1. Career
Planning
Seminar
David Obert, DO FACEP, FAAEM
Assistant Medical Director
Assistant Clinical Professor of Emergency Medicine
UNSOM Emergency Medicine Residency Program
University Medical Center
Las Vegas, Nevada

2. Today’s Goals
Develop an Organized Approach to the Job Search
Review Some Common Pitfalls in EM Positions
Look at Basics of the Business of Emergency Medicine

3. Why Do This Talk?
Success is Planned
Failure Just Happens

4. The CV is done……….Now Identify
Priorities
Have you discussed what is important with your
family/significant other?
Are your priorities the same?

5. Important Factors
Location
-put the dot on the map
The number one priority of most
graduating physicians

6. Important Factors
Money?
The second most important factor…..
How are you paid?
You must compare apples to apples
Hourly plus benefits = Total
Compensation

7. Important Factors
Employee vs Independent
Contractor relationship?
Have you thought about the differences and which you
prefer

8. Independent Contractor
a. Minimal control issues
b. Paid gross hourly wage
(you pay your own taxes, FICA,
benefits)
c. Freedom to work without restrictions
d. Identity questions-
-Who do you work for/Loyalty?
e. Ownership/Equity unlikely

9. Employee Status
a. Rules/Policies to adhere to
b. Employer controlled
c. Net hourly pay
-Taxes deducted
d. Can have restrictions on outside
work
e. Stronger identity to group/hospital
(employer)
f. Stability and benefits

10. Important Factors
Work Environment?
 Time off
 Shift length
 Shorter shifts mean longer career
 Healthier lifestyle for you
 Shorter shifts reduce your risk of suits
 Shorter shifts improve patient satisfaction

11. Work Environment
Importance
How happy is the staff?
How good are the supporting departments?
How friendly/supportive is the medical staff?
How Happy are the Patients?
Low patient satisfactions may reflect underlying
problems

12. Work Pace?
How many patients per hour
are you expected to see?
2.3-2.5 reasonable in average environment
What is the admission rate?
Reflects acuity therefore work/stress load

13. What interruptions must you suffer?
 Codes out of the ED?
 Emergency deliveries?
 Writing admission orders?
How do you document your work?
 This is a speed vs risk management issue

14. Important Factors Summary
You must decide what is important to you
Discuss the factors and get family input
List them in order
Must have
Want to have
You may not find the utopia where a job
meets all your criteria

15. The Phases Of Finding A Job
Identify potential opportunities
Email/phone call screening
 Acquire general information
Narrow the search to 3 to 5 places

16. How Do You Identify Potentials?
Print Ads
Mailings
Conferences
Internet
Colleague referrals

17. What Should You Expect From
The Potential Employer?
Travel for you and significant other covered
for one visit
Reasonable expenses covered
Time to meet
Director
Partners
Hospital leaders
Community tour

18. Employer Trends Are
Location Dependent
In high demand areas or vacation spots, trip
expenses may not be covered
Unless you sign

19. What Do They Expect From You?
Show up as scheduled
Be open and honest
Express your desires/expectations
Don’t lead them on
Schedule adequate time to evaluate the practice
See the community
See the hospital
Make an objective evaluation

20. After The Visit
Phone call or email
In, out, on hold
Thank you card always a nice touch

21. Now…………to the 7 Stories

22. 1. Malpractice
You are recruited to a nice group in a nice city, but find
the job just isn’t what you expected. Like 63% of new
grads, you decide to look for another job about 21
months into your career.
You find you do not have “tail coverage” and it will cost
you $43,000 to leave…

23. Or
You go to a group where malpractice and tail are
covered, but when malpractice premiums go up, the
group asks you to sign a new contract whereby you
assume the responsibility for your tail.

