Burned out

Recognizing and addressing burnout in you and your staff.

By Debbie L. Miller | Feature Articles | Winter 2019

 

Practicing medicine has never been an easy profession. But it’s also not getting any easier. Perhaps that’s what makes burnout not only a reality, but also on the rise—and rising fast. Tait Shanafelt, M.D., chief wellness officer of Stanford Medicine, has found that burnout rates among physicians are now twice as high as that of professionals in other fields.

In the most recent data from a national research study, Shanafelt found that nearly 49 percent of physicians reported burnout, as opposed to 28 percent for other professionals.

Although physicians of all ages and time in practice can and do suffer from burnout, it’s actually the younger physicians who seem to be particularly at risk.

“Residency is the peak time for burnout,” Shanafelt says. One factor is the long hours required of training.

Female physicians report burnout at higher rates than male physicians. In one survey from Medscape, 48 percent of female respondents reported burnout symptoms vs. 38 percent of male respondents.

Specialty can also play a role. One Medscape survey cites the following specialties have the highest reported rates of burnout: critical care, neurology, family medicine, Ob/Gyn, internal medicine, emergency medicine and radiology. Additional issues also contribute. For example, working emergency department shifts can contribute to “a distortion in circadian rhythm,” says David A. Farcy, M.D., who practices at Mount Sinai Medical Center in Miami Beach and is president of the American Academy of Emergency Medicine (AAEM).Likewise, “Emergency departments are the safety net of America, social issues are mounting and resources are getting less.”

The two factors most often cited in the Medscape survey as contributing to burnout are “too many bureaucratic tasks” (cited by 56 percent of survey respondents) and “spending too many hours at work” (cited by 39 percent of respondents).

Shanafelt notes another factor: complying with the demands of electronic health records. “About 37 percent of a physician’s time in an examination room is spent entering EHR data into a computer,” says Shanafelt—time that could be spent with the patient, and time that still often requires data entry on nights and weekends.

Bringing burnout to light

The first step to getting help with burnout? Acknowledging there's a problem, says Antonia Francis, M.D. -Photo by Lauren Listor

The first step to getting help with burnout? Acknowledging there’s a problem, says Antonia Francis, M.D. -Photo by Lauren Listor

As recently as the late 1990s and early 2000s, the idea of physician wellness was rarely addressed as part of med school curriculum. Instead, the focus was on strength and resiliency. The message was this: physicians should do whatever was necessary to deal with the challenges of a career in medicine. That mindset created even more stress.

It took an increase in physician suicides to bring the matter to the forefront.

In 2012, the suicides of two residents in New York City shone a light on the issue of physician suicide. “As a result, the emergency community as a whole came together in 2016 to form a coalition of all emergency medicine groups to address wellness,” says Farcy. Goals of the coalition included defining the problem of burnout and determining ways to identify and prevent it.

Benefitting from the focus

For Farcy, the topic was deeply personal.

“During my medical school, emergency medicine and critical care fellowship training, physician burnout and wellness was never addressed,” he says. “We were taught to just press on.”

But while in residency at Maimonides Medical Center in Brooklyn, Farcy was a first responder on 9/11—an experience with memories that he put “in a box” and didn’t speak about to others.

Then, during a moment of silence paying tribute on the one-year anniversary, Farcy’s experiences hit him hard.

Farcy’s program director took notice and invited him to her office to talk. She suggested he get help and referred him to a representative from the ACGME. From there, he visited a psychologist trained in PTSD and survivor guilt—and got the help he credits with changing his life.

“I am grateful that my institution had a program in place and a plan to address the issue without fear of repercussion,” Farcy says.

Antonia P. Francis, a maternal fetal medicine fellow at NYU Langone Health Center, reports that while she hasn’t personally known any physicians who have committed suicide, “I trained at an institution that experienced two suicides of house staff within a three-week period, yet I can honestly say that during my medical training, the topic of suicide was not heavily stressed.”

Francis, who works a fairly typical 80-hour a week, says, “I experienced depression and burnout during my residency training and first year of fellowship,” she says. The first step was recognizing she had a problem. Then, she took action.

“I visited counselors and a therapist who specifically works with physicians who had mental exhaustion,” she says. “I also learned to practice mindfulness, started journaling for stress relief, and exercised more.”

When help doesn’t come

Untreated burnout can lead to medical errors, substance abuse, depression and even death.

“About 300 to 400 physician suicides are reported each year,” Farcy says, “but suicide in doctors is under-reported and often hidden, because a physician can make a suicide look like an accident.”

The AMA and STEPS Forward module (stepsforward.org) on physician depression and suicide reports that female physicians commit suicide at a 130 percent higher rate, and males at 40 percent higher rate, than that of the general population for each gender. Those statistics alone make burnout a problem in dire need of fixing.

Fixing the problem

Alleviating physician burnout is a complex challenge. Survey respondents cited more pay, fewer hours and patients, and fewer government regulations as key.

Early detection can also help. Farcy, who has been supervising residents in emergency medicine for 12 years, has seen and addressed depression and burnout in others. The early signs, he says, are “less involvement, less caring, and negative comments in a person who used to be very positive.”

Addressing burnout, however, comes with its own land mines. Sometimes when a physician who is depressed or approaching burnout speaks to their supervisor about the issue, the physician is forced to stop working or see a psychiatrist in order to be cleared to go back to work.

“Too often, this adds to the stress by causing a new burden on the physician,” Farcy says.

And when a colleague has moved beyond burnout to something deeper, expressing concern may not be enough. “By the time a doctor is in the early stages of depression, it is harder to get them involved in resilience,” says Farcy. “Telling them you need to go work out, do yoga, drink less, spend more time with your loved ones, etc., too often falls on deaf ears. The physician may hear it but won’t change or do these things because of their underlying depressive state.”

David Farcy, M.D., has seen and addressed depression and burnout in others. The early signs, he says, are "less involvement, less caring, and negative comments in a person who used to be very positive." -Photo by Rodrigo Varela

David Farcy, M.D., has seen and addressed depression and burnout in others. The early signs, he says, are “less involvement, less caring, and negative comments in a person who used to be very positive.” -Photo by Rodrigo Varela

The best answer may be in fostering a community that’s open to discussing burnout. Farcy says physicians need to feel free to talk openly, in a safe place, without being labeled as weak. “We have a wellness program where I work, and I have an open-door policy for anyone to be able to talk and share, without risk or fear of repercussion,” Farcy says.

“Once the person begins speaking, most important is listening and creating a plan,” he says.

Clif Knight, M.D., is senior vice president for education for the American Academy of Family Physicians (AAFP). He’s worked in private practice, as a hospital administrator, and as director of a family medicine residency program. As a residency program director, he witnessed resident burnout and tried to help his physicians recognize their symptoms and consider counseling and coaching.

Knight stresses that burnout is not due to a lack of physician resiliency, as was once commonly thought.

“It’s important to recognize that the majority of burnout is related to problems in the health care system and outside the physician’s control most of the time,” he says. “We need to fix the system’s problems instead of addressing only the resiliency and coping skills of individual doctors.”

Francis agrees. “Physician wellness isn’t only about individual and personal efforts, but about change on a broader level.” She suggests that institutional support and a change in our medical culture would go a long way to support physician wellness.

The path ahead

Now, medical education institutions are addressing burnout head-on. And there appears to be more help for physicians in the throes of burnout.

“Cultural and environmental changes are necessary to combat physician burnout,” says David A. Rothenberger, M.D., who advises on physician burnout at the University of Minnesota. “At our institution, we have a multi-year, major commitment from the top of the organization to devote time, talent and treasure to take on this problem.”

Rothenberger is also helping to build a coalition of those who want to address the issue of physician burnout. Currently, close to 80 individuals belong to the coalition, including academic and clinical leaders and staff.

Though progress is being made, Rothenberger says it will take a decade or two to fully address the issue.

“Achieving the needed transformation of the workplace culture to overcome the current physician burnout epidemic will take many years, and sustaining physician wellbeing is dependent on continuous effort to meet the future needs of physicians and other health care professionals,” he says.

 

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The way back home

These physicians chose to practice where their roots were. Their stories can help you, too, decide if moving back is the right call.

By Anayat Durrani | Feature Articles | Winter 2019

 

The saying goes: “Home is where the heart is.” And for many physicians, this holds true when it comes to deciding where to practice. That was certainly the case for Amanda Mooneyham, M.D., MPH. No matter where school or work took her, she always planned to return to the Northern California town of Redding, where she grew up, to serve the medically underserved in her community.

“When I started medical school, a community health needs assessment showed that Shasta County, California, needed an additional 17 primary care physicians just to meet the existing needs of the community—and [that] didn’t account for those leaving the workforce through migration or retirement,” says Mooneyham.

This was in 2009, and Mooneyham says the needs of her community have not improved since—even though many more people in the area have been able to access care through the Affordable Care Act. In fact, this is the pattern nationwide. As residencies and high-paying specialties lure physicians to big cities, rural areas like Shasta County, which encompasses the city of Redding, are experiencing a shortage of health care providers.

Many states are trying to attract doctors to rural areas with financial incentives, such as federal- or state-funded student loan reimbursement or repayment programs. But among physicians who grew up in these areas, many need no convincing. Plenty of doctors return to their hometowns to join family practices, rural practices or the practices where they did their residencies.

Returning to your residency

Amanda Mooneyham's hometown was in need of physicians. She answered the call and moved back to practice. -Photo by Jack Vu

Amanda Mooneyham’s hometown was in need of physicians. She answered the call and moved back to practice. -Photo by Jack Vu

After graduating from UC Davis Medical School in 2014, Mooneyham returned to Redding with her husband, a civil engineer. She had done her residency in Redding and ended up taking a job there as a teaching faculty member at Shasta Community Health Center Family Medicine Program. She’s also one of four core providers in their Medically Assisted Therapy clinic. There, she practices full-spectrum family medicine, including obstetrics and addiction medicine.

Mooneyham enjoys filling the need for providers in a rural area, and she also enjoys the rural pace of life. “My commute to work is all of seven to eight minutes each way,” she says. “The hospital is less than 10 minutes from the clinic. Most of the providers at our FQHC work four days per week, which helps me maintain a healthy work/life balance.”

Brandon Allen, M.D., also chose to stick to his roots. Born in Fort Lauderdale, he attended medical school at Florida State University College of Medicine and residency at the University of Florida. He completed his residency and final year as chief resident in 2013 and joined the University of Florida as an assistant professor in the department of emergency medicine and the assistant medical director of the adult emergency department.

Allen says his transition from chief resident to assistant professor was mostly seamless because he was already familiar with the university. “I knew the environment, and I wouldn’t be starting over in a new place,” he says. “I had created strong relationships with nurses, staff and providers outside of the ED over my residency that would be hard to replace or recreate.”

However, he says he did face an initial challenge in figuring out new working relationships with residents who had previously been his peers. “One day I was a resident, and the next I was an attending physician and faculty member,” Allen says. “How would I be perceived by residents who I had shared a seat with in conference or the same shift schedule? Would they listen to me as an attending? Could I be effective?”

He also had to figure out new relationships with his staff, since he became an assistant medical director following his last day of residency.

Allen says he worked through these challenges by modeling the traits of an attending faculty member whom he had always appreciated and respected. He always tried to be the first to see patients, so he could take advantage of teachable moments. He also took the time to review charts and send regular feedback emails on performance.

“I made a conscious decision to be effective over being popular,” explains Allen. He adds that transitioning to his new role as medical director has taken time. Some faculty members embraced him with open arms while others waited for him to prove himself.

“One of the ways I did that was to focus on standardization of practice with evidence-based protocols and pathways,” says Allen. By working to improve provider satisfaction and patient care, he earned other faculty members’ respect.

Joining a family practice

The opportunity to join a family practice is what attracted Drew Schmucker, M.D., back to his hometown of Olney, Illinois. “I was attracted to the idea of practicing in a small town so that I could have the scope of practice I wanted,” says Schmucker. “I do both inpatient and outpatient medicine as well as OB.”

Schmucker graduated from Southern Illinois University School of Medicine and completed his residency at Memorial Hospital of South Bend in Indiana before joining Carle Richland Memorial Hospital in Olney as a family practitioner. Carle Richland is a not-for-profit facility, part of the Carle Health System, which serves eight southeastern Illinois counties with a population of over 109,000 individuals.

Schmucker says there were quite a few advantages to heading home. Being close to family and friends was a big one. “I spent a lot of time away from home, family and friends because of school and residency,” he recalls. “I missed some birthdays, weddings, family get-togethers, etc.” Now that he’s closer, he says it’s been great to be present at these special events. And it’s nice to have family around since he and his wife now have a 10-month-old.

As a family practitioner, Schmucker has patients ranging from newborns to adults, and he offers obstetrics services to expecting patients. Practicing medicine in a town as small as Olney has given him the chance to diversify his skills and connect with his patients. When he started his career there, one of his biggest concerns was getting too busy, since there was such a great need for primary care in the area. He says he was afraid of getting overrun with too many patients and too much call, especially because he wanted to have a broad scope of practice.

But those fears have been put to rest. “I’ve been really fortunate to have a great first year of practice so far,” Schmucker says. “The hospital system I work for keeps my office running smoothly, and there is a great group of doctors here to share call with.”

He says it helped that he knew some of his office staff before he began working with them. They have developed close-knit relationships and have a lot of fun while seeing patients. Schmucker has also noticed he has a lot of flexibility working for a small hospital in a small town. If there are ever any problems with workflow or patient care, he says it’s easy to find the right person to talk to and get the issue resolved.

“I love taking care of patients here,” he raves. “Oftentimes, people have been waiting to get in for appointments or driving out of town. It’s so rewarding to deliver good care in a place where it is really needed.”

Patients are very appreciative of his work, and Schmucker says in some cases, these patients are people he has known for years. He even went to school with some of them. Knowing a bit about patients before they visit helps him provide better care. “It also keeps me grounded as I practice,” he adds. “Patients aren’t just cases of pneumonia or diabetes here. They may be old classmates, family members of old classmates, former teachers, coaches, family friends, etc.”

Practicing solo rural medicine

Fifteen years ago, J. Scott Litton, Jr. M.D., returned to his hometown of Pennington Gap, Virginia-which has a population of just over 1,700-to open a family practice. -Photo by Andy Stacy

Fifteen years ago, J. Scott Litton, Jr. M.D., returned to his hometown of Pennington Gap, Virginia-which has a population of just over 1,700-to open a family practice. -Photo by Andy Stacy

While moving to a small rural town may not be a top choice for many physicians, others wouldn’t have it any other way. One month after finishing his residency, J. Scott Litton, Jr., M.D., returned to his hometown of Pennington Gap, Virginia—which has a population of just over 1,700—to open a solo family practice. This year marks the 15th anniversary of Litton Family Medicine, P.C.

“It was always my plan to practice in my hometown,” says Litton, who attended medical school at the University of Virginia, then completed his residency at the Spartanburg Family Medicine Residency Program in South Carolina. “I was very blessed to have exposure to wonderful mentors, both as a volunteer before medical school and with my attendings in medical school and in residency.”

These mentors gave Litton perspective on rural family care. He says, “I was able to see how a small-town family physician can connect with patients and truly have an impact on modifying their lifestyle behavior and medical outcomes.”

Litton believes one of the biggest benefits of practicing in your hometown is getting the chance to care for people you have known and loved for many years. Several of his childhood teachers, athletic coaches, church members and family now use his practice.

