The anatomy of a physician contract

Your employment contract can make or break your practice experience. This guide demystifies its terms—teaching you what to consider, what to negotiate and when to get a lawyer.

By Karen Edwards | Fall 2016 | Feature Articles

 

The contract looked good. Great, in fact. Compensation, vacation, even health insurance—all good packages—but before the physician signed on the dotted line, he consulted an attorney, Gary Sastow, J.D., with the New York-based law firm Brown, Gruttadaro, Gaujean & Prato.

Good thing he did.

If the contract had been left as it was, the physician would have been burdened with $160,000 of tail coverage upon leaving the practice. And he would have been responsible for paying all of it.

The biggest problem plaguing physicians when it comes to contracts, according to Sastow, is that they’re concerned primarily with only one part of a contract. “They want to know how much they’ll be paid,” he says. Though compensation is a significant part of any contract, it’s not the only part, and let the physician beware if he or she doesn’t keep the other sections in mind as well.

A rise in physician employment

Vaagn Andikyan, M.D.

Determining what aspects of a job are the most important to you will help you know where to spend the most time and energy in your contract review. For Vaagn Andikyan, M.D., a New York gynecologic oncologist, a non-negotiable restrictive covenant became a deal breaker. · Photo by Shaina Diaz

Let’s face it: These days, most physicians are looking at employment contracts. A recent report from the consulting company Accenture states that only one in three physicians will be in independent practice by the end of 2016. The report also states that the number of physicians in private practice declined from 57 percent in 2000 to 49 percent in 2005, with most of the physicians who left private practice seeking hospital employment instead.

For some time, physicians drove this trend as they sought to escape long hours, risky revenue streams and increasing regulations, but the 2010 health care reform legislation that gave rise to accountable care organizations also gave hospitals and physicians new incentives to work together. That means today’s physician is likely to be an employed physician, and that, in turn, has greatly increased your need to have at least a rudimentary understanding of employment contracts.

Today the average hospital employment contract is between 20 and 30 pages long and has been prepared by the hospital’s attorney, says Sastow. In other words, there’s a lot of confusing legal jargon that could trip you up, and, Sastow adds, the hospital’s attorney will have written the document to the employer’s advantage.

Gregg Bertram, founder of Pacific ADR Consulting, which handles mediation and arbitration disputes for clients, echoes Sastow. “The contract is not a neutral document,” he says. “Don’t assume it’s harmless.”

Evaluating your contract

So when you’re handed an employment contract, how do you proceed?

“Start any contract review by asking yourself first what you want from the contract and from the job. What’s important to you: Is it your schedule? Your track for advancement? Focus on your career goals, the lifestyle you want to create, and then you can better decide what things you want to negotiate,” says Mathew Parker, J.D., of the management-side labor and employment law firm Fisher Phillips.

Hospitalist Vanessa Frost, D.O., says she prepared a top-three list of things she wanted from a job, and that included pro-rating her sign-on bonus over a two-year contract—advice she received from a mentor. “That way, at the end of the second year, you only owe half of the bonus if you decide to leave. You’ve worked off the other half.”

Once you determine your top priorities, your next step is to look over the contract.

“Some people never read the contract they’ve been handed,” says Sastow.

It’s true many hospital contracts are more or less boilerplate documents, especially for new physicians, says Derrick Handwerk, managing partner of Handwerk Multi Family Office, a Philadelphia wealth management consulting company. Still, he says, “it’s a good idea to know what’s in them before you sign on the dotted line.”

Contract anatomy

Most physician employment contracts follow a similar structure, and though you’ll want to pay attention to the whole contract, the following sections are ones that may deserve special scrutiny:

Job Location and Job Description. “Every contract should have in it a list of your job responsibilities and duties,” says Sastow. And the contract should be as specific as possible—not only in your job description, but also in where you will work and what hours you’ll work.

Sastow says he will put in the specific address of the facility or facilities where his client will work—office locations, hospital locations, clinic locations, whatever might apply. That’s because an employer may close an office location, for example, and want to transfer its staff to a satellite clinic in a nearby town—or, if it’s a multiple-state entity, to a location in a different state entirely.

“There is a lot of consolidation going around,” says Bertram. A move, whether it’s 45 minutes away or several hours away, can have a significant impact on not only the physician’s lifestyle but also his or her wallet. “Be alert to these sections,” says Bertram. “If you are signing with a hospital that has multiple locations, it’s important to nail down the locations where you’re expected to work and ask for notice if they do plan to move you.”

Vaagn Andikyan, M.D., a New York gynecologic oncologist, says he looks for work locations in contracts. “It’s important to look at them before you sign, because you could find yourself spread too thin if the hospital or practice has more than one location and expects you to work at all of them,” he says.

The employer still has the option of making that request or transferring physicians, but if the contract lists specific addresses, such moves are likely to trigger new negotiations regarding call hours or commuting expenses, says Sastow.

Besides job location, Parker also suggests paying close attention to the job description itself. “Responsibilities should reflect those within your field of specialty,” he says. If the contract has a broader statement, such as “tasks as assigned,” that’s worth negotiating, he says. Otherwise, you might find yourself performing tasks that may be above—or beneath—your level of training.

These sections may seem boilerplate, but it’s still a good idea to read them and make sure they reflect what you want from the job.

Compensation. Most compensation guidelines these days are set by corporate boards and groups like the Medical Group Management Association, says Handwerk. “The larger the hospital or group, the more likely it is the compensation rate will be standard,” he says.

And, frankly, there isn’t much room for a new physician to negotiate larger increases. “Young physicians don’t have much in the way of negotiating power unless they are in a specialty that’s needed by the employer,” says Sastow—or they are needed in a specific location.

If salaries are set in stone, Handwerk suggests negotiating other benefits. An inflation rider, for example, is a way to keep your salary from deflating as you work. “…Without a regular increase for inflation, doctors can find themselves working for less and less money each year,” he says.

Also remember that compensation isn’t just about salary. It covers benefits such as paid time off, CME reimbursement, health and disability insurance, forgivable loans, 401(k) contributions and maternity/paternity leave.

“Typically, these benefits are part of a hospital’s policies and procedures manual,” says Parker. “It’s important to understand what those policies are, so if there is something you need or want, like paternity leave, and it’s not in the manual, you may be able to negotiate it into the contract.”

Negotiations are more likely to take place if the employer is a smaller hospital or group, says Sastow. “For larger hospitals, these are usually standard policy and not negotiable.”But, as Bertram says, you never know until you try.

Bertram says it’s perfectly legitimate to ask questions of your own. “Ask employers about the financial strength of the institution,” he says.“If a hospital or group has shrinking revenues, that’s something you should know before you sign up.”

Elizabeth Clark Libert DrPareshMane ElizabethClarkPhotography 36

Thoracic surgeon Paresh Mane, M.D., consulted with an attorney on his employment contract, but ultimately handled negotiations with his employer himself.  · Photo by Elizabeth Clark

“Also, ask the hospital about its volume and growth potential,” suggests Paresh Mane, M.D., a Boston thoracic surgeon.

Call Hours. Next to compensation, call hours may be the most important section for physicians. “On-call hours will affect a physician’s career path and lifestyle,” says Parker. As the new hire in the organization, you can usually expect to work the worst hours, but if they are worse than other new hires, Parker suggests opening a dialogue with employers for a better schedule. “Most employers want to be fair,” he says.

But here again, you might want to ask your own questions, says Mane. For example, “Ask what the hospital will do if you work more than a certain number of hours. What will they do if your cases are above that limit?” He also suggests negotiating administrative time into your schedule so you can carve a day out each week for paperwork. As a surgeon, he has also negotiated block time in the operating room.

In other words, propose the hours you want for the lifestyle you want—but be prepared to negotiate. As long as call hours are kept reasonable and fair, that may be the best you can expect.

Termination and Tails. Employers typically provide malpractice insurance while you’re working at their facilities, but what happens when you leave and a patient files a malpractice suit over something you allegedly did? That’s covered by tail insurance, and that part can be tricky, as the example at the beginning of this article shows.

“Who pays the tail coverage and how much they pay may be negotiable,” says Sastow. But that negotiation is likely to depend on why you’re leaving.

If the contract is up—usually after a year—and you’re moving on to another workplace or if you’ve been terminated with cause, you can expect to pay a fair share or all of the tail coverage. However, you might want to negotiate language in your contract that makes the employer responsible for paying some or all of the tail if you’re terminated without cause. “Who pays for tail coverage depends on the reason the relationship is ending,” says Sastow. He adds: “If you’re dismissed without cause, you should negotiate language that says the employer will pay for tail coverage.”

That’s why it’s also important to pay attention to the termination section of contracts.

“The length of a contract can be misleading,” says Bertram. “Generally, contracts are for a one-year renewable term, but it’s not an absolute. You may be terminated without cause with a 30-, 60- or 90-day notice.”

“All contracts have an out clause,” says Cindy Fiorito, director of physician recruitment for Eagle Hospital Physicians in Atlanta. “Our contracts include without-cause language with a 120-day notice,” she says, adding that they will consider other notice lengths.

Generally, termination-without-cause sections are not negotiable, though most attorneys will try to eliminate the language. If left in place, they are what they are, and you need to be aware that they’re there.

Mane says he was able to negotiate the without-cause, 90-day notice termination clause in his contract to a longer term. “If you’ve moved to the area and just started practicing, three months is not enough time to let you find another job and move again,” he says. His negotiated language called for a 180-day notice period. Six months is long enough to find a new job, he says, adding, “It works both ways. If you don’t care for the environment, you don’t want to lock yourself into place either.”

In addition to negotiating a longer notice, you may also negotiate language that says the employer will pay you a certain amount if you’re dismissed without cause. “Or you may want to negotiate the restrictive covenants part of the contract if you plan to stay in the area,” says Jay Levy, J.D., a Florida attorney.

Just be sure, in any termination-with-cause section, that the cause is defined in the contract, says Levy. “There should be a clear understanding of what constitutes cause.” There should also be a “notice of default” in the contract, he continues. That means the employer will allow you a certain length of time to fix the problem. “That could range from 10 days to 30 days,” Levy says. Unless the offense is so egregious that no repair is possible, a notice of default will give you a chance to fix whatever problem you have or may be creating.

Restrictive Covenants. Of all the terms in a contract, this one may be the most contentious. A non-competition restrictive covenant says that, if you leave a practice (with or without cause), you may not work within a given distance from that hospital or place of employment for a set period of time. A non-solicitation restrictive covenant prevents you from soliciting your former patients for a set period of time.

Restrictive covenants should be taken seriously, says Levy. “Some people think they’re not enforceable. They are.”

If you can look at them from the employer’s side, they make sense, Levy continues. “The employer has gone to the trouble of bringing you in, marketing its practice and building its patient base. They don’t want to lose those patients if you leave. A restrictive covenant protects their business.”

But what if the patient has a good relationship with the doctor and wants it to continue? “A non-competition restrictive covenant doesn’t mean that the patient can’t see you,” says Levy. Of course, it may make their visit geographically inconvenient, but that’s their choice.

“I was ready to sign with an employer until I saw the restrictive covenant clause,” says Andikyan. The employer refused to eliminate the clause, “so I walked out. I wouldn’t sign a contract with a restrictive covenant clause included,” he says.

“If they’re in a contract,” says Mane, “you need to know what the language says. Any hospital facility, including an office that’s 150 miles away, may be included in the restrictive covenant language.” That, he adds, can be crippling if you intend to stay in the area.

Fiorito points out, however, that restrictive covenants may be just as limiting for employers. “If you’re a hospitalist who came to us from another job and you’re working under a restrictive covenant, it can send up a red flag,” she says. “We need to know all of the places you aren’t able to practice, because we may unknowingly assign you to facilities where you won’t be able to go.”

“I learned noncompete clauses are common in contracts where the employer is in a large urban area,” says Frost. In her experience, they are not negotiable, but she says she was able to add language to a contract that allowed her to come back to the restrictive area if she changed her position or if she wanted to return for a fellowship. “I didn’t want to be penalized for either of those,” she says.

Review and negotiation time frame

Once you have your contract, the employer will give you time to consider the offer. In some cases, the amount of time is set in the contract. Frost’s contract, for example, stated she had 14 days to respond to the offer.

That should give you time to consult an attorney with a strong understanding of health care law. If you do choose to use an attorney, most will understand you need a prompt review. “Unless they’re in court or very busy, I would imagine most attorneys will turn around a review in a few days,” says Levy.

Sastow says a week to 10 days is average, and Parker says the review process may take up to two weeks, depending on the size and complexity of the contract.

No matter what the time frame is, however, consulting an attorney may prove to be a wise investment. (See the sidebar “Why Hire an Attorney?”)

Whether you decide to use an attorney or not, physicians should keep one thing in mind, says Parker.

“The contract is the beginning of a relationship, one which has the potential to be long-term and worth millions of dollars,” he says. “It’s easier to dialogue about the parts that are important to you, so decide on those first. When it comes to any negotiations, however, it’s good to take a step back and consider it from the other side. A contract should be beneficial to both sides. You want to build a relationship that goes beyond the document. Keep that in mind when you negotiate, and it will pay dividends down the road.”

Karen Edwards is a frequent contributor to PracticeLink Magazine.

 

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Breaking the chains

Looking for more from your compensation? Develop a strategy for your student loans, and you may free up more income sooner than you think.

By James M. Dahle, M.D., FACEP, WhiteCoatInvestor.com | Fall 2016 | Feature Articles

 

“The rich ruleth over the poor, and the borrower is servant to the lender.” –Proverbs 22:7

There is no greater financial frustration for a resident or young attending physician than a large student loan burden, and the lack of financial training in the medical education system compounds the problem. As Vlad Kononchuk, M.D., an attending psychiatrist in Dix Hills, New York, says, “Frankly I did not have much of a strategy for anything when in residency, at least not for financial matters. It is hard to make those plans when you have so many other things on your plate!”

The costs of attending college and medical school have skyrocketed over the past two to three decades. When I started medical school in 1999, in-state tuition at the relatively inexpensive University of Utah School of Medicine was just $10,000 per year. In 2015, a mere 16 years later, that number had nearly quadrupled to $36,000 per year. Out-of-state tuition was nearly twice as high.

That trend has affected essentially every M.D. and D.O. school in the country. Out-of-state tuition can be particularly problematic, as displayed by the price tag at Michigan State University’s College of Human Medicine, which averages $73,000 per year just for tuition and fees. The Columbia University College of Physicians and Surgeons topped the private school list in 2015, at about $56,000. New York City is also an expensive place to live, so the total cost of attendance (COA) there is estimated to be as high as $94,000 per year for MS3s.

On average, D.O. schools are more expensive than M.D. schools. According to the Association of American Medical Colleges (AAMC), in-state M.D. students average $34,000 per year in tuition, fees and mandatory health insurance. Private M.D. schools average $56,000 per year, and out-of-state M.D. schools average $58,000. The D.O. averages do not include health insurance, but clock in at $44,000 for in-state and $49,000 for out-of-state, according to the American Association of Colleges of Osteopathic Medicine. The average debt upon graduation of those who took out school loans, $183,000 for M.D.s and $229,000 for D.O.s in 2015—as reported by the AAMC and the AACOM, respectively—is actually pretty amazing considering the cost of tuition.

