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In the world of medicine, job security is not a given. In this episode, we speak with Aaron Morgenstein, an orthopedic surgeon who discusses the challenges and uncertainties of being an employed physician. He explains the implications of the 90-day notice provision in most employment contracts and the risks and opportunities it presents. He also shares his advice on how physicians can evaluate and negotiate their contracts to maximize job stability and career satisfaction. Tune in to learn more about the realities of being an employed physician and how to navigate the changing health care landscape.

Aaron Morgenstein is an orthopedic surgeon.

He shares his story and discusses the KevinMD article, “Physicians are only good for 90 days.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Rate and review at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show, we have Aaron Morgenstein. He is an orthopedic surgeon. His KevinMD article that he co-wrote with Victoria Brown is titled “Physicians are only good for 90 days.” Aaron, welcome to the show.

Aaron Morgenstein: Hey, thanks, Kevin. Thanks for having me. Looking forward to it.

Kevin Pho: We’ll get into the article in a little bit. First off, briefly share your story and journey to where you are today.

Aaron Morgenstein: Yeah. For those that don’t know me, I’m an orthopedic surgeon. I was in private practice when I first graduated residency. I did that for two years. I really liked the people, but I knew it wasn’t for me; I wanted something else. So I left that position, and I started doing what some refer to as locums, but basically contracting directly with hospitals. I work about 16 days or so a month and then have the rest of the month off to do my side hustles.

Right now I’m working on my passion project, which is to help other doctors achieve a clinical arrangement that works for them, on a platform called FlexMedStaff.com, where we’re trying to encourage facilities and physicians to look at the staffing and recruitment model differently than we’ve done in the past, to try to keep people in medicine rather than leaving medicine.

Kevin Pho: I think what you said certainly resonates. I think a lot of doctors feel stuck in their current position. It could be orthopedic surgery like yourself; it could be primary care like myself. In general, what kind of options are available for physicians when it comes to creating their own schedule to help them stay in medicine?

Aaron Morgenstein: So I’m a big proponent of contacting hospitals or private practices yourself and saying, “Hey, I saw that you had a full-time job open, but I’m interested in something different.” Maybe I’m a PCP and only want to work three days a week. Maybe I’m a pediatrician who only wants to work four days a week. Some of these facilities are so accustomed to posting full-time positions that they don’t even think about what we want. Do we want a three-day weekend? Are you a surgeon who only wants to work three weeks a month?

So I think that there has to be education on both sides. The facilities, medical facilities, private practices, have to realize that there are people out there who are willing to work; they just may not want to work the full schedule. So it is difficult. A lot of people run to staffing agencies, you’re familiar with them, the locum companies, what I call the management companies. It’s kind of sad, because I think we should all just go direct, without the need for these middlemen, when it comes to working less than a full-time schedule.

Kevin Pho: And I’m certainly one of them. I only work 0.5 FTE, two to three days a week, in primary care internal medicine. Is there a difference between the primary care specialties versus the surgical specialties in your experience dealing with hospitals directly?

Aaron Morgenstein: Yeah, I think there is. It really depends on where you are, right? If you were in Boston or Chicago, most of those facilities are probably going to want full time. But if you’re willing to go an hour outside of those big cities, three hours outside of those big cities, a lot of those facilities, I’ve seen a change. Maybe they want a surgeon to come in for a day or two a week to do electives and clinic. Maybe they can’t find a hem-onc, so they’re willing to split the work, like you said. Instead of having one FTE, they’re willing to have 0.5 and 0.5 FTE over two people. So I think it’s really up to the facilities to start thinking differently about how they’re going to recruit people to their area, since they sometimes fail to recruit someone full time.

Kevin Pho: In general, how flexible are these facilities? I’m sure it depends whether it’s a large academic medical center versus a smaller practice in a rural setting. In general, how flexible are they when it comes to less-than-full-time employment?

