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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Putting lifestyle first

When physicians need a better work/life balance, some turn to creative scheduling solutions.

By Debbie Swanson | Feature Articles | Winter 2020

 

Ashish Goyal, M.D., created a flexible schedule that allows him to practice, teach and run a board review company. – Photo by Jenna Lee

The traditional expectations for a physician’s workload is one of churning out long hours without complaint, particularly those in the early years of their careers.

But today’s thinking is shifting. With the increased awareness of the dangers of stress and burnout and the importance of work/life balance, both physicians and employers are increasingly more responsive to a schedule that allows for some breathing room.

Stress and overload: not issues to ignore

Physician burnout, as defined by the Agency for Healthcare Research and Quality, is a “long-term stress reaction marked by emotional exhaustion, depersonalization and a lack of a sense of personal accomplishment.”

Burnout is a widespread problem. Medscape’s 2019 report states that 44% of physicians reported feeling burned out, 11% were colloquially depressed, and 4% were clinically depressed. It spans the specialties, and is reported slightly more by females (50%) than by males (39%), although a common belief is that males are less apt to discuss emotional problems. Even more worrisome: The report also states that 14% of respondents admit to having had thoughts of—yet have not attempted—suicide.

One of the best ways to alleviate burnout, as well as anxiety-related problems, is to maintain an adequate balance between your personal and professional life. Having enough time to spend with family, to engage in fitness and to simply unplug are important components to everyone’s physical and emotional wellbeing. Yet this is often out of reach for the physician running to uphold a 40-plus-hour work week. Sporadic vacations or personal days can help to periodically tamper mounting stress, but they aren’t long-term solutions.

So what can you do?

Today’s physicians are beginning to explore other options. In the 2018 Survey of America’s Physicians by The Physicians Foundation, nearly one-quarter of physician responders—22.3%— indicated they plan to cut back their hours in the next three years. That’s the largest number recorded since the survey began in 2012. Another 8.5% plan a switch to part-time, and 8.4% will turn to locum tenens. These are just a few of the avenues available to those eager to get a handle on their work hours.

Moving to a part-time role enabled Linda Hertzberg, M.D., to serve a greater role in professional associations. – Photo by Derek Lapsley.

Part time: not a bad career move

Working fewer than 40 hours a week may seem like a dream, but it’s becoming a regular arrangement. And according to the American College of Physicians, if you’re in need of a break, going that route may be better for your career than ceasing work completely.

“It can be difficult to return after a hiatus of as little as six months, since the break in CME credit accumulation, referral patterns and so on is hard to overcome. Working part time allows continuity with the addition of flexibility,” states ACP in a report.

Today’s climate is favorable for physicians negotiating for a reduced schedule.

“The impact of having to re-train someone is so significant, both financially and time-wise, that employers are much more interested in retaining good talent, than allowing them to go elsewhere,” says Honolulu-based physician Ashish Goyal, M.D. Goyal’s schedule accommodates his own multi-faceted career: he runs PediatricsBoardReview.com, practices clinical medicine and teaches.

Job sharing: finding your other half

If you don’t feel your current employer would accommodate a reduced schedule, consider instead asking to set up a job-share arrangement, in which two part-time physicians split the hours and responsibilities of one full-time position. This situation is potentially favorable to an employer, reports the ACP, since it avoids some of the issues raised with part-time shifts. Because a job-sharing arrangement is the same as employing one full-time provider, it creates minimal, if any, negative impact on the use of staff or office resources.

From the viewpoint of the two physicians involved, the arrangement is similar to a part-time position, with adding the need for routine communications between the two. Initially, the logistics need to spelled out: divvying up hours, shifts, holidays and call. Regular patients need to be informed of each physician’s schedule, and if any patients choose to overlap, both physicians should remain in contact to present unified, consistent care.

Locum tenens: you choose

Locum tenens work is another way to maintain some control over your work hours. With this, you temporarily fill in at different hospitals and/or practice groups for a pre-defined period of time. This may mean covering for a vacationing physician for a few weeks, taking over while someone is on leave, or providing extra help during a period of increased patient loads.

These opportunities are available through locum tenens agencies and exist everywhere, from the hospital a short drive from your home to the large medial group in a completely different state (provided you meet licensing requirements).

While many of the locum assignments are full time, it is still a means of reducing your workload over the course of a calendar year. Because you choose when you’ll work, the option exists to create respites between assignments as needed.

Telemedicine: not so futuristic

Decades ago, a physician working from home simply hung a shingle at their residence. Today, that idea may be obsolete, but the concept of working remotely isn’t. With today’s technology, more and more companies are hiring physicians who regularly consult with patients via mobile technology or video conferencing.

“Telemedicine is very much on the rise, (especially) in remote parts of the country, where patients don’t have access to specialists or even GPS,” says Goyal.

In addition to companies that specifically offer virtual encounters, many practices are accommodating such encounters as an enhancement to their routine services. This creates another way to reach a patient, meeting the needs of those with a demanding work schedule, who have mobility or transportation issues, or who are more comfortable in the privacy of their own home. It may be more suitable for certain specialties, such as psychiatry, radiology or follow-up care.

If it works for you and your employer, virtual patient encounters can result in both reduced hours at the office and less stress from commuting.

Is a reduced schedule right for you financially?

The idea of a lighter work schedule is almost always appealing, but for most people, it comes down to the numbers. Before you reduce your hours—and income—take a hard look at your minimum expenses, including:

  • Monthly living expenses: rent/mortgage, food, utilities, household support
  • Daily expenses: gas and commuting expenses, coffee/meals purchased out, sundries
  • Loans: auto, educational, personal
  • Insurance: malpractice, auto, disability, homeowners
  • Family/household support: child care, cleaning, landscape care, senior care or financial support, veterinary bills
  • Recreation: gym memberships, dining out, hobbies, sports
  • Long-term needs: retirement, home purchase, college plans, emergency fund

Identify both your “must-haves” as well as those things you could do without if need be. Adjust for how the situation might change after you reduce your hours; for example, you’d likely have a drop in commuting expenses, or less child care.

Also be aware of how your benefits may be affected by a drop from full-time status. Consider how your personal situation may add or subtract from the picture; for example, married physicians may be eligible for certain benefits through their spouse.

“Health insurance may be the biggest area affected,” Goyal adds. “(Your employer) may have a tie to full-time employees or those meeting a certain minimum number of hours per week. Other areas potentially affected include malpractice insurance, financial benefits such as 401(k) matching programs, retirement programs, pension or CME stipends.”

Another perk: room to grow

When caught up in the daily grind, you can probably think of a million things you’d do with an afternoon all to yourself. But when actually faced with extra free time on a repeat basis, you may find yourself restless or feeling idle. Before you make a schedule change, carefully think about out how you’d spend the time.

After working as a clinical anesthesiologist for 29 years and as an academic anesthesiologist prior to that, Linda B. Hertzberg, M.D., left her full-time position in private practice and switched to part time. While the change proved to be positive, she admits that at first, it was an adjustment.

“Initially, I felt like part of my identity was ripped away, especially since I felt that after all those years of practicing anesthesiology I was at the top of my game,” she recalls.

But she soon relished the time available. In addition to enjoying being able to pursue her personal interests, such as skiing, traveling, visiting friends and wine collecting, Hertzberg increased her involvement with professional organizations. She’s been a board member, officer, and (past) president of the California Society of Anesthesiologists (CSA); served as a California delegate to the American Society of Anesthesiologists (ASA) and is currently the ASA Director from California; serves on the ASA Board of Directors; and is the chair of the ASA’s Ad-Hoc Committee on Women in Anesthesia.

“This has always been work that I found professionally rewarding, so it is wonderful to have time to really focus on it,” she says.

Appealing to your employer

When you’re ready to negotiate with your employer, first switch your way of thinking. View your proposed arrangement from their perspective, and present it in a way that would highlight why it’s appealing to them. The ACP shares a few suggestions:

  • Has the practice has been trying, unsuccessfully, to hire a full-time physician? This can support your quest; advertising for part-time physicians may open up the field of applicants. “Women are the physicians most likely to want to work part-time and they represent 35% of all internists between the ages of 35 and 44, more than 40% of physicians under 35, and over 50% of medical school entrants,” the ACP reports.
  • In exchange for reducing your hours, are you willing to work some of the less-desirable shifts, or adjust your hours as needed to help when the practice has normal fluctuations in demand, or when other physicians are on vacation, or during busy times?
  • How will you participate in call rotations, and in what capacity?

The success of making such a switch also depends somewhat on your specialty.

“Anesthesiology definitely lends itself to per diem work, as may other specialties such as emergency medicine, hospitalist medicine, pathology and radiology that do not require an office-based practice, with continuity of patient care,” Hertzberg says. “The limiting factor in any specialty may be the overhead costs, and how willing your group or partners are to work out a part-time arrangement.”

Unwanted attention: dealing with coworkers

Deviating from the norm almost always invites opinions, so expect to become a topic of workplace conversations. You may face negativity, such as assumptions that you’re not fully committed to your career, that you’re not carrying equal weight. Or, you may hear belittling comments or outward jealousy.

But it may not all be negative. Co-workers who have been entertaining similar notions or feeling frustrated with their careers may applaud you for taking the initiative, and even seek you out for advice, questions, or moral support.

Regardless of the perceptions you face, remember that your business is your own, and you don’t need to explain or defend yourself to anyone aside from your supervisors. Your needs and opinions, and those of your family, are the only ones that really matter. Maintain your standards of professionalism and boundaries, stay committed to your decision, and any chaos among your coworkers will soon subside.

There’s no denying the demands of a physician’s career, and the high level of job dissatisfaction, anxiety and burnout physicians routinely experience. Working toward a more friendly, flexible schedule is one of the best ways to avoid sending your career into a downward spiral.

“It’s critical to find work/life balance so you can still enjoy your life,” says Goyal.

With a solid look at your own needs and aspirations, coupled with a careful analysis of your financial situation and your family’s needs, it’s possible for physicians today to create a more comfortable allocation of personal and professional time.

 

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Rainy day planning

What physicians need to know about liability, disability and life insurance and saving up.

By James M. Dahle, M.D. | Feature Articles | Winter 2020

 

“It is very easy as a physician to get this bulletproof mentality, but we can all get the same problems as our patients,” says Michael Lieb, D.O. – Photo by J&J Studios.

Thy fate is the common fate of all; into each life some rain must fall.” –Henry Wadsworth Longfellow

Physicians, more than most people, are well aware that bad things happen to good people. These “rainy days” may not be common, but they can be life-changing, especially if you are not prepared for them. In my work at The White Coat Investor over the years, I have run into dozens of physicians who encountered a “rainy day.” In this article, I’ll discuss four financial “rainy day” events common to physicians and how you can prepare for them while the sun is still shining.

Rainy Day 1: Being sued

Many doctors have an illogical, even unhealthy, fear of lawsuits. While the attorneys involved view a lawsuit as “just business,” it becomes personal for the doctor with the resulting lost sleep, defensive medicine and shortened career. Though a lawsuit is never pleasant, viewing it from the proper perspective is helpful. A lawsuit is a civil tort, not a criminal prosecution. It’s about money, not crime, and the vast majority of the time, it does not even involve the doctor’s money. Most of the time, the physician is essentially serving as a defense witness for an insurance company, whose money is really at stake. The doctor already spent her money when she paid the insurance premiums!

Avoiding lawsuits by practicing good medicine, communicating well with patients and their family members, and documenting well is obviously critical. An ounce of prevention is worth a pound of cure. However, once a lawsuit is initiated, insurance becomes the first line of defense. Insurance not only pays for any settlements or judgments, but it also covers the cost of defense.

The rule of thumb is to buy the same amount of malpractice insurance coverage as other doctors of your specialty and geographical area. A common benefit limit is $1 million per incident and $3 million per year. Each of the doctors interviewed for this article carried that limit, although higher limits (usually $2 million/$5 million) can be seen, particularly among high-risk specialties such as OB/GYN.

As Michael Lieb, D.O., a vascular surgeon in Hainesport, New Jersey, explained, “these are the minimum limits set by the state and I have not really heard of many people going above this.”

Be sure you understand how your policy works. If you (or your employer on your behalf) purchase a “claims-made” policy instead of an “occurrence” policy, be sure one of you purchases a “tail” policy in case you are sued after the policy ends.

Professional liability is not the only lawsuit risk you face. Personal liability coverage is also essential to purchase. Property coverage including auto, recreational vehicle, homeowner’s, and renter’s policies also include a liability component. However, the liability coverage on these policies is often much too low for the real risks you face. Increase the coverage and stack an “umbrella” (excess personal liability) policy on top of your property policies.

Lieb carries a $3 million umbrella policy because “it is quite affordable and more than my net worth currently. This level of coverage only added $500 to my annual insurance premium, as I already had the highest deductibles set on my homeowner and auto insurance. …I will likely increase this along the way.”

Despite common recommendations, the amount of needed coverage has nothing to do with your net worth, but more to do with the actual risks faced. Commonly recommended limits range from $1 million to $5 million. Luckily, personal liability insurance is dramatically cheaper than malpractice insurance, usually only a few hundred dollars a year.

Many physicians are concerned about the possibility of being successfully sued for an amount above their insurance policy limits. This is an extremely rare occurrence, but it is prudent to at least take a few basic “asset protection” steps as additional protection. These include knowing your state asset protection laws, titling property properly (married couples should use “tenants by the entirety” titling where available), maximizing the use of retirement accounts, and placing “toxic assets” such as rental property into limited liability companies. More advanced techniques such as overseas trusts, equity-stripping, irrevocable trusts, cash value insurance, and family limited partnerships may also be appropriate for some physicians in some states.

Rainy Day 2: Personal disability

By the time they finish college, medical school, and three to seven years of post-graduate training, the most valuable financial asset of a doctor is the ability to turn their specialized knowledge and skills into a revenue stream, i.e. their ability to practice medicine.

