Holding out for the right job
Where to turn
Anita J. Slomski
Your dream job? Of course you’d be able to spot it.
Not so fast, says Paul Valenstein, MD. As head of the pathology
division of the 58-physician Michigan Multispecialty Physicians
in Ann Arbor, Mich., Dr. Valenstein says he is "surprised how little
thought many pathologists give to the type of work environment that
would make them happiest." The biggest hurdle in many job searches,
he says, "is not finding what you want but knowing what you want."
And Dr. Valenstein should know. In addition to recruiting pathologists for
his group, he has hired dozens of technologists, computer specialists, and business
personnel in his clinical laboratory managing role as chief operating officer
of Allegiance LLC, a physician-hospital organization that includes a hospital
system and 750 physicians. He shared his hiring experiences in a recent talk
on employment negotiations and contracting for the CAP’s Virtual Management
College audio conference.
Ask yourself basic questions about the type of job you
want, and let the answers define your job search, Dr. Valenstein
Do you see yourself as a subspecialist or a generalist? Smaller
groups attract generalists while specialists are more at home in
larger practices. Do you want to teach? "Teaching is often attractive
to young pathologists who want to cement their recently acquired
medical knowledge. In time, however, those who do not have a natural
affinity for instructing others often lose interest in teaching."
How hard do you want to work? One of the quickest ways for a work
relationship to sour is if you and your fellow pathologists have
different ideas about when the workday should end or how engaged
a pathologist should be when on call. Be brutally honest, he says,
about the number of hours you want to commit to your job.
Which is more important to you: money or security? As in any business,
the higher your salary, the more vulnerable your job. A group that
pays its members handsomely runs the risk that the hospital or some
other client will find a less expensive pathology group with which
to do business. Where is home? Decide if you want to work in a large
city or small town, in a state with mountains or a shoreline, or
in a spot where a spouse can find work easily.
Clinical competence is important in any medical job, but too often,
employers spend all of their time assessing an applicant’s clinical
competence during an interview and pay scant attention to whether
an applicant will mesh with the group’s culture. That can be a big
mistake, says Dr. Valenstein, who admits to delving into "touchy-feely
stuff" during interviews.
"It’s fairly easy to identify pathologists with weak clinical skills; someone
from our group shows an applicant slides and other clinical material during
an interview," he says. "I’m much more concerned about hiring someone whose
expectations differ from those of the group. So I’ll tell an applicant as much
as I can about what our group is like-the good and bad aspects of our practice
and the uncertainties we face."
For an applicant, finding out about the internal workings
of the group may be tricky. "The stereotypical introverted pathologist
isn’t going to be very comfortable talking about relationships and
how the group interacts," Dr. Valenstein says. "And an applicant
finishing up a residency or fellowship will not be comfortable asking
about group dynamics."
Get a snapshot of the group by posing questions that elicit stories.
For example, to determine a group’s integrity, ask how mistakes
are handled, Dr. Valenstein suggests. "The answer may give you a
sense of the group’s commitment to patient care. Are they open about
mistakes? Do they correct reports so the correct diagnosis is clear,
even if it casts the group in a less than perfect light? If a practice
doesn’t own up to making mistakes, they have a denial problem. Everyone
Ask about the physicians who have left the practice—and
then call them and talk with them. "I would never take a job without
talking to departed pathologists and getting an explanation about
why they left that I really believed," says Dr. Valenstein. "Some
places hire young pathologists with vague promises that they will
become partners in three years. When that doesn’t happen, the pathologist
quits and the group hires someone new. "
Take the group’s history. What are the hallmark events in the
group’s past, and how has the group changed in the last year, or
the last five or 10 years? Consider querying the group about malpractice
lawsuits, and consult other members of the medical staff about the
The financial solvency of the hospital or parent corporation can
be crucial to your continuing employment—but is hard to assess.
"A hospital that is expanding can look sound but in fact be on shaky
financial ground because it is highly leveraged, whereas a more
dilapidated hospital may have lots of resources squirreled away
in the bank." But, Dr. Valenstein adds, "Unless you are familiar
with hospital finances, it will be difficult to explore this area."
