Life After Residency: What they haven’t told you…

1. 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 EmCare, Inc – North Division

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

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

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

5. Introspection: Know Thy SelfPersonality / 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

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

7. 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

8. Job OpportunitiesAcademic 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

9. Job OpportunitiesCommunity 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

10. Job OpportunitiesThe 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

11. Job OpportunitiesCommunity 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

12. Job OpportunitiesCommunity Hospitals: Large Corporations Examples: EmCare, EMA, Team Health, CompHealth, 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

13. Other Job Opportunities:Independent Contactor/Locums Examples: EmCare, 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

14. 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!

15. Switching Gears: The ER

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

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

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

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

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

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

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

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

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

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

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

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

28. The Bottom LineWhat are the average salaries nationwide?

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

30. The Bottom Line: What are the salary trends nationally?

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

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

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

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

37. 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 401k, matching dollar for dollar your contribution • SEP IRA: Self-Employed Retirement Account • Independent Contract Physicians • Maximum Contribution for 2012: $49,000

38. 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.

39. 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 401k at one company, “rolled” over, into an IRA since you can only have one 401k at one time. • Tax deferred

40. 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

41. 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.

42. 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.

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

45. $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

46. 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

47. 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!!!

48. Now it is time for the contract!

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

50. 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)