I definitely want to spend some time with you all on this next topic which I would think is one of the key issues for you. How many of you are not yet spoken for after fellowship, have a contract signed and sealed in hand? How many of you are still either applying now or will apply at some point in the future? So the majority, very good. Now the old person here in the front of the room is going to talk to you about interviews so I'll put in the disclaimer that my interview has happened a few years ago but I'll justify the few remarks by saying I've been on the other side of the interview quite a bit and maybe that's helpful too for some thoughts as to how to make your interview successful. And I'll just briefly put it into five steps essentially. And most of them have to do with preparation. The interview itself is sort of the fourth, second to last step in my mind and a lot of it has to do with your work in the lead up to it. And the first one as sort of cliche as it is in my mind the most difficult one, certainly for me has been the most difficult one. As you're sitting there in your fellowship, what do you know about all the options out there? So how in the world would you know what you might like or not like? You haven't even tried it yet, right? But that's no excuse to at least try to figure out knowing what you know today, what's your best guess of what you would like to do and by what you would like to do I mean not just you of course but everyone else around you, your family, your significant others, your whoever is going to move with you through life. And I mean not just in terms of what you want to do clinically but what else do you want to do when your life works, your work works. So what do you want to be doing where and what's your family needs? Maybe one might argue in reverse order here depending on whether or not you have a spouse like I do. She certainly reminds me that that's the most important one. And you might have a certain geography, you may want to do interventional endoscopy, you may want to do it in a private practice setting, you may want to do it in Alabama despite low vaccination rates, who knows? You won't get it all. Maybe would you let interventional go? Would you rather let Alabama go? Would you let some other criteria go? So how would you prioritize together with your family all these different things that are important to you? And then we're talking a lot during this course about practice setting, small group, large group. How do you find out if you don't know right now? Well again, you're starting to do it now. Take a lot of time, talk to the faculty here, get the faculty to connect you to faculty or other colleagues closer to your home or the place you're envisioning. So again, it comes back to the network. Once you've made your best guess, whatever it might be, then narrow the field in that same way. Talk to folks about you are looking for something in this geographic environment, non-academic. Well you happen to know Joe Vicari sits here and he is one of the lead folks in a practice that's not too far away. You might not know that but you may know someone else in the area here who you can ask who are the practices in this area. So word of mouth, social media, all the things that you do more naturally than maybe some of us, national, regional meetings, these kinds of courses. And again, getting involved with one of the societies will be very, very helpful to you. Not just because you'll learn clinical things but you have these kinds of connections that come in handy when you need them. Recruiting firms are available. We can talk a little bit about them later if you like. I personally have not used them. We could certainly, as any of the faculty here made use early on in your careers of recruiting firms. Can I see a hand from the faculty? No? That's a no. I get texted like every other day. Yeah, exactly. We're going to hear during the lunch break from HCA and I want us to hear a little bit about what they can do in that sense. So it's at least a consideration. This is the step for me and still, I go through interviews currently and looking to reorient my own job. This is the step that I spend a lot of time on which is essentially the pre-visit planning. So once you have targeted a practice or a short list of practices, have a decent general understanding. If you're interviewing with a non-academic sort of traditional private practice, go back to the talk Joe gave yesterday about that environment, how such a practice is structured. If you don't find it in those presentations, contact some people who know. So have a halfway decent understanding of sort of the mechanics of an academic group if you're applying in that direction. Collect information about the specific practice you're about to interview with and the practice website of course is a good starting point. Again, personal contacts. You can make a cold call. Ask to speak to leadership in the practice. Tell them you're interested in potentially interviewing. Can they tell you a little bit about themselves? If the secretary hangs up on you before you can say your name, you might have an answer. So figure out once you know the group you're about to interview with, figure out who the physicians are, not only how large the group is but what are their ages. Colleen just mentioned that about