Orthopedic surgeon Elly LaRoque, M.D., has given lectures to residents and fellows from Stanford, UCSF, and at American Academy of Orthopaedic Surgeons annual meetings on how to choose and start a practice. The content of her presentations is based on her own experience, research, and from talking to her colleagues who share accounts of their job searches. Her most valuable piece of advice? "Start looking early, at least a year in advance, unless you’re going into academics, in which case start even sooner," says LaRoque.
But how early is early? And how do you know what to do, and when? These are the questions that this article seeks to address in a way that will make your job search relatively smooth and painless.
The process can seem daunting and drawn out, but if you take it one step at a time, the end result will be - if all goes according to plan - your ideal job.
Practice management consultant Jack Valancy contends that one of the biggest mistakes physicians make during the job-search process is not thinking through what they’re looking for early enough. "If you don’t know what you want, anything will do," says Valancy.
Valancy, who helps physicians negotiate employment contracts and gives career guidance workshops to physicians in training, says that doctors need, first and foremost, to determine what’s most important to them both professionally and personally.
For some, it’s locating close to family and friends. For others, the type of practice - small office, large multispecialty group, employed opportunity, academic position, etc. - is high on the priority list. For still others, the most important factor may be finding a practice where the patient mix and types of cases available are well aligned with what the doctor most enjoys doing.
Location, practice type, case mix, compensation - these are important issues, and ones with relatively straightforward answers. The location is either on the coast or not. The practice is either a small group or it’s not. The pay is either $175,000 or it’s not. It can be more challenging to set search criteria around the more subtle issues.
"One key component is the culture of the practice," says Valancy. "A survey from a few years ago showed that 46 percent of physicians leave a job within three years, and the number-one reason had to do with cultural fit. You want a place where you’ll feel comfortable." Some practices are highly structured while others are more laid back, with physicians and staff on a first-name basis, for example.
"Look at different types of practices, and weigh the advantages and disadvantages," says LaRoque.
Upon completing her sports medicine fellowship in the Bay Area, she chose to go with a medium-sized private practice in part because of the flexibility and autonomy it offers. "There are fewer people making decisions," she says. "It’s easier to steer a smaller ship."
LaRoque appreciates being able to send her patients wherever she likes for physical therapy, for example, and schedule surgery quickly when needed. "In a smaller group, you can also set your own hours and call schedule," says LaRoque.
Another factor that Valancy says physicians should look at when considering a position is the flavor of the community. What’s important for someone who already has a family may be quite different from what someone who is 29 and single wants. "Cultural isolation is another issue, particularly for foreign-born physicians," says Valancy. "I had one doctor tell me that if he’d wanted to see Russians, he’d have stayed in Russia. But, for many people, having a cultural connection is very important."
"Be thinking about all of this 18 months out to narrow your focus," says Valancy. "Go through what your key issues are. Evaluate different types of jobs, and determine if they are consistent or inconsistent with your key issues."
Once you’re clear on what you want, then and only then should you start talking to your network of contacts, getting in touch with recruiters, and sending out your CV. Start out picky. When you’re open to any opportunity in any place under any terms, the choices can be paralyzing.
Cheryl O’Malley, M.D., is program director for the internal medicine residency training program at Banner Good Samaritan Medical Center in Phoenix. She says residents should seek out and make good use of resources that are available to them during training. "At our institution, we have a House Staff Transition Program Coordinator who reviews CVs and knows where jobs are in our community. She’s a real advocate," says O’Malley.
O’Malley also advises young doctors to remember that the connections they’ve made throughout medical school and residency are valuable assets when it comes to the job search. "It will be the people you know and have worked with who can speak on your behalf and recommend practices that they think would be a good fit," says O’Malley. "Build those relationships and ask for information and advice from these mentors."
Valancy seconds the motion. "Every other physician you know is your network," he says. "Don’t be shy about calling colleagues and asking around at conferences." Very often, one contact leads to another, which leads to another, and before you know it, you have a good job lead.
"The corner that physicians paint themselves into is that they don’t give themselves enough time. You want to start negotiating at least six months in advance so that if an opportunity doesn’t work out, you have time to keep looking," says Valancy.
