Six years ago, Kirk Withrow, MD, had never heard of cigar box guitars. Today, he has made over 100 of the quirky instruments and recorded a number of albums featuring them. He also holds down a day job as a head and neck surgeon and assistant professor at the University of Alabama at Birmingham School of Medicine. To find out more, 

 recently spoke with Withrow about his offbeat hobby.

MD: How did you get interested in making cigar box guitars?

 I was a third-year resident at UAB doing my ENT residency, and one of my patients was a cabinet maker. During the course of his stay in the hospital, we talked intermittently about music. He mentioned these cigar box guitars, which I had never heard of. Before he came back to the clinic, he gave me a call and said he wanted to bring me one, so he did and from there I kind of fell in love with playing those instruments. That one was a three-string guitar, and I’ve since started playing mostly four-string guitars that I make. … The way a six-string guitar is tuned has just never really made sense to me. I can play chords on a guitar, but I have never been able to play a six-string guitar all that well and I have never really enjoyed it. Five strings seemed like plenty, and four strings seems like just the right amount to me now.

MD: How long was it from when your patient gave you a cigar box guitar to when you first made one yourself?

 I would say it was probably within a month or two after he gave me that first one that I went to [a cigar box guitar festival in] Huntsville and it was maybe a few more months after that before I decided to tackle my own. It was definitely a very simplistic instrument compared to the ones I make now, which are still simple instruments. It was a three-string guitar with no frets, so you play it with a slide. That makes it a lot easier because you don’t have to worry about how high the strings are, you don’t have to worry about getting the frets in a perfect position because you just play it with a slide. From there, every time I’d make another one, I’d change it a little bit or add something to make it sound different.

MD: How did you learn to make cigar box guitars?

 I mostly taught myself. One of the interesting things about a lot of [these] guitars is that once you take the strings off, the bridge that the strings go over is a moveable thing and you can just open the box right up. So I took [the one my patient gave me] apart and dissected it and saw what he did and thought about the parts that I could do or that I wanted to use or change and went from there. And some of the guys I met at Huntsville I talked to and would get ideas from what they would do, but mostly I taught myself. I hadn’t really been active in any woodwork at all at that point. I had normal run-of-the-mill household tools, but started acquiring a few more here and a few more there for more specialized parts of making guitars. It’s really a lot of trial and error—sometimes you make some that aren’t that great and you think about how you might change them to make them better.

MD: How long does it take you to make a cigar box guitar now, from when you sit down to start until it’s ready to go?

Well, like anything, there is a range. One time some folks from the local NPR station wanted to make an audio clip of making the guitar, and I was able to put together a very simple, playable three-string guitar in just about an hour. But I would say on average I probably spend more along the lines of 10 or 15 hours. It gets to be pretty tough to measure because there’s not all that much concentrated time. It’s more a little part here and there and you just hope to get back to it in the next day or two.

MD: Why use cigar boxes as the basis of these instruments?

It’s not a new concept. It’s kind of a historical instrument that has been played by people for ages. A friend of mine has some plans from the 1800s or so, and you’ll see a Revolutionary War soldier playing a cigar box fiddle. In the past people made instruments out of what they had available. You know there’s lots of cigar boxes and you just put a stick in there and string some wire over it and you can make some sounds. So it really comes out of that. You can use anything that is a hollow vessel or a chamber. You can use a tin, it could be round, you could use a wine box. I saw a guy that made a mailbox instrument.

MD: What kind of music do you like to play using these guitars?

I play mostly old-time music, sort of pre-bluegrass fiddle tunes and hill country blues like north Mississippi blues and then I sort of change it all so that it’s speeded up a little bit. As a banjo player, I always want to play things real fast.

MD: You’ve recorded a few albums, are those all using the cigar-box guitars?

Yep. There may be some instances where I have used other instruments that I haven’t made, but not many at all. For the most part I have used the ones I have made or occasionally instruments that other people have made for me.

MD: How many albums have you recorded at this point?

Let’s see, I’ve recorded one under a band called Buckeye with a drummer who played drums I made for him. Then I recorded a couple just under my name that are more old time. Then when my son was born, I stayed at home for about a week when my wife was recovering and I was kind of watching him and during that week I recorded an instrumental album called 

 with either the guitars that I had made or his crib toys for extra sound effects and so forth. It was sort of imagining what it might be like if you were in the womb and the next day not, how strange it might be. Then I recorded one more recently, that was all more or less kids songs, called 

. That was pretty much all with the instruments that I made myself. So I guess five or six albums in all.

Less now than in the past. I’ve got two kids now and when I finished my residency and started work I was under the false impression I’d have more time, but I have less time. I’d like to say that I played more than I do, but I still play mostly at festivals and things like that.

MD: So you’ve never been tempted to become a full-time musician or a full-time instrument maker?