Aaron Morgenstein: I have found that the independent hospitals, so the ones with two hospitals or less, are the ones that are more agreeable and willing to modify their traditional staffing models. I have found that these larger institutions, you’re familiar with them, I won’t mention them here, but you’re familiar with those institutions or networks where they have 10, 20, 30-plus hospitals, are less amenable to things like this, and they are so quick to run to staffing agencies and management firms. Whereas the independent hospitals that are really focused on treating their community, and treating their community with good physicians, and wanting to keep their physicians happy, I think those are the ones that are willing to work with physicians, specialists, hospitals, PCPs, etc., to try to find something that works for all parties.

Kevin Pho: All right, your KevinMD article that you co-wrote is titled “Physicians are only good for 90 days.” Now tell me, how did this article come together?

Aaron Morgenstein: Yeah. So however many years ago, I was graduating residency, and I was looking at multiple different contracts, and I found it interesting that basically you could be let go in 90 days. It was funny, because as a young person, you’re so accustomed to hearing physicians say, “I have a two-year agreement,” or “I have a three-year agreement.” I’ve never seen that before. I know there are some doctors out there who supposedly have them, but I personally have never seen someone offer me a guaranteed contract for two or three years.

When I was in my first job, I remember them saying, “Well, the money’s guaranteed,” and this and that, and I said, “No, I could be let go at any point.” That’s what’s nice about the contract: It protects the physician to some degree, because you can get out of a bad situation. But it’s also a really bad thing. COVID proved to us that many physicians were let go using that 90-day clause.

So it has always been on my mind, and I was so excited to write it. To be honest with you, Kevin, as soon as I wrote it, I knew that I wanted to submit it to you, because I thought you had the broadest reach.

Kevin Pho: So in general, how common is that 90-day notice? Is it ubiquitous in every physician contract?

Aaron Morgenstein: So it’s a little bit different for everyone. I think if you do independent contractor work or locums-type work, it can go down as low as 30 days. After I wrote the article, and this wasn’t known to me, it’s definitely becoming more common that those 90-day clauses are becoming 120-day clauses or even six-month clauses. To me, that’s a bit concerning, because if you’re in a bad situation, which many physicians are, maybe you’re mentally in a bad place, and you’re being forced to stay there for six months in a bad place. I think that’s unfair to you. So the 90-day clause definitely benefits both parties.

Kevin Pho: When physicians are negotiating an employment contract and they see something like a 60- or 90-day clause, what options do they have in perhaps removing it or modifying it?

Aaron Morgenstein: So I’m not a lawyer by any means, but my experience is: Go with a clause or a notice period that’s comfortable to you. I do think 90 days is a good one, because if you were to provide 90-day notice, on average it can take about two to three months to get credentialed at a new facility, if it’s in a state where you have a medical license. So I prefer the 90-day clause. Sixty days is good. I don’t really like the 30-day.

But I’m dealing with a physician that I was helping negotiate an interesting contract. She negotiated for two weeks a month, but she’s unable to leave her current facility because they have locked her into a six-month notice. That’s difficult, because you can just tell she’s in a bad place, and she needs to move on, and she can’t get out of this thing.

Kevin Pho: What options do physicians have if they’re locked into a six-month notice or a 90-day notice and it’s really a toxic situation? How easy is it to break that contract?

Aaron Morgenstein: I think that’s a question to ask a really good health care attorney. Yeah, I don’t know how best to break those. I’ve been in positions where I’ve thought about breaking them, and you just get really concerned or scared that they’re going to come after you, and we all know that the facilities have deeper pockets than us.

Kevin Pho: So you mentioned that during COVID, a lot of physicians were let go because of these 90-day contracts. COVID, I think, made a lot of doctors realize that our job security isn’t what it once was. So what were your thoughts when you started hearing these stories about physicians being let go after being given their notice?

Aaron Morgenstein: Yeah. So, Kevin, the interesting thing is I thought I would be fired. I thought I’d be canned. I went down to my folks’ place in Florida because I thought I would never get re-employed, but that wasn’t the case. I had a nice two-week vacation, like some of us did, and I got back to work.

