The who, what, when and how of contract negotiation

Approach your next employment contract with flexibility, knowledge and backup support.

By Debbie Swanson | Fall 2020 | Feature Articles


Remember—especially when working with large hospitals or practices— that you may be presented with a standard contract with little wiggle room, says Houtan Chaboki, M.D. – Photo by Arielle Lewis

Your long-awaited dream is finally within sight. You’ve been offered a promising job! You’re just one signature away from a celebratory dinner. But don’t reach for your jacket just yet. No matter how excited you may be to seal the deal, there’s one more crucial step: contract negotiation.

The first contract you receive isn’t necessarily the one you’ll sign. Most employers expect some back-and-forth after they deliver your employment contract. These lengthy documents are written by attorneys paid to protect an employer’s interests first. Before you sign, you should take time to read and understand what you’re agreeing to. That way, you can identify any clauses that are vague, missing or not in line with your best interests.

Step 1: Getting ready

When you’re contemplating a job, it’s important to weigh your priorities. What do you and your family need and want from the arrangement? Your priorities may have shifted throughout your medical journey, so if you haven’t revisited them recently, now is a good time.

Clarify your vision

You probably have some ideas about what you want your career to look like. Now is the time to make sure your job offer lines up with the picture you have in your head. Take these factors into consideration as you do:

Location. Does the job require relocation? Is that feasible for you and your family? Do you plan to stay in the area, even if you don’t stay at this job? If so, review any restrictive covenant carefully as it may limit your future mobility.

Finances. How much debt do you have? Can you afford to move? Consider negotiating for loan forgiveness, a relocation stipend or a signing bonus to help offset these burdens.

Lifestyle. What kind of schedule are you looking for? What other responsibilities do you need to keep in mind? Be sure you understand your expectations in terms of days and hours worked.

Other endeavors. What else is on your plate, both professionally and personally? Do you have an entrepreneurial nature and want to start a side business? Do you plan to do other medical work on the side? Take note of any restrictions limiting such activities.

Career direction. What do you hope to be doing in five or 10 years? Is this job a good steppingstone toward that goal?

Ongoing learning. What are you interested in learning more about? Education doesn’t end with medical school, so make sure this job supports continued learning through mentors, educational opportunities or other avenues.

These considerations will help you determine whether this job and this contract fit your needs. Just as you planned out your education and residency, you now need to map out your career to reach your professional goals.

“[You] need to be happy with the scope and trajectory of your individual practice,” advises R. Bryan Butler, M.D., a surgeon at Orthopaedic Medical Group of Tampa Bay. “For instance, as a shoulder-and-elbow-trained specialist, when I chose a group or location, I wanted to make sure that the majority of my practice would entail shoulder and elbow patients.”

Ramp up your knowledge

As you were winding down your academic years, you probably received plenty of career guidance to land a residency or fellowship or craft your CV and nail your interviews. However, young physicians don’t always receive much advice about employment contracts. The good news is just a few hours of research can quickly get you up to speed. Search online for sample contracts, ask your medical schools for resources, and reach out to past mentors or professors for help.

Some employment issues—such as insurance costs and regulations—vary greatly by region, so tailor your efforts to your location. Consider your specialty, too. Supply and demand for specific types of physicians play a big role in salary, perks and your overall leverage. Finally, consider your background, skills and education. What do you bring to the table, and do your credentials give you an advantage in negotiations?

Line up supporting resources

Employers have plenty of legal minds on their side. It wouldn’t make sense for you to go without. Before you sign a contract, have a lawyer review it. Choose an attorney who is familiar with physician employment contracts. If you need help finding someone, check with alumni associations, nearby medical schools or colleagues for recommendations.

“M.D.s do not usually have training in business and law,” says Scott Goldsmith, M.D., president of Orthopaedic Medical Group of Tampa Bay. “It’s prudent to have [a lawyer] mark up the document to point out possible areas of concern for you. There are always points of the contract that need to be addressed further, so if the attorney sends back a contract without any red marks, it would be wise to seek alternative legal advice.”

Your lawyer will charge a fee, but it’s money well spent. Legal review can help improve your job satisfaction and prevent conflicts during or after your employment. Plus, you may even recoup the cost directly or indirectly if your lawyer helps you negotiate better terms.

In addition to seeking legal guidance, you should also tap into your medical network for their knowledge.

“Talk with other doctors you trust, others finishing up residency or fellowship proctors [with whom] you established a relationship. You can do this without divulging specifics. Speak in broad strokes,” suggests Goldsmith. “Have an intelligent conversation about what’s reasonable, what they’ve been seeing, without revealing any personal details.”

Step 2: Getting down to the nitty-gritty

It may be the last thing you want to do at the end of the day, but don’t put off reading your employment contract. Whether it’s a page-long letter or a hefty 30-page document, it’s well worth analyzing. Don’t just expect your lawyer to read it for you. This review should be a mutual exercise.

“Remember that [your] attorney is being paid to look after your best interests, but at the end of the day, you alone get to decide if you believe the contract is fair for you,” Goldsmith says.

Even with help, it’s up to you to take the reins in your contract negotiation. “The importance of representing yourself is paramount,” says Scott Goldsmith, M.D. – Photo by Alicia Johnson

What am I looking for?

Gather some sticky notes and highlighters as you prepare to mark up the document. Flag things you don’t understand or don’t agree with. Make note of anything you plan to research or ask colleagues about. Look also for what’s missing. Sometimes, informal agreements you discuss in an interview don’t find their way into the contract, and you’ll need to have them on paper if you want them enforced.

Be on alert for vague language or sparse descriptions, such as “perform duties as required” or “participate in call rotations in compliance with the group.” These open-ended statements put no limit on what can be asked of you, and they don’t provide benchmarks you can use to measure your performance.

“Get the job expectations in writing as much as possible—specifically with certain areas, such as call expectations, weekly clinical work responsibilities and even how add-on cases are handled,” suggests Goldsmith. “As the new hire, will you get access to the same work as the others? Is there a true collaboration among the surgeons, or is it more of a pyramid scheme?”

Don’t skim or give a half-hearted effort. Just as your lawyer’s copy of the contract should come back with notes, your own copy should be marked up when you are finished with it.

What’s off limits?

While you shouldn’t hesitate to voice any and all concerns you identify, be aware that some areas may be out of your employer’s control.

“Everything is potentially negotiable. However, for large hospitals or practices, there may be a standard agreement with little wiggle room,” says Houtan Chaboki, M.D., president of Potomac Plastic Surgery in Washington, D.C. For example, health, dental or vision insurance coverage likely can’t be changed. Similarly, he adds, “The noncompete clause is less likely to be negotiable.”

“[Other] areas, such as scope of practice or schedule management are more likely to be negotiable. For example, the physician may only want to see certain types of patients on specific days,” explains Chaboki.

“Also, [hold off on asking] how many operating rooms you will have,” Butler says. “This takes time to develop, and it is unlikely that a group is going to be able to guarantee high surgical volume and multiple rooms right off the bat.”

One more area to keep quiet about: phone bills and mileage reimbursement. “These are usually reserved for partners,” says Butler.

If you have an impending major life event, such as a wedding or new baby coming up, it’s better to raise questions about it now, rather than request time off right after you come on board.

A word about salary

Salary is always a hot topic in negotiations, but there’s not always much wiggle room. “At my private practice group, all our new hires straight out of fellowship have the same starting salary,” Butler says. “Most groups are not going to want to negotiate much on salary until the new hire has proven him or herself.”

“There are instances, however, where someone might have a unique skill set or has longer experience or serves in area that is in desperate need for someone right away. If these or other factors are present, then there is more room for negotiation,” Butler adds.

There’s a wide range of compensation models. Physicians early in their careers usually receive a fixed salary, possibly with a productivity bonus. More experienced physicians might be offered a more variable salary. It’s generally difficult to negotiate a different compensation model than the standard one your employer offers, but it’s still important to understand it. Make sure your contract fully explains your compensation, how long it is guaranteed and any external factors that may affect your income.

Partnership potential

You might have your eye on becoming a partner, or you might just be happy to have landed a good job. Either way, now is the time to get the details in writing. “What are the criteria necessary to become a partner?” Goldsmith suggests asking. “When are you eligible to start accruing equity? What are the requirements based on: RVU, collections, number of years in the practice?”

Even if you don’t aspire to partnership, be sure your contract supports whatever type of professional growth you have in mind.

Can I streamline this process?

As you’re plodding through your contract, you may begin to wonder: What’s the most important area to focus on? That answer varies greatly from one physician to the next. A doctor with a young family may place a premium on keeping regular hours, while another physician may seek complex clinical cases, and yet another may be focused on benefits.

Think back to whatever goals and aspirations you identified at the outset, then consider how this contract lines up with those. If there’s anything that will influence your future or interfere with your happiness, put it on your list to discuss.

Step 3: Head to the table

You’ve pinpointed areas to discuss, soaked up knowledge from your attorney and trusted colleagues, and done your own research. All that’s left is a few conversations with your future employer. Easier said than done, you may be thinking. But don’t let nerves or the voice in the back of your head deter you.

It’s up to you

Your lawyer is a helpful resource for identifying points of contention and explaining standard terms. But beyond that, it’s up to you to take the reins and make sure you’re satisfied with the contract and the job itself. “Ultimately, your lawyer will not be working with your [colleagues] and future partners. You will. The importance of representing yourself is paramount,” says Goldsmith.

Advocating for yourself might feel less intimidating with a buffer, but direct communication is much more effective. Avoid relying on email or using a go-between. Instead, phone calls, Skype or Zoom sessions and face-to-face meetings are the best methods.

Don’t rely on memory

Don’t hesitate to bring notes along with you to meetings or have them on hand if you’re talking via phone, Skype or Zoom. That way, you can refer to all the points you want to cover—and your ideal outcomes. Make note of any supporting data you’ve found, such as average local starting salaries for your specialty.

Be flexible

Not every issue is of equal magnitude. You’ll have to compromise in some areas to get what you want in others. Organize your requests by priority: 1) factors that affect whether or not you’ll accept the job in the first place, 2) important concerns that you can afford to be more flexible about, and 3) perks that would be nice to have but not necessary. If you’ve prioritized ahead of time, you’ll be ready for the necessary give-and-take.

Remember to be open-minded throughout the discussion. Listen to other ideas, make notes, ask questions and don’t rush to agree or disagree with anything until you’ve had a chance to digest everything.

Don’t be pacified

Ideally, your negotiations will be professional yet friendly. But be careful. Friendliness can be a way of dismissing your concerns. You don’t want empty reassurances, such as: “Oh, don’t worry about that. That’s never been enforced!” or “That’s just our lawyer. She loves her legal language.” It’s tempting to smile agreeably and take this on good faith, but at the end of the day, if something isn’t in writing, it’s not enforceable.

Negotiations require a fine balance of persistence and politeness. Gently push these friendly reassurances a bit further by saying something like, “That’s good to hear. Given that, can we omit it from (or add it to) the document, please?”

Keep it in neutral

You’re likely to experience an array of emotions during negotiations. You may feel intimidated by your prospective employer and their lawyers, worried that you are asking too much, or even offended by a comment someone makes. Regardless what’s going on inside your head, try not to appear ruffled or get heated. Remind yourself that this is just business. Your employer is protecting their own interests, just as you are protecting yours.

Even if you realize mid-negotiations that you won’t be taking this job, don’t do anything you might regret. If you lose your cool, that reputation might precede you elsewhere.

When to walk away

If your employer won’t—or can’t—accommodate one of your key points, you have a decision to make: Do you accept their terms or walk away? “Ask yourself if you can live with that specific term,” suggests Chaboki. You may know the answer right away, or you may need some time to weigh the pros and cons.

If things don’t shake out the way you want, you can always ask to revisit the issue in a few months, once you’ve proven yourself as a valuable employee. But make sure any arrangements to renegotiate terms are added to your contract in writing. Verbal promises are easily forgotten.

Of course, some issues are too important to put on hold. If you’re not comfortable waiting to revisit an issue later, it may be time to part ways. “Something that I learned from my father in regard to negotiations is that if you are going to negotiate hard, you have to be willing to walk away,” says Butler. “What I have added to that over the years is that you should not be willing to walk away unless you have a plan B.”

Negotiations are never easy. Remind yourself that this is just one more step in the process of landing at your dream practice.



Revenue and RVU’s

A physician’s guide to productivity-based compensation.

By Laurie Morgan | Fall 2020 | Feature Articles


“It takes a little legwork to understand [productivity compensation], but it’s worth it,” says Samuel Gerhardt, D.O. – Photo by Jesse and Gena Photographers

Whether you’re fresh out of residency or simply looking for a change, odds are some of the job offers coming your way will include a productivity component. According to the Medical Group Management Association’s (MGMA) 2019 compensation survey, nearly a third of primary care positions and more than 22 percent of specialist positions include some portion of productivity-based compensation.

For many physicians, this prospect is nerve-racking. Productivity-based compensation isn’t guaranteed, which is why a lot of physicians favor straight salaries. But rejecting productivity-based compensation out-of-hand may be costly, especially over the long run. By limiting your search to straight-salaried positions, you could be missing out on great employers or locations, and there’s a good chance you’re also losing money.

“Some docs shy away from productivity incentive compensation because they’re concerned about or don’t understand it, but they’re leaving money on the table,” said Samuel Gerhardt, D.O., chief family medicine resident at Methodist Community Hospital in Henderson, Kentucky. Just like medicine, business and finance are specialized fields with their own terminology, which physicians rarely hear or use in medical school and residency. Then along comes an offer with a multifaceted compensation plan, and he says, “What usually happens is the physician sees the complex pay model and drops it because they don’t understand it.”

Gerhardt points out that physicians are by nature accustomed to basing decisions on their own expertise. Productivity compensation plans can play havoc with that expectation. “When you’re in a situation where you’re no longer the expert, you back off,” he says. “When you only understand the base salary, that’s the only thing you can look at.”

Productivity compensation in context

“It very much is my experience that physicians are nervous about productivity, but I don’t think they should be,” says Seger Stacy Morris, D.O. – Photo by Hunter Hart

Some physicians are also concerned that emphasizing productivity takes the focus off of patient care. Seger Stacy Morris, D.O., internal medicine program director and division chief of Mississippi internal medicine programs at Baptist Memorial Medical Group in Oxford, Mississippi, says, “It very much is my experience that physicians are nervous about productivity, but I don’t think they should be.”

