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What doctors wish they had known

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Brooke BuckleyWhen Brooke Buckley, M.D., was searching for her first position as a general surgeon in 2007, she didn’t appreciate how important it was to make the organization’s future plans a focus of the interview. It didn’t cross her mind to ask about the direction of the organization, much less how her surgical role might be modified in the future.

Turns out that one system’s plan for regionalization—funneling patients from small outpost hospitals into big medical centers where services and doctors are consolidated—would significantly influence the types of cases she would be treating in the future. And that wasn’t the direction she wanted her career to take.

You’re looking for a job that utilizes your skills, fulfills your drive and lets you grow as a physician. What could go wrong? Plenty, if you’re not on the top of the job-search game.

Admittedly, you can’t unearth every nuance about a place until you’re actually part of it. But you can learn a bevy of lessons from others who enjoy the benefits of retrospect. What should they have asked or done that they didn’t ask or do to get the most from their interviews and site visits? Their hindsight could prove great foresight for you!

Job search: Don’t miss the basics

Conducting a thorough job search is critical in realizing your professional dreams. You want to have enough opportunities to weigh your options and enough information to get an accurate picture of each one. But what did physicians who have already transitioned from training to full-fledged practice fail to do or notice in pursuing their own positions?

One piece of advice echoed by many is to pay closer attention to the tactics necessary to structure a productive pursuit: Begin early to target the best options, conduct due diligence and negotiate a good deal. Additionally, don’t be afraid to widen your search to options normally below your radar. Even though your dream practice is on one coast or the other, it may be worth your while to listen when a hiring team from an institution elsewhere in the country calls. By recalculating your GPS, you might uncover a very satisfying career in a place you never anticipated. As one physician noted: “The landscape of your work and home life becomes dramatically different as you finish training and jump into your first job. So it’s worthwhile to be open-minded…to explore situations that may have seemed unorthodox in the past.”

Christian Millett, M.D., knew he was a city person who’d likely end up in a metropolitan practice after graduating from residency in 2011. Even so, he wishes that he had extended his potential options to a few rural opportunities—if for no other reason than comparison. Instead, Millett added Boston and Philadelphia to a list of possible locations when Washington, D.C., didn’t yield enough choices initially. Later he’d circle back, eventually finding a great opportunity with The Dermatology Center, a Germantown and Bethesda, Maryland-based practice with an office in D.C. But at least he had broadened his market by looking elsewhere. “You have to expand your search,” he says, “if things aren’t popping up exactly the way you’d like.”

Once you’ve spotlighted a place, don’t be shy in nailing down the business particulars of your search. Your life will be less stressed if you can muster questions such as “How much time does hiring usually take?” “What people or committees are involved?” “What can I expect going forward?” Clarify the reimbursement policy for site visits while you’re at it to save yourself a surprise in the end.

Joaquin J. Garcia, M.D., would be much more inquisitive today about the hiring process than he was when he first joined Rochester, Minnesota-based Mayo Clinic in 2009 as a surgical molecular pathologist. Granted, his offer came within days of interviewing for the job. But since employers can’t always pounce on plum candidates quickly, it’s worth your peace of mind to know the next steps. Now as Mayo Clinic’s vice president of recruitment, as well as assistant professor and vice chairman of laboratories and medical director of the histology laboratory, Garcia notes: “People often feel they should know within a month if they’re getting the job. But by understanding the timeline and the layers of scrutiny, you can take a little pressure off yourself. You’re freed up to look at other opportunities.”

Rick NgoSite visits: Make them count

A Skype or phone interview can help you decide if you want to pursue an opportunity in earnest. A site visit, however, yields the kind of nuanced information about space, technology and coworkers best acquired face to face. Yet what did physicians who’ve navigated this terrain before miss that you should target during your visit?

Besides physically touring as many places in the community as possible, job-search veterans say they wish they had focused less on the physical plant and more on the people. Yes, it’s important to scope out infrastructures and layouts. You want to know if the technology to support your specialty exists and, if not, how you get it. But meeting, talking to and getting a sense of your potential coworkers is value-added information you shouldn’t let pass.

Rajneet Lamba, M.D., found the standard meet-and-greet visits informative and pleasant in 2009 as he identified his position as hospitalist/assistant site director for Tacoma, Washington-based St. Joseph Medical Center. Yet shadowing other physicians could have demonstrated how they collaborate and navigate key technology, such as EMR. “It would really have given me insight into what day-to-day practice might be like,” he says.

