Cover Story-Field Guide
Finding and Starting A Job
Before you even start your job search, think about what you want in your first (or next) job. Establish your own “look fors,” says Dennis Davito, director of provider placement for Mankato Clinic. Davito says young physicians who are finishing residency or fellowship need to consider three things before launching a job search: location, lifestyle, and practice style. Are you willing to sacrifice salary for the chance to live in Hawaii? What kind of balance do you hope to strike between your work and home life? Are you the type of person who is entrepreneurial and likes to make decisions independently? Do you one day want to be part owner of a practice? If so, becoming an employee of a large integrated system may not be right for you. “I don’t know that job seekers will find the perfect balance, but they need to find what works for them,” Davito says.
Joel Oberstar, M.D.
Specialty: Psychiatry
Where working: University of Minnesota
Finished training: in 2006
About my first year in practice:
The transition from trainee to attending physician was a challenge, especially since I completed my fellowship here and then transitioned into a supervisory position at the same institution. On the one hand, it was easier because I was familiar with the staff. On the other hand, moving into a supervisory position overnight poses some interpersonal challenges from time to time.
What I didn’t learn during my training (but wish I had):
Neither medical school nor residency/ fellowship really provided a good sense of the financial aspects of the practice of medicine. Understanding some of that would have been helpful.
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When should I start looking?
According to Louis Ling, M.D., associate dean for graduate medical education at the University of Minnesota, most residents start their job search at the beginning of their final year of residency. Those in specialties that are in high demand may already have offers by that time. However, Ling says, most residents have some type of commitment by Christmas of that year. “Those who don’t still find jobs, but they’re the left-over jobs,” he says.
If you are interested in staying on as faculty at your training program, he recommends letting your training program chair know as soon as possible, as he or she can help you prepare for an academic career.
How do I find out about job openings?
The Internet has become the go-to place for job-seeking physicians at all career stages, according to recruiters interviewed for this guide. Most specialty and state medical society websites have online recruitment sections. Many allow physicians to create a web CV and employers to post job openings. For example, the Minnesota Medical Association’s (MMA) online Physician Career Center allows you to create an online profile and CV and view job openings in Minnesota and other states. Other more general physician employment sites include PracticeLink, PracticeMatch, and the National Rural Recruitment and Retention Network (3RNet). Many list jobs by specialty and geographic location and let you sign up for email alerts, which will tell you when a new listing in your specialty is posted.
Recruiters recommend perusing ads in medical journals as well. “It’s an older sourcing activity, but most of us still do print ads,” says Judy Brown, a physician recruiter for Children’s Hospitals and Clinics of Minnesota. National publications such as the Journal of the American Medical Association, New England Journal of Medicine, and Annals of Internal Medicine, and local or regional journals such as Minnesota Medicine publish ads for positions and link to them on their websites.
But print and online ads represent only one route to a new job. Brown also recommends networking—especially with faculty and colleagues from residency who may know of opportunities. “Residents who graduated the year before oftentimes can tell you whether there’s an opening where they’re practicing,” she says. Some local medical societies also provide networking opportunities for residents and fellows. The Minnesota Radiological society, for example, hosts roundtable sessions where future practitioners can get to know members. In addition, many faculty members have connections with people and institutions across the country and may be able to offer helpful insights or introductions.
If you know where you want to practice, scan the employment sections of the websites of clinics and health systems within that community or connect with physician recruiters who work for those organizations. In-house recruiters are employed by the health system or clinic and live in the community where it is located, making them well-versed in what the area has to offer and motivated to find candidates who will stay with the practice for a long time. The Association of Staff Physician Recruiters (www.aspr.org) has an online directory that allows you to search for in-house recruiters by state and organization.
Search firm recruiters, who are paid when they fill a position, can be helpful if you’re looking nationwide. However, Lynne Peterson, manager of physician recruitment for Fairview Health Services, says that if you’re looking specifically in Minnesota, they might only be aware of a few opportunities, as many organizations rely first on their in-house recruiters to fill positions.
How do I survive a job interview?
Interviewing for a job can be intense. The process itself may start with a phone call. If that goes well, candidates are usually invited for a day-long visit.
Test-Drive a Job
One way physicians can try out different types of jobs is by doing locum tenens work. Michelle Alfano, administrator for Whitesell Medical Staffing in Buffalo, Minnesota, says she’s currently working with two recent residency graduates who plan to spend a year doing just that.
