This month's issue of features an excellent article on finding a job as an orthopaedic surgeon (see "Tips for Evaluating and Obtaining Employment.") by Bishoy Gad, MD; Paul Saluan, MD; and Alan W. Davis, MD. Although the piece is directed mainly at residents and fellows, I hope everyone reads it because it provides an excellent overview of the current landscape in terms of practice opportunities. I suspect, for many of you, this landscape has changed quite a bit since you graduated from residency.
I found the article especially interesting because of my own career evolution, which has taken me from private practice to hospital employment. Recently, I have been on the "dark side," negotiating with young doctors seeking to join our practice. Additionally, I was recently offered a copy of author Dennis Hursh's 2012 work, The Final Hurdle: A Physician's Guide to Negotiating a Fair Employment Agreement, for review. Buyers of his book also have access to a 20-minute webinar that provides a nice summary of the book's contents.
Mr. Hursh is an attorney who specializes in representing physicians in contractual matters in Pennsylvania. He also runs the Physician Prosperity Program as a "contract review and negotiation service." In the book, Mr. Hursh promotes this service, but also makes recommendations for selecting other independent attorneys.
The book does not aim to fill the role of an attorney in helping to review contracts and assist in negotiations. Rather, Mr. Hursh wants readers to understand some of the key language and issues from both sides to make the process more efficient. I found the author's experience with the forces and interests that drive various aspects of the contracting process most valuable. Personally, I wish I'd read his book and Dr. Gad's article before starting both of the jobs I've held in my practice life.
No matter your current circumstances—be it happily situated, looking around, and/or hiring new partners—obtaining a more complete view of the employment landscape will enable you to focus your thoughts, understand and differentiate your needs from your wants, and prepare you to communicate more clearly with attorneys as well as hospital and practice administrators.
Both the book and the article are relatively quick reads, but are densely packed with useful information. Having chartered these waters from both shores, I wanted to highlight concepts that can be particularly challenging.
Striking the right tone
During employment negotiations, remember that you are not selling a car. If the negotiation is successful, you will be working closely with the people across the table from you for a long time. Project strength by coming into each meeting well prepared. Discuss the key points with your attorney and establish "guard rails" for the negotiation.
Some hospital systems work more quickly than others. I think one of the first goals of negotiation should be to establish a timeline that allows time for back and forth discussions and letting positions soften. Remember, though, that if you wait too long, you may miss out on other opportunities or have too little time to get on insurance panels.
An important part of being prepared also includes having a complete understanding of what a potential employer wants from you. For some jobs, call coverage is king; other organizations are focused on building specialty practice capabilities into their networks. Because of this variability, always remember to ask your interviewers why they are hiring. The more the practice's or hospital's needs overlap with yours, the greater the chance of long-term success. If you are interested in building a specialty practice in elbow surgery, but a practice desperately needs an orthopaedist who covers call and treats hip fractures, your practice development will be all uphill. This may also be true for those of you with academic interests or innovative plans for your practice.
I will not hire someone who isn't a "team player," but that doesn't mean the candidate should just cave on important points. The other side needs to know that you care about the issue under discussion. Importantly, though, remember to keep the interactions friendly. If things start getting a little tense, having an attorney represent you who can play the "bad cop" can be helpful. You can also soften tricky requests by suggesting they were the attorney's ideas.
Mr. Hursh points out that when someone tells you "this is our standard contract," he or she may be attempting to pull the wool over your eyes. All contracts are—at least, in part—negotiable. That said, it should be clear what is negotiable and what isn't.
Compensation is important; however, it is far from the most important issue. Arguably, for most orthopaedic surgeons, the biggest issue is not the initial pay package, but may instead relate to whether a group's or hospital's reputation is poor, the area is oversaturated, or the physicians are very senior and happy with their patient load, and are therefore uninterested in chipping in for marketing. All of these issues can stunt your practice's growth.
Just as important is the answer to this question: What do they expect for the money they are paying? I think most of us are spending more clerical time typing into electronic medical records than we would have predicted a few years ago, so support for dictation services, scribes, and members of the clinical team—especially nurses and physician assistants—all make a huge difference in the actual experience of day-to-day practice. Honestly, I think the investment in your clinical team is as important a part of your overall compensation as the wages on your W-2 form.
