finding a job and negotiating an agreement in allergy/immunology - aaaai 2015
TRANSCRIPT
Tao T. Le, MD, MHSAssociate Clinical Professor
Department of MedicineUniversity of Louisville
Partner, Central Allergy & Asthma
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Disclosures None
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Most Important Advice
Be honest with yourself!!!Don’t try to impress your program director or other fellowsDo what you want to do
Choose Your Own Adventure
Career optionsFinding a job and interviewingContract negotiationsAAAAI FIT exit survey
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Why did you go into AI?Patients
Continuity, treating familiesInteresting diseases
Allergies and asthmaImmunodeficiencies
ScienceTLRs and interleukins, oh myLove working with mice
All of the above
What Do You Want to Do?Just see patientsWork as part of a teamBe the boss
Control all aspects of practiceWin a Nobel prizeBe president of AAAAI or ACAAI
Options After FellowshipFirst decide your primary job activity Clinical
Taking care of patientsResearch
Clinical, epidemiological, or bench/translationalEducation Other
Administrative/leadershipRegulatory Entrepreneurship
Clinical OptionsPrivate practice
Individual/soloSmall groupLarge groupMultidisciplinary
Hospital employeeAcademic
Research OptionsAcademicResearch instituteHealth department
EpidemiologyIndustryClinical practice
Clinical research
Other OptionsHealthcare organizationsFDAInsurance companiesOther institutions
Secondary schoolsBoard review organizations
Most won’t start here
Research OptionsAcademic
Large range of research optionsHigh level of prestigeExcellent environment for research
CollaborationRelatively lower payYou are not your bossMust pay for yourself - grants
Research OptionsResearch Institute
Excellent research environmentFocus must fit instituteIf institute changes focus, uh ohLess opportunity for other options
Clinical Teaching
Research OptionsHealth Department
EpidemiologyPublic HealthGovernment job securityLower pay
Research OptionsIndustry
You are not your bossMust have clinical applicationsPay usually goodResearch results drive careerDo not have to get grants
Research OptionsClinical practice
Primarily drug studiesSmall investigator initiated studies possibleNo large multicenter trials (NIH)Income tied to patient recruitment
Single Specialty OptionsPrivate practice
Individual Be your own boss Need to develop patient base
Small group Shared control – cooperation Built in patient base
Large group Follow the rules Must be comfortable with group
Multispecialty GroupsAmbulatory +/- hospitalsLarge – heavy PCP expansionSalary + incentive compensation (vs fee for service)RVU productivity modelSome equity opportunity – shareholder vs. partnership
Multispecialty GroupsPros
Stability/predictabilityBuilt in referralsMore mature business model with metricsLess administrative hassleManagement opportunities
ConsOverhead Inequality in productivity models/compensation plansBureaucracy/politics
Clinical OptionsAcademic
You are not the bossProductivity may not be rewardedBilling/collections providedTeaching opportunitiesAdministrative opportunitiesMore prestige
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Job HuntingMost important thing is to be honest and true to
yourself!Make a list of the things that are most important for
you and your familyMake a list of the things that are most important
about a potential practice
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Important Factors When Choosing a Job
Geographic location 65%Practice Setting 49%Spouse/family reasons 49%Professional growth opportunity 46%Call schedule 44%Compensation 43%Benefits 39%Prestige of employer 24%
MGMA
Job Hunting
Start looking late summer or early autumn of the last year of fellowship
ResourcesMajor specialty journals (JACI and Annals) have job listingsAAAAI and ACAAI have job placement centers on their
websitesACAAI has job fair at its annual meetingLocal allergy societies in the target regionWord of mouth from physicians—especially from mentorsMedical headhunter services
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Job Hunting• Send letters of inquiry to ALL practices in a
desired location• Many practices contemplate hiring before
advertising • Research the practice and personalize the letter if
possible
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Have a Successful CVBe conservative and professionalUse a conservative font and avoid overuse of bold, italics, and
underlined textBe concise and only include relevant information Information should be complete, accurate, and currentPrint on a laser printer, high quality paper, or consider professional
printing, print on one side onlyThe first page is considered the most important
Don’t try to fit everything on one page A 2 to 4-page CV is considered average for a young professional
Know the CommunitySize of communityProximity of family and friendsEmployment opportunities for spouseGeneral economic and social structureQuality of schools
Know the CommunityHousing costsRecreational opportunitiesArea and patient demographics
PopulationEconomic background and stabilityDemand for specialty
Preparing for the InterviewCollect and analyze preliminary information Bring a list of prepared questionsDress for successBe earlyDo not plan any other events for the same day
Gathering InformationNumber of physicians (small versus large group) Setting – urban, suburban, or ruralOffice locations – single office versus several satellite
offices
Gathering InformationType of practice (academic versus private practice;
single specialty versus multi-specialty) Patient population characteristicsCommonly encountered conditionsHow would a new allergist fit in?