According to Morris, modern medical training doesn’t give physicians a good sense of the workload they’ll be able to handle. These days, residents are assigned fewer patients than in the past. “Physicians coming out of training are not being trained in starting a business,” he explains. “They’re being trained to be employed. Volume is completely deemphasized, even discouraged, in most programs. Throughout your training, there is very little about what the real world will expect in terms of your productivity.”

In some ways, Morris says, productivity expectations have changed more in training than in actual practice. Doctors are in short supply, and patients need care. But the same regulations that seem to deemphasize volume, including the Affordable Care Act, also mandate that access to care be more universal.

“Some physicians get interested in MIPS [merit-based incentive payment system], thinking that it [and other quality programs] will change everything,” Gerhardt says. “But improved quality won’t replace the need for people who can see more patients. Speed and efficiency are still what makes money in any setting.”

In the simplest terms, productivity-based compensation is pay based on the volume of work a physician does. Volume can be calculated in a variety of ways, which complicates things a bit. But a well-designed productivity incentive program can be a much fairer arrangement for both physicians and employers than a one-salary-fits-all contract.

“Some physicians are risk-averse and just want to know what they’ll be paid,” says Satish Prabhu, M.D., pediatrician and owner of Rainbow Kids Clinic in Clarksville, Tennessee. “But their employers want to share risk.”

Prabhu says productivity-based compensation can be a win-win because physicians can earn more pay by allowing their employers to manage risk. It also helps reward clinicians who face unexpected increases in workload—for example, from an unusually stressful flu season or a colleague’s maternity leave or retirement. This can head off resentments and boost morale.

Productivity-based compensation can also provide more flexibility, Prabhu adds. For example, a physician could take on more work to help with buying a home, paying down debt or planning an extended vacation.

How productivity compensation models work: A brief overview

Compensation is typically structured as a mix of salary and incentives, including bonuses. The salary is the guaranteed portion: the amount you get for showing up to work and completing the basic requirements of your job. Additional incentives are a way for your employer to recognize your work and encourage you to create more value.

Incentives are usually based on some productivity measure, typically calculated based on billable services or actual collections. They can make up a tiny percentage of your overall compensation or as much as 100 percent. The American Medical Association reported in 2016 that an average of 32 percent of physician compensation was tied to personal productivity.

In hospitals, HMOs and other large organizations, productivity is often calculated using work RVUs (wRVUs), a standardized measure of physician effort assigned to each CPT billing code. Andrew Hajde, CMPE, assistant director of association content at MGMA, sees an ongoing trend of larger employers moving away from measuring productivity using revenue and toward an RVU-based approach.

Work RVUs are a fairer way to gauge work and effort,” he says. RVUs track the type of work performed instead of revenue. This frees physicians from worrying about how much a patient’s health plan pays or how effective the billers are. Also, most electronic medical records systems make it easy for physicians to track their own RVUs.

Revenue-based productivity measures encourage proper coding and documentation, too. Employers want to be sure physicians give these administrative tasks sufficient attention, since they determine how much and how quickly your employer will get paid.

Before your search: Empower yourself with information

Productivity compensation could be a part of any job packages you’re offered, and you can’t evaluate these offers unless you understand the terms and know what you’re signing up for. Arm yourself with knowledge to help make sure you’re getting a fair deal.

Start by getting familiar with common productivity benchmarks. For example, many organizations use MGMA compensation and cost survey data to set thresholds for incentives. Accessing the complete survey data requires a subscription, but the association publishes select metrics each year through other channels. Older MGMA data is also available online. Specialty societies often do their own surveys, too. Many make some reports available for free—or at a low cost—to members.

If you’re not yet at ease with CPT coding, you should also study up on billing. It will serve you well in your new job, and it’ll also help you make the most of productivity compensation. Since CPT codes provide the RVU data that often determines productivity, it’s crucial to understand coding relevant to your specialty. That way, you can get an idea of how billing patterns will affect your income.

“Your specialty society and other medical organizations are good places to start,” Morris says. He adds that E/M University can also be a great resource and says that without a solid understanding of CPT coding, you could end up seeing more patients than necessary to meet your RVU goal.

Researching supply and demand can help you gauge how hard it will be to build a panel and reach your productivity goals. There are many online databases to help you calculate how many physicians in your specialty are practicing in your target location and compare those numbers with population trends. As Prabhu points out, it’s much easier to build a high-productivity practice if the patient population is growing and new patients are looking for doctors.

Mike Blaney, M.D., a general surgeon and founder of Live Healthy MD in Augusta, Georgia, adds that your employer’s contracted insurers (a.k.a., payer mix) may also affect your earning potential. “In Beverly Hills, you’ll find 80 percent or more of your patients will have good commercial insurance with excellent reimbursement. But in other parts of the country, your practice might be as much as 50 percent Medicaid,” he says.

Payer mix will directly impact productivity pay that’s tied to net collections. It can also affect how much your employer can afford to pay you in salary. Having a basic understanding of reimbursement economics can help you understand the sort of offers you might get and if there’s room to negotiate more pay for higher productivity.

Ask about key factors that enable productivity

Your own initiative is essential to hitting volume targets, but it’s unlikely you’ll reach your highest levels of productivity without help. One of the first things you should ask an employer is what kind of resources you’ll have. You’ll want to know if your employer plans to invest in marketing your new practice and how much business development you’ll be expected to do on your own.

For specialists, developing a network of referring primary care physicians takes time. Will you be able to rely on overflow from other physicians in the practice to fill your schedule while you make connections in the local community? Will you receive a higher salary while you build your stream of patients—and if so, for how long?

“Some physicians have the personality to go and sing their own praises,” says Blaney. “Others have more farmer than hunter mentality.” It’s important to know what kind of self-promotion you’ll need to do and how you plan to do it, given your personality and skill set. If you’re building a flow of referrals from scratch, you’ll need to know how long the practice expects that to take and if you’ll receive a higher guaranteed salary during that build-up period.

Primary care physicians should ask how many new patients are joining the practice each month and how they’re assigned. If the local market is not growing, how does the practice plan to attract new patients for your panel? The type of patients makes a difference, too. For example, if you’re in an OB/GYN practice where maternity care is the fastest way to earn productivity compensation, you need to make sure there are enough new patients of childbearing age.

Prabhu suggests pediatricians ask how newborns are assigned. Babies have many more check-ups per year than older children, so infant patients can boost a pediatrician’s numbers. Similarly, he adds that a pediatrician taking over for a retiring physician should ask about that doctor’s patient demographics. If many of those patients are teenagers, they may leave a gap in the panel when they move on to an adult primary care practice.

Physicians should also make sure they’ll have enough support staff. Hajde says physicians should ask questions like, “Will I be able to get an extra medical assistant if I’m a high performer? Will I get a scribe?”

Prabhu agrees. His practice was one of the first in Tennessee to be certified as a patient-centered medical home (PCMH). He explains, “We created our own workflow initiative to help our physicians achieve the standards of PCMH and enable them to focus on patient care.” Prabhu says it’s critical to make sure your employer understands how to support you in ways that increase productivity and reduce stress.

Scheduling is an important factor, too, according to Prabhu. He recommends physicians ask about available time slots and whether they’ll have input in setting them.

If you have any doubts about how realistic the productivity expectations are, don’t hesitate to ask for details. Morris says, “A good recruiter should be able to show you the number of patients you need to see to break even and how much you’ll make if you see two or three more than that.” It’s fair to ask for and expect examples of how the practice’s physicians meet their numbers, along with details about their schedules and staff support.

Test assumptions and look for “gotchas”

Once you’re comfortable with the basics of an offer, it’s time to dig into the math. As you do, challenge your assumptions and watch out for “gotchas” in the contract. It’s important to ask detailed questions to make sure you fully understand how you’ll be paid if you accept the job.

In some settings and some specialties, some of your work may not be legally eligible for bonus pay. For example, hospitals can’t incentivize you to recommend procedures they profit from. So if you take on a role as a cardiologist, reading echocardiograms may be excluded from productivity calculations.

“Different settings have different rules,” explains Morris. “In a large group, where the machine is not owned by the group, those readings can count toward productivity. But if you’re employed by the hospital and the hospital owns the machine, they can’t incentivize doctors to do that work.”

Billing processes can determine what counts toward productivity, too. For example, surgeries or maternity care may be billed as a global package. If your job will include maternity check-ups, surgical assists or follow-ups, those activities may be excluded from your productivity calculations.

If you’re inheriting a panel, the practice’s definition of an active patient is also important. “Some practices may consider a patient who hasn’t been seen in 18 months to be inactive, but others might not until it’s been three years,” Prabhu says. As you can imagine, if the panel you inherit includes a significant number of patients who haven’t returned for two or more years, it may not provide you with the volume you need to reach your productivity goals.

If your productivity is calculated based on your practice’s profitability, you’ll also need to pay attention to how overhead is allocated. In a multispecialty practice, the economics may even differ from physician to physician.

Blaney recalls that early in his career, he was bringing in much more revenue from cash-based bariatric surgeries than some colleagues whose patients were primarily on Medicare or Medicaid. Because the cost allocations were based on revenue, he was charged for more of the overhead than he was actually consuming.

“I was bringing in 70 percent of the revenue but was paid only 25 percent of it after overhead,” he says. Luckily, he was able to work out a fairer arrangement with his practice. But not everyone is so lucky. Once you’ve signed a contract, it can be hard to revise the terms, so it’s important to understand how overhead will work upfront, when there’s still time to negotiate.

Get help if you need it

Studying up on productivity arrangements might feel like delving into the business side of things you hoped to avoid by going into medicine. But as Morris advises, you still need to know enough to make sure you’re not getting taken advantage of.

Instead of throwing up your hands in frustration, get help from experts who can fill in the gaps in your knowledge. For example, you can reach out to consulting businesses like Gerhardt’s MedAnalysis Practice Consultants, which he recently started to help physicians compare compensation offers.

Legal advice is also indispensable. “Get a health care attorney—not just a regular business attorney, but a lawyer with experience with health care and physician contracts—to review any contract you’re considering signing,” Morris recommends.

A salary-only deal might seem simpler and safer in the short term, but it likely means leaving money on the table. Plus, there’s really no such thing as a job where productivity isn’t important. Even if you sign a salary-only contract, your employer will still be evaluating the value you bring to the practice. As Hajde explains, “In most cases, physicians do have to grow their business. If they don’t do it, health systems may have to let them go. It’s the reality of being a physician today, the same as any other business.”



Decoding your employment contract

There are few steps more critical in accepting a job than decoding the offer.

By Chris Hinz | Fall 2020 | Feature Articles


“In assessing a position, consider the opportunity it affords for building a successful career to achieve your goals,” says Alicia Arnold, M.D. That includes both professional and personal goals. – Photo by Christy Janeczko

Before you sign any agreement, you want to be confident that you’ve identified a practice opportunity that meets your professional and financial goals while satisfying your personal style and needs. Truth is, there are any number of factors to consider, especially if you’re weighing multiple options.

But you want to make sure that you make the right choice—even if an offer sounds like a lucrative gem. “You shouldn’t be seduced into accepting a job that may be be financially better than another job, but in the big picture is not going to get you where you want to be,” says Franco Fazzalari, M.D., cardiothoracic surgeon at Beaumont Hospital in Royal Oak, Michigan. “It may be a good solution for two years, but in the long run it’s not going to work out and you’ll have to find another job and move on. You really want to avoid that.”

Whether you’re destined for a staff job in a major health system or a partnership track in a private independent practice, it’s critical that you uncover as many particulars as possible not only about the compensation package, but also any other terms that might affect your tenure. And since decoding is all about getting into the business weeds, let’s begin with those financial and other basics that are paramount to understanding offers—and making choices.

Evaluating the financials

“A contract is only as good as the people behind it,” says Jose Avitia, M.D. – Photo by Sweet William Photos & Films

As a new hire, your initial employment contract likely will include a flat or straight base salary tied to your specialty with a possible bonus topper tied to your productivity. Since various payment structures can drive an offer, you need to focus not only on the dollar amounts, but also how they’re derived, especially if they’re anchored in your performance.

If, for instance, there’s an annual bonus, you want to know more than just what you’ll earn and when you’ll see it. How is the amount set and might those metrics change? Your new employer is likely to use one of two production formulations: Relative value units (RVUs), the Medicare measure of value for individual physician services, or net revenue, the profits calculated from actual dollars coming into the practice. But what expectations are tied to the numbers? How many patients must you see per day? What level of RVUs will you need to generate? And what might be asked of you beyond clinical care? You may not get all of the details in your contract or an addendum, even though having everything in writing is certainly preferable. At a minimum, you want to hear a clear explanation as to what might unfold.

Although practices generally make incentives achievable, it’s up to you to find out if they’re really doable. For instance, if the organization has built in a potential bonus based on the success of the department or larger entity, how often do physicians actually receive one? Likewise, if it’s based on your own productivity, how difficult is that to achieve? (And is there any punitive action for failing to meet goals?) If there’s a 15 percent quality bonus, for instance, is the average capture rate 14.5 percent—or 3 percent?

Keep in mind that the shape of your compensation package may very well depend on where you land. For instance, if you’re soon-to-be employed as a staff physician of a major group or medical system, you’ll likely enjoy an initial benefits package that a small independent private practice usually can’t match. What you probably won’t enjoy is the long-term profit-sharing advantages of being a future partner in that independent group. If you’re looking at options in both camps, you clearly want to study the risks versus rewards, particularly of taking a financial step back initially for a potential ownership stake later. “It may or may not be worth it,” says Jon Appino, principal of Contract Diagnostics. “You need to consider all of those things when you’re doing your due diligence.”

When decoding any opportunity, you want to make sure that you target those aspects of the offer that might affect your ability to build your patient base and make or save money as well as pay off debt. How will the practice market your position? Can you work extra to earn extra income? And will you still be able to develop other interests, not to mention a healthy work-life balance?

