Basics of looking for a job in Allergy and Immunology

1. Tao T. Le, MD, MHS
Associate Clinical Professor
Department of Medicine
University of Louisville
Partner, Central Allergy & Asthma
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2. Disclosures
 None
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3. Most Important Advice
Be honest with yourself!!!
Don’t try to impress your program director or other
fellows
Do what you want to do

4. Choose Your Own Adventure
Career options
Finding a job and interviewing
Contract negotiations
AAAAI FIT exit survey

5. slideshare.net/taolemd

6. Why did you go into AI?
Patients
Continuity, treating families
Interesting diseases
Allergies and asthma
Immunodeficiencies
Science
TLRs and interleukins, oh my
Love working with mice
All of the above

7. What Do You Want to Do?
Just see patients
Work as part of a team
Be the boss
Control all aspects of practice
Win a Nobel prize
Be president of AAAAI or ACAAI

8. Options After Fellowship
First decide your primary job activity
Clinical
Taking care of patients
Research
Clinical, epidemiological, or bench/translational
Education
Other
Administrative/leadership
Regulatory
Entrepreneurship

9. Clinical Options
Private practice
Individual/solo
Small group
Large group
Multidisciplinary
Hospital employee
Academic

10. Research Options
Academic
Research institute
Health department
Epidemiology
Industry
Clinical practice
Clinical research

11. Other Options
Healthcare organizations
FDA
Insurance companies
Other institutions
Secondary schools
Board review organizations
Most won’t start here

12. Research Options
Academic
Large range of research options
High level of prestige
Excellent environment for research
 Collaboration
Relatively lower pay
You are not your boss
Must pay for yourself - grants

13. Research Options
Research Institute
Excellent research environment
Focus must fit institute
If institute changes focus, uh oh
Less opportunity for other options
 Clinical
 Teaching

14. Research Options
Health Department
Epidemiology
Public Health
Government job security
Lower pay

15. Research Options
Industry
You are not your boss
Must have clinical applications
Pay usually good
Research results drive career
Do not have to get grants

16. Research Options
Clinical practice
Primarily drug studies
Small investigator initiated studies possible
No large multicenter trials (NIH)
Income tied to patient recruitment

17. Single Specialty Options
Private practice
Individual
 Be your own boss
 Need to develop patient base
Small group
 Shared control – cooperation
 Built in patient base
Large group
 Follow the rules
 Must be comfortable with group

18. Multispecialty Groups
Ambulatory +/- hospitals
Large – heavy PCP expansion
Salary + incentive compensation (vs fee for service)
RVU productivity model
Some equity opportunity – shareholder vs. partnership

19. Multispecialty Groups
Pros
Stability/predictability
Built in referrals
More mature business model with metrics
Less administrative hassle
Management opportunities
Cons
Overhead
Inequality in productivity models/compensation plans
Bureaucracy/politics

20. Clinical Options
Academic
You are not the boss
Productivity may not be rewarded
Billing/collections provided
Teaching opportunities
Administrative opportunities
More prestige

21. slideshare.net/taolemd

22. Job Hunting
Most important thing is to be honest and true to
yourself!
Make a list of the things that are most important for
you and your family
Make a list of the things that are most important
about a potential practice
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23. Important Factors When
Choosing a Job
Geographic location 65%
Practice Setting 49%
Spouse/family reasons 49%
Professional growth opportunity 46%
Call schedule 44%
Compensation 43%
Benefits 39%
Prestige of employer 24%
MGMA

24. Job Hunting
Start looking late summer or early autumn of the last
year of fellowship
Resources
Major specialty journals (JACI and Annals) have job listings
AAAAI and ACAAI have job placement centers on their
websites
ACAAI has job fair at its annual meeting
Local allergy societies in the target region
Word of mouth from physicians—especially from mentors
Medical headhunter services
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25. Job Hunting
• Send letters of inquiry to ALL practices in a
desired location
• Many practices contemplate hiring before
advertising
• Research the practice and personalize the letter if
possible
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26. Have a Successful CV
Be conservative and professional
Use a conservative font and avoid overuse of bold, italics, and
underlined text
Be concise and only include relevant information
Information should be complete, accurate, and current
Print on a laser printer, high quality paper, or consider professional
printing, print on one side only
The first page is considered the most important
 Don’t try to fit everything on one page
 A 2 to 4-page CV is considered average for a young professional

