Your job-search timeline

Learning of other physicians’ job-search journeys can help you anticipate, plan and execute your own.

By Marcia Layton Turner | Feature Articles | Spring 2018

 

“Much of the education on searching for jobs was acquired in passing while talking with those ahead of us in training and through each other as we went through process,” says Sunny Jha, M.D. Photo by Dawn Bowery Photography

“Much of the education on searching for jobs was acquired in passing while talking with those ahead of us in training and through each other as we went through process,” says Sunny Jha, M.D. Photo by Dawn Bowery Photography

Until you get to your job search, the path to a career in medicine is quite regimented: Study a pre-med curriculum. Apply to medical school, then to a residency program. After residency, you either apply for a fellowship or begin looking for a job. And that’s when the systematic, methodical process vanishes, leaving some physicians unsure of how exactly, or when, to begin their job search.

“The search process lacks any sort of formal structure, so it is unlike anything most young physicians have ever experienced,” explains Sachin “Sunny” Jha, M.D., MS, assistant clinical professor of anesthesiology at the University of Southern California (USC) in Los Angeles. “I had an idea that the job process would be a long exercise with varying degrees of uncertainty and unpredictability,” he says. “Prior to this point in medicine, everything more or less had a process.”

The path to a new opportunity doesn’t come with a pre-written map or compass. So it can help to hear what other physicians’ job searches looked like as you chart your own course.

“Like many aspects of medical education, this is one of the things that you don’t formally ‘learn,’” says Jha.

The success of your search, and the order in which you uncover and pursue opportunities and resources, is largely dependent on timing. Allow yourself ample time to explore all the jobs that may be available to you so you can negotiate from a position of strength, rather than being rushed and under pressure to accept anything that’s offered.

Design your plan

Zachary Liner, M.D., started his job search 17 months before he would be available. Photo by Michael Caswell Photography

Zachary Liner, M.D., started his job search 17 months before he would be available. Photo by Michael Caswell Photography

When it comes to looking for your first or next job, “Start early,” advises Zachary Liner, M.D., an interventional radiologist with North Oaks Imaging Associates in Hammond, Louisiana. Liner began his job search in the middle of his first fellowship after residency and before he had even started his second fellowship—17 months before he knew he’d be available to start.

According to the 2017 Survey of Final-Year Medical Residents conducted by Merritt Hawkins, a national health care search and consulting firm, 72 percent of medical residents start their job search within or before a year of finishing residency; 28 percent wait until they are six months from completing their training before beginning their job search in earnest.

Patty Shipton, physician recruiter with Penn State Health in Hershey, Pennsylvania, says that a year is just about right for a physician’s job-search process. Physicians in their last year of residency or fellowship generally start looking for a position in early fall, she says. That’s when recruiters begin attending career fairs and conferences armed with a general idea of upcoming openings that will need to be filled. Shipton also collects CVs for unexpected openings that occur from time to time.

Chris Mason, D.O., MS, is regional medical director for the Western region of American Physician Partners and is based in Albuquerque.

Mason points out that, thanks to the fact that there are “far more physician jobs than there are candidates…it’s a resident’s market.” (He’s quick to point out that this varies by specialty and location, however.)

The earliest a resident can commit to a job is right after their intern year. And while that’s not typical, it’s possible, he points out. To entice physicians to sign as soon as they’re eligible, employers may offer incentives including sign-on bonuses, stipends and loan forgiveness.

The major downside to signing a contract so early in the job-search process is that you’re committed to work somewhere long before you’re finished with residency. During that time, you may make all sorts of decisions that could interfere with that employment arrangement. For example, you might decide you want to live elsewhere in the country, you might get married to someone who wants to live somewhere else, or you might decide you want to work for a specific practice or even switch specialties. A lot can happen over the course of several years of training.

Zero in on desirable locations

By early fall, most physicians usually know where they want to be geographically, says Shipton. She finds that they often they want to move to be closer to family. Or they’re clear about whether they want a big city or small, urban or rural setting, mountain or beach, or a specific region of the country.

Many have also started to research which hospital systems or practices have openings in their specialty—or are likely to soon.

Liner’s medical specialty of neurointerventional radiology is what he calls a “super subspecialty.” “There aren’t a lot of people who do what I do,” he explains, which means that there aren’t as many programs or spots available, and “once spots are filled, they’re filled,” he says. “I had to start early to have a chance of getting one of those openings.”

Making his job search even more challenging was that not only was Liner looking for a position in a field with very few openings each year, but he also had a very small geographic target area. Most interventional radiology jobs exist in major cities, he explains, but he and his wife had decided that after living in New Orleans, Texas, San Francisco, and Rochester, New York, they wanted to make southern Louisiana home—where he and his wife had grown up. He knew that his odds of finding an interventional radiology opening in southern Louisiana were slim, so he wanted to start introducing himself to anyone in Louisiana who might have a need for a physician with his skillset.

“It was constantly on my mind that the job I wanted wasn’t open—that I had to create it,” he says. Few programs were looking for a doctor with training in both body and neurointerventional radiology. “It’s a unique skillset that sets me apart,” says Liner, but with so few hospitals and practices actively looking for someone with such unique training, he was aware that his job search could be difficult. It was likely he would need to convince a practice that he would be a valuable addition, and work with them to create a new role rather than take over an existing position.

Be aware of established milestones

Depending on your specialty, there may be opportunities at specific times of the year, such as at educational conferences and medical association meetings, to be considered for upcoming openings.

Jha, who was looking for a position in academic medicine, discovered after the fact that many academic departments interview graduating residents at the ASA (American Society of Anesthesiologists) annual meeting in October. Looking back, he says he should have started earlier and taken advantage of this interview opportunity.

Ask your colleagues if your own specialty’s conference has a similar setup. If so, try to attend.

Mason recommends networking through various local and national chapters of your specialty’s professional organizations. Take advantage of residency events and physician groups that provide opportunities for residents to mix and mingle with health care representatives. “Get involved,” Mason advises, to get to know attending physicians who can serve as referral sources and connectors to your dream practice.

Take a proactive approach

Don’t hesitate to be proactive.

“If there’s a place you’re interested in, don’t be afraid to reach out to the recruiter,” Shipton says. “They may know of a future opening coming up.” Most in-house physician recruiters serve specific departments, so it’s useful to identify which recruiters are responsible for hiring physicians in your specialty at the employers you’re targeting. In-house physician recruiters are uniquely qualified to represent the opportunity and community for which they’re recruiting, as they are directly employed by the facility. It’s their friends and family whom you’ll be treating.

Another option is to retain the help of an agency or staffing firm in your search. An agency may be able to alert you to jobs at multiple specialties through one point of contact.

Liner decided that he needed the support of a professional adviser to help track down a potential employer that would meet all of his criteria. He chose Jeff Hinds, MHA, of Premier Physician Agency in April 2016.

Liner worked on a cover letter and updated his CV to be sent out to prospective employers. He then sent out “feeler emails” to about 40 practices that Hinds had identified in cities and towns in Louisiana, Texas, Alabama and Mississippi to see what kind of interest there might be in a doctor with his training and experience. He also checked physician job boards and applied to a few opportunities.

Almost immediately, Liner began receiving phone calls in response to his campaign. Although most recruiters said, “We don’t have a place for someone with your skill set,” they also told him they would keep his materials on file in case something opened up later. Liner then followed up later with those that had expressed an interest to check in. Back-and-forth phone calls from the feeler emails continued for about six months, says Liner.

Among the many “we don’t have a spot for you” phone calls were six calls from practices that were interested in speaking with Liner, three of which were in Louisiana.

Jha describes his initial job search activities as passive, as he applied and interviewed “broadly” for jobs in both academic medicine and the private sector. “I had been passively searching for jobs in both environments, collecting contacts within different departments,” says Jha.

Then at around the midpoint of his fellowship year, he began directly reaching out to different departments and groups he was interested in. “The department where I did my fellowship kept a list of key contacts within groups around the country, which was instrumental in securing many of my interviews,” he says. In addition, some physician job boards and physician recruitment agencies also provided outreach ideas.

His proactive approach worked. “I actually got my job by directly emailing the chair of my department,” he says.

You can be proactive even without having a name provided. On PracticeLink.com, for example, you can search by specialty, zip or employer, and reach out directly to the in-house recruiter representing the opportunity or organization.

Schedule site visits

For the next five months, from August 2016 to January 2017, Liner flew out to interview with six different groups. He had one interview in August, three in September, one in November, and one in January. Many took weeks to schedule because he had to travel from his fellowship in San Francisco to the south during times he wasn’t required at the hospital. Finding common schedule availability was challenging.

Liner had a strong sense that practices that initially said “no” because they didn’t have any openings at the time might eventually turn into a “yes” if a partner decided to move or retire. So he made a habit of staying in touch with all the practices and hospitals in his geographic search area.

As he scheduled first visits with some groups, he was also scheduling second visits to two practices that had made offers following the initial site visit. He completed those two visits in January.

After reviewing CVs gathered at conferences in September and October, Shipton’s next step is to schedule on-site visits to see if there may be a fit. During October and November, she typically invites the top in for a first on-site visit. Based on those in-person interviews, the interview team and department leadership collectively decide whom to invite back for a second visit, often with their families. Those generally occur in November and December. Offers are then made between December and February, she explains.

Liner made it known to the practices he was considering that he was going to take his time in making a decision. Because he had started his job search so early, he had the luxury of time to thoroughly research each practice and speak with different people and departments within each practice.

While there is a standard recruitment process and timeline, Shipton says, there are factors that can slow it down or speed it up. For example, the availability of a physician to start work can drive how quickly the process concludes. If he or she finishes residency on June 30, the earliest possible date they could start would be July 1. “But many people want to take some time off [after residency], to move and get settled,” says Shipton, “and that can affect when they start.”

Likewise, candidates who are especially responsive can move the process along faster than normal.

Negotiate a contract

As his second site visits were underway in January 2017, Liner began receiving offers. Over the next two months, he began negotiating with three practices. Most contract negotiations don’t take two months, says Liner, “but we were all cautious,” he says. “No one wanted to make any snap decisions.”

Twelve months after he started his job search, Liner accepted a job offer from a practice in Louisiana.

Be prepared for credentialing

In order to prevent any delays in receiving your hospital credentials or medical license, make sure you have quick and easy access to the personal information your employer will need, suggests Jha. That means collecting recommendation letters as soon as possible, keeping accurate and up-to-date procedure logs as you go through training, and scanning personal documents, such as identification, degrees, other licenses and immunization records so that you can send them at a moment’s notice, he recommends.

“Be patient and start early so you can begin working on time,” Jha advises.

Shipton says that credentialing, which can include a background check, review of letters of reference and other documentation, can take anywhere from one to three months depending on the state in which you’re applying.

Make your own timeline

While there are common timelines for finding, considering and accepting a new position, there are also many extenuating circumstances. The typical timeline is just that: typical, but not the rule. Liner was looking for the equivalent of a needle in a haystack in Louisiana, so his timeline was extended. You can take a different approach, or operate at a faster or slower speed. It’s up to you.

You can decide for yourself how much time to invest in identifying potential employers, researching programs, sending out CVs, talking to recruiters, visiting hospitals and practices in person, negotiating a contract, and preparing for your new role.

Based on his job search, Liner recommends holding out for the right job. Don’t rush the process, he says. “You can find the right group; you just have to allow yourself the time to find it.”

You’ll also make a better decision if you do your own due diligence before signing any contracts. Ask lots of questions—“you can’t ask too many,” Liner says—to ensure you’re making the best decision for you.

Marcia Layton Turner is a frequent contributor to PracticeLink Magazine.

 

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Where should I work?

Decide what practice setting is right for you by taking a close look at your options.

By Debbie Swanson | Feature Articles | Spring 2018

 

Shoshana Ungerleider, M.D., counts a variety of specialists and continual learning opportunities as benefits of working at a large organization. · Photo by Mischa Photography

Shoshana Ungerleider, M.D., counts a variety of specialists and continual learning opportunities as benefits of working at a large organization. Photo by Mischa Photography

The job search can be all-consuming, with countless criteria to consider. But before you begin to think about location or benefits, you should decide what type of practice you’d like to join. Whether you see yourself at a big city hospital, a specialized clinic or a group practice, evaluating where you fit best will help you make up your mind about other factors.

Throughout your medical journey, you’ve glimpsed many practice settings. Rethinking each is valuable as you begin your career search. This overview of practice settings will help illuminate your options as you start looking for a new practice.

Solo/private practice

Opening a solo practice was once the dream for most aspiring physicians, but it’s now the road less traveled. Between 1983 and 2014, the percentage of physicians practicing solo dropped from 41 to 17 while the percentage of physicians in practices larger than 25 rose from 5 to 20, according to the American Medical Association.

There are many reasons for this drop in private practice. Complying with government regulations can be difficult, and many physicians prefer a setting where they can expect a stable income and steady hours. Additionally, private practice involves more administrative work than some other settings.

However, some physicians are still drawn to the autonomy of private practice. Fayne Frey, M.D., a dermatologist based in West Nyack, New York, chose being a solo practitioner for the control she has over her patients’ care and her own schedule.

“I can see as many or as few patients as I want and adjust my schedule as needed,” Frey says.

But Frey admits there are drawbacks. For instance, she says private practitioners have less leverage when it comes to negotiating with insurance. “They’re not as interested in me as they are a big group,” she says.

Group practices

Physicians opting for group practices find a setting that provides more leverage with insurance companies, greater profitability and improved quality of patient care. Group practices vary in size and scope. Single-specialty groups tend to be smaller, employing an average of eight physicians, while multispecialty groups employ an average of 25 physicians.

Single-specialty groups can be a prime environment for learning more about your specialty and fine-tuning your skills.

However, because every physician in the group practices the same specialty, referrals rarely come from within, and a practice’s existing patients tend to gravitate to whichever physician they have seen before. A new physician may need to be proactive about getting his or her name out and building a client base.

The amount of autonomy varies widely in this setting. At some single-specialty groups, physicians are highly involved in setting standards and procedures. At others, physicians have less say. And while single-specialty groups often have more leverage with insurance companies than solo practitioners do, smaller groups still face similar struggles with insurance agencies and regulatory compliance.

