Wednesday, August 29, 2007

Hunting Season

With fall comes a new season: recruiting new physicians.

For cardiology groups nationwide there is a vigorous push to recruit the best and brightest of our medical school fellowship candidates to join groups of specialists and subspecialists.

But inevitably when I interview candidates, I find the same debate circulating in the young cardiologists’ minds: private practice or academics?

Most cardiology candidates come from an academic background: that is, lots of support staff, collegial interaction daily, work hour restrictions, a familiar turf, a call-night hierarchy that filters the less important nurses’ calls to the resident and in-house physicians before the call to the attending.

In contrast, there is the siren song of the "mega-bucks" private practice setting. While initially appealing, this appeal is quickly tempered the realization that higher wages come at significant personal cost. Aggressive business practices of today's successful private practice groups demand more from their young cardiologists: seeing more patients in less time, no work hour restrictions (work until the work is done), being directly responsible for a patient’s care, understanding the complexities of billing and diagnosis codes, and often working alone late at night to accomplish these business goals. How many graduating fellows are prepared for this? I dare say, none of them.

So they sit in my office for their first interview for the big wide world and squirm. Appropriately. These are tough decisions.

Sure, there are practices that have tried to balance the transition from fellowship to an attending by developing mentor programs or lightening the load in the clinic for a few weeks. But there is no substitute for experience – irrespective of the practice environment encountered. Having come from a military practice setting, then private practice, now back to a somewhat hybrid practice situation, I felt it might be helpful to share a few the thoughts about what attendings-to-be should consider during this transition period:

(1) It is helpful to remember that about 50% of all first-year physicians change jobs. Don’t over-commit to a large fancy home, huge mortgage, and don the "golden handcuffs.”

(2) Look at the practice environment you are entering. Is the hospital fiscally sound? Do people in the community want to bring their families there, or to the competing hospital across town? Is the group well-respected in the community? Are most of them older and due to retire soon?

(3) Probably the most important question to understand as you enter a new practice environment: Who’s the competition? Irrespective of practice setting today, everyone is in competition for patients and the almighty health care dollar. If you’re walking into a practice with rose-colored glasses, take them off and get real. Research your environment.

(4) Ask to call someone who just left the practice. Why did they leave?

(5) Know the community. Take time to be sure it is safe, conducive to raising a family (if that is your goal) and has an acceptable cost of living, schools, etc. Realize that tough-to-recruit places generally have higher starting salaries: if you’re offered $400,000 your first year, you'd better know why.

(6) Learn how to bill. If you have no clue what a CPT or ICD-9 code is and how they interact, you'd better learn. Like it our not, this is how you will be paid. I can honestly say that I left hundreds of thousands of dollars on the table early in my career because I had no clue how to bill.

(7) Does the practice have a business manager, or are you and your physician-colleagues expected to perform this function yourself? Who will make sure you are billing correctly, hire and fire staff as needed, be sure human resources standards are kept, manage billing processes? Having been in a private practice without a capable business manager at the start of my career, I'd never do this again.

(8) Understand compensation arrangements. Is the practice a socialist "even-split" model or a productivity "eat-what-you-kill" model. Is it a balance of the two? Most practices will support your salary initially, but after the one- to three-year grace period, how will you be paid? Is there a buy-in to the group? If so, how it it handled?

(9) Have an exit strategy. Although no one wants to consider this initially (call it the "rose-colored glasses" phenomenon), this might be one of the more important considerations. For instance, if you decide to leave a practice, will you be responsible for a "tail" of malpractice insurance? If there a restrictive covenant? If so, is there another practice outside the covenent where you could work at to prevent having to move your family, or would you have to move to a new town if the practice opportunity falls through?

(10) Consider your experience and expertise when negotiating salaries and benefits. New attendings have little negotiating ability in this regard, but people who have been out in the world a while bring real-world experience to the table and might be able to demand a higher starting salary. That being said, be sure to inquire about the growth potential both professionally and financially should things work out.

In the end, the decisions are still tough. Certainly not all areas are covered here (I'd welcome other suggestions), but careful consideration of these ideas are sure to help smooth the transition from trainee to attending physician.

Best of luck.