Ethan Handler, M.D.

Refinancing his student loans was like “kicking off the training wheels,” says Ethan Handler, M.D. Doing so, however, also helped him refocus on attacking the debt. · Photo by Kat Schleicher

However, those averages obscure the fact that, according to the AAMC, 32 percent of M.D. students graduate with more than $200,000 in debt, and 8 percent graduate with more than $300,000. In addition, since most residents do not even pay enough on their debt to cover the interest, many of those who start residency owing $200,000 finish owing $300,000 or more. So if you feel you are in a deep hole with your student loans, know that you are not alone. There is little you can do at this point about the depth of the hole, but there is a lot you can do to get out of it as fast as possible if you practice lifestyle control and proper debt management.

Although some physicians will have their debt paid off by their employers or forgiven by the federal government, the vast majority will eventually have to pay off their student loans themselves. The secret to doing this is to live a lifestyle similar to your resident lifestyle for a period of two to five years. For example, if you owe $200,000 and have an attending salary of $200,000, you can live on $50,000, pay $50,000 in taxes and put that other $100,000 toward your student loans, eliminating them completely within two years. In order to do this, however, you will need to resist the siren call you hear from peers, friends and family to grow into (or beyond) your income as soon as you can. With proper lifestyle control, most physicians can be out of debt within two to five years of residency graduation. It isn’t complicated, but it does require discipline.

Unfortunately, the other key to getting rid of your debt—proper student loan management—is far more complicated. In fact, it can be ridiculously complicated to determine the proper path during residency because a multitude of options are available to minimize interest accumulation, minimize payments and remain eligible for government forgiveness programs. Proper student loan management can even affect the best way to file your taxes and the type of retirement account to use as a resident. Much of this information I learned the hard way. As a resident who got sick of financial professionals ripping me off, I decided to educate myself on the basics of personal finance and investing. Since then, I’ve been sharing what I learned with other physicians—both in my book, The White Coat Investor, and on my blog of the same name. In this article, I’ll share some of that same information with you. Due to the complicated nature of the in-residency loan management process, this article will provide only brief general rules for residents while encouraging them to learn more about this complicated topic from other sources or to obtain professional advice. Prior to listing these rules, I’ll define the commonly used federal government programs residents need to know about.

The federal programs you need to know

Public Service Loan Forgiveness (PSLF) is a program that allows for complete tax-free forgiveness of your remaining federal Direct Loans after making 120 qualifying monthly payments, no matter how much debt you have left. The programs whose payments qualify include the standard 10-year repayment plan and the three income-driven repayment plans: Income Based Repayment (IBR), Pay As You Earn (PAYE) and Revised Pay As You Earn (REPAYE.)

Income-driven repayment plans have several common features, but the main one is that the payments are dependent only on your income (and family size) and not on the amount of debt you have or the debt’s interest rate. You can determine what your payment amount would be by taking your income and subtracting 150 percent of the federal poverty line for the size of your family. The remaining amount of money is called your “discretionary income.” IBR requires you to pay 15 percent of your discretionary income toward your student loans, while PAYE and REPAYE require 10 percent. For most residents, those payments don’t even cover the interest on the loans. The discretionary programs have a forgiveness feature too, but physicians rarely take advantage of it because it doesn’t apply until 20 to 25 years have passed, and even then, the amount forgiven is considered taxable income. REPAYE has an additional interesting feature in that half of the interest not covered by the monthly payments is subsidized by the government, effectively lowering your interest rate.

Rules for residents

With that brief introduction to the government programs, let us consider three general rules for residents trying to navigate through these complex decisions.

Rule 1 for Residents: If you hope to obtain PSLF by working for a 501(c)3 nonprofit after completing residency, then you want to stay in a government income-driven repayment program during residency.

Rule 2 for Residents: Minimizing payments, minimizing interest accumulation and maximizing loan forgiveness may be mutually exclusive. For example, the best way to minimize payments is to defer your loans until residency completion, but you’d better expect them to be a lot bigger at the end than they were at the beginning! The best way to maximize loan forgiveness is to make payments that are as small as possible during residency through one of the government programs. Which program will allow you to do that best, however, varies according to your marital status, spouse’s income and the type of student loans.

Refinancing your loans can help you to minimize interest accumulation, but it also turns the loans into private loans, which are no longer eligible for Public Service Loan Forgiveness. The private lenders who refinance loans for residents do, however, allow for very small payments ($0 to $100 per month) during residency. To make things even more complicated, the latest government income-driven repayment program, REPAYE, may partially subsidize the interest on your loans, effectively lowering the interest rate to a level below that which you would get from a private lender. This is because residents don’t typically qualify for the lowest rates from private lenders. Instead of the 2 to 4 percent an attending might be able to get, a resident will probably only be offered a rate of 5 percent.

Rule 3 for Residents: The best government program for most residents is the REPAYE program. There are two caveats to this, however. The first is that, depending on how much their spouses earn, married residents may be better off in the IBR or PAYE programs and filing their taxes as Married Filing Separately. The second caveat is that if you decide to go for PSLF after residency, you will likely want to switch from REPAYE into IBR or PAYE upon residency completion in order to maximize forgiveness. IBR and PAYE payments are capped at the 10-year Standard Repayment Plan payment, whereas REPAYE payments may rise above that level, depending on your income.

Decisions after residency

As an attending, the decisions become much easier. If you are directly employed by a 501(c)3 nonprofit or government employer, you should pick the income-driven repayment plan that gives you the lowest payment, pay the minimum on your loans, and obtain PSLF after 120 total payments. If you are not eligible for PSLF, you should probably refinance your loans with a private lender. Various terms and rates are available from at least 20 lenders, and what you qualify for will depend on your credit and debt-to-income ratios. You may be able to lower the interest rate on your loans from 6 to 8 percent in the federal programs to 2 to 5 percent, saving thousands in interest each year. Of course, just because you refinance doesn’t mean you want to forget about those loans and go on the minimum payment plan. You don’t get out of debt by taking on more debt; you get out of debt by living like a resident for two to five years and throwing a huge chunk of money at those loans every month—whether the interest rate is 7 percent or 3 percent.

Ethan Handler, M.D., an otolaryngologist and cosmetic surgeon practicing in Oakland, California, worried a little bit about refinancing his loans. He knew that he would “lose the government-provided safety blanket” to go into forbearance or have income-based payments in case something happened to his income. He ended up refinancing his loans at 3.5 percent and found that it was like “kicking off the training wheels. Once I refinanced and no longer had the safety net of hardship or forbearance, I took more responsibility for my debt. What had previously looked like a funny and absurdly high number ($240,000 upon residency graduation) on paper became something I’m working hard to erase.”

There is also some risk that the government could change the PSLF program. The Obama administration has made budget proposals that, if passed by Congress, would limit the amount of forgiveness to just $57,000.

Amanda Weinmann, M.D.

Amanda Weinmann, M.D., opted to live frugally while paying off her student loans—a choice that allowed her to pay toward her debt while in residency. · Photo by Tim and Madie Photography LLC

Amanda Weinmann, M.D., an attending family physician in St. Paul, Minnesota, didn’t like that the program seemed so politically uncertain—not to mention the fact that no person has yet received forgiveness through the program. (The program requires 120 monthly payments after 2007, and there have not yet been 120 months since 2007.) The idea of dragging out payments on the $162,000 she graduated medical school with was very unappealing. “I was psychologically uneasy with making payments that didn’t even cover the unsubsidized interest, and I felt that, since I borrowed the money and had the means to pay it back, I should.” By living frugally, she paid off a car, avoided credit card debt, funded a Roth IRA and paid off $64,000 of her student loans while in residency.

Another alternative for those concerned about the political viability of the program (aside from avoiding it altogether as Weinmann did) is to save up the equivalent of the debt on the side in an investing account. If the program disappears or becomes severely limited, the funds in the side account can be applied to the debt. If forgiveness materializes as expected, the side account will provide a boost to your retirement nest egg.

Owen Vincent, D.O., a family physician practicing in Prairie du Chien, Wisconsin, uses this approach. He works for a 501(c)3 and is going for PSLF for his $315,000 in student loans. He states, however, “I’m also saving as much as I pay each month in taxable accounts [above and beyond my retirement savings]; so if [PSLF] doesn’t work out, I’ll throw a lot of money at those loans quickly and get rid of them, and if it does work out, I’m that much closer to financial independence eight years from now.”

Employer loan assistance

In interviewing physicians for this article, I was surprised by just how many of them had received loan assistance from their employers. This is an increasing trend among physicians and non-physicians alike. The classic example is the military with its various programs including the Health Professions Scholarship Program, which pays for tuition, books, fees and a stipend for medical students, and the Financial Assistance Program, which pays an annual grant (currently $45,000) plus a monthly stipend to residents in exchange for a service obligation.

The National Health Service Corps (NHSC) offers similar programs. The NHSC loan repayment program offers up to $50,000 toward your student loans in exchange for a two-year commitment to an NHSC-approved site. The NHSC also offers a scholarship program similar to the military HPSP program in that the student receives tuition, fees, other educational costs and a living stipend in exchange for a commitment to serve in an NHSC-approved job. Each year of support in medical school requires a one-year commitment, with a minimum of two years. The scholarship is generally considered the better deal, but the loan repayment program has its advantages as well. This program, however, is generally available only for primary care providers, mental health providers and dentists.

Vincent, who expects Public Service Loan Forgiveness, found that he also qualified for a state-specific, rural provider, tax-exempt loan repayment of $50,000. Kononchuk, too, was surprised to discover that he qualified for a New York loan repayment program designed for physicians treating underserved patients. He says, “I see way too many people not even consider such programs, as they assume that if they don’t live in a rural area, they won’t qualify. Guess what? I work in NYC and I still met criteria!” If he stays in the same job for five years, the program will have paid his entire $150,000 student loan burden.

The bottom line is that more and more employers, states and communities are offering student loan repayment programs and the qualifications are highly variable. You may be surprised what you can find. Vincent says: “My locale may not be for everyone—as some would never dream of living more than an hour from a Target—but I’ve found the slower pace allows for more meaningful time with family, friends, patients and hobbies. Plus, the much lower cost of living has done wonders for my financial situation.” If you, like Vincent, are willing to work in a geographic locale where few physicians are interested in working, you may find you have significant negotiating power. Even if you cannot get a higher salary, consider asking for assistance with student loan repayment.

Whatever your strategy for your student loans, the keys are lifestyle control and educating yourself about proper loan management. As Weinmann says, “It’s literally worth tens of thousands of dollars to spend a little time educating yourself about loan options. If you compare that to your hourly rate as a resident, you’ll find this to be a great use of your limited free time.”

James M. Dahle, M.D., FACEP is the author of The White Coat Investor: A Doctor’s Guide to Personal Finance and Investing and blogs at whitecoatinvestor.com. He is not a licensed financial adviser, accountant or attorney and recommends you consult with your own advisers prior to acting on any information you read here.

 

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Apples and oranges: how to compare job offers

Compensation is important, but comparing your offers when making a job change means more than just looking at the bottom line. Are you evaluating every facet of the opportunities?

By Bruce Armon | Fall 2016 | Feature Articles

 

During the course of your career, you will make many changes: finishing training and taking that first job, advancing within an organization, switching jobs, moving to a different town or, eventually, retiring.

You may initiate many of these changes. Family situations may cause some. Your employer may precipitate others. Still others may result from mergers, acquisitions, affiliations or consolidation as health care continues to evolve. Regardless of the cause of a change, when it is about to occur, you will need to evaluate and compare multiple opportunities.

Comparing opportunities by weighing the costs and benefits of various options is critically important. And crucial to a proper cost/benefit analysis is the understanding of what is most important and viable to you in both the short- and long-term. Which job will protect your future and provide you the flexibility you need for the next opportunity you’ll pursue down the road?

Weigh it: Familiarity

The road through residency and fellowship can be long and winding with an uncertain future. After finishing training, you might weigh the option of staying at the same academic medical center.

There are benefits to staying in the same environment: continuity, familiarity, and the opportunity to teach junior residents whose strengths and weaknesses are known. There are also potential costs to staying at the institution where you trained. You may struggle to be seen as a peer rather than a trainee. You may find upward advancement difficult in a crowded division or department. And you may be more accepting of less compensation in exchange for the comfort of staying at a familiar institution.

To help you evaluate

If you’re considering whether to stay in your current program or not, ask yourself:

  • What is my relationship like with my mentors here? How long will they practice here?
  • What are the growth opportunities?
  • Will I always be viewed as a resident or fellow, or will I be able to be viewed as a colleague?
  • Would I be better off in a different environment that would broaden my professional experiences?
Caren Kirschner, M.D.

Geographic location, quality of life and benefits were most important to Caren Kirschner, M.D., as she evaluated opportunities. · Photo by Colin Lenton

Caren Kirschner, M.D., had three primary considerations when comparing opportunities after completing residency at St. Christopher’s Hospital for Children in Philadelphia: geographic location, quality of life and benefits. Each was of equal priority, and more important to her than other criteria such as starting salary or advancement opportunities.

Kirschner chose to join a private practice, but familiarity still played a role. “I grew up in the Philadelphia area and went to medical school and completed my residency in Philadelphia. I knew I wanted to stay in the immediate Philadelphia area, and I really wanted to avoid an unpleasant commute,” she says.

Weigh it: Geography

As in Kirschner’s case, geographic location is a top consideration for many physicians comparing job options. Geographic preferences are mostly personal, but there are also practical and legal issues regarding the area in which you choose to work.

Professional liability insurance costs vary among regions largely because of each region’s reputation of being provider-friendly in legal matters and because of its history of suits, judgments and settlements. If the cost of professional liability insurance is significantly more in one community than another, that may affect the salary that can be offered by an employer—and your choice to practice there.

Noncompete clauses prohibit physicians from practicing within a certain distance from their previous employer for a certain amount of time after they leave that employer. A clause’s scope may vary depending upon your specialty, employment setting and the competition in an area. If you know you want to be in a specific community for a long time, a noncompete stipulation may be the most important section of your contract. In states that prohibit noncompetes, you may find that employers include a liquidated damages clause to ensure that physician employees pay damages if they practice within a certain radius during a certain time frame after their employment ends.

Cost of living is another consideration tied to geography. How much of your salary will go toward housing, property taxes, groceries and transportation? Will you need to budget for private school tuition in one practice location and not another?

To help you evaluate

Plan to talk with realtors, local school district officials, leaders in the local hospital and others who will provide objective information. Ask about anything that’s particularly important to you: cost of housing, school options, athletics and other recreational activities, and turnover of other physicians.

