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Physician Employment Contracts

Varun Verma MD- Physician Employment Contracts on the JoinAndwise.com platform

Originally published on the Andwise Blog.
Andwise empowers physicians to take control of their financial future.Founded by physicians and technologists who previously launched salary transparency and career navigation tools at Doximity™, we aim to help you achieve financial independence without it burning you out.

Physician employment contracts are sometimes incredibly complicated documents. It can be difficult to understand them, and it can be daunting trying to negotiate anything. Some of us simply focus on compensation and not much else. This is a mistake. Before signing an employment contract, every physician should take time to understand key sections of the contract. If you don’t have the bandwidth to do this yourself, there are lawyers who specialize in contract review. Additionally, Andwise has built a contract intelligence tool to highlight some clauses that will be of interest to most physicians so that you can have some awareness and make more informed decisions.

The contract term, compensation, benefits, non-competes, and duties/responsibilities are the main areas of concern for many of us. Compensation models can vary widely by specialty with some including only a salary, others include a salary plus bonuses based on productivity bonuses and quality performance bonuses may also be added, and others seem to be strictly based on productivity models with no base salary. It is also imperative to be aware of geographic non-competes when reviewing employment contracts. These can severely limit your ability to earn a living where your family is settled (think about your house, the importance of your kids in their current schools, your extended family and friends in the area, and/or your spouse/partner’s job).

Here’s a few other things to look out for based on my previous experiences being an employed hospital physician across a dozen healthcare systems:

1/ Termination without cause

Every contract will list a ‘Termination for Cause by Employer’ section that has many reasons your employer may fire you – lapses or ineligibility to renew your medical license, certain violations reported to your state medical licensing board, if you lose medical staff membership or clinical privileges at any partner hospital/clinic, if you’re convicted of a felony or serious criminal offense, if you are struck down with total disability and unable to perform your job role, and many other things. Read this section carefully, and act accordingly.

However, there is also another section that you should read carefully. Despite having a one- or two-year contract signed, there is usually a legal way for either party to terminate the relationship early that has nothing to do with your ability to do your work. Remember that this may be a blessing or a curse depending on your circumstance. Since you have no idea how day-to-day life as an employee may be just from a site visit and interview, you may find yourself unhappy, overworked, and keen to move on and find other opportunities. This kind of clause can help you escape your misery without having to ‘tough it out’ for the entire contract duration. Also, many unforeseen things happen in life such as marriage, divorce, illness etc. that may necessitate you having to leave your current job.

On the other hand – your employer may decide that although you’re technically competent, haven’t broken any of the bylaws, haven’t lost your license or failed a drug test and hence they can’t fire you ‘for cause’ … you may just not be a good match for their organization. Or something else may have changed on their end – maybe they need to slash the budget, close down your service line, or have decided to replace with you an advanced practice provider – this clause gives them the ability to get rid of you without having to keep you on for the full duration of the contract.

When negotiating the number of days – remember that getting credentialed at any new job can take some time (especially if you’re moving out of state). 90 days seems standard in many contracts I’ve seen, I would be wary of 180 day clauses because being forced to stay in an unpleasant situation will make it even more unbearable. However, I would be careful in trying to negotiate this clause down below 60 days because even if all your ducks are in a row for your new job – bureaucracy and delays within credentialing committees aren’t uncommon (and most places only have such teams meet only once a month). If you don’t rely on your clinical income to pay your bills and live life – and you value the freedom to walk away – then maybe a fewer number of days is ideal for you.

Look for something similar to this: “Termination Without Cause by Either Party. Either Party may terminate this Agreement without cause by providing XX  days written notice of termination to the other Party.”

 

2/ Who covers the cost of tail malpractice insurance

Tail coverage is liability coverage for physicians that extends beyond their previous ‘claims-made’ medical malpractice insurance coverage. If you had an ‘occurrence based’ malpractice policy in force while you were working, you will not need tail-coverage when you change jobs or retire.

The reason you need tail coverage is because States have different statutes of limitations to bring forward medical malpractice claims. You could get hit with a malpractice claim years after your employment. It’s likely in your best interest to make sure your employer will pay for this since depending on your specialty it can be very expensive. If your contract doesn’t specify who will pay – that isn’t a good sign, and it will undoubtedly create confusion, lead to disputes, and ultimately you may find yourself on the hook. One of my plastic surgeon friends had to split the cost of $38,000 with his former employer because the employment contract failed to specify who would pay and neither party was interested in ‘lawyering up’ and suing the other.

