Where to practice?

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

By Debbie Swanson | Feature Articles | Spring 2020

 

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

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

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

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

Hanging up your shingle: private practice

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

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

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

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

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

Excitement and variety: hospital employment

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

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

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

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

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

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

Joining the team: group practices

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

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

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

A unified focus: single-specialty group practice

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

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

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

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

Combined expertise: multispecialty group practices

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

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

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

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

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

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

Embracing opportunity: locum tenens

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

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

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

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

Satisfaction and benefits: working for the government

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

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

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

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

So how to choose?

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

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

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

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

 

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Luis Diaz Quintero, M.D.

Snapshot | Spring 2020

 

Luis Diaz Quintero, M.D., created a profile on PracticeLink that he then used to apply for jobs. - Photo by Colin Lyons

Luis Diaz Quintero, M.D., created a profile on PracticeLink that he then used to apply for jobs. – Photo by Colin Lyons

Employer: Apogee Physicians, Lincoln, Illinois

Residency: University of Chicago NorthShore Program

In practice since: 2019

Quintero enjoys music, playing instruments and sports.

What surprised you about your first post-residency job or job search? It was easier than I expected to find a job. There are many opportunities out there for different topics or areas of expertise.

What’s your advice for residents who are beginning their job search? Understand what you want and what your priorities are: family, location, hours, type of job (hospitalist vs. outpatient care, etc.), salary, visa, so you can filter your options.

What was the most important factor in your search for a new job? Visa sponsorship and location.

How did you find your job? I created a profile with my CV attached to it in PracticeLink and submitted applications to the positions I found interesting. The process was much easier than expected, and I was surprised with how many options and opportunities there are.

How did PracticeLink help you in your job search? PracticeLink made the process of looking for a job very easy by allowing me to adapt my search to my own specific needs.

 

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Proposals to control drug costs

Lawmakers propose a variety of solutions as drug prices rise faster than the rate of inflation.

By Jeff Atkinson | Reform Recap | Spring 2020

 

The prices of drugs for which Medicare spends the most money have increased substantially more than the rate of inflation—in some cases by more than nine times.

In 2016-17, the Kaiser Family Foundation reported that 60 percent of all drugs covered by Medicare had list prices that increased more than the rate of inflation. Medicare enrollees who did not receive low-income subsidies spent, on average, about $500 out of pocket on prescriptions. More than 1 million enrollees who needed specialty drugs or other expensive drugs spent more than $3,200 per year out of pocket.

With the mounting burden of drug prices, pressure grows on lawmakers and candidates to ease the burden. The main proposals are as follows.

Allowing Medicare to negotiate prices

The Medicare Modernization Act of 2003 prohibits Medicare from negotiating prices of drugs paid by Medicare.

Several bills before Congress would change that. House Resolution (H.R.) 3, introduced by Rep. Nancy Pelosi (D. Calif.), would repeal the noninterference provision and direct the secretary to negotiate prices on at least 25, but no more than 250, brand-name drugs without generic competitors. The drugs initially subject to negotiation would include the ones on which the government spends the most money. The Congressional Budget Office projects that this measure would save the government $345 billion over a six-year period.

Using international benchmarks

H.R. 3, along with several other proposals, would direct the government to set prices with reference to the prices paid by leading industrialized countries. H.R. 3 specifies six countries: Australia, Canada, France, Germany, Japan and the United Kingdom.

In general, the “maximum fair price” for a drug under the act would not be more than 120 percent of the average price for the drug in the six designated countries. Other proposals use different reference points, such as the average price for the drug in other countries or the lowest price paid by any of the designated countries.

A variation on using prices charged to other countries would be to restrict price increases to the rate of inflation. Some proposals also would lower costs by allowing consumers to purchase drugs from other countries, provided the FDA has certified the source is safe.

Taxes on excess profits

To help enforce the new price regime, H.R. 3 and other proposals would place a tax on drug company profits if the companies charge in excess of the benchmark price. Such taxes could be up to 95 percent of the “excess” profits. In addition, civil monetary penalties could be imposed up to 10 times the difference between the “maximum fair price” and the price that was charged. Related proposals would eliminate or limit tax deductions by drug companies for expenditures on marketing.

Caps on out-of-pocket payments

Another way to ease the burden on patients is to limit their out-of-pocket payments. Currently, the amount a patient would have to pay for drugs under Medicare is open-ended, although catastrophic coverage reduces the burden after the patient has paid approximately $8,500. (The precise amount varies with the health plan and types of drugs purchased.)

H.R. 3 would limit out-of-pocket expenses to $2,000. Bernie Sanders’ Medicare-for-All would set the limit at $200.