Knowing the standard of living that your base salary would provide in a community is also important, particularly when you are considering relocating to an area with which you have limited familiarity. Get a clearer picture of the areas you’re considering with help from these websites:

  • CNN Money (cnnmon.ie/28PPyEd): A straightforward online calculator.
  • Sperling’s Best Places (bit.ly/1wO6KTN): A calculator that factors in food, housing, utilities, transportation and health costs.
  • Bankrate (bit.ly/1gTzoZ0): Detailed cost comparisons for a few dozen common cost-of-living items, from ibuprofen to tennis balls.
  • The U.S. Department of State (1.usa.gov/1RrNOPI): A list of helpful resources regarding salaries, cost of living and relocation, including links to various chambers of commerce as well as realtor and retirement information.

Weigh it: Compensation

Two jobs that both pay $150,000 annually may result in very different standards of living depending on where each is located. But there are also other factors to consider as you compare compensation. The salary in the contract is just the beginning.

A fundamental premise that you must understand as you compare compensation offers is that your total pay (base salary, bonus, benefits) will be based upon some variation of return on investment—the return you provide on the investment employers make in you. Employers will pay you less than what you generate in revenue because the resulting margin will help fund their other operations, which may include less profitable practices. Your responsibilities—whether clinical, administrative, research or a mix—also affect your compensation.

Employers typically pay physicians based on one of three models: straight salary (with or without bonus opportunities), productivity, or profit-centered.

Straight salary. The straight salary model guarantees you a specific amount of pay for a defined period of time. No matter how hard you work, how many patients you see or how many procedures you perform, your salary remains the same.

Productivity. Under this model, you are paid according to your personal productivity. This may be measured as cash in the door, work relative value units (wRVUs), patient encounters, number of call shifts, overnight shifts or another standard. This model often includes a lower base salary or draw, but the more productive you are, the more money you can make.

The wRVU measurement eliminates bias based on the payer mix of a physician’s patients. For instance, a physician who treats only uninsured patients likely generates far less cash in the door than a physician who treats only privately insured patients. But if they work the same number of hours and see the same number of patients, they should have the same number of wRVUs.

Profit-Centered. A profit-centered model bases your salary on both your productivity and your expenses. Your compensation depends on both the opportunities you have to generate revenue and your ability to keep expenses to a minimum.

If you’re considering an opportunity with this payment model, it is important to understand the approximate revenue you can generate and how expenses are calculated. Are expenses determined pro-rata (for example, if there are five physicians in the profit center, they are each responsible for 20 percent of the expenses), or are they based on some other formula?

For some employers, the compensation model may be negotiable. If you’re more comfortable with one model over another, it’s worth asking your potential employer if their model is flexible. The response will likely depend on the size of the practice and how developed its infrastructure is. Other employers may start you with a straight salary that shifts to a productivity model at some pre-determined point in time.

To help you evaluate
Diane Godorov, D.O.

When evaluating offers, “having an objective, unbiased resource to help you set compensation expectations is very important,” advises pediatrician Diane Godorov, D.O. · Photo by Kelly Giarrocco

Diane Godorov, D.O., is a pediatrician who has worked in several different settings including private practice and urgent care. “It is important to know what you are supposed to earn and how realistic it is that you can attain proposed bonuses,” she says. “Having an objective, unbiased resource to help you set compensation expectations is very important.”

One source of objective data is the Medical Group Management Association (MGMA), which publishes several reports compiling annual compensation data for physicians. MGMA data shows how salaries are affected by factors such as specialty, years of experience, size of practice and geographic location and can help you understand the physician marketplace.

For physicians pursuing academic medicine, the Association of American Medical Colleges (AAMC) publishes physician compensation data. AAMC reports include detailed information about how compensation is affected by faculty level, departments and specialties, and the mix of clinical work, teaching and research.

Many employers use national surveys such as the above to set salary and bonus caps at the median or 75th percentile. By creating this cap, an employer can ensure that compensation is based on fair market value and balanced among peers. Ensuring there is a salary floor, too, can ease your anxiety of switching from a job with a guaranteed salary to one that may be variable and based on factors outside your control.

Another compensation factor to be aware of is that, if your practice includes clinical or academic research, your employer may expect you to secure grant dollars to cover part of your own compensation. If the grant dollars are eliminated or reduced, your compensation may be adjusted accordingly. In many instances, receiving additional grants may not increase your compensation, but it can allow additional research to be performed by hiring additional staff.

Weigh it: Benefits

Benefits are an often-overlooked piece of the compensation package, but they can make a significant difference both in dollars and in quality of life.

For Kirschner, “maternity leave was an important consideration of any job offer.” As a pediatrician and a hopeful mother, she prioritized this benefit as part of her job search.

It’s important to understand how the benefits you’re offered compare both monetarily and toward your quality of life. What is the value of the health insurance and vacation time offered, or the funds available for CME? How about the value of the retirement program or the professional insurance coverage offered?

An opportunity with a lower base salary but excellent benefits may actually be better than one with a higher base salary and few or no benefits.

Weigh it: Family Fit

Stuart Ort, M.D., was a successful otolaryngologist in California for eight years. He practiced with one other physician and had no employment-based reason to switch jobs. But as he weighed his happy job situation with a desire to be closer to family in the New York City area, family took the higher priority.

In his search for a new practice, Ort says his “major consideration was finding a non-academic institution or group where I would be able to focus the vast majority of my time and energy on clinical work.”

Ort reached out to friends in the New York City area and ultimately identified a large single-specialty ear, nose and throat practice. Even though it is a much larger practice than his former employer, Ort reports that he is “very happy with how transparent the practice is and the fact that no one feels like they are missing out or are getting unfairly treated.” Despite moving cross-country to a very different practice environment, Ort says his new practice is a “great fit.”

To help you evaluate

To help ensure your new practice and community meet you and your family’s needs, ask these questions:

  • What is the real estate market and school district like?
  • Does the community offer access to my and my family’s religious, educational and extracurricular needs?
  • How close would I be to family and friends?
  • How is the climate and environment?
  • What community do most physicians live in? What is the commute like?
  • What do physicians in the area do when they’re not working?
  • What do other physicians and their families like best about living and working there?

Comparing your options

Some physicians compare the job-search process to a dating game: you meet a lot of different people interested in getting to know you better, and they all want to see if you are compatible with them. Once you are interested, the employer prepares a contract to make the relationship official.

Mike Srulevich, D.O., who recently changed jobs, was philosophical as he considered a new opportunity. A change in jobs “can be transformative on several levels,” he says. “You may have been doing the job for years, but all of a sudden it’s a new culture, a new schedule and a lot of different personalities.”

Taking a new job, he says, is “like buying a new house: Finding it might be the easiest part.” Once you sign the employment contract, you must “navigate the paperwork, coordinate schedules and unpack life as it formerly was [in order to] start a new and different professional life.”

Just as in house-hunting or dating, physicians who are comparing options must understand and prioritize their own short-term and long-term goals. Choosing among multiple options is never easy. As you weigh the costs and benefits of opportunities, make sure you have carefully defined your own objectives. Additionally, make sure that the language of your final contract is consistent with these objectives and matches your impression of the opportunity. Identifying what matters most to you will help you make the choice that is most professionally and personally gratifying.

Bruce Armon is chair of the health care practice group at Saul Ewing LLP and frequently speaks to physician audiences and other health care audiences. He has helped hundreds of physicians and practices over the years with contractual, compliance, reimbursement and regulatory issues.

 

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Protecting what you’ve built

You’ve worked hard for your money—both current and future. What steps should you take to protect it?

By James M. Dahle, M.D., FACEP, WhiteCoatInvestor.com | Feature Articles | Winter 2017

 

Many physicians carry a profound fear of losing their personal assets due to a mistake at work. By understanding just how rarely this actually occurs, you can alleviate these fears—and make reasonable decisions about which steps to take to protect your assets. According to the National Practitioner Data Bank and health care cost writer David Belk, M.D., the number of paid claims against physicians between 2003 and 2014 dropped from 15,000 per year to 9,000 per year, with only about 2,000 of those paying out more than $500,000.

Plus, almost half of those claims occurred in just six states: New York, Pennsylvania, New Jersey, Massachusetts, Maryland and Illinois. In fact, the amount of money paid out per capita in New York is 2,969 percent higher than that of North Dakota and 39 percent higher than that of any other state.

According to a 2012 study published in the Archives of Internal Medicine, only about 55 percent of claims go on to become lawsuits, and the vast majority of those are resolved before going to trial, which means that less than 5 percent of claims end up going to trial. Of those that went to trial, 80 percent of them are decided in favor of the doctor. Of those that were not decided in favor of the doctor (about 1 percent of claims), the vast majority of awards from the jury are within the limits of the policy. Most of those that are above policy limits are then reduced to be within policy limits during the appeals process.

All that to say, the likelihood of your having to pay from your personal assets in any given year is less than one in 100,000, despite the astronomical awards often widely publicized. For example, in 2009’s Hugh v. Ofodile, a jury in New York famously awarded a plaintiff a $60 million verdict for pain and suffering following a thigh lift surgery. After two years of appeals, the verdict was reduced to $600,000, which was well within policy limits.

Tried and true techniques

Given the extremely low likelihood of having to pay out of personal assets, you needn’t lose any sleep over this issue. Rather, it is reasonable to limit the time, money and effort you spend protecting against this extraordinarily unlikely outcome. You should also consider the ethical dilemma involved in any asset protection plan—that if the plaintiff was legitimately damaged through your negligence, you have a legal and ethical duty to make it right financially, even if it involves the loss of your personal assets. Many would consider it unethical to engage in a scheme to prevent a plaintiff from collecting what is rightfully his.

Your first reasonable line of defense against any liability claim is an adequate insurance policy. Liability insurance policies not only pay any judgment that may come due, but just as importantly, pay for the cost of the defense, no matter how many years it may take.

Physicians tend to worry most about malpractice liability, which is defended using a professional liability policy, but they should also worry about their personal liability, which is defended using a homeowners, renters or auto liability policy. In addition, the wise physician adds an “umbrella” policy on top of these policies to provide liability coverage of $1–5 million. The good news about umbrella policies is that you can buy a great deal of insurance for a very low price. Several million dollars of coverage is typically available for less than $500 a year—dramatically less than a malpractice policy.

A malpractice policy needs to be both adequately sized and maintained for an adequate length of time. The general guideline for deciding how much coverage to carry is to match what’s typical for your state and specialty. For example, emergency physicians in Utah typically carry a policy with limits of $1 million per occurrence and $3 million per year.

Eric Tait, M.D.

In addition to proper insurance coverage, Eric Tait, M.D., recommends identifying an asset protection plan. · Photo by Kelli Durham

Eric Tait, M.D., an internist with Central Houston Medical Group in Texas, notes that his employer provides coverage of $200,000 per occurrence and $600,000 per year, so that is what he carries. Carrying less coverage could expose you to additional risk of paying out of pocket. More coverage, on the other hand, may make you more of a target due to “deep pockets.”

For insurance coverage to be adequate, it must remain in force until the statute of limitations runs out, which is typically two years from discovery of the error in question or two years from the time the plaintiff turn 18. You can get this length of coverage by purchasing either a “tail” policy in addition to your “claims-made” policy or by purchasing an “occurrence” policy (which includes tail coverage) from the get-go. When signing an employment contract, be sure it is very clear how your tail will be covered, because the cost of a tail is often two to three times the annual premium for a claims-made policy. Ideally, your employer will cover that cost under any circumstances, but this varies greatly among employers.

Sanghamitra Sadhu, M.D., a nephrologist with Renal Care Orlando in Florida, carries a claims-made policy. “If I change jobs, I hope to negotiate it as a sign-on bonus or part of my compensation package at the new job.”

Tait doesn’t advise relying solely on insurance. “For me it is equally important to have an asset protection plan in place as it is to have malpractice insurance,” says Tait.

Though this can greatly benefit you in the case of a lawsuit, it is important to realize there are no guarantees with asset protection. An attorney or insurance agent promising an iron-clad technique is usually overselling his favored technique. Any asset protection technique is designed to make it harder and more expensive both to find out what you own and to actually get it. The idea is to make it take more time, effort and money to get to your assets.

In addition, asset protection laws are always state-specific. What works in one state may not work in another. Not only do the likelihood of being sued, the likelihood of losing a trial and the expected payout vary by state, but so do the assets that creditors protect. The ultimate protection against your creditors is to declare bankruptcy. Then you keep whatever your state protects, and you lose what it does not. In practice, however, it is more typical for a defendant to settle for some amount rather than to go through bankruptcy. For example, a physician may have a lien placed on his home as a result of the judgment and may simply take out a second mortgage to pay off the lien.

Many states have a “homestead” law that protects a certain amount of your home equity from your creditors. The value protected varies dramatically, however. Florida, for example, protects property of unlimited value (up to 160 acres in rural areas and half an acre in urban areas), but Alabama protects only $5,000 of home equity ($10,000 if you’re married). Obviously, from an asset protection standpoint, it is better for a Florida physician to have his wealth in his home than it is for an Alabama doctor. Practically speaking, that might mean a Florida physician would buy a slightly larger house and pay off the mortgage faster. Sadhu, the nephrologist in Florida, admits buying a little more house than she otherwise would have due to this homestead law. “We have been hitting our mortgage aggressively with extra payments every year once we have met our retirement savings goal for the year. [The homestead law] did influence our decision with regard to how much house we bought. We decided we would buy the kind of house we dreamed of and save in other areas of our lives.”

John Odette, M.D.,

The homestead law in Texas, where John Odette, M.D., is an ophthalmologist, protects up to $1 million and mentions some very specific assets, such as two firearms and up to 120 chickens. · Photo by The Bird & The Bear

The homestead law in Texas is also interesting. Not only is up to $1 million protected, but $30,000–60,000-worth of very specific personal assets are also protected, including two firearms and up to 120 chickens. John Odette, M.D., an ophthalmologist at Austin Eye in Austin, doesn’t own 120 chickens but does say that he “plans to buy a little more house than I otherwise would as asset protection, although not too much more.”

Aside from a homestead in a few specific states, the best asset protection technique for most doctors is simply to maximize contributions to retirement accounts. In most states, 100 percent of your 401(k) and IRA balances are protected from creditors in bankruptcy. In some states, plans compliant with the Employee Retirement Income Security Act (ERISA), such as 401(k)s, receive more protection than IRAs. In other states, only an amount “reasonably necessary for support” is protected, so be sure to know the law in your state when fashioning an asset protection plan.

Some states also provide protection for the cash balance of insurance products like whole life insurance and annuities. Insurance fees result in a heavy drag on returns in these products, but for a physician who highly values asset protection benefits and actually lives in a state where these benefits exist, it can make sense to place some money into them. Odette, for instance, has strongly considered purchasing a whole life insurance policy primarily for the asset protection.