A physician’s future income is primarily protected with disability insurance. This insurance not only protects those depending on you from the loss of your income, but it also protects you! The most important thing to know about disability insurance is that you need to get something in place early in your career, when the cost is lowest, when you are healthiest, and when a permanent disability would be most devastating. The second most important thing to know is the definition of disability in your policy. You want the broadest possible definition of disability—specialty-specific, own-occupation. Consider the story of Stephanie Pearson, M.D., FACOG:

“At the height of my career as an OB/GYN in Philadelphia, I was kicked by a patient during an exceptionally difficult delivery,” she says. “I sustained a torn labrum that developed into a frozen shoulder. After surgery, I had considerable range of motion deficits and nerve damage that prevented me from performing the material and substantial duties of my job. Unknown to me at the time, my health system’s group disability insurance did not cover work-related injuries, and I was eventually terminated for being unable to satisfy my contract. Workman’s Compensation did not kick in immediately; I actually had to go to court to get the benefits that I deserved. Without the private disability insurance that I had obtained early in my career, we would have certainly had to sell our home. My children did not have to change schools or feel the brunt of my career-ending injury. While I was going through rehabilitation and trying to figure out what to do next with my career, my family did not have to worry about financial ruin.”

Private disability insurance helped Stephanie Pearson, M.D., navigate a career-ending injury without completely disrupting her family. – Photo by J&J Studios

Pearson transitioned to a career as an insurance agent and opened her own firm (Pearson Ravitz) to help physicians understand and protect against this significant risk. Her story illustrates not only the importance of having a policy, but also the differences between a group and an individual policy. While individual policies are more expensive and difficult to qualify for, they usually have a stronger definition of disability, and thus are more likely to pay out in the event there is any “gray” in your disability—and there often is. Individual policies are also portable when you change employers and generally have level pricing throughout your career.

David Antonio Mateo de Acosta Andino, M.D., is a plastic and reconstructive surgeon practicing in McAllen, Texas, married to a nurse anesthetist. They found the process of applying for disability insurance frustrating because “the insurance company really had very little grasp of what could represent a pathology down the line that could prevent either of us from practicing our professions.” He ended up with a $15,000 policy from Mass Mutual, one of the “Big Six” companies who offer own-occupation coverage to doctors. (The others are Guardian, The Standard, Ameritas, Principal, and Ohio National.)

As a general rule, one should buy a large enough disability benefit to cover spending needs and retirement savings, as most policies stop paying around age 65. However, some physicians may not need any disability insurance at all. Myung Sun Kim, M.D., an internist in Eugene, Oregon, doesn’t carry any at all. “With a financially independent spouse and extended family, I believe it is an option to ‘self insure’ for disability,” Kim says. Most physicians end up with policies with a disability benefit of $10,000 to $25,000 per month, although residents can often only afford $5,000 to $7,500 until they finish their training. They should buy a future purchase option rider on their policy. Lieb did not, and relates the following anecdote about his mistake:

“I did not get the future increase option as a resident. …Unfortunately, at the end of my fellowship I was diagnosed with hemachromatosis and when I went to get my new policy as an attending, my premium was going to be four times the standard policy for my level of coverage, and they would only offer benefits for a 10-year period instead of up to age 65. Obviously, this was a shock and not something I could afford. I shopped around and after medical underwriting, Ohio National gave me their highest health rating, as the disease was caught very early and with continuous medical management would have a low likelihood of future problems.”

Riders are extra “bells and whistles” on a policy that usually come with an additional cost. In general, every doctor should have a partial/residual disability option, which pays a benefit while they are partially disabled. Residents and other doctors expecting dramatically increased income should buy a future purchase option rider. Doctors in the first half of their career should consider an inflation protection rider as well.

Rainy Day 3: Death

Another important “rainy day” to discuss is the death of a doctor. If other people depend on your income, you need life insurance, and lots of it. The idea behind life insurance is that the financial life of your loved ones should be the same whether you die prematurely or not. Early in your career, when you are broke or worse, you likely have a large need for life insurance. Later in your career, that need decreases until it disappears completely when you become financially independent. If you and your family can live the rest of your lives on your nest egg, then they can certainly do so without you!

Since the need for a death benefit is temporary, it is almost always best to buy a term life insurance policy. Due to very high commissions, many insurance agents try to sell physicians whole life or other types of permanent life insurance policies, with a lifelong death benefit. Since everyone will die eventually, this benefit is much more expensive to provide, and so the policy premiums to pay for it are much more expensive, often eight to 20 times as much as a term policy.

The policy then becomes so unattractive in comparison that the agents often use secondary benefits to get people to buy the policy. The main secondary benefit used is the ability to borrow against the death benefit, which like all borrowing is tax-free but not interest-free. The problem with mixing insurance and investing in this manner is that you end up with the worst of both worlds—expensive life insurance you don’t need and a very low returning investment!

Since death does not involve all of the shades of gray that come into play with disability, life insurance contracts are much simpler and easier to understand than disability insurance contracts. If you are healthy, the process is very simple. Determine how much insurance you want, how long you will need it for, and who will sell it to you the cheapest. You will then need to provide vital signs, blood and urine lab tests, and a questionnaire about your health history and habits. Sign your contract, make your first premium payment, and you are all set.

How much insurance do you need? Well, first determine what you want insurance to pay for. What is the financial plan in the event of your untimely death? Perhaps you want the mortgage paid off. Perhaps you want $100,000 per child for college expenses. Perhaps you want your spouse to never have to work again. Even stay-at-home parents may wish to carry some insurance, as there would be significant costs involved to hire someone to replace their child care, food preparation, shopping, cleaning, laundry, money management and transportation duties. Add all of this up, round up to the nearest million, and that should be the amount of term life insurance that is purchased. A typical physician will be covered with $1 to $5 million in term life insurance. The good news is that the premiums on even those large amounts are much cheaper than disability insurance, not to mention malpractice insurance!

Some physicians, recognizing that their need for insurance will go down over the course of their career, opt to “ladder” their policies. Agnes Wang, M.D., a urologist in San Francisco, carries $4 million in coverage split between a 20-year and a 30-year policy. Even in expensive San Francisco, “It would be enough off our mortgage,” she says. Other doctors don’t buy insurance at all. For example, Dhaval Pau, M.D., a critical care physician, does not own a life insurance policy because he has a physician spouse, no children, and no debt. Lieb found himself in a different situation, and says:

“I chose a $3 million, 20-year term policy, as this will be enough for my family to live comfortably until the kids go to college. My wife and I discussed this and she would ultimately go back to work, but this amount of benefit would allow her to continue to stay home with the kids until they go to college. I did not choose a larger policy as I do not believe it will change their lifestyle dramatically from $3 million to $5 million and so was not worth the extra premiums. We also already have college funds set up for the kids.”

Determining how much life insurance to carry may not be an exact science, but it is important to personalize it to your situation. The length of term is similarly customizable, but most doctors end up with 20- to 30-year, level premium term policies. It is relatively easy to use online websites to determine the going rate for your policy. Buying from an independent agent allows you to buy the least expensive policy that meets your needs. The expertise of the independent agent becomes even more important if you are not healthy or have dangerous hobbies. They can “shop you around” to the various companies informally before making a formal application that could be denied and cause you difficulties getting adequate coverage later in life.

Rainy Day 4: Emergency fund

While most attending physicians can easily pay for minor emergencies such as a plane ticket or a broken appliance out of their monthly cash flow, many early career doctors would be well served to have a traditional emergency fund equal to three to six months of expenses invested in very safe, liquid assets.

Perhaps the most significant emergency a doctor is likely to face is job loss. Even if you have long-term disability coverage, it usually does not kick in for 90 days, and there are plenty of reasons for job loss besides disability. A traditional emergency fund reduces the stress of knowing how to pay household expenses for months while you seek out new work and wait on licensing and credentialing. Of course, the less you spend, the smaller your emergency fund can be.

Andino’s emergency fund is a year’s worth of expenses, and Lieb’s is currently similarly sized, although he says it is far more than he really needs and plans to invest a good chunk of it soon.

Other doctors interviewed for this article find themselves in the middle, with emergency funds of $20,000 to $25,000. The main point is to have something. Not only does it get you in the habit of saving, but it also prevents the use of high interest rate credit cards for emergencies and the psychological reassurance that you can take some profitable risks with your investments and your career.

Money is a lot like oxygen. You don’t think about it until you don’t have quite enough of it, and then you can think of nothing else. An emergency fund prevents a lot of financial worries. Thankfully, none of the doctors interviewed for this article have ever had to use their emergency fund, but each of them is still grateful to have it.

Rainy days affect doctors just as much as their non-physician peers. Insuring against financial catastrophe and making sure you have cash on hand to cover deductibles and waiting periods will enable you to ride out financial storms until your retirement savings become large enough to provide financial independence. As Lieb explains, “Just like the weathermen, no one seems to be very good at predicting when it is going to rain, and how much. I have seen many colleagues have terrible things happen that they were not financially prepared for. It is very easy as a physician to get this bulletproof mentality, but we can all get the same problems as our patients. …I sleep a lot better at night knowing that my family is protected.”

Wang agrees: “It seems like a lot of money to spend on something you hope to never use, but I hope that my family and I are lucky enough to never need it.”

Real physicians just like you are sued, become disabled, die, lose their jobs, and encounter other rainy day emergencies all the time. Be prepared for them with a smart insurance plan and an emergency fund.

James M. Dahle, M.D., is the founder of The White Coat Investor.

 

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The truth about student loan repayment

How physicians can tackle their biggest burden.

By Jason DiLorenzo | Fall 2019 | Feature Articles

 

Student loan repayment programs have evolved even since Larry Burchett, M.D., graduated med school in 2006. – Photo by Simone Anne

Larry Burchett, M.D., remembers graduating from medical school in 2006, excited that he’d matched to his preferred emergency medicine program and begin training.

“But that first year, it’s hard, man,” says Burchett. “I didn’t expect that; $42,000 doesn’t go very far in California.”

Burchett graduated medical school with about $160,000 in federal student loans, which he still carries today because his rates were fixed at nearly 2% in 2010.

Fast forward to today, where a debt load of roughly $200,000 is the average for physicians graduating from a public medical school, and often well over $250,000 from private or osteopathic programs. With fixed rates as high as over 7%, it’s easy to surmise that Burchett’s profile would be envied by most medical graduates today.

But fortunately for those who are keeping up on an ever-evolving and complex student loan repayment marketplace, relief is available for early-career physicians today.

Evolving options

Increasing physician debt levels and available federal and state repayment and forgiveness options have dramatically changed the economics of becoming a physician, and these factors are beginning to impact the career decisions of young doctors.

Jared Wenn, D.O., is one such graduate; the surgeon is the sole breadwinner supporting his family of four on a training salary.

“I needed to borrow more money than I thought I needed through school,” Wenn says, resulting in federal student loan debt of more than $400,000. Now, with five years of residency ahead and possibly up to four more years of fellowship, Wenn could reduce his out-of-pocket student loan payments by over $350,000 by pursuing the Public Service Loan Forgiveness Program. Burchett, by comparison, didn’t have this program available when he graduated in 2006.

Medical trainees today can uniquely position for this program by using an Income-Driven Repayment plan while training with a non-profit hospital.

The repayment landscape

For graduates entering training, going into a standard or extended-term payment plan at today’s average debt level and rates isn’t affordable ($200,000 on a 10-year plan is roughly $2,250 monthly), so early-career physicians often seek payment relief throughout training.

REFINANCING

Refinancing is an option for many graduates today. Simply explained, refinancing means a private lender or bank pays your federal student loan debt, and you’re committed to paying a set amount monthly for a set term, at hopefully a lower rate than your federal loans. When federal benefits such as reduced payments, interest subsidies and loan forgiveness become no longer available, that’s the point when many physicians today can and should lower the cost of their debt by refinancing if possible.

The issue comes with how to leverage the market to find the best rate. Most lenders advertise the same broad range of rates, but the only way to get firm offers is to go through the application and underwriting process, which can be cumbersome and often involves a hard credit pull.

Refinancing products, rates and participating banks have evolved rapidly over the past few years, so it’s important that you have a good understanding of the current marketplace, or have a reliable advocate who can assist with the process and help determine when refinancing is suitable.

Mike Greenberg, M.D., sought out help to understand the nuances of Public Service Loan Forgiveness. – Photo by IHNY

INCOME-DRIVEN LOAN REPAYMENT

Now let’s spend some time on the newest and most complex of the federal repayment options today: income-driven loan repayment (IDR).

Of the five income-driven repayment plans available today, there are really three that are most suitable for today’s house-staff and early-career physicians with federal student loan debt: Income-Based Repayment (IBR), Pay As You Earn (PAYE), and the newest available program, Revised Pay As You Earn (REPAYE). Where the term IDR is used below, it is a reference to all of these programs.

INCOME-BASED REPAYMENT

IBR was launched in 2009 and is a federal repayment program that limits monthly loan payments to 15% of your discretionary income.

To be eligible, a partial financial hardship must exist, which means that this 15% of your discretionary income, calculated on a monthly basis, is less than what you’d be required to pay on a 10-year standard repayment plan. This hardship exists for most trainees with federal student loan debt, as 15% of the discretionary income for a single resident with a $50,000 salary would result in roughly a $400/month payment. The 10-year standard monthly payment on $220,000 of debt, by comparison, would cost about $2,500/month. Clearly, a hardship exists.

IBR is also a qualifying repayment plan for the Public Service Loan Forgiveness (PSLF) program. Taxable loan forgiveness is granted through IBR after 25 years of repayment. However, payments in IBR are capped at the 10-year standard payment amount established when the borrower entered IBR. Because of this cap, many attending physicians would pay off their loans through IBR before the 25-year forgiveness period expires.

IBR is least used by today’s graduates with the introduction of these next two options.

PAY AS YOU EARN

PAYE was launched in 2012. PAYE limits payments to 10% of a borrower’s discretionary income (instead of 15%), and taxable loan forgiveness would be granted after 20 years of repayment.