Loss of patent protection

Rep. Lloyd Doggett (D. Texas), Sen. Sherrod Brown (D. Ohio) and more than 100 other Democrats are sponsoring bills to alter patent protections for pharmaceutical companies in the event drug prices are not considered fair to Medicare beneficiaries and taxpayers (H.R. 1046 & S. 377). The Secretary of Health and Human Services would be authorized to issue licenses to companies other than the original manufacturers to allow manufacture of generic versions. This presumably would have the effect of dropping prices for the drugs.

Panel with power to limit prices

Another proposal is to create a federal panel with the power to set drug prices. Factors the panel would consider in setting drug prices include: research and development costs, costs of production, size of the market, and availability of alternatives for the drug.

Major reform of drug policies is unlikely in 2020. Results of the election will determine the likelihood of future legislative reforms.

Jeff Atkinson is a professor for the Illinois Judicial Conference and has taught health care law at DePaul University College of Law in Chicago.

 

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Navigating the job-search journey

When to do what to find your dream practice.

By Marcia Layton Turner | Feature Articles | Spring 2020

 

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

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

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

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

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

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

Planning ahead

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

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

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

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

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

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

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

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

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

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

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

When to start looking

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

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

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

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

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

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

The typical timeline

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

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

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

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

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

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

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

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

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

What can slow the hiring process?

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

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

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

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

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

 

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Navigating student loan repayment

These resources can help ensure you’re taking advantage of any and all available opportunities to reduce your debt.

By Jason Dilorenzo | Financial Fitness | Spring 2020

 

As a student debt advocate for graduate health professionals going on 10 years, I’ve seen myriad changes in the student loan marketplace in recent years. Today, there are more than 10 federal repayment plans available, including several income-driven repayment (IDR) plans that offer affordable loan payments and potential forgiveness, most generously through an increasingly-utilized Public Service Loan Forgiveness (PSLF) program.

We’ve also seen the growth of a private refinancing marketplace and more than 75 federal and state loan repayment programs to those who work in select rural or underserved areas for specified amounts of time.

In addition to the federal and private options available, physician employers are increasingly offering their own student loan benefits in the form of upfront bonuses for student loan repayment, annual repayment and, most recently, “contribution” platforms that pay down student debt monthly.

Physicians today are finishing up medical training with an average of over $200,000 in debt, and many of you are carrying twice this amount. So how do you make sense of all these repayment and forgiveness options to ensure you’re maximizing your savings opportunities?

Federal loan forgiveness

The average medical resident earns slightly more than $50,000 per year, and the average monthly payment on a 10-year Standard plan at $250,000 in debt is around $2,800 per month. It’s clear to see then why payment relief is needed during training. This relief often best comes in the form of one of the federal Income-Driven Repayment (IDR) plans. These plans offer reduced payments along with generous interest and forgiveness benefits.

There’s a “fork in the road” often reached when you’re transitioning to practice, because until you know you no longer qualify for federal forgiveness and earn enough income to pay down debt more ambitiously, refinancing your loans to a private lender is often not appropriate.

In a majority of projections I run for graduates who qualify for the PSLF program, after 10 years of qualified employment including residency and fellowship, the amount paid is $150,000 or more less than what they borrowed.

Note that residency and fellowship programs are typically nonprofit and PSLF-qualified, so borrowers are able to count these years toward the 10 required for PSLF.

For-profit employers

Employees at for-profit organizations and independent contractors do not qualify for PSLF. Some employers in these situations may offer upfront or monthly student loan repayment as a benefit. Refinancing is almost always appropriate if available, but a borrower’s underwriting profile will ultimately dictate how competitive rates will be.

Nonprofit and public service employers

Employees at nonprofit organizations and in the private sector uniquely qualify for PSLF. Approved by Congress in 2007, this program provides a path to tax-free loan forgiveness for anyone directly employed by a federal, state or local government organization, or directly by a 501c(3) nonprofit.

PSLF “salary boost”

But not all nonprofit employees should be pursuing PSLF. If the payments required in an IDR would pay off all eligible federal loan debt in 10 years, there’s no benefit and refinancing would be appropriate.

A critical consideration is what we call the “PSLF Salary Boost.” In a sample candidate analysis, we calculated that for the six years following a four-year training term, a nonprofit employment offer was worth an additional $72,000 per year in salary when the reduction in payments from PSLF was contemplated. (Determine your “boost” with the free tool at bit.ly/3506Hrf.)

Federal and state repayment programs

The AAMC publishes a comprehensive list of available federal and state loan repayment programs at bit.ly/39n3k1a.

It’s important to note that PSLF can also be used if a federal or state repayment program qualifies and doesn’t eliminate all of your debt, but there is an overlap of benefit in that the repayment amounts reduce debt positioned for forgiveness through PSLF.

