David Obert, DO FACEP, FAAEM
Assistant Medical Director
Assistant Clinical Professor of Emergency Medicine
UNSOM Emergency Medicine Residency Program
University Medical Center
Las Vegas, Nevada
Develop an Organized Approach to the Job Search
Review Some Common Pitfalls in EM Positions
Look at Basics of the Business of Emergency Medicine
Why Do This Talk?
Success is Planned
Failure Just Happens
The CV is done……….Now Identify
Have you discussed what is important with your
Are your priorities the same?
-put the dot on the map
The number one priority of most
The second most important factor…..
How are you paid?
You must compare apples to apples
Hourly plus benefits = Total
Employee vs Independent
Have you thought about the differences and which you
a. Minimal control issues
b. Paid gross hourly wage
(you pay your own taxes, FICA,
c. Freedom to work without restrictions
d. Identity questions-
-Who do you work for/Loyalty?
e. Ownership/Equity unlikely
a. Rules/Policies to adhere to
b. Employer controlled
c. Net hourly pay
d. Can have restrictions on outside
e. Stronger identity to group/hospital
f. Stability and benefits
Shorter shifts mean longer career
Healthier lifestyle for you
Shorter shifts reduce your risk of suits
Shorter shifts improve patient satisfaction
How happy is the staff?
How good are the supporting departments?
How friendly/supportive is the medical staff?
How Happy are the Patients?
Low patient satisfactions may reflect underlying
How many patients per hour
are you expected to see?
2.3-2.5 reasonable in average environment
What is the admission rate?
Reflects acuity therefore work/stress load
What interruptions must you suffer?
Codes out of the ED?
Writing admission orders?
How do you document your work?
This is a speed vs risk management issue
Important Factors Summary
You must decide what is important to you
Discuss the factors and get family input
List them in order
Want to have
You may not find the utopia where a job
meets all your criteria
The Phases Of Finding A Job
Identify potential opportunities
Email/phone call screening
Acquire general information
Narrow the search to 3 to 5 places
How Do You Identify Potentials?
What Should You Expect From
The Potential Employer?
Travel for you and significant other covered
for one visit
Reasonable expenses covered
Time to meet
Employer Trends Are
In high demand areas or vacation spots, trip
expenses may not be covered
Unless you sign
What Do They Expect From You?
Show up as scheduled
Be open and honest
Express your desires/expectations
Don’t lead them on
Schedule adequate time to evaluate the practice
See the community
See the hospital
Make an objective evaluation
After The Visit
Phone call or email
In, out, on hold
Thank you card always a nice touch
You are recruited to a nice group in a nice city, but find
the job just isn’t what you expected. Like 63% of new
grads, you decide to look for another job about 21
months into your career.
You find you do not have “tail coverage” and it will cost
you $43,000 to leave…
You go to a group where malpractice and tail are
covered, but when malpractice premiums go up, the
group asks you to sign a new contract whereby you
assume the responsibility for your tail.
Malpractice: Claims Made vs.
Occurrence: you are covered when the event occurred regardless
of when the claim is made
Claims made: you are covered if you are working and paying
premiums when the claim is made
Tail coverage required to cover you after you leave a job
Make sure coverage is guaranteed by your employer
You Must Know about Tail Coverage
This is an absolute “must have” …
Must be clearly addressed …who pays?
If you leave voluntarily
If group fails, gets bought or loses their contract
If you get terminated for any reason
Why The Big Deal?
Normally 2 ½ times annual premium
Could be over $20,000 in your first year
Must be paid up front, sometimes in three to six installments
Can you afford
$3,000-$9,000 per month
for 6 months?
Is Tail Coverage Required?
Medical Liability Insurance is
Some groups make you agree to buy
I would not take any position where
this issue is not clearly
Assume if it is not mentioned in
your contract you don’t have it!
2. Wealth Building/Retirement
You get a job offer which provides health and retirement
1) You find out after moving that you must work a full
calendar year, and be there the last day of the year,
before you enter the retirement program, or
2) You find out you must be there 5 years to be fully
“vested” if you leave
Retirement Program Issues
When do you get funded?
What does this mean???
Can You Maximize Contributions?
The Cost of Not Funding Retirement
Failure to Fund Fully is a Huge Loss
in the Future
$30,000 invested now could be >$480,000 when you need it
at age 65
Why do you need to start early?
Rule of 72
Divide your average rate of return into 72
That equals doubling the time of your investment
6% return takes 12 years to double
8% return takes 9 years to double
12% return takes 6 years to double
Financial Return Examples at 8%
$29,000 invested at age 30 could be $464,000 at age 66
If you add an additional $15,000 401k contribution:
$44,000 invested at age 30 could be $704,000 at age 66
What is Vesting?
Retirement is funded, but you get a reduced % if you leave
In many programs you must stay 5 years to be vested
Remember … 63% of us change jobs in the first 2 years
If you join an organization with a vesting schedule retirement
program, you need to stay for the duration!
Questions to Ask about Retirement
When do I get funded?
How much gets funded?
Who directs the investments?
Is the Money mine if I leave?
