Wednesday, January 30, 2008

Physician Recruiters and Divine Justice

Deceased physician recruiters realize to their great dismay that they are stuck in hell! Why?

They were told "heaven is oversaturated", so they chose a place with "easy access to heaven".

Saturday, January 26, 2008

A Physician's View of Job Search

A colleague of mine wrote this comprehensive piece on job search, short and to the point. Wise. True. You will see why physicians always will give you more and better information than any recruiter.

The best jobs are with:

1. People you know
2. People recommended by the people you know
3. People who know the same people you know (listen carefully to the people you know)

You have to know what YOU want first:

academic versus private versus mixed
solo, small group, big group, employee of a large concern
small town versus metropolis
Coasts versus center
North versus south

Once you decide on the above, you have to do the market research. Get a directory from your society, count the number of society members in each state (this takes some time). Then take go to US census site and take population in that state for your target population (Pediatrics, young adults, middle aged, Medicare). Then figure out practitioners/100k target population. The places that have the lowest number are the places where you will likely do best in solo or small group practice. The places that have the higher numbers generally are the more desirable places to live, and you should consider joining a group. Another good resource is the Dartmouth survey of medicine which has a listing of specialists/population for almost every burg in the city. For example, in White Plains, NY, if you hit a pedestrian, you just hit a doctor. Also, do this for the major referring specialties for your practice - you need feeder fish.

So, if you are a shark, you need to know where the feeder fish are, and if there are already a bunch of sharks there.

Watch for signup bonuses - contract may say it is a "zero interest loan", or part of your buy-in, or other nonsense.

Watch for dictators - they are the majority partners and have the practice of burning through young people to keep costs low. Don't be a slave.

Get a handle on what is the MGMA average for your intended practice situation - your department should provide you with this. Negotiate starting above the mean.

Don't get enamored of the metropolis - you'll probably never afford housing. Better is if you work in a friendly, but out of the way place (much more doctor friendly) - then you can buy a pied-a-terre in San Francisco, Manhattan, or Aspen, or all three, if you invest in carwashes, gas stations, or become a slum lord in your small town.

If your spouse can't go where you must go, it's easier to divorce at your stage than at later when your net worth is higher (not from personal experience, but from watching a lot of car crashes).

Also, consider this: if you can find one or two other people to form a practice and commit to a three year business plan, and find a hospital willing to finance you (joint venture), you can start your own practice from scratch and make your own rules. You'll be hungry to start, but you won't beholden to a dictator and can become one yourself! (don't). If you find a partner, and you see an ad for more than one of your positions in Montana, go and stick up that hospital in Montana. If you don't have a partner going there with you, tell the hospital that you'll do the work of two and that you'll hire your own partner, and have them give you that other position's salary for all that extra work you're promising.

Actually, if you want to make money, go into hedge funds. You have no business in medicine.

In your specialty, you have billable services tied to revenue generating activities. Take the 10 most common activities and figure out ~how long it takes and ~how much it reimburses. From this, order these in terms of revenue density (reimbursement/average time). The priority from a purely financial viewpoint is to maximize the revenue dense items and minimize the revenue diffuse items. Things like GETTING TO KNOW YOUR PATIENT is probably why you went into medicine and is not billable, but necessary to generate the revenue dense items.

Rounding on inpatients and hanging out at the hospital and volunteering for committees are also revenue negative. In your figures, then budget a workweek and figure out how you wish to spend your time. For all the revenue negative or less dense times, figure out the opportunity cost compared to what would happen if all you did was the revenue densest activity. The difference between the balanced scheme and the fully revenue dense scheme is the money space that you should negotiate under.

You can then structure a business plan that includes using residents, physician extenders, and MLP's (slaves, slaves, and sharecroppers) to soak up some of the revenue less dense and negative activities and let you spend more time doing the revenue dense activities. Better yet, get the hospital to pay for these functionaries so that you are set free to sit in a windowless room and read EMG's day and night or whatever revenue densest activity it is you have.

Grim, but the hospitals and more knowledgeable practices crunch these numbers, and so should you. Radiology - pure revenue, no wasted motion of the jaw or ask me what - just neurons firing - is the extreme example. But again, money is not why you went into medicine, so let's step away a bit and get real and budget your ideal week of work. You have to know what it is that will keep you running on that wheel and how much it is worth.

If you find that the chairman - recommended jobs are not exactly what you want, you then have the recruiting industry. As long as you are mobile and not wed to absolutely having a metropolis with a Chinatown, and you realize that first jobs are like first wives, the recruiters are not so bad if you know what they're good for.