Another important asset protection technique involves titling assets correctly. In many states a married couple can title their home as “tenants by the entirety,” which means that both people own the entire house, rather than each owning half. In effect, this means that a suit against just one of them cannot take the house. Sadhu and her husband use this technique. “My home state of Florida recognizes tenants by the entirety, so this is the best way to title our house from an asset-protection standpoint, since it protects our homestead from a claim against either my spouse or me. This is vital for us, being a two-physician couple.”

Tenancy by the entirety is a much better option than a technique some physicians use—putting everything in the spouse’s name. You are far more likely to lose your assets in a divorce than in a malpractice lawsuit. That hasn’t stopped Tait from titling his primary residence in his wife’s name and his secondary residence in his own. He notes, however, the main reason for that was not asset protection, but to increase the ability to obtain leverage for his secondary profession as a real estate investor. Tenancy by the entirety isn’t available in Texas anyway.

Techniques to go above and beyond

Once you get beyond these well-known protected assets and titling techniques, asset protection strategies start becoming significantly more complicated and more expensive. At this point, a physician desiring more asset protection ought to take a look at reducing the risk in his life. That might mean moving to a state with fewer malpractice claims and lower payouts. An OB-GYN might drop obstetrics, and a general surgeon might drop trauma coverage. It might mean getting rid of the family dog, the pool and the trampoline in the backyard. It could mean not inviting your child’s friends on your boat and not serving alcohol when entertaining. But at a certain point, most reasonable people agree that you cannot eliminate all risk from your life.

Some physicians wonder whether they can reduce their risk by incorporating their practice. Unfortunately, malpractice is always personal, so having a shell corporation doesn’t provide any protection from professional liability, although it could have some usefulness from business-related liability (such as if an employee sued you for breach of contract).

Limited liability companies also have some useful asset protection possibilities, although the amount of protection they provide varies highly by state. Limited liability companies or LLCs are used to segregate “toxic” assets, such as rental properties, from “safe” assets, such as a portfolio of mutual funds. The idea is that if someone gets hurt on your rental property, the most he can receive is the value of that LLC, which contains only that particular property. LLCs can also make it more difficult to figure out exactly what you own. This was important to Tait following an incident at one of his investment properties. “At one of our apartment complexes, we experienced a violent crime early on in our ownership. News cameras were everywhere. The news agencies tried to find out who owned the property, but because of our structures, they could never find out. We were not negligent in any way, but we surely did not want any unwanted public exposure.”

Another use of LLCs occurs in states where creditors are limited to a “charging order” to get what they are due. A charging order basically says that if the LLC distributes income, the creditor gets their cut of it. Whether or not an LLC actually distributes income, however, is under the control of its owners. To make things even more interesting, an LLC is usually a pass-through entity from a tax perspective. So it is possible not only not to distribute income from the LLC, but also to send the creditor the tax bill for that income! Needless to say, in some states, this technique can be quite the incentive for a creditor to settle for less.

One of the best asset protection techniques is simply to give your money away. That which does not belong to you cannot be taken from you. This might mean establishing a charitable trust, funding 529 plans and Uniform Gift to Minors Act (UGMA) accounts for your children or putting money into an irrevocable trust. Like any asset protection technique, this needs to be done long before you are ever sued lest it be viewed as a fraudulent transfer. In fact, any technique done solely for the asset protection benefit is likely to be undone by a judge. It is always better to have a reason related to your business purposes or your estate planning to implement an asset protection technique.

There are more exotic asset protection techniques like family limited partnerships and off-shore accounts that can be useful in certain circumstances. Some of these are scams, many are overpriced, and all are usually unnecessary given the rarity of being successfully sued for an amount above your policy limits. If you are interested in these sorts of techniques, you should consult with a reputable asset protection attorney in your state.

Investing and saving as asset protection

Truthfully, most docs spend too much time worrying about asset protection and not enough time worrying about far more common causes of not reaching their financial goals. One common reason doctors and many others do not reach their goals is the death or disability of the breadwinner. Both of these issues are easily insured against. A doctor may earn $5–10 million during her career. Thus, her earning power is her most valuable asset. Disability insurance is expensive, but critical in the years prior to financial independence. A good individual disability policy typically costs 2–6 percent of the amount of income protected. So a policy that pays a monthly benefit of $10,000 in the event of disability would likely cost a healthy doctor in her 30s a few hundred dollars per month.

Premature death is also a risk worth protecting against. Luckily, term life insurance is much cheaper than disability insurance, so it is relatively inexpensive to purchase a policy of $1–5 million to provide for loved ones in the event of death. A healthy 30-year-old doctor can buy life insurance for as little as $280 per year per million dollars of coverage. Both types of insurance are best purchased from an independent agent who can sell you a policy from any company.

Another common reason doctors don’t reach their financial goals is inadequate savings rates. A doctor who wishes to maintain his lifestyle in retirement should be aiming to save 15–20 percent of his gross salary for retirement throughout his career. It doesn’t matter what your asset protection plan is if there are no assets to protect!

Inflation, taxes and investment fees are an investor’s chief enemies. Inflation is best protected against by taking an adequate amount of risk with the portfolio. A portfolio invested 100 percent in CDs, savings accounts and bonds is unlikely to grow adequately once the effects of inflation are taken into account. Most doctors will need to take on at least some risk with their investments by including risky assets like stocks and real estate in their portfolios. Your tax burden can be lowered by investing inside of tax-protected accounts such as 401(k)s, Roth IRAs, and even health savings accounts and 529 college savings accounts. Finally, investment fees can be minimized by reducing the frequency of your transactions (which is likely to boost returns anyway), by making sure you’re paying a fair price for any needed financial advice, and by using low-cost investments such as index funds.

Physicians spend more than a decade developing the knowledge and skills necessary to earn their high salaries. They continue to work hard throughout their careers. No wonder they are interested in protecting their assets from potential creditors as well as the corrosive effects of inflation, taxes and investing fees. Smart spending decisions combined with an intelligent investing plan and a reasonable asset protection plan will help you reach your financial goals.

James M. Dahle, M.D., FACEP, is the author of The White Coat Investor: A Doctor’s Guide to Personal Finance and Investing and blogs at whitecoatinvestor.com. He is not a licensed financial adviser, accountant, or attorney and recommends you consult with your own advisers prior to acting on any information you read here.

 

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A Moonlighter’s Guide to the Galaxy

Moonlighting during residency can be a boon to your professional skills and your wallet. The guide covers how to get a moonlighting gig and how to prepare for it.

By Derek Sawyer | Feature Articles | Winter 2017

 

Like ice cream on a hot day, moonlighting can be an epic idea or an epic mess, depending on your preparation for the situation. (A little luck never hurts either.)

Moonlighting, or having a secondary job in addition to your main employment, is a popular option among residents looking for additional income and experience. Having been a health care recruiter for more than 10 years, I’ve learned a thing or two about moonlighting to share with you, like where to find opportunities, how moonlighting can help you down the road and what newbies should know. Many moonlighting opportunities are available because they are in unpopular locations, but that doesn’t mean they can’t deliver your desired outcome—plus a little extra.

Why moonlight?

Erik Stamper, D.O.

Erik Stamper, D.O., had a rough first shift as a moonlighter during residency. Though his story isn’t the norm, it’s still an important warning to understand the total environment. · Photo by Wirken Photography

Speaking of outcomes, why is moonlighting a good idea? Simply put, it’s the best way to get out of your comfort zone and see medicine outside a controlled academic environment. Plus, it can help you get a head start on paying back those student loans. Since the monetary benefits are pretty self-explanatory, I would like to focus on a few other benefits of being exposed to a new setting at this point in your career. You may not be getting these benefits in your program’s curriculum, but they will complement the clinical skills established there.

Leadership experience. As a resident you have many chances to hone specific clinical skills (which, it goes without saying, are critically important), but in many situations throughout your career you will find yourself in situations that call for you to be more of a general than a foot soldier. Though it’s fantastic that you can intubate anyone while blindfolded, what happens when patients begin to stack up and you don’t have the time to properly handle each one? This is when it is critical to know your team and available resources, as well as how to best motivate them to achieve results in the quickest manner. As I will expand on later, your nursing support can make or break your shift, so having their buy-in is key. This doesn’t mean you need to order them pizza everyday (although that doesn’t hurt), but you do need to take the time to mesh well with the folks you will be counting on.

Political/relational experience (i.e. playing nice in the sandbox). No matter where you go, there will be folks who will be easy to get along with and there will be … the others. Unfortunately, as a resident you won’t usually receive the benefit of the doubt right away; you will have to earn it. This may take some time, but in the interim, moonlighting provides an excellent chance to learn how and when to push colleagues, specialists and others to get the help you need. Though I would not recommend being too blunt initially, you will need to be able to establish yourself if you want to care for your patients properly and get the requisite support. Speak with your current attendings; they have no doubt encountered similar situations and should be able to provide tips on handling difficult personalities while still getting what you need.

Steve Roberts, M.D.

When moonlighting, be sure to identify who can act as a second opinion. “Having backup that is only a phone call away helps me even in the most isolated locations,” says Steve Roberts, M.D. · Photo by That’s a Pretty Picture

Confidence. It is my belief that what separates pro athletes from amateurs is merely practice and a high level of confidence in their abilities (which pretty much comes from practice). It is one thing to conduct a complicated procedure with three techs, two attendings and a partridge in a pear tree, but what happens when it’s just you? Do you know what to do? Do you know whom to call to find out? Your confidence level will not only be blatantly obvious to all those around you but will also be infectious. If you know you can handle a situation, others will follow.

Perspective. To promote consistent clinical practice, most academic or residency environments are designed to be as controlled as possible. But part of learning is understanding multiple perspectives, and in many cases these perspectives can only be gained in the flesh. For this reason, emergency and internal medicine physician Sam Clemmons, M.D., emphasizes the importance of moonlighting as part of the educational process. Clemmons, who started in the military, has worked in both rural and urban settings. He is currently the president of Elite Emergency Service in Franklin, Tennessee, handling contract management on a large scale. The variety of his background has helped him gain a perspective on all aspects of medicine, which in turn helps him understand and contribute to it on a macro level.

How to find opportunities

Moonlighting opportunities usually aren’t hard to find, and there are often multiple options available, making you a chooser rather than a beggar. Moonlighting positions vary greatly depending on your geographic location and specialty, but in most cases they can be found in the same two ways—online and through word of mouth.

The internet is by far the best place to start; it will give you the ability to scour all opportunities available before making your decision. The more you know, the more leverage you have.

Talking to your attending, previous grads, local recruiters and others in your circle is another great way to find moonlighting jobs. Health care is a small community—take advantage of it. Out in the field, your CV will not take you nearly as far as a reference. The more contacts you have who will vouch for your clinical and leadership skills, the easier it will be to find a moonlighting position and, eventually, a permanent position.

Before your search, it is important to note that many residency programs have policies in place regarding moonlighting. Some will allow only third-year residents to moonlight, and others have geographic or clinical restrictions. Be sure to check with your supervisor or program director early on so that you fully understand those restrictions. One last thing to keep in mind is that the Accreditation Council for Graduate Medical Education (ACGME) has set an 80-hour cap on the total amount of combined educational and moonlighting time residents and fellows may work in any given week (including in-house call activities). Be sure you have a good grasp of any additional applicable rules in your area and specialty.

Moonlighting pitfalls

Now that I’ve highlighted the positive benefits of moonlighting, I need to take a moment to lay out some of the pitfalls you can run into. To get started along that road, I have included a short story from Erik Stamper, D.O., who is now assistant emergency medical director at Research Medical Center in Kansas City, Missouri:

My first shift moonlighting was during my third year of residency. I drove two hours to get some real-life ER experience [at a facility that] happened to be about a one-hour ambulance ride from the nearest larger facility.

We had no specialty backup coverage, but, hey, they were paying me a decent rate. I was told that I would only see one patient per hour and at most 12 total in a shift. There would also be double coverage, so I was told the other provider would help me with questions I may have about transfers, admissions, processes, etc.

The attending physician I was working with was board-certified in internal medicine, [and] half of my shift would also be covered by a moonlighter (whom I was told was board-certified in ophthalmology). After 15 minutes of conversation during my first shift, the attending physician said she was going to get some food to eat and take a break. She never came back.

So, in short, after 15 minutes I was the only physician available in a facility [with] which I had very little orientation (if you count the 15 minutes), and an ambulance was bringing in a stroke patient. The first patient I saw was a stroke [whom] I gave TPA after a negative CT head for hemorrhage (thankfully they had an off-site radiology service to read CTs). My shift was hell, and those 12 patients promised to me quickly became 25 with five transfers to larger facilities. By the way, the second-half moonlighter, the ophthalmologist, never showed up for his shift. I survived that shift only because the nurses were great and realized I was left for dead by the other physicians. A nurse at this facility told me that when the other doctors realized an EM resident was working, they typically left or took very long breaks. After my shift, I got in my car and drove back home two hours at 2 a.m. Did I mention the odd shift schedule availability? I never went back to the facility and ended up moonlighting at a facility that was farther away but had more specialty backup coverage and double coverage that was also staffed and was run by a national EM group.

Phew! Though Stamper’s situation isn’t the norm, it is still a scenario you could find yourself in if you don’t know what to look for before you step foot on-site. To ensure your shift goes as smoothly as possible, take the time up front to review the following clinical and logistical suggestions.

These will not prevent all possible curveballs but should minimize your chances of getting caught off-guard with a preventable situation.

Clinical suggestions

EMRs. Since the days of the ol’ paper T-sheets, EMRs have been evolving at a rapid pace—with many companies adding their own variations to make their systems unique. This means that while some things are similar or common sense, others can be completely counterintuitive depending on the system you were trained on. Fortunately, most systems are accessible remotely, so you can spend some time familiarizing yourself with the ins and outs even if you aren’t on-site. Stamper noted that if you are unable or too tired to finish all of your charts post-shift, you can do charting at home and play around with the system so you will be more efficient during your next shift.

Orientation. The term “orientation” can mean different things to different folks. Some hospitals consider orientation to be as simple as giving you a badge, a few passwords and a map to the restroom, while others provide entire shadowing shifts to get you acclimated. Regardless, find out what the orientation process will entail and whether you are comfortable with it. Ask who will be conducting the orientation and, if possible, be sure it’s the medical director or a long-time attending at that specific location. Though it’s not always possible, it is a good idea to ask for a shadow shift prior to starting a shift on your own. You will be extra help, so you should not be pushed to work outside your comfort zone the first time you are working independently.

Emergency Medical Treatment and Labor Act. The regulations under EMTALA regarding transfers and admissions can vary by location, and it is your responsibility to be in the know. As you can see from Stamper’s story, a variety of scenarios can pop up unexpectedly. Knowing your way around patient transport laws and hospital subspecialty coverage can help you avert a potential disaster. It’s important to realize that you will be the physician responsible for the care of any patient during transport, and you may need to write orders for the paramedic or flight crew. Think through potential problematic scenarios and determine what you would do if a woman in labor shows up when you have no OB coverage and the nearest accepting facility is 30 minutes away. If you are uncomfortable or don’t know what you would do in cases covered under the EMTALA laws, you are increasing your chances for a lawsuit. “Don’t assume risk or think that you will be able to figure it out because learning on the fly is how you get sued,” Stamper says.