“They can experience what it’s like to work in an ED in Mora or St. Peter, or a clinic in the Twin Cities and get a taste of the different environments and the paces of different practices.… It lets them get their feet wet without the commitment,” she says. Whitesell works specifically with family medicine, internal medicine, and emergency physicians.
Although locum tenens work offers a chance to find out what it’s like to work in a Level 3 trauma center, for example, or to take a month off between gigs to backpack through Peru, physicians who work for these agencies are independent contractors and don’t receive health insurance and other benefits. They also are responsible for paying their own employment and Social Security taxes.
Alfano says if you’re considering locum tenens work, be sure to ask about how you will be paid. “Some companies only pay every 30 days or require you to work a certain number of hours to make a certain pay scale.” Also, ask how long of a commitment the locum tenens organization expects, whether they will pay for your malpractice insurance, and whether you will need to pay for malpractice tail coverage after you leave.
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During the visit, you will meet with the partners and clinic administrators or managers as well as staff from credentialing, marketing, and other areas with whom you will be working. You also will tour the facility and the community. The visit usually includes a lunch or dinner with the partners and other key players in the organization.
This is the time to ask questions: What is the clinic’s practice model? How many patients will you be expected to see in a day? How often will you be expected to take call duty? What types of patients will you see, and what sort of conditions are typical? Will you be expected to see patients in the clinic on your first day? Will the organization provide training on coding, billing, and referral practices?
Asking the right questions can be difficult for young physicians who haven’t had much interviewing experience. “It’s OK to go into the interview with a list of questions,” says Fairview’s Peterson. It’s also OK to take notes during meetings.
In order to help residents and fellows weigh the pros and cons of various opportunities, Kyle Kircher, M.D., of Mayo Clinic put together a worksheet for evaluating practices that includes a list of questions that address four areas: 1) autonomy (Who leads the organization? How is it governed? What are its values and the practice philosophy of its partners?); 2) financial factors (How will I be paid? And if you’re joining a smaller group, What is the organization’s financial situation? How much cash does it have on hand? How much debt does it hold? What are the days in accounts receivable? What is the practice’s marketshare within the community?); 3) support factors (Where will my office be? Will I have to share a nurse? Will I have the equipment I need? Will I have to travel from one facility to another to see patients?); and 4) what he calls “happiness factors” (What are the internal and external politics? What kind of physician turnover has the organization had? What about other staff turnover?).
Kircher also recommends that candidates ask about issues specific to their specialty. For instance, radiologists should ask about the type and age of equipment used and the availability of teleradiology for night coverage. Those going into academic medicine should ask about details relating to tenure.
Also be ready to answer questions. Kircher says you should be prepared to describe situations in which you had to be a team player, show leadership, demonstrate flexibility, and be patient.
In addition to asking and answering questions, look around. Watch how the physicians interact with each other, with nurses and other staff, and with patients. Brown suggests sitting in the waiting room for a few minutes before the interview begins and observing what happens as patients check in. “It gives real good insight into the type of patient population the clinic serves as well as how the patients are treated from the minute they walk in the door.”
The Family Factor
When doing a site visit, Mankato Clinic’s Davito suggests bringing along your spouse or significant other. “They’re very important to the decision-making process,” he says.
During the visit, he or she can tour the community, meet with a real estate agent, learn about schools, and find out about resources, services, groups, and activities available in the area. “If a candidate has a strong affiliation with a religious sect and the community doesn’t have such a congregation, they should know that up front,” Fairview’s Peterson says.
Some larger health care organizations will work with spouses or significant others to help them find jobs. If a wife or husband is unable to find employment in a community, the couple may not wish to stay long-term.
Another factor physicians need to consider is the social environment of the practice and community. For years, residents and fellows have been surrounded by colleagues in similar circumstances—working long hours, having little money and big debt, recently married, and sometimes with young families. That’s often not the case when they start practice. “A big surprise to physicians when they go out and join a practice is that most of the partners may be older and at a different stage in life,” the university’s Ling says. “For those who move out of town for a job and don’t know anyone, this can be a huge problem. And it can be especially difficult for a spouse who might not have the benefit of having a work partner.”
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Take note of the facilities. Are lab and X-ray services on site? Are there electronic medical record (EMR) and electronic bookkeeping systems? Kircher notes that a lot of training programs have very good EMRs. But he points out that because a number of practices still use paper charts or are only starting to roll out electronic record systems, you may need to decide whether you’re willing to work in a practice that isn’t quite state-of-the-art.
