MedicalPhysician Q&A

20 Questions: Michael Rack, MD, Sleep Medicine

Michael Rack, MD grew up in Southern California. He graduated from the University of Iowa College of Medicine in 1997. He completed combined residencies in Internal Medicine and Psychiatry at West Virginia University-Morgantown in 2002. He completed a Sleep Disorders Medicine fellowship at the University of Mississippi in 2003.

He stayed on at the University of Mississippi as an Assistant Professor of Psychiatry and Internal Medicine until 2005, when he left to start Somnus Sleep Clinic in Flowood, MS.

He is a diplomate of the American Board of Internal Medicine, the American Board of Psychiatry and Neurology (Psychiatry), and the American Board of Sleep Medicine. He is a member of the American College of Physicians and the American Academy of Sleep Medicine. 

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He is on the Behavioral Sleep Medicine Committee and serves as an Accreditation Site Visitor for the American Academy of Sleep Medicine. He is also a Clinical Assistant Professor of Psychiatry at the University of Mississippi. Recently, he was kind enough to sit down with SDN and share his perspective on his specialty with our users.

Describe a typical week at work.
I spend approximately three days a week seeing outpatients at Somnus Sleep Clinic, a 6-bed sleep disorders center near Jackson, Mississippi. I own the clinic with 2 non-physician business partners. I spend one to two half days a week reading sleep studies at Somnus Sleep Clinic, and also read some sleep studies on the weekends. Approximately two days per month I perform sleep lab accreditation inspections for the American Academy of Sleep Medicine. This frequently involves travel to another state. Once a month I provide psychiatric care for mentally retarded and autistic adults at several group homes. Several times per month I travel to a rural hospital approximately 45 miles from Jackson and perform sleep consults. I am also helping to set up a sleep lab at that hospital.

What mix of clinical/research/teaching work do you do? How much power do you have to change that mix?
Most of my work is clinical. I do some research, but this is purely voluntary on my part. Several times a year, I write a sleep disorders review article for Medlink Neurology. I am also analyzing some data from the Jackson Heart Study with a colleague who is a nephrologist at the University of Mississippi Medical Center. In addition I am working on a case report with my wife, who is a psychiatrist at the University of Mississippi Medical Center.

If you had it to do all over again, would you still become a doctor? (Why or why not? What would you have done instead?)
I probably still would become a doctor, but if I had to do it over again I would have taken some advanced mathematics classes in college and explored the possibility of becoming a quantitative analyst for a hedge fund.

Why did you choose your specialty?
I became interested in sleep medicine while completing an internal medicine/psychiatry residency at West Virginia University, Morgantown. I find the multidisciplinary nature of sleep medicine, which involves psychiatry, neurology, ENT, pediatrics, pulmonology, and general medicine, fascinating. Sleep medicine also has a profitable cognitive procedure (polysomnography) which requires no manual dexterity on the part of the physician.

Did you plan to enter your current specialty prior to med school?
No, prior to medical school I planned on becoming a primary care physician.

Now that you’re in your specialty, do you find that it met your expectations?
Sleep medicine is a rather narrow field to limit one’s practice to, and it is rather repetitive. I do some general psychiatry also. I wish that I could do a primary care clinic once a week, but I lack the infrastructure at my clinic to do this.

Are you satisfied with your income?
I am not satisfied with my income for 2007, but it should improve in 2008. My sleep lab has been gradually increasing the number of sleep studies performed, and it should soon be up to 100 per month. When that number is reached, it should result in an acceptable income.

What do you like most and least about your specialty?
I like reading sleep studies the most. The repetitive nature of a sleep clinic- primarily evaluating for and treating obstructive sleep apnea- is what I like the least.

If you took out educational loans, is/was paying them back a financial strain?
My educational loans were not excessive due to the help of my family. Paying them back was not a financial strain.

