time. 

5. I also used the multiple-choice questions that SCCM has which can be found here. The questions themself were not hard. They are more factual and you either know the answer or you don't. It really helped me in solidifying my concepts a bit more, to be frank. The question bank gives you approximately 240 questions. Again, I am not sure if this helped me but I would rather just pass the boards in one attempt than have to do it all over again and hence I did it. 

Once I kind of went through the resources mentioned above once and then I did it a couple more times till I remembered the reasoning and rationale for almost all the questions. 

My personal journey/timeline

Thanks to my colleagues I had approximately 1 week of time off prior to the boards. My studying was not as pristine as I would have liked it to be but overall when you practice PICU you kind of are learning at the same time. Also, the one thing that really is nice about the ABP boards is that they ask you clinically relevant questions and things that you will encounter in your day-to-day practice which is way better than the obscure genetic questions that you would see in the pediatric boards. 

Date of Exam: Nov 3, 2022

Date of result: Dec 12, 2022

Result: Passed

How to buy a car at/below MSRP?

I bought my car (Subaru Forester LTD) in 2021, during the so-called car shortage which happened due to the micro-chip shortage during the pandemic. Since this was my first car, I was not really sure what I should be doing. During my research, I came across youtube videos by the 'Your auto advocate' group https://www.youtube.com/@YourAdvocateAllianceYAA  and started following them and learning more about car buying terminology through their free deal school course at https://community.joinyaa.com/c/deal-school/. It teaches you about car financing and quick terminologies to make you a smarter car buyer. 

After going through the deal school and learning the terminology/tricks of the trade, I created a pseudo-email account and started sending emails to different car dealers in the area, since I did not want to be spammed by the dealers with their 'last-minute' deals. I used the email templates that the team at @yaa so painstakingly have written, which can be found here [https://joinyaa.com/guides/email-templates-to-buy-a-car-online/] I am sure they have updated the templates since the last time I used them, but I got a decent deal on my car so I have no qualms in recommending them. Please note: The dealer will ALWAYS try to get you to come to the showroom to give you a good deal, but please do not fall for that trap. If they cannot send you an email with their so-called 'good deal' then it is NOT worth driving to the dealership. If they want your business they will need to work with you for it. 

Also, the yaa group had an add-on that looked up the car's VIN and could tell you have long the car sat on the dealer's lot. This just gives you some bargaining power when you are at the dealership. https://joinyaa.com/cars/#/ 

So coming to my journey. I started scrolling through the videos as noted above at the beginning of 2021 to just understand stuff. I started my search in earnest on June 20th, 2021, and finalized the car by June 22nd, 2021. I work in Wisconsin and I am comfortable driving around for a good deal, I contacted dealers in Illinois, Iowa, Minnesota, and Wisconsin. The dealers in Chicago gave me the best quote but the dealer in Iowa was amazing. Since in addition to the deal, he was ready to give me a FREE loaner vehicle till my car came in, and hence I decided to go with him.

The breakdown of my deal is approximately like this.
$ MSRP
-$2,566  Discount
$MSRP-discount-> Sales Price plus state tax and fees

Thanks to my credit score I got 0% financing for 36 months and hence I am paying it over 3 years.  I really could not have done/learned how to buy a car without the team at your-auto-advocate and a big thank you to Zach Shefska, Ray Shefska Kimberly Kline, and many others who directly/indirectly helped me in finalizing the deal.

The dealership that I worked with was C&S Subaru in Waterloo [www.candscarcompany.com] and the person I worked with was Mr. Scott Thurn. (319) 291-7321 Office; (319) 415-8051 Cell

Things that I liked about my dealer

1.  The deal (got it below the MSRP)
2. Free loaner vehicle till the car came in 
3. Just being very responsive and super helpful and no additional sale gimmick. 
4. Even though he got the car I wanted from a nearby dealer he did not up the price because of that.

If you need any more detail please let me know.

Neil Fernandes

How/where do I open a Roth individual retirement account?

This post is NOT financial advice and I AM NOT A FINANCIAL advisor. Please talk to a financial advisor if you have one. 

This post is on how to open a Roth IRA while in training (residency/fellowship) and save 6k in a tax-free account per year (this post is in 2021 when the contribution limit is 6k). The general rule of thumb is to go for Roth (post-tax) when you are in training and a pre-tax (traditional) account when you are in your peak earnings (attending) years [Reason for this advice is your tax bracket changes based on the money you make].

