Starting Out: Wet Behind the Ears

Practice models have evolved since the days of the cozy Marcus Welby-esque offices that once served as the common starting point for new doctors emerging fresh from their residencies. You’ll still find one- or two-doctor practices, but nowadays you’ll also find gargantuan groups staffed with dozens of physicians and a colossal staff, filling every medical niche possible. And while there are groups that focus on only one area of medicine, there are now multispecialty clinics also, with cardiologists alongside dermatologists next to gynecologists - a specialist on staff for seemingly every square inch of the body. Some practices are owned by the doctors themselves, while others answer to nearby hospitals. Many practices focus on research, others exist in academic settings, while still others are called to community outreach. The list goes on and on - enough to make a resident’s head spin when trying to chart the future.

But not if you know yourself well, says Kenneth Hertz, an Alexandria, La.-based senior consultant for the Medical Group Management Association (MGMA).

“When deciding which type of practice to join, which offer to take, you have to first understand what makes you tick,” says Hertz. “What’s your vision of the perfect practice? What kinds of things are important to you? What drives you?”

Hertz says that most doctors on the hunt for their first jobs in private practice don’t take the time to think this through. Instead, they just leap at the job that offers them the most money - practice particulars be damned. But that can be a mistake, landing them in a setting where they are neither happy nor comfortable. And so, most new doctors don’t stay in their first job for more than five years, says Hertz.

Who are you?

To answer this properly, Hertz says, sit back and reflect on the sort of practice environment that would best suit you.

Take cardiologist Ajay Marwaha, who will soon finish his fellowship training at Geisinger Medical Center in Danville, Pa. Marwaha says he carefully deliberated when searching for a job last year. “I’m interested in cardiac imaging, which is an up-and-coming subspecialty of cardiology,” he says. “I wanted a practice big enough to accommodate my interest - not a small practice where I’d just be a general cardiologist unable to do advanced imaging. And after thinking about it for a while, I realized I wanted a single-specialty practice that was already dominant in its market.”

Marwaha found The Heart Group, a 15-doctor practice in Lancaster, Pa., that offered him exactly this. He starts in July.

Kevin Price dreamed from early on - even before attending the Philadelphia College of Osteopathic Medicine - of launching a solo practice, where he would garner satisfaction from tending to a core of patients throughout their lifespan. But during his residency, while he was pursuing his solo-practitioner goal, veteran doctors dissuaded him with a reality check of what new solo practitioners face in today’s market. “They explained that start-up costs would be prohibitive and that I’d probably need to get a small-business loan,” Price recalls. “They said it’s not easy to establish a patient base when you’re a brand-new doctor, that it would take months to get credentialed - and paid - through the insurance companies, and that I’d have to spend so much time doing paperwork that my time with patients would be limited. I changed my mind.”

But Price didn’t give up the dream entirely. He just modified it by opting for the next-best scenario - joining an older, established solo physician in Cumberland, R.I. Now he is in (almost) exactly the setting he wanted - without all the start-up pressures and challenges.

Price is by no means alone. Large practices might seem like the trend these days, but according to a 2005 survey from physician recruiting firm Merritt, Hawkins and Associates, almost one-third of all new doctors coming out of residency are choosing to go solo or join a practice with just one other doctor.

Location, location, location

Location is also key when determining your optimal work path. Hertz says that new doctors should ask themselves: Do I want to be in a city and have access to all the amenities and culture a city offers? Or would I be happier in a rural setting?
Do I want to be where it’s warm or snowy? Do I want to live near family or somewhere completely new?

According to Owen Dahl, a long-time practice management consultant in The Woodlands, Texas, it’s usually the spouse who prevails in this area. “They say, ‘Look, I’ve sacrificed enough. This is where my family is, and that’s where we’re going,’ or ‘This is where I’ve gotten a job, and now it’s where I’d like to go,’” says Dahl.

That’s how it ended up for internist Hafusat Abosede Oni. As she completed her residency at Broward General Hospital in Florida last year, her attending physician helped her find the perfect job in the area, one that would allow her to fulfill her passion: to work with the medically underserved. But Oni’s husband suddenly received a job offer in Dublin, Ohio, and he wanted to take it. Oni had to switch gears and begin searching anew in that area. Fortunately, she found what she wanted in Third Street Family Health Services - a practice in nearby Mansfield that also focuses on the underserved, and is run by people she liked.

Grab your pardner ’n do-si-do

Having a say. Partnership. Control. New physicians need to do plenty of soul-searching on these topics before job searching, says Dahl. “The smaller the practice, the more involved and in control you’ll be, and the converse is true. In bigger practices, if you want to buy a widget for $300, you have to ask someone and get approval.”

Cardiologist Marwaha considered this. At the large practice he plans to join later this summer, he will be eligible for partnership in three years. So having some say in what happens in the practice will take a while, but for Marwaha, it’s worth the wait.

But perhaps you lean more toward Oni’s thinking. “I wouldn’t want to be a partner,” she says of the six-provider practice she joined last year. “I practice medicine for the fun of it now. I am an employee - I just get a paycheck, and I don’t have to worry about overhead or malpractice. This is the way I like it.”

