What “managing up” can do

Better communication among physicians and between physician and patient can help improve the entire health care experience.

By By E. Coy Irvin, M.D., MBA | Fall 2013 | Remarks


As more family physicians and  internists have decided to concentrate on outpatient medicine, positive relationships and effective patient hand-offs have become critical for good patient care.

The technique of “managing up” has been taught by many experts over the past few years as a way of improving the customer service experience. Managing up helps the patient experience by alleviating their concerns about the service and quality of care they will experience in our system. In addition, managing up can improve the relationship between referring physicians and the hospitalists who care for their patients while they are in the hospital.

As we see the separation of inpatient care and outpatient care become more common, patients rightfully are concerned about who will care for them during a severe illness, the very time when they need the most attentive care. Not only will the new doctor be a stranger to them, but so will many of the staff at the hospital. Quite possibly, the attending hospitalist will change during the patient’s hospital stay, shaking the patient’s floundering sense of security even further. This all leads to the clear need for exceptional hand-offs of the patient, their information and the intended plan of care.

Many times we have witnessed patients questioning whether one physician communicates with the other physician when they say, “Do you guys talk to each other?”

This can seriously undermine confidence in our medical care. It also puts our patients and ourselves at risk for unintentional catastrophic accidents and possible legal action.

It is imperative that physicians improve communication and relationships so that when an outpatient physician hands off the patient to an inpatient physician, or when one inpatient physician hands off to another, there is true communication of the needs, status and intended treatment plan of the patient’s medical condition.

Part of the process can be aided by using managing up techniques to educate the patient so that they understand the transfer of care that is about to occur. Remember, this is a two-way street: Not only does communication and managing up need to occur at the time the patient enters the hospital, but it also has to occur during the hospitalization if there is a transfer of care. Finally, it occurs again at discharge of the patient back to the outpatient physician.

So not only does managing up improve the patient’s perception of the hospitalist, it can also improve the perception of the outpatient physician in the eyes of their patient.

Imagine a scenario where the outpatient physician, upon deciding to admit the patient to the hospital, tells the patient, “Mrs. Williams, I am sending you to the hospital. I no longer go to the hospital, so I’m going to place you with the hospitalist service. I’m not sure who the hospitalist is today, and I am not sure you will see the same doctor each day. I’m sorry for this, but I can no longer make rounds on hospitalized patients.”

What would you think if you were Mrs. Williams? You probably wouldn’t have much faith in the hospitalist that would care for you.
Now what if the outpatient physician had said, “Mrs. Williams, I am sending you to the hospital. You will be cared for by my hospitalist service. The hospitalists are an extension of my office practice, and they care for my patients on a daily basis. The hospitalists are experts in inpatient medicine and will know just what to do to help you get better. I trust them to care for my patients as I would trust them to care for my family. We will give them all the information we have on you, and upon discharge, they will share with me the information about your hospital stay.”

Now Mrs. Williams feels reassured that not only will she get good medical care, but also that her information will be passed from one physician to the other. The accepting hospitalist will feel better about taking care of the outpatient physician’s patients, and we will all find taking care of Mrs. Williams to be easier because she trusts the physician’s judgment.

As a physician and consultant who works with both hospitalist programs and medical staff, I see daily the need for better communication across the system. Not only do we need to communicate better physician-to-physician and physician-to-patient, but we also need to improve communication between physicians and hospital staff. Using the techniques of managing up can result in a marked improvement in the final goal for all health care providers, both clinical and non-clinical: Providing the best and the safest care of the patient. Why? Because it improves teamwork, something on which our patients directly rate us. Another positive effect of managing up is that the technique helps to reassure the patient who is nervous and scared about their illness. And our patients will directly benefit from a better coordination of care.

E. Coy Irvin, M.D., MBA, is Chief Medical Officer and Vice President of Medical Affairs for McLeod Regional Medical Center in Florence, S.C.



5 Simple rules for new docs

Your training may have ended, but that doesn't mean your learning has stopped.

By John Mandrola, M.D. | Remarks


Here are five nuggets of wisdom for new doctors entering the private world.

1. Ignore your pay stub. It is true, unless you were a heck of moonlighter, you just got a pay raise. Congratulations. But I implore you to keep living as if you were still in training. Drive an inexpensive car. No, check that, embrace that clunker like it was a pink phone case—something that sets you apart. Don’t add to your debt by buying a huge house. Say no to the country club. Live close to the hospital. Use the extra monthly income to pay off loans. Think of the word: cushion.