“My initial concern was that everyone in town has either known me since I was a kid or grew up with my parents,” he adds. “Everyone has always referred to me as ‘Scotty’ as a child, and ironically enough, many of my patients still call me Scotty, rather than Dr. Litton.”

He says that in a small town where everyone knows everyone, physicians have to politely and firmly draw certain lines about providing care. Whether he’s working as the varsity sideline doctor at a high school football game or simply attending church, people often expect him to answer their medical questions about anything at any time. Over the years, he’s learned how to handle people who get too pushy.

“I simply tell them that I practice medicine in the office, and I am happy to go over all their concerns or questions, but they must make an appointment and continue the discussion in a confidential setting,” says Litton. “Everyone has pretty much grown accustomed to it.”

He always finds it rewarding to help people but says it’s especially meaningful when you’re helping people with whom you have an emotional connection. The flipside of this is that people he cares about inevitably become sick or ill. “When I have to deliver bad news or comfort a grieving family, I just sit there and cry and pray with them,” says Litton.

A passion for his community also led David O. Barbe, M.D., MHA, to open a solo practice in his hometown. As he finished his residency in family medicine at the University of Kansas, Barbe says he and his wife had an easy decision in front of them. They had both grown up in the same small town of Mountain Grove, Missouri—with a population under 5,000—and as a nurse, she shared his conviction that the area needed more providers.

“We both knew that we wanted to return to our area of rural southern Missouri, and we saw it as a mission. That area has been underserved for as long as I can remember,” says Barbe, who attended the University of Missouri–Columbia School of Medicine.

Barbe had seen firsthand that the area never had enough physicians. He says the health care facilities there were few and far between, and there was no hospital. He knew he wanted to serve that population. “We went in eyes wide open,” he adds. “And although there were physicians in that community, joining with one of them wasn’t quite the right fit. So we opened a solo practice from scratch.”

Barbe established a solo practice in traditional family medicine, including obstetrics, endoscopy and minor surgery. “That was daunting, but we managed to pull together a simple one-physician office,” he says. “We opened our doors on August 1, 1983 and had essentially a full panel of patients the very first day. I have never regretted it or looked back.”

Over time, Barbe expanded his independent practice to two sites with several physicians. “I practiced solo for four years before I recruited my first partner,” he recalls. “She and I built that practice as an independent practice. In fact, we established a second office in a community about 25 miles away.”

After 15 years in independent practice, Barbe joined Mercy Clinic in Springfield, Missouri, a 650-physician multi-specialty integrated group. He saw merging as a way to bring more resources into his community and serve them better than he could as an individual physician.

Barbe is now vice president of regional operations for Mercy and oversees five hospitals, 90 clinics and more than 200 physicians and advanced practitioners. “But despite that growth and success, my practice eventually came full circle,” he says. “The physician who’d been with me for 22 years retired and another who’d been with me for 18 moved, leaving me as a solo practitioner, back to how I started.”

At first, he didn’t succeed in recruiting another physician to join him, but then his own son chose family medicine as a specialty and began seriously considering coming back home to practice. “He’s now decided to do just that,” says Barbe happily. “It wasn’t because of my pushing or encouragement. It was because he saw some of the merits of a rural practice that I experienced throughout my career.”

Advice for going home

Whether you’re excited about moving back home or just contemplating the idea, physicians who have done it have advice to share. They say it’s important to think carefully about the decision. Allen, who returned to work where he completed his residency, says a physician returning home should expect some people to struggle to embrace your new position.

“Having the self-awareness to understand your role and how your strengths and weaknesses may affect that will hopefully assist with prevention of burnout and/or dissatisfaction with your decision,” he says.

And Schmucker says physicians returning home to join an existing practice or hospital should talk with administrators about their expectations.

Let your employer know what you hope for in your role and address any concerns ahead of time. He also recommends talking with area doctors to see what the environment is really like. When he did this, Schmucker says, “I could tell they were happy and felt like the hospital was receptive to their concerns.”

Having this discussion ahead of time has allowed Schmucker to do all the things he wanted to do in practice while maintaining work/life balance.

He says one big help has been that the hospital arranged for some hospitalists to come in and share call on the weekends. “That gives me most weekends to spend more time with family, catch up on work at home and travel,” says Schmucker.

Litton, who opened a solo practice in his hometown, says no matter what specialty a physician chooses, he or she shouldn’t ignore the benefits of family medicine. “Sure, you won’t make as much money as a neurosurgeon, but if you start out and keep your practice small, then you can have a very good lifestyle with a very comfortable living,” he says.

The one mistake he says he made many years ago was not saying no enough. “Our practice is pretty much covered up on a daily basis,” he says. The heavy workload results in long hours and less free time than he would like, so now he’s trying to find balance by not accepting new patients for a time.

When Barbe opened his solo practice 35 years ago, he says he had to learn a lot on his own. Then, as now, medical students and residents weren’t taught about running a business as part of their training.

He says that’s something the American Medical Association—of which he’s president until June 2019—is trying to address. The AMA Accelerating Change in Medical Education Consortium is finding better ways to coach and prepare students for the future.

But whether physicians choose to pursue a solo practice or join a practice, Barbe says more physicians need to consider practicing in a smaller area.

“I want to debunk the myth of professional or social isolation in a rural community,” he adds. “Many physicians fear that in a rural community they’ll be too far from a good restaurant or sports or activities for their children.”

While it may take a little more effort to access some of those social amenities, most small communities are within driving distance of a larger community or metro area.

“I don’t think enough physicians give careful consideration to their opportunities in that regard,” Barbe says. “Rural America is a wonderful place to practice and raise a family.”

Mooneyham has found that to be true.

Her relocation to Redding—where her parents and brother still live—turned out to be a smooth move for her and her husband. The firm where her husband was working in Sacramento had a large corporate office in Redding. Now, her husband’s new office is only a quarter mile from her hospital.

Her advice for physicians considering moving home is simple: Do it. She believes it is especially important for those from underserved communities to return because they have insider knowledge of those areas and will be welcomed with open arms.

“There is a certain intimacy when working with other health care providers who have a connection to who I was before becoming a physician,” says Mooneyham. “It is likewise also rewarding providing care to those who know me as ‘Amanda,’ before I became ‘Dr. Mooneyham.’”

 

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Leveling up

How to prepare for a leadership role — even as you’re just starting out.

By Laurie Morgan | Feature Articles | Winter 2019

 

If you’re like most new physicians embarking on your career, you might not be thinking ahead to a management role. Your priorities are likely finding the right place to practice and, above all, helping patients.

But even if you don’t envision running a health system, hospital department or independent practice in the future, you should still be seeking out opportunities to develop leadership skills. These abilities will bolster your career as a physician—whether you see yourself in a corner office one day or feel certain you’ll always focus on patient care.

After all, some level of leadership is inherent in every physician role. Staff will look up to you and expect you to lead the way, and your employers will rely on you to guide new initiatives and solve problems. Learning to lead better can help you not only advance your career but also care for patients more effectively.

Filling a gap in your medical training

Mark Deshur, M.D., says it doesn't take a title to be a leader. "Even without a formal role, you can make a difference in how things are being done." -Photo by Colin Lyons

Mark Deshur, M.D., says it doesn’t take a title to be a leader. “Even without a formal role, you can make a difference in how things are being done.” -Photo by Colin Lyons

Despite their benefits, leadership skills rarely get attention in medical school and residency. With so many clinical priorities to cover, it’s hard to make room for non-clinical topics in the curriculum.

“Lots of physicians don’t want to accept that management skills are important,” says Maria Chandler, M.D., MBA, founder of the MD/MBA dual-degree program at University of California, Irvine and president of the Paul Merage School of Business Association of MD/MBA Programs. “But this is a disservice to medical students. We’re telling them [clinical education] is all you need, yet it’s not true.”

This focus on direct patient care is admirable, but it may be shortsighted. Chandler believes management training helps physicians care more effectively for patients. For example, physicians with business knowledge can be better advocates for clinical priorities. She explains, “If you’re interested in preventing chronic disease, you can learn to make the economic case for that.”

That’s one reason Chandler advises all physicians to learn some leadership basics. She says they should do so “as early in their careers as possible.” Once there’s an “M.D.” or “D.O.” after your name, people will expect you to guide them, regardless of your age. Many of these people—including the nurses, MAs and other staff you’ll work alongside—provide essential support for patient care. Working well with this team will require training you didn’t receive in medical school, and some of what you learned might even be counterproductive.

Unlearning the superhero myth

According to Dike Drummond, M.D., CEO of TheHappyMD.com, many physicians enter the workforce with misguided expectations. “In medical school and residency, there are no leadership courses. You learn by osmosis, and here’s how it works: you see patients, reach a diagnosis and write orders, and the rest of the care team waits on you,” explains Drummond. “You’re taught subconsciously that only you have the answers. But what kind of leadership style is that for team-based care?”

As a result, Drummond says that most doctors internalize a “Lone Ranger, workaholic, superhero, perfectionist ideal” in medical school. This mindset not only burdens physicians; it also makes it harder for staff to help. Nurses and others will follow your lead. If they’re always waiting for your orders, they’ll be underutilized and probably less motivated, too.

And when staff members don’t feel supported as part of the care team, patient safety can be affected. “It’s been proven in numerous studies that a lot of people feel too intimidated to say anything to a physician—even if it’s a life-threatening issue,” adds Chandler. “Leadership training can help physicians learn to create an atmosphere of teamwork.” In a culture where staff feel comfortable raising concerns, patient care improves.

To build team leadership skills as a physician, Drummond says the critical first step is learning to listen and ask questions. “Your staff can always help,” he explains. “They want to help. But they’re not going to elbow you out of the way.”

Once you start asking staff how they can assist, Drummond says they’ll likely respond with many useful ideas. When you enable them to take on more meaningful roles, they’ll be happier and more engaged, too. That means more support and less stress for you as a physician, more attention for your patients and higher career satisfaction for the entire team.

New clinical and economic approaches are making the ability to lead diverse teams more critical than ever. Patient-centered medical homes require high-performing care teams, and alternative reimbursement models—with evolving definitions of value and quality—require physicians to lead change, sometimes in tandem with administrators.

Chandler says physicians don’t always see these opportunities as being directly tied to patient care. “Many doctors think of taking on leadership responsibilities and roles like serving on committees as a chore,” she says. “All some of us want to do is see patients—like a surgeon who’s tied up in an OR 80 hours a week and inadvertently gives up their input.”

But she says by getting involved in leadership, physicians can impact more patients while helping hospitals and health care systems make better decisions and reduce costs.

Don’t wait for an official title

In the business world, budding leaders learn the art of managing up, down and across—or in other words, finding ways to influence the workplace even when they aren’t in charge. Physicians can benefit from learning to do the same. This starts with recognizing opportunities to help not only their patients and their subordinates but also colleagues at all levels.

Mark Deshur, M.D., MBA, vice chair of operations in the department of anesthesiology, critical care and pain medicine at NorthShore University HealthSystem in Chicago, has found this to be true in his own career. He says he knew from the beginning that he would eventually seek some sort of leadership role, explaining, “I knew I wanted to be part of the decision-making process, not just subject to others’ decisions.”

Deshur learned early on that you don’t have to wait until you have formal authority to contribute ideas to improve your workplace. “We have so many people in my practice who are leaders without titles,” he says. “Even without a formal role, you can make a difference in how things are being done. You see an opportunity to do something a little differently and a little better, and that improves things for everyone else.”

And making suggestions isn’t just good for others. It’s also good for you. “It creates more career satisfaction and better engagement in the practice because everyone wants to feel that when you’re going to work, you’re making the place better,” Deshur explains. He adds that phrasing a suggestion as a question is a good way to persuade others without putting peers and senior colleagues on the defensive. “For example, you could say, ‘Do you think if we tried X, it might be an improvement?’”

At practices that welcome this type of input, younger physicians get to develop their leadership potential and prepare for formal management responsibilities down the road, Deshur says. He recommends assessing prospective employers by asking recently hired doctors if they’ve been allowed and encouraged to suggest changes.

Managing upward can be especially challenging in the medical world. Physician training favors on-the-spot decision-making, and this tends to develop reactive management skills rather than proactive ones. As a result, some supervisors only communicate with their subordinates when there’s a problem, which can be discouraging for young physicians who want to do well. Scheduling a regular check-in with your boss can help you confirm you’re on track.

Mentors provide invaluable guidance

If you nurture relationships with your boss and other experienced physicians, you may find they become long-term mentors. These mentors can be invaluable as you navigate key career decisions. “I’ve been very fortunate to have several mentors I’ve leaned heavily on,” Deshur says. “Even though my career trajectory was different than theirs, they helped me take a step back and think about what my strengths and weaknesses are and what am I interested in.”

Deshur didn’t have to look far for his mentors. He found them in his direct managers. “I was lucky that I had them right in front of me,” he says. “But if you don’t have mentors readily available, seeking out one or two people who can give you feedback and advice is so important. So many people have tremendous experience to share that you can learn from.”

Finding mentors may require effort and creativity, but one easy way to start is to keep in touch with older physicians you admired during your training. If your job takes you to a different part of the country, ask them to introduce you to respected colleagues in the area.

Joining your local medical society can also help you form relationships with physicians from a range of specialties, especially since society leaders are often interested in becoming mentors. The nurses at your new hospital are another great resource as they undoubtedly have insights about which doctors are most admired.

To MBA or not to MBA?

Deshur says finding mentors helped him prepare for another major step in his leadership plans: pursuing an MBA. “It was in the very back of my mind, since I’d taken business classes in college. But I kind of forgot about it during the early years in my practice,” he says. “Then my boss, who was also a mentor, told me how he’d gotten an MBA mid-career and asked me if I was interested in it.”

Deshur’s mentor urged him to enroll in the executive MBA program at Northwestern’s Kellogg School of Management. Because the program was located nearby and designed for working professionals, Deshur could enroll without leaving his practice. He credits his employer and fellow anesthesiologists for helping him through.

“You can’t do it in a bubble. You need the support of your practice,” he says. “My boss was very supportive. He helped me get the time off that I needed and encouraged the other 50 people in the department to support me.” Deshur’s colleagues ensured he was able to attend required classes on Friday mornings and swapped call schedules with him as needed.

“As a department, we’d benefitted from the leadership of my boss, who had attended the same program,” Deshur recalls. “So I think people thought, ‘If we help Mark take on more, that can help our entire group.’”

Often, the entire organization benefits when a physician earns an MBA, so your employer may also help pay for it. This is especially true if you’re promoted to a role that requires advanced leadership or negotiating skills, such as heading up a department, says Gregg Bass, communication and marketing specialist at Auburn University’s Harbert College of Business. And when tuition assistance from your employer isn’t available, you might be eligible for financial aid.

Auburn’s Physicians Executive MBA Program is pioneering a new wave of MBA offerings tailored to busy physicians who go to school while working full time. “The majority of our program is distance learning,” Bass says. Physicians can access the curriculum online on their own schedule. Five short residencies on campus at Auburn are required, but students get these dates in advance so they can plan ahead.

Chandler believes a physician shouldn’t put off pursuing his or her MBA. She says, “It only took me two years of being out of training [and] seeing patients to realize there might be something more I’d want to do later, besides only seeing patients for my entire career. The worst case is you wait so long that you realize the opportunities you’ve missed.”

