The plans of President Trump and congressional Republicans for reducing health care spending are a work in progress. Republicans prioritized tax cuts for people with high incomes, as well as increased spending for defense and border protection. As part of the process, they looked for areas in which to reduce spending. Social services and health care are among the areas likely to take the biggest hits.
The largest potential reduction in health care spending is from the Medicaid program, which serves low-income people. Earlier this year, the American Health Care Act (introduced in the House) and the Better Care Reconciliation Act (introduced in the Senate) would cut Medicaid.
At the time of this printing, the Congressional Budget Office estimated that the most recently introduced act (the Senate version) would cut Medicaid spending by $772 billion over the next 10 years.
The reductions in Medicaid spending would result from having fewer people enrolled in Medicaid and from changes to the funding formula for Medicaid. Currently, federal payments to states for Medicaid are open-ended. The more a state spends insuring its people, the more the federal government reimburses the states.
Under the Republican plan, states would receive fixed amounts that would not increase based on the scope of coverage provided by state Medicaid plans. The fixed amount would either be in the form of a block grant to each state or a limit on how much the federal government would pay per enrollee. Additional reductions in Medicaid spending could come from allowing states to reduce the benefits that enrollees receive.
Subsidies for health insurance
The second largest reduction in federal health care spending would come from elimination of the subsidies that have helped people purchase non-group health insurance. The subsidies were provided under the Affordable Care Act (also known as Obamacare). The Congressional Budget Office estimated that eliminating subsidies under the Senate’s Better Care Reconciliation Act would reduce federal outlays by $408 billion over 10 years.
According to the Congressional Budget Office, 9 million people received subsidies for insurance in 2017.
Instead of directly subsidizing payment of health insurance premiums, the Trump plan would give people tax credits when they purchase insurance. The Kaiser Family Foundation analyzed the impact of eliminating insurance subsidies and substituting tax credits and found that government costs would increase.
According to Kaiser, when insurance companies lose revenue from lack of federal subsidies for insurance, the insurance companies will raise premiums by an average of 19 percent. The increase in premiums will result in higher tax credits for those who purchase insurance, and, thus, reduce tax revenue to the federal government.
Kaiser estimates that added cost to the government by shifting from subsidies to tax credits would be $2.3 billion in 2018.
Cuts at NIH
President Trump’s proposed budget for 2018 cut $5.8 billion from the National Institutes of Health (NIH). That amounts to an 18 percent cut of NIH’s $31.7 billion budget. Tom Price, Secretary of the Department of Health and Human Services, said the cuts will be for “indirect” costs of research, such as payments that the department makes to universities to cover the administrative costs of running research programs.
Congress is likely to push back on the proposed sharp reductions in research spending.
Establishment of high-risk pools for sale of insurance is among the reforms considered by some Republicans. The pools become particularly important if the mandate for individuals to have insurance is dropped and if insurance companies are allowed more flexibility on setting rates, including basing rates on an individual’s pre-existing conditions.
In that circumstance, the cost of insurance is likely to become quite high or not be available for some individuals. A high-risk insurance pool would be a market of last resort. If the insurance pool is funded only by the insured’s premiums, people seeking insurance may technically have “access” to insurance, but they probably will not be able to afford it.
If the government subsidizes the insurance pool, insurance may be affordable, but it will cost the government more money. In this scenario, the government will have closed down some programs, only to have opened others—a strategy that may or may not save money.
Jeff Atkinson is a professor for the Illinois Judicial Conference and has taught health care law at DePaul University College of Law in Chicago.
The demand for physicians and other health care practitioners is high. So just as you keep up with the latest best practices in your field, you also should keep up with best practices on your résumé or CV. A weak one can cause you to be passed over in spite of your strong qualifications.
In general, a good CV or résumé is specific, true, achievement-focused and relevant. There are a few simple procedures you can perform on your résumé to optimize outcomes. Based on input from seasoned recruiters, here are tips to make it easy for recruiters to find you and match your qualifications to an organization’s needs.
Streamline the formatting
Most recruiters use search engines and applicant tracking systems (ATSs) to find and process CVs. These tools have parsing functions to scan and pull information. If your CV has graphics, text boxes, unusual bullet styles and frilly fonts or other fancy formatting, it may confuse the parsing function, which could result in your CV being passed over by search engines or mishandled by an ATS.
Spell out acronyms, and include keywords to help with search engine optimization. A few carefully chosen keywords will work better than an overdose of semi-relevant ones. Keywords will include your areas of specialty, so they probably will show up as you list your education and career history. However, use the more common terms that recruiters are likely to use when searching. For example, use “coronary angioplasty” rather than “percutaneous coronary intervention.”
Know whether you need a résumé or CV
“Short and sweet” is a good rule of thumb, but an academic or clinician is more likely to use a curriculum vitae (CV) than a résumé. Depending on your definition of the two terms, you may want both or at least a hybrid. Some consider a CV a simple listing and a résumé as a creative tool for “selling” yourself. You can create a hybrid by formatting the first two pages as a résumé and then set up additional pages as a CV-style list.
While a résumé in just about any other profession should be no longer than two pages, a CV can run several pages long. Be sure to include all your education, including residencies and fellowship training. List the following—especially the most relevant:
Creating a CV is not an open invitation to be verbose. For example, while you definitely want to list accomplishments for each position, list no more than five under each position. Choose accomplishments that are not only significant, but also relevant to the position for which you’re applying.
Make sure your achievements shine
Recruiters will be looking for your ability to deliver results, so list your key achievements. Be specific about the goals you achieved. Rather than something vague like, “led new process implementation,” state what the new process was, your role in the project and the impact on the organization.
Across industries, there is an increasing focus on metrics. The more you can quantify your accomplishments, the better. You can use actual numbers (such as “Launched asthma community outreach program and enrolled 125 patients”) or percentages (“Developed new ablation method reducing procedure time by an average of 7 percent”).
Either way, provide enough context to show the impact. For example, if your objective was to reduce procedure time by 5 percent, make it clear that you exceeded the goal.
Decide whether to include a cover letter
You’ll need to decide this on a case-by-case basis, but in general, the answer is “no.” The recruiters we talked to said they deal with information overload just like everyone else, and they rarely pay much attention to cover letters. In addition, a cover letter is essentially another page susceptible to infection by typos and grammatical errors.
However, some employers will ask for a cover letter. In that case, apply the same approach you’re using with your résumé: specific, true, achievement-focused and relevant. Treat it as an executive summary, tailor it to the open position and organization, and limit it to one page. For example, if you’re applying for a leadership position in the joint replacement program at a large medical center, explain how your background and experience are directly relevant and set you up for success in the role. If you’re applying for a role in a different location, communicate why you’re planning a move.
Don’t hide any gaps
Plenty of people take breaks during their career, and they aren’t automatic black marks. Maybe you took time for additional schooling (a medical degree plus an MHA or MPA can be powerful combination) or moved to a new state because your spouse was transferred. A legitimate gap only becomes a problem when you try to gloss over it. Smart recruiters will spot gaps, and without an explanation, they may jump to their own conclusions.
List the gap in the chronology of your career along with jobs, including dates and a brief explanation. Just the same, be careful about providing too much information, like your age, relationships or children. Employers aren’t allowed to ask for that kind of information, and you shouldn’t offer it.
Pay attention to the first impressions you give
Think of your CV as your envoy in the talent market. You want that envoy to represent you in the best light. Even if you aren’t actively looking for a new position, a solid, up-to-date CV can benefit you. Post it to relevant professional job boards, and a recruiter just might bring an interesting opportunity to your attention. Overall, a good CV helps you optimize your market presence.
There’s a lot for new physicians to understand when they are considering new employment opportunities.
If you’re nearing a contract review or compensation negotiation, take the time to understand the following keys to success.
Understand: The role of fit
Negotiating your contract and compensation are two of the more difficult areas to address when interviewing for a job. But before broaching those two topics, you must first make sure you find the right practice or position based on your personality, objectives and family needs. Yes, compensation is an important piece of that. However, first making sure the organization and community are good fits for you and your family will help the contract and compensation negotiations be much easier. Both you and the employer will be willing to give and take if they’re confident in a long-term arrangement.
Understand: Who’s on your job-search team
As you schedule interviews, you can ask your in-house recruiter about common employment contract terms and negotiable points. In-house recruiters are employed by the hospital, clinic or practice. You can also ask how compensation is handled in the contract and within the particular location or area you will be working. Organizations write contracts to cover many different physicians and specialties; therefore, there are areas in the contract that will not be negotiable. Other sections, such as those covering signing bonuses, loan repayments and moving expenses, may be topics for discussion.
Understand: How you will be paid
It is important to ask the right questions to understand how you will be paid. Some things to consider: Is the position with a teaching facility with a salary and incentives? Is it a private practice or employed position that uses wRVUs (Work Relative Value Units) to determine compensation based on work performed and appropriate billing practices?
