In response to my recent post Medicine is Well and Truly Screwed, so I Quit, an endocrinology fellow asked me, “For fellows who are looking for first jobs, what are some things/questions you would highly recommend we look out for/ask?” Realizing that my initial inclination to tell her it’s all hopeless and to give up now might be construed as somewhat unhelpful, I decided to more carefully consider her query. As is often the case, I’m not always sure what I’m going to say until I start writing, so strap in and let’s see if I can come up with some good advice – or just advice.1
First, figure out what you want
OK, Captain Obvious, tell me something I don’t know.
No, seriously, I’m not sure enough young doctors about to finish training really devote enough time to envisioning what they want their typical workday to look like – or, perhaps more importantly – what they don’t want their typical workday to look like.
When I was a fellow, almost everything I did was enjoyable. I’m sure that was partly due to the novelty of doing and learning a lot of things for the first time, partly due to the heady feeling of gaining increased competence in my chosen field, and partly due to the fact that I absolutely loved working with my attending physicians. I might see four or five patients over the course of a half-day clinic, spending as much time as needed pontificating with my mentors over diagnostic and treatment plans.
The point is: from my former perspective as a green fellow, a typical day of outpatient endocrinology appeared to be kind of fun. Did I consider the fact that, as a trainee, I didn’t carry the burden of ultimate responsibility for the treatment decisions I made with my mentors? How would that weigh on me once I set out on my own? What about the pace of the day? How many patients would I need to see in my “real” job? Would that number necessarily mean that much of my reading and pontification would need to be squeezed into occasional breaks in the action that normally would be used to go to the bathroom and eat?
Consider this illustrative anecdote: In the months leading up to starting my post-fellowship job, I called a former fellow from my program who had been out in solo practice for a few years. I asked her advice regarding how to build a practice at the group I would be joining. When I inquired about building a weight-management component to my practice, she surprised me with her response. Apparently, she – like me – loved her fellowship weight-management experience, working with a prominent researcher in the field. But when she tried to replicate her fellowship experience in private practice, she found it decidedly not fun, for a host of reasons that would probably take us too deep into the weeds. The point is, she wound up jettisoning weight management from her practice, which she never guessed would come to pass.
I took the feedback she gave me to heart and proceeded much more intentionally than I might have otherwise. Ultimately, there proved to be infrastructural obstacles in my organization that prevented me from faithfully duplicating my mentor’s weight-management practice model. But, had it not been for my discussion with that former fellow, I might have been more willing to make detrimental compromises to get the weight program off the ground. And, if I had gone down that road, I think my chances of being dissatisfied with the end result would have been even higher.
So, endocrinology fellows, I urge you to talk to as many people as possible who used to be in your shoes. If you think you want to go into private/group practice, leverage your contacts and ask them what their days actually look like. How many patients? How much time for new vs established? Is the EMR usable? Is there a viable dictation option? How much work is left to do at the “end” of the day? You get the idea. Better yet, see if any of the private practice endos in your local area would let you shadow them for a day here and there. You might be surprised at the things you learn.
On the other hand, if you think academic medicine is your jam, unless you’re wedded to your current institution you should be leveraging your contacts at other institutions to see what the academic/work culture is like elsewhere. This is especially important if you have done all or most of your training at a single university. I went to a different academic center for every stage of my training, and I learned that every place has its own priorities, quirks, practice styles, etc.
On the third hand, maybe you’ve been reading too many Hormones Demystified rants, and now you’re not sure that you even want a traditional outpatient or academic job. If you know roughly where you want to live, consider locum tenens as a way to test drive various practices in your desired geographic area. Or, perhaps you want to look into hospital-based diabetes service/endocrine consultant positions, which might have flexible/tradeable shifts and a call schedule that is actually negotiable (depending on how desperate the hospital is for your services). Or maybe you’re an Epic (or other EMR) power user, and you want to find an organization that will take you on at 0.3-0.5 FTE (full-time equivalent) to help their physicians maximize efficiency, HCC (hierarchical condition category) coding, etc. Maybe you can even pair the latter with a part-time diabetes service gig at the hospital.
You get the idea – first, just try to figure out what you want. However, you must be openminded and humble enough to realize that, no matter how much research you do, what you think you want may not prove to be what you actually want.2 Of course, this isn’t unique to making decisions about your career; the concept holds in the rest of life. But the process of becoming a full-fledged endocrinologist involves a fairly regimented series of steps, usually completed over the course of 13-14 years (from the beginning of college through the end of fellowship). This rigid process socializes us to not consider what we want; rather, we learn to put our heads down and grind it out, no matter how tough it gets. I’m here to tell you: This marks the beginning of a new era, in which you are now in the pilot’s seat instead of the jump seat, and you can hit the eject button if you feel that’s the right way to go. Remember that little nugget, should you ever be in the unfortunate position of feeling trapped in a terrible job.
Next, find the right people to (tactfully) pepper with questions
The next sections will necessarily be biased towards doing due diligence on traditional private/group practices, as that is where I have the most experience. Of course, I have contacts who run the gamut – from group practice to academic medicine to the pharmaceutical industry – and there will be at least some overlap between vetting a group practice job and an academic or hospital-based job.