The growing number of flexible MBA programs makes it easier to pull the trigger, even while working as a full-time physician. “They make all different shapes and sizes of MBA programs now,” Chandler says. “There are fully online programs, one-year programs, hybrids, evening-weekend programs—all kinds of options to fit the needs of people.”

Another reason not to delay: the skills and professional connections you’ll develop in an MBA program can open new doors. If you’re facing a career change or just feel ready for one, an MBA can be a powerful catalyst.

“We’ve had physicians who are taking on leadership roles in hospitals, physicians who want to leave practice to work in pharma” says Bass. “Recently, we had a trauma surgeon with many years of experience who realized he wouldn’t be able to do that physically demanding work forever and wanted to prepare for something new.”

New opportunities might also come in the form of entrepreneurship. Bass says several physicians in the Auburn program turned their class projects into real-life business ventures. Similarly, Deshur says getting his MBA encouraged him to turn a software program he wrote as a resident into a product. Today, hospitals and practices all over the country use his on-call scheduling solution.

If you already have a great idea that can really make a difference in the industry, Chandler says you might need business training to make it a reality. “I knew a couple of intensive care docs,” she recalls. “They were five to 10 years out of school. They were trying to help save lives by bringing telemedicine to rural areas where intensive care resources were scarce. I said to them, ‘You need MBAs to take this thing and make it big.’ They both enrolled while still practicing and building their venture. It’s hard, but if you’re motivated enough, you can do it. Knowing why you’re doing it—to achieve a goal, to learn a new set of skills—can make it easier to stay focused.”

Creating a healthier health care industry

Vidya Bansal, M.D., started a group for physicians of South Asian decent-a community that has helped her develop her own leadership skills. -Photo by Rachel Moore

Vidya Bansal, M.D., started a group for physicians of South Asian decent-a community that has helped her develop her own leadership skills. -Photo by Rachel Moore

Chandler believes pursuing an MBA is worthwhile not just for the career advancement but also for the personal development. It’s intellectually invigorating. “I found I missed school, missed learning,” she explains. “Doing the MBA while working was hard, but it filled the education void. If you’ve only studied medicine, it’s so intriguing to study something else.”

She adds that an MBA program is just one way to be a lifelong learner. Other development opportunities can also help physicians enjoy their careers. “I get emails from physicians who are many years into practice who are burned out,” she says. “I think one remedy to burnout is to give yourself additional skills so you have options. Your options can be in all different directions.”

Chandler believes today’s physicians can and must take on more leadership roles to improve the profession and make it appealing to the next generation of talent. “It’s like we’ve had blinders on,” she explains. “But we have to think about how to compete over the long-term with other employers who want smart, talented, young employees.”

Pediatrician Vidya Bansal, M.D., has found a way do just that—helping other physicians while developing her leadership skills. Early in her career as a pediatrician, Bansal wasn’t sure where to look for support. So she turned to Facebook and started a private group for physicians of South Asian descent: Desi Physician Moms. When Bansal first founded the group in 2015, it had only 14 members, but she’d struck a nerve. The group soon took off, and today more than 7,000 physicians are members.

“I started it for personal reasons, to find support,” Bansal explains. “I wanted a place where I could share and not feel alone.” What began as a hobby quickly became a lifeline for women physicians dealing with issues like domestic abuse and harassment at work. Over time, the group has evolved into a dynamic nationwide community with an annual conference, a subgroup to support single moms, and mentorship opportunities for medical students. Recently, it launched a foundation to help to women of all professions who are struggling with abusive relationships.

Along the way, Bansal has seen her leadership skills blossom. “To build the foundation, we had to build a team,” she explains. And in order to manage that team while building the foundation and keeping up with full-time clinical work, she’s had to learn to lead others and delegate tasks. Most of all, she says, she’s learned the value of speaking up for herself and for other women.

“What we don’t teach anywhere in medical school or residency is how to be your own advocate,” Bansal explains. “It comes down to being in control of yourself and what you will expect and accept. I feel great for the residents in our group who have a network of colleagues to tell them these things now. You have to find it from within. That’s what we’re trying to teach each other to do. It’s about unity and paying it forward and about fixing what we see that needs fixing in medicine and in women’s lives.”

Chandler emphasizes that everyone can find enrichment from learning at least a bit about leadership. It might not look the same for everyone, but whether you learn from an MBA program, a book, mentors or other activities, leadership training will benefit you professionally and personally.

“Developing a leadership mindset helps bring out some qualities you might not otherwise tap,” Chandler explains. “It allows you to express other talents. Learning about leadership and learning about business gave me a lot of personal satisfaction. You start to see the whole pie, not just the perspective of medicine.”

Laurie Morgan is a partner at Capko & Morgan, a boutique practice management consulting group. Learn more about our contributors on page 20.

 

 

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What physicians make (and why)

Nothing looms quite as large for your future as negotiating the best compensation package possible.

By Chris Hinz | Fall 2018 | Feature Articles

 

Negotiating compensation requires an understanding of the value of your skills and an assertive approach. Both helped Theresa Rohr-Kirchgraber, M.D., further her career. -photo by Rebecca Shehorn

Negotiating compensation requires an understanding of the value of your skills and an assertive approach. Both helped Theresa Rohr-Kirchgraber, M.D., further her career. -photo by Rebecca Shehorn

Obviously, you want a nice financial payoff for your skills. After all, they’re worth top dollar by every professional measure. But there are big picture realities to consider, too. Specialty, practice type and geography have already shaped your final offer in ways that you might or might not have suspected. How do they move the dial up or down?

Words like value and supply versus demand come immediately to mind. They’re the underlying drivers that make these three factors so important in what you’re able to earn. They’re also key to many of the compensation surveys administrators use as one critical tool in designing how much you’re going to make.

“It’s not just a random executive pulling a number out of a hat and offering it to a physician in hopes that he or she will take it,” says Jon Appino, principal of Kansas City, Missouri-based consulting firm Contract Diagnostics. “It tends to be very purposeful and calculated from the employer’s perspective on what administrators are offering most of the time.”

As to the specific roles of specialty, practice type and geography, let’s take a closer look.

Specialty

The specialty you’ve chosen will be the biggest determinant of your compensation by far. Even though primary care physicians and their non-surgical specialty colleagues are well-paid professionals, providers in procedure-rich specialties tend to rise to the top of medicine’s financial hierarchy.

Why? They experience the highest reimbursement rates for the complex tasks they perform, which ultimately is reflected in their pay. Simply put, if you’re in orthopedics, anesthesiology, cardiac and other surgeries, what you do will likely put you in the cat bird seat in commanding a top salary. Of course, other forces, such as supply and demand, can help shape any package. At its core, however, compensation is often less about the number of patients that you see and more about the nature of your services and the value assigned to them.

RVUs lead the way

Wherever you are in your medical career, you can’t underestimate the role of two acronyms — RBRVS and RVU —in how much you’re ultimately paid for your work. Shorthand for resource-based relative value scale and relative value unit, both terms have been integral to most physician practices since 1992, when the Centers for Medicare & Medicaid Services (CMS) launched RBRVS to bring consistency to the way that it pays physicians and health facilities for their services.

By assigning specific values—the RVU part of the system—to every CPT (current procedural terminology) code, Medicare, Medicaid, and some private insurers alike have a standard methodology by which to issue reimbursements.

But how do those values eventually turn into compensation? Hiring entities have their own formulas for parlaying work product into salaries and productivity bonuses. Many still use volume-related metrics such as number of patients or the amount of fee-for-service collections to craft a plan. As more payers rely on RVUs in calculating reimbursement, however, those values become increasingly critical compensation measuring sticks. If your package depends on RVUs, you want to make sure you understand the particular schema, given the plethora of complicated methodologies using them today.

In determining production and incentive bonuses, employers are primarily interested in physician work or wRVUs because they account for the time, training, technical skills and judgment a physician employs in diagnosing and delivering care. Other components—practice expense or peRVUs and malpractice RVU or mRVUs—are baked into the reimbursement pie to account for the higher direct, indirect and liability costs of providing the service.

“This is all about the effort expended in order to provide a service,” says Fred Horton, president of AMGA (American Medical Group Association) Consulting. “We’re not going to pay you based on some other type of overhead or malpractice methodology. We’re going to pay you based on your work.” Adds Travis Singleton, senior vice president of Dallas-based physician recruiting firm Merritt Hawkins: “The net outcome is to equate difficulty and value to what the physician does.”

Winds at selective backs

Even within a specialty, your ability to command top dollar is still a mixed bag depending on other forces. Being a pediatric neurologist, for instance, may increase your compensation into the medical subspecialty realm, but not into the procedural realm. As to other specialties, supply and demand is the focus. Pathologists, for instance, have been harmed lately by a difficult market. Appino can only speculate as to the reasons—perhaps technology has improved efficiency or training has produced too many. Yet with fewer job openings now than in the past, employers have the upper hand. On the other hand, rheumatologists and other short-supply specialists such as neurologists and urologists are definitely seeing an uptick in their financial outlook. With an aging population demanding their skills, in many cases they can write their own tickets.

And what about primary care? You’re likely still bringing up the compensation rear, even with promises since RBRVS originated in the 1990s that your field would one day be rewarded equal to that of procedural-based groups. Citing AMGA survey comparisons of 20 specialties between 2009 and 2017, Horton notes that orthopedic surgery still holds the top place with family medicine, internal medicine and pediatrics anchoring the bottom. “Basically, they haven’t moved at all,” he says. “The wealth hasn’t really been redistributed as promised.”

That doesn’t mean, however, that there aren’t promising exceptions. As a residency program faculty member with Jacksonville, Florida’s St. Vincent’s Family Medicine Center, Robert Raspa, M.D., is in charge of 30 family medicine physicians, with 10 not only graduating each year, but also heavily recruited for their skills.

New physicians may need to be assertive about their worth even as they’re being wooed. Theresa Rohr-Kirchgraber, M.D., preaches the value of assertiveness to her residents and fellows as the executive director of the Indiana University National Center of Excellence in Women’s Health.

Rohr-Kirchgraber, who is also the Barbara Kampen Scholar in Women’s Health, doesn’t have to look further than her own experience as an example.

Board certified in both internal and adolescent medicine, she went to bat for herself after discovering that her primary clinical appointment in pediatrics was costing her thousands of income dollars. Although she held a secondary appointment in internal medicine and saw mostly adult patients, administrators weren’t keen on upsetting the parity applecart with her pediatric colleagues by just changing her status but keeping her in the adolescent division.

It took some negotiating, but Rohr-Kirchgraber succeeded in switching the appointments. In practical terms, she now has fewer interactions with her adolescent medicine colleagues, but she’s finally on par salary-wise with other internists. “We’re always trying to be nice and helpful because we’re just so grateful,” she says. “But we have to recognize that we bring a completely different set of skills to the group. We need to understand our worth.”

Practice type

The majority of newly recruited candidates—some estimate as high as 70 percent—will join hospitals, medical groups, urgent care centers, clinics and other structures as dedicated hires, not necessarily future owners. What does employment specifically mean for your compensation package? For starters, you may not be bearing the brunt of the business responsibilities shouldered by your self-employed colleagues, but you’re also likely to experience a lower average income as a price for the freedom.

At least one survey, Medscape Physician Compensation Report 2017, demonstrates that while increased numbers of physicians are choosing an employed position, they’re also likely to earn less than their self-employed counterparts. The 2017 results reflect overall differences of 28 percent between the $343,000 average earnings per year of providers willing to take on the business demands of private practice and $269,000 for their employed peers.

Whether you’re hired by a health system or perhaps even a group, your compensation will be built initially on a base salary, which provides a predictable income level for your clinical services. The package will also include an incentive bonus that rewards your productivity and, in some cases, the standard of your work. Beyond the type and volume of your services, you may have to demonstrate your worth via quality outcomes plus other harder-to-quantify measures such as patient satisfaction and corporate citizenship.

More than likely, however, you’ll be rewarded based on some sort of volume metric. Even though there’s wide variety in the incentive models and formulations used today, there’s a better-than-average chance that your plan will revolve around RVUs.

“We can say that we want to move to quality, but fundamentally mathematics still work on volume,” Singleton says. “To me, RVUs are the bridge from volume to value. It’s the best we have at the moment.”

The nuanced ins and outs

It’s incumbent on you to understand the parameters of your specific plan, given the potential nuances. For instance, depending on the formula, the incentive portion of your deal may involve a modest kick-in for the first and second years while you develop sea legs and a following. After that, your salary may be gradually reduced or even eliminated, leaving you dependent solely on whatever productivity and/or earnings structure your employer has in mind.

Whatever the case, you need transparency. Too often, say experts, physicians look at the numbers and just assume what’s behind them rather than understanding where they come from or how they’re set. “One of the things that continues to amaze me is how many physicians can’t recite how they’re being paid,” says Horton, noting his surprise at job incumbents who don’t know the ins and outs of their original compensation packages. “They’re able to tell me how much they make but they can’t necessarily articulate the mechanics. And that’s really important.”

Geography

In medicine, like business, location is often everything—including playing a role in what you can earn, especially given supply and demand for your skills. When considering the trifecta of factors—compensation, location and practice type—that are key to any job decision, Appino suggests prioritizing the two most important ones since you likely can’t have all three.

Why so? Popular places to live and work may not offer the best shot at the best deal. If you’re willing to accept a smaller package, by all means hang tough for that idyllic place you’ve always associated with a great life. But if money is a priority, you might need to open your eyes to areas of the country that hadn’t been on your radar.

It takes more than compensation to make a physician happy in a new job. “Our feeling is that if you want to attract good people then you have to give something better than anyone else,” says Salim Surani, M.D. -photo by Dustin Baker

It takes more than compensation to make a physician happy in a new job. “Our feeling is that if you want to attract good people then you have to give something better than anyone else,” says Salim Surani, M.D. -photo by Dustin Baker

Mega trends at work

Regional analyses from the Merritt Hawkins 2017 Review of Physician and Advanced Practitioner Recruiting Incentives confirm that physician salaries tend to be highest in the Midwest and Southeast. Both areas are top pay strongholds, say the authors and other experts, because of a healthy dose of fee-for-service medicine, good payer mixes with comparatively high reimbursement rates and a large number of productive, independent physicians. There’s also a lower physician-per-capita ratio.

Conversely, physician incomes tend to be a bit suppressed on the West Coast because it’s typically the highest capitated market with the most managed care, says Singleton. Likewise, lowered physician incomes on the East Coast, particularly the Northeast, also reflect a relatively high prevalence of managed care/capitated compensation plans as well as competition.

That’s not to say there aren’t pockets that run counter to existing trends; just that you should be aware of umbrella forces driving compensation where you might want to work and live.

Final thoughts

Whatever your specialty or skills, you’ll need facts on hand to achieve a financial payoff that befits your experience and skills. By knowing how specialty, practice type and geography move the dial on any offer, however, negotiations may no longer loom quite so large.

 

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Contracts with benefits

What’s included in a typical physician employment contract? This helpful guide lays it out.

By Debbie Swanson | Fall 2018 | Feature Articles

 

Ensure you know just what’s expected in return for any financial incentives in your employment contract, recommends Afshin Khaiser, M.D. -photo by Seth Morris

Ensure you know just what’s expected in return for any financial incentives in your employment contract, recommends Afshin Khaiser, M.D. -photo by Seth Morris

After months of filling out paperwork, traveling and dry cleaning your interview suit, you’ve finally landed an attractive job offer. Congratulations! But don’t collapse onto your sofa just yet; there’s still one more matter to deal with. Pour a cup of coffee, grab your favorite color highlighter and settle in to read your employment contract. This document spells out everything about your new position, from the hours you’re expected to be at work, to perks such as travel compensation, to the handling of malpractice claims that may pop up decades after you’ve left the employer.