Look for something similar to this: “Employer shall purchase on behalf of Physician appropriate extended reporting insurance coverage (“tail coverage”) for claims, demands, or actions reported in future years for acts or omissions during the period Physician is employed by Employer.”

3/ Limitations on your side gigs/“exclusive engagement”

Since employers expect you to be focused on your time at work – they can and often do stipulate that you need written approval ahead of time for any outside work as a healthcare professional. If this is something you are interested in pursuing, perhaps it is best to have the conversation ahead of time and have it written into your employment contract. You won’t have much recourse if you sign the employment contract with prohibitions, and if your request is denied at a later time.

An example of the language is: “Physician shall only provide professional, clinical, managerial, directive, consultative or other services as an employee of Employer, and shall not provide professional, clinical, managerial, directive, consultative or other services to or on behalf of any third party, whether or not for compensation, without Employer’s prior written consent.”

Also, obviously your employer will not cover the malpractice insurance for your side gig and they often have terminology to outline this: e.g. “ Physician understands that in the event Physician provides such services to or on behalf of any third party, Physician shall be responsible for securing insurance coverage for any such services and shall not be covered in connection with such services by Employer’s provided insurance coverage.”

 

4/ Royalties and intellectual property

Have an awesome idea for writing a book or invention? Don’t get ahead of yourself since your employer may lay claim to a percentage or all of your work. If you’re a full-time employee, your employers are paying for your full time effort and you may have a hard time proving you didn’t use company resources while working on the project.

They may specify that you’re only eligible for a fixed dollar amount of profits, or a percentage, or all of it goes to the institution.

Examples of such language Institutions include to stake their claim:

Fixed Dollar Amount

e.g. 1 “If Physician, with the prior written approval of the Employer, generates honoraria, royalties or other revenues in connection with giving lectures, writing books or articles, or carrying out medical/legal reviews, Physician may retain only such revenue up to a maximum amount of XX Thousand Dollars ($XX,000.00) per year. Employer will be entitled to any amount more than XX Thousand Dollars ($XX,000.00) per year.”

Percentage

e.g. 2 “In general, royalties on Inventions, Copyrightable Works, and Tangible

Research Property, net of certain expenses attributable to protecting and licensing the

property, are distributed as follows: 25% to the Creators, 25% to the Creators’

Laboratory or Unit, 25% to the Creators’ Department or Service and 25% to the

Creators’ Institution.”

They own it all.

e.g. 3 “The Medical System owns all Intellectual Property, whether tangible or intangible, developed by an Employee within the Scope of Employment or using Medical System Resource”

Varun Verma M.D. is a board-certified internal medicine physician, patient advocate, entrepreneur and author.  He is a co-founder of Andwise – a company dedicated to helping physicians thrive. Dr. Verma graduated from New York University, Rutgers Robert Wood Johnson Medical School, and returned to New York University for his internal medicine residency. Since then he has worked in a dozen hospitals, across five states and three countries. In addition to his clinical pursuits – he is a published author, has co-founded a venture-backed healthcare IT startup, and serves as an advisor to startups. His interests include patient advocacy, patient safety, physician burnout, healthcare professional wellness, healthcare startups, healthcare IT, and quality improvement.

 

The information contained in the Andwise blog is for educational purposes only. It  should not be considered financial, legal or medical advice. The author and Andwise Inc. disclaim any and all liability to any party for any direct, indirect, implied, punitive, special, incidental or other consequential damages arising directly or indirectly from any use of the blog. The blog is provided as is, and without warranties.

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Patience and Listening

The twilight of spring brings graduation season, our ritual of milestone celebration towards a still to be defined professional and life goal. I distinctly recall the evaporation of this vagueness for my medical school graduation. It felt more concrete, more substantial in its singularity than the accumulated individual graduations preceding, and necessarily prerequisite. However, possessing an MD and being a doctor are not one in the same. Fortunately for physicians, we have a highly regimented and ostensibly replicable apprenticeship program in our various disciplines, across the country. The graduated responsibility granted during the process of learning embedded in working is quintessential to our professional maturation. As the current iteration of graduates begins their intern year (you!), they’ll undoubtedly receive sage advice from august physicians, which will undoubtedly be drowned in the incessancy of pager beeps during the first overnight call.