Employer benefits

Some employers will offer upfront money or annual payments (such as $20,000 per year for up to five years) to be allocated toward student debt, which is considered taxable income. Increasingly common are “contribution” plans, where an employer makes a pre-determined monthly payment to an employee’s student debt servicer. Proposed legislation may allow both employer and employee to receive a tax break when a student loan benefit is offered, and I’d expect this type of offering to grow exponentially if such legislation is passed.

You won’t know what student loan benefits might be available to you if you don’t ask!

Jason DiLorenzo is executive director of Doctors Without Quarters, which serves as a bridge between transitioning physicians and their potential employers, and PSLFjobs.

 

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Licensing, credentialing and hospital privileges— oh my!

Taking care of the logistics of your next job search.

By Marcia Horn Noyes | Feature Articles | Spring 2020

 

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

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

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

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

Expectation meets reality

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

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

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

State-to-state frustrations

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

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

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

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

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

At your disposal: a credentialing facilitator

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

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

Basic elements of credentialing

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

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

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

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

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

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

A credentialing advantage

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

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

Mitigating delays

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

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

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

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

The future of credentialing: speeding the process through technology

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

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

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

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

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

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

Marcia Horn Noyes is a frequent contributor to PracticeLink Magazine.

 

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How tight is the job market in your specialty?

The PracticeLink Physician Recruitment Index can help you gauge the relative ease or difficulty of your job search.

Spring 2020 | Vital Stats

 

What’s your competition like? For job-seekers of all kinds, it can be hard to know. A simple PracticeLink.com search for opportunities in your specialty will give you an indication of the demand for physicians like you, but without knowing who else is vying for those jobs, it’s hard to get an accurate picture of supply.

How many other candidates in your specialty are actively looking for jobs at the same time? And how does that number correspond to the number of opportunities available?

That’s where the PracticeLink Physician Recruitment Index comes in. The Index is a relative indication of the ease or difficulty of job searches in various specialties based on supply and demand information gathered by the PracticeLink system quarterly. The larger the “jobs per candidate” number for your specialty, the better your potential standing in the market.

The change in rank reflects the specialty’s movement since last quarter.

The Most-Challenging-to-Recruit Specialties are those specialties with the highest demand-to-supply ratio in the PracticeLink system. The specialties on this list likely won’t come as a surprise to candidates; they’re often narrow fields.

The Most-In-Demand Specialties represent the specialties that have the most jobs overall posted on PracticeLink—specialties for which the demand for physicians is highest. For the Index, we then rank those in-demand specialties according to the supply. Those at the top represent specialties with the most jobs available and the fewest candidates per job.

After reading these Indexes, ask yourself: Do these Indexes match my experience of searching for a job in my specialty? Do I need to widen or narrow my job-search parameters as a result?

This PracticeLink Physician Recruitment Index was pulled January, 2020. Candidate ratios include physicians who have registered with PracticeLink.com within the past 24 months.

 

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Free resources for your job search

PracticeLink offers assistance online, in person, over the phone—and even in your mailbox.

By Chris Scites | PracticeLink Tips | Spring 2020

 

Through my role with PracticeLink, I have had the opportunity to attend a number of specialty conferences. In 2019 alone, I represented PracticeLink at SHM, ACP-IM, ACOG, AAFP-FMX and ACG. It’s a pleasure to meet face-to-face with some of the physicians and advanced practice providers who use PracticeLink throughout their job search, and introduce PracticeLink to those who haven’t yet started.

One of the first questions I get asked by those in that group is, “How can PracticeLink help me in my job search?”

How can PracticeLink help?

The answer I always give is that PraticeLink helps physicians through the job search in the same way that a fully outfitted operating suite helps a surgeon. It provides the tools you need when you need them.

PracticeLink provides you, the job seeker, with a complete set of resources that helps you find your dream practice using the criteria that are personal and important to you.

Search for jobs

You don’t have to create an account on PracticeLink to see the opportunities posted at more than 5,000 hospitals, health care systems, medical groups and independent practices. When you search anonymously on PracticeLink, you can select from a number of filters in the search tool that allow you to view opportunities based on criteria such as geography, visa waivers, or if it’s an academic position.

If you choose to create a PracticeLink profile, you’ll unlock even more tools. Specify the criteria you’re looking for in your next opportunity, and we’ll send you a Job Messenger email that notifies you of new opportunities that match. You can also use PracticeLink or PhysicianCV.com to enter your professional information and create a downloadable CV if you don’t already have one.

Creating a PracticeLink account also gives you the choice to share your criteria and profile with in-house physician recruiters. Sharing your profile allows in-house physician recruiters—recruiters who work directly for the organizations for which they’re recruiting—the ability to find and evaluate you for their opportunities. This means that the recruiter has the opportunity to consider whether you’d be a good fit even before they reach out.

