Ready, set, visit

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

By Debbie Swanson | Feature Articles | Summer 2020

 

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

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

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

Phase one: Soak up information

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

Study up on the employer

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

Some steps to take:

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

Investigate the location

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

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

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

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

Confirm your arrangements

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

Be sure to clarify:

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

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

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

Review your agenda

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

Make sure you know:

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

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

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

Get your answers ready

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

Some typical interview questions include:

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

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

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

Get your questions ready

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

A few great questions to ask include:

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

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

Phase two: It’s showtime

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

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

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

The nuts and bolts: Interviews

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

The important extras: Social events

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

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

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

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

And in your free time…

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

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

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

Phase three: Return and reflect

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

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

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

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

Debbie Swanson is a frequent contributor to PracticeLink Magazine.

 

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What shapes your search?

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

By Therese Karsten | Feature Articles | Summer 2020

 

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

Know that different markets and specialties have different recruitment cycles

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

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

Get your CV ready

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

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

Contact prospective employers early

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

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

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

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

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

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

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

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

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

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

Remember, some searches march to their own beat

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

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

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

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

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

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

Everything takes longer than you think

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

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

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

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

Before you take just one more interview…

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

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

Contracting concerns

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

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

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

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

Licensing and credentialing

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

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

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

Physician couples need to start earlier

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

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

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

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

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

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

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

Don’t be late to the table

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

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

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

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

 

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Bore no more!

How to keep your interviewer engaged.

By Marcia Horn Noyes | Feature Articles | Summer 2020

 

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

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

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

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

Study up on interview skills

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

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

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

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

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

Top five interviewing questions

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

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

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

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

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

Avoiding cringe-worthy responses

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

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

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

What are your strengths and weaknesses?

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

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

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

Tell me about yourself

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

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

Why are you interested in this practice?

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

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

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

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

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

Where do you see yourself in five or 10 years?

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

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

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

Curveball questions

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

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

Ending with a firm footing

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

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

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

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

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

How to deliver your answers

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

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

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

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

 

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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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