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June 2, 2020

In 2019, after 20 years in practice, Laurie Montague, M.D., was growing restless. The Manchester, New Hampshire, family doctor found she was spending more time on paperwork and administrative responsibilities and less on what she truly enjoyed: caring for patients. She also wanted to be closer to her daughter, who was expecting her first child, in Cincinnati.

But those were just the beginning of the changes Montague wanted to make. Conversations with a physician recruiter, along with the self-knowledge gained from two decades of work experience, enabled Montague to assemble a more extensive wish list of things that she knew would make her happy in a job and that she lacked at the position she then held with the Department of Veterans Affairs.

With that list in hand, the recruiter found a position for Montague with Primary Health Solutions, a federally qualified health center based in the Cincinnati suburb of Hamilton, Ohio, near her daughter. The center has a staff to handle administrative issues, leaving Montague and other clinicians free to focus entirely on patient care. And the contract the recruiter negotiated on her behalf includes many of the other items on her list, such as a role teaching residents, a four-day workweek and six weeks of vacation, providing Montague ample time to spend with her daughter and new granddaughter.

Six months into the job, Montague rates it a 9 on a scale of 10. “Nothing’s ever perfect, but it has become something where I look forward to going into work in the morning,” she says.

The must-haves and deal breakers

Until recently, finding a position as satisfying as Montague’s wasn’t a significant problem for most doctors. That’s because the majority were self-employed, either as solo practitioners or partners in a small group, and thus had the freedom to shape their job as they wished.

But the number of physician practice owners has dwindled in recent years, and by 2018, employed doctors outnumbered those with an ownership stake in their practice, according to AMA data. That means before starting a job search, whether they’re first out of training or making a midcareer switch, doctors need to envision what would make them happy in a job. Then they need to develop specific criteria for making that vision a reality — the must-haves and the deal breakers  — and be prepared to negotiate them as part of their employment contract.

“Standard institutional employment contracts are framed in a way that benefits the employer’s interest, not the individual doctor’s,” says Richard Roberts, M.D., J.D., emeritus professor of family medicine at the University of Wisconsin-Madison School of Medicine and Public Health. “And unless you’ve thought ahead of time about what’s important to have or not have in your contract, you may not get what you want.”

Get it in writing

Having the must-haves and the deal breakers in writing becomes especially important when a work situation changes in ways the doctor doesn’t like. “If everything goes great from the day you’re hired, the contract just sits in a file cabinet,” Richard Roberts says. “It’s when things start to fall apart that the contract gets pulled out. So when negotiating a contract, you need to picture yourself at your most vulnerable because those are the situations when the contract becomes your one source of power.”

Because of his legal background, Richard Roberts has provided informal employment counseling to many physicians he taught when they were medical students. A mistake he frequently sees is waiting too long to begin the process of introspection that job and career decisions often require.

“It’s not that I want young doctors spending all their residency years talking to headhunters, but I do want them to be thinking about their priorities,” Richard Roberts explains. And while doctors may think informally about these things during the early years of training, as they begin considering employment offers, they need to do it in a more systematic fashion, he says. That might be through some form of decision matrix or discussions with a spouse or a significant other or close family members. “Once they (doctors) do that, it becomes much easier to shape a contract that’s more to their liking,” he says.

Going through this process is also helpful to employers, Richard Roberts adds. “In my experience, most employers aren’t seeking to shortchange the doctor, because it’s not in their interest to treat this highly compensated person badly. But the employer doesn’t necessarily know what the doctor really wants unless the doctor makes it clear,” he notes.

Evaluate the compensation package

Not surprisingly, financial compensation is a major consideration when mulling a job offer, especially for young doctors eager to enjoy the fruits of their years of training and to start paying off student loans. In that regard, there is good news for primary care doctors, who are seeing a steady increase in the size of their compensation packages.

Most hospital systems and large multispecialty practices today pay their employed doctors a base salary plus a productivity bonus, which kicks in once the doctor exceeds a predetermined threshold of relative value units (RVUs) in a certain time frame, usually quarterly, explains Mike Belkin, J.D., FACHE, CMPE, a divisional vice president with the physician recruitment firm Merritt Hawkins in Dallas. All those elements — base salary, the RVU threshold for earning a bonus and the dollar amount per RVU beyond the threshold — may be negotiable, he adds.

“It will depend on how challenging it is for that facility to get you to move to that location,” Belkin says. “That gets into the supply-and-demand equation. If the hospital is in a desirable area, it isn’t as motivated to pay you a higher salary, lower your bonus RVU threshold or pay you more per work RVU.”

Richard Roberts notes that employers often will include additional financial incentives that doctors need to consider when comparing the overall size of compensation packages. For example, $250,000 would seem like a significantly better starting salary than $220,000. “But what if the $220,000 employer has better benefits, offers a signing bonus and has a student loan repayment incentive? That might really change the picture,” he says.

Money isn’t everything

For all the focus on compensation, doctors have to balance it against factors such as location, workplace culture and relationships with colleagues when deciding whether to take a job. Jon Appino, founder and principal of Contract Diagnostics, a consulting firm based in Kansas City, Missouri, that specializes in reviewing physician contracts, echoes that view. He distinguishes between what he terms “lifestyle practices” and practices for which the emphasis is on maximizing earnings.

“I think a physician needs to decide in advance which of those they’re looking for,” Appino says. “If they want eight weeks of vacation to start and minimal call, it might require sacrifices to their income.”

“I don’t think that money buys happiness. It can buy candidates, but it doesn’t necessarily keep them,” says Lucien Roberts III, M.H.A., FACMPE, practice administrator for Gastrointestinal Specialists Inc., a gastroenterology practice in Richmond, Virginia.

Lucien Roberts, who conducts initial screening of candidates for the practice, says it recognizes the importance of ensuring its physicians can earn a comfortable living. But in the end, he adds, “what we’re really looking for is someone who wants to buy what we’re selling, which is a team approach to patient care. So I’m focused on that, and the money part is secondary.”

Lucien Roberts says an important part of his screening process is taking candidates to the practice’s three offices. “I like to see how they talk to my staff,” he says. “If they don’t look down on them and treat them as some kind of lesser species, then I know that’s someone we want (as) part of us.”

The on-site visit is equally important from the doctor’s perspective, says Lucien Roberts, because it’s an opportunity to observe the organization; talk to physicians, administrators, lower-level employees and patients; and thereby get a feel for the organization’s values and culture. “When I was advising residents in their job searches, they might say about a particular place, ‘There’s such a good vibe about the place, they share my commitment to helping the underserved and seemed to share all my values.’ And that has a lot do with whether you’re going to be happy somewhere,” he concludes.