Some factors to consider for the ideal employment scenario.
Dear Director,
As I start my job search, what are the characteristics that I should be looking for in a job after residency?
The job that works for you may be as unique as you are, as all of us consider different variables in finding the perfect job. However, there are a variety of things for each person to consider and then you can individually prioritize them.
Location
I have always admired people whose job search includes multiple areas around the country. In reality, most people start by choosing a specific location. This is often related to where you grew up or where other family members or friends are living.
Opportunities for your spouse and/or children relating to work/school/activities, cost of living and the size of the city/town must factor into your consideration as well. I have worked with several docs who wanted to try out living in the D.C. area, only to have them realize within a few years that they missed their family or at least wanted to be closer to their family for reasons related to children or their parents’ health.
Many residents also take jobs that are located within 50 miles of their residency. This is often related to professional contacts and understanding the local job market better than they do job markets in other cities.
Once you decide on the general location, many people then factor in commuting time, potentially excluding good emergency departments where their commute would be too long. With today’s job market, don’t be afraid of a commute. Recently, I’ve talked to people who live on the east coast and work on the west coast as well as people who live in Colorado and commute to California.
People
The most important aspect of my job is my colleagues. This is a broad category and can be broken into subgroups, such as your co-workers in the department, physicians around the hospital and your nursing team. I have been generally blessed with having worked with great emergency physicians at all my jobs.
However, the culture and skill set among the docs working outside of the ED has varied from hospital to hospital. There are certainly some groups of docs within the hospital that the department should work well with. My short list includes the hospitalists, cardiologists, intensivists and radiologists.
If there is a frequent wall put up by the hospitalist about who they want to admit and who can go home, you are frequently going to be frustrated. You may make some bad decisions and the department flow will be poor. Having a cardiologist who trusts you to make the right call on the STEMI is great. Having a cardiologist you can call directly who won’t think you’re an idiot to discuss a possible STEMI before you call the STEMI team is really great.
I love having an ICU with intensivists who can really help out with critically ill people, or at least understands that an intubated post arrest patient without a STEMI is going to them and doesn’t require a multi-hour work up in the ED.
I’ve been elsewhere where the ICU docs would say the ED patients were too sick for the ICU, needed to be transferred, and then wouldn’t come do a consult and help guide management.
We’re all in this together and nursing is certainly critical for providing good care and having satisfaction with your job. Medical directors are generally very aware of the nurse’s employee satisfaction survey and how the relationship with the doctor is scored.
It’s certainly fair game to ask a question during an interview about relationships and the people. At the end of the day, we spend a lot of time with the people at work. We want to provide high-quality care and enjoy the people we work with as much as possible.
Culture
Culture is set by the department leadership as well as the hospital leadership. Every department has a little bit of its own culture when it comes to coverage, productivity demands, sign out, night and holiday coverage, training, etc. Some of this you can seek out during the interview process. Some of it you’ll figure out later.
Teamwork, collegialism and relationships are outcomes of the culture. You don’t need to have regular group happy hours, but it’s certainly nice when there’s a group of docs you enjoy hanging out with outside of work. And when you have a crashing patient, don’t you want your colleagues to see if you need help or to stay late to help empty out the waiting room before they leave you for your single coverage nightshift?
The hospital may also determine some of the culture. Some hospitals have expectation related to waiting time, throughput and patient experience that are different than others. No hospital wants to do poorly in this regard although some find the 50th percentile acceptable given other constraints/challenges while at other hospitals this would be unacceptable.
Hospital Resources
I spent my career working in high-volume urban EDs with pretty good hospital resources. Admittedly, I have been a little bit spoiled. I know many people who like working in smaller emergency departments, rural emergency departments and critical access hospitals.
Resources is not just your radiology services, but also your consultant service availability, and your ED staffs nurses, techs and other support staff. The amount of resources available and the amount of time you will spend transferring patients varies throughout each of those types of emergency departments.
A friend of mine just left his high-volume urban emergency department to start working in a more rural emergency department with less resources and more transfers. He loves it.
Most ER docs do not have the types of resources you’ve become accustomed to at a tertiary care academic medical center, such as 24/7 MRI and many do not have a cath lab at their site, but it does not mean the ER is not providing high-quality care. One could argue, these emergency physicians are providing a greater service to the community because they’re using more of their emergency medicine skill set than many of us who practice in larger EDs with more resources.
Chair/Medical Director
People leave their boss, not their job. This isn’t just a management saying. I’ve definitely found it to be true. Although the chair or medical director may not be your top priority, making a decision about how much you will like working for him or her (as well as their boss and the hospital CEO) should be a consideration.
The chair will determine the culture of the group and ED. As important to a new doc, you want someone who is committed to developing and mentoring you. Ask a question during your interview about the feedback process and how often you’ll expect feedback. Also, every new doc usually generates some sort of complaint in their first few months.
Sometimes this is from a patient, but it may come to your director from a nurse, hospitalist or consultant. Ideally, your chair has your back when cases or relationships go poorly. While we can usually defend you, sometimes we just need to commit to educating you going forward while protecting your job.
Schedule
I have often said that the most powerful person in the department is the one who creates the schedule. They have control over honoring your schedule requests, that may allow you to take that long weekend, getting the vacation you want and how tired you are going to be after a run of nights before you come back.
Although the artificial intelligence of many of the scheduling software packages is really good and can produce a very good schedule, there still needs to be an individual who takes responsibility for the schedule.
Many groups have a nocturnist. It doesn’t mean you won’t work nights, but it likely means you’ll work less nights. Other sites will have a night and/or weekend pay differential so you can volunteer for those shifts and make more money.
You should know how the schedule is made, ask the docs how they like their schedule, see how fair it is when it comes to shift distribution and holidays, and see if there are perks given to the more senior docs.
Type of Employer
I have been a partner in a democratic group and have also spent large chunks of my career working for large contract management groups. I have been an employee as well as a 1099 independent contractor. Some of my best friends have been employed by their hospital or through their hospital’s physician group. I feel like I have seen most of the available models.
As a physician who is, in part, responsible for maintaining the contract between my group and the hospital to run the emergency department, I’m definitely stressed about this more than my friends who are chairs employed by their own hospital. It is very unlikely that a hospital will replace their own physician group with an outside contracting group though it has happened.
With that said, my general personal rule of thumb is that if I like my job, like the hospital, get paid fairly, and the paycheck cashes every time, I really have not been concerned about whether I was a 1099 independent contractor or an employee. This is a separate discussion from staffing and management philosophies, which can vary from group to group.
There are pretty legit formulas that help define coverage and it’s useful to know the expected productivity of the doc. I’ve seen democratic groups completely take advantage of their non-partners and I’ve also seen CMGs struggle to make payroll (though this was in the early 2000s and I have much more confidence in the large CMGs now).
I know other people who firmly believe that being in a democratic group and being able to sit at the table to make decisions about your group is the most important factors in choosing a job. If you’re focused on finding a group with partnership, just be sure you clearly understand the partnership track, financial implications and what the recent track record has been with converting non-partners to partner.
Next Month
There are certainly a lot of factors to consider when evaluating a potential job. Next month we’ll discuss pay, key operational issues and some extra perks that may factor into your decision.