On average: How many hours a week do you work? How many hours do you sleep each night? How many weeks of vacation do you take?
I work about 60 hours per week. I sleep 7-8 hours each night. I don’t like to take long vacations. I attend frequent CME conferences during the year (4-5 per year) and take anywhere from 1 to 4 workdays off at a time to attend these. I do try to travel back to Southern California at least once per year; I will sometimes take off 4 workdays for this.

Do you have a family and do you have enough time to spend with them?
I am married to a psychiatrist and have a 7 year-old son and a 4 year-old daughter. I have enough time to spend with them.

In your position now, knowing what you do – what would you say to yourself 10 years ago?
Pay more attention to your retirement accounts while you are residency. Don’t keep your money in stock index funds during a bear market. Don’t make rapid changes in your allocation, but do react to market changes. Beware of falling knives.

What information/advice do you wish you had known when you were a premed? (What mistakes or experiences have you encountered that you wished you had known about ahead of time so you could have avoided them?)
I would advise premed students to begin doing hospital volunteer work or obtain some type of medical position as soon as they begin college. This will help in the medical school application process.

I would advise residents to retain the services of a good accountant and lawyer immediately upon finishing training (or sooner if they plan to practice in the same area they trained).

From your perspective, what is the biggest problem in health care today?
The old social contract between physicians and society has broken down. In the past, doctors would provide call coverage for local ER’s and would provide some charity care. In return, doctors were provided generous reimbursement by Medicare and private insurers. Increasingly over the last decade, society has become unwillingly to subsidize doctors’ charity care and ER coverage; Medicare and private reimbursement has been cut to the bone. As a result doctors have limited the insurance plans they take and fled local hospitals/ER’s. Cherry-picking specialty hospitals are proliferating.

From your perspective, what is the biggest problem within your own specialty?
Becoming an independent sleep specialist requires a large capital investment. It takes approximately $250,000 to start a 4-bed sleep lab.

Changing Federal regulations threaten the financial viability of sleep labs. For example, CMS (Medicare) is in the process of approving portable sleep monitoring for the diagnosis of obstructive sleep apnea. This would have a negative financial impact on many sleep labs.

What is the best way to prepare for this specialty?
Sleep medicine is a one year fellowship after a psychiatry, neurology, ENT, family practice, pediatrics, or internal medicine residency. The best way to prepare is to do one or two sleep medicine elective months during residency. Sleep medicine is becoming a more competitive fellowship, and it is hard for someone who has only completed an internal medicine residency to get- general internists are competing with pulmonary specialists for slots. If a resident is trying to go straight from internal medicine residency to sleep fellowship (rather than doing a pulmonary fellowship first), some sleep research during residency would be helpful.

Where do you see your specialty in 10 years?
There will be more hospital associated sleep labs but fewer freestanding sleep labs. There will be more physicians with sleep board certification. However, the number of doctors who practice sleep medicine full time will decrease; most will practice sleep medicine part time in conjunction with the specialty they trained in during residency.

What impact do mid-level providers have on your day-to-day practice?
I do not work with mid-level providers. Some sleep physicians utilize mid-level providers for patient follow-up visits, which allows the physician more time to read sleep studies.

What types of outreach/volunteer work do you do, if any? Any international work?
I don’t do any international work. I am an active member of the American Academy of Sleep Medicine and serve on its Behavioral Sleep Medicine Committee.

What do you like to do for relaxation or stress relief? Can you share any advice on finding a balance between work and life?
For relaxation and stress relief, I am currently taking online classes for an MBA at Mississippi State University. I also have two blogs, sleepdoctor (http://sleepdoctor.blogspot.com/) and rebel doctor (http://rebeldoctor.blogspot.com/). I also find playing no-limit Texas Hold’em relaxing. As far as finding a balance, my advice is that if a physician is feeling overworked, he should examine his work activities and drop the lowest paying or least enjoyable one.

