Moving to the next phase, your career after fellowship, involves big decisions and sometimes an overwhelming number of questions. Here are some tips on organizing your thoughts around them.
In general, there are 3 choices for your long-term career: academic practice, employment, or private practice. The attributes for each practice choice are not mutually exclusive and are what you make of them. There will be trade-offs. For example, you should find intellectual stimulation in all types of practice, not just academic practice. And although private practice is supported by revenue resources alone, academicians require a ramp-up to independent funding, and in the employment setting, time is money. Autonomy can be an area of potential tension, because there will be a natural offset in larger practice settings where there is less autonomy and more automation. No matter what choice you make, the essential considerations for pursuing this next phase are quality of life, geographic location, finances, and practice setting. Thinking through your personal and professional needs, presenting yourself well, and obtaining the right information will help you make the right decision that will reflect positively 30 years later (Video 1, available online at www.VideoGIE.org).
No amount of gestalt or guesswork can replace thinking through the questions you need to consider as you contemplate your future career. An inventory of your personal and professional needs before you start looking for a job is the task at hand. Examples of considerations for your personal life should include the must-haves that are essential to your quality of life. What do you hope to do with your spare time? If global travel is important, how close is the nearest large airport? What will you not live without? For example, is it important to you to have a symphony, a theater company, or rock climbing nearby or just within driving distance? How do you spend your discretionary income? What are the professional opportunities for your partner? How does having children or planning a family affect other needs, such as quality of schools?
The other part of your inventory should consider your professional needs. Some gastroenterologists want exposure to all aspects of practice, including the satisfaction of caring for a patient with a chronic disease while still being active in the acute, inpatient setting. Others may wish to avoid one or the other. Some want to be focused on certain procedures and may even bring a desirable and lacking skill set to a group. By contrast, you may want to have subspecialty support for some procedures, such as EUS or ERCP, or for certain chronic conditions such as inflammatory bowel or liver disease.
Evaluate the important aspects of autonomy and group governance. It may be important to be involved in the spectrum of decision making required to run a healthy practice, or you may want to defer much of this decision making to others. Consider the aspects of managed care and how comfortable you are with care driven by clinical care paths and protocols. Now is a good time to understand how you interact with others in terms of a need or a reluctance to delegate.
An approach to a potential opportunity is shown in Figures 1 and 2. Your initial contact (Fig. 1) with a potential employer or group should focus on their needs and culture. For example, a phone conversation can be used to make introductions, describe your experience and qualifications, and inquire about what kinds of skills are being sought, how an additional physician will be used by the group, and the overall care philosophy and strategic plan of the group. Develop more specific questions about work flow, scheduling, patient problems, support staff, and ancillaries for later in the conversation.
Hopefully a second interview, in person, will be scheduled at practices that are desirable to you and your partner. You are selling your character and experience, but this visit will be the time to understand income structure (including starting and potential income), path to partnership, range of income for other partners, distribution of income from all sites of service and ancillaries, details about practice overhead distribution, payer mix, collection rates, financial position with affiliated hospitals, and so on. Some information may need to be generated and provided in follow-up. Your homework should include discussions with other physicians, administrators, and clinical support staff to learn about their impressions and group reputation first-hand (Fig. 2).
Request proforma and contract templates that you can review in detail with an experienced health care administrator, accountant, and attorney. The proforma should minimally include a section on expected revenue (based on a realistic ramp-up in patient visits and procedures, with an estimate for income based on such factors as actual payer mix and current contracts and collections) along with expenses (eg, attributed rent, appropriate staffing, information technology, liability). Understand any and all assumptions in the proforma and how any bonus is calculated and paid. Key issues to be covered by the contract should, at minimum, include the compensation model and formula, expected coverage for liability, and descriptors of termination definitions and cause, should this come to pass.
The group will be learning about your qualifications and professionalism, your aspirations and leadership qualities, and even intangibles that might not be reflected on a resume, such as civic mindedness. As you visit the site and follow up on details, you will need to exercise due diligence about the structure, the proforma, and the contract; also look for subtle clues that may be helpful signals to the group’s culture. Observe interactions with clinical staff and administrators. Meet facility staff and engage their experience.
My husband and I based our final decision about my practice on 3 factors that were most important to us. Family was first because we wanted our children have connectedness, and we wanted to be a resource for aging parents. The culture of the group, which we found to be tested and tried, was key, as was the trusted clinical acumen and work ethic of my partners. Although no practice setting could ever be perfect, as we reflect on this decision years later, these factors have remained the highest priorities for us personally and professionally as we keep the inevitable challenges in perspective.
The author disclosed no financial relationships relevant to this publication.
Published online: August 20, 2019
© 2019 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.
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