Multispecialty groups tend to employ more physicians than single-specialty groups, and they also offer a wider spectrum of services. Most multispecialty groups are general in focus, but some revolve around a certain area, such as diabetes or cancer care.

“It’s common to see some type of primary or family care included [in a multispecialty group], as well as several other specialties,” says Philip Masters, M.D., FACP, vice president of membership and international programs at the American College of Physicians and an adjunct professor of medicine at the University of Pennsylvania School of Medicine.

Masters believes this diversity benefits physicians. “With several doctors within a group, a multispecialty practice offers built-in support and consultation. It’s easier to send patients to other doctors or to consult with and get guidance yourself,” he says. “Overall, the process is streamlined for patients and easier for the doctor.”

However, multispecialty groups don’t always offer as much autonomy as smaller group practices. With more clinicians, these practices require more protocols for smooth operations. Those protocols may be developed by executive management, not physicians themselves. And as you’d expect, workplace dynamics can sometimes be difficult when multiple specialties are involved.

When interviewing at either type of group practice, consider whether a hospital acquisition is likely and whether that affects your interest in the group. According to the Physicians Advocacy Institute, hospital ownership of group practices increased 86 percent from 2012 to 2015—representing a 50 percent increase in the number of physicians employed by hospitals.

Hospitals

“It gives me a feel good feeling that they’re not just after profits, but to serve and to help,” says Michael Burdi, M.D., of working at a religiously affiliated hospital. · Photo by KLK Photography

“It gives me a feel good feeling that they’re not just after profits, but to serve and to help,” says Michael Burdi, M.D., of working at a religiously affiliated hospital. Photo by KLK Photography

Hospitals remain a popular work setting for physicians. According to Physicians Advocacy Institute, hospital employment of physicians steadily increased between 2012 to 2015, with regional growth rates ranging from 33 to 59 percent across the nation.

Most hospitals offer a complete spectrum of medical and surgical procedures on both inpatient and outpatient bases. But beyond that, hospitals vary greatly in terms of size, affiliation, specialty, patient population, levels of emergency and trauma care, for-profit or nonprofit status and more.

As an employer, a hospital offers physicians some of the same advantages as a large multispecialty group practice. You’re among a large, diverse medical population, and the environment is usually intellectually stimulating and modern.

“Having many different specialists, as well as fellows, available at all times is a benefit of working in a large institution,” says Shoshana Ungerleider, M.D., an internal medicine physician at California Pacific Medical Center in San Francisco. “There are also numerous monthly opportunities for continued learning through lectures, grand rounds, events and conferences.”

With round-the-clock, year-round staffing needs, hospital employment allows physicians to choose shifts that suit their lifestyles. “From early in my residency training, I enjoyed working the night shift. Now as an attending, working nights affords me many days off to do the other things I enjoy outside of medicine,” she says.

Teaching hospitals not only provide hands-on clinical experience to medical students, but also enriching opportunities for practicing physicians.

“Teaching [other] doctors, along with taking care of patients, pushes me to stay up on all of the latest data on diagnostics and treatments for patients,” says Ungerleider, adding that she also enjoys the opportunity to give back.

Faith-based hospitals are also common. MergerWatch reports that the number of Catholic owned or affiliated hospitals in the United States grew by 22 percent between 2001 and 2016, and 14 percent of acute care hospitals in the nation are owned by or affiliated with the Catholic Church.

Michael Burdi, M.D., an orthopedic spine surgeon at Mission Hospital Regional Medical Center in Mission Viejo, California, enjoys the altruistic mindset of his religiously-affiliated hospital. “I do get a sense of service to the community. It gives me a feel-good feeling that they’re not just after profits but to serve and to help,” Burdi says.

While working for Mission, Burdi has been able to spend time treating underserved populations. “Years ago, I took trauma calls at the Camino Health Center, a clinic which provided care to those who couldn’t otherwise afford it,” he says. “To me, that’s an example of what a faith-based hospital does.”

Stephen Tocci, M.D., chair of the orthopedics department at Mission Hospital, adds that religiously-affiliated board members keep the hospital grounded in their mission. “We have nuns serving on the board who bring a great deal of experience and provide a balance of humanitarianism and compassion,” he says. “Having them present at the leadership level provides an ongoing sense of service and upholds the hospital’s defense of the underserved.”

Some faith-based hospitals restrict care and referrals for certain types of services, such as reproductive and end-of-life services. If you’re considering employment at one, make sure you’re informed about their policies.

Government

Many sectors of the government employ physicians as well. For example, the Veterans Health Administration is the largest integrated health care system in the United States, providing care at 1,245 facilities and serving more than 9 million enrolled veterans each year.

Physicians who work for the VA find it rewarding to care for patients who have served our country. “These are some of the best patients in the world,” says Shereef Elnahal, M.D., Assistant Deputy Under Secretary for Health for Quality, Safety and Value. “I’ll never forget some of the patients I have treated.”

Jennifer MacDonald, M.D., Director of Clinical Innovations and Education in the Office of Connected Care, agrees. She says, “The vets are extremely grateful for their care. …They have a lot of pride, and that makes it very rewarding as a provider.”

Because many of their patients have undergone physical or psychological trauma, VA physicians are trained to take a holistic approach. They screen for mental health, lifestyle issues and substance abuse among other health concerns.

The VA is also highly focused on research and innovation. In 2017, the Department of Veterans Affairs ranked 17th on Reuters’ list of the world’s most innovative research institutions.

MacDonald says the VA also provides telehealth. “To follow up on someone who was discharged, I can call up a video visit, [which easily] fits into my day and doesn’t require the vet to drive in to see us,” MacDonald says, adding that in FY 2016, more than 2 million patient visits were conducted via telehealth.

Correctional medicine

Correctional health care is another growing opportunity for physicians. It may sound like a difficult work environment, but Mohammad Khan, a board-certified psychiatrist in Dallas, says that providing medical care in correctional facilities offers variety and new challenges.

“It was quite rewarding to diagnose and treat them,” he says. “The combination of personality disorders with mental illness was quite high in adults. In the juvenile facilities, the biggest problems were lacking a stable home structure.”

Khan found correctional services to be vigilant when it came to ensuring physician safety, and he enjoyed working alongside other medical professionals, such as counselors and therapists.

Federally Qualified Health Centers

Physicians can also find enriching government opportunities at Federally Qualified Health Centers (FQHCs). These clinics and health centers provide comprehensive care to uninsured and underserved populations. And because it is often financially and logistically difficult for their patients to access medical care, FQHC doctors quickly learn to wear many hats.

“From a professional perspective, [you’ll encounter] many medical and psychosocial issues that may be less commonly seen in other practice settings,” says Masters, who worked at an urban FQHC setting early in his career. “Since centers are required to provide comprehensive care, you’ll work closely with other medical professionals.” He adds: “It is [also] nice to know that you are helping in a place where good care may be difficult to find.”

Locum tenens

Medical practices have extensive staffing requirements—and physicians sometimes get ill or go on leave. That’s when locum tenens physicians step in. Locum tenens physicians take over when a doctor is unavailable for as briefly as a day or for as long as several months.

What it lacks in job permanence and stability, it makes up for in variety. Physicians are attracted to locum tenens work because it allows them to explore different practice settings and locations.

Planning your next move

Identifying your preferred setting can help with your job search, but it’s also smart to remain flexible. You never know how a practice might surprise you. For example, you may find a small group practice where management determines procedures or a large practice where physicians have a lot of say. Remain open to possibilities.

Like most major decisions, the practice setting where you’ll fit the best often comes down to a gut feeling. The environment that appeals most to one physician may sound completely unappealing to another. So do your research, talk with your advisors, and reflect on your goals. In the end, you’ll find the answer by listening to your true calling.

 

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6 Questions you must ask in your job search

A physician’s job search is full of questions. Asking yourself these along the way will help you find your dream practice.

By Chris Hinz | Feature Articles | Spring 2018

 

Job Search Chart with keywords and icons Flat Design

The job interview process involves a lot of questions. You’re trying to find the best match for your experience, work style and skills. Meanwhile, your future employer is trying to find the best match for its culture and staffing needs. But the most important questions you ask throughout the process may be the ones that you ask of yourself. In a job market flush with opportunities, it’s important to direct your job search, narrow your options and quickly determine what setting is best for you.

David Hass, M.D., is course director for the Young Physician Leadership Curriculum for Connecticut State Medical Society/Yale New Haven Hospital and a physician with Gastroenterology Center of Connecticut. He explains, “You can’t cast a wide net and hope that every opportunity that draws you in is going to be the perfect opportunity. Instead, you need to set parameters for yourself as to what you think will really make you happy both personally and professionally.”

Start with these six questions to help clarify—then achieve—your goals.

Question 1: What do I want out of my job?

The culture of the community and practice was an important factor for Michael Antolini, D.O., in his job search.

The culture of the community and practice was an important factor for Michael Antolini, D.O., in his job search.

As you start looking for opportunities, consider who you are personally as well as where you’re headed professionally. Focus not just on your strengths and weaknesses, but also on your personality and preferences. That will help you define what practice type, size, configuration and culture will work best for you.

Ask yourself: What do I want my work and private life to look like? Would I thrive as an employee or as an independent practitioner? Do I prefer working with other specialties or just my own? What would make me happy, confident and energetic at work?

“I tell residents, ‘It’s both a good and bad [thing] that you basically can go anywhere because there are so many job options,’” says Heather Gavitt, provider recruiter for AtlantiCare in Atlantic City, New Jersey. Zeroing in on a practice type can narrow the virtually unlimited choices. “It can help you cut down on the places that you’re looking at so that you have a manageable pool before you move further and overwhelm yourself.”

When Joshua Cohen, M.D., wanted a career change, he took inventory of his skills and asked colleagues and friends for input. They told him he had a knack for taking charge and would thrive in a leadership role.

Cohen came up with two goals: 1) to help a lot of people, and 2) to tackle a variety of challenges in his day-to-day work. “I wanted something that was going to be different every day,” he says. “I wanted a challenge or project that I’d have to learn how to do and then integrate into my job.”

He found the perfect opportunity at Teva Pharmaceuticals in Frazer, Pennsylvania, as global medical director and medical lead for migraine and headache.

This role allows Cohen to be involved in leadership and tackle new challenges every day. Most importantly, he can focus on his passion: improving the lives of migraine sufferers. “I really wanted to do something that would be meaningful to the patients I had treated for all of these years,” he says.

Question 2: Is the work environment at this practice right for me?

Your search isn’t over once you find a practice that matches your criteria. You need to evaluate the offer—beginning with the work environment. Do administrators foster a supportive environment? Will you be able to flourish as a physician and maintain a healthy work-life balance? You can get a sense of the workplace dynamic from your interactions and observations throughout the interview process. If prospective colleagues are genuinely content, you’ll feel, see and hear it.

You can ask a few questions to help assess the environment. For starters, why is the practice hiring? Longevity speaks volumes about the practice leadership, as does high turnover.

“Sometimes physicians are blinded by the things that look good,” says Wanda Parker of The HealthField Alliance in Danbury, Connecticut. “But why have six people, for instance, left this practice? There could be some red flags.”

You should also ask about workload and policies. How much time will you be spending at the office, and will you have enough time left over to enjoy your personal life? Is it a democratic environment where everyone has a say, or is the decision making top-down? And what about the management style? Whatever the case, you want to know that the structures and environment will suit you.

Michael Antolini, D.O., asked these sorts of questions before accepting an offer for a family practice position with Access Health in Lochgelly, West Virginia. Lochgelly is near Beckley, where Antolini had completed medical school rotations and had family. Antolini enjoyed the practice’s collegial atmosphere, and he had met several of its physicians during his rotations. “It’s always been nice to walk down the hall and bounce ideas off of people who you know and trust because they taught you what you know,” he says. “I now participate in training other residents the same way.”

Parin Patel, M.D., is targeting her job search by looking for an academic or hospital setting. She’s now a fourth-year obstetrics and gynecology resident at The University of Texas Medical Branch in Galveston. She’s excited to merge clinical duties with teaching, and she also wants to motivate younger doctors to become leaders in their specialties. As president of the American Medical Women’s Association resident division and an active participant in American College of Obstetrics and Gynecology, Patel enjoys being a voice for the profession.

Wherever she ends up, Patel hopes to find a practice with colleagues who share her commitment to the underserved. “I want to work with people who understand and are supportive of someone who wants to provide care to patients potentially not able to find it anywhere else,” she says.

Question 3: Can I be professionally successful here?

For a profitable, satisfying career, you need to find a position where your skills are in demand. Consider the local community and its patient population. You’ll want to know not only how your competition stacks up, but also basic information about the local economy. Will it support a stream of patients for your specialty?

Examine the professional opportunity at the practice itself. If you’re replacing another physician, you’ll likely have a patient base ready when you arrive. But if administrators plan to use your skills to grow the practice, you’ll likely have to start building your patient base from scratch.

In either case, make sure you understand how the group intends to launch you, and if they’re willing to invest in equipment and support services. If you’re a surgeon with expertise in robotics, for instance, you don’t need to bother with a practice that won’t purchase the equipment for you to do your job. “You have your skills,” explains Jane Born, CEO of Born & Bicknell in Boca Raton, Florida. “You want to bring them to a facility that truly wants and needs them.”

You should also ask about travel. If you’ll be practicing at more than one facility, consider how that travel time might affect your ability to see patients. Productivity impacts compensation, and splitting your time among several locations might reduce your efficiency.

“You need to ask yourself, ‘How much time am I spending in my car or away from the office?’” says Patrice Streicher, associate director and professional development coach at VISTA Staffing Solutions in West Allis, Wisconsin. “How much of my life will be spent doing that compared to what I really love: practicing medicine?”

Zach Lopater, M.D., considered these sorts of questions in his last job hunt. Since radiation oncologists depend on referrals, he wanted to make sure his future employer had enough connections with other providers for him to attract patients. He knew he’d need physicians to send patients his way in order to produce consistent numbers. “The key was: ‘Am I going to have enough patients?’” he says. “‘Was I stepping into a hostile practice that was going down the drain, or was it a strong practice?’”