I think that physicians need to realize that there’s not true job security in being a physician. I think that when you say the words “job security,” you have job security as in you will be able to find a job anywhere in this country, but you may not have a job at that facility if something like COVID happens, or there’s a bad situation, or a change of administration. So I think you do have to be concerned that we don’t actually have true job security and that we could easily be let go. Now, you can find a job another place, but picking up a family and all the other things that go into moving to a new destination make it much more difficult for us as physicians to find our next opportunity.

Kevin Pho: So let’s zoom out a little bit. Through your side hustle, I’m sure you’ve dealt with hospitals and medical institutions. A lot of physicians, during training, we don’t get a lot of information or insight when it comes to negotiating jobs, right? We don’t know what goes on behind closed doors. What are some things that you’ve learned through your side hustle about employment contracts? What are some things that surprised you that you didn’t learn during training or even looking for your first job?

Aaron Morgenstein: Well, I work with a lot of physicians now. I’m not necessarily a coach; I just provide a little bit of mentorship. I think the key is education. You have to educate yourself about what’s in that contract in order to negotiate. I also think that if you’re going to negotiate, you’d better have good rationales for why you think you’re going to be paid. Don’t just say, “Hey, I get paid because I’m a surgeon.” No, know some data out there. Know the data of what other folks are getting paid and that kind of stuff.

When I speak with a facility and I’m interested in a new opportunity, I try to hit home with four or five different things. How is malpractice going to be paid? How are we going to deal with our compensation rate? Is there going to be an indemnification clause? What’s the non-compete going to look like? There are only four or five things that I really care about when I’m negotiating, because the rest of it is kind of the fluff, right? These contracts are anywhere from eight to 20 pages long. There’s a lot of fluff in there, and I’m only focused on the key elements, because I want to keep my negotiation short. Unlike boxing, it’s not meant to go 12 rounds. Negotiating, you want to settle an agreement within three or four rounds, and that’s it.

Kevin Pho: Now, do you do a lot of negotiating yourself, or do you have an attorney represent you?

Aaron Morgenstein: I think the right thing to do is try to negotiate yourself. Why have a middleman negotiate for you? Learn the material yourself, educate yourself, learn some negotiating tactics if you want, and do it yourself. I think it puts a bad taste in the facility’s mouth if you’re having someone else negotiate for you. Because let’s say there’s an issue at the hospital, or you have a practice-related issue: Are you going to run to a lawyer to call the administration to help you out? No, you’re going to try to continue that conversation, or to grow that relationship with the facility that you started during those negotiation phases.

Kevin Pho: So when negotiating yourself, what happens if there’s a point of contention and you’re negotiating with whoever the hospital supervisor is? How does that normally go?

Aaron Morgenstein: Yeah, I think you have to enter any conversation or any negotiations willing to back out of those negotiations. If I don’t think things are flowing, if I don’t think they’re as sincere as I am, or they’re not interested in a long-term relationship, then I’ll kindly back out of the negotiations. If it’s going to get contentious, that’s just not for me. Maybe it’s for other people, but it’s not for me.

Kevin Pho: And where did you learn how to do this? Like I said before, a lot of doctors don’t get a lot of training in this. How did you learn? What kind of resources do you recommend?

Aaron Morgenstein: Practice. I think you have to review your own contracts. This is something I learned from my father, who’s also a surgeon: You’d better read every one of your contracts, and you’d better understand every paragraph, and then, if you want, you hand it off to a lawyer to see if you read it correctly. The first few times I reviewed a contract, I did have a supplemental review by an attorney.

In the end, if you read it well and the contract’s in English, then you should understand it well. But what I found is that if you read a contract and it seems to be a lot of legal jargon and it’s confusing, it likely does not benefit you, and if it doesn’t benefit you, then it’s probably not best to sign it. I can guarantee that if you present something like that to a lawyer, they’re going to tell you to have it edited.

The other thing I’ll add, Kevin, is that over time, I’ve read enough contracts that I’ve actually copied and pasted some things for different contracts. So I know what clauses and provisions I want to edit, and I have examples of what I would like them to be edited to, so I can just send that back to a hospital’s lawyer to make those edits.

