WHEN SIMA PENDHARKAR, MD, MPH, went looking for her first job, she knew she wanted to work as a hospitalist at a teaching hospital on the West Coast. So when she got a job offer from a prestigious teaching hospital, she jumped at the opportunity. It wasn’t long, however, before she began to sour on her new job. “I was working a lot of nights and swing shifts, and I really didn’t have a life,” she says, “For almost two years, I felt like I was working around the clock 24/7, so I just quit without even having another job.”
Looking back, Dr. Pendharkar, who today works as a hospitalist and a hospital administrator in New York, wishes she had asked a lot more questions. But she was young and her first job offered her academic opportunities in a city she liked, so she said “yes” without pushing for enough details, particularly about shifts and coverage.
Dr. Pendharkar is far from alone in taking—and quickly leaving—a first job right out of training. Industry experts estimate that about half of new physicians will leave their first job within one to three years.
“If somebody calls out sick, will you get called in to cover, and will you be paid for that?”
Experienced doctors and recruiters say one reason for that attrition rate is that new physicians tend to focus too much on one factor like location or pay. Young physicians often assume that if the pay is good or the location is right, all the other details will work themselves out.
How can you make sure you’re not unhappy in your first job? A good starting strategy is asking yourself some hard questions about where you want to work. Then pitch detailed questions to prospective employers about everything from pay to scheduling and workloads.
The trouble with “teaser rates”
For many new physicians, money looms very large in their job search. But industry veterans point out that the total dollar amount a practice is offering may not be the most important factor.
Let’s say, for example, that a group is offering what sounds like a great salary. You’ve checked out compensation data from surveys, and the pay package is running 10% to 20% above average.
But it’s not uncommon for private groups to provide a guaranteed paycheck for a year or two to give you time to build a patient population. The catch: That guaranteed compensation then goes away, and you’re paid based on the number of patients you see.
It’s a situation that family physician Rick Kellerman, MD, hears about all the time. “Residents say, ‘I’ve got this great offer and I’m going to make all this money,’ ” says Dr. Kellerman, professor and chair of the department of family and community medicine at the University of Kansas School of Medicine in Wichita.
“If you’re working for a value-based model, you probably won’t be churning through as many patients.”
But fast-forward a year or two, and it’s a different story. “They received guaranteed compensation for two years, but now they’re being paid based only on productivity,” says Dr. Kellerman. “They can’t make the same level of income as their previously guaranteed salary.”
That’s when trouble begins. When physicians realize that they’re not earning what they expected, they often can’t just pick up and leave. Their contract contains a noncompete that effectively prevents them from practicing at another group in the surrounding area. If they want to leave their job and continue to practice, they need to relocate.
“I tell residents to be really careful when it comes to these ‘teaser rates,’ ” Dr. Kellerman says. “You have to look two years down the road and ask how you’re going to be paid.”
Volume or value?
Recruiters also point out that health care is changing from paying physicians based on how many patients they treat (volume) to how well they care for those patents (value).
The difference between value and volume may sound abstract, but it will have important ramifications not only for physician pay, but patient volume and practice style. That’s why Tommy Bohannon, vice president of Merritt Hawkins, a national staffing firm in Irving, Texas, urges physicians to ask some basic business questions of the groups they interview with.
For example, ask if the practice gets most of its revenues from seeing patients, so it’s primarily benefiting from the volume model of medicine. If that’s the case, Mr. Bohannon says, expect to focus on seeing as many patients as possible a day.
“You have to look two years down the road and ask how you’re going to be paid.”
In that type of practice, Mr. Bohannon says, “Your financial lot in life is going to be determined by how much revenue you generate and how much revenue you collect. That’s going to trickle down into the type of patients you see, the hours you’re asked to keep and the patient volume you’re expected to maintain. Those things are going to affect the flavor of your practice.”
At other types of practices, patient visits may represent only part of the revenue picture. These groups may see revenue from other services like imaging, physical therapy or cosmetic procedures. “In this type of setting,” says Mr. Bohannon, “it may be OK to lose money on patient visits because you’re making it up on the ancillary side.”
And if you’re in an environment that gets significant revenue from quality improvement efforts (think health systems trying to avoid Medicare readmission penalties), seeing as many patients a day as possible may actually be discouraged. “If you’re working for a value-based model,” Mr. Bohannon says, “you probably won’t be churning through as many patients. But you have to ask yourself if the bureaucracy is going to drive you crazy.”
Another pitfall for new physicians is scheduling. In her first job, back-up coverage (or the lack thereof) quickly turned into a major problem for Dr. Pendharkar. “I had to pick up 12 or 15 extra shifts without getting paid,” she recalls. “If somebody calls out sick, will you get called in to cover, and will you be paid for that?” If you don’t ask those questions up-front, employers might make such policies up as they go. “And once you’re already in a position, it may be tough—and even awkward—to negotiate a solution that’s in your favor.”
Dr. Kellerman also believes that schedules can be a minefield for physicians just starting out. “One complaint I hear from graduates is that they move into a town to share call with four other physicians,” he explains. “They think they’re going to be on call every five nights, but then two of those physicians leave. Now they’re on call every third night.”
That kind of situation highlights the need for new physicians to really delve into practice dynamics and culture. “You need to understand the situation you’re getting into and that it might change,” Dr. Kellerman says. “It’s not that anybody lied or anything like that, but you have to think through what could happen if something changes.”