27. Know the CommunitySize of community
Proximity of family and friends
Employment opportunities for spouse
General economic and social structure
Quality of schools

28. Know the Community
Housing costs
Recreational opportunities
Area and patient demographics
Population
Economic background and stability
Demand for specialty

29. Preparing for the Interview
Collect and analyze preliminary information
Bring a list of prepared questions
Dress for success
Be early
Do not plan any other events for the same day

30. Gathering Information
Number of physicians (small versus large group)
Setting – urban, suburban, or rural
Office locations – single office versus several satellite
offices

31. Gathering Information
Type of practice (academic versus private practice;
single specialty versus multi-specialty)
Patient population characteristics
Commonly encountered conditions
How would a new allergist fit in?

32. Gathering Information
Reason for hiring
Typical workload
Number of patients seen daily
Work hours
On-call days
Seasonality
Hospital consult responsibilities
Location
Frequency
Cross-coverage of other service, if in a multispecialty group

33. Gathering Information
Insurance payor mix
Local practice ecosystem
Other allergists and subspecialists – collegial vs.
competitive
Non-allergy competition
Primary care physicians/NPs and referral patterns
Turnover of physicians and staff

34. Gathering Information
Support staff ratio
Will you have your own nurse or medical assistant
Who’s in charge/who makes the decisions
Leadership and governance
Office manager/administrator

35. Gathering Information
Structure of the group
Independent contractors
Partnerships/PC/PA
Employer/Employee
Is future partnership an option?
How is this determined?
What is the timeframe?

36. Gathering Information
Starting salary
Benefits package
Fair market value of practice/buy-in/partnership
Access to financial books/records
Shadow the physicians in clinic
Speak with staff

37. During the Interview
Listen more than you talk
Promote strengths and any areas of expertise
Act professionally and never feel “too at home”
Do not speak negatively of other practices

38. After the Interview
Make notes of a practice after you interview
Follow up with a thank you letter
Samples in the Practice Management Resource Guide

39. Digging Deeper
Speak with other physicians in the community
What is the reputation of the group?
Speaking with any physician who has left the
practice
Sit in the office waiting room, speak with patients
Call the office to schedule an appointment and
speak with staff

40. Offers
1-3 may be expected
Verbal vs. written
Is NOT an employment agreement

41. Get a Good Attorney
With experience in medical employment contracts
Referrals form the local societies, hospitals or state
societies.
National Society of Certified Healthcare Business
Consultants
http://www.nschbc.org/

42. Resources
 AAAAI Practice Management Resources Website.
http://aaaai.org/members/resources/practice_management/
 Le, T., ed. AAAAI Practice Management Resource Guide, www.aaaai.org.
 NAIA-FIT Mentor-Mentee Program
 NAIA Academic Career Development Webinars.
http://aaaai.org/members/only/assemblies/webinars/
 Best Friend’s Guide to Finding a Practice. CHG Healthcare Services and ASPR, 2006.
http://www.comphealth.com/pdf/physician/perm/aspr_best_friends_guide.pdf
 NEJM Career Center. http://www.nejmjobs.org/career-resources

44. What a Good Contract Does
Clearly spells out specific terms and conditions for
employment including:
Employment status and scope of work
Compensation/benefits
Employer’s responsibilities
Restrictive covenants
Term and termination provisions
Balances the interests of both physician and employer
REMEMBER: GET IT IN WRITING!!!

45. What It Can’t Do
Define the culture, leadership, values of a practice
Ensure that you chose the optimal practice opportunity
for your circumstances
Guarantees a successful employment experience

46. Employment Status
Who are you?
Employee
Contractor
Shareholder
Status can determine:
Type of compensation/benefits
Tax burden
Liability in the event of a malpractice event

47. Your Responsibilities
Typical clinical duties
Typical schedule
Typical clinic locations
Hospital consults
Call duties
Non-clinical duties
Administrative responsibilities
Community activities

48. Employer’s Responsibilities
Office space, computer
Nursing and support staff
Supplies
Transcription services
Billing services
Car allowance/insurance, cell phone
Licensure, credentialing, board certification

49. Cash Compensation
Guaranteed base salary +/- annual pay increases
Productivity bonus
Signing bonus
Relocation expenses
Negotiating hint:
Do reality check on achievability of productivity bonuses