Matchmaker, matchmaker, make me a match! Typically, a practice makes a contract with a recruiter on contingency of a hire - typically this fee runs about $15-20k. If they hire you without a recruiter, the practice keeps that $15k - which is good negotiating room. Recruiters are then like a real estate agent and use their own ad language. But if you must, you should USE them. If you are a good candidate, their relationship just became worthwhile - to the tune of 15k. That's like a $300,000 house.

Don't be an easy mark. Let them know you are looking at other positions with other recruiters. Get them to pitch more than one position at you. That way, you can ask compare and contrast questions. They are your job-finding assistants and make them earn their keep. Get data - how many hip replacements at that hospital? How much trauma? How many orthopods? How many primary care physicians? Who else is practicing in your field there? The good recruiters will have this info.

Find out specific locations and do your homework. The web makes it very easy. Is that Lexus dealership in another state? Are there more WalMarts than Targets in that town? Is Applebee's haute cuisine in that burg? Get staff lists of that hospital and figure out where people trained and where they are from.

Check out the real estate in that town - you can get a baronial estate in North Dakota for what you pay for a studio in Manhattan. Know the school system if you have lil'uns. Is the place on Craigs list (or in really nowhere)? If so, what are these people buying and selling from each other? Woodcarvings of bears or antique Shaker dressers? Crossbows and used computers from the 90's or timeshares in Cozumel and slightly used Espresso machines? Unspeakable acts with fat strangers or skinny ones? Check out the symphony if they tout one - does it thrive (count number of different shows, less than 4 and you recognize all of the pieces and this is a symphony in trouble). Check out the Broadway shows they tout and see what the locals like (Mamma Mia or the Rockettes Christmas Extravaganzapalooza). Count the number of Starbucks, and you get a general count of New York City blocks this town is equivalent to.

At interview, look at the people you'll be working with. You'll spend most of your time with them rather than the people and activities that you love. Check out their teeth. Do they have a singing fish on the wall? Who is going to drive you crazy?

Negotiating - get a number and tell them you'll get back to them. Collect at least two offers.

Have a medical contract lawyer review - costs between 300-1000 bucks and is worth every penny if you have a good one. Make sure your malpractice is covered, including your tail and your next tail (cost of leaving - is it impossibly high?).

And finally, unless you're married to a woman (and then she decides), you decide by going eeniee meenie miney moe, and go with the place that gives you the most peace of mind.

Friday, January 25, 2008

More "Recruiter Speak"

Another contribution to understanding what recruiter ads really mean...

"family-oriented community" = everyone in town is related.
(If I divorce my wife, is she still my sister?)

"good hunting and fishing" = moose population greater than human population.

"little managed care penetration" = Medicare/Medicaid heavy

"beautiful region" = isolated

"salary guarantee" = loan

"many recreational opportunities" = small town

"$400K income potential" = on call 24/7 without help.

Send me your translation tips!

Saturday, January 12, 2008

Better Tools For The Physician Job Search

Years ago I asked my chief resident how I could find a job. He answered: "Just ask all the attendings and if that doesn't work, call a scalper", and nowadays he would have added, "go on the internet".
Well, I googled the terms "Physician jobs" and "ObGyn jobs". The results were a disaster: Recruiter website after recruiter website, then the websites that post recruiter ads, then the recruiting companies, then the occult and hidden recruiter ads disguised as "advice" that sneak up on you on student and fellowship websites, and on general health websites, and so on. In short, recruiters dominate the internet. This is severly misleading and a gross distortion of reality.

Recruiters only seem to be important when you look on the internet. In reality, they aren't. Accoring to my personal impression recruiters handle between 10-15% of jobs. A telephone survey of 1000 practices, unplublished, done by "" was consistent with this. A recruitment company researched the issue and arrived at an estimate of 33% of jobs, something that I believe it to be too optimistic.

So how do we find jobs? Print and direect internet advertising by employers may be responsible for filling 20-40% of jobs - in my estimate.

The remaining roughly 50% of jobs are filled by word of mouth, by direct personal contacts.

This has serious implications on how a physician should look for a job.

Networking should be effort number one, because most of the jobs are filled through personal contacts. This includes talking to anybody who is willing to listen and presenting them your "elevator pitch". The elevator pitch is a short presentation that includes who you are, what you are looking for, what makes you special and what makes you different than the rest. Handing out a business card with your contact info and maybe the elevator pitch is a good idea.
Networking includes contacting hospitals in the area where you want to work, I have discussed this in previous posts.