Gathering InformationReason for hiringTypical workload
Number of patients seen daily Work hours On-call days Seasonality
Hospital consult responsibilities Location Frequency Cross-coverage of other service, if in a multispecialty group
Gathering InformationInsurance payor mix Local practice ecosystem
Other allergists and subspecialists – collegial vs. competitive
Non-allergy competitionPrimary care physicians/NPs and referral patterns
Turnover of physicians and staff
Gathering InformationSupport staff ratio
Will you have your own nurse or medical assistantWho’s in charge/who makes the decisions
Leadership and governanceOffice manager/administrator
Gathering InformationStructure of the group
Independent contractorsPartnerships/PC/PAEmployer/Employee
Is future partnership an option?How is this determined?What is the timeframe?
Gathering InformationStarting salary Benefits packageFair market value of practice/buy-in/partnership Access to financial books/recordsShadow the physicians in clinic Speak with staff
During the InterviewListen more than you talkPromote strengths and any areas of expertiseAct professionally and never feel “too at home” Do not speak negatively of other practices
After the Interview
Make notes of a practice after you interviewFollow up with a thank you letter
Samples in the Practice Management Resource Guide
Digging DeeperSpeak with other physicians in the communityWhat is the reputation of the group?Speaking with any physician who has left the
practiceSit in the office waiting room, speak with patients Call the office to schedule an appointment and
speak with staff
Offers
1-3 may be expected
Verbal vs. written
Is NOT an employment agreement
Get a Good AttorneyWith experience in medical employment contracts
Referrals form the local societies, hospitals or state societies.
National Society of Certified Healthcare Business Consultantshttp://www.nschbc.org/
Resources AAAAI Practice Management Resources Website.
http://aaaai.org/members/resources/practice_management/ Le, T., ed. AAAAI Practice Management Resource Guide, www.aaaai.org. NAIA-FIT Mentor-Mentee Program NAIA Academic Career Development Webinars.
http://aaaai.org/members/only/assemblies/webinars/ Best Friend’s Guide to Finding a Practice. CHG Healthcare Services and ASPR, 2006.
http://www.comphealth.com/pdf/physician/perm/aspr_best_friends_guide.pdf NEJM Career Center. http://www.nejmjobs.org/career-resources
What a Good Contract DoesClearly spells out specific terms and conditions for
employment including:Employment status and scope of workCompensation/benefitsEmployer’s responsibilitiesRestrictive covenantsTerm and termination provisions
Balances the interests of both physician and employerREMEMBER: GET IT IN WRITING!!!
What It Can’t DoDefine the culture, leadership, values of a practice
Ensure that you chose the optimal practice opportunity for your circumstances
Guarantees a successful employment experience
Employment StatusWho are you?
