Choosing a Practice Setting
Finding a Match Between Your Personal Priorities and a Practice Setting Requires Honest Introspection and Doing Your Homework
Brian W. Cook, MD, FACEP; Associate Director, Emergency and Urgent Care Services; St. Joseph Mercy Hospital; Medical Director, Emergency and Occupational Health Services, Saline Community Hospital; Faculty, University of Michigan St. Joseph Mercy Emergency Medicine Residency Program; EMRA President, 1989-90
Developing Personal Priorities
Before you begin your search for a practice setting, take the time to be introspective. Define what motivates you. Employ your definition to set priorities for your choice of practice setting.
Residents are notoriously overworked and reluctant to take time out to plan their future. I can't stress enough though how critical this planning is to your long-term happiness and satisfaction! The time you spend will be repaid many fold. Travel, interviewing, decision making and relocating are all time consuming. Most time consuming is the aggravation and stress of making a bad choice and having to start the entire process again. Following the general steps of preparation outlined in the last insert by Dr. Lindsay will start you on the road to success. Then you need to set your priorities.
Decide first if geography is a prominent concern. If you are set on living in a particular area, limit your search there. Don't waste your time or anyone else's interviewing in a locale where you don't want to live. If you are not set on one specific area, define the ideal qualities of a community in which you would like to live. This will give you a measure when you narrow down your choices.
Next, consider where compensation stands in your priorities. If the highest available compensation is your priority, plan to pass on many otherwise attractive possibilities. Compensation is market-driven. Thus desirable positions, those that offer academic opportunities or life-style advantages, will attract quality individuals without offering the highest compensation.
Find out how physicians whose training is similar to yours and who are practicing in similar locations are compensated. Start by discussing this with the attendings in your program. If you are serious about negotiating the best possible contract, call any emergency physician that you can make a connection with who is practicing in a setting similar to the ones you are seriously considering. You can usually negotiate compensation in a comparable range if you take the time to investigate.
Balancing time for personal pursuits (relationships, hobbies and other fun stuff) with your career is always difficult. Be realistic about the extra time required to advance your career. If recreational activities are a higher priority than career advancement, don't interview for positions that require 2,000 clinical hours per year. In any situation, it is important to define your clinical commitment.
Ask whose responsibility it is to cover shifts when the group is short-handed. If you negotiate inflated compensation for additional clinical time, the group won't call you in for additional shifts unless it is absolutely necessary. On the other hand, if extra income is your goal, additional hours won't be a problem. If you want to advance your career along administrative or academic avenues, plan ahead. You will advance only if you make it a priority and dedicate time to developing the appropriate skills.
Obviously, if some sort of indirect patient care (e.g. research, teaching or administration) is a priority, you must select a setting that offers opportunities in these areas. Explore the institution's or group's track record for advancing careers. Call the physicians that they claim to have helped and ask about specifics regarding support and access to resources.
Finding the Right Practice Setting
There is no "best," "right," or "wrong" practice setting. The settings are almost as varied as the individuals who practice in them. The pursuit of happiness requires finding a match between you and the practice setting.
A university setting provides special opportunities for academic advancement. Universities are geared toward research and provide role models for academic success. The university setting should encourage you to challenge the status quo. Teaching opportunities should abound. A key to approaching the university setting is to establish the expectations for advancement. Also, be sure to ask what resources (e.g. protected time or lab space) is available to help you advance.
A community hospital setting brings you as a practitioner into more direct contact with patients. An emergency physician will usually work more clinical hours in the community setting. But, there are fewer nonclinical demands on your time. In this setting you can focus on providing quality, un-scheduled care to those in need.
Before committing to a practice setting, be sure that you understand what the scope of your practice will be in that setting. The availability of consultants varies greatly among institutions. Some emergency physicians love to be on the "front line" and handle all initial case management, sometimes as the only physician in a hospital for part of the day. Others enjoy the security and intellectual stimulation of readily available consultants. The important point is to understand the situation ahead of time and to judge where it falls in relationship to your own comfort zone and experience in providing care.
Health care is currently in a rapid state of change. Larger hospital and care delivery systems are forming in many areas. As you investigate different settings, consider the stability of the hospital or system that you choose. Assess the potential for changes in the hospital's status and scope of care. Even if you can't predict or control the changes that might occur, you shouldn't be caught totally unaware by them.
