In this series addressing the training of the rural physician, we've covered education, residency, procedures, rural problems and the type of intellect--the generalist's mind--suitable for people providing health care in remote locations. But once young doctors have completed medical training, how should they go about finding a job in a rural location? This post will discuss job-seeking and job choice for rural doctors.
Residents often get so swept up into the crushing pace of their daily lives that it is well into their final year before they realize they have to get a job just like everyone else. Fortunately, doctors are generally in high demand and many employers will be on the hunt for their services. Common wisdom would have you pursue your first job through a number of standard venues:
- Specialty-specific conferences, where prospective employers will have booths in the vendors hall.
- Classified listings through your national specialty organization, such as the American Academy of Family Physicians Classifieds and Career Ads, the American Academy of Pediatrics PedJobs site, and the American College of Physicians Career Connection.
- Physician headhunters.
My advice to residents turns the common wisdom on its head. Attending conferences may be useful, but I have yet to meet anyone who found their dream job in the vendor's hall. Classified listings are often out of date once they hit print, although the online versions might be more timely. As for headhunters, my only experience with them was getting calls in the middle of busy days when I was trying to get sterile gloves on and got interrupted by someone saying "Doctor Chan, Fred Friendly here with DocGrabbers. Do you have a minute to discuss some great opportunities in primary care?" Uh, no.
My advice to final-year residents preparing for rural practice: Decide where you want to live, then find a job.
Most of the doctors I've talked to say location matters to their job satisfaction. Even the most perfect job in the world will become a burden if you have to make a lot of sacrifices just to be near work. This is especially true if you plan to live in a small community more than 60 minutes drive from the type of environment in which you feel comfortable. If you like leather bars, you'd better not move farther away from the Castro than Berkeley; if you live for long backpacking trips, you'd better live within sight of the Sierras. To tell the truth, even a 60 minute drive is too long when it's Wednesday afternoon and you develop a wicked hankering for steamed shrimp dumplings with finely chopped chives. Trust me, these cravings have as great an impact upon your professional life as your call schedule.
So be carefully picking a place to live. Don't take anyone's word for it, go and visit the place, and visit more than once if you can. I started thinking about Rural even before entering medical school and took a few long weekends up here, in different seasons, to see if I really liked it. One time I was wandering aimlessly in one of the larger towns south of where I live now and saw a small crowd of people dancing down a road. It was the local samba association's Carnival parade. There were about eighty dancers, an antique fire truck, and a boom box, and the whole parade lasted about 15 minutes. As I watched the dancers samba-ing away, I knew I had found my new home.
Once you've chosen a location, do one simple thing: send a copy of your CV to the county medical association. I did this on one of my vacations in Rural, not thinking I'd get a response. I emailed a PDF to the medical association's secretary, and the same afternoon I had phone calls and emails inviting me for interviews. Mind you, I was on vacation and didn't have an interview suit, but people told me to come and meet them anyway. It was much later that I told them I never wear suits, but that's another story.
Identifying the region in which you want to live narrows your job search considerably and you can spend your time considering the merits of fewer positions in depth, rather than a larger number of positions superficially. Some things to consider and negotiate:
- Moving allowance: This is usually part of a first job offer, but ask if your new employer can cover more of your move than they initially offer. If they can't, be aware the cost of your move is tax-deductible if you are moving more than 50 miles away for a new job.
- Insurance and retirement benefits: I've addressed how important these are in the Meconomics series, Part Four and Part Five. Read the material your prospective employer gives you carefully. Consult with a more experienced colleague or a trusted financial advisor if you don't understand the benefits you're being offered.
- First-year schedule: What kind of clinic schedule are you expected to have? How often will you be on call? Ask to see printed call schedules, because numbers never tell the whole story. Talk to the doctors already working there.
- Opportunities to do outpatient procedures/special clinics: If you are going into a primary care position, it really helps if you're allowed to block out special clinics for office procedures or other special kinds of visits. For example, in my FQHC I was allowed one afternoon clinic per week for procedures, which meant I could fit many more in than I would have been able to do on a standard clinic schedule.
- Administrative time: Every primary care job should address how you will be compensated for a reasonable amount of administrative time. Review this term in your contract carefully. You will do a lot of admin in primary care and you should have the opportunity to be paid for a reasonable amount of time to fill out paperwork, keep up with labs and refills, etc. If you take on any extra responsibilities, ask if you can be compensated specially. For example, at my FQHC, we'd often have clinics staffed by physician's assistants but no doctors, especially around the holidays. I agreed to be available for consultation on these days, but only for a bit of extra admin pay.
- Signing bonus?: Some locations are so difficult to staff that you may be offered a signing bonus to take the job. Even in more desirable locations, you might ask for and be granted a bonus if you are an experienced doctor in some needed specialty. Don't get stars in your eyes about these bonuses; read their terms carefully. There is usually some minimum contract commitment, staged payments, and repayment penalty if you leave before the time requirement.
Finally, when you've settled on a job you like and a community you like even better, it's time to face the paperwork. AAMCAS and ERAS are nothing compared to the paperwork you need to do for your first doctoring gig:
- If you are moving to a new state, you must apply for a medical license. This can take months, so start early. You usually need to be fingerprinted, submit copies of your current license and DEA certificate, and several documents to verify graduation from medical school, including certified copies of diplomas, grade transcripts, and a lovely piece of paper that says "Theresa Chan was a medical student here from xxxx to yyyy dates and graduated in good standing in yyyy." Redundant? Yes.
- You will have to read, understand, and sign a contract for your new job. Some good advice I did not follow was to engage the services of a lawyer familiar with physician's legal matters review any contract before you sign it. This service comes with a pretty good price tag, but if you are working with a reputable attorney, you can at least feel assured that the document you will be signing is within industry standards for your line of work. I think it's a good idea.
- You have to be credentialed for all the insurers to whom your professional services will be billed. This includes Medicaid and Medicare (including obtaining a National Provider Identification number), and any of the big private firms active in your new state and region. The slab of paper involved in credentialing is truly staggering. I don't know why it is not effectively computerized yet, but it is not. Just brace yourself.
- You must apply for privileges at the hospital(s) where you'll be caring for patients. Again, this involves a truly horrendous stack of paperwork and the writing of a check to the medical staff office of the hospitals. You'll have to provide professional references and documentation of all the procedures you want to be able to perform. This is why record-keeping of your procedures during residency is very important.
Once you've filled out all this paperwork and followed up on all the lost documentation, incorrectly filled out zip codes and other queries, you'll be a fully-fledged rural doctor! Now the hard part begins.
Next Week: Ideal personal qualities of a rural doctor.