Lifeline. This is simple but important: Be sure to have the phone number of another attending whom you trust and can call during your shift. (Also be sure to warn him or her before your shift—you might be calling for help at 3 a.m.) Steve Roberts, M.D., a traveling emergency medicine physician who floats at facilities throughout the Midwest and Southeast with EmCare, pointed out that having a second opinion can make all the difference in the world, especially when you find yourself in a unique situation. “The longer I do this, the more I realize what I do not know. Having backup that is only a phone call away helps me even in the most isolated locations,” says Roberts. It is always difficult to be prepared for all possible scenarios, so having resources identified just in case is a prudent idea.

Last but not least, do your homework on the facility and your specific unit. Have a strong grasp of the coverage and specialty backup available. Look for information regarding mid-level providers and nurse-patient ratios. If there’s anything you can’t find on your own, be sure to ask the director!

Logistical suggestions

Contracts. Handshake deals have their place in friendly competitions and Super Bowl wagers, but in employment scenarios, get everything on paper—ideally in contract form. That being said, not every single detail may be listed in the main contract itself, so keep all written correspondence for backup on any promises made.

While not the most important aspect of moonlighting, rate is obviously an important piece of the puzzle. Rates will vary in amount and structure depending on location and specialty, so make sure you understand your pay rate up front. If you are being paid based on RVUs, ask about the average RVUs per hour at that location. If you have metrics, bonuses or other incentives, make it a point to understand the ins and outs. Roberts recommends speaking with one of the attendings already working there (offline if possible). Pick his brain to see what other folks are currently making, as well as his thoughts on it.

Reimbursements. Additionally, dig into any expense/travel reimbursement options with the company. Since many moonlighting opportunities are in rural settings, there is a good chance the company will offer to pay travel or reimburse for it (if not, remember to write it off on your taxes), so be sure to ask. Also, inquire about the specifics, such as what kind of hotels they’ll cover (there’s a big difference between a Super 8 and a Homewood Suite with a kitchenette), whether you can get the travel points, how long it takes to be reimbursed, what the mileage rate is, whether can you fly instead of drive, whether per diems are offered, etc. After a long, stressful night shift, the last thing you’ll want to deal with is a hotel issue that prevents you from getting to your bed. Getting this hammered out in the beginning will not only save you from some gray hairs, but may also earn you some travel perks along the way.

Insurance. Confirm that malpractice coverage is provided and that it is high enough to cover any potential issues per the state guidelines. Malpractice varies quite drastically from state to state, but most states make it easy to obtain the insurance guidelines as well as recommended coverage levels. If you are unsure what you have, just ask the company to provide you a copy of the certificate of insurance (COI). That is probably a good idea in either case.

Lastly, trust the organization you are working for. Whether it be a large company with the resources to back you up in case of any issues or a smaller company that can react very quickly, know whom to contact with potential travel or clinical issues—and make sure you can count on them to help. Roberts points out that it is critical to find someone in the organization to trust. This may be the head of the program, a recruiter or a scheduler. An ideal scenario is to get the security of a large company but the relationship associated with a small group—trust people not institutions. Oh, and I’ve said it before but I’ll say it again: Get everything in writing!

Moonlighting can be immensely rewarding on both a clinical and personal level in addition to providing some extra money while you’re in residency. I can’t overstate, however, how important it is to be prepared when you arrive. Following these simple steps and doing your homework can make all the difference in the galaxy.

Derek Sawyer is a physician recruiter for American Physician Partners.

 

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Physician burnout (And how some hospitals are helping with it)

If you’re feeling emotionally exhausted, detached or dissatisfied, you may be experiencing burnout. But the prognosis is good—hospitals and medical schools are finding many new ways to tackle the problem.

By Debbie Swanson | Feature Articles | Winter 2017

 

“Practicing medicine is my true calling. I enjoy it immensely,” says Crystal Moore, M.D., Ph.D., a successful anatomic and clinical pathologist at Hampton Veterans Affairs Medical Center in Hampton, Virginia. “It’s not just what I do; it’s who I am.”

But Moore admits things weren’t always easy. When completing her residency at Duke University, she became irritable, had difficulty sleeping and lost her joy. Difficulties at home added to the drain: Her mother and sister were terminally ill, and she was raising two young sons while dealing with a failing marriage.

“I did what many doctors do: grit my teeth and bear it. Keep moving, no matter how worn out you are by life or work,” Moore recalls. Once she successfully completed her residency, she acknowledged the problem. “I had nothing left in the tank. I didn’t look for full-time employment. I was emotionally, physically and psychologically spent.”

A visit to her doctor helped—she was able to begin the process of sorting through the issues weighing her down. Looking back, she admits it was “ridiculous” to have gone so long without seeking help.

Dr Crystal Moore

Physicians facing burnout should seek intervention early. Says Crystal Moore, M.D., Ph.D.: “What I know most of all is Physician, heal thyself.” · Photo by Fowler Studios

“Being a physician is hard work on many levels. Add life and stir, and you may have a recipe for the perfect storm,” she reflects. “What I know most of all is Physician, heal thyself.”

In any profession, it’s normal to feel stressed, tired, even completely fed up at times. But when bad days become the norm and good days are few, it’s time to take action. Career burnout is a real problem—one particularly prevalent among health care workers. In addition to mental and physical suffering, studies show that physician burnout can negatively affect the care you give your patients, causing increased medical errors, riskier prescribing patterns and lower patient adherence to disease management plans.

But burnout doesn’t have to be a career-ender. There are ways to prevent—and recover from—the negative feelings of burnout.

Part 1: The background

The term “burnout” was the brainchild of psychologist Herbert Freudenberger, who popularized it in the 1970s as a way to collectively describe the consequences that can arise in people employed in high-stress careers with set ideals. He noted that burnout was particularly prevalent among workers in helping professions, such as health care.

In the 1980s, researchers Christina Maslach and Susan E. Jackson, with the University of California, Berkeley, extensively studied burnout in the service industry and devised the Maslach Burnout Inventory, a measurement tool used to assess symptoms. The team defined the syndrome around three constructs:

  • Emotional exhaustion: feeling emotionally drained and exhausted.
  • Depersonalization: negative or detached feelings toward your recipients of care (patients, in physicians’ case).
  • Reduced personal accomplishment: negatively evaluating yourself and feeling unsatisfied with job performance and achievements.

Not all three must be equally prevalent to classify the overall problem as burnout. Some research suggests intensity of symptoms varies by gender: Men tend to experience more depersonalization, while women tend to suffer more from emotional exhaustion.

Today the problem is not only common among medical practitioners but also on the rise. According to the 2015 Medscape Physician Lifestyle Report, 46 percent of all physician respondents reported burnout, an increase of more than 16 percent from the 2013 survey. Critical care showed the highest rates at 53 percent, while emergency medicine was second at 52 percent. Both internists and family physicians also showed a significant rise, from 43 percent in 2013 to 50 percent in 2015.

Ingredients may vary. Demanding hours, challenging cases, pressure from clients or colleagues—the factors that lead to burnout are many, and vary greatly with each individual. Aside from professional stressors, personal problems like marital or relationship conflicts, child care difficulties or financial concerns further stir up the waters. Everyone processes problems differently, so it’s impossible to point to specific conditions leading to the outcome of burnout.

For physicians, the changing landscape of health care can be a trigger. With more physicians today opting to work for a hospital or health care system—75 percent in 2011 as compared to 25 percent in 2002—management difficulties are more common. According to a study by Jackson Healthcare, a significant gap exists between what executives perceive, and what physicians report, as their level of engagement and alignment. Although most physicians responded they were “proud” to be associated with their employers, they also cited negatives: lack of trust in leadership, lack of involvement in decision-making and lack of recognition for their expertise.

What to do. If you’ve noticed your job satisfaction waning, a good first step is to visit your own doctor. Underlying medical conditions, a nutritional imbalance or health issues may be exacerbating your negative feelings. Counseling is also beneficial to learn some coping strategies and recognize possible adjustments to make in your lifestyle. Resources may be available through your employer or health insurance company. (You’ll find further tips in the sidebar “Stop! Don’t leave your current job just yet.”)

Part 2: What hospitals are doing to help

Increasingly, hospitals and practice groups are taking steps to address burnout, recognizing that the alternative—losing skilled employees—is costly. Many have implemented preemptive initiatives to foster unity, address common problems and teach prevention and coping skills. Medical schools are also developing curriculums to teach students ways to manage stress throughout their careers.

The following are some examples of such programs across the country.

California Pacific Medical Center: balanced scheduling. Historically, physicians are known for working long hours spanning consecutive days. But a work-focused lifestyle has been waning in popularity as awareness of the need for balance has become more universal. At California Pacific Medical Center in San Francisco, a group of about 30 hospitalists came together to adopt a scheduling system that would support a more balanced lifestyle.

“We implemented this system about 10 years ago, realizing that the current system wouldn’t be sustainable. Many physicians had young families, and working frequent, entire weekends interferes with that,” says medical director Rob Taylor, M.D.

The group advocated for and implemented a system that schedules higher numbers of physicians during the week and in return requires physicians to work fewer weekends. “We wanted to assign greater value to off-hour shifts as well as weekends. The weekends we do work are busier as a result,” Taylor adds.

Taylor says he and the group as a whole have enjoyed this approach to scheduling. “It eliminates stress. And if a physician needs to take time off, knowing that we have coverage makes it that much easier,” he adds.

Aravind Mani, M.D., a hospitalist in the group, agrees that the balanced clinical schedule helps keep stress at bay. “I have the opportunity to make requests that accommodate my personal time, vacations and other needs.”

Cleveland Clinic: coming together for enrichment and learning. At the Cleveland Clinic, a mandatory training program not only strengthens providers’ ability to communicate with patients but also instills a sense of unity.

Kathleen Neuendorf, M.D.

At the Cleveland Clinic, one training program helps providers manage their clinical encounters, minimizing stress and saving time. “A common reaction we’ll hear from the attendees is relief,” says Kathleen Neuendorf, M.D. · Photo by Full Bloom Photography

The eight-hour program, called “R.E.D.E. to Communicate: Foundations of Healthcare Communication” (pronounced “ready”), teaches practical, realistic communication skills, giving participants valuable tips on how to manage their clinical encounters.

“It’s something that many providers struggle with silently,” says Kathleen Neuendorf, M.D., medical director of the Center for Excellence in Healthcare Communication at the Cleveland Clinic, which runs the program. “A common reaction we’ll hear from the attendees is relief—knowing they’re not the only one having difficulty with a certain type of patient encounter or conversation.”

By enhancing basic communication skills, physicians minimize stress and save time. For example, one tactic covered is sharing an agenda early in patient encounters. “You go into an encounter knowing what you’re going to do: talk, do an exam, discuss labs. Making your patient aware of this agenda in the first few minutes of the visit benefits both the patient and the provider,” explains Neuendorf.

Other skills include making empathetic statements and dealing with patient emotions. In addition to the mandatory basic class, which covers situations common to all providers, there are also optional, half-day classes that focus on specific specialties and patient populations.

But beyond just gaining communication skills, Neuendorf adds that the class is a chance for physicians to get away from daily demands, connect with one another and realize that others share similar difficulties.

“We do it in a place where it isn’t easy for a provider to run back to their desk to do some quick work,” Neuendorf says. “It’s in a quiet setting, to encourage them to take a step away from their work.”

In research done by the Office of Patient Experience, communication skills training has been shown to improve patient satisfaction scores, promote physician empathy and self-efficacy and reduce physician burnout.

University of Wisconsin School of Medicine and Public Health: learning mindfulness. As part of a one-year study on creating a culture of mindfulness in medicine, Cindy Haq, M.D., attended a seminar designed to teach mindfulness to medical professionals. Upon completion, she was optimistic that this was a strategy beneficial to her fellow physicians.

“It was a fabulous opportunity for deeper learning and to learn how to teach strategies to deal with the daily pressure and stress common to a physician,” recalls Haq, who was one of five participants in the study through the Integrative Medicine Program in the Department of Family Medicine and Community Health in the University of Wisconsin School of Medicine and Public Health.

A family physician and professor at the University of Wisconsin, Haq soon began sharing her findings with her peers and began incorporating talk about compassion training in the Training in Urban Medicine and Public Health (TRIUMPH) classes she was teaching. These classes prepare students to work in urban, medically underserved populations.

“It’s easy to become engulfed in problems. You can’t solve them on your own; they’re bigger than you,” says Haq, adding that she’s seen many well-intentioned students become overwhelmed.

The session was so well-received by her students that she made it a weekly event. Haq looked at the training as a tool she could give to students, “a way to stay in the game without becoming overwhelmed—something hopefully that these students could carry through their careers.”

Mindfulness—the practice of training your mind to stay in the present—may be a new concept to many, but its roots extend to Hinduism as early as 1500 B.C. Today the practice is a widely recognized tool for stress reduction and wellness.

“Mindfulness training is a great way to help maintain peace of mind, clarity, and not let the mind run away with itself. It teaches you to recognize your thoughts, and maintain calmness of mind in the face of chaos and confusion,” says Haq.

After the one-year study, all five of the primary care leaders who participated reported personal value from the training, with one describing it as “life-changing.” Each went on to foster a variety of mindfulness activities to benefit colleagues, medical students and patients.

Carolinas HealthCare System: tapping into external resources. At the Carolinas HealthCare System, a group of senior administrators and physician leaders recently came together to develop ways to improve wellness and decrease burnout among physicians and advanced care practitioners. This physician wellness committee, now in its second year, has launched a number of different efforts, such as creating a website of resources and encouraging regular meetings to come together to discuss difficult cases.

One of the more popular efforts involves lectures delivered by Wayne M. Sotile, Ph.D., from the Sotile Center for Resilience in Davidson, North Carolina.

“It’s not a system-wide effort yet, but he’s met with multiple departments,” says wellness committee member David Fisher, M.D., director of neonatology at Levine Children’s Hospital, part of the Carolinas network. “We’ve experienced education of our faculty and staff through recurrent seminars and lectures, which have all been well-attended.”

Sotile, who has worked in the area of resilience for more than 30 years, calls burnout “a new, old problem. It’s now getting a lot of attention, but it’s been a problem forever.”

Sotile’s seminars present evidence-based strategies and tactics to curb burnout in a hospital setting. “I’ll deliver digestible bites of information, let them think about it a while, then come back again to reinforce it and do more training,” he says.

While he says he can help physicians cultivate coping skills, he also points out that they usually can’t do it alone. “I help them take responsibility for what they can change—their own attitudes and coping skills. But change needs to be accompanied by some practice redesign, some engagement from the organizations.”

Feedback so far has been positive, from both staff and administrators.