Complete an interview

To communicate your criteria and fit for new opportunities even further, complete a Candidate Interview with one of PracticeLink’s Physician Relations representatives. We’ll reach out to you when you register at PracticeLink.com for a short interview to delve into the whys of your ideal practice. Why you are interested in the location you’ve indicated? Do you have family nearby, enjoy the activities in the community, or are just interested in somewhere new? Why did you decide on your specialty, and what kind of environment are you looking for in a new practice?

The information you provide through this brief interview helps you stand out in the PracticeLink system. In-house recruiters use the information to learn why you may or may not be a good fit for the opportunities they have available.

During the interview, feel free to ask your physician relations representative any questions you have about your job search. The team speaks to thousands of physicians each year and can answer any questions you have about your job search, CV and more.

Get help in person

Remember those specialty conferences I mentioned earlier? Stop by the PracticeLink booth at nearly two dozen conferences each year to receive free job-search help, create a job-search profile, enter to win a $500 Visa gift card and pick up some swag!

Or attend a PracticeLink Live! Career Fair in a city near you (see page 21 for details). Each PracticeLink Live! event brings employers from across the nation right to you. Learn about their communities and opportunities while networking and enjoying a complimentary buffet dinner and drinks. Free parking, free attendance, a free job-search seminar and $1,000 in door prizes are featured at each event. Register to attend at info.practicelink.com/2020-practicelinklive.

Access free resources

In your mailbox and on the PracticeLink website and FirstPractice.com, you can access all kinds of helpful career resources. In quarterly themed magazines (like this one), PracticeLink aims to help you thoroughly understand and prepare for your job search. Learn about everything from negotiating a contract to how employers are helping physicians achieve the right work/life balance.

This is just a brief overview of the tools and resources that PracticeLink makes available to help you with your job search—and we’re always working on ways to add more. PracticeLink is more than a job board; it’s a complete set of tools to help you find your dream practice. •

Chris Scites is PracticeLink’s director of physician relations. Reach his team for free job-search help and to complete an inDepth Interview at (800) 776-8383.

 

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Free medical apps

The World Health Organization and Phoenix Children’s hospital are behind these useful tools.

By Iltifat Husain, M.D. | Spring 2020 | Tech Notes

 

In this edition of Tech Notes, I look at two free medical applications that do a tremendous job of using a phone’s best features to help with patient care. One is a must-have for those who travel for volunteer medical work around the world. The other is a necessity for any medical provider who works with pediatric patients.

WHO Surgical Safety Checklist App

Price: Free. iPhone, iPad: apple.co/37fQL5H. Android: bit.ly/39nEP3G

There are a significant number of physicians and health care providers that go to other countries to volunteer for brief periods in resource-limited areas. Oftentimes, these providers are doing surgical procedures and working with multilingual teams. The World Health Organization (WHO) Surgical Safety Checklist app is absolutely critical if you’re one of these providers or part of a team that does this type of work.

The app, presented by WHO and the United Nations Institute for Training and Research (UNITAR), details the Surgical Safety Checklist developed in 2008 to increase the safety of patients undergoing surgical procedures. The app is a way for surgical teams to go through an electronic form of the checklist, and it is applicable to all members of the team: surgeons, anesthesiologists, nurses and surgical assistants. The WHO checklist has been studied and shown to significantly decrease morbidity and mortality of surgical procedures.

The app has three main sections: before induction of anesthesia, before skin incision, and before patient leaves operating room. Each of these contains a series of questions you are supposed to go through at the appropriate stage of the surgical course.

You have the option of viewing all of these questions in a list form, but the main reason I’m featuring this app is that you can use voice commands to go through the checklist. I’ve reviewed hundreds of medical applications, and never seen one that utilizes voice commands to go through a checklist or various prompts.

Even if you don’t use the voice commands, the user interface is beautiful. The screen has huge text and large buttons—critical when you’re in the operating room and might be wearing gloves. Obviously, you wouldn’t use this app when you’re sterile, but I can imagine a tech turning on the voice prompt of the app and allowing the anesthesia and surgical team to listen.

When you complete the checklist (or portions of it), it gets saved in a calendar and time stamped. Having a time stamp forces the team to do the checklist in real time, when it matters most.

There are two areas the app could be improved: Reference sections and languages. The WHO has a great list of tools and resources on their website when it comes to implementation of the checklist. This would have been a great opportunity to put a list of references to these resources or even place those resources within this app.

The second area the app could have been improved is languages. On their website, the WHO has several different translations of their application. This is particularly important when the application is being used in different countries or if you are working with a multilingual team in an area with limited resources.

