Now is the time to pat yourself on the back. You’re a physician ready to tackle the world after years of studying, long hours and low pay. Although you’re in your final year of residency, you’re feeling a little overwhelmed and unsure about the future. You want to make wise practice decisions, but are you really prepared to do so?
Since you’ve worked exceedingly hard to reach this point, it’s important to spend time developing a career path for your future and avoid career mistakes.
In order to provide practical advice for residents upon completing their residency, PracticeLink Magazine sought the opinions of five physicians who focused on nine major mistakes residents should try to avoid. They believe these miscues will have a crucial impact on whether you will be happy with your medical career or not.
For many residents, applying for a fellowship or finding a job is a difficult career choice. Start looking for a fellowship approximately 18 months to two years before your residency ends - even if you’re not sure you want to pursue a fellowship, says Karen Dallas, M.D. Dallas is completing a one-year fellowship program with the BloodCenter of Wisconsin, in association with the Medical College of Wisconsin. "I waited until the last year, and it was almost too late," she says. "When I applied, many of the programs weren’t accepting applications anymore."
When Dallas was accepted for her fellowship at the BloodCenter of Wisconsin for her position as a hematopathologist, she received a letter of acceptance, which she signed. "There was nothing listed in the letter as to what would be required of me or exactly what I was agreeing to. The only information I had was the pay." For example, she didn’t know whether she’d be required to do a research project or be on call every day. She thought it would be "worked out" when she got there.
"Now, the rules have changed as of November 2010 because the leadership of the program has changed. There are rules which I would never have agreed to," she adds. "Doctors tolerate this unfair work situation because they think it’s just an extension of their residency training, but a fellowship is more like a pre-job."
In order to avoid this situation, Dallas recommends making sure the fellowship requirements are clearly spelled out.
Susan Wilturner, M.D., has been a solo practitioner in family practice and metabolic medicine for eight years. Now located in Los Gatos, Calif., she recommends speaking with recruiters earlier rather than later. Wilturner points out that most residents are not approached by physicians or hospitals handing them business cards, asking them to join the practice.
Recruiters don’t cost residents any money, and they can provide residents with options. With the time constraints residents are under, it’s difficult to look for potential jobs. "If recruiters come to your hospital, make sure you sign up and attend these seminars," Wilturner says.
Wilturner worked with several recruiters before she settled on one whose job it was to help "pair her up" with established doctors in the area. She was seeking physicians in the same specialty so they could share overhead. "If you’re certain you want a solo practice from the start, this is a good step to take to help you get established in your practice," she says. But,
Wilturner warns, be careful not to underestimate the time it takes to find the work option that meets your needs.
Wilturner says residents shouldn’t rule out opening a solo practice or be intimidated by this decision. "You can create the environment you want, what services you offer, and the time you spend with the patient," she says. "You can shape and grow the practice into your own investment."
Think carefully about the first job you take after residency, and ask probing questions to make sure you’ll like it. Most likely, as a new doctor within the practice, you’ll have to sign at least a one- to two-year contract.
"Being miserable for one year or longer is a long time," says Jamie Hutton, M.D., of Bluestone Pediatrics in Harrisonburg, Va.
Hutton says too many residents jump at their first job offer because they are so excited about completing their residency - and the money is enticing. Sometimes, money becomes the only factor they consider.
It is difficult to determine how many job offers each resident should consider before making a final decision since it depends upon whether he or she knows where they want to practice.
In Hutton’s case, she knew she wanted to return to her hometown area, and realized her choices were limited due to the number of pediatric practices in the surrounding communities.
Too many residents jump at their ﬁrst job offer because they are so
excited about completing their residency - and the money is enticing.
"Don’t be lured by very high salaries, especially in psychiatry," says Steven Schlozman, M.D., associate training director for child psychiatry at Massachusetts General Hospital in Boston.
"Our residents get cards in the mail almost every day offering them outlandish salaries. But what they are being asked to do on the job is not doable."