Most income packages offered to new physicians are determined by regional market factors and compensation surveys conducted by organizations such as MGMA. Salaried positions with incentives are usually easy to understand. However, many practices compensate their physicians using a wRVU model. This compensation is based on work units performed rather than the number of patients seen. Ensure you understand how you will be paid for what you do.
Understand: What benefits are offered
In addition to compensation, you need to ask about the benefits offered by the employer. Typically, employers offer health insurance, license fees, medical staff dues and continuing medical education stipends. Also, many physician employees get three to four weeks of paid vacation and CME time. If your compensation is based in part on productivity, you will need to understand how your income may be affected when you take time off.
Understand: Your options for retirement
Many employers also provide retirement plans. In general, hospitals and health system employers offer a better range of benefits and more retirement options than private practices. Also, most employers pay for malpractice insurance. One thing to remember to ask about in the contract is if the employer pays for malpractice “tail” coverage. This covers incidents that happen during employment but are not litigated until after employment ends.
Understand: An attorney’s role
Once you have interviewed and have been offered a contract, we recommend consulting with a health care attorney to help you evaluate the contract. Choose an adviser who has experience working with physician contracts. Try to negotiate a flat fee with the attorney, and keep them focused on the areas in the contract that are negotiable. This will save you time and money. Do not have the attorney involved in the negotiation discussions. You should be the one who speaks directly with the organization about your contract.
Understand: Your role in your job search
Remember, you need to look for the right opportunity—clinically, professionally and personally. Take some time to make sure you ask questions. It is your responsibility to understand the employment contract and compensation offer. Make notes on anything that you do not understand or that needs clarification, and ask questions along the way. For more help on these topics, download our free 10-step job search guide.
Tammy Hager is PracticeLink’s director of client and physician relations. Reach her directly at (800) 776-8383 ext. 459.
When investigating potential jobs or opportunities, it’s easy to get excited about large sign-on bonuses, inflated hourly rates or what appear to be substantial benefits packages—because these are all compensation tools used to catch the eye of prospective candidates.
Not so fast, my friend! To consider total compensation, you need to see the complete picture, one that includes all these factors as well as a way to gauge the value of them as it relates to your situation.
In this article, we will take a shallow dive into some of the more common forms of compensation and address how to find common denominators so that you can fairly compare one factor to the rest of the package (as well as compare to others that may be markedly different).
Apples: Your needs
Jason Eppler, M.D., recommends consulting an oft-overlooked source about a group’s reputation: the grapevine. Other physicians, nurses and ancillary staff can give great indicators about the culture, metrics and long-term viability of the group.
It may seem like advice you would get in a fortune cookie, but “know your needs” is a critical step.
Erik Petersen, D.O., regional medical director for American Physician Partners, noticed the recurring theme of preparation.
Medicine continues to demonstrate a lack of standardization regarding overall compensation across specialty and geography. Every situation is different. Family, geography, loans and other debt, investments, businesses, charity work and more can all play big roles in whether you should accept a high pay rate and fewer benefits or vice versa.
“At the end of the day, having a firm grasp on your own limitations and flexibility will increase your chances of avoiding otherwise unseen pitfalls along the way,” Petersen says.
If you have a 7 percent interest rate on your student loans, for example, then it could be less helpful to have a 401(k) match instead of loan repayment benefits.
This isn’t to say that starting a retirement plan is a bad thing, just that your financial focal points will change as your personal situation does.
In addition, when a prospective job is presented to you, the employer or recruiter will communicate all the reasons they think the job would be a great fit for you. Their reasons might include a great health care package, shorter shifts, free lunch in the hospital cafeteria or any number of things.
On the surface, these benefits sound wonderful…unless your spouse has access to a benefits package, you prefer longer shifts for more days off, and the cafeteria isn’t open during your night shifts. In this case, a higher straight hourly rate or more contributions to your 401(k) might be more ideal.
In short, there are several ancillary and sometimes unique offerings that an opportunity will provide, and knowing which ones will benefit you the most will help you determine which items are of value and which are not.
5 more tips for evaluating your contract and compensation plan
Jason Eppler, M.D., recommends the following when evaluating a contract and compensation plan:
1. Do your research
In addition to checking online and industry sources, be sure you check the proverbial grapevine. Other physicians, nurses and staff can give great indications about the culture and viability of the group.
2. Remember, a handshake is not a guarantee
Any agreed-upon conditions or incentives must be written into your contract, or they do not exist. Clarify performance incentives and partnership track opportunities, and get the details included in your contract.
3. Know the difference between a noncompete and a noninterference clause
Noncompete clauses generally prohibit physicians from practicing within a certain geographic area for a defined period of time. Noninterference clauses prohibit physicians from going behind the backs of their contract holders to undermine the contract. In exchange, these physicians are free to work at other emergency departments in the area, or to be hired by a new group that might win the contract at the contract holder’s hospital.
4. Be wary of contracts that offer a pot of gold
Extremely high rates might signal that the opportunity is taxed by several challenges, such as high patients per provider hour, poor staffing, high provider turnover, overwhelming metric goals, etc.
5. Don’t settle for standard if something doesn’t align
Most employers will offer the convenience of a standard compensation package or contract. There is nothing standard, however, when it comes to the livelihood of you and your family. But most new employees don’t ask for a change, due to fear of being arrogant or ungrateful. Contract negotiations can be stressful by nature, but they certainly don’t have to be malignant. If so, you may need to ask yourself if this is the right group for you.
Oranges: The location
Most compensation packages are centered around a principle you learned back in middle school economics: supply and demand.
More desirable areas and a higher concentration of available physicians will equate to lower pay rates. The easiest examples are Hawaii and the Florida Keys. Both have a line out the metaphorical door for providers waiting to get in, but both by and large also have the lowest pay rates in the country.
On the flip side, many locations that are less desirable for a multitude of reasons will carry higher compensation packages. Keep in mind that a “less desirable location” is not necessarily a bad location; its supply is just less than the general demand.
Location also comes into play when considering the area’s cost of living and local taxes—two factors that can potentially have the largest impact on your take-home pay after all is said and done. Be aware of the tax laws where you intend on living and practicing, as there can be additional state, county and township taxes.
As a fan of a particular football team which will remain nameless (but resides in Jacksonville, Florida), I can say that a major draw for free agents is no state tax. As a free agent in your own right, you should take into account the difference in your taxable income, which can be as high as 10 percent of your annual pay (e.g. a $30,000 difference each and every year on $300,000 in annual salary).
Apples: The benefits
The next step in comparing your compensation offers is to establish a common denominator. In this case, the almighty dollar is the easiest. This doesn’t mean that you are only out for the money, but, instead, can offer a way to find the relative value of each portion of your compensation package.
Though this may sound complex, it can be determined simply by establishing the annual dollar value of a benefit, then dividing that by your projected hours over the course of the year.
A simple example would be two weeks of PTO, for which you would simply multiply your hourly wage by the hours provided.
A more complicated scenario, however, could revolve around hitting a performance bonus, which in itself contains some uncertainty.
To determine the value of a bonus, you must consider not only the dollar amount, but also the statistical likelihood of hitting that target each time.
(I must also note that job satisfaction is obviously a key component here, but for the sake of brevity, we will assume that whatever jobs you are comparing are ones that will fulfill your clinical and professional needs.)
If your employer is willing to contribute all or even a portion of your health/vision/dental benefit premiums, that’s hard to beat.
In reality, the company contribution to your plan is the true benefit here.
To determine the value of this portion of your compensation, divide that monthly amount by your number of hours.
As a side note, make sure that the network also covers your local hospital and desired clinical network.
Oranges: Employee type
There is no right or wrong answer here, and your specific circumstances play the biggest factor. According to Jay Widler, a consultant at Financial Designs in Overland Park, Kansas, “The current financial environment makes this a great time to work as an independent contractor. Health care reform, deduction allowances and other tax and investment rules make it a manageable, financially advantageous status for physicians. You should consider all the positions available to you and talk with a financial consultant who specializes in working with physicians to compare offers and determine which financial arrangement works best for you.”
As an employee, your employer will pay a portion of taxes as well as minimize the effort required when it comes time to file your tax return. Benefits, retirement and other group benefits are offered (sometimes at lower rates) and managed for you, which can be a big timesaver.
As an independent contractor, business expenses qualify as a tax write-off. Scrubs, gas, travel, health care premiums, etc., are all tax-deductible. Managing your taxable income is a top priority for a contractor. Being able to knock yourself down a tax bracket or two can easily make a five-figure difference in your annual take-home pay. You can also save significantly more for retirement in a tax-deductible plan (up to $54,000 per year vs. $18,000 as a W-2 employee).
Creating an entity can allow more financial planning advantages and possibly an extra layer of liability protection.
An independent contractor’s benefits are portable, and you can tailor them to your own needs. For example, a single, healthy 35-year-old male may need different coverage than a 45-year-old with a heart condition and family.
