Finding a Job and Negotiating an Agreement in Allergy/Immunology - AAAAI 2015

Tao T. Le, MD, MHSAssociate Clinical Professor

Department of MedicineUniversity of Louisville

Partner, Central Allergy & Asthma

slideshare.net/taolemd

Disclosures None


Most Important Advice

Be honest with yourself!!!Don’t try to impress your program director or other fellowsDo what you want to do

Choose Your Own Adventure

Career optionsFinding a job and interviewingContract negotiationsAAAAI FIT exit survey


Why did you go into AI?Patients

Continuity, treating familiesInteresting diseases

Allergies and asthmaImmunodeficiencies

ScienceTLRs and interleukins, oh myLove working with mice

All of the above

What Do You Want to Do?Just see patientsWork as part of a teamBe the boss

Control all aspects of practiceWin a Nobel prizeBe president of AAAAI or ACAAI

Options After FellowshipFirst decide your primary job activity Clinical

Taking care of patientsResearch

Clinical, epidemiological, or bench/translationalEducation Other

Administrative/leadershipRegulatory Entrepreneurship

Clinical OptionsPrivate practice

Individual/soloSmall groupLarge groupMultidisciplinary

Hospital employeeAcademic

Research OptionsAcademicResearch instituteHealth department

EpidemiologyIndustryClinical practice

Clinical research

Other OptionsHealthcare organizationsFDAInsurance companiesOther institutions

Secondary schoolsBoard review organizations

Most won’t start here

Research OptionsAcademic

Large range of research optionsHigh level of prestigeExcellent environment for research

CollaborationRelatively lower payYou are not your bossMust pay for yourself - grants

Research OptionsResearch Institute

Excellent research environmentFocus must fit instituteIf institute changes focus, uh ohLess opportunity for other options

Clinical Teaching

Research OptionsHealth Department

EpidemiologyPublic HealthGovernment job securityLower pay

Research OptionsIndustry

You are not your bossMust have clinical applicationsPay usually goodResearch results drive careerDo not have to get grants

Research OptionsClinical practice

Primarily drug studiesSmall investigator initiated studies possibleNo large multicenter trials (NIH)Income tied to patient recruitment

Single Specialty OptionsPrivate practice

Individual Be your own boss Need to develop patient base

Small group Shared control – cooperation Built in patient base

Large group Follow the rules Must be comfortable with group

Multispecialty GroupsAmbulatory +/- hospitalsLarge – heavy PCP expansionSalary + incentive compensation (vs fee for service)RVU productivity modelSome equity opportunity – shareholder vs. partnership

Multispecialty GroupsPros

Stability/predictabilityBuilt in referralsMore mature business model with metricsLess administrative hassleManagement opportunities

ConsOverhead Inequality in productivity models/compensation plansBureaucracy/politics

Clinical OptionsAcademic

You are not the bossProductivity may not be rewardedBilling/collections providedTeaching opportunitiesAdministrative opportunitiesMore prestige


Job HuntingMost important thing is to be honest and true to

yourself!Make a list of the things that are most important for

you and your familyMake a list of the things that are most important

about a potential practice


Important Factors When Choosing a Job

Geographic location 65%Practice Setting 49%Spouse/family reasons 49%Professional growth opportunity 46%Call schedule 44%Compensation 43%Benefits 39%Prestige of employer 24%

MGMA

Job Hunting

Start looking late summer or early autumn of the last year of fellowship

ResourcesMajor specialty journals (JACI and Annals) have job listingsAAAAI and ACAAI have job placement centers on their

websitesACAAI has job fair at its annual meetingLocal allergy societies in the target regionWord of mouth from physicians—especially from mentorsMedical headhunter services


Job Hunting• Send letters of inquiry to ALL practices in a

desired location• Many practices contemplate hiring before

advertising • Research the practice and personalize the letter if

possible


Have a Successful CVBe conservative and professionalUse a conservative font and avoid overuse of bold, italics, and

underlined textBe concise and only include relevant information Information should be complete, accurate, and currentPrint on a laser printer, high quality paper, or consider professional

printing, print on one side onlyThe first page is considered the most important

Don’t try to fit everything on one page A 2 to 4-page CV is considered average for a young professional