The payment cap is also the borrower’s 10-year standard repayment amount, and PAYE is a qualifying repayment plan for PSLF as well.

Only borrowers who have no outstanding balance on a federal student loan issued prior to October 1, 2007, and who took out a federal student loan on or after October 1, 2011, are eligible.

REVISED PAY AS YOU EARN

REPAYE become available in December of 2015, and it may make sense for continuing housestaff to consider entering it. It offers:

  • 50% of accruing interest paid by government (unsubsidized loans become partially subsidized!)
  • 10% of discretionary income required (just like PAYE), and also PSLF eligible. If you switch into REPAYE from IBR, the 10-year forgiveness clock won’t reset (unless you consolidate)
  • Household income will be used regardless of how you file taxes
  • 25-year taxable forgiveness for graduate students
  • No cap to payments (10-year standard in IBR & PAYE)

Once you enter one of these IDRs, you cannot be removed from it (although you can switch between them as appropriate), even if the hardship that qualified you does not exist after training. (Hopefully the hardship does not continue, and you have an increase in income!) Therefore, a critical part of your repayment strategy is to perform an analysis and determine the best course of action based on your salary and sector of employment after training.

Paying more

I’m often asked, “If I can afford to make larger payments than required in an IDR while I’m in residency or after, should I?”

This is an important question, and my answer is somewhat counterintuitive. I generally believe you should NOT pay more than required through an IDR during training, because those overpayments likely compromise both your subsidy savings and potential loan forgiveness. In addition, unlike in forbearance, interest is not capitalized while you’re in training and have the hardship that qualifies you for these programs.

Instead of overpaying on your loans, I would suggest placing that extra in a money market or savings account. Even if you get 1% return on these funds, it’s actually outperforming the accruing interest on your loans because the interest isn’t capitalizing during your training.

If your employment after training no longer positions you for significant loan forgiveness, you’ll be able to apply this savings toward the repayment of accrued interest before it capitalizes.

If you remain employed by a non-profit or government entity after training, this savings can be retained and allocated to other vehicles.

PUBLIC SERVICE LOAN FORGIVENESS

Often the most generous federal program young physicians can leverage today is the Public Service Loan Forgiveness Program (PSLF).

Approved by Congress in 2007, this program provides tax-free loan forgiveness for anyone employed by a federal, state or local government organization, or directly by a 501(c)(3) nonprofit.

For a majority of medical graduates, full-time qualified employment combined with 120 monthly payments (10 years) under an income-driven repayment plan (IDR) can result in a much lower out-of-pocket cost than the amount borrowed.

Many medical graduates begin pursuing this program at the onset of training, as their residency years usually count as public service, and the IDR plans make economic sense during that time. As a result, there are an increasing number of physicians who are seeking PSLF-qualified job opportunities post-training today. Due to an evolving legislative climate, recent and proposed changes may impact the appropriate action plan to maximize PSLF, and understanding this marketplace can only help you.

Understanding your salary equivalent

An overlooked yet critical consideration for medical trainees today is what I call the “PSLF salary boost.” Though it’s understood that academic positions typically offer lower salaries than private practice roles, “the gap between academic and private salaries is closing,” says anesthesiologist Mike Greenberg, M.D., who graduated from St. George’s University in 2014 and transitioned to an academic position at Johns Hopkins after four years of PSLF-qualified training.

“For me, pursuing PSLF was a no-brainer,” Greenberg says. But several years ago, misinformation and a lack of education at medical school graduation left many graduates unaware or misinformed about how to maximize this opportunity. Greenberg took it upon himself to learn about the PSLF program and eventually found Doctors Without Quarters (DWOQ) to guide him while he focused on his training.

As Greenberg can attest, student loan savings should be factored into the economic analysis of any PSLF-qualified job. This can often make nonprofit roles more economically attractive than for-profit opportunities.

In the chart above, the salary “boost” is represented for a graduate who had $250,000 in debt at graduation, did four years of training with a PSLF-qualified employer, and then was offered two jobs: one with a nonprofit at $175,000 in starting salary, and one with a for-profit at $200,000.

For the six years following training, the nonprofit salary was worth an additional $73,000 per year when PSLF savings was contemplated as a pre-tax salary boost.

The risks of repayment plans

Recent headlines about 99% of Public Service Loan Forgiveness applications being denied have created unnecessary alarm for many graduates pursuing PSLF. These headlines certainly do not inspire confidence for those purposely paying the least amount possible with hopes of having their debt forgiven tax-free, but these headlines were no surprise to this author.

The PSLF program was introduced 11 years ago with little media attention and even less guidance from the U.S. Department of Education and their loan servicers. Borrowers likely pursued PSLF without reading the details of how the benefit worked. Here’s a quick list of the reasons PSLF applications are denied:

  • Ineligible loans: Only federal direct loans are eligible for PSLF. Federal Family Education Loans (FFEL), Perkins, private and other types of loans are not eligible.
  • Insufficient payments: People applied for forgiveness prior to making the necessary number of payments, thus increasing the number of denials.
  • Wrong repayment plan: We have seen many new clients using extended and graduated repayment plans that are not PSLF eligible.
  • Paperwork errors: Of the denied applications, 28% were due to missing or incomplete information.

By using the Employment Certification Form for PSLF, available from the Department of Education, graduates with direct loans using an IDR while working full-time for a qualified employer receive confirmation of qualified payments along the way.

Regarding future changes to PSLF, borrowers at nonprofit programs should be reassured by a few things. For one, the Master Promissory Notes you signed to borrow each loan for medical school included language about PSLF and your right to utilize the program. Thus, a legal contract between you and the federal government says you borrowed under the assumption that you’d be able to utilize the PSLF program under the terms of the program at the time you took out the loan.

Secondly, if you’re actively working towards repaying your loans through the PSLF program and have made economic decisions based on the program’s details, you’ve demonstrated a reliance on the terms as they exist today. As such, the federal government may be obligated to grandfather you and others in the same situation through any changes to the laws.

Even if you do everything right in the pursuit of PSLF, there’s still risk associated with waiting 10 cumulative years before applying for this tax-free forgiveness.

For example, a client of ours who was six years into practice with a 501(c)(3) hospital was recently notified that his employer was being bought by a for-profit organization. Through no action of his own, once his paycheck is being issued by the hospital’s new owner, he’s no longer PSLF-eligible and would need to change jobs to remain on track for forgiveness.

Physicians should always be saving money to grow alongside accruing interest while they are making reduced loan payments through an IDR in the case of unforeseen circumstances that disqualify them from loan forgiveness.

Navigating the complexities

If you’re not staying abreast of your options as you progress in your career, be sure to identify and work with an advocate incented to help you maximize your savings vs. those who may have a conflict of interest, such as a lender or servicer. Also, take note that traditional financial advisors, including those with CFP designations, are usually not trained on the concepts covered in this article.

The student loan repayment marketplace has become much more complex over the past decade. And though debt levels are high, unique and often substantial opportunities for savings exist for those who navigate the marketplace strategically.

Jason DiLorenzo is the founder of Doctors Without Quarters LLC, a national student debt advisory firm dedicated to the financial wellness of early-career graduate health professionals.

 

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Is moonlighting right for you

The pros and cons of working extra shifts.

By Karen Edwards | Fall 2019 | Feature Articles

 

Moonlighting gave Justin Smith, M.D., experience in clinical decision-making. – Photo by Lindley Battle

Moonlighting isn’t a new practice, but lately, it’s become increasingly common. The physicians choosing to do it span a wide variety of specialties and settings. Some begin moonlighting as early as their second year of residency, while others pick up additional shifts even after they’ve officially retired.

Physicians’ reasons for moonlighting vary, but the increasing trend can be traced, at least in part, to a shortage of physicians. In 2016, the Association of American Medical Colleges predicted that the U.S. will face a deficit of 61,700 to 94,700 physicians by the year 2025. No wonder more and more opportunities to moonlight are becoming available. Here’s what you should know as you consider whether or not those opportunities are right for you.

Internal vs. external moonlighting

“There are two types of moonlighting,” explains Richard Williams, M.D., residency program director at the University of Nevada, Reno. Internal moonlighting means picking up extra shifts with your current employer or, if you’re in residency, within your residency program under faculty supervision. External moonlighting means working for a different hospital or employer altogether.

Since many residents are working with a limited license, external moonlighting isn’t an option for them. However, some residency programs, including the University of Nevada, do offer internal moonlighting opportunities. “The faculty supervision and moonlighting within the residency program is why internal moonlighting can be done with a limited license,” says Williams.

Behind the moonlighting controversy

Before you sign up for extra shifts, it’s important to recognize that the practice is sometimes controversial, especially for residents. Some residency programs won’t allow moonlighting, period. Others only allow third-year residents to moonlight. Most require residents interested in moonlighting to receive written approval from a supervisor or program director.

At the University of Nevada, for example, moonlighting by residents is permitted but not necessarily encouraged. “Any discussion of moonlighting in our program is driven by the residents,” says Williams. “It’s not something we bring up. The university’s moonlighting policy is published on our website, so if a resident wants to see what it is, there’s that option.”

Beyond program-specific rules, residents must obey the Accreditation Committee for Graduate Medical Education’s guidelines. The ACGME has capped the number of educational and work hours for residents at 80 hours per week. “The 80 hours applies to all work the resident performs, whether the extra shifts are internal or external,” explains Catherine McCarthy, M.D., professor of family and community medicine at the University of Nevada. Picking up extra shifts runs the risk of putting residents over that limit.

As for hospitals, most consider staffing moonlighting shifts “a necessary evil,” according to Dan Bensimhon, M.D., who moonlighted as a cardiology fellow. Keeping a hospital staffed at all hours is a logistical nightmare. A flu epidemic or mass emergency could strike at any time, but a lull could leave them overstaffed with full-time doctors—at the expense of a hospital’s bottom line.

“Many hospitals will typically staff toward their average census for a given season and fill the gaps with part-time physicians or doctors looking to pick up extra shifts,” explains Bensimhon. “Others will contract with locum tenens groups to fill those slots.”

This may explain the increasing number of physician-founded, physician-owned companies picking up the moonlighting baton. Suneel Dhand, M.D., for example, cofounded DocsDox, an online resource that connects moonlighting physicians and health care facilities, and Bensimhon formed Moonlighting Solutions to help physicians find moonlighting opportunities and help hospitals understand their staffing needs.

Some of these companies cater specifically to non-hospital employers. CrowdRx, founded by Andrew Bazos, M.D., an orthopedic surgeon specializing in sports medicine, provides medical services to concerts, sporting events and other large events. Its chief operating officer, Connor Fitzpatrick, says that while these setting are different from a hospital, the same skill sets are required.

The advantages of moonlighting

Financial benefits

For residents especially, the extra money moonlighting provides is alluring. “You’re restricted by what you can make as a resident,” says Daniela Lamas, M.D., a pulmonary and critical care physician. When she began to moonlight, the extra paycheck gave her more money than she was making as a resident—and her first taste of the future.

“I saw it was possible to make good money at something I love doing,” she says. The extra shifts also helped with student debts and the high cost of living during her residency at Columbia University College of Physicians & Surgeons in New York City.

Paying down debt is a powerful motivator for many physicians, but there are other ways to generate income outside of moonlighting shifts. “I never moonlighted as a resident,” says Joel Schofer, M.D., although he now does so in addition to serving as a military emergency care physician. During residency, he earned extra cash by writing articles for professional publications.

Of course, residents aren’t the only ones who enjoy the financial benefits of moonlighting. “Traditionally, there were two main groups who moonlighted: Physicians at the beginning of their careers, including residents and fellows, who moonlighted to supplement their income and pay off debt,” says Dhand. “The second group included physicians at the end of their careers who were looking to wind down their practices but also continue their income stream.” Schofer notes that more and more physicians lately have turned to moonlighting to supplement stagnant income levels.

Increased independence

Justin Smith, M.D., is an electrophysiology fellow at Wake Forest Baptist Health and a hospitalist for Cone Health Medical Group and several locations of Novant Health. He saw moonlighting in residency as a chance to “test the waters in making clinical decisions.”

Similarly, Bensimhon says it helps residents develop decision-making skills. “In residency, you make decision by committee,” he explains. “Moonlighters learn to trust their own judgments and become more confident in their skill sets.”

The opportunity to understand the full medical experience is what drove Ameeth Vedre, M.D., to start moonlighting during his cardiology fellowship. “I learned what it’s like to act as the cardiologist of the day. It gives you a huge advantage over those who don’t moonlight,” he says. “You have the ability to pick up the ropes faster and to build your confidence level.”

“When you’re a resident, you’re under certain constraints you don’t have on a moonlighting shift,” says Lamas. “There’s a greater sense of autonomy when you moonlight.” Even seasoned physicians experience a sense of freedom from moonlighting. “Physicians at all stages of their careers—increasingly frustrated with modern-day clinical practice—are also moonlighting as a way of regaining some autonomy and control over their schedule,” says Dhand.

Exposure to new situations

Moonlighting can also expose you to patients you might not otherwise see as a resident or in your daily practice. That helps build confidence and knowledge. For example, Schofer says military physicians outside of combat zones “are working primarily with a young and healthy population.” In order to see the full scope of patients, these physicians need to practice outside the military. “It’s something I’d encourage,” he says. “It helps put military physicians on par with their colleagues.”

Military physicians aren’t the only ones who need additional exposure. “These days, especially in the area of primary care, a physician will diagnose a problem, then a specialist is brought in to treat it,” says McCarthy. At rural clinics, residents who moonlight are able to both diagnose and treat the problem, so they learn and do more than their non-moonlighting colleagues.

Matt Friedman, M.D., an emergency physician and medical director at CrowdRx, says that pay is a tertiary concern for many of the residents who work the company’s events. They’re primarily interested in the learning experience. “You can make more money working in the ER,” he says. “We even have some medical students who do research for us. They find it’s an eye-opening experience as well.”