And that’s okay! I know for a fact I received excellent guidance on managing the rigors of residency while sorting through the disorienting process of identifying career path. I also know for a fact that while I heeded some, I regretfully forgot most. However, what is now keenly manifest with lens of hindsight, is that that this advice only buttressed lessons learned only through invaluable experience. The camaraderie of your instant colleagues and friends, witnessed and experienced emotions across the human condition, the asymptote like learning curve, and the gradual sense of craft via implementation of painstakingly acquired knowledge, often under duress, is without substitute. As I reflect on my intern year and residency, I can say I thoroughly enjoyed it and suspect at the end of my career I’ll view it as one my favorite professional experiences. Admittedly, there is no better assuager of the difficulty, sleep deprivation, and loneliness experienced during residency than time away from residency. Moreover, my views are shaped by the luxury of being single and without children at that time, whereas some of my colleagues had to balance considerable family responsibilities as well. Even with these concessions, I still loved my training and I suspect you will as well.

So what did I learn during my intern year and training in general that is transferable? I struggle with this, because my most impactful personal lessons allayed my most irrepressible personal flaws. As such, what was necessary for me may not be applicable to the current generation of physicians are who are hopefully more evolved and, well, woke. I was incorrigibly arrogant, impetuous in wanting to be heard rather than hearing others, and guilty of ingrained preconceptions resulting in uninformed assumptions on staff, nurses, patients, and colleagues in other disciplines. To be fair, these are seemingly axiomatic to physicians, facilitating rapid self-acceptance, particularly during the inevitable periods of self-pity invoked by 80 plus hour weeks, nights and weekends spent in a drab, cold call room. To paraphrase Yoda, it took years to unlearn what I had learned.

Through public and private humiliations, thousands of patient interactions, a gently critical wife, and identification of my personal role models, I arrived at the two skills which have helped me the most professionally and personally: patience and a genuine ability and interest in listening to others. These may seem trite, and superficially simplistic, but I’ve found to be incredibly challenging but most rewarding when to implemented into practice. I recognized within the first few months of internship that if I were to achieve any degree of professional satisfaction, it would be a career built upon these pillars.

Patience is multifaceted, silently contorting to be of utility in nearly all situations. You will rarely get credit when you exercise it, but it’s absence will palpably disheartening to those in your charge. I was praised for my patience growing up, but that was an untested version. The residency workload is intense and compounded by your still maturing clinical acumen. As a consequence, I found myself impatient with patients when they were elaborating on their histories in a manner I found tangential, or when it didn’t align with my assumed diagnosis; with nursing staff or techs when I had comically naive expectation of instantaneous execution of my orders rained down from the Mt. Olympus of call room computers; out of myself for not knowing as much as a 3rd year resident or a board certified attending with two decades of experience. I was impatient with my status of my life compared to my non physician peers, my paycheck, and the seemingly interminable training. Residency goes at light speed, but the end of it always seems to be on the opposite end of the universe.

This crystallized rather quickly in my second month of training, on the afternoon end of a particularly brutal 30-hour ICU call. My patient, a new paraplegic from a motor vehicle accident and suffering through the relentless medical complications thereof with astounding positivity, kindly asked me to be less curt with his wife when she was asking questions about his progress. I was crushed, but it still took a while to morph a self-absorbed notion of personal failure into a tangible lesson.

I suppose this episode straddles the nebulous boundary between patience and listening, and perhaps they’re poles of the same thing. Too often though I found myself speaking (and interrupting) first, thinking second, and breezily listening third; perhaps it was a misplaced attempt to broadcast my sense of my own intelligence. Perhaps I felt that only after certain conditions were met, would someone merit my undivided attention. With time a few things stood out: There are many, many people far smarter than me. If they’re not smarter than me they’re more experienced than me, which inexorably makes them smarter than me. Perhaps most importantly, I recognized the large swaths of knowledge, insight, skilled judgment I was leaving by the wayside. When I didn’t focus on the person in front of me, I undervalued them and my own education

