5 things to look for in your first (or next) practice – Organizational fit for physicians

Many residents and fellows end up changing jobs after a few years in their first practices. But, switching jobs is inconvenient, and it can be costly. Wouldn’t it be better to find a better fit from the start?

As you consider your job options, priorities such as salary may naturally take on outsized importance, though other factors like organizational structure ultimately make a bigger difference in your job satisfaction. Subtle nuances in evaluating offers could impact your decision-making for better or worse.

Here are five things you should keep in mind when searching for your first (or next) position—along with some useful ways to assess them in your decision-making.

1: The right location for you

You may think you’ve heard this one before. Virtually every article about physician job hunting says that location is one of the most important factors in choosing your first job out of training. As you think about the right location for you, some factors to consider when choosing are less obvious—but still very important

Patient base. Clifford Stark, D.O., primary care sports medicine physician and sports medicine fellowship program director at Zucker School of Medicine at Hofstra/Northwell at Plainview Hospital in New York, says that your choice of community could have a big impact on your patient base. When he was building his practice at the Chelsea Piers in New York City in the early 2000s, the location helped him attract more of the young, active patients he hoped to work with. These patients were excited by the idea of a primary care practice that offered sports medicine, which was a novel idea at the time. He says getting a feel for the local patient base is an important reason to visit an area before deciding to move there.

“Zoom interviews are common now,” Stark says. “We do them for our fellowship program because it’s so hard for residents to get time off. But for your job, you should visit the practice, talk to people, go out to dinner or drinks and ideally even spend a day—and while you’re there, look around. You’ll see people who could be your patients. Maybe they’re driving around in expensive cars. Are those the patients you were expecting to work with? On the flip side, if you’re interviewing at a place in an inner city and you’re thinking what you really wanted to do is suburban medicine, that’s a sign the job isn’t the one for you.”

Cydney Kilduff, manager of physician and APP recruitment at Corewell Health, agrees. “Especially in primary care, the demographic makeup of your patient base can vary a lot depending on the location,” she says. She advises thinking through whether you’re interested in making older patients, lower-income families, or any other specific demographic a significant focus of your practice.

Life outside work. Kilduff also suggests that when choosing a location, prioritize what you like to do when you’re not working— something you may not have considered for many years.

Heath Jolliff, D.O., emergency medicine physician, medical toxicologist and certified executive coach in Columbus, Ohio, agrees that what you’ll want to do with your newfound free time — whether that’s visiting family, building a new social life, or enjoying activities like sports, theater or fine dining — should be a top priority in choosing where you’ll live.

“Maybe you’re thinking you want to stay where you’re doing residency or finished residency, but it’s not where you grew up. So why does this place appeal to you? What is it about this location?”

Jolliff says he’s had physician-coaching clients who’ve chosen jobs where they’ve loved the work but later found the location didn’t suit their personal lives. Sometimes single attribute of a location, such as natural beauty, may be so appealing that the physician doesn’t think deeply enough about other important ingredients, such as the dating pool or community culture. Years later, this can mean another costly move and the discouraging prospect of having to start over.

It’s also easy to underestimate the importance of practical considerations, says Maria Guevara Hernandez, M.D., program director for MercyOne Internal Medicine at MercyOne Des Moines Medical Center in Iowa. A high cost of living may make it difficult to save for other important goals like owning a home, traveling and starting a family. A lengthy commute is also costly and siphons time away from things that keep work and life in balance: relaxation, hobbies, family and socializing.

“When looking for a job, one of my priorities was a city with a lower cost of living, where I could save more to start a family and travel,” Guevara Hernandez says. She adds that it’s helpful to consider whether you’ll have a support system nearby as well. “Being close to friends, family or a supportive community can boost your emotional well-being and provide a safety net during challenging times.”

Learn about locations before your job search. Jolliff adds that if you’re still in residency or fellowship, there may be opportunities to check out locations you’re considering before you have to make the big decision or even start interviewing.

“A lot of programs will pay for you to go to a conference every year. Many programs are happy for you to write a paper because it’s like an advertisement for the hospital and the university,” he says. While at the conference, you’ll have the chance to meet colleagues from all over the country and learn about their experiences living in other places.

Stark and Jolliff say that your training may even provide an opportunity to live and work in a place you’re seriously considering.

“I highly recommend you start your job search several months before you finish and try to do a rotation [in a practice or geographic area you’re considering]. If your residency will allow you to do a rotation, then you can see firsthand what it’s like. That’s a free test run,” Stark says.

Stark comments that if you have a family, it’s even more critical to choose your job location wisely. “Consider not just the cost of picking up and starting over; consider the potential cost of making your family miserable.”

2: A culture that fits and work/life balance

With all the attention paid to burnout and work/life balance in recent years, you’ve likely already heard about the importance of a physician-friendly environment and “cultural fit” in choosing a job. But how do you go about assessing these things?

Prepare to ask questions and observe. David Rebedew, M.D., a family practice physician in Janesville, Wisconsin, recommends developing a list of targeted questions to ask during interviews and site visits to help you assess organizational culture and employee satisfaction.