Note that Valancy says you want to be negotiating six months out. That means starting your search at least a year in advance of when you want to begin practice.
Now is the time to decide if you’re going to do your own search or use a recruiting agency. If your focus is tight in terms of geography and practice type, you can probably conduct an effective search on your own. If you’re casting a wide net, however, an agency could be helpful. (Note: If you conduct your own job search, you may work with an "internal" or "in-house" recruiter who is employed by a hospital or medical group. That’s different from an agency recruiter.)
During the second year of his three-year emergency medicine residency at Harbor-UCLA, Moses Graubard, M.D., started thinking about what he wanted next.
He considered applying for an administrative fellowship, but decided against that, and began to look for practice opportunities. Had he wanted to remain in Southern California, his job search would have been easier because of the contacts he’d made. But Graubard’s heart was in San Francisco. He began putting out feelers in the Bay Area.
As it turned out, Graubard’s search was short and sweet. "I sent my résumé to a couple of California-based ER groups and to Kaiser," he says. "Kaiser flew me up, and I spoke with the department head and director and they said to come on board. So I thought, why not start here. The people seemed happy, and there was good camaraderie."
He especially appreciates that the Kaiser system offers excellent specialty coverage and that the pace is busy but reasonable. "The pay may be a little less than in some private hospitals, but is comparable with many of them, and the stress level tends to be lower," he says.
That was the case for James Gilmore, M.D. His job search was made relatively easy by the fact that his specialty - pediatric radiology - is in demand only in certain types of facilities and primarily in large metropolitan areas. The former physicist who returned to medical school in his late 20’s says that even though his choices were somewhat limited, he and his wife knew they wanted to live with their two young daughters somewhere in the west once he completed training. "We both have family in Arizona, and looked from the Rockies west to the coast, and from Seattle down to San Diego," says Gilmore.
It was during the last year of residency that Gilmore began seriously looking for a job, while he still had one fellowship year to go at Stanford. "All the headhunters advertised, but I did my own search," says Gilmore.
He considered six opportunities total, but interviewed at only two: one in San Diego and one in Portland. The latter won out, and Gilmore accepted a position with the nonprofit Legacy Emanuel system there.
"We liked the culture here in Portland, and the job was a little more attractive, both the package and the day-to-day work," says Gilmore, who interviewed during September and October of his fellowship year and accepted his offer from Legacy in December.
Gilmore says he feels he made the right choice and he’s enjoying his job. "The most important aspect of the job is how the partners in the group interact with each other. We have an amicable relationship," he says about his 12-person, hospital-based radiology group.
What advice would he give other doctors about the job-search process? "Start early; the earlier the better," he offers. "Utilize your personal connections. Department chairs are usually well connected."
If you’ve taken the time to find out exactly what you’re looking for, don’t be afraid to take the first opportunity if it’s a great fit - even if you have other interviews lined up. By the time you finish all of your interviews, that great opportunity could be gone.
If you know for certain, as family physician Ronda Azelton, D.O., did, that you want to live within a fairly narrowly targeted geographic area, you can conduct an efficient and successful search on your own. "We have family in the Kansas City area and wanted to live within a four-hour drive," says Azelton. She and her husband, Rob, figured out how many miles that was and drew a circle on a map to indicate where they would consider.
As the couple got serious about narrowing their choices, they made lists of their must-haves, wants and absolutely-not-wants. They knew that settling down with their toddler, Perry, in a community no larger than 60,000 was their first choice. Azelton had done her residency in a rural area of 2,000, followed by a maternal/child and C-section fellowship in Chicago.
"We knew we’d be OK in a small town and with everything that goes along with that," says Azelton. "I wanted to be able to do OB and C-sections and be in a group of three to four, we wanted a shopping center within an hour’s drive, and we wanted a place with a strong church." Employment for Rob, an academic athletic trainer, was also a big factor.
"We typed up our list of criteria and put it in a binder," says Azelton.
That binder became the place to collect information about opportunities as they were evaluated. Seven possibilities made the first cut, and Azelton emailed those. Two were quickly ruled out, and phone interviews were scheduled with the remaining five. She then narrowed the search further and went on three site interviews.