Experience working with and managing a team

Moonlighters also learn how to work alongside other medical personnel. Fitzpatrick says, “At our events, residents learn and experience what it’s like to be on the other side of the hospital run. They experience what it’s like to work with first responders onsite. For many, it’s their first opportunity to do so.”

It’s not just learning to work with hospital teams, says McCarthy. She has worked with University of Nevada residents at a Burning Man concert and explains, “Yes, you learn what it’s like to supervise, but you also learn how to work with patients from all over the world.” That’s an opportunity that these residents only were able to experience through moonlighting.

A chance to test drive without commitment

External moonlighting offers yet another advantage: the chance to test drive a job or hospital without making a commitment. “By working a few moonlighting shifts, you can determine if the hospital’s culture, position and personnel are going to be a good fit for you,” Schofer says.

Vedre agrees: “It’s a benefit for you and an employer to judge how the relationship will work. And it gives a moonlighter an opportunity to look at a variety of different systems to find the best fit.” Some physicians even like moonlighting so much that they look into locum tenens arrangements.

Having a trial period can be a major benefit to residents who aren’t sure what setting they want to practice in. “Nearly half of physicians will leave the first job they take after training within two years,” says Bensimhon. “By moonlighting with a hospital or practice during their fellowship, moonlighters get a chance to sample different jobs and hospital settings, and they are more likely to find the right job the first time around.”

It’s also a major benefit to the hospitals. Williams says family medicine residents at the University of Nevada, Reno who take the opportunity to moonlight in rural emergency rooms often decide to locate to rural areas to practice. This is a huge plus for these communities, which are often notoriously short of physicians.

The downsides of moonlighting

An increased risk of burnout

Practicing physicians and residents have demanding schedules as it is. If you’re not careful, adding hours to your workweek is a quick way to wear yourself thin. However, moonlighters say this can be avoided by setting hours that work for you and your lifestyle. “I never experienced burnout,” says Smith. “If I was getting close, I adjusted my hours.”

Moonlighting terms differ, but the arrangement usually involves contracting for a block of time, such as an entire weekend, or spreading the time throughout the week, such as a few hours in the evenings.

No matter how you choose to moonlight, McCarthy says to remember: “Sleep is important.” That’s one of the major reasons residents are capped at 80 hours of work a week, and it’s easy to neglect rest if you’re not careful.

At one point, Lamas was moonlighting at two different hospitals in addition to her full-time research fellowship. “I realized I was becoming exhausted, and I cut down from as many as five shifts a month to two or three. Eventually, I gave up one of the moonlighting jobs,” she says. “The money is great, but you can’t afford to drop the ball on your health or on the work you do in your current position.”

Less time for family life

Many physicians are drawn to moonlighting because it offers the opportunity to provide more for their families. However, there are two sides to that coin. If you’re working more, you have less time to spend with your family, which can wreak havoc on quality time.

This is especially true because of the times of day and year when moonlighters tend to work. Vedre says opportunities to supplement income usually come from working odd hours, including weekends and holidays.

To ensure that extra shifts don’t put a damper on your family life, Vedre recommends keeping an open dialogue with your loved ones. “Discuss your moonlighting opportunities with your family, and decide together what will work best for everyone,” he says.

Increased responsibility

Increased independence is one of the reasons physicians decide to moonlight in the first place, but this autonomy is a double-edged sword. “Moonlighting can be empowering,” says Lamas, “But it comes with a huge responsibility.

“Anything can happen at night,” says Bensimhon. If you do decide to moonlight, you will still have access to more experienced physicians, but you have to be ready to handle whatever comes up. That can be trickier at some locations than others.

On a hectic night, this can quickly place you outside your comfort zone. “Moonlighting in a high-risk area can also expose you to potential legal risks,” adds Schofer.

If the increased responsibility worries you, you’re not alone. “Not all residents are ready to moonlight,” says Smith. But if you decide to start as a resident, it’s best to ease yourself in. “Start moonlighting internally first,” Smith recommends. “If you moonlight externally, be careful with where and how much you moonlight. You don’t want to be in a position where you’re over your head in terms of the kind of patient care you can deliver.”

Before you moonlight

If you decide to moonlight externally, you’ll be an independent contractor, not an employee. That means there are a few additional factors to consider.

1 Ask about liability insurance

It will be up to you to determine who pays for your liability insurance. “If you are moonlighting externally, you are no longer working as a resident and no longer under any supervision,” Williams says. “That means you need to make sure your malpractice insurance is provided for.”

Bensimhon agrees, adding that it’s best to confirm these details ahead of time: “Ask [prospective employers], ‘What kind of coverage will I have?’ If it’s occurrence-based coverage, that’s fine. Everything is covered. But if it’s a claims-made policy, make sure it comes with a tail.”

Military physicians are covered by the government’s tort claims act as long as they are treating patients as part of their duties. But the same may not be true for military physicians who moonlight at a veteran’s center or event. Schofer says, “They think they’re covered because they are treating veterans, but they’re not.” Just like civilian physicians who moonlight at outside facilities, military physicians should also ask what kind of coverage they will receive.

2 Get the right licensure and certifications

Before you begin moonlighting, it’s important to know what your hospital’s moonlighting policy is and then make sure you’re following it down to the letter. You don’t want to get caught violating a contract or a residency policy.

You also need to be sure you have all of the required licenses and certifications. This can be especially tricky if you’re near state lines.

3 Prepare for salary negotiations

As an external moonlighter, you’re functioning as an independent contractor. That means you are free to negotiate any payment structure that both you and the employer can agree to. PracticeLink.com offers a wide variety of resources on negotiating, and it’s best to read up beforehand.

4 Leave enough time for your job search

If you’re considering moonlighting while in residency or while actively looking for your next position, realize that the extra hours might interfere with your job search. “Moonlighting will cut into your personal time,” Williams warns.

Since residents generally start their job search efforts a year out, moonlighting may eat into the time you have to find an employer. On the flipside, a moonlighting position may lead to a full-time job—especially if you are moonlighting in order to test drive a position or facility.

5 Wait for the right opportunity

There are plenty of moonlighting opportunities out there. That means you can afford to be picky. Make sure the opportunity involves the type of work you want to be doing. “Moonlighters like to feel good about the work they do,” Bensimhon says. “Although the money is important to help make ends meet, making a difference for patients is what really makes the extra work worth it for most of us.”

You should also make sure you know who you’ll be working with and for. “Research the hospital or company you will moonlight for, and make certain it is a bona fide company,” says Fitzpatrick. “Verify who exactly you will work for.”

Is moonlighting right for you?

All of those interviewed here would recommend moonlighting to colleagues. But ultimately, Vedre says, “It’s an individual decision—and one that should be made thoughtfully.”

Smith adds that one lesson he learned as a moonlighter is that medicine is not as clear-cut as it’s often presented in residency. “I discovered nuance,” he says. That’s the kind of lesson that comes usually after years of experience.

Finally, Lamas says that while moonlighting isn’t a good fit for everyone, the benefits outweighed the downsides for her. “Everything is a trade-off,” she says. “But I consider every incremental experience I’ve had as a physician, whether moonlighting or on my regular job, as increasing my education. All of it has made me a better physician.” 

 

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What’s in a compensation package?

Before you can negotiate, understand how your offer was created.

By Debbie Swanson | Fall 2019 | Feature Articles

 

“Consider what you bring to the position,” recommends Rose Berkun, M.D. “Assess your own self-worth.” – Photo by IHNY

You may be focused on salary when you’re job hunting, but salary alone isn’t an accurate portrayal of compensation. Other elements of a benefits package have significant monetary implications, and even benefits without dollar signs attached can make a major difference when it comes to work/life balance. If you don’t take these into account as you negotiate and consider offers, you could be leaving something on the table.

“Upwards of 25 to 35 percent of a comp package is the benefits,” says Richard Roberts, M.D., JD, professor emeritus of family medicine at the University of Wisconsin School of Medicine and Public Health. “Newer doctors don’t often think about benefits. It’s their first time evaluating this. As a resident, you just got what you got. But now, you can negotiate.”

Here’s some inside information on holistically evaluating your compensation package.

Part 1: Understanding salary

In many other professions, employees earn a set annual salary, but that’s not always the case for physicians. “Forms of compensation vary greatly between specialties and practice types,” explains Roberts. “The most common salary model for a new doctor is often straight salary, which may include some productivity-related bonuses.”

You may be offered a traditional fixed salary or one that depends on other factors. Understanding the different models can help you decide which suits your financial and personal preferences.

COMMON SALARY MODELS

A straight or fixed salary is most familiar: comply with the terms of employment and receive a pre-determined sum, delivered incrementally over the year. This model is attractive for planning and budgeting, but it may leave ambitious physicians hungry for more motivation.

Some things to consider with a fixed salary: Is the salary adequate to meet your financial needs? Do you believe it’s a fair amount in terms of your specialty—and on par with what your peers are receiving, regardless of gender or race? When will you be eligible for a raise? How frequently will you get paid: weekly, bi-monthly or monthly?

A variation on the salary model is salary plus incentives or bonuses, which provides a fixed yearly sum plus the opportunity to earn additional financial rewards. These rewards are contingent on certain pre-defined measures, such as productivity, quality, performance, adherence to non-clinical obligations and other factors. This model’s appeal is that it offers the security of a steady paycheck along with the opportunity to earn more.

“Lots of institutions have bonus structures, [which] are highly variable,” says Jennifer Hunt, M.D., chair of the department of pathology and laboratory services in the College of Medicine at the University of Arkansas for Medical Sciences. “More and more, I think, are relying on RVU-productivity-type bonuses, where if an M.D. has a productivity at a certain benchmark level then they will get a bonus after that level.”

Some things to consider with salary plus bonuses: What is the breakdown of salary versus bonuses and incentives? Is the salary alone enough to meet your financial needs? Are the incentives clearly defined, or are they subjective? Can you satisfy the incentive criteria by yourself, or will you have to rely on other individuals or departments to reach your goals? Are the requirements fixed or subject to change?

Other salary models are productivity-based, meaning your salary is calculated using your contributions to the practice. This model may appeal to physicians highly focused on improving the practice or bringing in new business, yet it is sometimes criticized for fostering a competitive work environment. A variation on this model is a conversion plan, which allows you to earn a fixed salary for the first few years then change to a productivity-based model.

Some things to consider with a productivity-based arrangement: Are earnings based on RVUs, total amount billed or total amount collected? If earnings are based on collections, what percent of billings does the group typically collect? What is the breakdown of patient insurance types (commercially insured, Medicaid or uninsured)?

A different type of model is the equal shares arrangement, which is common in group practices. After deducting expenses from yearly earnings, the remaining funds are divided among the physicians. This incentivizes everyone to work toward a productive year, but some downfalls include a lack of tangible recognition for high performance, skill level or experience.

Some things to consider with equal shares: Does the physician group have a wide range of skills within the physicians employed? Are there any additional incentives to compensate high producers?

The capitation model has dropped in popularity since its peak in the late 1980s and early 1990s, but some regions of the United States still use it today. With this model, your salary is based on the number of patients enrolled with a health plan for a certain amount of time. This model is often praised for delivering efficient care, as there are no incentives for tests or additional procedures. However, some physicians criticize capitation for a lack of control over salary because it’s dependent upon enrollment rather than care provided.

Some things to consider with capitation: Are there any modifications in place to adjust for patients who require extensive services? Are there any bonuses in place?

WHAT SALARY MODEL IS BEST FOR YOU?

When interviewing, you should research what compensation methods are common in your region and your specialty, but choosing the best one for you is a personal decision. Consider the following questions:

  • What hours are you able to work? What hours do you prefer?
  • What are your fixed financial obligations?
  • What are your long-term financial goals?
  • Are you comfortable with a variable income?
  • Do you enjoy marketing your services and promoting your business?
  • Do you want the potential to earn more?
  • Do you work better when presented with incentives?
  • What is your work style? Are you more comfortable with a defined workload, or do you like to control your own productivity?

FIXED OR VARIABLE?

Variable physician salaries allow you to earn more by increasing productivity or meeting other goals. This model has obvious upsides, especially if you’re highly motivated by financial incentives. However, you should take time to consider all the aspects involved.

“If the M.D. relies on hospital systems, ancillary staff whom they don’t manage, or advertising and market share for the institution (not the practice), productivity could suffer as a result of executive decisions,” explains Hunt. “For example, if a surgeon cannot book cases because the hospital is always full and there are ER diversions, then they might not meet productivity targets, through no fault of their own.”

She adds that compensation models based heavily on productivity can present some challenges, explaining, “Although incentives and bonuses based on added productivity can be great, I think it is also strategic to get as much in guaranteed base compensation as possible, especially if the M.D. is going to rely on the hospital or system for the functioning of their practice.”

BE AWARE OF WHAT’S FAIR

In a perfect world, salaries would be consistent across the board, and any differences would be based upon measurable factors, such as experience or performance. But in reality, inequities exist. The best way to protect yourself is with knowledge.

“Do your research ahead of time,” says Rose Berkun, M.D., clinical assistant professor of anesthesiology at the University of Buffalo Jacobs School of Medicine and Biomedical Sciences. “Medscape’s [annual physician compensation report] is a good place to turn.” You can also ask your alma mater or specialty associations for any studies or data they have on current physician salaries.

Once you’ve determined what’s typical for your personal situation, specialty and geographic area, reflect on your past accomplishments, education and training. “Consider what you bring to the position,” Berkun encourages. “Assess your own self-worth. Have you done research, been published or volunteered somewhere, such as at Doctors Without Borders?”

“Be aware of the gender pay gap,” recommends Berkun. “Women should be offered the same salary as their male counterparts.” However, this isn’t always the case. Medscape reports that male physicians earned 18 percent more than female ones in 2018, compared with 16 percent more in 2017.

Don’t be afraid to speak up, whether that means making a case for your own worth, questioning inequality, or simply requesting a higher starting figure. “If you start at a disadvantage, the gap only increases,” Berkun says.

