Launching Your Career in Pediatrics: Getting Started

Transcription

1 Launching Your Career in Pediatrics: Getting Started Thinking of a location to practice medicine or open a practice is an important decision. There are a number of considerations that any pediatrician will need to examine before making a final decision. Pediatricians often choose their jobs based on several factors family needs, spousal considerations, recreational and cultural opportunities, friends, size of the community, lifestyle, income guarantees, and benefit plans. This section will look at the most important things to consider when joining or opening a practice. Personal and Family Needs Financial Considerations Assessing the Community Practice Types Current Trends in Malpractice Professional Relationships and Opportunities Personal and Family Needs Family needs and wants are often at the top of the list when considering where to practice. Many pediatricians who have young children often choose to move closer to family and relatives for support. The location of where a spouse can work is an important factor when determining a location, as well. Also important are the availability of educational, cultural, and recreational activities. If you love outdoor activities, you may wish to move to regions that offer those advantages. As more women enter the field of pediatrics, there has been an increase in demand for careers that offer a work/life balance. This demand has prompted many pediatricians to seek careers that offer job sharing and part-time and flexible work schedules. The American Academy of Pediatrics (AAP) Women in Pediatrics Web site has more information about issues facing women in pediatrics. The same dynamics hold true for those on the opposite end of the spectrum retiring pediatricians (Shrier DK, Shrier LA, Rich M, Greenberg L. Pediatricians leading the way: integrating a career and a family/personal life over the life cycle. Pediatrics. 2006; 117: ) To make a decision about where to practice, it is important to assess your goals. Clarify your career objectives. Do you want to practice a specific style or philosophy of pediatrics? Are you a team player or someone who likes to go it alone? What type of location would you like to be in rural, suburban, or urban? What kinds of patients do you want to serve? - 1 -

2 What are your future goals? Do you enjoy working shifts? Do you prefer inpatient or outpatient care? Do you like the idea of hospital or academic practice, a clinic practice, or a private office? How many hours do you want to work? Do you mind working a lot of evenings and weekends? How often do you want to be on call? Is the practice committed to being a medical home for its families? What kind of lifestyle do you want outside the office? Exposure to urban life opportunities Outside adventures Financial Considerations Salary The region of the country where you practice will likely determine your lifestyle and practice income. Surveys of pediatric salaries show that incomes are highest in the Midwest and Southeast, with the lowest salaries in the Northeast and on the West Coast. The following chart from the US Department of Labor Bureau of Labor Statistics provides the annual mean and median wages for pediatricians practicing in all states based on 2007 data. The annual mean wage also varies by years in practice. For general pediatricians annual mean wage: $145,210; annual median wage: $140, 690. STATE/COMMONWEALTH ANNUAL MEAN WAGE ANNUAL MEDIAN WAGE Alabama $145,950 $139,610 Alaska $140,140 $135,070 Arizona $149,440 a - 2 -

3 Arkansas $135,100 $106,030 California $155,230 Colorado $165,820 a a Connecticut Delaware $135,860 $141,580 $132,360 $132,530 District of Columbia $74,830 $73,230 Florida $146,970 a Georgia $109, 280 $110,430 Hawaii $150,070 $136,180 Idaho $131,010 $139,430 Illinois $122,870 $117,130 Indiana b $142,580 $135,470 Iowa $151,250 a Kansas $141,300 $134,890 Kentucky $189,280 a Louisiana $170,280 a Maine $153,810 a Maryland $116,950 $115,

4 Massachusetts $147,310 $145,240 Michigan $140,810 $133,470 Minnesota $163,540 a Mississippi $152,270 a Missouri $136,790 $144,540 Montana $97,090 $99,300 Nebraska Nevada $171,340 $ a a New Hampshire $150,360 a New Jersey $146,450 $135, 270 New Mexico $156,660 a New York $141,960 $134,110 North Carolina North Dakota $159,390 $129,450 a 126,980 Ohio $147,410 $139,690 Oklahoma $182,000 a Oregon $159,130 a Pennsylvania $139,440 $127,550 Puerto Rico $83,650 $64,

5 Rhode Island $144,220 $140,410 South Carolina $132,460 $137,900 South Dakota $177,620 a Tennessee $156,560 a Texas $151,820 a Utah $159,170 a Vermont $117,460 $110,220 Virginia $133,220 $126,910 Washington $135,160 $130,230 West Virginia $162,500 Wisconsin $161,430 a a Annual wages have been calculated by multiplying the hourly mean wage by 2,080 hours; where an hourly mean wage is not published, the annual wage has been directly calculated from the reported survey data. a This wage is equal to or greater than $70 per hour or $145,600 per year. Data extracted on May 20, According to the Medical Group Management Association (MGMA) Physician Compensation and Production Survey Report Based on 2006 Data, for salaries of physicians who are new to practice (1 2 years), the median income for general pediatricians is $130,633 and $192,664 for neonatologists