Know the CommunitySize of communityProximity of family and friendsEmployment opportunities for spouseGeneral economic and social structureQuality of schools

Know the CommunityHousing costsRecreational opportunitiesArea and patient demographics

PopulationEconomic background and stabilityDemand for specialty

Preparing for the InterviewCollect and analyze preliminary information Bring a list of prepared questionsDress for successBe earlyDo not plan any other events for the same day

Gathering InformationNumber of physicians (small versus large group) Setting – urban, suburban, or ruralOffice locations – single office versus several satellite

offices

Gathering InformationType of practice (academic versus private practice;

single specialty versus multi-specialty) Patient population characteristicsCommonly encountered conditionsHow would a new allergist fit in?

Gathering InformationReason for hiringTypical workload

Number of patients seen daily Work hours On-call days Seasonality

Hospital consult responsibilities Location Frequency Cross-coverage of other service, if in a multispecialty group

Gathering InformationInsurance payor mix Local practice ecosystem

Other allergists and subspecialists – collegial vs. competitive

Non-allergy competitionPrimary care physicians/NPs and referral patterns

Turnover of physicians and staff

Gathering InformationSupport staff ratio

Will you have your own nurse or medical assistantWho’s in charge/who makes the decisions

Leadership and governanceOffice manager/administrator

Gathering InformationStructure of the group

Independent contractorsPartnerships/PC/PAEmployer/Employee

Is future partnership an option?How is this determined?What is the timeframe?

Gathering InformationStarting salary Benefits packageFair market value of practice/buy-in/partnership Access to financial books/recordsShadow the physicians in clinic Speak with staff

During the InterviewListen more than you talkPromote strengths and any areas of expertiseAct professionally and never feel “too at home” Do not speak negatively of other practices

After the Interview

Make notes of a practice after you interviewFollow up with a thank you letter

Samples in the Practice Management Resource Guide

Digging DeeperSpeak with other physicians in the communityWhat is the reputation of the group?Speaking with any physician who has left the

practiceSit in the office waiting room, speak with patients Call the office to schedule an appointment and

speak with staff

Offers

1-3 may be expected

Verbal vs. written

Is NOT an employment agreement

Get a Good AttorneyWith experience in medical employment contracts

Referrals form the local societies, hospitals or state societies.

National Society of Certified Healthcare Business Consultantshttp://www.nschbc.org/

Resources AAAAI Practice Management Resources Website.

http://aaaai.org/members/resources/practice_management/ Le, T., ed. AAAAI Practice Management Resource Guide, www.aaaai.org. NAIA-FIT Mentor-Mentee Program NAIA Academic Career Development Webinars.

http://aaaai.org/members/only/assemblies/webinars/ Best Friend’s Guide to Finding a Practice. CHG Healthcare Services and ASPR, 2006.

http://www.comphealth.com/pdf/physician/perm/aspr_best_friends_guide.pdf NEJM Career Center. http://www.nejmjobs.org/career-resources

Tao Le, 02/14/2016

update with PM guide

What a Good Contract DoesClearly spells out specific terms and conditions for

employment including:Employment status and scope of workCompensation/benefitsEmployer’s responsibilitiesRestrictive covenantsTerm and termination provisions

Balances the interests of both physician and employerREMEMBER: GET IT IN WRITING!!!

What It Can’t DoDefine the culture, leadership, values of a practice

Ensure that you chose the optimal practice opportunity for your circumstances

Guarantees a successful employment experience

Employment StatusWho are you?