Alicia Arnold, M.D., and her husband, both radiologists, considered various practice types and parts of the country before making Eau Claire, Wisconsin, home because of the excellent practice environment and reasonable cost of living. The two settled on Medical X-Ray Consultants, a small radiology private practice where her husband is now a partner and she’s been both a full-time and per diem provider. Besides meeting their professional requirements to provide personalized, high quality care, the choice gave her flexibility not only to care for a growing family, but also to convert her interest in public speaking and community health education into a part-time role as a local medical correspondent. Arnold’s advice to others: “Most of us were called to medicine as a lifelong career, not merely a job. In assessing a position, consider the opportunity it affords for building a successful career to achieve your goals.”

Weighing benefits and future plans

When it comes to benefits, you’ll likely see a standard mix including health insurance, vacation time, personal days, a retirement plan, annual raises with cost-of-living adjustments and possibly even parental leave. Even though the package may be cut and dried, make sure that you review the provisions. For instance, depending on how professional liability coverage is structured, you may or may not like the ramifications should you leave the place. So if it’s the one item holding you back from taking the job, see if it’s grist for discussion. “Be prepared to negotiate for what you think is fair and appropriate for your long-term career success,” Arnold says, noting that it may be difficult to renegotiate in the future. “You’re not being a bad team player by asking for a more advantageous contract.”

Continuing Medical Education

Do they value continuing medical education enough that they encourage such pursuits and even include the specifics in your contract? Do they pay for and give you separate time off to pursue it? And what about other efforts that could put a cherry atop your competence—for instance, are there regular patient case conferences? “If there isn’t that kind of teaming and learning going on,” says Brigitta Glick, founder and CEO of San Antonio-based Provenir HealthCare, “then it’s going to be a far less attractive model than others if that’s important to you.”

Restrictive Covenants

Whether you’re employed by a health system or independent practice, your position isn’t guaranteed forever. Besides sporting a typical shelf life of two to five years, initial employment contracts have a standard out clause that says usually within 30, 60 or 90 days either side can call it quits. (In some cases, 180 days, if you’re terminating the relationship.) Your focus, however, should be on the restrictive covenant or non-compete clause. You’ll want to drill down on any parameters—time, distance or other conditions—that might cramp your ability to practice and live should you decide or have to move on. Assume that the practice intends to impose it, especially if administrators don’t want to lose a high-producer to a local entity. “So many folks think, ‘There’s no way they can keep me from practicing in the area,’” says Patrick D. Souter, JD, of Gray Reed Attorneys & Counselors. “Well yes, there is. The employer can be protected just as much as the employee.”

In addition to understanding the clause, you want your own attorney to take a look. He or she may be able to restructure it so that you can practice in the area, perhaps in another direction. “It’s a big consideration if you’re looking at a practice and the restrictive covenant says 50 miles and five years,” says Wanda Parker, physician recruiter at The HealthField Alliance. “That basically means that you’ll be out of business.”

After completing his interventional pain management fellowship in 2017, Travis Bailey, D.O., had two goals in mind. First, unlike many colleagues in his specialty who gravitate toward hospital settings, he wanted to be in private practice. Second, it had to be in or near his hometown of Valdosta, Georgia. When his solo practice merged with another group to form VOA: Spine and Musculoskeletal Institute, Bailey insisted on removing the non-compete clause from an agreement that was otherwise very fair in its salary, bonus potential and benefits that would help him stay ahead of the professional curve.

Today, he’s not only on a path to partnership, but he’s carved out a career that fits him to a “T,” combining clinic hours and pain procedures with general anesthesia stints at two hospital locations. His advice to other physicians? Be assertive. “There are always going to be some changes,” Bailey says. “That’s to be expected. But you shouldn’t be nervous or even scared about asking for them.”

The next phase

Even before signing your employment contracts, you want to make sure that the transition from this package to the next phase is clear. For instance, if you’re getting a base salary with a productivity bonus, does it automatically renew, or will you transition into a different structure? And what does that look like? You need assurances in writing that at a given point, you and your bosses will have a heart-to-heart as to how your compensation and working relationship will change.

As to partnership, although there are far fewer opportunities than in years past, ownerships still exist. If that’s in your future, it merits the same kind of due diligence you’d undertake in buying into any business. Granted, your future employer may not let you review the books or pick apart the financials this early in the game. “That’s a very touchy discussion,” says Parker. Nor will you likely see what Appino calls “granular specifics”—“on this day for this dollar you will be a partner”—in your employment contract. But you have a right to ask for information that will help you (and your accountant or attorney) learn if the practice is financially solid and both capable and serious about offering you a stake.

Also, make sure that they’re willing to commit in writing what you’ve both agreed to verbally. At the very least, you should have a framework as to the formula and track—what will the process look like and what will the buy-in actually entail? Will your participation involve a direct payment, sweat equity, or a lower paycheck over time? Moreover, will you have access to all, some or none of the practice’s long-term investments?

In any case, you don’t want to be blindsided down the road by the price or how it might work. As Fred Horton, president of AMGA Consulting, notes: “Somebody should be able to sit down with you, and say, ‘Here’s an example of how it’s worked in the past.’”

When Jose W. Avitia, M.D., joined Albuquerque-based New Mexico Cancer Center in 2012, he liked what he saw in his initial employment contract. It not only included a reasonable base salary and bonus potential for a beginning oncologist/hematologist, but also a very specific two-year track to partnership. Besides meeting a minimum productivity standard, he’d have to demonstrate that he was a good citizen of the group, treating patients well and fostering strong relationships with referring physicians and the staff. As to the numbers, the buy-in wasn’t a lump sum dollar payment upfront. Instead, his share would be built with time and “sweat equity.”

More importantly, Avitia had a good sense that if he’d meet the benchmarks, senior physicians would follow through on their promises. The group had a structured evaluation process to let him know well in advance that he was on track and, if not, what he needed to do to get there. He also had a sense, from potential colleagues, how the process and ownership track actually worked. “They weren’t going to find some obscure thing that would keep me from being a partner,” he says. “They were very transparent and that was very helpful.”

Assessing your chance of success

Before you accept any offer, you want a sign that the owners or administrators actually have backup to show that you’re a necessary cog in their wheel, whatever your specialty, and that you have a reasonable chance for success. For starters, what’s the basis for the position? Has the organization included it in the business plan or done a recent proforma to calculate the needs and financial benefits of adding someone with your skills?

You have a vested interest in learning if the community is saturated with too many stellar providers or ripe with a real opportunity for you to make a dent by marketing your services and developing referral relationships. Jesse Hackell, M.D., vice president and chief operating officer of Pomona (NY) Pediatrics, notes: “You should be asking, ‘Is there enough business here to support me?’”

Practice support

Indeed, besides learning if the environment is conducive to your brand of medicine, you want a sense that it will be a good incubator for your business. Whether you want a long lifespan or see this as a steppingstone, it’s critical to find out if this is a dynamic workplace or a revolving door. Pay close attention if you’re filling a vacancy created by an exit that’s seemingly part of a trend. You not only want to know how your future colleagues have done in meeting expectations, but that the numbers are attainable for you. “You want to make sure that you’re not stepping into a practice where they recruited five physicians,” says Horton, “and they’re all gone because they didn’t build a practice in time.”

Avitia was confident that he was dealing with a solidly established practice that not only included potential mentors who had been there for 10 or 20 years, but also younger physicians who were experiencing what he hoped to experience. As a partner since 2014, he’s been more than satisfied with his choice. “A contract is only as good as the people behind it,” Avitia says. “If they treat their patients with respect and dignity, then they’re going to treat their employees, partnerships and other relationships in the same manner.”

Final thoughts

In decoding any offer, make sure to keep a perspective. Just because you’re looking at a lot of money doesn’t mean it’s a good job any more than it’s a bad job just because it’s not a lot of money. Likewise, a perfectly written contract with little risk to you still might mask what could be a nightmare working situation. You may have to walk away even after negotiating everything you wanted.

Conversely, if the first draft of the agreement puts all of the risk in your court, that doesn’t mean the employer is unwilling to work out the kinks. Maybe an otherwise great practice just hasn’t been in the business of hiring recently and needs a friendly reminder as to what’s fair.

Whatever the case, when in doubt, tap your common sense. For most physicians, it’s a pretty solid GPS. Whether your antenna is telling you that this a great place with honest physicians just like you or you’re feeling an entirely different vibe, listen to your heart and act with your head. “Physicians have good gut instincts,” Appino says. “They should trust them.”



Ready, set, visit

How to turn a site visit into the ultimate fact-finding mission.

By Debbie Swanson | Feature Articles | Summer 2020


“Don’t just focus on the organization wanting to hire you,” says Mark Anderson, M.D. “Be sure it’s a place you want to work.” – Photo by Michael Comulada

Just like touring colleges and universities, visiting employers is one of the best ways to evaluate your options. Of course, COVID-19 put some of those on hold; but in-person visits are sure to regain their importance. And when they do, plan for several days of interviews, meetings and extras, such as tours, meals or social gatherings. You’ll meet potential supervisors and coworkers, and you’ll have a chance to picture your future at a new place.

If things go well, you’ll finish each visit with a clearer idea of whether or not an employer is a good fit. That means you’ll be prepared to make a decision if and when you receive a letter of intent. But a successful visit depends on proper preparation. Follow these tips to make sure you get the most out of your time.

Phase one: Soak up information

The first step begins at home. Invest time researching the prospective employer, the region and the individuals you’ll be meeting. This will not only help you formulate your own opinion of the place, but also help you come across as a serious and committed applicant. The more you know about the employer, the more invested you’ll appear.

Study up on the employer

You probably have some preliminary knowledge about the organization you’re visiting, but now it’s time to learn even more. Go beyond basic facts about the practice and location. Instead, try to understand their mission, philosophy and outlook. After all, until you know what they stand for, you can’t really be sure you want to work there.

Some steps to take:

  • Review the organization’s website. Read staff bios (especially those of the people on your agenda), press releases, company history and philosophy, and anything else you find interesting.
  • Ask your recruiter for marketing material. While this information will all be framed in a positive light, it’s useful for understanding the image an organization wants to present.
  • Explore their social media presence to learn more about day-to-day affairs. See what’s being said about them.
  • Tap into your network to see if you know anyone with a connection who can tell you more via phone or email. Your professional associations or alumni organizations may be able to help.
  • “See [what] awards the organization may have been given, like best place to work or outstanding hospital or practice,” suggests J. Mark Anderson, M.D., founding partner at Executive Medicine of Texas. He adds that you should also pay attention to community ratings and reputation. “Is this place respected within a community? You can improve or devalue your future résumé by working there,” he says.
  • Take notes as you go. Everything you learn is valuable as you assess an employer. It’s also fodder for small talk during downtime on your visit.

Investigate the location

It’s likely you’ll be considering positions in a variety of locations, both familiar and unfamiliar. Local issues are often overlooked in the job search, but they can be a major factor in finding the right fit. For example, if you discover a great job in a bustling city, but the school system and crime rate aren’t ideal for raising your young kids, maybe that job isn’t so great after all.

Start by getting a clear idea of the factors that matter to you and your family, then rank the priority of each. Next, gather information about local demographics, crime rates, recreational opportunities, school systems, senior care, transportation/walkability, cost of living, etc. As you’re working, create a list of places worth visiting in person, such as places of worship, schools, recreational facilities and more.

If your spouse or significant other plans to accompany you, create a plan to make the most of the trip. Much of your time and energy will be occupied by meetings and interviews, so your companion can work through your list of places to explore or set up meetings with realtors, schools or job recruiters.

Remember to maintain an open mindset when it comes to regions, says Daniel Paull, M.D., founder and CEO of Easy Orthopedics in Colorado Springs, Colorado. Paull himself attended college in New York and medical school in Miami, so when he started looking at residencies, the Midwest wasn’t on his radar. However, he says, “When I interviewed for residency at the University of Toledo, I saw that all of the residents seemed happy.” On top of that, he discovered that Toledo had a low cost of living, very little traffic and friendly people. He never thought he’d end up there, but it turned out to be the perfect fit. That’s why he suggests: “Be flexible. Be ready to go anywhere.”

Confirm your arrangements

If you’re coming from a distance, discuss travel arrangements with your prospective employer ahead of time. Usually, your recruiter or contact person will arrange the flights, lodging and other transportation details, but don’t make assumptions. Some organizations expect you to take care of these things yourself.

Be sure to clarify:

  • Who is responsible for making your travel arrangements
  • What expenses are covered, such as flights, ground transportation or meals
  • Any monetary limits you should adhere to
  • What documentation you’ll need to provide for reimbursement and when to submit it
  • Whether you’ll have downtime in your agenda to explore the area or need to arrange that time on your own
  • Which events your travel companion (if you have one) is invited to, such as dinners or meetings with other spouses or families

It’s also wise to let your recruiter know as early as possible of any dietary needs or special requests. For example, if you want to meet with a realtor or your spouse wants to meet with a recruiter in his or her field, your contact person might be able to help.

As with any trip, you’ll need to make some arrangements on your own. Don’t forget to find a pet sitter, babysitter or anything else you need ahead of time so you won’t have any distractions while you are away.

Review your agenda

Your agenda should arrive well before your visit. Even if you’re busy with your residency program or other responsibilities, don’t wait to review it at the last minute. You might have questions you need to address with your recruiter ahead of time.

Make sure you know:

  • The location and length of any meetings on your schedule, as well as the name and contact info of the person you’re supposed to be meeting
  • The dress code for non-interview events
  • How to pronounce any difficult names listed on your schedule

The earlier you can get these details sorted out, the better. But as the date grows near, don’t forget to confirm that nothing has changed. Stay flexible if the times, locations or people on your agenda get switched around.

Daniel Paull, M.D., ended up in the Midwest for residency—a location he hadn’t expected. “Be flexible.
Be ready to go anywhere,” he says. – Photo by Brian Kwan

Get your answers ready

It’s impossible to anticipate exactly what you’ll be asked over the course of your interviews, but you can brush up on typical topics. If you don’t already have a list of common interview questions, reach out to your medical school’s career or alumni center. Remember to ask about any other information they have on best practices for interviews.