You should also assess the status of emergency medicine as a specialty within the institution you are considering. Look at the departmental status and at the level of involvement of emergency physicians within the medical staff structure. Do emergency physicians have full active status? Do emergency physicians chair committees? Are they officers in the medical staff hierarchy? What is the general tone of interactions between emergency physicians and consultants? The answers to these questions will have a significant impact on the quality of your clinical life.
You need to compare high, medium, and low volume settings as they match your personal abilities and preferred methods of practicing. The higher volume setting provides more excitement and variety of cases. The low volume setting provides more time for patients and for educating them and their families. If you are considering a setting with a markedly different volume than you have experienced, take the time to observe one or more entire shifts in that setting before committing yourself to that environment.
A related issue is the contrast between inner city, suburban and rural settings. In addition to volume differences, the overall environments and expectations vary greatly. Once again, the most important thing is to become familiar with any environment before you commit and to consider the personal implications of the environment carefully. If you are not comfortable and happy in the setting, your patients and coworkers will not be happy with you either.
Wellness issues should be measured. Do your prospective coworkers value health and balance between personal and professional life? How is staff scheduled? What input do you get into the schedule, holidays, and vacations? Take the time to talk to full-time emergency physicians in your prospective setting to get a feel for their life style and level of satisfaction. There is no substitute for this direct exploration of a setting to make sure that you find a match.
Assessing the Emergency Physician Group
Emergency physician group structure is currently an area of intense interest and debate. I personally believe that there are pros and cons to any structure, and that this is yet another area where you should seek a personal match. You would be wise to read information published by the various emergency medicine organizations in order to gain some understanding of the issues. Information is key to making a good choice. You will inevitably make some decisions, actively or passively, regarding group affiliation since emergency medicine is by nature a group specialty.
Emergency physician groups come in a wide range of sizes. At one extreme is the single hospital group. This structure is quite simple, allowing for a close relationship among all the members and for direct input into most of the decisions that are made for the group. At the other extreme are large, multi-hospital groups. They are less intimate, but they may provide for a wide variety of clinical and administrative opportunities. They also may provide some economies of scale and increased leverage in dealing with insurance or managed care companies. This choice is somewhat analogous to those between small towns and large towns, or between a small college and a large university. Make some conscious judgement as to which you will find most comfortable.
Also at issue is the question of partnership. Some groups are owned by a minority of the physicians involved in the practice. Others allow for more open entry into partnership. There are almost as many different arrangements as there are groups. Do not assume that all small groups are open and that all large groups are closed in regards to partnership. Instead explore the details of the relationships within each group you consider. Also, be quite wary of basing your decisions on promises of future rewards or partnership. Try to find an arrangement that you are happy with from the beginning. If you have a need for control and strong input, consider that as you weigh your options. Don't enter a group with no history of adding partners if that is going to make you unhappy. Likewise, don't join a group that expects all members to play an active role in decisions and to divide administrative duties if you plan to work 40 hours per week then disappear. Pay close attention to Dr. Suter's comments on the topic of partnership in the next insert in this series which deals with contracts.
Another issue that will be covered in the contracts insert is that of employee versus independent contractor. Dr. Suter outlines some important financial comparisons that must be made. Also, you will have to make some additional efforts to fund your own benefits and to manage your money (i.e. save for taxes and retirement) as an independent contractor. On the other hand, there are some potential tax and retirement advantages to being an independent contractor.
In addition, I suggest that you decide how critical you feel it is to have a consistent income month by month. Salary is the most secure flow of income. Next would be an hourly rate. Less certain is fee-for-service. This last bases your income on productivity. Often a minimum guarantee is made to infuse some security into the fee-for-service arrangement. This last is my preferred method. I have always been more satisfied when I know that I make more when I am working harder. This is especially relevant if you are very productive as a clinician. Also this method takes some of the sting out of the busier days in the department. Pay close attention to all of the details of reimbursement. Surprises in this area are likely to make you unhappy.
If you get serious about a particular practice, take the time to inquire about the reimbursement details from one or more of the full-time clinicians in the practice.
Good luck in your pursuit of the best possible practice setting. Remember to consider all of your options carefully. There is no substitute for time and attention to this important decision. You are only committed to a practice for as long as your contract stipulates. Yet it gets easier to practice the longer you stay in the same department, and if you decide to move, it should be for positive reasons, not to escape a bad setting. Also remember that there are no perfect practices or departments. Temper your expectations with reality. If you work at this though, the pros will outweigh the cons and you can be a generally happy and productive emergency physician.
Published in EM Resident, October 1996.