EmployeeContractorShareholder
Status can determine:Type of compensation/benefitsTax burdenLiability in the event of a malpractice event
Your ResponsibilitiesTypical clinical dutiesTypical scheduleTypical clinic locationsHospital consultsCall dutiesNon-clinical duties
Administrative responsibilitiesCommunity activities
Employer’s ResponsibilitiesOffice space, computer
Nursing and support staff
Supplies
Transcription services
Billing services
Car allowance/insurance, cell phone
Licensure, credentialing, board certification
Cash CompensationGuaranteed base salary +/- annual pay increases
Productivity bonus
Signing bonus
Relocation expenses
Negotiating hint:Do reality check on achievability of productivity bonuses
BenefitsFamily health insurance
Dental insurance
Disability insurance
Life insurance
BenefitsPension/401k
Vacation and sick pay/PTO
Family leave
CME allowance
Malpractice/Tail CoverageLiability insurance
Ex.: $1MM/incident, $3MM aggregateOccurrence – cover lawsuit at anytime if policy in force at
time of incidentClaims-made – covers lawsuit if policy in force at time of
filing
Tail coverage – supplements claims-made policyCoverage for claims made after policy terminatedTrend in shifting cost to employee
Malpractice/Tail CoverageNegotiating hint:
Ask for employer to pay for tail if termination without cause or if you fulfill a threshold term of the contract
Other Employment/ActivitiesTypes of activities
MoonlightingSpeakingResearch/publishingSignificant volunteer activities
Is it permitted?
Other Employment/ActivitiesWho owns the income?
Negotiating hints:Carve out anticipated activitiesSpeaking may be a win-winCheck if your malpractice covers moonlighting
EquityExpectation of achieving partner or shareholder status
Specified in a separate agreement
Usually after a fixed period of time and/or with qualifying performance
There may be a junior vs. full partner level
There may be a buy-in vs. sweat equity model
Practice may offer financing
There may be a pay-out when you retire
Buy-In FactorsNature of the employment agreement – does
employer profit from your labor?
Practice valuationTangible assetsIntangible assets or “good will”Liabilities
Discounted cash analysisValue increases with practice revenueDiscounted by expected rate of return
Partnership HintsGet specifics regarding time to partnership, buy-in
requirements, pay-out calculations, etc.
Ask about previous physicians who made or did not make partner
Ultimately requires mutual trust and open communications
TerminationTermination for cause
Reasons: loss of license or malpractice insurance, death, felony conviction, “material breach”
Usually immediate
Termination without causeEmployee usually has reciprocal rightNotice periods range 60-90 days
Negotiating hints:If “material breach,” ask for a period for “cure”Ask for longer notice period if you think you need it
Non-Compete AgreementPrevents departing physician from competing with
employer Specifies restricted region (i.e., 5-50 mile radius)In force for 1-2 yearsEnforceability varies from state-to-state
Negotiating hints:↓ duration, especially for early terminationLimit restricted region to office where you were basedLimit applicability to overlapping servicesSubstitute with non-solicitation agreement
Non-Solicitation AgreementPhysician forbidden from recruiting patients or staff
away from employer
May practice in the same area
Sometime used in place of non-competition agreement
Negotiation hints:Clarify that public communications like newspaper ads
does not violate agreement
Medical RecordsUsually belong to employer
Physician may need access to defend against a malpractice action, credentials committee investigation or medical board inquiry
Negotiation hint:Ask for reasonable access should you leave the practice
Dispute ResolutionCan mostly be settled between employee and physician
Otherwise, disputes settled in courts
Each party typically covers own fees
Negotiation hints:Ask that any unresolved dispute be submitted to
confidential mediation and binding arbitrationAsk that loser pays winner’s legal costs
Small vs. Large PracticeSmall practices may offer more:
Flexibility in contract termsWillingness to negotiate
Large practices may offer more:Standardized agreementsWider range of benefits
Final ThoughtsUse an experienced attorney
Request a letter of intent ahead of the contract
Don’t hesitate to negotiate
Beware of one-size-fits-all contracts
Make sure guaranteed pay is enough
Consider total comp package
Never accept a verbal promise. Get it in writing!!!