6 References and Additional Resources The 2002 AAP Periodic Survey provides an overview of pediatrician s characteristics. Pediatricians Leading the Way: Integrating A Career and a Family/Personal Life Over the Life Cycle, February 2006 Pediatrician Workforce Statement, Pediatrics, July 2005 The Pediatrician Workforce: Current Status and Future Prospects, Pediatrics, July 2005 Physician Compensation and Production Survey Report Based on 2006 Data, MGMA Physician Placement Starting Salary Survey Report Report Based on 2005 Data, MGMA Recent Graduate As the cost of higher education continues to rise, so does the amount of loan debt. Many members of the AAP emerge from medical school or pediatric residency with a balance of more than $125,000 in student loans. It is important to obtain qualified advice before entering into any loan repayment or employment agreement. There are many government programs that offer repayment programs. It is essential to learn about the commitments and expectations before entering into any formal agreement. Examine the source of funding and the fine print, and consult mentors on your faculty and in your student affairs office before entering into any commitments (Pediatrics 101: A Resource Guide from the American Academy of Pediatrics) The following links provide general information as a starting point for research. Consult with your college financial aid officer and other qualified advisors before committing to any financial arrangement. Resources Association of American Medical Colleges (MD)2: Monetary Decisions for Medical Doctors A database of state and other loan repayment/forgiveness scholarship programs with an interactive guide to information from state health departments, medical schools, federal programs, and military agencies - 6 -

7 A chart showing tuition and student fees for first-year medical students, 2004 to 2005 (log-in required) National Institutes of Health Pediatric Research Loan Repayment Program in return for a 2-year commitment to your research career, the National Institutes of Health will repay up to $35,000 per year of your qualified repayable education debt plus an additional 39% of the repayments to cover your federal taxes, and may reimburse state taxes that may result from these payments. Student Loan Consolidation information on loan consolidation programs. Indian Health Service Loan Repayment Program Service Center Applicants sign a 2-year agreement and provide full-time clinical practice at the Indian Health Service facilities or approved Indian health programs. In exchange, a portion to all of their educational loans will be repaid. National Health Service Corps Applicants will serve on an interdisciplinary team to focus on community health. In exchange, applicants will receive job placement assistance, a competitive loan repayment program, an opportunity to join the National Health Service Corps Ready Responders as a US Public Health Service commissioned officer, and preceptorship and mentoring. Assessing the Community Whether you are considering opening a practice, joining a practice, or relocating, there are a number of things to consider before making the final decision. In real estate, the 3 most important considerations when buying a house are location, location, and location! The same is true of a pediatric practice. Many of the decisions about practices and lifestyles will be determined by your preferences about where you would like to live and work. Following are some tips on selecting a community in which to practice: The most basic approach to assess the requirements for pediatricians is to determine the employment opportunities and competition for patients. Consider trends in the local obstetrician demographics. Contact the local chamber of commerce to find migration trends and the opening of schools, homes, and hospitals. This is often a good predictor of whether the location will be viable

8 It is important to know if the community in which you plan to practice is a younger community with new families emerging or an aging retirement community. Identify where patients live. The rule of thumb is that patients will drive 20 minutes to see a doctor. Any farther, patients will look for a doctor closer to where they live. However, this rule may not apply to rural physicians. Consider the number of retail-based clinics (RBCs) in your area. If there are no RBCs, this is a good time to establish your pediatric office in a central location near a major retail location to get ahead of the competition in the future. If RBCs do exist, make sure the practice you are starting or joining is providing competitive hours and values customer service. Families are using RBCs mainly out of convenience. If your practice can compete by providing the same or better level of convenience, your expertise as a pediatrician will far outweigh the services provided at an RBC. It s a win-win situation for you and your patients. More resources on RBCs can be found on the AAP Practice Management Online Web site. Consider the number of pediatric care professionals in the area.\ Urban Versus Rural Locations There are many differences between practicing in a rural versus an urban location. Those who choose to practice in a rural area usually prefer to do so in an effort to use all skills learned during residency. It is common for practicing pediatricians in rural areas to perform resuscitations, intubations, and lumbar punctures. It is often their responsibility to stabilize and care for children who are chronically ill. See Table 1 in Trends in the Rural-Urban Distribution of General Pediatricians (Pediatrics. 2001;107:e18) for more information. Practicing in an Urban or Rural Population Urban More technology Rural Less technology More networking opportunities Less on-call and weekend hours Independent practitioner with less networking opportunities Need to be available more (on call, after hours, and weekends) - 8 -