Many times, Schlozman points out, the job offer will state "’the call schedule to be discussed.’ Never spend time checking out a job offer if they are going to have you on call every single night - especially if you have a family. You want to make sure you don’t miss out on those years with your children because you can never get them back."
Schlozman says residents interviewing for a job should ask: "Am I the only doctor of this kind in the area? What are the resources in my area for continuing medical education, and who will cover for me if I want to go on vacation?"
In addition, pay close attention to the colleagues that you’ll be working with to make sure your work environment is something you can tolerate. Talk frankly with the doctor and the doctor’s spouse. Bring your spouse or significant other with you so they can assess the situation as well.
Mark Potter, M.D., director of the family medicine residency program at the University of Illinois Medical Center in Chicago, believes finding people you can trust to work with is very important. Unfortunately, some of Potter’s graduates have gotten into business arrangements with people who weren’t as forthright as his graduates would have liked. It’s crucial to determine if you can trust your future partners. Arrange to spend time with them, and bring your spouse or partner with you. They may see things that you don’t.
"Keep in mind if your spouse or partner isn’t happy, you won’t be happy with your career decision. They need to have their turn for a decent life situation."
And don’t forget to consider the community environment, the schools for your children, recreational activities, cultural opportunities and the cost of living. All of these should factor into your decision.
If you really hate paperwork, consider being on staff at a hospital. As Schlozman points out, your salary may be a little less, but you don’t have to be responsible for the paperwork.
There is a big shift in medicine as hospitals are recruiting graduating physicians from their residency programs. A hospital-based practice has many perks, such as health insurance, an administrative staff in place, and other benefits.
When you’re in private practice, you can be overwhelmed keeping up with your notes, seeing your patients and returning their phone calls. If you don’t fill out the insurance forms in a timely manner, you don’t get paid and are essentially providing care for nothing. "Residents don’t realize that the paperwork can be totally overwhelming at times," says Schlozman. "It’s not just practicing medicine anymore."
Residents must decide if they want to be small business owners or start out as attending physicians at a hospital. "If you don’t want to be a small business owner at the same time you are learning how to be an attending doctor, then being an employee is simpler," Potter says. "Becoming an employed physician may be a better fit for you."
Potter recommends to his residents that they pay to have an attorney look at the contract, one who knows the "ins and outs of medical hiring. Department heads and program directors can also provide valuable experience by noting the current trends in hiring."
Rarely do medical residents get any teaching information about how to negotiate a contract. "Not negotiating a contract could be the biggest mistake of your life," says Hutton. If you can, she recommends talking to people who are older than you, who have already made mistakes. They are the ones who can teach you the most.
Hutton points out that women physicians should make sure there is a maternity leave clause in the contract if they plan to start a family.
Hutton says it’s also important that the contract offers some disability insurance. If it’s not in the contract and you can’t negotiate it in, you must purchase it yourself.
"The contract isn’t written in stone," says Wilturner. "Make a Xerox and mark it up. Then negotiate. Don’t be fearful of saying what you don’t like in the contract. If you don’t ask, you can’t receive a better contract. You are worth a lot more than you think you are."
"Because many residents don’t know what they’re worth, research the area you plan to practice in and find out what you should be paid. Unfortunately, many practices will take advantage of residents because they have no idea what the pay should be," says Hutton.
Even as a solo practitioner, you can find contract problems with the other physicians you plan to share overhead with. Initially, Wilturner thought an agreement had been finalized with two other physicians. "When I saw the proposed contract, it was very different from what we discussed. It was like the physicians had a loss of memory," she says. "Each of us would have shared space, and had our own practice. In theory, we would have been three different businesses. The contract they showed me gave them direct access to my earnings as opposed to trusting me to pay one-third of the rent and supply expenses. The physicians even wanted to manage my bank account."
Refusing to accept this contract, Wilturner got access to a list from the local hospital of all the family practice doctors in the area and sent them a fax explaining she was new to the area and wanted to start her own practice and share expenses.