So patience and listening. If it seems anticlimactic, it’s because it is. The grander themes on the role of medicine and the human condition have been more eloquently elaborated upon by many talented physician writers. They are worthy reads and will supplement your own experience as you sculpt your career into what you want. There are other pieces on self-preservation and combating the loneliness that can seem enveloping, also worth your time. My general advice is purposefully vague, but hopefully holds small value in recollection during trying patient and professional encounters. They are hard skills to master and implement, particularly when time seems perpetually unavailable and the work demands are ever increasing. However you will get better at your craft, your acumen and decision making will speed up exponentially, and all of a sudden you will have more time even in small ten minute encounters to experience why you went into medicine in the first place. Residency, and internship in particular, is hard; but I loved it and hope you have as rewarding of an experience as I did.

Mitul Gandhi M.D. is Board-Certified in Medical Oncology, Hematology, and Internal Medicine and works at Virginia Cancer Specialists

Dr. Gandhi for Virginia Cancer Specialists

 

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Discomfort Is The Currency Of Your Dreams

If I could go back in time and advise myself as I began residency, I’d tell myself that “Discomfort is the currency of your dreams.”

Life Coach Brooke Castillo imparted this wisdom in a podcast interview with a fellow entrepreneur, Amy Porterfield. This idea is aptly applied to medical training, which is notoriously tough. There is a lot to learn in a short period of time, from medical knowledge to navigating difficult conversations. The experience gained in training forms the groundwork for a medical career; it’s not supposed to be easy.

Unfortunately, our tendency to resist or dwell on discomfort can make it worse, increasing the associated negative feelings, and wasting precious time. Instead, consider: if you’re uncomfortable in medical training, that means you’re doing it right. If I could advise my younger self, I’d tell her to lean into the discomfort as she learned each of the following:

Patient care

As you learn to care for patients, there are plenty of mistakes to be made. Sometimes you’ll beat yourself up over an error; other times you’ll be reprimanded by a superior. You’ll be corrected by everyone from the Department Chair to the janitorial staff. As uncomfortable as this can be, accepting feedback is part of your job as a trainee. The senior residents and attendings you admire have spent years honing their skills. To achieve their results, they have endured discomfort, and grown through the process, to achieve the dream of helping their patients. Accepting discomfort as part of the learning process will help you to avoid augmenting your own pain.

When you struggle to get an order set to the pre-operative nurse through the new electronic medical record (EMR) despite many attempts, for example, you may want to bang your head against the desk. You could worry about why you have trouble with these order sets, while your peers seem to get it just fine. Rather than avoiding the EMR or asking someone else to do the task for you, get extra help with Information Technology (IT) if needed. Learn to work through the disconnect in workflow, communicating with the nurse, even when you feel like giving up. Navigating these kinds of challenges in a high-stakes, time-constrained, or frustrating environment can mold you into a better doctor if you let it.

Self-directed learning

After you have half-jogged, half dragged yourself around the hospital all day, when you arrive home, crashing on the sofa may seem like the next logical step. But no matter how much you’ve learned during the day, it’s not enough to become a solid physician. You need to leverage time outside the hospital too. This will often involve leaving home, securing some caffeine, and reading until you’re bleary-eyed.

Tomorrow, on rounds, the surgeons may “pimp” you on the five most common causes of pancreatitis, and it’ll be scary. If you can’t rattle them off on the spot, it can feel like public humiliation. The Socratic method is uncomfortable, but it’s preparation for the moment you are asked the same question by an anxious mother. The toiling and testing you endure will allow you to answer her with confidence, and explain the next steps in her son’s work-up. Her relief and comfort is your reward. In this way, pushing yourself to learn all you can is the currency of your dreams.

Becoming part of the team

Effectively working within a healthcare team involves a steep learning curve. Immersed in a new culture, you learn how each member contributes, from nursing to ancillary staff. There is a communication style unique to the environment, which you must hone as a physician and leader. There is a diplomacy to working with those around you, as you learn and make mistakes in training (and beyond). During this process, your ego will be tossed about, like a little sailboat on a stormy sea. This is normal. Learning team dynamics and their countless nuances is a challenge.