9 More commuting time More physicians = more competition Access to subspecialists and children s hospitals Larger salaries Greater need = less competition Often will need to contract with subspecialists Where Children and Their Families Go for Health Care The American Academy of Pediatrics (AAP) partnered with Dartmouth Medical School, Center for the Evaluative Clinical Sciences, to develop Mapping Health Care Delivery for America's Children. This Web site provides the status of current available national, state, and city data on the following: Children younger than 18 years per clinically active pediatrician Percent of clinically active pediatricians who are female Median household income Percent of Hispanic children younger than 18 years Percent of children 5 to 17 years old in linguistically isolated households It is important to note that while some areas in the United States appear to have a large number of pediatricians, these pediatricians are still employed and working. Practice Types There are a variety of practice options and structures available to pediatricians. Following is an overview of the various structures. Solo Versus Group Practice Solo Practice Group Practice Hospital Owned More individual freedom Less individual practice freedom Not as much physician autonomy Federally Qualified Health Center Not as much physician autonomy Academic Health Center Not as much physician autonomy Longer work hours clinical and business Shorter work hours Work on a schedule Work on a schedule Work on a schedule - 9 -

10 Complete responsibility for the business Less need to be involved in business aspects Subject to employee constraints Subject to employee constraints Subject to employee constraints High public/patient visibility Less personal visibility with public and patients Marketing department Marketing department Marketing department Extremes of financial return Built-in on-call coverage Centralized patient record keeping Business risk Less opportunity for informal professional consultations More limited working capital Total involvement in business concerns High-tech practice will depend on expenses Lower medicolegal/business risk More opportunity for informal professional consultations Access to larger amounts of working capital Less opportunity for involvement in business Greater chances to be involved in high-tech practice Set growth pattern More limits on rapid income growth Determine benefit structure Established benefit structure Low to no legal/business risk Required referral patterns Cost allocation to physicians Systemdetermined decisions Better access to equipment and better equipment Steady flow of income Established benefit structure Centralized patient record keeping Low to no legal/business risk Required referral patterns Limitations due to federal funding regulations Systemdetermined decisions Better access to equipment and better equipment Steady flow of income Established benefit Centralized patient record keeping Low to no legal/business risk Required referral patterns Access to larger amounts of working capital. Possible administrative limitations Systemdetermined decisions Better access to equipment and better equipment Steady flow of income Established benefit structure structure Source: American Academy of Pediatrics, Committee on Practice and Ambulatory Medicine. Management of Pediatric Practice. 2nd ed. Elk Grove Villlage, IL: American Academy of Pediatrics; 1991 and American Academy of Pediatrics. A Guide to Starting a Medical Office. Elk Grove Village, IL: American Academy of Pediatrics; 1997 Solo Practice Solo practices are for pediatricians who want to own and manage their own practice. This physician is responsible for all aspects of the practice, including establishing policies and

11 guidelines, staffing, office hours, finances, and legal. Expense Sharing This type of practice may be as simple as 2 pediatricians sharing office space and staff but operating as independent practices. This provides some relief from the financial burden of overhead and office operations and provides some relief from finding night-call coverage. Patients should be made well aware that the 2 physicians have separate practices. If there is no written agreement and patients assume that the physicians are partners, both physicians may be implicated in malpractice litigation. Partnership A partnership is an association of 2 or more persons for the purpose of carrying on as coowners of a business for profit. The partners in this arrangement invest together to make a profit. In this structure, each partner has equal rights and management and also shares the risks and responsibilities. New partners are usually brought in after acquiring the consent of all existing partners. Like marriages, there needs to be compatibility in medical practice and management philosophies among partners. Partners can also expect to receive a formal accounting of all partnership affairs. On the other hand, all partners may be liable for each individual partner s wrong acts or acts of commission or omission assumed by the partnership as a whole, inviting individual liability for any legal action against the partnership. Also, in much the same way partnership gains are shared equally, so may losses be expected to be shared. Multi-specialty (Large and Small) Single-specialty groups pool the resources of several pediatricians. The legal arrangement becomes important and is essential to define the roles and responsibilities of the partners. Multi-specialty groups provide a pool of other medical and management skills, but with significantly less personal autonomy. Corporate Practice Working for a large corporate health care provider is another option. Corporate practice reduces the personal and financial risk to the individual physician, while also providing opportunities to shelter income through a qualified retirement program. A large health maintenance organization (HMO) office allows pediatricians to practice without business or administrative concerns. This provides a great deal of security in terms of salary and benefits and eliminates the need to be concerned about administrative and business aspects of practice. Government and federal health care facilities provide another practice outlet. Academic practices provide many of the same benefits. Lastly, niche practices such as emergency department or delivery room coverage, working with specific disease entities like obesity, or substance abuse centers provide yet another practice outlet. Advantages include limited liability to the individual practitioner; centralized

