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Subspecialists lead revitalized market for residents

While cardiologists are leading in salaries, generalists are still in demand—in select parts of the country

From the December 1999 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.

By Phyllis Maguire

Despite dire predictions of a physician glut, residents are discovering a healthy job market.

Recruiters acknowledge that today's residents receive fewer job offers than job-seekers two years ago, with almost 25% now receiving 10 or fewer solicitations. But they also point to a booming job market for subspecialists and a healthy market for generalists outside of major cities.

Subspecialties bounce back

The big news this year is the strong rebound in subspecialty opportunities and salaries.

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Openings for subspecialists declined sharply through the 1990s, due in large part to the growth of gatekeeper models and discounted fees. But now, the growing popularity of open-access insurance plans allows patients to see more subspecialists without a primary care referral. That has created new opportunities nationwide for fellows entering the job market.

There are signs too that subspecialists are filling vacancies left by older physicians, who seem to be opting for early retirement more frequently than primary care physicians. Frustrated by slashed fees and administrative hassles, a number of subspecialists are stepping down after 15 or 20 years, leaving the field open for younger colleagues.

"But don't expect that trend to continue indefinitely," said Roger G. Bonds, executive director for the National Institute of Physician Career Development in Atlanta. "Early retirement in a few years should level off and positions will get filled around the country."

Subspecialist salaries have not yet bounced back to the historic highs seen earlier in the decade, but analysts point out that this too helps account for subspecialists' popularity. Because subspecialist pay has leveled off, payers and employers can now afford to hire more new fellows.

Cardiology is now internal medicine's most intense subspeciality recruit, and practices are willing to pay starting cardiologists "numbers that have just gone off the map," said Mark E. Smith, a vice president of Merritt, Hawkins & Associates, a Dallas-based physician recruitment firm. "In non-urban locations, starting cardiologists can expect nothing less than $250,000, going up to $325,000. In urban settings, the range would be $175,000 to $225,000." These 1999 figures represent a 4% to 6% salary increase over the previous year.

Gastroenterologists and hematologists/oncologists are also in demand. Gastroenterologists can expect starting incomes of $133,000 to $220,000, with a median of $160,000 (an increase of more than 5% between 1997 and 1998). Hematologist/oncologists are being offered from $146,000 to $200,000, a 9% boost.

The importance of geography

While the job market in primary care isn't quite as robust, generalists are still finding good positions, particularly when they look outside of cities. Primary care opportunities are also more plentiful in the south and in the Midwest than along the coasts.

Husband-and-wife internists Tresa A. Teehan, ACP­ASIM Associate, and Robert G. Teehan, ACP­ASIM Associate, learned the value of location when they were looking for work last spring. The couple, who were both trained at Milwaukee's Sinai Samaritan Hospital, wanted to work in the Milwaukee suburbs, she in part-time primary care, he in urgent care or occupational medicine. It took only four months for the pair to get positions, but instead of being close to Milwaukee, they now live and work 90 miles away in Manitowoc, Wis.

"We would have loved to have stayed closer to the city for the shopping and the amenities," Dr. Robert Teehan said, "but the jobs just weren't there."

Experts point out that urban opportunities for generalists do exist, but that the salaries are lower. "Instead of making $160,000 that first year, you're looking at perhaps $115,000 or even lower," said recruiting expert Mr. Bonds.

Practices in outlying areas are also more likely to offer appealing incentives, like the $25,000 signing bonus the Teehans both received. (Signing bonuses are common, though they typically don't run that high.)

One of the most enticing carrots residents are being offered is loan forgiveness, where employers pay down student debt, typically over a three-to five-year period. Such offers are rare in major metropolitan areas, except for hard-to-fill positions in inner-city areas. Other incentives may include extra vacation time or a hefty CME budget, amenities that aren't typically offered with city jobs. Relocation allowances are also standard and average about $7,000.

And some employers are offering incentives to start the process early. Practices may offer stipends of $5,000 to $10,000 to residents willing to sign on a year before graduation.

More remote positions can offer another big plus: more freedom from managed care constraints. According to a survey by Merritt, Hawkins & Associates, more than half of all last-year residents would prefer to not work in a managed care environment--a pipe dream if you're going to practice in a city. In some parts of the country, such as California, that expectation is unreasonable even for positions more than 100 miles outside major metropolitan areas.

Physicians who take lower salaries to stay in cities typically work for large health care systems like Kaiser Permanente. "Kaiser pays much less, but physicians know that they are going to have a very structured environment," said Mr. Bonds. "They also know that, for the most part, they can practice medicine and not have to worry about the business side. That's a very big perk."

International medical graduates

While international medical graduates (IMGs) who are permanent residents are able to find jobs, the market is increasingly tight for those holding temporary visas.

For IMGs with J-1 (graduate exchange program) visas, the situation is particularly tough. According to a spokesperson for the U.S. Department of Agriculture (USDA)—the federal agency that processes J-1 waivers for medically underserved rural areas—waiver requests have fallen to about a third of what they were two years ago.

Several factors are behind that steep drop, including fewer underserved areas and stricter waiver requirements. Employers must now prove that they extensively recruited physicians who are citizens or permanent residents before they can request a waiver, and each employer can now request only two waivers per calendar year.

And H-1B (professional worker) visas that allow IMGs to avoid waiver issues are increasingly hard to get. Hospitals are reluctant to process the paperwork to sponsor H-1B visas for incoming residents, and foreign computer programmers being hired by American companies now compete with incoming IMGs for the limited number of H-1Bs. While some analysts speculate that competition for H-1B visas may relax once Y2K is history, others believe that the influx of foreign programmers will not abate as long as the American economy stays strong.

The result is a precarious job market for IMGs with temporary visas. Lazaros A. Nikolaidis, ACP­ASIM Member, opted for a fourth year of cardiology fellowship at Pittsburgh's Allegheny University Hospital when his third-year job search proved disappointing.

According to Dr. Nikolaidis, who earned his medical degree in Greece, IMGs should expect to get offers much later than U.S. graduates do. They are also likely to spend several months in employment limbo while a waiver request is processed or one type of temporary visa gets converted to another. "It is really an exercise in nerves," Dr. Nikolaidis said. "It is completely a buyer's market, and there is very little room for negotiation."

For IMGs, even more than for U.S. graduates, it is crucial to start looking early.

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