Where in the World Should I Work?

Dear Director,
As a senior resident, I was hoping to make a final decision about my future job by the end of the year. The problem I’ve found is that all  the offers I’ve gotten look similar.  What intangibles do I need to consider to be sure I make the best choice?
Signed,
Waiting

I’ve always been a little envious of the person who could move anywhere in the country for the best job, the best money or even the best weather. In reality, location often tops the list of considerations as we juggle proximity to our residency with the needs of our families. Will your spouse be able to get an average or a great job? Will your kids require a new school? Do you have friends in the area? These considerations can make or break a particular locale when deciding on a job. Since you’ve already interviewed, I’ll assume you’ve taken location into consideration and move on to other factors.

Type of Hospital
There are almost as many different hospital environments as there are jobs to choose from. Community, academic or hybrid? Urban, suburban or rural? Each environment may require a slightly different personality. Certainly, working in a 100,000 annual visit ED is different than the 20,000 visit department, though the patients per clinical hour may actually be the same. Both can be chaotic, but probably for different reasons. Also, consider if your future hospital is a trauma center or has a peds ER and how they are staffed. Do you rotate through the peds ER or fast track and are traumas managed by a trauma team, or do they come in to the regular ED?

People
When I think about job satisfaction, it usually starts with the people that you’ll work with. Consider three groups: physician colleagues, the ED team (nurses, techs), and your medical director. I look for colleagues who are really cut from the same cloth as me and will approach patients similarly. After all, these are the people you’ll be in the trenches with, will be receiving sign out from and, equally important, will be giving sign out to. In a perfect world, there would be a good age/experience distribution and the group wouldn’t be too in-bred (hiring people from a variety of different residencies and regions). Their training and expertise would also be consistent with what you value. The relationship with nursing is critical. Open communication and good feedback between the two groups makes for a much nicer work environment than if there is tension or a lack of communication.

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I had a hospital president tell me that it’s much more important to have a good boss in your first 5-10 years of work than to have the perfect job. For the most part I agree. The learning curve is as steep in your first year out of residency as it was in your intern year; your future boss needs to be able to develop and mentor you as well as protect you from some of the political land mines that frequently explode in your first few months in a new job. A good medical director will also help guide you by developing your professional interests outside of your shifts, with activities that will help keep your career and professional skill set growing and your risk of burn out minimal. Finally, find a medical director that works a decent amount of shifts, so they understand what’s going on clinically, and who is accessible to you through regular office hours.

Environment
This is a generic term used for everything about the ED besides the staff. It can be the patients, acuity, and work load, etc… What are the patients per hour? Look closely at the physician schedule and the amount of coverage. How is the relationship between the ED and its hospital community (hospitalist, radiologists, intensivists, and cardiologists are consistently the most important), as well as the community around the hospital. Consider what the efficiency – lab and radiology turnaround time, admission boarders, etc… – is like in the ED. Any of those things will impact your attitude and your productivity, which could impact your pay check. Take into account whether the community is growing or shrinking, in which case ED volumes may fluctuate, along with ED physician coverage. Also, does the community have an economic vitality to sustain the hospital and ED budget? How diverse is the patient community? I find diversity is critical for seeing the spectrum of emergency medicine that we trained for, and which keeps the job interesting. I remember one job I interviewed for where the chairman described a large portion of their ED volume as “anxious soccer moms with chest pain who needed Ativan prescriptions.” To me, that didn’t sound particularly interesting day in and day out, and I never went to work there.

Malpractice
The sad truth is that if you practice emergency long enough, you will eventually get sued. Though it probably doesn’t vary within a community, I have found that each city or region has a malpractice climate. This could be related to the patient community or to the malpractice “caps” within the state. All things being equal, I’d rather work in a climate that is more doctor friendly than plaintiff friendly. If you are locked into a region for other reasons, at least consider your individual policy. The big difference is whether it’s “occurrence” or a “claims made” policy. Occurrence covers you when the “incident” occurred while claims made is designed to cover the date that the suit was filed. Therefore, if you have a claims made policy and you left your job and got sued a year later, your malpractice would be covered, but only if you bought the “tail” for the policy. Since the “tail” must be purchased, the critical piece of the puzzle is, “who buys the tail?” Since you left the group, it may fall to you to purchase, and this part of the policy can cost you tens of thousands of dollars that will come out of your pocket. It can certainly cost enough that you might think twice about leaving a job, or twice before taking a job that isn’t covering your tail.

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Employee vs. Independent Contractor
While there are some tax and maybe even some retirement advantages to being an independent contractor, being an employee is certainly less complicated – other people worry about taking the right amount of money out for taxes and then get you benefits. I’ve been both and while there are financial pros and cons to each, my personal experience is that most people are satisfied with either status as long as they feel they are compensated fairly. While this topic could be worthy of an entire discussion, neither is a deal breaker in my mind.

Money
It’s tough to know if you’re compensated fairly, but you can start by perusing the Daniel Stern and Associates Annual Salary Survey. Also, compare your job offers and make sure they seem similar. The most I ever got paid was in a 100% RVU productivity model and I busted my butt for it. I would not recommend starting in a place like that right out of residency. If the offer seems ridiculously out of whack with other offers you received, look closely at the work environment and the expectations. Rarely does healthcare allow us just to give money away. When you compare offers, make sure you’re comparing a
pples to apples. Line up each piece of the compensation package, from hourly salary to retirement contributions to benefits and bonuses. The hardest part may be comparing jobs that differ by 20-40K annually. No doubt about it, when considering school loans and being underpaid for the last 8 years, money is important. However, break it down and consider what $20k a year is on a monthly basis after taxes—about a thousand bucks. When you’re bringing home $12k monthly, that thousand dollars might not mean you need to sell your soul or end up in an environment that’s crazy busy and dangerous.  After all, it’s considerably more than you made as a resident. That said, I have a harder time making that argument when the salary differs by $40-50K, and depending on your school loans, that kind of money difference may be worth a year or two of heightened stress.

Conclusion
Life until now has been a sprint. You excelled in college, worked hard in medical school and then got in to an EM residency. But your career is a marathon, not a sprint. So make a good, thoughtful decision about your new job. Although a large percentage of new grads will leave their first job within two years, changing jobs comes with its own stress and time commitments. At the end of the day, take the time to investigate your options, get to know your potential colleagues and the hospital landscape, and compare all of the variables. You’ll be glad you did.

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Michael Silverman, MD, is a member of Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center.