Next stop — — The real world

By Julian Willoughby, MD, MPH

After 10 years of post-college education and training, I have finally completed all the requirements and gained the experience I need to start my career as an attending physician. We, as physicians-in-training, often refer to this as entering the “real world.” I am looking back and would like to share just a few of my thoughts and experiences with all of you who are racing to this same point.

I am now just 2 months from starting my career as an attending physician, and life has never been crazier. By the end of the summer I will have completed a competitive sports and spine fellowship, moved halfway across the country, purchased my first home, witnessed the birth of my first child, and started my first “real world” job.

I remember sitting down with my fellowship director at the beginning of the academic year last summer when he outlined the year to come, and stated that I should start looking for a job in September. I was somewhat shocked, thinking: “ok, I need to study for written boards coming up in August, then start looking for a job in September, all while trying to actually train for said job somewhere in-between.” How was I supposed to know what job to look for when I hadn’t even gotten a grasp on my sub-specialty?

My philosophy regarding my career-path has always been: ‘Don’t look too far forward for risk of stumbling on what’s right under your feet.’ While this statement could also be re-branded as the “procrastinator’s motto” — it worked well for me up to a point. That point came last fall at the AAPM&R career fair. I had gone to the career fair the year before for practice, and came away with lots of interviews and calls and opportunities. However, now it was real. Whether I was more nervous or much more selective, the fair did not seem nearly the success as my practice run the year before. Although I was not panicking yet, I was getting worried about my options
and the time left to explore them.

Fast forward to the spring, and although I did not have anything nailed down, I did have a few options I was closely considering. None of these came from a job fair or a wanted ad. This brings me to point #1 — you will most likely find your job through someone you already know. Networking at conferences and fairs is important, but you will find that your most meaningful and exciting opportunities will come from those individuals and organizations that have already seen what you’re made of and what you can do. Certainly make sure you start going to as many relevant conferences as possible and meet people, but more importantly, in everything you do, do
it well. Show up and be interested. Get a mentor. Reach out to prominent figures in your field. If possible, set up an elective month with them, or anyone that does what excites you. Get involved with organizations on the local and national level. You will find that each opportunity you take gives you a platform to excel and creates more opportunities. For me, these came
through a few simple places: a rotation where I made a particularly good impression, an elective I set up where the attending became a mentor and a personal friend, or an organization where I volunteered and went above and beyond. Doing similar things throughout your residency will be far more valuable than frequently searching the job boards.

While great career opportunities are likely to present themselves — sometimes it can be really difficult to sort out what actually is great opportunity, what is not, and in what ways can you shape it to your goals. This, of course is the matter of contract negotiation. I will not discuss the
job interview process, as most of us are quite proficient at this point in our careers after college, med school, and residency interviews. However, one area most of us have never had to experience is the negotiation of a contract. We are so used to just accepting what is offered that we have never had the chance to shape our own workday. This brings me to point #2 — get a lawyer. Regardless of how simple you think your contract is, or how good a deal you think you are getting, it will be worth it to get a lawyer for simple contract review. They will typically cost between $500-$1,500 and be worth every penny. I recommend getting a lawyer located in the geographic area of where you will be working, as laws will vary state-to- state and you want someone who is experienced in working with physicians and healthcare institutions in that area. While each of these topics could be an article unto themselves, some things you should review with the lawyer include: signing bonuses, restrictive covenants, period of guaranteed pay, and tail insurance.

In regards to signing bonuses — your lawyer, if they have worked with that employer before, will often know if they are willing to provide a signing bonus, and what may be a reasonable range. Even if they don’t, do not be afraid to ask for one. While certainly a potential employer can revoke an offer at any time, typically the worst reaction you would get to a request for a signing bonus would be “no.” There really is no risk to asking, and potentially lots to lose. A friend of mine told me their lawyer helped them secure a very significant signing bonus that he would never have thought to even ask for. This will be useful for you as you are likely relocating and starting a new chapter in your life. Speaking of relocating — relocation allowances are separate of the signing bonus and can also be negotiated. Typically they should easily cover your expenses for a full service relocation, but you could also use this as bargaining in a signing bonus, especially if you do not have to relocate or have minimal expenses. Bottom-line, discuss with your lawyer and ask for a reasonable signing bonus.

Restrictive covenants (or “non-compete” clauses) are very commonplace and often unavoidable. A restrictive covenant is essentially a clause in a contract that defines a restriction in an employee’s post-employment activities should that employee separate from the organization. Typically, for physicians, this is a geographic limit to where you can practice medicine in relation to your employer after you leave the company. Although we can only imagine why this would not be beneficial for us,it is understandable that the organization would want to protect itself. You can imagine how difficult it might be for a hospital system that invested in your early career, helped you build a solid patient base, then you leave and take 80% of your patients with
you to a clinic you open right across the street. Since you used the organization’s resources, facilities, and advertising while building your practice, it would be unfair to leave and take a subset of patients you built with you. Whether or not a restrictive covenant is “enforceable” varies state-to- state and court-to- court. Typically states that do enforce these covenants only do so if the covenant is reasonable in scope, duration, and geographic area. The covenant also cannot unduly burden the general public or the individual physician.1 The important thing to remember is to review the covenant with your lawyer and if there are parts that seem too burdensome or concerning, you can often modify it. Courts often also make a distinction between soliciting former patients and treating former patients — so just remember to not worry if you find yourself separated from your employer, They cannot take away your right to use your hard-earned skills to make a living for you and your family. Just realize you may have to start over in terms of building a patient-base.

In regards to period of guaranteed pay — remember that this is important as often you will be starting from “zero” and needing to build your own patient base for your practice. If you are working in a place that is primarily productivity-based pay, you would really struggle without a cushion-period where your pay is guaranteed. Typically, the time frame for a guaranteed salary is 2 years. From my discussions with other young attendings, this time will fly, and it may still be difficult to get quite to where you need to be production-wise. So be sure that you work towards getting this important income safe-guard as you are getting started.

Briefly, in regards to tail insurance, make sure your institution provides it. This is basically malpractice insurance that will cover you for a certain time after you leave the practice, for any lawsuit or issue that occurred during your time there. This is crucial, as any future employer will not want to cover a lawsuit that occurred at a prior institution, and it could be financially disasterous to face a lawsuit on your own without insurance.

Most importantly of all regarding employment negotiations: GET IT IN WRITING. Do not trust any promises, statements, assurances, or other discussions with anyone in the company or practice unless it is written out in your contract. I personally ran into issues myself where details were discussed verbally and even in emails, but in the last moments, things were changed or altered. If your potential future employer is unwilling to put something you discussed and agreed upon in writing, this should give you pause. So, when comparing opportunities, you should only compare what is put before you in black and white. Assume everything else is subject to change.

Although I feel lucky that my procrastination did not degrade my job opportunities, and my lack of knowledge in negotiations did not prevent me from making some beneficial adjustments, there are certainly some things I wish I had known and done differently. The time to enter the real world is right around the corner for all of us, and hopefully these thoughts will help you enter it with just a little more confidence!

Julian Willoughby, MD, MPH, recently completed his Sports Medicine fellowship at the Shirley Ryan AbilityLab and Northwestern University. He also serves as the ACGME PM&R Representative for the Resident and Fellow Council of the AAP.

Breitenbach. (July 2013). “What physicians need to know about restrictive covenants.” Medical Economics. Retrieved July 20, 2017 from



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