12 management; continuity of life beyond the career trajectories of existing physicians; pension and profit-sharing plans that may be superior to solo practice or partnerships; tax incentives; and presence of other benefits that are more cost-efficient because of scale (eg, health benefit, life insurance, disability, malpractice discount). Disadvantages include need for an extensive organization to manage personnel, legal paperwork, tax, and accounting; need for higher start-up costs; and potential tax consequences (eg, corporate versus income tax). Corporate practices may exist in several forms HMO groups, government or federal health care centers, hospital-based practices (eg, academic groups, hospitalist groups, emergency department physicians), and boutique practices (eg, substance abuse, surgical centers). These may all be structured very differently depending on local standards, community and state laws, and preferences of organizing groups. Each may have various arrangements for a physician s role and responsibility within the group, including profit sharing, vesting time, amount of call, and academic partnerships. Academic and Hospital-Based Practices With the growing demands of outpatient practices, hospital-based practices are growing in almost every community. They may develop as an initiative of local physicians, or hospitals may choose to contract with them. They may offer around-the-clock care that primary physicians find difficult to provide. Having hospitalists has been shown to improve quality measures including length of stay, mortality, and 30-day readmission rate in several common inpatient diagnoses. Evidence also shows that hospitalists reduce costs and length of stay while achieving the same or better patient outcomes achieved by non-hospitalists. Hospitalists often practice in group-type structures; they may be simple informal arrangements among a group of physicians within a community who share hospital calls with or without teaching responsibilities, or they may be more elaborate corporate organizations that employ individual physicians. Some may even be organized on a national scale, with local franchises that operate within a community but are answerable to corporate headquarters. They may cover one or multiple hospitals depending on the demand and the particular relationships that exist between the group and hospital administration. In much the same way corporations offer benefits of scale in terms of sharing expenses, employee benefits, and tax advantage, groups that are more organized offer the advantage of monitoring the quality of care provided by their physicians. These groups may have methods in place to assess outcomes, lengths of stay, patient satisfaction, and reimbursement values. Physicians who practice within such a setting report the following advantages: Satisfaction of working within a team Satisfaction of contributing to the improvement of inpatient care or hospital processes Flexibility of work hours (i.e., not necessarily 9:00 am 5:00 pm) Opportunities for various educational interactions (eg, with other specialists,

13 residents, medical students) Opportunity to have nonmedical responsibilities (eg, administration, quality assurance) as much or as little as one wants Large variety of clinical cases, which are often acute and whose successful outcomes provide enormous satisfaction Being kept on one s toes Most physicians who work in this setting will report difficulty and even boredom with the daily grind of an office practice, which often seems to involve the same medical problems over and over. These physicians also perceive the business side of keeping a practice afloat not to their liking. They express a high comfort level with a hospital setting and the pace that such work involves. On the other hand, depending on the level of specialty required, length of training time, and challenge of working in a high-pressure field that may be dominated by males, some women may not find this to be a suitable practice alternative. Furthermore, practice turnover may turn the work hours from an advantage to a disadvantage, since regardless of the number of covering physicians, the group will still be committed to providing 24/7 care. Physicians in practice transitioning to or new graduates contemplating a hospitalist position should ask themselves a number of questions. What is the nature of the organization? Is it a corporation, a partnership among physicians, or a hospital-based group? Will a physician be an employee of the corporation or of the hospital? What is the basis of the corporation s relationship to the hospital? What is the organizational structure? Who will serve as my direct supervisor(s) and what are his or her responsibilities? What is the group s composition? Are they all general pediatricians? Are there family or nurse practitioners? Who are the actual physicians participating in the call rotation? What are the responsibilities of each physician who takes calls? What is the call rotation schedule? Are there outpatient responsibilities or emergency department coverage apart from inpatient calls? Where will these be conducted? Which hospitals does the group cover? If more than one, are there different responsibilities or expectations with each hospital setting? Are the patient load and population different with each hospital? If one is relocating, what is the approximate distance between each hospital and one s residence? Is there a central office location for the group? What are other physician responsibilities apart from direct patient care? Are there administrative duties or teaching responsibilities? Are these expected, required, or optional? If one were to supervise or teach, does this involve nurse practitioners, physician assistants, other nursing personnel, residents, or medical students?