Don’t forget to consider call, lifestyle and even commute time, recommends Jennifer Hunt, M.D. – Photo by Ashley Sanders

Part 2: What else do you need?

Salary is only a starting point. Dig deeper into the details of your package to tally up the impact of benefits. For example, a relocation allowance can help during a move, while an attractive family health plan can ease your finances throughout the year.

“The total compensation package is more involved than you’d imagine,” says Roberts. “Classically, the focus of a package is the two Cs: cash and call. Physicians look for a lot of cash and less of call. However, the importance of those issues fades after the first few years as other parts become more important: disability, life insurance, time off, continuing education, as well as the people you’re treating and the community you’re working with.”

Here’s a rundown on some of the benefits most important to a physicians.

CALL EXPECTATIONS

For most physicians, being available to respond to patients during off hours is just part of the job. This is especially true for newer physicians. Your comp package should outline the frequency, compensation and logistics of call.

“Usually with larger groups, you’ll have less frequent call,” says Berkun, adding that call requirements also vary by specialty. “For example, I’m in anesthesia and have to be physically present for calls. With other specialties, such as pediatrics, you may be able to take some calls from home.”

Understand your employer’s expectations upfront and be realistic about the impact call will have on your personal life. Be mindful of your family and others important to you. If you aren’t at home often—or are frequently interrupted during your free time—everyone’s happiness is affected.

Compensation for call is also important. According to Becker’s Hospital Review, the four most common methods are: a daily stipend (36% of respondents), an hourly rate (27%), a per-shift stipend (14%), and an annual stipend (12%). Each of these has its pros and cons, and you need to keep in mind that additional earnings from call may be offset by the need to hire household support or childcare.

MALPRACTICE INSURANCE

Everyone needs insurance . Typical benefit packages include medical, vision, dental, life and disability policies. But for physicians, there’s one more potentially career-saving benefit to consider: malpractice insurance. Before signing a contract, you need to understand what kind of malpractice insurance your employer offers and how much it will cost you.

The cost to you varies greatly from employer to employer. A hospital, academic institution or large practice group may contribute to your premiums, while a smaller group or practice may expect you to pay it all yourself. Some employers take regular contributions from your salary, while others require a lump sum upon termination of employment. Additionally, premiums for some policies vary over time or are based on years of service, so it’s important to understand how they are calculated.

As for the type of policy, malpractice insurance falls into two categories: occurrence-based and claims-made. Occurrence-based policies cover you for any claim made against you while you were working on behalf of the employer, regardless of when the claim is raised. If a patient files a claim 10 years after you changed employers, you are still covered. Claims-made policies only cover you while you are an active employee. If a claim is raised post-termination, the policy will not cover you—even though you were an active employee when the event in question took place.

If your contract offers a claims-made policy, you’ll want to add an extended reporting endorsement, also known as tail insurance. This critical yet costly addition extends claims-made malpractice coverage after termination. And no matter what else is in your contract, make sure that a lawyer reviews the malpractice terms and that you understand any limits or maximums.

PAID TIME OFF

You may be expecting to work long hours, but even so, everyone needs time away from the office. Your compensation package should detail an amount of paid time off. According to SullivanCotter, physicians’ annual PTO benefits typically range from 25 to 35 days. This may be presented as a bundle, or the days may be designated for specific types of leave, such as:

PAID VACATION TIME

Vacation supports a healthy family life and a good work/life balance. Having more of it may help prevent burnout, while having too little may leave you stressed. According to the 2017 Medical Group Management Association Provider Compensation Survey, physicians typically receive three to seven weeks of vacation time.

PAID SICK LEAVE

Some employers require you to accrue sick days by working a certain length of time, while others offer an allotted number per year or even unlimited sick days. It’s helpful to know what you can and can’t use these sick days for and if you’re allotted any personal days. These allow you to take paid days off without dipping into your vacation days.

FAMILY LEAVE

You should also discuss plans regarding family leave and understand what your employer offers. “Maternity and family leave is important to negotiate ahead of time,” says Berkun. “Some states have a mandate for time off, [which means] you won’t lose your job but no mandate for it to be paid. Negotiate for both the number of weeks off and if it’s paid.”

Similarly, the Family and Medical Leave Act of 1993 requires that any employers with more than 50 employees maintain a job for any employee who must take time off due to a family obligation. However, there is no requirement that this time be paid.

EDUCATION AND PROFESSIONAL ENRICHMENT

To keep your knowledge current and renew your medical license, you’ll need to continue learning by taking courses, attending conferences and maintaining professional organization memberships.

“Continuing education benefits have shrunk greatly over the years,” says Roberts, adding that an allowance for this can mean sizable savings for a physician. “Things like a membership to a specialty society can run anywhere from $750 to $1,500.

In addition to coverage for courses or events, you’ll want to make sure you’ll receive your salary while you’re away from work, as well as a stipend to cover expenses related to travel, educational supplies and food.

According to SullivanCotter, annual allowances for CME typically range between $3,500 and $5,000 with paid time off between five and 10 days.

While it’s possible to save money by meeting educational requirements online, Roberts points out that there are benefits to gathering in person with colleagues.

“Attending a conference or class is a useful form of networking and helps to avoid becoming disconnected from other physicians,” he says. “I’ve always come away feeling energized and with new ideas.”

APP COMPENSATION

Advanced practice providers (APPs) are skilled medical professionals qualified to extend or provide patient care, such as nurse practitioners, physician assistants, behavioral health specialists and more. The use of APPs is widespread; however, most states require some level of physician supervision or direction.

Your package should explain how much time you’ll spend overseeing APPs, and your compensation may depend partially on how much time you spend with APPs. This might be measured by hourly rate or patient encounter, or your employer might apply a revenue-less-expenses model.

According to the 2017 SullivanCotter Physician Compensation and Productivity Survey, approximately 71% of hospitals surveyed have physicians who supervise APPs. Of these, 48% provide compensation for APP supervision in addition to a physician’s base salary.

RECRUITMENT INCENTIVES AND BONUSES

The United States is headed toward a significant physician shortage, which is good news for physicians on the job hunt. According to a 2017 study commissioned by the Association of American Medical Colleges, the deficit is estimated to reach a shortage of 8,70043,100 for primary care physicians, 19,80029,000 for surgeons and 18,60031,800 for specialty physicians by 2030.

With employers eager to recruit talent, incentives are a common part of the compensation package. Look for relocation reimbursement, student loan payments, a signing bonus or other pre-determined bonuses. Don’t be afraid to consider these issues when negotiating.

As with any part of your package, read the terms carefully and ask questions. For example, with any bonus money delivered at the start of your employment, find out if you incur a penalty if you do not remain employed for a set period of time. Similarly, make sure a bonus is truly additional money, not a front-loaded portion of your salary.

RETIREMENT

It’s never too early to think about retirement, even if you’re fresh out of residency. Retirement contributions equate to money in your pocket, as well as peace of mind, and they’re a key piece of any compensation package. SullivanCotter reports that the average employer retirement contributions range from 3 to 7% of salary. This may be paid through an employer contribution, a matching program or a salary deferral.

Part 3: Pulling it all together

You’ve thought about salary, considered benefits and arrived at a fair approximation of the financial worth of your package. But you’re not finished yet. There are a few other factors that may not be spelled out on paper but will influence your financial situation and personal satisfaction nonetheless.

REGIONAL ISSUES

Housing, groceries, transportation, taxes and other expenses vary depending on where you live. In an area with a high cost of living, even a large paycheck may quickly disappear. Conversely, you may live quite comfortably on a mediocre salary in an affordable area. Before making decisions, research a region’s cost of living and run your salary through a cost of living calculator.

Malpractice insurance premiums also vary by region, since there are different laws and coverage requirements in different states. A lawyer in the area is usually the best source of information on what’s required and how much you should expect to pay for it.

Finally, physician supply and demand can be wildly different from city to city and state to state, and your specialty makes a difference. “It’s a market economy,” says Roberts. “Be aware of the market rates in your area. For example, central and southeastern United States is the highest salary for a family M.D.

SUPPORTING A HEALTHY LIFESTYLE

Financial security is important, but so is your happiness and that of your family. Keep potential burnout in mind as you evaluate your compensation package, especially since 44% of responding physicians reported feeling burned out in Medscape’s 2019 report.

Job factors that can add to or prevent burnout include call hours, paid time off and insurance benefits, but sources of stress or comfort are different for every individual. For example, if student debt is a major area of personal worry, a loan repayment benefit may add to your peace of mind and reduce your risk of burnout.

Scheduling also has a huge impact on personal contentment. You may be full of focus and dedication as you head into your new job, but even so, you need to be realistic about your need for rest and relaxation.

An all-work-and-no-play approach is never successful.

“Things I often see people forget to account for are commuting time, excessive call requirements, mandatory extra duty (particularly for short-staffed services), and whether a group or department is family-friendly,” says Hunt.

Measure your commute time carefully. A good schedule may not be as great as it seems if you have to spend a long time in transit.

“Your commute never comes out of your work time,” says Hunt. “It comes out of your home life time. Carefully factor how much time you will be at home, versus not at home.”

Other benefits that support a healthy lifestyle include wellness programs, onsite gyms or membership reimbursement, opportunities for sabbatical leave, flexible work schedules, physician lounges, family and/or spouse support groups and mentorship programs.

Understanding and selecting a compensation package is a major endeavor, particularly early in your career when the terminology and expectations may be fairly new to you.

For the best outcome, seek the expertise of seasoned physicians as well as a health care attorney. Remember that your happiness is closely tied to that of your loved ones, so you should listen to their needs and concerns.

Finally, be flexible and don’t stray too far from your established priorities with your final decision. 

 

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Physician, know thyself

Identifying your best work environment starts with asking yourself these questions.

By Marcia Horn Noyes | Feature Articles | Summer 2019

 

Tiffany Shiau, M.D., changed her specialty after a period of soul-searching. – Photo by Jonathon Evans

As Tiffany Shiau, M.D., neared completion of her medical degree from Sidney Kimmel Medical College, née Jefferson Medical College, many people gave her advice about which specialty to choose. Often, the refrain went something like this: “Hey, I did this rotation in ophthalmology, and I think it would be a great fit for you.”

Shiau knew ophthalmology offered controllable hours and fewer night calls, two of the lifestyle factors physicians covet most. After all, it’s the “O” in the so-called ROAD to happiness: radiology, ophthalmology, anesthesiology and dermatology. But when she finally decided on ophthalmology, she wasn’t just banking on a catchy phrase or her colleagues’ advice. She also considered her own experiences.

“At Jefferson, we were affiliated with the Wills Eye Hospital, one of the nation’s top eye institutes,” Shiau says. “Everyone there was amazing. And as a medical student trying to determine what daily routines are like for different specialties—as well as determining how happy people are in their field—I spent time considering whether I could see myself hanging out with these people outside of work.”

After weighing all the factors, Shiau gave a resounding yes to ophthalmology. She assumed it would be a good fit for her personally and began her residency in Buffalo, New York. Four months later, she left the program and switched to internal medicine.

“I came to realize that what other people say is just one input. In the end, it doesn’t matter how people see me unless they really know me. Only then might they have a better chance of understanding what values are important to me,” Shiau says. “During this soul-searching time, I asked myself a lot of questions: ‘What is my gut sense telling me? What feels like the right thing to do?’”

As Shiau considered those questions, she realized that although she liked the field of ophthalmology and the people she worked with, she didn’t like the procedural part of the work. In ophthalmology, she explains, “You can’t really avoid operating on people’s eyes.”

By the time med students reach their fourth year, they usually know what specialty and practice environment they want to pursue. Most make a straightforward choice and are happy with it, but that’s not always the case.

Shiau took an extended journey from medical school to the start of one residency to a primary care residency in an academic setting. Two and a half years later, she took a full-time clinician job on the West Coast, and she says she doesn’t regret one piece of the circuitous route.

The path from medical school to residency to practice isn’t always a straight line. According to the Association of American Medical Colleges, almost 75 percent of medical students change their specialty choice before residency. Twenty percent of residents and 16 percent of physicians make a change and head in a different direction. The uncertainty can be daunting for medical students, who are steeped in a culture of perfectionism, accustomed to excelling in academic settings and trained not to show any weakness.

Mirror, mirror on the wall

Taking a long look in the mirror is important for anyone contemplating a new job or career change, but it’s especially critical for physicians. Emergency medicine physician and associate director of an emergency department in Hartford, Connecticut, Joyce Perfetti, D.O., says you can get lost in the job otherwise. She explains: “Doctors love taking care of other people. That’s why we went into this profession. It’s easy to lose yourself in something that you love.”

Self-reflection becomes even more crucial when others are involved in a career decision. “Not only do I need to know what’s important to me, but I also need to know what’s important to my family, my partner,” Perfetti explains, adding that being honest with yourself is imperative during a period of introspection.

“When you are not honest with yourself and you don’t self-reflect on what your priorities are in life and how they balance with your work—whether those priorities are family, travel, health or working out—you are going to feel a loss, and your family might feel that loss as well,” she says. “There are other things important in your life, and you don’t want to sacrifice those. You don’t want to neglect your family, and you don’t want to neglect yourself.”

Not surprisingly, self-neglect is rampant as physicians juggle competing priorities. Often, they put professional obligations above their own needs and push their bodies to do more with less sleep. Physicians have been known to cope with work pressures in unhealthy ways, including consuming excess caffeine or sugar, skipping exercise and even using drugs. The joy of practicing medicine dissipates, and burnout hits hard.

Perfetti says burnout can be prevented by paying attention to mental health and taking time for recreation. “When you start feeling tired and on days off start losing interest in those things that you love, it’s perhaps time to work out, go for a hike with your family or take a much-needed vacation.”

In the long road to career satisfaction, the only constant is change. Your family situation changes. Your circumstances change. Your goals change. Perfetti experienced this herself during residency. Early on, she thought she wanted to work in a demanding environment, but by the time she finished, her priorities had shifted.

