How to choose the right practice and love your job

Justin F. Klamerus, M.D., thought he would be content to remain at Johns Hopkins after his medical oncology training and join the hospital’s lung cancer faculty.

Like many young physicians, Klamerus’ plans changed, and he returned to his roots in northern Michigan, where he’s putting his skills and training to good use as director of cancer services for a collaborative group of cancer centers that includes Northern Michigan Regional Hospital in Petoskey.

Plans change for many reasons. Sometimes the reason comes out of the blue, or in an unexpected job offer, or when a young physician realizes a year or two into their first job that it’s not a good fit.

Choose the right practice the first time

Preventing a problem from occurring in the first place saves time, money and trouble for everyone, especially if a physician leaves soon after they’ve joined. “It’s really hard on patients, particularly with primary care providers,” says Bell. Often, it’s as simple as the weather or distance from home and has nothing to do with colleagues, patients or the work.

No matter the reason for the disillusionment, poor fit with both the employer and the community often can be prevented.

The best way for young physicians to prevent repeating mistakes made by those who’ve come before is to learn from colleagues and pause to prepare for job interviews and transition to practice.

“As with most anything in life, including when a medical student makes the transition from classroom learning to learning with patients, there is a big leap,” says Klamerus. “I think the same leap exists for young physicians entering their first job.”

Employers want to reduce physician turnover

Employers understand the damage caused by physician turnover. Keeping physicians happy is a big priority. And most physicians enter their first job searches with big ideas about long-term relationships.

Still, there are too many variables and unknowns for every first job to work out right.

“Most people have no idea what questions to ask, how to go about the process, and how to figure out for themselves what sort of environment they really want to be in,” says Lawrence D. Ward, M.D., MPH, FACP, an internist who recently began a position as vice chair for clinical practice at Thomas Jefferson University Hospital in Philadelphia and is current chair of the American College of Physicians Council of Young Physicians.

In his previous position on Temple University’s faculty, Ward helped conduct yearly meetings to talk with residents about timelines for applying and focusing on practice choices. He has heard young physicians talk about issues such as lack of support or flexibility in their first jobs.

Of course, it can be tough to make the transition from residency to practice, and that can be compounded when a job doesn’t turn out quite as expected, when expectations are misaligned, or when the community turns out to be a poor fit.

“You have to know the situation you’re getting into when you join a practice,” says Derrick R. Ward, M.D., a board-certified allergy, asthma and immunology specialist with Kansas City Allergy & Asthma Associates, P.A.

He has been with the five-physician practice—his first job—for nearly five years, and became a partner after two years.

When Derrick joined the Kansas City practice, he says he felt confident clinically, but less prepared for the day-to-day operational aspects of running a business.

“I feel like you don’t really get that in medical school,” he says. “You’re trying to learn everything else, and there’s not a lot of time to learn business at the same time.”

The best practice is preparation

Make the most of the support you have while still in residency to prepare for your job search and prevent some future surprises and disillusionment.

“Read articles that tell you the questions you need to ask and think about,” says Lawrence Ward. (See sidebar at right.)

Derrick Ward says it helps to talk with physicians close to your age who understand the current climate and who have been hired recently. They can help you understand average salaries and current bonus structures, relocation and how most practices handle weekend call with new physicians.

“You need comparable numbers and comparable experiences,” Derrick says. He adds that when he started looking for a job, he sent e-mails to graduated fellows he knew and talked to others. “And I have tried to do the same thing for people who have come to me after I left training.”

Deborah M. DeMarco, M.D., FACP, associate dean for Graduate Medical Education at the University of Massachusetts Medical School, says that her administrative director often helps young physicians out.

The university also offers practice management workshops for all of the university’s 500-plus residents to help with skills such as looking at a contract and what to look for in a practice.

Formal help from programs to prepare you for your job search and the reality of practice vary.

Klamerus says that the Association of American Medical Colleges has recognized the need for business training by putting forward core competencies that address system-based practice issues. How formal the business preparation is depends on the residency training program, says DeMarco. “For example, family medicine programs have as part of their accreditation requirements that they have to have a practice management curriculum.”

The recruiters and other contacts you meet when interviewing can also help.

“Obviously we all tend to sell our organization, but we’ve got to be transparent about what young physicians will experience when they get here,” says Bell. “Because if they get here and it’s not what they understood it to be, they’re going to leave.”

Once you start at the practice, it’s often up to you to seek help from mentors and others.