ResourcesA Physician’s Guide to Employment Contracts
http://www.mmaonline.net/Portals/mma/Publications/Reports/Physicians_Guide_to_Employment_Agreements.pdf
A Primer on Employment Contractshttp://www.aafp.org/fpm/20021100/73apri.html
Demystifying Common Terms in Employment Agreementshttp://www.aafp.org/fpm/20030600/38demy.html
ResourcesLifting Restrictive Covenants
http://www.aafp.org/fpm/20010400/50limi.htmlAnatomy of a Physician Employment Contract
http://www.nejmjobs.org/career-resources/physician-job-contract.aspx
Avoiding Physician Employment Contract Pitfallshttp://www.nejmjobs.org/career-resources/physician-job-contract-2.aspx
National Society of Certified Healthcare Business Consultantshttp://www.nschbc.org/
AAAAI FIT Exit SurveyWeb-based survey designed and implemented by
the AAAAI Workforce Committee with input from the AAAAI Practice Management Committee to:Document the career choices of graduating FITs and
their rationalesElucidate the employment market for graduating FITsIdentify trends in the current economic climate
Sent to all FITs graduating June 2012 and June 2013
Results 147 responses (78 in 2013, 69 in 2012)
Demographics 2012/2013, n=147
Female (%) 61%
Age, mean (SD) 34.0 (4.0)
Race
White 42%
Asian/Pacific Islander 38%
South Asian 15%
Middle Easterner 5%
Black 0%
IMG (%) 28%
Primary ActivityActivity %
Patient Care/Clinical Practice (Non-Academic)
54
Patient Care/Clinical Practice (Academic)
30
Research – Academic 7
Other 3Undecided 3
Primary Work SettingWork Setting 2012 % 2013 %
Solo Practice 1 3
Small Group Allergy Practice 25 24
Large Group Allergy Practice 12 15
Multispecialty Group Practice/Clinic
12 12
Hospital/Ambulatory Care Center
3 3
Managed Care/HMO -- 3
Academic Medical Center 35 32
Military/U.S. Government 4 1
Undecided 6 5
Base CompensationBase Salary Academic Practice
< $80,000 18% 8%
$80,000-99,999 8 5
$100,000-119,999 18 5
$120,000-139,999 24 10
$140,000-159,999 14 30
$160,000-179,999 8 15
$180,000-199,999 6 8
$200,000-219,999 2 11
$220,000+ 4 8
Pearson chi-square (df=8) = 21, P = 0.007
Incentive CompensationBonus Income Academic Practice
None 63% 49%
<$10,000 17 21
$10,000-$19,999 4 21
$20,000-29,999 2 6
$30,000-39,999 8 0
$40,000-49,999 4 4
$50,000+ 2 0
Pearson chi-square (df=6) = 15.3, P = 0.018
Signing BonusSigning Bonus Academic Practice
None 90% 71%
<$10,000 8 15
$10,000-$19,999 2 8
$20,000-29,999 0 1
$30,000-39,999 0 3
$40,000-49,999 0 3
Pearson chi-square (df=5) = 7.8, P = 0.167
BenefitsWork Setting Practice Academic
Medical Insurance for Self 62% 84%
Medical Insurance for Spouse/Dependents
53 68
Dental Insurance 58 84
Disability Insurance 43 70
Malpractice Insurance 78 96
Paid Vacation 77 96
Retirement Plan 44 70
CME/Professional Meetings 66 73
Car Allowance 6 0
Ownership/Partnership?Clinical Practice %
Yes 36
No 50
Not Sure 13
Starting My Own Practice 1
Timing of Equity OwnershipClinical Practice %
At starting (eg, buying in to the practice) 4
At or before first anniversary 6
At or before second anniversary 22
At or before third anniversary 34
After third anniversary 13
Not sure 21
Personal Debt LoadAcademic Practice
<$100,000 64 43
$100,000-199,000 19 34
$200,000+ 17 24
Pearson chi-square (df=2) = 6.2, P = 0.046
Compensation SatisfactionCompensation
SatisfactionAcademic Practice
Very Satisfied 23% 36%
Somewhat Satisfied 46 50
Somewhat Dissatisfied 23 6
Very Dissatisfied 8 8
Pearson chi-square (df=3) = 7.7, P = 0.039
Long Term ProspectsWill you be there
>3 years?Academic Practice
Yes 53% 73%
No 11 14
Undecided 36 13
Pearson chi-square (df=2) = 9.7, P = 0.008
Ease of Job HuntDid you have a difficult time
finding a satisfactory position?
Academic Practice
Yes 45% 49%
No 51 50
Haven’t looked yet 4 1
Pearson chi-square (df=2) = 0.99, P = 0.611
Career SatisfactionWould you recommend the specialty of Allergy and Immunology to medical students or otherphysicians in training?
%
Yes, with enthusiasm 82
Yes, but lukewarm 18
No, but not strongly 1
No, emphatically --