The Light at the End of the Tunnel

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Author: MohammedMoiz Qureshi, MD
AAEM/RSA President
Originally published: Common Sense March/April 2019

As of January 1, 2019, current second year residents in three year programs have officially completed half their residency! Just under 18 months away from completing a long and grueling journey. It’s remarkable how much you grow from a fourth year med student to a semi-competent senior resident in the ED. As we look forward to the second half and start looking at the next stage in our careers there is an overwhelming feeling of unease in terms of where to begin the “grown-up” job search and what to assess and prioritize.

This holds especially true in three year programs, where there is a dedicated focus on learning the skills of the trade and not as much time to delve in to personal areas of interest and determining where/how to apply and interview. In a recent statistic, almost half of new physicians end up changing jobs in their first five years out of residency. So how do we go about finding our dream job? There are way too many varying factors to make a generic set of rules and most everyone can gauge the geographical locations they are interested in but further than that I have narrowed down some factors that all of us should review prior to signing that contract.

The Dollar-Dollar Bills
Obviously and rightly so, one of the first things to look at is the proposed salary. With an average of roughly half a million dollars of debt for graduating residents, finding a job that will help pay off that debt is imperative. But salary and benefits should be evaluated in a broader context. A lucrative salary may not be so lucrative if you’re practicing in tax heavy California or are contracted to work twenty-one 12-hour shifts in solo coverage with 100K annual visits and high acuity. Considering independent wellness and overall liability is a huge component that is not nearly harped enough. Along those lines, a lesser salary may not truly be less if cost of living is low, CME reimbursements are high, and there are included benefits of housing and transportation stipends. (Yes, those jobs, albeit most at international hospitals, do exist.) It is also important to assess RVU vs. set salary, often times there are offers of a minimal base salary that appears laughable, but the RVU incentive is great and you end up with more than you would with just a higher set salary. So yes, you may be required to do some math and compare cost of livings and asking for numbers for average take home over the last five years for every place you interview will create a more even playing field.

The “Man”
When starting the job search it is important to understand the types of employers we are looking at and who you are going to be answering to. The most common set ups are democratic groups, hospital systems, and corporate groups, also called contract management groups (CMGs). CMGs like EmCare and TeamHealth have some hundreds of contracts with hospitals to staff their EDs. This means when you work for a hospital that contracts with a CMG, you are an employee of, or an independent contractor, with the CMG and paid by the CMG. So what’s the difference? Recognize that not all practice opportunities are equal and there will be glaring disparities. Look for those that have the highest employee satisfaction and will give you the best support for a long and happy career in emergency medicine. CMGs have been found to increase profit by acquiring more contracts and minimizing physician pay. This can lead to unfair compensation. Many CMGs have also been found to enforce fee splitting in which they are essentially charging you a fee for the privilege of having a job. Often times to work in particular location we have to accept that. Some CMGs do not allow open books. As a professional, from a legal and personal standpoint, you should know what is being billed and collected for your professional services. Federal agencies hold us responsible for billings and collections and not keeping tabs can leave you susceptible to crippling liabilities.

Also know that not all CMGs are bad and sometimes given your location constraints you may have to, or even want to work for a CMG. A third of all EPs work for one and in a lot of regions a CMG may be the only option. Being employed directly by a hospital, university, or individual contract-holder, is no guarantee at better work conditions and can be equally abusive and exploitative. There are democratic groups that have essentially unobtainable partnership tracks and on the flipside there are CMGs that follow fair and equitable business practices, like due process and open books. So being diligent and evaluating the proposed contract and asking the right questions will help assess what you are obliging to.

Scope of Practice
As an EP we are trained to manage almost anything that walks in through the door. And while that may be the case, there are clinical cases that we as individuals enjoy managing more. So if you don’t enjoy trauma and chest tubes, or contrarily can’t go a day without placing a central line, looking at the volume and acuity of your potential workplace is important. Geography plays a big role in this but often times certain hospitals in the same location can have very different patient populations depending on Trauma classifications.

You’re likely to deal with blunt tractor trauma in an Amish population like we do here in Hershey, but we don’t see as many penetrating gunshot wounds like inner city Detroit. So location remains paramount when looking at EM jobs as higher paying jobs could come in locations where acuity or litigation is higher. States like Texas and Florida have Tort Reform Laws that limit litigation and will prove to be more protective for physicians versus cities like Washington, D.C. that have some of the highest litigation in the country Its for these reasons that also recognizing who accounts for malpractice insurance premiums and claim settlements is key when evaluating opportunities.

Asking the Suits
Once you’ve found a potential job opportunity that appeals to you and have been offered a contract, head straight over to an employment attorney. Shelling out $500 to have a contract looked over that is evaluating a six figure salary with huge liabilities is truly a drop in the bucket. Ask them to go through and find clauses of concern and also let them know what you understand of the contract. Often times there are blatant misunderstandings and clarifying the terms is of utmost importance. It may be steep to cover on a resident salary but may be well worth the investment if it saves you from a debilitating year-long contract. Furthermore, having experienced faculty read over your contract and review benefits, malpractice coverage, insurance coverage, etc. provides a second set of eyes to ensure no acute oversight. If something comes up fishy, confront it. Ask questions and points of clarification to ensure you aren’t contractually signing away every weekend on what you thought was an alternating eight shift a month contract.

The end is in sight. And while it is a terrifying reality that after years of supervision and back up, we may truly be on our own, it is also an exciting opportunity to come in to our own. We have the clinical skills and the medical knowledge and now it is time to join the ranks of those before us and serve the communities we swore to help in all of our med school personal statements. Finding the right capacity to do so through our jobs remains one of the final hurdles and just like the innumerable hurdles we’ve crossed to get here, I’m sure we will each find our niches in the months to come. We’re EM trained: Ask the right questions, consult for help and trust your gut, it has worked for us so far.