No. Interestingly, right before I started medical school there was a band in my hometown that was just sort of taking off. And the day they sent me a letter saying I got into medical school, this guy called me wondering if I wanted to sign up with them to play banjo and go on tour. I did have a brief second where I thought, “Well, that might be all right.” But I think I made the right choice.

MD: Sort of a fork-in-the-road moment there.

 Yeah, briefly. I realized it wouldn’t be for me. Even though they’ve done pretty well, I would still get tired of traveling around. Plus, if you start to do something because you have got to do it, it kind of takes a lot away from it. If I was forced to make music or instruments, then it becomes like a job and it’s not that fun.

MD: Do you see any overlap between the experience of doing surgery and making instruments?

 I do. It’s interesting because the whole idea of making instruments has really changed the way that I think about everything. You just sort of realize that you can do lots of different things. You can make these instruments and make music and record it all on your own. It opens your mind up that maybe you don’t have to follow the exact same thing as everybody else is doing to do something well.

MD: How many cigar box guitars have you made at this point?

 I couldn’t say for certain, but probably between 100 and 200. Plenty, to the point where sometimes I’ll put them up for sale on Etsy. If you start making anything, it’s like rabbits, they just multiply, and then you’re like, “Where do I put all these things?” and then you just give them to people. I’ve got a room in my house that’s just full of them and that’s not considering all the ones that I’ve gotten rid of.

MD: When you’re sizing up a box, what makes a good cigar box as the raw material for a guitar?

 Most cigar boxes are made out of wood, so that helps. I had one guy not that long ago ask me to make a guitar and his grandfather had this old cigar box and he specifically wanted that one used. It was cardboard, so I had to build a box inside the box so it would hold up. A wooden box is good, and from there, if I’m making a regular-size instrument, I try to get a pretty big box because you can get a deeper, fuller sound out of a bigger resonator, or bigger box.

MD: Of all the guitars you’ve made are there any that stand out as ones you’re most proud of at this point?

 I’ve made probably four, five, maybe six resonator guitars where I use an aluminum cone and put that on the inside and then it basically is a second resonator, so it increases the volume a lot and they tend to sound and play really well and then you have to put a metal cover plate over the top of it and so that gives me a chance to do some metalwork, which is nice, and they look fancier, but they certainly play and sound better for the most part. One or two of those that I have in particular are probably the ones I play the most because I can play them and get more sound out of them without plugging them up if I don’t need to.

Articles

Cover Story

Six years ago, Kirk Withrow, MD, had never heard of cigar box guitars. Today, he has made over 100 of the quirky instruments and recorded a number of albums featuring them. He also holds down a day job as a head and neck surgeon and assistant professor at the University of Alabama at Birmingham School of Medicine. 

Cigar Box Guitar Hero

A number of years ago I was seeing a female executive for a physical exam. As I chatted with the sixty-something female CEO she remarked: “women sell themselves short,” attributing the lack of women in top management positions to their tendency to opt for less ambitious “mommy track” positions. While I had certainly heard these words before, that day they hit closer to home. At the time I was in year nine of employment at the Emory Clinic and feeling professional success in my job, which included a leadership position within my practice. I was the senior woman in my group, the university-based general medicine practice of Emory, and a busy and well-liked internist. Though at the time I had been recipient of various departmental awards, I was still an assistant professor—a detail that was, in fact, a chip on my shoulder. However, no woman in my practice had ever been promoted to associate professor.

When my first child was born in 1999 I had opted for “part-time” status, 75 percent of full-time, gradually increasing my work load after my second child turned four to 90 percent of full time. My husband is an interventional cardiologist and our work-life balance had been tough. Thankfully, I had a wonderful nanny who helped out at home.

Now, working full time in a medical practice that I started, I reflected on those years again after reading a recent editorial in the 

 on part time women in medicine. The piece, 

, authored by Karen Sibert, an anesthesiologist, argued that federal funding for residency training was wasted on women who increasingly opt for part-time positions. In fact over 50% of female physicians report seeing patients fewer than 40 hours per week (most commonly 30 to 40 hours per week), compared to men, who more commonly report spending 41 to 50 hours per week on patient care. When I posted Dr. Sibert’s editorial on Facebook it was met with a flurry of impassioned negative responses by many of my female physician colleagues, who have opted for the flexibility of part-time primarily in order to accommodate their domestic roles as primary caregivers of young children.

In my experience women working “part-time” in medicine and earning “part-time” incomes often add professional work into their unpaid time—seeing extra patients, taking equivalent call despite a part-time salary, and in the academic setting, taking on unpaid teaching, or educational administrative positions. In fact, I recognize that it was my part-time status that enabled me to participate in these types of activities and actually helped my reputation in my division, allowing me to pursue professional interests that I would not have had time for otherwise.