One can open a Roth IRA account in ANY of the well-known trading companies like Vanguard, Fidelity, Charles Schwab, etc. The drawback of these companies, at least for me at the beginning of my financial journey was not knowing what to invest in. In other words, I really did not know much about the stock market, index funds, etc. Hence, for those who are still new to investing and want to play it safe but still get a head start on investing I recommend the company Betterment to do the investing. They generally invest in low-cost index funds which is what you want to put your money in instead of stock-picking. 

1. Once you open your account via the above link or http://betterment.com/friend-referral-offer?referral_key=neilfernandes2 you will get to a page where you will have to open your account. 
2. In the middle of the page, you should have an option saying 'Get Started'
3. Click on that and then go through the steps (should be pretty self explanatory)
4. Once the account set up is done you should reach the following screen 
   
   
5. Click on the option 'Invest for retirement'
6. Fill in the details (another couple of sell explanatory questions)
7. Towards the end, you will have an option to open a 'Roth IRA' which is what I would pick
8. Decide on how you will fund the account-> transfer the money-> and bingo you are done. 
9. You are now a proud owner of a Roth IRA. Money grows now tax-free!

Please note that Betterment charges you an advisor fee, which is around 0.1% or something like that which comes to a couple of dollars. Once you do become financially literate, you can rollover the money to another account like Vanguard or Fidelity which should be really easy to do. However, when you are taking baby steps in the journey of financial planning and while you are learning to become a better doctor, worrying about money should be the last thing for you.

A big thank you to the Whitecoat investor for helping me start on my financial journey!

Tips for new attendings

I had written on a post when moving between residency and fellowship. You can find the link here http://neilnf.blogspot.com/2018/06/moving-tips-for-residents.html   

I am updating the post to make it more all-inclusive and financial savvy. 

Things to do before graduating and planning the move.

Disability insurance: 

This is one thing that skyrockets as soon as you get out of residency/fellowship. I would try to get this one ASAP since your earning potential and disabilities will only go up as you get older. This insurance just safeguards your family and you, should something happen to you. I have found the following links to be really useful when trying to understand disability insurance and would recommend reading the same. 

The White coat investor is an amazing site for financial literacy, and this is the one for disability.

• https://www.whitecoatinvestor.com/disability-insurance-introduction/. It is a series and I would try to go in order

The following links are quick facts on the same so that you can quickly understand it.

• https://www.whitecoatinvestor.com/what-you-need-to-know-about-disability-insurance/
• https://www.whitecoatinvestor.com/top-ten-questions-physicians-ask-about-disability-insurance/

Group vs individual (an eternal dilemma during residency is if we need it but I hope these links are useful)

• https://thephysicianphilosopher.com/group-disability-insurance/
• https://www.whitecoatinvestor.com/ama-disability-insurance/ 
• https://www.whitecoatinvestor.com/how-i-review-existing-individual-disability-policies/

Utilities

You will have to end your current utilities i.e., water, electricity at your current place and begin the same at the new location.

Use USPS mail forwarding service to forward any/all mail addressed to you at your old location to the new place https://bit.ly/3pPwqia. There is a charge of <$2 when I did this, but this is worth it.

Bank accounts

• Close old accounts that you will not use and streamline the ones that you will use going forward.
• Consider opening a new bank account in the new job place to get account opening bonuses (check https://www.bankrate.com/banking/ or https://www.doctorofcredit.com/best-bank-account-bonuses/ for the latest information.
• I would recommend updating your banks with your new details around 2 weeks before the move since this will help you in using the same as address proof for getting your driver’s license (they need 2 forms of address proof). 

Credit cards

Consider opening new credit cards since you may have a LOT of expenses while you are house hunting/doing a house make over. My list of credit cards is as follows https://maxrewards.app/refer/neilf120 

International graduates

Do not forget to update USCIS with your new address since your immigration is linked to the same. https://www.uscis.gov/addresschange 

Financial tips

This podcast/video by the white coat investor is worth a watch https://www.whitecoatinvestor.com/financial-priorities-as-a-new-attending/. In summary

1. Do a back door roth IRA 
2. Max out the 401k/403b
3. Max out the 457b if available- This is a judgment call since it depends on the financial stability of your practice.
4. Max out the HSA (please note that you can contribute money ONLY for the months you are eligible) For example, for me I became eligible in Aug and hence I can contribute only 300*5months= $1500.
5. DO NOT opt for COBRA since you can retroactively activate it should you become ill.