Becoming a physician is the culmination of years of studying and working hard. Like any mental or physical condition, no one chooses to become overcome by the problem of burnout. Fortunately, its effects can be reversible; as Moore found, burnout can be a temporary interruption from a satisfying, fulfilling career in medicine. Taking action early is the best way to regain joy in the career you’ve worked hard to attain.

 

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Setting yourself up for site visit success

Getting ready to set foot on-site? Follow these tips to handle your site visits like a pro.

By Marcia Layton Turner | Feature Articles | Summer 2016

 

If you’ve been offered the opportunity to be interviewed on-site at a hospital or practice, congratulations! Not only have you made it one step further in your job search, but you’ve also reached a critical turning point. The site visit is the point at which hospitals and practice administrators have decided you may be a fit for the position they are trying to fill. No longer are they trying to screen you out, as previous phone conversations, requests for your CV and emails were designed to do. Now they are trying to screen you in—to entice you to consider joining their team.

The site visit is the point at which the hiring power shifts subtly from the health care organization to you, the physician. That doesn’t mean you’re a shoo-in guaranteed a contract, but to be invited to interview in person does mean you’re closer to an offer. Now it’s time to decide if you want one. Is this job right for you? Is this community one in which your family would thrive? Is this a good move for your desired lifestyle? Those are all important questions to be asking yourself as you embark on a site visit.

Landing the site visit

A site visit is really just a fancy term for an in-person interview that happens on location at a health care facility rather than via video or phone. To offer you such a visit, the recruiter or hiring physician has to have decided that you could be a valuable addition to their team. To get to this point, the following things have likely already occurred:

  • You’ve submitted your CV in response to a job posting, or you’ve sent it to a recruiter who had reached out to you regarding a specific position.
  • The recruiter has interviewed you by phone to prescreen you for the hospital or practice.
  • You’ve had a phone or video interview with an administrator or a lead physician so that he or she could assess whether you would be a good fit for the position.

If, after talking to an administrator, you sound as though you would be a good match, it is likely you will be invited to interview in person on-site, explains Justin Sharpe, physician recruiter at Tallahassee Memorial HealthCare in Tallahassee, Florida.

Out-of-town interviews are common for site visits because “the vast majority of people post-residency are relocating,” says emergency medicine physician Matthew Krauthamer, D.O., national medical director of special operations of the East Group of TeamHealth. The first site visit usually lasts one day and consists of three to five hours of interviews plus dinner, he explains. A second site visit may not be needed for a staff position but is typical for a leadership position.

Making a positive impression

Because most of the major career questions will have been asked and answered before you touch down at a potential employer’s facility, the first day or two on-site will be your opportunity to make a positive impression overall. “We know they’re clinically sound [at that point],” Sharpe says of prospective hires, “so now we’re checking more for a team and location fit.” During the site visit you should be asking yourself, “Can I see myself here?” Your potential employer should be asking the same thing.

To help answer this question, Sharpe pays a lot of attention to a candidate’s demeanor and personality. But he doesn’t want to spend time getting to know a persona you’ve created to match what you think they’re looking for, so be yourself. That’s critical.

Do be aware, however, that you are being evaluated. “Be on point from the moment you step off the plane,” recommends Sharpe. Dress professionally and show confidence as you interact with potential colleagues. Sharpe also looks for social skills. “Do men open the door for women, or do they let people exit the elevator before getting on?” he asks. Nuances like these indicate the candidate’s social awareness.

Though spouses often accompany physicians on site visits, maintain the appropriate level of involvement. Though rare, there have been cases in which spouses have dominated meetings or taken over casual dinners, peppering hosts with question after question. That’s not the way to make a good impression. That said, recruiters are certainly aware of how integral spouses are in decision-making. “The saying goes, ‘You get the spouse, you get the physician,’” says Sharpe.

Timing is everything

“Use your time wisely,” adds Sharpe, who suggests scheduling time to visit local resources that would be important to you and asking the recruiter to help connect you. That might mean taking a look at real estate, meeting with local school administrators, checking out fitness clubs or running groups or visiting any other places of particular interest. “You only have so much time, so use it,” he says.

Tallahassee Memorial typically includes two site visits as part of the interview process. The first is generally filled with interviews and colleague discussions, as well as a community tour to help the candidate get a feel for the city. The second is used to introduce a partner or spouse to the area or to do some house-hunting.

“After the first visit, candidates will generally know if they’ll be made an offer,” says Sharpe, “but we try to get to 90 percent agreement before [bringing the candidate] back a second time. That way we are less likely to spend additional time and effort with a candidate who is not seriously considering joining our team.”

Money matters

Site visits are effectively all-expenses-paid. The organization that is interviewing you should cover everything from airfare to hotel costs, meals, a car rental and even activities for kids who come along, says Sharpe. “We try to ensure the doctor doesn’t have to pay out of pocket for anything. We want them focused on the job and getting to know the location.”

Paying for such trips is expensive, admits Sharpe, who estimates that the average site visit costs a hospital roughly $3,000. “It’s an investment on our part,” he says, but it’s one hospitals and practices are happy to make for a chance to land a strong addition to their team.

Easing in to a position

Though the time between a site visit and a signed contract varies greatly from case to case, Hani Najm, M.D., suspects the total time it took to bring him on board at his current position may be among the longest. Najm, who is chair of pediatric and congenital heart surgery at Cleveland Clinic in Ohio, had no plans to leave the successful pediatric cardiology practice he had built from scratch in Riyadh, Saudi Arabia. He had said he would leave his practice only if he retired or if he received the offer of a lifetime.

Then Cleveland Clinic Children’s Hospital approached him about leading a new congenital heart program.

The hospital reached out in November 2013 to gauge whether he would even consider a move to head the new program. They had a phone conversation that got Najm thinking. The move “would add a lot to my career, put me at the next level of achievement,” he says.

So in January 2014, Najm traveled to Cleveland and spent four days there. On this initial visit, Najm toured the clinic, became familiar with the facility’s infrastructure, and saw firsthand how employees are taken care of. Cleveland Clinic had assigned a staff member from the office of recruitment to assist Najm during his stay. “He got all my questions answered, found a realtor to show me the schools and neighborhoods,” says Najm. Having that one point of contact proved very helpful.

During the first visit, Najm’s priority was to see and spend time where he might work. But he also toured the suburbs, looked at schools his children might attend and explored areas just outside the city where he could bike.

He returned to Saudi Arabia seriously considering a move. There were roadblocks, however—including finding someone to take over his practice in Riyadh and securing work for his wife in the U.S. It took several months, but by August 2014 Najm was ready to return for a second site visit, this time with his family. He stayed a full month as a visiting surgeon with all the privileges of an employed surgeon. Cleveland Clinic had arranged for a work visa and an Ohio medical license so he could get a taste of what life would be like there.

“They made me feel that they were not just trying to hire me, but that their intent was to transform the pediatric cardiac care program. They wanted me to succeed,” he says.

He returned to Saudi Arabia impressed with what he had seen. His wife had also fit well, so she was in favor of the move. In March 2015 they finally made the decision to accept the offer.

In November of the same year, after he had accepted the new position but before his family moved, Najm made a third site visit, which lasted five days. That time allowed him to complete all his employment paperwork and make housing arrangements for his family. “That last visit made the start at the Clinic easy,” he says. In January 2016 he officially started work.

Narrowing a long list

Though Najm wasn’t looking for a new role when he was approached by Cleveland Clinic, Ryan Lawless, M.D., found his job after conducting a thorough search. An attending in Houston at the time, he and his family had decided it was time to start looking for a new position.

At the start of his search, Lawless and his wife made a list of geographic regions they thought would be a fit for them. All of the cities had to have a major sports team—bonus points if it was Major League Baseball—a good public school system and a reasonable cost of living.

Daylene Wilson lawless 21 of 28

Proximity to a major sports team, a good public school system and a reasonable cost of living topped the preferences list of Ryan Lawless, M.D., and his wife, Stephanie.

Once his geographic list was developed, Lawless asked his mentors if they would send reference emails to their colleagues at hospitals in his desired areas. He also began his own searches online, and while he was at conferences, he took the opportunity to network with physicians from some of the facilities on his short list.

As a result of these efforts, Lawless was asked to submit his CV to a number of hospitals. He then narrowed his options to five, all of which he was invited to visit. Before traveling, however, he did a considerable amount of research to get to know each hospital. He wanted to be sure it was a potential fit before investing the travel time.

Lawless says that during his time on-site at each of the five hospitals, he tried to get a sense of two main things: the atmosphere of the hospital and the busyness of the trauma center. To gauge how friendly a facility was, he took notice of what the physicians were doing—whether they were talking to each other and whether office doors were open, for example. He was used to a busy trauma center and knew that he wanted something similar, but finding one was a challenge. He had to be close enough to a major city to get the level of activity he was after and also close enough to a nice area for his family to live.

His wife, Stephanie, accompanied him on all second site visits (he had four), which are a bigger deal than the first, Lawless says. “That’s when you talk about salary and benefits and bring your spouse.” Thanks to his successful and informative site visits, today Lawless is a trauma and acute care surgeon at the Denver Health Medical Center, as well as an assistant professor of surgery at the University of Colorado School of Medicine.

Where preparation and serendipity meet

Janani Krishnaswami, M.D., MPH, would have been as proactive in her job search as Lawless was—had she been sure a position in her specialty of preventive medicine even existed. Trained in internal medicine and preventive medicine, Krishnaswami ideally wanted a position that combined her interest in solving the root causes of diseases with her desire to teach and do community work. But she had resigned herself to taking a fully clinical primary care job with little opportunity for systems-level research when she says she “stumbled across a fellowship in community medicine in Los Angeles.”

This was a turning point for her and her career. Committed to continuing work in preventive medicine, Krishnaswami “aggressively” sought mentors at UCLA and Southern Cal to help her develop courses for students. She cold-called, she emailed, she networked liked crazy, and she found a mentor at UCLA.

Janani Krishnaswami

Moving from Los Angeles to Harlingen, Texas, didn’t seem likely for Janani Krishnaswami, M.D., MPH—until she and her husband spent time on site and found the job and location to be a great fit.

Not long after she became an adjunct faculty member at UCLA and an associate program director of a new preventive medicine residency, Krishnaswami updated her LinkedIn profile to keep it current. Shortly after adding her new role, a recruiter reached out to her by email about a preventive medicine opening. “There aren’t many preventive medicine physicians in the U.S.,” she explains, “and I wasn’t looking for a position at that time.” She also wasn’t looking to leave L.A. But she did click on the link the recruiter sent and saw that it sounded like an ideal position for her.

Encouraged by her husband to at least consider it, Krishnaswami responded to the recruiter’s email about two months later, asking if the job was still available. It was. They had a quick call, she sent him her CV, and he connected her with the dean in charge of the preventive medicine program at the University of Texas Rio Grande Valley for an informal phone interview. At the end of the call, she was told that the dean would love to have her come interview in person with the other physicians.

She was curious at this point and kept an open mind but “didn’t think the odds were good” that she would end up taking the position.

About three weeks later she and her husband traveled to Harlingen, Texas, to check out the opportunity. UTRGV flew her in to interview with about eight people involved with the program over a day and a half. “After the first day, I was exhausted,” she says.

She left feeling intrigued but still unsure she wanted to move. She was then invited back for a second round of on-site interviews, which included her giving a presentation at the Hidalgo County Health Department. During that presentation, she realized how well the opportunity matched her career interests and personal strengths.

At that point, she and her husband also knew she was pregnant, so they were considering what kind of community would be best for their family. They spent more time driving around the area and visiting with potential colleagues. One physician invited them home to dinner, and Krishnaswami had the chance to ask his wife lots of questions about life in the small city, which was opposite L.A. in so many ways.

Krishnaswami ended up accepting the position and is now program director of the preventive medicine residency program at UTRGV.

By spending time on-site, Krishnaswami, Lawless and Najm were able to picture themselves in their new roles, get a feel for the organizational culture and ask many questions of recruiters, administrators and potential colleagues. In the end, all three physicians landed jobs that were excellent fits for their career goals and families.

 

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Doubling down: Your spouse’s role in your job search

Don’t go it alone! When it comes to the job search, your spouse can lend ears, eyes and hands to help you find the right fit.

By Debbie Swanson | Feature Articles | Summer 2016

 

Securing a new job is an exciting step in your journey toward practicing medicine, but the job search itself can be a lengthy and time-consuming process. If you have a willing spouse, partner or significant other, the perfect assistant may be right by your side. They can play key roles—from keeping the job search organized and making initial contact, to acting as a sounding board as you evaluate your options, to traveling with you to on-site visits.

Developing a plan for working together can make the process run more smoothly and help you avoid costly errors down the road. Here are some tips for teaming up.

Lend another set of eyes

It may sound like a simple step, but having someone else look over your documents before you send them off can be critical: You won’t make a strong initial impression if your CV contains errors, typos or vague information.

Your spouse or partner—keenly aware of your goals—is in a great position to look over your materials and offer input. At minimum, a quick proofread is always in order; your own familiarity with the documents can easily result in overlooked errors. But if your partner’s talents are in writing or English, solicit more feedback. Is your background clearly spelled out? Are you sounding too modest, or too confident? Is each cover letter properly tailored for the desired position? Incorporate their feedback to improve your materials.

Keep things organized

A major job search can generate an overwhelming surge in correspondence, especially when relocation is a possibility. A spouse available and willing to take on the task can play a vital role in keeping information organized.

First, centralize the flow of information: Choose one email address and phone number for all job-related correspondence. Then talk with your spouse to clarify what steps they are willing to perform. These may include:

  • Entering your CV and contact information into job banks, such as PracticeLink.com.
  • Recording job inquiries made by you and noting the manner of them (online, by phone or other).
  • Generating a list of all recruiters’ names and contact information and making note of those already contacted.
  • Making note of all responses received.
  • Keeping a list of action items and items in progress.
  • Giving each job prospect an interest level: high, medium or low.
  • Making note of the reasons for deciding against any opportunities.

A spreadsheet is a good way to track incoming and outgoing correspondence. It also provides both of you with a document that you can quickly scan for a snapshot of your current situation.

Be the first point of contact

If you’re working unconventional hours, returning phone calls can be difficult. In addition to monitoring the flow of information, your spouse may be willing to be your first point of contact—making preliminary phone calls or writing email responses. Most in-house recruiters consider this standard procedure.

“I’ll often talk to the spouse initially, who will explain the job is for her husband, who’s at work,” explains Cheryl Weisenberg, physician recruiter at AdvantageCare Physicians in New York City.

If your spouse is going to take on this role, discuss the following:

  • Specifics about the type of position you’re looking for
  • Any terminology they’ll encounter
  • Possible questions and preferred answers
  • Topics to be avoided
  • Your upcoming availability for phone calls, overnight visits or interviews

Though recruiters are used to interacting with physicians’ spouses, be sure that communicating via your spouse doesn’t go on too long. Steven Shasteen, senior physician in-house recruiter at Alaska Native Tribal Health Consortium, says recruiters are also eager to connect with the actual candidate.