14 Does the group have subspecialty or surgical support? If so, who and where? Does it require transferring patients from a primary hospital to a tertiary one? What is the rate of physician reimbursement? What is the basis of this scale (eg, seniority, productivity, patient load, call load)? How is one s productivity calculated and what factors go into this calculation? How does one s productivity affect compensation and future raises? What benefits are offered to physicians? Do these include health coverage, malpractice liability, other insurance coverage, and retirement funds? If transferring from another practice, will the group offer tail coverage? What constitutes terms of separation, termination, and contractual breach? Are there any restrictive covenants (eg, geographic practice restrictions)? What are the laws of the state governing all of this and what are the responsibilities and liabilities if one assumes this position? You may need to consult your state medical board or a local lawyer. Retail-Based Clinics While the AAP does not support the RBC model of care for children, families are using these types of clinics. Located in retail settings (eg, pharmacies, supermarkets), these clinics provide families with a convenient location and the ability to multitask. While this may seem like a benefit to the family, the care provided at an RBC is very limited and only fragments the medical home. Practices must educate their patients on the importance of the medical home, but also provide a practice setting that meets the needs of busy families today. Practices must acknowledge the changing health care market and respond to remain competitive. Providing a medical home for patients can be challenging financially and administratively, but it is the best model of care for children. More resources on RBCs can be found here. Current Trends in Malpractice Pediatricians are sued less than other specialties approximately 33% of pediatricians are sued in their career. However, the indemnities are 25% higher. (Donn SM. Is there really a relationship between medical liability, risk management and quality improvement? Pediatricians and the Law. AAP News. 2007;2:1 1) Malpractice coverage is necessary. There are 2 main options to choose from when deciding on malpractice coverage claims-made or occurrence-made policies. It is very important to understand the differences. Claims-made policies will only cover you during the time you hold the insurance policy; thus, once you leave the policy you will not be covered for any claims. For instance, if

15 you were in practice from January 2008 and left your job and policy in January 2009, after January 2009 you will not be covered for any claim made, even if it is regarding an incident that occurred between January 2008 and January However, you maybe able to purchase a tail, which can cover any claims filed about incidents during the time you had claims-made policy. Occurrence-made policy, on the other hand, covers all claims regardless of when the incident in dispute occurred. In other words, even after the policy expires, it still protects you from any claims filed for incidents that occurred while the policy was in force. This policy tends to be more expensive Resources Malpractice Insurance, American College of Physicians Evaluating an Insurance Policy, American Medical Association Exclusive Survey Malpractice Premiums: Starting to Level Off, Medical Economics Is There Really A Relationship Between Medical Liability, Risk Management and Quality Improvement? AAP News. Professional Relationships and Opportunities Nearly 50% of physicians who practice in towns with a population of fewer than 2,500 grew up in a town with similar statistics. Studies show that there is a strong correlation between where a pediatrician went to post-training studies and where he or she chooses to practice. You will also want to consider the professional relationships and networking opportunities that you have had. Often, your mentors and professors can serve as references and resources as you locate a place to practice. Your State AAP and Medical Society Contacts AAP chapters are organized groups of pediatricians and other health care professionals working to achieve AAP goals in their communities. There are 59 chapters in the United States and 7 chapters in Canada. The US chapters generally are drawn along state lines, but 2 states with large populations (New York and California) constitute more than 1 chapter. In addition, 2 chapters serve pediatricians in the uniformed services (east and west, divided by the Mississippi River), and Puerto Rico and the District of Columbia are also separate chapters

16 I Already Belong to the National AAP; Why Should I Become a Member of My Chapter? Advocacy Increase your knowledge of and participation in legislative and advocacy activities at a local level. Increase involvement in the legislative arena to positively influence the quality of pediatric practice and the welfare of children in your state. Build coalitions with other organizations working toward improving children s health and well-being. Promote the interests of pediatricians in the AAP. Leadership Participate in chapter committees in areas of interest. Serve as part of the chapter leadership team in an official officer capacity. Networking Network with other pediatricians with similar interests. Improve chapter membership participation on national AAP affairs. Education Receive regular chapter newsletter and other informative mailings. Attend local continuing medical education meetings and chapter annual meetings to further necessary educational requirements. To learn more about your state chapter, visit Launching Your Career in Pediatrics: Finding the Job For many, choosing a location to open or join a practice is the first step in searching for a job. Once a location has been determined, the job search begins. This next section will provide tips on the following: Searching for a job Researching the practice and community Recent graduates Identifying goals Timeline summary Working with recruiters Preparing a curriculum vitae and cover letter The interview

17 Negotiating an agreement Searching for a Job There are many ways to look for a job, from headhunters to posting your résumé on the Web to looking in journals, but one very important way is through networking. A personal recommendation and interaction go a long way. Some of the key people to network with include Residency director and faculty. Contact the residency or training director and faculty at the institution where you trained. Many local pediatricians provide residency directors with job openings. Local agencies. Contact the local medical society or American Academy of Pediatrics (AAP) chapter. Many times these groups are aware of pediatricians looking for new associates. PedJobs. Visit and register with PedJobs at Hospital. Many hospitals will assist with practice setup if they have a need for a new pediatrician in the community. Additionally, many hospitals, local health centers, and urgent care centers are building primary care networks and are looking for physicians to staff them. You may want to consider contacting a hospital that delivers newborns because there may be opportunities to cover the nursery and delivery room. Additionally, some hospitals hire hospitalists to care for newborns, inpatients, and patients in the emergency department. Local pediatricians. Once you have decided on a location, get a list of the pediatricians in that area. Contact them expressing interest in working for them. If they are not hiring, they may be aware of other colleagues who might be looking for an associate. Events. By attending events, you can meet other physicians in the area. Colleagues. Your former and present colleagues are a great resource. They are the ones who have worked alongside you and know you well. Colleagues can be helpful if an opening becomes available at their practice or if they hear of another opportunity. Colleagues can include people you have interacted with in high school, college, and medical school. Ask. The best advice is Ask, ask, ask! If people are not aware of jobs, many times, they will refer you to someone who is aware. Recruiters. The use of recruiters can be very beneficial to a new job seeker. The recruiter s primary goal is to fill a position for the clients they represent, whether hospitals, health systems, or clinics. Following is additional information on working with recruiters. Remember to tell everyone you know that you are looking for a job because you never