It doesn’t hurt to ask your prospective employer about the tenor
of the group’s relationship with the hospital administration and
medical staff leadership. But you might not get a candid answer.
Further, relationships may change after you’re hired.
Other questions applicants might consider asking: What is a typical
workweek, and how do the pathologists cover for each other? Who
makes key decisions—the leader, shareholders, or everyone
in the group? Do the pathologists in the group expect to earn more
than the average pathologist in the region? Would the group consider
selling the practice? And if so, how will non-shareholders be treated?
Is the group’s staffing tied to income or workload? Dr. Valenstein’s
group has an internal agreement, for example, that there will be
no downsizing if the reimbursement environment sours. Downsizing
would occur only in response to a drop in work volume.
Employment negotiations are a cooperative exchange of information.
But they also have a competitive element, where each party considers
extracting more than the other may want to offer. For most people,
this is where the sweat starts to flow. Dr. Valenstein recommends
reading a few books on negotiation (see "Where to turn") so you
can anticipate the give-and-take process and keep your anxiety in
check. Also, research pathologists’ salaries in advance so you can
realistically assess an offer. The CAP, American Medical Association,
and Medical Group Management Association publish salary surveys
that can help employers and applicants understand the marketplace.
Negotiating is an art, but Dr. Valenstein ticks off a few tenets to keep in
mind. "You’ll learn more from listening than you will from talking. Also, no
matter how much you prepare, you’ll always negotiate with incomplete information
because you don’t know everything about your employer or what the future holds.
Be willing to accept uncertainty. Be prepared to trade, and don’t expect to
get everything you want. And never be dishonest—misrepresentation will
come back to haunt you. If you can’t tell the truth, keep your mouth shut."
After the group has made you an offer, you may be tempted
to sign the employment contract after only a cursory read. Don’t.
The employment contract will contain information not discussed during
the interview. Review this new information carefully and continue
discussions if something in the contract makes you uneasy.
In general, the larger the employer, the more rigid the employment
contract and the less negotiating latitude you’ll have. "With some
big employers, you pretty much have to be a nationally recognized
star to craft your own deal," Dr. Valenstein says. And don’t be
fooled into thinking the large organization necessarily offers more
job security. "A large employer may be less likely to go under,
but that security doesn’t always extend to its work force. The large
employer may be more willing to shed staff when finances are tight,
even if staff are doing a good job," he adds.
Some employment contracts will specify that your employer can
fire you at will, while others require cause for discharge. An employee’s
attorney would favor a contract that allows a group to fire a pathologist
only for cause—serious quality problems, a felony conviction,
or loss of license, for example. Dr. Valenstein is more pragmatic.
"The distinction between termination at will and for cause isn’t
as clear-cut as many people think," he says. "The moment your employer
wants to spend your salary another way, you’re vulnerable. The best
employment security is to be a good value to your employer. The
employer will always reserve the right to terminate you if things
don’t work out, one way or another."
Instead of wrestling over grounds for termination, make sure you’ll
receive adequate time to find another job if a parting of the ways
becomes inevitable, Dr. Valenstein advises. Notice periods range
from 30 days to six months.
Often, hospitals will require every pathologist in a group to
relinquish his or her medical staff privileges if the hospital contracts
with a new pathology group. Such "clean-sweep agreements" may be
offensive to a prospective employee, but they are becoming more
and more typical, Dr. Valenstein reports.
Terms of the group’s post-termination non-compete clause deserve
a close look. Although many physicians mistakenly believe non-compete
agreements are not legally enforceable, the courts have upheld the
rights of group practices to prevent former employees from competing
against the group. At the same time, physicians also have a right
to practice their profession and have successfully challenged restrictive
covenants that are too broad geographically or too long in duration.
But that’s an expensive battle to fight. Because most groups won’t
tailor a restrictive covenant for an individual physician, you’ll
have to decide if you can live with the contract’s non-compete terms.
"Keep in mind that a restrictive covenant can work in an employee’s
favor," Dr. Valenstein says. "For one thing, it may stabilize a
group because it keeps other employees from leaving just because
they are having a bad day or a bad month."
