Side story….so over the weekend I received a cease and desist order from the corporate legal counsel of Ambien. Turns out that somehow they caught wind of the fact that I was about to write another overly long-winded blog directed towards physicians who are exploring new professional opportunities.
It is my understanding that sales have steadily declined over the past 3 years, which by itself is not really anything that should cause an analytics team to divert their focus from internal company processes. However, supposedly there are three rather steep and sudden declines that have moved the meter enough to clause some sleepless nights for the employees who work for a company specializing in avoiding sleepless nights. Oh the irony….
And with that let me begin by saying this is part 4 in an ongoing (some readers would say “never-ending” would be the more appropriate word choice) series of blogs to aid you in your ability to find the optimum balance between boredom and white noise in order to speed up your trip to REM-ville.
You can reference the others here:
Part 1: The Company You Keep
Part 2: Wide Nets have Large Holes
Part 3: It’s All Relative
Falsehoods aside, for this guaranteed-to-work sleeping pill I want to focus on the process that takes place once you have received your offers.
You are the physician. It has been a long and arduous process in finding the positions that you want to move forward in the process with. You’ve fielded calls from millions of those pesky recruiters pitching you every location from Alaska to Florida. You’ve had to change your number and get a new email address just to avoid having your inbox and voicemail from reaching maximum capacity by 8:15AM every morning.
Somehow, through all of that you were able to narrow everything down to 4-5 opportunities that you sincerely have interest in. You’ve found the time to cram phone interviews into your busy daily schedule. You’ve repeatedly faxed over your references, only to have to do it again and again because the fax machines were down. You also managed to change your call schedule around 4 – 5 times in order to accommodate the site-visits to each hospital. By now I am sure this process, that seemed so exciting at the beginning, has now worn you down over the 4 – 6 months that it has taken.
So here you are, exhausted and sitting at the kitchen table with 5 offers in hand. Each offer is about 15 pages long and is just different enough to make you have to really pay attention to the fine print at a time when you just want the process over with.
So here is the good news:
You are wanted, you are in demand. It is always good to be able to choose from plenty of options, as opposed to having your choice made for you due to a lack there of.
Now the bad news:
You can’t make every hospital happy. Like the NCAA tournament, there will be only one hospital that wins the tournament for your services.
After everything you have been through, this now has the chance to be the most stressful part of the process. Every health system, hospital, and practice structures their contracts a little differently based on the following:
• Quality incentives
• RVU minimums
• RVU threshold to bonus
• Dollar amount per RVU
• Loan repayment
• State or federally qualified grants
• Call stipends
• Retention bonuses
• Visa sponsorship
All of that to say, there are a lot of different factors to consider just when exploring the monetary value of your contract. Then there are other factors to explore such as:
• Restrictive covenants / Non-compete
• Vacation
• Benefits
• Retirement
• Salary guarantee
• Legal / Monetary repercussions based on breaking your contract early
This is all just the tip of the iceberg as there are many other pieces of the contract puzzle to consider. These are just the most common discussion topics that I find myself working with physicians to disaggregate in order to attempt to make an “apples to apples” comparison.
With all of that in mind I want to offer four lessons that I have learned through helping physicians navigate this process:
1. Communicate, communicate, communicate! I know, I know…. you are busy and tired. But, this is the most vital part of 
the process, even if the communication is not entirely positive. When you receive the offer, make sure you let the hospital know you received it. If you need more time, let the hospital know. Not only is this a matter of professional courtesy, but it also ensures that your offer is still “on the table” by the time you make a decision. Believe it or not, a lack of communication can be perceived as either a lack of interest on your part or a lack of professionalism, neither of which are good qualities to exude regardless of the profession you are in.
2. The perfect opportunity does not exist. Let me repeat, the perfect opportunity does not exist. This is largely a give and take process and this is where the level of importance that each of your search priorities can help you make a decision.
Which is more important to you? Location or Outpatient only opportunity? Call volume of at least 1-5 or Epic EMR? Costco within 3 hours (believe it or not I have seen this as a top priority) or 400 cases annually? Large metro or large base salary?
While there is always room for negotiation, the question you have to ask yourself is “Are my top priorities negotiable?”
