Starting in private practice

[Nonphysiologic]

Hey guys

So recently a lot of pain docs have been telling me their biggest regret was not starting private practice (solo or one other partner) earlier.

Honestly this seems super daunting and all I Know is academia. I like the idea of solo or a small private practice a lot but am scared to take a huge loan and I get tired thinking of all the business aspects that I'd have to learn. Also I like the idea of having a safety net after fellowship and colleagues I can bounce ideas and questions off of. But the earning potential and independence of private practice is alluring. The other problem is I want to be in a metro area in a top 10 populated city sooo I'm not even sure about how feasible my dreams are.

Any other solo or small group practicioners can maybe shed some light? Any good resources I can read in regards to starting my own practice? How can I research a potential city or suburb? Honestly I don't even know where to begin in regards to starting a solo private practice .

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[drusso]

Hey guys

So recently a lot of pain docs have been telling me their biggest regret was not starting private practice (solo or one other partner) earlier.

Honestly this seems super daunting and all I Know is academia. I like the idea of solo or a small private practice a lot but am scared to take a huge loan and I get tired thinking of all the business aspects that I'd have to learn. Also I like the idea of having a safety net after fellowship and colleagues I can bounce ideas and questions off of. But the earning potential and independence of private practice is alluring. The other problem is I want to be in a metro area in a top 10 populated city sooo I'm not even sure about how feasible my dreams are.

Any other solo or small group practicioners can maybe shed some light? Any good resources I can read in regards to starting my own practice? How can I research a potential city or suburb? Honestly I don't even know where to begin in regards to starting a solo private practice .

Start small like a micro-practice. Implement a full-suite, integrated EHR/PM/Scheduling system Athena--not for long term, but for your start up phase. You'll outgrow it eventually, but in the beginning you'll have nothing better to do than figure it out. Get a credit line from a bank, general and liability insurance, and a good attorney to help with employee handbook/human resources. Hire a consultant to help with insurance contracts. Get in front of any and everyone's face to you can to market yourself.

There is no greater reward and satisfaction than charting your own way and not being beholden to hospital administrators, etc.

 

[functionalbee]

Hi non physiologic. I read your posts with interest. I am also a non anesthesia resident like you who has applied pain and am very worried for the upcoming match. I need your help to make plan b. Will you help me. Can I have your email ID.

 

[Disciple]

Hey guys

So recently a lot of pain docs have been telling me their biggest regret was not starting private practice (solo or one other partner) earlier.

Honestly this seems super daunting and all I Know is academia. I like the idea of solo or a small private practice a lot but am scared to take a huge loan and I get tired thinking of all the business aspects that I'd have to learn. Also I like the idea of having a safety net after fellowship and colleagues I can bounce ideas and questions off of. But the earning potential and independence of private practice is alluring. The other problem is I want to be in a metro area in a top 10 populated city sooo I'm not even sure about how feasible my dreams are.

Any other solo or small group practicioners can maybe shed some light? Any good resources I can read in regards to starting my own practice? How can I research a potential city or suburb? Honestly I don't even know where to begin in regards to starting a solo private practice .

There's the sticking point. You need to do your homework on the area/your targeted community, before hand and come up with a plan that has a high probability of success. Get all your ducks in a row, before you take out the loan.

Good place to start (http://www.city-data.com)

Look before you leap.

 

[Stim4me]

Wait for the election. Makes a big different if aca continues or dives further. Nobody knows what Hiliary will do. Most important issues is site of service fees. If we are equalized to hospital fees you will survive. If not, our income will tank due to CMS mandates and quality measure penalties targeted to pp only...

 

[hyperalgesia]

Hey guys

So recently a lot of pain docs have been telling me their biggest regret was not starting private practice (solo or one other partner) earlier.

Honestly this seems super daunting and all I Know is academia. I like the idea of solo or a small private practice a lot but am scared to take a huge loan and I get tired thinking of all the business aspects that I'd have to learn. Also I like the idea of having a safety net after fellowship and colleagues I can bounce ideas and questions off of. But the earning potential and independence of private practice is alluring. The other problem is I want to be in a metro area in a top 10 populated city sooo I'm not even sure about how feasible my dreams are.

Any other solo or small group practicioners can maybe shed some light? Any good resources I can read in regards to starting my own practice? How can I research a potential city or suburb? Honestly I don't even know where to begin in regards to starting a solo private practice .