EmployeeContractorShareholder

Status can determine:Type of compensation/benefitsTax burdenLiability in the event of a malpractice event

Your ResponsibilitiesTypical clinical dutiesTypical scheduleTypical clinic locationsHospital consultsCall dutiesNon-clinical duties

Administrative responsibilitiesCommunity activities

Employer’s ResponsibilitiesOffice space, computer

Nursing and support staff

Supplies

Transcription services

Billing services

Car allowance/insurance, cell phone

Licensure, credentialing, board certification

Cash CompensationGuaranteed base salary +/- annual pay increases

Productivity bonus

Signing bonus

Relocation expenses

Negotiating hint:Do reality check on achievability of productivity bonuses

BenefitsFamily health insurance

Dental insurance

Disability insurance

Life insurance

BenefitsPension/401k

Vacation and sick pay/PTO

Family leave

CME allowance

Malpractice/Tail CoverageLiability insurance

Ex.: $1MM/incident, $3MM aggregateOccurrence – cover lawsuit at anytime if policy in force at

time of incidentClaims-made – covers lawsuit if policy in force at time of

filing

Tail coverage – supplements claims-made policyCoverage for claims made after policy terminatedTrend in shifting cost to employee

Malpractice/Tail CoverageNegotiating hint:

Ask for employer to pay for tail if termination without cause or if you fulfill a threshold term of the contract

Other Employment/ActivitiesTypes of activities

MoonlightingSpeakingResearch/publishingSignificant volunteer activities

Is it permitted?

Other Employment/ActivitiesWho owns the income?

Negotiating hints:Carve out anticipated activitiesSpeaking may be a win-winCheck if your malpractice covers moonlighting

EquityExpectation of achieving partner or shareholder status

Specified in a separate agreement

Usually after a fixed period of time and/or with qualifying performance

There may be a junior vs. full partner level

There may be a buy-in vs. sweat equity model

Practice may offer financing

There may be a pay-out when you retire

Buy-In FactorsNature of the employment agreement – does

employer profit from your labor?

Practice valuationTangible assetsIntangible assets or “good will”Liabilities

Discounted cash analysisValue increases with practice revenueDiscounted by expected rate of return

Partnership HintsGet specifics regarding time to partnership, buy-in

requirements, pay-out calculations, etc.

Ask about previous physicians who made or did not make partner

Ultimately requires mutual trust and open communications

TerminationTermination for cause

Reasons: loss of license or malpractice insurance, death, felony conviction, “material breach”

Usually immediate

Termination without causeEmployee usually has reciprocal rightNotice periods range 60-90 days

Negotiating hints:If “material breach,” ask for a period for “cure”Ask for longer notice period if you think you need it

Non-Compete AgreementPrevents departing physician from competing with

employer Specifies restricted region (i.e., 5-50 mile radius)In force for 1-2 yearsEnforceability varies from state-to-state

Negotiating hints:↓ duration, especially for early terminationLimit restricted region to office where you were basedLimit applicability to overlapping servicesSubstitute with non-solicitation agreement

Non-Solicitation AgreementPhysician forbidden from recruiting patients or staff

away from employer

May practice in the same area

Sometime used in place of non-competition agreement

Negotiation hints:Clarify that public communications like newspaper ads

does not violate agreement

Medical RecordsUsually belong to employer

Physician may need access to defend against a malpractice action, credentials committee investigation or medical board inquiry

Negotiation hint:Ask for reasonable access should you leave the practice

Dispute ResolutionCan mostly be settled between employee and physician

Otherwise, disputes settled in courts

Each party typically covers own fees

Negotiation hints:Ask that any unresolved dispute be submitted to

confidential mediation and binding arbitrationAsk that loser pays winner’s legal costs

Small vs. Large PracticeSmall practices may offer more:

Flexibility in contract termsWillingness to negotiate

Large practices may offer more:Standardized agreementsWider range of benefits

Final ThoughtsUse an experienced attorney

Request a letter of intent ahead of the contract

Don’t hesitate to negotiate

Beware of one-size-fits-all contracts

Make sure guaranteed pay is enough

Consider total comp package

Never accept a verbal promise. Get it in writing!!!

