I was recently part of a panel aimed at helping physician trainees make the transition to becoming full-fledged independent practitioners, and a member of the panel said something that struck an important chord with the audience when he mentioned that new doctors are probably the most developmentally delayed professionals in society. When you think about the fact that for some of us, the first “real” job we have starts as thirty-somethings, the speaker was right on. After all, many of us have yet to develop much of a head start on retirement, and some don’t even understand how to select a suitable health insurance plan let alone out how to negotiate an employment contract.
Even the process of getting one’s first job itself — not unlike applying to medical school, residency, and possibly fellowship — can require a great deal of time, stamina, and travel. To quote the insomniac narrator from the movie Fight Club, you wake up at Sea-Tac, SFO, LAX. You wake up at O’Hare, Dallas-Fort Worth, BWI — Pacific, Mountain, Central, lose an hour, gain an hour. The travel can be both exhausting and disorienting, especially when you must wake up the next morning with a smile on your face (and often wrinkled shirt) and explain why you are a better hire than the other 10 rock star doctors (who probably all showed up with the same neutral suit you take everywhere) looking to make their mark.
Then there is the second interview, appointment with a realtor, meeting with hospital administrators, etc. On top of the stress of trying to figure out what might be the best fit, you may have to worry about your training program tampering with your application in hope of retaining you as faculty. I’m just a simple guy from the Midwest. I had no idea that I was so important as to generate so much attention.
Just when you think you’ve succeeded and that first practice is ready to bring you aboard, you must suddenly flip that smile upside down and dig into the terms of your employment with no training or expertise whatsoever. Physician employment contracts are often tens of pages in length and contain so much unfamiliar verbiage that it can easily boggle the mind of the new doctor, intelligent as he or she is.
You are quickly forced to understand things like malpractice tail coverage, accounts receivable buy-in, incentive-driven supplementary income, the difference between a 401(k)/403(b) and a 457(b), and the anti-capitalistic concept of the non-compete clause. Then there are academic positions which have horribly complicated track options that spell out extensive research and/or publication requirements, most of which have little or nothing to do with healing the ill. I just want to take care of sick people in exchange for fair compensation. Can’t somebody else handle the business side of it all and give me a fair salary? As cynical as it sounds, there are plenty of people (including doctors) ready to take advantage of that sort of naivete.
Atul Gawande wrote about this in 2005, and not a lot has changed for new doctors. He explained that had no idea what the actual charges were for his surgical services let alone how to negotiate for his rightful share of the recovery of these fees in his first years of practice. This is a very common scenario, and if I can be frank, just about all of us learn our lessons the hard way regardless of how many attorneys review our contracts or how many questions we ask. To make matters much worse, a lot of doctors must enter into an agreement to not work for a competing practice within a certain radius for two years if the job doesn’t work out.
Physician salary, not unlike that of many other professionals, is both shrouded in mystery and taboo to discuss. Medical training programs attempt to broach the business of medicine in a very remote way by touching on the concept of a relative value unit (RVU) which is the factor that converts a patient interaction to a payment, but since no residency program is willing go through an actual contract with you, new doctors are always going to be at a disadvantage.
What’s more, the academic physicians often doing the training may have little to no knowledge of how private practice medicine works. Medical schools charged with training primary care physicians are furthermore disincentivized to teach many of these concepts lest students learn that opting for primary care may involve a marked financial sacrifice. It is not uncommon for a specialized surgeon, for instance, to earn ten times that of a pediatrician.
Even within radiology, a private practice doctor in a needy area can easily make triple the income of an academic radiologist in a popular city. Since a lot of the most specialized care takes place in large urban training centers, there is a propensity for the highest quality of care available to be delivered by the lowest paid doctors. In the meanwhile, metropolitan practices have grown larger while using their size, market control, and consolidation of subspecialized physicians to snuff out smaller players. Then when you become the only game in town, practice kingpins can hire at low wages and/or simply sell their ownership to venture capitalists.
Even hospital-employed doctors are often powerless to having their employment contracts sold to a national physician management groups. Medicine is more and more reflecting the economic practices that have resulted in the American wealth gap, though practicing doctors are not the ones winding up at the top of the financial food chain. In many ways, physicians are to blame, as they are all-too-often willing to hand the management reigns over to someone else.
As I was sitting in a Cincinnati hotel lobby preparing for one of my last job interviews, I saw a group of exuberant men and women in their early twenties congregating for a pre-interview dinner for a graduate program in molecular and developmental biology. It occurred to me at that moment that the only other time I had ever been in Cincinnati was when I was in my early twenties interviewing for the same graduate program a few years before I decided to pursue medicine instead. They asked if I had any advice. I called upon Matthew 10:16. “Behold, I send you out as sheep in the midst of wolves. So be wise as serpents and innocent as doves.”
Cory Michael is a radiologist.
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