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A Guide to Finding the Perfect Job as a Surgeon

Important Tips

  1. Hire a contract lawyer (should have experience in medical negotiation/contract in the state where you will be working), contracts are the springboard for the development of the relationship – important to understand what issues are critical to your success vs aspirational
    1. They will have a sense of what is normal and what is abnormal
    2. You can not overcome poorly designed practices through contract negotiations, the practice either sets new hires up for success with good systems in place or they do not.
  2. You must ask about the possibility of private equity acquisition – have they discussed it, are they pursuing it, how will it impact your hiring and decision-making about any potential salary reduction, roll-over equity, future decision-making.
  3. Meet or speak to everybody who will be at your location or working closely with you. (Some groups may try to hide red flag partners during the interview process).
  4. Try to answer as many of these questions ahead of time through your network and what’s available online.
  5. When you are in the contract phase, you must get the answer to your questions in writing (this is vital), otherwise you have no course of action when the promises do not happen

Intro Questions

  1. What is the need? Why are you hiring? What is the role I will be filling?
  2. What is the vision for the group? Plans for expansion?
  3. What are the goals/direction of the department and division?
  4. Describe the culture of the group. What type of person would thrive here? Any issues retaining staff?
  5. Ask everybody you interview with what they are expecting you to do/what role you are filling.

Clinic and OR

  1. What will my week look like? What is typical breakdown for OR vs. clinic?
  2. Outpatient
    1. How many office sites will I go to?
    2. How is this determined? (Some hospitals will promise one OR location, but force you later on to work out at a satellite hospital to get your OR time, you need to location in writing)
    3. Is the culture to schedule outpatient visits and OR on the same day?
    4. Know the neighborhoods of the clinics you work in (affluent neighborhoods = likely better payor mix)
    5. Are multiple other partners trying to build the same practice you want in the same location?)
    6. Know the types of cases that the partners like to do. Is there a gap you can fill?
    7. What is the lead time for patients to get in to see current docs? (Is there enough volume to sustain another surgeon?)
  3. OR
    1. Will I have block time? And when will it be? (need specifics, if they do not have an obvious plan and written promise, then this is a red flag)
    2. Can I get block time once I establish my practice? How many OR days a week can you develop? (Only on Friday evenings or weekends?)
    3. Is the culture to schedule outpatient visits and OR on the same day?
    4. How are residents/first assists assigned to the OR (if residents are in the hospital)?
    5. Can I run 2 rooms?
    6. Equipment
      1. Check the inventory of the currently used instruments in the OR
      2. Can I bring in additional instruments if they are not currently available?
      3. What regulatory process do the MDs go through to bring in new equipment into the OR
      4. What are the financial ramifications of me using a Depuy hip if the hospital has a contract with Stryker?
    7. Mentoring Opportunities
      1. Do senior partners scrub with the associates in the beginning?
      2. Do partners double scrub on more complex cases?
