College of American Pathologists
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Holding out for the right job

Where to turn

March 2002
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 advises.

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 makes mistakes."

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 pathologists’ reputations.

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 negotiations.

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 buy-in.

"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 will be.

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 retirement fund?

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.