"It finally came down to which package looked better," says Azelton. She signed with CoxHealth, a large system based in Springfield, Mo., and is in a practice in the small town of Monnet, Mo., with two colleagues. The group offers the full spectrum of family medicine, including about 30 deliveries a month.
Azelton feels she made the best choice. "I’m employed by the hospital, so I’m not having to fight tooth and nail for my salary, and we have the resources of a big system like interventional radiology and specialists to refer to," she says. "We don’t have as much say in things like the EMR or equipment, but they don’t dictate how many patients we have to see, which is nice. A lot of systems do."
When beginning the job search process, Azelton says to be open and be organized. "Write things down," she says. Indeed, when you’re talking to five or six different practices, it’s easy to become confused about who’s offering what. Azelton also reminds physicians who have families to keep their family’s desires in mind. "They don’t have everyone recruiting them. Find out what they need early on," she says. "They have to live there too, and they have to be happy."
When it comes time to start looking at a contract, due diligence is essential. "Do your research to find out, for example, what’s fair overhead for your specialty," suggests LaRoque. The Medical Group Management Association (mgma.com) is a good resource for this and other statistical data, such as average salaries by specialty and region.
Before signing anything, ask a contract attorney to review your contract. Repeat - a contract attorney. Not your sister-in-law who is in-house counsel for a business, or your father who does family law. Graubard received good counsel in this regard from his program director and attending physicians. "They said to look at the contract very carefully, have a lawyer review it, and make sure the finances of the group are transparent," he says.
The paperwork involved in starting a new job as a physician can be overwhelming and surprising. It may take as long as six months to obtain a state license.
Marilyn Hill, director of physician services at Beebe Medical Center in Delaware, suggests accomplishing licensing and credentialing processes simultaneously. "In hospital credentialing, we’re required to conduct primary source verifications," says Hill. Add to this the fact that the committees designated to approve credentials may meet only monthly, and you’ll understand why getting a head start on this process is critical.
Furthermore, credentialing with the insurance companies may also take six months.
Be prepared to work with employees in the medical staff office who might need your help gathering documents that verify your education, training and professional references. Don’t hesitate to be pleasantly persistent, like following up with your references from residency. "If one document is missing from the file, it can delay the process by a month or more," says Hill. "Try not to get frustrated - expect the process and be prepared." Hill points out that some hospitals and state licensing boards still require applicants to show up for an in-person interview. "Don’t assume all states are the same," says Hill. "Ask, especially if there is a distance to travel, so you can plan to incorporate time in your schedule for an interview."
International medical graduates have also been facing additional challenges, such as H-1B caps and limited state slots allowed in medically underserved areas. "If there are any visa concerns, address those early with your legal advisor. Review the state requirements, and know your deadlines," says Hill.
On the personal side, once you have a signed contract in hand, you’ll want to think about where you’ll live. Will you rent for a while, or buy a home immediately? How far away from the hospital or clinic is reasonable? Do you want to live in an urban or suburban area? In what proximity to schools, shopping, restaurants, outdoor activities and place of worship? Keep all of this in mind as you work with a local realtor to find your new home.
Once you know where you’re going, there are still plenty of details to handle before you begin practice. Here are a few final tasks that will likely require your attention.
• Follow up on credentialing and licensing paperwork and make sure everything is moving along. Check on the status of your insurance provider applications, including Medicare.
• If you are going into an established office, work with the office manager about what you need in the way of staff, equipment or supplies that may be unique to your style of practice. If you’re setting up your own office, now is the time to secure office space and order equipment and supplies.
• Make an appointment with your accountant and/or financial planner to create a plan for student loan debt repayment, budgeting for your first few years in practice and planning for retirement.
• Schedule movers, shut off and turn on utilities, notify friends and family of your new whereabouts, and tend to the dozens of other details associated with relocation.
If, while reading this article, your eyes have glazed over and you feel overwhelmed about what’s ahead of you, try not to panic. Take a deep breath, and go back to the beginning of the process: simply thinking about what you’d like your future to hold.
If you remain clear about your goal and stay organized as you go through the job-search process, you’ll no doubt land the practice opportunity that’s meant for you.
Karen Childress is a frequent contributor to PracticeLink Magazine.