Now yer talkin’

Once you’ve pondered and then settled on your own personal choice issues, how do you go about finding the right practices in the right places and landing the interviews?

After fixing on a geographical location - where his siblings live - Marwaha simply opened a phone book and cold-called practices in that area. For him, this worked. Other possibilities include searching online, using any of the plethora of cyber-classifieds such as www.monster.com. Also, consider hospitals - many assist physicians with recruiting other physicians. Dahl suggests that once you’ve identified the market you want to be in, call the administrative offices of each local hospital to see if they are helping to place new physicians in local practices.

Additionally, try getting in touch with a few physician recruiters, who are paid by practices to find talented physicians. But be careful: Such recruiters abound across the country - not all of them good. Hertz’s advice is to contact the National Association of Physician Recruiters and ask for its membership list, as members have agreed to adhere to high ethical standards. Or, he says, simply ask your fellow residents for a recommendation.

Finally, don’t dismiss the good, old-fashioned way to find a job: networking. “Any opportunity to get into a group of doctors in your specialty is good,” says Hertz. “Meet them, talk to them, and just keep your antennae up.”

This is how Price learned of the solo practice in Cumberland, R.I., that he joined after residency. The physician was a community doctor at the hospital where Price had been doing his residency. Over time, their casual conversations led to a job offer. “That is the best way to find jobs,” says Price. “Now I’m affiliated with a good doctor who I came to know well before joining him.”

In the ring

Once you’ve secured an interview, Hertz recommends arming yourself with all sorts of details about the practice in order to ask insightful questions. A Google search may help with this info-gathering. At a minimum, read the practice’s entire Web site from its home page to the “Contact Us” pop-up. And expect common queries such as: Why are you interested in this job and this community? What do you know about the area? Who else are you interviewing with? How many patients would you like to see per day? What are your long-term goals?

Remember, though, that you are interviewing the practice’s physicians as much as they are interviewing you. Thus, Hertz says to leave no stone unturned when it comes to your questions on work environment and the practice’s expectations of you. Failing to flip over and examine these stones can lead to job dissatisfaction later. “Ask them about the things that often don’t surface but should,” says Hertz. “For instance, what’s the culture like there? Would you be expected to work as part of a team of doctors or mostly on your own? Will they give you regular feedback about your performance? How? Will the practice do marketing for you to help you build a client base? Will they expect you to do any sorts of public presentations? How often?”

And then there’s the money. Without asking specifically what your salary would be (more on that below), you need to find out exactly how compensation is calculated. If this is a multispecialty clinic, do all doctors earn the same amount? Or do the specialists make more? If so, do they consequently pay more in practice expenses? How are bonuses calculated? Does the practice offer medical school loan forgiveness to its new doctors?

Don’t be shy. Hertz notes that some new physicians are hesitant to ask such questions, but it’s best to initiate open and honest discussions early on. If the physicians there bristle at any of it, maybe this isn’t the best place for you. “And isn’t it better to find out now?” suggests Hertz.

Whatever you do, avoid long, awkward pauses between questions and answers, says Ray Thomas of the Deerfield Beach, Fl.-based physician recruiting firm National Health Partners; they can be the kiss of death. “Don’t let there be silence,” he says. “It makes everyone uncomfortable.”

The final frontier

So let’s say the interview goes swimmingly, with mutual rapport firmly established. Friendly phone calls and e-mails between you increase; the practice is getting close to extending an offer. You’re excited, naturally, and you’re tempted to jump right in when the offer comes.

Don’t, says Thomas. “The job offer is like an engagement ring after the dating game. Instead of accepting right away, you need to play coy for a little while.”

This is not just to play silly games, but rather to ensure that every detail of the impending relationship is hammered out before you commit. Once the offer is tendered, you are in the position to negotiate, says Thomas. Tread carefully, and consider the following:

• Let the practice bring up money first. You may undercut yourself if you preemptively suggest an amount. After the practice puts forth an offer, then you can choose to negotiate for more - whether or not the first offer was more than you counted on, says Dahl.

• Determine where the practice stands on loan forgiveness. Is it willing to pay down your medical school loans, or at least part of them? Now is the time to push for this.

• Find out how soon you can become a partner/owner in the practice. This is providing that that’s your goal, of course. How much will it cost you to be a partner? Now is the time to negotiate this.

But don’t get too aggressive, warns Thomas. If you try to rewrite the entire contract, you’ll scare off your suitor. Pick a few points you’re willing to fight for, and leave the rest, he advises.

In the end, Hertz says it all comes down to your comfort level with the people you work with, the structure of your work environment, and the job you’re doing: “To brush past any of those nonchalantly while interviewing is a mistake that could cost you time and money. Don’t do it.”

Suz Redfearn is an award-winning healthcare writer living in Falls Church, Va., who for more than 15 years has written for a variety of publications, including The Washington Post and Men’s Health. She can be reached via editor@physicianspractice.com.
This article originally appeared in the March 2007 issue of Physicians Practice.