Where to practice?

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

By Debbie Swanson | Feature Articles | Spring 2020

 

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

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

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

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

Hanging up your shingle: private practice

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

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

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

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

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

Excitement and variety: hospital employment

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

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

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

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

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

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

Joining the team: group practices

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

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

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

A unified focus: single-specialty group practice

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

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

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

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

Combined expertise: multispecialty group practices

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

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

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

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

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

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

Embracing opportunity: locum tenens

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

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

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

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

Satisfaction and benefits: working for the government

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

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

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

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

So how to choose?

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

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

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

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

 

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Navigating the job-search journey

When to do what to find your dream practice.

By Marcia Layton Turner | Feature Articles | Spring 2020

 

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

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

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

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

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

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

Planning ahead

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

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

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

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

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

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

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

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

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

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

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

When to start looking

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

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

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

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

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

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

The typical timeline

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

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

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

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

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

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

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

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

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

What can slow the hiring process?

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

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

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

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

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

 

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Licensing, credentialing and hospital privileges— oh my!

Taking care of the logistics of your next job search.

By Marcia Horn Noyes | Feature Articles | Spring 2020

 

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

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

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

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

Expectation meets reality

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

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

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

State-to-state frustrations

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

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

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

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

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

At your disposal: a credentialing facilitator

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

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

Basic elements of credentialing

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

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

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

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

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

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

A credentialing advantage

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

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

Mitigating delays

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

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

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

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

The future of credentialing: speeding the process through technology

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

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

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

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

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

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

Marcia Horn Noyes is a frequent contributor to PracticeLink Magazine.

 

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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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