Where In the World Should I Work?

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Director’s Corner on Finding a Job

Dear Boss:
I am a senior resident looking at several very good job offers, but I’m having trouble deciding on the best. They all are convenient to where I want to live and will give me a good income. The first one is a very busy ED where it appears that the docs make about 30% more than the going rate in the area through an rvu based incentive system. The second ED had a great staff and it felt like a great fit but the pay is a well below the first ED. The third ED offers a giant signing bonus, looks like it could be a little tough to work in, and the pay is in line with the second ED. The signing bonus, though, could cut my school loans in half. Any thoughts on how to prioritize?
Dear Choices,
Number one on the priority list for job search is location and it sounds like you have that figured out. Although no job is perfect, it sounds like you have three great options, so let’s review some pros and cons for any job.


There’s no free lunch. Places that offer large signing bonuses or very high hourly rates expect a lot of hard work in return. This frequently translates to high acuity, which is fun and what we’re trained to do, and also a higher-than-average patients per hour pace. I have no doubt that some residents can handle this pace and acuity right out of residency, but I don’t believe that this environment is a good fit for every graduating resident (nor every attending emergency physician for that matter). Let’s face it, some people work slower than others and don’t multitask as well. I heard recently that young grads, less than 3 years out, get sued more often than docs with more than three years of experience. Would a high acuity, high volume ED set you up for that? Maybe. Depends on your training and what kind of environment you thrive in. I do think there’s a benefit to having incentive systems in place and being compensated for the work you do is appropriate and fair.

Look beyond the bonus. Let’s look at the giant signing bonus because something big enough to cut deep into school loans might even tempt me. My experience tells me that large signing bonuses come out when EDs are desperate to recruit, either because it’s a new management team or the ED has severe problems. You admitted that it looks tough to work in, but let’s examine the specific factors that would make an ED a difficult environment to work in. How easy is it to admit patients there? Is there a hospitalist group or are admissions done by private practitioners who may not want to admit uninsured patients? Who writes admission orders and does the EP respond to floor codes, emergencies, other incidents, etc… How is trauma handled? Will surgeons come in from home to help manage the trauma patient? CT and ultrasound availability? What about standard types of consults like peds and obgyn? Answering some of these questions could give you insight into the reason behind the huge sign-on bonus and help you know if the job is worth the money.

Job satisfaction. Your second job, while not solving your debt problems, could be good for your mental health. But before you rush in based entirely on environment answer a few questions. Is the pay fair for the job? Will you continue to enjoy the work environment going forward? At the end of the month, will you have enough money to pay back school loans and live comfortably? How important is a positive work environment to your mental health?


A winning combination. After working in several different environments like you’ve described and talking to numerous chairman, I’ve found that job stability and recruitment frequently come down to a few things. You need a group that you trust and like, after all, you’ll take and give sign out to these individuals and you’ll need to cover each other for emergencies. You’ll want a reasonable acuity and patient volume (I want to see enough cool stuff each day, but don’t want to stay hours after each shift cleaning up). You need to have good resources – hospitalists, ancillary services, and radiology availability to name my top three – fair and healthy scheduling, and ultimately fair pay.

Personal best. What job is best for you requires you to list your skills, needs, and happiness factors. Your priorities today may be different in several years and that may require a job change as well, which is definitely possible in our line of work. Each job has great potential but each one will also negatively impact you in some way. Take the time to investigate each thoroughly before making a decision. Fortunately, most areas around the country need board eligible emergency physicians so a well trained resident with a good personality is in the driver’s seat. Sit back, enjoy the ride, but know what road and type of conditions to expect.

Submit your questions for the Directors Corner by emailing editor@epmonthly.com

Mike Silverman, MD, is chairman of emergency medicine at Harbor Hospital in Baltimore and on the faculty at the TeamHealth Leadership Academy


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