2. Keep an open mind. Yes, we know that you are up on the latest techniques, having seen and perhaps even used the latest laser, balloon or robot—tools that our hospital cannot afford. You are also well-versed in spreadsheets and abstract writing, and you probably know many well-published people—maybe your former teachers were “thought leaders.” That’s great. Nifty even.

But the thing is, now you are on your own. That humble technician who scrubbed in with you has seen many young docs flail. She has seen the mistakes you are about to make. Listen to her, respect her, pretend she is a professor. She wants to help you; she will help you, if you let her.

Likewise, the older docs around the hospital will help you too. Though many of us trained when procainamide was still available, and taking night call meant carrying a bag-phone around, we have probably done your primary procedure 7,399 more times than you have. We have limped out of the hospital in dismay after causing the complication you have yet to cause. We look at your newness with envy. We want to learn from you. You have capital; don’t blow it by acting too much like a cardiologist.

3. Be nice to people. Not just the obvious people, like the woman who sets out lunch in the doctors’ lounge or the procedure schedulers, but everyone else too. This hospital will be your new home. You will see these folks at the grocery, on the ball fields with your kids and soon enough you will need medical care. You are the new kid in class; people want to make friends with you. Let them.

4. Call your referring docs. To folks of my era, this came naturally. The phone call to the referring doctor after a consult or procedure served two purposes: one was to keep the primary care doc in the loop, and the second was to introduce yourself, and perhaps your new specialty. (For me, electrophysiology barely existed in 1996.) But now, the alliances between hospitals and doctors act to create barriers between medical colleagues. I would urge you to call a primary doctor even if they are owned by another institution. Not only because it is right-minded, but also because the changing marketplace may soon make partners of you two.

5. Have fun. Don’t let the checklists, forms, protocols, cubicle-doctors and metastasis of quality measures get you down. At the end of the day, your special skills, which came from years of hard work, will ultimately help you better mankind. This is a large treasure indeed. And it is immensely fun.

Author: John Mandrola, M.D., is a cardiac electrophysiologist practicing in Louisville, Ky. He is also husband to a palliative care doctor, a father and a bike racer. He blogs at drjohnm.org



The Advantage

Seeking out a healthy organization will make a difference in your life and practice.

By Patrick Lencioni | Remarks | Summer 2012


In the field of medicine, there is quite obviously considerable time spent on addressing the health of patients, but perhaps there is less time spent on the health of the organization providing the care.

Finding an organization where productivity and morale flourish and politics and confusion are minimized is essential to the well-being of any medical professional. Because healthy organizations typically out-perform their counterparts, a healthy hospital or medical facility will attract and retain the best doctors, nurses and staff and ultimately provide better care.

The environment

You may already know how it feels when your workplace seems unproductive and the employees seem undervalued. Understanding what organizational health is and what it looks like can help you evaluate future employers and find a functional, effective work environment.

According to our work and the model found in The Advantage, healthy organizations:

1. Build a cohesive leadership team. The first step is all about getting the leaders of the organization to behave in a functional, cohesive way. If the people responsible for running an organization, whether that organization is a corporation, a department within that corporation, a start-up company, a restaurant, a school or a hospital, are behaving in dysfunctional ways, then that dysfunction will cascade into the rest of the organization and prevent organizational health. And yes, there are concrete steps a leadership team can take to prevent this.

2. Create clarity. The second step for building a healthy organization is ensuring that the members of that leadership team are intellectually aligned around six simple but critical questions (see page 68). Leaders need to be clear on topics such as why the organization exists and its most important priority for the next few months. Leaders must eliminate any gaps that may exist between them so that people one, two or three levels below have complete clarity about what they should do to make the organization successful.

3. Over-communicate clarity. Only after these first two steps are in process (behavioral and intellectual alignment) can an organization undertake the third step: over-communicating the answers to the six critical questions. Leaders of a healthy organization constantly—and I mean constantly—repeat themselves and reinforce what is true and important. They always err on the side of saying too much, rather than too little. This quality alone sets leaders of healthy organizations apart from others.

4. Reinforce clarity. Finally, in addition to over-communicating, leaders must ensure that the answers to the six critical questions are reinforced repeatedly using simple human systems. That means any process that involves people, from hiring and firing to performance management and decision-making, is designed in a custom way to intentionally support and emphasize the organization’s uniqueness.