At Radiation Associates of Macon in Georgia, Lopater found exactly what he was looking for. The practice already had a close relationship with a medical oncology group in the same building, so sharing patients and information was an established routine. “It’s been a very strong practice with very good relationships,” Lopater says. He now enjoys a steady stream of patients and sees a variety of cases, from breast, lung and prostate cancer to head and neck cancer.

Question 4: Is this the right community for my family and me?

It’s natural to focus on your employer during a job search, but you shouldn’t overlook the town you’re moving to. If the area is a total mismatch to your personality or your family’s personality, it can deplete your energy and drive—and make everyone unhappy.

Ask yourself and your significant other how the setting will work for you and your family. Are there professional opportunities for your spouse or partner? Plenty of activities for your children? Do the schools in the area offer what you’re looking for? Finally, does the place offer the lifestyle you want? “One exam room looks just like the next,” Streicher says, “so your questions should be based on what occurs in your life and your loved ones’ lives outside of that room.”

Finding a geographic location that supports her family’s religious needs is an important piece of post-residency planning for Parin Patel, M.D.

Finding a geographic location that supports her family’s religious needs is an important piece of post-residency planning for Parin Patel, M.D.

As Patel and her husband, Nikul, look for their next home, they are prioritizing proximity to a major airport nearby. And while they’re willing to live outside the Northeast, they want visiting family to be relatively easy.

It’s also important for them to be able to worship their Hindu faith as members of a BAPS temple. BAPS congregations are scattered across the country, and Patel is using their locations to direct her search. As a result, she’s expanded her options to cities that she hadn’t previously considered.

Because the denomination is closely knit, Patel anticipates knowing people already or meeting people who are familiar with her temple in New Jersey.

Question 5: What do I want my future to look like?

Think about your job not only in the short-term but also in the future. Having a sense of where the position might take you can help determine if it’s truly the best fit. Will the environment sharpen your skills? Do you expect to stay put, or is it a stepping stone to another place?

“Physicians should ask themselves, ‘Where do I want to be professionally and personally in five and 10 years?’ says Emily Glaccum, recruiting principal at The Medicus Firm. “Then they need to figure out what characteristics of a practice opportunity will most likely help get them to those goals.”

Lopater, for instance, put autonomy and partnership at the top of his wish list. He not only wanted a pleasant work environment, but also some control over business decisions. His biggest must-have was a written guarantee that he’d make partner in two years if he showed his worth. “I wanted a position where I could stay long term and not have to uproot my family once I settled in,” he says.

Other opportunities offered higher initial pay, but Lopater believed Radiation Associates had a long-term interest in him. They were willing to make a firm commitment. In turn, he was willing to make a little bit less at first because he was confident he’d be a partner in year three. It was a busy organization, and the practice recently made good on their two-year commitment by making him partner.

Question 6: What’s my fallback plan if this job doesn’t work out?

As you enter the home stretch with any offer, you’ll likely have high hopes for the future. You’ve done your homework and made informed choices. And if your initial vibes are positive, it’s hard to envision everything crashing around you. But what if things don’t unfold as nicely as you envision? Do you have a plan B? It’s smart to anticipate your next steps if your new position doesn’t live up to your expectations.

“Physicians should do what I call ‘fear setting,’” says Streicher. “They should ask themselves, ‘OK, if I take this job and it isn’t what I was told it would be—or the people aren’t what they appeared to be—what would I do? What are my outs?’ I think that’s really a very practical step in making a decision.”

Your backup plan should lay out your options if you leave the position you’re considering. Where would you go next? What sort of practice would you look for?

If you want to remain in the same community even if you leave your job, make sure your contract has a favorable out clause. And if you’re not excited about an opportunity from the get-go, perhaps you should reconsider your acceptance. “Chances are it’s not going to work for whatever reason if you already have those feelings,” says Parker.

Even if you love your job and don’t plan to look elsewhere, it’s smart to have a contingency plan. Since starting his job, Antolini has sought additional leadership roles. As medical director of four nursing home facilities, he sees 80 elderly individuals each week in addition to his clinic hours. He loves his job and the location, but he wants to have options if his circumstances change. With geriatric medicine on his CV, he’s confident.

“If it all came crashing down tomorrow, I feel good about just presenting what I’m doing,” he says.

 

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Mission medicine 2.0

These medical missions make it possible to give back even with a busy schedule.

By Jane Brannen | Feature Articles | Winter 2018

 

Shortly after emigrating from Italy to Washington, D.C., in the 1940s, Joseph Aloi, M.D.’s grandmother and her brother became ill.

“They were taken care of by physicians—providers that volunteered their time to take care of people without resources in Washington, D.C.,” says Aloi, who is chief of endocrinology at Wake Forest Baptist Health. “I’m very much aware that my family experienced the generosity of strangers, so I feel that it’s important to help pay that back.”

Aloi has been able to do just that after finding a nonprofit health organization that made volunteering possible with his busy schedule. He has served annually for almost a decade and a half, proving that even with a full-time workload, physicians can find ways to volunteer. Read on to learn more about three organizations helping physicians serve patients across the world—even from the comfort of their own homes.

Reaching the world: International Medical Relief

Lynette Morrison, M.D.

Lynnette Morrison, M.D., went on her first medical missions trip in 2011—and has traveled with IMR five more times since.

From booking travel plans and learning about another culture to getting the proper licenses and ensuring safety, there is a lot to do to prepare for an overseas medical missions trip. It can be daunting for many first-time volunteers who want to give back, but who don’t know where to start or who don’t have time to do all the legwork themselves.

That is what inspired Shauna King, MPH, to found International Medical Relief (IMR). She was working for a nonprofit health care system in Colorado at the time and realized there was a need for simple, worry-free ways for physicians to volunteer. “I had a lot of doctors looking for opportunities to serve and was just trying to find one that was a really simple way for them to give back,” she says. “It became a calling to start the organization.”

King now leads a team that makes overseas missions as turnkey as possible.

Lynnette Morrison, M.D., saw this turnkey experience firsthand when she first traveled with IMR to Ghana in 2011. “I was so impressed by their organization—just how everything was set up,” she says.

Morrison was a medical school student at the time. That first experience with IMR influenced her career path. “I actually went to a rural family medicine program because I was inspired by the work overseas,” she says. “In rural family medicine, it’s more like what we do in the mission trips. You don’t have specialists. You’re relying on what you can do, what you have access to.”

Since that trip to Ghana, Morrison has traveled with IMR five more times: twice as a resident and three times as a practicing physician. It has taken her around the world, including Uganda, the Philippines, Panama, Zambia and Senegal. She says these experiences have made her a more well-rounded physician for her patients back home, where she works as a family physician with a specialty in wound care at MedExpress Urgent Care in Springdale, Arkansas.

Her mission work has also influenced her personal outlook on life. “It really is rewarding,” she says. After seeing families in developing countries make do with so little, she has found herself focusing less on material goods.

IMR offers a wide variety of trips, some more rugged than others. “We work with a lot of indigenous tribes, so when we do that, we are obviously in a much more remote area,” explains King. “But then we work in some locations where they have really, really beautiful accommodations or resorts. There’s still a lot of need, but team members can be more comfortable.”

For each of these trips, IMR prepares its volunteers ahead of time. “We want our teams to go into the field feeling comfortable and confident,” says King. “We do a lot of pre-field training.” King and her staff use online training and conference calls to help team members prepare. These calls, along with Facebook groups, also allow team members to get better acquainted before they travel together.

IMR offers continuing education credits through pre-field training, so some employers may reimburse part or all of the cost of the trip. A trip with IMR can cost anywhere from $2,500 to $4,500 per person, according to King. Some physicians pay these expenses out of pocket and view it as a donation, while others raise funds for their trips.

“We actually have a customized fundraising portal,” says King. “It already has a sample letter in it, so they don’t need to do anything except send it out. And then 100 percent of the money that they raise goes directly into their account to offset their trip.”

Most of IMR’s clinics have a primary care focus, but physicians of all specialties are needed. “We take physicians of all capabilities and varieties,” says King. “Our clinics are really basic…so if a physician has been specializing in a particular area for a long time, they might be getting back to the basics of the grassroots of medicine.”

A typical IMR trip lasts just seven to 10 days, but IMR maintains long-term relationships in the area to ensure continuity of care. “We want to have sustainable solutions for the communities that we serve,” explains King. “We have long-term solutions with short-term opportunities.”

This flexibility allows many physicians to work with IMR who would not otherwise be able to serve abroad. “I’ve talked to colleagues that have said, ‘I really want to go, but I don’t have the time,’” says Morrison. “I would say, ‘Go on one. Just go on one. It doesn’t matter where. Just go on one and have that experience.’ It’s very good to go somewhere that’s out of your comfort zone. You’re going to see things that’ll help you practice.”

For more information about serving with IMR, visit internationalmedicalrelief.org.

Serving stateside: The Health Wagon

Ernani Sadural, M.D.

Ernani Sadural, M.D., serves central Appalachia through The Health Wagon. Of the experience, he says: “One comes back enriched and invigorated, hopefully even renewed in their faith in their life’s work and purpose.”

You do not have to go overseas to make a tangible impact in the lives of patients who lack access to health care.

The Health Wagon, a nonprofit based in southwest Virginia, is just one of the many organizations working to provide free, accessible care. They offer a wide array of volunteer opportunities that do not require international travel, and are ideal for a physician’s busy schedule.

“We serve the most vulnerable in our population that do not have access to health care,” explains Ashley Fleming, outreach coordinator for The Health Wagon. “The Health Wagon, with its mobile clinic and two stationary clinics, has remained a pioneer in the delivery of health care in the central Appalachian region for more than three decades.”

“The Health Wagon is probably the gold standard as far as the volunteer free clinic,” says Ernani Sadural, M.D., director of global health at RWJBarnabas Health and co-founder and chief medical officer at LIG Global. “It’s just run by extremely dedicated, compassionate people, then add in the southern charm of the people that work in The Health Wagon with the beauty of the landscape of Appalachia.”

The Health Wagon’s largest annual event, a three-day health clinic, happens every July in Wise, Virginia. They find creative ways to work with the resources available. The event is held at a community fairgrounds, providers see patients in barns, and the pharmacy is in an 18-wheeler. Patients come from all over Appalachia to be seen. Some even spend the night in the parking lots for a chance to see a doctor.

“They’re very appreciative, so that’s a big reward of being a provider there,” says Aloi, who has served with The Health Wagon annually for almost 15 years.

“The fact that we were able to practice medicine just for the pure sake of medicine for the fellow man without respect to compensation … makes for a purely enjoyable experience, whether it’s for one day or one week,” says Sadural. “One comes back enriched and invigorated, hopefully even renewed in their faith in their life’s work and purpose.”

To allow volunteers to make a big impact in a short amount of time, The Health Wagon stays highly organized. “It’s remarkably efficient,” Aloi says. “Your time won’t be wasted.” Because The Health Wagon has a permanent presence in the area, they are able to help with continuity of care after a physician’s trip is over.

“We tailor patient schedules to fit the needs of our volunteers,” says Fleming. “Volunteers can come for a few days or for a couple weeks—whatever works best for them.” Plus, physicians from all specialties are welcome.

Volunteers cover their own travel and lodging, and out-of-state providers must have a temporary volunteer medical license through the Virginia Board of Medicine. The Health Wagon recommends allowing two or more weeks for this. Aloi says the state of Virginia typically makes licensing a smooth and fairly inexpensive process. “For people coming out of state, it’s very easy to stay licensed.”

Volunteering with The Health Wagon or a similar stateside organization is a chance to learn more about life in other parts of the U.S. and develop a deeper understanding of others.

“I’m originally from Chicago,” says Sadural. “I’d never been to Appalachia, and I admit that I had my own preconceived notions.” Volunteering with The Health Wagon opened his eyes to what life was like for patients who did not qualify for Medicaid, yet could not afford health care premiums.

“I gained a deeper understanding and appreciation of these people” Sadural says. “For me, that was the biggest joy—being accepted into their community and allowed to learn from them.”

For more information about serving with The Health Wagon, visit thehealthwagon.org.

Making a difference without making a trek: The MAVEN Project

If you are looking for a flexible opportunity closer to home, you can’t get much closer than volunteering right from your laptop. New telehealth technologies have made that possible, and innovative nonprofits like The MAVEN Project are using them to overcome geographic barriers and fill gaps in health care access.

“What we’re trying to be is Match.com meets Peace Corps for volunteer doctors,” says Lisa Shmerling, JD, MPH, executive director of The MAVEN Project. “We’re really targeting health care organizations where a primary care provider is accountable for the care of uninsured and/or Medicaid patients that have a problem getting access.”

The time commitment is a minimum of just four hours per month, with no travel time required. By pairing volunteer physicians with understaffed clinics, The MAVEN Project helps rural and low-income patients who normally wouldn’t get timely access to health care. In many cases, timing makes all the difference.

Shmerling recalls the story of one hematologist volunteer who realized a patient had a treatable form of cancer. “The patient was going to go into renal failure within days if they didn’t get seen,” says Shmerling. “We were told that the patient was scheduled to see an oncologist, but not for another month. So, that was an example where we really escalated the issue, and the patient was seen within days.”

David Hurwitz, M.D., a California-based rheumatologist who has logged over 100 volunteer hours with The MAVEN Project, echoes this. “The patients have been waiting forever to see a rheumatologist, and they’re very grateful for getting a consultation,” he says. “Both the clinic staff and the patients seemed on the whole very grateful for my help.”

Hurwitz says volunteering through the The MAVEN Project has helped him carry out his passion for treating patients who otherwise couldn’t see a provider. “I’m a big believer in extending medical care to the population as a whole,” he says, adding that often there simply aren’t enough physicians to see all the patients who need to be cared for. “I saw that there was some way to help meet that need, which is what MAVEN was structured for.”