a third of gastroenterologists currently in this country are 55 years or older and therefore within a few years potentially of retirement. So is this a very old group, a very young group? Is it a group that's recently added a lot of members, that's recently lost a lot of members? If folks have exited that group, why in the world did they exit? So come up with some of those kinds of issues before you go there. Don't sit there at the table in the middle of the interview while you're trying to do five things at the same time and multitask and then think about the next question. What I do is I write down a list of questions on index cards and I have them here and I take them with me. And during bathroom breaks and coffee breaks and lunch breaks, I go to a quiet place and I take out the index cards and I cross off the stuff that I've addressed and I remind myself what I still need to ask before I go back home. Nowadays depending on the area, the geographic area where you're applying, there can be significant competition by which I mean if it's a private practice environment, are there five practices down the same street or is there only one practice in 300 miles? What's the competition in the area? And again, in terms of what questions you may want to ask, you can maybe use some of those pointers to come up with a complete list for you. You want to understand essentially the people who work there, not only the physicians but all the folks who work there, the structure of the practice and the environment that practice is in. And I would structure my questions along those lines. So when you think about the people and you start talking to them, get a sense for what motivates them. And sometimes it's more obvious than you think and it's depressingly obvious that people constantly talk to you about money or this is very efficiently run, we're doing a lot of endoscopy, we're higher paid than any other practice in the area. Depending on how you feel about that being the dominant factor, that's important for you to know. Then there's practices and I keep pointing towards Joe because I happen to know your practice better and I'm not favoring his over any other but in your practice, everyone shares the same income essentially. You throw it all in one pot and it's not productivity based predominantly but it's really, it goes, the hepatologist, whoever does more endoscopy, less endoscopy, they're all equally, I'm probably telling it wrong but they're equally valued in terms of how compensation works. So try to get a sense for those kinds of surrogate points that might point you in certain directions in terms of practice philosophy. Ask them about what they think could be done better in their practice, what needs to change still. In a non-academic private practice environment, ownership eventually becomes somewhat important to understand. So there are buckets in a private practice, the ambulatory endoscopy center, potentially a pathology lab that they might own, an anesthesia group that they may employ in the GI practice that contribute to the economic well-being of the practice and that the physicians oftentimes have to buy into. So first of all, understand what sort of the different elements of the practice are and secondly whether or not there's a financial buy-in. And then again in terms of the environment, who are the hospitals around them, the competitors. And how do you fit into those folks, that structure, that environment with your own philosophy? Maybe you are very driven, productivity driven and you would not care so much for a practice that essentially pays everyone the same or vice versa. So give it a little bit of thought as to how you might fit in there and then get them to talk to you a little bit about their expectations. When you're joining that practice, what do they expect from you? Is there a ramp up phase? How quickly are you expected to essentially be on your own and be equally productive potentially? Will they help you build your practice? Initially you have no patient referrals. Where do they come from if you're the new physician? Will they come from other partners? Will there be some centralized mechanism whereby they help you get these early referrals? Are you expected to do outreach and go to referring providers, give talks, get your name and your face out there? How does that work? And then again in terms of formalities and thinking forward in a private practice you want to have a sense for the path to partnership. Usually in most practices you will get an employment contract for a year or two and then the opportunity to become full partner in the practice. How does that work? Who makes that determination? Is it all the other partners in the practice? Is it just the board? Is it potentially just the president? And likewise in an academic environment you've heard Dr. Dominance talk about that environment yesterday. How does career advancement work within that specific group that you might be talking about? And who makes those decisions and what are the criteria? Compensation, the question comes up a lot about when, what's the best time for you to ask about, hey, how am I getting paid and how much will I get paid? And do I need to wait? Is the first interview really the best time to do that? And again we'll take a quick poll of the faculty. I personally would tell