“What’s offered varies with the type of practice; hospitals and academia might offer more perks, while private practice is more like a small business,” says Afshin Khaiser, M.D., an internal medicine physician based in Illinois.

Though it’s paramount to read the document from start to finish, don’t worry if you feel at least somewhat confused. Deciphering it can be tricky, yet it’s a valuable learning experience. Here are some tips and insight into some of the sections.

Seek a resource

After years in academia, you probably don’t shy away from heavy reading. But this lengthy, legalese-rich document is seldom completely understood by a lay reader. Most physicians—at least early in their careers—consult with a lawyer experienced in physician employment for guidance and reassurance before they sign.

Early in her career, Sylvie Stacy, M.D., a preventive medicine physician in Birmingham, Alabama, sought a lawyer to review her contract before she accepted a position as a medical director, which involved both clinical and administrative work.

“At the time, I had a minimal understanding of all the important factors and the meaning of the various clauses,” she says, adding that the lawyer did suggest some changes “…to protect me if something went wrong, or if I had a disagreement with my employer down the road.”

Stacy went on to have a positive employment experience—but felt that the legal consultation was both reassuring and educational.

“Since then, I’ve done a lot of independent contracting work, with numerous contracts to review. I have felt comfortable doing the review and negotiation myself,” she says.

Some parts are simple

Not every aspect of your employment contract is cryptic or controversial; some just lay out the boundaries of your contract.

Every contract has a defined time period, beginning with a start date and ending with some type of contract termination date. Choosing a start date may seem like a no-brainer, but reflect upon the date before agreeing; once you start working, free time might be at a premium. If you’ll be relocating, remember to build in time to get yourself set up. Or, if you’ve been going full speed ahead since medical school, consider slipping in a few days for some r&r.

Your contract will also state how long it remains valid; it may expire after one year, automatically renew on its anniversary date, or remain effective indefinitely. Make note of this date, as it’s easily forgotten as the years roll by.

Other areas to look for: the type of relationship you are entering into (employee or independent contractor); whether you are full time or part time; and the name and location of your employer. Your primary employment address should be defined, along with any expectations regarding traveling between offices, if applicable.

Ease the burden of moving

It’s great when your new employer offers to assist with your relocation expenses when a move is required. This is more common with larger establishments and hospitals. Covered expenses could range from only the initial expense to transport yourself and your belongings to something more inclusive of the price to get settled: hotels, meals, and public or rental transportation.

“There’s sometimes a maximum dollar amount toward your cost of relocating. Sometimes they’ll help with other things, like a loan to help buy a house,” says Keith J. Chamberlin, M.D., medical director of PeriOperative Services at Marin General Hospital and CEO of Chamberlin Health Care Consulting Group, Inc., in California.

Equally important is making sure your contract spells out anything required of you in return.

“There is a risk involved (for the employer): If you come out and leave soon after, that’s not a good outcome,” Chamberlin says. “A common stipulation is that if you don’t stay six months, you have to pay it back.”

A health care attorney's review on an employment contract gave Sylvie Stacy, M.D., a sense of reassurance. It also helped prepare her for future reviews. -photo by Eric and Jamie Photo

A health care attorney’s review on an employment contract gave Sylvie Stacy, M.D., a sense of reassurance. It also helped prepare her for future reviews. -photo by Eric and Jamie Photo

Upfront cash

A sign-on bonus is a common tactic to entice you to come on board. This is especially appealing to new physicians eager to knock off student loans and set up housing. While money is always attractive, don’t get too carried away, warns Khaiser.

“Don’t get too caught up with a number,” Khaiser reminds. “The amount may seem great, but read the fine print—there’s always something attached. For example, if you don’t stay at the company long enough, you may have to pay it back.”

What’s important is understanding your obligation. Be sure to get all the details clarified in your contract.

Know what’s expected of you

Exactly what are you being brought on board to do? This should be clearly spelled out in the areas of responsibility section of your contract. Reject any vague wording or an open-ended definition, such as “will perform duties as assigned.” Look for targeted, specific items, such as: clinical expectations, nonclinical obligations (paperwork, records, phone calls), requirement to serve on boards or committees, expectations of teaching or training others, involvement in research, and more.

Also consider what your employer must provide you to support these efforts: equipment, time, staff, lab access, etc. Get these agreements in writing; this could prove useful in the event of termination.

Another important area is your availability for on-call hours.

“Understand these expectations,” says Khaiser. “For example, are you required to come into the hospital when needed? How many calls do they expect you’ll have in a night? Will you be expected for work the morning after a particularly busy night of call?”

Don’t be afraid to speak up, he adds. “Sleep is important, and you need to take care of yourself.”

Plan for time off

Breaks from your typical workweek are an integral way to avoid burnout, remain compassionate, and focus on what initially drew you into medicine.

Paid time off includes sick time, disability and family leave. Offerings vary greatly based on type of employer and their benefits package. Be sure you understand how these items are calculated and accrue, and how they are treated if unused at year’s end. Also consider how your personal priorities may change within the time span of your contract; what is agreeable today may change over time.

Vacation time and continuing medical education (CME) are two important areas of paid time off. Vacation is time to use as you wish—key to maintaining a healthy outlook. CME is time intended for you to further your medical education by attending conferences, taking a class, or another educational event. CME is typically required both by your employer and to maintain your medical license.

“The contract should stipulate the number of weeks of (paid) vacation time and CME time,” says Chamberlin, adding that each should be broken out specifically. “For example, two weeks CME and four weeks vacation. You usually can’t extend the total, but may be able to negotiate the combination.”

Reimbursement of CME expenses

Whether you fly to a conference, register for an online course or drive to a lecture at a local university, there are always some expenses involved with CME. If your employer has offered to contribute toward CME expense, look for a dollar amount you have available.

Planning the end of your employment

It may seem strange to be thinking ahead to when you terminate this employment, but an unexpected or poorly planned exit could have detrimental consequences on your finances, career and professional standing. Get the details spelled out now so you’ll know what to do if the situation arises.

One area is assignability. It’s common for hospitals and practices to undergo acquisition, consolidation, or mergers, but what’s important is how this would impact you. If your contract is defined as assignable, your employment would continue uninterrupted under the new ownership. If it is non-assignable, your contract is terminated upon the change of ownership—meaning you’re either in need of finding new employment or negotiating a new contract with the new owner.

If you’re signing a non-assignable contract, consider what would ease the turmoil of an unexpected loss of employment. The American College of Physicians suggests negotiating for the inclusion of a cash settlement, or adding language that would release you from any restrictive covenant.

Termination notice defines the amount of time both you and your employer must provide prior to ending the employment relationship. This should be fair and equal for both sides; you shouldn’t be required to provide 120 days of notice while your employer only has to give you 60.

When Stacy had her attorney review her contract, this was one area he adjusted. “[He extended] the time frame for contract termination, and removed wording that would allow immediate termination by the employer in certain circumstances,” she recalls.

Most contracts also specify that an employment can be terminated either “for cause” or “without cause.” A “for cause” termination points to a specific reason for the termination. “Without cause” is much more open-ended; you are free to give notice without a reason, but likewise, the employer is free to let you go for no reason.

“[Avoid agreeing to] a situation where they can fire you at any time—especially important if you relocated or have a family,” advises Chamberlin. “For a brand-new employee, it’s good to have protection in place, such as that they can’t fire without cause for 90 days. After the 90-day mark, get additional protection in place, such as 180 days of notice going forward. That gives both parties adequate time to make new arrangements.”

Post-termination considerations

Issues related to your employment could arise long after you’ve packed up your things and settled into a new situation. Planning for them in your contract is another integral step toward safeguarding yourself.

You’ll probably build up a base of familiar patients who routinely seek your services. Your contract should address the proper means of notification of your departure. In other words, who will tell your patients of your impending departure? Typically, the employer will distribute a letter before you are free to discuss it openly.

Your contract may seek to limit your interactions with patients through a non-solicitation clause. This prevents you from recruiting patients to join you at your new location. If such a clause exists, ask for a clear definition of solicitation. Getting this in writing will help you know what you can and cannot say to your patients, as well as the guidelines to follow.

A non-solicitation clause may also try to prohibit you from treating patients who choose to follow you to your new location. Most experts agree that enforcement of this is questionable; courts often support the patient’s right to seek any doctor of their choosing. Check with your local legal expert if such language is included.

Another post-termination issue might be a non-disparagement clause, which prevents you from making negative or defamatory comments about your employer both during employment and post termination. This clause should be equally in effect for both parties, also preventing the employer from making disparaging remarks about you.

Understand any restrictions

Sometimes referred to as a non-compete clause, the restrictive covenant is another area to read carefully. This defines limits on where you can work after leaving your employer. For example, it might prohibit you from working for a similar type of practice, within a range of 12 miles, for five years post-employment.

This clause protects the employer by preventing you from going to a direct competitor, sharing confidential information, or drawing patients away from the practice. Though it’s a common part of most employment contracts, make sure the language is not overly prohibitive.

“If you live in an area you like and want to remain there long term, try to negotiate, ” says Khaiser.

You are legally bound to uphold anything you sign your name to, but be aware that not all states equally enforce restrictive covenants. It’s best to run the language past a health care attorney to understand your obligation, your state’s stance, and to make sure that the language is not overly prohibitive.

Protect your other income

Even if you don’t have an additional stream of income today, opportunities could present themselves down the road, so be sure your contract addresses work performed outside of the practice both related and unrelated to medicine.

For anything related to medicine, compensation may become an issue. According to the ACP, “the contract should state explicitly whether money earned from outside sources is to be considered private compensation, paid directly to the individual physician, or more typically as part of the group’s overall income.”

The contract should also identify any restrictions on non-medical activities—for example, if you play in a band or own a coffee shop. Though it is usually clear that such compensation is your own, there may be restrictions on time or type of work allowed. According to the ACP, “groups usually preclude physicians from performing outside services that will interfere with their ability to fully satisfy their practice obligations.”

Protect your future

One of the most critical sections of your employment contract is the handling of malpractice insurance. This protects you against liabilities that may arise while you are acting on behalf of the hospital, practice group or academic institution.

Coverage varies depending on the type of situation. A hospital or large practice may pay some or all of your malpractice insurance premiums, while a smaller group or practice may expect you cover your own. Your contract should define any limits or maximums on the policy, who is responsible for premiums, and any breakdown of coverage.

The type of policy is an important distinction; it will be either “occurrence based” or “claims made.” In an occurrence-based policy, any incident that arose during the boundaries of your employment period is covered, regardless of when it is raised. In a claims-made policy, only incidents that are raised while you are an active employee are covered; anything raised after your termination date are not, even if they originate from service provided while you were an active employee.

It’s not uncommon that a patient raises a claim years—even decades—after you treated them, so with a claims-made policy, look for the inclusion of an extended reporting endorsement, more commonly known as tail insurance. This is offered by the malpractice insurance carrier as a way to extend a claims-made policy to include anything raised against you post-termination.

“Be cognizant of what is covered in your contract; having tail insurance is non-negotiable,” Khaiser says. “The number-one thing is to protect yourself and your license.”

Tail insurance is costly; employers may split the cost with you, usually by deducting your contribution directly from your paycheck. Sometimes the employer will offer an incentive plan, in which the cost to you decreases each year you remain with the practice. The ACP points out that sometimes a provision states that the employer will pay tail premiums if the employer terminates the physician without cause, but if the physician is terminated for cause, the burden of cost falls to the physician.

Carefully read the details and don’t hesitate to negotiate for the best arrangement.

Moving up the ladder

You may be thrilled with your new job exactly as it is, but it’s never too early to think of the future. Your contract should address issues important to your career advancement, such as the frequency of your employee review, criteria for promotions or advancement, or the possibility of partnership.

Each time you receive an employment contract, you’ll become more adept at what to watch for. But regardless of how familiar you become, it’s always important to read it thoroughly and then consult with a lawyer or seasoned colleague. Changes or adjustments made before you sign can have lasting benefits for you and your family, improve your finances and protect your professional future.

One of the most critical sections of your employment contract is the handling of malpractice insurance.

Changes or adjustments made before you sign can have lasting benefits for you and your family, improve your finances, and protect your professional future.

 

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Contract negotiation – what recruiters want you to know

Understanding the ins and outs of contract negotiation can make the process smoother for everyone involved.

By Anayat Durrani | Fall 2018 | Feature Articles

 

“I called at least 30 hospitals and recruiters just inquiring about the need, compensation and getting a real feel for what my market was,” says Adam Parker, M.D. -photo by Andrew Welch

“I called at least 30 hospitals and recruiters just inquiring about the need, compensation and getting a real feel for what my market was,” says Adam Parker, M.D. -photo by Andrew Welch

Contract negotiations aren’t taught in medical school or residency, so many young physicians feel unprepared. With a lack of negotiation experience, they may hesitate to make requests. But experts say new physicians shouldn’t feel shy about asking questions or negotiating for better terms. Read on for answers to a few common questions about contract negotiation.

What terms are up for negotiation?

One common mistake young physicians make is accepting the first offer, even when there are points you’d like to discuss. Certain parts of your contract could be up for negotiation —or at the very least, raised in conversation.

“The most obvious components deal with salary, signing bonus, moving expenses, but several more subtle aspects can be discussed—including length of contract, expectations regarding number of patients to be seen daily or RVU goals,” says Zachary P. Castle, D.O.

Castle worked with an in-house recruiter to land his current position as an outpatient family medicine physician for a branch of Midland Health in Texas. He says the experience was terrific but adds that not everything is negotiable. “There are sometimes where things are not able to be changed due to legal reasons or possibly hospital and/or company policy,” he says.

Of course, what’s up for negotiation varies among hospitals and health care systems.

At Columbus Regional Health in Columbus, Indiana, physician recruiter Kaelee Van Camp says term length and compensation are both negotiable. Term lengths start at five years, but the health system will consider terms as short as three years.

Nicola Frugé, a physician recruiter at Rush Health Systems in Mississippi, says Rush considers requests to adjust base salary, fixed compensation, RVU, encounter rate, sign-on bonus and loan repayment terms. However, Frugé says Rush will not negotiate vacation days, standard benefits, relocation reimbursement, contract lengths, the non-compete clause or termination rules.

“For contracts, most physicians have used an attorney to review their contract, so we have received minor changes to the wording. Generally, we do not change much with our contracts. They are standard,” says Frugé.

Cheri Spencer, physician recruiter for West Tennessee Healthcare, says her organization doesn’t negotiate on the medical education loan repayment program or relocation allowance. “We would be open to negotiate the transition bonus or salary if the physician can make a strong case for a higher amount. Our goal is to reach a fair agreement where both parties feel satisfied with the results,” says Spencer.

If an employer isn’t willing to explore the clauses most important to you during a negotiation, it may be a sign that the position isn’t a good fit. The opposite can also be true: If an offer looks too good to be true, it probably is. “Beware of a salary that is much higher than other offers received,” explains Van Camp. “Is it a number you will be able to maintain when you convert to a productivity model?”