In the past several decades women have made significant gains toward equal status in medicine. According to statistics from the 

, in the year that I graduated from high school, 1986, 31% of medical school graduates were women. In 1994, when I graduated from medical school, 39% of graduates were women, and in 2010 48% of medical school graduates were women. However, as in other fields, women still lag far behind men in terms of their 

. In terms of income, significant gaps also remain. In the past these income disparities have been attributed to differences in work hours and a tendency for female physicians to enter primary care fields. However, a provocative recent study published in 

 found that an average gap of $16,819 in salary between newly trained female and male physicians could not be explained by controlling for these factors.

Why should we care about having female physicians? Studies have suggested some differences between male and female physicians. Findings include:

		Women may spend more time with their patients

		Women have different communication styles—they are perceived as more empathic and sensitive

		Women tend to employ more participatory decision-making styles, which are correlated with higher patient satisfaction

		Women tend to emphasize preventive services more

		Women are more likely to discuss lifestyle and social concerns

Of course these observed differences are highly variable depending on the individual physicians in question. Interestingly, male gynecologists have been rated as more empathic and sensitive than male physicians in other fields. Nonetheless, there is strong female preference for female gynecologists. The interaction between gender and patient preference is complex. One interesting study looked at 

 and found that male patients of female physicians were the most satisfied customers, compared with female patients of these same female physicians, who were the least satisfied group. Patients have different expectations about communication between male and female physicians and this may impact their satisfaction with care.

Going back to the female CEO, I too have been let down at times by what I have perceived as a relative lack of career ambition in some female physicians. Thinking about it, however, I’ve been equally let down by male physicians with what I viewed as misguided professional goals. If women can best manage their careers in medicine as part-time then so be it. Society will benefit, perhaps we will learn something from one another, and women in medicine are already paying the price.

Dr. Mavromatis is a primary care physician in Atlanta, Georgia. 

This article was originally posted on her blog, 

, which she describes as “a conversation about health topics for both patients and health professionals.”

Physician Voices

Are female physicians less ambitious than their male counterparts, or are they pursuing different professional goals that may benefit the profession in the long run?

Part-time Women in Medicine: Are They Pulling Their Weight?

It’s not unusual for an adolescent to cry when he or she has to visit the doctor. What is unusual is that they cry when it’s time to leave the doctor’s office. But that’s the case at Thornburg Pediatrics in Naples, Florida, one of the only concierge pediatric medicine practices in the country.

“Siblings of sick patients or even well children love coming to the office because they get to run around and play in such a child-friendly atmosphere,” says Brian Thornburg, MD, of the practice he has run out of his home since 2006. “Some of them actually bring their friends because they want to hang out at the office.”

Thornburg has been married to Helen Thornburg, MD, since 2001. He worked at a successful, high-volume pediatric practice, she as an emergency medicine physician. But with a growing family of seven children, they often dealt with the struggles of blending marriage, family, and professional careers. That’s when his wife left her career to stay home full-time with their children, and Thornburg set out to open his own practice.

“It was unsettling and scary because I was stepping off into an unknown, and there was only one other [pediatrician] in the country at the time that was doing [concierge pediatric medicine],” Thornburg says. “But I looked at what I would want to receive as a parent if I weren’t a pediatrician myself, and designed the whole practice from that perspective. I started making only home visits, and within a year I became so busy that I had to centralize an office, because more and more parents were coming for that more personalized style.”

Parents like it because, unlike a traditional visit to the pediatrician that might last 7-10 minutes, Thornburg spends as much as one hour with a child and his or her family. Children like it because the practice is on a farm with a full playground, outdoor garden, and farm animals. In fact, Thornburg and his family promote self-sustainability, and grow a wide variety of organic fruits, vegetables, and herbs in their gardens. It’s a lifestyle he tries to impart to his patients and their families.

“The practice’s whole philosophy addresses the epidemic of obesity and developing healthy eating habits,” Thornburg explains. “I hold gardening classes, so the families can learn how to do this themselves. I give a little lecture before the gardening class, and then we go outside and I show them the different techniques. We actually have the kids and their families planting and potting, and then I get feedback from the kids about how they’re eating their food. They’re excited to eat healthier, and they also learn a life skill that can serve them in the future. There’s lots of confusion with food and what’s safe and what’s not. Well, you know if it’s grown in your back yard it’s most likely safe.”

The children also learn a lot about life in an environment that includes cows, goats, chickens, guinea hens, and peacocks. “We just birthed a calf a couple of months ago,” Thornburg says, “so the children enjoy coming here to visit the baby calf.”

For the past five years, Thornburg has been working on a manual—a how-to book so that other pediatricians could implement similar set-ups in their practices. More recently, that manual has grown into Innovative Pediatrics, LLC, a full-fledged practice management company that can walk physicians through the entire set-up, and then assist with business support until the practice is established. Thornburg launched the endeavor at this month’s American Academy of Pediatrics meeting in Boston.

