Life After Residency What they havent told you

Life After Residency: What they haven’t told you… N. Adam Brown, MD FACEP FAAEM Emergency Department Chairman and Medical Director United Medical Center Washington, DC Regional Recruitment Champion Em. Care, Inc – North Division

Overview • Introspection • Job Opportunities • Expected Compensation • Benefits • Contracts and Negotiations • Time-Line • Review of Business Definitions • Actually Medicine

Introspection • Know yourself • Know your priorities • Know your market place • Know your options

Introspection: Know Thy Self Personality / Temperament • Adventure Seeker? • Fearless • Like it frenetic • Inconsistent backup doesn’t bother you • You like performing a thoracotomy without immediate back-up

Introspection: Know Thy Self Personality / Temperament • Even-paced and steady • Do you? • Like to check email, read an article or the news • Like to supervise more • Get stressed when there are 5 -6 patients waiting for you to see

Introspection: Know Your Priorities This versus That • • Cash Location Lifestyle Practice Type (Priorities change over time. )

Job Opportunities: Multiple Variations on the Theme • Academic: University Hospital/Tertiary Care • Community Hospital: Academic Affiliated • Community Hospital : Private Democratic Group • Community Hospital: Private Group: Non-Democratic (Small Corp Owned) • Community Hospital : Private Corporation Group • Locums • Independent Contractor

Job Opportunities Academic Hospitals: The Ivory Towers Examples: Jefferson, University of Chicago • Salaried: Insulation but lower than standards* • Great Benefits • Teaching and Academic Research • Up-To-Date/Evidence-Based Medicine • Tertiary Care Hospitals • Subspecialty Back-up • Departmental Strength • Continued Learning Across the Spectrum

Job Opportunities Community Hospitals: Academic Affiliates Examples: • Salaried: Insulation (often higher than The Tower) • Benefits: similar to the Tower’s Benefits • Academics (but less expectation to teach and research) • Affiliations for transfer • Less Departmental Sub-specialization and may have less subspecialty back-up

Job Opportunities The Democratic Groups What does it mean? • Partners • Profit Sharing • Shared Decision • Shared Risk: Volume, Economics, Staff, Equipment • Non-Salaried • Bonus structures Benefits Plans : Variable Business Model: (You own the business. ) Pressure for Generating Income Potential for Highest Income: >$350, 000 May require partnerships with buy-ins

Job Opportunities Community Hospital: Small Corporation Examples: Maryland Emergency Physicians • Hourly Rates, Non-Salaried but Guaranteed Hours • Income Potential for Area • 150/hr (in Maryland) • Benefits Package • Community Hospitals or Multi-Site Groups • Possible Profit Sharing • Bonus structuring • Your job is tied to the business. • Open Books v. Non-open books

Job Opportunities Community Hospitals: Large Corporations Examples: Em. Care, EMA, Team Health, Comp. Health, Kaiser Permanente* • Non-Salaried, Guaranteed Hours, Hourly Compensation • Insulated Salary • Bonuses: Often tied to RVUs • Benefits: Usually Variable/Low • *Some Corps give Stipends to pay for Benefits • Flexible Lifestyle • Multiple Practice Models within a Corporation

Other Job Opportunities: Independent Contactor/Locums Examples: Em. Care, Other Staffing Agencies • Varied Salary: Determined by where and how much you work. • Salaries can be $150 -220/hr (Location and Volume Dependent) • Tax Benefits • Benefits: Limited and Self-Purchase • Lifestyle: Highly flexible • Travel: Can be extensive and can be paid for… • Multiple Practice Opportunities or One Hospital

Other Factors in your decision: Know Your Marketplace • Discover which EDs are in your area of interest • Research the group that manages them • Research job opportunities and pay scales • Supply and Demand Applies Here!

SWITCHING GEARS: THE ER

Emergency Department • Patient/The Customers • Percent of Admissions • Payor Mix • Number of Patients Seen - Total • Number of Patients Seen - by ED MDs • Trauma

Emergency Department • Physical Plant • Telemetry • Major Case Rooms • Pediatric Equipment • Security • Signage • Lounge/Breakrooms • Bathrooms • Food Options

Emergency Department • Physical Plant • Number of Beds • Waiting Room Size • General Appearance • Chart Flow • Patient Flow • Lab / X-ray Proximity

Emergency Department • Ancillary • Lab • X-ray • Special Procedures • Ultrasound • CT • IVP • Angiography • Proximity • Results Reporting

Emergency Department • System • Type of charting • Fast Track • Holding Area • Patient Admissions • Patient wait times and turn around • Chart Availability • Patient Tracking

Emergency Department • Administrative • Department Status • Seat on the Medical Executive Committee • Medical Director • Reporting Relationships • Emergency Medicine Committee • Transfer Policies

Emergency Department • Staffing • Physician Hours • Nurse staffing • LPNs, RNs (CEN, ACLS) • Mid-level Practitioners • NPs, PAs • Back Up Systems • Triage - 24 hours/day

Emergency Department • Equipment • Input into Budget • Input into Equipment Selection • Intubation Equipment/Ultrasound • Discharge Instructions • EMR • Electronic radiographs

Administration • Board/hospital administration • (elected, appointed, power) • CEO (background, interest) • To Whom does ED report? • Expectations • Temporary privileges • Physician removal • EMTLA history

Medical Staff • Credentials Committee • Temporary privileges • Emergency Medicine Committee • Purpose / Composition / Control • Writing Orders • Transfer / Admission Issues

Hospital • Bed Size • ICU/monitored Beds • Structure (public, not-for -profit, for profit) • Financial Situation

Job Opportunities Salaries: The Bottom Line • Academic Salaries • Democratic Group Salaries • Partner • Junior Partner • Associate • Corporate Salaries • Locum Salaries • Regional differences • Volume changes • Benefit differences • Flexibility

The Bottom Line What are the average salaries nationwide?