How should physicians prepare for negotiation?

When you’re applying for a position, it’s important to learn as much as you can about the organization and the department ahead of time. Maycie Elchoufi, M.D., says preparation is key in advance of a negotiation. Elchoufi, who is board certified in internal medicine, says you can learn a lot through a few well-targeted internet searches. Get an understanding of the organization so that you can ask questions in person about the organization’s leadership, its strengths and weaknesses, goals, challenges, competitors, funding and turnover rate.

“These types of questions are important because you need to have a clear understanding of whether this organization’s trajectory is aligned with your own professional and personal goals,” she explains.

Frugé says this background research shows when candidates respond to offer letters. She says some candidates are “very savvy on business and economics of hospital vs. private employment models” while others are not. She recommends that physicians read about compensation models and try to understand RVUs, contracts and other pertinent details. (See page 47 for a start.)

Adam Parker, M.D., just completed his internal medicine residency. He prepared for his job search by first getting a feel for the landscape: “I started early in the fall of my last year in residency and began by using PracticeLink and other such websites to find available jobs for my field in my area and in adjacent states.”

“I cast a wide net to get the best possible offers,” Parker says. “I called at least 30 hospitals and recruiters just inquiring about the need, compensation and getting a real feel for what my market was.” Parker worked with Frugé and began a position with Rush Foundation Hospital this summer.

Spencer suggests physicians just coming out of training speak with a colleague in a practice setting similar to the one they’re targeting. She often works with residents or fellows who only get advice from physicians in academic settings, and she says this advice does not always transfer well to private practice or hospital employment models.

Spencer says she always reminds newly trained physicians that they are not expected to know contract language. She encourages them to hire attorneys if they are uncomfortable negotiating. “I also tell them to know their worth and pay attention to the need of the practice or hospital,” she says, adding, “Negotiation is largely supply and demand.”

Elchoufi says she’s always hired an attorney review her contracts. “[Attorneys] can point out items that might become problematic later, language that may need to be modified and areas in which [employers] may be more or less amenable to negotiation,” she says.

However, Elchoufi didn’t ask her attorney to attend the actual negotiation process, as she felt prepared to do so on her own. Researching salary data was an important part of this preparation, and Elchoufi says physicians should know their numbers. It’s not enough to tell an employer that your friends and colleagues are getting offers in a particular range.

“Use data from sources such as MGMA [Medical Group Management Association],” recommends Van Camp. “Be willing to share the details of an offer you have already received. Know how compensation in your particular specialty is commonly calculated.”

Elchoufi says that in her experience almost everything is negotiable. But in order to negotiate, physicians need to know their own value—and how other physicians in similar positions are typically compensated.

“For example, if you are offered a salary of, say, $250K but you really wanted $400K, you need to know ahead of time what salary range is the industry standard for that position,” she explains. “If the salary that you have in mind is not in that range, then what is it about your experience and skill set that makes you feel the additional $150K is a reasonable request?”

Spencer says that before every negotiation, she tells each physician two things: what items are not negotiable, and what requests can’t be accommodated. That way, candidates know if trying to make both sides happy is like trying to fit a square peg in a round hole.

Ultimately, Elchoufi says, physicians should remember negotiation is just a conversation. “Getting a ‘no’ to your request is not necessarily a dead end,” she says. “Ask open-ended questions. Try to get the other party to share what it is that they need, what problem are they trying to solve. Then you can gear your responses accordingly.”

As Andrew Gowdey, M.D., prepared to leave training and find a urology practice, he turned to a health care attorney, other physicians and an in-house recruiter. -photo by Savannah and Philip Kenney

As Andrew Gowdey, M.D., prepared to leave training and find a urology practice, he turned to a health
care attorney, other physicians and an in-house recruiter. -photo by Savannah and Philip Kenney

How long does the hiring process take?

From interview to contract review to negotiation and more, the hiring process involves several different steps. The timeframe for each can vary depending on the size and type of employer—as well as how much negotiation you end up doing.

Castle interviewed in early November. He received a letter of intent outlining basic terms shortly after. “I signed and submitted this in January and received the full contract a couple weeks later,” says Castle. “From that time, I believe it took about a month to sign it. So the total process from start to finish took about four months.”

According to Spencer, a draft contract typically arrives two to four weeks after the interview. She recommends that physicians complete negotiations within a week to 10 days.

Once when Elchoufi was applying for a new position, she says she went from initial phone call to seeing patients in under three months, but she adds that this is uncommon. In her experience, four to six months is more typical.

“It really depends on how much the employer needs someone with your qualifications, as well as logistics such as obtaining state licensure, getting credentialing completed, etc.,” Elchoufi explains. “In any case, don’t be in too much of a rush, even if you end up needing to do locums for a while. If you’re rushed, you’ll have a tendency to jump to something that may not necessarily be an optimal fit.”

Frugé says every candidate is different. Typically if she gets good feedback from the specialty group and the rest of her administrative team after an interview, they extend an offer letter within a two-week timeframe, but it can vary.

“Once the offer letter is signed, we begin on the contract which usually takes about two weeks,” she says. “The actual contract negotiations can go quickly or slowly depending on the candidate and his or her attorney. Overall, I would say the whole process can take four to six months from beginning to end.”

Van Camp and her team make it a goal is to provide an offer within 48 hours of any interview, but this doesn’t always happen. When multiple candidates are interviewing for one position, her team can’t get back to every candidate as quickly as they would otherwise.

“We will always communicate that to all the candidates,” she adds. Don’t be afraid to ask what the timeline is for the decision-making process if it is not given.

In Parker’s experience, the process typically takes between two to four months. He says this timeframe gives physicians enough time to “search out several options, talk to several different recruiters and get an idea of what situation fits you the best before making a hasty decision.”

How do in-house recruiters work with physicians and attorneys?

Of the hospitals Parker spoke to during his job search, he says only two (including his future employer) were represented by in-house physician recruiters. He says he preferred working with in-house recruiters because they have a vested interest in recruiting applicants who are good fits for their hospital systems.

“In addition, since they were local to the area of the hospitals, they were able to provide in-depth, special and more appealing responses about their local areas,” says Parker. “I felt the larger recruiting firms just Googled a town and told you about it or told me to do that myself for research.”

When it comes to the negotiation itself, both Van Camp and Frugé say they like working directly with candidates when they can. Though Frugé sometimes works with candidates’ attorneys and reviews contracts with attorney edits, she generally prefers to communicate directly with the candidates. Frugé says candidates often email her questions or ask questions about their contracts via conference call.

She adds that she never minds if a candidate asks lots of questions about the contract, saying it’s “better to be thorough and understand everything upfront rather than be surprised by something after the deal is done.” In fact, she appreciates when candidates show thoroughness and attention to detail.

Van Camp advises physicians to do the negotiation themselves. “Your attorney is an excellent resource for the data to back up your request, but you should understand the contract and your requests well enough to negotiate yourself,” she says. “The negotiation process is one more opportunity to see if the employer is someone you can work with.”

Spencer says she always tells a physician to make all of their requests in the first pass and encourages them to use an attorney at least when negotiating their first contract. Spencer says she tells candidates that this is a time where they won’t know everything but that she’s there to help.

Castle says he spent a lot of time carefully reading through the details of his contract. He regularly discussed the terms with his wife. After familiarizing themselves with the contract, they asked an attorney to read it. He says the attorney explained things they did not understand and suggested potential changes.

“After discussing our thoughts with my employer, they made most of the changes to make us more comfortable with the contract, and we moved forward from there,” says Castle.

Andrew Gowdey, M.D., who is in his fourth year of urology training, signed a contract with Rush Hospital where he will begin working next year. He consulted an attorney to review the initial contract and also spoke with practicing physicians who had been through the process.

“I made specific changes and then went over with my attorney on the details of the contract that were not evident to me upon first review,” he says. “Personally, I think it is important to consult an attorney and be actively involved in the process of contract negotiation.”

Parker for one did all of the negotiation himself and didn’t think an attorney was necessary. “It is an added cost, and in general, they do not understand what a particular physician brings to the table, so to speak. And I felt I was better suited to sell myself than they were,” he explains.

What can’t an in-house recruiter help you with?

In-house recruiters are invaluable resources, but you’ll still have to do some additional research yourself.

“Recruiters in general—including in-house recruiters—may not necessarily know that, say, the community wellness department at their organization is in need of someone to spearhead employee health initiatives,” says Elchoufi. “Or that there might be talks of starting a pre-op clinic for the orthopedic department to streamline referrals and efficiently clear medical patients for surgery in order to increase revenue, decrease wait times and increase patient satisfaction scores.”

That’s where a little legwork on the physician’s part is valuable. Elchoufi suggests physicians talk to recruiters at various organizations. Sometimes speaking with one recruiter will spark questions to ask other recruiters in the future. And if there’s a particular hospital or a city you’re interested in, Elchoufi says to reach out directly to an in-house recruiter there and find out what opportunities might exist for your specialty.

Remember, negotiation is about give and take

No matter what terms you hope to negotiate, it’s important to establish a strong working relationship with your future employer. Good communication habits will also improve the negotiation process.

Gowdey says recruiters help build a bridge of trust between employers and prospective employees. When he negotiated his compensation allocation and specific day-to-day obligations, he says the hospital was very receptive to his requests. And the terms they asked him to agree to in turn were also reasonable.

“If a recruiter and hospital can be transparent on the front end of negotiations, then it will make the process much easier,” says Gowdey. “I would encourage physicians to be upfront with their concerns.”

Frugé agrees that a good negotiation is all about communication. She says the process “helps to build trust and helps [physicians] to get to know their employer better as well as for me to get to know them better.”

She likes to hear back from candidates after interviews, even if they choose jobs elsewhere. This keeps the communication lines open for employment opportunities in the future.

 

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Your best health care cv

Your CV creates your first impression with an employer. What does yours say about you?

By Debbie Swanson | Feature Articles | Summer 2018

 

Imagine you’re about to make a speech before a distinguished gathering of professionals. While you’re being introduced, you wait nervously—knowing that this introduction will make or break your presentation. Depending on what they hear, audience members will either perk up or tune out.

Your curriculum vitae has that same power. It can portray you as a desirable candidate or cause your reader to yawn and flip to the next applicant in the pile.

Whereas resumes are typically shorter and used for standard job applications, a CV is required for many fellowships, residencies, research positions, graduate schools and more. It’s also the standard job-seeking document for most health care professionals. Keeping an up-to-date version on hand can mean the difference between submitting an application early or scrambling to complete paperwork at the eleventh hour.

Part 1: What to include

Treat your cover letter as your personal sales pitch, recommends physician recruiter Heather Peffley. · Photo by Hillary Muelleck

Treat your cover letter as your personal sales pitch, recommends physician recruiter Heather Peffley. · Photo by Hillary Muelleck

Because it is so comprehensive, a CV is divided into sections. Academic history, work experience and research experience are standard, but other sections may also be included if relevant. Academic sections typically come before professional ones.

Information should be presented neatly and consistently. Begin each section, except for your identification, with a header. List dated entries in reverse chronological order (using a month/year format) and use alphabetical order for undated items, such as interests or skills. Sections include:

Identification: Include your name and contact information at the top of the page.

  • Details to include: Your formal name, address, city, state, country and country code. Provide at least two means of contact: email address, home phone number and/or cell number.
  • Tip: Be sure to include M.D. or D.O. next to your name so recruiters don’t have to hunt for it.

Personal statement: Some career advisers recommend including a personal statement about your goals, while others say a cover letter is a better place to relay this information. If you do choose to include a personal statement, keep it to one concise paragraph.

  • Details to include: Two to three sentences explaining where you are in your career, what your goals are, and why you are a good fit for the position.
  • Tip: Include a personal statement if you’re using a recruiting service, as it helps recruiters identify you and understand your strengths.

Education: Only include schools where you earned a degree or certification. If you transferred or withdrew from a school, you should omit this from your CV but be ready to provide details if asked.

  • Details to include: List the institution’s full name, the degree/certification obtained, month/year bestowed, major and minor(s), thesis or dissertation (if applicable), city, state and country.
  • Tip: Include the dates of your degrees. “This provides [verifiable] confirmation of your credentials and demonstrates experience or rank, often required for positions,” says Heather J. Peffley, PHR, FASPR, physician recruiter at Penn State Health in Hershey, Pennsylvania.

Professional certifications and licenses: List all of your current medical accreditations, certifications or licensures.

  • Details to include: Name of the accreditation, state (if applicable), year it was bestowed and expiration date.
  • Tip: There’s no need to include license numbers on your CV.

Awards and honors: List any honors and awards you have received, such as volunteer recognitions, academic distinctions, professional recognitions, military decorations and scholarships. Don’t overlook anything that might be relevant. “Were you a chief resident?” asks Peffley. “If so, include that.”

  • Details to include: Name of the award/honor, the year you received it and the granting organization. Include a one-line description if necessary. If an item is self-explanatory, no elaboration is needed.
  • Tip: “From a resident perspective, I wouldn’t go past college,” says Zachary Kuhlmann, D.O., OB-GYN residency program director for KU School of Medicine-Wichita. “For practicing physicians, I’d stop at college/medical school and residency.”

Professional experience: Provide a complete timeline of all your paid employment since medical school. If you served in the military, you can include it here or in a separate military experience section.

  • Details to include: Dates, job title, employer name, city and state for each position. Describe the role—including clinical experiences you gained, skills you developed and results you helped to achieve. If you have changed careers, highlight skills that will transfer to the medical field.
  • Tip: Use a month/year format for dates, advises Peffley. “This is a requirement for foreign nationals [who] require visa sponsorship and has been adopted as a best practice on CVs,” she says.

Research experience: List any research you have conducted or assisted with.

  • Details to include: Dates, funding granted, the name of the research leader, your role/title and a brief summary of the project and your responsibilities.
  • Tip: Review your research outcomes before your interview. “If you have research listed, be sure to know about it so if someone asks you about it, you can tell them,” Kuhlmann says.

Publications: List all published work you authored, co-authored or contributed to, including journal articles, abstracts or presentations. Your CV should become an archive of all your publications.

  • Details to include: Title of article or presentation, type of item, your role, date presented or published and where it appeared.
  • Tip: Jot down each presentation as it occurs, so you don’t forget. “In residency, you lose track of some of the presentations you may give,” says Stephanie Kuhlmann, D.O., associate professor of pediatrics at KU School of Medicine-Wichita. “You forget about all the little things you do. Even though they’re kind of small, they can get you a promotion. Every little thing you do can go on you CV.”

Teaching experience: Include any involvement in teaching, tutoring, classroom assisting, curriculum development or similar activities. Training fellow undergraduates, through peer mentoring or student orientations, may also be applicable.

  • Details to include: Name of the institution where you provided instruction, your role, the subject and month/year.
  • Tip: Teaching is a valuable skill in the medical profession. Adding teaching experience to your CV may give you an opportunity to talk about it later during your interview.

Volunteer experience: List unpaid work and community involvement. If your volunteer service includes sitting on more than one board or you have a highly relevant board appointment, consider creating a separate section for board memberships.

  • Details to include: Name of the organization, type of organization (if necessary), your title, dates involved and a brief description of your contribution.
  • Tip: Trim this section by including only the most significant or relevant positions. Including brief volunteer stints or unrelated items could detract from more impressive endeavors.

Extracurricular activities and interests: Include non-professional pursuits, such as participation in sports, music and art as well as any certifications.