“The practice would be tailored to the pediatrician’s own interests,” Thornburg explains. “It doesn’t have to be animals. If the pediatrician is a musician or an artist, they can create their own atmosphere that would be child welcoming and professional.”

Thornburg says he is excited by the way Innovative Pediatrics has come together in such a short time, and believes it has the opportunity to change, to some degree, the way medicine is practiced.

“It’s a common sense approach,” Thornburg says. “You have the opportunity with the time that is available to see the patient, to get to know the parents and the child very well, so that you can practice better medicine. And one of the hot topics in medicine is what are the outcomes? Don’t just treat the person and they leave. What’s really important is what happens afterward. So, you’re able to have amazing follow up, and the parents just smile when they get a phone call back from a doctor. So, it’s really exciting what this can do.”

Feature Article

It's not unusual for an adolescent to cry when he or she has to visit the doctor. What is unusual is that they cry when it's time to leave the doctor's office. But that's the case at Thornburg Pediatrics in Naples, Florida, one of the only concierge pediatric medicine practices in the country.

Florida Pediatrician Teaches Healthy Lifestyle to Children, Families

Doctors are, famously, workaholics. That's just the way it's been forever, at least as far back as my memory goes. You work crazy hours in residency, you graduate and work like a dog to establish your practice or to become a partner in your practice, and then you live out your career working long hours because there just aren't enough hours in the day to do everything that needs to be done. I remember, growing up in the '80s, that my friends whose parents were doctors were latchkey kids whose dad (usually the dad, then) was never at home when we were hanging out in the rec room playing Atari.

Not much had changed by the time I went to medical school. There was recognition of the fact that burnout was an issue -- that divorces, alcohol abuse and suicides were more common among physicians than in other professions. The unspoken implication was that being a doctor was difficult and stressful, which increased the risk of these consequences of an over-burdened professional life. These stresses were accepted as part of the turf, as a necessary part of "being a doctor." It wasn't optional, and indeed, most physician teachers that addressed the matter chose to sublimate it into a mark of nobility. Being a physician was a calling and a duty, and a physician must gladly subordinate his or her own happiness and well-being to the service of their flock.

But things have changed, or at least a slow shift is in progress. It was probably ongoing when I was in training, though I was pretty oblivious at the time. I see it more and more clearly as time goes on. Young physicians have different priorities now, and they are making career decisions based on a more self-centered set of values.

, revealed that graduating residents place "free time" and "lifestyle" as their top priorities in choosing a position, above even financial considerations. Young doctors are opting for large multispecialty practices and for hospital employment in droves -- stable and predictable practice environments -- and the practice model of small group or independent practitioners withers on the vine. At the same time, driven by slightly different motives, residency hours are being restricted.

This has provoked a chorus of curmudgeonly disapproval from many, especially from within the surgical specialties. 

Does all this bother anyone else? I wonder what people expected? Did they not know that being a doctor involves commitment and self-sacrifice?

Being a doctor is not a job like being a banker or contractor. It is a life. The decision to become a doctor should carry as much weight as the decision to enter the priesthood. Medicine is not a dilettante's profession. Make the commitment or get out.

Which, I think, aptly summarizes the position of the "old guard” -- the guys who paid their dues and expect the next generation to do the same. But we (and I still include myself in this group) who are younger don't agree, at least not entirely. It seems like the demands of this profession are, in part, not intrinsic to the job but rather culturally and institutionally generated -- and thus, subject to change. Why should I spend my entire career working 60 hours a week? Is that necessary to maintain my skills? Is it worth the cost to my family and my personal life? Is it more important to me that I am a "good doctor" than it is that I am a good father and a good husband? I don't think so, and in fact, personally, I identify myself 

Note that I am referring to a career, not to training, where there is some argument in favor of intense experience. That is a different topic.

So I am entirely in favor of the movement towards more humane and livable practice environments for physicians. And I do not think this movement is going to reverse itself, but rather, will become the new standard going forward. The phenomenon of 

, or "the replacement of old guards of organizational members and leaders with newer cohorts who have different beliefs, opinions, and values," will likely slowly but inexorably change the culture of medicine towards one in which the accepted, default position is that physicians have robust extra-professional lives.

John Mandrola, an electrophysiologist, is cautiously supportive of this transition, but 

poses the unsettled question of whether this is good or bad for patients.

To some degree, it's a clear win for patients. A well-rested surgeon performs better. An ER doc who is suffering from burnout is not the one you want treating your child. An internist who retires at age 50 because the office life is too demanding represents "brain drain" as the most experienced and valuable docs flee the workforce.

The surgical and procedural-based specialists seem to have the most resistance to this change, and they do have some valid points. There is a correlation between how many times you do a procedure and how well you do it. You can learn to do a lap chole in residency, but you may not be really good at them until you have done a few hundred in the first few years of your practice. Further, surgeons have a different relationship with their patients, usually shorter duration but much more intense. This makes it harder to place boundaries on intrusion of their practice into their personal lives.