Apples: Bonus/metric incentives
It’s hard to ignore the increasing focus on the variety of metric incentives like patient satisfaction and quality-based measurements, because they are an ever-growing part of health care.
These typically are considered to be indicators of consistently good patient care and satisfaction. As a portion of compensation, it is important to have a good understanding of how they are tracked and the consistency of success. In many cases, you may need to rely on other departments within your system to achieve your goals, so situations like nursing shortages, volume variance, etc., can play a big role. Be sure to speak to other folks who work there to get a feel for if you are walking into a well-oiled machine or a 1978 Cutlass.
Oranges: Opportunities for advancement
The most successful negotiators calmly approach the table with facts. This approach helped Tony Briningstool, M.D., consider-and meet-a group’s benefit requests.
I would be remiss not to mention a partnership track, although there is such variety here that it is tough to lump them all into one group.
Two of the biggest factors to consider are your ability to achieve partner status and group liability. In most partnerships, there is a certain time frame or set of criteria that must be achieved before you become fully vested in the group.
These goals need to be reasonable and attainable and should also have some sort of guarantee. Once the goals are met, the partnership should be granted. The track record of the previous success of potential partners is the best indicator of how viable the option is, so don’t hesitate to ask about it.
Group liability is another easily overlooked factor in a partnership. According to Jason Eppler, M.D., emergency department director at Research Medical Center Emergency Room in Kansas City, Missouri, “partners can incur mutual liabilities not incurred with practice groups in which a physician is an employee. In a simple partnership, partners are financially liable for any malpractice claims against their partners, whether or not they were involved in the claimed incident. Most democratic groups avoid these sorts of problems by creating partnerships in the form of ownership of shares in a corporate entity. Equal shareholder status can create a functional partnership in group decision-making and other areas important to the physician, while reducing the legal and financial risks of a classic partnership.”
Apples: Payment structure
A relative value unit (RVU) is simply a unit of measure by which to judge the dollar value of any medical action.
According to Petersen, “if you go into a RVU-based comp model, be sure you feel very comfortable not only with the financial aspects of the plan itself, but also your ability [to] chart and knowledge of billing practices.”
In addition, be sure you have a method of obtaining feedback and chart reviews so you can continue to improve your documentation and accurately capture all services rendered. Knowing how to document procedures, critical care, etc., can play a huge difference in how much you are able to bill over the course of months or years, which in turn will directly affect your compensation.
One other main cause for heartburn among even the savviest negotiators is the dreaded counteroffer. Each situation is obviously a little different, but the number-one rule is to approach it rationally and with facts. On more than one occasion, I have been presented with the following line: “I just feel like I deserve more money.” That is, of course, not the best approach to justifying additional compensation.
Tony Briningstool, M.D., chief medical officer for American Physician Partners, shared the following story as an example:
“Recently we encountered a situation where our company would be taking over an existing practice of emergency providers from a different organization. In this particular case, both benefits packages couldn’t be more diverse from different in-network health providers. They had 401(k) match and PTO whereas we did not, but our base rate was set higher to account for some of these differences.
After we presented our initial proposal, we were sent a request for a meeting with all the providers to sit in person and discuss the differences and address questions.
After sitting down to the meeting, we were presented a typed, two-page breakdown from one of the current providers that detailed their benefits. This included the value of each portion of the package, as well as the rates of four nearby hospitals as a comparison. Based on this well laid-out research, the group presented a thoroughly thought-out counteroffer that was backed with evidence. After taking that information back to our team, we were able to shift around some of our package to allocate more money into the base rate and thereby meet the total compensation number that the group thought was fair.”
In this situation, the approach taken by the providers was just as important, if not more so, than the counteroffer itself.
While no method has a 100 percent success rate, laying out a logical argument based on facts and data of the surrounding market certainly has the best chance to be considered.
In closing, I wanted to touch on a point that I think is one of the most critical and most often overlooked ideas in negotiating: making sure the package is viable in the long term.
If you are lucky enough to stumble across a position that is willing to pay well above the market value, then it is certainly worth investigating—but understand that it may very well not last. In addition, if you find yourself making more than the rest of the physicians around you, you can bet that the clock is ticking on the longevity of that position.
To reiterate, be sure to do your homework! This is so you can not only maximize your total compensation, but also make sure it is a sustainable rate for your employer.
Derek Sawyer is a physician recruiter for American Physician Partners.
Just as finishing residency and passing boards are like the final pages of the prologue to a career in medicine, receiving a formal offer and the accompanying employment contract from a practice or health system opens the first chapter of what every new physician hopes will be a fairytale career. Knowing the steps new physicians should take before they ever see their first patient is key to a happy beginning.
Step 1: Understand what your contract covers
A medical employment contract isn’t something to be skimmed before passing it off to a friend who is an attorney to see if anything jumps out. What was promised in the interview and negotiation process doesn’t mean anything unless it is in the contract.
Every medical employment contract should clearly define three core elements: how to get in, how to get out, and how to get paid.
That means a contract should address the expenses the practice will cover and what you will be responsible for, as well as any expectations surrounding your performance, patient volumes and call schedule availability. It may or may not contain a non-compete agreement. The bonus or profit-sharing plan should be spelled out in detail. If the practice situation involves a net-income guarantee, the exact structure should be clear. Any medical employment contract should address malpractice coverage and how settlements are determined/handled. For private practices, there should be a section dealing with the path to partnership, if possible.
Request the numbers
If your compensation arrangement involves anything other than straight salary, such as a bonus or profit-sharing arrangement, ask to see a pro forma. A pro forma is a business document that provides a realistic assessment and projection of how many patients per day you will be able to see, and RVUs for patient encounters based on research and past experience. This will give you an idea of how easy or hard it will be to achieve any incentive-based compensation.
Step 2: Find an attorney to review the contract
Should an attorney review your medical employment contract before you sign? Not necessarily, but in most cases, yes. Regardless of the size of the organization offering the contract and whether it’s a “standard” contract or not, if there is anything you do not understand or have concerns about, ask an attorney who specializes in health care contracts to look at it.
Having it reviewed by a friend who is an attorney—but who doesn’t focus on medical employment law—is not sufficient. He or she likely doesn’t have the knowledge base needed to point out something that is off or that can be better negotiated in your favor.
Typically, an experienced health care attorney will cost at least $250 to $350 per hour. A contract review, depending on the complexity, may cost $2,000 or more (for reference, Afferent offers a flat rate of $750 for a contract review by a health care attorney). Reading the contract and noting any of your concerns—known as “redlining”—before giving it to an attorney can expedite the process and save money.
Before hiring an attorney to review the contract, ask about their process. Beware that organizations offering a cut-rate price for legal review of a medical employment contract may be outsourcing the review to another country, like India or the Philippines. Or they may only have a paralegal look at it before an attorney signs off without so much as thumbing through it.
Step 3: Apply for a state medical license
Obtaining a medical license from a state licensing board can take anywhere from 30 days to 9 months depending on the state.
Any issues surrounding medical licensing should have come up during the interview process, but there’s always a chance that something was missed.
Consider using the Federation Credentials Verification Service (FCVS) from the Federation of State Medical Boards when applying for a state license, which creates a permanent, lifetime portfolio of credentials you can use to speed up the process if you ever need to apply for another state license.
Step 4: Get settled in your new community
Rather than buying a house in a new city, consider renting for at least six months in the area where you and your family may eventually want to settle. By renting, you will be able to save for a larger down payment and determine if an area is the right location for work and play.
Additionally, more than 25 percent of new physicians leave their first practice within the first two years. Not being tied up in a mortgage increases flexibility and is one less thing to stress about if there’s an early separation from the practice.
Step 5: Start building your practice before you start
Don’t wait until your first day to start marketing yourself. Ask the organization if someone can introduce you to potential referral sources before you even begin. Draft a biography and ask the practice’s marketing person to post it online. Volunteer to write an article or blog post for the website or any publication with which the practice may have a relationship.
Give yourself a strong start
By following these steps, you can limit the amount of unknowns as you find a career and transition into practice.
When we are looking at a potential place to live, we all have different desires and criteria: cost of living, area population size, quality of local schools, culture and entertainment offerings, and availability of outdoor activities. If “excellent local golf courses” is on your list, you will want to have a few golf towns in particular on your radar.
Grand Junction, Colorado
In Grand Junction, Colorado, locals enjoy more than 300 days of sunshine each year, which certainly aids local golfers in getting to the greens. For physicians, there are ample job opportunities at hospitals that position Grand Junction as a medical hub, drawing patients from surrounding counties for care.
In Grand Junction, residents enjoy excellent weather, breathtaking panoramas and scores of outdoor activities, like hiking, backpacking, mountain biking and golf. In the context of this outdoorsy town of 60,000 people, there is a strong job market for physicians. So much so, that a husband and wife pair of physicians with unique professional focuses could find jobs and build careers with St. Mary’s Medical Center in Grand Junction.
