Things I wished I knew during my first job search

[anonperson]

For the residents/fellows starting to search for jobs or are in job negotiations, I thought I would post some of my experiences/mistakes/near misses. I had a situation where I nearly got screwed royally but got very lucky and wouldn't want these things to happen to other residents/new docs

I'm hoping others can post their thoughts/experiences.
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1. Be very wary of a job where there is a retired physician owner/administrator and they have physician employees.
-You will never have access to the books and you never really know how much you are generating etc
-In these situations, it is not uncommon for the owner to have family members who are "employees" who are collecting a paycheck while not doing anything.
-I joined a practice set up exactly like this. A retired OB GYN who had hired a few other doctors. I joined due to a stable salary structure and wanting to be close to my parents etc.
-He was collecting a salary as an administrator doing jack $hit. So was his wife and kids although this was not explicitly stated, but known throughout the office. I slowly learned that he had some family friend on payroll etc. We were paying for the whole damn family.
-There is no equality in this situation and the party line will always be to work harder and longer because the people at top make more $$$$
-In my experience and in talking with some friends who got into similar situations, these practices will likely fall apart/fail. Everyone needs to pull their weight.

2. Supervising midlevels sucks
-As a rule, they are not great. Sure a few may be semi competent but that is only with careful and close supervision
-Generally, if you are an employee and are being asked to supervise a midlevel, it is only to take the fall if there is any mismanagement on their part
-The scam is there are usually multiple midlevels who are seeing a ton of patients and you will be signing off on a certain number of charts. Even if you review 20% of them, that is 80% unaccounted for that they can and will mess up.
-Remember it is your reputation on the line and you are the big fish if a lawsuit occurs. Get enough lawsuits/judgements, you can't get malpractice insurance.

3. If you have claims made malpractice insurance, do everything possible to make it so your employer covers your tail
-I stupidly signed a contract where I was responsible for my tail since my malpractice was claims made (no occurrence policies for my specialty)
-The practice I was apart of collapsed after ~6 months.
-My tail was $23,000
-This is having been out of fellowship for only 6 months and I had never been named in a lawsuit in residency/fellowship/or in those six months in practice.
-It's not a huge amount, but for a new attending, to pay $23,000 is bull$hit and a hit to the bank account. Basically a huge scam from insurance companies
-These tails are 2.5x your mature premium. Depending on your specialty this can be anywhere from $15,000 to $100,000. The guys I worked with had tails of ~$70,000. Think about this when choosing a job.
-At this point, I would never take a job where my tail wasn't covered.
-I was lucky in that I got my next employer to pay my tail

4. When interviewing at a practice, make sure to talk to most if not all of the physicians
-When I interviewed for my position, I talked with one of the physicians (Doctor A). I was told that I would be replacing one of the other doctors (Doctor B) who they didn't have me talk with. I didn't think that was a big deal.
-After I signed my contract, I found out that actually Doctor B was sticking around but Doctor A was actually leaving
-He had no real incentive to be forthcoming. He didn't lie to my face exactly but it would have changed how I did things

5. Make sure there is a termination clause with and without cause
-Usually termination without cause requires giving notice, anywhere from 30-90 days.
-My contract had no termination without cause statement, so I was essentially stuck. I could only get out if the practice terminated
-I figured it was a steady paycheck but I had signed a 3 year contract.
-Bad mistake on my part. I got lucky the practice dissolved.

6. Try to have your contract spell out call coverage and clinical duties etc.
-When the group was in the process of falling apart. It went from 4 physicians down to 1 (me).
-The group owner tried to strong arm me into taking call 10-12 times a month so he could keep things going while he tried to recruit/trick another physician to join the practice
-Luckily this was spelled out in my contract (maximum call numbers etc) and I told him to f$ck off and just fire me so I could search for new employment(on the advice of my lawyer). He was stuck and he knew it.