However, these hurdles are logistical barriers which can be overcome, at least in part. The use of trained and experienced physician extenders can greatly streamline the non-operative elements of care and allow the surgeon to focus his or her time where it carries the most value: in the OR and at the bedside.

The greater question of whether this is good for patients relates to the looming physician shortage. If physicians, as a group, are cutting back on their time at work, this will require a larger workforce to deliver the same amount of care. There are some efficiencies that can be gained, especially through the use of PAs and NPs, which may mitigate the matter. However, it's hard to escape the conclusion that the trend towards a firmer life-work boundary for doctors will exacerbate the physician shortage.

I don't think that's an argument against greater work-life balance in medicine. That's still good policy. The consequences need to be acknowledged and addressed, and it's worrisome because little is being done to address the physician shortage in the first place. But it doesn't change the fact that the ability of doctors to have stable and fulfilling extraprofessional lives is good for both doctors and the patients we serve.

And in any case, the argument of whether this is a good thing or a bad thing is about as important as a debate over the tides. It's happening, as the result of thousands of individual docs all making the same personal choices and it's very unlikely to change. So we had best recognize it and make plans to deal with it.

an ER physician and administrator living in the Pacific Northwest. 

This article was originally posted on his blog, 

, which he describes as “The accidental blog of a semi-accidental ER doc living in the Pacific Northwest.” 

Young physicians are changing the rules when it comes to work-life balance.

Work-Life Balance for Physicians

As advisors to physicians throughout the country, we are often asked to help doctors to protect assets against future lawsuits. From this experience, we often learn what misconceptions physicians have regarding how to protect their assets from potential lawsuits. In this article, we hope to dispel some of the incorrect assumptions that you may have and shed some new light on opportunities for further asset protection.

The first misconception that most physicians have is that they should only protect their personal assets from potential lawsuits. Nothing could be further from the truth.

In fact, the practice’s important assets are the most vulnerable to lawsuits, especially in a group practice. That is because any malpractice claim or employee claim (sexual harassment, wrongful termination, etc.) against 

 of the doctors threatens all of the assets of the practice. In other words, if you are in a group practice, you are underwriting all of the acts and omissions of all of your partners, to the extent of your practice assets.

Certainly, your cash flow and income are the most important assets. The good news is that the tools that protect your cash flow also typically help you save on income taxes and build retirement wealth. These include qualified retirements plans (including defined benefit plans to 401(k)s to combination plans and more), no-qualified plans, fringe benefit plans, captive insurance arrangements and more.

Beyond your cash flow, the practice’s accounts receivable (AR) are typically an important asset. Your AR is what you, in fact, work for. What most physicians don’t realize is that a lawsuit against the practice itself, created by a wrongful act of any of the partners, threatens all of the AR in a typical practice setup. Certainly, there have been cases where physicians had to work for free for a number of months because of the lawsuit judgment resulting from the act of one physician created a loss of the AR for the entire practice. Don’t let this be you.

Other important practice assets include the practice real estate, if any, and valuable equipment. If your practice has valuable real estate or equipment, it must separate these assets from the main practice. There are a number of tactics to protect real estate and valuable equipment from potential lawsuits against any of the physicians or the practice itself.

The most common asset protection misconception that physicians have regards their personal asset protection — shielding their personal assets from potential lawsuits.

In this endeavor, asset protection attorneys approach a challenge much in the way a physician approaches being a patient. Like physicians, asset protection professionals first will try to get a client to avoid “bad habits.” For a medical patient, bad habits might mean smoking, drinking too much or maintaining a poor diet. For a client of ours, bad habits might include owning property in their own name, owning it jointly with a spouse or operating any medical practice with business assets exposed.

In fact, we use an asset protection rating system for a client’s overall situation: from —5 (totally vulnerable) to +5 (superior protection). Exposing business assets, owning property in your own name, etc. — these are examples of –5 situation.

In this way, before we implement any sophisticated asset protection planning, we want to move the client from a -5 to at least a low negative or neutral number. This means eliminating any of the “bad habits” named above and others.

If you see yourself as a physician who has business assets exposed and owns personal assets in your name or jointly with a spouse, you should talk to an asset protection advisor immediately. You don’t want linger too long in the -5 category, as it’s only a matter of time until you get “sick.”

If you are in a situation where you want good, basic asset protection, but do not want to pay more advanced tools, then basic asset protection tools like family limited partnerships (FLPs) and limited liability companies (LLCs) should be used. Essentially, these tools will provide good asset protection against future lawsuits, allow for maintenance of control by you, and can provide income and estate tax benefits in certain situations.

Specifically, these tools generally will keep a creditor outside the structure through “charging order” protections. These protections typically allow a physician to create enough of a hurdle against creditors to negotiate favorable settlements. For these reasons, we often call FLPs and LLCs the “building blocks” of a basic asset protection plan. We may also layer in domestic irrevocable trusts, such as life insurance trusts or charitable remainder trusts.