you that I would make that decision at the time of the interview as you're sitting there and you get a sense for what feels right. I think it's totally legitimate. It's an important issue for you to know how the financial aspects of your work will work. So I don't see any reason to postpone that to a second, a third, a fourth visit. Now I wouldn't walk into an office and say, hey, by the way, before we go any further how much are you going to pay me? So tack that on towards the end, I would suggest, of your interview and not necessarily postpone it if it's something that needs to be discussed. How do you guys who interview fellows, Colleen, Virga, Linda, Joe, Drew, how do you approach this? About how pay is structured in the group, how the general philosophy of the group. I would not expect a question about specific salary. I might give them that information, but I will flip that and mention that it's quite possible the response to that question would be tell me what you expect. So just two things. You don't want to negotiate against yourself, but you also want to be thinking about that in case the question gets flipped on you. As I said yesterday, I think we're a little different. We throw it all on the table. You don't even have to ask us in our group on the first interview. You will see cash flow statements for monthly for about a year. You'll see the history of physician salaries. You'll see call schedules. We throw it out there from the very beginning. I, like Klaus, think it is fair game. I think Colleen put it great yesterday. It's not necessarily the first question or the first question on the first date, but start general, start by opening the door with some simple questions about finances, and then I would say go in for the kill over time. Let me point to, we're going to hear from a couple of junior colleagues who've just made that transition last year, but I'll get them to weigh in now maybe briefly. Rebecca, when you interviewed in a private practice setting, how did compensation come up in the conversation and when? Yeah, I really appreciated the practice that I ended up joining. We had a telephone conversation before I went for the interview or was invited or whatnot, and they put it all out there right then on that phone, telephone interview without me even asking. And then the competitor group, I went, had a full day of interview, didn't bring it up, had a drink session in the evening, brought it up and was told, we don't talk about that on the first date. I didn't like that answer and the way it was given in the first place, but it also kind of turned me off. Got it. And very good. Mohamed, maybe you recently interviewed in a more academic setting, how does compensation come up there? Yeah, I mean, I think for academics that my experience was that there is not a whole lot of chance to negotiate salary because academic salaries are more or less fixed, especially for General J and even for like me as an advanced endoscopist, all the four places, academic places I interviewed, they were like, well, this is what a fresh assistant professor or a salary is. And I think some of you attended the ASG endo hangout on this topic and I said what I learned over time was that you have more negotiation power, not in terms of salary, but in terms of resources that you can ask for. So if you want protected time, you could negotiate that. If you want like throwing a research fellow, a coordinator, depending upon what your background is or an administrator or how much endoscopy days you want. So you have more sort of negotiation power in the support you get, but not as much in salary early on in academics. That's what I thought. Right, Dr. Dominick, is that you've had much more experience in that. Yeah. I would agree with that. And when I interview people, I've done a lot of that over the years. I just put it out there what the salary range is. It's not up to me to decide the final salary, it's up to our chief of staff, but I tell them what to expect so they don't have to wonder and ask. And I had one person say, when I told them about our salaries, they said, oh, well, you get what you pay for, I guess. That kind of turned me off. That was the end of the interview. All right. Very good. And there's a couple of resources we can circulate that you can use. You'll see some of that mentioned during the lunch talk that HCA is giving as well. Let me maybe just finish a couple of slides. So the contract issues we're going to address separately, and Drew is going to talk to us a little bit about that in a moment, but I know there's going to be plenty of issues that we probably want to discuss about the interview. But let me just finish my thoughts here, and then we'll take some questions. So the interview itself goes without saying, I mean, hopefully, don't go in there cocky and you're coming from the Mayo Clinic, Ferga, right, or the, oh, that wasn't nice. I'll take that back, I'll take that back. But be yourself, and it's really a performance to some degree. You've interviewed before, you know it, you have to, which is why you really need to be prepared going into it. Have your ducks in a row in terms of what you want to ask, because you're observing them and at the same time responding to questions from them. What I have found useful is as you're going through a full day and a list