24. Malpractice: Claims Made vs.
Occurrence Insurance
Occurrence: you are covered when the event occurred regardless
of when the claim is made
Claims made: you are covered if you are working and paying
premiums when the claim is made
 Tail coverage required to cover you after you leave a job
Make sure coverage is guaranteed by your employer

25. You Must Know about Tail Coverage
This is an absolute “must have” …
Must be clearly addressed …who pays?
 If you leave voluntarily
 If group fails, gets bought or loses their contract
 If you get terminated for any reason

26. Tail Coverage…
Why The Big Deal?
Normally 2 ½ times annual premium
Could be over $20,000 in your first year
Must be paid up front, sometimes in three to six installments
Can you afford
$3,000-$9,000 per month
for 6 months?

27. Is Tail Coverage Required?
Medical Liability Insurance is
required
Some groups make you agree to buy
tail coverage

28. Bottom Line
I would not take any position where
this issue is not clearly
addressed !!
Assume if it is not mentioned in
your contract you don’t have it!

29. 2. Wealth Building/Retirement
You get a job offer which provides health and retirement
funding.
1) You find out after moving that you must work a full
calendar year, and be there the last day of the year,
before you enter the retirement program, or
2) You find out you must be there 5 years to be fully
“vested” if you leave

30. Retirement Program Issues
Delayed entry
When do you get funded?
Vesting
What does this mean???
Can You Maximize Contributions?

31. The Cost of Not Funding Retirement
Failure to Fund Fully is a Huge Loss
in the Future
$30,000 invested now could be >$480,000 when you need it
at age 65

32. Why do you need to start early?
Rule of 72
 Divide your average rate of return into 72
 That equals doubling the time of your investment
6% return takes 12 years to double
8% return takes 9 years to double
12% return takes 6 years to double

33. Financial Return Examples at 8%
average
$29,000 invested at age 30 could be $464,000 at age 66
If you add an additional $15,000 401k contribution:
$44,000 invested at age 30 could be $704,000 at age 66

34. What is Vesting?
Retirement is funded, but you get a reduced % if you leave
 In many programs you must stay 5 years to be vested
 Remember … 63% of us change jobs in the first 2 years
If you join an organization with a vesting schedule retirement
program, you need to stay for the duration!

35. Questions to Ask about Retirement
When do I get funded?
How much gets funded?
Who directs the investments?
Is the Money mine if I leave?

36. How do you Build Wealth?
Avoid big “buy ins”
Avoid big “buy outs” (tails)
Fund your retirement fully
Get a piece of the pie
Be a distance runner
 Be in this business for the long term

37. 3. Open Books
You are made a very nice offer to join a physician owned,
“democratic” group.
You work there several years, and when you ask about
partnership, you find out one or two guys own the contract.

38. 1)You then find out he gets paid substantially more by the
hospital than he is paying you and your colleagues.
or
2)You find the owner has “retired” but still manages a
very nice living “managing” the group. His son-in-law is
one of your colleagues, and he seems to be making a
pretty good living.

39. What are Open Books?
Each physician should be able to determine:
- Where the money came from
- Where the money went
- Billing costs
- Management fees
- Salaries
- Expenses

40. Why are Open Books Important?
It’s YOUR Business!
It’s YOUR Money!
Open Books keep everyone honest
- Are all partners equal?
- Is everyone compensated the same?
- What are you paying your business manager?
- Are you getting the best deal on benefits and services?

41. What is a Democratic Group?
Is it one doctor one vote?
What gets voted upon?
How are votes conducted?
What is the Ownership Structure?

42. Questions to ask about Ownership
- Who are the owners of the group?
- What % does each own?
- How is partnership offer determined?
- Has anyone not been offered partnership, and if so, why
not?
- What does ownership cost, and what does it get me in
return?
- Are the books open and when?

43. 4. Equity
You are recruited to a group with the promise of $120/hr
for clinical time, and a reasonable buy-in to partnership
at 2 years for “about $40,000.”
You actually get paid about $100/hr, and the buy-in will be
$120,000.
For that $120,000, you get to share bonuses … but you are
not told how much they are.

44. or
You keep getting promised partnership “next year,” and when
it is offered the buy-in is $250,000 … after you have been
there 5 years … and you find out there are tiers of ownership.