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    Y. S.
  • January 30, 2008
Very interesting. Thanks a lot.
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    N.P.
  • February 1, 2008
someone edited out my comment because i said "it put me to sleep". what i should have said was this- it seems like he was more focused on money. All of his answers were short and robot-like.
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      TS
    • May 29, 2013
    My thoughts exactly. If you want to be an entrepreneur, don't be a physician. Money is a terrible reason to become a doc and you are likely to never be satisfied. Plus, there are many, many easier ways to make money. The problem is that few of those ways guarantees an above average salary like medicine does and I think that appeals to the would be entrepreneur's necessity to hedge their bet. In my experience, those docs are never happy. Yes, I'm a doc, but hopefully for all the right reasons.
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    ghostfoot
  • February 2, 2008
A conversation with this doc should cure anyone's sleeping troubles.
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    Patti
  • February 2, 2008
Thanks so much for doing the interview, Dr.Rack. It was very informative.
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    futuredoc
  • February 3, 2008
Wow, this interview was depressing. This doctor is an accomplished man but he really seems unhappy with his low salary. On top of that, he fears he'll be put out of business soon. His dream job(other than being a physician) is a quantitative analysis for a hedge fund?? money, money, money!
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    Gio
  • February 3, 2008
All about money.
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    $$$$
  • February 3, 2008
he has need to worry about his $$$ because sleep studies may not be the evidenced-based work-up for OSA any longer:
http://www.annals.org/cgi/content/abstract/146/3/157?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=PSG&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT (from the annals)
perhaps this hits on a larger point. here is a doctor who, as many have pointed out, appears really interested in making money. his business holdings and personal success may now come at the cost of unnecessary procedures (see above article); unnecessary billing; unnecessary cost to consumers. just throwing it out there.
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For those who think all I am interested in money here is my response:
1. I didn't make up the questions myself; I was asked if I was happy with my income and answered the question honestly. I don't spontaneously complain about my income. This year I will probably make a little bit more than last year, and expect to earn somewhere between the income of the average pcp and the income of the average psychiatrist.
2. I volunteer on the Behavioral Sleep Medicine Committee for the American Academy of Sleep Medicine. I also do accreditation site visits for the AASM. Although I am reimbursed for this, it is at a lower rate than most doctors can make working a day in the clinic.
3. I was trying to give med students a realistic look at the field of sleep medicine. Unless you want to be a wage slave (working for someone else) the rest of your life, anyone who goes into sleep medicine better have some business knowledge. When you are cosigning for six figure lines of credit, you better know what you are doing.
4. Do you students expect clinical practice to be all fun and games? Seeing patients one after another can be a grind at times- that's why it's called work. I do still find the specialty interesting- did you notice where I wrote that I am involved in research and attend frequent CME conferences - but seeing one sleep apnea pt after another can be repetitive. That's life.
5. Do you object to my advice to find an accountant and lawyer? A practicing doc's taxes are too complex to do on his own. A lawyer is necessary to help structure one's practice and to comply with Stark/antikickback regulations. Even if one wants to be a wage slave and work for someone else, a lawyer is still necessary to review employment contracts.
6. I have never paid more than $20,000 for a car. I currently drive a 2006 Pontiac Grand Prix that I bought used. Before that I drove a Toyota Corolla that I bought used.
7. All of my stock/mutual fund investments are in retirement accounts. Planning for retirement is important. I have to fund my own retirement, no employer is currently doing it for me. During residency, I didn't pay enough attention to my retirement investments and it cost me.
8. An interest in finance/business does not necessarily mean that someone is interested in making a lot of money. Many financial analysts make less than MD's. I was exaggerating a little bit when I said I wanted to be a quantitative analyst. My dream job (besides being a physician) would be portfolio management- not because of the income potential but because I find the field of finance/investing interesting.
9. I don't play Texas no-limit hold'em that often, and when I do, it's usually for relatively low stakes.