Simply Sayin’: Medical Jargon for Families

Price: Free. iPhone, iPad: apple.co/351LddO. Android: bit.ly/360Ethv

Phoenix Children’s hospital continues to produce fantastic apps for the pediatric patient population. While these apps are central to their health system, they can easily be utilized by other children’s hospitals and pediatricians around the country. This particular app is tremendous for providers and patients when it comes to pediatric procedures and treatment modalities.

The name and the description might make it seem that Simply Sayin’ Medical Jargon for Families is only for patients, but the app can be utilized by providers as well. Simply Sayin’ opens with four options: glossary, preps, drawing and pictures.

The area providers can use the most is drawings, which contains more than 40 pictures that you can annotate with children and family members. For example, if you’re trying to explain what a GJ Tube is, you can select that drawing and automatically show the GJ tube overlaying the stomach with surrounding anatomy.

The best part of the drawing section is that providers are able to draw on the actual picture with different colors. One of my favorite drawings is for asthma. When you click on asthma, you are shown how the lungs look during an asthma attack.

The other three sections of the app—glossary, preps and pictures—are meant to be used by family and patients on their own. I think preps is the best section for patients and family members. Going through any type of medical procedure is anxiety-provoking for both children and parents. In this app, users are presented with bullet points and pictures on the procedure, why it’s being done, and the steps that will happen.

This is a great app for pediatricians, pediatric surgeons and pediatric nurses to use with their patients. It’s also a great application to recommend to parents. •

Iltifat Husain, M.D., is editor-in-chief and founder of iMedicalApps.com. He’s also assistant professor of emergency medicine and director of medical app curriculum at Wake Forest School of Medicine.

 

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Choosing the smaller side

Live & Practice

By Liz Funk | Live & Practice | Spring 2020

 

After 17 years of practicing in Connecticut, Stephen Siegel, M.D., moved to Boulder to take advantage of the work/ life balance and outdoor activities. - Photo by Castner Photography

After 17 years of practicing in Connecticut, Stephen Siegel, M.D., moved to Boulder to take advantage of the work/ life balance and outdoor activities. – Photo by Castner Photography

Physicians choose to practice in rural towns and small cities for myriad reasons: They prefer to live among nature, they thrive at a pace that is lively but not breakneck, or they value having ample living space to spread out. For other physicians, perhaps a dream job or family draws them in. These areas do not have the hustle and bustle that congests city life, but they do have thriving communities, diverse entertainment, dining options, and of course, patient populations that are unique and varied, which offer physicians interesting opportunities to learn and grow professionally.

Boulder, Colorado

Thirty miles north of Denver, Boulder, Colorado is a quirky haven surrounded by breathtaking mountain ranges. Nestled in the foothills of the Rocky Mountains, Boulder has a population of 100,000, although that figure surges when the University of Colorado is in session. Boulder is also an interesting case study in urban planning. The city has unique zoning laws that prevent suburban sprawl around Boulder and maintain its character and strong sense of place.

Stephen Siegel, M.D., moved to Boulder in February, 2018, to practice urology at Boulder Medical Center. He previously practiced in Connecticut for 17 years, but the day-to-day life wore on him. “The commute was hard and the lifestyle was difficult,” he says. He made a cross-country move to join the team at Boulder Medical Center, where he enjoys the work/life balance he had been craving. “Boulder Medical Center is a place that understands that the lifestyle of all of its physicians and employees is important. We all work hard, but we also make time to enjoy life outside of medicine,” he says.

Patrick Menzies, CEO of Boulder Medical Center, says, “The group has a culture of work/life balance.” Boulder Medical Center sounds like an inpatient hospital, but it is not. Says Menzies, “It is a 70-year old physician-owned multispecialty practice consisting of 84 providers in 18 specialties across five outpatient clinics in the region.” There are also clinics at three hospital locations. “We are primarily an outpatient-centric organization with hospital relationships across all specialties,” says Menzies.

This unique structure is attractive to physicians as it is a “high quality collaborative clinical environment that functions much like a mini-academic setting,” says Menzies. Siegel echoes the benefits of Boulder Medical Center’s approach. “I enjoy being in a multispecialty clinic owned by the physicians. I enjoy having peers nearby to help care for my patients,” says Siegel. “I appreciate that if a patient of mine has an issue that is outside of urology that there is a primary care doctor and specialists around the corner that can help provide the assistance that is needed. I get to work with great doctors who also are great people who care about our patients.”

At Boulder Medical Center, culture is king and Menzies recruits physicians who will be a good match for the group’s balanced approach to practicing. Says Menzies, “We are not looking for candidates that want to work six to seven days a week and 12- to 15-hour days and look to earn the 90th percentile in compensation. While we do not begrudge anyone for seeking out this direction, it is simply counter to the underlying culture of the group… We are seeking people that understand and are attracted to the outdoor lifestyle and appreciate what it means to live in this incredible place inside and outside of their clinic.”

