Danny Issa, MD
Interventional Endoscopist and Assistant Professor of Medicine
UCLA David Geffen School of Medicine
September-October is an exciting and unique time of the academic year. It is that time when the first-year fellows start getting to the cecum consistently (kind of!). The second-year fellows settle down on what they want to do in life post-fellowship and get a good grasp on a research project or two. It is also that time of the year when the third-year and fourth-year fellows start looking for their first job as gastroenterologists. Here are some tips that can help graduating fellows with their job search.
1. Looking for a Job Is a Process
Like most big steps in your medical training and life, looking for a job is a process. You learn more about what you are looking for and what is offered as you go through it step-by-step. It is always recommended to start early. Most fellows start thinking about their ideal first job at the end of the second year. However, the actual process usually begins in the third year. During the planning phase, be brutally honest with yourself. Know which of the following factors make you happy in a job:
- What type of practice do you see yourself at?
- How much money do you want to make?
- Where do you and your family want to live?
- What kind of hours do you want to work?
The sooner you set your priorities and outline your goals, the easier it will be, and the more open slots will be available. But, on the other hand, if you are open to moving, you will need to dedicate time to visit and compare different options to settle for the best-fitting job.
2. Know What Type of Practice Fits You Best
A few practice types are available for graduating gastroenterologists. It is paramount to know which style works best for you. Usually, this is something you know early in your training. Knowing the type of practice you want to pursue makes everything easier for you down the road. Here is a breakdown of the common practice types in the United States.
Traditional Academic
These are the university-based academic positions. Usually, when you choose an academic job, you must be interested in at least one of the two main tracks: teaching or research. Teaching is gratifying for many, while research needs more planning and goal setting. Academic practices tend to see more complex referral cases.
On the other hand, you can utilize the resources available at large/medium-size centers. Most universities have dedicated steps for promotion at the academic level. Some start you as an “instructor” for one or two years, followed by an “assistant professor” rank. When you meet the promotion criteria (which usually takes about seven years), you move up to the “associate professor" and, later, “professor” rank. The promotion criteria are based on education, program building or scholarly activities. It is recommended that you inquire about these criteria and perhaps meet with a representative from the promotion committee while interviewing for an academic job. Many academic jobs offer a fixed guaranteed salary for the first two to three years, followed by an RVU (relative value unit) model based on your productivity. However, some continue to offer fixed salaries. There are advantages and disadvantages to both.
The average income for a gastroenterologist in the US, according to the annual Physician Compensation Report, is over $400K. Although most opening positions are expected to be advertised, some academic openings might not be searchable on a “quick” Google search. I advise contacting the head of the division directly if you have a strong interest in a specific program.
Private Practice
Private jobs often mean joining an established group of gastroenterologists or a multispecialty practice. These jobs usually require long hours of work and come with higher compensation. Having more control over your schedule is a significant attraction that physicians usually have in addition to being more lucrative. It is essential to ask about a fixed guaranteed salary to start and a track toward partnership.
The latter means, at one point, you may become a partner and benefit from additional revenues such as shares in the ambulatory surgical center, the pathology lab or others. It helps tremendously if these opportunities are written in clear legal language.
Call schedule is another big factor when it comes to private practice. How many physicians will be rotating in the call schedule? How many nights per week and weekends per month? Do you have to cover multiple hospitals?
These are all important points to clarify early during the negotiation period.
Hybrid
Over the past few years, many major academic centers started expanding into the community, building new endoscopy units and clinic offices, or acquiring/affiliating with community hospitals. As a result, hybrid jobs are becoming more common. You need to know the details of such a job:
- How much time will you spend at the “main campus”?
- Will you have encounters with trainees?
- How is the compensation based?
- Perhaps most importantly, how many locations do you have to cover?
Usually, these positions give you the autonomy of community jobs while maintaining connections with an academic center. You will typically have access to the resources available at the university, which can help you take better care of your complex patients yet still be able to refer the conditions you don’t treat. Knowing these specifics and ensuring they meet your search criteria will help both sides.
Veterans Administration
There has been a national trend toward favoring Veterans Administration (VA) jobs over the past decade. The VA departments now commonly have many young and mid-career faculty. In a VA setting, you have firm job security. Patients will always be available. Resources are abundant when it comes to staff, equipment and expertise. VA grants are also less competitive than national grants.
On the other hand, salary is less in the VA, with no RVU system; therefore, limited possibility to increase your income when you work harder. Another challenge could be a lower-case volume when it comes to therapeutic endoscopy, for example.
GI Hospitalist
While its use in gastroenterology remains narrow, several recent articles showed a positive experience with the GI hospitalist model. This model provides job security, given the extremely common hospital admissions for primary GI diagnoses. It removes the need for marketing and the dependence on referrals. You will be performing endoscopic procedures almost daily, and it likely offers more free time with the one week on–one week off schedule.
Alternately, there is no continuity of care as you would only be responsible for inpatients. Advanced practice providers (such as nurse practitioners or physician assistants) will likely improve efficiency and decrease burnout. More data is needed to understand the potential advantages and disadvantages of a GI hospitalist model.
Of course, many factors play a role in which type of practice to choose, including family situations, student loan debt and others. Remember that recent surveys show that many physicians change their first job after three years, although traditional teaching is to aim for five to seven years.
3. Talk to Your Mentors and Advisors
Having a willing mentor who has your best interest at heart is essential during the training and in your early career. You should do your best to find a mentor, either locally at your training program or remotely. Discuss your career goals with the mentor early on. Inform them about your geographic interest and ask for help connecting you with certain places of interest.
I’ll take the chance to remind you that ASGE offers a mentorship program called Beyond the Scope. Mentors can be in their early career or senior level and from various practice settings and geographic and demographic characteristics. The program is designed to cultivate relationships between fellows or early career physicians and experienced gastroenterologists.
Contact Bina Mesheimer (bmesheimer@asge.org) for more details.
4. Taking the Next Steps
Let’s say you completed the interview and are ready to sign. It is highly recommended that you have the contract reviewed by an attorney. In addition, specialized employment attorneys can help you ensure you did not miss anything important in the contract, especially regarding compensation structure, non-compete, tail insurance, etc. Therefore, it is important to compare your projected salary to the Medical Group Management Association (MGMA) national report of that same year, which shows the median starting compensation based on your geographic area. Traditionally, Midwest and Eastern parts of the country have higher starting compensation, followed by Western and, finally, Southern states.
Here are some useful links for contract reviewing services (no conflict):
Physician’s Contract Review
Resolve Custom Contract Review
I found it helpful to classify my requests when negotiating a contract: important points (deal breakers) versus things I like to have but are not essential. For example, sign-on bonuses and relocation reimbursement are helpful to ask for, and most places offer them. Still, they are not deal breakers if the job sounds otherwise excellent. On the other hand, in some cases, dedicated time for endoscopy or dedicated research time are “must-haves.” Another detail to pay attention to is the non-compete policy. Although that is usually institution-based and hard to negotiate, you need to know it ahead of time before signing.
5. Final Comments
Job turnover is high the first few years into practice. Research shows that most graduates don’t take the time to go through the process, which can explain the high turnover. Don’t jump into a job for the wrong reasons. Know your goals and your deal breakers. Professional and personal happiness usually go hand in hand. Consult with your family and your mentors. Trust how you actually feel after you’ve interviewed. Be honest and transparent and, lastly, be excited; you finally get to choose, and hopefully, you’ll pick the right job for you.