      3. What is the culture of the partners with respect to mentoring?
      4. Who is available and willing to mentor young surgeons? (‘How often do attendings scrub together for a difficult case?’)
  4. New Patient Referrals
    1. What is the protocol for new patients that call the department?
    2. Is there a rotating schedule or do new patients preferentially go to the junior partner? (You need to know if senior partners are just cherry picking the best paying insurances)
    3. If there’s not a provider in the group that is able to treat a certain condition, what providers or group do you usually refer to?
  5. Trauma Call
    1. How often would I take trauma call?
    2. What does call entail? Level? Coverage area? Typical cases? etc
    3. What is the protocol for “big trauma” that comes in?
    4. Does it get passed off to the trauma faculty or is this frowned upon?
    5. If you are uncomfortable with hand or pediatric trauma you should also ask how this is handled for the practice.
    6. How much trauma call will I be expected to take?
    7. Do all partners participate in trauma call?
    8. Is there an “age-out” policy for trauma call?
    9. Ask who is on call with you in terms of a PA or physician extender. Ask whether that person will see consults and if they are available to operate with you for on-call cases.
  6. My Office
    1. What is the overall hierarchy of the office?
      1. Departmental Administrator – role, responsibility
      2. Office Manager – does my secretary report to the office manager? Who handles disciplinary issues with my secretary?
      3. Are there centralized departments within the group
        1. Appointment scheduling?
        2. Surgery scheduling?
        3. Medical Records
          1. EMR – what type?
          2. Dictate notes?
          3. Electronic radiographs? (important because many private practices do not have them) AND can you access EMR and radiographs from all satellite office sites (in case patients get seen at different locations)
      4. Transcription “in house” or out-sourced; turnaround time for dictated notes
        1. Operative reports – dictated? Templates?
        2. MRI/testing pre-authorization? Who performs these tasks?
    2. Do I get to hire my own secretary?
    3. How are secretaries paid for in the group?
    4. Are there “physician-extenders” (Nurse practitioners, physician assistants, etc…)?
      1. When can I hire a PA/NP? What is this based on? How is this paid for? What happens to his/her collections?
      2. How are the physician extenders paid for? Do their salaries come directly out of my income or is there a “group” sharing of costs?
      3. What happens to their collections? Is there a “tax”?
    5. How is malpractice covered?
      1. Tail coverage provided?
    6. How is overhead determined? Know estimates of direct and indirect costs. (Some totals are as high as $600,000 worth of costs each surgeon is responsible for).
    7. If you are interested in research, inquire about the available infrastructure and other surgeons’ involvement in the past.
  7. Hospital staff support?
    1. Do you get physician assistant coverage in the OR or for admitted patients if there is no resident coverage or in addition to resident coverage, is it a personal PA or hospital PA? Do they see ER consults for initial eval? Do I have to pay or support the cost of that support?
  8. Future
    1. What will my niche be?
    2. Where do you see the group going in the next 5 years? What is the vision for the group? Plans for expansion?
    3. Why are you hiring? What is the need? What is the role I will be filling?