For example, he recommends asking people, “What’s your favorite part about working here?” Rebedew says that “any answer other than ‘the people’ is probably a red flag about the culture.”

High turnover is also a signal that people are unhappy. Rebedew suggests gauging turnover by asking people (including staff) how long they’ve been with the practice.

Guevara Hernandez recommends carefully observing coworker interactions during site visits to gain insights into team dynamics.

“Pay attention to body language and communication. Are team members respectful and engaged in discussions? Do you notice any signs of tension?” If possible, she says, it’s a good idea to attend team meetings or rounds.

Guevara Hernandez also likens the physician’s side of the interview process to interviewing a patient.

“You can use the same skills you use when interviewing a patient to elaborate your differential diagnosis, like asking questions that encourage specific examples. For instance, you can ask hiring physicians or prospective colleagues to describe a situation in which a disagreement occurred and how it was resolved, or to share how collaboration between physicians and staff works on a daily basis.”

Jolliff says whether people spend time with each other outside of work is an indicator of how much they enjoy working together. He recalls a fellow physician describing his lukewarm attitude toward the culture in his practice succinctly: “I like everybody in the group. But there’s no one I would want to go out and have a beer with or go out to dinner with. We just don’t seem to gel that way.”

A workplace where colleagues spend time together outside of work might not be as important to you. But for many people, it’s comforting to know that colleagues at a prospective employer enjoy doing non-work activities together, especially if you’re moving to a location that’s completely new to you.

Guevara Hernandez says clinical autonomy is a crucial aspect of culture. You’ll want to confirm that physicians are included in decision-making about department policies and the allocation of resources—and anything related to patient care. If the culture is such that your autonomy will be undermined by excessive paperwork, administrative tasks, protocols that are too restrictive or micromanagement driven by non-medical concerns, your morale will suffer and you’ll find it harder to do a good job. To get a read on clinical autonomy, Guevara Hernandez suggests asking an open-ended question like, “What resources and support are provided to ensure physicians have the autonomy to make appropriate care decisions?”

Rebedew suggests you look for organizations in which the top executives are physicians. When the senior management is predominantly businesspeople, there could be greater risk of business goals outweighing physicians’ priorities.

To confirm that physicians have an effective voice, Rebedew suggests asking questions like, “How responsive is management to physician feedback? What are some recent changes that were made based on your input?” and “How are changes communicated? Can you provide a recent example?”

Look for programs that show a commitment to physician well-being. “Something we all learned in the pandemic is that burnout is very real,” Kilduff says. “Ask about resources to support physicians.”

Employee assistance programs (EAPs) are commonplace. Other services you might benefit from include confidential mental health services, benefits programs that support healthy lifestyles, and surveys that regularly seek physician feedback.

Some organizations have customized programs of their own to help their physicians thrive. For example, Kilduff says that Corewell offers a “concierge” service for physicians. The service is available to help with all sorts of personal tasks, from errands to oil changes to party planning and beyond.

3: Mentors and career opportunities

Though a culture that encourages clinical autonomy is important to ensure you feel respected and are able to serve your patients well, autonomy without sufficient support can add to the stress of starting your first job.

“New physicians can feel overwhelmed if there aren’t mentors available to help,” says Guevara Hernandez.

For example, ordinary challenges like learning a new EMR can create unnecessary anxiety if you’re also trying to learn the administrative ropes in a new setting—all while facing productivity targets. A mentor can help you quickly find resources to help with things like customizing templates, learning patient financial policies, or understanding insurance authorization rules much more quickly.

Jolliff says that while mentors used to be found solely through networking, mentorship has become so valuable that some organizations are formalizing the process.

“I know of a hospital where the chief medical officer is setting up all new physicians with a mentor for at least the first year. I think it’s important to have a mentor, especially if you didn’t train at your new institution, because you may know the medicine really well but not how things are done in the new place. It’s helpful to have somebody you can talk to and ask them what the best way is to do things.”

Looking ahead. Jolliff says that you should also keep the longer term in mind when evaluating opportunities. The structure of the organization, and even the demographics of the physician ranks, may bolster or limit your ability to pursue future goals.

For example, he says, if you’re envisioning a move into management at some point, the age of your colleagues could be important. If you join a group staffed largely with physicians who are all around your age, that could mean you’ll all be competing for a single opportunity when a senior position eventually opens up.

Guevara Hernandez agrees that researching the potential for growth within an organization is important. Depending on your interests, other areas you might want to ask about include quality improvement initiatives, teaching and clinical research.

“You’re going to do this for 30 years, and that’s such a strange concept,” Jolliff says. It’s those “down the road” aspirations—research, leadership, practice ownership— that will help keep you interested in your job throughout a long career in medicine.

4: Compensation— and clarity about how you’ll earn it

It’s no secret that your pay will be an important factor in your job satisfaction. But compensation plans can be complicated, especially where productivity pay is concerned. Comparing apples to apples can be challenging.

For example, productivity pay calculations are sometimes based on a percentage of revenue or net collections. In other cases, especially at larger organizations, productivity may be based on RVUs (relative value units). Since RVUs are based solely on the work performed and not the money eventually collected, it can be tempting to assume an RVU-based productivity plan is always preferable. But doing the arithmetic to compare offers is important.