Some typical interview questions include:

  • Why did you choose this organization/region/specialty?
  • What motivates you as a physician?
  • Where do you hope to go with your career?
  • Do you have any specific jobs or experiences that shaped who you are today?
  • What special skills would you bring to this job? What do you hope to gain from it?

Spend some time formulating answers to these questions—and any others you think you might be asked. The more you practice, the more natural your responses will be. Try to bring in specific examples from your own experiences whenever possible. This creates a more memorable impression.

You should also be ready to discuss the items on your CV. Review it before the meeting to refresh your memory of all the dates, places, names and details you have listed.

Get your questions ready

You aren’t just evaluated on your answers. Interviewers also expect you to ask good questions. The more specific to the position and organization, the better. Avoid very general inquiries or any questions you could easily answer by checking their website. And save questions about benefits or compensation for later in the process.

A few great questions to ask include:

  • Who would I report to?
  • What goals would I be expected to achieve?
  • What is the organization’s plans for growth?
  • Besides clinical work, what other obligations will I be expected to meet?

“It’s also OK to ask how your performance will be assessed and what key performance indicators they usually use for physicians,” says Walter Gaman, M.D., a founder and chairman of the board at Healthcare Associates of Texas.

Phase two: It’s showtime

When the day arrives and your site visit begins, things tend to move quickly. Your planning and research will come in handy. Knowing where you need to be, who you’ll be meeting and how you’ll be getting around will raise your confidence and counteract interview jitters.

A good mindset to have is that you want to make a good impression on everyone you meet, from the person who meets you at the airport to the server at dinner and even other hotel guests. You never know who knows whom or who might report back on your behavior.

“Plan to stay in interview mode from the time you arrive until you return to the airport,” recommends Paull.

The nuts and bolts: Interviews

Interviews and meetings are the main reason for your visit, so you want to create a strong, positive impression. Plan to arrive to each appointment early. If you end up waiting, use the time to review your notes, do some valuable people watching or mentally prepare yourself. Greet everyone in the room with a firm handshake and steady eye contact, and split your time between listening and talking. Distribute your attention evenly among everyone involved. Be careful not to overlook anyone. And make sure to learn and note everyone’s names so you can follow up with questions and thank-you notes.

The important extras: Social events

A typical visit also includes informal activities. Expect to find a group meal, campus tour, local sightseeing or some other outing on your agenda. These events are an opportunity to meet and assess your potential colleagues, and they also help your interviewers evaluate how you might fit in with the group.

“There’s almost always a dinner, which is a good way to get a feel for things,” Paull says. “You can often bring your spouse or significant other, but if you aren’t sure, ask your organizer.” Even though these events are informal, you shouldn’t drop your professional demeanor. “I’ve seen situations where people drink too much, or [get carried away] dancing. That never goes well,” warns Paull.

And while a social event usually doesn’t warrant wearing a full suit, you should still lean toward a professional look. “If they say casual, make it more business casual,” explains Gaman, adding that if you have tattoos, it’s best to cover them up. When in doubt, err on the conservative side.

Remember that these events serve two purposes. You’re not just showing a prospective employer your personality; you’re also gaining valuable insights about their culture. Watch what goes on around you and trust your natural reactions. “People who are genuinely kind are kind to everyone. On the contrary, if the interviewee or interviewer is rude to the staff, that’s a potential red flag,” says Anderson. “Social gatherings are a great place for both parties to observe the other.”

And in your free time…

You’re likely to stay busy during your site visit, but don’t let that stop you from poking around on your own. For starters, talk to as many people as you can. Residents can be a good measure of an organization, according to Paull. “Would they do this program again?” he suggests asking. “They may not tell you directly, but you can probably get an idea by the way they answer you. Follow their cues. Probe a bit deeper. Make note of any strange or reluctant responses.”

You can also learn a lot from careful observation. “Pay attention to how the administration interacts with the staff and other physicians. If they smile at each other and greet each other warmly, that’s a good sign. It’s all about the body language. It will tell you what you can’t ask,” adds Gaman.

Finally, do as much exploring as you can. Take a brief walk between meetings, visit the cafeteria and gym, and accept any invitations that appeal to you. The more exposure you can get to people and places, the better you’ll understand the environment.

Phase three: Return and reflect

After a few packed days of meetings, you’ll need a breather to pause and digest the experience. While the experience is still fresh in your mind, review any materials you picked up, transcribe your notes and jot down pros and cons. If a companion traveled with you, review their notes and listen to their impressions. You may find it helpful to create a spreadsheet of relevant factors, especially if you are exploring multiple opportunities.

Get your final paperwork out of the way early. Send thank-you notes promptly, and follow up with the contacts you made. If you’ve got any outstanding questions, send them to the recruiter right away.

A site visit can be exhausting, but if you’ve planned it out, you’ll leave with the information you need to make a decision. Do your research before the visit, then make the most of the time you’re there. Give yourself time to process everything you saw, heard and felt. When it’s all over, you’ll have a better sense of whether or not you want to accept an offer.

And remember, every interview is a two-way street. It’s not just about securing a job offer. It’s about finding the right job for you.

Debbie Swanson is a frequent contributor to PracticeLink Magazine.



What shapes your search?

Build enough time into your job hunt to fully evaluate the parts most important to you.

By Therese Karsten | Feature Articles | Summer 2020


Just like there’s no one way to interview, there’s also no one timeline that fits every physician’s job search. The search for a neurosurgeon physician couple looking nationally is completely different than that of a single family medicine resident wanting to stay in the community where she’s training. So let’s take a look at a few factors that can help you understand your own job-search timeline.

Know that different markets and specialties have different recruitment cycles

Finding a job depends on finding an employer who is looking for someone with your credentials to start at a time that meets your timeframe. Physician recruiters have both planned recruitment cycles —new positions posted due to the addition of a new site, growth at a current practice or backfilling a retiring physician—and unplanned to fill an immediate need from a physician leaving either voluntarily or otherwise.

Although the biggest interview visit surge for planned recruitment initiatives is in the winter to meet late summer/early fall start dates, know that subspecialists tend to start interviewing as much as 18 to 24 months before desired start date. The most desirable candidates are signing contracts a full year before their intended start date.

Get your CV ready

At least a year before you complete training, have your CV updated, critiqued and proofread by faculty and resources. Sara Lehman is the GME liaison for HCA Healthcare in West Florida. She is the career resource for more than 600 residents in nine programs and helps them with every phase of the job search.

She advises her residents to have their CVs done 12 to 14 months before they complete training, and to build in time for inevitable rotational struggles when there will be zero time to work on your job search.

Contact prospective employers early

Many times, residents delay their job search because they know physicians who didn’t start looking until spring and had no problem starting work a couple of months later.

“Residents who delay often do so because they don’t know there are logistical differences between their friend’s local hospitalist job and an outpatient job in another state,” Lehman says. “Licensure lead time, hospital credentialing and payer enrollment take several months, so the employer for that perfectly amazing job in Idaho started interviewing candidates in late fall and made an offer in January.”

The resident who waits until spring to start searching for a job misses that train entirely. “He or she is in my office, panicking because advertised jobs are moving forward with others who already interviewed,” she says. “Undoubtedly, there are more doors open to residents who start the job search early.”

At least a year before you complete training, contact the physician recruiters listed on some jobs that interest you. Ask them when you should start applying in that market, and for any tips to help you navigate that employer or region.

For example, recruiters in Denver and other in-demand cities like Austin, San Diego and Seattle advise candidates in highly competitive specialties not to wait for an interview invitation if they are 100 percent committed to the location.

They might suggest planning a trip at your own expense, and let practices know three to four weeks in advance that you will be in town. Usually, you will get at least a meeting, which may turn into a full-blown interview. Every year, we see candidates who present well in person “jump the line” and end up with job offers while a chief resident from a bigger-name program is still waiting for somebody to offer to pay for travel.

Beating the “why doesn’t she have a job yet?” perception

Employers suspect a resident or fellow is still on the job market in the spring because they are not receiving or closing job offers. Perhaps references are lukewarm or would-be employers backed away.

When you approach an employer in mid-spring, answer their unasked question in your cover letter or initial interview call.

If you were waiting to see where your significant other matched in fellowship, tell us. If every free weekend you traveled to the bedside of a terminally ill parent, tell us. If you just broke off an engagement and are now free to look in your dream location, explain that. Those are all reasonable explanations for being late. Some faculty advise withholding personal information on the basis that employers are only entitled to know that you are now available. That is true…but none of the possible explanations going through the employers’ minds are flattering to you. Transparency on your part can motivate a recruiter to advocate for you. Put a recruiter’s concerns to rest so they can make sure you are not overlooked.

Remember, some searches march to their own beat

Some large groups have very defined recruitment cycles designed to synch with their next year’s staffing projections, budgets and practice nuances.

One year I was helping a huge anesthesia group staff for the opening of a new hospital. We needed 13 hires to be ready to staff ORs and OB deck. Interviews started in September and ran through November. All of the other major groups in the market were on the same cycle, so it was no surprise to anesthesia residents and fellows to hear that regardless of interview date, offers would go out in December, once the partners had met all of the candidates. Offerees would have a two-week deadline to sign the letter of intent.

I remember the disbelief in the voice of a chief resident from a top-tier program who called me in February after his first-choice contract negotiations fell through. “I’m sorry,” I told him. “We have offers out for all of the positions and unless we have a turndown, the committee is electing not to conduct further interviews.” Was it shortsighted to not look at an exceptional candidate off-cycle? Maybe, but their process worked. It was not going to change unless they could no longer fill open spots with quality physicians.

The J-1 visa waiver cycle drives the recruitment timeline for Wesley Neurology Associates in Wichita, Kansas. Mohammed Hussain, M.D., a vascular and interventional neurologist, explains why his group starts interviewing neurohospitalist candidates 18 months before their anticipated start date.

“The state gives out J-1 visa waivers on a rolling basis starting the day the window opens on September 1,” he says. “In order to make sure that we get a J-1 waiver, our immigration attorney asks that her firm receive CVs and PDFs of the signed contracts by August so that she has time to prepare the waiver applications for submission the first week the window opens.”

Every year, the hospital has declined some highly qualified applicants because it is simply too late in the J-1 cycle to interview, offer and execute a contract in time to be sure of receiving the waiver.

Everything takes longer than you think

I see wide-eyed concern and occasionally deer-in-the-headlights panic when I tell a room full of last-year-of-training residents that they should have their first round of interviews by November.

Why so early? Every step prior to seeing your first patient in the new job takes longer than candidates expect. It can take days—even weeks—to get through initial email and telephone or Skype screening steps. Physicians, practice managers and administrators all have to agree that you are a likely fit with the position and the timing is right to bring you in for a visit.

Once we get to “yes” for the site visit, we have to find a date that works for everyone. Based on my Outlook e-chains, it can take anywhere from four to 32 emails to lock in a date for candidates to interview. Be patient and responsive.

To help move along site visit planning, check your schedule and have two or three possible dates in mind for a site visit. Think twice before you request a weekend or date adjacent to a holiday. And don’t offer a date you haven’t checked. Scheduling gaffes do tarnish your halo.

Before you take just one more interview…

Even the best-laid plans to be done with interviews by Christmas and under contract by St. Patrick’s Day can be derailed when Mother Nature shuts down airports with Snowmageddon. The one delay under your control is decision paralysis.

Once you have looked at several good job options and have a fair offer in a location where you and your family can thrive, resist the temptation to keep accepting interviews “just in case” the perfect job is out there. Too often, perfectionism backfires. A great offer might get rescinded because you can’t commit.

Contracting concerns

The first bumps and bruises in any new employer/employee relationship often happen after you have agreed on the major terms and before you execute the contract. You’ve agreed on salary, sign-on bonus and RVU rate…so what could go wrong?

If the practice hasn’t recruited in a few years, they may be waiting on their attorney to produce their draft. A hospital system may still need to obtain approvals if the position was not budgeted. A change in salary, an increased sign-on bonus, more PTO or CME or a new start date all have significant impact on the financial picture and must go through another round of approvals.

On your side of the table, your attorney could derail the ideal timeline. Line up your attorney in advance, and give them an estimated timeline for your contract review. Do your own research to know what your peers are seeing for RVU, PTO, CME. Read the contract thoroughly, and give your attorney a list of your questions and your thoughts. If you received instructions from your employer about negotiability, be sure to relay instructions to your attorney. Many corporate physician contracts are locked-down corporate templates, and nothing except what was filled in the blanks will change.

Once you and an employer agree to move forward to contract, a complex process kicks into gear. By the time you are ready to sign, there may have been as many as 20 professionals from recruitment, legal, operations, contract administration and finance certifying that there are no improper elements in the contract being offered to you. Anytime you have that many people involved in a process, there can be delays.

Licensing and credentialing

Obtaining a medical license takes on average three months, though it can take just six weeks for a graduating resident in many states. It can take up to seven months for physicians with practice histories or any hiccup in their records. Your licensure may be tabled with requests for more information if:

  • Your residency or fellowship was not accredited during part of your training
  • Your medical school was not accredited for any portion of your four years
  • Your residency training was outside the U.S.
  • Your residency or fellowship had any periods of probation or remedial repeat of rotations

The credentialing team can prepare for their 90 to 100-day sprint while your licensure is pending, but nothing can officially move forward until you have your state licensure. Similarly, payers will not move on the process of adding you as a provider for their health plan members until you are licensed.

Physician couples need to start earlier

As a rule, a physician couple should be at least a couple of months ahead of their classmates on the job search. This is especially true if one of you is either super-subspecialized, or in a highly competitive or highly saturated specialty for the cities in which you want to live.

Hal Anderson, M.D., contacted me about 18 months before he was scheduled to complete emergency medicine residency. His wife would be ready to start practicing family medicine the same month.

Anderson explained that his wife’s family medicine job search may look “easier” on the surface because of the number of options, but the couple will have to balance their commute times and make sure they could move to family neighborhoods in great school districts without career disruption.

“Bottom line,” he says, “we have to start early because we have to talk to more potential employers to find the two very best jobs that are geographically compatible, where we can grow professionally and start paying down our education debt.”

Physician specialists need the most time to carve out a two-physician relocation. Christina Wright, M.D., and James Wright, M.D., contacted practices a full two and half years before they will complete neurosurgery residency at Case Western Reserve and fellowships in complex spine surgery at the Cleveland Clinic.