“When I went into residency, I thought I’d work in the busiest, craziest ER I could find. I wanted to see it all and be deeply involved in a trauma center. I thought I wanted that for life,” she says. “If I had stayed in that environment, I knew I would face quite a bit of burnout. Although I did love that for training—and I do love the aspect of it in terms of a long-term career—I didn’t think it was the right thing for me at this time in my life.”

Today Perfetti works in a busy community hospital. Although it’s not a trauma center, the emergency department does see some traumas, and that’s enough for her. “Right now, this is the best fit for me, because it allows me to see a lot of pathology,” she says. “I still see a lot of critical care, it’s just busy in a different way.”

Personal think time

Seeking advice from colleagues, family members and mentors can be helpful, but it’s most important to know your own mind. Your career path, specialty and practice environment are personal choices, and you need to consider for yourself how they align with your lifelong goals—not just someone else’s opinion. Digging deep to uncover your values, interests, personality and skills almost guarantees a richer and more satisfying personal life.

Oftentimes, asking yourself good questions is the most challenging part of reflection. You spend more time with yourself than anybody else does, but that time doesn’t always equate to self-knowledge. Unearthing your own preferences and tendencies can be difficult, but it’s the only way to find much-needed clarity. It will help you identify the ideal practice setting, patient population, specialty and work environment for you. It will also help you find a good fit when it comes to your employer and colleagues.

Questions for getting to the core

Expanding on the Greek maxim “To know thyself is the beginning of wisdom,” Socrates taught that “The unexamined life is not worth living.” And it’s true—examining yourself will have a deep personal impact and help you reach your future goals. But self-reflection doesn’t have to be intimidating. There are no right or wrong questions, just different ways to approach the process. One easy way to start is by following this framework.

1 Consider your interests (your hobbies, passions or anything that captivates your attention):

  • What activities in my life kindle a fire inside?
  • What activities would I miss if I could no longer do them?
  • As a child, what types of activities did I do that led me into medicine?
  • If I didn’t have to worry about money, what would I be doing?
  • What gets me riled up? What problem in the world would I most like to fix?
  • What topics do I find myself always arguing against or defending to others?

2 Consider your personal values (your strong beliefs, personal missions and anything else meaningful in your life):

  • What is something true in my life no matter what?
  • What would I like to avoid in my future career?
  • What does quality of life mean to me?
  • Which core value can I not compromise on?

3 Consider your personality (your temperament and preferences):

  • How do other colleagues, mentors and family perceive me?
  • What kind of work environment best suits my personality?
  • What work environments would feel restrictive and stifle my enjoyment of medicine?
  • What type of colleagues do I like working with?
  • What type of patients do I like caring for?

4 Consider your strengths and weaknesses (your talents, abilities, skills and character):

  • What are my strengths and weaknesses?
  • What is one medical task I love doing even when I’m exhausted and under pressure?
  • What do I fear when it comes to practicing medicine?
  • What have I done in my life of which I’m most proud?
  • Which failure have I turned into my greatest personal achievement?
  • Do I have a self-limiting belief, and if so, why do I have it?
  • What do I believe is my highest possible achievement in medicine?

5 Consider your family (your partner, spouse and/or children and what they want):

  • How will any decision impact my family or loved one?
  • Will this new work environment benefit my family—or take anything away from them?
  • Do I have the full support of my partner and family with my new job prospect?

By asking probing questions to uncover your deepest personal values and desires, you’ll be more likely to find the right practice environment. And if you’re still struggling to answer these questions, ask yourself one more: “Who knows me well enough to help me decide which work environment is right for me?”

For Shiau, a big part of her decision to trade an academic setting on the East Coast for a full-time internal medicine clinical setting on the West Coast was her desire to connect with people. “Ultimately, when my husband and I decided to move to California, I decided not to stay in academics because my personal values were to provide good, comprehensive, kind care to my patients,” she says. “Two and a half years into my first job, I knew I didn’t want to stay in academics any longer. I wasn’t dreaming up an educational project or anything like that.”

Self-reflection doesn’t end once you find your first practice, says Stefanie Gilbert Manuel, M.D. She sets aside time regularly to consider her goals and progress. – Photo by Whole Heart Studios

Self-reflection beyond the hire

In the two and a half years since she completed her residency, Stefanie Gilbert Manuel, M.D., has been practicing emergency medicine in Rockville, Maryland. She says that self-reflection becomes even more important as your career progresses. “The self-reflection piece drives the process of finding a job, while also giving a frame of reference or focus for the next steps a physician takes with future goals,” she explains. Without that introspection, Manuel cautions that it’s easy to get lost in all the different types of residencies and job environments.

Manuel spent time considering both her personality and preferences while searching for her first job. Right out of residency, she looked at a variety of job settings: academic, community-based, mixed, and those with a teaching focus. She then considered her strengths, weaknesses and values, and she evaluated how different settings lined up with these.

“For me, it was important that once I finished residency that I get out on my own and hone my skills, rather than taking an academic setting position where I would be supervising many residents,” says Manuel. “I needed autonomy once out of residency. It was important for me to formulate my own treatment plans and procedures for my own growth development, which would build confidence.”

As she went on to evaluate each employer, Manuel used specific criteria. First, she looked for physicians at each practice with similar backgrounds to hers, reviewed their track records and asked them for input. Next, she considered the makeup of group practice to ensure they embraced diversity instead of just talking about it. Finally, she evaluated the kind of support each employer gave to physicians working their way up to leadership roles

This self-reflection helped Manuel choose her first position. She signed with US Acute Care Solutions (USACS) because the physician-owned group’s values and mission aligned with her own. “In addition to the company being open and receptive to feedback, the group practice has a big push for women in leadership and embraces diversity,” says Manuel.

Now a practicing emergency physician, Manuel carves out time for ongoing introspection. “I have a note on my calendar, set for every couple of months, to go through and update my curriculum vitae. I spend time reflecting on what I’ve done and then line out the next steps and goals I want to consider.”

By prioritizing introspective habits, she finds she’s more able to remember and document her achievements, which will be crucial for future opportunities. Regular reflection also helps her make sure she’s continually stretching herself and gaining clinical skills.

Perfetti also works for USACS, albeit in a different city. Both emergency physicians value the leadership opportunities they’ve been offered. In fact, both recently completed the company’s year-long intensive leadership course, the USACS Scholars Program, which is designed to “mentor and develop acute care physicians with leadership potential into candidates for leadership positions throughout the company.”

The program is helping Perfetti accomplish goals she set for herself during self-reflection. Early this year, she moved into an administrative position and says it’s a good fit. “Prior to entering the Scholars Program, I felt like I was being drawn to the business aspect of things. I love seeing how the hospital works and also learning more about how the USACS works within the hospitals it serves,” she explains, adding that she’s been able to balance new administrative duties with clinical work. “I love emergency medicine, and I never want to leave it. I still wanted to work full-time clinically.”

Whether you, like Perfetti and Manuel, quickly find the perfect job or, like Shiau, you follow a labyrinthine path to career satisfaction, it’s important to set aside time for reflection. Considering your personal values, strengths and weaknesses will help you start your career on track—and continue to lead a fulfilling life. Because you can only know the right path when you truly know thyself.

Marcia Horn Noyes is a frequent contributor to Practice Link Magazine.

 

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Moving for work?

How physicians can manage through site visits and relocation when a new opportunity arises.

By Linda Childers | Feature Articles | Summer 2019

 

Ann Cheung, M.D., moved from Boston to the San Francisco Bay Area to begin her pediatric residency at UCSF Benioff Children’s Hospital, drawn to California by the hospital’s excellent reputation and her desire to live on the West Coast.

But she didn’t realize the amount of planning it would take to move from the East Coast to the West.

While some physicians move to pursue new employment opportunities, others relocate to be closer to their families or to take on new career challenges presented by in-house hospital recruiters, physician recruitment agencies, alumni associations, professional membership organizations and more.

Though accepting a job as a physician in another city or state can be exciting, the actual move is often a time-consuming process. Considerations such as selling your existing home, securing new housing and transitioning your family to a new city can make it a challenge. Here’s how to make it less difficult.

Know what’s available

Relocation assistance for physicians varies from one hospital system to the next, but doctors typically receive funding to help with their relocation, as well as guidance in locating a realtor. Throughout the interview process, you’ll find out (or have occasion to ask) what the relocation package entails, and what temporary housing and moving expenses are covered.

Many hospitals will also offer a list of preferred relocation vendors, such as moving companies. Using a preferred mover could cut down on the paperwork you’ll need to complete; if you choose a company on your own, you will be asked to submit receipts for reimbursement.

At Phelps Health, a nonprofit community hospital in Rolla, Missouri, physicians are offered a competitive compensation package that includes a three-year contract, $35,000 signing bonus, a stipend from contract to starting date, and a $3,000 monthly student loan repayment, among other benefits.

“For physicians moving to the area, we also offer a $15,000 relocation package,” says Elizabeth Hedrick, senior physician recruitment and business development specialist at Phelps Health. “Because we’re a rural area, our compensation package is very competitive and includes helping physicians get their student loans paid off and enjoying 30 paid vacation days each year.”

In addition to relocation expenses, some hospitals offer physicians housing assistance.

“All of our residents are offered a $2,400 moving stipend and a $3,000 yearly housing stipend,” says Pamela Simms-Mackey, M.D., FAAP, director of the GME and Pediatric Residency Program at UCSF Benioff Children’s Hospital in California. “Both are in their union contract, which is up for negotiation this year, and I expect that amount to increase as housing costs have increased over the past three years.”

Pediatrician David Burnham, M.D. moved his family from Minnesota to Pennsylvania. Add extra time to your job-search plan when moving out of state. – Photo by Timothy Gangi

Plan for a successful site visit

Before you plan to move however, you must successfully complete the interview process.

When applying for a job opportunity in another city or state, your initial interview will probably be conducted via phone or Skype. If that goes well, you’ll be invited to an in-person site interview to meet the team. These kinds of visits may include a tour of the facility and one to two days of interviewing with administrators as well as other physicians and colleagues.

As you schedule and complete the site visit, be prepared to be screened, background checked and asked for professional references.

The on-site job interview gives you an opportunity to determine if you are a good fit with the hospital, the team and the new community. It is important to arrive prepared. Conduct background research on the hospital or medical group you are interviewing with in order to ask specific questions about your role, expectations for the job and what your schedule might look like.

Autumn Ashcraft, provider recruitment manager for Borrego Health in Escondido, California, says it is important for physicians to remember that interviews are a two-way process. That means you should be prepared to not only answer questions, but also to inquire about issues such as performance expectations, goals of the institution, and how your skills can help them meet their goals.

“Ask about the organizational culture and expectations such as productivity requirements,” Ashcraft says. “It’s important for physicians to make sure they’re comfortable with their anticipated patient volume as well as the organization’s mission and vision.”

Ashcraft says it can be advantageous for a new physician to ask if it is possible to speak with another provider in the same specialty area and even shadow them for a specific period of time.

She stresses that physicians should be clear about what they are looking for in a new opportunity, the colleagues they want to work with and the type of schedule they want to maintain. Additional questions may cover what electronic medical records systems and other technology are being used in the workplace in order for you to determine how steep the learning curve will be.

For physicians who are not sure about what to wear to the site visit, recruiters say it is fine to ask.

Considering your family’s needs

Hedrick encourages physicians to involve their spouses in the process by bringing them, and if appropriate, their children, on either the first or second site visit. Though family members do not sit in on the formal interview, Hedrick says it gives them a chance to tour the area and meet with a realtor.

“If people are unfamiliar with Rolla, they often envision a rural area where chickens and livestock are crossing the roads,” Hedrick says. “The reality is we’re a college town that services six counties, so in-person visits can really give physicians and their families a clearer picture of what it’s like to live here and what the community has to offer.”

Hedrick and other recruiters regularly recommend realtors who can offer physicians and their families tours of homes and neighborhoods. In addition, these local experts can provide information on public and private schools, safe neighborhoods, transportation options and more.

Realizing that relocation affects the entire family, physician recruiters often work to make relocation easier for everyone by sharing what it’s like to live in the area and connect them with local resources.

Brittany Kulp, senior medical staff recruiter at Tower Health in Allentown, Pennsylvania, says she frequently introduces a candidate’s spouse to the spouses of other physicians during a site visit. Families who have lived in the area for a longer period of time can answer questions about things to do in the city, schools, clubs, churches, and serve as familiar faces to those who are moving to a new area.

“Sometimes we’ll treat the physician and their family to a day at a local zoo or museum so they can experience the area firsthand,” Kulp says. “It’s important to get the entire family’s buy-in and make sure everyone is happy in order to make the transition easier.”

Kulp recommends allowing time to tour neighborhoods and explore the community while on a site visit, especially if it’s an area you’ve never visited before.

Research the city where you will be working to determine if you can see yourself and your family living there.

Ann Cheung, M.D., moved from the East Coast to the West for her pediatric residency in California. – Photo by Christian Erickson

Budget for your move

Once she accepted a job offer to move to the West Coast, Cheung began conducting price comparisons to determine whether it would be more cost effective to move her belongings, such as furniture, across the country or to buy new furniture in California.

And though she didn’t need a car in Boston, she knew she would need one to navigate the Bay Area.

“I spent a lot of time figuring out whether I wanted to lease a new car or purchase an older car,” she says. “And since I accrued a lot of items between college, working and medical school, I used apps like LetGo to sell my belongings in order to save on costs.”

With the average California home selling for more than $593,000, Cheung turned her sights to renting and found another resident who was familiar with the area and was also looking for a place to rent.

“Buying wasn’t possible with either of our budgets,” Cheung says. “Fortunately, we were looking for similar things: a relatively short commute to work, safe neighborhood and reasonable price for the Bay Area. She was in the Bay Area so she would FaceTime me so I could look at potential apartments.”