I would personally work employed for a few years, save up some money, learn as much as possible about billing and business, etc. It's definitely possible to jump head first into the unknown and survive. But there have been casualties...

 

[Ligament]

Wait for the election. Makes a big different if aca continues or dives further. Nobody knows what Hiliary will do. Most important issues is site of service fees. If we are equalized to hospital fees you will survive. If not, our income will tank due to CMS mandates and quality measure penalties targeted to pp only...

Agree with this. If Crooked Hillary is elected, I don't see private practices (taking insurance) surviving. Only concierge and self pay will survive. Hospitals will become local monopolies of insurance accepting businesses.

 

[Disciple]

Agree with this. If Crooked Hillary is elected, I don't see private practices (taking insurance) surviving. Only concierge and self pay will survive. Hospitals will become local monopolies of insurance accepting businesses.

The next question is concierge and self-pay what?

Procedures only, no opioids? I don't foresee enough volume in that without doing other contracted work.

Comprehensive Pain Mgmt + Addiction Medicine/Wellness?

What does the forum think?

 

[101N]

Some blend of non-opioid pain mangement/Addiction/structured opioid refill clinic (CDC) is the only way forward.

 

[Disciple]

I don't see a lot patients doing cash pay or concierge for non-opioid pain management (unless you're doing a chiro/acupuncture type practice) or structured refills at CDC levels (they can go to through their hospital based insurance for that at lower cost).

I guess that leaves Addiction Medicine for the well to do CS population?

This is giving me heartburn.

 

[drusso]

I don't see a lot patients doing cash pay or concierge for non-opioid pain management (unless you're doing a chiro/acupuncture type practice) or structured refills at CDC levels (they can go to through their hospital based insurance for that at lower cost).

I guess that leaves Addiction Medicine for the well to do CS population?

This is giving me heartburn.

Disciple, take a Tums: Just the other day, another long-time patient came in and said, "Ever since my PCP sold their practice to [large behomenth of a health care system] their office feels more and more like a Medicaid Clinic."

So, concentrate on services that are not offered or done poorly in your community--safe/appropriate opioid management, concierge addiction, rational interventional, etc. The more brow beating that patients have to endure from their internist and insurance companies about there being "no evidence" for ESI's, meds, injections, etc the more they will beat a path to your door. Face it, for most patients the only evidence they need is that SEE Joe is moving better on the golf course these days ever since he came in to see you for his shot. Let the health systems choke on the gristle of government payers while YOU concentrate on skimming the cream. Fiddle while Rome burns.

There will always be room for high quality, patient focused private practices...these are the "salad days," but steak is on the horizon...especially if Hillary wins (which she will) and the (not-so) Affordable Care Act becomes reified into a single payer system (which it will). Welcome to Canada!

 

[hyperalgesia]

I think an opportunity might be to charge for other aspects of the encounter. By BCBS carrier contract, which I just renewed, says you can't charge a "concierge fee".

I heard about an EMR company that charges each patient for the use of the EMR. It's a small fee per visit I believe. Then the EMR company pays the medical practice 1/3rd of the revenue. So it's like the doc is part owner of the EMR. Can't seem to find the company name...

 

[Stim4me]

Disciple, take a Tums: Just the other day, another long-time patient came in and said, "Ever since my PCP sold their practice to [large behomenth of a health care system] their office feels more and more like a Medicaid Clinic."

So, concentrate on services that are not offered or done poorly in your community--safe/appropriate opioid management, concierge addiction, rational interventional, etc. The more brow beating that patients have to endure from their internist and insurance companies about there being "no evidence" for ESI's, meds, injections, etc the more they will beat a path to your door. Face it, for most patients the only evidence they need is that SEE Joe is moving better on the golf course these days ever since he came in to see you for his shot. Let the health systems choke on the gristle of government payers while YOU concentrate on skimming the cream. Fiddle while Rome burns.

There will always be room for high quality, patient focused private practices...these are the "salad days," but steak is on the horizon...especially if Hillary wins (which she will) and the (not-so) Affordable Care Act becomes reified into a single payer system (which it will). Welcome to Canada!