7. Be aware of how PTO is calculated and reimbursed if you leave the practice
-When the group dissolved and we got our last paychecks, my PTO was conveniently not included. My employer initially claimed it was a mistake. He then tried to state that since the PTO was being accrued I had only earned half of what was stated in my contract and based on my time off, he only owed me for like 2 days of PTO when in actuality it should have been 10 days worth of PTO.
-Per the state of California, PTO has to be paid out immediately, so I had to threaten him with a labor law complaint/violation (which would have cost him $$$$ on his part)
-That fear finally got him to pay up. It was several thousand dollars. Not a life changing amount but honestly it was the principal of the situation.
-I only knew this after talking with my lawyer

8. Have an employment lawyer review your contracts etc
-It can be expensive but is worth it

9. Do not underestimate the ability of other physicians to try to royally screw you over
-The level of greed of some of these guys is ridiculous
-If the guy who owned the practice I was apart of wasn't such a greedy prick and trying to work people to the bone, he could have kept the practice going indefinitely. But he got greedy and basically couldn't get a steady supply of physicians to join the practice due to the turnover.

10. Chances are your first job will not last
-You may get lucky and find a great job that you will stick with but most likely not
-Be mentally prepared for this
-Understand if there are non compete clauses in your contract that put some type of geographic limitation if you end up leaving
-Also understand if these are enforceable where you live
-Thankfully for myself, they are illegal in my state

11. Check your 401K matching vesting schedule
-Sure your employer may have a great 401k match, but there will be a vesting timeline
-Make sure you know what that time frame is because it can be 3-5 years. If you leave after 1-2 years, you may only be eligible for like 25% of the matched amount and not the full amount.

The above is in no specific order but just some thoughts.

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[Green Man]

Agree with all of the above and here are some more points to add...

## Job search
- You do NOT need a recruiter to look for a job. You can find all the jobs yourself. Practicematch and practicelink are some examples. Ask your attendings/connections about academic jobs that may not be advertised. Avoid the advertisements from 3rd party recruiting companies. Usually they describe high $$$ to lure you. Contact IN-HOUSE recruiter directly.

Remember 3rd party recruiters get paid 10% of your first year salary. Your future job will deduct it from your sign on bonus, etc.

## First contact
- Very important to know what are the absolute requirements in a job for you. Eg, malpractice with tail coverage, certain call schedule, inpatient or outpatient
- If you like the job description, you may send your CV and application. If you are not sure, just call or email in-house recruiter with 3 main things that would make or break your application. For example, if they don't offer tail coverage, you don't need to waste time applying/having interviews

## Turnover rate
- Ask the physician/recruiter how's the turn over rate over the last ten years. You will be surprised by the answer. One physician started telling me how people leave due to certain issues and he himself is bitter. If I didn't ask that question, everything sounds like rainbows..

## Money talk
- To avoid wasting time, make sure you know the salary range prior to site visit. Ask the In-house recruiter or physician that interview you on the phone.
- Of course they will have room to negotiate after your visit. But if it's $80,000 difference from the beginning, you know you're not gonna get that.

## Who you meet on site visit
- Be Ware of places where only old founding physicians meet you and young new hires trying to avoid you or not given opportunity to meet. Maybe they are busy or don't want to tell you how bad the place is.

## Letter of Intent
- Start negotiating with LOI. Even though it's not legally binding, you lose leverage when you agree to base salary, number of shifts etc in LOI.

## Contract review
- Hire a Healthcare attorney from the state (of your job). Every state has different laws.

## Negotiation
- Be polite but assertive. No matter who it is, CEO or regional director, don't be intimidated. They WANT you.
- Don't fall into trap that the first contract offered to you is standard for the organization. If it's a bad contract, it's a bad contract. If it does not describe your shifts, paid time off, you won't get whatever you were promised by dozens of people you met throughout the interview.