of interviewers, try to ask them some of the same questions, see if you get the same answers. If there's no consistency and they're all over the place, then that might mean something to you. Sometimes I get the best information sitting, waiting for my next interviewer. Talk to the secretary. I have a friend who got his first job many years ago now, but got it because he had 10, 15 minutes, someone forgot about him in the waiting area. He used the time to talk to the secretary, and the secretary afterwards talked to the lead guy, the president of the group, and said this guy was so nice, he didn't get upset, he didn't get frustrated, he asked me about all my children, at the end of the 15 minutes, I knew everything about his, and the president said, hey, let's take a look at the guy. So the main point being, think beyond just, here's the next 20 minute interview slot when you're looking at practices. Physicians who leave the group, that's a dicey issue, and oftentimes you wouldn't know that unless, again, you have a network of folks in the geographic area and they've told you there's someone who's left, and by the way, that practice hasn't been able to hold a position for the last five years. People are always running in and running out. If there's any way you have to find those folks, it may not be unreasonable to try to get some information from them directly or indirectly, realizing that their view is going to be colored and biased, of course. But to the extent that you might learn something from them, it may still be a good add-on. And last not least, and this is the least tangible and, in a way, for me, the most important aspect, if I get away from an interview and I say that they said all the right things, they're going to make me division chief, they want me to build their endoscopy, but the guy was just a weirdo. I don't get any warm and fuzzy. Then that means something to me. And I don't know how you approach those kinds of situations, but I would suggest that if it just didn't feel right, no matter what was said, I would at least think about that. And then afterwards, when you weigh the pros and cons, I would suggest you send formal thank you notes to everyone you met there. Life has a funny way of coming around, and there may be a situation two years, five years, 10 years down the road where some of the folks you met there, for whatever reason, become important again to you. So if you didn't like that academic place, that practice, don't tell them, you guys are nuts, I'm not going here. Thank them, send them a thank you note, and leave it at that. You've reoriented yourself in a different direction, but thank you for taking the time to speak with me. If other than become better networked, you take anything away from me today, take away that before you sign anything, get an attorney. And the reason I emphasize that every time I talk about this topic is these attorneys are expensive, and you look at their hourly rates and you say, do I really need to spend $350 an hour on one of these guys when I'm already deep in debt? That might be the best $350 you are spending in a long time. There are things in the fine print of these contracts that you absolutely want an expert to take a look at. And some of them are state-specific. So in an ideal situation, once you know where you're heading or want to head, see if you can identify an employment lawyer who in that state or general environment who can help you with it. That money is well spent, and I really mean that. You may think you can read this stuff and understand it all, but unless it's the easiest one-pager of a contract, don't ever do that and spend the money. So I'll leave it there. I said before, you're in a good spot now. You're in a very structured training environment. Make use of it before you leave there. And the things that ultimately in the post-fellowship world will baffle you potentially are some of the emergency situations. Can you really put a decompression tube in if in this world Minnesota tubes are still used here and there? Figure out how to do that and learn it because there's no one going to stand next to you. There is no attending in the middle of the night in the ICU once you are out potentially in a smaller place. So try to think about on-call and emergency situations. Try to get your scoping skills up to speed. Doesn't necessarily have to be every 10 minute, 20 minutes. Shouldn't be every 10 minute colonoscopies, but it shouldn't be every hour and a half colonoscopies either. That may be tolerated for a short while during the onboarding phase in a new group, but not for long. And then once again, build your network. So I'll stop here and let's take a few minutes. We can catch up a little bit during the breakout sessions this afternoon, but I want to take some time for questions or comments from the faculty stuff that I haven't mentioned that's important to point out. Linda. I have one comment about going to the legal review. If money is an issue, go to your institution's medical legal department. A lot of times they have somebody there who can either review the contract for you for somebody who works in the system itself. Like when I was at University of Illinois, they had a MDJD guy who was in charge of safety and stuff, but he did $200 contract reviews for residents and fellows because he knew