The summer of 2007 was a heady time for Scott Silver, MD.
His fellowship in vascular surgery at Wayne State University in Detroit, Michigan, was drawing to a close. Finally, after all those years of study and specialized training in cutting-edge endovascular surgeries, he was about to graduate into the job market. Medicine was an open field.
"The first thing that happened is I got pretty excited about being finished and how great life was going to be afterward," Silver says. "So you get on the Internet and there are all these ads all over the country, and you see the money and you think it’s a lot, and you think it’ll be awesome."
He imagined practicing in a picturesque small town, similar to the ones in North Carolina where he’d done his residency, but his first interview was a sobering experience.
"The hospital was too small. The town was too small," he says. "I didn’t know exactly what I wanted, and I knew I had to figure it out."
That’s when the work began.
Silver’s experience isn’t unique to his specialty or his fellowship program. Residents and fellows often report they emerge from their programs fully prepared to handle patients but unprepared to confront the job market and the complicated process of landing the right job. There might be some job counseling near the end, but many young physicians report they get no counseling at all - and even the physicians who know exactly where they want to practice can find themselves confronted with a bewildering array of decisions. The result can be a chaotic start to a demanding career.
As the associate vice president of professional staffing for the Geisinger Health System in Danville, Pennsylvania, Cindy Bagwell is responsible for finding the right match between her organization and the residents and fellows who are looking for jobs.
For Geisinger, this means that references check out, there is a clear path to board certification, and that the job applicant will like Danville.
"We look to see if they’re a fit for our community," she says. "Do they have ties to the community? We try to figure out why this area of the world interests them. In addition to geographic fit, we’ll find out what other things are important in their lives beyond a career. What extracurricular activities are important? What about their families?"
Gloria Parrish, the vice president of marketing Medical Doctor Associates (MDA), a contract locum tenens and search firm in Norcross, Georgia, agrees.
In Parrish’s experience, one of the leading reasons physicians quit jobs is because of a clash with culture - either with the work setting or the community.
"I’ve seen firsthand how quickly doctors can become disgruntled with a situation, and often it’s the spouses. They might not be included in the recruitment process, and when they get to town, they aren’t as smitten," she says. "When we ask [the doctors] where they’re going, about a quarter don’t know," she says.
Parrish urges young doctors to think about a wide variety of factors, ranging from the obvious ("Do I want to work in a hospital or a private practice?") to the subtle ("Are they negotiating fairly?").
"It’s more than, ’Can I be happy in this location?’ " she says. "It’s ’Do they practice medicine the way I like? Am I exposed to new innovations? Is the pay there?’ "
The picture is complicated by the sheer variety of options available to young doctors: Rural or urban? Group or solo private practice? Hospital or university or some kind of hybrid?
Everyone in the physician placement industry agrees that the first thing doctors should do when embarking on a job search is to draw up a list of non-negotiable items. These are the things you simply won’t bargain away. Maybe you want to live near family. Maybe you want to work in a large hospital. Maybe you want the option of buying into partnership.
Bagwell says it’s important for job-seekers to evaluate all of their options. Even in a single health system like Geisinger, there are multiple career paths, including staff physicians, affiliated practices, and even academic positions.
In the beginning of their careers, Bagwell says, many physicians "model what they know" either sticking with the organization where they trained or going right into academics.
Whatever they are, "must haves" will frame your job search. Immediately, you’ll probably be able to exclude most of the job opportunities you’ll come across.
For Silver, this meant he wouldn’t be able to work in the picturesque small town he had imagined.
"It takes a certain population base to support a vascular surgeon," he says. "In a metropolitan area, that’s not a concern."
Silver also knew he wanted access to the catheter labs and advanced imaging tools he had been trained on. He specializes in placing aortic and carotid artery stent grafts, in addition to technically demanding surgeries. This means he needed to find a hospital with a robust vascular program and sophisticated diagnostic imaging capabilities.
Surprisingly, money dropped off his list pretty fast. "I had some idea of what I was worth," he says. "I had worked hard and deserved a certain amount, but I didn’t think about it much after that. I had specialized training and I wanted to do a certain kind of surgery."