Brian Davidson, M.D., who trained as an anesthesiologist at the University of Colorado Anschutz Medical Campus, became aware early in his career that there was a need for doctors’ perspectives in hospital leadership.
“It always bothered me through medical school and beyond that there weren’t more physicians making decisions in health care,” Davidson says. “Then I realized that it wasn’t so simple, and that it requires education and experience.”
Davidson earned his MBA in health care administration at the University of Colorado Denver, and completed a health care administration fellowship at the University of Colorado Hospital. Davidson became the vice chair for the anesthesiology department and served in leadership roles at the University of Colorado Hospital.
Davidson’s wife, Amy Gagnon, M.D., also has deep ties to the University of Colorado.
“I did my undergraduate degree and medical school at the University of Colorado,” she says. “I knew from medical school that I wanted to do maternal fetal medicine. I was interested in the medical complications and the ultrasound aspect of maternal fetal medicine. I was fortunate to match at the University of Colorado for my residency and a three-year fellowship in maternal fetal medicine.”
When a top position at St. Mary’s Medical Center in Grand Junction, Colorado, opened, Davidson interviewed and was hired. He’s now president.
The hospital, part of SCL Health, also had a need for a maternal fetal medicine specialist, and Gagnon was hired as well.
“It’s a complex hospital in a relatively rural area,” Davidson says. “We provide a lot of services here, and they’re services that are not typically found in a smaller area like this. We have two helicopters and a plane, and a strong aeromedical program. A third of our patient volume comes from outside of our county, Mesa County. We’re a Level II trauma center, but we act like a Level I trauma center. We have a Level III NICU. We offer cardiac surgery and neurosurgery, and we have a primary stroke center.”
The nearby Community Hospital, a 501(c)(3) non-profit hospital in Grand Junction, is also equipped to provide a variety of services.
“We have state-of-the-art equipment in a state-of-the-art facility,” says Ryan Schultz, director of physician relations for Community Hospital. “We employ several surgical specialties. We have a fellowship-trained general surgeon. We have an OB-GYN surgical women’s clinic. We have an occupational medicine clinic and community care clinic.”
Community Hospital is a 60-bed facility; 24 of these beds are in fully private med-surg rooms. The hospital also has eight LDRP rooms and a 12-bed intensive care unit. Additionally, Community Hospital operates nearly 30 outpatient clinics.
Schultz is most heavily recruiting for primary care physicians. “Our organization has always been an outpatient focused hospital. It all starts with primary care,” says Schultz.
When Schultz speaks to prospective job candidates who are not familiar with Colorado, he has good news to deliver about the Grand Junction area, especially in relation to the weather.
The city averages more than 300 days of sun each year, with a traditional four-season climate and low humidity.
The comfortable weather is one of the many lifestyle components Shultz discusses with potential employees.
“When I’m talking with prospective candidates, we talk a lot about the lifestyle of living in Grand Junction,” Schultz says. “They are attracted to here for the outdoor lifestyle. They’ll say, ‘We’re avid hikers and we enjoy backpacking and golf.’ If candidates are looking for not just a place to work, but also a place to raise a family and build a life, they’ll usually bring up their interest in outdoor activities in that first phone screen.”
Schultz says when he is recruiting for Community Hospital, it is attractive when physicians mention their love of the outdoors, as it indicates they will be a good cultural fit in more ways than one.
“We have this active outdoor culture with a really affordable cost of living,” says Mistalynn Meyeraan, marketing and public relations director for the Grand Junction Visitor and Convention Bureau. “The town itself is 60,000. The greater community—we’re a valley—is 140,000. We have four seasons. We have amazing orchards. We are a hub for produce and for wine—this is Colorado wine country.”
Of course there is also golf, a popular activity as long as one can train their focus on their swing, rather than on the beautiful surrounding mountain ranges.
“One of our courses has a backdrop of this dramatic red rock canyon,” says Meyeraan.
Like many area residents, Davidson and Gagnon are hiking enthusiasts.
“The hikes around here are great. Having grown up in Denver, the hiking available in Grand Junction is just as good, if not better,” Gagnon says. “It’s nice to be able to work your day at the hospital and then be outside.”
Gagnon said there is even a hiking trail within five minutes of the hospital that offers several miles of scenic hiking.
“We call them ‘lunch loops’ because some people will go for a little hike on their lunch hour,” she says.
The plethora of outdoor activities is not the only draw for prospective candidates. Davidson says the environment at St. Mary’s is much like a family.
“It’s the second largest employer in all of Mesa County. We employ 2,400 people. So approximately 1 in every 50 people in the town work here. One in 25 have a family member work here,” Davidson says. “It makes work less distinct from the rest of the your life. The community within the hospital is really strong.”
In family-friendly Toledo, Ohio, there are 26 public golf courses in addition to numerous courses owned by private clubs, many of which offer programs to introduce children and teens to the game. Coupled with excellent job opportunities and an easygoing patient population, Toledo is an ideal location for physicians to practice medicine (and their swing!).
Daniel McCullough, M.D., a bariatric surgeon for ProMedica Physicians General Surgery, appreciates how his work resolves a problem for patients, as opposed to treating a symptom. “Oftentimes in medicine, when you’re working with a patient, you’re treating the symptom or you’re managing the symptom; but you’re generally not able to cure what’s going on. With weight loss surgery, in a year when your patient has lost weight, they don’t have diabetes anymore or they don’t have high blood pressure,” he says.
McCullough says that he discovered his calling—weight loss surgery—in a roundabout way. McCullough was born and raised in Toledo. He completed his undergraduate, graduate and medical degrees in Ohio and a fellowship in Virginia. “I originally wanted to be a hematologist. I did my undergrad at Miami University of Ohio and earned a degree in chemistry,” he says.
McCullough moved to Columbus, Ohio, to pursue his master’s in medical biochemistry and nutrition at The Ohio State University. He conducted research on medical weight loss and third stage trials for weight loss.
“We worked with patients making changes in their diet, exercise [and] nutrition; medical weight loss is any non-surgical approach to weight loss,” McCullough says. “Across the hall, the bariatric surgeons were working with patients who were losing weight and keeping it off. I came to realize that the recidivism rate for medical weight loss was problematic. It was extraordinarily high.”
After that discovery, McCullough decided to train to become a bariatric surgeon.
“My first rotation was with Mark Kligman, M.D., an excellent bariatric surgeon and my mentor in the whole business,” McCullough says. “He pulled me over to the dark side; I already had this dual interest in nutrition and weight loss. At the time, bariatric surgery was still in its infancy, but the seed was planted in my head.”
Today, McCullough is a bariatric surgeon for ProMedica, a health system with four hospitals in metro Toledo and 12 hospitals across northwest Ohio and southeast Michigan. There are more than 900 physicians and advanced practice providers employed by ProMedica.
Another major health system in the Toledo area is Mercy Health, a Catholic health care ministry that operates three hospitals in the greater Toledo area and four hospitals within an 80-mile radius of Toledo. In Toledo, Mercy Health – St. Anne Hospital is a 128 bed facility; Mercy Health – St. Charles Hospital is a 410 bed facility; and Mercy Health – St. Vincent Medical Center is a 568 bed facility.
“We are broad in terms of the fact that we have everything from a Level I trauma center to the region’s only burn and reconstructive skin center. We are comprehensive stroke certified. We have the only 24/7 mobile stroke unit in the country,” says Tom Leeds, director of medical staff recruitment at Mercy Health. Additionally, all of Mercy’s metro Toledo hospitals have a da Vinci Robot, including the new da Vinci Xi surgical system.
Leeds says that, at any given time, he recruits for 45 to 55 positions. “The focus in our market for Mercy Health is primary care, neuroscience, vascular surgery, orthopedics and pediatric subspecialties,” he says.
Toledo has a population of 280,000 and a metro population of 600,000.
“There are an inordinate amount of great things to do in the Toledo area,” says Richard Nachazel, president of Destination Toledo. “We have an internationally acclaimed museum of art. We have a beautiful smoke-free casino. The casino has one of the best steakhouse restaurants in the city. We have two iconic professional sports teams: the Toledo Mud Hens, who are popular in baseball circles, and the Toledo Walleyes. They’re a hockey team and they just won their division. They made playoffs for the Kelly Cup.”
And then, of course, there is golf. Toledo has contributed significantly to the history of golf.
“A man named S.P. Jermain was known around the United States as the father of public golf,” Nachazel says. “He built the first golf course west of New York City here in Toledo, Ottawa Park. It was built in 1899. In 1920, they added a second nine holes.”
S.P. Jermain also founded the Inverness Club, opened in 1903, which is today a well-known course that has hosted two PGA Championships and four U.S. Opens.
In 2021, the Inverness Club will host the Solheim Cup, which, according to Nachazel, “is the highest level of professional golf competition for lady golfers.”
However, no need to be intimidated by the Inverness Club’s stature.
Nachazel says that, because golf is part of the culture in Toledo, many courses are family-friendly and even encourage children to learn the game.