In essence, these tools will provide adequate asset protection relating to an asset protection score of +2. Obviously, these asset protection benefits are reliant upon proper drafting of the documentation, proper maintenance and respect for formalities, and proper ownership arrangements. If all these are in place, the physician can enjoy basic asset protection for a relatively low cost.

Advanced strategies for ultimate asset protection

For many physicians, a basic asset protection plan, which has some potential vulnerability, is not good enough. A +2 on their asset protection score is not enough to give them the psychological comfort that they want. Other clients realize that the best protection comes from tools that actually can help clients create wealth. For this reason, these clients use advanced structures to put themselves at a +4 or +5, the ultimate asset protection score.

Like a physician giving the ultimate medicine or most effective surgical procedure, asset protection consultants rely on a number of tools to provide ultimate asset protection.

The term “qualified” retirement plan means that the retirement plan complies with certain Department of Labor and Internal Revenue Service rules. You might know such plans by their specific type, including pension plans, profit sharing plan, money purchase plans, 401(k)s, or 403(b)s. Under federal bankruptcy law, and nearly every state law, these plans are totally protected against lawsuits and creditor claims — enjoying +5 protection status.

These allow a physician to put funds away at the practice level and enjoy them in retirement. Also, these types of plans can be used in addition to qualified plans. In many states, they can be funded by exempt (+5) asset classes. Even in the states where there is no (+5) exemption, a (+2) LLC can typically be used to provide a solid level of protection.

In this technique, the owners of a medical practice actually create their own properly-licensed insurance company to insure all types of risks of the practice. These can be economic risks (reimbursements drop), business risks (electronic medical records are destroyed), litigation risks (coverage for defense of harassment claims or HCFA audits) and even medical malpractice (keeping some risk in the captive and reinsuring the rest). To maximize the protection of the CIC, many physicians establish trusts to own the CIC.

Each state law has assets that are absolutely exempt from creditor claims, thereby achieving a +5 status. Many states provide unlimited exemptions for cash within life insurance policies, annuities, and primary homes. Make sure you seek an expert on this to find out the exemptions in your state.

Asset protection planning, like any sophisticated multi-disciplinary effort, is a matter of degree. Nothing in life is 100% certain (except perhaps death and taxes — subjects of other articles). For asset protection planning, this adage holds true.

In your asset protection plan, make sure you understand the cost and benefits of the various tools you employ. It will help you not only protect the wealth you have already built, but may assist you in building greater after tax wealth for your retirement and beyond.

 is a principal of the financial consulting firm OJM Group. 

 is also a principal. David and Chris have co-authored 

For Doctors Only: A Guide to Working Less and Building More

, which is available for free (plus $5 S&H) by calling (877) 656-4362.

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Money and Finance

Many physicians have misconceptions regarding how to protect their assets from potential lawsuits. This article separates myth from fact and sheds new light on opportunities for asset protection.

Asset Protection: A Matter of Degree

It can be challenging to help patients make substantive lifestyle changes during brief office visits. A good place to begin is at the beginning—with breakfast. Helping patients understand that starting the day right can have a major impact on their weight and health is a relatively simple step that can pay big rewards.

Scientific findings on the benefits of a healthy breakfast have been piling up for years. The Physician’s Health Study found that those who ate two servings of high-fiber cereal for breakfast per week reduced their risk of heart failure by almost 20%.

Eating breakfast regularly also appears to help improve lipid profiles. In one study, women who did not eat breakfast had higher levels of total and LDL cholesterol. Those who did not consume breakfast also showed marked blunting in their insulin response.

By the time we wake up, most of us have gone at least twelve hours since our last meal. Skipping breakfast extends this fast even longer, and by lunch it has been up to eighteen hours since our last feeding. By mid-morning, we are starving, and the donut we know we shouldn’t eat becomes irresistibly appealing.

We now have excellent research that shows that these extended periods of starvation slow our metabolism; since there’s not enough energy coming in, our bodies work to preserve the calories we have stored, making it harder to lose weight.

What we eat for breakfast also has an effect on how easy it is to lose weight. In one study, participants who ate cereals, quick breads, or muffins for breakfast had a lower Body Mass Index (BMI) than those who ate meat and eggs. The study also found that eating whole grain and cooked cereals for breakfast produced better results than did ready-to-eat cereals or muffins.

 There is also recent evidence that whole grain rye porridge is more effective than whole grain breads at producing satiety.

Other studies have shown that breakfast skippers tend to have a higher BMI. At the same time breakfast eaters with a lower BMI are likely to consume meals more regularly throughout the day. Similarly, those eating early in the day are less likely to snack later on and to snack more sensibly when they do snack.

