Whether you’re looking for your first practice opportunity or your fifth, options abound. What constitutes the “perfect job” depends entirely on your practice style, personality, values, and how hard you want to work.
It’s no secret that more physicians are opting for employed positions today, viewing them as more secure and having a lower hassle factor. But even within the realm of employed opportunities, there is a wide variety of choices offering greater and lesser degrees of autonomy, security, recognition and income. And each comes with its unique challenges and benefits.
In this article, we profile five physicians working in five very different settings: the military, locum tenens, a rural clinic, correctional medicine, and in a big city clinic caring for underserved patients.
Their stories illustrate just how varied careers in medicine can be and underscore the fact that doctors have plenty of latitude when it comes to how and where to practice.
Serving the underserved
As a medical student, Edgar Bulloch, M.D., volunteered at a free clinic where he treated uninsured patients who might not otherwise have been able to afford medical care. This experience piqued his interest in working with underserved populations. “That’s what initially drew me in. I had very good mentors in that program. They were doing so much for patients, for no compensation,” says Bulloch.
When he completed his OB/GYN residency at Texas Tech University Health Sciences Center in El Paso two years ago, Bulloch, 35, considered an academic career where he would have been both teaching and caring for underserved patients. But as he began exploring practice options, he heard about an opening at Family Health Centers of San Diego (FHCSD). A nonprofit federally qualified health center (the second largest in the country), FHCSD was founded in 1970 and has 33 sites, including 13 primary care clinics, in and around the San Diego area. Their mission includes providing comprehensive care for uninsured, low income, and medically underserved patients.
“It was the first interview I went on and I really enjoyed everyone I met,” Bulloch says.
After going on a few other interviews, Bulloch decided that Family Health Centers was the best fit for how he wanted to practice medicine. “FHCSD has great support staff and I felt that I could do everything needed for the patients,” says Bulloch.
Too often, low-income pregnant women receive little if any prenatal care and simply show up in hospital ERs in active labor—a less-than-desirable situation to be sure. “Here, they’re getting comprehensive visits throughout their pregnancies and we have a better understanding of patients when they go into labor. This means safer deliveries and better outcomes,” says Bulloch.
At FHCSD, patients have access not only to physicians, but also to health educators, nutritionists and social workers. “Each patient has a case manager,” says Bulloch. “If they need help finding insurance or getting on MediCal, they’re not alone. There are so many resources available to patients and I really like that.” Bulloch is fluent in Spanish, which serves him well in caring for a large Hispanic population. Translators are available for caregivers who are less fluent in the wide variety of languages spoken throughout San Diego County.
Due to inflexible work schedules and lack of transportation or childcare, ensuring continuity of care can sometimes be a challenge for doctors working with low-income patient populations. Bulloch says compliance is not a big problem at FHCSD. “We have a young, healthy population of pregnant women and most patients trust you and do what they need to do.” It helps that FHCSD has unique incentive programs for women that encourages them to receive comprehensive prenatal care. Patients receive Baby Bucks when they keep appointments, “money” they use to buy everything from diapers to baby clothes at FHCSD’s Baby Boutiques stocked with items donated by the community. Women also receive a free car seat for their newborn if they attend all of their prenatal appointments.
FHCSD has nine OB/GYNs on staff who rotate through all of the system’s clinics that provide obstetrical services. This allows women to meet each doctor at least once over the course of her pregnancy so that when it’s time to deliver, she is in the capable hands of a physician with whom she’s familiar. Bulloch holds privileges at several area hospitals. His practice is about 75 percent obstetrics and 25 percent gynecology.
Bulloch finds his work so satisfying that he’s helped recruit two OB/GYNs who were a year behind him in training to join FHCSD. Because of the system’s status as a federally qualified health center, professional liability insurance is covered by the government. This allows FHCSD to offer competitive salaries. “I could probably earn a little more working in another group, but that’s not why I went into medicine,” says Bulloch. “The program of care here is so integrated that I don’t have to worry about business and can focus on finding the right diagnosis and treatment for each patient. It’s very rewarding.”
Duty to country
When he’s not serving his country on the other side of the globe, Lt. Col. (Dr.) James Sebesta, M.D., practices general and bariatric surgery at Madigan Army Medical Center in Tacoma, Wash., where he lives with his wife, Janelle, and their six children. Sebesta, 48, always planned to go to medical school, but he didn’t necessarily have his sights set on a military career. “A friend was going to check out the Uniformed Services University of the Health Sciences in Bethesda and I went along, thinking it would be a free trip to D.C. I fell in love with the school,” says Sebesta.
Following medical school, Sebesta did his internship year at Madigan and then went on a two-year tour as a medical officer before returning to Madigan to complete his surgical residency in 2002. He’s been there ever since, but again, this was not necessarily his original plan.