“There is a young people’s golfing program at courses in the area called First Tee. Inverness has a First Tee program,” Nachazel said. “The whole goal is to build the popularity of the game with youngsters. I am teaching my grandson and granddaughters. The courses in Toledo are very welcoming to children.”
“If you like to golf, Toledo is great,” McCullough agrees. “There are fabulous golf courses, public and private. There are more than two dozen golf courses within Toledo.”
McCullough’s leisure time tends to revolve around his family, including his three children, who are 15, 12 and 10.
“Toledo has a lot of activities for kids,” McCullough says. “We have one of the best zoos in the country and a great children’s museum downtown.”
Overall, McCullough says the best part of living and practicing in Toledo is the friendly, easygoing people. Their congenial nature makes patients easy to work with.
“One of the best parts of practicing in Ohio is the people,” McCullough says. “Patients show up for appointments, they listen to you, and they are grateful. Toledo is a great place to practice medicine. I love it.”
Millard Collins, M.D., is an advocate for both primary care and the Nashville area. He also serves on staff at Meharry Medical College.
Located just outside Nashville, Franklin, Tennessee, is perfectly situated for doctors, families, country music lovers and golfers alike. Its sunny weather and southern hospitality infused with the hustle and bustle from the nearby metropolis makes Franklin a best-of-both-worlds hub for physicians.
Millard Collins, M.D., has a passion for family practice. He is the interim chair and an associate professor of family and community medicine at Meharry Medical College, the medical school affiliated with Nashville General Hospital, a teaching hospital with 125 beds. Collins also serves as the associate dean for student affairs at Meharry Medical College.
“Being a native New Orleanian, I attended Xavier University of Louisiana, the only black Catholic institution in the nation,” Collins says. “They are a leader in guiding black students toward the health science professions; some people say there is a pipeline between Xavier University and Meharry Medical College.”
Collins knew as an undergraduate that he wanted to work in health care. He was accepted to Meharry Medical College, where he completed four years of training. During that time, he decided to pursue family medicine and sees himself as an advocate for family practice today.
Collins says that there are negative messages that medical students absorb about family practice that keep them from pursuing the specialty, thus creating the shortage of family practice providers that many hospitals and health systems experience.
“I have been surprised to learn that not all medical schools have family practice as a required rotation. The message that is sent to learners is, ‘It’s not important, you don’t make as much money, it’s plan B, etc.,’” he says.
Rather, Collins says that some family practice doctors like the steady schedule of working in an office, while others engage their entrepreneurial spirit and start their own family practices.
“Much of my career has been dedicated to setting the record straight,” he says. “I want to let students know about the versatility of family practice.”
Another physician employer near Franklin is LifePoint Health, a publicly-traded company that owns and operates 72 hospitals in 22 states. LifePoint operates Southern Tennessee Regional Health System Lawrenceburg, a full-service community hospital south of Franklin.
Jess Judy, LifePoint Health’s senior vice president for physician relations, says that a great deal of the medical staff at Lawrenceburg live in Franklin. Judy says physicians “don’t get lost in the shuffle of a large metropolitan market,” and have the opportunity to truly focus on patient care.
“Our hospitals are very engaged in clinical quality and patient experience,” Judy says. “LifePoint Health as a company—and I think this is a real differentiating factor—is the only national for-profit hospital company in the country that participated in the Hospital Engagement Networks. This was a Center for Medicare and Medicaid Innovation program to drive and improve quality. LifePoint was a participant, and we met or exceeded all of our quality and harm reduction goals across the country.”
Furthermore, Judy said that a key factor that distinguishes Lawrence Hospital is its affiliation with a multihospital system.
“It has the depth of resources of a large corporation as opposed to a freestanding community hospital,” Judy says.
Life in Franklin seems to echo this best-of-both-worlds theme of having the comfort of a southern community with a high quality of life, infused with some of the energy and action of nearby Nashville.
“We’re located 17 miles south of Nashville. That is a convenient place to have a hub of health care,” said Matt Maxey, PR coordinator for Visit Franklin. “Williamson County, where Franklin is located, is the most affluent county in Tennessee. Lots of physicians and folks in the health care industry live here. We have the top school system in the state.”
Maxey says Franklin has a distinct southern feel, especially when one strolls down the historic downtown Main Street area.
“The whole county has done a great job to preserve the small-town atmosphere while still providing all the services of a bigger town,” he says.
These services, of course, include golf. Maxey says Franklin has two public golf courses and about 30 private clubs. He also says the PGA hosts a tournament in Franklin in June each year.
Collins is just one of the physicians who takes advantage of the area’s great golf. He especially enjoys Hermitage Golf Course, a public course that was rated top public course in the state of Tennessee by PGA.com.
“I like to get out and play during tournament times. It’s a great way to talk to people, to get to know people over four and a half hours,” Collins says. “Our area has some of the most beautiful golf courses.”
When Collins first considered attending Meharry Medical College, he had a certain picture of the area in mind.
“The only thing I thought was that it was a country music city. Boy, was I wrong. Nashville epitomizes diversity. It’s a city heavy on education, [with] lots of colleges and universities. The city and the surrounding suburbs are growing exponentially. It’s a great central hub. When I first came here, I was surprised! But now I’m very, very glad to call it home.”
“You can find me at one of four places. I’m at church, I’m at the hospital, I’m with my family, or I’m on the golf course,” says John Farr, M.D.
Any conversation about top golf towns in the United States would be incomplete without Augusta, Georgia, home to the Masters Tournament. Golf fans flock to Augusta each year in April to participate in the festivities.
“We have a little tournament here that’s pretty fun,” says John Farr, M.D., chief medical officer of Doctors Hospital in Augusta, referring to the Masters. “Golf is real big here. We have lots of options. We can play golf here year-round, 365 days out of the year.”
Farr started golfing in college. His interest in medicine developed even earlier, after his grandfather passed away from a heart attack.
While at the Medical University of South Carolina, Farr focused his studies on family medicine. He was interested in the emphasis on preventive medicine and the deep relationships that family physicians have with their patients.
Farr served in the Army as a family physician for 21 years, 16 of which he spent at Dwight David Eisenhower Army Medical Center in Augusta. Approximately 10 years ago, he started making the transition toward administrative medicine.
“I really enjoyed the ability to impact medicine on a larger level, which you’re able to do on the administrative side of the house,” Farr says.
When Farr was ready to retire from the Army, Doctors Hospital in Augusta offered him an opportunity to join their administration, which he accepted. Today, he is the organization’s chief medical officer. Doctors Hospital is a tertiary medical center with 354 beds.
“We have a great team of people in this hospital who are really dedicated to our mission,” Farr says. “We take care of patients and their families to the best of our ability. It’s a fun place to come to work.”
Farr also has high praise for life in the Augusta area. It is where he raised his two teenaged daughters, and where he has spent the better part of his life.
“Augusta is a great size city. It offers a lot without being too big,” he says. “I like the climate, I like the friendliness of the community, I like being in a military community, and it’s a great place to raise a family.”
Another attractive quality about Augusta is the relatively low cost of living and ease of finding affordable housing, says Julian J. Nussbaum, M.D., an ophthalmologist, professor and chair of the Department of Ophthalmology, and chief executive officer of Augusta University Medical Associates.
“I have many faculty members who were able to afford a home right away,” he says. “I even have residents who have families who are able to buy a home in Augusta, stay for a few years, and then sell their homes when they leave. They don’t need to rent an apartment.”
Nussbaum is emphatic about the area’s high quality of life and its economic fortitude.
“The military’s entire cyber-command station is located in Augusta. We were relatively recession-proof in 2008 because of the number of government positions here,” Nussbaum says.
Augusta University Medical Center is expanding. Nussbaum’s team recruits across a wide spectrum of specialties, including cancer therapy and medical and surgical oncology; bariatric surgery; pulmonology and certain subspecialties in ophthalmology, such as retinal surgery and neural ophthalmology; cardiothoracic surgery and cardiology; and gastroenterology.
Augusta University Medical Center also operates the Children’s Hospital of Georgia, and Nussbaum says he recruits candidates for nearly all pediatric specialties.
When Nussbaum and his recruitment team talk to physicians interested in joining their organization, they make sure to mention the area’s warm weather and plethora of activities, including golf.
Not a golf fan? Deterred by crowds? Not to worry.
“One of the other things that people may not know is that quite a lot of people rent their houses out—their full-time residences—during that week [of the Masters],” says Lindsay Fruchtl, vice president of marketing and sales for the Augusta Convention & Visitors Bureau. “A lot of the residents sometimes go out of town during the Masters and make some extra money.”
Though some residents choose that route, Farr is one Augusta resident sure to not miss a golf event.
“I often say that you can find [me] at one of four places,” says Farr. “I’m at church, I’m at the hospital, I’m with my family, or I’m on the golf course. That is a very focused and intentional way that I live my life.”