Depending on what each clinic needs and whether a volunteer physician is licensed in the same state as the clinic, MAVEN volunteers may serve through direct consultations, curbside consultations or mentoring. In direct consultations, the physician builds patient relationships and consults on individual cases. This typically happens with more complex cases and requires a physician to be licensed in the same state as the patient.

A day before each direct consultation appointment, Hurwitz says he typically gets a summary from a secretary, as well as access to electronic medical records. “A nurse would bring the patient in and introduce the patient to me,” he explains. “Then I’d see the patient, and a doctor would come in, and I would discuss the diagnosis and the plan with the doctor.”

In curbside consultations, however, a volunteer physician is not directly involved with an individual patient. Instead, he or she offers advice about a panel of cases. “Each state defines it differently,” says Shmerling. “It’s as if you were in the office and you’re getting a walk down the hall and you ask your pal, ‘What do you think about this case?’”

In mentoring relationships, a seasoned physician volunteer offers expertise to help clinic staff improve their services. “You get paired up with a nurse practitioner, for example, on a regular basis,” Shmerling explains. Mentees can use the sessions to learn about specific medical issues, get business advice or simply ask questions they have never had a chance to ask elsewhere. Says Shmerling: “Our ultimate goal is to increase the capacity at the health center.”

Shmerling says the organization works to make the technological side of things easy for volunteers. “We use a technology called Zoom,” she explains. The HIPPA-compliant application is quick to download, and it allows physicians to video conference, see patients and even share screens.

The MAVEN Project also smooths the process by covering malpractice insurance. Any physician who has been in practice for at least two years is welcome. Some of The MAVEN Project’s volunteers are retired physicians who want to continue making an impact.

Without the barriers of travel time, insurance costs or technological difficulty, you can easily get involved and help fill gaps in health care availability across the U.S.

Shmerling, who has been with The MAVEN Project since it was founded in 2013, hopes the number of physicians who regularly volunteer with health care organizations like hers will continue to grow. She says, “We would like to see a trend where someday everyone who’s in practice gives back by volunteering for some of these most vulnerable populations.”

For more information about serving with The MAVEN Project, visit mavenproject.org.

 

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How to triage your debt

Your income—and your outflow—are high contributing factors to your family’s overall quality of life. From student loans to mortgages, this guide helps you get your debt under control.

By Debbie Swanson | Feature Articles | Winter 2018

 

Caleb Butts, M.D.

A shared focus and commitment to the end goal helped Caleb Butts, M.D., and his wife, Tricia, pay off student loans in just a little more than four years.

When Caleb Butts, M.D., was visiting his alma mater, the University of South Alabama College of Medicine, he made a quick stop into the financial aid office.

“I’d been in there so much as a student, asking questions about loans, that I thought I’d stop in to say that I’d finished paying my loans back,” he says. His visit was unexpected by the financial aid officer. “She cried,” says Butts. “She knows all these medical students taking out loans, and never hears how it turns out.”

What was even more noteworthy than his visit was the speed with which Butts reached debt-free status: 4 years and 4 months after starting repayments. Butts credits the discipline and goal-oriented mindset of both himself and his wife, Tricia.

“We wanted to aggressively address the loans now, rather than let them linger,” he says. They based their budget on one income, despite their dual-income status. “We didn’t want to have to go backward [after having children], so we lived off one income, and used the other to pay down the loans.”

Whether you’re just getting started or you’re unsatisfied with your present payback plan, there’s a wide spectrum of approaches to use to pay off your educational loans. Key to success is knowing what’s available, and choosing the best plan for your family.

Devising a plan

It can feel overwhelming when it’s time to repay your medical school loans. But rest assured: Most physicians start their professional careers in the exact same situation.

Three-quarters of medical school graduates leave school with a significant amount of debt, according to the Association of American Medical Colleges. The AAMC’s survey shows that in the class of 2016, 76 percent of new medical school graduates began their career with loans to pay back, with the median educational debt level for that year’s graduates at $190,000. Thirty-two percent of graduates carry debt from undergraduate school, while 73 percent accumulate debt in medical school.

“Despite the high cost of education, it is absolutely possible to pay off [medical school] loans and have a perfectly nice lifestyle,” assures Julie Fresne, the AAMC’s director of student financial services. “There’s strong job security and excellent income potential with the career.”

If you’re searching for the best approach, start by brushing up on the programs available to you. The AAMC’s website is a good place to begin, and they also offer counseling at many different medical schools. Your medical school may also have financial experts or counselors on site, or provide referrals to trusted advisors.

One thing to keep in mind: The best payback options that may have existed for your mentors or even colleagues not much older than you may actually cost you thousands if used today.

“The menu of options is much broader than it was 10 years ago, when graduates had lower debt and rates were variable,” notes Jason DiLorenzo, founder and executive director of Doctors Without Quarters (dwoq.com), a firm that helps early-career physicians approach their student loan repayment strategically. “The newer income-driven options make the most sense for many of today’s house staff, federal forgiveness is now available, and the private marketplace offers lower rates in many cases.”

Justin Kribs, CFP, counsels medical students and recent graduates at Oregon Health and Science University. He says there’s no one-size-fits-all advice for managing your debt.

But there is a solution to fit everyone’s situation, Kribs assures, and tells students to start by making an evaluation of their goals and plans. “You’ve worked hard to get this far, now look ahead to what is in your future: buy a house, retirement, household obligations? What are your career plans?”

The right plan will be a balance of your own priorities and the best available payback solutions.

Public Service Loan Forgiveness

Erica Marden, M.D.

Resident Erica Marden, M.D., chose a repayment plan that maintained her eligibility for PSLF.

If you’re planning to go into public service, you may be eligible for Public Service Loan Forgiveness (PSLF). Eligible borrowers in this program make 120 qualifying monthly payments toward their federal direct loan over 10 years, after which any remaining principal and interest is forgiven. According to the IRS, the amount forgiven through PSLF is not considered taxable income. Repayments can begin as early as residency. Presently nearing it’s 10-year anniversary, PSLF is approaching the first year anyone could be eligible for forgiveness.

PSLF appeals to Erica Marden, M.D., a second year psychiatry resident at the University of Vermont. She is currently making payments through a PAYE repayment plan.

“These payments will count as qualifying payments toward PSLF,” she says, adding that she hopes to receive forgiveness after 10 years.

While PSLF presents a great opportunity for those whose professional plans align with the program, new participants should proceed carefully. Thoroughly research what constitutes a qualifying position, and remain informed. Changing legislation (or changing jobs to a non-qualifying employer) could affect your participation.

If you’re concerned about Congress changing the PSLF rules, consider making large payments to cover the debt in an accessible vehicle. Then, if the benefits change unfavorably, redirect the investment toward your loans.

The standard route

All federal student loan borrowers are eligible to enroll in the default standard repayment plan. This simply calculates your total amount due over 10 years and derives a monthly repayment amount.

This plan offers the lowest overall cost to the borrower over any other repayment plan when loan forgiveness isn’t an option, but it comes at the cost of a potentially high (and for trainees, likely untenable) monthly payment. For those who carry a low balance, have an achievable plan for making the payments, and aren’t considering career options with loan forgiveness available, this could be a good option.

Butts chose to tackle his loans with the Graduated Repayment Plan, which begins with a lower monthly payment, then increases periodically over the next 10 years. “I was able to make the monthly payment, but most months I planned to add extra. Also at the end of the month, whatever we had left over was used to further drive down the principal.”

Though the standard payment plan can work for some, many physicians seek other, more accommodating options.

Income-driven repayment plans

Income-driven repayment plans are critical for physicians just starting out.

“These plans are based on income, not debt. And if you keep to the plan, after time, the balance is forgiven,” says Fresne. “The payment amount is usually comfortable, something which most residents can make.”

In 2007, as a result of the College Cost Reduction and Access Act, Income-Based Repayment (IBR) was created. It went into effect in 2009. The Pay As You Earn (PAYE) program came later, in 2012. Under these plans, you can calculate your monthly loan payment based on a percent of your discretionary income.

Pay As You Earn (PAYE)

Pay As You Earn (PAYE) usually offers the lowest monthly payment, which is set at 10 percent of your discretionary income. According to the Federal Student Aid website, “your spouse’s income or loan debt will be considered [for PAYE] only if you file a joint tax return.”

After 20 years of making qualified payments, any remaining debt is forgiven.

Federal Student Aid reports that, to be eligible for PAYE, you must be a new federal borrower on or after October 1, 2007, have received a Direct Loan disbursement on or after October 1, 2011, and demonstrate financial hardship.

Income-Based Repayment

IBR determines your monthly payment based on your discretionary income. For borrowers on or after July 1, 2014, payments are based on 10 percent of your discretionary income, with a repayment term of 20 years. Those who borrowed prior to this date are capped at 15 percent for a 25-year repayment term. You must demonstrate financial hardship to qualify. (Most residents and fellows will meet this requirement.) Stafford Loans, PLUS Loans and Federal Consolidation Loans are eligible. Loans refinanced with private lenders aren’t eligible for IBR.

Revised Pay As You Earn (REPAYE)

The most recent option, created in 2015, is the Revised Pay As You Earn (REPAYE) plan. Borrowers who have a Direct Loan and financial hardship may qualify, regardless of the loan origination date. REPAYE calculates monthly payments no higher than 10 percent of your discretionary income. Payment is calculated over either 20 or 25 years, depending on if the loans were for undergraduate study or graduate/professional study.

“The most attractive benefit of REPAYE is that only half of outstanding interest is charged during periods of negative amortization,” DiLorenzo says.

With all income-driven payment plans, you need to supply documentation to verify your income and profile, and resubmit this each year, even if your financial situation hasn’t changed. Failure to do so risks losing your plan and being converted back to a standard plan.

If you qualify for PSLF, payments made under these income-driven payment plans are presently considered qualifying payments.

Balance forgiveness

Another benefit of the income-driven plans is balance forgiveness. At the end of your payback period of either 20 or 25 years (depending on your plan), any remaining debt is forgiven.

While that is enticing, it’s not completely without warning, says James M. Dahle, M.D., founder and editor of The White Coat Investor (whitecoatinvestor.com), a financial blog for physicians.

“That forgiveness, unlike PSLF, is taxable—meaning you’ll owe a tax bill that could be substantial,” says Dahle. “For most docs with anything but a terrible debt-to-income ratio, the debt will have been paid off in less than 20 years anyway, so there won’t be anything left to forgive.”

Shopping around: refinancing

Interest rates on federal loans are not always the most competitive, so physicians often refinance to a private company to gain a more attractive rate.

A note about refinancing: to qualify for Public Service Loan Forgiveness, you’re required to remain with a federal loan program.

In his blog, Dahle says a determining factor to consider in refinancing is at what point you are in your career. If you’re an attending physician who is not pursuing PSLF, refinancing could save you significant interest. Residents, however, should usually only refinance private loans that are ineligible for income-driven repayment plans (see the sidebar on page 45).

“If you are a resident, the government REPAYE program is often a better choice than refinancing as it effectively subsidizes your interest rate to an amount less than you can currently refinance the debt to,” he says. Plus, once you refinance your loans with a private lender, you cannot go back to the income-driven repayment programs or PSLF.

Frugal living

For Butts, good, old-fashioned frugal living was his route to repaying quickly.

“It may seem like simple advice, but live on less than you earn, use the rest to pay back loans. Make a budget every month with what’s coming in and what’s going out,” he says.

Dahle suggests that, rather than upgrading your lifestyle in parallel with increases in income, you delay lifestyle upgrades, and instead direct new income toward your educational debt.

“It will be far harder to cut back your lifestyle later than never to have upgraded it in the first place,” Dahle says.

Delaying repayment

Rather than defaulting on your loan, which will have lasting negative consequences, some physicians have considered one of two programs that permit temporary pauses in payments: deferment and forbearance.

Deferment is granted based upon certain issues, including financial hardship and status as a student. When loans are in deferment, you do not have to make payments, and you aren’t responsible for any interest that accrues on subsidized loans. You must apply for deferment and supply documentation to support your case.

Forbearance is another option that may sound appealing, but keep in mind that your loans will continue to accrue interest during this time, which will capitalize once the forbearance period ends. Over years, your loan balance will significantly increase.

Lynn M. O’Connor, M.D., M.P.H., now director of the Women’s Colorectal Care Program at ProHealth Care Associates in New York, used forbearance while in residency at The Johns Hopkins Hospital and Union Memorial Hospital in Baltimore. However, while in forbearance, the compounded interest added up— increasing her balance due when it came time to begin paying.

“I needed to put a large lump sum towards my loans just to bring my loans out of arrears [and] get them to a point where they could be refinanced,” she recalls.

That’s why DiLorenzo doesn’t recommend forbearance for physicians starting their careers now. “You don’t want all that interest accruing and capitalizing against you. Loan forgiveness and the reduction of accruing interest is much more favorable using income-driven repayment rather than forbearance or deferment.”

With an income-based repayment plan, DiLorenzo points out, your payment amount in residency can be as low as $0—and still position you for loan forgiveness while reducing accrued interest.

Protecting yourself and family

Whatever your loan balance, consider how your family would manage an unforeseen loss of income.

“It’s important to have a risk management plan in place,” says Kribs, advising that the ideal components include disability insurance, life insurance, health insurance and umbrella insurance. Read your employment contract carefully to understand what is offered, and if any additional coverage is needed.

During loan repayment, the more important elements are disability insurance and life insurance. Some advisors recommend you purchase the maximum amount of individual disability insurance you qualify for, which provides a tax-free benefit of about two-thirds of your income in the event of total disability. They also recommend purchasing 8 to 10 times your income in term life insurance. However, many residents find it difficult to afford as much insurance as they need at this critical time in their careers.

Though no one likes to think about life insurance, it’s essential if your payback plan is based on a dual income.

“Honestly, it is usually the spouse that is under-covered; if the individual with the loans passes away, then the loans could possibly be discharged due to death. However, if the spouse passes away, then the person with the loans still has the loans,” Kribs says.