Indeed you’ll likely need to do more than swoop in for a few hours with the hiring physicians. Even if the partners come across as trustworthy, you should meet the other doctors just to see whom you might turn to for a second opinion or help in building your skills. Also, by being in the environment, you get a sense of the environment. If all hands are still on deck long after their shift has ended or staffers seem edgy with each other and cool to patients, it may not be the most productive place to work. Then again, your fact-finding could reveal people committed to good medicine and quality of life balance.

When Lena B. Palmer, M.D., MSCR interviewed at Loyola University-Chicago Stritch School of Medicine in 2011, she made sure during her site visit that she had identified the support mechanisms related to her academic tasks. She recommends doing the same due diligence about your clinical responsibilities. In addition to being an assistant professor, this gastroenterology-epidemiology subspecialist would be treating patients in Loyola’s Maywood, Illinois-based clinic. So while she wasn’t shy in asking fellow physicians if they had appropriate resources, talking to nurses, nurse managers and other ancillary staffers would have been helpful, too. “At the end of the day,” she says, “if you’re bogged down doing extra administrative work, or you don’t have people to help you in other ways, you can’t focus on your career priorities.”

During her first job search, Buckley, who is now director of Acute Care Surgery at Annapolis, Maryland-based Anne Arundel Medical Center, concentrated on the surroundings: What was the shape of the OR? How bright were the lights? Did the linoleum floor have cracks? At the time, scoping out the physical environment seemed important, albeit in hindsight was “very superficial.” So during her next search, she paid less attention to the facility per se and more attention to the professionals in it. By focusing a keen eye on her future work mates, she had a much better gauge of the culture and cohesiveness of the group. “In the middle of the night, whether or not you have a shiny floor in the OR isn’t as important as having a nurse who’s happy to be there, pulling your instruments,” Buckley says. “That was kind of lost on me in the beginning. But now I understand that it’s very important.”

The interview: Dig deep

Because the mission of any interview is to get a job offer, you want to do everything in your power to convince the hiring physicians that you understand the practice’s needs and are a great fit. At the same time, you want to cover your own issues. But what did physicians who’ve maneuvered interviews in the past overlook that you should set your sights on?

While focusing on the physical and technological plusses of each potential employer, it can be easy to take your eyes off another ball—the stability of the practice and your future finances. New physicians should pay less attention to the immediate money and more to the longer-term deal and prospects for building a successful practice. That requires getting the inside scoop on compensation models as well as future salary increases, bonuses and restructured deals. How will they be figured? And how would production and the payer mix factor into earnings?

Even as the Affordable Care Act changes the payer landscape in ways not yet fully understood, you need to know how private pay versus Medicaid and Medicare might figure into your caseload, collections and ultimately your pay. And with compensation often reliant on the traffic you generate, make sure that you’ll see your fair share of new patients and that there’s room for your skills.

After completing his general surgery residency in 2003, Rick Ngo, M.D., FACS, snagged his first job at a busy Houston practice. Because the doctors pitched the need for an extra surgeon, he thought he’d be tapping into their patient overflow—in addition to his own new cases—in building his practice base. That, however, was not the case. He was more dependent on generating his own volume than assuming their extras. When Ngo moved on seven years later to his present Houston practice, Southwest Surgical Associates, he not only knew enough to press about patient allocation, but also had established a positive reputation in the community—so netting a stream of new cases wouldn’t be an issue.

“I’m glad that I built up my own base,” Ngo says. “But I wish I had done a better job during that first search in determining how I was going to build my clientele. It was an important lesson that I think every new doctor needs to learn.”

Lili Lustig, D.O., ACOFP wishes now that she had focused like a laser on how future rewards would be calculated when negotiating her first job in 2012 at South Pointe Hospital based in Warrensville Heights, Ohio. As a soon-to-be faculty member of the hospital’s expanded osteopathic family residency program, she wasn’t concerned about the formula her bosses would use to decide such items as salary increases and bonuses. But how would production figure into the mix, especially since her time is divided between clinical and educational pursuits? Although tracking patient traffic is relatively easy to quantify, precepting family medicine residents is trickier to measure. “I didn’t really understand how someone’s value is determined—nor did I ask,” she says. “But you really need to know so you have a sense of what the future holds.”