  • Details to include: List each item and be ready to discuss. These items also make good small talk over lunch or in meetings.
  • Tip: Use this area to demonstrate that you are a well-rounded individual and to showcase relevant skills. For example, distance running can demonstrate self-discipline, and performing in an orchestra requires teamwork. “I’m OK with putting some eclectic things on a CV, but phrase it in a professional manner,” Zachary Kuhlmann recommends.

Professional affiliations: List career-related groups, committees or societies you have participated in.

  • Details to include: Name of affiliation, dates involved and position or role.
  • Tip: Typically, it’s best to focus on current affiliations. If you do include lapsed memberships, be prepared to explain the reason you left. It may come up in an interview.

Other qualifications: Provide non-medical talents or skills, such as foreign language fluency, cultural experiences, personal interests or special motivators.

  • Details to include: List a brief summary of each item. Be prepared to verify and discuss.
  • Tip: “When I reviewed CVs from medical students, what I remember most was their life experiences,” says Jacqueline Huntly, M.D., president and founder of Athasmed, LLC in Savannah, Georgia. “If you have experiences that aren’t typical or things you achieved or overcame, it can help give a feeling for you as a whole—not just data on a resume.”

Part 2: What to know

Some of the most memorable CVs Jacqueline Huntly, M.D., has reviewed included unique accomplishments or interests. · Photo by Amber Jasso

Some of the most memorable CVs Jacqueline Huntly, M.D., has reviewed included unique accomplishments or interests. · Photo by Amber Jasso

Some parts of preparing your CV are common sense, but other important considerations aren’t so obvious. Here are some do’s and don’ts to keep in mind.

Don’t go it alone

Even if you have first-rate medical credentials, grammatical errors or poor organization could jeopardize your chances of being taken seriously.

“If there are grammatical errors or inconsistencies in the personal statement or publications, you’ve got to wonder how that will reflect in basic care,” Kuhlmann says. “Will they miss something?”

Whether you enlist assistance from the start or do so later while reviewing your first draft, it’s smart to bring in a set of trained eyes. A career counselor or writing professional can make sure your material is polished. Plus, industry standards change frequently, and a professional will ensure your document reflects current best practices.

In addition, you should seek the opinion of one or two people who know you well. Consider family members, mentors or trusted colleagues. They can help you project an authentic tone and personality. They may even point out strengths and skills you’ve overlooked.

Perfect your language

Tone and word choice play important roles in shaping a reader’s first impression of you. Huntly explains, “[Your CV] must convey that you’re a professional with good use of language.”

Reviewing example CVs can give you a sense of the right language to use. Get samples by contacting your medical school’s alumni office, asking colleagues and mentors or looking online.

Some tips for achieving a professional tone:

  • Use strong verbs. For example, “executed” and “spearheaded” make powerful alternatives to “worked.” To get ideas, consult a thesaurus or search online for “resume verbs.”
  • Replace buzzwords or jargon with simpler language.
  • Avoid repetitive phrasing or overused words. Variety will make your CV more compelling.
  • Define project names and spell out acronyms.
  • Minimize superlatives. Words like “very” or “best” rarely add value, and when overused, they reduce your credibility. “Don’t embellish. What you put down should speak for itself,” says Huntly.

Dealing with employment gaps

Your employment timeline is one of the most scrutinized sections of your document. Prospective employers hope to see a flawless record, beginning with medical school. But that may be unrealistic.

Instead of worrying or trying to hide lapses in employment, it’s best to address them, according to Kelly Sennholz, M.D., an emergency medicine physician in Denver. “Put it all out on the table, because it will come up,” she says. Two or three weeks are insignificant, but any lengthier gaps should be documented and labeled with a neutral or positive descriptor, such as educational travel, cultural pursuits, relocation, etc.

Early in her career, Sennholz took time away from medicine to start a company, which she documents on her CV as “time creating a business.” “I keep the description simple, so they can’t decide if they like or dislike it,” she says. “I have answers ready if they ask, and they always do.”

Be ready to talk about any employment lapse if an interviewer asks. Take the opportunity to present it in a flattering light. “For example, if you traveled to Africa and you toured some medical facilities, perhaps there’s a story or vignette you could use [about] what you were learning while traveling,” Sennholz suggests. “They’re looking for red flags, personal flaws, so don’t give them one.”

Even a less-than-ideal career gap can be presented positively. “It’s not a career death sentence,” says Zachary Kuhlmann of a gap. “But be prepared to discuss it and how you’ve grown and how that experience made you better.”

Scattered work history? Don’t worry

Not every physician follows a straight path from college to practice. Some start in a different area of health care, while others may initially pursue a non-medical career. So don’t worry if your work history seems lacking. Instead, put a positive spin on what you’ve done.

Some candidates feel non-medical employment isn’t worth mentioning, but that’s not always the case. For example, a former school teacher could emphasize teaching, multitasking and time management skills, all of which are useful traits for physicians.

If you’ve been hitting the books for several years without accumulating much work experience, you can still emphasize how you learned and grew during that time.

“There are ways to demonstrate initiative and leadership skills even though they occurred in an educational setting,” Peffley says. “Include details about your ranking, any accolades or awards you received, etc. These elements may be translated into skills also earned through work experiences.”

Whatever your background, the key is to shine a spotlight on your achievements and skills, while showing how you’ve spent your years productively. “Trust who you are and respect the decisions you’ve made along the way,” says Huntly. “Even if you’ve made a mistake, focus on what have you learned from it.”

What not to include

Though your CV is a highly detailed document, it’s not completely comprehensive. A few pieces of information are best left out. Omit personal details, such as age, sex, gender identity, family structure, religious affiliations or marital status. “By indicating this information, you are essentially inviting someone to make an assumption about you and/or your abilities—and not always in a positive light,” says Peffley.

Immigration status is another area that may provoke a biased reaction, but applicants requiring visa sponsorships may need to open that conversation anyway. Peffley explains, “You may simply add ‘citizenship status: requires visa sponsorship’ on the CV.”

Most experts suggest you leave off the names and contact information of your references. This protects their privacy and enables you to share the most current information with prospective employers. Including “references available upon request” is unnecessary, as it’s assumed applicants will supply references.

Finally, never include anything that’s not 100 percent accurate. False or intentionally misleading information has no place in a professional document and can permanently damage your reputation.

Part 3: The cover letter

In addition to your CV, you’ll need one other document: a cover letter. This letter should be uniquely targeted to every opportunity. Peffley suggests you consider it your personal sales pitch, explaining, “[Use it to] illustrate why an employer interests you, and how you may positively contribute to—more importantly, impact—their organization.”

Letters are usually one or two pages and have a friendlier, more personalized feel than the CV. They are organized in three sections:

The introduction: A short paragraph that explains where you are in your career, touches on your goals and identifies the opportunity you are applying for.

The body: One to three paragraphs that identify what makes you a good fit for this position, mention any mutual connections and highlight any unique qualifiers. Peffley suggests explaining where you get your motivation and drive. “Outlining what inspires you may prompt the reader to want to learn more,” she says.

This can also be the place to put a positive spin on any potentially questionable areas in your CV. “Letters can be an appropriate spot for addressing issues,” Huntly advises. “If you’ve followed a different path or changed directions, give reasons why that was part of your journey and convey that you are committed now.”

The conclusion: A paragraph thanking your readers for considering you, reiterating your interest and expressing enthusiasm about hearing from them.

As with your CV, a cover letter with grammatical errors, inaccurate statements or poor word choices will work against you, so it’s best to consult a professional. To save time down the road, formulate one or two generic versions, which you can later tailor to suit each application.

Loosely translated from the Latin for the course of one’s life, a curriculum vitae should be a comprehensive record of your noteworthy accomplishments. Creating this document can feel daunting. But if you reach out for help and update your CV annually, you’ll maintain a current CV that reflects your achievements and presents you as a desirable candidate.

Debbie Swanson is a frequent contributor to PracticeLink Magazine.

 

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Notes from the other side of the interview desk

Ever wonder what’s happening on the employer’s side? An in-house physician recruiter shares notes.

By Therese Karsten | Feature Articles | Summer 2018

 

Over my three decades of working in health care and countless physician interviews, I’ve learned that the job-search process looks a little different from my side of the interviewer’s desk. I wanted to roll back the curtain to show physician candidates what happens on the recruiter’s side, so I polled others in the field for their take. Their answers can help you land and plan your interviews.

We will probably Google you

A recruiter’s Google search of Brent Herron, M.D., illuminated the “why” behind his request for an atypical schedule: charity work that made him a great candidate. · Photo by Jamie Rubeis

A recruiter’s Google search of Brent Herron, M.D., illuminated the “why” behind his request for an atypical schedule: charity work that made him a great candidate. · Photo by Jamie Rubeis

After reviewing your CV to confirm that you meet the basic criteria, there’s a good chance a recruiter, administrator or physician will turn to Google before inviting you to interview. This isn’t an attempt to dig up dirt; employers simply want to connect the dots. We’re looking to confirm that you’re a promising candidate, and we’re crossing our fingers that we don’t to see any red flags.

At some organizations, an online search is a routine part of the vetting process; at others, they’re conducted unofficially. For example, a curious senior partner might look while reviewing CVs on her home laptop.

Checking out social media profiles is still a hotly debated practice. Some hospital systems prohibit recruiters from searching anything other than official databases.

“Google searches incur the risk that the recruiter will turn up photos or indications of age, gender or country of origin that could be used as grounds for discrimination,” explains Christy Bray Ricks, MHA, FASPR, senior director of physician recruitment for LifePoint Health. One of Ricks’ former employers prohibited online searches not only to prevent inadvertent exposure to information associated with an equal opportunity protected class, but also because information on social media can present a skewed picture.

“There simply isn’t a way to forget information about extramarital affairs on a blog. No way to un-see the small town newspaper’s lurid and detailed account of a patient death,” Ricks says. “That information may not be accurate or relevant to the employment decision, so better to avoid it entirely.”

Not all organizations play by those rules. Many contend that anything that pops up in a search engine is fair game for review. Whether you agree with the practice or not, the smart thing to do is to prepare to be Googled. Open a browser window in incognito mode, Google yourself and see what pops up. Do a search for every name and nickname that might be associated with you, and don’t stop at the first page of entries. Then ask a tech-savvy friend or family member to do the same and see what they can find.

Look at your public footprints through the eyes of the senior partners at your previous employers. If you’d be proud to show a photo to those physicians, then it’s fine to keep public. Pictures of you with your dog, out with friends, even holding a glass of wine are all great. But no photos, posts or memes about alcohol impairment or recreational drug use should be publicly visible.

With the legalization of marijuana in several states, many younger physicians assume it’s no big deal to post memes and photos implying recreational use. Not so. Health care employers in Colorado, Oregon and California are worried about adverse selection—individuals who want to move to their states for unlimited legal access to their drug of choice.

Candidates should also delete photos that are distinctly unflattering, disturbing or sexually suggestive. Ask friends and family not to tag you in any posts that they would not show a prospective boss. I recently saw a female resident whose teenage cousin had tagged her in a string of selfies with zombie and witch filters. The photos weren’t scandalous, but they showed tongues out, strange hand gestures and cleavage—the kind of thing a 17-year-old’s friends would love. Thankfully, the resident removed the photos within a few days, but even that brief posting could have cost her an interview invitation if a physician interviewer had picked that week to Google her.

Bruce Guyant, Director of Provider Growth and Integration for Novant Health in North Carolina, also warns physicians to think twice before posting about their political or social activism. “With my previous hospital system, we had to back away from a candidate who blogged and posted extensively about a particular hot-button issue,” he recalls.

It was a tough decision. “At the end of the day, though, the CEO could not shake the concern that this physician’s weekend and evening activities would attract attention and impair her ability to build a practice in a conservative community,” Guyant says. “They worried that her activism could result in isolation for her—and evening news footage of protestors in front of the hospital.” He acknowledged that she would fit beautifully in more politically diverse markets, but her public expression of her views could make her and the facility a target.

Google results aren’t always a deterrent for employers. Sometimes a search reveals unique stories that help a candidate be successful. For example, I’m working with Brent Herron, M.D., a family medicine resident. Herron wants an atypical schedule: working late some days and taking some Fridays off to train for triathlons and manage endurance sports events. Typically, that kind of flexibility is earned over time, and practice administrators worry about priorities when a candidate asks for Fridays off even before interviewing. Several practices passed on Herron without reading anything other than his schedule criteria.

So I asked a hospital-employed practice to take a second look at Herron and sent along a link about his community involvement. Before going to medical school, Herron started a nonprofit that helps endurance athletes raise money for the nonprofit of their choice. He explains, “The inspiration came from my father being diagnosed with multiple sclerosis and my realization that everyone has a ‘multiple sclerosis’ in their life that motivates them.”

The practice considering Herron cares for a large, urban, younger adult demographic—exactly the kind of working adults who would value weeknight appointments. Once his prospective employers understood why Herron made the request, they began to see how his schedule could work well for their practice.

Another kind of Google hit that makes our day? An engagement announcement or wedding website. It’s wonderful to see pictures of a happy, glowing couple, and the narrative about what you enjoy doing together in your spare time usually confirms what we have already heard about why you’re a good fit for our community.

Google searches can also fill in the blanks for employers. I once had a terrific practicing candidate with a three-month gap on his CV. Gaps like this can be a red flag because they are often associated with substance abuse rehab. He had quit his job and listed his availability date as three months in the future. After a Google search, everything made sense. He remains unnamed here because he prefers that no one on planet Earth remember he was (excruciatingly briefly) a contestant on reality TV show “The Bachelorette,” which required him to stop practicing for three months.

We’ll talk to more than just your references

“There is an extended, diverse pool of people involved in vetting a candidate,” explains Brian Pate, M.D., chair of pediatrics at KU School of Medicine-Wichita. “You can’t predict who they might know at your training facility.”

Pate says it’s common for other department physicians, staff or facility administrators with ties to your training institution to have feedback about a candidate’s reputation. “The important thing to know is that, unlike formal references from your program director and faculty, the informal opinions afford 360-degree exposure,” he says. “If a physician is accountable and professional only to those above him or her…we often learn about it.”

Once during a hospital tour, Pate says a faculty member recognized a candidate as a former peer. “We unexpectedly received detailed feedback of how this individual was perceived as difficult to work with by peers, learners and hospital staff,” Pate says. “This information contributed to the overall impression of the applicant.” He encourages physicians in training to remember that preparing for a successful interview begins with a daily commitment to professionalism and best practices in their current positions.

Ricks agrees. “It surprises me that candidates don’t realize how much networking goes on in physician recruiting,” she says. “Most health systems are on a shared candidate management system. …If a candidate interviewed at a sister hospital in another state and didn’t get the job, I can call my colleague and find out how that interview went and get details that might not have made it into the database.”

It works the other way, too. “Networking can be a real plus for candidates who have made a good impression,” Ricks says. And a referral from a trusted colleague grabs a recruiter’s attention.

Shared databases can also reveal discrepancies between a candidate’s account of competing offers—and the truth. For example, physician recruiter Christopher Link recalls a candidate who was considering one offer from a group in the Midwest and another from Link’s employer in a different state—both HCA facilities.

“Maybe [the candidate] simply didn’t believe us when we told her that we stay in close touch as soon as we see that a candidate is engaged with another HCA hospital. It simply doesn’t make business sense for two hospitals in the same system to get into a bidding war,” Link recalls. “[The candidate] repeatedly tried to leverage our offers against each other using partial truths and omissions about the other offer in an attempt to secure better terms.”