Buying a home

Educational debt and minimal employment history often present obstacles to new physicians hoping to qualify for mortgages. That’s why lending institutions have created doctor’s mortgages, often offering:

  • A lower down payment, often under 10 percent
  • No required private mortgage insurance
  • An employment contract in lieu of pay stubs as proof of employment

Doctor mortgages may carry a higher interest rate, and typically require you to use some of the bank’s other services, such as a checking account. But if you are set on making a home purchase with less than a 20 percent down payment, it can make a lot of sense, freeing up cash that can be used to pay down student loans.

Most physicians eventually establish a doable method for getting ahead of their medical school debt.

“Use the resources at your medical school or residency to educate yourself as much as you can,” says Marden.

And don’t feel you have to have it all figured out; as your career evolves and federal programs change, reevaluate your situation and adjust your plans accordingly.

 

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Does work-life balance exist for physicians?

Striving for balance is a thing of the past. Think “integrated” instead.

By Marcia Layton Turner | Feature Articles | Winter 2018

 

work life balance word cloud

Yes, work-life balance is possible in medicine. That’s the good news. You can have a personal life and a fulfilling career simultaneously. But unlike in previous generations, when you were either working or not working, work and personal lives are now commingled. That’s not necessarily bad news, but effective time management becomes the key to feeling like you have time to yourself.

Work-life balance looks different today than even a few decades ago, says Peter Angood, M.D., CEO of the American Association for Physician Leadership. Where prior generations were able to switch back and forth between their many roles—physician, spouse or partner, parent, child, friend, volunteer, caregiver—today’s physicians have to juggle multiple roles.

Years ago, physicians were much better able to control the amount of work they did. It was possible to move between working and not working, explains Angood. During the times you weren’t working, you would spend time with family and friends at home, or enjoy time engaged in your hobbies and outside interests. And at work, there was no outside interference from your personal life.

Today, it’s nearly impossible to separate your life into two clearly distinct states of being. “Doctors are more accessible, causing a disproportionate amount of time to be spent on work,” says Kyle Etter, vice president/partner at Consilium Staffing in Irving, Texas.

Consequently, an “integrated lifestyle” is more the possibility than being able to separate work from personal life, according to Angood.

Instead of balance, we need to strive for a better blend.

Making time for life

Cedric "Jamie" Rutland, M.D.

Even with a formidable work schedule, Cedric “Jamie” Rutland, M.D., feels he has a balanced life. “It’s OK if you don’t have balance at the beginning
of your career,” he says. “You work your way up the mountain. You can’t expect to start at the peak.”

Cedric “Jamie” Rutland, M.D., a pulmonary and critical care physician with Pacific Pulmonary Medical Group in Riverside, Calif., estimates that he works more than 100 hours a week, including spending one to two nights a week at the hospital. “Work-life balance? I feel like I have it,” he says. Work-life balance, he explains, doesn’t necessarily mean that you’re spending equal time on both.

Rutland, who has a wife and two children, may arrive home tired from a long stretch at work, but says, “Being tired is not an excuse for not doing anything” with his children, who are often excited to see him. So he pushes through, gives his family time and attention when he’s home, and sleeps when he can.

It’s a challenge to be both physician and family man, but Rutland feels a personal responsibility to be there when his patients need him. “You take an oath to care for patients,” he says, and people get sick 24 hours a day. “If someone gets sick at 5 and my shift is over at 7, I stay,” he says. “You have to take care of them.”

Setting boundaries

Jill Garripoli, D.O., owner and physician at Healthy Kids Pediatrics in Nutley, New Jersey, says that, “Good people go into medicine to help people.” Perhaps for that reason, it’s so easy to let work consume all your waking hours. Early in her career, Garripoli believed she needed to be at work all the time. Her thinking has shifted in recent years, especially after hearing about a doctor who got an ulcer after working 12-hour days, six days a week. That was a wake-up call.

Her typical day involves seeing patients in the morning, taking a lunch break during which she will often run, and then seeing patients in the afternoon and sometimes into the evening. She works five days a week plus alternating Saturdays with her P.A. She’ll be at work 8:30 a.m. to 5 p.m. most days, but only 2 to 5 p.m. on Wednesdays, so she can have a break from patient care in the morning.

Garripoli defines work-life balance as having enough time to be a good physician and still have enough time to be with her family. And she’s made some changes recently to ensure there is a balance of activities outside of work, starting with “giving myself the freedom to say, ‘I don’t have to be there 24 hours a day.’”

She also surrounded herself with people who help her have a life outside of work. “I found a partner who helps keep me balanced, who forces me to see there is life outside work,” she says. She also found a skilled P.A. to share some of the weight of call.

Finally, she asked herself, “What makes me happy?,” which, she believes, “is a simple thing to do yet no one thinks about it.” Having a demanding and stressful career requires an equally relaxing and rejuvenating time away from work in order to achieve balance. So Garripoli tries to set up things she can look forward to and that make her happy outside of work. This could be a weekend getaway or a monthly massage, she offers as examples. They help motivate her during grueling times at work.

Jill Garripoli, D.O.

Another physician’s health scare was a wake-up call for Jill Garripoli, D.O., to introduce more balance to her work life.

Shifting focus

Balance means something different to each individual, and it can evolve over time.

For Khadeja Haye, M.D., national medical director for OB/GYN Hospitalists for TeamHealth in Atlanta, “Work-life balance is the flexibility to enjoy life outside of medicine. To be there for your family, to be there for personal events, to pursue interests outside of work…while still having the opportunity to take good care of your patients.” Haye’s outside interests include yoga, cello (which she recently picked up again after having played in high school) and golf (which she played in college).

Early on in her career, Haye says that her work-life balance “tipped more toward work.” Her focus was on her career and on building a foundation. “It was a conscious choice to work more on my career early on,” she says. “I felt fulfilled,” she says, and was very comfortable with the decision she made. When she wasn’t working, she traveled and spent time with her friends.

But now as a wife and mother, Haye has shifted that balance to allow for more time on the personal side of the equation. She made the choice to transition from a role in private practice to a hospitalist with a leadership role. That change also gave her the time to pursue an MBA degree. Now Haye works three to four 24-hour shifts a month, travels about one night a week, and then works as many as 40 to 60 hours a week from home on administrative responsibilities. “Now I have to be more creative in my scheduling, to maximize the time when I’m not working in order to achieve balance,” she says.

Finding the right fit

What does balance look like for you? What do you want your schedule to look like? What do you want time for? Do you need blocks of time to compete in downhill ski competitions during the winter, or evenings off so you can tuck your kids into bed? When you’re clear about that, it becomes easier to find a position that can offer the mix you seek.

“The key is early conversations,” says Etter. During the initial interviews, “Be upfront about your motivations. Emphasize work-life balance. Set expectations and be honest,” he advises.

For many physicians, finding the right employment fit is vital to obtaining work-life balance. One way to determine if a position offers enough balance is to ask questions during the interview process to understand the culture, says Eric Dickerson, managing director and senior practice leader, academic medicine, with Kaye/Bassman International in Plano, Texas. Some of the best questions that get at balance and workload expectations are:

  • What is a typical day like here?
  • What’s the number-one challenge you’re trying to solve by hiring someone in this position?
  • What would you want the person selected for this position to accomplish in the next two to three months? In the next year?
  • Is this a new role or a replacement role? Why did the previous person leave? Or why is the role now needed?

The responses to these questions can help you assess whether you’re willing to invest the kind of time and energy that will be necessary to be successful in that role.

“Organizations realize they have to be honest to prevent physicians from leaving quickly,” says Dickerson. While only 5 to 7 percent make a career move because the job they were promised is different from what they were given, Dickerson says, the cost to recruit a replacement is significant. And employers want to avoid setting anyone up to be disappointed.

Dickerson recommends looking for signs of the organization’s culture, such as:

  • Are people smiling?
  • Do they greet one another?
  • Is the interviewer greeting others? Does he or she know everyone?

“A culture of friendliness is aligned with balance,” observes Dickerson, so look for indicators that employees are happy and like each other if balance is important to you.

Haye recommends asking pointed questions about the amount of personal time that will be available to meet your needs. For example:

  • “I try to travel to see my parents who live overseas once a quarter. What is the amount of vacation time allocated for this position?”
  • “I’m in the middle of pursuing an MBA. How flexible are the work hours?”
  • “I’m also a caregiver for my grandmother. Would I have the ability to work from home part of the week?”

Ideally, the response you hear acknowledges your needs and explains how the hospital or practice can make the situation work. And if you don’t hear that, that may be a clue that perhaps a fit does not exist.

It’s especially helpful, says Dickerson, if you have the opportunity to speak with someone already on staff who is in a similar life stage, since each stage has different needs, and a different definition of balance.

The generational shift underway

When Garripoli was interviewing for her first job 11 or 12 years ago, her potential boss asked about her vacation expectations. “Oh, we can talk about that later,” Garripoli replied, fearing that talking about time off would make her sound like she wasn’t willing to work hard. That fear seems to be completely gone with the latest crop of physicians, she observes. “Newer doctors are very forthcoming about what they want,” she says, and what they want is work-life balance.

Rutland, on the other hand, thinks that discussions about vacation, flex time, and time off shouldn’t occur right off the bat. When he interviews a newer physician for an opening and is asked, “How much time do I have to spend at work?” he knows they’re not a fit for his particular practice. He recommends staying away from that question altogether.

“Medical schools don’t teach about business,” says Rutland, leading some new physicians to have high salary expectations despite only wanting to work a few hours a week.

That is not true of all newer physicians, of course. Many others, facing huge student loan debt, are more likely to do extra work to supplement their income, says Etter, even working during downtime to make some financial headway.

Understanding your power

Though not all positions can be shaped to fit a physician’s personal needs when it comes to work-life balance, many can be. And because of the huge shortage of physicians, it may be possible for organizations to meet specific schedule requests. It depends on the severity of the need and the individual demands being made, Etter explains. For example, if a candidate wants to work three days a week and a client wants them to work five days, there may be room for compromise.

Angood explains that the demand for work-life balance reflects a business cycle. Earlier generations had more patient time, less paperwork, and clear delineation between work and personal life. Then, physicians became overworked, saddled with administrative tasks, hit with huge insurance premiums, and accessible to patients at any hour. The industry, and newer physicians, are now reacting to compensate for all this extra work, says Angood. “The workforce is caught in the middle.”

“The driver needs to be a focus on quality and efficiency of system performance” in order to be able to provide any type of work-life balance, says Angood.

Balance through the years

While establishing a reputation through hard work early on in one’s career seems to be a common experience among many newer physicians, that doesn’t mean that work will remain the focus forever. Says Rutland, “It’s OK if you don’t have balance at the beginning of your career. You work your way up the mountain. You can’t expect to start at the peak.” That climb also allows you to gain experience you might never have had otherwise.

Now that Rutland is several years into his career, he acknowledges that his goals are shifting. “My goal isn’t to work 137 hours a week for the rest of my life.” To that end, he and his wife set five goals for the next 18 months that they work toward together. It helps them remember why he is investing so much time right now at work. At the end of 18 months, the duo sits down again to review their progress and to set new ones.

While Garripoli focused heavily on work early in her career, once she was established, she made conscious changes because she recognized she “was losing sight of [her] personal life.” Today she is taking steps to delegate more of her workload to her skilled team members.

Haye, too, chose to rebalance her life away from work and more toward a personal life, changing jobs in order to achieve a balance that better met her needs and career goals.

Toward a more integrated lifestyle

We’re in a transition phase from the on/off cycle of work to a more integrated lifestyle, says Angood.

Haye is witnessing this evolution. “I’m not sure if it’s good or bad,” she says. Thanks to technology that connects physicians to work and home 24/7, you can take care of personal tasks while at work. That’s in the plus column. “But it’s bad when you get emails while on vacation,” she points out.

Haye believes it’s up to the individual to manage the amount of access their work life has to their personal. “It’s up to the individual to set boundaries and make it less intrusive.”

 

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Compensation Comparisons: Evaluating Apples and Oranges

Compensation comes in many forms. This guide helps you evaluate what each piece is worth to you.

By Derek Sawyer | Fall 2017 | Feature Articles

 

When investigating potential jobs or opportunities, it’s easy to get excited about large sign-on bonuses, inflated hourly rates or what appear to be substantial benefits packages—because these are all compensation tools used to catch the eye of prospective candidates.

Not so fast, my friend! To consider total compensation, you need to see the complete picture, one that includes all these factors as well as a way to gauge the value of them as it relates to your situation.

In this article, we will take a shallow dive into some of the more common forms of compensation and address how to find common denominators so that you can fairly compare one factor to the rest of the package (as well as compare to others that may be markedly different).

Apples: Your needs

Jason Eppler, M.D.

Jason Eppler, M.D., recommends consulting an oft-overlooked source about a group’s reputation: the grapevine. Other physicians, nurses and ancillary staff can give great indicators about the culture, metrics and long-term viability of the group.

It may seem like advice you would get in a fortune cookie, but “know your needs” is a critical step.

Erik Petersen, D.O., regional medical director for American Physician Partners, noticed the recurring theme of preparation.

Medicine continues to demonstrate a lack of standardization regarding overall compensation across specialty and geography. Every situation is different. Family, geography, loans and other debt, investments, businesses, charity work and more can all play big roles in whether you should accept a high pay rate and fewer benefits or vice versa.

“At the end of the day, having a firm grasp on your own limitations and flexibility will increase your chances of avoiding otherwise unseen pitfalls along the way,” Petersen says.

If you have a 7 percent interest rate on your student loans, for example, then it could be less helpful to have a 401(k) match instead of loan repayment benefits.

This isn’t to say that starting a retirement plan is a bad thing, just that your financial focal points will change as your personal situation does.

In addition, when a prospective job is presented to you, the employer or recruiter will communicate all the reasons they think the job would be a great fit for you. Their reasons might include a great health care package, shorter shifts, free lunch in the hospital cafeteria or any number of things.

On the surface, these benefits sound wonderful…unless your spouse has access to a benefits package, you prefer longer shifts for more days off, and the cafeteria isn’t open during your night shifts. In this case, a higher straight hourly rate or more contributions to your 401(k) might be more ideal.

In short, there are several ancillary and sometimes unique offerings that an opportunity will provide, and knowing which ones will benefit you the most will help you determine which items are of value and which are not.