Perhaps most important, pay attention to your gut feeling. Do you sense tension within the organization? Will you be comfortable having the physicians in the practice care for your patients when you are not available? Are they the kind of people you want to call “partner”?
Immediately after the visit, write down your thoughts and impressions, especially if you are considering a number of opportunities. And don’t be afraid to ask follow-up questions or even come back for another visit. “It’s better to spend the time and money up front to make sure it’s a good match rather than have someone want to leave after six months,” Brown says.
What are some warning signs I should look for?
“If you’re interviewing with an established department and have little or no time with the physicians in that department, it usually means there’s an issue in that department or recruitment is happening without their buy-in,” says Brown of Children’s.
Another potential sign of trouble is if the physicians and administrators can’t answer certain questions. “They may want the position but haven’t thought through all the additional support needs that go along with it,” she says. Consider it a red flag if they can’t address issues such as office space and operational and clinical support. Being expected to see 20 to 25 patients a day but not having the exam rooms, and reception or nursing staff to make that happen can be a set-up for frustration and failure.
In addition, you should pay attention to the people you meet during the visit. “You should either speak primarily with physicians or at least with 50 percent physicians, 50 percent administrators,” Brown says. If you find yourself spending most of your time both during the day and at lunch and dinner with administrators, find out why the physicians are absent.
Brown says other signs of trouble are when the partners and administrators won’t talk openly about the practice’s financial health and when the practice has a high rate of turnover among staff. “If the practice has trouble keeping nurses, it might be a tip-off that something is amiss,” Davito says.
Brown says candidates should also note the level of respect with which they’re treated and with which the physicians treat each other, the nurses and support staff, and the patients.
What should I consider in a job offer?
Most physicians in Minnesota work for large organizations that have standard employment contracts. The contract should include details about compensation, benefits, leaves, expense reimbursement, liability insurance, facilities and support, the scope of services the physician will perform, and where he or she will perform them (for example, one clinic or several), requirements for maintaining licensure, the workload expectations, the call schedule, standards of practice, and non-compete clauses or restrictive covenants.
Mankato Clinic’s Davito notes that contracts usually cover things that don’t change over time and that details about starting dates or certain benefits may be covered in a policy statement. “What’s not covered in a contract could be covered in a policy,” he says. “If you have questions, ask about that.”
Patricia Westerberg, M.D., FACOG
Specialty: Obstetrics/gynecology
Where working: Grand Itasca Clinic and Hospital in Grand Rapids, Minnesota; first job was with a private practice in Minneapolis
Finished training: in 2001
Biggest surprise: My first day of private practice went very well until I realized I had forgotten to complete the billing sheet on every single patient.
What I didn’t learn during my training (but wish I had): Billing. We are not taught about it in school, and as a result, few of us can complete billing with accuracy. Far into their professional careers, many physicians still don’t understand Medicare rules and regulations. It’s one area that should be addressed in training.
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Karolyn Stirewalt, legal counsel for the Minnesota Medical Association, says physicians should watch out for vague or ambiguous language in a contract. Any ambiguities should be clarified in writing prior to signing. If the written clarification is made as an addendum, then the addendum should be referenced in the contract itself.
The contract should spell out whether it automatically renews after a given period and how much notice the physician will have to review or renegotiate it. In addition, the contract should describe what happens when one party decides to terminate it early. If you decide to leave, how much notice will you need to give? Does the notice need to be in writing? If the employer wants to terminate the contract, will you be offered a severance package? How long will it last? What benefits are covered? And who covers the cost of tail coverage for malpractice insurance?
In addition, the contract should describe the benefit package, including health and dental insurance, long- and short-term disability insurance, life insurance, pension or profit-sharing arrangements, and malpractice coverage. It should outline the expenses for which the practice will reimburse you (licensing fees, dues and memberships, journals, CME), whether there is a signing bonus and how it is distributed. It also should indicate the amount of leave you will have for vacations, continuing medical education, board exams, illness, having or adopting a child, caring for an ill relative, and bereavement. If you’re relocating for your job, the offer should also spell out what sort of relocation expenses the practice will cover.
Also, be aware of non-compete clauses or restrictive covenants that place limits on the location in which you may practice after you leave the job. “Covenants are usually valid and enforceable so long as they are reasonably tailored in terms of scope and duration … and are not found to restrain trade,” Stirewalt says.