Derrick Ward says he is fortunate to have an excellent administrator who helped explain to him how to read financials, for example. Some employers have formal orientation and mentoring programs to provide resources to new physicians.

Bell says Corvallis Clinic believes in a team approach. “We have a group of people, not just a physician, be mentors to our young physicians,” she says. The formal program includes checking in with the physician regularly on issues such as staffing and information technology.

The clinic even provides new physicians a “cheat sheet” at the end of orientation with photos of key staff and contact information to make it easier for them to get help.

A practice development committee meets quarterly to review the young physician’s progress. You can take informal steps on your own initiative to garner similar support at a new job.

Take time to reflect before taking a new job

Katherine Pryor, senior physician recruiter for the UMass Memorial Medical Center in Worcester, says that in spite of repeated visits and discussions with physicians and their spouses, some just find the location unsuitable.

“We tell them to first talk to each other about where they want to be,” she says. For instance, do they want to be near their parents?

Bell says that the number-one reason her practice has lost first-time physicians is because they had moved away from their families.

Klamerus emphasizes that, before selecting practices to talk with and forming questions to ask, you should pause for self-reflection.

“I think a lot of young trainees make decisions to go to undesirable areas they don’t want to live in, their family doesn’t like, or that are too far from their family—yet they take the job because it pays well or because of some short-term gain from the decision,” he says.

Pryor agrees, adding that some young physicians “go for the gold” partly because of enormous loan debts. “I don’t know if they give enough thought to: Do I want to live here; can I get along with these people; do I want to work with these people?”

The self-reflection period before the search begins definitely should involve those most impacted by the decision, namely spouses. “We encourage physicians to bring their spouse or significant other to our practice management seminar,” says DeMarco. It also helps to include a mentor—the peer who can help keep you grounded in the reality of today’s practice and offer expectations.

Learn to move on when the job isn’t right

Self-reflection can help if you feel trapped in a bad first job, too.

Klamerus advises people to pause and “think about the reasons for their dissatisfaction, what those really are.”

Sometimes, there are issues that physician leaders can address, such as compensation or weekend time off. Other issues are not so easy to fix—like the area’s climate or geography.

“A job is not like a residency,” says Lawrence Ward. “You’re not locked into it.” He says young physicians should go into the job search with this frame of mind: If you get into the position and realize you have made a mistake, first try to work it out. But if you can’t do so professionally, realize you can leave. Ward says knowing it’s OK to change takes some of the pressure off.

“They feel so much anxiety in choosing that first job, and they want to get it perfect. Sometimes it’s just not perfect. And sometimes it’s necessary in a professional way to change jobs.”

(Before you make a decision to restart job search, do be sure you fully understand the implications of ending your agreement.)

Self-reflection can also help you decide if any disillusionment is from general adjustment to practice or specific to the practice, colleagues or situation.

Unless you based your decision purely on compensation or geographic location, there probably were some characteristics about the practice and physicians that attracted you in the first place, and it might be time to reflect on those as well.

If the decision was based purely on compensation, that’s a lesson for your next search.

Derrick Ward warns against making a decision based purely on geography if possible. He says young physicians who do should be sure they have not signed a contract with a non-compete clause. “These can really hamstring you if you leave the practice; there’s a good chance that you’ll have to leave town because the clause can lock you out of the geographic area.”

Most of all, physicians who are unhappy should work with the practice to correct whatever is fixable and maintain the same openness and transparency that’s most valued during the job search, even when departing.

With all that Bell orchestrates at Corvallis to help new physicians, some still have issues, but remain silent about their concerns.

“I check in often with new physicians,” says Bell. “I invite them to my office for coffee, have lunch with them; we talk a lot. In spite of that, I occasionally get people who are unhappy after 18 months, but have never said a word.”

Bell says that all young physicians should talk about their concerns and give the organization an opportunity to fix things for them. She adds, “You need to be really frank with people about how things are going for you, and if they’re not receptive, you’re in the wrong place.”

Klamerus says that carefully thinking about long-term goals before the initial job search can help prevent much turnover among young physicians. “What are your five-year, 10-year and 25-year goals?” he says. “It sounds cliché to say that, but it should be in every part of the decision you make.”

And if the first job doesn’t work out, Klamerus adds: “Life is too short to be in a job that you’re not fulfilled by. You should remedy that because you won’t be good to us if you’re not satisfied.”