Networking includes sending a letter to every single physician in the area where you want to work and introducing yourself with a letter that essentially says the same as the elevator pitch. You may or may not include your CV in this letter. You will find the addresses and all other contact information of any physician anywhere at, where you can buy them for 50$ each. I have described this elsewhere in this blog.

Mailing a letter to each physician in your target area is especially useful, since you find all the physicians that have not advertised yet, that are just thinking about maybe hiring someone. This is great, since it gets you in before the competition. You automatically find all the physicians that have already advertised. They will simply think you are responding to their ad, even if you have never seen the ad. You will also reach all the physicians that have contacted recruiters, and you will be especially welcome, since your application does not have a 20K price tag attached (the fee the recruiter charges for brokering a candidate).

So, with one single activity, sending a letter to every physician in your target area, you reach absolutely everyone.
You tap the "hidden job market" as well as all other "markets". You cannot do better than that.
You can do this yourself, or you can have a company such as "" do it for a fee.

Compared to networking and direct mail, all other methods of searching for a physician job pale. By looking only at print ads and internet ads you are limiting yourself at 30-40% of the job market, and by searching through recruiters, you limit yourself to about 15% of the job market.

Why is the Internet and why are the print media dominated by recruiters? Because they pay. Follow the money! Recruiters pay websites to post their ads and the websites do not mind giving them a little "editorial space" - and, voila, you have a nice editorial touting the "advantages" of recruiters. Print media need advertising, and they need recruiter ads. They survive because of these ads. And they do not mind publishing a few nice articles presenting the "advantages of working with a recruiter".

And so you have a completely slanted view of the "physician job search" on the net.

It does not help the balance of published material that physicians have no interest whatsoever in writing about the almost embarassing topic of "job search". They just get it done and go to work. Write about it? Please...I have better things to do with my time!

And that is the reason why every new generation of graduating residents and fellows do not use the best tools to find a physician job. They simply do not know. And they fall for one of the thousands of slanted and partial websites prepared by recruiters. And the older, exeprienced physicians do not bother telling them how to find a job. We need to raise awareness of what physicians can do to find the jobs they want.

A physician job seach is a straightforward thing: contact all potential employers by mail. And Network. Done.

If you are interested in detailed info about techniques, in tips, in experiences, in books about physician job search, in new ways of using email alerts and websearch techniques, if you want to find more helpful weblinks, good websites, help in writing cover letters, CVs and more, please browse through my blog.

You will find it all. And it will be from a physician - for physicians. No financial interest, no pushing recruiters nor recruiter agendas, just good, straightforward, helpful info. How it should be.

Thursday, January 10, 2008

Physician Friendly States - Consider Them in Your Job Search

Where are you going to practice? States actually are quite different when it comes to being "Physician Friendly". Massachusetts for example deters physicians with high cost of living and one of the lowest reimbursements in addition to unusually restrictive state rules, such as being forced to carry malpractice insurance as a condition to licensing, prohibition of balance billing and other unsavory goodies, which for my own good I cannot mention here. But then of corse, everybody just cannot explain why, oh why there is a primary care physician shortage in Massachusetts! I don't know either, can't figure it out.
This article by an editor of "Physician Practice" is worth reading. I am quoting an abreviated version with gracious permission from the author - Thank you!

Begin quote:

The Best States to Practice: America's Physician-Friendliest States
By Bob Keaveney, executive editor of "Physicians Practice"

Kansas, South Dakota, Oklahoma, Indiana and Texas are the most physician-friendly in the country, according to Physicians Practice's biannual analysis. We examined factors that affect a doctor's ability to work relatively hassle-free while still making a nice living, and found that the big flat, open spaces of America's Midwest outshine the glitzier coastal states as attractive places to practice medicine.

We emphasized factors such as malpractice climate, reimbursement, and cost-of-living — not so-called "quality-of-life" issues, we find that the simple-life states tend to fare best. Places like Hawaii, New York, and California may be terrific places to live, but the cost of living is just too high. Also, densely populated states tend to be similarly thick with physicians.

Our methodology
We didn't consider the subjective, so-called "lifestyle factors", the main ingredients of the "best places to live" rankings, Since there is no particular "lifestyle" that most physicians would agree is ideal. For those rankings, see Money magazine's, found at, and Sperling's BestPlaces, As for Physicians Practice, we sought to identify the best places for a physician to work.

