Oh Henry
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Hey docs out there, listen up: the secret to building a career that will mature as you do is simple: know thyself and plan accordingly.
 
A surer sign of spring than the first robin or the first motorcycle accident is a group of senior residents who are finally trying to decide what they’re going to do for a living. News flash to all residents: you’re being graduated, not coronated. What you need is something called a “job.” No matter how bright you may think you are, you’re going to realize shortly that the work you do depends about 10% on medical knowledge, 40% on your social work skills and 50% on your ability to figure out what other people are thinking. Is this bad? Can’t say, but it is reality. One thing that will come across your mind very quickly is that the residency prepares you reasonably well to look at disdiadokokinesis; it does not prepare you well to lay the groundwork for a career that will last, maturing and changing as you enter new phases of life.

The most important part of your job search is recognizing the fact that there are multiple forces at work. It’s not just where you’d “like to live.” It is a combination of factors including the health of your parents and your spouse’s parents, where you can practice the kind of emergency medicine that interests you and where you can continue to advance your education and your skill levels.

The Job Hunt Rulebook

You are in charge of you
Don’t blame anyone else. You are correct: this is not dermatology. If you think you’re going to find a job working Monday through Friday, 8-5, you’ve made a serious error. Emergency physicians work three-quarters of the time that other professionals are off. Tell me which dermatologist actually has Sunday night hours. You need to figure this in to your long-term lifestyle plans.

There is no perfect job
Every job is a trade-off. There may be small differences in pay, but any physician who takes a job for a pay difference of $10,000 a year needs to have their head examined. There are so many factors involved that the small differences in opening pay really should not be the driving force.
   
Know thyself and plan thy life
You have to do what you really want to do in this life if you hope to have any degree of satisfaction. If you actually like EMS (for whatever reasons may be driving you) that’s fine. Make sure it’s a part of the job. If you really don’t like repeating things a thousand times over in a kind and loving way, don’t take a position with a residency. The biggest mistake most residents make is in never writing a mission statement. I’m willing to bet that the average resident spends more time planning his or her vacation than planning their life. They’ll research which ski mountains have the best snow and the cheapest passes, but they won’t have asked intelligent questions about the region or hospital that they’re going to.

The law of supply/demand doesn’t change
The job of emergency medicine is like all other jobs. It lives in an economic climate. The laws of supply and demand never change. If you want to go to a particular place which is located in a highly desirable area, there will be more competition for the job. There is no question that the cost of living in New York City is higher than in Pine Bluff, Arkansas. Also, in Pine Bluff, they pay you more money. Which means that your overall lifestyle, ability to save, etc… is greater in Pine Bluff.

Look to the future
In 20 years, only two things are possible. Either you’ll be 20 years older or you’ll be dead. Most of you will be 20 years older. Ask yourself some real questions. What do you want this life to be? What do you expect to be doing at age 50, 60 and 70? Anyone you thinks they’re going to be retiring early needs to think again. You’re going to have to be doing something to earn a living for a long period of time. So get a life. You’re going to have to work longer than you expected. So go figure that out, and figure that in to any job selection.

Think first. Move less
Moving is always hard. You have to pull your kids out of school. You have to change your address and buy new furniture. The reason that there are such a large number of people who change jobs between the ages of 18 and 24 months out of their residency is that they didn’t ask the right set of questions before they took the first job.

6 Questions every EP should be asking if they are in the job market

What is this job I’m applying for?
Is it a bait and switch? Always ask where you’re actually going to spend your time and what you’re actually going to be doing. I’m reminded of Shakespeare’s character Sir John Falstaff who, in his holster, carried food and wine instead of a weapon. He knew that he would rarely be fighting, but he would always be hungry.

What do your 55-year-old docs do on a daily basis?
Residents are trained in the mushroom theory: Keep ‘em in the dark, feed ‘em shit, watch ‘em grow. No one ever tells you that some day you’re going to be 55, your shoulder is going to be sore and wrestling drunks is going to become much more difficult. The smartest residents I know ask this question when looking into a position. The best groups know how to mature a physician’s career. They start out doing a large amount of intense ED work at odd hours and lots of excitement. And then as they move through their career they get more opportunities to work shorter shifts, urgent care, travel medicine, etc… and other activities which will lengthen the career. It doesn’t take very long to realize that opening the chest in the ED is merely the first step of the autopsy. If I never have to do that again, I will be a happy man. At a certain point in time in your practice, you’re going to want to have fewer midnight shifts. You’re going to want to have more time with your children. You’re going to want to have a different experience set and if you don’t know what the 55-year-old physicians in a particular group are doing, you’ll never know what that life is really like.

What is the package?
The actual dollar figure is not nearly as important as the entire renumeration package and its relationship to something called the implicit price corrector. 500k in San Francisco won’t buy you a garage. 100k in Flint, Michigan buys you Flint, Michigan. The implicit price corrector is a reflection of what you can buy for your money. What do baby-sitters cost? What does insurance cost? What is your purchasing power and how much purchasing power are you going to need to maintain a certain lifestyle? This is not a mystery. This type of information is available on the internet. You can basically find out what a dollar is worth in various communities in the United States. Why more physicians don’t ask this question is beyond me.

What’s the liability coverage?
You should never take a job until you’ve seen a copy of the declaration page of the liability insurance policy. This is as important a document as you have in your folder. It’s like your marriage certificate: hopefully you never need to reference it, but if you do, you ought to have it. It is essentially personal negligence not to have looked into this situation and know exactly what coverages are with you on the job and what goes with you when you leave. Non-tail policy insurances are still out there and should be avoided like the plague.

Who owns the hospital?
One out of every 11 hospitals in the United States changed hands last year. You don’t own the hospital and your group doesn’t own the hospital. Even academic programs will have changes in ownership. Changes in ownership may affect the underlying contractual basis of your work. Always know whether your job is going to be there if the hospital changes hands.

Is the hospital viable?
The payments to the hospital through medicare, medicaid and various insurances, are a matter of public record. You get to know if that hospital is in the red or the black. You get to know whether the payments to that emergency department are keeping up with various costs. The new rules of economics are essentially the old rules of economics. If you ain’t bringing money in, you don’t have money to pay to your doctors. Watching that trend is an excellent way of knowing which way your hospital is going.

Parting Words: This bit of wisdom is passed on to you by someone who has watched virtually thousands of compatriots bitch, piss and moan about their job situations over the years. It is not simple. It is not an easily understood equation, but residents: This is your life and it’s worth the effort. Put this all together before you put your name on the line.
 

Comments   

# MDMihaela Ivan 2009-05-19 00:14
Dear Dr. Henry,

If you ever consider "retiring early" or changing your career, I suggest you pick up writing (seriously!). I am actually a PCCM fellow, yet I read every word in your article (which I don't even do with the New York Times articles).
Thank you for the great advice, which I think applies to all of us looking for a job.

Mihaela
Reply
# Asst. Director, EDJohn Hipskind 2009-05-22 01:06
Between listening to Risk Management Monthly, drinking your wine of the month picks and reading outstanding articles like this, it is no small wonder that I still love my work in the ED after 14 plus years.

Thanks again,

John
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