Life After Residency
By Amy Lynn Sorrel Texas Medicine April 2016

Dell Medical School Residency Program Incorporates Job-Hunting Skills Into Formal Training

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Education Feature — April 2016

Tex Med. 2016;112(4):31-36.

By Amy Lynn Sorrel
Associate Editor

From running a practice to navigating complex delivery and payment systems, there are many aspects of the business side of medicine physicians typically don't encounter during undergraduate and graduate training. While that's changing as medical schools and residency training programs keep pace with value-based care, Austin internist Sherine Salib, MD, says one fundamental is still largely missing as young physicians prepare for the real world: how to get that first job. 

The associate professor of internal medicine at The University of Texas at Austin Dell Medical School created a crash course for residents to learn some of the job-hunting basics they'll likely encounter postresidency. From contract negotiations to noncompete clauses and medical liability tail insurance, "residents go out into private practice and suddenly they are hearing about these things for the first time. Yet these are major considerations that can impact you as a physician for years to come," Dr. Salib said.  

The Texas Medical Association and other state and specialty medical societies do a good job of filling in the gaps with business of medicine resources that address employment contracts and other topics. (See "TMA Resources.") 

But Houston hospitalist Thanh N. Pham, MD, says the negotiation skills she learned sooner rather than later in Dr. Salib's Life After Residency class were critical in starting her career on the right track and making sure all the hard work she poured into her clinical training was worthwhile. 

"We are prepared medically to be good physicians. But if I hadn't gone through this course, I don't know that I would be as happy in my job. And if I'm happy in my job, I can take care of my patients better, and they are happier, too," she said. "Ideally, we all want a good job. That's what we go to medical school for. We want to take care of patients. But it's also your life."

Real-World Skills

In fact, a majority of residents finishing their training — 56 percent — say they received no formal instruction regarding business issues such as contracts, compensation arrangements, interviewing techniques, and reimbursement methods, according to Merritt Hawkins 2015 Survey of Final-Year Medical Residents. Forty-four percent say they received some formal training in those topics. More than one-third, 39 percent, said they felt unprepared to handle the business side of medicine; only 10 percent said they were very prepared. 

Third-year trainees in Dell Medical School's Internal Medicine Residency Program at University Medical Center at Brackenridge must attend the Life After Residency session. They spend an afternoon in a classroom getting a formal introduction to the concepts of physician employment contracts; restrictive covenants or noncompete clauses; different types of medical liability insurance; and basic job-hunting, interview, and negotiation skills. (See "Life After Residency Curriculum.") 

Dr. Salib clarifies the conference does not provide formal legal training. She and other faculty arm residents with a working vocabulary and demystify the job-seeking process by sharing their personal experiences and facilitating small-group discussions and question-and-answer sessions. 

She starts residents off with tips on starting their job searches and conducting successful interviews but spends the bulk of the time on contract and negotiation basics. She helps residents prioritize what they want most out of a job, whether compensation, benefits, or a flexible schedule.  

Scouring the literature, Dr. Salib found most residency programs don't formally teach residents how to secure a job or navigate employment agreements before they graduate into the real world. Among just a handful of published examples, some programs emphasize instruction on general practice management skills: A psychiatry residency program at Baylor College of Medicine in Houston, for example, has trainees spend a half-day per week running the business side of a clinic alongside their clinical duties. An anesthesia program at the Medical College of Wisconsin uses a weekend retreat to educate residents on medical liability risk and regulatory compliance. 

"I really felt that the contract aspect was a specific area of need," Dr. Salib said, adding the etiquette of negotiation can have lasting effects. Her own experience taught her, for example, that "the medical community is really fairly small, and tightly-knit and interconnected, so you want to keep good relations with everyone. Even if you don't end up taking a particular job, you may in the future, or you may end up working with them."

Dr. Salib interviewed in Austin with several physician groups, and one of those practices contacted her several years later with a job opening she was able to secure for one of her residents.

Personal Experience

In fact, the course emerged largely from Dr. Salib's experience having received no formal business training during her traditional internal medicine residency and being thrown into what she describes as the "sometimes treacherous waters of postresidency employment," in an article she coauthored in the September 2015 issue of the Journal of Graduate Medical Education with Alejandro Moreno, MD, also an associate professor of internal medicine at Dell Medical School. 

Before moving to an academic setting, she started in private practice with a large physician group. As the job hunt began, "I thought the world was my oyster, and lo and behold, I saw all these worrisome terms repeated in all of the contracts — things like noncompetes and tail insurance — I had never heard of before." 

Fortunately, one of Dr. Salib's potential employers had an in-house attorney sit down with her, affording what she describes as quite an educational session. 

"But at the time, I wasn't sure what my priorities were because I didn't understand what these things were," she said. "Suddenly, I realized if I have a 20- or 30-mile noncompete [restriction] for a year or two, and if I have a massive tail [insurance policy] I have to pay out of pocket, this can definitely impact me financially and my ability to change jobs quite dramatically." 

When Dr. Salib became a faculty member, she made it a point to counsel her third-year residents about carefully scrutinizing any employment contract offers. After several years, residents approached her about holding a formal educational session, and Dr. Salib has held the class for roughly five years now. 

Overcoming Barriers

The overall absence of residency curricula addressing the finer points of that first job "seems to be dependent on the faculty at a particular program who, working in an academic setting, may not be as affected by issues more specific to private practice," she said. 