After years of preparing for and envisioning your future employment, it’s thrilling to be within reach of a job opportunity that seems like the perfect match. Though it’s tempting to eagerly pack up your job-search paperwork and focus on settling into your new place, slow down—one of the most important steps lies ahead. Carefully reading and reviewing your new employment contract—before you sign the dotted line—can make a difference not only in your new job, but also on your career path.
Here are six mistakes that it’s especially important for new physicians to avoid.
Mistake #1: Aside from your spouse, no one else has looked at your contract
Physician employment contracts don’t make for breezy reading. Most are lengthy and filled with cryptic terminology and specific details that are often hard to discern. And you need to understand not only what’s written, but also what’s missing. For these reasons, most physicians—especially those early in their careers—turn to people more experienced for help.
“The employment contract was filled with legal jargon,” recalls Harry Salinas, M.D., a plastic surgery chief resident at Harvard University. “Even though I’m used to reading difficult material, this was just another language.”
Salinas turned to a lawyer to review his contract, who negotiated changes on his behalf. “She helped in a lot of ways, from translating the legal terminology, to changing some of the language and negotiating some of the restrictions,” he says.
“Having someone on your side to do these negotiations is incredibly helpful when you are still busy in your last year of residency,” adds ophthalmologist John Prenshaw, M.D., who benefited from consulting with an attorney regarding his future contract while he finished residency.
You can’t go wrong by getting input before you sign, whether you’re looking for negotiating help or just a second opinion. So where should you turn?
A lawyerwho is experienced with physicians or employment law. Ask colleagues or your alumni association for referrals.
Your medical school, which may have resources available to students. Inquire at your career services or placement office.
Prior employees of the hospital or practice to which you are going.
Experienced colleagues whom you know well, such as a professor, mentor or coworker.
Remember to use discretion. Share the actual contract or personal details only with highly trusted individuals or those with whom you’ve entered into a professional agreement, such as a lawyer.
Before you sign: Seek input from a trusted and knowledgeable resource.
Other areas to consider
The areas covered in an employment contract are numerous. In addition to those mentioned in this article, take a closer look at the following factors:
Restrictions on outside income, such as that from speaking events, books or articles authored, or even non-medical sources of income, such as hobbies
Terms and conditions around bonuses
Time allotted for non-clinical obligations, such as paperwork and patient calls
Benefits package, including family leave, vacation time, sick leave, etc.
Relocation expenses, if any
Expected weekly hours, on-call expectations and holiday coverage
Primary location of employment, if multiple offices exist
Treatment of travel time, if covering multiple offices for one group or hospital
Length of employment contract, if any, and renewability
Performance reviews, raises and promotions
Mistake #2: You haven’t identified what’s important to you
When you began job hunting, you probably prioritized your goals and preferences. Now that you’re about to seal the deal, a quick review of these items is in order. The stipulations you’re about to sign onto can steer you toward—or away—from your intentions.
“Many times residents or fellows are so excited [about employment that] they don’t think of their long-term personal goals,” says attorney Philip Sprinkle, senior partner with Akerman LLP in Washington, D.C. Sprinkle volunteers to review employment contracts of recent graduates through the University of Virginia’s Medical Alumni Association.
“It sounds elementary, but I start each and every meeting with questions about the doctor,” he says. Responses help him to identify areas of focus. For example, if either the physician or the spouse has deep ties to a region, he’ll put the spotlight on the noncompete agreement.
Some areas to consider: long-term career goals, outside revenue (such as public speaking or writing), family obligations, amount of debt, scheduling issues and more. And don’t assume your professional needs will be satisfied.
“I’ve had docs hired under the lure of being interventional radiologists when, in reality, the group just wants them to read film,” Sprinkle recalls. “In one case, we made the equipment and the commitment a contractual requirement, which gave the doc an easy out when the group did not get it. In another case, the radiologist himself had to terminate without contractual protections, and it cost him pay and severance costs.”
Before you sign: Review and prioritize your goals, both personal and professional, and consider if the contract limits or supports them.
Before solidifying his contract, Harry Salinas, M.D., consulted with other physicians in his network to develop language specific to his future goals.
Mistake #3: You haven’t looked closely at insurance coverage
Professional liability insurance, better known as malpractice insurance, may be one of the most important elements in a contract. Without solid coverage, your career, home, assets and property could be at risk.
There are two main types of insurance. “Occurrence-based insurance covers you for claims even after you leave the company. Claims-based, which is cheaper for the employer, covers you only if a claim is made during your employment. Get occurrence-based insurance, if they’ll agree to it,” says Sprinkle.
If you’re offered a claims-based policy, be sure an extended reporting endorsement is included—commonly called an ERE or “tail” insurance. This extends your insurance coverage to include claims that are filed after you’ve left an employer, but arise from work you performed while you were employed. Tail coverage is quite expensive—calculated at 50 to 250 percent of your overall insurance premium, according to the American Academy of Medical Management.
“Ideally, have the employer pay for the tail if they will agree,” recommends Sprinkle. Negotiating a 50-50 arrangement is another option.
If you are responsible for all or a portion of the payment, be sure you understand the terms. Usually the employer will collect it at the end of your employment period by withholding enough of your final paychecks to cover the cost. To physicians early in their careers, this loss of income can yield a significant financial blow.
When negotiating a new position at the end of his residency at the University of Virginia, Prenshaw ran into some concerns with the tail coverage.
“The original wording in the employment contract was that I was responsible for tail coverage, no matter what the circumstance,” says Prenshaw. This meant that if he was terminated early in his employment—with only a few paychecks under his belt—paying for the expensive coverage would be a financial struggle.
With the help of Sprinkle, they came up with more agreeable terms. “We negotiated that I wouldn’t be responsible for the tail if, during the first 18 months of employment, I was terminated without cause, died or became disabled,” Prenshaw says. “[Without this clause], it is unlikely I would have been able to afford the tail coverage [had an early termination occurred].”
Before you sign: Study the details of your professional liability insurance. Be sure you’ll have—and can afford—coverage for claims raised post-termination.
Mistake #4: You haven’t thought about the noncompete clause in your contract
Standard to most employment contracts is a restrictive covenant, which prevents you from terminating your employment and immediately going to work for a group or hospital that is deemed a competitor. More commonly known as a noncompete clause, these can severely limit your future options.
“Many people have the wrong idea that covenants aren’t enforceable,” says Nanette O’Donnell, partner with Duane Morris LLP in Miami. “It varies by state, but states do enforce them.”
Typically, the clause defines a mile radius, as well as a length of time, that restricts you from working for a competitor—for example, within a 10-mile radius of your former employer for a period of two years.
“It’s best to work with someone to negotiate the language and to soften the restrictions,” O’Donnell suggests. Reducing either distance or time (or both) is preferable.
Also make sure you are fully aware of the scope of the restriction. “If you’re working for a large entity with multiple offices, the location restriction may apply to every office of your employer, greatly expanding the geography within which you are restricted from practicing,” O’Donnell adds.
When evaluating a noncompete agreement, an important factor to consider is your ties to the region. If family obligations, a spouse’s employment or education options require you to remain local, a strict restrictive clause could cause your prospects for new employment to dwindle. If you and your loved ones are open to relocating, you may be less affected by the clause.
Before you sign: Consider your life over the next three, six or 10 years. Where might you be seeking employment?
Hilary Fairbrother, M.D., turned down an offer with a large group in favor of a smaller practice after reading through the group’s proposed employment contract.
Mistake #5: Assuming the job is so perfect, you’ll never think about leaving
You hit the jackpot with your potential new job: ideal location, growth opportunities, impressive salary and benefits. But curb your enthusiasm briefly enough to consider that someday you’re likely to change jobs. When that day comes, you’ll thank yourself for taking the time now to hash out any post-termination details.
One factor is the amount of notice required when announcing your termination. Typically, word of impending job termination is delivered to the employee or employer a set number of days before the targeted departure date. Thirty or 90 days is common.
“I’ve seen notification requirements be as long as 18 months,” says Heather Fork, M.D., dermatologist and founder of Doctor’s Crossing in Austin, Texas. “That’s really too long. Even six months is difficult, as most hiring companies want you to be available sooner.”
Fork says a notice of 90 days seems ideal. “That’s enough time to get your things in order and work with recruiters.”
Though less common, some contracts don’t specify a time requirement. “If there’s nothing stated in the contract, it leaves you free to go. It’s really up to the individual. That could be OK for some people, as long as you don’t mind potentially being given short notice,” says Fork.
Reason for termination is another key point; employees are either terminated “for cause” (often for issues with performance) or “without cause” (usually for reasons unrelated to the employee). Specifics vary among employers, so be sure you understand these definitions and their related details. For example, before you are terminated for cause, will you be given an opportunity to correct the problem?
Finally, if you will be relocating for the job, you may want some additional protection, adds O’Donnell.
“You don’t want to move for a job and then get terminated a month later,” she says. “Ask for a longer termination notice, (include) the ability of both parties to terminate only for cause, or negotiate to have your relocation expenses reimbursed.”