18 know what opportunities may arise. Having a curriculum vitae (CV) or résumé ready to distribute can help make the most of a time-sensitive opportunity. Resources Medical Economics: Finding a Job: Step 1: What Do You Want? Medical Economics: Finding a Job: Step 2: Start Looking Researching the Practice and Community When you have narrowed down the search to a few practices, it is important to research the practice and staff working at that location to determine if it would be a good fit for you. The following are guidelines to assist in this process: Talk with other pediatricians about the reputation of the group that you are considering. Are they respected as good doctors? Look at the CVs of the partners in the practice as well. Do they have a Web site and what can you learn about them from it? Who is the local competition? Talk with the medical society about local medical issues. Call the chamber of commerce and learn what the community has to offer. Is the hospital open to new physicians or closed? Who would be your collaborator and competition? Recent Graduates The obstacles facing recent graduates and current residents looking for a position in pediatrics are different from those who have previously undertaken this process. Recent graduates are often individuals who have pursued a career path without any experience in job searches. These individuals transitioned from one level of training to another since high school. With this perspective, the foundational skills of a job search need to be reviewed. Specifically, recent graduates are often at a loss as to when to look for a job and how to design a CV and cover letter. Identifying Goals In the first year of residency, residents should identify their career goals and attempt to tailor their training appropriately. If this entails further subspecialty training, activities that strengthen the resident s interest such as research and appropriate mentorship should be started. However, for those interested in general pediatrics, exploring different practice types while under the umbrella of training can offer much insight. Look to shadow and work in various practice locations. Residents should explore an academic practice, a rural practice, an urban practice, and all the variations in between. Discussions with program directors about career goals can be very fruitful during the later aspects of the intern year

19 For those looking for general practice, the second and third years give residents time to hone in on the location and types of practice that they are suited for. This is important because various locations may have different requirements for licensing and skill sets. For instance, an academic position may not require in-hospital coverage and thus documentation for procedural skills and staff privileges within a hospital may not be as important. Those looking in a different state may also need to start working on how to obtain a medical license and credentialing in that state. For those interested in further subspecialty training, the second and third years involve further research and applying to the specialty of choice. Currently, pediatric subspecialty match involves the National Resident Matching Program on a subspecialty-bysubspecialty basis. There has been a recent move to involve all subspecialties in the match program, but some continue outside of the match. As the specialty of choice is identified, the application process must be identified early to avoid missing the appropriate application cycle. Timeline Summary Postgraduate year (PGY)-1 Focus on surviving the intern year. Assess fit with possible careers during various rotations. Explore career goals by establishing a mentoring relationship. PGY-2 Pursue electives to explore career opportunities. Decide between general versus subspecialty practice. Initiate research as needed to strengthen career choices. Create CV and identify programs for fellowship. Identify timing for various subspecialty fellowship applications. Match for fellowship programs. PGY-3 Identify suitable primary care positions and send out cover letters and CV during the early part of the year. Interview during the middle portion of the year for primary care positions. Solidify primary care positions and negotiate contracts and benefits during the second half of the year. Match for fellowship programs

20 Fellowship Application Schedule as of Spring 2008 Specialty Admission Participates in Match Cardiology Spring to summer PGY-2 Yes Gastroenterology Spring to summer PGY-2 Yes Rheumatology Spring to summer PGY-2 Yes Allergy and Spring to summer PGY-2 Yes immunology Nephrology Winter to summer PGY-2 No Pulmonary Rolling PGY-2 No Endocrinology Rolling PGY-2 No Neonatology Winter to summer PGY-2 No Hematology/oncology Spring to summer PGY-2 Yes Critical care Fall PGY-3 Yes Emergency medicine Fall PGY-3 Yes Sports medicine Winter PGY-3 Yes Resources Association of American Medical Colleges Electronic Residency Application Service National Institutes of Health: Preparing the Curriculum Vitae National Resident Matching Program New England Journal of Medicine: Writing Compelling Physician Cover Letters New England Journal of Medicine: Working With In-House Physician Recruiters University of Chicago: Department of Pediatrics Career Planning Working With Recruiters In transitioning from training into the workforce, residents commonly receive solicitation from physician recruiters. In approaching recruiters, the job seeker needs to understand the market that the recruiter serves. Although there are national recruiters, frequently recruiting firms operate in a specific geographic area. In addition, keep in mind that the recruiter s primary goal is to find physicians for their clients. Thus, the job seeker should always be mindful that the recruiter is an extension of the position and approach interactions carefully and professionally. The use of recruiters can be very helpful to streamline the search process but does not eliminate all of the hard work. The networking that may result from this relationship can be very beneficial to a new job seeker. The following are some helpful guides in working with recruiters:

21 Know thyself. Because opportunities can be endless, it is important to have a specific picture in mind of your ideal practice before working with a recruiter. Is it in a city or suburban town? Is it a partnership or salaried employee position? Will there be hospital-based work or clinics only? By focusing your goals, the recruiter can better work with you to identify the practices that would be a good fit for you. Recruiters work for the companies for which they recruit. More importantly, they do not work for you. Recruiters job is to find suitable candidates to fill the positions for which they are hiring. In a November 5, 2004, Medical Economics article, Finding a Job: Step 2: Start Looking, Gail Weiss states that the use of recruiters may limit your bargaining power because the cost of using the recruiting firm may curb the employer s appetite for working with you on compensation such as moving expenses. Know who you are working with. You should be comfortable with recruiters style and approach. Before starting a relationship, you should check out credentials such as the history of the business, duration of stay for previous placements, companies that they have worked with, and their areas of specialty geographically and medically. Confidentiality. Finally, one of the common mistakes in working with recruiters involves not protecting your confidentiality. The key is to work with a couple of recruiters (some have suggested 2-3) and work with them closely in identifying opportunities. Prior to starting any relationship, you should insist that you maintain control as to where your CV goes. If you lose control of the relationship and fail to establish confidentiality, your CV may get out to the same employer many times over from different recruiters and thus give the employer the impression that you may be desperate to find a job. As residents and new job seekers, your time is limited and the use of a recruiter allows for additional networking opportunities. However, knowing what you want ahead of time, understanding the recruiter relationship, trusting the recruiter, and protecting your confidentiality will make sure that this is a positive experience for all parties. Preparing a Curriculum Vitae and Cover Letter Writing a CV sounds easier than it may be despite its importance to applying to general pediatrician positions and subspecialty fellowships. Although the Electronic Residency Application Service of the Association of American Medical Colleges has composed a CV for all medical students applying for residency, the components of a job-specific CV differ. There are many online resources available for help in writing a CV, but what is frequently most helpful is to look at a mentor s CV and use that as a guide in creating your own. The PedJobs CV Builder is available to assist in constructing a CV

22 Once a CV is created, cover letters are needed to submit applications for positions. In general, the cover letter expresses the interest in a position, summarizes the qualifications of an applicant, and ties those skill sets to the needs of an employer. All this is accomplished in a direct, well-written letter. Finally, cover letters should always be targeted to a specific position and employer. (Example cover letters are included.) The CV and cover letter are often the deciding factors on whether you will be called for an interview. The person hiring for the job will look at these documents to gain an understanding of your training, experience, volunteerism, and most importantly, what you can bring to the position. Therefore, it is important that these documents look professional and accurately relay the pertinent information about yourself to the reader. Following are some tips on creating a CV and cover letter: Be sure that the CV and cover letter provide an accurate description of the work that you have done over the course of your training. Include titles, names, and dates for each job that you have had since school. List all job duties for each position or training experience. The positions should be listed in chronologic order. The cover letter should specify why you are a good fit with the practice and position. Check all grammar and punctuation. Be sure that your contact information is included and up to date

23 Sample Cover Letter 1 DATE NAME, TITLE STREET ADDRESS CITY, STATE ZIP Dear Ms Smith: I am writing in response to your recent classified ad for a full-time pediatrician. I am in my final year of pediatric residency and will be graduating in June I will be boardeligible and intend to sit for the pediatric board examination later this fall. I am interested in starting with a practice this summer. During my pediatric residency, careful listening, vigilance, compassion, and enthusiasm enabled me to excel during my outpatient and inpatient rotations. Although it is a challenge to provide treatment for children who are more acutely ill or sometimes chronically ill, the true reward is in watching them heal and improve. Working as a primary care pediatrician will allow me the chance to continue to play a major role in this process. I also look forward to teaching and supervising students and residents if the opportunity arises. I am organized and hardworking, and work excellently as a team player. I hope to join a practice where I can use my current skills and continue to grow and develop new ones as I gain experience. My pediatric training at <name of pediatric hospital> has given me diverse exposure to primary, secondary, and tertiary care pediatric medicine. Because this is a large children s hospital, I have become comfortable with working in an environment where one may have to see 20 to 30 patients a day. I have an interest in asthma management as it pertains to primary care pediatrics. I also love the continuity and the preventive care aspects of this field. I am fluent in German and can speak conversational Spanish as it pertains to medical history taking. I am excited about joining a practice and feel that I would a great addition to your team. Enclosed you will find my CV. Please call me at 888/ or me at resident@pediatrics.net if you are interested in talking to me further. Thank you for considering me