If you want to moonlight or do volunteer work, you should discuss this with the employer and put all agreed-upon terms in a written addendum, if they are not already addressed in the contract.
Although some elements of the contract such as time off may not be negotiable, recruiters say employers may be willing to sweeten the offer by helping repay a loan or increasing the CME allowance.
Fairview’s Lynne Peterson recommends that physicians coming out of residency and fellowship review the contract with an attorney before signing. “It’s an agreement that they’ve never entered into before, and they need to make sure they’re well-informed of what it says,” she explains. The MMA maintains a list of attorneys who routinely review physician employment contracts. To find one, contact Stirewalt at KStirewalt@mnmed.org.
How do I get a license?
In Minnesota, the Board of Medical Practice grants medical licenses. To apply online, go to www.bmp.state.mn.us and click on License and Regulation. Getting a permanent license can take as long as 20 weeks. Applicants must make a personal appearance before a board representative before receiving a permanent license. Generally, you need to submit an application at least two months prior to the board meeting. The physician application fee is $200, the annual fee is $192. New physicians can apply for a temporary license, which costs an additional $60. It can be issued once the board receives your application and documentation (usually within four to six weeks), unless there are issues that must be addressed.
A Word about Compensation
Evaluating compensation packages can be challenging for new physicians. “Clinics have their own formulas. I’ve never seen any that are the same, and I’ve been working with clinics for 20 years,” says Tim Schmidt, a certified public accountant with Lurie Besikof Lapidus and Co. in Minneapolis. “So a new person coming into a clinic really doesn’t fully understand the differences in the compensation formula from one prospective employer to another.”
In Minnesota, a number of clinics and health systems offer new physicians a base salary plus a production bonus that might be tied to gross charges, net charges, collections, or relative value units. As physicians gain seniority or buy into the practice, that formula can change based on the income and expenses of the group.
Schmidt says one of the mistakes young physicians make is to focus on their earnings in the first two years, rather than considering the potential over the course of their career. “They need to think long-term, and that’s hard for physicians who are just starting out and have debt.”
When weighing offers, both Schmidt and Mayo Clinic’s Kircher recommend that new physicians talk with a CPA, the practice’s business manager, or one of the partners in order to get clarity. “Most groups won’t reveal their formulas, but they will explain the concepts of the formula and provide guidance so that if you work X, you can expect to receive about Y,” Schmidt says.
Kircher also recommends asking about the previous year’s compensation. “It’s fair to ask what a first-year ENT made last year based on the compensation formula. Try to get some hard-and-fast comparisons that you can understand.”
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Once you get your medical license, you will need a federal narcotics registration if you will be prescribing, administering, or dispensing controlled substances. Narcotics registrations (also referred to as DEA numbers) are issued through the Department of Justice Drug Enforcement Administration. You can apply online at
www.deadiversion.usdoj.gov. The cost of a three-year registration is $551. Make sure when you apply that your DEA number will be registered in the state in which you plan to practice.
Although not a license, you also will need a National Provider Identifier (NPI) number before you begin practice in order to get paid by private and government insurers. Your program may have obtained one for you as a resident; but if not, it takes approximately two days to get a number. Obtaining one is free. Go to the National Provider System website and apply online at https://nppes.cms.hhs.gov/NPPES/Static
Forward.do?forward=static.npistart.
How do I get hospital priveleges and credentialed with payers?
When you get a job offer, you’ll probably get a packet from your future employer that will include applications for privileges at the hospitals where you will be working and for credentials with insurers you will be billing. “As it stands today, the amount of paperwork you have to complete and the fact that it’s duplicate paperwork is the most challenging part of getting credentialed,” says Tracey Torgersen, project manager for the Minnesota Credentialing Collaborative, a joint project of the MMA, the Minnesota Hospital Association, and the Minnesota Council of Health Plans that is trying to simplify the process.
Torgersen says large organizations have staff who will help you wade through the forms, answer questions, and make sure you’ve signed in all the right places and submitted all the necessary supplemental information. However, physicians who work for a small group may have to contact the individual hospitals or health systems and health plans themselves in order to receive the forms. They can also download a copy of the Minnesota Uniform Credentialing Application, an 18-page form that is used by most major payers in Minnesota other than the state and federal governments.