Before you sign: Consider what you need for a smooth termination of employment.
Mistake #6: You didn’t look closely at the salary and compensation structure
By the time the employment contract is drawn up, your salary is usually already established. It’s still prudent, however, to confirm that it appears as you expected, and that the compensation structure aligns with your personality, lifestyle and work ethic.
Physicians are commonly paid in one of two types of payment structures: salary-based or productivity-based. Productivity-based structures can be either relative value unit (RVU) based or collections-based.
“Some personalities prefer the flat salary model, which tends to be one where your earning potential is less, but so are the hours,” says Salinas. “In a productivity-based system, your guarantee is usually lower, but the ceiling is higher, as long as you put in the work.”
The structure that works for you is a highly personal choice. “I know that I will be much happier and busier in a system that rewards productivity,” says Salinas.
Also consider any unique situations. One thing important to Salinas was including language in the contract that covered the two types of patients he anticipates serving.
“[At my new position], I’ll primarily be doing reconstructive surgery for cancer patients,” says Salinas. “But I also do cosmetic surgery, and many times, this is the same population. I needed to plan pre-emptively how to incorporate any out-of-pocket [cosmetic surgery] patients into my RVU-based contract with the cancer center.”
Before solidifying his contract, he asked around within his network and at similar hospitals to develop the language to address this situation.
Before you sign: Be sure the salary structure supports your work style, goals and interests.
Time to negotiate
You’ve scoured your employment contract and found a few areas that leave you questioning. Now what? It’s common to have a round of discussions before the contract is finalized. Here are some tips for success:
Prioritize: Weigh the importance of each area in question, identifying those that have the greatest impact on you. “A mentor gave me this advice early on,” recalls Salinas. “I made a list of what things were deal breakers, and what I could live with.”
Do your research: Gather information on each area you’ll be discussing. Feeling knowledgeable will enable you to present your case more confidently.
Be flexible: Present a trade-off in exchange for something you want. “Offer something you’ll do, such as offering to work an evening shift in exchange for being able leave early on other days,” suggests Fork.
Above all, remain calm. One of the most universal rules of any negotiation is to keep your emotions in check and maintain a professional demeanor. Even if it becomes obvious the negotiations aren’t successful and you may pass on the job, always leave behind a good impression.
When it’s best to walk away
If the final offer still has you raising an eyebrow, step back and determine if this job is really the best fit for you. Though you may be eager to land a job, don’t agree to one with which you feel uncomfortable.
Emergency medicine physician Hilary Fairbrother, M.D., vice chairperson of the Medical Society of the State of New York’s Young Physicians Section, was entertaining an offer from a large group right out of residency. After reviewing their lengthy employment contract and consulting with an attorney, she was left with some concerns.
“One issue was that I could be fired at any time, with or without cause,” she recalls.
Fairbrother knew that an unexpected termination so early in her career could present financial difficulty.
“Also, I was supposed to provide notice if I were to terminate, but the employer did not have to. That seemed very lopsided,” she adds.
Further unsettling was a vast restrictive covenant, which could make remaining in the New York area difficult in the future.
Though she brought her concerns back to the group, hoping to negotiate, she reached an impasse and eventually decided it was best to decline.
“I (soon) joined a smaller group where I didn’t have as many restraints,” she says. “It was the right decision for me.”
Poring over an employment contract and hashing out details can seem like an unwelcome hurdle when you are so close to your dream of working as a physician. But it’s time well-spent. Whether you go it alone or pair up with a trusted colleague or professional, you’ll thank yourself later for careful decisions made today.
Olusegun Oyewole, M.D., M.P.H., registered with PracticeLink and was immediately connected to opportunities that fit his needs. He found his job on PracticeLink.
Specialty: Internal medicine (hospitalist)
Employer: Apogee Physicians
Residency: Mercy Catholic Medical Center (2017)
Oyewole enjoys spending time with his wife and three kids, playing soccer, listening to country music, and studying the Bible.
What surprised you about your first post-residency job search? I was surprised—and at the same time pleased—by the opportunities that started flooding my email box the day after I uploaded my CV to PracticeLink. That began the process that eventually culminated in securing my first job.
What’s your advice for residents? Don’t wait till the 11th hour before you start your search! Some time between the later part of the penultimate year to the early part of the final year, you should begin your search. That will allow you enough time to carefully weigh all your options before committing to a job.
What were the most important factors in your job search? Visa sponsorship; a competitive compensation package; opportunities for my wife, who is an RN; and good schools for my kids were all factors.
How did you find your job? I stumbled on PracticeLink.com when I started my search for a job online. I was so fascinated by the comprehensive nature of the website that I uploaded my CV immediately.
How did PracticeLink help you in your job search? PracticeLink turned out to be the vital link to my job with Penn Highlands Healthcare in Dubois, Pennsylvania.
Any other advice? Before you start your job search, take time to define what matters most to you. That will serve as a guide and keep you focused.
You’ve likely heard that the key to negotiating a physician employment contract successfully is research. That includes learning the industry standards for compensation in your specialty and geographic area, identifying what you bring to the table in terms of experience and expertise, and assessing “the landscape of the organization,” says Jeffrey Vogel, M.D., M.P.H., attending physician in occupational medicine with Cambridge Health Alliance and instructor of medicine at Harvard Medical School in Boston. “People will take you seriously if you’ve done your homework,” he says.
Recognizing that not all aspects of an employment agreement are negotiable is also important. This ensures that you focus on modifying terms that will actually benefit you without coming across as difficult or unrealistic.
Studying potential employers is smart, but it’s only half the equation. It’s also important to consider your priorities, says Bonnie Mason, M.D., retired orthopedic surgeon and founder of Beyond the Exam Room, which educates physicians about business and financial concepts not taught in medical school or residency training. What do you want a position to provide? What’s important to you?
Mason devised a phrase to represent the factors physicians should consider: Your DALAR Profile (pronounced “dollar”). DALAR stands for decision-making; amount of autonomy; lifestyle; altruism or volunteer opportunities; and revenue or income. What do you want in each of these areas? “Employers are clear about what they want [in an employee],” says Mason. It’s important that physicians are equally clear about their professional and personal priorities.
The compensation package
Considering negotiating? Start with evaluating your priorities, recommends Bonnie Mason, M.D. What do you want a position to provide? What’s important to you?
Through salary should not be the only—or leading—factor you consider, says Mason, the overall value of the total compensation package is one way to quantify the value a potential employer is offering. It is a way to compare the different employment options you may be presented. The elements of a standard compensation package may include some or all of the following:
Salary: Including base pay and bonuses (signing and/or based on productivity)
Benefits: Health insurance, life insurance and disability coverage, among others
Continuing medical education (CME): Money to pay for required CMEs
Leave: Paid or unpaid vacation, sick time, maternity leave
Student loan forgiveness/repayment options
Cell phone expenses
Start by assigning a dollar value to each item on this list. “Once you understand the basic compensation package, you can try to move the values around,” says Mason. For example, if you don’t need moving expenses paid, you can ask to trade that for something else, like a signing bonus or more vacation time. Or maybe you can ask for more CME money instead of a cell phone plan.
What is not possible to negotiate, says Vogel, are the benefits that are rolled out organization-wide, such as health insurance plan options and 401(k) plans. It is neither feasible nor legal, in some cases, for an organization to create a customized health plan or 401(k) offering just for you. So don’t waste time or energy trying to convince a practice to switch its insurance carrier or up its retirement plan matching percentage. It’s not going to happen.
Know your numbers
You can expect potential employers to be helpful and collaborative because they want to hire you. But that doesn’t mean you’ll get everything you ask for.
Before you start setting arbitrary minimums as far as your desired salary is concerned, it will be helpful to know what the industry standards for compensation are for your specialty, says Vogel. Research what the salary is for the 25th, 50th and 75th percentiles in your specialty to get a realistic framework for what you may be paid. Vogel’s experience negotiating his employment contract was very positive. He was also well prepared for the discussion, having researched appropriate salary expectations for his specialty and the hospital system in advance.
Also find out the hospital baseline average, to know how it compares to other locations. If you discover that the average salary hospital-wide is $300,000, you shouldn’t expect to be offered close to that one year out of residency, Vogel says.
That baseline number can be useful for negotiating if you learn that the organization you’re talking to is currently paying under the 25th percentile. Your goal should then be to try to convince the hospital to pull its entire baseline up in order to increase your potential starting offer. That is an easier sell if your research uncovers that doctors are leaving due to dissatisfaction with the salary.
The conversation might sound something like: “I see that your retention rate is below the national average. Now might be a great opportunity to re-evaluate your baseline in order to retain more of your experienced staff.” That approach turns your recommendation regarding an across-the-board salary increase into a benefit for everyone, including the hospital.
Understand the business side
Understanding how much it costs to recruit and hire you, how much revenue you’ll be generating for the organization, and what you can do to increase that revenue can aid your negotiations with for-profit organizations.