10. The changes coming to sleep medicine won't put me out of business.
11. My business holdings aren't that much anymore; I currently can't publicly say more about this.
12. I am not motivated by a desire to be rich, I would however one day like to be out of debt. I do enjoy being (mostly) self-employed. I am through with being a wage slave. I'd rather earn less than make a lot of money working for someone else.
13. That article applies to only a narrow subpopulation of osa patients. Polysomnography is still a very necessary procedure. I do not bill inappropriately. I follow the standards of the American Academy of Sleep Medicine. If you are interested more in the home testing vs psg debate, you can read my blog (you might find some of the comments by sleep technicians interesting). Treating severe osa is easy. Evaluating those with equivocal symptoms and treating mild to moderate osa is challenging.
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    Counterpoint
  • February 4, 2008
Dr. Rack, thanks for your responses. I think the responses above must be from students who have not experienced real life medical practice yet.
I fully agree with Dr. Rack on paying more attention to retirement accounts in residency, paying off debt, and making sure your business as a physician is financially viable. To brush off this advice as being 'all about money' is silly and short-sighted. We learn very little about business in medical school, and it is a major discredit to our profession since then we are in many cases expected to run businesses.
How can healthcare function if not as a business? It is different than other businesses in the way it has to function, as Dr. Rack points out, because we want to be able to provide care to everyone who needs it, for free if we have to. But if we are not concerned with making money, we will see more hospitals going out of business than wee already are. And that's not good for anyone's health. I'm a completely liberal hippie, and even I realize that. How can the poor get care when no doctors are taking Medicaid, and Medicare is giving you a fraction of what it costs to actually see patients?
Those of you who are critical of the viewpoints above should think a little harder - what Dr. Rack says is just logical, not cold. The Medicare/Medicaid payments have been going down, not up. Businesses can't function if the payment for their services continues to decrease, but they are trying to offer more services to more people, and in the face of inflation. I think more of us need to take an MBA-style look at medicine, healthcare is headed for a sorry situation otherwise.
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    Michael Rack, MD
  • February 4, 2008
thanks for the support, Counterpoint.
Maybe I was a little hard on students in my comment. I was young and idealistic once too. Certainly the clinical aspects of sleep medicine and taking care of patients are critical. I have a sincere interest in business/finance, and chose to highlight some of those aspects of sleep medicine in my answers to the 20 questions. I tried to provide some information about the specialty that you won't hear from any
medical school professor. If anyone has any questions about the fascinating field of sleep medicine, feel free to PM me, or post in the sleep medicine forum.
thanks
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    Ron Bennett
  • February 4, 2008
thanks for the honesty. Many of the dr. I speak to wish they had done something in business-not for money, but to have a more family oriented lifestyle. 60 hrs a week is the norm and many have call for the majority of their careers. as Dr. Rack stated wagers make good money, but you answer to someone else. I personally left business to go into medicine. Money is very important to meeting the daily needs of life. Dr. Rack simply is helping many of you who may have only worked as TA's or tutors set some priorities before you purchase the $500k home right away.
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    $$$$
  • February 4, 2008
i think i was wrong for implying that dr rack was 'in it for the money.'
as a student, though, i def entered the game an idealist and am day-by-day being frustrated by reality. i think there may be something to the fact that we future MD's are not good at business dealings. maybe it underscores the fact that medicine, in principle, should be a field where idealists can thrive, since after all it attracts so many of them. ok, maybe that sounds loopy.
i am only coming from houston, tx, the home of the 'largest medical center in the world,' the texas medical center. sure its nice, but you can bet your ass the closest anyone without insurance is going to get to MD anderson is the ****-end of the medical center, the county hospital. the idealist in me cries out against what MBA style medicine is doing, the inequality its creating, etc.
but, nevertheless, i believe i was wrong for implying that about dr ruck, and i offer an anonymous online apology and rescind my anonymous online critique. clearly, he isnt one of the folks raking it in and living lavishly without regard for his patients. sorry.
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    LM
