In Part 1 of this post, I started answering a question that an endocrinology fellow posed to me: “For fellows who are looking for first jobs, what are some things/questions you would highly recommend we look out for/ask?” As I am wont to do, I got carried away and replied with more than 3000 words, so I had to end it prematurely and come back for round two. I think the advice in that piece applies equally well to established endocrinologists looking for a new gig, as well as physicians of other stripes, so please go read it if you haven’t already.1
In no particular order, here are some more things I find especially important when vetting a physician job:
Non-compete clauses are more important than ever
Why do I make the above claim? Because the trend toward consolidation into ever-larger healthcare organizations has drastically reduced the number of different healthcare systems and private practices to which you can jump if your current job is terrible. I’m going to offer a few thoughts on how to think about this issue, but keep in mind that I am not a lawyer; the fact that I lived in proximity to one during my formative years does not make me any more competent in this arena — it only means that I lost most arguments while growing up. So none of what I say constitutes legal advice, and you should absolutely seek consultation with a healthcare attorney before signing a contract with your target organization.
When it comes to non-compete clauses — also known as restrictive covenants — you’ll find that they range from being completely absent from a contract to being draconian in their severity. Regardless of whether you plan to work in a state where non-competes are enforceable, you need to be extremely careful about signing any contract that contains one. Even under the best circumstances, in which your state has laws more favorable to workers, if your target organization gets its back up and decides to sue you for breach, it has the potential to be stressful and expensive, even if you win. Given the size of the organization for which you will likely be working, I can pretty much guaranty that it’s going to hurt you more than it will hurt your employer.
It would be easy for me to say, “Don’t sign any contract with a non-compete.” But that would be terrible advice, as these clauses are ubiquitous, they are often non-negotiable, and their presence in a contract does not automatically make an otherwise promising job a poor choice. Obviously, if you or your attorney can negotiate elimination of the clause or better terms, do that. But be prepared for a large organization to put the contract in front of you and say, “Sign it. Or don’t, if you don’t want want to work here.” The days of being able to negotiate substantial contract changes with these giant employers may be mostly over, unless you have a skillset that is rare and in high demand. Spoiler alert: If you’re an endocrinology fellow, you’re probably not going to merit the same indulgence as would a cardiothoracic transplant surgeon.
Here comes the important part: If you find a job you like enough to consider taking, do your best to negotiate the terms of the non-compete. Once you get the best offer you’re going to get, you need to do your due diligence to determine whether there is a reasonable array of other opportunities in the region, should your prospective gig go south.
Consider the following example: The non-compete you are asked to sign precludes you from practicing within 20 miles of your organization for two years post-separation. You work there for a couple of years, it sucks, and you decide to leave. You find another healthcare system 25 miles away from your current office, interview for the endocrinology position they’re offering, and you get it! You give the contractually-required duration of notice to your current employer, who hears about your new gig. You are then contacted by your employer’s legal department, which informs you that they are going to sue you for breach of contract.
Well, it turns out that your current employer has been gobbling up smaller practices around the region, and now the closest outpost of your current organization is only 10 miles from the office at which you’ll be located with your target organization.
But, but…that’s not fair! My current office is 25 miles away from my new office! They can’t do that!
Maybe they can, maybe they can’t. What’s the precise wording of your non-compete? Is it vague enough to where a crafty lawyer could parse the language that way? Perhaps you’ll win this lawsuit, perhaps not. But you’re going to have to defend it, all the while trying to focus on the things that matter in your life with this sword of Damocles hanging over your head. You don’t need this kind of stress.
Or how about this example: You’re looking at a job at Man’s Best Hospital. They don’t ask you to sign a geographic non-compete, but you are presented with a non-compete that says you can’t see any MBH patients for two years post-separation. You sign the contract with MBH, grind it out for a few years, and then decide to open your own practice just a few miles away.