Sometimes scheduling confusion can bleed into paid time off. Cory Fawcett, MD, a retired surgeon from the West Coast who specializes in financial and career planning for physicians, offers the tale of a colleague who—as an employee of a large group—received four weeks vacation. But when he put in a request for his final week of vacation one year, he was told he didn’t have any time left.
The problem? His group had asked him to spend a week attending a CME conference. “The practice wanted him to do this new thing in the office, so they pushed him to go to this CME program,” Dr. Fawcett says. “But they counted his time away as vacation time.”
A job you can grow in?
Another area new physicians should ask about: career growth. “It’s important to find an employer who’s committed to your career progression and understands your interests,” explains hospitalist Dr. Pendharkar. “Talk about what you see yourself doing in five or 10 years and make sure the employer can help you nurture those interests and achieve those goals.”
Good institutions, she adds, should be transparent about their advancement process. “You should feel comfortable asking questions about what that looks like,” she notes. And answers to those questions can reveal important details about the group you’re interviewing with.
“Is the organization in such disarray that it just wants to fill open shifts, or is there some sort of structure or organization to focus on aspects you’re interested in? Make sure you’re not just going to be a clinical workhorse and stuck in a monotonous position—and that you’ll have an opportunity to explore your interests as you discover them.”
If you want to do procedures, Dr. Kellerman adds, talk that over with any prospective practice to make sure such opportunities would be available—and that your group would support you.
“Find out who the competition is in town and whether you can get privileges for the procedures you want to do,” he says. “If you want to do OB, will there be a fight to get privileges? Will you have the support of the hospital, and what are back-up plans if you’re out of town?”
As Dr. Kellerman notes, “We have a lot of graduates who do colonoscopies, and they run into privileging issues with health systems that want everything referred to only certain physicians.”
As for finding a practice that will support your career goals, there’s good news: Groups of all sizes and types are doing a better job providing growth opportunities.
According to Mr. Bohannon, as health systems and other large organizations have purchased physician groups, they’re realizing that many doctors want more than just working as an employee. As a result, many are offering physicians opportunities outside of patient care.
Even smaller groups offer options for physicians who want to do more than see patients. “If you join a group,” explains the financial and career coach, Dr. Fawcett, “you won’t necessarily have to run a large practice. You’re sharing that responsibility with other people, and the more senior partners are probably going to run the practice. But as you grow, you’ll develop into that more senior person and you will slowly take on more and more of those controls.”
Edward Doyle is Editor of Today’s Physician.
Employee vs. self-employed
WHEN NEW PHYSICIANS are job-hunting, a few up-front choices will affect their entire job search. One is the decision to work as an employee or be self-employed. Do you want to only see patients in your first job, or do you want the responsibility of running and owning a group?
Many new physicians assume they want to be employed by a large group or health care system. After spending years learning how to treat patients, many think they want no part in running a practice or learning the business side of medicine.
“Are you a leader or a follower, an employee or an entrepreneur?”
Tommy Bohannon, vice president of Merritt Hawkins, a national staffing firm based in Irving, Texas, says that many young physicians he talks to are looking for a predictable income and a good work-life balance.
“They want to collect a paycheck every two weeks and not have to worry about management or business decisions,” he says. “They’re more concerned about time off, flex scheduling and job sharing.”
It’s a legitimate point of view, Mr. Bohannon points out, particularly given the challenges of running a medical practice today. “As an independent practitioner,” he explains, “you have a lot of responsibilities. You have to keep an eye on costs, staffing levels, supply decisions, rent and utilities, and collections. Dealing with payers is complicated, and if you’re not good at collections, you’re going to have a tough time.”
But according to Cory Fawcett, MD, a retired surgeon from the West Coast who specializes in financial and career planning for physicians, too many doctors may be rushing to decide to work as an employee. He spent most of his career in a small practice as a self-employed group owner.
“A lot of residents never stop to think about how they want to work,” Dr. Fawcett says. “Are you a leader or a follower, an employee or an entrepreneur? Are you an academic physician who wants to write papers, or do you want to see patients?”
Before you give a knee-jerk answer, Dr. Fawcett warns, think about what you’re giving up in terms of autonomy by working as an employee. (Dr. Fawcett is the author of “The Doctors Guide to Starting Your Practice Right,” with advice for physicians on finding a job and negotiating employment contracts.) If you choose to work as an employee of a large organization, he adds, “You will not be picking your nurse, the person who answers the phone or your next partner. These will all be choices your employer makes, not you.”
Rick Kellerman, MD, professor and chair of the department of family and community medicine at the University of Kansas School of Medicine in Wichita, tells residents to think about autonomy in terms of their own work hours.
“Under a productivity mode, the more patients you see in a private practice, the more money you put in your pocket,” says Dr. Kellerman. “That’s different from someone telling you that you’re seeing an average of 12 patients a half day, but you have to bump that up to 14. You start to think, ‘Who am I working for?’ ”
Time off is another area where the decision to be an employee or self-employed makes a big difference. While employees typically get a set amount of paid time off, that’s not always the case for practice owners.
In a private practice, Dr. Fawcett explains, physicians often have to pay a portion of the group’s overhead. Go on vacation, and that overhead still needs to be paid. “I used to joke that when I took vacation in private practice, I actually lost money because I was still paying my share of overhead and not earning anything. That pushes some physicians to never take time off.”