Most academic centers, for instance, provide seamless liability insurance coverage for faculty, even after they've left their job, known as occurrence-based coverage. Physicians in private practice, on the other hand, usually have to buy separate retroactive coverage — known as a tail insurance policy — to cover prior liability claims if they change jobs or locations. Also in the academic world, noncompete clauses that restrict where a physician can practice after leaving a job are usually specific to graduate medical education, whereas in private settings, prohibitions can extend more broadly. 

"Unless faculty have come from a private setting and have been through these issues, it doesn't always come up as [an educational] need," Dr. Salib said. 

She also acknowledges time constraints in already-packed residency training curricula. But she condensed her course to fit into one of the afternoon training sessions already built into residents' schedule so it doesn't interfere with other duties and educational activities. 

More importantly, embedded in the course are some of the Accreditation Council for Graduate Medical Education (ACGME) competencies that residency programs must teach, and Dell's internal medicine residency program uses the course to help satisfy some of those requirements. 

"You can look at negotiation skills, and you can say that's part of interpersonal communication," Dr. Salib said, adding that such skills can apply globally, regardless of employment setting, and even beyond to help with negotiating insurance contracts, for instance. 

"But the fact is, residents said, 'We want this,'" she emphasized.

Starting Off Right

Whereas it can take some physicians two or three tries to land their perfect job, thanks to the crash course, Dr. Pham said she found hers on the first try last September when she joined a large, private hospitalist group close to home in the Woodlands area of Houston. 

She stands among a great majority of residents, 92 percent, who prefer employment with a salary to start off their career versus independent practice, according to the Merritt Hawkins survey. And like Dr. Pham, most residents are heavily recruited and get serious about their job search at least one year before finishing their residency training.

The Life After Residency course boosted her knowledge and confidence as she dove into the competitive job pool, and when several offers came her way, she was not afraid to turn down those that did not meet her criteria. "I felt very comfortable in the job hunt and very prepared."

Many of the prospective employers who interviewed Dr. Pham were surprised when she began conversations over noncompete clauses, tail insurance, and scheduling preferences. 

Indeed, her negotiation skills paid off. 

Her current employer initially offered a two-year noncompete agreement, which Dr. Pham negotiated down to one year. She asked for and received 20 days off instead of 15, having received similar offers from other prospective employers. And in response to the initial three-year employment agreement on the table, "I said I'll do one, and if I like you, I'll stay, and if you like me, you'll make me stay, too." 

Most residents surveyed by Merritt Hawkins listed flexible schedules and compensation as their top priorities, suggesting the need for keen negotiation skills. (See "What Residents Want.") 

Dr. Pham's employer also agreed to pay for her continuing medical education costs and state and specialty society memberships, including TMA membership. When a coworker asked Dr. Pham how she got such a flexible schedule, "I just said I asked for it. He said he didn't know to ask." 

Nor did Dr. Pham have any introduction to the business side of medicine until residency, having received no exposure in medical school. She agrees it was not difficult to fit into her schedule, and even if it were, she found the education worthwhile. 

"It's just as important as the medical concepts we learn, but in your three or four years of medical training, you hear the same things reiterated over and over again. This [job-hunting skills] is about when you are in the real world, which you don't know until you get there. You are no longer under the shadow of your program, and you want to make sure you make the right choices at the get-go." 

Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.


What Residents Want

Most residents rank flexible schedules and compensation as their top priorities for their first practice, suggesting the need for keen business skills. 

  • Geographic location: 69%
  • Lifestyle: 61%
  • Adequate call/coverage/personal time: 60%
  • Good financial package: 58%
  • Proximity to family: 48%
  • Good medical facilities/equipment: 48%
  • Specialty support: 32%
  • Educational loan forgiveness: 19%
  • Low malpractice area: 18% 

Source: 2015 Survey of Final-Year Medical Residents, Merritt Hawkins  


Life After Residency Curriculum

Topics and Educational Objectives  

  • Job search: tips to prepare a curriculum vitae, network, and prepare for interviews
  • Employment contracts: basics of compensation models, benefits, termination and noncompete clauses, medical liability insurance, and implications for job changes
  • Negotiation basics: fundamentals of effective negotiation and principles for determining priorities 

Source: "Good-Bye and Good Luck: Teaching Residents the Business of Medicine After Residency," Journal of Graduate Medical Education, September 2015

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Negotiation Skills Pay Off

Houston hospitalist Thanh N. Pham, MD, says the negotiation skills she learned in the Life After Residency class at The University of Texas at Austin Dell Medical School were critical in starting her career on the right track.

When she was looking for her first job, her current employer initially offered a two-year noncompete agreement, which she negotiated down to one year. She asked for and received 20 days off instead of 15. Instead of accepting the initial three-year employment agreement, she agreed to one year. 

Dr. Pham's employer also agreed to pay for her continuing medical education costs and state and specialty society memberships, including TMA membership. 


TMA Resources 

Visit the Business of Medicine Resource Center for tools and guides for employed and independent physicians alike, including Business Basics for Physicians, The Physician's First Employment Contract, and Employment Contracts for Physicians: The Comprehensive Guide, Second Edition. Continuing medical education credits and member discounts are available.

TMA's Resident Video Library has on-demand resources to help residents survive the transition into active practice (members only). 

Residents also can sign up for TMA's free Starting in Medical Practice seminar by contacting TMA Practice Consulting at (800) 523-8776 or by email to schedule a seminar date. 

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December 05, 2016

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