You are very careful to instruct your receptionist to decline to schedule appointments for any of your prior MBH patients, as well as for any patients with a MBH primary care physician. After six months in private practice, things are going pretty well. The practice is growing, your schedule is filling, and it seems like you’re getting the hang of this entrepreneur thing. Wait, what’s this…oh, MBH is suing you for breach of contract. It turns out that MBH defines a MBH patient as any patient who has ever walked through the doors of MBH for any reason. That means that anyone who has ever had a blood draw, a walk-in clinic visit, or a vaccination at MBH is off-limits to you. Uh-oh.
All this is to say, ignore the non-compete at your peril. While it might be possible to negotiate (i.e. pay) your way out of a restrictive covenant upon separation, chances are the dollar number is going to be high, and remember you’re an endocrinologist playing with insulin pumps — not an orthopedic surgeon rodding femurs. If your target organization really needs you that badly, you can ask if they will buy your way out of the non-compete, but this should be a strategy of last resort — not a substitute for doing your due diligence before you sign anything.
And finally, not for nothing, if you’re moving to a new city for this job, I strongly recommend renting a place until you’re pretty sure you’re in it for the long haul. Obviously there are many variables involved in making the decision to rent vs buy, but it’s best to avoid being tied to an area financially, should the housing market crash after you buy your new digs and start your new job. I get that you’ve probably been renting apartments since forever, you’re sick of picking up your life and moving every few years, and you’re dreaming of the house you’ll buy with your newfound doctor money. Unless you plan to make this new city your home regardless of what happens with this first job, think twice before buying a place.
Call schedules and inpatient consults
Of all the things that have potential to cause you great pain on a daily basis plus weekends, call schedules and inpatient consults have to be in the top five. Before I dive into this section, however, I must disclose my strong bias against call and consults, which is based on my personality type. I’m the type of person who, if paged in the middle of the night, is not getting back to sleep for at least an hour. If I get paged during the weekend or any other quality family time, it completely takes me out of the moment, such that I tend to perseverate on whatever the call was about for at least an hour afterwards. I don’t even like to carry the pager anywhere I can see it, because just noticing it makes me edgy — I need to be able to almost forget I’m on call in order to not exist in a mild state of clench.
I thought that I would eventually become accustomed to being on call and it would bother me less, but that never materialized. Further, I should note that I really didn’t receive that many calls during my clinical career, nor did I have to go into the hospital very often (more on that shortly). In fact, I chose endocrinology as a specialty in part because of the lack of emergencies and heavy call volume. And I chose the practice where I spent my career in part because it seemed like call and consults weren’t going to be too onerous. All that is to say, I had one of the best call-and-consult situations you could possibly want, but it was still an intrusion in my life that I hated when it happened. So if you’re anything like me, you’ll want to read the rest of this section very carefully.2
If you’re joining a practice that already has other established endos, you will want to question them closely about the call schedule. Some practices do not take after-hours phone calls from patients; rather, they have policies that direct all such calls to the primary care provider. That will be significantly better than being first in-line for questions nights and weekends. While you might get the occasional call from a PCP who doesn’t know what to do about the problem they’ve been contacted by a patient to solve, that should be rare.
If your target department does take patient phone calls, however, you will want to know that they have policies in place that they enforce regarding what they will do after-hours and what they won’t do. While I have found that the vast majority of patients are reasonable and generally respectful of my time, it only takes a handful of bad apples to spoil your weekend.
Another thing you must investigate is whether your target endo department has a “community” call schedule, or some other type of shared arrangement with endocrinologists at other local organizations. While this can be great for decreasing the frequency with which you are on-call, it is decidedly less great when the different departments have different policies regarding what type of calls they handle. If your department doesn’t take patient calls, but the one across town does, and you share call with them…well, that is not good news for you. Conversely, if your group accepts patient phone calls but the group across town doesn’t and those endos refuse to take your patients’ calls, that is also going to bite you in the butt.
As for inpatient, ICU, and ER consults: I have heard of endos who love these consults and actively seek them out to make more money. I don’t know any of these docs personally, so I can’t adequately steel-man their position. All I can do is tell you that I absolutely detested going to the hospital, which was a tremendous time-suck and not at all worth the hassle or money (neither for me, nor for the patient most of the time!).
