American College of Physicians: Internal Medicine — Doctors for Adults ®

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Tips on finding a first job you'll want to keep

Sorting the Prince Charmings from the frogs takes research—and realistic expectations

From the July/August 1998 ACP-ASIM Observer, copyright 1998 by the American College of Physicians-American Society of Internal Medicine.

By Maureen Glabman

SAN DIEGO—If you're getting ready to look for your first job, start early, do a lot of research—and don't be surprised if you still don't end up working in the practice of your dreams.

At an Annual Session presentation this year on how new residents and fellows can find the right jobs, panelists said that first jobs often serve one purpose: helping new physicians ferret out the positions that aren't right for them. As a result, the panelists said, first-time job-seekers can expect to kiss a lot of frogs before meeting their Prince Charmings.

Linda Hawes Clever, MACP, editor of the Western Journal of Medicine and chair of the department of occupational health at California Medical Center told the audience that about 40% of new physicians change jobs after their first year out of training. Patrick Molloy, a consultant specializing in physician careers from Manhasset, N.Y., explained that the high turnover rate is due to new physicians taking jobs with incomplete or erroneous ideas about their patient care duties and their roles in the group.

By knowing what to ask potential employers, however, you can avoid the trial and error process encountered by many new physicians—and maybe even find a job you'll like. Here are some factors to keep in mind to avoid making a bad decision:

  • Timing. Panelists advised residents and fellows to start job searching at least a year before they want to begin practicing. Groups looking for doctors start to interview six to 18 months before they need someone, according to surveys by the Medical Group Management Association, a trade organization for group practices that is based in Englewood, Colo. In addition, remember that it can take six months or longer to get a medical license in some states and three to six months to get credentialed by some HMOs.
  • Options. Before you go to your first job interview, consider all the practice options available and the practice setting that most appeals to you. Mr. Molloy said that besides traditional careers, there are also hospitalist jobs, positions with HMOs, government jobs, and positions in managed care organizations and nursing homes. Even part-time work is becoming more accepted, Mr. Molloy said.
  • Location. Define your ideal location. If you love to ski and a great job is available in Florida, you should probably think twice before packing your bags. There may also be family considerations. Before deciding that an area is right for you, look at real estate listings to make sure there is affordable housing. Also inquire about schools for your children and the availability of loans to buy a house.
  • Recruiters. Finding the best practice opportunity requires research, which is why many physicians work with recruiters. While recruiters are perfect if you have waited until the last minute and can't job hunt because you're studying for the boards, there are downsides. For one, recruiters receive 20% to 25% of your first year's salary. While that fee is usually paid by the employer, Mr. Molloy said it gives recruiters a powerful incentive to talk you into a job that may not be perfect for you.

"Be careful," said panelist Douglas Hegstad, FACP, chair of the division of ambulatory care at Riverside General Hospital in Riverside, Calif. "Back when I was looking for a job, a recruiter told me about a glowing opportunity in a town in Virginia. When I went to look at it, I found none of the doctors in town were interested in having me start a practice." Dr. Hegstad said that despite resistance from local physicians, the hospital was anxious to have another internist admitting patients—and the recruiter wanted a fat commission.

In addition, recruiters sometimes will ask you to sign an exclusive contract, an arrangement that limits your ability to sign up with more than one recruiter. Experts, however, warn against signing exclusive contracts. "Sometimes recruiters don't deliver," Mr. Molloy warned. (To find a recruiter, call the National Association of Physician Recruiters at 407-774-7880, or go to its Web site at www.napr.org.)

  • Contacts. If you prefer not to work with a recruiter, start by cultivating relationships with physicians in areas where you want to work. Get to know local pharmacists, surgical equipment dealers, hospital personnel, pharmaceutical representatives, medical support staff, and state and county medical society workers. These people know who's retiring, who's expanding and who's moving. They will also be able to help you assess the value of each opportunity.

Other sources of opportunities include the classified ads in medical journals and trade magazines and on the Internet. To find Web sites that post physician positions, go to a search engine like Excite (www.excite.com) and type in the keywords "physician" and "employment."

  • Interviews. Once you find a practice that is worth an interview, be sure to bring your spouse. Mr. Molloy said that most groups will pay for a spouse's visit for one simple reason: Physicians frequently leave practices because their spouses are unhappy.