Joining a healthy organization early in your career will greatly increase your chances for growth and development and ultimately job satisfaction.

Assessing the culture

Before you even consider a new position, the interviewing process can be very revealing. Here are some of the signs to look for to help gauge an organization’s health.

1. Do the people interviewing you appear to be on the same page about where the hospital is headed, who they are and what they value? If you interview with more than one person and they are not on the same page regarding the hospital’s goals, direction and culture, it could be an indication the company is not focused on organizational health.

2. Does the interviewer seem interested in getting to know you beyond your specialty or skill set? Great organizations are looking for employees (or in your case physicians) that fit their culture from the executive suite down to the cashier. If they are not asking questions beyond résumé skills, that may be a red flag.

3. Does the organization appear to have a process for bringing in new doctors? Is there any kind of orientation where the leaders lay out expectations, talk about the culture and share business plans and goals? If the hospital does offer this to new physicians, this could be a good sign that the organization is trying to foster a healthy culture.

There are few organizations that have a more important mission than those in the medical field. Finding an organization where employees thrive and politics are minimal can literally make all the difference.

Patrick Lencioni is the author of 10 business books including the new release The Advantage: Why Organizational Health Trumps Everything Else in Business, and the national best-seller, The Five Dysfunctions of a Team. He is founder and president of The Table Group, a management consulting firm.



How can you calculate your worth as a physician?

Wondering if your compensation offers are in line? So did I.

By Steven R. Bruhl M.D. and David A. Bruhl | Remarks


Finding a job right out of residency is a complicated and daunting task. Although many young physicians might think they have some idea about their expected income, they often have difficulty correctly assessing the effects of different practice settings and geographic regions on their relative worth.

Once a salary and sign-on bonus has been agreed on, many new physicians fail to ask exactly what measuring stick their employer will use to evaluate their productivity and corresponding future income.

My experience with finding the perfect job was no different, and as practices started sending me contracts and benefit packages the size of small phone books, the same questions kept running through my mind: How do I know what I’m worth? How do I know which contract offers are fair, and which are attempts to take advantage of my financial inexperience?

After several hours of sifting through the various contracts, I knew I was in over my head, so I met with the business manager in charge of the cardiology practice where I was completing my fellowship.

Almost immediately, she recommended I consult the same resource their practice and hundreds of other practices use for answering these questions: the Medical Group Management Association (MGMA) manual.

Every year, the MGMA sends out the Physician Compensation and Production Survey to medical practices in order to obtain current information about the compensation and productivity of physicians around the country.

These surveys are provided to all specialty types, practice structures and regions of the country. The results of these surveys are then organized and compiled into charts to help medical practices gauge their own productivity and compensation.

Medical groups often use this information to set their own internal benchmarks for establishing future compensation and productivity standards for current and new physicians.

What I learned from the MGMA manual was that, although there are a myriad of potential variables that go into what determines a physician’s salary, there are six major practice variables that are tracked and that appear to consistently affect a physician’s compensation. They are: practice ownership, group type, geographic section, demographics, partners in practice and call responsibilities.

I found that by using the information in the MGMA manual, I was further able to estimate the average salary of a specific job offer based on the characteristics of each practice.

For example, let’s assume you are an invasive cardiologist and receive three identical compensation packages from three different practices. Practice 1 is a non-hospital owned, single-specialty group type located in a large metropolitan city in the Eastern region, such as New York City.

Practice 2 is a non-hospital owned, single-specialty practice located in a smaller metropolitan city in the Midwest, such as Cincinnati.

Practice 3 is a hospital-owned, multispecialty practice group, located in a non-metropolitan city also in the Midwest, such as Dearborn, Mich.

The first step in determining the average salary of Practice 1 is to look up the average salary for an invasive cardiologist working in a city over 1 million people and record the value. Next, look up the average compensation for an invasive cardiologist working within that region of the country.

Do the same thing for an invasive cardiologist working in a non-hospital-owned practice setting as well as an invasive cardiologist working in a single-specialty practice.

If you add up the average salaries from all four variables and divide by four, you will get what is likely an even closer estimate of the average annual salary for an invasive cardiologist working in Practice 1.

If you then repeat this process for your other job offers, you can now compare the average expected salaries of all job opportunities side by side.