  • February 5, 2008
I appreciate Dr. Rack's highly informative and realistic perspective on his career. Finances and compensation are issues that every physician needs to consider, beyond simply the blind idealism that a lot of pre-meds display.
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    N.P.
  • February 5, 2008
Now that was some passion. Thank you so very much for your responses in your comments. This was very helpful and will give me some insight for my future. Those comments were very interesting to read. Thanks again and best of luck in your practice.
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    bert blanchard
  • February 6, 2008
is a wholly owned by physician sleep lab also considered an IDTF and if so, is there a category for office based sleep centers other than hospital based?
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    Sarah M. Lawrence
  • February 6, 2008
Thank you Dr. Rack, for doing the interview and for coming here to answer questions and interact with students. Your time and thoughtfulness is appreciated!
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    JJ
  • February 11, 2008
I am a psychiatrist and finds my work to be fascinating. I thought about med-psych combined residency for a while but then decided that psychiatry is a much better fit (medicine and many aspects of it are quite repetitive). However, pure outpt psychopharmacologic appointments that last 10-15 minutes each can be quite mechanical/boring as well. That's why it is imperative to mix it up with interesting psychotherapy cases and some inpatient psychiatry work.
Why do people come up with the term "ROAD to success" = Radiology, opthalmology, anesthesiology and dermatology? Because medical students think about money a lot. That's the reality of things and that's how our society encouarges. It is ok for premeds to get 4.0 GPA and feel good about themselves, but it is not good for doctors to make $500k and feel good about themselves? After all, you are judged by your grades when you are in school. When you graduate, well, you are judged by money and power. The higher the better! Same concept. Why do politicians want to climb up power structure? After all, the higher they climb, they further away they are from "the people" who elected them and need their help.
If I were not in medicine, I would be in mutual fund/money management as well. It is just such a fascinating field. I am talking about "investing," not "speculating." Knowing the companies well, dissecting them and understanding investors' psychology are all fun things to do. At the end of day, losing millions of dollars for your client will piss him/her off but unless you embezzle their funds, you are very very unlikely to get sued (not like doctors nowadays).
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    Phaedrus
  • February 12, 2008
STOP THE PRESSES!
It's shocking to see such honesty in an 'official' interview with a doctor. Dr. Rack, I hear you, and I appreciate what you're saying. All good advice. This is the type of stuff veteran docs will tell you in private, but even they usually clamp down in 'on the record' talks if the topics of money or the business of medicine arise.
Just because we're young idealists who want to save the world, doesn't mean we won't one day have a family, mortgage, and a need to actually pay off some of this multi-hundred thousand dollar debt! Further, Private Practice is a business, even if it's essentially a non-profit endeavor for the modern socialist med student. A little money and business education go a long way in dealing with these problems.
Finally, there's absolutely nothing wrong with insisting on adequate financial compensation for the 35 years of blood, sweat, and tears it takes to become a physician. If ALL I wanted was to serve the needy, I would have become a social worker/activist - THOSE are the people who affect large numbers of lives.
Thanks for the great insight, Dr. Rack, and good luck to you and your practice. I respect the 'I'm no wage slave' notion, and was very proud to have escaped wage slavery myself!
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    Ambar
  • March 13, 2008
Thanks Doc for the honest replies. It is really helpful to hear it as it is. As an aspiring med school student, I needed to know the facts. I appreciate your insight.
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    PG
  • January 8, 2009
I am going to give you my own personal account of sleep medicine .... you can see some contrasts with Dr. Rack's ideas.
I use to practice as internist for a while at a well known academic setting with a back ground in neuropharmacology and a big bag of published research.
I was initially thinking, I will be a pulmonary/critical care physician but the realities of practice of medicine and the fact that I was making these desicions when I was a bit older helped me decide not to go for CCM. I chose to have a better lifestyle basically. I was interested in the sleep medicine from many years ago so I explored it more and found it to be really interesting. I was lucky to be able to do a fellowship in the sleep medicine.
