How To Find A Job

July 9, 2009
Jeff Brown, MD

Time was when docs never thought about that phrase. After training, you started your practice; a self employed small business.

Time was when docs never thought about that phrase. After training, you started your practice; a self employed small business. And the stats that are available tell us that years ago only about 1% of docs changed their practices every year. More recent information pegs that amount at about 10%.

Why the change? An almost perfect storm of factors have come together to put tremendous economic pressure on physicians. First of all, the cost of medical training has soared to the point where the average young doc starting practice is at least $150,000 in debt.

Secondly, the cost of starting a solo practice has risen to six figures. You need that much to both set up and sustain the practice for the 6 months or so that it takes to ramp up an accounts receivable to the self-sustaining level. We are talking a big load, regardless of the specialty. And the most tech-oriented specialties, such as radiology, make the entry cost impossible for a solo practitioner.

The third factor is that the loan climate is such that getting one to initiate a practice without any collateral other than your newly minted MD is problematic. I contrast, the current climate to my experience, lo these many years ago, when a banker I spoke to had but one question; "What do you need?"

Two more factors are worth mentioning. The first is that in many areas, even if you are able to rustle up the money, hanging out a shingle won't bring in a patient; they're all attached to managed care plans. So, unless you get access to these populations, which is often neither easy nor quick, you have little chance of paying your bills.

The other factor is that with the entry costs hugely escalated and cash flow indirect, coming from insurance companies, the need for some level of business acumen and training is essential. As you all have experienced, few schools or residencies provide adequate preparation in these areas. National organizations like the AMA now do have some programs, but they are late to the game and not integral to your training in the trenches where you can see it applied.

Of all the talks I have given to medical audiences, the most attended was the one I was asked to give by graduating residents on how to find a job. Because a job is what they needed, having little chance or desire to open their own practices. True, banding together for collegiality also makes sense, but economics are driving this train.

And there has been a demographic shift along with a changing medico-economic landscape. In spite of starting behind the economic 8-ball, docs surveyed say that they do not have the demonic drive to work long hours to build success, as my generation did. Shared practices, maternity issues, and a more balanced lifestyle are important to the current generation.

I spoke to Dr. Kerch, the CEO of the American Association of Medical Colleges, who documented these changes. I argued passionately for the need to widen the medical training curriculum to include some practical knowledge of administering the kinds of organizations that docs work in. We are expected to be leaders but are not given all the tools to do so, and this results in wasted time, money, and effort. Ultimately, this waste compromises the medical wellbeing of our patients, which is our sworn obligation. But you know as well as I that medical training has never been a pedagogical leader, and in our most conservative of professions, change comes slower than we might like.

So, a job with an immediate salary, no buy-in, predictable hours, benefits, no pressing need for management knowledge, and an instant practice has increasingly become the norm. To many of us who did it the other way, it may even sound pretty good, though you do have to give up some of your autonomy.

And, make no mistake, surrendering your hard-won autonomy is a big sacrifice. Both because it has been a traditional factor in people's decision to go into medicine, and because it has been drummed into us by our training and by the legal system that we bear personal responsibility for what we do. But economics and a team approach to patient care are moving us to a new era.

So, having now briefly described the context of why many docs are looking for a job, instead of creating one, stay tuned for next blog, when I'll actually get down to brass tacks. The Perils of Pauline live on....