Also, a non-compete clause may encourage groups to invest in individual
employees. "We pay for our pathologists to go to certain meetings
to acquire special skills, and we promote them in the community,"
Dr. Valenstein explains. "A pathologist who capitalized on these
skills or introductions to take business away from the group would
be misappropriating the group’s investment. "
Dr. Valenstein cautions pathologists not to become fixated on
the contract’s termination clauses. "It’s like focusing on a prenuptial
agreement at the time of marriage; it sends the wrong signal," he
says. "More often than not, clinical productivity and maintaining
good relationships do more to ensure a successful employment arrangement
than anything about termination in an employment contract."
In fact, a physician who has made an effort to foster cordial
relationships in the group may find his or her employer willing
to relax the restrictive covenant if the physician departs. Dr.
Valenstein knows of a pathologist who left another group to work
at a nearby Veterans Affairs hospital. "The group waived the restrictive
covenant because there was no risk that the departing physician
would share the same set of patients, and the group wanted the pathologist
to succeed in his new endeavor," he recalls.
Independent contractors need employment agreements that spell
out specific duties, but contracts for employed physicians frequently
omit job descriptions. That’s advantageous to both parties, Dr.
Valenstein says. "In an employee-employer relationship, you want
flexibility because the work the employee performs will evolve over
time." Be sure to discuss your initial duties, however, during your
On the other hand, your compensation must be spelled out in the
contract and not left to a verbal understanding. If your salary
includes incentive pay, the formula for calculating the bonus and
the criteria for earning it should also be spelled out. While the
contract should establish that you’ll have an annual compensation
review and an opportunity for a salary increase, Dr. Valenstein
warns against insisting that the amount of salary increase be included.
"You are negotiating at a tremendous disadvantage because you
don’t know what partners or tenured professors are earning," he
says. "It may be better to put in the contract that you’ll be treated
fairly, and leave the increases to future negotiations."
Besides, employers are loath to commit to specific salary increases
in advance, because they don’t know how much money will be available.
In Dr. Valenstein’s group, new pathologists are put on a track that
leads to a "partner" salary. After the first year of employment,
a pathologist will receive a salary increase equal to one-third
the difference between what he or she earned the previous year and
what a senior physician earned. The following year, the salary increase
is equal to one-half the difference. Eventually, compensation equalizes.
"I don’t know what a new pathologist will earn her second year,
and I don’t know what I will earn that year either. But with this
formula, I can look an applicant in the eye and explain that we
will be traveling in the same boat," Dr. Valenstein says.
The contract should also identify when you’ll be considered to
become a partner, an owner, or tenured—provided your performance
is acceptable. "Employers often don’t spell out the time line and
employees may arrive with assumptions that don’t come to pass. This
creates tension that could have been avoided," Dr. Valenstein says.
If you have the option of becoming an owner, make sure the contract
establishes how the buy-in will be calculated. Some groups require
owners to purchase "good will" as well as a share in the hard assets
of a practice. Others, like Dr. Valenstein’s group, have a nominal
"The purchase price is simply a share of our commonly owned assets.
When we retire, we sell our shares in the practice to the next generation
under the same terms. It costs next to nothing to become an owner
here," he says, "but we all work hard."
If the buy-in price is considerable, the contract should state
whether you are required to get your own financing or if the group
will float you a loan and what the interest and repayment schedule
Also look for the following in the employment contract: Who will
pay malpractice insurance and what is the coverage? If the insurance
is of a claims made type, will the tail cover you after your employment
ends? What benefits are you being offered? How much time are you
allotted for vacation, sick leave, short-term disability, and continuing
medical education? How much will your employer contribute to your
Above all, be flexible when negotiating. This sends a strong message
to your future employer that you’re committed to a long-term relationship.
Dr. Valenstein’s group recently struggled over which of two outstanding
candidates would get a job offer. Ultimately, the candidate who
showed the most flexibility was hired.
"This candidate convinced us he was a better match for our group
as it exists today. He was wise about human nature and the importance
of maintaining relationships. But someday," Dr. Valenstein says,
"I hope we can hire the other candidate, too."
Anita Slomski is a writer in Evanston, Ill.