Oranges: The location

Most compensation packages are centered around a principle you learned back in middle school economics: supply and demand.

More desirable areas and a higher concentration of available physicians will equate to lower pay rates. The easiest examples are Hawaii and the Florida Keys. Both have a line out the metaphorical door for providers waiting to get in, but both by and large also have the lowest pay rates in the country.

On the flip side, many locations that are less desirable for a multitude of reasons will carry higher compensation packages. Keep in mind that a “less desirable location” is not necessarily a bad location; its supply is just less than the general demand.

Location also comes into play when considering the area’s cost of living and local taxes—two factors that can potentially have the largest impact on your take-home pay after all is said and done. Be aware of the tax laws where you intend on living and practicing, as there can be additional state, county and township taxes.

As a fan of a particular football team which will remain nameless (but resides in Jacksonville, Florida), I can say that a major draw for free agents is no state tax. As a free agent in your own right, you should take into account the difference in your taxable income, which can be as high as 10 percent of your annual pay (e.g. a $30,000 difference each and every year on $300,000 in annual salary).

Apples: The benefits

The next step in comparing your compensation offers is to establish a common denominator. In this case, the almighty dollar is the easiest. This doesn’t mean that you are only out for the money, but, instead, can offer a way to find the relative value of each portion of your compensation package.

Though this may sound complex, it can be determined simply by establishing the annual dollar value of a benefit, then dividing that by your projected hours over the course of the year.

A simple example would be two weeks of PTO, for which you would simply multiply your hourly wage by the hours provided.

A more complicated scenario, however, could revolve around hitting a performance bonus, which in itself contains some uncertainty.

To determine the value of a bonus, you must consider not only the dollar amount, but also the statistical likelihood of hitting that target each time.

(I must also note that job satisfaction is obviously a key component here, but for the sake of brevity, we will assume that whatever jobs you are comparing are ones that will fulfill your clinical and professional needs.)

If your employer is willing to contribute all or even a portion of your health/vision/dental benefit premiums, that’s hard to beat.

In reality, the company contribution to your plan is the true benefit here.

To determine the value of this portion of your compensation, divide that monthly amount by your number of hours.

As a side note, make sure that the network also covers your local hospital and desired clinical network.

Oranges: Employee type

There is no right or wrong answer here, and your specific circumstances play the biggest factor. According to Jay Widler, a consultant at Financial Designs in Overland Park, Kansas, “The current financial environment makes this a great time to work as an independent contractor. Health care reform, deduction allowances and other tax and investment rules make it a manageable, financially advantageous status for physicians. You should consider all the positions available to you and talk with a financial consultant who specializes in working with physicians to compare offers and determine which financial arrangement works best for you.”

As an employee, your employer will pay a portion of taxes as well as minimize the effort required when it comes time to file your tax return. Benefits, retirement and other group benefits are offered (sometimes at lower rates) and managed for you, which can be a big timesaver.

As an independent contractor, business expenses qualify as a tax write-off. Scrubs, gas, travel, health care premiums, etc., are all tax-deductible. Managing your taxable income is a top priority for a contractor. Being able to knock yourself down a tax bracket or two can easily make a five-figure difference in your annual take-home pay. You can also save significantly more for retirement in a tax-deductible plan (up to $54,000 per year vs. $18,000 as a W-2 employee).

Creating an entity can allow more financial planning advantages and possibly an extra layer of liability protection.

An independent contractor’s benefits are portable, and you can tailor them to your own needs. For example, a single, healthy 35-year-old male may need different coverage than a 45-year-old with a heart condition and family.

Apples: Bonus/metric incentives

It’s hard to ignore the increasing focus on the variety of metric incentives like patient satisfaction and quality-based measurements, because they are an ever-growing part of health care.

These typically are considered to be indicators of consistently good patient care and satisfaction. As a portion of compensation, it is important to have a good understanding of how they are tracked and the consistency of success. In many cases, you may need to rely on other departments within your system to achieve your goals, so situations like nursing shortages, volume variance, etc., can play a big role. Be sure to speak to other folks who work there to get a feel for if you are walking into a well-oiled machine or a 1978 Cutlass.

Oranges: Opportunities for advancement

Tony Briningstool, M.D.

The most successful negotiators calmly approach the table with facts. This approach helped Tony Briningstool, M.D., consider-and meet-a group’s benefit requests.

I would be remiss not to mention a partnership track, although there is such variety here that it is tough to lump them all into one group.

Two of the biggest factors to consider are your ability to achieve partner status and group liability. In most partnerships, there is a certain time frame or set of criteria that must be achieved before you become fully vested in the group.

These goals need to be reasonable and attainable and should also have some sort of guarantee. Once the goals are met, the partnership should be granted. The track record of the previous success of potential partners is the best indicator of how viable the option is, so don’t hesitate to ask about it.

Group liability is another easily overlooked factor in a partnership. According to Jason Eppler, M.D., emergency department director at Research Medical Center Emergency Room in Kansas City, Missouri, “partners can incur mutual liabilities not incurred with practice groups in which a physician is an employee. In a simple partnership, partners are financially liable for any malpractice claims against their partners, whether or not they were involved in the claimed incident. Most democratic groups avoid these sorts of problems by creating partnerships in the form of ownership of shares in a corporate entity. Equal shareholder status can create a functional partnership in group decision-making and other areas important to the physician, while reducing the legal and financial risks of a classic partnership.”

Apples: Payment structure

A relative value unit (RVU) is simply a unit of measure by which to judge the dollar value of any medical action.

According to Petersen, “if you go into a RVU-based comp model, be sure you feel very comfortable not only with the financial aspects of the plan itself, but also your ability [to] chart and knowledge of billing practices.”

In addition, be sure you have a method of obtaining feedback and chart reviews so you can continue to improve your documentation and accurately capture all services rendered. Knowing how to document procedures, critical care, etc., can play a huge difference in how much you are able to bill over the course of months or years, which in turn will directly affect your compensation.

One other main cause for heartburn among even the savviest negotiators is the dreaded counteroffer. Each situation is obviously a little different, but the number-one rule is to approach it rationally and with facts. On more than one occasion, I have been presented with the following line: “I just feel like I deserve more money.” That is, of course, not the best approach to justifying additional compensation.

Tony Briningstool, M.D., chief medical officer for American Physician Partners, shared the following story as an example:

“Recently we encountered a situation where our company would be taking over an existing practice of emergency providers from a different organization. In this particular case, both benefits packages couldn’t be more diverse from different in-network health providers. They had 401(k) match and PTO whereas we did not, but our base rate was set higher to account for some of these differences.

After we presented our initial proposal, we were sent a request for a meeting with all the providers to sit in person and discuss the differences and address questions.

After sitting down to the meeting, we were presented a typed, two-page breakdown from one of the current providers that detailed their benefits. This included the value of each portion of the package, as well as the rates of four nearby hospitals as a comparison. Based on this well laid-out research, the group presented a thoroughly thought-out counteroffer that was backed with evidence. After taking that information back to our team, we were able to shift around some of our package to allocate more money into the base rate and thereby meet the total compensation number that the group thought was fair.”

In this situation, the approach taken by the providers was just as important, if not more so, than the counteroffer itself.

While no method has a 100 percent success rate, laying out a logical argument based on facts and data of the surrounding market certainly has the best chance to be considered.

Apples and Oranges Photo

Oranges: Longevity

In closing, I wanted to touch on a point that I think is one of the most critical and most often overlooked ideas in negotiating: making sure the package is viable in the long term.

If you are lucky enough to stumble across a position that is willing to pay well above the market value, then it is certainly worth investigating—but understand that it may very well not last. In addition, if you find yourself making more than the rest of the physicians around you, you can bet that the clock is ticking on the longevity of that position.

To reiterate, be sure to do your homework! This is so you can not only maximize your total compensation, but also make sure it is a sustainable rate for your employer.

Derek Sawyer is a physician recruiter for American Physician Partners.

 

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6 Mistakes You’re About to Make on Your Employment Contract

Put the pen down, and step away from the contract! Before you sign, make sure you're not making any of these classic mistakes.

By Debbie Swanson | Fall 2017 | Feature Articles

 

After years of preparing for and envisioning your future employment, it’s thrilling to be within reach of a job opportunity that seems like the perfect match. Though it’s tempting to eagerly pack up your job-search paperwork and focus on settling into your new place, slow down—one of the most important steps lies ahead. Carefully reading and reviewing your new employment contract—before you sign the dotted line—can make a difference not only in your new job, but also on your career path.

Here are six mistakes that it’s especially important for new physicians to avoid.

Mistake #1: Aside from your spouse, no one else has looked at your contract

Physician employment contracts don’t make for breezy reading. Most are lengthy and filled with cryptic terminology and specific details that are often hard to discern. And you need to understand not only what’s written, but also what’s missing. For these reasons, most physicians—especially those early in their careers—turn to people more experienced for help.

“The employment contract was filled with legal jargon,” recalls Harry Salinas, M.D., a plastic surgery chief resident at Harvard University. “Even though I’m used to reading difficult material, this was just another language.”

Salinas turned to a lawyer to review his contract, who negotiated changes on his behalf. “She helped in a lot of ways, from translating the legal terminology, to changing some of the language and negotiating some of the restrictions,” he says.

“Having someone on your side to do these negotiations is incredibly helpful when you are still busy in your last year of residency,” adds ophthalmologist John Prenshaw, M.D., who benefited from consulting with an attorney regarding his future contract while he finished residency.

You can’t go wrong by getting input before you sign, whether you’re looking for negotiating help or just a second opinion. So where should you turn?

  • A lawyer who is experienced with physicians or employment law. Ask colleagues or your alumni association for referrals.
  • Your medical school, which may have resources available to students. Inquire at your career services or placement office.
  • Prior employees of the hospital or practice to which you are going.
  • Experienced colleagues whom you know well, such as a professor, mentor or coworker.

Remember to use discretion. Share the actual contract or personal details only with highly trusted individuals or those with whom you’ve entered into a professional agreement, such as a lawyer.

Before you sign: Seek input from a trusted and knowledgeable resource.

Mistake #2: You haven’t identified what’s important to you

When you began job hunting, you probably prioritized your goals and preferences. Now that you’re about to seal the deal, a quick review of these items is in order. The stipulations you’re about to sign onto can steer you toward—or away—from your intentions.

“Many times residents or fellows are so excited [about employment that] they don’t think of their long-term personal goals,” says attorney Philip Sprinkle, senior partner with Akerman LLP in Washington, D.C. Sprinkle volunteers to review employment contracts of recent graduates through the University of Virginia’s Medical Alumni Association.

“It sounds elementary, but I start each and every meeting with questions about the doctor,” he says. Responses help him to identify areas of focus. For example, if either the physician or the spouse has deep ties to a region, he’ll put the spotlight on the noncompete agreement.

Some areas to consider: long-term career goals, outside revenue (such as public speaking or writing), family obligations, amount of debt, scheduling issues and more. And don’t assume your professional needs will be satisfied.

“I’ve had docs hired under the lure of being interventional radiologists when, in reality, the group just wants them to read film,” Sprinkle recalls. “In one case, we made the equipment and the commitment a contractual requirement, which gave the doc an easy out when the group did not get it. In another case, the radiologist himself had to terminate without contractual protections, and it cost him pay and severance costs.”

Before you sign: Review and prioritize your goals, both personal and professional, and consider if the contract limits or supports them.

Harry Salinas, M.D.

Before solidifying his contract, Harry Salinas, M.D., consulted with other physicians in his network to develop language specific to his future goals.

Mistake #3: You haven’t looked closely at insurance coverage

Professional liability insurance, better known as malpractice insurance, may be one of the most important elements in a contract. Without solid coverage, your career, home, assets and property could be at risk.

There are two main types of insurance. “Occurrence-based insurance covers you for claims even after you leave the company. Claims-based, which is cheaper for the employer, covers you only if a claim is made during your employment. Get occurrence-based insurance, if they’ll agree to it,” says Sprinkle.

If you’re offered a claims-based policy, be sure an extended reporting endorsement is included—commonly called an ERE or “tail” insurance. This extends your insurance coverage to include claims that are filed after you’ve left an employer, but arise from work you performed while you were employed. Tail coverage is quite expensive—calculated at 50 to 250 percent of your overall insurance premium, according to the American Academy of Medical Management.

“Ideally, have the employer pay for the tail if they will agree,” recommends Sprinkle. Negotiating a 50-50 arrangement is another option.

If you are responsible for all or a portion of the payment, be sure you understand the terms. Usually the employer will collect it at the end of your employment period by withholding enough of your final paychecks to cover the cost. To physicians early in their careers, this loss of income can yield a significant financial blow.

When negotiating a new position at the end of his residency at the University of Virginia, Prenshaw ran into some concerns with the tail coverage.

“The original wording in the employment contract was that I was responsible for tail coverage, no matter what the circumstance,” says Prenshaw. This meant that if he was terminated early in his employment—with only a few paychecks under his belt—paying for the expensive coverage would be a financial struggle.

With the help of Sprinkle, they came up with more agreeable terms. “We negotiated that I wouldn’t be responsible for the tail if, during the first 18 months of employment, I was terminated without cause, died or became disabled,” Prenshaw says. “[Without this clause], it is unlikely I would have been able to afford the tail coverage [had an early termination occurred].”

Before you sign: Study the details of your professional liability insurance. Be sure you’ll have—and can afford—coverage for claims raised post-termination.

Mistake #4: You haven’t thought about the noncompete clause in your contract

Standard to most employment contracts is a restrictive covenant, which prevents you from terminating your employment and immediately going to work for a group or hospital that is deemed a competitor. More commonly known as a noncompete clause, these can severely limit your future options.

“Many people have the wrong idea that covenants aren’t enforceable,” says Nanette O’Donnell, partner with Duane Morris LLP in Miami. “It varies by state, but states do enforce them.”

Typically, the clause defines a mile radius, as well as a length of time, that restricts you from working for a competitor—for example, within a 10-mile radius of your former employer for a period of two years.

“It’s best to work with someone to negotiate the language and to soften the restrictions,” O’Donnell suggests. Reducing either distance or time (or both) is preferable.