Whatever the situation, you want to corral as many details as possible. No topic is too small to entertain during the interview and request in the contract. Make it clear, for instance, how you’ll be sharing overhead, especially if you don’t do the niche high-tech procedures your partner is skilled at or you’re not in the office every day. Do you expect the organization to cover your continuing medical education or professional fees? And even though partnerships and buy-ins are routine interview grist, get the timing in writing. Conversely, learn how the non-compete clause really works.

When Michael Pokabla, D.O., was searching for his first glaucoma position in 2010, he didn’t focus on money-related questions when he interviewed. But two years later when he and his wife decided to relocate from southern Illinois to upstate New York, he paid closer attention to what a partnership could look like. Hoping that his new position with Albany-based Glaucoma Consultants of the Capital Region would be long-term, Pokabla probed until he was comfortable that the practice’s buy-in schedule and terms matched his needs. They did. “Most groups know after a year or two where things are going,” he says. “But if your contract suggests waiting longer to start the process, you might be waiting too long.”

John Villacis, M.D., is happy that his search in 2004 netted his current position as an allergist/immunologist for The Austin (Texas) Diagnostic Clinic. After his interview process, though, he realized that he should have clarified the non-compete’s distance requirement. Since the multispecialty practice’s 117 physicians are spread in satellite sites throughout the metropolitan area, it made a difference which address would be used to satisfy the “within X miles” provision. If every location were included, he’d have to leave the city to set up another practice. Fortunately, Villacis’s contract provided a primary office address, which would be used for calculating the non-compete distance. That would leave him plenty of space to practice in Austin—in the unlikely event he decided to move on.

“Part of me felt like I was wasting their time asking a lot of questions,” he says. “But in retrospect, I realize that it’s really important to have all of your concerns addressed.”

Indeed, be professional in all your dealings, but also assertive in your requests. You might be flummoxed as to how far you should go in interrogating your interrogators, but remember that interviews are two-way streets. As long as your questions don’t interfere with HIPPA compliance or require privileged information, everything should be on the table. You don’t want to leave the interview disappointed that you didn’t get your concerns addressed. So broach your concerns with the same fervor you use to demonstrate why you and the job are a fit.

As a molecular pathologist, Delecia LaFrance, M.D., FASCP knew she had specialized knowledge. But as a recent (2013) fellowship graduate, she also wasn’t comfortable asserting her expertise. That is, until she realized the importance of demonstrating that she was ready and eager to run a molecular lab and teach. Not only that, her interest area—exploring biomarkers for cancer and other diseases—would be a plus for their program. Today, as a clinical assistant professor at the University of South Carolina School of Medicine in Columbia, LaFrance encourages new doctors to exude confidence in their interviews. “I wish I had been more aggressive at first in saying, ‘Hey, this is what I want to do. This is how I can help,’” she says. “I would have appeared more decisive to interviewers so they’d know, ‘She’s not just interested generally. She’s really interested in us. She’d be an asset to our department.’”

As assistant professor and associate training director of the University of Wisconsin-Madison’s psychiatry residency program, Claudia Reardon, M.D., found the perfect match for her skills. But she still wishes that with her hire in 2010, she’d been more assertive in securing dedicated time for her teaching duties. Although she’d eventually correct the situation, it took several years and a concerted effort to show her employer tangible reasons to approve her request. In the process, Reardon learned a lesson that she now passes on to seniors in her negotiation seminars: Be assertive from the get-go to get a great deal. “It’s often hard for new graduates to ask for things since they’re coming from a position that’s relatively lacking in power,” she says. “But they’re in a much better bargaining place if they feel empowered to make their requests upfront rather than waiting until later.”

One final note

The goal of a job search is to be so content in your ultimate choice that you don’t have to do this again anytime soon. Conducting interviews and site visits that cover all the particulars can put you in good stead wherever you target and ultimately land. Even if you get a second bite of the apple down the road, it’s worth your future to learn as much as possible now, especially from others.

When Buckley embarked on her second job search, she went looking for a position where she’d be able to lead as both an individual physician and clinical staff member. She made sure, for instance, that the doctors had a governance structure through which they could wield control, especially over clinical changes.

Today, as the director of her hospital’s Acute Care Surgery Program, Buckley combines administrative tasks with surgical shift obligations. Even though she had to give up her elective practice, she’s often able to treat the sickest patients and the ones who need the most demanding care—just what she was looking for.

“I had to give up some of the things I enjoy the most to do this job,” Buckley says. “But there are other intellectually challenging pieces that make that choice worthwhile.”

Chris Hinz is a frequent contributor to PracticeLink Magazine.

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Chris Hinz

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