Kevin Pho: A lot of times, I hear medical institutions and hospitals say, “This is a standard contract. We have all the doctors sign that.” So how do you respond when they typically say this?

Aaron Morgenstein: I’m happy to review those contracts, but with many of those facilities, I wind up not negotiating if there’s a red flag or a deal breaker in there. Sometimes there’ll be a deal breaker like a non-compete, or there’ll be an indemnification clause that I don’t like, and if they’re not willing to edit it, then I have to move on.

Kevin Pho: And what are some typical red flags that you find a lot of doctors miss that are not immediately apparent in these contracts? What’s something that’s not obvious that physicians should be wary of when reading an employment contract?

Aaron Morgenstein: The one that worries me the most is the indemnification clause.

Kevin Pho: And what is that?

Aaron Morgenstein: Good question. Basically, with a facility or a management company, you would have to hold them harmless if there was litigation. So let’s say there’s a malpractice claim against you, and the patient sues you, the staffing agency or the management company, and also the hospital. If in your contract there’s an indemnification clause that does not benefit you, you could be on the hook for paying the legal fees or the financial settlement that is waged against the middleman, the management company, or even the hospital. And there is no insurance to protect you from losing on an indemnification clause. So that’s the one I worry the most about.

The other ones, that I know you’re familiar with: If you’re doing an employment model, you want to be more concerned about the non-compete. We know that a lot of those are excessive, and in some states they’re not even applicable, but they’re still in there. I think that malpractice is a key one that I worry about. I want to make sure that my practice is covered, not just while I’m there, but if I were to leave, so how is tail insurance covered? Those are three major issues I’m going to be worried about, and then I’m going to also worry about compensation.

Kevin Pho: We’re talking to Aaron Morgenstein. He’s an orthopedic surgeon. His KevinMD article that he co-wrote is titled “Physicians are only good for 90 days.” So, Aaron, tell us about the mindset physicians should have, knowing that a lot of these contracts aren’t necessarily the guaranteed ones that physicians may be used to. How should physicians adjust their mindset when it comes to their next job?

Aaron Morgenstein: It’s such a difficult subject matter. I wish we had a rent-to-own model. I wish you could try out a job for three months and then sign. Unfortunately, medicine’s not designed that way, and I understand, but that’s how I wish it was. I think that you have to go into every job knowing that it’s going to be trial and error. Is it going to work out for you? We don’t know. I think you have to give it time, but not all opportunities that appear good on paper actually are, as you know. And you have to realize that if you’re not happy, you have to have the right mindset that maybe moving on is a better thing.

I see too many physicians, and this is my personal take, I see too many physicians wanting to quit medicine completely, as in, it’s practice medicine or quit medicine. I don’t fully understand that. I think that when physicians are wanting to quit, you have to think: Is it the facility, or the clinical arrangement you have? You spoke of doing 0.5 FTE, which is fantastic. That’s the clinical arrangement that works for you, and so other people might stay in medicine if they were to think about that. Those are two modifiable things, right? Can the facility improve the treatment of a physician, and can they improve the clinical arrangement that they set up with physicians? So I’m not sure that answers your question, but it’s very difficult to know if a job is going to go long term, whether you’re going to be there for two years or you’re going to be there for 20.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Aaron Morgenstein: I think that as physicians, we need to realize that we spent our entire 20s, a lot of us, sacrificing to learn the art of medicine. With so many physicians leaving, I think we all need to find a way to stay in medicine and provide good care, because at some point we’re going to need a physician to take care of us, or we’re going to have a loved one who is going to need help. So I think what I’m trying to promote to others is: Find something that works for you, something that provides you the flexibility, maybe the autonomy, to practice medicine how you want to practice, and also having the time off to enjoy your side hustles, your side businesses, and most importantly, your family.

Kevin Pho: Aaron, thank you so much for sharing your time and insight, and thanks again for being on the show.

Aaron Morgenstein: Thanks, Kevin.