When asking questions, there are a few tenets you must keep in mind:
- Don’t talk to recruiters; it’s a waste of your time.
- When you have to talk to a recruiter to get further in the interview process, don’t believe anything they say.
- You know the saying, “Trust, but verify”? Yeah, forget that. In this case, do not trust anything you are told by a recruiter. Importantly, this extends to physician administrators responsible for interviewing candidates.
Why do I include this advice at the very beginning of the “ask questions” section? Because you need to understand that the recruiter’s priority is to fill an opening with a candidate who seems competent and has a decent EQ. Nowhere on their checklist does it say, “Help the candidate determine whether this job is really the right fit for him/her.” A very good physician administrator knows that it doesn’t do anybody any good to go through the process of hiring and onboarding a new physician, only to have that physician leave in the first 1-2 years due to irreconcilable differences. Not only is it disruptive to the physicians and staff in the department, it’s bad for patient care and it is ridiculously expensive to go through the process again. Unfortunately, you may or may not be dealing with a good physician administrator. So I repeat: do not trust anything they say.
To whom should you pose your gazillion questions?
- Physicians, nurse practitioners, and physicians assistants who actually work in the Endocrinology department
- Nurses, medical assistants, and receptionists (if applicable) who actually work in the department
- Any manager or other administrator who is directly responsible for the operations and financial performance of the department. It’s usually more important to pay attention to how they answer your questions and what they don’t say, as opposed to what they do say.
- Any physicians who have left the practice (this is very important, for reasons that should be obvious)
- Anyone in your target organization who you know to be a malcontent, dissenting voice, or otherwise a rabble rouser (tactfully ask around, you might be surprised at how easy it is to find these folks and how much they want to spill the beans)
Now it’s time to ask a lot of questions. A lot.
You endocrinology fellows are all a bunch of smart cookies (you got this far, didn’t you?), so these next few sections will not be an exhaustive list of all the questions already in your quiver. Rather, I will simply emphasize a few things I find very important and possibly point out one or two things you hadn’t considered, in no particular order…
Taking over a practice versus building a practice
Will you be taking over for a departing physician, or is the department expanding such that you’ll need to build your practice from scratch? If the former, then you absolutely must talk to that departing physician, to get a sense of whether your practice style is similar enough to facilitate a smooth transition. I cannot tell you how many times – in all medical departments – I’ve seen a freshly-graduated resident or fellow come in and take over for a more established physician who had only a casual relationship with evidence-based medicine, but a devoted stable of patients who thought this doc walked on water. Please realize that I’m not painting all older doctors with this brush; but I have noticed this often enough for me to consider it a thing.3
In any case, it’s not just an old/young thing when assessing compatibility. Let’s say you became an endocrinologist in spite of diabetes care, not because of it. Well, if the departing physician has a diabetes-heavy practice, it’s not a good match. You should not take that job unless the department has a clear plan to transition diabetes care to, for example, specially trained nurse practitioners.
Further, if you’re assuming someone else’s practice, you should ask the other partners about that doc’s patient panel. Do they have a hard time covering for him/her because they can’t make heads or tails out of his/her incomprehensible EMR notes? Do the partners get more after-hours phone calls from that doc’s patients, perhaps because the doc doesn’t give clear instructions on after-visit summaries, or perhaps because that patient panel is just higher maintenance?
This is also where talking to clinical staff and other office staff can be very helpful. If it’s at all possible to arrange an after-work happy hour to chat up the staff, I’d recommend that, as they’ll be very busy when you visit the office. Plus, they may be on their best behavior in the office, which is frustrating if you’re trying to dig for dirt. While it can be somewhat illuminating to watch someone try to not say what they’re really thinking, I much prefer sitting across from people in a relaxed atmosphere, where they feel slightly more comfortable being honest. I cannot emphasize enough that the office staff often know way more about the patient panel you’re about to assume than the other doctors in the office do, so solicit the staff’s opinions and give them a fair amount of weight.
While I have seen physicians successfully assume practices to which they were not well-matched, you should be aware that the first 1-2 years will be somewhat painful. Those of you with a reasonably developed sense of empathy will feel lousy as patient after patient learns that you’re not going to be to them what Doctor X was to them. They will leave, and you will eventually be able to cultivate the type of practice you want. But also remember, the patients who leave will tell their PCPs, “I don’t like that new endocrinologist, because she doesn’t do [insert complaint here] like Doctor X used to do for me.” You subsist on referrals from PCPs, so it’s really not good to get a “reputation.”
So it sounds like building a practice from scratch is the clear winner, yes? Not so fast. What’s the demand for an[other] endocrinologist at the organization? What metrics are they using to justify their claim that there is “high” demand (they will never tell you that demand is anything other than high)? There are no-brainer cases where the existing department has a 4-6 month wait for new patients. Under those conditions, sure, hire away. But for the tougher scenarios, if you think your target organization is using the same sophisticated financial modeling software that hedge fund managers use, uh…no, they’re not. They are making assumptions based on crude, back of the napkin calculations, and you don’t want to stake your livelihood on that.