I agree with this. Also be reassured you won't have a lot of high end pp sprouting up around you. The cost of entry become higher and higher

 

[SSdoc33]

Agree with this. If Crooked Hillary is elected, I don't see private practices (taking insurance) surviving. Only concierge and self pay will survive. Hospitals will become local monopolies of insurance accepting businesses.

no problem if you dont like hillary or the ACA. but to model yourself after trump is a disgrace. you are better than that

 

[Ligament]

no problem if you dont like hillary or the ACA. but to model yourself after trump is a disgrace. you are better than that

I wish I could successfully model myself after Trump, but I'll never be able to employ tens of thousands of people of all races and sexes and make billions of dollars in my lifetime like he did.

 

[Stim4me]

I wish I could successfully model myself after Trump, but I'll never be able to employ tens of thousands of people of all races and sexes and make billions of dollars in my lifetime like he did.

Like he said, he's smart ... Government is rigged

 

[Ducttape]

he must be - you are paying taxes for him, since he isn't paying any...

 

[hyperalgesia]

When you have a capital gains loss, you deduct it. I deduct it. Trump deducts it. It's an open question if you want businesses to continue to be allowed to deduct cap gains losses but for now it's what every business does. Obviously.

I would love to see the dishonest, smug media to lose this election.

 

[Ligament]

he must be - you are paying taxes for him, since he isn't paying any...

Based on what evidence? A tax return from 1995? The NYT has ZERO evidence that he has paid no tax for 18 years...the extrapolated that out of their butts.

You realize that was 21 years ago? He said himself on TV long ago that he had a billion dollar loss.

The point is he had a billion dollar loss and recovered from it. Our country has had a multi trillion dollar loss and we need somebody that will help us recover from it, not CREATE it as Comrade Obama and Crooked Hillary will do.

 

[Stim4me]

Even more crooked is that his taxes were leaked illegally.... But peeps Like ducctape tend to ignore those "law and order" facts and look away.

You see the BLM peeps almost maul an Asian trump supporter. Bernie and Hilary supporter are thugs and criminals... Trump supporters are hillbillies and intellects. Strange times...

 

[lonelobo]

Even more crooked is that his taxes were leaked illegally.... But peeps Like ducctape tend to ignore those "law and order" facts and look away.

You see the BLM peeps almost maul an Asian trump supporter. Bernie and Hilary supporter are thugs and criminals... Trump supporters are hillbillies and intellects. Strange times...

I agree with half of that statement

 

[SSdoc33]

Based on what evidence? A tax return from 1995? The NYT has ZERO evidence that he has paid no tax for 18 years...the extrapolated that out of their butts.

You realize that was 21 years ago? He said himself on TV long ago that he had a billion dollar loss.

The point is he had a billion dollar loss and recovered from it. Our country has had a multi trillion dollar loss and we need somebody that will help us recover from it, not CREATE it as Comrade Obama and Crooked Hillary will do.

no, we dont know the full story. trump takes a billion dollar loss, then later declares bankruptcy so he doesnt have to pay up on his debts, yet somehow he has "billions" of his his own dollars hidden from both his creditors and from the US taxes. what he has done MIGHT be legal. we dont really know. but we do know that it is a sh$tty way to go thru life, and that he has made his money off the backs of the working man by exploiting our legal system.

the system is rigged, alright.

 

[SSdoc33]

I wish I could successfully model myself after Trump, but I'll never be able to employ tens of thousands of people of all races and sexes and make billions of dollars in my lifetime like he did.

you also didnt get 10 million bucks from your dad along with his business contacts and goodwill that had been engendered.

you work for your money honestly and pay your taxes. nothing to be ashamed of. you can look yourself in the mirror without vomiting.

 

[hyperalgesia]

no, we dont know the full story. trump takes a billion dollar loss, then later declares bankruptcy so he doesnt have to pay up on his debts, yet somehow he has "billions" of his his own dollars hidden from both his creditors and from the US taxes. what he has done MIGHT be legal. we dont really know. but we do know that it is a sh$tty way to go thru life, and that he has made his money off the backs of the working man by exploiting our legal system.

the system is rigged, alright.

Since the IRS confirmed he is under audit I am fairly confident his tax behavior is legal. I think everyone pays the minimal legal amount of taxes they can. And I mean the absolute bare bones minimum. Capital loss deduction is not a "loophole". I am pretty sure that scrutiny of Hillary's tax records during the recession would reveal a capital loss deduction. If she took a loss and didn't report it, I will think she is spacey If the Chinese try to pull one over on us, who would you rather have watching our money?