Although there is no doubt that this method is a relatively crude attempt to estimate the salary of a specific practice setting—and no doubt lacks dozens of variables important to the equation—the composite estimates are at their core based on actual reported salaries of physicians working in your specialty within each specific practice setting.

Although the process of averaging four different compensation values based on four different variables is imperfect, these values can help shed light on the current trends in compensation as well as your relative worth in a given practice setting.

In about an hour, I was able to construct a chart comparing the average expected compensation from my top three job offers. Although all of the initial salaries were within 10 percent of each other, I found that the proposed salary for my favorite was 25 percent lower than my estimate from the MGMA manual.

With this knowledge and the counsel of other advisors, I counter-offered for 25 percent more than my initial offer, plus a bonus salary based on my productivity.

To my somewhat surprise, the hospital agreed to my three-year salary proposal, but suggested that my bonus salary be based on a specific work revenue value unit standard, also known as wRVUs.

Their initial productivity goals seemed somewhat high and unrealistic to my lawyer and me. So by referring to the standards published in the MGMA manual for my specific practice structure, we were able to work out a wRVU standard that was more appropriate for my specific practice setting.

From my experience, I found the MGMA manual to be a powerful tool in sorting out my financial value across very different practice settings. However, I would advise anyone consulting the MGMA manual to remember that the data should be use as a general guide rather than as a weapon.

Furthermore, if your potential employer intentionally or unintentionally tries to suggest that your proposed compensation is out of proportion to the average for your area, you may be able to use information in the MGMA manual to show otherwise.

Don’t overlook call responsibilities when discussing your relative productivity. Because call responsibilities often generate little to no direct revenue, make sure this variable is not overlooked when discussing your relative productivity.

Each practice is unique, and it is impossible to tease out the exact value of any particular variable, much less the exact value of a physician in that practice setting. However, using the variables that are known and understanding how they tend to affect compensation will help you better approximate your worth in a given practice setting and take some of the guesswork out of the negotiation process.

Although the process of estimating your worth is somewhat tedious, time-consuming and expensive, I would urge every physician to take the time and spend the money necessary to consult with physicians, practice managers and a lawyer experienced in physician contract law.

In the end, every hour and every dollar spent will likely pay dividends that go far beyond your starting salary.

Steven Bruhl, M.D., is a third-year cardiology fellow at the University of Toledo Medical Center and will be taking a position as a cardiologist at Mercy Tiffin Hospital in Tiffin, Ohio. David Bruhl is a lawyer with Rohrbachers Cron Manahan Trimble & Zimmerman Co.

The views expressed in Remarks are solely those of the author and may or may not be shared by PracticeLink or its advertisers.



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How to love your job

By exploring your answers to just a few questions, you can find a job and location you love.

By Andrew Harrison | Remarks | Winter 2011


For the past seven years, I have studied human motivation and careers. Part of those six years was spent traveling the country interviewing people who love their work. After 95,000 miles and 145 interviews, I have been able to learn from people of diverse backgrounds, ages and careers.

When I was asked to write this section, the first person that came to my mind was Dr. Hillary Beberman, a family medicine physician. Her journey to becoming a doctor was not a simple one. She left a well-established career as a financial journal writer to follow her passion in medicine. Although she enjoyed her writing job, something was missing. “The pay was great and I was exposed to some great things, but I wasn’t fulfilled. I asked, ‘Is this what I want to be doing for 50 years? Am I helping people?’ I wanted to make a difference. I didn’t know if being a financial journalist let me feel like I was doing that,” she told me.

The change hit her immediately. “In medical school I was very interested in the subject, and it was the goal I really wanted.”

Life did not stop during medical school and residency. Beberman lost her younger sister to cancer, got married between her second and third years, and had a baby during one residency. “Being a resident is brutal, and I didn’t know if this was for me,” she says. “There were times I was ready to quit. I couldn’t take it. I missed my newborn son. I said, ‘What am I doing, this is crazy.’”

But she pushed herself. “I almost quit, but this was my goal. I knew the pain was temporary, and in 20 years I’d look back and ask, ‘Why did I quit?’ Now I can say I’m so happy doing what I’m doing.”

There are many factors that go into loving your work. Yet you just don’t snap your fingers and have the job you love. The career equation is not that simple, but it can be solved. Here are two lessons from my book that have helped me, and others, on the career road.

Lesson 1: Find out who you are

In order to love your job, you need to understand yourself. That is easier said than done, but many times, we don’t put in the time and effort to know who we are. And that leads to us not being happy with the choices we make.