#tipsfornewattendings

Sending/receiving money from your loved ones

So should your family want to send you money from your home country (for me it is India/INR) to the place you are currently living (for me it is the USA/USD/$) how would they have to go about it? The general norm/websites that I could find always go the opposite (from the USA (USD/$) to India(INR/₹), but should you need to do India to the USA this post should help you.

I personally use Transferwise to do the transaction. The minimum/maximum amount that one can transfer will be based on which country you are sending the money from. The money generally gets transferred in 3-4 business days and you can get the best rate possible, which means more money to you. The setup process is simple but you will need some sort of identification (driver license/passport), to make sure you are a legit person and not a computer bot. So one can create an account for his/her family and himself/herself and get money with not a lot of hassle.

The entire process (from the person sending money) in short is as follows. 

1. You need to open an account with Transferwise. You can use my referral link here and get up to 600USD for free with no transaction fees.
2. You have to confirm that you are a human being and they ask you for either driver's license/passport for identity verification purposes
3. How much money you want to send. You will get to know at this step HOW much the receiving person will get along with the transaction fees that they will charge 
4. Who do you want to send the money to- You will need information on the receiving person (their bank account details like account number and routing number)
5. How would you like to pay: They give options for bank transfer/card transfer (depends on the country you are sending the money from)

Now should you choose bank transfer in the above step, the way that I understand it is that you have to make a transfer to THEIR (transferwise) bank in your home country and then they transfer the money to THEIR (transferwise) bank in the recipient country and then to YOUR bank account finally. In all, this is the reason for the lag period of 3-4 days, given the multiple middle players. OR you can watch this video where he explains the process. 

The other reason I like transferwise is that they will give you a debit card, in which you can open an account in any country in the world and it will function as a traveling card! So instead of getting a cashier's check for my trip to Europe or use my credit card with no transaction fee, I can just open an account in the local currency, and then I can transfer my money to that account. The exact details can be read about over here or watch the video here

What are the ways you transfer money to or from your home country? Let me know in your comments and I can update the post should it be useful.

Guide to Global Entry by an Indian citizen

I used to always feel jealous when I saw the TSA-precheck customers zip through the TSA line and I have always wanted to do that. As I am an Indian citizen, I do not qualify for TSA as only American citizens and LPRs qualify for the same. However, there is something that is called Global entry which includes the TSA precheck which I applied and got approved for. This post is regarding the same.

First off a brief overview of what is Global Entry: 

Global Entry allows expedited processing for pre-approved, low-risk travelers when they arrive in the US at select airports. Instead of standing in line, program members proceed to Global Entry kiosks, present their machine-readable passport or U.S. permanent resident card, place their fingerprints on the scanner for fingerprint verification and complete a customs declaration. The kiosk issues a transaction receipt and directs the traveler to baggage claim and the exit. Aside from avoiding processing lines and paperwork, another benefit of the program is TSA Precheck eligibility.

People who can apply for Global Entry: U.S. citizens, U.S. permanent residents, and citizens of Colombia, the United Kingdom, Germany, Panama, Singapore, South Korea, Switzerland, and Mexico. (Depending on the country, visas may be required.) Canadian citizens and residents are also eligible for Global Entry benefits through membership in the NEXUS partnership (the agreement that allows members expedited processing when entering the United States and Canada).

 My application process is as follows. 