 

[Ligament]

you also didnt get 10 million bucks from your dad along with his business contacts and goodwill that had been engendered.

you work for your money honestly and pay your taxes. nothing to be ashamed of. you can look yourself in the mirror without vomiting.

No I did not. But that does not make Trump much less of a businessman. Trump got 1 million from his dad, not a multi-billion dollar empire that he built.

Also, I'm not going to vote for the racist, sexist Democratic party and their incredibly corrupt and traitorous candidate. Their candidate has taken hundreds of millions of dollars from corporations and enemy nation states. Trump has taken nothing from them.

 

[Ducttape]

i wouldnt bother arguing with them, ssdoc. a certain proportion of the population are unable/unwilling to see their favorite politician - Clinton or Trump - denigrated, and will rely on spin tactics to cover the faults of their candidates.

for anyone complaining that these pages were illegal because they were leaked... they should look in the mirror and ponder why they did not equally complain when wikileaks leaked Clinton emails or when wikileaks leaked the DNC emails that cost Wasserman-Schulz her job.

 

[hyperalgesia]

i wouldnt bother arguing with them, ssdoc. a certain proportion of the population are unable/unwilling to see their favorite politician - Clinton or Trump - denigrated, and will rely on spin tactics to cover the faults of their candidates.

for anyone complaining that these pages were illegal because they were leaked... they should look in the mirror and ponder why they did not equally complain when wikileaks leaked Clinton emails or when wikileaks leaked the DNC emails that cost Wasserman-Schulz her job.

My only point is that if my accountant told me there was a tax deduction or "loophole" or whatever that would legally save me a lot of money, sign me up immediately. Are you guys seriously suggesting that trump should have NOT claimed a loss and taken the deduction? No one gives to the IRS when they don't have to. NO ONE!

 

[DrCommonSense]

Agree with this. If Crooked Hillary is elected, I don't see private practices (taking insurance) surviving. Only concierge and self pay will survive. Hospitals will become local monopolies of insurance accepting businesses.

Most specialist doctors will be making about 30-50% over PCPs as per Obamacare.

It will be the MBAs running things and making the big dollars. The CEOs, executives of hospitals, pharma CEO, insurance CEO/VPs, etc. that make the big dollars.

Also, physicians will still be screwed with malpractice.

 

[Ducttape]

No one is claiming that they wouldn't take A tax deduction.

What is concerning is that 1. Here is a politician who is claiming he is working for the good of the common man but he has never shown an interest in doing so in the past 2. Here is a man who says he is "one of us" when he has had advantages that no common man will ever dream of having access 3. He is telling people to believe that he would fix a broken system that he has reaped huge benefits from, but his tax plan says nothing of closing any of the loopholes he took advantage of. I'll bet he wants his kids to be able to take advantage too

and how good a businessman is he to lose $916 million in the first place? He got it back - great for him. But is he going to lose $916 Billion of "our money" and be able to get it back in 4 years, or just leave us and our children to foot the bill...


Sent from my iPhone using SDN mobile

 

[DrCommonSense]

No one is claiming that they wouldn't take A tax deduction.

What is concerning is that 1. Here is a politician who is claiming he is working for the good of the common man but he has never shown an interest in doing so in the past 2. Here is a man who says he is "one of us" when he has had advantages that no common man will ever dream of having access 3. He is telling people to believe that he would fix a broken system that he has reaped huge benefits from, but his tax plan says nothing of closing any of the loopholes he took advantage of. I'll bet he wants his kids to be able to take advantage too

and how good a businessman is he to lose $916 million in the first place? He got it back - great for him. But is he going to lose $916 Billion of "our money" and be able to get it back in 4 years, or just leave us and our children to foot the bill...


Sent from my iPhone using SDN mobile

Can't lose more money than Obama/Hillary.

They literally DOUBLED the amount of debt (8 to 10 trillion by the time his 8 years are up) despite artificially low interest rates that keep debt growth down due to lower payments on the debt.

Also, a "loss" on paper can be a good tax situation. If he made billions but "lost" 916 million, he can claim that as a tax deduction. You have to look at the overall win/lose situation. If he has a net worth of 10 billion, he has to be doing something correct.