In some cases, your list of non-negotiable factors will be influenced by outside events. This happened to Y. Melissa Chan, MD. Chan graduated from her residency in anesthesiology from the University of Texas-Houston in 2007. It was her plan to accept a job with the university and pursue an academic track.
But five days before she was to start working, she learned of a rule change in the state of Texas. Under the new rule, she would need to take the Texas Medical Jurisprudence Exam before she could get a medical faculty license. Before the change, faculty licenses had been exempt from this requirement. Without that license, she couldn’t work.
"They couldn’t tell how long it would take to get the license, so I had to find something quick," Chan says, and she quickly accepted a locum tenens assignment in Yuma, Arizona.
To help narrow the focus and come up with the list of must-haves, it’s crucial that you - and your spouse or significant other if relevant - take a hard look at the various components of a practice opportunity and rank them. According to Silver, each job opportunity only has a gallon of value - it’s up to you to decide how to fill that jug. The following considerations are key:
The setting. Private practice, group, solo, hospital, academic? Each offers a different work experience, as well as different career paths.
In a hospital, for example, doctors are on staff, so they are employees of a larger system. For some, like John Schmitt, MD, an otolaryngologist who practices in Portsmouth, Ohio, this is perfect. They don’t want to worry about staffing issues, rent, billing, and all other things that go along with a private practice.
Other physicians, however, have no interest in being a staff doctor and dealing with office politics and seniority.
This fit Silver’s needs. "I decided I wanted to be in a private practice and be my own boss someday," Silver says. "I didn’t want to blaze a trail for myself in a solo practice or be an employee."
Some physicians, like Chan, seek out an academic setting. This, too, comes with its own set of considerations. Do you want to teach? Is the tenure ladder too slow? Do you enjoy the university hospital environment?
Each of these questions must be answered before considering any individual opportunities.
The culture. Cultural questions may be hard to unravel in a few quick interviews, but they’re all important. What is the personality of the practice? Do the physicians practice medicine in a way you’re comfortable with? Are there religious or ethical considerations to your style of practice that are vital or some that seem integral to the practice you’re considering that might rub you the wrong way? Do you want to work with a particular patient mix? How hard do you want to work? Is it compatible with your family situation?
"I worked at one place that was so impersonal," Schmitt says. "You can work like that, but it’s not pleasant."
For Chan, her non-negotiable item was practice independence. "The most important thing for me is I want to be in a practice where I don’t feel pushed to do cases that are riskier," Chan says. "Let’s say someone comes in for a 10 o’clock surgery, but they had a burger and fries at seven, and it’s a completely elective case, but no one wants to wait for eight hours for the stomach to empty out. There’s pressure there. Every anesthesiologist would know what I mean."
Location. Ideally, any physician could pick the town where she wanted to practice and find a job. In the real world, it’s not that simple. There may not be a need for your particular specialty in that town, or perhaps the available opportunities aren’t in the right setting or don’t offer any opportunities for growth.
Once you’ve narrowed your search and actually visit a community, pay attention. "Keep your eyes and ears open," Schmitt says. "That’s how I approached Portsmouth. "What’s housing like? What’s the nearest city? Is there shopping? Schools? Entertainment?"
The technology. Technically demanding specialties often require advanced equipment that can run into the millions of dollars. In some cases, your career might be hampered by a lack of experience on the newest technology. Therefore, when evaluating a potential employer, it’s important to make sure you’ll have access to the technology you need to grow in your profession.
With all the opportunity out there, Bagwell says it’s easy for physicians to become overwhelmed with their choices. "They haven’t focused their search, so they do the shotgun approach, and they interview, and interview, and interview, and then they have trouble making a decision."
Bagwell recommends that job-seekers first narrowly define their criteria, then limit their interviews to four to six. Though it may sound like a no-brainer, when it’s time to start the actual interviews, be sure to make time for them.
"A big mistake a resident will make is to indicate interest, and we say, ’yes, we want to interview,’ and they say they can’t come for six to eight weeks," Bagwell says. "That’s a lost opportunity right there. It’s important to be available in a timely fashion."