We considered the following:

Malpractice climate — We disqualified any state considered "in crisis" by the American Medical Association.
Physician-patient ratios — In our analysis, a lower ratio is better. Using an examination conducted last year by the New York Center for Health Workforce Studies (based on 2004 data by the U.S. Census Bureau, the AMA, and the American Osteopathic Association), physician-patient ratios affect a range of factors, from physician salaries to contract flexibility. The consolidation of commercial payers is putting a squeeze on practices. Having fewer physicians in your area increases your leverage.
Cost of living — Using data from the second quarter of 2006, the U.S. Bureau of Economic Analysis indexes the states against one another, with a median score of 100; the higher a state's score, the higher its cost of living. Thus, a lower score is better. For example, Hawaii scored 161.3; Oklahoma, 88.5.
Reimbursement — Medicare uses a similar indexing system for its Geographic Adjustment Factor. Hawaii's adjustment factor in 2006 was 1.044; Oklahoma's, 0.913. Commercial payers often tie their reimbursement rates to Medicare. For our analysis, the higher the score, the better.
Cost of living/reimbursement margin — These measures are closely linked; neither can be examined in a vacuum. Some states have costs of living that are relatively high or low in comparison to reimbursement rates. We evaluated and contrasted both of these indices to gain a sense of which states actually fared best.

Selecting America's most physician-friendly states is a subjective task. We recognize that factors affecting your particular quality of practice and life will include many additional variables.

Texas: A new law, passed with the assistance of the Texas Medical Association (TMA), established caps on noneconomic damages — money for pain and suffering — that plaintiffs can win in a malpractice suit. "I think the liability climate is one of the best, especially for physicians," says Ledon W. Homer, the TMA's president.

"We've found that a lot of doctors who relocate and never go back have gone from California to Texas," says Mosley. He made this exact move himself 15 years ago, and he found the stories of a unique Texas culture to be accurate. "One of the first things I saw was a bumper sticker that said, 'I'm from Texas. What country are you from?' And it really is like its own country."

Indiana is one of only two states to appear on our list all three times we've conducted this analysis. Its malpractice climate is "currently OK,", its cost of living is the 12th-lowest in the nation, and for every 100,000 residents, it has 180-200 physicians. "One thing that's kind of unique about Indiana that a lot of people don't really know about is that it really has a lot of great universities," he says. "Notre Dame, Purdue, Indiana University, Valparaiso, Ball State. People don't really think of Indiana as an academic university kind of place, but it is."

Oklahoma offers rock-bottom cost of living and comparatively low physician density (150 physicians per 100,000 residents)- combined with good reimbursements and generally higher incomes.

Kansas has the seventh-lowest cost-of-living, low physician density, and good reimbursement. were the deciding factors. Several physicians report that the biggest advantage is the people. Heartland folks just seem nicer. There's more respect for physicians. There's a greater willingness to trust."
Good economics make Kansas a great place to be a doctor. You can get a really nice home for a lot less than you'd pay in California. Kansas does have a $250,000 cap on noneconomic damages.

South Dakota has a friendly malpractice climate, they have the [noneconomic damages] cap. But it's also supply and demand, the supply of physicians is fairly low. The Plains state remains one of America's least-dense with doctors per capita. It also has the ninth-lowest cost of living.

Consider what matters - Don't get us wrong. We're not suggesting you pack your bags and move to Topeka or South Bend. We do suggest, however, that if you're ready to move — and more of you than ever, it seems, are — start your search by asking yourself what you're looking for in a practice setting and lifestyle, and then look for areas that meet those needs. Many physicians start with a place in mind, and then hope for the best, which is exactly the wrong way to proceed.

You may have familial or some other personal connection to a particular area; that's fine. But if you're just trying to indulge a fantasy by, say, insisting on practicing in Hawaii, then you're possibly setting yourself up for disappointment.

Consider the practice's size, compensation model, call-coverage policies, opportunities for partnership, and culture. Think also about how well-run the practice seems. For example, ask about average patient wait times (more efficient practices tend to have shorter waits) and about its use of information technology.

Bob Keaveney is the executive editor of Physicians Practice . He can be reached at

End quote

Sunday, January 6, 2008

"Competitive salary" a useless term

One of my pet peeves in job ads is the term "competitive salary". This term means nothing and therefore deserves translation and explanation. Below is what "competitive salary" can mean, and, to make it more tiresome, it can mean any one and all of these.