Rosemary Haefner, CareerBuilder’s VP of Human Resources, said, “Believe it or not, most people don’t take time to sit and think about what they want to do. We’re very much programmed to take a job to have a job. A paycheck to have a paycheck.”

The advice is to take the time and put in the effort to analyze who you are and how that ties in to your job goals.

Here are a few important questions to ask during your self-actualization process:

  • When it comes to work, what do I naturally enjoy doing?
  • What am I naturally good at?
  • What energizes me?
  • What stresses me?
  • What motivates me?
  • What annoys me?

Once you have the answers to those questions, the next step is to examine the big picture of your work environment. The answers to these questions will help shape your environmental choices:

  • Do I want to go solo, or be part of a small or big group?
  • Do I want a rural location, the suburbs or the city?
  • What type of patients do I want to work with: wealthy, middle class or those in financial need?
  • Do I want to see a high volume of patients in shorter bursts? Or work with a smaller number of patients for a longer duration?
  • What type of physician-patient culture do I want to be a part of?
  • What type of peer culture do I want to be a part of?

The more data points you can have, the better educated your decisions will be. Learn from the experiences of others. Find a physician more experienced than you. Buy him or her coffee or lunch, explain your goals, and ask for their career advice. Their stories and input will be of great benefit.


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Check your ego and let trust flow

Tell the truth in every situation, and you’ll build a culture of trust among physicians, nurses, administration and patients.

By By Brian Jones | Fall 2010 | Remarks


As a business consultant, speaker and trainer to hospitals, physician practices and others, I have been hearing a lot about trust recently.

Some might dismiss trust as a “touchy-feely” concept, but I have spoken to many hospital CEOs, CMOs and physician practice leaders who trace many of their challenges to a lack of trust.

This lack of trust can be between management and staff, between physicians and nurses, between physicians themselves, and even between members of management.

And we are not doing a very good job of hiding our lack of trust from our work forces and colleagues.

In fact, in one recent study by the American Nurses Association (ANA), about half of nurses say that they would not be comfortable having a loved one receive care where they work.

The study concludes that these nurses have lost trust in their employer—so much so that they wouldn’t want their child or parent to be cared for in their facilities. There’s a business case to be made for rebuilding this kind of trust, because word-of-mouth marketing, especially from employees, is the most valuable type of marketing for a healthcare facility.

Before we go any further, let’s define what trust means. Trust is the ability to be vulnerable and fully present and real in all interactions.

Trust is usually better defined by what it is not: politics, meetings after the meeting, defensiveness, and ego-driven decision-making. My experience in health care tells me we have a ways to go when it comes to driving these destructive traits out of our hospitals, practices and offices.

What can be done to retain or restore trust in a healthcare workplace? In our book, Ordinary Greatness, my co-author Pam Bilbrey and I examined this question, and here is what we found.

Tell the truth

Sounds simple, but most employees we interviewed as we researched Ordinary Greatness who had lost trust in their boss could tell some story about a time they felt they were lied to, spun, or were told less than the unvarnished truth.

The boss often has a different perspective when confronted about this disconnect, and blames “the script HR gave me,” the employee’s unrealistic expectations, or the economy.

Physicians who are not aware of some of their blind

spots will not be likely to inspire trust.

But is there ever a reason not to tell the whole truth? Our commitment to protect confidentialities aside, be sure you are telling the truth in every situation.

A friend of ours asks his young children every night when he tucks them in, “Did Daddy tell the truth to you today?” We asked him why he did this. He said, “Because I want to avoid situations where my kids think I lied to them when in reality we just had a misunderstanding. For example, if my kids ask me if I could take them to the park, I might say yes, thinking I will do it this weekend, when they were thinking of today. I want to catch that stuff as it happens.”


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Meet Your Medical Matchmaker

Physician recruiters are more than mere placement pros. Here's why they deserve your highest trust and respect.

By David Andrick | Remarks | Summer 2010


MARKET ANALYST. REAL ESTATE EXPERT. COMMUNITY HEALTH ADVOCATE. SALESPERSON. MEDICAL       ADMINISTRATOR. ACCOUNTANT. STAFF DEVELOPER. LIFE COACH. These are just a few of the hats worn by in-house hospital physician recruiters. Their broad knowledge base and confident personality puts their working relationships with physician candidates at the top of the totem pole.

