By Nadege T. Gunn, MD and Mitchell L. Shiffman, MD
The field of hepatology is rapidly evolving. We know there will be no shortage of jobs as people continue to eat food and drink alcohol in excess. With that being said, your remaining fellowship months are rapidly coming to a close. The days of co-signatures and mandatory didactic sessions are over. It is finally time to independently manage your patients. Though you may be apprehensive, you are more ready than you think.
Choosing your first post-fellowship job is no easy feat. So many factors go into making this critical life decision. But let us assume you have found your dream job. The location suits your family and recreational lifestyle. The schools are second to none for your children, your spouse will have no problem finding work, and the facility is not only aesthetically pleasing but nationally ranked in patient care. Most importantly, the doctor’s lounge has the best selection of free food.
You get a call from the hospital administrators that there is mutual interest and a contract for your review. You are emailed a one page terms sheet followed by 40 additional pages of language that might as well be in Haiku. You are told to review the terms and escalate any questions or concerns. The problem is you don’t know what to ask.
Fellowship does not prepare you to understand the physician employment contract and the benchmarks you will be held to in order to earn your living. The employment contract is daunting and rather intimidating to say the least. Our hope is that by the time you finish reading this article you will become familiar with what to expect in your employment contract and how to approach the negotiation process.
The following are the top seven items to carefully review or consider before you sign the bottom line.
Full-time practice has a variety of definitions. You want to be sure you know what “full time” means to your future place of employment. This may mean 40 direct patient care hours per week, including office visits but also call coverage, inpatient rounds, research, and educational services. We all know that most physicians work well over 40 hours per week. Often times these parameters are not clear within the contract. Be sure to talk to the currently employed providers about a typical day in the life and whether or not it aligns with your work/life balance. For example, if you are on call, do you take only those assigned to your practice or all Emergency Room unassigned patients? What is the call frequency? How many holidays will you be expected to be on call? Is the call schedule shared equally or is it heavier on the newly employed? How much time off will you be allotted and how is time off earned? Do you have time carved out for inpatient or administrative responsibilities?
Being a full time physician does not afford much time for extracurricular activities, but you should be aware of the policies in this regard. Perhaps you want to earn a little extra money on your time off doing a few colonoscopies to maintain your skills or you want to be on the speakers’ bureau for a drug company you have come to really respect. You should ask that your contract speak explicitly to this as not all contracts do. You also want to know if any of the additional income you earn will be subject to scrutiny and possibly capped to a certain dollar amount. You don’t want to find yourself trapped when situations like these arise. These extra activities are often helpful to keep you well rounded and on the cutting edge of medicine.
As you consider your offers, you may see high dollar amounts for sign-on bonuses, relocation, retention, and continuing education (CME). Though they may seem generous and enticing, be sure you make them work best for you. Calculate how much money you really need to move and perhaps transfer the difference to your sign on amount. Sometimes you may be allotted more money to relocate then you truly need. Keep in mind sign on bonuses are usually subject to taxes, leaving you with very little in the end.
When it comes to CME, budget for the conferences and meetings you typically attend and ask for more money if the allotment will not be enough to cover you. When you are away for CME you will not be in office seeing patients. Will you be given paid time off for these days? What are the terms for these allowances? Can you travel internationally? Should you terminate your employment for any reason, will you be subject to paying back any of these monies (with interest) and in what time period?
During fellowship you could spend over an hour with a patient and no one would bat an eye. The importance then was that you learned something and prepared a power point to share with your friends. Now your time is money and you should be prepared to understand the Physician’s Work Relative Value Unit (wRVU). This four letter demon will make or break you in practice.
Initially, you may be paid an income guarantee for the first one to three years. This is to allow you time to overcome learning curves and build your practice. After this honeymoon period, you will likely be held to certain productivity benchmarks.
Every patient encounter, whether a new patient in the office or a follow up on rounds, has a wRVU assigned to it. Many employment contracts allocate a dollar amount to each wRVU you earn based on Centers for Medicare and Medicaid Services (CMS) guidelines and compared across all specialties per the current Medical Group Management Association (MGMA) value.
The average dollar amount paid in salary support per wRVU is $40 to $60. The average annual wRVUs generated by many medical specialists is well documented. However, this data is not easily defined for a hepatologist. The best estimates for the average annual wRVUs generated by a hepatologist varies from about 4000 to 8000 and this depends upon how many endoscopic procedures the hepatologist performs and the work environment. In general, hepatologists who work in an academic medical center generate about 2 - 3000 wRVUs less than what a hepatologist could make in a community based practice. Spend some time researching this and how many wRVUs you could generate. What determines how many wRVUs will be the expectation for your employer? What happens if you fall below this? Understand what your personal practice will be like. How much time will you spend doing procedures versus office patient care? How many new patients? How many follow ups? As you can imagine, procedures and new patients have higher wRVU allocations than non-procedure follow up visits. Take a few moments to think about your comfort level. How many patients can you feasibly see in a day without compromising your lunch hour or sanity and do the math. Also, try to speak with someone over physician compensation regarding these compensation algorithms. Will you be given a base salary or will your earnings be based entirely on production? Is your employer’s formula one that sets you up for success or could you see yourself starving to make ends meet?
This is pretty straightforward, but be sure to understand what health benefits and retirement savings plans are inherent to your employment agreement. Does your health system match your contributions to a 403b/401k after a certain term? Does your employer have other tax deferred savings options after you have maximized your contributions according to IRS limits? Is your health insurance providing good prescription coverage, reasonable co-pay and deductible amounts and giving you a nice selection of health care providers for your family?
Importantly, are there opportunities for you to earn additional money for research studies, resident and mid-level supervision, academic appointments, quality, or patient satisfaction engagement incentives? Some organizations will pay you a stipend when you supervise nurse practitioners or physician assistants. If you take the time to precept mid-level providers you should be compensated for doing so. Be sure to know what items may add to your income and become familiar with the pay schedules and regulations for these avenues.
In order for your employer to protect their patient base, they need to be sure that if you terminate your employment for any reason, your patients cannot follow you and in essence separate from your employer. For this reason, your employment contract will have a restrictive covenants section which prohibits you from setting up a practice within a certain mile radius of your former practice.
In the modern day of health systems and dozens of hospitals within a small area owned and operated under the same umbrella, you can find yourself forced to move out of the area temporarily to earn a living. Pay close attention to the limits your employer places on this. Are the non-compete distances based on where you physically park your car every day or does it also involve hospitals you’ve never been to? How long will you be held to a non-compete and can you buy your way out of it if needed?
The jury is out on this. Most employment contracts seem to have fairly generic formats and touch on the topics we have listed. If you go in well informed and stand your ground on issues you will not waiver on, you may not need an attorney at all. However, many may also argue that it is nice to have a pet alligator on your side at that negotiation table. You want to be sure to choose someone who is very knowledgeable in physician contract law and will take the time to comb through every line of your agreement so you are not locked into any sticky situations in the future. Attorneys are costly so try to arrange a one- time fee for services as opposed to an hourly arrangement. Costs can add up quickly.
All in all, hepatology is exciting and you have chosen a field that will stimulate your mind each day. When you finally choose your workplace, go in armed with the information necessary to make your first job one that will reward you personally, intellectually, as well as financially every day without exception. When you feel all your questions are answered and nothing makes you uncomfortable, you have found the right place. Good luck!