You may be able to negotiate a different malpractice coverage plan—usually not, in my experience—but be sure to ask about tail coverage if a claims-made policy is being offered. Always ask for a (higher) moving allowance and sign-on bonus. Ask current practice associates or employed physicians about any trouble they've had getting reimbursed for meeting costs, licensure fees, or professional organization dues.
Young doctors do not ask much about retirement plans, which is a mistake. Differences in the parameters of these plans can add or detract tremendous value from your compensation package. Discuss the tax implications and other aspects of the retirement plan with an accountant if you don't understand them.
If you are from the area where you are considering working, or were trained there, you will have a decent sense of the real community need for your skill set. Still, I would suggest that you ask everyone you meet during your interviews about current staffing levels, and contact the competition to ask, as well. Can you get a sense of how long it takes new patients to get into the office? How long is the surgery wait list?
Similarly, most of us know to ask about equitable call arrangements, but how about geographical reach? If you are expected to cover multiple offices or hospitals, your compensation will suffer after the "guarantee" period ends. Long commutes are frustrating and can kill practice efficiency.
Finally, I would advise you to ask if you will be expected to share your intellectual property licensing, consulting, or medicolegal fees.
"Interview" your interviewers
Whether you are joining a practice or a healthcare system, leadership and operations are key facets to long-term success. Find out who is in charge of what, and make sure there is a clear organizational structure that designates who has the authority to make big decisions. Are physicians included at the highest levels of strategic planning and decision making? When you interview, be sure to ask everyone how long it takes to get problems fixed, supplies ordered, and poor employees rehabilitated or fired. Always remember that a poorly run practice may leave you vulnerable in various ways, such as when it comes to violations of the Health Insurance Portability and Accountability Act.
Ask everyone, at every level of the organization, about employee turnover in their area. Do your due diligence. At the very least, contact physicians who have left the group. In addition, find out things such as whether the practice or hospital is forward-thinking and whether it has an outcomes measurement process. If it is a private practice, determine whether ancillaries have been added, and find out whether you will be participating in profit generation from those ancillaries. Also ask whether there are restrictions on other work you might want to pursue.
Especially if you are moving to a new state, it is important to understand that state's malpractice climate and approach to restrictive covenants. If you need help, seek out the assistance of an attorney who specializes in these areas.
Other things to investigate may include the culture of the local medical community. I once interviewed with a practice that fined physicians several thousand dollars for cursing. Clearly, cursing isn't professional, but this culture would be a better fit for some doctors than others. Mr. Hursh recommends reading the policy manuals, and I am sure that's a good idea, as is finding out whether your level of interest in research or pro bono care matches up well with that of the practice or hospital system.
Warning signs and pitfalls
Obviously, different administrators and providers will have different perspectives. But if the answers to common questions are too variable (or too rehearsed), be careful.
An unwillingness to negotiate is a warning sign, as are promises that it will "all work out" no matter what's in the contract. There are some areas in which practices, and especially hospital systems, simply cannot negotiate, but those should be limited. Remember, your leverage only decreases after you've signed the contract and moved your family. Moreover, the opportunity costs of moving go up after you've invested yourself heavily into building a practice in a new location.
It's easy to add "schedules" to the contract. For hospital systems in particular, the person with whom you are negotiating may be rotated into a different job every 12 to 18 months. The new administrator will (legitimately) deny any knowledge about the verbal terms of your employment. For this reason, it's crucial to get everything in writing from the start.
I've come to understand that calculating fair market value is as much an art as a science. Mr. Hursh discusses how to work with appraisers, but also notes that "there are several widely accepted approaches to valuing a practice, and appraisers tend to select the approach that favors their client." This might be true when valuing call coverage and other fees. Of course, hiring your own appraiser might give you another view to the value of a property or service, but it's expensive and does not mean those on the other side will want to accept your appraisal any more than you want to accept theirs.
Now that I've gone through this process from both sides a few times, I have seen how otherwise great physician/practice matches fail during the interview or negotiating process. On the new doctor side, I cannot overemphasize the importance of preparation. As Dr. Gad and colleagues point out, we've gone through years of training, but may have very little real-world business or legal experience. The more you know, the better you will communicate your positions to your own attorney and to the "other side."
My pet peeve? No nibbling! Establish and clearly define your "must-haves" and your "nice-to-haves." If the must-haves just aren't there, save yourself and the practice a ton of time and move on. If you get what you wanted, don't start adding new requests. Establish a timeline for the negotiation with the other side and stick to it. Good luck!
Eeric Truumees, MD, is the editor-in-chief of AAOS Now.