Humility is everything. For example, while interviewing a patient, you realize you missed a key part of their history, changing the conversation between you. Rather than acting like you knew something you didn’t, or blaming a colleague, you can quickly acknowledge the feeling of unpreparedness, and move on, working to rectify any gaps in knowledge.

When you inevitably order the wrong medication or dose, fix it right away, and realize that to err is human. Being wrong is the price of entry in medicine, and your team can help alert you when this occurs. In fact, when all staff feel empowered to speak up regarding potential medical errors, it makes the care environment safer.

Patient communication

Communicating with patients is a worthy challenge, especially in times of duress. When health fails, or devastation occurs, we help guide the patient and their loved ones through it. Navigating these situations requires developing a skill-set. Sometimes displaced feelings of grief, confusion, and anger fly our way. When this occurs, stepping into the discomfort can help you become a compassionate and masterful communicator. As a budding physician, this work is the currency of your dreams.

Self-care

Accepting discomfort as a part of the training process is an act of self-care in itself. Doing so will help you move through training with resiliency and agency. When you view discomfort as a tool for growth, rather than something inflicted upon you, there is no need to dwell on how things should be different. Like the soreness that comes from working a muscle, you can feel the burn of fatigue, and accept the discomfort that lasts days later, knowing you’re getting stronger. There are countless ways to care for yourself in training, and I recommend practicing some, like those described in this tongue-in-cheek beauty guide for interventional radiologists.

I sometimes catch myself avoiding uncomfortable moments, or procrastinating on tasks I need to accomplish. The work of a doctor can be complex, mundane, grueling, or joyful, depending on the day. Sometimes it can be all these things at once. Embracing discomfort in training will allow you to become the best physician you can be. You’re the driving force when you realize that discomfort truly is the currency of your dreams.

Tired Super Heroine is an interventional radiologist and toddler mom in Southern California, writing about career, lifestyle, and financial empowerment for physicians. The blog can be found at tiredsuperheroine.com

 

Tired Super Heroine

 

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Advice For New Physicians: Thriving During Your Residency Odyssey

Even though my own internship was a decade ago, I vividly remember the transition from student to resident. Residency was monumental in my path to becoming a physician. There were obvious changes; people now called me “doctor,” my misshapen short white coat was upgraded to a comforting full length one, and I was often the first one paged to respond to patient problems. Coupled with the positive aspects though, I also faced some challenges. I struggled with depression, my relationship with my girlfriend was strained, and I felt overwhelmed as I contemplated switching specialties after my second year (from ophthalmology to internal medicine).

Despite the stress, I look back with fond recollection and a realization that the tremendous experiences and camaraderie can never again be replicated. As a resident, I was privileged to help take care of an underserved population in New York City, learned from inspiring teachers, and worked hard alongside talented co-residents (some of whom will undoubtedly be lifelong friends, and one of whom I married).

This is my advice for thriving during your own residency odyssey:

Take Care of Yourself.

This sounds obvious but not enough residents make this a priority. News headlines and blogs are exploding with discussions about physician burnout (and sadly also the prevalence of physician suicide). It’s imperative that we begin investing deliberate effort into physician wellness. My four cups of coffee per day, depression-fueled binging on cookies at midnight, lack of exercise, and suboptimal sleep did not make for good health. By the end of residency I weighed nearly 15lbs more than at the start. The simple fact is that if you don’t take care of yourself, then you won’t be able to effectively take care of your patients. Whatever challenges you face, you must seek help from loved ones, peers and professionals to actively manage them. Too many highly-functional intelligent professionals try to power through obstacles and then one day shatter because they refuse to tackle problems in the manner as they would advise their patients.

Be Interested in Others.

This starts with your patients. Mrs S is not just “some demented lady in bed 3.” Taking time to truly learn about the patient will help you maintain empathy, and get you through the brutal paperwork, bureaucracy and inefficiency that is omnipresent in healthcare. This attitude should also extend to your coworkers, nurses, techs, and all the non-physician professionals that make healthcare possible. You’ll have to interact with these nice folks for at least a year (and maybe 7 years if you become a neurosurgeon). Finally, learn their names and introduce yourself. As Dale Carnegie teaches “a person’s name is the sweetest sound to that person.”

Make Time to Learn.