Stark says, “Do you want RVUs? Maybe, but not necessarily. Percentage of revenue might be a better deal. But if you’re considering a plan based on revenue, you’ll need to know how effective the billing process is and how good the contracted reimbursements are.”

If your compensation will depend on any type of productivity calculation, you’ll want to understand how busy you’ll be from the start. Is the practice already so fully booked that there will be no problem filling your calendar? Or will marketing be required — and how much help will you get with that if so?

Stark adds that even if you’re offered straight salary or guaranteed income, you should still be mindful of productivity. While the guarantee will protect your salary and your job in the short term, eventually, your production will need to cover your costs.

Jolliff advises looking closely at benefits as well as cash compensation when comparing offers. Things like life and disability insurance, 401(k) contributions and the cost of your health plan all have significant financial value that should be calculated to ensure you’re comparing like-for-like.

“I’m a very big proponent of getting a financial adviser who works with physicians,” he says. He adds that you should look for an adviser who provides consulting services on a fee basis and isn’t trying to sell you financial products.

“We just don’t speak that [financial] language necessarily. We weren’t taught it in residency or medical school,” Jolliff says. Without help doing the essential math, it’s easy to rely on a false assumption. “I remember that in one group that I worked in, we were all 1099 employees. Our residents would say, ‘But you’ve got to buy your own insurance!’ And I would say, ‘Yes, but here’s what it looks like when you price it out.’ And I showed them that as a 1099, I actually did better than I would have as an employee. But you need someone to walk you through it.”

It’s natural to be concerned that any offer you’re seriously considering is competitive and fair, Rebedew says.

But Rebedew also says that it’s easy to overweight compensation in your decision-making. He says that lifestyle factors, such as flexibility, could be a lot more important to your happiness down the road.

“Be sure to ask specific questions like, ‘How long are my appointment times?’ ‘How long is parental leave?’ ‘If my child has a concert/appointment, do I have the option of blocking my schedule for a couple hours?’ ‘Would an extended vacation (say, three weeks) be possible?’ ‘What if there is an emergency and I am no longer available for call?’”

Kilduff adds that you needn’t worry too much about your offer being competitive — because the organization you’re interviewing with is already doing so. “We all get that. It’s the price of admission. We know we’d better be coming in with something competitive.” That’s why she says it’s usually a mistake to “lead with money.” “Money is not going to be the only thing that makes you happy.” More important, she says, is that other things could make you unhappy much more quickly.

Jolliff also says that deciding on a job mainly because of financial incentives can sometimes lead to regrets.

“There are a lot of incentives I’m seeing now for physicians that involve things like paying off some of your student loans or paying moving expenses. But you have to stay for a certain period of time. If you have to stay for five years and you decide you don’t like it and want to leave, you’ll have to pay that money back. And usually, physicians didn’t save that money — they used it to pay their student loans or for the move. So they’re facing not only an expensive move across the country, they also have to pay back that chunk of money.”

5: A contract that reflects your understanding of terms

Once you think you’ve found the job that’s right for you — and the hiring organization does, too — you’ll be presented with a contract. At this final phase, it’s a good idea to hire a lawyer—one with experience with physician employment contracts—for expert advice.

An attorney can help you with your first priority, which is to be sure you understand what the contract says. Even when you’re fairly confident you understand what certain legal terms mean, an experienced attorney can advise you on how they’ll play out in real life.

It’s also a good idea to keep detailed notes of any verbal commitments made to you during your negotiations. You and your attorney can make sure they’re documented in your agreement.

Rebedew adds that since they have experience negotiating with multiple healthcare organizations, “attorneys experienced in physician contracts may also be able to offer advice on signing bonuses, contract terms for things like call, and any non-compete clause or other restrictive covenant.”

With respect to restrictive covenants, Stark says some people assume they’re no longer a factor because of the publicity about state laws restricting their use in some areas. But he says it’s probably risky to assume you can ignore restrictive covenant language.

“People say that they’re going away or that they’ve heard they’re hard to enforce, but you can’t count on that.” He points out that practices hiring new physicians usually lose money on them in their first few years. On top of the physician’s compensation and benefits, the practice may also need to invest in marketing. This is why practices are motivated to protect their investment by restricting your ability to leave your job and set up shop down the street.

Rather than immediately trying to remove a restrictive covenant altogether, Stark says, assess the spirit of it. Is the group trying to be fair? He adds that if a geographic restriction is relatively narrow, it will have less of an impact on your ability to pursue a new job in the same location.

Stark adds that while an experienced attorney can help you with your final negotiations, sometimes there will be little room to change standard contract terms, especially with larger organizations, mainly because of concerns about fairness. You may need to rely more on your gut feeling about the people and take a bit of a leap of faith.

“Keep in mind that they may hesitate to modify their agreement because that could be perceived as favoritism.” At some point, he says, it will be clear that no more changes or negotiating is possible. “Then it becomes just a matter of how comfortable you are.” •