It’s not just about the payday.
Dear Director,
As I start my job search, what are the characteristics that I should be looking for in a job after residency?
Last month we discussed the importance of location, people (including the medical director), hospital resources, the schedule and employment models when developing your priority list. There’s still a few more things to consider as you finalize your priorities.
Pay
Your pay absolutely matters. However, I intentionally didn’t list it in Part I of this article and hopefully it’s not your top priority. By your second job offer, you should have a good understanding of the local market rate. Five or ten dollars an hour rarely makes a difference compared to the value of working with a good team. Since there is no free lunch, very high paying jobs or those with huge sign on bonuses should have you asking questions about why they have to pay so much higher than the standard rate.
Many jobs have hourly rates. Other places have compensation tied to productivity. Know what you’re getting into and what the group average is. I’ve interviewed docs who clearly wanted or didn’t want productivity-based pay.
Some really wanted to bet on themselves and get compensated for seeing more patients. Others didn’t like the “risk” inherent in patient volume. Everywhere I’ve worked has always had patients in the waiting room, so we were never at a loss for patients.
Some jobs will have night shift differentials. Make sure you end up comparing apples to apples, meaning take each line of compensation (salary, bonus, CME, value of benefits, PTO, etc…) and compare them to each job so you understand the total package. Hourly rates are typically higher for 1099 jobs since those jobs don’t usually come with benefits.
For those considering jobs in high volume EDs, please reflect on your own speed. Whether this impacts your pay or not, it’s important to find an ED that fits your pace and style of work. Keep in mind that essentially all attending jobs have you seeing more patients than your residency, but some places are really pretty crazy.
If you have average speed, i.e. the number of patients you see per hour and your average length of stay are typical of your resident colleagues, going to an ED that intentionally understaffs because the doctors are very fast and they want to maximize their profit/productivity pay, may not be a good fit for you.
I remember recruiting someone who had it narrowed down between my site and a neighboring hospital. The acuity and productivity requirements for my site were not particularly demanding whereas the other ER had much higher acuity and required the doctor to be much faster. When I was discussing this during a reference check with his residency director, the residency director made it clear to me that this particular doc did not belong at the faster facility. While this doc was quite successful at my facility in the short and long run, he may not have had the same success had he chosen the other site.
Operations
There are numerous aspects and questions to ask around ED flow and operations as well as responsibilities associated throughout the hospital. None of these are likely make or break components from an overall decision-making point of view, but each may contribute to the satisfaction or frustration you experience with each shift.
You may also have thoughts about the patients you want to care for. I’ve met several docs who preferentially want to care for disadvantaged patients and/or who have an aversion to the “high maintenance” patient. Many docs just want high acuity. Be sure to ask about the patient type.
Let’s start with annual patient volume. There’s low, medium, high and then chaotic. The volume band that you fall in really relates to the number of docs working at once and typically in-house resources. I was a patient in a low volume ER once. When I got there, I was the only patient in the ED.
An hour later, there were 15 patients for the single cover doc to see. It can definitely be feast or famine, but that’s usually the exception. Although all ERs usually require an extra gear when there’s lots of patients, understanding the patients/hr and the acuity are what really matters. Related to this is the admission rate and also what percent of those are going to the ICU. My belief is that early in your career, you’re much better off working at a high acuity ED, where you will grow your skill set and push you to continue to improve as a clinician.
Once you know the volume and acuity, you can compare it to the physical footprint. Although it seems like every ER doc I know is seeing patients in the waiting room and hallway spaces, ideally, your ED has enough physical rooms to see patients.
Along with the physical number of rooms is whether there are other parts of the ED you’ll see patients—an intake area, fast track section, holding area, obs unit, chest pain section, etc…A question that comes up is whether you are responsible for designated rooms/sections or whether docs see patients anywhere in the department. This will typically depend on the size of the ED and how things are divided up.
Although there’s a handful of EMRs that cover the majority of hospitals/EDs nationally, going to an ED where you have a familiarity with the EMR is a nice way to start. All of us can learn a new EMR and certainly some are more end user friendly than others, Related to the EMR is how charting is done. Scribes were very popular a few years ago and may be used at the site though the newer generation dictation microphones are shockingly good and have led to a decrease in scribe utilization. I have a friend who pays out of his own pocket for his personal scribe (who he hired and trained) and he really thinks it’s worth the money. Some EDs provide each doc a scribe and absorb the cost.
By the time ED volume hits 25,000 annual visits, most EDs have added an advanced practice clinician (APC). I’ve been working with them since I was prepping their suture trays when I was an ER volunteer in college. Use of APCs varies from ED to ED from triage to fast track to main side. Expectations around supervision and co-signing charts will also vary from site to site. This is worthy of a conversation during the interview and make sure you’re comfortable with the way the APCs are supervised.
You can’t talk about operations without talking about lab and radiology turnaround time (TAT). While I’ve never met an ED director who didn’t want faster lab and rads TAT, certainly getting a big picture understanding of the processes and availability is worthwhile, including what hours of the day radiology is in house and what films are you responsible for reading yourself.
Another question to ask involves responsibility for codes that take place on the floor. At many smaller hospitals, it’s likely the ER doc responding. Even at big facilities, we may be responding to CT for codes (particularly if we think it’s our patient).
At my facility, we’re third in line for pediatric airway emergencies. I can’t remember the last time we needed to respond, but everyone should know we go if we get asked. While all of us are usually pretty happy to run a code, the issue is what happens if we have a sick patient in the ER that needs immediate attention.
While this may not come under operations, and perhaps not even a first-tier priority, the malpractice policy is one of those things you want to understand. The policy you are provided will follow you for your career. Hospitals have been pretty consistent in making sure groups obtain appropriate coverage so the bigger question for you is whether it’s occurrence or claims made, and if it’s claims made, who pays the tail. Occurrence policies follow you for when the “claim” happened.
For instance, my policy for 2019 covers me for all patients I saw in 2019 through the statute of limitations. A claims made policy covers you for the date of the actual claim.
If my group had me on a claims made policy in 2019 and I left in 2020, I’d need to buy a “tail” to cover me going forward for the patients I saw in 2019 and the portion of 2020 when I worked. Your group may pay for that or they may pass that expense on to you (check your contract).
Extra perks
I know some great ERs that are bogged down with extended stay psychiatric patients and placement issues. Even with good psych and case management in the ED, these patients can be challenging and time consuming. But they’re even more so when you lack psych coverage and ED case managers.
Most hospitals don’t have this kind of coverage 24/7, but it’s worth a question during your interview as well as when you talk to other docs who work there what their experience is and how time consuming these patients are versus passing them on to psych and/or case management.
Conclusions
Whatever stage of your career you’re in, searching for a new job is both exciting and stressful. If you’re like me when I’m making a decision about a new job, I create a spread sheet with my top priorities, assign a level of importance or weight to it, and then grade each ED I’m considering.
I can generate a final score and then I see if the winner passes my gut check. Understanding your individual priorities will help you make the right decision when the job offers roll in.