24 Sincerely, NAME, Resident Sample Cover Letter 2 DATE NAME, TITLE STREET ADDRESS CITY, STATE ZIP Dear Mr Smith: I am writing to express my sincere interest in a job opportunity that your practice recently posted on I am currently a board-certified pediatrician at a large private practice clinic in southern Washington. I have 4 years of experience in private practice. I am looking to relocate to your area so that I can be closer to my family. My primary goal is to join a group practice that will provide me with the opportunity to practice the best standard of care in pediatrics. I am interested in a practice that will allow me to focus on outpatient pediatric care, especially preventive medicine. I have experience in inpatient primary care pediatrics as well and look forward to continuing those skills if the opportunity allows. As a former chief resident, I have a passion for teaching and would welcome the chance to interact with medical students and residents as well. I feel it is essential to be a strong advocate for my patients and an active participant in their care. I have served in various leadership roles at my current practice and hospital and would like to continue to do so in my career. I feel that by becoming a part of the decision-making process in my practice and hospital, I can make a difference in my local medical community. I currently work 4 days per week and 1 weekend per month, seeing an average of 25 patients per day. I have an on-call schedule of 1 in 7. Our calls typically include emergency department consultations, phone triage, admitting patients into the hospital, and attending high-risk and cesarian deliveries. I am fluent in English and skilled in conversational Spanish. I strongly believe that your practice has the potential to enable me to achieve all of my

25 goals. I would welcome the opportunity to speak with you directly. Please contact me if you are interested in setting up an interview. I have attached a copy of my CV. Please call me at 888/ or me at myname@pediatrics.net. I look forward to hearing from you. Thank you in advance for your time and consideration. Sincerely, NAME, MD, FAAP The Interview Once you have identified a practice opportunity, you will start the interviewing process. It is important to know that the interview is for the person hiring for the position and the person seeking the position. The interviewer will use this meeting as a way to determine if you are a good fit with the practice s mission, staff, and position. The interview is also an opportunity for you to examine the practice to determine if it is a good fit for you. Therefore, it is important to prepare for the interview beforehand and come with questions about the practice and community that can help you make this decision. Five Steps of the Interview 1. Get acquainted. Are you compatible? 2. Find out about the practice goals, philosophy, lifestyle, and working relationships. 3. Ask questions about the practice. Number of patients seen (per year, per day) Staffing ratios Income and financial stability Partnership opportunities and procedure Marketing techniques to gain patients Comfort with technology Payer mix Others 4. Assess practice and candidate attributes. 5. Negotiate a deal. Depending on your location and the location of the interview, the first encounter will be by phone, by , or in person. When arranging an interview, determine who you will be interviewing with, if your expenses for travel will be covered, and what the expectation is from you

26 Tips for the Interview Dress professionally for this interview. Business attire is most appropriate, even in a casual practice. Bring your CV along as well as any other information about yourself which you feel would be helpful. Make eye contact with your interviewer and listen carefully to the questions. Be sure that you answer all of the questions completely. Talk with the partners and also the staff. If possible, speak with some of the patients about what they like about the practice. As you begin your questions, do not start by discussing salary. It is better to understand the practice structure and responsibilities before getting into financial questions. If the interview will occur by phone, be sure you schedule this at a time when there are no disturbances. Be sure that there is no background noise. Following are some questions that you may wish to ask the interviewer about the position or practice. Interview Questions Following is a useful checklist to take when going in for an interview with a prospective practice. Keep in mind that most interviews proceed from the informal (eg, getting to know each other, seeing if the new physician is a good fit) to the more formal (eg, contract negotiations). Keep the checklist in the back of your mind, but avoid coming across as too forward or pushy. Remember that the group may have a set of criteria by which you are being evaluated as well. How is the practice organized? Is it a partnership or corporation, or are the physicians all employed? Who makes up the group? Are they all general pediatricians? Are there family or nurse practitioners? Is everyone working full time? Who are the actual physicians participating in the call rotation? What are the responsibilities of each physician who takes calls? What is the call rotation schedule? Are there hospital responsibilities? Do these involve nursery calls or inpatient admissions? Does the group use area hospitalists? What kind of nursing support does each physician have? Will each doctor have a medical assistant, licensed practical nurse, or registered nurse, or do they share a pool of nurses? How does the office flow? Will each physician have a set of examination rooms or does everyone use a common set of rooms? How are patients checked in and out? What is a typical workday for each physician? How do they schedule well and follow-up visits versus acute visits?