“I thought I’d do my payback time and then figure out what to do next,” he says. But as that juncture neared, Sebesta did some career soul searching. “I broke out a piece of paper and wrote down everything I wanted in a job. I wanted to train residents, do research, and take care of patients how I thought they needed to be taken care of. I realized that I had the perfect job, that I was doing it right now,” says Sebesta. He’s now been a physician officer for 10 years and enjoys caring for members of the military, their families and military retirees.
Sebesta appreciates the fact that, even though there is a certain level of bureaucracy associated with being in the military and budgets are often tight, he doesn’t have to deal with the business side of practice. “I get to focus on medicine,” he says. His schedule is not unlike that of a civilian physician. “We divide call up between partners. There are 10 of us now because no one is deployed. I take call one weekend a month or every other month and three to four weeknights a month,” Sebesta says.
Having been deployed four times (once to Iraq and three times to Afghanistan), Sebesta says deployment is both the best and the worst part of being a military doctor. “They send you to bad places and you’re in harm’s way, but you get to do amazing things to save lives. Being away from the family is hard, but it’s an adventure, sort of like a six-month camping trip,” he says. Physicians who serve in the Army are not permanently attached to a single unit for deployment. Instead, when they’re needed to go overseas, they’re assigned to a unit for a period of time. Sebesta’s deployments have been between six and eight months in length.
Returning stateside after a deployment is an interesting experience. “The practice side is easy. You just jump back in and start working,” says Sebesta. At home, re-entry can be a bit more challenging. “The family has figured out their own rhythm of doing things. You slowly move yourself back into that and figure out where you fit in,” he says.
Sebesta advises physicians considering a military career to get in touch with a recruiter.
“Based on the needs of the Army, the doctor’s skills, and how long they’ve practiced, they get a rank, go through officer basic training, learn how to put on the uniform, and start practicing medicine,” he says. Basic training? For doctors, it’s not like you’ve seen in the movies. “I stayed at the Holiday Inn,” says Sebesta. “They’re not yelling at you or shaving your head.”
Sebesta is passionate about his career as a military physician. “It has its challenges with deployments and budget issues, but the vast majority of us love being here,” he says. “For me, it’s a great place to practice medicine.”
On the road
Kristen Kent, M.D., is 37, single, enjoys traveling, and is taking full advantage of the fact that at this stage in her life she has the flexibility to practice medicine on her own terms.
Kent completed her emergency medicine residency at the University of Massachusetts Memorial Medical Center in Worcester in 2006. While in training, she moonlighted as a locum tenens physician and enjoyed it enough to go that route full time upon completing her training. “Then I joined a group in Cincinnati and worked with them for a while before going back to locum tenens,” says Kent.
“I feel like I have a lot of flexibility with my schedule,” says Kent. For example, she had no issues taking time off recently to go on a cruise with her dad.
Kent currently works in two locations—one near her home in Ohio and the other on Cape Cod—through LocumTenens.com and Vista. Her assignments generally run for at least three months, and she’s had offers to stay on permanently several times. For now, she’s keeping her options open and continuing to work locums. “I get to practice in different environments and I get to travel,” says Kent, who is hoping to work in Alaska next summer and will likely accept engagements in Illinois in the meantime.
Kent typically works between 100 and 140 hours a month, which is considered full time for emergency medicine. “I still work nights and weekends and holidays, but I have flexibility with my schedule,” she says. “I can fit in other things while I’m working. In Cape Cod, I work for four days and then have four days off.”
The biggest challenge of working locum tenens, says Kent, is getting to know the culture and systems at each new location. “Every place is a little different in how they manage patients. Some have hospitalists and some have private physicians who admit,” says Kent. “And things are not always as they were presented. You have to be flexible.”
Kent says any physician considering locum tenens should give it a try. “It’s an excellent opportunity. You get to travel wherever you want, even outside the U.S.,” she says. “I moved a lot growing up and I like seeing different places, regions of the country and cultures. My friends joke that I can sit in an airport and guess where people are from based on their accents and shoes.”
Care without judgment
Internist Norman Johnson, M.D., was in private practice in 1994 when he first became acquainted with correctional medicine. “A friend worked in a prison and when he had patients who needed to be hospitalized, I’d admit them,” says Johnson. He quickly recognized that prisons and jails needed better systems for delivering care to their unique patient populations, and in 1995 he co-founded Health Professionals LTD.
In 2002 he founded Advanced Correctional Healthcare, a company that designs programs and provides risk management services for correctional facilities. In the interim, Johnson worked in jails and prisons for 15 years and continues that practice on a part-time basis today.
Johnson says the ideal doctor to work in a correctional facility is a primary care physician who has the ability to demonstrate empathy and also be somewhat parental.