Unlike independent recruiters, in-house physician recruiters aren’t motivated by commissions and meeting quotas; rather, they work within the healthcare delivery system to ensure that the healthcare needs of their communities are met with the proper mix of medical and surgical specialists. They are responsible for expanding the medical staff either through start-up practices or growing practices in the specialties identified through their medical staff development plan. So when they tap you for an interview, your role could be that much more meaningful and worthwhile.

A professionally trained quasi-clinician

Many in-house physician recruiters receive ongoing professional training from the American Academy of Medical Management (AAMM) or through the Association of Staff Physician Recruiters (ASPR). The AAMM provides intensive seminars for frontline in-house professionals who are responsible for contracting, compensating, managing and retaining medical professionals. The ASPR, comprised of more than 1,000 in-house physician recruiters, also offers education and training to its members.

The typical in-house physician recruiter has spent hours interacting with hospital administrators to help prepare and develop a medical staff development plan, approved by the board of directors, that maps out policies for sourcing candidates and identifying practice opportunities. In doing so, the recruiter gains a keen understanding of the key differences among clinical specialties. Grasping the distinction between an invasive and interventional cardiologist,  and what goes on in the cath lab versus the operating rooms, becomes second nature. This knowledge also comes in handy later on when the recruiter is required to explain the credentialing process with the hospital’s insurance carrier.

When a physician recruiter contacts you, it’s not some willy-nilly, seat-of-the-pants call; rest assured that you are being considered as the right fit within a strategic employment
plan. Of course, the recruiter is in the business of selling the benefits of a hospital, a community and a practice opportunity. Yet it behooves the recruiter to match the right practice setting to you as a qualified physician, so you’ll be an asset to the organization both now and for the long term.



No Excuses: Making Time to Make Changes

A medical mission trip provides a wealth of rewards for one plastic surgeon and the dozens of children she helped heal.

By Angeline Lim, MD | Remarks | Spring 2010


Angeline Lim, MD

Angeline Lim, MD

I AM OFTEN ASKED HOW I FOUND TIME TO ATTEND A recent mission trip in China to repair cleft lips and palates. I have to explain that some of my favorite moments in plastic surgery have been on these missions. There is already such breadth and depth to plastic surgery, but these trips have added sparkle to those dimensions.

I was asked to be a part of this trip to Changde, China by LocumTenens.com, and having had such incredible cleft surgery experiences in Guatemala and Mexico, I jumped at the opportunity. We’d be spending two weeks at a hospital in Hunan province with a team of almost 40 American medical providers and about 20 local Chinese staff.

Spearheaded by the generous folks at the Chinese Agape Foundation, the focus of this medical mission trip to Changde was purely cleft lips and palates. Additional support came from the Jackson Family Foundation, the CARIS Foundation, and SmileTrain. more »



The Power of Asking

There is no weakness in asking. If we wait for someone to give us what we want, chances are we might never get it.

By Leslie A. Knight, MD, FAAFP | Remarks | Winter 2010


If you made a list of things you were given just because you asked for them, how long would your list be? First class upgrades? Airport meal tickets? Rental car upgrades? Full college and medical school scholarships? Paid trips to professional meetings? Increased responsibilities at work? more »



No One Taught Me How to Do This in Med School

In-house programs, such as the Cleveland Clinic, place primary emphasis on support and assistance to empower graduates and individuals as they become skilled at managing their own job search.

Could an in-house recruitment program help you in your job search? A few simple tips could make the difference.

By Joey Klein & Lauren Forst | Fall 2009 | Remarks


Becky is a neurology resident at the Cleveland Clinic in Cleveland, Ohio. When she graduates in July, she hopes to land a job in Chicago so she can join her husband, with whom she’s been apart for a year, while he completes his cardiology fellowship. Ron, a colorectal surgery fellow, is 33-years old. He’s been training to be a surgeon for as long as he can remember. He’s never looked for, or had, a job. He feels lost as to where to look, how to write a cover letter, if he should use a placement agency, how much he should expect to make, and how to move forward if he gets an interview or a contract. Roland and his wife Bushra are both on J-Visas (a visa for non-immigrants to come to the United States for training purposes). They have no CVs, no cover letters, and are looking for opportunities in the same city that can offer a J-1 Waiver (special permission to stay in the country without the usual requirement of returning to one’s home country for two years) so they can stay in the United States together. more »


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