ResourcesA Physician’s Guide to Employment Contracts

http://www.mmaonline.net/Portals/mma/Publications/Reports/Physicians_Guide_to_Employment_Agreements.pdf

A Primer on Employment Contractshttp://www.aafp.org/fpm/20021100/73apri.html

Demystifying Common Terms in Employment Agreementshttp://www.aafp.org/fpm/20030600/38demy.html

ResourcesLifting Restrictive Covenants

http://www.aafp.org/fpm/20010400/50limi.htmlAnatomy of a Physician Employment Contract

http://www.nejmjobs.org/career-resources/physician-job-contract.aspx

Avoiding Physician Employment Contract Pitfallshttp://www.nejmjobs.org/career-resources/physician-job-contract-2.aspx

National Society of Certified Healthcare Business Consultantshttp://www.nschbc.org/

AAAAI FIT Exit SurveyWeb-based survey designed and implemented by

the AAAAI Workforce Committee with input from the AAAAI Practice Management Committee to:Document the career choices of graduating FITs and

their rationalesElucidate the employment market for graduating FITsIdentify trends in the current economic climate

Sent to all FITs graduating June 2012 and June 2013

Results 147 responses (78 in 2013, 69 in 2012)

Demographics 2012/2013, n=147

Female (%) 61%

Age, mean (SD) 34.0 (4.0)

Race

White 42%

Asian/Pacific Islander 38%

South Asian 15%

Middle Easterner 5%

Black 0%

IMG (%) 28%

Primary ActivityActivity %

Patient Care/Clinical Practice (Non-Academic)

54

Patient Care/Clinical Practice (Academic)

30

Research – Academic 7

Other 3Undecided 3

Primary Work SettingWork Setting 2012 % 2013 %

Solo Practice 1 3

Small Group Allergy Practice 25 24

Large Group Allergy Practice 12 15

Multispecialty Group Practice/Clinic

12 12

Hospital/Ambulatory Care Center

3 3

Managed Care/HMO -- 3

Academic Medical Center 35 32

Military/U.S. Government 4 1

Undecided 6 5

Base CompensationBase Salary Academic Practice

< $80,000 18% 8%

$80,000-99,999 8 5

$100,000-119,999 18 5

$120,000-139,999 24 10

$140,000-159,999 14 30

$160,000-179,999 8 15

$180,000-199,999 6 8

$200,000-219,999 2 11

$220,000+ 4 8

Pearson chi-square (df=8) = 21, P = 0.007

Incentive CompensationBonus Income Academic Practice

None 63% 49%

<$10,000 17 21

$10,000-$19,999 4 21

$20,000-29,999 2 6

$30,000-39,999 8 0

$40,000-49,999 4 4

$50,000+ 2 0

Pearson chi-square (df=6) = 15.3, P = 0.018

Signing BonusSigning Bonus Academic Practice

None 90% 71%

<$10,000 8 15

$10,000-$19,999 2 8

$20,000-29,999 0 1

$30,000-39,999 0 3

$40,000-49,999 0 3


BenefitsWork Setting Practice Academic

Medical Insurance for Self 62% 84%

Medical Insurance for Spouse/Dependents

53 68

Dental Insurance 58 84

Disability Insurance 43 70

Malpractice Insurance 78 96

Paid Vacation 77 96

Retirement Plan 44 70

CME/Professional Meetings 66 73

Car Allowance 6 0

Ownership/Partnership?Clinical Practice %

Yes 36

No 50

Not Sure 13

Starting My Own Practice 1

Timing of Equity OwnershipClinical Practice %

At starting (eg, buying in to the practice) 4

At or before first anniversary 6

At or before second anniversary 22

At or before third anniversary 34

After third anniversary 13

Not sure 21

Personal Debt LoadAcademic Practice

<$100,000 64 43

$100,000-199,000 19 34

$200,000+ 17 24


Compensation SatisfactionCompensation

SatisfactionAcademic Practice

Very Satisfied 23% 36%

Somewhat Satisfied 46 50

Somewhat Dissatisfied 23 6

Very Dissatisfied 8 8


Long Term ProspectsWill you be there

>3 years?Academic Practice

Yes 53% 73%

No 11 14

Undecided 36 13


Ease of Job HuntDid you have a difficult time

finding a satisfactory position?

Academic Practice

Yes 45% 49%

No 51 50

Haven’t looked yet 4 1


Career SatisfactionWould you recommend the specialty of Allergy and Immunology to medical students or otherphysicians in training?

%

Yes, with enthusiasm 82

Yes, but lukewarm 18

No, but not strongly 1

No, emphatically --

Health & Medicine

Finding a Job and Negotiating an Agreement in Allergy/Immunology - AAAAI 2015