The Centers for Medicare and Medicaid Services (CMS) and the Minnesota Department of Human Services can supply the paperwork needed for getting credentialied with Medicare and state-funded health insurance programs. You can find out about participating in state programs at www.dhs.state.mn.us, click on Partners and Providers. More information about participating in Medicare can be found in CMS’s Medicare Physician Guide: A Resource for Residents, Practicing Physicians, and Other Health Care Professionals. To obtain a copy, go to www.cms.hhs.gov and click on Outreach and Education and MLN Products.
To sign up with TriCare and CHAMPVA, health plans that serve veterans and their families, go to www.tricare.mil/provider/provider_cert.cfm or www.va.gov/hac/forproviders/forproviders.asp.
The credentialing forms typically ask for your license and DEA numbers, NPI number, work history, educational background, details about residencies and fellowships, which hospitals and clinics you plan to work at, and personal information. Along with the completed paperwork, you will need to submit to the hospital or health plan a copy of your medical school diploma, medical license, DEA number, and the approval letter for your NPI, and proof of board certification.
Once you’ve submitted the paperwork, getting hospital privileges takes about 60 days, and getting approval from health plans takes about 90 to 120 days.
The credentialing process will soon get easier. The Minnesota Credentialing Collaborative plans to launch a secured website (www.mncred.org) by early 2009 through which physicians can enter their information into a database and select the hospital or health plan they want to share that data with.
How do I get malpractice insurance?
New physicians typically apply for coverage when they get a job offer. If you’re employed by a large organization, the administrative staff may provide you with forms and help you through this process. If not, you may be on your own to find coverage.
Troy M. Duininck, M.D.
Specialty: General surgery
Where working: Brainerd Medical Center
Finished training: in 2004
About my first year in practice:
The first year was both difficult and exciting. It was exciting to be doing the job for which I had trained the last 10 years. It was a difficult transition going from being a resident to being a staff surgeon. In residency, there was always someone at a higher level to look to or rely on. Once in practice, that responsibility is yours. I will say that my partners were very supportive whenever I needed a hand.
Biggest surprise: How much time I spent doing paperwork, administrative work, coding, and things that don’t seem to be about the patient at all.
What I didn’t learn during training
(but wish I had):
From the standpoint of caring for patients—the medicine side of the job—I felt very well-prepared. From the standpoint of the business of medicine, I wasn’t prepared well at all. Billing, coding, dealing with insurance companies were all very foreign and difficult to learn.
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Physicians starting out should know that there are two types of malpractice insurance policies: occurrence and claims-made. Occurrence policies cover insured events that happen during the policy period, regardless of how much time lapses before the insurance company is notified of the claim. It is the broadest type of coverage and the most expensive.
The vast majority of policies issued in Minnesota are claims-made policies, which cover insured events that are reported during the policy period. Claims-made policies are relatively inexpensive during the first few years of practice, as there is often a significant period of time between when a physician treats a patient and when a claim is filed. However, if you switch carriers, you will need either tail coverage from the old carrier or nose coverage from the new one in order to protect against claims filed for events that happened when the original policy was in place.
Approximately 30 companies offer medical malpractice insurance in Minnesota. Midwest Medical Insurance Co. is the largest and is endorsed by the MMA.
How do I stay current in my field?
The Minnesota Board of Medical Practice requires physicians to obtain 75 hours of CME credit every three years in order to maintain licensure.
The board does not mandate the content of the courses. However, it does require that the 75 credits be American Medical Association Physician Recognition Award (AMA PRA) Category 1 or equivalent (for example, American Academy of Family Physicians prescribed credit), which means they are granted by CME providers accredited by the Accreditation Council for Continuing Medical Education and meet certain standards.
Various types of events and activities may qualify for CME credit, including national conferences and workshops and live teleconferences of local workshops, seminars, grand rounds, or scientific meetings; recorded audio and video segments; and self-directed online modules that address topics relevant to clinical practice. Physicians also may earn credit by participating in journal-based CME in which they read and review or reflect on a peer-reviewed article that an accredited CME provider considers worthy, learning procedures and skills that involve new medical devices or surgical techniques, writing potential exam questions, reviewing manuscripts for possible publication in journals, or taking part in performance-improvement activities.
Most of the large hospital and health systems in Minnesota provide CME offerings. In addition, a number of websites offer comprehensive listings. For example, the Annotated List of Online Continuing Medical Education site (www.cmelist.com/list.htm) provides a long list of online offerings. The MMA’s website also has links to CME providers, including those in Minnesota, as well as a calendar of upcoming CME events www.mmaonline.net/ProductsandServices/EventsEducation/tabid/67/Default.aspx.