First, unless your group gets so many consults that they actually build time for them into their outpatient schedules, you will be going to the hospital before or after work. That means you are either getting to the hospital at 5:30-6am or 5:30-6pm. Is the hospital adjacent to your clinic, or is it a drive across town? Will you have to fight traffic to get from there to your office in the morning or from your office to the hospital in the evening? How far is the hospital from where you will be living, should you have to go in on the weekend? Will you be covering more than one hospital?
Not only will you spend a fair amount of time in transit, but unless the hospital and your target organization are one and the same, you will need to learn two EMRs, two dictation systems, etc.3 If you go to the hospital frequently, you may get the hang of it. But if you go rarely, it will be like the first time, every time, and it’ll be a thrash.
Over the course of my clinical career, I found that almost every inpatient endocrinology “consult” could be handled over the phone, sometimes with a little bit of remote chart review. Granted, I wasn’t receiving consults from a tertiary referral center, so most of what I’m going to say doesn’t apply to major academic institutions with legitimate endocrine emergencies. With respect to the typical community hospital setting, you certainly will want to know if the partners at your target department have socialized the hospitalists, intensivists, and ER docs at the local hospital to accept your phone advice in lieu of your physical presence. If they haven’t, and they tell you to expect at least one consult every time you’re on call, I would think twice before accepting that job.
But what about making more money? Shouldn’t I want to do hospital consults to generate more income this early in my career?
I encourage you to do the math. If you add up all the time you spend in transit, trying to track down nurses and medication administration records at the hospital, reviewing records, dictating/writing a note, calling other consultants on the case, etc, you will find that it is most likely not going to be worth the extra wear and tear on you and time away from your loved ones. You want to make more money? See an extra patient or two in the office and spend a fraction of the time doing that. It is better to spend ten minutes on the phone with a hospitalist and another 10-20 minutes doing remote chart review, and answer all the hospitalist’s questions for free. Consider it the tax you pay to get to go home and have dinner with your family.4
I realize that many of you are fellows, and you’ve been marinating in the academic medicine environment for years. Some of you may even have a DMS (diabetes management service) at your academic hospital that is staffed by endocrinologists, so you may be resigned to the idea that you have to see inpatients out in the real world. It just isn’t so. In the real world, many community hospitals have robust diabetes management protocols and hospitalists who aren’t afraid to use them. If your target organization seems like an amazing place to work except for all the inpatient diabetes consults, well…you should meet with the head of the hospitalists and see if he/she would be willing to work with you on implementation of a diabetes management protocol, assuming that your prospective partners would welcome this development.
When I interviewed for the job I would take post-fellowship, it was my first encounter with an organization that presented me with a list of “core values.” The Medical Director earnestly explained to me that it might not be the right place for everyone, because not everyone would share these values. Frankly, I found the whole song and dance absurd, as these values consisted of the obvious pablum one would serve up in marketing materials for any healthcare group. It would be just as ridiculous for me to disagree with any of the core values as it would be to say, “You know that bit about ‘doing unto others as you would have them do to you’? Yeah, I’m not in favor of that.”
Over time, however, I came to appreciate the way in which some of our better physician administrators used the core values as their North Star when making difficult decisions. Unfortunately, as the organization grew and many low-level administrators were promoted to middle and then upper management, the core values were weaponized into cudgels, wielding whichever value could justify an unpopular decision that had already been made.
Briefly, the culture at my group today is terrible, and there is absolutely no reason to believe it will ever improve. But if you were to sit in on any all-physician meeting, you would think that we’re all doing wonderful things to make this one of the country’s best places to work. I know for a fact that some of our upper level physician administrators don’t believe it, but they are politically savvy enough to realize that there is no upside to proclaiming their true feelings in a public forum to all the docs.
All this is to say, it is very difficult to understand the true nature of an organization’s culture from the outside. This is especially bad news for you, because your interview day will be spent meeting with various cheerleaders for the group. While it’s better to talk to cynics and malcontents, you may not get the chance. So, if you’re getting the runaround from the cadre of optimists you meet, try asking the question this way: “With respect to physicians who have left the group or current docs who express dissatisfaction with the culture, what would they say are the organization’s major problems or flaws?”