“We know that few hospitals recruit two physicians in the same specialty, let alone the same subspecialty, in the same recruitment cycle—so we started early,” explains Christina Wright.

“Reaching out early allowed us to identify programs that might be interested,” says James Wright. “We were particularly looking for hospitals or systems with multi-year strategic plans for development in our specialty. Those facilities were very happy to talk to us this far in advance. …Several practices expressed that it might be possible to make adjustments in future hiring plans to accommodate us both.”

Don’t be late to the table

If you start late, hospitals and groups will flag your file for urgent or expedited handling, pay extra fees and generally move heaven and earth to get a good physician into a great job. The back flips stop, though, when it comes to negotiating for extras and flexibility that might have been on the table six months earlier.

“I had one candidate who kept asking for the stipend we offer to candidates who sign early in fellowship,” says one Florida physician recruiter. The surgeon was negotiating his contract when he had two days left in his fellowship. “It’s not happening” she told him. “That is something on the table for candidates who are willing to commit to us early and who allow us plenty of time.”

At the end of this process, you will have a good job! If you start early to allow for delays and setbacks, you will enjoy the process a lot more and show up relaxed and excited for that magical first day of your new job.

Therese Karsten is the division director for physician recruitment for the Continental Division of HCA Healthcare.



Bore no more!

How to keep your interviewer engaged.

By Marcia Horn Noyes | Feature Articles | Summer 2020


Sending a written thank-you note is a great way to stand out after an interview, says Nicholas Jones, M.D. – Photo by Kris Janovitz

By the time you reach residency, you’ve done your fair share of interviews—first for colleges, then for med schools and once again for residency programs. As your job hunt begins, you may dread the prospect of enduring even more. After all, once you’ve done a few interviews, they all start to seem the same—especially if they happen virtually. Interviewers ask questions you’ve heard a million times before, and you find yourself giving the same answers over and over.

If it feels that way to you, imagine what it’s like on the other side of the table. Physician recruiters and other hiring managers have to sit through even more interviews than candidates do—season after season, year after year. So when they hear rehearsed answers from candidates, it’s only natural that their eyes glaze over and they tune out. If you want to make a good impression, it’s essential that you stand out with thoughtful, authentic answers.

So how do you avoid dull conversations and formulaic responses on the interview trail? Read on to hear tips from three seasoned physicians who know what it’s like not just as interviewees but also as interviewers.

Study up on interview skills

For most physicians, med school and residency involve virtually no training on the job search or the business side of medicine. That leaves a gaping hole in an otherwise exhaustive education, and it makes many physicians feel unprepared. From billing, human resources and marketing to salary negotiations and navigating interviews, there are all kinds of topics physicians entering today’s workforce have to figure out on their own.

That’s why Atlanta-based plastic surgeon Nicholas I. Jones, M.D., says doctors have to prepare for interviews outside of their residency training. “Physicians are so focused on learning how to operate and take care of patients that we don’t spend time doing anything but that,” says Jones. “If you do pick up those skills, it’s because you actually sought them out on your own.”

Travis Ulmer, M.D., an emergency medicine physician and the chief clinical recruiting officer for US Acute Care Solutions, agrees with this assessment. He says traditional medical training leaves little time to work on one’s overall career skills. As a result, he finds that most of the applicants he interviews are apprehensive about being themselves.

“They tend to stick to more robotic and canned answers,” says Ulmer. But he’s optimistic about bridging the skills gap, explaining, “Getting additional interviewing practice through the use of mock interviews or talking to residency training mentors—especially the ones that interview new doctors—can go a long way.”

In 2007, Ulmer completed his emergency medicine residency at Ohio State University Hospital, where he served as chief resident. He says he had to rely on natural instinct and wing it when he interviewed for his first position. He readily admits that he could have presented himself better than he did back then. “The internet and YouTube had not gotten to where [they are] today,” he says. “More resources exist now to help people with many aspects of interviewing.”

Top five interviewing questions

Every interview is different, as is every interviewer. But a standard set of questions is pretty common. No matter what kind of practice you’re looking at, what job you’re applying for or if the interview is virtual or in person, you can bet some of these questions will be asked:

  • Who are you? Tell me about yourself.
  • Why are you interested in this practice?
  • Where do you see yourself in five or 10 years?
  • What are your greatest strengths?
  • What are some of your weaknesses?

Now that he’s on the other side of the interview table, Jones says he views the standard questions with a grain of salt. “Those questions facilitate answers that are definitely rehearsed,” he says. “When I interview people, I like authenticity.” As a result, Jones doesn’t pay as much attention to cliché answers, but says the questions are still part of the interview ritual. And though a standard answer may not impress him, he does take note if he gets the sense that an applicant isn’t being genuine in his or her answers.

By preparing for these five questions, you’ll start out calm, confident and composed. That will help you even when the interview transitions to more difficult questions. And if you come prepared, you’ll be less likely to give lackluster responses that make your interviewer’s eyes glaze over.

“Getting additional interviewing practice through the use of mock interviews or talking to residency training mentors…can go a long way,” says Travis Ulmer, M.D. – Photo by Simon Yao

Avoiding cringe-worthy responses

You want to wow hiring managers with your wit, experience and charm. But that’s a lot more difficult if you consult the internet for the so-called right answers instead of using self-awareness to find an original response. Dig deep to find out what truly makes you shine, then base your answers around that. But as you’re doing so, be careful you don’t seem too candid—or worse, unprofessional.

For example, Ulmer says new physicians often make the mistake of thinking that everything will change after they leave residency. For example, some think they’ll no longer have to deal with certain types of presentations or populations. But Ulmer says difficult patients exist in every practice and in every environment.

“It’s a big red flag to hear an ER physician say they hate drug-seekers or taking care of patients who should be treated at lower levels, like urgent care,” he says. “This idea of a perfect patient population is unrealistic and stands out to me as something that is going to be a problem down the line.”

What are your strengths and weaknesses?

Ulmer says candidates open up about their strengths and interests, but they often shy away from discussing their weaknesses. Instead of speaking candidly, they try to answer the question as positively as they can. However, Ulmer warns, “There’s only so many ways to do so without drawing some type of attention to yourself.”

Giving a good response when an interviewer asks about your weaknesses requires self-awareness. It’s better to explain what you’re working on than to act as if you have no flaws. Ulmer explains, “We all know that we are not perfect clinicians. It’s a continuous journey toward that your whole career. I appreciate the younger clinicians that are aware of their weaknesses, aren’t afraid to admit them and show interest in getting better.” In his opinion, only physicians who acknowledge their shortcomings can start working on them.

Jones says he encounters the most cliché responses when he asks about weaknesses. The worst offenders include: “I don’t know how to tell people no,” and “I’m a perfectionist and work too hard.” Saying that you don’t have—or can’t think of—any weaknesses is also cringe-worthy. That type of response indicates a serious lack of personal insight.

Tell me about yourself

This icebreaker question from hiring managers can trip up interviewing newbies. Some applicants launch into long soliloquys about their life stories. If you spend too long answering this question, you’ll use up a good portion of the interview slot talking about your personal life instead of your qualifications.

The best response to this question is an elevator pitch. Craft a succinct, informative answer that describes you in a nutshell. If you need inspiration, look at the way entrepreneurs describe their startups. Think of it as a persuasive brief to pique an employer’s interest. Then move on to the rest of the interview, so you can highlight your medical skills and experience.

Why are you interested in this practice?

Employers almost always ask this question, so you should carefully consider your answer ahead of time. A good response not only requires extensive background research on the practice and its staff but also self-reflection. You should be able to articulate how the position aligns with your skillset and personality.

Jones recognizes that new physicians often have limited information about the practice before the interview. If that’s the case, he says honesty is the best policy. If you don’t have a specific response, it’s OK to say something like: “I just really wanted to come back home, and of all the practices that I researched, you had an opening. I went to your website, saw some of your pictures, talked to some of my colleagues, and it seems like a good fit for me for these reasons.”

Clive Fields, M.D., co-founder and chief medical officer of VillageMD, says he uses this question to make sure the doctors he hires have the same priorities as his organization. “I want to hear about a physician’s commitment to practice and live in the communities that we serve,” explains Fields. Since VillageMD emphasizes community building, he wants doctors who will get to know everyone from the cashiers at local grocery stores to the chiefs at local fire stations.

For example, if a candidate wants to live on the north side of town because it has good elementary schools, Fields says that’s a sign it’s not a good fit. The office is 40 miles away on the south side. “Doctors may say they won’t complain about the commute, but they will complain because it is the wrong place for them to be,” he says.

A compelling answer to this question can move you to the top of an employer’s list. But if you don’t have a good answer ready, it can be the kiss of death. After all, if you don’t know why you want to work somewhere, the employer doesn’t really have a good reason to hire you. Spend some time before each interview evaluating why it’s a good fit. That way, you’ll be ready to articulate a clear answer.

Where do you see yourself in five or 10 years?

Yes, this question has been done to death, but it’s essential for helping managers hire candidates who match what they’re looking for. An honest answer may not always land you the job, but it will almost certainly prevent years of unhappiness if you’re not a good fit.

Jones illustrates this exact point with two hypothetical scenarios: “Let’s say I work for a practice [that is] basically looking for low-paid interns for a hospital contract that pays the practice X amount of dollars to provide hospital coverage.” These types of practices, he says, don’t expect you to grow a patient panel or do any of the cases. They simply need physicians to fill some shoes and may not be as worried about retention. “If that’s the case, and someone says that in five years they want to have their own practice, then they may actually be a great fit,” he explains.

If, on the other hand, the practice wants to eliminate high turnover rates, someone who plans to settle down might be a better option. “If someone says that in five years they and their spouse want to settle down in the area and start a family, that sounds like a much better fit than the physician who says that in 10 years he wants to become this reality TV host doctor with his own show that earmarks him as the plastic surgeon of Atlanta,” Jones explains.

Curveball questions

In other industries, interviews sometimes involve oddball questions to test critical thinking skills, problem-solving and working style. Managers lob questions like “What’s your superpower?” and “If you were an animal, which would you be?” or ask employees to tackle puzzles and challenges. For the most part, medical interviewers steer clear of this rigmarole. Instead, they tend to gauge candidates’ clinical decision-making skills with scenario-based questions.

Still, physician candidates may encounter one or two off-the-wall questions along the way. Refrain from rolling your eyes or putting up a protest. Instead, play along as best you can. There are no right or wrong answers. These questions simply exist to give hiring managers information about how you approach difficult, unexpected or high-pressure situations.

Ending with a firm footing

At the end of almost every interview, you’ll be asked if you have any questions. You might want to ask about salary, vacation, 401(k) matching and insurance coverage, but you’re better off using this time to show you understand what the practice needs and how it fits into the broader health care industry. You can do just that by:

Confirming that your skillset is a good match for the organization. You can gain valuable information by addressing some of your limitations and seeing how an employer responds. For example, you might say something along the lines of: “I did my training in a private institution and didn’t get much experience in some of the procedures you do regularly here. I’m really interested in how you will help me fill that gap.”

Displaying your intellectual curiosity. Fields says he looks for candidates who ask real questions. He wants to know that a physician understands what big shifts in the medicine landscape mean on a day-to-day level at practices like his. He says well-read physicians want to learn about things like chronic care management programs, transitions of care and other coding support around clinical documentation and quality measures.

Exhibiting your commitment to the practice’s goals and mission. An interview isn’t just about your skillset. Your outlook and personal mission are also important. Show employers what you care about by asking questions like: “What kind of reputation are you trying to develop in the community?” and “How can I contribute to that effort?”

“We are looking for physicians that are asking those kinds of questions and when they do, it shows a certain amount of preparation for the organization for which they are interviewing,” explains Fields. “Culturally, the kind of intellectual curiosity that we would like to see from our young doctors shows us that ultimately they are on target for becoming our old doctors and will lead our practice in the future.”

How to deliver your answers

Saying the right things is only part of the equation. Your delivery and demeanor also matter. Jones, Ulmer and Fields all agree that once you have your responses down pat, it’s time to double check the five basics of physician interviews:

  1. Maintain eye contact
  2. Project appropriate body language
  3. Be articulate and specific
  4. Project confidence
  5. Dress appropriately

After the interview, Jones says there’s one more essential step. Send handwritten thank you notes to each and every person you spoke with. These should be written with pen and paper. “It goes way further than any email,” he says. “If you send me an email, I may not even read it. However, if you send me a handwritten note, I think, ‘This person really wants this job.’”

Marcia Horn Noyes is a frequent contributor to PracticeLink Magazine. She is a former television news reporter, newspaper and magazine journalist. She writes about health, fitness, career and frugality.



Where to practice?

A look at the most common models that physicians encounter in the job search.

By Debbie Swanson | Feature Articles | Spring 2020


“There is no one-size-fits-all job coming out of residency,” says Carlene MacMillan, M.D. “Getting too caught up on finding the perfect job can mean losing opportunities to learn about different systems of practice.” - Photo by Jakub Redziniak

“There is no one-size-fits-all job coming out of residency,” says Carlene MacMillan, M.D. “Getting too caught up on finding the perfect job can mean losing opportunities to learn about different systems of practice.” – Photo by Jakub Redziniak

During the job search, there’s plenty to focus on: growth opportunities, patient profiles, salary, benefits and geographic location, to name a few. But before you think about any of those details, you need to figure out what employment model best suits you. From a Level I trauma center to a small specialized practice to a varied group practice, there are many settings in which to practice medicine. Each comes with its pros and cons.

Considering your ideal employer will make your search more efficient. You can weed out places that aren’t a good fit and focus on the ones that are. That means you’ll be more likely to end up in a job you love and avoid having to do the search all over again in a few years. This summary of the popular employment models will help you get started.

Hanging up your shingle: private practice

Striking out on your own is a time-honored vision of being a doctor. Though its popularity has declined in the past few decades, going solo can still be attractive. In a 2018 survey, the Physicians Foundation reported that the number of physicians in solo practice had risen just slightly from 2016 to 2018, but the overall number was still smaller than it was in 2012.