“While talking to the spouse is helpful, we need to get to the physician fairly quickly,” he says. “The spouse could be running the search without really knowing what the physician wants.”

In addition, there are legal issues involved. “For example, with compensation, I need to speak directly to the physician themselves. They can share the information with their spouse, but I can’t do that,” adds Weisenberg.

Determine your goals as a couple

Picturing where you’ll eventually work is probably something you’ve done for years. Now that you’re about to jump deeper into the job search, your spouse plays a key role in helping to establish search criteria.

Together you should discuss all the factors involved with a major move: desired location, community, educational and professional opportunities and more. (For a list of factors and considerations to get your conversations going, see the sidebar.) Be honest and don’t hesitate to question or even disagree with each other. For example, if your husband is an avid skier but cheerfully agrees to the idea of moving to Florida for your career, dig a little deeper to discuss how that arrangement would work for him.

Once you’ve settled on some basic criteria, keep your search within those parameters; don’t waste time exploring an opportunity that one or both of you strongly opposes. Weisenberg has seen cases where that has resulted in conflict.

“I worked with a young graduate from California, and the spouse didn’t want to move to New York City. Unfortunately, the situation ended in divorce; (the spouse) would not come,” she recalls.

Manish Mehta, M.D., wound management and hyperbaric medicine physician at Orange County Wound and Hyperbaric in Santa Ana, California, recalls that discussing and evaluating criteria with his wife, Renay, was a key factor in finding the right position.

“Two minds think better than one. One may think of something that the other doesn’t or has not considered,” Manish Mehta says. “[The] job search is the most vital part of a doctor’s life; it heavily impacts you and your family’s lifestyle and future. So communication and [your spouse’s] involvement are key. Assess your priorities with your spouse: Is it money, family, location or lifestyle?”

Renay Mehta agrees that these discussions were invaluable. “We discussed geographic proximity to family, local resources for kids, school ratings, real estate costs and more.”

Speak for the entire family

All members of your family, including children or extended family living with you, will be affected by the changes accompanying your new job. Your spouse can help to make sure everyone’s needs are factored into the discussion. Ask them to devise a list of the factors important to the children or extended family, as well as anticipated changes over the next three to five years.

Marci Jackson, physician recruitment manager at Marshfield Clinic in Marshfield, Wisconsin, agrees that considering the entire family’s needs goes a long way toward making a successful match.

“If the children are in middle school or older, their needs are almost as important as the adults and may have significant influence in the decision,” says Jackson.

School and child care are the obvious requirements, but don’t hesitate to give weight to any relevant hobbies, talents or interests. For example, if your rising hockey star ends up two hours from the nearest ice rink, or your budding political activist lands at a high school without a debate team, the long-term satisfaction of the family may suffer.

“If the family isn’t happy, the physician will soon start looking for other career options,” says Jackson.

Plan for their own career

While considering other family members’ needs, your spouse or partner may fail to give enough thought to their own situation. Be sure to ask them to take time out to consider their own goals and plans.

If the job change will affect their professional path, spend some time discussing how they’ll adapt. Do they want to search actively for a job prior to the relocation or wait until after the move? If you are both in a medical profession, do you prefer to work at the same facility or separate?

“Particularly in some occupations, such as IT, spouses want to find a job (before the move),” says Shasteen, adding that most recruiters will try to make introductions even outside of their realm of interest.

Whatever your spouse decides, be sure you’re both on board with the approach.

When physician Ryan Baker was finishing up his fellowship at UCLA, his wife, Kristina, had plans to continue her career in special education but was comfortable putting her job search on hold until after the dust from the relocation settled.

“I wanted to get the family settled,” she recalls. “I knew I’d get my foot in the door somewhere and work my way to a position I’d want.” Within a few months of the move, she found a job she was happy with.

“I was fairly confident she’d find work, given her interest in special education in general,” recalls Ryan Baker, who is now settled as a pediatric hospitalist and outpatient pediatric sports medicine physician at Providence Sacred Heart Medical Center and Children’s Hospital in Spokane, Washington.

Prepare for a deeper conversation

Once an opportunity begins looking like a serious possibility, most in-house physician recruiters will want to engage in a detailed conversation with your spouse or significant other. While they may have already spoken during preliminary conversations, this conversation will be different: Their goal is to get to know your family.

“If you don’t talk to the spouse early on, the whole effort can be a waste of time,” says Shasteen. “You have to build a rapport and a relationship with the person to make sure they’re a fit.”

For example, Shasteen, who recruits physicians for employment in Alaska, says he tries to make sure that the couple is up for the unique climate of the area. “You want to make sure the lifestyle will fit and, ideally for this area, that there’s some interest in outdoor recreation.”

Prepare for this conversation together by reviewing the joint criteria you’ve already established, as well as any other family needs, such as career or educational options.

Present a unified front

Once it comes time to hit the road for meetings and interviews, don’t plan to go it alone. Your prospective employer usually anticipates meeting all the decision-makers. Bringing along your spouse or partner helps present a unified front, relaying that you’re both informed—and on board—with the move.

One recruiter recalls a situation in which a physician traveled from the East Coast for a site visit, but his spouse did not accompany him due to difficulties rearranging her work schedule and the schedules of their school-age children.

The physician assured the recruiter that his wife was on board with the move, and he took the job. But it turns out that the couple wasn’t on the same page. In the end, the physician’s family only stayed in the new location for a month before returning back home. After several years of trying to make it work, the physician left to rejoin his family in their previous location.

It may be tempting to travel solo for the first visit with plans to return together if a job seems promising. But due to the logistics involved, it can be tricky to set up another round of meetings or a second extensive tour. Plus, you never know when something will surprise you—an opportunity that seemed mediocre on paper may suddenly come to life when you’re walking through the hospital or dining with some potential co-workers. It’s best if you’re both available and present from the start.

Dr Alashari

While considering a relocation from Florida to South Carolina, Akram Alashari, M.D., brought his wife, Karima, to visit the potential new employer. That helped her “get the vibe of the personalities working there,” Alashari says.

Akram Alashari, M.D., surgeon and critical care physician at Grand Strand Medical Center in Myrtle Beach, South Carolina, says that the opportunity for his wife, Karima, to meet the faculty and staff of the hospital proved helpful in his recent job change and relocation from Florida.

“The faculty took us both to dinner the night before [the interview], where she met everyone,” he explains. “The following day, they invited her to meet the CEO and COO of the hospital.”

He says her input helped shed additional light on how the couple would fit into the environment.

“She was able to get the vibe of the personalities working there, and she also got an understanding of their family situation so that we could have potential friends as opposed to just work partners [or] colleagues,” he recalls.

Manish and Renay Mehta add that another benefit of traveling together was the opportunity to discuss things while the impressions were fresh in their minds.

“Right after the interview [was a great time] to connect and discuss the pros and cons of the particular area and our areas of interest,” Renay recalls.

Divide and conquer

A one- or two-night visit can go by very quickly, particularly if you are preoccupied with interviews and meetings. Having your spouse available to gather valuable impressions and tour the surrounding area will help maximize your visit.

Obtain your agenda ahead of time so you both know what kind of free time is available. If you’re working with a recruiter, they may have already made arrangements for a realtor or someone else to provide a tour of the community. If not, be sure to make similar arrangements well ahead of time.

Before each trip, discuss what your spouse should try to visit. For instance:

  • Schools, day care centers or senior centers
  • Neighborhoods and homes at various price points
  • The local library and/or community center
  • Coaches of youth sports or high school teams, or enrichment centers for children’s interests in art, theater or music
  • Major shopping areas, grocery stores and entertainment
  • The local chamber of commerce

Alashari says his wife was instrumental in exploring the community. “She met with a real estate agent to look at homes in the area while I was interviewing. This gave us a better understanding of the community and school systems while I assessed the work situation,” he says.

As a result of their team coverage of the area, they both left with a good feeling about the prospective job, which Alashari ended up taking.

“My advice to physicians looking for a job would be to have their significant other travel with them,” Alashari says. “It helps get an understanding of the community, the hospital, as well as the potential future partners. Also, the spouse may pick up on things that the interviewee is not noticing, focused more on work-related issues.”

As you navigate further along your journey toward achieving your professional goals, including your spouse as a key player in the job search will result in an outcome that benefits everyone involved.

“Don’t just act quickly; it’s easy to jump to the first job offer, especially right after residency,” advises Manish Mehta. “Take the time to consider: What is the most important to you and your family?”

 

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5 job-search questions physicians aren’t asking

Evaluating practice options? These five questions will help you know what factors to consider—about your career and about yourself.

By Laurie Morgan, MBA | Feature Articles | Summer 2016

 

Dr Marlene Grenon

Listening to your gut is so important,” says Marlene Grenon, M.D., about the work culture you choose. “…You need to find the right fit.”

Marlene Grenon, M.D., associate professor of surgery at University of California, San Francisco, and adjunct professor at the International Space University, Strasbourg, France, has known since she was a teenager that she wanted to pursue aerospace medicine. Having a clear vision gave her a leg up in career planning because it narrowed her options, but even for those committed to a specific niche of medicine, there are still many choices to make. These choices affect everything from your ability to avoid burnout, to having a satisfying balance of work life and family life, to keeping your options open down the road.

“Listening to your gut is so important,” Grenon tells her mentees at UCSF. “The environment that you work in, the team that you work with, it’s so important. You need to find the right fit.”

Your gut can help you find the environment that will make your first—or next—job satisfying and rewarding. But to engage your instincts and choose well, it’s important first to ask the right questions. That means not only thoroughly examining your would-be employers but also examining yourself. Here are five important questions you may not have considered that can help you tackle important career decisions with confidence—whether you’re contemplating a specific job or just trying to decide on a practice setting.

Question 1: Have I built the right network?

A strong, diverse personal network is an invaluable asset in career decision-making. One key reason is that not all jobs are posted publicly; your ideal fit may come through a friend or other trusted contact, especially one you’ve worked with before.

Azra Ashraf MD

Azra Ashraf, M.D., MPH, was more open-minded about practice settings and compensation models in her second job search than she was in her first.

Azra Ashraf, M.D., MPH, a plastic surgeon in private practice in Washington, D.C., recently left behind a role that wasn’t a good fit in favor of a job she found through a friend she met in residency. She believes working with contemporaries leads to a natural rapport that fosters a positive work experience. “Now I’ll work alongside friends whose personalities I already know and whose values I know I share.”

Even though networking is valuable in career planning, many new physicians are unaware of its importance. After all, it’s not something you’re taught in medical school or residency, where the focus is almost entirely on academic credentials and clinical skills.

“Too many young physicians think that if I tick the right boxes, if I go to the right medical school and do the right residency, that’s enough” to set them on their way, says Andrew Cain McClary, M.D., staff physician with Grand Rounds and consulting assistant professor of pathology at Stanford University. But mentors and connections won’t materialize without effort, he says. “Success is about the hustle, too.”

Networking can feel awkward to young professionals in any field, and physicians are no exception. But you don’t have to look too far to establish—or re-establish—a diverse network. In addition to friends from med school and residency, family members and undergraduate classmates can be valuable connections.

“My undergraduate friends kept me connected to the business world, helping me learn where investors see opportunities in medicine,” McClary says. He began to see an intersection of technology and the “old-school” slide analysis process of pathology. This first led him to think about a move to Silicon Valley to explore startup opportunities driven by the Sand Hill Road venture capital community.

Josh Parker, M.D., a pediatrician with Pediatric Wellness Group in Redwood City, California, adds that advisers from outside your immediate circle also provide essential perspective in evaluating your career options. “Without help from people with business knowledge or more experience in medicine, it’s hard to even know what questions to ask potential employers.” Understanding the implications of contract terms, for example, is easier with help from others with relevant experience.

Question 2: Am I limiting my options unnecessarily?

When student loans loom large, many young physicians are tempted to pursue only those opportunities that offer the highest or most secure compensation. But after working in a role that wasn’t a match for her goals or work style, Ashraf now sees value in being more open-minded about practice settings and compensation models. In her new position, her income will be based entirely on the revenue she generates—and she is confident she’ll be happier.

“Our structure is solo practices with cost-sharing. I’ll have the autonomy to pave my own way,” she says. The structure gives her the freedom to make decisions about marketing and staff additions because these costs would come out of her own revenue stream.

Financially this may seem risky, but income promises in more typical employment situations may not be realistic either, especially if they’re based on aggressive, best-case productivity goals. “What I’ve learned is that if it looks too good financially, it probably isn’t realistic,” says Ashraf.

McClary also believes it’s important to be open-minded—even when considering your first job and even when loans are a concern. “The financial burden is ridiculous, but you can’t lose sight of how needed we are.” If your skills are indispensable, a company that could use them might even help with the loan burden.

Rather than fighting disruptive economic trends, McClary suggests that young physicians can choose to apply their training to new medical and business models. Startup ventures that seek to transform the way health care is delivered—like the one McClary works for—are scooping up young physicians and expanding their options for contributing to medicine.

“The skill set you gain in medicine is so valuable. You can apply that knowledge in many settings,” adds Grenon. She notes that, even for physicians who start out in a typical practice setting, there are many opportunities to switch to, for example, a pharmaceutical company or a health care startup down the road. “You can apply your knowledge to a completely different area.”

Question 3: Do I know what’s needed to be successful?

Every job comes with expectations, both written and unwritten. It’s not uncommon for a physician learning the ropes to encounter surprises and frustrations if the rules for success aren’t clear.

“When you’re a new doctor in a large organization, your superiors will notice if, say, you’re ordering a blood test for every kid with a cough and a runny nose,” Parker says. “It’s appropriate for them to question, but it’s also normal to need to learn these things” when you’re in your first job.

Parker advises those evaluating opportunities to ask how they would receive input from more experienced colleagues within an organization—and what that organization’s culture dictates about asking for help. Is it OK just to knock on a colleague’s door—or is there a more formal process? “Before accepting a position, be sure you know what you’ll be evaluated on, how feedback is delivered and how you’ll get help to improve,” Parker adds.

Productivity goals are common in physician contracts, and it’s important to understand what is required to meet them. Asking about the number of patients you’ll need to see each day to meet revenue goals will help you clarify expectations—but your ability to keep pace is just one piece of the productivity puzzle. You’ll also need to be sure that enough patients are available for you to see.

“One challenge was that it was hard to attract referrals because we accepted only a handful of insurance plans,” Ashraf explains. “Primary care physicians want to refer to surgeons that meet their patients’ preferences,” and most patients place the ability to use their insurance at the top of the list.

When compensation is tied to revenue goals, it’s always a good idea to be sure you’ll be able to accept the health plans that are most popular among your target patients. And if the practice doesn’t already have enough overflow demand to keep you busy, you’ll also need to know what help you’ll get to attract more patients. For example, have important marketing channels such as hospital relationships and an informative website already been established?