“We live in a beautiful, highly educated, engaged, innovative community, with great outdoor activities like hiking, biking, climbing, skiing, etc., and terrific weather for much of the year,” says Menzies. Boulder boasts 300 days of sunshine a year.

Thus, the people are a big part of what makes Boulder special. In 2017, National Geographic magazine named Boulder one of the happiest places to live in the world. Part of this is likely due to the athletic, health-conscious nature of the area. Says Menzies, “BMC [Boulder Medical Center] has a number of past and present elite class competitive athlete physicians. We tend to attract physicians that are seeking a healthy, active, outdoor lifestyle.”

Siegel enjoys hiking on the “innumerable” trails around the city and cycling on the bike-only paths that run all across Boulder. Says Siegel, “I like walking my dog who is welcomed and given treats at stores and restaurants around town…. The vibe of the town is one in which people have pride in where they live and are excited about all there is to do. The energy especially picks up when the [University of Colorado] college students are in town, with more lectures for the public and sporting events to attend.”

One challenge that Boulder transplants may encounter is the cost of living and competitive housing market. City planners are aware of how special their community is and they have enacted legislation that prohibits the development of suburban subdivisions and limits new building within city limits. Additionally, 1990s local lawmakers created a “green belt” of 33,000 acres of public parks that essentially enclosed the city and prevented acquisition of this land by real estate developers.

This has had the effect of preserving the intimate, low-key “vibe” that Siegel described, but it has also driven up real estate prices. People want to live in Boulder, and the intentionally limited supply and high demand puts the cost of living on par with more metropolitan areas. (The average home price in Boulder is $660,000.)

Still, those who want to relocate to Boulder make it work. Menzies says that there are a large handful of BMC physicians whose spouses work for top echelon companies with offices within commuting distance. “We tend to see physicians with family members in tech, sciences and academia due to our proximity to global companies such as Google, Amazon, Apple, Twitter, University of Colorado and a number of scientific labs,” says Menzies. Menzies is currently recruiting physicians in internal medicine, family practice, endocrinology and neurology.

Siegel is very happy that his career brought him to Boulder. “The size of Boulder is one that is big enough to provide at least one of everything. If you are looking for a specific cuisine, it is here. If you are looking for art or culture, it is here.” Red Rocks Amphitheatre, an internationally recognized outdoor performance venue, is a mere 20 miles away.

“My only complaint is that I wish I had moved here years ago,” says Siegel.

Hagerstown, Maryland

If you’re looking for a high quality of life with a hint of southern charm, look no further than Hagerstown, Maryland. With a population of 40,000, Hagerstown is the sixth largest city in Maryland. Its picturesque downtown makes for a lively gathering place for this tight-knit, quasi-southern community.

Victoria Giffi, M.D. became familiar with Meritus Medical Group when her husband took a position there a few years before Giffi finished her training. In fact, there are a number of happenstances that led Giffi to build a career as a hematology and oncology specialist.

Says Giffi, “I come from a medical family, so as a young adult, I resisted a medical career for as long as I could. My undergraduate degree is actually in music, but I quickly realized that I was not talented enough to make a career out of music. I started to volunteer at the hospital next to my college and realized that I enjoyed getting to know people and found it rewarding to help them feel better. I took a job as a phlebotomist and nurse’s aide.”

Around this time, Giffi’s father developed bladder cancer. Giffi felt the anxiety and grief common among families with a loved one battling cancer, but it was also a watershed moment for her: she was fascinated by her father’s cancer treatment. “He received one of the earliest generations of immunotherapy and was cured of his disease. The concept that putting an irritant into the bladder to cure cancer intrigued me. Having realized by this point that I liked both the social and the scientific sides of medicine, I decided to apply to medical school.”

Giffi has been deeply loyal to the University of Maryland School of Medicine, located in Baltimore. After finishing medical school, she stayed for a residency in internal medicine and a chief residency and fellowship in hematology/oncology.

When Giffi interviewed at Meritus Medical Group in Hagerstown, she clicked quickly with the oncology group. She says, “I appreciated the humor and support of my prospective colleagues, as well as what seemed like a collegial relationship with other specialists. Physicians cannot work in a bubble. No matter where you work, you have to have the ability to discuss difficult cases with those around you. The tumor board at Meritus, along with the oncology group—which is comprised of physicians of various levels of seniority—was attractive to me.”

Today, Giffi and her husband are settled in Hagerstown, where they are raising a family. Says Giffi, “I enjoy being in an area small enough to have a community feel. My children can see that their contributions can make a difference, both at school and volunteering. I enjoy having access to the outdoors and large cities at the same time.” Giffi says that, having moved from Baltimore, she has a special appreciation for the lighter traffic.