The advantages of going solo are many. Without partners or a management team, you have autonomy over how you run your practice. You also have the flexibility of setting your own schedule, which can be appealing if you have a young family or another enterprise on the side. There’s also more flexibility over income. After covering overhead and expenses, the remaining revenue is yours to use as you see fit.

Many solo practitioners enjoy getting to wear many hats. In addition to clinical practice, you’re the decision-maker for all aspects of running the business—from budgeting and choosing equipment and supplies to training new employees and marketing. How you split your time is up to you, and you can hire staff to oversee the segments of business that aren’t your strong suit.

“Private practice, as I presently maintain, is often more financially rewarding. It affords the freedom to set [your own] schedule but often comes with additional stresses of becoming a small business owner,” says Michael Sinel, M.D., who now runs a solo practice after having worked in both a hospital and a multispecialty clinic.

Going solo certainly has its disadvantages. Your practice may not be as appealing to insurance carriers, who set their sights on bigger fish. You won’t have the advantage of strolling down the hall to collaborate with a colleague. And when it comes to divvying up call hours or planning time off, no alternate physicians are readily available. Balance can also be an issue. Because the solo physician juggles so many responsibilities, carving out consistent non-working hours can be a challenge.

Excitement and variety: hospital employment

Hospitals are a popular choice among physicians, and that popularity is rising. As of early 2018, the number of physicians employed by hospitals had grown by 70 percent since mid-2012, according to a study released by Avalere Health and the Physicians Advocacy Institute. This is due in part to the rapid rate at which hospitals are acquiring medical practices. In the same timeframe, the number of physician practices acquired by hospitals grew from 35,700 to more than 80,000.

Regardless of how physicians end up there, hospital systems offer many advantages. Chief among these: variety. Hospitals typically offer a more diverse set of patient cases, and hospitals also vary widely from one another. Factors such as overall popularity, patient demographics, typical caseloads, specialties and more will affect your day-to-day experience. The managing entity also influences the hospital environment. A hospital may be privately owned, government-run, religiously or academically affiliated, or run by physicians. Each of these systems will affect the hospital differently.

Another bonus is the availability of resources. Large or small, most hospitals have a wide array of medical personnel, labs and equipment. For a newer physician, this presents many learning opportunities. And since other employees are responsible for things like paperwork, routine care and non-clinical tasks, physicians can focus more on patient care.

“I found the collegiality and opportunities to learn through the extensive experience of my senior colleagues to be invaluable,” says Sinel. He was a full-time hospital employee at Cedars-Sinai Medical Center in Los Angeles early in his career. He says, “The collegiality, clinical conferences and easy access to multiple specialists were critical in developing well-rounded medical competence and confidence.”

After becoming an associate clinical professor at the UCLA School of Medicine, Sinel began complementing his clinical work with teaching. “I greatly enjoy the combined intellectual stimulation and clinical challenges,” he says.

Hospital work does have some downsides. Although many employers these days emphasize work/life balance, hospital physicians still tend to work long shifts and non-traditional hours. Patient arrivals can be unpredictable, which means shifts don’t always end when they’re supposed to. And depending on hospital location, a physician may frequently witness issues stemming from gun violence, drug addiction or homelessness. It can be wearying to treat these issues over and over again.

Joining the team: group practices

The group practice model traces its roots to the late 1800s when the Mayo Clinic in Rochester, Minnesota, widely regarded as a the first group practice, opened its doors. By 1929, the Mayo Clinic was world-renowned and employed 386 physicians and dentists. Today, group practices are common, and they vary greatly in size and number of specialties.

One major appeal of the group practice model is that it means having colleagues. From collaboration and learning to coverage for call and holidays, there are benefits to being part of a group. Groups also usually have administrative and support personnel who free physicians from business-related tasks. And group practices offer a fairly predictable patient flow, enabling physicians to maintain routine shifts with minimal holiday, weekend or late-night work.

However, if you’re considering a job at a group practice of any kind, you should be aware of the growing trend toward hospital acquisitions. From 2012 to 2018, hospital acquisitions of group practices have increased by 128 percent. Before accepting any group practice job, you should understand how likely that is and how it might affect your employment, so don’t hesitate to ask about it during an interview.

A unified focus: single-specialty group practice

Single-specialty group practices are exactly what they sound like: organizations that employ several physicians in the same specialty, such as orthopedics or OB/GYN. These groups tend to be smaller, but the model is popular. In a 2012 survey by the American Medical Association, 45.5 percent of physicians called single-specialty practices the most common arrangement.

For a new physician, working with established colleagues in your specialty presents a valuable learning opportunity. Many single-specialty groups are run by physicians, meaning you may have a say in decision-making and practice direction. But it’s not unusual to have a management team, particularly in larger groups.

Some practice groups evolve from a solo practice, as was the case with Brooklyn Minds Psychiatry, a mental health group practice in New York cofounded by CEO Carlene MacMillan, M.D. “It has been quite a journey from being a sole proprietor working in solo practice several years ago to being CEO of a growing psychiatric practice,” she says. “[We] now have 14 clinicians and a staff of approximately 40 people.”

One downside of a single-specialty group is the lack of referrals. When a group only offers one specialty, patients have to go outside the group for additional types of care, and there aren’t referrals coming from other specialties within the practice. Another downside is that patient distribution may not favor newcomers to the practice. If you’re exploring a specialty group practice, be sure to ask how patients are distributed and whether you’ll be responsible for establishing your own patient panel.

Combined expertise: multispecialty group practices

"When I started my career, a group practice made a lot of sense, as there was a steady referral base," says York Yates, M.D. - Photo by Austen Diamond

“When I started my career, a group practice made a lot of sense, as there was a steady referral base,” says York Yates, M.D. – Photo by Austen Diamond

Multispecialty group practices employ physicians in different areas of medicine. These groups are typically larger than single-specialty groups; some even employ thousands of physicians. Unlike single-specialty groups, multispecialty groups have the upside of internal referrals. Patients are likely to stay within the group when they need additional care from a different physician.

York Yates, M.D., has been in plastic surgery at the Tanner Clinic, a multispecialty group in Layton, Utah, for 16 years. “When I started my career, a group practice made a lot of sense, as there was a steady referral base,” he says. “Referrals build the practice, and it’s nice to have physicians you respect to whom to refer. There is also a nice sense of camaraderie and community in a multispecialty group.”

The downsides of multispecialty groups often center around group dynamics. Some physicians or specialties may feel that they are more valuable than others or that they attract more patients and deserve more dividends. Management style can be an issue. Many larger mixed-specialty groups are run by a management team, and leaders may or may not come from a medical background. Most larger groups operate with established practices and protocols, which can also create conflict. “[A physician may] find that decisions in the group’s best interest may be at odds with their own,” adds Yates. “Those who have a tough time compromising [may] struggle in a group practice setting.”

Yates has observed his practice grow and change over time. This is common as groups evolve and expand their offerings. “As my practice has matured, we have stopped offering insurance cases, and the environment I practice in runs more like a solo practice within the multispecialty clinic. I have a separate EMR, separate billing, separate branding and separate advertising,” he says.

Embracing opportunity: locum tenens

A newer model of employment, locum tenens arrangements began in the 1970s and quickly caught the attention of both physicians and employers. A locum tenens physician is a licensed, qualified physician who takes short-term assignments, as brief as a few days or as long as a year. These assignments fill in when a physician becomes temporarily unavailable or an employer experiences a temporary caseload increase. Locum opportunities are available all over the country and are typically found through a staffing agency.

Many physicians are attracted to this model due to its flexibility and variety. It offers the chance to explore different practice settings and geographic locations while meeting and working with new colleagues. However, downsides include a lack of job permanence and financial stability as well as the emotional strain of changing your work environment frequently.

Miechia A. Esco, M.D., a vascular surgeon, has been a locum tenens physician for five years through Having previously worked in many other practice models, she appreciates the flexibility of locum work and its work/life balance benefits.

“I work as much or little as I desire and in locations that I choose. [This] gives me the freedom to travel, enjoy hobbies and spend time with family and friends,” she says. “For instance, I took a month off to climb Mount Kilimanjaro and explore the region. There was no pressure to ask for time off, worry about vacation days or to find coverage.”

Satisfaction and benefits: working for the government

Almost every sector of government needs physicians. Aside from the typical government-run hospitals and clinics, physicians also work for government bureaus, correctional institutions, research labs and more. These roles range from serving as a private physician to an individual or a group to conducting medical research and serving as a physician in a hospital or clinic.

Many of these opportunities allow you to put a different spin on the traditional clinical practice of medicine. For example, a recent job listing for the CIA describes the role as follows: “Utilizing your clinical expertise in a medical consultation model, you will help advance the CIA mission where it intersects with medical issues.” Other bureaus, such as the FBI and CDC, offer similar opportunities.

VA hospitals and clinics are another type of government employer. VA health care facilities are widespread, serving more than nine million enrolled veterans and their families each year, and these institutions are held in high regard. In 2017, the Department of Veterans Affairs was ranked #17 by Reuters in their list of the World’s Most Innovative Research Institutions. Many physicians find the work rewarding as it offers a chance to help veterans and their families.

Regardless of your place of employment, government benefits can offer significant savings. For example, under the Federal Tort Claims Act, federally-employed physicians have certain financial protection against common malpractice lawsuits. And the Public Service Loan Forgiveness program allows some government-employed physicians to erase their student loan balances after meeting certain stipulations. If government work appeals to you, it’s worth researching the specific details of these policies to see how they might benefit you.

So how to choose?

Finding the right employer can be an overwhelming experience, and for physicians, there are extra criteria to take into account. Before weighing your options, take a step back and consider the following questions:

  • Do you prefer to spend your time mainly on clinical work, or do you enjoy wearing a variety of hats?
  • Do you enjoy collaborating with others, or do you prefer to solve problems through solitary research and study?
  • Do you prefer being surrounded by people practicing a variety of specialties or diving deep into your specialty?
  • What other commitments or restrictions are on your plate?
  • Consider your personality and lifestyle. Do you prefer a set schedule, or can you handle long and/or unpredictable hours?
  • What type of management do you prefer: physician-led or non-physician-led?
  • Do you like to network and market yourself?
  • Do you like variety or predictability in your workday?
  • Do you thrive in a fast-paced, fluid environment, or do you like organization and structure?

Remember that what’s right for someone else isn’t necessarily right for you, and that what appealed to you a few years ago may no longer be what suits you now. And though you want to make a wise decision, remember you can always change course if you take a wrong turn.

“There is no one-size-fits-all job coming out of residency,” MacMillan says. “Very few doctors keep the first job they took. I certainly did not, but I’m grateful for the job that I had. Getting too caught up on finding the perfect job can mean losing opportunities to learn about different systems of practice.”



Navigating the job-search journey

When to do what to find your dream practice.

By Marcia Layton Turner | Feature Articles | Spring 2020


Ann Peters, M.D., maximized her presence at specialty conferences to network and conduct informal interviews to find a job in a new city. See this issue’s physicians in exclusive video interviews at - Photo by Nick Hanyok

Ann Peters, M.D., maximized her presence at specialty conferences to network and conduct informal interviews to find a job in a new city. See this issue’s physicians in exclusive video interviews at – Photo by Nick Hanyok

Although physician job openings exist 365 days a year, it’s not always easy to find the right practice with the right compensation, the right work/life balance and the best timing. But understanding the typical timeline and key milestones along the way can help smooth that journey.

Interestingly, that timeline has been shifting in the last decade. According to a 2019 survey from Merritt Hawkins, 82 percent of residents began seriously examining practice opportunities more than one year before completing their residency in 2008. By 2019, that number had shrunk to 25 percent. Meanwhile, the number of residents who began the search six months before completing their training rose from one percent in 2008 to 26 percent in 2019. In other words, the job-search process is now starting as much as a year later for many residents.

The factors that physicians consider important in their job search have also shifted slightly. In the same 2019 survey, geographic location (77 percent), adequate personal time (74 percent), lifestyle (71 percent) and a good financial package (75 percent) were the four most important factors to residents. And whereas 22 percent of residents were open to hospital employment in 2008, 45 percent were interested in 2019. In 2008, 24 percent of residents were open to partnering with another physician. But by 2019, only seven percent were interested in a similar partnership. Interest in other settings—such as single specialty groups (23 percent in 2008 compared to 20 percent in 2019), multispecialty groups (16 percent both years), and outpatient clinics (eight percent in 2008 to negligible in 2019)—remained fairly stable

But no matter what type of position you’re looking for or what time of year you’re looking, the major milestones of the job search are fairly similar. And though your specialty or contractual obligations may influence your timeline, it’s still helpful to know what to expect as you look ahead to finding your next job.

Planning ahead

“At a minimum, the physician hiring process takes around six months,” says Ellen Mullarkey, vice president of business development at Messina Group, a staffing firm in Chicago. “But it can take as long as a year from the time you submit your application. That’s why I always recommend medical residents submit their applications by September of their last year of training.”

Physicians who are already employed and thinking of making a switch will want to build in time to give adequate notice. According to Mullarkey, “A lot of physician contracts include a termination clause that requires at least 90 days’ notice. Some clauses even require years of advanced notice before you’re legally allowed to leave. So you have to take this into account before pursuing other opportunities.”

But if you’re getting started late, don’t despair. Geami Britt, M.D., now an obstetrician and gynecologist with Novant Health Providence OB/GYN in Charlotte, North Carolina, says her fourth year of residency was underway before she got serious about the job search. She admits she was “very, very late” in comparison to many of her colleagues, some of whom had jobs already lined up by the start of their fourth year.

“I’m the first generation in my family to go into medicine, so I wasn’t familiar with the process,” she explains. She’s since learned that most residents try to finalize their post-residency jobs early in their fourth year so that they can turn their attention to studying for their June board certification exams.

When Britt began her own job search, she started with the question of geography. She was conflicted about where she wanted to be. She considered everything from staying close to her family in the Florida Panhandle to moving across the country to Seattle. Meanwhile, she was deluged by emails. “I was feeling the pressure,” she says, recalling the experience of seeing 30 emails in her inbox. “It was overwhelming.”