I cannot overstate the importance of company culture to your overall happiness, nor can I overemphasize the sheer breadth of what is affected by culture. For example, are you going to be treated like a professional of high standing or a revenue-generating widget? In the former circumstance, workers in your IT department will call you Dr. Harrison; you can block out your schedule for an hour to take a meeting; and non-physician administrators will actively seek your input before they launch major initiatives that can affect your workflow. In the latter, IT workers will casually refer to you as Chris; your manager will be looking over your shoulder and asking when you plan to make up that hour of time; and non-physician administrators will answer only to their superiors, which never includes you.5
Unfortunately, even if you do your due diligence and find that your target organization has a decent culture, it’s kind of like the stock market — past performance doesn’t necessarily predict future performance. Many healthcare systems are under the same tremendous financial stress and are simultaneously experiencing the same rapid growth as they absorb smaller practices around the region. This will almost certainly lead to shifts in culture, and not in a good way. But there’s only so much you can control, so seek out as much information as possible — that’s the best thing you can do.
Well, that’s it for Part 2. Let me know in the Comments below if you have any other questions that might merit a Part 3!
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.
Image Credit: Photo by Tim Gouw on Unsplash
- Part 1 covered: figuring out what you want; figuring out who to talk to at your target organization, who not to talk to, and how to listen to them effectively; the importance of knowing whether you’ll be building a new practice vs taking over a departing physician’s practice; and the importance of negotiating the longest duration salary floor possible. [↩]
- Hopefully you are not like me, and you can handle being on-call like a true mensch. [↩]
- I assume you already know this, but just because your target organization and the hospital both use the same EMR, if they are using customized versions of that same EMR, you will still have to learn two very different EMRs. [↩]
- Obviously, this advice becomes less practical as the number of consult requests increases. For me, it was rare to have more than 1-2 per week, so I was almost always able to handle them by phone. [↩]
- For the record, I am fine with non-physicians at work addressing me by my first name, once we know each other well. But I do believe it is a sign of respect to use Dr. So-and-So until then. [↩]
2 Replies to “How to Find Your Dream Endocrinology Job in a Dysfunctional System — Part 2”
I have appreciated your honesty and words all these years. You wrote the TRUTH when no one was sharing it. You have been open about your emotions and life. I have been able to relate and connect. As a primary care doctor working at a MBH it was hard to hear you write about endocrine call and should think about primary care answering the phone calls. Pause here …. think about your colleagues, the answer might be is there a nurse triaging and answering calls? Not other colleagues who work at the MBH with you that are also struggling and have 25 min to answer all a patients questions, regarding thyroid, weight gain, fatigue, plus HM and immunizations, etc …. You get it!
Dr. Miller, I really appreciate this comment, and you are totally right. My commentary about how to handle endo call is borne out of selfish preservation, without much regard for my primary care colleagues. And I also agree with you that feces flows downhill and tends to land on PCPs. I wish I had a good rationalization or justification for this, but I don’t. I just have to admit that I’m kind of a jerk on this one issue, and I beg your understanding that I’m a flawed human.
If it makes it any better, in my system, there was a nurse firewall between the PCPs and the after-hours patient phone calls, though I admit that the firewall didn’t come into existence until maybe 5-10 years ago. Prior to the nurse firewall, the PCPs would get hammered with calls every time they were on – it was awful according to a few of my colleagues.
My department generated very few of these after-hours patient phone calls in the grand scheme of things, but your point is no less valid. Please know that I appreciate you and every other PCP out there; y’all have the toughest job in medicine.
Edit: One thing I did forget to point out is that the average Endo department has fewer than a handful of docs, which does make the call frequency fairly high. Reasonable people can disagree about whether it’s preferable to have high-frequency, low-volume call vs low-frequency, high-volume call. But it’s worth noting, at least, that small Endo departments will automatically have high-frequency call unless they share call with the rest of the Endo community docs.