Accept the Offer of Employment..or Not?

by Elizabeth Hofheinz, M.P.H., M.Ed., August 22, 2019

After years spent in training—training that typically doesn’t include information on how to vet a practice—many orthopedic surgeons don’t have the knowledge or time to undertake thorough due diligence on an institution.

Location, location…and compensation.

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William L. Craig III, M.D., an orthopedic surgeon with OrthoCarolina, says, “For many young surgeons one of the top driving factors is geography, meaning that they will limit their search to a certain area. This is often related to having family nearby, and thus is naturally a joint decision if the surgeon is married.”

Dan Riew, M.D. is Director of Cervical Spine Surgery at the New York Orthopaedic Hospital/Columbia Orthopaedics in New York City. “Young surgeons going into academic medicine sometimes put too much emphasis on the starting salary when choosing jobs, which is understandable given the amount of student loans they have amassed. In academic medicine, success is defined by publications, presentations, teaching and peer recognition, as well as revenue generation. So, it is important to choose a job where you can succeed in all of these areas. As far as income, it is important to find out how one’s compensation is determined. The best system is one that is transparent with a formulaic approach that takes into consideration all of the measures of academic and clinical success. But the devil is in the details.”

In private practice, says Dr. Craig, when addressing the all-important salary issue, dig deep. “Compensation is multifaceted, and many things should be considered. What is the length of the contract? How many hours are expected of you? What are the expectations for becoming a shareholder? Are there certain financial or productivity expectations that must be met in order to be eligible? What other factors are physicians evaluated on in order to become shareholder? How are decisions handled within the group? Who makes them? Are they group-wide decisions or are they made by a board?”

In the era of waning physician control, seeking out areas that one can control has its benefits, says Dr. Craig. “One of the primary things you want to consider is the extent to which you will be afforded a good degree of autonomy and decision making. Do you have some say in the clinical expectations or where you see patients? Are you expected see patients five days per week or do you have a half day off? Do you have guaranteed time for your cases?”

Part of being autonomous is having the right kind of assistance when you need it. Thus, advises Dr. Craig, make sure you ask what kind of help is available in terms of nurses, nurse practitioners, medical assistants, etc. “Is there one person assigned to you or do you have to share that person’s time with another physician? If there are no physician extenders, then could one be hired?”

But back to the zenith of control in a practice…management. “In a private practice model, decision making in the management of a practice ultimately rises to the shareholder level as those individuals are responsible for the financial and operational components of the practice. The average time between hiring and the point at which someone becomes a shareholder is about two years. Prior to that the focus is on building a practice, doing the clinical work, and establishing a reputation in the community.”

“Typically, as a private practice doctor, when you become a shareholder your financial viability is based on your clinical work in combination with your administrative work—with no guaranteed salary. You do as well as the company does, and you are offered the ability to shape the direction of the practice. Some people want to be part of that, while others do not. A lot of younger surgeons just want to focus on their clinical work.”

Regardless of how much you want to be involved with the leadership of the practice, do your best to make sure to vet the financial health of the organization. Dr. Craig: “What do their account receivables look like? How many days? What does the patient base look like in terms of payor mix (is it primarily governmental payers, etc.) Are there ancillary income opportunities such as durable medical equipment, physical therapy, occupational therapy, Ambulatory Spine Centers, etc.?”

It is also vital to have a sense of why they want to bring you aboard. “You will want to determine if a given practice has a true need for your specific skills and talents,” advises Dr. Craig. “If so, is that need based on other physicians who are retiring or is it emanating from growth. Are they so busy that patient wait times are unusually long? Or is this need based on geographical growth because they are trying to grow into another market?”

And don’t forget about call. “You want to ask how often you are expected to take call and where. In addition, find out what the call is like in terms of pace…slow or frenetic. And is the same amount as one of the partners who has been in practice for 20 years or is there some kind of system where the more senior partners take call less frequently?”

Dr. Riew, who has spent his life in academic medicine, notes, “Many of the same issues that Dr. Craig mentioned also apply in academics, except that you report to the chair and the chair has the ultimate control over most issues. If he/she and you cannot come to satisfactory terms, your ultimate recourse is to leave. Ideally, in academia you don’t want to move around because you spend vital time developing your practice, referral patterns and your database — and you can’t take that data with you, as it belongs to the university. I had a database with thousands of my operative patients at Washington University in St. Louis, but when I left, it remained there. And leaving can be quite disruptive, for you, as well as your family. For a young surgeon who has not even passed the boards this is particularly troublesome.”

In determining if an offer of employment is a good fit for you, says Dr. Riew, ask what the chair is like. “I’ve been fortunate to work for some of the best chairs in orthopedics but everyone has heard stories about horrible chairs. These individuals have a great deal of sway over whether you will be satisfied with your job. If possible, contact physicians who worked there previously, as they are likely to be frank about the pros and cons of the job.”

If there is a dispute about what was promised, only words on paper matter. Dr. Riew: “If someone is promising you lots of OR time and resources, once you sign on the dotted line, you may find that these things do not come to fruition.”

So what does Dr. Riew advise as far as red flags? “If an academic center says to you, ‘We are going to hire you, but you will be at a satellite facility.’ This may be a great clinical opportunity, but it could also be difficult to do research or teach residents. In most academic institutions you gain respect based on your research and the degree to which you have published in peer reviewed journals. What is the point of being in academia if you are not able to perform meaningful research or teach?”

Echoing the concerns of Dr. Craig, Dr. Riew notes, “Whether you are an employee of a hospital or a university, you report to someone. Ideally, they will let you be independent and give you the freedom to pursue your interests. If you are a hospital employee, then you may be expected to fill in for other physicians and you essentially cede a lot of control over your workload and schedule.”

And as always, say our experts, seek the advice of counsel when signing on the dotted line.