Also make sure you are fully aware of the scope of the restriction. “If you’re working for a large entity with multiple offices, the location restriction may apply to every office of your employer, greatly expanding the geography within which you are restricted from practicing,” O’Donnell adds.

When evaluating a noncompete agreement, an important factor to consider is your ties to the region. If family obligations, a spouse’s employment or education options require you to remain local, a strict restrictive clause could cause your prospects for new employment to dwindle. If you and your loved ones are open to relocating, you may be less affected by the clause.

Before you sign: Consider your life over the next three, six or 10 years. Where might you be seeking employment?

Hilary Fairbrother, M.D.

Hilary Fairbrother, M.D., turned down an offer with a large group in favor of a smaller practice after reading through the group’s proposed employment contract.

Mistake #5: Assuming the job is so perfect, you’ll never think about leaving

You hit the jackpot with your potential new job: ideal location, growth opportunities, impressive salary and benefits. But curb your enthusiasm briefly enough to consider that someday you’re likely to change jobs. When that day comes, you’ll thank yourself for taking the time now to hash out any post-termination details.

One factor is the amount of notice required when announcing your termination. Typically, word of impending job termination is delivered to the employee or employer a set number of days before the targeted departure date. Thirty or 90 days is common.

“I’ve seen notification requirements be as long as 18 months,” says Heather Fork, M.D., dermatologist and founder of Doctor’s Crossing in Austin, Texas. “That’s really too long. Even six months is difficult, as most hiring companies want you to be available sooner.”

Fork says a notice of 90 days seems ideal. “That’s enough time to get your things in order and work with recruiters.”

Though less common, some contracts don’t specify a time requirement. “If there’s nothing stated in the contract, it leaves you free to go. It’s really up to the individual. That could be OK for some people, as long as you don’t mind potentially being given short notice,” says Fork.

Reason for termination is another key point; employees are either terminated “for cause” (often for issues with performance) or “without cause” (usually for reasons unrelated to the employee). Specifics vary among employers, so be sure you understand these definitions and their related details. For example, before you are terminated for cause, will you be given an opportunity to correct the problem?

Finally, if you will be relocating for the job, you may want some additional protection, adds O’Donnell.

“You don’t want to move for a job and then get terminated a month later,” she says. “Ask for a longer termination notice, (include) the ability of both parties to terminate only for cause, or negotiate to have your relocation expenses reimbursed.”

Before you sign: Consider what you need for a smooth termination of employment.

Mistake #6: You didn’t look closely at the salary and compensation structure

By the time the employment contract is drawn up, your salary is usually already established. It’s still prudent, however, to confirm that it appears as you expected, and that the compensation structure aligns with your personality, lifestyle and work ethic.

Physicians are commonly paid in one of two types of payment structures: salary-based or productivity-based. Productivity-based structures can be either relative value unit (RVU) based or collections-based.

“Some personalities prefer the flat salary model, which tends to be one where your earning potential is less, but so are the hours,” says Salinas. “In a productivity-based system, your guarantee is usually lower, but the ceiling is higher, as long as you put in the work.”

The structure that works for you is a highly personal choice. “I know that I will be much happier and busier in a system that rewards productivity,” says Salinas.

Also consider any unique situations. One thing important to Salinas was including language in the contract that covered the two types of patients he anticipates serving.

“[At my new position], I’ll primarily be doing reconstructive surgery for cancer patients,” says Salinas. “But I also do cosmetic surgery, and many times, this is the same population. I needed to plan pre-emptively how to incorporate any out-of-pocket [cosmetic surgery] patients into my RVU-based contract with the cancer center.”

Before solidifying his contract, he asked around within his network and at similar hospitals to develop the language to address this situation.

Before you sign: Be sure the salary structure supports your work style, goals and interests.

Time to negotiate

You’ve scoured your employment contract and found a few areas that leave you questioning. Now what? It’s common to have a round of discussions before the contract is finalized. Here are some tips for success:

Prioritize: Weigh the importance of each area in question, identifying those that have the greatest impact on you. “A mentor gave me this advice early on,” recalls Salinas. “I made a list of what things were deal breakers, and what I could live with.”

Do your research: Gather information on each area you’ll be discussing. Feeling knowledgeable will enable you to present your case more confidently.

Be flexible: Present a trade-off in exchange for something you want. “Offer something you’ll do, such as offering to work an evening shift in exchange for being able leave early on other days,” suggests Fork.

Above all, remain calm. One of the most universal rules of any negotiation is to keep your emotions in check and maintain a professional demeanor. Even if it becomes obvious the negotiations aren’t successful and you may pass on the job, always leave behind a good impression.

When it’s best to walk away

If the final offer still has you raising an eyebrow, step back and determine if this job is really the best fit for you. Though you may be eager to land a job, don’t agree to one with which you feel uncomfortable.

Emergency medicine physician Hilary Fairbrother, M.D., vice chairperson of the Medical Society of the State of New York’s Young Physicians Section, was entertaining an offer from a large group right out of residency. After reviewing their lengthy employment contract and consulting with an attorney, she was left with some concerns.

“One issue was that I could be fired at any time, with or without cause,” she recalls.

Fairbrother knew that an unexpected termination so early in her career could present financial difficulty.

“Also, I was supposed to provide notice if I were to terminate, but the employer did not have to. That seemed very lopsided,” she adds.

Further unsettling was a vast restrictive covenant, which could make remaining in the New York area difficult in the future.

Though she brought her concerns back to the group, hoping to negotiate, she reached an impasse and eventually decided it was best to decline.

“I (soon) joined a smaller group where I didn’t have as many restraints,” she says. “It was the right decision for me.”

Poring over an employment contract and hashing out details can seem like an unwelcome hurdle when you are so close to your dream of working as a physician. But it’s time well-spent. Whether you go it alone or pair up with a trusted colleague or professional, you’ll thank yourself later for careful decisions made today.

 

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You + Them: Creating a Deal That Works for Both of You

Understanding what’s negotiable—and what’s not—will help you focus your energy and your conversations.

By Marcia Layton Turner | Fall 2017 | Feature Articles

 

You’ve likely heard that the key to negotiating a physician employment contract successfully is research. That includes learning the industry standards for compensation in your specialty and geographic area, identifying what you bring to the table in terms of experience and expertise, and assessing “the landscape of the organization,” says Jeffrey Vogel, M.D., M.P.H., attending physician in occupational medicine with Cambridge Health Alliance and instructor of medicine at Harvard Medical School in Boston. “People will take you seriously if you’ve done your homework,” he says.

Recognizing that not all aspects of an employment agreement are negotiable is also important. This ensures that you focus on modifying terms that will actually benefit you without coming across as difficult or unrealistic.

Studying potential employers is smart, but it’s only half the equation. It’s also important to consider your priorities, says Bonnie Mason, M.D., retired orthopedic surgeon and founder of Beyond the Exam Room, which educates physicians about business and financial concepts not taught in medical school or residency training. What do you want a position to provide? What’s important to you?

Mason devised a phrase to represent the factors physicians should consider: Your DALAR Profile (pronounced “dollar”). DALAR stands for decision-making; amount of autonomy; lifestyle; altruism or volunteer opportunities; and revenue or income. What do you want in each of these areas? “Employers are clear about what they want [in an employee],” says Mason. It’s important that physicians are equally clear about their professional and personal priorities.

The compensation package

Bonnie Mason, M.D.

Considering negotiating? Start with evaluating your priorities, recommends Bonnie Mason, M.D. What do you want a position to provide? What’s important to you?

Through salary should not be the only—or leading—factor you consider, says Mason, the overall value of the total compensation package is one way to quantify the value a potential employer is offering. It is a way to compare the different employment options you may be presented. The elements of a standard compensation package may include some or all of the following:

  • Salary: Including base pay and bonuses (signing and/or based on productivity)
  • Benefits: Health insurance, life insurance and disability coverage, among others
  • Continuing medical education (CME): Money to pay for required CMEs
  • Leave: Paid or unpaid vacation, sick time, maternity leave
  • Student loan forgiveness/repayment options
  • Moving expenses
  • Cell phone expenses

Start by assigning a dollar value to each item on this list. “Once you understand the basic compensation package, you can try to move the values around,” says Mason. For example, if you don’t need moving expenses paid, you can ask to trade that for something else, like a signing bonus or more vacation time. Or maybe you can ask for more CME money instead of a cell phone plan.

What is not possible to negotiate, says Vogel, are the benefits that are rolled out organization-wide, such as health insurance plan options and 401(k) plans. It is neither feasible nor legal, in some cases, for an organization to create a customized health plan or 401(k) offering just for you. So don’t waste time or energy trying to convince a practice to switch its insurance carrier or up its retirement plan matching percentage. It’s not going to happen.

Know your numbers

You can expect potential employers to be helpful and collaborative because they want to hire you. But that doesn’t mean you’ll get everything you ask for.

Before you start setting arbitrary minimums as far as your desired salary is concerned, it will be helpful to know what the industry standards for compensation are for your specialty, says Vogel. Research what the salary is for the 25th, 50th and 75th percentiles in your specialty to get a realistic framework for what you may be paid. Vogel’s experience negotiating his employment contract was very positive. He was also well prepared for the discussion, having researched appropriate salary expectations for his specialty and the hospital system in advance.

Also find out the hospital baseline average, to know how it compares to other locations. If you discover that the average salary hospital-wide is $300,000, you shouldn’t expect to be offered close to that one year out of residency, Vogel says.

That baseline number can be useful for negotiating if you learn that the organization you’re talking to is currently paying under the 25th percentile. Your goal should then be to try to convince the hospital to pull its entire baseline up in order to increase your potential starting offer. That is an easier sell if your research uncovers that doctors are leaving due to dissatisfaction with the salary.

The conversation might sound something like: “I see that your retention rate is below the national average. Now might be a great opportunity to re-evaluate your baseline in order to retain more of your experienced staff.” That approach turns your recommendation regarding an across-the-board salary increase into a benefit for everyone, including the hospital.

Understand the business side

Understanding how much it costs to recruit and hire you, how much revenue you’ll be generating for the organization, and what you can do to increase that revenue can aid your negotiations with for-profit organizations.

A note about academic contracts

 Jeffrey Vogel, M.D., M.P.H.

Jeffrey Vogel, M.D., M.P.H., suggests researching the industry standards for your specialty’s compensation. Identify the salaries in the 25th, 50th and 75th percentiles to get a realistic framework for what you might expect to be paid.

It is often possible to negotiate an agreement that meets your needs for compensation and benefits and helps you achieve your long-term career goals. The same is true within an academic setting, though the process is different because the role you are applying for is not solely revenue-generating. You’re there to teach and conduct research that elevates the reputation of the hospital or university, in addition to contributing to creating a new income stream for the organization. For that reason, there are fewer elements of the contract that can be modified, less that can be negotiated. But the differences in process are evident from the start.

To begin with, the contract itself is typically issued by the chairman of the department in which you’ll be working, rather than a recruiter. It should outline your responsibilities and the associated compensation, says Virginia R. Litle, M.D., FACS, professor of surgery and chief, division of thoracic surgery at the Boston University School of Medicine. Most initial contracts are for a three-year term and are subsequently renewed on an annual basis.

When applying for your first job in academic medicine, there is not much room to negotiate, says Litle. There are guidelines for what assistant professor positions pay, based on geographic location. There is little room for variation, she says. On the research side, however, it may be possible to request research support on top of your salary. Called “start-up money,” this research funding is a set amount granted for a set period of time, such as $25,000 or $50,000 for three years. Potential new hires can ask for more research funding or for a different length of time, though such funding typically aligns with a professor’s contract term.

You may also be able to ask for more “protected time,” or the time set aside for research. For example, 10 or 20 percent of your workweek may be designated for research work. That’s the protected time. Early in your career, it may be more difficult to be granted more protected time, however, and typically you want to be operating and applying your skills at this stage.

You could also ask for a research coordinator, depending on your research interests. Even if you share the coordinator with others, the role is integral to completing most clinical research for consenting, maintaining databases and processing institutional review board paperwork.

If you’re applying for something other than your first job, you will want to take a step up, which may include seeking a promotion or a program director position. In evaluating your request for a higher salary, more research funding and perhaps more lab space, the university will likely look at your skills and reputation, your research track record, and the number of publications you’ve contributed to, says Litle. “The higher you rise, the more negotiating you can do,” she says.

In academics, some physicians stay at the associate professor level for the remainder of their careers, though 8 to 10 years is more typical, she explains. The speed with which doctors are promoted typically reflects their publication and funding record.

Sometimes to get what you need, you have to make motions to leave. As with any job, you don’t want to do this unless you actually have an offer from another institution that meets all your needs. But having an offer in hand from another university can make you that much more desirable to your current employer and allows for negotiations with both parties, explains Litle. Jumping from one university to another is not considered a negative. According to Litle, “People move around a lot in academics.”

Intellectual property rights

Another difference between academic and hospital or private practice jobs is the rise of contracts demanding rights to supplemental income earned by physicians. It has long been customary in academic settings to include a provision in the contract that stipulates that any supplemental revenue the physician makes while an employee is the property of their employer, says Mason. “However, we’re seeing more private practices, not just universities, writing into contracts that any supplemental revenue that the physician generates—from speaking, intellectual property or stock dividends, for example—belongs to the employer.”

Mason says that [for] “employers [to] collect revenue from work done relevant to clinical responsibilities and patient care is reasonable.”

After all, you are their employee, she points out, and most employment contracts lay claim to new ideas developed during the workday. In the case of an independent idea, however, you may want to claim ownership.

In general, you “want to retain the right to create, innovate and problem-solve” for your own benefit, she says. “Practices are often willing to negotiate this point,” she says, but you need to be aware of it and how best to modify it to meet your personal goals and objectives.

Terms to understand

Beyond the compensation package, there are other elements of your employment agreement that you’ll want to hone in on, says Mason. The big three include duties and responsibilities, noncompete clauses and termination clauses. These are sections that you will be unable to remove completely, but you may have room to ask for minor changes.