50. Benefits
Family health insurance
Dental insurance
Disability insurance
Life insurance

51. Benefits
Pension/401k
Vacation and sick pay/PTO
Family leave
CME allowance

52. Malpractice/Tail Coverage
Liability insurance
Ex.: $1MM/incident, $3MM aggregate
Occurrence – cover lawsuit at anytime if policy in force at
time of incident
Claims-made – covers lawsuit if policy in force at time of
filing
Tail coverage – supplements claims-made policy
Coverage for claims made after policy terminated
Trend in shifting cost to employee

53. Malpractice/Tail Coverage
Negotiating hint:
Ask for employer to pay for tail if termination without
cause or if you fulfill a threshold term of the contract

54. Other Employment/Activities
Types of activities
Moonlighting
Speaking
Research/publishing
Significant volunteer activities
Is it permitted?

55. Other Employment/Activities
Who owns the income?
Negotiating hints:
Carve out anticipated activities
Speaking may be a win-win
Check if your malpractice covers moonlighting

56. Equity
Expectation of achieving partner or shareholder status
Specified in a separate agreement
Usually after a fixed period of time and/or with
qualifying performance
There may be a junior vs. full partner level
There may be a buy-in vs. sweat equity model
Practice may offer financing
There may be a pay-out when you retire

57. Buy-In Factors
Nature of the employment agreement – does
employer profit from your labor?
Practice valuation
Tangible assets
Intangible assets or “good will”
Liabilities
Discounted cash analysis
Value increases with practice revenue
Discounted by expected rate of return

58. Partnership Hints
Get specifics regarding time to partnership, buy-in
requirements, pay-out calculations, etc.
Ask about previous physicians who made or did not
make partner
Ultimately requires mutual trust and open
communications

59. Termination
Termination for cause
Reasons: loss of license or malpractice insurance, death,
felony conviction, “material breach”
Usually immediate
Termination without cause
Employee usually has reciprocal right
Notice periods range 60-90 days
Negotiating hints:
If “material breach,” ask for a period for “cure”
Ask for longer notice period if you think you need it

60. Non-Compete Agreement
Prevents departing physician from competing with
employer
Specifies restricted region (i.e., 5-50 mile radius)
In force for 1-2 years
Enforceability varies from state-to-state
Negotiating hints:
↓ duration, especially for early termination
Limit restricted region to office where you were based
Limit applicability to overlapping services
Substitute with non-solicitation agreement

61. Non-Solicitation Agreement
Physician forbidden from recruiting patients or staff
away from employer
May practice in the same area
Sometime used in place of non-competition agreement
Negotiation hints:
Clarify that public communications like newspaper ads
does not violate agreement

62. Medical Records
Usually belong to employer
Physician may need access to defend against a
malpractice action, credentials committee investigation
or medical board inquiry
Negotiation hint:
Ask for reasonable access should you leave the practice

63. Dispute Resolution
Can mostly be settled between employee and physician
Otherwise, disputes settled in courts
Each party typically covers own fees
Negotiation hints:
Ask that any unresolved dispute be submitted to
confidential mediation and binding arbitration
Ask that loser pays winner’s legal costs

64. Small vs. Large Practice
Small practices may offer more:
Flexibility in contract terms
Willingness to negotiate
Large practices may offer more:
Standardized agreements
Wider range of benefits

65. Final Thoughts
Use an experienced attorney
Request a letter of intent ahead of the contract
Don’t hesitate to negotiate
Beware of one-size-fits-all contracts
Make sure guaranteed pay is enough
Consider total comp package
Never accept a verbal promise. Get it in writing!!!

66. Resources
A Physician’s Guide to Employment Contracts
http://www.mmaonline.net/Portals/mma/Publicati
ons/Reports/Physicians_Guide_to_Employment_Ag
reements.pdf
A Primer on Employment Contracts
http://www.aafp.org/fpm/20021100/73apri.html
Demystifying Common Terms in Employment
Agreements
http://www.aafp.org/fpm/20030600/38demy.html

67. Resources
Lifting Restrictive Covenants
http://www.aafp.org/fpm/20010400/50limi.html
Anatomy of a Physician Employment Contract
http://www.nejmjobs.org/career-
resources/physician-job-contract.aspx
Avoiding Physician Employment Contract Pitfalls
http://www.nejmjobs.org/career-
resources/physician-job-contract-2.aspx
National Society of Certified Healthcare Business
Consultants
http://www.nschbc.org/