If your top priorities are “variable” such as call RVUs, compensation, vacation, procedures, bonuses, or loan repayment, then yes, largely all of your offers are still valid and negotiable….within reason.
If your top priorities are “fixed” such as location, private practice, catchment area, or annual projected case volume, then no, in most cases you will not be able to negotiate these items and may possibly be able to eliminate a couple offers due to their inability to fulfill these “fixed” priorities. If you know that your family will only live in warm weather states, then unless you’ve figured out a way to transport the state of Minnesota farther south, it’s probably safe to say it’s a waste of everyone’s time to negotiate the Minnesota offer.
3. The perfect offer does not exist. Let me repeat, the perfect offer does not exist. Just as I mentioned before, this is give and take as well. There is a reason that the old adage of “You can’t have your cake and eat it too,” exists.
Sometimes being in demand can lead to believing that you, in fact, can have your cake and eat it too or as physicians like call it “work/life balance.” Trust me on this, in all professions you are going to have work to earn your money. In this case, the higher your base salary is, then the higher your RVU threshold to bonus will probably be.
If you are getting a generous sign-on bonus, then you probably won’t get as much in student loan repayment or vice versa. If you want to live near a large metro or on the east or west coasts, then the chances are pretty good that your compensation package will potentially be lower than the compensation packages that you could potentially receive at a rural opportunity or position in the Midwest.
This is where I have seen offers “die on the table” so to speak, because sometimes when you are in demand it is possible to lose sight of the idea of “give and take.” The truth is, it is not realistic to negotiate with a hospital in San Diego, CA using an offer from Arlington, NE. Regardless of what you have heard, Arlington, NE is not at the top of the list of desirable locations in the United States. For this reason, they know they are going to have to pay more to get you to choose to practice there. In other words compare “like” to “like” both geographically by region and by location within each region.
The other roadblock I have seen when negotiating offers can happen when the focus becomes about singular aspects of the compensation packages and attempts are made to negotiate those pieces individually without considering the value of the entire packages.
For example, you are comparing 2 rural offers in the Midwest. Both are offering a $300,000 base salary with 4 weeks of vacation and full benefits. However, Midwest rural opportunity A is offering a $40,000 sign on bonus and $120,000 in student loan repayment. Midwest rural opportunity B is offering $100,000 in sign on bonus and $60,000 in student loan repayment.
The value of both compensation packages are the same, but I have seen problems arise and offers disappear when individual items such as the student loan repayment from opportunity A is used to raise the student loan repayment of opportunity B, while keeping the substantially higher sign-on bonus of opportunity B the same. This is when opportunity B may ask for the offer letter from opportunity A to serve as proof. You can guess the type of negative impact that this can potentially have on an employer’s want to negotiate further.
4. If you are going to bring items to the table to negotiate, bring all of the items at once. Another old adage holds true here, “Time kills all deals.” Believe it or not, I think I have the company record for the longest contract negotiation at 13 months. If the lengths of my blogs are any indication of my ability to navigate the contract negotiation process, then 13 months probably does not surprise you all that much.
That being said, the physician I was working with brought each item that he wanted to negotiate to the table individually. Each time the hospital came to the table they thought it was going to be the last time. They would agree to the change, send the contract up to legal to be rewritten, and then send it back to the physician’s lawyer for approval. Each time, time that process took roughly 4-6 weeks.
By the third time the physician brought back another change, the hospital began bringing in new physician candidates to consider. After the fourth time, the hospital quit returning phone call and the physician was able to experience the unfortunate pleasure of starting the job search process all over again from the beginning.
That little anecdote is akin to me having you, the reader (considering there are any), start reading this blog over again from the beginning. Which by the way, if you were able to make it this far then I know a good sleep specialist that I can refer you to.
Travis Brown is a regional account manager for the Physician Division of Aureus Medical Group. He specializes in identifying the “right fits” for each individual hospital, health system, and physician he works for. He is in his second year with Aureus Medical Group following his time in sales management and teaching elementary school. Originally from Arlington, NE, Travis graduated from the University of Nebraska-Lincoln with a degree in Education and in his free time he enjoys spending time with his family, coaching basketball, and skiing in the mountains of Colorado.