The best part of all this research is that it gives us a simple piece of tried-and-true advice that we can pass on to our patients: Make time for a healthy breakfast. Indeed, with a little planning, grabbing a bowl of high fiber cereal, a few pieces of whole grain toast, or a muffin or quick bread can be far faster and less expensive than stopping at a fast food joint for a (less-healthy) sausage biscuit.

Pairing the carbohydrates with some protein is important to ensure satiety until lunch—cereal with milk or yogurt, whole grain breads with an egg, reduced-fat cheese or peanut butter, or even some quality granola and yogurt. Breakfast can be an excellent time for a serving of fruit as well.

Many of my patients still believe that dietary cholesterol—eggs and shrimp in particular&mdash;has an effect on their cholesterol levels. It is important to reassure them that for most people, this simply isn't the case.

A 1999 review of two large studies showed no evidence of a link between egg consumption and cardiovascular disease. The researchers' conclusion stated, "These findings suggest that consumption of up to one egg per day is unlikely to have substantial overall impact on the risk of CHD [coronary heart disease] or stroke among healthy men and women."

 The researchers did find, however, that consumption of eggs by diabetics might lead to a higher risk of cardiovascular disease. And another study showed that those who ate two or more eggs daily increased their risk of heart failure by 64%.

1. Have some carbohydrates (cereal) and protein (milk or yogurt) with a piece of fruit

2. Breads should be served with a protein. Select a bread choice, a topping or spread, and one item from the protein list.

				Bite-size Shredded Wheat or Shredded Wheat and Bran

				Raisin Bran (Check for added sugar content, especially high fructose corn syrup)

				Whole Wheat Toast (the higher the fiber content the better)

				Reduced-fat Cream Cheese (“light” cream cheese is best for spreading)

Cooking and Dining

It can be challenging to help patients make substantive lifestyle changes during brief office visits. A good place to begin is at the beginning-with breakfast. 

Breakfast: Still the Most Important Meal of the Day

We recall that someone, somehow dragged a 300-year-old sailing ship out of the depths of Stockholm’s harbor about 50 years ago and there has been something in the media recently that preserving the wood has again become a problem. And we remember that — although Sweden was always Top Dog in the many centuries of war in those latitudes &mdash; for almost 200 years Sweden has been able to maintain its neutrality and avoid the destitution that war costs nations. We know Swedish diplomat, Raoul Wallenberg, saved tens of thousands of Jews from the Nazis and that the generosity of industrialist, Alfred Nobel, has given prizes for more than a hundred years.

We know this and all about those jewels of design Saab and Volvo cars. And IKEA and ABBA, Absolut Vodka and Swedish meatballs, and Swedish massage and the midnight sun. But what about the people? From the crime novels sweeping across America penned by Stieg Larsson and Henning Mankell, one might expect Swedes to be humorless even morose but they are not; though they 

 been described as the most intolerant tolerant people in Europe.

Swedes stride elegantly along their boulevards, content, elegant — and tall. Walking behind them is like following an American basketball team through an airport. The only criticism one might make of those Swedes strolling the streets of Stockholm is they seem just a little bit smug that their culture, society and life is the best in the world &mdash; and they may well be right.

is a delightful destination for visitors. Its tourism board is comfortable in English and competent and helpful, and it has the best tourist office in Scandinavia. Sweden, a country a little larger than California, has a population of nine million people and its capital’s greater metropolitan area is home to about two million.

The city itself has 800,000 residents but it seems smaller: all its attractions are easily seen on foot or with public transportation. 

, a local touring company not only runs easy HopOn HopOff busses but similar boats. After all, Stockholm has been called the Venice of the North and as you walk around you never forget this is “the city that floats on water.”

You can see a significant amount of Stockholm in three days. You probably should consider staying in the south part of the city close to the water and the main railway station — that’s where most of the attractions lie. It’s also just a few hundred yards to the north to where you get the Arlanda Express train to the airport and, closer still, going south, you find the Gamla Stan (Old Town) and the Royal Palace &mdash; sure fun for tourists lucky enough to get there early for the changing of the guard. Remember, if you get there late you’ll be standing behind all those tall Swedes!

As you check out hotels online understand hotels can be reasonably priced at times in Stockholm. The Sheraton Stockholm Hotel on Tegelbacken 6 downtown had rooms for about $200 a night when we stayed there, significantly less than what most upscale European hotels charge. Don’t judge Sheraton by its performance in the United States; international Sheraton is a far superior product.

The famous Grand Hotel stands next to the 

, which is a wonderful repository of Swedish artifacts and national art. A bust and painting of George Washington show up surprisingly here. Washington sat for Jean Antoine Houndon’s sculpture in Mount Vernon in 1785 and posed for Adolf Ulrik Wertmüller in 1795; it’s a revelation to find them so far from home. De Vries’ 

The Six Regents and Beadle of the Nieuwe Zijds Institute for Outdoor Relief of the Poor

 (1657). The horse looks as if it would be more fun.