“I refer to Hagerstown as a ‘Goldilocks’ location, in that it is not too big, not too small, it is just right,” says Amy-Catherine McEwan, a physician recruiter for Meritus Health. “Hagerstown has all of the benefits of living close to major metropolitan areas without the higher costs of living. Our physicians can find anything from a Victorian farmhouse to a brand-new custom-built home at a fraction of the cost [found] in other areas of the country.”

Hagerstown is also known for its distinct architecture. Many buildings and churches were constructed with “Stonehenge Limestone,” which was readily available in nearby quarries in the 1800s. Stonehenge Limestone is unique to Maryland. According to Betsy DeVore with Visit Hagerstown, “Much of the architecture in downtown Hagerstown dates back to the pre-Civil War era and also includes some mid-century modern, as well as newer, more current designs.”

Physicians are attracted to Hagerstown often because of the cutting-edge nature of Meritus Health’s facilities. The flagship Meritus location is Meritus Medical Center, a 257-bed facility that achieved Magnet Recognition status in early 2019. While not technically an academic medical center, the Meritus Family Medicine Residency Program offers opportunities for physicians to be involved as faculty members or lecturers.

Meritus also operates dozens of outpatient facilities, with special services ranging from behavioral health to digestive health to pediatric medicine. Meritus also operates several cancer centers. McEwan is currently recruiting specialists in endocrinology, gastroenterology, internal medicine, pediatrics, family medicine and psychiatry. When McEwan speaks with physician candidates about the area, she emphasizes that it’s family-friendly and replete with entertainment options.

Hagerstown has a number of popular annual events. One is “Augustoberfest,” held annually in August. Says DeVore, “The event was created to celebrate our official friendship with our sister city of Wesel, Germany. Much of the population of Hagerstown is of German descent. Authentic food, dance, music and lederhosen are features of this festival.”

Another one of the area’s most popular events is the Fort Frederick Market Fair, held annually in April at Fort Frederick, which dates back to the French and Indian War.

Perhaps the most defining aspect of practicing in Hagerstown is the kind and easygoing nature of the citizens, which in turn creates a pleasant patient population. Says Giffi, “I learn new things from my patients every single day. Sometimes it’s unrelated to medicine, like how to hunt bears, how to can peaches, and how to make kefir. Other times, they share advice to help me with potty training one of my stubborn children! Many times I am inspired by the grace and bravery with which people take bad news or make the most of every day knowing they don’t have very long.”

Regarding the practice itself, Giffi appreciates that her team has a shared affinity for getting to know patients and their families. Says Giffi, “I feel privileged to work in a place large enough to have this team, but small enough to feel like a family.”

Florence, Alabama

Florence, Alabama, is a scenic, small city in northwest Alabama that sits on the banks of the Tennessee River. This means that the area has all the amenities and charm of a southern town, plus ample water sports and outdoor activities. Florence has a historic downtown area, which hums with activity when the University of North Alabama is in session. Area physicians have the special opportunity to practice at a new medical center facility that opened in December 2018.

Nicholas Darby, M.D., has built his career around the importance of providing quality medical care to rural areas. “After graduating from college, I entered the Rural Medical Scholars Program, a program of the University of Alabama School of Medicine that allowed me to obtain a one-year Master of Science from the University of Alabama focused on Rural Community Health,” says Darby. He subsequently attended medical school at the University of Alabama. When he completed medical school, he headed about 50 miles south to Centreville, a small rural town in Alabama, to join a program called the Cahaba Family Medicine Residency Program. Darby says, “I spent about two-thirds of my time at a large federally qualified health center and the local, rural county hospital and the remaining third of my time at the large urban tertiary care centers associated with the University of Alabama at Birmingham health care system.”

When Darby finished his residency, his internal compass pointed him home: Florence, Alabama. Darby says, “As I was completing residency, I knew that I wanted to return to an area that was fairly rural and to a location where I could provide traditional outpatient and inpatient care. As I looked at several locations in my region, I found the ideal location right in my hometown of Florence, Alabama: North Alabama Medical Center.”

The facility is sparkling new. North Alabama Medical Center opened December 6, 2018, replacing Eliza Coffee Memorial Hospital. North Alabama Medical Center has 263 beds and serves as the primary referral center for northwest Alabama, southern Tennessee and northeast Mississippi.

Says Tina Holt, a physician recruiter there: “North Alabama Medical Center has a very strong diverse medical staff in all specialties including but not limited to cardiothoracic surgery, neurosurgery, oncology and one of the best orthopedic trained groups in the United States.” With a new facility comes brand-new, often state-of-the-art equipment. Says Holt, “They have all new equipment in imaging and the surgical services to include endoscopy lab as well as cardiovascular lab. NAMC has the Stealth Navigation and O-arm for neurosurgery.”