How do you Build Wealth?
Avoid big “buy ins”
Avoid big “buy outs” (tails)
Fund your retirement fully
Get a piece of the pie
Be a distance runner
Be in this business for the long term
3. Open Books
You are made a very nice offer to join a physician owned,
You work there several years, and when you ask about
partnership, you find out one or two guys own the contract.
1)You then find out he gets paid substantially more by the
hospital than he is paying you and your colleagues.
2)You find the owner has “retired” but still manages a
very nice living “managing” the group. His son-in-law is
one of your colleagues, and he seems to be making a
pretty good living.
What are Open Books?
Each physician should be able to determine:
- Where the money came from
- Where the money went
- Billing costs
- Management fees
Why are Open Books Important?
It’s YOUR Business!
It’s YOUR Money!
Open Books keep everyone honest
- Are all partners equal?
- Is everyone compensated the same?
- What are you paying your business manager?
- Are you getting the best deal on benefits and services?
What is a Democratic Group?
Is it one doctor one vote?
What gets voted upon?
How are votes conducted?
What is the Ownership Structure?
Questions to ask about Ownership
- Who are the owners of the group?
- What % does each own?
- How is partnership offer determined?
- Has anyone not been offered partnership, and if so, why
- What does ownership cost, and what does it get me in
- Are the books open and when?
You are recruited to a group with the promise of $120/hr
for clinical time, and a reasonable buy-in to partnership
at 2 years for “about $40,000.”
You actually get paid about $100/hr, and the buy-in will be
For that $120,000, you get to share bonuses … but you are
not told how much they are.
You keep getting promised partnership “next year,” and when
it is offered the buy-in is $250,000 … after you have been
there 5 years … and you find out there are tiers of ownership.
What is Equal Equity?
Equity is ownership and has some value
In most groups, that value is realized
- through periodic bonuses
- as a buy out when you leave
In most groups, the Equity is the value of the
Example of AR Calculation
Average Collection per patient = $100
Average volume is 2500 patients/month
Average billing company has 3 months collections
8 members of group
$100 x 2500 = $250,000/month
$250,000 x 3 = $750,000 good ARs
Less 12% for billing = $660,000
net good ARs
$660,000/8 = $82,500 each
Reasonable Questions Related to
What is value of ownership per share?
How is that distributed when I leave/retire?
How has value trended?
What is cost of buy-in?
What is that money used for?
What is the Return on Investment for the buy-in?
5. Contracts and Non-Competes
You join a group, and after becoming a partial shareholder
they get bought by one of the publicly traded mega
To get your share of the buy out, you must sign a
restrictive covenant which prohibits you from working in
any county in the US where the new group or one of
their affiliated companies has a contract, unless you
work for them.
You join a single hospital group. They lose the contract,
and the new group offers you a position. The former
group enforces a restrictive covenant which prohibits
you from staying and joining the new group. You must
relocate and start over in another city.
Three Important Clauses
Physician agrees not to directly or indirectly
engage in, solicit or perform work in Emergency
Department of hospital or other ED, except
pursuant to the terms of the existing contract
agreement. The restrictive covenant may
survive the term of the agreement for one or
May restrict you from a geographic area
Wherever the group has a business anywhere in the country
That is the catch of affiliated company
You either work for them, or you don’t work in that area
May cause you to relocate
Physician agrees not to engage in obtaining
the contract or rendering services in
competition to existing contract. Must state
time limitations and geographic boundaries.
You agree not to compete against your group or hospital
for a defined time in a specified business
Competing urgicare center
Will not persuade Hospital or other party
to terminate group contract, or conspire
to take over ED contract individually or
You can’t undermine the group’s
6. Fairness in Compensation
You get hired as a hospital employee. You subsequently
find out they hire whoever they can get, pay everyone
based upon a straight salary, and in fact pay the fast
track doc the same as you.
There is no incentive for working fast, and you quickly
discover you are carrying the load when it comes to
“moving the meat.”
Have you ever followed the guy who is slow and is always
How about the guy who makes everyone mad?
Is it better to follow the guy who is fast?
Should everyone earn the same amount?
Varies group to group, but …
Compensates based upon some performance criteria:
Patients per hour
RVUs per hour
Percentage of charges generated
Questions about Pay for
What are the rules of the game?
What metrics used?
When are you in a pay for performance relationship?
7. Fairness and Equity in Benefits
You and 4 other docs join a group at the same time. You
become friends, and find out each of you has a different deal
… different benefits, different pay, different moving
All five of you leave within a year.
This Summarizes Everything
In an Equal Equity Open Book Group this wouldn’t happen
- Equal pay
- Equal time off
- Equal benefits
If everyone is trained alike, they get the same package
- Any differences in compensation should be performance
- Do your homework
- Compare apples and apples
- Never say never
- Don’t burn any bridges
- Be a distance runner
Resources: Job Bank Web Sites
www.aaem.com, “Job Bank”
www.acep.org, “EM Career Central”
www.emra.org, “Job Search”
www.napr.org, (Nat’l Assoc. of Physician Recruiters)