 

[captaincrunch]

I think the advice above is very good. I would add a couple of things to the list. I apologize for the rambling, stream-of-consciousness nature of this post:

Make sure it's a good clinical practice. This should be numbers 1, 2 and 3 on your list. Would you receive care from your prospective colleagues? If not, run! Joining a well-respected, high-quality practice is perhaps the most important things to look for. I would accept a lower salary in order to join a group I genuinely like. If you can, ask some local doctors what they think about your prospective group. This is much easier to do if you trained in the geographic area or know someone from there. Don't work for shady operations.

Know what is important to you. What are you most concerned about? Geographic location, pay, work hours, procedures? When you're looking for work and negotiating a contract, don't get to caught up on things that don't matter as much to you. It might be worth a lower salary if the work hours/call allow you to have more free time, for example. This seems kind of obvious, but people often get too focused on salary and don't think about other things that matter to them. It's good to know ahead of time what matters to you.

Appreciate the difference between large and small groups. Smaller/independent groups will have much more leniency in terms of negotiating your contract. Larger, multi-specialty groups will have less flexibility. I work for a large group, so certain aspects of my contract were negotiated by my specialty collectively. We all have the same call responsibility, RVU bonuses, benefits, etc. There isn't really any room for negotiation on these until the next contract renewal. Many salary guarantees are actually provided by the hospital and/or foundation, rather than the group itself. There are some laws/regulations regarding how the money can be paid, so be aware of the local laws.

Don't forget about the hospital. This applies more to specialties that do work in the hospital. Make sure you like the hospital, and not just the group. A good interview should include meeting the hospital leadership, as well as the managers you would interact with. If you're a surgeon, make sure you meet the leadership in the OR (including the nurse managers), even if they don't work in your group. You're going to interact with these people a lot, so it's important to get a good vibe from them.

How does advancement work? Is this a strict employment contract or a partnership tract. If partnership is possible, what is the timeline? What is the buy-in? If it strict employment, how does advancement work? What kind of leadership roles are expected after 2-5 years? If the field is a procedural one, will you be able to bring new/different procedures to the hospital.

Hire a lawyer. In general, I would conduct negotiations yourself, but you need to understand the deal in front of you. While certain aspects of a contract are easy to understand (pay, benefits), others can be hard to. For example, is it clear what happens if you leave a group voluntarily vs with cause? Do you know what happens if someone makes a complaint about you? If not, have a lawyer walk you through it. They can make recommendations on what to ask for. It's more polite to ask for changes yourself, but having legal counsel is worth the money. The practices have their own lawyers; you should too.

Most "contract negotiation" lectures given by faculty aren't too helpful. Most teaching hospitals have a couple of these a year. If they're taught by a university faculty member, they probably don't really know what to look for. Take their advice with a grain on salt. Sometimes, they bring in someone from the outside, which may be helpful, but in general I found these talks lacking. Unless of course you're looking for a faculty position, in which case the process is vastly different.

Carry your own disability/life insurance. At least when you're young, you should be insured against these horrible events. This is particularly true if you have a family. Once you have built real wealth, you may be able to back off this (warning, I am not a financial advisor), but when you're starting out make sure your coverage can follow you.

Understand that some things can't be spelled out in a contract. Are you joining a practice that takes ER call? Your group may be contractually (and ethically) responsible for providing coverage 365 days a year. Let's say a senior parter abruptly dies. You and your other parters will have to pick up the slack until someone else can be hired regardless of what your contract says. That's part of being a doctor. What if there is some big shift in the local practice environment and your practice now covers another hospital? Guess what? You'll be working at another hospital, regardless of what was initially promised.

The only thing I disagree with above is the comment about mid-levels. I've worked with a number of mid-levels and in the appropriate setting they can really help. This is particularly true if you're in a procedural field that takes you off the floors for periods of time. Mid-levels can now bill independently. There is absolutely no reason to claim more involvement in a patient's care than you actually provided. But, if you dislike working with mid-levels you can try to avoid it. The use of NPs and PAs seems to be expanding so I suspect we'll all have to get used to it.