Strictly speaking, money shouldn’t come up until you’re down to a few opportunities, done site visits and been offered a job. Because many physicians recall their days of being broke in medical school, however, it’s not uncommon to put money into the equation prematurely.
According to the Association of American Medical Colleges, in 2007 the average indebted medical student graduated with just under $140,000 in loans, and at least 88 percent of students carried at least some debt. It’s only natural, then, to evaluate your worth as a physician and want to make decisions based on money.
Not so fast, according to practicing physicians. The salary is important, but it’s not the leading consideration, and it has to be kept in perspective.
"If you’re a workaholic, there’s the big dollars out there," Silver says "but you’re working all the time. There might be opportunities to make $600,000 a year, but you pay dearly for that. You’ve got to be honest with yourself about what you want."
Bagwell says she is sometimes impressed with the questions job candidates ask during interviews but cautions them about money.
"I’ll see them come in sometimes very prepared," she says. "They know the institution, which is very important. They have questions, but it’s very important how you ask those questions. We like questions, but it’s better to ask questions than make demands."
Behind these many considerations lurks another thing to keep in mind. Medicine isn’t like most other professions and physicians represent more than just another white-collar professional. In many ways, the quality of medical care in any particular community defines that community.
For Gail Rosseau, MD, this is the most important factor that young physicians should take into consideration when they start their careers. Rosseau is one of just 178 female neurosurgeons in the country, and she’s been widely published on skull base surgeries. She has been considered for the position of Surgeon General by the Obama administration.
Rosseau has worked only one place since completing her residency at the University of Pittsburgh. During her 17-year tenure with the Chicago Institute of Neurosurgery and Neuroresearch Medical Group, she has become the Chief of Surgery at the Neurologic and Orthopedic Hospital of Chicago, and an assistant professor of neurosurgery at Rush Medical College.
"The reason I chose this practice is because, during the interview, they asked what my goals were," she says. "I said I wanted to be the best skull base surgeon in the nation and [a committee member] asked, ’Why just the nation? Why just the best neurosurgeon? We want you to be the best person, wife, and doctor.’ "
This was an "Aha!" moment for Rosseau, who knew that she had found her home.
"I knew that far from a conflict between work and home, I was expected to develop home skills because it was recognized that those skills would bring something to the practice," she says. "You want to choose the job that allows you to be the best doctor but also the best person."
Since then, she has worked to give back to her community whenever possible, frequently speaking at schools and to groups about stroke prevention, science education, and mentoring. She has also made it her job to recruit for the field of neurosurgery, targeting women but also children as young as elementary- and junior high school-aged children because she says the specialty will soon be suffering from critical shortage unless efforts are made to open the profession.
"Patients don’t just call you because you’re a good doctor," she says. "They call you because they saw you speaking at the library."
Ultimately, both Silver and Chan ended up happily employed, although in different circumstances than they had imagined during their training.
After completing his interviews, Silver accepted a job with a small private practice in suburban Detroit. He has surgical privileges at William Beaumont Hospital in Royal Oak, Michigan.
Several factors influenced his decision. Silver was from the Detroit area, and both he and his wife had family in town. Moreover, because he had trained in town, he knew the hospital’s reputation and could easily work with his resident colleagues for background information on potential employers and for referral sources.
"Before I needed to network, I thought of networking as a dirty word, but it’s very valuable," he says. "It’s passing knowledge among colleagues."
He respects the senior partners who hired him, and the practice fits his needs well. He’s only on call once a month and he has access to the specialized equipment he wants.
"I feel that I made a good choice," he says. "Most days, I think I’ve got the coolest job in the world."
Instead of heading back to Houston as she originally planned, Chan continued to bounce enthusiastically between various locum tenens assignments from the summer of 2007 until late 2008. Her husband is in the military and is also in a medical program, so she experienced a range of options through locum tenens while he worked on his own training. She accepted assignments in Arizona, Oklahoma, and North Dakota.
Recently, she accepted a one-year contract position with Trinity Health in Minot, North Dakota. Trinity is a nonprofit network of hospitals and physicians.
"Last year, I begged my recruiter not to leave me in North Dakota," Chan says. "But I liked it. I really enjoyed it, and I don’t have any regrets."
Jon VanZile is a medical writer and editor.