Duties and responsibilities. In this section you’ll find information on the amount of time you’ll spend working each week, the frequency of call you’ll be required to take, whether you will have time for research and other specifics about your job responsibilities.

Though you can’t negotiate basic responsibilities, such as seeing patients or teaching hours, you may be able to ask for less call—or more call in exchange for more admin support.

Noncompete. Most practices won’t negotiate this clause out completely. However, you can ask for the terms to be reasonable in scope and duration.

For example, not being permitted to practice within a 10- to 25-mile radius rather than 25 to 50 miles, or having the noncompete in place for one year rather than five.

In many cases, the willingness of a practice to negotiate may hinge on the population density of the area. In larger cities, the scope of the non-compete can be smaller, due to the larger number of patients in a small geographic area, whereas in more rural practices, the non-compete radius may be larger because there are fewer doctors in general and your moving practices could cause a major shift in the marketplace.

Termination. Most contracts reserve the right to terminate you without cause, just as many states are employment-at-will states that require no cause for termination.

You can ask, however, to be given a notice of termination within a certain number of days, just as you may be required to give a 90-day notice before leaving.

You should also ask for payment of tail malpractice insurance to cover any claim made after you leave; payment is typically due within 90 days.

While you may be able to modify some of the specifics surrounding these elements slightly, you will not be able to change them materially.

Tread carefully

Though many aspects of your employment agreement are negotiable, attempting to negotiate every little detail “can make an employer leery,” cautions Steven Jacobs, physician recruiter with WellSpan Health in York, Pennsylvania.

You can ask lots of questions and push back on some requests, but not on all of them. “Three or four requested changes are typical for WellSpan,” says Jacobs. “More than that and we’ve got a problem. That’s a red flag to the practice.”

At that point, you risk coming across as very difficult to deal with, and employers may decide you’re just not a good fit.

“Ninety-five percent of the time, contract negotiations go smoothly,” says Jacobs. Which means that odds are good your negotiation will go just as well, as long as you don’t nitpick.

Pick your battles. When something is truly important to you, make it clear that you’re pushing hard for the change because you intend to remain on staff for many years—so terms will impact you for years to come.

In the end, “everyone wants the same outcome,” says Jacobs. So “be collaborative in the process, not adversarial…. The negotiating process is not there to hurt you,” it’s there to help you get what you need to be successful in your career.

 

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Moving for work? Read this first

Physicians looking to relocate for a new practice have even more to do throughout their job search. This guide breaks it down.

By Karen Edwards | Feature Articles | Summer 2017

 

Janet Young, M.D.

Janet Young, M.D., relocated twice in four years—once from California to Chicago, and once back.

For Janet Young, M.D., an emergency medicine physician, it made sense to relocate. The large group practice where she worked had offered her an opportunity at its Chicago location that she knew would benefit her professionally in the long term. So in 2008, she packed her bags, and along with her two preschool-aged children and an au pair, moved from Oakland, California, to Chicago. Her husband remained in California a while longer.

“I didn’t know anyone in the Midwest. I’d never even been there,” Young says.

The move would not be a long-term engagement. Less than four years later, Young and her family relocated again, back to Oakland.

Young is hardly alone in this relocation exercise. New physicians who train far from family and friends often return home once their training is complete. And more and more physicians are choosing to relocate even after a few years in practice. A 2016 report issued by health care data analysts SK&A found that nearly 14 percent of health care providers made some type of professional move within the past 12 months—keeping pace with what the U.S. Census Bureau says is the percentage of Americans who relocate each year.

It’s possible that new physicians relocate in even higher numbers. In 2011, Today’s Hospitalist stated that as many as 70 percent of physicians change jobs within their first two years. Jeff Hinds, president of the physician consulting firm Premier Physician Agency, believes this trend may be because, “early in their careers, most young physicians do not know how to fully evaluate their job options, nor at that point, even know which practice settings or locations are most conducive to meeting their professional and personal goals.” But relocating closer to family, or even moving for more opportunity, like Young, can also explain the frequent exoduses.

As anyone who has ever moved can tell you, however, relocating is not easy. That’s why it deserves careful consideration. Your experience, of course, will be unique, but their suggestions may provide you with a road map to make your relocation a bit easier.

1. Know your contract

Alexander Zaslavsky, M.D.

Alexander Zaslavsky, M.D., recommends applying for a license in your new state as soon as a relocation is in your future. It’s a process that “can take up to four months or longer,” he says. “Start early.”

First, understand the consequences of leaving your current job. “Physicians need an adequate exit strategy before making the decision to relocate,” says Hinds. “They need to review their contracts to fully understand the termination process and potential risks.”

It’s possible you’ll have to return at least a portion (if not all) of any signing bonus if you leave before your contract term is up. “Responsibility for purchasing malpractice tail coverage could also be tied to completion of the full contract term,” Hinds adds.

Any of these factors may play a part in your decision to leave—or at least in your timeline to relocate. “Seeking legal advice to help determine your ideal exit strategy is very important,” says Hinds.

2. Visit before you decide

In other words, “Don’t Skype the interview,” says Edie Webber, owner of Pinnacle Relocation Services. “You really have to go and visit in person.”

That’s the only way you will pick up on what Webber calls intangibles—the feel and culture of a place and the people who live and work there. “A place should make you feel welcomed and wanted,” says Webber, and that’s especially true of your potential workplace. “You’re going to spend a lot of time here with these people, so make sure you’ll feel comfortable before you choose to relocate,” she says.

A visit is also the best way to learn about the community where you hope to live. “Learn about the schools, about any work opportunities for your spouse if he or she will also be looking for a position, and seek out information about any cultural or recreational activities that you and your family enjoy,” says Hinds.

And just because you have lived in the area before doesn’t mean you can skip this step, says Ron Davis, senior vice president of MD Preferred Services, a website that helps physicians find professionals like realtors, attorneys and accountants. “Even if you lived or grew up there, unless you’ve made recent trips back to the area, don’t assume the place you left will look the same.” As he points out, training can take a while, and if you’ve added a fellowship on top of that, chances are the place has changed. “You need to visit it again if you haven’t seen it in a while,” he says.

Ying Hui Low, M.D., an anesthesiologist who recently moved from North Carolina where she trained to Lebanon, New Hampshire, suggests bringing along the important people in your life to visit a new location. “You want people to visit you, so it lets them become comfortable with the area, too,” she says.

3. Establish a timeline

Relocating involves a lot of moving parts happening simultaneously. Once you have the move scheduled on your calendar, you’ll need to establish a timeline so the transition will be smooth.

“One of the first things to do is apply for your state license,” says Alexander Zaslavsky, M.D., who relocated from a hospitalist job in New York City to a new position in Maryland—then, when his employer opened a new location in New Jersey, he moved again. “The licensure process can take up to four months or longer,” he explains. “That’s lost time and income if you delay the process. Start early.”

This is also a good time to start your paperwork. Eleanor Hertzler, recruitment coordinator for Patient First, says that three months is generally a good rule of thumb for the credentialing process. Credentialing and licensing timing varies from state to state.

“The process is very state-specific, so do some research for the state you’re moving to and plan accordingly,” she says.

“You should also notify your current employer two to three months in advance,” says Jeffrey Tsai, M.D., a regional director with CEP America who has relocated twice—from Chicago to Atlanta and then home to California. “At least let them know you’re thinking about a move.”

Your professional liability carrier will also need to know of your move, and, if you’re currently in practice, don’t forget to notify the Drug Enforcement Agency, any vendors you work with and of course, your patients.

You’ll also need to find a place to live. Allow about a month for this step, Tsai says.

Other factors to include in your timeline: Time to locate a job for a working spouse and time to check out schools. “A lot of this can be done online,” says Debra Phairas, president of Practice & Liability Consultants. “But of course you and your spouse will want to visit any potential employers and schools in person.”

Young offers one more “must” for your timeline if you have children. “I was lucky that my au pair moved with me, but if you’re relocating, establish your childcare option in advance,” she says.

Finally, consult with movers, realtors and recruiters. These experts can help you fine-tune your timeline.

4. Dive into the area

Yes, you’ve visited the area, but now is the time to explore it.

Each time Tsai moved, he took a month of vacation, he says. He used part of that time to travel. “When you’re working, you don’t have time for many vacations,” he says. But that month also allowed him to explore the area thoroughly, to look for a place to live, and to unpack.

Low says she also vacationed in the area prior to relocating. “After all my exams were over, I visited the area and the hospital and took a look around both,” she says. “Check out the amenities, things that are important to your lifestyle.”

By staying in the area, you’ll not only become familiar with various neighborhoods but also gain a better idea of the real estate market and what kind of properties might be available in your budget. “You can [also] determine commute times,” says Low. Just because a house appears to be close to the hospital doesn’t mean you’ll be able to get there faster if traffic in that area is heavy at the times you’ll travel, Low explains.

Hertzler says when she works with relocating physicians, she gives them a list that’s filled with helpful resources. “As recruiters, we don’t endorse any outside business, but we give our physicians referrals for things they may not think about, like mechanics, vets and dentists,” she says. If you’re checking out an area, you might want to put together your own list of frequently used services, then look to see what’s available in the areas where you’ll spend most of your time.

5. Consider living arrangements

Finding somewhere to live, of course, may be the biggest challenge facing the relocating physician.

Zaslavsky suggests renting an apartment or small home for a year. “Make sure this is the place you want to be before buying a house,” he says. “You may find you don’t like the job or the area, then what?”

Hertzler agrees. “If you’re not familiar with the area, it’s a good idea to rent a place for six months to a year to see if this is where you want to live. You may get here and decide you like another part of town better. Unless you know the area, I’d suggest renting when you first arrive.”

One practical, economical option is to follow Young’s path. “I rented a furnished apartment for a year,” she says. That way, there was no need to move furniture twice when she decided to move somewhere else.

Webber, however, says that, depending on the market, it can be much easier and less stressful to find a home ahead of time. “In tight markets, shopping and making offers from your hotel can create a lot of stress. If you can arrange a home shopping tour ahead of time, before the move, then the contract to close can be done during your absence,” she says.

“If you rent first with the intention of buying a home in a year, the home may actually cost you more,” Webber continues. If, for example, you relocate to an area where there is a demand for housing, which is often the case in cities, chances are prices will rise over the year—while your options narrow.

If you’re selling a home before you move, Webber also cautions you not to rely on “off-the-cuff” estimates of your selling price. “Don’t assume you’re going to make a good profit from the sale of your house,” she says. Sellers often underestimate their costs, in addition to any buyer’s expenses they may have to pay. “Get accurate numbers so you know what you will net when you sell,” she says.

While you’re gathering information, it’s also a good idea to sit down and prepare a projection for all the expenses you’ll run into when relocating, says Hinds. In addition to moving costs and buying and selling a home, there will also be costs for trips to the area and for licensure. “Also consider costs of daycare and even the costs of living in the new location,” he says.

6. Make your move

Now that you’ve visited the area, established where you’ll live, seen to your paperwork and any childcare needs, it’s time for the move itself.

Low said the move, for her, was easy. “I didn’t have any furniture or big items to move.” But for many, a move can be stressful.

“Changing location is listed as one of life’s biggest stress factors,” says Webber. “Hiring experts can help.”

She suggests you talk to your employer’s human resources department and ask for referrals. Hinds agrees: “Most hospitals have realtor partners they work with and can recommend,” he says. Phairas adds that office and group practice managers can also refer you to realtors, movers and other experts in the area.

Young, however, took a more self-directed approach: “I Googled realtors in the area,” she says. And Tsai credits his wife for taking on most of the house-hunting chores. For Zaslavsky, “My wife and I were a team. We looked at homes together.”

“Most physicians are experts in their field, but novices when it comes to relocating,” Davis says. “And health care is way behind corporate America in successfully relocating people.” Hospitals can only do so much. “They may refer you to a realtor and tell you where to get three bids for movers, then you’re on your own,” he says. But relocating involves much more. “A consultant or relocating company can bundle services like mortgage contacts, financial advisors and attorneys,” he says.

Will you be reimbursed for your relocation expenses? It depends on the employer and the location. Hertzler says employers generally help relocating physicians by putting together a benefit package that will ease moving costs. Whether that’s a signing bonus or a stipend depends on each situation.

Tsai says his employer did not help him with moving expenses. “But our company does offer a loan to assist with the move or it sometimes offers a signing bonus,” he says. A typical amount of the loan or bonus is $10,000—which seems to be the going rate for relocation expenses when they are offered, adds Hinds.

Says Webber: “You never know whether or not you’ll be reimbursed unless you ask.”

7. Get settled

By now, you’ve found a home, unpacked your boxes, and are starting to know your way around the hospital and maybe around your new community as well. But don’t stop there.

“This is the time to network,” says Phairas. Go to hospital meetings to meet your colleagues, and to medical and specialty society meetings to meet other physicians in the area, she says. These physicians can become friends or referrals, and they can also let you know about restaurants, parks, hiking trails and other things to do in the community in your area of interest, or maybe those of your spouse or children.

“Networking is important, and not just from a business perspective,” she says.

Hertzler says Patient First often arranges a dinner where relocating physicians can meet with other physicians from the local Patient First urgent care centers. “It’s a time to meet colleagues and their families, and to learn more about the workplace and the area,” she says.

It’s also important at this time to keep the happiness of your family in mind. You may be delighted with the new location and job, but if your spouse or children are having a miserable time of it, you may have to re-assess your priorities.

“Relocating can be a real culture shock for children,” says Davis. “It’s why your family’s needs and feelings must be considered before you actually make the move.”

Young says she gave herself a timeline. “I told myself and I told my family that we’ll give the location and the job two years. If after that time we weren’t happy, we’d move back. I think it’s really important to have an exit strategy like that, an escape route,” she says.

Even more essential, however, is taking time to decide if the move is right for you. “Before you move, you have to sit down and ask yourself why you’re making this move,” she says. “If you’re not sure why you’ve put yourself and your family through this, it’s not likely to work.” But you can’t let fear of the unknown and the occasional unpleasantness stop you either. “Don’t be afraid to relocate,” says Young. “There’s no advancement without risk. You’ll become a better person for it.”

 

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