“These patients are less likely to participate in their own care, and we’re charged with giving them everything they need, sometimes whether they want it or not,” says Johnson. “We have to do the right thing, while keeping in mind the cost to taxpayers and governments, both in dollars and in time.” Johnson’s philosophy is that individuals who are incarcerated, regardless of whether or not they’ve been found guilty of a crime, deserve quality medical care and respect.
Caring for incarcerated patients has challenges and rewards. “These patients come in on inappropriate drugs and they’ll want narcotics for minor problems,” says Johnson. “Many of them had doctors on the outside but they may have been non-compliant and not paying attention to their health. We get a shot at educating them. Patients in our jails get healthier. Their diabetes and hypertension improve while they’re inside,” says Johnson, adding that even “frequent flyers” who are released and then return to jail often come back in better health than when they were first seen within the system.
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“As the economy has worsened and states have done away with mental health programs, a lot of mentally ill patients are pouring into jails. Many of these people shouldn’t be there,” says Johnson. In this case, the goal is to get them on an appropriate drug regimen and link them with community services. “We cannot legally advocate for them, but we can work with the legal system to give them mental and medical health parameters so that they can sort things out,” says Johnson.
In the world of correctional medicine, prisons and jails are quite different. “Prisons are large and doctors usually work 40-hour weeks,” says Johnson. “Nurses line everything up, patients are pre-screened, protocols are followed, and if anyone gets really sick they’re sent to a hospital.” Physicians working in prisons do take after-hours call, except in facilities that are large enough to have doctors on duty 24/7.
Most jails are smaller than prisons and a full-time correctional physician might cover several facilities, traveling between as many as 25 over the course of a week checking in on and caring for inmates. “These doctors don’t see as many patients face-to-face because they’re spending time traveling,” says Johnson.
Interestingly, jail doctors tend to earn more than their colleagues who work full time in a single prison. “Correctional doctors earn based on the number of hours they work,” says Johnson. “If they’re in a prison, they’re likely salaried and earning in the range of $120,000 to $170,000 a year. Jail doctors are in the $150,000 to $200,000 range.”
Johnson says burnout among correctional physicians is not as high as one might imagine. Most facilities have nurses on staff and systems in place that make practicing medicine in the setting quite manageable. “You learn how to work with these patients,” says Johnson. “You cannot allow yourself to get hardened and think that everyone you see is manipulating you. You’ll miss something if that happens.”
The rural life
Family physician Troy Geyman, M.D., practices medicine in keeping with what your imagination likely conjures up when you hear the term “country doctor.” He covers his own practice in Bonners Ferry, Idaho, 24 hours a day, seven days a week, every day of the year. “It’s part of the job. You just do it,” he says of his practice choice. Geyman has admitting privileges at his local 20-bed critical access hospital and completes rounds each morning. He does get coverage from another local doctor for inpatients when he leaves town, but even then remains available by phone for calls about patients. “I don’t do house visits though. The county’s too large for that,” says Geyman.
Following medical school at the University of Arizona in Tucson, Geyman completed his family medicine residency at Self Memorial Hospital in rural South Carolina and then worked at a community health center in rural Michigan before settling in northern Idaho, about 20 miles from the Canadian border. He’s been there for 10 years. “I like doing the full range of practice,” says Geyman. He typically sees 45 to 50 patients a day, holds places in the schedule for walk-ins, and performs a wide range of procedures. Obstetrics is the one aspect of family medicine Geyman does not offer because the service is not available at his local hospital.
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Geyman appreciates the community-oriented aspect of practicing medicine in a rural area. He takes care of entire families and everyone in Bonners Ferry pretty much knows everyone else. “In more populated areas most people don’t even know their neighbors, let alone have a lot of relatives in the community,” says Geyman. He sees his patients around town outside the office on a daily basis. “That’s more positive than negative,” says Geyman, who does occasionally get medical questions from patients when he’s out and about. He takes that in stride. “I enjoy seeing patients and having that interaction,” he says.
Rural living suits the entire family. Geyman and his wife, Luann, have 12 children ranging in age from 4 to 22. Luann homeschools the children and everyone pitches in to take care of their sizable mountain ranch that features sheep, cattle and a pond. “The kids have responsibilities and chores and raise animals that depend on them,” says Geyman. “We have the ability to hunt and fish and hike out here. I can work in the morning and be on a mountain peak two hours later.”
“Some people come out here to vacation for a week, but we want to live like this every day,” says Geyman. If he and his wife want to get away to enjoy something that a city offers, they drive a couple of hours to Spokane or Coeur d’Alene. “We look at the big picture of living rural, what that means, like not having easy access to shopping,” says Geyman. “I might have to avoid hitting a deer or elk or moose driving to work, but I’m not fighting traffic and dealing with road rage.”
Karen Childress is an award-winning freelance writer who contributes regularly to PracticeLink Magazine.