A note about academic contracts
Jeffrey Vogel, M.D., M.P.H., suggests researching the industry standards for your specialty’s compensation. Identify the salaries in the 25th, 50th and 75th percentiles to get a realistic framework for what you might expect to be paid.
It is often possible to negotiate an agreement that meets your needs for compensation and benefits and helps you achieve your long-term career goals. The same is true within an academic setting, though the process is different because the role you are applying for is not solely revenue-generating. You’re there to teach and conduct research that elevates the reputation of the hospital or university, in addition to contributing to creating a new income stream for the organization. For that reason, there are fewer elements of the contract that can be modified, less that can be negotiated. But the differences in process are evident from the start.
To begin with, the contract itself is typically issued by the chairman of the department in which you’ll be working, rather than a recruiter. It should outline your responsibilities and the associated compensation, says Virginia R. Litle, M.D., FACS, professor of surgery and chief, division of thoracic surgery at the Boston University School of Medicine. Most initial contracts are for a three-year term and are subsequently renewed on an annual basis.
When applying for your first job in academic medicine, there is not much room to negotiate, says Litle. There are guidelines for what assistant professor positions pay, based on geographic location. There is little room for variation, she says. On the research side, however, it may be possible to request research support on top of your salary. Called “start-up money,” this research funding is a set amount granted for a set period of time, such as $25,000 or $50,000 for three years. Potential new hires can ask for more research funding or for a different length of time, though such funding typically aligns with a professor’s contract term.
You may also be able to ask for more “protected time,” or the time set aside for research. For example, 10 or 20 percent of your workweek may be designated for research work. That’s the protected time. Early in your career, it may be more difficult to be granted more protected time, however, and typically you want to be operating and applying your skills at this stage.
You could also ask for a research coordinator, depending on your research interests. Even if you share the coordinator with others, the role is integral to completing most clinical research for consenting, maintaining databases and processing institutional review board paperwork.
If you’re applying for something other than your first job, you will want to take a step up, which may include seeking a promotion or a program director position. In evaluating your request for a higher salary, more research funding and perhaps more lab space, the university will likely look at your skills and reputation, your research track record, and the number of publications you’ve contributed to, says Litle. “The higher you rise, the more negotiating you can do,” she says.
In academics, some physicians stay at the associate professor level for the remainder of their careers, though 8 to 10 years is more typical, she explains. The speed with which doctors are promoted typically reflects their publication and funding record.
Sometimes to get what you need, you have to make motions to leave. As with any job, you don’t want to do this unless you actually have an offer from another institution that meets all your needs. But having an offer in hand from another university can make you that much more desirable to your current employer and allows for negotiations with both parties, explains Litle. Jumping from one university to another is not considered a negative. According to Litle, “People move around a lot in academics.”
Intellectual property rights
Another difference between academic and hospital or private practice jobs is the rise of contracts demanding rights to supplemental income earned by physicians. It has long been customary in academic settings to include a provision in the contract that stipulates that any supplemental revenue the physician makes while an employee is the property of their employer, says Mason. “However, we’re seeing more private practices, not just universities, writing into contracts that any supplemental revenue that the physician generates—from speaking, intellectual property or stock dividends, for example—belongs to the employer.”
Mason says that [for] “employers [to] collect revenue from work done relevant to clinical responsibilities and patient care is reasonable.”
After all, you are their employee, she points out, and most employment contracts lay claim to new ideas developed during the workday. In the case of an independent idea, however, you may want to claim ownership.
In general, you “want to retain the right to create, innovate and problem-solve” for your own benefit, she says. “Practices are often willing to negotiate this point,” she says, but you need to be aware of it and how best to modify it to meet your personal goals and objectives.
Do you need an attorney?
Unless an attorney is an experienced employment lawyer, odds are good that their involvement in negotiations will drag out the process. Negotiations can take anywhere from two days to a month, says Steven Jacobs, physician recruiter with WellSpan Health, depending on an attorney’s familiarity with health care employment contracts. Lawyers who do not specialize in employment law will frequently push back on terms that can’t be changed, such as taking call.
That said, an employment attorney can be helpful in explaining contract language and clarifying what certain terms mean for you and your career long-term. The contract itself should be a verification of what’s been agreed to during the normal verbal back-and-forth that has occurred about the terms of your employment, explains Jacobs. There shouldn’t be anything surprising in it, but an attorney can review it with you to make sure nothing has been overlooked. “An attorney can provide a sense of security that a contract looks OK,” says Jacobs.
Use of attorneys during negotiations has increased in the past five to seven years, says Jacobs. Fifteen years ago, about 30 percent of physicians would retain an attorney to assist with their contract. Today that percentage is closer to 85 percent, he says. However, recruiters rarely deal directly with attorneys. Physicians use them more as behind-the-scenes advisers than front-line negotiators.
Jacobs recommends reading the whole contract from start to finish and asking yourself, “Does it make sense?” Then go back through with a recruiter or attorney and ask questions about any terms or requirements that are unclear to you.
Terms to understand
Beyond the compensation package, there are other elements of your employment agreement that you’ll want to hone in on, says Mason. The big three include duties and responsibilities, noncompete clauses and termination clauses. These are sections that you will be unable to remove completely, but you may have room to ask for minor changes.
Duties and responsibilities. In this section you’ll find information on the amount of time you’ll spend working each week, the frequency of call you’ll be required to take, whether you will have time for research and other specifics about your job responsibilities.
Though you can’t negotiate basic responsibilities, such as seeing patients or teaching hours, you may be able to ask for less call—or more call in exchange for more admin support.
Noncompete. Most practices won’t negotiate this clause out completely. However, you can ask for the terms to be reasonable in scope and duration.
For example, not being permitted to practice within a 10- to 25-mile radius rather than 25 to 50 miles, or having the noncompete in place for one year rather than five.
In many cases, the willingness of a practice to negotiate may hinge on the population density of the area. In larger cities, the scope of the non-compete can be smaller, due to the larger number of patients in a small geographic area, whereas in more rural practices, the non-compete radius may be larger because there are fewer doctors in general and your moving practices could cause a major shift in the marketplace.
Termination. Most contracts reserve the right to terminate you without cause, just as many states are employment-at-will states that require no cause for termination.
You can ask, however, to be given a notice of termination within a certain number of days, just as you may be required to give a 90-day notice before leaving.
You should also ask for payment of tail malpractice insurance to cover any claim made after you leave; payment is typically due within 90 days.
While you may be able to modify some of the specifics surrounding these elements slightly, you will not be able to change them materially.
Though many aspects of your employment agreement are negotiable, attempting to negotiate every little detail “can make an employer leery,” cautions Steven Jacobs, physician recruiter with WellSpan Health in York, Pennsylvania.
You can ask lots of questions and push back on some requests, but not on all of them. “Three or four requested changes are typical for WellSpan,” says Jacobs. “More than that and we’ve got a problem. That’s a red flag to the practice.”
At that point, you risk coming across as very difficult to deal with, and employers may decide you’re just not a good fit.
“Ninety-five percent of the time, contract negotiations go smoothly,” says Jacobs. Which means that odds are good your negotiation will go just as well, as long as you don’t nitpick.
Pick your battles. When something is truly important to you, make it clear that you’re pushing hard for the change because you intend to remain on staff for many years—so terms will impact you for years to come.
In the end, “everyone wants the same outcome,” says Jacobs. So “be collaborative in the process, not adversarial…. The negotiating process is not there to hurt you,” it’s there to help you get what you need to be successful in your career.
What’s your competition like? For job-seekers of all kinds, it can be hard to know. A simple PracticeLink.com search for opportunities in your specialty will give you an indication of the demand for physicians like you, but without knowing who else is vying for those jobs, it’s hard to get an accurate picture of supply.
How many other candidates in your specialty are actively looking for jobs at the same time? And how does that number correspond to the number of opportunities available?
That’s where the PracticeLink Physician Recruitment Index comes in. The Index is a relative indication of the ease or difficulty of job searches in various specialties based on supply and demand information gathered by the PracticeLink system quarterly. The larger the “Jobs per candidate” number for your specialty, the better your potential standing in the market.
The change in rank reflects the specialty’s movement since last quarter.
The Most-Challenging-to-Recruit Specialties are those specialties with the highest demand-to-supply ratio in the PracticeLink system. The specialties on this list likely won’t come as a surprise to candidates; they’re often narrow fields.
The Most-In-Demand Specialties represent the specialties that have the most jobs overall posted on PracticeLink—specialties for which the demand for physicians is highest. For the Index, we then rank those in-demand specialties according to the supply. Those at the top represent specialties with the most jobs available and the fewest candidates per job.
After reading these Indexes, ask yourself: Do these Indexes match my experience of searching for a job in my specialty? Do I need to widen or narrow my job-search parameters as a result?
This PracticeLink Physician Recruitment Index was pulled July 2017. Candidate ratios include physicians who have registered with PracticeLink.com within the past 24 months.