 

[Stim4me]

The masses have no clue about our complex tax scheme. The lay public essentially knows nothing above a basic high school level, if that...
didn't Hiliary and Bernie both confirm that their supporters live in their parents basements and are delusional...

 

[SSdoc33]

No I did not. But that does not make Trump much less of a businessman. Trump got 1 million from his dad, not a multi-billion dollar empire that he built.

Also, I'm not going to vote for the racist, sexist Democratic party and their incredibly corrupt and traitorous candidate. Their candidate has taken hundreds of millions of dollars from corporations and enemy nation states. Trump has taken nothing from them.

the clinton foundation feeds starving kids, provides money to support global health, and helps with disaster relief. it has literally saved thousands if not hundreds of thousands of lives.

https://en.wikipedia.org/wiki/Clinton_Foundation

as far as trumps money:

"A National Journal writer, S.V. Dáte, estimated Trump started with $40 million in 1974 when he became president of his father’s real estate company. By one estimate, the firm was worth about $200 million. Divided among Donald Trump and his four siblings, each would have received $40 million."

http://www.politifact.com/florida/article/2016/mar/07/did-donald-trump-inherit-100-million/


im not arguing that you vote for hillary. but your outright lies need to be called out. spout your propaganda somewhere else and educate yourself. otherwise, you sound as ignorant as trump. you can be a conservative without being ignorant.

 

[SSdoc33]

Can't lose more money than Obama/Hillary.

They literally DOUBLED the amount of debt (8 to 10 trillion by the time his 8 years are up) despite artificially low interest rates that keep debt growth down due to lower payments on the debt.

Also, a "loss" on paper can be a good tax situation. If he made billions but "lost" 916 million, he can claim that as a tax deduction. You have to look at the overall win/lose situation. If he has a net worth of 10 billion, he has to be doing something correct.

you got a source that says he is worth 10 billion?

 

[lonelobo]

No I did not. But that does not make Trump much less of a businessman. Trump got 1 million from his dad, not a multi-billion dollar empire that he built.

Also, I'm not going to vote for the racist, sexist Democratic party and their incredibly corrupt and traitorous candidate. Their candidate has taken hundreds of millions of dollars from corporations and enemy nation states. Trump has taken nothing from them.

Really?

https://www.icij.org/blog/2016/09/t...-business-iranian-bank-later-linked-terrorism

http://time.com/4433880/donald-trump-ties-to-russia/

 

[DrCommonSense]

the clinton foundation feeds starving kids, provides money to support global health, and helps with disaster relief. it has literally saved thousands if not hundreds of thousands of lives.

https://en.wikipedia.org/wiki/Clinton_Foundation

as far as trumps money:

"A National Journal writer, S.V. Dáte, estimated Trump started with $40 million in 1974 when he became president of his father’s real estate company. By one estimate, the firm was worth about $200 million. Divided among Donald Trump and his four siblings, each would have received $40 million."

http://www.politifact.com/florida/article/2016/mar/07/did-donald-trump-inherit-100-million/


im not arguing that you vote for hillary. but your outright lies need to be called out. spout your propaganda somewhere else and educate yourself. otherwise, you sound as ignorant as trump. you can be a conservative without being ignorant.

Cool story bro.



This is the reality of those "Clinton" foundations. Pay to play for lobby groups and billionaires.

 

[DrCommonSense]

you got a source that says he is worth 10 billion?

Forbes has him at about 4 billion, he has released information saying 10 billion.

Irregardless, he is very rich.

 

[SSdoc33]

Forbes has him at about 4 billion, he has released information saying 10 billion.

Irregardless, he is very rich.

so, you are only off by 6 billion?

he has a lot of assets in real estate, the value of which we all know can evaporate overnight.

yes, he is rich. so was Muamar Gaddafi

 

[DrCommonSense]

so, you are only off by 6 billion?

he has a lot of assets in real estate, the value of which we all know can evaporate overnight.

yes, he is rich. so was Muamar Gaddafi

Yeah thats why its very difficult to value with significant fluctuations for anyone attempting to gauge his wealth.

Clintons are pretty rich too giving 500K speeches to Goldman Sachs due to their "altruism" and care for humanity right?