69. AAAAI FIT Exit Survey
Web-based survey designed and implemented by
the AAAAI Workforce Committee with input from
the AAAAI Practice Management Committee to:
Document the career choices of graduating FITs and
their rationales
Elucidate the employment market for graduating FITs
Identify trends in the current economic climate
Sent to all FITs graduating June 2012 and June 2013

70. Results
147 responses (78 in 2013, 69 in 2012)
Demographics 2012/2013, n=147
Female (%) 61%
Age, mean (SD) 34.0 (4.0)
Race
White 42%
Asian/Pacific Islander 38%
South Asian 15%
Middle Easterner 5%
Black 0%
IMG (%) 28%

71. Primary Activity
Activity %
Patient Care/Clinical
Practice (Non-Academic)
54
Patient Care/Clinical
Practice (Academic)
30
Research – Academic 7
Other 3
Undecided 3

72. Primary Work Setting
Work Setting 2012 % 2013 %
Solo Practice 1 3
Small Group Allergy Practice 25 24
Large Group Allergy Practice 12 15
Multispecialty Group
Practice/Clinic
12 12
Hospital/Ambulatory Care
Center
3 3
Managed Care/HMO -- 3
Academic Medical Center 35 32
Military/U.S. Government 4 1
Undecided 6 5

73. Base Compensation
Base Salary Academic Practice
< $80,000 18% 8%
$80,000-99,999 8 5
$100,000-119,999 18 5
$120,000-139,999 24 10
$140,000-159,999 14 30
$160,000-179,999 8 15
$180,000-199,999 6 8
$200,000-219,999 2 11
$220,000+ 4 8
Pearson chi-square (df=8) = 21, P = 0.007

74. Incentive Compensation
Bonus Income Academic Practice
None 63% 49%
<$10,000 17 21
$10,000-$19,999 4 21
$20,000-29,999 2 6
$30,000-39,999 8 0
$40,000-49,999 4 4
$50,000+ 2 0
Pearson chi-square (df=6) = 15.3, P = 0.018

75. Signing Bonus
Signing Bonus Academic Practice
None 90% 71%
<$10,000 8 15
$10,000-$19,999 2 8
$20,000-29,999 0 1
$30,000-39,999 0 3
$40,000-49,999 0 3
Pearson chi-square (df=5) = 7.8, P = 0.167

76. Benefits
Work Setting Practice Academic
Medical Insurance for Self 62% 84%
Medical Insurance for
Spouse/Dependents
53 68
Dental Insurance 58 84
Disability Insurance 43 70
Malpractice Insurance 78 96
Paid Vacation 77 96
Retirement Plan 44 70
CME/Professional Meetings 66 73
Car Allowance 6 0

77. Ownership/Partnership?
Clinical Practice %
Yes 36
No 50
Not Sure 13
Starting My Own Practice 1

78. Timing of Equity Ownership
Clinical Practice %
At starting (eg, buying in to the practice) 4
At or before first anniversary 6
At or before second anniversary 22
At or before third anniversary 34
After third anniversary 13
Not sure 21

79. Personal Debt Load
Academic Practice
<$100,000 64 43
$100,000-199,000 19 34
$200,000+ 17 24
Pearson chi-square (df=2) = 6.2, P = 0.046

80. Compensation Satisfaction
Compensation
Satisfaction
Academic Practice
Very Satisfied 23% 36%
Somewhat Satisfied 46 50
Somewhat Dissatisfied 23 6
Very Dissatisfied 8 8
Pearson chi-square (df=3) = 7.7, P = 0.039

81. Long Term Prospects
Will you be there
>3 years?
Academic Practice
Yes 53% 73%
No 11 14
Undecided 36 13
Pearson chi-square (df=2) = 9.7, P = 0.008

82. Ease of Job Hunt
Did you have a difficult time
finding a satisfactory
position?
Academic Practice
Yes 45% 49%
No 51 50
Haven’t looked yet 4 1
Pearson chi-square (df=2) = 0.99, P = 0.611

83. Career Satisfaction
Would you recommend the specialty of Allergy and
Immunology to medical students or other
physicians in training?
%
Yes, with enthusiasm 82
Yes, but lukewarm 18
No, but not strongly 1
No, emphatically --