1. Create a trusted traveler profile here. https://ttp.cbp.dhs.gov/ 
2. Select Global entry and then create an account and then fill in the details as asked. One will be asked to pay a $100 non0refundable application fee (many credit cards will refund the same) In addition to personal information—name, email address, gender, eye color, height, language preference—it requires you to fill in your employment, travel, and address history over the past five years. It also asks if you've violated any customs or immigration laws or been convicted of a crime. Fill out the application and submit a $100 fee, which covers your five-year membership if approved, but is non-refundable if your application is rejected. You can pay by credit card or electronic bank transfer.
3. Once you have submitted the application, within 1-2 hours you should get an email from passport.admin@passportindia.gov.in with instructions on how to set up an appointment in India vs USA (the USA part is new and has just started in the last couple of months. The earlier rule was to make an appointment when going/planning to go to India). You will have to pay ₹500 in the Passport Seva Portal,  for their background check in India. Once the payment is made and appt is confirmed, the page will tell you the things to take to the appointment (E.g. Proof of address (Passport, aadhar card), application confirmation page or SMS confirming the appointment). During the interview, your fingerprints and photo will be captured and there will be some other formalities
4. Once this interview is done, one has to wait for the police clearance which can take anywhere from 1 day to a week. My dad and I went to our nearest police station to ask if this could be expedited and they obliged. They will need 2 neighbor Aadhar card photocopies with signatures to attest that you live at the home address that you have in your Aadhar card.
5. After this, it is all sitting back and wait for the conditional approval to be granted. (takes anywhere from 6months to a year). A good place to look for is FlyerTalk, where one can see what is the current status.
6. Once you are conditionally approved, you have to go to a nearby airport/GE location to attend an interview where they will ask why you want GE, show your documents. Do take your visa documents in addition to passport and driver's license.  Please note that scheduling an interview is painful as there are no dates for most cities. However, keep checking the list and you might pounce on a date should someone cancel 

My personal experience

• Passport appt 04/29/2019
• Police verification 04/30/2019
• Conditional approval 12/19/2019
• Interview 1/12/2020

A few sites that I found useful

• https://indianewengland.com/2019/10/indian-citizens-are-now-eligible-for-global-entry-program-in-the-us-here-is-how-to-apply/
• https://passport.in.ckgs.us/gep
• Application centers in the USA https://passport.in.ckgs.us/application-centers
• https://www.cbp.gov/travel/trusted-traveler-programs/global-entry/international-arrangements/global-entry-indian-citizens

Quick getaway with Spirit Airlines

One of my good friends from residency sent a Facebook group message to the rest of us who are in the field of Critical Care saying, "Hey we are having a party at the Lakehouse, do come!'. Given it has been a year since we have seen or spoken to each other I decided that I will head 'home' i.e. Cleveland for sure *hoping my chief gives me off that weekend*

So with the goal in mind made plans. I scoured the internet for flight deals and found the cheapest flight on 'Spirit Airlines'. I had been warned through ads colleagues and even Trevor Noah (talk show host who sneaks in quick punches on the airlines) that the experience will be horrible and there will be flight delays and I will be left stranded. Anyhow, cheap as I was I decided to take my chances. So this is my post on travel with Spirit Airlines. I have in no way been compensated by the airlines and this is my OWN thoughts on the trip.

Prior to packing I googled and checked what are the dimensions of the luggage that I can carry. To be frank any regular bag pack should be okay but I have just put the dimensions for those who like numbers. 18 x 14 x 8 inches (45 x 35 x 20 cm). Anything bigger than this will have to be checked or billed, which is EXPENSIVE. So please pack wisely for the trip. Please note that they do not have weight restrictions on the bag.

I packed my bag with essentials for a 2 day getaway. The check in process was painless, which I did 24hrs in advance. I got my boarding pass on the Spirit airlines app in Android and breezed through security. The boarding process itself was a bit confusing. I was on Zone 3 but I think the lady at the gate really did not care in which order we boarded so once Zone 1 was done we all just stood in a big line with a mix of Zone 2-4 in no particular order. Next came to stowing luggage either under the seat or in the overhead bins. Given I am tall I quickly put my bag in the over head bin and had all the room in the world to stretch my legs which was a blessing. The seats do NOT recline which is no a big bother to me but some people do complaint about the same online. Given I was post call I slept the entire duration of the flight. There was beverages that were served during the flight but all for a fee. So I would recommend shopping for drinks/food BEFORE getting on the flight. Once we landed it was the same process as any other flight, with disembarking in chaotic order. But disembarking nonetheless.

On the way back, same ordeal but the man at the gate announced that we had to board in Zones which was good to hear. I was again in Zone 3 and arrived at the gate when my time was ready. We boarded the flight in a safe and orderly manner and arrived at Boston on time and in one piece.

So in all, Spirit is great for a short trip/getaway and if you have very minimal stuff to carry. It is NOT great for long destination and if you have a lot of luggage. I would recommend any other airline as it will be cheaper in the long run.