What about when the organization wants you to set up shop at one of their satellite locations, where they’ve never had endo? How many PCPs are there in the referral network at or near the place you’ll be working? If the primary care presence isn’t robust, are there other types of referring doctors nearby who are driving the hiring of a new endo? You need to know if, for example, there’s a large contingent of nephrologists who are looking to have an endo come in and take over diabetes care for a large panel of patients on dialysis. If that’s your jam, then great, go for it. Maybe there are a couple of thyroid surgeons there who want to send all nodule/lymph node biopsies and post-thyroidectomy care to you. Again, if that’s cool with you, go for it. Just make sure you know everything about why the organization wants an endo and who they expect to be sending you patients.
If they don’t have a good answer regarding who will be sending you patients and you take the job anyway, be prepared to receive increasingly desperate emails from managers and the accounting department, when your schedule is not filling as fast as they hoped it would. The knee-jerk response to these queries about what you plan to do to get more patients is: “What the f*** did you think was going to happen when you hired a new consultant with an inadequate source of referrals?” But the knee-jerk response is not the appropriate one. No, they’ll want you to go visit primary care doctors’ offices during lunch for meet and greets, stand at the front door of the clinic greeting all comers and telling them who you are, and network at after-hours events.4 If you’re an introvert who has zero desire to aggressively promote him- or herself, this will be akin to torture.
The last thing I’ll say about building a practice from scratch is, if you are eventually going to be paid based on production, you should push hard for a salary guaranty (floor) for at least two years – three would be better. Chances are you’ll be outperforming the salary floor within the first 3-6 months if the demand is really as high as they say. But demand can soften for many reasons that are totally beyond the control of both you and the endocrinology department: a major employer in the region lays off thousands of workers, leading to many holes in your schedule; PCPs are leaving your group in droves, because it sucks to be a PCP and your clinic isn’t treating them well enough, so your referral base dries up; your organization plays chicken with a major insurer as the new year approaches, in an attempt to get better reimbursement terms, and neither side swerves, so the contract with that insurer is severed and now you can’t see any patients with that type of insurance, which turns out to be 15-20% of your panel.
While all of the aforementioned events will be mitigated by the tincture of time, having a 2-3 year salary guaranty will ensure that you have the luxury of waiting for time to work its magic with respect to filling your schedule. Because, speaking of guarantees, I can guaranty you that every physician in your department will be pressured to “don’t just stand there, do something,” regarding addressing the holes in the schedule.5
To be continued…
I’m pretty sure 3000+ words is where most people’s attention span maxes out, so come back soon (or subscribe to be notified of new posts) to learn more about how to vet a medical practice. In Part 2, I’ll give my take on non-compete clauses and other controversial topics!
By using this site and interacting in the Comments, you agree to abide by my Disclaimer. Please keep your comments respectful and refrain from ad hominem attacks. In the past, I’ve been permissive — no longer. The social and political discourse in our country has become so toxic that I cannot, in good conscience, allow my blog to provide a space for those who simply want to express outrage. If you disagree with something I’ve written, or something written by a fellow reader, fabulous. Make your argument in as dispassionate a way as you can, and we’ll all get along just fine.
If you are a physician or other healthcare provider of any stripe, our resident and fellow colleagues would love to hear your thoughts about vetting a medical practice. What do you wish you had asked before you accepted your job? What have you learned about the logistics of building a practice that would be helpful for trainees to know before they start interviewing? Since this is Part 1 of a multi-part post, try to focus on the issues discussed in this post if possible (figuring out what you want, figuring out who to talk to at the target organization, assuming vs building a practice, and asking for a salary guaranty).
Image Credit: Photo by Tim Mossholder on Unsplash
- Note that you don’t have to be an endocrinology fellow to benefit from the information in this post; much of it will apply to residents and fellows of all stripes.
- As my good friend at Reflections of a Millennial Doctor has explained quite eloquently throughout her blog.
- This should go without saying, but people are so sensitive nowadays, so…I know many, many docs who have been practicing for decades and they are simply awesome. Not only do they practice evidence-based medicine, but they have the experience to properly exercise clinical judgment when EBM can’t provide a good answer. Further, to be balanced, I have also seen many new attendings whose practice styles are so rigid that they don’t allow for meeting the patient where the patient is.
- If you think I exaggerated with the standing at the front door thing, I assure you I know a doc who was asked to do this.
- As an example of one near-term fix that may cause you long-term problems, consider the endo department that actively reaches out to all PCPs in the organization to refer any and all patients with diabetes. The effort to fill the holes is somewhat successful, but within 6-12 months, the department finds that its clinical staff can no longer keep up with all the paperwork, problems, emails, and calls regarding insulin pumps, continuous glucose monitors, and other diabetes drugs and supplies. Yes, diabetes care is super-important, but you must remember the 20/80 rule: even if only 20% of your practice is diabetes, it will consume 80% of your resources. Again, for sensitive folks out there, this isn’t a negative judgment of any kind; it is simply a statement of fact. Unless you work in a diabetes clinic that has been specifically set up and resourced to do nothing but diabetes, be careful.