Says Darby: “It is a privilege to have the opportunity to be one of the physicians at a very new facility with physical infrastructure that rivals any of the hospitals that I trained at in the urban tertiary setting.” The new facility has 14 operating rooms and two dedicated cardiovascular operating rooms. North Alabama Medical Center also operates 15 clinics for specialist and medical care.

Holt is currently recruiting specialists in gastroenterology, pulmonary, neurology, neurosurgery, primary care, palliative care, OB-GYN, pediatrics, endocrinology, radiology and rheumatology, as well as hospitalists. Says Holt, “Most all these positions are due to patient volume growth with the new facility being more of a tertiary center for surrounding hospitals.”

Holt says that the people of Florence are “the nicest people in the world,” which makes for an easygoing patient population and a team of employees who are friendly to newcomers (Darby has been at North Alabama Medical Center less than one year). Says Darby, “I have already quickly grown close to many of my patients. I am honored to have the opportunity to provide care to people who remind me of the great people that raised me and that I grew up around, and at times, quite literally knew me as a small child…. Equally as important, the staff and fellow physicians at both the hospital and my clinic have been superb—welcoming me right in, exemplifying an exceptional level of professional care, and creating a great environment for me to do the same.”

Darby greatly enjoys his life in Florence outside of work, too. Says Darby, “I love being outside on my kayak on one of the creeks—one runs behind my house! Some days I’m soaking up the beautiful remote nature around me and other days I’m trying to catch a trophy smallmouth or load up on redeye bass for the day. During the summer, I will enjoy riding around the lakes, proving to myself that another year has passed and I can still wakeboard and slalom ski.”

Darby and his wife also enjoy the collegiate atmosphere of downtown Florence. Says Darby, “In town, the college and historical yet trendy downtown area bring a certain unique energy to our rural community. My wife and I love to visit the University of North Alabama lion [statues], Leo and Una, together. They are where I asked her to marry me!”

Iron Mountain, Michigan

“This is a great place to raise a family,” says Adam Ryan, M.D., about Iron Mountain, Michigan. - Photo by Mark Hawkins

“This is a great place to raise a family,” says Adam Ryan, M.D., about Iron Mountain, Michigan. – Photo by Mark Hawkins

Iron Mountain is a city of approximately 8,000 located on Michigan’s Upper Peninsula and hugging the Wisconsin border. Naturally, the area is a haven for outdoors enthusiasts, and sports are a big part of the culture: ice hockey, skiing, hiking and biking are popular activities. One of Iron Mountain’s most notable features is the sense of community. Because the nearest cities are either 90 miles north or 90 miles south, residents have a strong sense of kin. This makes practicing in Iron Mountain especially pleasant for physicians, giving them the opportunity for more depth in their relationships with patients and their families.

For Adam Ryan, M.D., coming to Dickinson County Healthcare System was largely about coming home. “I am originally from the upper peninsula [of Michigan] and I wanted to come back. The area is beautiful and has great schools.” One of the things Ryan appreciates most about Iron Mountain is “the schools for my kids—this is a great place to raise a family.” Ryan attended medical school at the Michigan State University College of Human Medicine in East Lansing, located in the center part of the state. Ryan chose to specialize in OB/GYN, as he was attracted to “the unique combination of hospital and office practice.”

Ryan’s new professional home, Dickinson County Healthcare System, is a rural, non-profit community hospital with 49 beds. Dickinson County Healthcare System offers a wide range of outpatient facilities, including primary care, family practice, podiatry, orthopedics, occupational medicine, urology, urgent care and OB/GYN.

Says Ryan, “I like that my work is a combination of primary and specialty care. Delivering babies creates a close relationship with my community.” What Ryan appreciates about his work at Dickinson County Healthcare System is the team he works with. “I most enjoy feeling like I work with a family. We have great teamwork and wonderful administrative support,” he says.

Jacki Courney, a physician recruiter at Dickinson County Healthcare System, agrees that the geniality of the people of Iron Mountain make it a special place to practice.

Says Courney, “It’s a great place to raise kids—they can still ride their bikes down the street. We have good educational systems. We turn out a lot of professionals and students have the ability to earn college credit in high school, giving them great scholarship potential.” To foster community, “there is an active young professionals group with couples and family activities,” says Courney.

Courney is currently recruiting for family practice, pediatrics, orthopedics, internal medicine, urology, emergency medicine and ENTs.

For those who embrace the rural lifestyle, Iron Mountain will not disappoint. Ryan is one of the people who thrives in a rural environment, and he keeps busy outside the hospital. “I most enjoy the outdoor activities: skiing—alpine and cross country—ice hockey, trail running, mountain biking and swimming.” Ryan and his family also enjoy biking, hiking, kayaking and camping during the warmer months. “We have four seasons of recreation.”

 

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