Practice Systems and Governance

  1. Culture
    1. Describe the culture of the group?
    2. What type of person would thrive here?
    3. Recent departures? If so, why? Can I speak to him/her?
    4. Any issues retaining staff?
  2. Reputation of the practice
    1. How does the community view the practice? Favorable reputation? Get along with other practices? Friendly competition?
    2. Know all future partners and practice manager
    3. Never assume that someone left a group amicably just because the practice told you that (speak to the person that left). If they try to hide it, this is a red flag.
  3. Leadership of the group/practice
    1. Who manages the office/group? Physician or non-physician?
    2. How are decisions made? Democratic vote or dictatorship?

Finance Related

  1. Salary
    1. How is compensation structured during guaranteed period and after?
    2. After you cover your costs how much do you keep?
    3. After you cover your salary what do you keep?
    4. Know the dollar per RVU amount ($65-75 per RVU is average for spine as of 2024 for example)
    5. Senior vs Junior Partner’s salaries; peak potential income for your subspeciality?
    6. Ask the difference between what is billed (could be in the millions), vs what is actually collected (could be less than half of what is billed).
    7. Know caseload of seniors vs juniors, get RVU estimates if hospital practice. (10,000 – 12,000 average for spine, 40,000 is top percentile)
    8. Ask to see surgical caseloads for recent hires and partners in your subspecialty
    9. How much productivity is expected for new hires?
    10. Productivity bonus?
    11. Potential for claw back?
    12. Payer mix (this determines how is actually billed and collected, if all your patients are medicaid then you will not survive in a private practice setting).
  2. Practice expenses and Overhead
    1. How is overhead determined? Know estimates of direct and indirect costs. (Some cost totals are as high as $600,000 worth of costs each surgeon is responsible for).
    2. Indirect costs are those like facilities, leases…etc.
    3. Direct costs are your PA/NP, office staff…etc.
  3. Signing bonus
  4. Relocation allowance
  5. Benefits
    1. Retirement (401K match)
    2. Housing/mortgage assistance?
    3. Medical/Dental
    4. Vacation time
    5. Maternity or paternity if the applicant is planning it in the coming years!
    6. Educational allowance? (to pay for meetings, journals, dues, etc.)
      1. Meetings
        1. How many?
        2. Who determines if I can go?
        3. How is this reimbursed?
    7. Computer
      1. Do I choose?
      2. How often do you upgrade?
  6. Private Equity
    1. Has the group been approached by a PE firm?
    2. Has the group been negotiating with a PE firm?
    3. How will the junior associates be treated if PE buys the group?
    4. How much roll-over equity will I receive if PE is buying the group?
  7. Potential for “Passive Stream of Income”?
    1. Partnership
      1. How long until partnership consideration?
      2. How is partnership decided?
      3. Over the past 10 years, what % of people have NOT been offered partnership?
      4. What is the buy-in? Ask if you can buy into each ancillary separately or if these are bundled together with the practice buy-in.
        1. Office space
        2. MRI
        3. P.T.
        4. ASC (Even hospital groups are allowing ASC ownership)
      5. Productivity to be considered for partnership?
        1. What level of productivity is considered sufficient to be considered for partnership?
        2. How many surgeries/office visits, or how much revenue do you expect me to be bringing in by the time partnership is considered?
        3. Are these reachable goals?
      6. Real estate holdings (many private practices seem to have this and it gets very complex, good to ask because it can significantly increase your buy-in)
  8. Practice finances
    1. Ask to see accounting and books for the past 5 years. (If a good practice that is well run, they will be happy to show you the books, if they balk, beware).
      1. Say, “your mentor told you to ask this question” if it feels awkward.
      2. Ask specifically to see your subspecialty books as well
      3. Pay attention to compensation for both junior and senior level partners to get a sense of the career trajectory.
    2. You have to find what is going on behind the scenes
    3. Know the overhead, indirect and direct costs and how aggressive the management is about keeping costs down (people are too slow to fire and keep practices lean).
      1. Clarify exactly what the overhead is per physician/month…do not rely on a percentage that they may quote you….”our overhead is about 35%”….35% of what.

Negotiation

  1. Interview at multiple places and get multiple contracts to compare and contrast, use contracts against each other (if necessary)
  2. Initial contract offers are often lower, with the expectation that you will likely negotiate for more. It is worth asking to negotiate a sign-on bonus or additional salary.
    • Often, the leadership positions (chair of ortho or division chief…etc.) will have budgets for starting salaries on a bell curve of what they are allowed to offer. You need to know the MGMA data because often their budget tracks this metric for the average salaries for each subspecialty.
    • Everything is negotiable, you just need to ask.

If covering sports teams

  1. High school, college, pro do you prefer/are you comfortable with any/all.
  2. Will you get the referrals of your own players?
  3. Will you be covering non-orthopedic issues or is there a primary care sports doc involved as well?
  4. Is a doc required at all competitions? Are you doing it all or sharing, and if so who and how is the schedule being made?
  5. Are you covering training room?
  6. Are you acting as a “covering” physician for specific games and report to a medical director who oversees the team or are you the medical director/head team physician for the team?
  7. What are the emergency protocols for any given team/location?
    1. You’ll need to know this when you least expect it!

The Contract

  1. Restrictive covenant
    1. Is there a possibility for the restrictive covenant to not kick in until after 12 months of employment?
  2. Recurring themes of contracts:
    1. description of duties and practice location
    2. call coverage
    3. moonlighting
    4. term of agreement
    5. termination of agreement
  3. Don’t wait to put issues on the table right at the beginning. Get all your demands out up front. Whether it is moonlighting, call coverage…etc.

Stay tuned for more updates over time!

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