45. What is Equal Equity?
Equity is ownership and has some value
In most groups, that value is realized
- through periodic bonuses
- as a buy out when you leave
In most groups, the Equity is the value of the
Accounts Receivables

46. Example of AR Calculation
Average Collection per patient = $100
Average volume is 2500 patients/month
Average billing company has 3 months collections
pending (ARs)
8 members of group

47. AR Calculation
$100 x 2500 = $250,000/month
$250,000 x 3 = $750,000 good ARs
Less 12% for billing = $660,000
net good ARs
$660,000/8 = $82,500 each

48. Reasonable Questions Related to
Equity
What is value of ownership per share?
How is that distributed when I leave/retire?
How has value trended?
What is cost of buy-in?
What is that money used for?
What is the Return on Investment for the buy-in?

49. 5. Contracts and Non-Competes
You join a group, and after becoming a partial shareholder
they get bought by one of the publicly traded mega
groups.
To get your share of the buy out, you must sign a
restrictive covenant which prohibits you from working in
any county in the US where the new group or one of
their affiliated companies has a contract, unless you
work for them.

50. OR
You join a single hospital group. They lose the contract,
and the new group offers you a position. The former
group enforces a restrictive covenant which prohibits
you from staying and joining the new group. You must
relocate and start over in another city.

51. Three Important Clauses
Restrictive Covenants
Non-Competes
Non-Interference

52. Contracts
Restrictive Covenant
Physician agrees not to directly or indirectly
engage in, solicit or perform work in Emergency
Department of hospital or other ED, except
pursuant to the terms of the existing contract
agreement. The restrictive covenant may
survive the term of the agreement for one or
more years.

53. Restrictive Covenants
May restrict you from a geographic area
 Wherever the group has a business anywhere in the country
 That is the catch of affiliated company
You either work for them, or you don’t work in that area
May cause you to relocate

54. Contracts
Non-Compete Clauses
Physician agrees not to engage in obtaining
the contract or rendering services in
competition to existing contract. Must state
time limitations and geographic boundaries.

55. Non-Competes Example
You agree not to compete against your group or hospital
for a defined time in a specified business
Competing urgicare center

56. Contracts
Non-Interference
Will not persuade Hospital or other party
to terminate group contract, or conspire
to take over ED contract individually or
with others.

57. Non-Interference
You can’t undermine the group’s
contract

58. 6. Fairness in Compensation
You get hired as a hospital employee. You subsequently
find out they hire whoever they can get, pay everyone
based upon a straight salary, and in fact pay the fast
track doc the same as you.
There is no incentive for working fast, and you quickly
discover you are carrying the load when it comes to
“moving the meat.”

59. Incentive Compensation
Have you ever followed the guy who is slow and is always
backed up?
How about the guy who makes everyone mad?
Is it better to follow the guy who is fast?
Should everyone earn the same amount?

60. Incentive Compensation
Varies group to group, but …
Compensates based upon some performance criteria:
Patients per hour
RVUs per hour
Percentage of charges generated

61. Questions about Pay for
Performance
What are the rules of the game?
 What metrics used?
When are you in a pay for performance relationship?

62. 7. Fairness and Equity in Benefits
You and 4 other docs join a group at the same time. You
become friends, and find out each of you has a different deal
… different benefits, different pay, different moving
expenses.
All five of you leave within a year.

63. This Summarizes Everything
Above!
In an Equal Equity Open Book Group this wouldn’t happen
- Equal pay
- Equal time off
- Equal benefits
If everyone is trained alike, they get the same package
- Any differences in compensation should be performance
based

64. In Summary
- Do your homework
- Compare apples and apples
- Never say never
- Don’t burn any bridges
- Be a distance runner

65. Resources: Job Bank Web Sites
www.aaem.com, “Job Bank”
www.acep.org, “EM Career Central”
www.emra.org, “Job Search”
www.edphysician.com
www.emedhome.com
www.practicelink.com
www.napr.org, (Nat’l Assoc. of Physician Recruiters)