Realize it takes time and effort to acquire knowledge. A brilliant critical care attending once barked at me “reading UpToDate is not the only reading you need to do.” I scoffed at the time because I was looking for a quick-fix, but of course he was right. Making a sincere consistent effort to learn despite your difficult day is a real challenge. Did you do well in medical school and on Step 1, 2 and 3? Congratulations, but now all of that is behind you. Having a baseline knowledge is a prerequisite but not the end point. Remember that you’re not being judged by your performance on a multiple choice test anymore… real patient lives are on the line.The best residents I’ve seen begin reading board review materials as they go along during their training, rather than trying to cram in learning at the end. Malcolm Gladwell notes that 10,000 hours of “deliberate practice” are needed to become world-class in any field.

Don’t Abandon Your Other Passions.

Repeat after me: I will have a life outside of being a physician. You of course already know that there are no guarantees in life and time only moves in one direction. I am telling you very frankly that physicians can become patients at any moment, and that the future is actually quite uncertain. During residency I made it my mission to go overseas during every single vacation I had. I ate a lot of instant noodles to save up for these adventures, but it was well worth it. I also made time every week to reunite with old friends for a relaxing dinner. Many people do make time for things they love, but there are a few that seem to never escape the pull of the hospital. These physicians seem to be at greater risk for burnout. Plus, neglecting the outside world doesn’t guarantee that you’ll be smarter or save more patients than if you step away to energize during your time off.  I implore you to not abandon your other passions for your medical work. Make sure you live all aspects of your life.

Learn the Rules.

Every place you will ever work will have its own culture and set of rules. If you’ve made it this far you’ve probably realized that healthcare can feel like a dog-eat-dog world; with a hierarchy and rituals that must be respected. Dr A likes labs presented a certain way, Dr Z likes interns to be at the front and center of case presentations, but Dr Q wants you all to shut up, be invisible and listen to the attending. All of it is irrelevant in the end, and yet all of it is vitally important for your survival in training. Millions have come before you through this gauntlet. Learn the rules of the game, and you will thrive.

Realize That Criticism Is Not Personal.

When I was an intern, I responded to a rapid response that turned out to be a presyncopal episode in a patient that had just finished dialysis. I examined the patient, analyzed the labs, talked to the nursing staff, and initiated an appropriate plan (a small bolus of IV fluids). Immediately after I was finished, the private attending appeared and berated me in front of everyone. “You are the worst intern I have ever encountered!” I was frozen, I felt like crying, and I could feel my entire face quivering. What had I done that was so terrible? I knew I wasn’t encyclopedic in my medical knowledge but “the worst” seemed harsh. He was basically angry that I had touched “his patient” despite the fact that it was my job to go to rapid responses. Many will undoubtedly recall similar stories of people unloading their frustrations. You have little control over the personal lives or toxic personality traits of others. Learn from your mistakes, pay attention to actionable criticism from superiors, but don’t let random angry ramblings get you down.

Resolve to Be Better.

Having now worked as a hospitalist in a dozen different hospitals around the US – I’ve made it a goal to improve my interactions with coworkers. Despite this, I’ve had my momentarily despicable episodes. In one of my first attending jobs I became extremely irate with a nurse after she openly questioned my management in front of a patient’s family. I cut her off mid-sentence, presented her with the science, reiterated my sound treatment plan and then stormed off rather dramatically. However, I returned to the unit 10 minutes later to apologize for my actions. I remembered how horrible some of my residency interactions made me feel and realized that she was speaking out in the interest of the patient’s safety. I obviously should have acted differently. It takes conscious effort to not become that which you despise.

Remember Your Oath.

The Hippocratic Oath may have been conceived in ancient times, but it is still sacred and relevant. Every year the media is flooded by some inconceivable story of professionals doing bad things: scandals, billing fraud, unnecessary procedures, taking kickbacks… the list is endless. Strive hard to not to become one of these people. It’s bad for your career, it’s horrible for your family, and it is a complete waste of your talents and sacrifice.

I wish you well in your journey!

 

Varun Verma MD is a board-certified Internal Medicine physician who works as a hospitalist
Dr Verma


Varun Verma M.D. is a board-certified internal medicine physician who practices as a hospitalist. He believes that healthcare is a human right, and has worked across the US and internationally in resource-limited settings. You can read more of his posts at his blog, and connect with him via Twitter or Facebook.