Realizing she was somewhat behind, she began plowing through recruitment emails, weeding out jobs in locations she wasn’t interested in. She also sifted through her letters and postcards, and that’s when a card from recruiting firm Merritt Hawkins caught her eye. It mentioned a job opportunity in Charlotte, and she was intrigued. She called the recruiter to see if the position might be a fit.

That call was promising, so she scheduled another with the Charlotte-area recruiter and an interview with the group’s CEO. She received an offer in April and was excited to accept it. But shortly thereafter, as she was signing her contract, the office announced it would be closing. Her new job no longer existed. Within hours, her former recruiter called her and promised he would find her another job. “I’m calling everyone I know,” he said, trying to ease her panic. Despite the fact that he didn’t stand to earn commission, he landed Britt two more interviews in just over a week.

By May, Britt had narrowed the field to two opportunities, both in Charlotte. One was with a brand-new practice; the other was a local group that had flown her in, showed her around, and taken her to dinner. By the end of May, she received offers from both and accepted Novant’s.

Finalizing the contract took about two months, including the time it took for Britt’s lawyer to review the proposed agreement and offer feedback. There wasn’t much to change, Britt says. She signed the contract in early July 2019 and got to work. Though she was nervous at times about the process, she says, “I’m a faith-based person, so I knew it would all work out.” And it did.

On the other hand, starting early has its benefits. Ann Peters, M.D., a gynecologist and surgeon with The Gynecology Center at Mercy Medical Hospital in Baltimore, was a fellow at Magee-Womens Hospital at the University of Pittsburgh Medical Center when she began looking for a job in Baltimore, where her husband was based. She had completed her residency and was beginning her second and final year of fellowship. Limiting her geographic search to Baltimore, she found four academic openings, two in private practice, and one at Mercy.

To decide which of the seven might be the best fit, Peters reached out to schedule informal interviews during subspecialty conferences she planned to attend that fall. Her efforts paid off, and she landed three informal interviews at one of the conferences. After that, she was invited to two formal on-site interviews. About two weeks after those interviews, she received two offers. Contract negotiations began, and by December, Peters had her post-fellowship job locked down.

When to start looking

“I’m the first generation in my family to go into medicine, so I wasn’t familiar with the process,” says Geami Britt, M.D., of a physician’s job search. Working with a recruiter helped. - Photo by Sean Busher

“I’m the first generation in my family to go into medicine, so I wasn’t familiar with the process,” says Geami Britt, M.D., of a physician’s job search. Working with a recruiter helped. – Photo by Sean Busher

Just as Britt worked to minimize anxiety about her search, physician recruiters try to avoid panic on the hiring side. “We don’t want to make a desperate hire,” says Heidi Terzo, talent acquisition manager and senior physician recruiter with Deborah Heart and Lung Center in Browns Mills, New Jersey. Working at a small specialty hospital means that Terzo is almost always searching for a specialist. In fact, she usually has three to eight positions open at a time.

To give the center plenty of time to attract and consider top candidates, Terzo starts by gathering information from department heads and chairs about the type of person they’re looking for. This goes beyond what’s on their CV, Terzo explains. She asks what the department’s expectations are, which physicians the new hire will work with, what the team culture is like, and what kind of personality would be a good fit.

Once she understands who they’re looking for, Terzo gets internal approval for the position and spreads the word about the opening. She starts by placing ads on websites and those of professional associations and journals. She also meets potential candidates at medical conferences.

Even so, there’s no guarantee of success. “Searches can take up to a year,” Terzo says.

The typical timeline

For most physicians, the timeline begins with submitting a CV or online application. Recruiting firms and in-house recruiters alike are always gathering applications for various positions. From there, the process usually follows a series of milestones:

Application received. Within a day or two, the application or CV will be forwarded to the hiring party. If no positions are open at the time, the information will be filed for future openings. Terzo says the bulk of the applications come within three weeks after a job is posted.

Application reviewed. After gathering CVs, recruiting firms review applications to decide which candidates to refer. In-house recruiters do the same, keeping in mind what department heads have said they’re looking for. On average, this process takes two to three weeks.

First interview. After identifying top candidates, employers schedule the first round of interviews—usually about 30 days after applications are received. Sometimes these early interviews happen by phone or video, while others take place on-site.

At Deborah, for example, Terzo starts with phone interviews. She says this is “to gauge [physicians’] level of interest and to see who’s serious.” Her goal at that point is to determine which candidates might be good fits. She’s also looking for physicians with local ties, which may mean they’re more interested in the area.

Second interview. If a candidate looks like a good match, an employer may invite him or her for an in-person interview, especially if the physician hasn’t visited yet.

This usually happens about 60 days after the original application, and the hospital or private practice covers all travel costs. In total, there are usually at least three interviews involved in the hiring process, says Mullarkey. Some might be with practice partners, others with nurses or administrators. It all depends on the size of the group.

Contract offered. If an employer and physician agree that they’re a good match, the employer usually extends an offer and issues a contract about 90 days after initial contact. Then, negotiations begin.

Depending on the complexity of the contract and the availability of the attorneys involved in reviewing it, this stage can last several months. In total, the time between a job posting to a signed contract can be anywhere from 30 days to a year, says Terzo.

What can slow the hiring process?

When physicians are unfamiliar with the business side of the job search, it can slow the process down. And this unfamiliarity is common. In fact, in a 2019 survey, over half of residents said they hadn’t received formal instruction about the business of medicine, including issues like contracts, compensation arrangements and reimbursement methods. As a result, contract negotiations can drag out the hiring process for weeks and even months.

On top of contract negotiations, a number of other issues can interfere with a quick start to a new job. One is the relocation process. Physicians who own homes should allow extra time to sell their homes before relocating, while those with young families may want to wait until the end of the school year before moving. Another factor to consider: exams. Some fellows need time to study for certification before they can start jobs, which recruiters need to build into the hiring timeline.

Non-compete clauses can also affect a doctor’s availability. If your contract forbids you from working for a particular hospital system or within a certain geographic radius, it’s important to make sure your new position will not violate those terms. Confirming that can take weeks, and if you discover a conflict, taking legal steps to remove the restriction can take even more time.

Additionally, some physicians want a little break between finishing residency at the end of June and starting a new job.

To keep the process moving and ensure prospective employers know you’re still interested, Terzo recommends staying in touch. That way, you can make sure everything’s on track, report on your own progress and stay engaged with the team you’re working with. Britt admits that she “may have been more aggressive in following up than most” because she wanted to know where things stood and convey her continued interest. But that diligence turned out to be a good thing. Her regular check-in calls and emails helped her stay top-of-mind at Novant Health.



Licensing, credentialing and hospital privileges— oh my!

Taking care of the logistics of your next job search.

By Marcia Horn Noyes | Feature Articles | Spring 2020


It took Sara Hawatmeh, M.D., about nine months to become fully credentialed. Begin sooner rather than later, she recommends. -Photo by Zach Dalin

It took Sara Hawatmeh, M.D., about nine months to become fully credentialed. Begin sooner rather than later, she recommends. -Photo by Zach Dalin

As a new resident at St. Luke’s Hospital in St. Louis, internal medicine physician Sara Hawatmeh, M.D., had already secured her state medical license before starting residency, thanks to the help of her residency coordinator. After finishing postgraduate training, she had to become licensed as an independent physician. That process was also an easy one, since the state allows physicians to apply for future issuance. As a result, she had her new license within a day of her residency license expiration. However, the insurance credentialing process was a different story. “It was a nightmare,” Hawatmeh says.

Physicians across the country know that getting your state license, insurance license and hospital privileges is often a matter of “hurry up and wait.” The hurry up part is usually doable, but the waiting is agony. According to the American Medical Association, physicians should plan for at least a 60-day window between submitting a completed licensing application and the actual licensure granting date. Those who, like Hawatmeh, graduated from medical school outside the U.S. should expect it to take slightly longer. State medical licensing boards need time to evaluate each application fairly. But that’s not where Hawatmeh, who is now in private practice with her father, ran into the majority of her delays.

Expectation meets reality

Hawatmeh hired a third-party company to help with credentialing. She was told the process would take about 90 days. It took much longer. “I think it was about nine months before I was officially credentialed,” she recalls. If just one document is kicked back for missing, outdated or inaccurate information, the process will slow down or even grind to a halt. “The whole process was delayed by maybe a month due to a misplaced signature,” Hawatmeh says. She resubmitted documents, only to find out they still weren’t correct, without any explanation why. Later, she was told the documents had not been received, although she had proof that they had.

The process may not be as difficult for employees of hospitals or group practices. Hawatmeh says larger organizations have experienced staffers trained to navigate the process. “No one teaches you these things in residency,” she explains. “They send you out into the world, and you are expected to figure out.”

Although California- and Florida-based facial plastic surgeon Demetri Arnaoutakis, M.D., never dealt with the same delayed timeframes as Hawatmeh, he shares her frustrations about the mass of paperwork. “When you’re a physician and busy seeing patients all day or even a surgeon in the operating room, you can’t multitask when it comes to that stuff. You are expected to do the paperwork yourself without delegating it, so it takes time to gather all the documents and type out all the information needed. It’s a laborious process,” he says.

State-to-state frustrations

Arnaoutakis earned his medical degree at the University of Florida College of Medicine, then spent a year at Johns Hopkins hospital doing head and neck cancer reconstruction research. He then trained in head and neck surgery at UT Southwestern Medical Center in Dallas before doing a facial plastic surgery cosmetic fellowship in Beverly Hills. Each time he moved, he had to go through new state licensing.

“For example, when in California and trying to open an office in Florida, I had to get a Florida medical license, even though I already had a medical license in both Texas and California,” explains Arnaoutakis. He says getting his license in Texas took the most time. “Compared to Texas, where it took at least four to five months to process, I was surprised at how quick licensing happened in both California and Florida,” he says.

Family medicine specialist Ashley Hartt Anderson, D.O., holds medical licensure in both Texas and California. Unlike many other states, Texas requires physicians to pass a jurisprudence exam, so most people advise keeping the Texas medical license current once you have it.

However, Anderson says getting a California medical license wasn’t exactly quick or easy either. “It took months to get my license despite me being a military spouse and supposedly granted an expedited process.” She says the biggest difference between California and Texas is that California has two medical boards: one for M.D.s and the other for D.O.s. “I had no clue this was even a thing, since we have only one [governing body] in Texas,” she explains. Although Anderson went to a D.O. school, she trained at an allopathic residency program and didn’t take D.O. board exams past the ones required for medical school.

She also encountered snags with fingerprinting. “Since I wasn’t living in California, there was a special process to have it done,” she says. “The first set of fingerprints were invalid for some reason, which further delayed the process.” As a military physician, her husband had a totally different experience. “Military physicians can be licensed in any state, and he holds his from the state of Virginia,” she explains. “There, it is a very simple and relatively cheap process, and as a result, most military doctors get licensed in Virginia.”

At your disposal: a credentialing facilitator

Physicians have to wait on medical boards before they can practice, but that’s not the only hurdle to clear. The employer credentialing process can also involve delays and more paperwork. Senior director of site operations for US Acute Care Solutions Melissa Reese—who identifies as a credentialing geek—says, “We often expect that since doctors have gone through so much training that the credentialing process would be simple for them, but it’s just not something they are experts in.”

That’s why Reese and her team of 20 credentialing professionals work closely with their clinicians and hospital partners to ensure a smooth onboarding process. Reese says, “We coach our physicians through the process. It’s something they appreciate. We’ve had doctors leave and then return to the practice who later share their gratefulness for our process because not all organizations offer such credentialing help.”

Basic elements of credentialing

Before beginning employment, a physician has to produce documents and fill out forms that rival daily EMR documentation. Reese says the vital elements for employment credentials and hospital privileges fall into five common areas:

Basic demographic information. For starters, you’ll need to fill out your full name, address, birthdate, contact details, social security, DEA, NPI numbers, etc.

Work, education and training details. You’ll also have to provide copies of your medical school diploma, internship/residency completion documentation, and information about former employers and hospitals where you’ve held staff privileges.

Legal information. This information may have implications for malpractice or licensing issues. If you answer “yes” to any questions about board sanctions, a host of other documents will be required.

Peer references. Another important element is contact information for your peer references. Be sure to remind them to keep an eye out. If your references don’t respond to an email, it can delay the credentialing process—even if the initial request went into the spam folder or arrived while they were on vacation.

Competency documentation. Reese says more hospitals than not are now looking for proof of competency. They want to see a certain number of procedures in the last few years, ensuring that you have been actively working in your field.

A credentialing advantage

Although there’s a strong call for uniform requirements among licensing boards, the idea of automatic reciprocity between state medical boards has mostly been tabled. Licensing and credentialing requirements vary for each state, facility and type of work. Reese says the biggest variations come from hospital systems with different processes, different bylaws and even different meeting cycles. “Most of our hospital partners will quote 60-90 days or 90-120 days,” she explains. She adds that the group functions as an emergency department, so most hospital partners help prioritize their physicians.

Counterintuitively, new physicians have an advantage over experienced ones when it comes to credentialing. A doctor who has been in business for 20 years, worked at 30 different hospitals and held multiple state licenses will have more paperwork to deal with than one who is fresh out of residency. For a new medical graduate, Reese says the verification goes much faster, explaining, “The bigger their history, the longer it takes to complete the process.”

Mitigating delays

Ashley Hartt Anderson, D.O., recommends keeping all the information requested for the credentialing process in an electronic file. - Photo by Jonathon Evans

Ashley Hartt Anderson, D.O., recommends keeping all the information requested for the credentialing process in an electronic file. – Photo by Jonathon Evans

Delays can happen at any point along the way. Since Arnaoutakis’s two older brothers are both physicians and had warned him about these delays, he was better prepared than most to face credentialing. But even he experienced long waits and overwhelming amounts of paperwork. Along with Hawatmeh and Anderson, he has some tips for new physicians about to face their first credentialing rodeo:

  • Get started before your start date. Delays are almost guaranteed, so begin sooner rather than later, says Hawatmeh.
  • Make sure that you are organized and well-prepared, because it may take a while, says Arnaoutakis.
  • Do your research. Go beyond the general websites for different insurers. Pick up the phone and call those insurance companies so that you fully understand what paperwork is needed, says Hawatmeh.
  • Be prompt with your responses to minimize setbacks, says Arnaoutakis.
  • Keep all credentialing information in a file. An electronic file is best, as that’s typically how it is requested, says Anderson.
  • Track your continuing medical education hours and make a timeline of deadlines, says Anderson.
  • Make copies of every document that you’ve submitted, including emails, so that you have proof of submission, says Hawatmeh.
  • Make a checklist for yourself, and don’t wait until the last minute, says Anderson.
  • Finally, Anderson says new physicians must stay on top of state and hospital board statuses to ensure the application gets processed. Otherwise, it could take much longer than expected.