And who says the Swedes come hard to humor? The work of beloved painter Carl Larsson (the “Swedish Norman Rockwell”) displayed on the walls of the museum would amuse any visitor. The mural at the entrance shows a dignitary being painted as if on a stallion whereas the artist has him posing in a padded chair.

 at Narvavägen 13-17 is farther afield to the northeast above the promenade Strandvagen. You might want to ask your hotel concierge to map your route. It has exhibits from the Stone Age to the Vikings and the Middle Ages.

As far as museums go the most popular seems to be Vasa, the ship that sank in 1628 to be dragged from the sea after 333 years. Its final resting place is its own private museum. Give yourself enough time though, because your wait could be as long as squeezing in to see the changing of the palace guard. The easiest way to get to Vasa, the ship, is by boat, and the same Strömma On Off boats then carry you off to the second most popular attraction in Stockholm, Skansen. Here picnic grounds, an amusement park, a children’s zoo, windmills and open air museums with docents and musicians in costume compete with all their outdoor attractions in what was once the royal hunting grounds.

Horse drawn carriages stand in Skansen to take children for rides as they do in front of the Royal Palace, sometimes in odd juxtaposition to Coca Cola vans. Beyond the palace lie the Nobel Museum and the arched alleys and cobbled streets of Gamla Stan, the Old Town.

If you take a day to sail on an On Off boat to most of the museums, allow another day to walk this beautiful city. The tourist areas don’t seem to have the heavy traffic of most American cities and Scandinavia has been in the forefront of creating pedestrian malls that delightfully exclude cars.

There is time to wander and ask yourself questions: What does that sign point to, why is that statue waving, what happened to the sails of that windmill, who owned those magnificent homes by the water? If you ask passersby, you’ll be answered often in fluent English; Swedes are amiable, proud of their city and pleased to tell you about it.

Only if you walk will you find the part of this continent the world should never forget: the tribute in a subdued city square to Raoul Wallenberg who died in prison helping Europe’s Jews avoid a similar fate.

It’s especially sad to think that a country like Sweden that tries so hard — and so successfully &mdash; to place a safety net under its people couldn’t protect its diplomat. And that he will never stand on a midsummer’s night in Stockholm and watch the midnight sun finally yield as the city falls asleep.

The Andersons, who live in San Diego, are the resident travel & cruise columnists for Physician's Money Digest. Nancy is a former nursing educator, Eric a retired MD. The one-time president of the NH Academy of Family Practice, Eric is the only physician in the Society of American Travel Writers. He has also written five books, the last called

The Man Who Cried Orange: Stories from a Doctor's Life

Travel and Leisure

Most Americans are not well versed on European history, especially that of Scandinavia.

Stockholm Syndrome

What better time than now to get tough for winter? Brush up on your knowledge—just in case you should get smacked by a very large snowball.

Seriously, who doesn’t like the word “free?” Of course, we know nothing in life is 

 free … except for the games on this interactive site. Trust us on this one.

The website that tackles everything from “How Albert Einstein’s Brain Worked” to “How DNA Evidence Works” is now available as a free app. Just don’t look at “How Computer Addiction Works.” We’re just sayin’…

“From the uprisings across the Arab world to the devastating earthquake, tsunami and nuclear disaster in Japan, there was no lack of news in 2011. Reuters photographers covered the breaking news events as well as captured more intimate, personal stories. In this showcase, the photographers offer a behind the scenes account of the images that helped define the year.”

Whimsical paper art fun. As for the ending: Are these the shadows of the things that will be, or are they shadows of things that may be, only?

This program uses Google Earth to help you locate and view aerial photos of “all the weird, cool, beautiful places” you find. There are hundreds of pre-loaded images available for viewing.

Use TripLine to make animated maps of your travels and “share where you're going, where you are and where you've been with the people you care about.” The TripLine player allows you to create maps with “an animated line moving across the map with a soundtrack,” just like in the movies!

This iPad app is “an easy-to-use design tool that lets you annotate, animate, and narrate explanations and presentations. You can create dynamic interactive lessons, activities, assessments, and tutorials using Explain Everything's flexible and integrated design.”

MoMA Abstract Expressionist New York (AB EX NY) app

Download this free app to view highlights from the major 2010—2011 exhibition "Abstract Expressionist New York" and its related publication on your iPad. Use this app to “view superb high-resolution images of selected Abstract Expressionist works. Learn more about the artists and NYC history with a multimedia map of studios, galleries, bars, and other points of interest. Watch in-depth videos on key works of art, browse a glossary of art terms, read about the exhibition and exhibition publication, share your favorite works on Twitter, and more.

 Editor’s Choice award-winning app has been described as “the best streaming music platform on the iOS market thanks to a deep music well, new on-demand streaming, playlists, and over 150 channels.”

Volume 2 Issue 3