“Many of our residents have roommates or significant others that they split their rent with,” Simms-Mackey says. “It’s rare for a resident to be able to afford to live alone or purchase a house in the Bay Area.”

Determine a realistic timeline

For physicians moving to another city or state, careful planning can serve to eliminate any potential surprises that might arise along the way.

Looking back on his move from Minnesota to Palmer Township, Pennsylvania, pediatrician David Burnham, M.D., wishes he had allowed for additional time in planning his move.

“I didn’t realize how long it would take to close on our new home in Pennsylvania or that obtaining medical licensure in a different state would take three months,” Burnham says. “I mistakenly thought both processes would be similar to Minnesota.”

Because they couldn’t move into their home right away, Burnham and his family lived in an extended stay hotel for three weeks after arriving in Pennsylvania and had to store their furniture and other belongings in a storage unit.

Although he is very happy in his new job and location, Burnham wishes he had started the job search process sooner and built in extra time for purchasing a home, obtaining licensure and becoming familiar with the new area. The timing, however, worked out.

“In retrospect, I’m glad we planned the move to coincide with our kids’ school schedule,” says Burnham, whose kids are 12, 15 and 21. “They were able to finish the school year at their school in Minnesota and then start the new school year in Pennsylvania.”

Conduct due diligence online

Thanks to the internet, researching the cost of living, potential housing, and different cities and states has never been easier.

Damon Davis, M.D., a urologist at Mercy Medical Center in Baltimore, Maryland, says he was able to conduct a lot of research online before he relocated from East Lansing, Michigan.

“I grew up in the Baltimore area, so while I was familiar with the area, I was also able to look up things online such as school rankings and test scores for my three children,” Davis says. “I also connected with a realtor and supplemented that by looking at homes online and determining their proximity to the hospital and schools.”

Sites such as NerdWallet.com offer a free cost of living calculator that compares the cost of living in a physician’s current city to the cost of living in cities where they are applying for jobs. Niche.com has rankings of the best school districts in the country and links to nearby homes.

Planning carefully for a move, embracing resources that can make the transition easier, and anticipating the issues that may arise can make the move easier for your whole family.

 

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5 steps for interview prep

How to rock the interview and win the job.

By Debbie Swanson | Feature Articles | Summer 2019

 

Ask colleagues about their professional achievements— but stay away from anything personal you find on social media, recommends Stacy Potts, M.D. – Photo by Mike Hendrickson

Wouldn’t it be great if you could just walk on board to your perfect job? There’s just that one hurdle: the job interview. Interviews can be stressful for everyone involved, but the good news is there are steps you can take to calm your nerves and make a winning impression. From self-reflection to research and planning, the effort you invest ahead of time will pay off in the long run.

Step 1: Evaluate your priorities

Preparing for an interview isn’t just about researching an employer or rehearsing your answers. You should also walk in with a clear understanding of what you want in your career. Whether you need to take an afternoon off to do some soul searching or you’ve known your dream practice setting all your life, spelling out your and your family’s priorities is one of the best ways to guide a job search.

Define the job you want

For starters, what exactly is your vision for the future? Periodically reevaluating this vision can help you determine which job opportunities line up with your goals.

“Understand what’s important to you,” recommends Paula M. Termuhlen, M.D., Regional Campus Dean at University of Minnesota Medical School, Duluth campus. “Once you have a good sense of [this], you can learn more about the organization.”

As you define your vision, consider the following:

  • Practice setting: Do you want to work in a hospital, join a group practice or go solo?
  • Future growth: Are you focused on clinical work, or do you aspire to research, teach or join academia? Do you want to become a partner or move into a leadership position eventually?
  • Salary expectations: How much do you need to earn to meet your expenses? What are your financial goals for the future?
  • Motivation and mission: What initially drove you to go into medicine? What experiences so far have brought you the greatest satisfaction? The least satisfaction? Do you have a personal mission?
  • Location: Do you thrive in a certain climate or region? Are you up for relocating, or do you have ties to a certain place? Is there a particular patient population you’re especially interested in serving?
  • Lifestyle: What type of schedule works best for you? What are your obligations outside of work? What times of day do you feel most productive?

These questions are a good starting place, but everyone’s vision includes different priorities. Take time to assess any other factors relevant to your life, your immediate needs and your long-term goals.

Consider your family

You don’t live in a vacuum. Whether you’re single and eager to explore or married with children and pets, the job you choose will influence the people in your life. It’s important to ask for their input—even if you think you already know their opinions.

“No matter where you are in the continuum of medicine, you’ll be spending a significant portion of your waking hours at work. The people important to you also need to be happy, satisfied and successful without your physical presence,” says Termuhlen. “You need the support of the people close to you.”

As you talk with family and friends, make sure to address these areas of conversation:

  • Employment: Will your spouse or partner need a new job? What setting provides adequate opportunities for his or her field of work?
  • Transportation: Do you need to be close to an airport or another transportation hub so you can easily travel to family back home? Does anyone in your immediate family need access to public transportation in your new city?
  • Region: Do any of your family members have a strong preference for or against a certain climate or geographic region? Are any of them passionate about a sport or activity that’s only available in certain settings?
  • Children: What are your children’s needs? Consider schools as well as recreation, arts and athletic programs. How might your family change in the next five to seven years?
  • Family support: Do you need to consider childcare, senior resources, religious organizations or any other special circumstances?

Once you develop a list of your family’s priorities, combine it with your own and use both lists to drive your job search.

Be prepared to speak eloquently about any part of your CV during your interview, says Christa Zehle, M.D. Review important dates and research before you go. – Photo by Jaclyn Schmitz

Step 2: Research the opportunity

Educating yourself about the workplace, the position and the community will not only make you look more prepared, it will also help you feel more confident. Your interviewers will appreciate the effort you’ve put in, and you’ll be more equipped with background information.

Explore the program and organization

These days, it’s easy to learn about an employer even before you’ve stepped foot in their building. “Use the organization’s web presence to find out as much as possible and ask people with whom you have connections,” suggests Termuhlen, adding that a spreadsheet can be a helpful way to track details.

Start with the basics: the organization’s history, size and specialties. Then dig deeper on their website to learn about their core values, partner organizations, charitable programs and plans for growth. You can also look at their media releases or search Google News to find out what big events or changes they’ve experienced lately.

If you speak directly to any of the organization’s employees, focus on their firsthand experience instead of facts you can easily find online. Ask about their job satisfaction, the corporate culture and what a typical workday involves, as well as what they think about the area and community.

As you collect information, make note of things that strike you as either positive or negative. These may become topics for conversation in your interview.

Get to know your interviewers

You’ll feel more comfortable if you familiarize yourself with your interviewers ahead of time. Scan your meeting agenda for each person’s name, then take a minute to look up his or her bio on the organization’s website or LinkedIn. Search online for anything they’ve published in professional journals or national publications.

When searching online, you’re likely to uncover personal details as well as professional information. Stacy Potts, M.D., associate professor at University of Massachusetts Medical School, says you should avoid paying attention to this.

“It’s nice to mention information to make a connection, but keep to what you find in professional bios, not social media,” she explains. Congratulating someone on a publicized professional accomplishment is fine, but asking about his or her eldest child who just went to college could be off-putting.

You should also try to learn name pronunciations ahead of time. If a name seems especially cryptic, ask your recruiter for help or call the physician’s office to hear the receptionist’s pronunciation.

Find out what the area offers

Whether you are flying to an unfamiliar destination or driving to a nearby city, designate some free time to explore the area. It’s not just the job that needs to be right for you and your family. The area should be a good fit, too. Don’t assume an employer will work this time into your schedule. If you have a full itinerary, consider staying an extra night or ask if your meetings can be spread out so you can explore.

“Asking that can be looked highly upon,” says Potts. “It shows that the applicant has a clear idea of what they need and a level of commitment. Also, being able to voice your own concerns is good for your future role.”

Before you go, identify what neighborhoods, schools, religious establishments, recreational areas and other sites you’d like to visit. Set up any appointments, such as a meeting with a realtor or a colleague, ahead of time.

Step 3: Prepare what you want to say and ask

The question-and-answer session makes up the bulk of any interview, and it’s also one of the easiest portions to prepare for. Don’t assume you can figure out what you’ll say on the spot. You’ll thank yourself later if you sort out your thoughts beforehand.

Rehearse your answers

Practicing your answers to interview questions can instill a sense of confidence and ensure that you communicate key points effectively. There are plenty of resources available with lists of typical questions—both those geared to general job seekers and those specific to physicians. Your alma mater’s career center is a good place to look for one of these lists, and you can also search online for similar resources.

As you read through questions, try to formulate your responses. Take into account the unique aspects of your own career and areas of interest, then think about weaving these details into your conversation. A candidate who shares a memorable story or personal experience will leave a stronger impression.

“Find out what parts of this job line up with your priorities. [Prepare to] mention those things in the interview. Also bring up past experiences that line up with these items,” Potts suggests.

In addition to preparing for standard questions, remember that your interviewers will likely want to discuss your background and application materials. Review all the information you’ve provided and refresh your memory of the dates, names and details.

“Avoid putting anything down on paper that you aren’t ready to speak eloquently about,” says Christa Zehle, M.D., interim senior associate dean for medical education and associate dean for students at the Larner College of Medicine at The University of Vermont. “For example, if you say you’ve done research, be able to provide more information.”

Create your list of questions

The interview isn’t just about your answers. You should also bring questions of your own. Employers look highly on candidates who pose thoughtful questions, and asking them will help you uncover important details about the job you’re applying for.

“Ask genuine questions. Don’t just ask for the sake of asking something. Show that you have some familiarity and you’ve done your homework,” recommends Zehle. “Ask about a unique component or something specific about the program. Avoid topics such as compensation, call schedules or salary.” While the latter may be valid questions, it’s best to save those for your recruiter or raise them later in the process.

Write your questions down and feel free to bring your list with you. “Pulling out your list of questions at the interview is fine,” says Potts. “It shows engagement—that you’re taking the experience seriously.”

Identify a mentor

The abundance of information you’ll take in during an interview would be overwhelming to anyone. It’s helpful to have a close friend or family member you can talk with about your impressions, and it’s equally important to have a seasoned medical professional who is willing to help guide you.

“Find a mentor with more experience than you. You need someone neutral to the process to guide you, a trusted friend or colleague,” says Termuhlen, adding that you can also reach out to someone who has the type of job you’d like to end up in. “Even if you don’t know them, you can introduce yourself and explain that this is the type of job you’re hoping to have someday,” she explains. “Most professionals would be receptive to this.”

Step 4: Prepare to make a good impression

Your credentials may have gotten you in the door for an interview, but once you arrive, your presentation and social skills will determine whether or not you get the thumbs up. Take some time to assess your strengths and weaknesses.

Do a practice interview

Whether you’re just starting off or relocating after 10 years of clinical work, it’s always smart to take a critical look at your interviewing habits. One of the best ways to do that is to watch yourself on tape.

“Mock interviews are invaluable for spotting things you may not realize, such as non-verbal communication or nervous habits,” says Zehle. Ask your alma mater’s career center if they offer mock interview sessions or, she suggests, “Just have a rudimentary session where a friend asks you some questions and you video your responses on your iPhone.”

As you watch your performance, you may discover areas for improvement. For example, you might notice you tend to ramble or don’t maintain eye contact. “Try to address any weak areas so that you portray confidence and carry yourself well at the interview,” Zehle suggests. “Practice your weaknesses.”

And don’t forget to notice your positive traits. If you greeted your interviewer with a warm smile or firm handshake during your practice interview, make sure to do the same when it’s the real deal.

Prepare your wardrobe

You are likely to have a few different meetings on your schedule— everything from a breakfast meet-and-greet to a facility tour to a meeting with prominent department members. Dressing appropriately for each is part of making a good impression. “Every interaction will count,” says Potts. “You should be able to appear relaxed at each kind of gathering.”

For the interview itself, you can’t go wrong with a suit: a dress shirt, slacks or a skirt, matching jacket, a tie if appropriate. Choose subtle or neutral colors. For other events—such as a tour or meal—avoid a last-minute scramble by asking about the dress code in advance. If you’re unsure, ask your recruiter or contact the restaurant directly.

Don’t forget to take weather into account. If you’ll be going in and out of a car or doing extensive walking, dress for the elements and have something in which to carry your paperwork and personal items.

Even with a less-formal gathering, don’t stray too far from professional boundaries. This isn’t the time to be flamboyant. You want people to remember your skills and personality, not what you were wearing. “Use common sense,” says Potts. “Look relaxed, but don’t go overboard.”

What you wear contributes to your confidence, so don’t take shortcuts. Select comfortable clothing that boosts your self-esteem. Avoid anything that might preoccupy you, such as a stained shirt or slacks that don’t fall right. You’ve worked too hard to get to this point to let your clothing steal your focus.

Collect your materials

Most of your paperwork will be taken care of by the time you sit down for the interview, but it doesn’t hurt to carry extras with you just in case. Use some type of portfolio case to carry a spare copy of your CV, contact information for your references and any other relevant paperwork.

Don’t forget to update your list of references and verify their contact information. “As a courtesy, let them know they may be getting a call,” Zehle says. That way, they’ll be prepared to say glowing things about you.

Step 5: Plan logistics ahead of time

As you get closer to your interview day, do everything you can ahead of time. Small steps will make the difference between arriving rested, focused and on time instead of frazzled, distracted or late.

Deal with last-minute details before the last minute

Before your meeting, consider all the logistics of the day. Figure out your transportation plan and investigate traffic patterns to decide when you need to leave. Leave plenty of extra time—even if you’re already familiar with the location. If you’ll be using a transportation service, call ahead of time to confirm their schedule. Have an alternate plan in mind, just in case.

If you have children, confirm there is a plan (and a backup plan) for their care. Be sure your family members know what hours you’ll be unavailable and, if need be, designate an alternate contact person.

