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Dear Director,
I was just asked to take over as medical director of another ED in our hospital’s system. While I want to be a chairman one day, my kids are young and the timing just doesn’t seem good right now. Am I shooting myself in the foot for other jobs down the line if I say no now?

If location is the key to real estate, timing if likely the key when it comes to promotions and job offers. I interviewed for my first chair job when my daughter was 1 month old. I also withdrew from the search because I thought my life was challenging enough at the time. However, I started my first chair job when my second child was 6 weeks old. So what was the difference? I realized that smoothly aligning the right job with my personal life might never happen – that if I waited for “perfect timing” I’d be waiting forever.

The company’s perspective
Recruiting for a chair job differs from the routine recruitment process for attending staff that may take place over 6, 9, or even 12 months. Even if I have a doctor leave months before I have someone new starting, our staff can typically make up the loss of one doc for a while. But there would be considerable chaos if an ED went without a medical director for the same length of time. Whether a chair position opens because the hospital CEO wants a new one, the management company thinks change will improve performance, or a new ED organization comes into the company or hospital system and an “in-house leader” is needed, medical director positions are usually recruited for and filled with a sense of urgency.

Companies usually keep a short list of people who are next on the depth chart, but what I’ve seen lately is that the depth chart is more like the shallow end of a pool. Companies find themselves in need of enthusiastic players who are excited for the opportunity - not people who fret and mull over every pro and con of a job offer.

Your perspective
Promotions that come knocking may differ from the opportunities that you may seek out, particularly if you are early in your administrative career. The offer may be for a smaller-volume ED with less coverage than you’re used to, or with a different patient mix. The commute may be worse. While there are clearly variables that you can’t control, as one of my mentors told me, “It’s the chair’s job to make it a great work environment” - so if there is something you don’t like, odds are you can work to improve it.

When being recruited for a job, you need to start by being honest with yourself and understanding your career arc—where you want your career to go and at what pace it should travel to get there. While I don’t think I ever would have moved around the country to become a medical director, I’ve met many emergency docs who have as they worked their way up to busier and higher-profile EDs and administrative responsibilities that kept pace with their self-imposed time line.

A new job, particularly a new administrative job, is typically a lot of work. My experience, personally and from watching colleagues, is that the learning curve and hourly commitment is pretty steep for at least 6 months - usually 12. After that, the work tends to settle down, and you may even have more control over your schedule and personal time than you did before the administrative position.

But it’s likely that your personal life will always be busy, whether your kids are little and require time and attention at home, or your kids are older and require time and attention for homework and getting shuttled to and from activities. The job environment, the hospital conditions and support services, the commute, and your personal situation are all fair considerations and need to be balanced against your individual desire to advance within your company and the potential opportunity for other promotions if you turn this one down. Since the life expectancy of an ED chairman is 5-7 years, no promotion should be thought of as a life sentence - and it’s possible that you can discuss and even negotiate a downstream exit strategy if you’re helping out your company today.

Consequences of saying no
While the upside to saying yes and taking the promotion could be endless, there are typically consequences of saying “no.” For starters, you’re putting the people who are offering you the job in a worse spot - and they will likely remember this interaction. Depending on their situation and personality, they may hold a grudge that could rear its ugly head in a variety of ways. A potential consequence if you do say no and you’re committed to a hospital network or a group is that turning down an administrative job today might mean that the next job offer won’t be as good or could be years away.

The good news is the bench for talented potential physician administrators isn’t very deep, so that if you’re really talented and interested in the next position, it’s unlikely that you’ll be passed over just because the timing wasn’t right this time. Of course, if too much time goes by, those younger docs will be more experienced and could be ready to move up the ladder; someone too junior to be considered last time could be ripe for the job now.

If you’re saying no
Let’s face it, there are lots of reasons why you might turn down a promotion and a reasonable boss will understand. I had a friend diagnosed with cancer and about to start chemo — not a good time to take the promotion he was offered! My friend Jen had a spouse in Iraq and was working full-time while taking care of her two small kids. Her goal was keeping her mind and family together while worrying about her husband getting killed in a war. Again, an unusual circumstance that a reasonable company should understand.

Before you say no, be sure to talk to a trusted advisor to review the rationale behind your decision. What will you say when you turn down the job, and what would it take to get you to take the job? If you’re considering turning down the job but then say yes, you must be sure that your heart and mind are fully committed to the job – otherwise you are likely to fail.

A few pointers during your deliberations:

1. It’s fine to ask for 1-2 days to consider the offer and discuss it with family. However, have a concrete deadline and respond by that time with a definitive answer.

2. If you are going to say “no,” consider if there is anything you could change about the offer/situation to make it a “yes.”  If these are within the bounds of reason (don’t ask for double the pay unless you want to get laughed at) then consider negotiating and making these requests and then living in peace if those essentials were unable to be met. Negotiation may lead to extra money, reduced clinical hours, or a delayed starting date. Think it out thoroughly, ask for it, but then if you get what you want, you need to accept the job.

3. Finally, don’t burn bridges. This can happen if you accept a job, then develop “buyers remorse” and change your mind. Think hard and do your research before saying yes, because reneging later will hurt your career.

Conclusion
Timing is rarely perfect when it comes to considering unsolicited job promotions. Companies, including hospital networks, are usually facing time constraints to find new leaders and may not have many options. I’ve learned from my own experiences, as well as watching colleagues, friends and my wife change jobs, and believe the timing of a job change rarely ideally aligns with our personal lives. Sure, a new job environment can sometimes be a dramatic change from what we’re used to, but ultimately it’s the administrative opportunity that matters - and that may be the most important factor in determining our career path.


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

 

 

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