Other aspects of the practice infrastructure—such as EHR and other technologies and the number of support staff members per physician—also contribute significantly to physicians’ ability to be fully productive. If possible, it’s helpful to meet the staff who would support you in order to gauge their commitment to growing your practice. Benchmarking data from organizations like the Medical Group Management Association is another excellent tool to help you infer how well a potential employer supports its physicians with staffing, as well as its comparative financial performance.

Question 4: How can I stay creative and engaged?

The pace of change in health care and the increasing demands placed on physicians make burnout more of a consideration than ever. Even when considering your first position, it’s not too early to think about how you’ll stay challenged, motivated and committed to medicine.

“In medical school, you’re learning all these facts,” says McClary. “If all you’re going to do at work is repeat those facts, you’re going to burn out. Burnout is real.”

“We’re all searching to make a difference in the world and help others,” Grenon adds. A mix of activities—from practicing, to teaching, to performing research—helps her stay engaged. “When we’re doing research, we’re at the edge of science, and we have to think of new concepts. We have to be creative to find better ways to solve problems.”

While Grenon’s academic post helps her stretch her intellectual muscles, physicians in large health systems and private practices can also find opportunities to grow and contribute in new ways, even if they have to look a little harder. Clinical research pairs well with private practice, for example.

Other physicians look to give back through volunteer opportunities at home or abroad. Ashraf takes an annual trip to Pakistan, where she works with a colleague to treat victims of domestic violence. The flexibility to commit time to this volunteer work was another factor that she weighed in choosing her current position.

“You become unidimensional in medical school,” Ashraf says. “When you start your career, it’s your chance to go back to your original vision, to what led you to seek your degree.” In addition to her volunteer commitment, for Ashraf, getting back to her original vision meant reconnecting with her interest in public policy, which led her to pursue a master’s in public health during medical school and also influenced her choice of a new practice.

McClary also notes that it’s more possible than ever to pursue multiple tracks at the same time and that variety keeps your career fresh. “Our training involves a rigid system. But your career can be flexible—there’s pharma, outpatient work, digital health. You can freelance and participate in several options.”

Question 5: Does this organization fit into my long-term vision?

When you’re considering options for your first job after a lengthy academic journey, your long-term career may be the last thing on your mind. But even if your future goals are yet to be determined, it’s useful to pin down some of your priorities—if only to avoid feeling stuck later on.

“Don’t forget to consider what happens when the contract ends,” advises Parker. If the contract you’re evaluating doesn’t specifically discuss renewal or extension, you may not be able to stay with the practice at the end of your term. That can be a problem if the contract also includes restrictions that prohibit you from joining another organization in the same area—especially if you’ve invested a lot of time and energy creating a patient panel you are no longer allowed to serve.

Building a practice in one spot can also make it financially unattractive to start over in another community later on, which can be a big challenge if you had your heart set on settling down somewhere else.

“I recommend thinking about where you want to live and trying to find a position there, keeping in mind that there has to be enough demand for your specialty in the area,” says Ashraf. Contracts that include financial perks that have to be earned out, such as loan repayments or relocation expenses tied to the contract term or revenue goals, can also make moving costly if your plans change before the terms are met.

Location may also be a factor if you’re hoping eventually to switch from a traditional practice environment to another industry such as pharmaceuticals, devices, biotech or health IT. In that case, it pays to do some research before deciding where you’ll land; your options extend beyond the best-known venture capital hubs of the Silicon Valley, Boston, New York and Los Angeles. Energy and capital for pharmaceutical research, biotech ventures and other types of health care startups have coalesced more recently in places like Tampa, San Diego, Houston, Austin, Nashville and the Research Triangle region of North Carolina.

And what if the job you’re considering is one you hope to stick with for the long haul? It’s important to get a close read on the practice’s own five- or 10-year plan. For example, if you’re joining a small private practice and expect you’ll prefer that environment, try to assess the practice’s commitment to staying independent.

“Smaller practices often end up selling and joining up with larger groups because a senior partner decides to retire and none of the other partners wants to deal with managing,” Parker points out.

If you believe you’ll want to be a partner yourself someday, try to understand the motivations and priorities of the current partners—as well as what it would take to join them down the road. For example, would you need to buy in to become a partner? And should you think about management training along the way?

Regardless of how sure you are that the setting attracting you today is the best one for you long-term, you may find that it’s a perfect fit once you’ve started—so find out whether the organization plans to keep moving in the same direction in years to come.

Your first step in a long career—with many potential paths

A common theme shared by Ashraf, Grenon, McClary and Parker is the benefit of remaining open to a wide variety of possibilities. After so many years of studying and preparing, it’s natural to want to make the best possible choice in your first role on your own as a physician. But remember that your vision of an ideal career may change as you progress.

In many ways, there’s never been a better time to be a physician. Opportunities abound in many settings. Wherever you land in this job search, you’ll learn something to help you in your next role. The key at every stage is to consider—and be open to—your many potential options.

 

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How real physicians search for jobs

Candidates weigh in on how they found their dream practice

By Marcia Layton Turner | Feature Articles | Spring 2016

 

For physicians, there’s no such thing as a typical job-search process. Some physicians explore several practice types; others choose one early on. Some need visa help; others don’t. Some stay put; others move across the country. These variables and many others mean your search may include twists and turns your colleagues never experience.

The good news is that’s OK. Your goal is finding a practice that fits you. After all, that’s the test of a successful job search: Are you happy where you land? Exactly how you land there is up to you.

We found three physicians whose job searches were quite different, yet all successful. Here’s how they found their perfect fits.

The proactive approach

The physician perspective

Otolaryngologist Michael Vietti, M.D., had been actively looking for a new position for about a year before accepting a role as a staff physician at Wilson Health in Sidney, Ohio.

His search tactics consisted mainly of speaking with the steady stream of contingency recruiters who called with new opportunities and regularly scanning online job postings. The sites he checked most frequently included academies such as the American Academy of Otolaryngology, as well as career sites such as PracticeLink. It was there that he spotted a listing at Wilson Health in Sidney, Ohio, a little more than an hour from his former position in Columbus.

Before beginning his search, Vietti had made a list of what he was looking for–the must-haves as well as what he was willing to give up.

Although Vietti was willing to give up his Columbus location, he recognized that his spouse was less interested; she wanted to stay in the Columbus area until their child finished high school. A position in Sidney was close enough that he could almost commute.

So Vietti did a little research, looking into Wilson Health’s staff roster, facility, and digging to uncover any recent issues. Seeing that there might be a fit, he called the in-house recruiter, David Andrick, directly for the scoop. After that conversation, he submitted his CV for consideration, followed by a couple of trips to Sidney to meet with staff members and administrators in person. He also asked Andrick for a list of staff members he could call about the hospital’s work environment.

The more he learned about Wilson Health, the more Vietti saw that it met all of his must-haves.

Dr Vietti

Otolaryngologist Michael Vietti, M.D.

Vietti’s search was successful in part because he was patient. And that’s the advice he offers other physicians regarding their own search: “Take your time.” Don’t jump at the first opportunity. “It’s a business decision,” he points out, so try and look at each facility or practice objectively as you weigh your options. Don’t be pressured into signing a contract on your first site visit, or before you’re sure this is the best opportunity for you right now. Take the time to carefully research and vet each opening.

Today, Vietti drives back and forth between Columbus and Sidney two or three times a week, spending alternating nights at an apartment close to the hospital. “There’s no such thing as perfect,” he says, but for him, Wilson Health came close.

The employer perspective

Rather than sitting back and hoping to be contacted, David Andrick, director of physician recruitment and relations for Wilson Health, takes a decidedly proactive approach to get in front of physicians who may be thinking about making a move. He advertises in journals, posts on websites like PracticeLink, uses contingency recruiters, sends direct mail and attends national specialty meetings.

In fact, Andrick did all of these things in order to attract attention from leading otolaryngologists when the hospital had an opening about 24 months ago. “One doctor had retired and another was pulling back on his hours, so we needed to fill that role,” Andrick says.

In this case, it was the PracticeLink posting that caught Vietti’s eye. Andrick asked for Vietti’s CV, reviewed it, and set up a site visit soon thereafter. The fact that Vietti was almost local was promising from the outset.

“We have good schools in a small town with a solid hospital,” says Andrick. “It’s a nice place to live and work,” which Vietti already recognized. For candidates from outside the area, Andrick tries to “get personal fast,” to help prospective hires feel a part of the community right from the start. Because if they can see themselves living and working in Sidney, the recruitment process becomes much easier.

Andrick hires 6 to 12 physicians a year, so “bringing one or two new doctors in can have a major impact” on hospital operations. In Vietti’s case, that impact has been all positive. “He did more ENT surgeries in 2015 than we had done in the last five years combined,” says Andick. “He has been one of our most important placements to date.”

Because of the size of the facility, hiring is “a very selective process,” says Andrick. Once a need is confirmed in the community, Andrick initiates the outreach process to find candidates. Even then, however, Wilson Health is extremely selective. Because it is a smaller community, it’s important to bring in people who will be a good fit. Says Andrick: “You have to be careful who you recruit because you’re going to have to live with them.”

Referrals open doors

The physician perspective

The bonds Laura Hahn, M.D., formed with internal medicine faculty members during her residency ultimately led to her perfect job. After graduating from West Virginia University School of Medicine, Hahn started a residency at MedStar Union Memorial Hospital in Baltimore. She hoped to stay in the area after residency, so she started networking and exploring opportunities in earnest during her third year. She spent time in clinics and shadowed in an outpatient setting to learn more about it. Shadowing confirmed her inclination toward an outpatient-only practice in Baltimore.

Once she knew where she wanted to end up, Hahn let others know what she was after. Communicating her goals attracted the attention of attending physicians. “I had several attendings talk to me about openings,” she says. They subsequently made introductions for her. “The doctors were eager to help,” says Hahn. Since they knew her well, the physicians could see she would fit well in such a practice. “You develop close relationships with faculty, and they see you in action and how you are with patients,” says Hahn. Those relationships gave her an in with local practices where her attending physicians worked.

Laura Hahn MD

A residency at a smaller community hospital helped Laura Hahn, M.D., stand out and build relationships with her colleagues—two attributes that came in handy when she began her job search.

A residency at a smaller community hospital helped Hahn get to know those physicians, too. She had only 11 internal medicine residents in her class, compared to the typical class size of 30 to 60 at larger hospitals.

But even in a small class, Hahn stood out because she wanted to pursue a practice position in Baltimore straight out of residency instead of applying for a fellowship. She asked attending physicians lots of questions about contract negotiation, employers’ reputations and their personal experiences with the hiring process. As a result, Hahn says, “I had all the attention from the attendings.”

Hahn began interviewing with several practices in October of her last year in residency and finished up in December, accepting an offer from the first place she had met with: Mercy Medical Center. “I saw how different the practice was, how open and honest they were in response to my questions,” she says. No other practice gave her the same comfort level.

But she didn’t just rely on her impression from that one interview. Hahn also spoke with physicians already employed at Mercy. Sandy Edwards, senior vice president of physician delivery systems at Mercy, interviewed Hahn, gave her a list of all the physicians at Mercy and each of their email addresses, and encouraged her to ask them for an insider’s perspective on the workplace. Hahn emailed about 10 on that list; all of them responded and assured her they were very happy with their employer.

The employer perspective

When one of Edwards’ physicians told him that “the best resident we’ve ever had” was interested in working at Mercy, Edwards acted quickly to bring in Hahn and interview her.

Edwards felt the need for speed in hiring because finding primary care physicians is highly competitive. “There is a tremendous shortage of primary care doctors, with their numbers declining for the last 20 years…even as the number of doctors needed rises,” explains Edwards. He says that the shortage in 2000 was the equivalent of 9,000 doctors and that by 2025, that figure will rise to 65,000. In the short term, that means there are fewer people to recruit.

To attract strong candidates to grow a practice or replace a retiring physician, Edwards relies heavily on the 210 physicians at Mercy to identify and recruit new physicians.

Fortunately for physicians who want to do primary care in Baltimore, Mercy is a solid option. “We are known as doctor-friendly. We treat everyone as professionals, and we have a good reputation,” says Edwards.

The try-before-you-buy approach

The physician perspective

Like Hahn, leading pulmonologist Thomas O’Mara, M.D., was in demand. He was already at a private practice in Charleston, South Carolina, when recruiters started calling.

After relocating to central New York to be closer to family a few years later, O’Mara started searching for a permanent position that would provide a good salary and security for his family. “With private practice, you know that you have pay coming in—the security of a regular paycheck,” he says.

He was looking primarily for a permanent position, but he also considered other career options. He filled out an online request to learn more about locum tenens work and almost immediately received a call from a recruiter from CompHealth in Utah. The recruiter explained how locum tenens positions worked. O’Mara was intrigued but not ready to give up his search for a steady paycheck.

But the recruiter was persistent, checking in regularly to see if he could do anything to interest O’Mara in a trial position. “[He] did not give up,” says O’Mara about the recruiter. Although O’Mara was fielding plenty of other recruiter calls, his discussions with the CompHealth recruiter were different. “He was always very nice, professional, courteous, and he always remembered little details that no one else did,” says O’Mara.

Then one day, the recruiter called and told O’Mara, “I’ve got a place in South Carolina that could really use you for a weekend. Why don’t you give it a try?” Figuring he had little to lose since there was no commitment beyond that weekend, O’Mara agreed. “I was hooked after that,” he says.

That opportunity to work as a locum tenens physician allowed O’Mara to learn what employers expected, what the routine was like, who he would be working with, and what issues could arise. It was exactly what he needed. It helped him see that many of his preconceived notions about locum tenens were inaccurate.

Instead of working a full week for a regular paycheck, O’Mara can now decide how much he works and, effectively, how much he earns. Today, he works about two weeks away from home and then flies home and has two weeks solid with his family. In 2015, O’Mara took five straight weeks of vacation. “I couldn’t have taken that time off in private practice,” he says.

The employer perspective

Rachael Fletcher now serves as O’Mara’s key contact at CompHealth. Fletcher and O’Mara have worked together so long that their professional relationship has also become personal. “I consider him a friend,” says Fletcher.

As a friend, Fletcher has a good idea which opportunities are good fits for O’Mara and his family, and which he would never consider. She knows him so well that in some cases she can convince him to take a second look at assignments he initially would have rejected. Fletcher invested time in understanding what is important to O’Mara, and she does this with all the physicians she recruits.

During the initial interview process, Fletcher looks for key attributes. “I’m looking for someone who is trustworthy, who is going to get [his or her] paperwork in on time, and someone who is flexible,” she says. Locum tenens physicians need to be highly adaptable. They have to switch between different types of facilities and workloads. Thus, during the first call with a potential locum tenens physician, Fletcher asks a series of qualifying questions to assess how well a candidate would fit the job and how easy it would be to bring him or her on board.

Having interviewed O’Mara, the team at CompHealth knew he would quickly become in-demand, and he has. His temporary employers regularly ask him to sign a permanent contract, and he always declines. After initial hesitation, O’Mara has learned to love the locum tenens life.

Marcia Layton Turner is a frequent contributor to PracticeLink Magazine.

 

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