1. "Competitive salary" can mean that the employer's offer is in the range of the average salary according to the MGMA (Medical Group Management Association) lists.
This is the explanation I heard from a recruiter: "The MGMA does a tremendous job tracking each specialty, how much revenue a particular physician brings in, how large the population draw must be for a specialty to make sense to either expand or create. The industry of health care has many cut and dried business formulas. The RVU production model is one prime example of one of those formulas. An average OBG generates $1,413,436 in revenue annually for in/out combined and has a total RVU of 13,166 with each RVU valued at $43.49. For example the median salary for OBG physicians is $271,425 and if I had a really, really good opportunity I would refer to the percentile to indicate the range of salary. For example the 75th percentile for OBG is $350,000. So since my opportunity is "competitive" you can assume it's average and not over-the-top fantastic because I didn't refer to the percentile." - End of quote.
Well, NOW you know, right? You, like every job seeker, have nothing else to do but to pay the MGMA $520 for this info as soon as you start looking! And now of course you have this $520 list of averages sitting right on your desk.
This particular recruiter considered herself quite smart while in reality she is lost in her own world and has forgotten that the MGMA info is not readily available to everyone. SHE may know the averages, but YOU do not. If you read her comment closely, she says "competitive means average". Now that is great information...

By the way, here are two links to find out an approximate information of this kind, at least as national averages, even if this does not say much:NAPR
and Merritt and Hawkins

Another big problem that this recruiter chose to overlook is that this "average" varies. The average varies by experience, and it can vary from 180K in the first year to 270K after 5 or 6 years, this average varies by location, meaning in the South and in the Mid West it usually is higher and in New England it is lower, the average varies tremendously by HMO "penetration", it varies tremendously when you compare rural with urban areas and finally it varies by employer. Recruiters are not very concerned with urban jobs since they do not get them anyway.

And, how competitive is it? Very or hardly? Even if you knew the "average salary", is this particular salary competing in the 30%, 40%, 50%, 60% or 70%? You see, "competitve" spans probably more than 100K...

Turns out that "competitive" means NOTHING.

Do the following: When the recruiter asks for your CV, say that your CV is "competitive" and therefore you do not need to send it to him or her. Then may he or she will get the message.

2. "Competitive salary" is an evasive phrase used by employers that have not yet decided what they want to pay. They prefer to see what the candidates expect and then negotiate down from there.

3. "Competitive salary" is used by employers who want to take advantage of you. They are hiding the fact that their salary is below average. Sure it competes, but on the loosing end. They will only tell you after long talks, and after they feel that they have you on the hook, how little they really want to pay.

So, in summary, "competitive salary" is a completely useless term, and one that in the majority of situations works against you! Refuse to accept it and demand a clear statement about anticipated salary, such as "150-180K depending on experience". Statements like these should be the norm. Expect them, ask for them. Should an employer (or a recruiter if you really need one) not be upfront about the salary range, this may be a red flag.

Friday, January 4, 2008

Reading recruiter ads

Funny and sad at the same time, but very true. You need a dictionary to read recruiter ads. Since the funtion of recruiters is to sell the leftover jobs to unsuspecting and inexperienced physicians, to fill the less desirable jobs, the jobs that everybody else has looked at and declined, well, because of this physician recruiters have to be very, how should we say this, "creative" in their wording.

The colleagues of "Ace Medical" in Gardenia, California, who have created the blog "careermedicine", have published their own tips about how to decipher recruiter lingo. Careermedicine is a good blog. Their idea is to share the experiences made during job search as well as during the opening and running of a medical practice. Publishing these experiences for the benefit of your colleagues is not done often enough. We all have valuable experience to share and we should share them. It will help us survive the avalanche of insurance abuse and government overregulation, the two main problems for physicians today.

But here is the quote from the careermedicine website about recruiter language:

Reading the Physician Recruiters Ads

Well, on a lighter note , here is the code for understanding those mailers sent to you by the Physician recruiters:

1) Located in the heart of paradise = a very very rural area.

2) Charm of a small town life = Here fine-dining is Apple Bees

3) easy access to all amenities = If you drive couple of hours looking for it!

4) 15 minutes inland from the ocean = Be careful! lots of hurricanes!!

5) For those who love outdoor activities = It is deep in the jungle.

6) Enjoy year long skiing = You got it! Very very cold!!

7) Opportunity of a lifetime = We are having tough time finding applicants.

8) Opportunity to do it all = No specialists available will be on your own.

9) Low cost of living = If you buy that house in the Ghettos.

10) Option of Partnership track = Just kidding!!

Thank you careermedicine!