She met eight physicians until she felt comfortable with one of them. They had shared space, totally separate businesses, and one of the physicians even took her under his wing. They stayed together for three years in this arrangement.
One clause in the contract that can cause a problem for new residency graduates is a non-compete clause. New residents encounter this clause quite frequently in their contracts. If you sign a contract with a non-compete clause, points out Potter, it can include that you can’t practice within a 15- to 30-mile radius. "If you agree to sign a non-compete clause, make it as narrow as possible," he says. "The ideal contract doesn’t have this clause." By agreeing to a non-compete contract, if you want to leave the practice, you may have to move to another city - which could include the need to sell your home and put your children in a new school.
Potter emphasizes that it’s important for residents to have knowledge about malpractice insurance tail coverage. After you leave a practice, tail coverage covers malpractice claims that are made after a doctor leaves - but that concern care provided while in that job.
Tail coverage protects you from claims that you haven’t been sued for yet at the time you leave a practice. Tail coverage can be bought for one year or longer, depending upon your specialty. Tail coverage is often inexpensive for the first year of a practice, but it can rise in price to tens of thousands of dollars, which can limit a doctor’s ability to change jobs.
"As a result of the cost of tail coverage, physicians may feel trapped by the cost of changing jobs and can’t leave the practice. They may not have the money to pay for this insurance."
Potter suggests that new physicians try to get their employer to pay for tail coverage for the first few years and have this written into their contracts, or negotiate for "occurrence-based" malpractice insurance rather than "claims made" malpractice insurance.
Dallas says doctors need to be in a "study mentality" if they want to take and pass their boards. Planning a post-residency vacation? Bring your books with you and plan to study two hours a day. Yes, even while on vacation.
In her opinion, taking a break and going on vacation is not a wise choice because it gets residents out of the habit of studying.
Hutton has seen her fellow residents, upon ending their residencies, become so busy with life and going on vacation that they forget about studying. Then the boards sneak up on them and they panic. This may result in having to take them over.
She recommends studying one to two hours a day starting nine months in advance so you can still live life.
"I wouldn’t put off taking the boards," says Schlozman. "It’s not worth the risk. The boards are a huge investment, and new doctors don’t want to have to pay that money twice."
Says Potter, "I encourage all my residents to sit for their boards at the first opportunity because the knowledge is fresh in their mind. Residents shouldn’t think they won’t work as hard after they get a job and will study later. That can be a mistake."
Planning a post-residency vacation?
Bring your books with you and plan to study two hours a day.
Yes, even while on vacation.
A key mistake Hutton indicates many residents make is not knowing how to manage their money. "Once many residents get that first paycheck, they’re going to buy a new car, new house or buy all the things they couldn’t afford before," she says. "Don’t do it."
Instead, new doctors need to think about spending their money on malpractice insurance, disability and life insurance, and school loans. Those are all big-ticket items.
"Many doctors live beyond their means because they don’t have a business education. All they know is medicine," she says. Consequently, Hutton strongly recommends each resident start looking for a financial advisor who has experience working with young physicians.
Many physicians are getting their first job in their late 20’s or early 30’s, which means they are 10 years behind many people who already have retirement accounts and college funds for their children. Think about the future. "A good rule of thumb I’ve learned from my financial advisor," Hutton says, "is don’t spend more than 40 percent of your paycheck for items like food, car payments, clothes, entertainment, vacations and nursery school for your children. The 60 percent is for long-term benefits such as a home, insurance, retirement account and an educational savings plan."
Check out the demographics of the area and find out what it costs to buy a house and what the taxes are. Schlozman wants graduating residents to realize they need to be sure they can afford to live where they’re going to work. "Now more than ever, there’s uncertainty as to what future salaries will be," he says. "This is a risk right now as we go through this transition in medicine."
Vicki Gerson has been writing medical articles for more than two decades. She lives in Northbrook, Ill.