We’re evaluating you on your presentation

Personal, handwritten thank-you notes to his interviewing team helped Sultan Mahmood, M.D., stand out—and get the job. · Photo by Danielle Shearon

Personal, handwritten thank-you notes to his interviewing team helped Sultan Mahmood, M.D., stand out—and get the job. · Photo by Danielle Shearon

When recruiters and administrators talk about “presentation,” they don’t mean beauty, style or media-perfect diction. But how you choose to present yourself when you make a first impression matters—because your judgment is what’s really on display.

According to Mary Wine, administrator at Advanced Orthopaedic Associates in Wichita, Kansas, overly casual attire sends the wrong message. “I haven’t had anyone show up in scrubs yet, but I have seen candidates show up for a formal interview in khakis and an open collared shirt,” she says.

Unless you have explicit instructions to the contrary, you should interview in a suit and tie or the female equivalent. “First impressions are lasting,” Wine says. “Effort shows that you are serious about wanting to join my group. Formal business attire demonstrates that you will know how to dress on the day I need to take you to meet hospital administrators with whom we have important contracts.”

Interpersonal skills are also important. Guyant says that if an applicant mumbles in a phone message, there will be no call back. “I am assuming that you are putting your best foot forward when contacting a prospective employer for the first time,” Guyant explains. “Accents are not an issue, but clear and comprehensible verbal communication is a job requirement.”

“The first opportunity a candidate has to demonstrate that is on a phone message to the recruiter,” he says. “If you mumble, whisper or speak so fast I can’t understand you, it’s likely that my patients and medical staff would end up confused and frustrated with you. I will put my time to more productive use, and I instruct my recruiters to do the same.”

Another element of professional presentation is the post-interview thank-you note. Since most communication today takes place by email, an interview panel takes notice of handwritten notes.

“Dr. Sultan Mahmood, a gastroenterologist I recently signed, sent thank-you notes to everyone on his itinerary, including me,” recalls Marci Jackson, FASPR, physician recruitment manager with Marshfield Clinic Health System in Wisconsin. “The front of the note was a family picture: the physician, his physician wife and his two children. With each note, he thanked that person for something specific.”

Mahmood says taking notes throughout the interview day was the key to personalizing these notes. Otherwise, minor details about each interviewer fade quickly from memory. “Having been on the receiving/interviewing side as a fellowship interview,” he says, “I knew that a personalized note can make a difference.”

Jackson agrees. “During an interview, it’s difficult to get the full measure of someone’s personality,” she says. “The courtesy and warmth demonstrated by Mahmood’s special thank-you note lent depth to our final impression of him. …I think it was important in the department’s decision to offer.”

We get wary when you say you’re open to any location

Andrew Walker, CMSR, FASPR, director of physician recruitment and contracting for CarePoint Healthcare, says recruiters get skeptical when physicians say they’re interested in 10 or more states. “I just know what I will hear when I screen this physician. He’ll say he is open geographically and is really focused on finding the right job,” Walker says.

There are other reasons physicians may give. One might say that since he doesn’t have family in the country, he’s able to settle wherever he finds the best job. Another might say she’s spent her whole life on the East Coast and is ready to experience something new.

However, we recruiters interpret these explanations in the context of our own experience. We speak to hundreds of candidates—month after month, year after year. And we’ve learned it’s easier to attract a candidate who is interested in a specific region. “If I’m recruiting for my site in Utah, I know that the candidate likely to accept if offered and put down roots in my community is the one who has a good reason to want to live here,” explains Walker.

That reason does not necessarily have to be family, but there had better be a well-articulated explanation if decision-makers are going to take the candidacy seriously.

“Recruiters know from experience that physician candidates underestimate the pressure they will get from family about living a 10-hour travel day away,” Walker says. If your extended family lives near each other—but five states away from your job—the pressure to move home and raise your kids near family will only intensify over time. Your remote job will probably last a few years, at most.

Recruiters can tell when a candidate is all-in for the long-term—hell-bent on becoming partner and gunning for a department head job in five years. Great cultures are built by these passionate physicians. “If my group has two candidates with roughly equal credentials … the one who is fired up about building a life here and genuinely excited about our practice is going to have an edge,” says Walker.

Candidates can jump to the top of employers’ hot lists by adding details in their cover letter to explain their interest in the area. For example, a candidate might write: “I’m interested in this job because my older brother and his family live in [suburb name], and my best friend from college lives downtown. Our wives are also friends, and we visit or vacation together almost every year.”

Or perhaps: “I have no ties to [city name], but I visited twice for medical conferences, and my husband and I simply fell in love with your city. Everywhere we looked, everyone we met reinforced the feeling that this was our ideal home. We are also looking at [other city] and [other city], but your city is our No. 1 choice, and we are excited about starting to explore.”

We can’t tell you everything

Most employers won’t tell you why you didn’t get the interview or the job. Typically, hiring managers and recruiters can only say they are moving forward with another candidate. This zipped-lip protocol developed as so many rules do: through lawsuits.

Any further discussion runs the risk of an EEOC complaint or, at the very least, unpleasant discussions with legal counsel, internal ethics committees and HR executives about a candidate’s complaint. Even at small practices that aren’t subject to EEOC regulations, the rationale for hiring decisions isn’t shared with the candidates.

Another thing employers and recruiters won’t tell you? Any troubling details about the practice itself or the local economy. Ricks wishes more candidates would do their due diligence on the job market instead of blindly trusting a prospective employer’s projections.

“Operational leaders call it ‘optimization’ when they eliminate unsustainable practices,” says Ricks, adding that this euphemism often means that “the physician is out of a job or has to move to another community.” To avoid getting “optimized” out of a job, Ricks recommends asking your interviewers: “Have you laid off or decided not to renew any physician contracts in the past five years?”

Before accepting a job, you should be sure that the employer is financially sound and that the area can support another physician in your specialty. Google the hospital system to find out what other news outlets, patients and employees are saying about an employer. You can also ask neutral third parties, such as the local chamber of commerce, to verify demographic trends.

We want you to find a good fit

Even though we can’t tell you everything while you’re interviewing, physician recruiters and employers want you to find a good fit. We’re always working to make the application and interview process easier to navigate. Once you understand what the process looks like from our side of the interviewer’s desk, you can put your best foot forward—and help us help you land the right job.

Therese Karsten, MBA, CMSR, FASPR is the director of physician recruitment for HCA Physician Services Group.

 

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10 Questions to ask in your next interview

Is this new opportunity the right practice for you? Asking these can help you decide.

By Karen Edwards | Feature Articles | Summer 2018

 

During the interview process, Jennifer Allen, M.D., recommends getting a feel for how much time will be spent on nonclinical activities— not just call. · Photo by Scott Patrick Myers

During the interview process, Jennifer Allen, M.D., recommends getting a feel for how much time will be spent on nonclinical activities— not just call. · Photo by Scott Patrick Myers

It took the premature death of his father to convince Josh Valtos, M.D., to leave a thriving cardiac surgery practice and move closer to family.

Amy Canuso, D.O., made a similar decision when she moved her family from Guam to Iowa. Although she was not unhappy with her practice in child and adolescent psychiatry, “For us, it was the right decision,” she says.

For Jennifer Allen, M.D., it was the end of her family practice residency that spurred action.

Though each of these physicians had different motivations, each found a job search squarely in their future.

Looking for work is hardly a new phenomenon these days for physicians—or anyone else. According to The Balance, an online publication that covers personal finances, the average person changes jobs 10 to 15 times over the course of his or her career.

Physicians aren’t exempt from work transitions. And with that comes the biggest question: Will the change be a good move…or not?

“It’s an employee market out there for physicians,” says Valtos. The market needs you. But how can you decide if a job offer is the right one for you and your family?

Certainly, completing residency or fellowship or deciding on a geographical move are among the many reasons why physicians look for work. But they’re not the only reasons. Pinnacle Health Group conducted a survey several years ago to learn why physicians change jobs. We will look at some of the reasons they compiled as a way to prompt questions you should ask before accepting a job offer.

No matter what questions you decide to ask, however, one thing is clear: The more questions you ask before, during and after the interview, the more likely you will be to find the right fit for you and your family.

Compensation questions

First on the Pinnacle Health Group survey on why physicians change jobs (or opt not to take them in the first place) is the need for a higher salary.

“Of course, in a job interview, physicians are primarily focused on getting the job and how much the job pays,” says Jeff Decker, division president, locum tenens for the recruiting firm AMN Healthcare. “Because of the debt level they assume while training, they’re programmed to get out there and start working as soon as they can for as much as they can. If they’re motivated to pay down debt, though, they can jump into a job too fast without taking other factors into consideration.” But yes, he continues, salary is going to be a substantial part of any job interview.

Before entering any interview, you need to determine your salary needs. There are other questions on this topic that you may want to ask:

1 Do you have the resources to meet my salary needs now and in the future?

“Physicians who join a private practice may not be given as high a starting salary as physicians who are employed by a hospital or health system, but they may receive supplemental incentives, like relocation, student loan assistance and sign-on bonuses,” says Chris Corde, system vice president of physician recruiting for OhioHealth.

“However, physicians who enter private practice may have a greater long-term earning potential because they can have ownership or are able to retain a greater share of their work.” Before your interview, consider your financial goals and make sure you learn about your long-term salary prospects from any potential employer.

Allen suggests asking about the employer’s overall financial health. “With so many mergers taking place and hospitals going under, you’ll want to know what the employer’s financial strength is,” she says.

Decker agrees. “Don’t be afraid to ask these kinds of questions,” he says. “Ask about the economic health of the business and ask if there are things down the road that could be problematic.” You don’t want to accept a job offer if the hospital is prepared to do lay-offs in the months ahead.

2 What will my income look like in the first year—and after?

“Income guarantees” are becoming a thing of the past. “With this type of contract, the physician is assured a base income, usually for one or two years. But it is really a loan that has to be paid back,” says Decker. However, the loan is usually “forgiven” in exchange for the physician staying in the community for a certain number of years.

“In the early days, most of our contracts featured income guarantees. Now, it is about three or four percent, as almost everyone recruited today gets a salary,” he says. “After a year or two that may segue into pure production, so you have to be prepared for that.”

If that is the case, Decker recommends asking during the interview what kind of loads other physicians carry. “You can deduct in your head the number of patients you will need to see to meet your compensation goals,” he says.

“Those types of contracts (salary with no payback and bonuses paid when care metrics are met) turn the clinician to a salary employee,” says health care consultant Tom Davis, M.D. “But that’s what a lot of them want.”

If you’re not sure what the best compensation arrangement will be for your practice and family long-term, you can try asking a question to help you understand the review process involved.

Canuso recommends: “Can I re-negotiate pay after my contract ends?” If the answer is “no,” at least you can decide on the job opportunity with that knowledge.

3 Is compensation here driven by volume or quality?

“That’s one question to ask that will help you determine some answers,” says Decker. Different employers have different values, so it’s a good idea to determine what drives an employer before accepting a position there. Salary, productivity, even academic systems have their pros and cons. “You need to know what system you are most comfortable working under, and choose the job accordingly,” says Canuso.

Lifestyle questions

"As we grow older, we need to ask ourselves, 'have my priorities changed?'" says Valtos. Doing so can help you determine if a new practice will better fit your needs. · Photo by Morgan Knight

“As we grow older, we need to ask ourselves, ‘have my priorities changed?'” says Valtos. Doing so can help you determine if a new practice will better fit your needs. · Photo by Morgan Knight

Also ranking high on the Pinnacle survey are several items that translate to lifestyle. Lengthy hours or a high call schedule are two reasons many physicians opt out of a job offer or the job itself. Other lifestyle reasons include underutilized medical skills and an unmet need for growth and upward advancement.

“As we grow older, we need to ask ourselves, ‘have my priorities changed?’” says Valtos. After you have paid off medical school debt, your focus may shift from money to lifestyle. Again, that means you need to first establish your priorities before looking for work. With priorities in mind, your questions can focus on what’s important to you. If lifestyle is at the top of your priority list, here are a few questions you might want to ask a prospective employer:

4 What’s the call schedule?

If you are interested in maintaining a work/life balance that works for you and your family, this is an important question to ask. You will not only want to know what hours you will be expected to work, but where you will be expected to work. Some facilities have satellite clinics where you may be assigned, so even if you do not object to the late-night or early morning shift, you may have a different perspective if you need to factor in a 45-minute commute to the satellite facility.

“If you’re applying at a hospital that has a network, ask if there are ancillary facilities you’ll rotate to,” says Decker. That’s true whether the work is during regular hours or on-call shifts.

It’s also a good idea to ask if you will take call from community-based providers, says Corde. If so, how will that impact you? It is conceivable you might be taking on all the late-night work from community providers who would rather not work outside their regular hours.

Another question to pose is, “Can I take scheduled vacation?” Hospitals with high patient volumes may not be thrilled with the idea of new physicians scheduling vacations in the first year, but, says Decker, if vacations are frowned upon as a general rule, you will want to know about that policy upfront.

5 How much time will I spend on nonclinical activities?

“One question I wish I had asked during the interview is, ‘How much time will I spend finishing charts?’” says Allen. “Electronic records didn’t work, so I was spending an hour and a half beyond my scheduled time to complete charts each night,” she says.

Davis says the complaint is not uncommon, so he urges job applicants to ask about time commitments needed for all non-clinical activities, including completing records.

“Ask about any meetings you’ll be expected to attend as well as any additional training that will be required,” he says.

Know before you sign up for the job exactly what kind of hours will be required to complete each day. “If you find yourself working outside of your regular hours, you might ask, in the case of completing records, if you can leave the hospital and remote from home to finish your work,” says Allen. If it appears you will be expected to spend your own time on non-clinical tasks, she adds, “ask if you will receive some sort of compensation for the extra time in terms of cash or vacation, or if it’s simply expected of you.”

Have a potential employer walk you through a typical day at the facility. “Ask ‘What will my first week be like?’” says Corde. Then go further. “Ask ‘What will my first month be like? My first year?’” This will give you a better idea of the employer’s expectations and how they match up with your priorities.

“I ask for details of the day-to-day job,” says Allen. The information you learn will help you better decide if this is the right practice fit for you.

“Will I see mostly inpatients? Outpatients? Will there be a mix? I ask myself, ‘In what sort of setting do I enjoy practicing the most, and with what patient demographic?’” says Canuso. The answer will help you with your job decision.

6 What kind of growth opportunities will I have?

If advancement opportunities are important to you, remember to ask about them during the interview. “Ask ‘How can I make partner?’ if this is a path that interests you,” says Valtos. Or if your goal is to rise higher in hospital leadership, ask “What is the pathway to medical director?’”

“Many new physicians will sign up with an employer in a part of the country where they want to live, work there long enough to pay down their debt, and then decide their career move,” says Davis. So, before you ask an employer about growth opportunities, make sure the job and community is a place where you see yourself and your family staying long enough to advance your career.

Questions for the family

Number 10 on the Pinnacle survey on why physicians leave (or do not accept) jobs involves the family and its comfort level in the community.

“My family was entrenched in our community, so when I looked for work, I decided not to move them. It was better for everyone if I commuted to work,” says Allen. That meant she needed to restrict the area in which she searched for a job, but it was a solution that worked best for everyone. “I was already commuting for my residency. The job I found was actually closer than my previous commute had been.”