The Bottom Line: What are the regional differences in salaries?

The Bottom Line: What are the salary trends nationally?

The Bottom Line: What are the practice setting salary differences?

The Bottom Line: What are the hours per week you will work?

Job Opportunities Comparing Apples to Apples: “The Hourly Rate” • Base rate • Bonus Sign-On (usually one-time) • Bonus potential • Hours for full-time • Benefits

Job Opportunities: The Benefits • Vacation (paid? ) • Malpractice • Disability: Short and Long • Travel Expenses • 401 K • Profit Sharing • Health Insurance: $500/mos

Mind Numbing Financial Definitions • 401 K • Volunteer Pre-Tax contributions up to $16500 yearly to the stock market • Why? • Investment • Pre-tax, taxed when you retirement when you are in a lower tax bracket (maybe) • 401 K Match • Money your employee deposits to your 401 k, matching dollar for dollar your contribution • SEP IRA: Self-Employed Retirement Account • Independent Contract Physicians • Maximum Contribution for 2012: $49, 000

More definitions… • • Profit Sharing • Retirement account contribution • Above the “match” • Portion of the company’s profits Vested/Vesting Schedule • The matched money that becomes yours after a period of time with a company • (i. e. Your employer matched your $16500 contribution making it $33, 500 in your retirement account. If you are vested, you get to retain that money in your account. ) • Vesting Schedule: The percent of available matched money that you can keep. • 1 year of employment: 25% Vested • 2 years of employment: 50% Vested, etc.

More definitions… • IRA: Individual Retirement Account • Roth IRA: you make too much (don’t worry about it) • Traditional IRA: After-Tax dollars contributed to the stock market, that is tax free at maturation. • Roll-Over IRA: Money from a 401 k at one company, “rolled” over, into an IRA since you can only have one 401 k at one time. • Tax deferred

Even more definitions… • Short-Term Disability • Kicks in after 30 days of disability • Often a low monthly payout • Usually pretty cheap to buy • Long-Term Disability: • Kicks in after 90 days of disability • Usually expensive: $450. 00/mos for approx $200, 000 in coverage • Higher monthly payouts

And a few more definitions… • Own-Occupation Long-Term Disability • Specific long-term disability for your profession (i. e. EM specific) • The most expensive • The most coverage: • i. e. - You break/ mangle your hand = You can’t intubate = Owner occupation insurance. • Whereas with simply LTD, if you break your hand, you may be able to find another job and your disability pay is reduced. • Monthly payouts are close to what you make if you were working.

And lastly… • Malpractice Insurance • Malpractice Tail • Are you covered for a malpractice case on a patient that you saw when you were working for a company that is filed against you after you leave a company. • Often covered in your benefits, but you must ask!!

43 EM Malpractice: Where Are We? • Emergency Physicians have high risk, but not highest risk • Slightly above all physicians Jena, AB et al. NEJM, 2011.

MY Principle of the 2’s 2 complex pt’s / hour = $200 of compensation

$200/hour…But… • But the devil is in the details…What’s included in that number… • Malpractice: $35/hr • Health Insurance/Dental Insurance: $6000/yr • 401 k Match (free retirement money) $16500/yr • Disability Insurance $5000/yr • Vacation: 2 weeks = 70 hrs work • Hospital Dues • State Licenses/DEA Licenses/CDS Licenses • CME • Company profits

Other cost examples… • All DEA Licenses: $551. 00/license • 1 DEA #/state • State License: $350 to >$1000. 00 (FL) • Most are around $500 -700 • CDS (controlled dangerous substances) • Required in some states • $30 to $350 • Collateral Documentation for Licensure • $200 - $500 • (license verifications, education verifications, medical examiners score verifications) • Board Costs • Oral Boards/Written Board/Course/Travel: $5000. 00

Take home message… • This isn’t like matching for residency. • Many opportunities in many locations • Wide range of income opportunities • Find the right opportunity for you and your family/spouse/partner • Consider Salary • Consider Location • Benefits • Advancement potentials • LIFESTYLE!!!

Now it is time for the contract!

Contract Details… • Salary • Sign-On Bonus return • Means for Salary Increases/Advancement • Non-Compete Clauses • Benefits Package • Partnership tracks (offered, buy-in, etc. ) • Fluff: Legal Stuff • Termination

Time Line • Job Search (1 -2 months, maybe longer) • License 2 -3 months (up to 9 mos!!) • Ohio: 9 months • Illinois: 3 months • Indiana: 2 months • Texas: 7 months * • CDS License 3 weeks (Controlled Dangerous Substance License) • DEA License 3 weeks • Hospital Credentialing (2 weeks to 2 months)

A few bits of advice • Have a lawyer review your contract. • Visit more than 1 or 2 hospitals. • Negotiate, negotiate • Salary (even in academic centers…shhh!) • Sign-on bonus (even in academic centers…shhh!) • Extra education pay • Increased hourly rate • Vacation time • Incentive Pay • Discuss advancement • You are in the driver’s seat. This isn’t residency anymore. • Your skill is lucrative. Expect compensation for such.

A Few More Pearls… • Make a list of your options. • Remember that no job is perfect. • Choose the best job for you and your family. • Don’t be lulled in by a dollar figure. • You will find a job!!

• You will find a job! • Do not settle! • You have a lucrative skill. • Questions: • adambrownmd@gmail. com • 215 -620 -9116