Do your best to streamline your morning: gather your wardrobe, pack a light snack, tuck any needed medicine or toiletries into your bag and fill a water bottle. Anything you can do in advance is one less thing to remember on your way out the door.

Practice self-care

By now, you probably have a handful of strategies for getting through challenging situations. An interview is just one more opportunity to put these coping skills to work, whether that means waking up early for a run or tucking a protein bar into your jacket in case you barely eat at the colleague luncheon. Now is the time to implement any habits that help you feel your best.

With an already busy lifestyle, it’s easy to procrastinate about interview preparation or assume you’ll just deal with issues when the time comes. But by getting a head start, you’ll be able to stay focused when the interview comes—and land your dream practice.

 

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It takes two: your spouse’s role in the job search

Starting early and speaking up can help physicians and their partners choose a career—and a location—that they both can love.

By Karen Edwards | Feature Articles | Spring 2019

 

Stephanie Benjamin, M.D., is an emergency medicine resident and author of “Love, Sanity, or Medical School: A Memoir.” – Photo by Derek Lapsley

Starting the post-residency job search can be daunting. You’re working long hours, studying for boards and trying to have some semblance of a personal life. How are you supposed to add anything to your schedule, let alone a job search? The solution is to take things one step at a time. And if you’re married or in a committed relationship, the good news is that you’re not tackling this journey alone.

Just don’t forget to start early. “It depends on your specialty and where you would like to work, but most residents should start their search 12 to 18 months from their completion date,” says Jen Kambies, FASPR, director of special initiatives at the Cleveland Clinic. It’s the one job-search mistake she sees most often. “Applicants can underestimate the time it takes to get licenses and complete the credentialing process,” she explains.

Wendy Barr, M.D., MPH, residency program director of Lawrence Family Medicine Residency in Massachusetts, agrees. “I hear residents tell me they’re too busy to start their job search,” she says. “But I remind them, the whole point of residency is to get a job. If the search is delayed, they can go a month or two without a paycheck while they wait for the paperwork to be done.”

So here’s a rough roadmap to make getting a head start easy. Read on for the steps you should be taking—and how your spouse or significant other can help:

Getting ready for the search together

Physician

“Medical school and residency are so regimented. A job search marks the first time new physicians have the freedom to choose their path. It’s scary and exciting at the same time,” says Barr.

Before you begin your search, sit down and decide what you’re looking for in a job. Do you want to stay where you are or move? And if you’re moving, what kinds of job opportunities does your spouse need to find in the area? What salary range do you expect to earn?

You need to answer these questions even if you plan to stay put in your current location, so it’s best to start making decisions early. “Lack of clarity is one of the biggest reasons for procrastination,” says Kenneth Hertz, FACMPE, principal consultant with the MGMA Consulting Group. He says that once you’ve set goals and made some decisions, you’ll be better able to focus your search.

John Rodriguez, M.D., an orthopedic surgeon at Texas Orthopedics in Austin, says job applicants need to think beyond salary requirements. He recommends considering other important factors, such as job freedom and flexibility.

Stephanie Benjamin, M.D., a fourth-year emergency medicine resident at UCSF Fresno and author of Love, Sanity, or Medical School: A Memoir says not to pigeonhole yourself. “Determine your priorities and think every decision through so you are building the career that you—and not someone else—want,” she says.

That’s what Sasha Thomas, M.D., did when a job opportunity in Kansas came up unexpectedly. At the time, he was practicing in North Carolina as an executive health physician. “My wife and I sat down with legal pads and made lists of the pros and cons of staying where we were or moving to Kansas,” he says. “We took everything into consideration.” Ultimately, the pair decided to move.

Spouse

“You should be having ongoing conversations with your spouse about lifestyle, location and career goals throughout residency and throughout your lives,” says Lara McElderry, creator and host of the Married to Doctors podcast. When you do talk, she says it’s important to “be honest with your feelings, and keep an open mind.”

Stephanie Benjamin’s husband, Alex Angeli, says he asks his wife questions to ensure she’s making decisions that will truly make her happy. “I’ll ask her what move makes more sense to her in terms of what she wants to accomplish professionally,” he explains. “What location will help toward that goal?”

Doing the preliminaries (residency, years 1-3)

Physician

“The first thing you should do before a job search, if you haven’t already, is pull together your curriculum vitae or update it,” says Kambies. “It’s the first thing you’ll be asked for when you contact anyone for a job.”

Matt Wilson, M.D., a hospitalist and clinical assistant professor at the University of Kansas Medical Center, says he used free online resources to help with writing and formatting his resume. “I also asked a couple of residents a year ahead of me to send copies of their CVs for me to look at,” he says.

Don’t forget to check your social media presence. “We address this from day one,” says Barr, explaining that your public persona may prevent you from getting a license in certain states. “All social media accounts should be set to private—only visible to family and friends,” advises Wilson. And Benjamin says that even though she uses only her first and middle name on media sites, she’s still careful about what she posts.

Now is also the time to research potential locations and make other preliminary preparations. “Handle the process like it’s a job,” says Hertz. “Take notes on paper or online. Hone your interview skills. Spend time researching jobs. Sign up for PracticeLink.”

Faculty can be great resources during this time since many of them have developed a wide network of professional connections. “One of our residents had to narrow his search to Texas and North Carolina because those were the best places for his wife to find work,” recalls Barr. “He asked if any of the faculty had connections to either of those places. It turned out we did.”

Spouse

As a physician’s spouse, there’s a lot you can do to take the weight off your partner during this phase of the search. For instance, you can help with his or her CV. McElderry says, “Most physicians will take care of the writing themselves,” but if you’re skilled at communication, you might be able to pitch in.

Even if you don’t help draft your spouse’s CV, you should give it a once-over before it goes to an employer. Angeli did exactly that for his wife during her job hunt. He proofed her CV and helped organize it. “I also made sure it had her voice,” he says. “It highlighted what she wanted in a job and what she can offer.”

If you have time, you can also help research locations and job opportunities. “In your initial conversation with your spouse, choose the top three geographic areas where you want to live and work and expand from there,” advises Kambies.

“It helps to build a spreadsheet,” adds McElderry. “Organizing prospects will help you both better determine the best jobs and areas to explore.” Once you’ve narrowed the field, she says you should learn as much as you can about the area. She explains, “I researched everything: climate, schools, cost of living, neighborhoods and commute times.”

Kavitha Thomas, Sasha Thomas’ wife, took a less structured approach to her research. “My husband’s a data person; he made spreadsheets,” she remembers. “I’m a feelings person. I researched the area and tried to imagine what it would be like to live there.”

Lara McElderry created and hosts the Married to Doctors podcast. “Be honest with your feeling and keep an open mind,” she says when helping a physician spouse through their job search. – Photo Zayne Williams

Starting your active search (residency, summer of year 3)

Physician

This is the point where physicians can fall behind, according to Kambies. “They become extremely busy and the search for a job can fall off their radar. On occasion, they will wait until after their boards to start the search, but that is the time when they most need to be reaching out to recruiters and prospective employers.

“Starting early doesn’t hurt,” advises Kambies. “We don’t know what our needs will be two years out, but if this is a place you want to work, you can contact us if nothing else and form a relationship.”

That’s exactly what Wilson did. “At the end of my second year, I emailed the head of the hospitalist program at my medical school since I wanted to work there,” he says. “They told me to contact them around September when they were ready to start hiring for the next year.”

After reaching out to an employer, it’s a good idea to let the organization’s contact guide you through the process, according to Debbie Gleason, director of physician recruitment for The University of Kansas Health System. “This person is often an in-house recruiting professional who will be adept at road-mapping the process and provide guidance for the timing of the next steps,” she explains.

Spouse

This part of the process is a good time to play the role of motivator and coordinator, says Gleason. “Spouses and significant others could be helpful in gathering documents that will be needed for updating CVs, completing applications and other paperwork that will be necessary once a decision is made about what position will be accepted,” she explains.

You should also plan to go with your spouse on site visits. “Many hospitals will set up realtors for you and school tours—and may even connect working spouses to contacts in their field,” says McElderry.

“It’s not unusual for in-house recruiters to offer to visit with spouses to answer their questions about the community or professional options,” adds Gleason. If this resource is available through an employer, she recommends taking advantage of it.

Conducting interviews and site visits (residency, autumn of year 3)

Physician

At this point, you should have your interviews and site visits arranged. Before any interview, Gleason says it’s a good idea for physicians to research potential employers. “It can be a way to show they’re serious about the position and the community as well as enhance the research they started at the time they launched their job search,” she explains.

When it comes to the interview itself, Hertz says small stuff matters. “Be professional, dress appropriately, remember basic social skills,” he recommends. And Rodriguez says it’s worthwhile to imagine yourself on the other side of the table. “I changed how I thought about the job search,” he says. “I try to see it from the other side, to think about the employer’s needs. Would I be a good hire for them? I want to make sure I’m what they’re looking for.”

Thomas says he goes into every interview with a list of questions. “The employer’s responses will help you make a better decision about the position because you’ve raised points that are important to you,” he explains.

And while you’re thinking about what’s important to you, Barr says to remember that employers are not allowed to bring up your family unless you do. Depending on your situation, you may choose not to. “There can be discrimination with regard to physicians and families,” she says. That’s true whether the applicant is male or female, so if this is something that concerns you, keep your family out of the interview.

Once you’ve finished the interview, your contact at the employer will likely give you a timeline for the decision. Follow-up emails and calls are appropriate. “The timing can vary, but I would say an email every week or two is likely appropriate,” Gleason says.

Spouse

Since a job decision will affect both of you, it’s a good idea to join your spouse for on-site visits. “Alex comes to every potential job site to help check out the city and to ensure the location would provide professional opportunities for him as well,” says Benjamin.

“The site visit was helpful,” agrees Kavitha Thomas. “No matter how much research you do, you don’t know how things really are until you experience the place for yourself.”

If you have kids, consider their interests and needs as you tour the area. For example, during her site visit, McElderry wanted to learn about the orchestras and sports teams at local schools because she knew those would be important to her children.

No matter what you hope to learn while you’re visiting, make sure you remain professional throughout the stay. Hertz warns, “You don’t want to say anything negative about your spouse that could get back to the employer.”

After a site visit, Hertz recommends offering to write thank-you notes to employers. It’s an easy way to take something off your spouse’s plate. You should also sit down with your spouse and discuss expectations for the typical work/call schedule and vacations.

“Be part of the conversation,” says Kambies. You’ll want to provide your feedback before a job offer is accepted and contract negotiations begin. “We had these conversations early on,” remembers Wilson. “That made the whole process relatively smooth.”

Making your decision (residency, winter of year 3)

Physician

If you started your job search a year in advance, you should have an offer by January at the latest, says Barr. But before you can accept a job, you have some decisions to make—especially if you’ve received multiple offers.

“Most in-house recruiting professionals would expect that candidates are looking at other opportunities,” says Gleason. “It’s perfectly acceptable to let organizations know you’re looking at other opportunities and to ask for their timeline.” This will let you know how long you can safely delay your decision.

But organizations have their own timelines for considering candidates for positions, which means you may or may not have as much time as you think. Effective communication and long-term decision-making may be better tools for negotiating offers than pitting employers against each other.

According to Gleason, if physicians falter at the finish line, it’s typically because of one of two reasons: compensation expectations or contract negotiation parameters. “A physician going into a job search should research what factors play into their particular personal family needs and practice setting type and location,” she says. “Understanding a potential compensation model for a future position and what is reasonable for their geographic setting and practice type is highly important.”

She adds that many organizations have standardized contacts. “It’s not uncommon for only a few components of the agreement to actually be negotiable,” she explains. “An interviewing physician would do well to understand this aspect as he or she begins discussions.”

When you’re presented with a contract, Rodriguez says, “The first person you negotiate with is yourself. Are you happy with the terms? Then sit down with your spouse and discuss it together.” Only after these steps should you negotiate with an employer.

Spouse

As your spouse makes career decisions, it’s reasonable for you to weigh in. “You’re in a partnership with your spouse, but the job will be just as much a partner in your relationship,” explains Angeli. “This is something you need to be involved in.”

McElderry says asking your spouse questions can help him or her make a decision. For example: Are there good mentorship possibilities at the facility? Does the workplace culture seem like a good fit? Will he or she enjoy the coworkers? How is the salary structured?

“I think it’s helpful to talk with the spouses of physicians who work there,” she adds. “They may give you a better idea of what kind of relationship your spouse plans to enter into.”

Your own career may affect your spouse’s choices. “My wife’s biggest priorities were location and job opportunities,” recalls Wilson. “Thinking back to medical school, there was a particular residency program that I loved but ranked low because I knew my wife wouldn’t be able to easily find a job there.”

However, according to Barr, these roles are often reversed. In a two-career marriage, the non-physician spouse often makes the professional sacrifices during residency because of the match. “When it comes time to finding a job, that’s where I think the physician spouse might want to give the non-medical member of the marriage a bit of an edge,” she recommends.

No matter where you land, you and your spouse should base your decision on the jobs and lifestyle you feel are right for your family. And if you end up relocating, Gleason says it’s best to have all hands on deck. Help your spouse with relocation planning and transitioning your children to a new community and school.

Throughout the job-search process, a spouse is often part of the decision-making. And that’s as it should be. That’s why Gleason recommends that physicians include partners in their research, thought processes and decision-making from the very beginning. “This will reduce any additional delays in deciding on an offer,” she says.

“Talk to each other even when you’ve made the move,” adds Kavitha Thomas. “Know things will change. If that happens, begin the process again—knowing you can make it work.”

“I hear residents tell me they’re too busy to start their job search. But I remind them, the whole point of residency is to get a job. If the search is delayed, they can go a month or two without a paycheck while they wait for the paperwork to be done.”

“Lack of clarity is one of the biggest reasons for procrastination,” he says, adding that once you’ve set goals and made some decisions, you’ll be better able to focus your search.

“You’re in a partnership with your spouse, but the job will be just as much a partner in your relationship.”

 

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