If you do have family, like Valtos, you will want to spend as much time as possible learning about the community before you step foot into the interview.

“My wife and I are pretty good researchers,” says Valtos. Before moving from Missouri to their new home in northeast Alabama, they went online to find the best community fit for their family. “We looked up the health of the community, school rankings and school performance records, crime statistics, even weather reports,” he says. By the time of the interview, you should not have many questions left to ask about the community, he says.

Still, here are a few you might ask to help determine if you and your family will feel comfortable there:

7 What is the community’s demographic?

If you’re looking to surround yourself and your family with people of similar ages, what part of town would be best for you to look in? What activities are available? Are there places for colleagues and friends to meet outside of the workplace? Whether you are interested in fine dining and theater or professional sports and barbecue, you need to know if this is a place where you and your family will fit in for an extended period of time, says Allen.

Says Valtos: “You want to ask yourself if you can see yourself here in 30 years.”

Also, says Decker, ask what the pace of the community is like. “An urban environment is going to be a different pace from a rural or even a suburban environment.” Which pace best suits you and your family?

8 What help do you offer families?

It is not unusual these days for hospitals to work with realtors who can help find homes for physicians moving into the area. The realtors are familiar with school districts and can likely introduce you to school administrators as well as provide up-to-date information on school performance records and rankings.

Canuso, who recently moved from Guam to a small Iowa community, says, “When I interviewed for my job, the hospital administrator even arranged for us to tour the schools and meet with the principals.”

Help with house hunting as well as school introductions can be a significant asset for new physicians. So can job placement services that can help a spouse find work in the new community. Hospitals often tap their networks to find employment opportunities for trailing spouses who left their jobs behind.

If any of those services would be helpful, ask about them during the interview.

9 What help do you offer to new physicians?

During the interview, Allen suggests asking if there is a support system in place for new physicians. If networking and collegiality is important to you, then ask if the physicians mingle outside of work, says Allen. Becoming familiar with other staff members, even making friends, can be a crucial part of fitting into a new workplace.

Before you accept a job offer, it can also help to talk with physicians who work or have worked at the facility.

“I asked to speak to a few physicians who work for the hospital,” says Canuso. “I also wanted to meet the clinical managers and nurses on the inpatient ward. Ultimately, you are going to spend more time with co-workers than you do with family, so I wanted to get a sense of potential for mutual respect and general temperament of potential co-workers. This is a rural hospital, so the professionals who work there want to be there—and that means a great deal to me.”

You can also get help from your hospital’s recruitment team. “Recruiters can also be phenomenal in terms of research,” says Valtos. “They can give you insights into the job, the employer and the community you can’t get anywhere else.”

10 What about…?

Of course, any question you ask during an interview will be unique to your own situation. The questions already covered are general in scope and will benefit most applicants. Here are a few questions that are slightly more specific. Chances are, you’ll want to ask a few in your interview:

  • What are your turnover rates? How many new hires stay after the first year? Davis says this will give you a feel for how satisfied employees are who work there. Valtos also suggests asking the employer about turnover rates. “Ask the recruiter how many physicians have come and gone from this location and why. Or, ask the employer why they’re looking for a new physician,” he says.
  • How long has the job been posted? If the employer has been looking for a while, says Corde, you may want to ask why.
  • Is there a non-compete clause? You’ll want to understand any restrictions if you choose to look for another job in the area in the future.
  • What is the employer’s mission? Do they have serving community at the top, or is it focused on profit? Ask how the mission affects daily life at the organization.
  • When can I expect to hear back? Candidates can forget to ask this following the interview, says Corde. Ask what the next step is before you leave.

“Don’t be afraid to ask questions,” says Valtos. “After all, you’re the one who is ultimately going to work at this place, in this culture and live in this community. Make sure you ask all of the questions you need to help you make the right decision.”

 

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Your job-search timeline

Learning of other physicians’ job-search journeys can help you anticipate, plan and execute your own.

By Marcia Layton Turner | Feature Articles | Spring 2018

 

“Much of the education on searching for jobs was acquired in passing while talking with those ahead of us in training and through each other as we went through process,” says Sunny Jha, M.D. Photo by Dawn Bowery Photography

“Much of the education on searching for jobs was acquired in passing while talking with those ahead of us in training and through each other as we went through process,” says Sunny Jha, M.D. Photo by Dawn Bowery Photography

Until you get to your job search, the path to a career in medicine is quite regimented: Study a pre-med curriculum. Apply to medical school, then to a residency program. After residency, you either apply for a fellowship or begin looking for a job. And that’s when the systematic, methodical process vanishes, leaving some physicians unsure of how exactly, or when, to begin their job search.

“The search process lacks any sort of formal structure, so it is unlike anything most young physicians have ever experienced,” explains Sachin “Sunny” Jha, M.D., MS, assistant clinical professor of anesthesiology at the University of Southern California (USC) in Los Angeles. “I had an idea that the job process would be a long exercise with varying degrees of uncertainty and unpredictability,” he says. “Prior to this point in medicine, everything more or less had a process.”

The path to a new opportunity doesn’t come with a pre-written map or compass. So it can help to hear what other physicians’ job searches looked like as you chart your own course.

“Like many aspects of medical education, this is one of the things that you don’t formally ‘learn,’” says Jha.

The success of your search, and the order in which you uncover and pursue opportunities and resources, is largely dependent on timing. Allow yourself ample time to explore all the jobs that may be available to you so you can negotiate from a position of strength, rather than being rushed and under pressure to accept anything that’s offered.

Design your plan

Zachary Liner, M.D., started his job search 17 months before he would be available. Photo by Michael Caswell Photography

Zachary Liner, M.D., started his job search 17 months before he would be available. Photo by Michael Caswell Photography

When it comes to looking for your first or next job, “Start early,” advises Zachary Liner, M.D., an interventional radiologist with North Oaks Imaging Associates in Hammond, Louisiana. Liner began his job search in the middle of his first fellowship after residency and before he had even started his second fellowship—17 months before he knew he’d be available to start.

According to the 2017 Survey of Final-Year Medical Residents conducted by Merritt Hawkins, a national health care search and consulting firm, 72 percent of medical residents start their job search within or before a year of finishing residency; 28 percent wait until they are six months from completing their training before beginning their job search in earnest.

Patty Shipton, physician recruiter with Penn State Health in Hershey, Pennsylvania, says that a year is just about right for a physician’s job-search process. Physicians in their last year of residency or fellowship generally start looking for a position in early fall, she says. That’s when recruiters begin attending career fairs and conferences armed with a general idea of upcoming openings that will need to be filled. Shipton also collects CVs for unexpected openings that occur from time to time.

Chris Mason, D.O., MS, is regional medical director for the Western region of American Physician Partners and is based in Albuquerque.

Mason points out that, thanks to the fact that there are “far more physician jobs than there are candidates…it’s a resident’s market.” (He’s quick to point out that this varies by specialty and location, however.)

The earliest a resident can commit to a job is right after their intern year. And while that’s not typical, it’s possible, he points out. To entice physicians to sign as soon as they’re eligible, employers may offer incentives including sign-on bonuses, stipends and loan forgiveness.

The major downside to signing a contract so early in the job-search process is that you’re committed to work somewhere long before you’re finished with residency. During that time, you may make all sorts of decisions that could interfere with that employment arrangement. For example, you might decide you want to live elsewhere in the country, you might get married to someone who wants to live somewhere else, or you might decide you want to work for a specific practice or even switch specialties. A lot can happen over the course of several years of training.

Zero in on desirable locations

By early fall, most physicians usually know where they want to be geographically, says Shipton. She finds that they often they want to move to be closer to family. Or they’re clear about whether they want a big city or small, urban or rural setting, mountain or beach, or a specific region of the country.

Many have also started to research which hospital systems or practices have openings in their specialty—or are likely to soon.

Liner’s medical specialty of neurointerventional radiology is what he calls a “super subspecialty.” “There aren’t a lot of people who do what I do,” he explains, which means that there aren’t as many programs or spots available, and “once spots are filled, they’re filled,” he says. “I had to start early to have a chance of getting one of those openings.”

Making his job search even more challenging was that not only was Liner looking for a position in a field with very few openings each year, but he also had a very small geographic target area. Most interventional radiology jobs exist in major cities, he explains, but he and his wife had decided that after living in New Orleans, Texas, San Francisco, and Rochester, New York, they wanted to make southern Louisiana home—where he and his wife had grown up. He knew that his odds of finding an interventional radiology opening in southern Louisiana were slim, so he wanted to start introducing himself to anyone in Louisiana who might have a need for a physician with his skillset.

“It was constantly on my mind that the job I wanted wasn’t open—that I had to create it,” he says. Few programs were looking for a doctor with training in both body and neurointerventional radiology. “It’s a unique skillset that sets me apart,” says Liner, but with so few hospitals and practices actively looking for someone with such unique training, he was aware that his job search could be difficult. It was likely he would need to convince a practice that he would be a valuable addition, and work with them to create a new role rather than take over an existing position.

Be aware of established milestones

Depending on your specialty, there may be opportunities at specific times of the year, such as at educational conferences and medical association meetings, to be considered for upcoming openings.

Jha, who was looking for a position in academic medicine, discovered after the fact that many academic departments interview graduating residents at the ASA (American Society of Anesthesiologists) annual meeting in October. Looking back, he says he should have started earlier and taken advantage of this interview opportunity.

Ask your colleagues if your own specialty’s conference has a similar setup. If so, try to attend.

Mason recommends networking through various local and national chapters of your specialty’s professional organizations. Take advantage of residency events and physician groups that provide opportunities for residents to mix and mingle with health care representatives. “Get involved,” Mason advises, to get to know attending physicians who can serve as referral sources and connectors to your dream practice.

Take a proactive approach

Don’t hesitate to be proactive.

“If there’s a place you’re interested in, don’t be afraid to reach out to the recruiter,” Shipton says. “They may know of a future opening coming up.” Most in-house physician recruiters serve specific departments, so it’s useful to identify which recruiters are responsible for hiring physicians in your specialty at the employers you’re targeting. In-house physician recruiters are uniquely qualified to represent the opportunity and community for which they’re recruiting, as they are directly employed by the facility. It’s their friends and family whom you’ll be treating.

Another option is to retain the help of an agency or staffing firm in your search. An agency may be able to alert you to jobs at multiple specialties through one point of contact.

Liner decided that he needed the support of a professional adviser to help track down a potential employer that would meet all of his criteria. He chose Jeff Hinds, MHA, of Premier Physician Agency in April 2016.

Liner worked on a cover letter and updated his CV to be sent out to prospective employers. He then sent out “feeler emails” to about 40 practices that Hinds had identified in cities and towns in Louisiana, Texas, Alabama and Mississippi to see what kind of interest there might be in a doctor with his training and experience. He also checked physician job boards and applied to a few opportunities.

Almost immediately, Liner began receiving phone calls in response to his campaign. Although most recruiters said, “We don’t have a place for someone with your skill set,” they also told him they would keep his materials on file in case something opened up later. Liner then followed up later with those that had expressed an interest to check in. Back-and-forth phone calls from the feeler emails continued for about six months, says Liner.

Among the many “we don’t have a spot for you” phone calls were six calls from practices that were interested in speaking with Liner, three of which were in Louisiana.

Jha describes his initial job search activities as passive, as he applied and interviewed “broadly” for jobs in both academic medicine and the private sector. “I had been passively searching for jobs in both environments, collecting contacts within different departments,” says Jha.

Then at around the midpoint of his fellowship year, he began directly reaching out to different departments and groups he was interested in. “The department where I did my fellowship kept a list of key contacts within groups around the country, which was instrumental in securing many of my interviews,” he says. In addition, some physician job boards and physician recruitment agencies also provided outreach ideas.

His proactive approach worked. “I actually got my job by directly emailing the chair of my department,” he says.

You can be proactive even without having a name provided. On PracticeLink.com, for example, you can search by specialty, zip or employer, and reach out directly to the in-house recruiter representing the opportunity or organization.

Schedule site visits

For the next five months, from August 2016 to January 2017, Liner flew out to interview with six different groups. He had one interview in August, three in September, one in November, and one in January. Many took weeks to schedule because he had to travel from his fellowship in San Francisco to the south during times he wasn’t required at the hospital. Finding common schedule availability was challenging.

Liner had a strong sense that practices that initially said “no” because they didn’t have any openings at the time might eventually turn into a “yes” if a partner decided to move or retire. So he made a habit of staying in touch with all the practices and hospitals in his geographic search area.

As he scheduled first visits with some groups, he was also scheduling second visits to two practices that had made offers following the initial site visit. He completed those two visits in January.

After reviewing CVs gathered at conferences in September and October, Shipton’s next step is to schedule on-site visits to see if there may be a fit. During October and November, she typically invites the top in for a first on-site visit. Based on those in-person interviews, the interview team and department leadership collectively decide whom to invite back for a second visit, often with their families. Those generally occur in November and December. Offers are then made between December and February, she explains.

Liner made it known to the practices he was considering that he was going to take his time in making a decision. Because he had started his job search so early, he had the luxury of time to thoroughly research each practice and speak with different people and departments within each practice.

While there is a standard recruitment process and timeline, Shipton says, there are factors that can slow it down or speed it up. For example, the availability of a physician to start work can drive how quickly the process concludes. If he or she finishes residency on June 30, the earliest possible date they could start would be July 1. “But many people want to take some time off [after residency], to move and get settled,” says Shipton, “and that can affect when they start.”

Likewise, candidates who are especially responsive can move the process along faster than normal.

Negotiate a contract

As his second site visits were underway in January 2017, Liner began receiving offers. Over the next two months, he began negotiating with three practices. Most contract negotiations don’t take two months, says Liner, “but we were all cautious,” he says. “No one wanted to make any snap decisions.”

Twelve months after he started his job search, Liner accepted a job offer from a practice in Louisiana.

Be prepared for credentialing

In order to prevent any delays in receiving your hospital credentials or medical license, make sure you have quick and easy access to the personal information your employer will need, suggests Jha. That means collecting recommendation letters as soon as possible, keeping accurate and up-to-date procedure logs as you go through training, and scanning personal documents, such as identification, degrees, other licenses and immunization records so that you can send them at a moment’s notice, he recommends.

“Be patient and start early so you can begin working on time,” Jha advises.

Shipton says that credentialing, which can include a background check, review of letters of reference and other documentation, can take anywhere from one to three months depending on the state in which you’re applying.

Make your own timeline

While there are common timelines for finding, considering and accepting a new position, there are also many extenuating circumstances. The typical timeline is just that: typical, but not the rule. Liner was looking for the equivalent of a needle in a haystack in Louisiana, so his timeline was extended. You can take a different approach, or operate at a faster or slower speed. It’s up to you.

You can decide for yourself how much time to invest in identifying potential employers, researching programs, sending out CVs, talking to recruiters, visiting hospitals and practices in person, negotiating a contract, and preparing for your new role.

Based on his job search, Liner recommends holding out for the right job. Don’t rush the process, he says. “You can find the right group; you just have to allow yourself the time to find it.”

You’ll also make a better decision if you do your own due diligence before signing any contracts. Ask lots of questions—“you can’t ask too many,” Liner says—to ensure you’re making the best decision for you.

Marcia Layton Turner is a frequent contributor to PracticeLink Magazine.

 

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