I found the practice of sleep medicine much more interesting than a lot of other fields that I have experience with (that includes meaningful experience with being closely involved – as a job – with the fields of trauma, vascular Sx, ENT, Lasers in medicine, bench and clinical research and internal medicine!)
I think a student should not forget that no matter what subspeciality they choose, they will end up having to deal with a few limited conditions and it is going to feel repeatative. Yes, in a sleep clinic you have to do a long semi structured interview. But, the analysis of this information and formulation of plan in these cases has been an absolute pleasure for me.
Some center focus on sleep apnea that’s when it can get boring. But if you manage to have a good name in the region then you will have consults for a lot of other issues . You can be seeing patients with other problems for up to half of your practice. I talk about patient with conditions like RLS, Parasomnia, narcolepsy, eating and movement disorders etc. that helps your morale but hurts your pocket since you will order less polysomnograms. Aslo if you mange to get a lot of doctors order your tests from their office that can be helpful but a bit frustrating when you read the test.
Another thing is that if you find a way not to have "non physicians" as co-owners of your center - I did not find that way yet, then your income will be way higher. I know some successful people who make numbers comparable to ortho but I think that should not be the comparison because there is only one life and we should do the thing that we like as Micheal Rack said. I also think the business of medicine is an extremely important part of your job … if you do not like it go be an employee but you will be hearing how bad you are for the rest of your life. I was thinking this aspect is a bit exagerated in Micheals notes but remember he is studying MBA now and directing a medical business …. What did you expect?
Another issue about sleep medicine is that since it is conected to a big revenue, there is a lot of local politics with other doctors and hospitals involved in the practice that will be ongoing and inate to the business model that you have.
If somebody likes to think about whats wrong with the patient in depth, make difficult differential diagnosis, has a technological savey and does not mind spending several hours in front of a computer in each week then sleep medicine will be very rewarding to practice. It will provide you with a lush lifestyle (ofcourse talking about physicians) and has a good income.
By the way all sleep specialists agree that for most of the people PSG is really important test to be done and other tests if done are just as good as they get - maybe poor boy version of the real thing, and I am sure as somebody in the field of medicine you know that couple of articles are not enough. Maybe in few more years we know more but most of the people thing as Dr. Rack said just for the minority of the people who can not come to the sleep lab it is a good thing to do home monitoring. It is almost the same as saying D-Dimer can replace the CT of chest to diagnose PE ... well yes maybe in a minority of the cases we settle down with just a normal D-Dimer. The home monitoring is being pushed by the ENT/Head and neck physicians to get rid of sending the patient to the sleep lab before they do some surgeries that are mainly not effective … look at Jan issue of sleep medicine journal for the meta-analysis … do not listen to them !!! just joking
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    MS3 reader
  • February 6, 2010
OK...A D-Dimer is used to RULE OUT a PE.
You're welcome.
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    M S M
  • December 23, 2010
I am a board certified psychiatrist and interested to take last Sleep medicine Board exam ,2011 without Fellowship in Sleep Medicine.ABPN and ABIM want iterpretation of raw data of 200 Polysomnograms and 25 Sleep Latency tests at the time of application i.e. 4.30.11 -last date to apply.Can anybody advise me how to get those training in short period of time -like volunteer in sleep clinic etc.Thanks
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    Stephen Crowe, MD
  • December 27, 2010
Knowing Dr. Rack personally (I trained after him in sleep medicine), I can tell you that he is probably one of the most well rounded and intelligent individuals I know.
His advice to me and in this interview has always meant to help. Thanks to Dr. Rack for giving an honest assessment. There is one thing that I would like to underscore from his comments...that is, every challenge is an opportunity. As you enter your field and major changes start to occur, try to see it as an opportunity to grow. Attitude is everything.
Thanks Dr. Rack for our perspective.
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    Chris
  • March 29, 2011
Mike is a good guy and one of the smartest people I met in undergrad (UCR). I was his room mate my freshman year in the academic dorm. Funny I went on to Iowa and saw him on the street (had no idea he went on to continue his studies there as did I). Congrats Mike on the business and finishing your studies!
Chris Trulin

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