Your success at any job is based on how well you work with the people you are joining and how much you share their philosophy of medicine. As a result, physicians considering working at a small group should make it a point to meet all their potential partners.

It's also important to find out who owns the practice or organization you're thinking about joining. "If you're getting promises the group will buy equipment and build new facilities," Mr. Molloy said, "make sure the promises come from the owners. They are the only ones who can make good."

And if you're considering working for a large group, talk to the administrator and other physicians who work in your specialty. Large groups typically mean less paperwork, more fringe benefits and expanded opportunities. The downside is less income and less individual control over patient care, Mr. Molloy said.

  • Incentives. Half of all recruiting today is for internists and family practitioners, Mr. Molloy said. Demand is so high that most new internists will likely be offered financial incentives such as payment in part of an educational debt, a signing bonus of between $10,000 and $15,000, or financial help to set up shop in an underserved area.

Unfortunately, these incentives come with commitments that may be difficult to break. If you want to leave these practices, for example, you may have to pay back your incentives with interest or up to $10,000 to help recruit your replacement.

  • Attorneys. Most doctors sign employment contracts without benefit of legal counsel. Of those physicians who do use attorneys, many rely on a relative who works for free—but who also has no experience in negotiating medical contracts.

Mr. Molloy recommended hiring an attorney who resides in the state and region where you plan to practice. He also said that the attorney should be familiar with physician employment contract negotiations, not just contracts. State or county medical societies can usually help find a good health care attorney.

Before you sign any paperwork, talk about fees. Lawyers usually charge anywhere from $150 to $400 per hour. To avoid sticker shock when you get the final bill, ask your attorney to tell you when your bill reaches $1,000, $2,000 and so on. While legal fees can be expensive, Mr. Molloy said that the money spent on an attorney is often recouped in extra salary or benefits gained in the negotiation process.

  • Bonuses. If you will earn any kind of bonus or extra pay for productivity, ask the practice to put in writing exactly how—and when—you'll receive that compensation. Also make sure to ask what happens to your pay after your first year.

Typically, you'll receive a salary during your first year. If your salary after that is based on productivity or how much income you generate, ask how patients are allocated, how many hours you will be expected to work and whether pay is based on utilization guidelines and patient satisfaction surveys.

  • Duties. Patient care duties must be clearly spelled out, particularly when it comes to responsibility for call. Dr. Hegstad from Riverside General told of one internist who joined a three-person group and signed a contract stating that she would accept "reasonable call." Since she was new, he explained, the established physicians felt it reasonable she should take half of call duty, with the other three splitting the balance.
  • Benefits. Health insurance and vacation pay are usually automatic benefits, but make sure the employer will also pay for life insurance, disability, relocation and malpractice coverage. One key with malpractice insurance is to be sure the employer will pay for tail coverage, which covers you in case you decide to move on and a patient from your previous practice decides to sue you years later. Other benefits open to negotiation include medical society dues, journal subscriptions, time off to pursue continuing medical education (CME), coverage of CME expenses, hospital staff dues, auto expenses, cellular phone and pager costs, and pension or profit sharing.
  • Getting out. The terms of resignation, severance and termination must also be clearly stated. Many contracts include restrictive covenants. Typically, these clauses state that if you leave, you may not set up practice within a specific geographic distance for a certain period of time. According to Mr. Molloy, at least 38 states enforce such agreements, whereas states like California tend not to enforce them. The best bet is to try to get this clause stricken from the contract. If it can't be stricken, try to have the restrictions reduced.
  • Going solo. Finally, physicians brave enough to start or buy a practice face many more caveats. They must be aware of local population growth, changes in area demographics and changes in the physician population serving the area. If you are buying fixed assets such as real estate and medical equipment, have the practice assessed by a qualified appraiser. Will the seller stay on for at least three months, preferably nine months, to assist you in converting patient loyalty, referral patterns and hospital privileges?

Solo practitioners must also know how to set fees. "New physicians tend to undervalue their services, which makes it hard to increase fees when you realize how much it takes to run a practice," Mr. Molloy said.

Maureen Glabman is a Miami-based writer who specializes in health care.

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