Bill and Hillary are worth in the 100s of millions since leaving office. It was probably due to them helping the poor in Africa right?

That Bill is a saint!

 

[SSdoc33]

Yeah thats why its very difficult to value with significant fluctuations for anyone attempting to gauge his wealth.

Clintons are pretty rich too giving 500K speeches to Goldman Sachs due to their "altruism" and care for humanity right?

Bill and Hillary are worth in the 100s of millions since leaving office. It was probably due to them helping the poor in Africa right?

That Bill is a saint!

the clinton's net worth is 62 million, so you are again off by a factor of at least 2.

http://www.thedailybeast.com/articl...e-not-worth-100-million-as-new-ad-claims.html


are all republicans allergic to facts?


bill is a skirt chaser. no doubt about it. he certainly has his demons. yes, they make money off of their political celebrity. he was a hell of a president, though. and hillary will be the next one, so you should probably get your facts straight

 

[DrCommonSense]

the clinton's net worth is 62 million, so you are again off by a factor of at least 2.

http://www.thedailybeast.com/articl...e-not-worth-100-million-as-new-ad-claims.html


are all republicans allergic to facts?


bill is a skirt chaser. no doubt about it. he certainly has his demons. yes, they make money off of their political celebrity. he was a hell of a president, though. and hillary will be the next one, so you should probably get your facts straight

Here's fortune magazine on Clinton net worth being CONSERATIVELY estimated at 110 million:

http://fortune.com/2016/02/15/hillary-clinton-net-worth-finances/

Here's another: http://moneynation.com/hillary-clinton-net-worth/

Bill + Hillary= 111 million

Of note: The Clintons reportedly have some of their money in blind trusts that prevent even them from knowing their exact net worth. If those trusts were created in 2011, they may account for the $17 million drop in Hillary Clinton net worth figures also.


Dailybeast is a liberal rag that is in bed with Clintons:

https://en.wikipedia.org/wiki/The_Daily_Beast

Of note:
" The Daily Beast is owned by IAC, where Vice Chair of the Clinton Foundation, Chelsea Clinton, serves on the board of directors.[19]"

Wow sounds like a real "independent" source you got there.

Liberals seem allergic to facts


Get your facts straight.

 

[Ducttape]

sigh... I sometimes dream that the American people could have gotten their act together beforehand, and we could have had a real good choice, like Sanders vs. Kasich...

why don't we get back to arguing what we really know a lot about, like level 1 evidence for regenerative medicine?

 

[hyperalgesia]

It's incredible what you can afford if you totally sell out the public trust. The more power you have over public policy, the more trust you have to sell... I can only imagine the kind of house the Clintons will be able to afford after they sell out the presidency a second time.

http://www.nytimes.com/2016/08/11/us/politics/clinton-homes.html?_r=0

 

[Yo GabbaPentin]

the clinton foundation feeds starving kids, provides money to support global health, and helps with disaster relief. it has literally saved thousands if not hundreds of thousands of lives.

https://en.wikipedia.org/wiki/Clinton_Foundation

That is funny. I hate all of the candidates... but THAT is funny!!

 

[lonelobo]

It's incredible what you can afford if you totally sell out the public trust. The more power you have over public policy, the more trust you have to sell... I can only imagine the kind of house the Clintons will be able to afford after they sell out the presidency a second time.

http://www.nytimes.com/2016/08/11/us/politics/clinton-homes.html?_r=0

Show me a president in the modern era that after having left office is not significantly better off financially......500k speaking fees is part of the gig

 

[nvrsumr]

I am not a trump fan but his son had a good comment after last nites debate. What product has Pres. Clinton sold to be worth 100 million? What has he created? He is a 100 millionaire selling access and influence. That isn't cool. Gaudy gold hotels are at least real assets.

 

[metadr]

Both Clinton and Trump has their biggest assets in their names... The names Trump and Clintons are itself sold. A speech from Clinton is worth money just as a random building owner paying money to put the "Trump" on the building.

 

[hyperalgesia]

Show me a president in the modern era that after having left office is not significantly better off financially......500k speaking fees is part of the gig

If someone is truly out of public service, I have absolutely no problem with what they charge. But Hillary never was really out. This is obvious when you look at her fees.
http://freebeacon.com/politics/fact...make-as-much-for-speeches-as-hillary-clinton/