The future of credentialing: speeding the process through technology

The arcane process of gathering documents, then submitting and resubmitting those documents for recertification, hospital privileges, a new employment contract or insurer certification is ripe for innovation. Hawatmeh, Anderson and Arnaoutakis all say a centralized, secure database could make the process much easier for clinicians.

Streamlining the process would help physicians who want to move states, add new insurers to their practices or offer Medicare and Medicaid. It would also enable groups and hospitals to onboard physicians faster. “So, if you are trying to get a license in Florida, California, Texas or New York, then perhaps they could just pull your information forms from a prior state in which you were practicing,” says Arnaoutakis. “That would help facilitate things.”

Some physicians pride themselves on being highly organized. They stay on top of the paperwork and record due dates for license renewal and hospital privileging information. Others rely on services like the Federation Credentials Verification Service (FCVS), which allows clinicians to establish a confidential, lifetime professional portfolio that can be forwarded upon request.

The money adds up. Spend hundreds of dollars for this license and hundreds for that certification, and before long, thousands of dollars have slipped through your fingers. Fortunately, a few companies, such as Austin-based Intiva Health, have started to address credentialing inefficiencies. Intiva Health was founded in 2006 as a staffing agency but has since created Ready Doc, a credential management platform that uses distributed ledger technology (DLT) to authenticate a document’s veracity over time.

The company’s roots are in practice management, placing anesthesiologists at hospital facilities. The CEO was looking for ways to automate the process, and over time, new technologies made it possible to create secure audit trails for documents. Intiva Health realized that adapting these technologies to health care could make the entire industry more efficient and prevent things from falling through the cracks.

Until that longed-for future when uniform medical board requirements exist and a central document repository is accessible, Hawatmeh and the other doctors have one message to impart: Don’t underestimate the time it takes for the credentialing process or the frustrations that may come with it. •

Marcia Horn Noyes is a frequent contributor to PracticeLink Magazine.



Finding the right practice fit—the first time

Right out of training, the money can seem the most important. But taking a more holistic view of your job search can land you at a place you’ll be happy to stay.

By Karen Edwards | Feature Articles | Winter 2020


Spend some time ideating your ideal job. “If you know the answers,” says Penelope Hsu, M.D.,“it will inform the kinds of questions you ask at the interview.” – Photo by TL Wedding

Penelope Hsu, M.D., walked into the job with high hopes. “I didn’t notice how toxic the workplace was at the interview,” she says. “I was nervous, I was worried about getting the job, and I wasn’t paying attention.” In hindsight, she says the clues were there. “I was on a unit and heard the phone ring. It kept ringing—no one answered it.”

A short time in, Hsu realized that she wasn’t in the kind of workplace culture she wanted. She had just come from working in the ER for six years, where she’d experienced a completely different culture: “There, everybody was focused on the same goal. We were motivated, we collaborated, we pulled for each other.” Her new job, however, soon showed a workplace that was inefficient and non-communicative. “No one talked with anyone,” she says. Three or four months into the job, Hsu realized the position she had taken was not going to work out. Six to seven months in, she was looking for a new opportunity.

Stacy Smith-Foley, M.D., loved her first job. She was in a radiology group that practiced at the top of its game, and its philosophy of putting patients first was morally and ethically aligned with her values. She stayed 10 years and only left when the practice was destroyed by a fire.

Finding a first job where you’ll be happy to stay a while isn’t easy. A recent survey by an Atlanta-based recruiting company found that half of the 500 physicians the company surveyed left their first job after five years. More than half of those stayed on the job only one or two years.

Jonathan Pagan, M.D., left his first job after a year. “It was a tough decision,” he says. “But if you’ve made the wrong decision the first time, admit it. The longer you stay, the harder it will be to leave.”

Not to mention that, the longer you stay in a culture that doesn’t fit your goals or values, the greater your chances are for burnout and medical errors. A 2018 study by the New York University School of Medicine and another 2018 study by the Stanford University School of Medicine suggest that workplace culture can play a more important role in reducing physician burnout and medical errors than improving safety protocols or using checklists.

“Workplace culture is huge when considering a job,” says Gretchen Nolte, team lead for physician and advanced provider recruitment for Indiana University Health. “But each person’s right fit is going to be different. You have to follow your instincts.”

So how do you determine what the right workplace culture is for you?

Consider these five steps.

1 Determine what you want in a workplace

You won’t be able to recognize the right practice fit until you first determine what you want in a workplace.

“As new physicians, we are told where to be,” says Pagan. “Fit doesn’t play into it. We’re at the whim of match algorithms. We’re programmed to take what we get.”

“As a new attending looking for a job, we think we are lucky enough to be given a job,” says Hsu. “But the best part about being an attending is that you finally become in control of your destiny, to a degree. That provides the freedom to ask yourself what is it that I want, does this job fit me, is this job good enough for me rather than the other way around.”

Hsu suggests before starting a job search, decide what your values are, what’s important to you, and what your ideal job would look like. What kind of environment do you want to work in? “If you know the answers,” Hsu says, “it will inform the kinds of questions you ask at the interview.”

“Ask yourself what your typical day should look like,” says Smith-Foley. “What would your worst day look like? Know what you value before you look for a job.”

Physicians seeking their first jobs often prioritize the wrong things, like salary or location, says Pagan. “Of course, salary is a pre-requisite. You need to know you’ll make enough money to take care of yourself and your family. And location can be important. But if you want to be happy on the job, you need to prioritize what a comfortable environment would be for you.”

For Pagan, it was important to work in a place where he felt he could make a contribution and a difference in people’s lives. He wanted to work where other people shared those values.

Yes, money is important. “But if you want to be happy on the job, you need to prioritize what a comfortable environment would be for you,” says Jonathan Pagan, M.D. – Photo by Jon Yoder

Don’t forget to also discuss your goals, values and priorities with your family. Consider their input. “My wife has had to sacrifice a lot along the way, so I prioritize her views more than my own,” says Pagan.

“I had a lot of conversations with my spouse before making our move,” says Smith-Foley. “We made a pros and cons list and finally decided that the opportunity I was given was one that we couldn’t say no to.”

Michelle Roland, M.D., has moved around a lot in her career, including jobs in Tanzania and Botswana before returning to her home state of California. With each move, Roland says she first received “100% input from my family.”

2 Research the workplace before you make your site visit

“The first thing you can do, if you’re interested in a job, is to research the company’s website,” says Nolte. “Go to the ‘About Us’ section and look for the kind of buzz words that reflect what you’re looking for.” If teamwork, compassion, patient-centric care and leadership are among the values you’re looking for, see if they are listed in this section.

“If you can speak to someone with firsthand knowledge of the employer, that’s even better,” says Nolte.

“If you have a network, use it,” says Hsu. She had learned some red flags about the poor fit from an old co-worker, but by then the information came too late to help. “My suggestion is to reach out to your network while you are still researching,” Hsu advises.

Roland did her primary research online, “but I spoke with my colleagues for a reality check. I wanted to know what the place was really like and if they thought I would be happy with the work.”

Brendan Kolber, national sales director with MGMA, says you can often find those with firsthand knowledge of a facility by networking at the local medical association. “Members will give you the inside scoop and let you know about the pros and cons of the place. What you don’t want to get hung up on is reading patient reviews on a website,” he says.

Pagan read local publications to learn more about the organization with which he was interviewing and was pleased to see articles about the growth and expansion of the facility. “That’s usually a pretty good indicator of the employer’s financial health as well as its leadership position in the community,” he says.

Smith-Foley also checks a facility’s financial health online to understand its business health. “Is it in the black or in the red? If it’s in the red, how has it changed, or how is it changing, to turn things around?”

3 On the site visit, notice everything

The site visit will reveal much about a workplace culture if you take the time to notice everything—like Hsu’s experience with the ringing telephone that went unanswered.

“Look around you,” says Nolte. “How happy do the employees look? Do they look like they want to be there?” And when you meet team members, Nolte adds, pay attention to their demeanor. Are they professional, respectful, open?

“Spend as much time at the workplace as you can,” says Pagan. “Two days is best, because you will learn more on your second day there. You’ll have more candid conversations with the people who work there.”

“You might even ask if you can shadow one of their physicians for a day,” Hsu says. That way, you’ll see for yourself how things work and how communication is handled. “But,” she adds, “You should strive to meet as many people as you can, including other team members. Talk to them about why they work there. Are they happy? What do they like about the job? What’s the worst part?”

Smith-Foley also suggests paying attention to how things are done while on the site visit. For example, notice if handwritten records are still a feature of an organization that might become a time-consuming task likely to be an impediment to your work/life balance.

There are other red flags to watch for, says Andrew Walker, national director of business development-organizational membership with MGMA. “Make sure you receive a detailed agenda prior to an on-site visit,” he says. Is the agenda a “mixed bag” – including visits with both physicians and non-physicians? That’s a good sign. “It should be a grab bag of people, a wide array, because you’ll get a more truthful picture of the workplace.”

“If you witness a conversation that is disrespectful, or it’s unfriendly or uncomfortable in some way, ask about it,” says Nolte. “If there is not a good answer, the workplace may not be a great place to work.”

“Watch for a lack of transparency,” says Pagan. “If you can’t meet with everyone, like the CEO, or with any of the support staff, that’s a red flag. You should be able to talk with anyone, about anything. If the only questions that are being answered are business questions, then you have the right to be worried.”

“How much time did they spend with you? How engaged were they when they were with you? That will tell you a lot about a place and the people who work there,” says Walker.

Here again, says Nolte, trust your instincts. “Consider the entire process,” she says. “If you go through the process, and if something doesn’t feel right, then that position is probably not the right fit for you.”

4 Ask the right questions at the interview

Communication and transparency are key during the interview. You should receive open, honest answers to every question you ask, says Nolte.

You should be prepared to ask lots of good questions, says Kolber. Of course, you are going to ask the inevitable: How much will I be paid and for what? “You need clarity on that,” says Kolber. “Changes in the marketplace and new pay structures have placed increased pressures and stress on physicians. Attaining all the facts you can upfront will allow you to make an informed decision about your job opportunity.”

Those stresses, as already discussed, can lead to burnout, along with uneven call distribution. “You’ll want to ask about that as well,” Walker adds. But he suggests going even further with your questions. “Ask employers what steps they’ve taken to provide physician health and wellness opportunities. That’s going to show you how they value physicians at their workplace and their well-being.”

5 After the site visit, keep investigating

You should have a good idea after your research, your site visit and the interview whether the workplace is going to be the right cultural fit for you, but don’t forget to check out the area to make sure it’ll be a good fit as well.

“Does the community meet your needs and the needs of your family?” asks Nolte. Most workplaces will connect you with a local realtor who can take you on a tour of the area and show you places where you might want to live, she says.

“My wife and I went on school tours as well,” says Pagan.

“We wanted to live in a small, tight-knit community,” says Roland, but it was also important to her to connect with people who are like-minded. She found that in the small California town where she’s living now—but it took research and some searching.

Just as you did when you initially sat down to determine your values and the kind of workplace you wanted to be a part of, now is the time to sit down and assess your experience.

“Were you treated with respect while you were there?” asks Kolber. “How were you received? Did you feel welcomed, or was there a sense that something didn’t feel right? Spending time to evaluate your feelings, both good and bad, about the environment, staff and fellow physicians is an exercise I encourage.”

“How was your family treated?” Walker adds. If you still have questions or hesitations, now is the time to ask why. “Use your instincts to uncover and ask more questions.”

After his site visit, Pagan spoke with colleagues, mentors and those familiar with the practice patterns at the facility before he accepted the offer.

“Set up a vision of your ideal life for you and your family. What would it be like?” asks Hsu. After the interview and the site visit, compare your vision to the job that’s open. Is it the job—and life—you want it to be?

“Ask yourself, does it match what I want?” If it doesn’t, keep looking. “It’s easy, when you’re first starting out, to have a feeling of desperation.” But accepting a job offer out of that feeling is no way to start your career.

“If you’re not sure about the job, be honest,” says Smith-Foley. “Make a second visit. Advocate for yourself and what you want.”

But what happens if you take the job, and, like Hsu, soon realize that this is not the workplace for you?

“It’s a situational problem,” says Nolte. “If you’ve uprooted your whole life by moving there, give it some time. Talk to your direct supervisor about any issues that are troubling you—the sooner the better.”

“In some cases, you can help shape the culture of the place, in terms of communication or patient care,” Pagan says. “But give yourself a time limit to affect the change. You don’t have to stay there.”

…Unless, of course, you have slipped on a pair of what Walker calls “golden handcuffs.” “If you’ve earned a signing bonus when you took the job, you’re on the hook for that money if you leave,” he says. Just be aware of that when you enter into negotiations. “Be aware of what you can do if you want to exit a three-year contract in the first year,” says Kolber. “The new workplace might help you repay the signing bonus if they really want you.”

If you do decide to leave shortly after accepting a job offer, use it as a learning tool, says Kolber. “Ask yourself what worked, what didn’t so you know what to look for at your next workplace.”

“Stay open to opportunities, and remain flexible,” suggests Roland. “Don’t worry if your first job doesn’t last forever. In fact, that can be a really good thing.”

Furthermore, says Hsu, “It’s unrealistic to think your first job will last forever. Priorities change, especially with families. Your own values and priorities may change. If you can’t incorporate those changes into the job you have, it’s time to leave.”

“All you can do,” says Pagan, “is to make the best decision you can at the time, and work hard while you’re there. If it doesn’t work out, it’s not your fault.”

But by following the tips provided here, chances are you will find the perfect job fit for you—even on your first try.

Karen Edwards is a frequent contributor to PracticeLink Magazine.




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