we were strapped for cash at that point. So if not there, they can at least give you recommendations of people to use in the area that are used to doing health care law. And you have to find somebody specific for health care. Is it a lawyer in the same institution, or would it be giving advice for other institutions? Sometimes they give you recommendations for outside. The other way to find out is senior fellows who have graduated. A lot of times there's also somebody. If your residency or fellowship has a union, a lot of times they offer discounted rates for certain legal access, if you will, as well. Rebecca? Yeah, I just wanted to piggyback off that. That's a really great comment. I did do that, and I used a lawyer through the union that we had at University of Washington. However, the word of caution is that lawyer wasn't familiar with the contract. That law is necessarily out of state would be the only thing to be aware of if your contract is out of state and kind of little differences they might not be educated on. Yeah, and I think you definitely, once again, I think you need legal advice. The other thing that's going to help you, again, is to know folks who know you well enough, you know them well enough, that they're colleagues who are willing to talk to you about some of the things that may be in contract. So if you have a non-compete clause, which many of these contracts have in certain areas where you're not allowed once you start with a certain group and you might leave that group, then within a certain radius around the group, you're not allowed to practice there for a certain amount of time. Well, is 10 miles reasonable? Is 50 miles reasonable? What's the current standard? If you have friends who've done this last year, your senior fellows or junior attendings, there, again, your network is helpful to get some of those less legal detail-oriented questions. There was a hand up here, yeah, a comment. So some of the participants would like to see the residency. Some of the residency program will invite a lawyer just to come and give a noon conference. Usually, they do it for free. The lawyer will come just so they can get the business. And then you can get the feeling about how good is the lawyer and how much they know. And of course, they're not going to give you any legal advice during the noon conference. But that would be a good quick review about how good is that lawyer, what you need to pay attention to, and what's important in that particular area. Because if you're going to practice in Chicago, the law is completely different than if you're practicing in Texas. So that might be something that will open the door for many of you guys. So you can maybe attend one of those noon conference lectures, even if during the residency program, they offer. Very good. Yes. I would understand that legal advice might change impact in the private world. But how open are academic institutions in receiving those kind of advice? Say, as you were mentioning, the 10-mile or 50-mile. I mean, they would say that this is just a standard. We can't make changes to this or that. That's right. So in general, and it's not only academic versus non-academic, but it has to do to some degree with the size of the entity. So a big university, there's a contract template. And they would be crazy, and it just wouldn't work to individualize that for every physician. Because if nothing else, you actually get yourself in legal trouble, potentially, if you carve out certain things for certain individuals. So they would not be very open at all in terms of modifying stuff like a non-compete clause. Now, all of that said, still, you're signing a very important document that potentially will determine your life for several years to come. I would still, even for any academic institution or any other contract, if at all possible, I would not sign that without a legal review. Because they might point something out where you say, well, I'm not willing to go there. Jason has his hand up. Yeah, I would just say, I know the University of Washington had non-compete clauses. Well, they have non-compete clauses. And I know early on, some people were able to negotiate their way out of that. And I don't know if they're still able to. I know they've gotten tougher on that. In the VA, there are no non-compete clauses. But we don't really have contracts signed. People are kind of just, you start working, you can leave, whatever. So if you're coming to the VA, I wouldn't probably spend the money on it. Because I don't know that it's money well-spent for something like coming to the VA. But I don't know if that would apply to going to Kaiser or a university. It still may be money well-spent. The VA is a very special world. OK, so everywhere but the VA. What else here? These groups offer language that talk about 55th median percentile for your level of training, and fair market value. I guess, to me, I can't speak for anybody else, it's very vague language. And when you Google it, maybe you might not get accurate information. How do you know what benchmarks or standards are being used by the people who offer you these contracts? Yeah, so the best way, again, is to get as many folks to hopefully somehow tell you the range in that geographic area. I would first say all of these so-called benchmarks and surveys have their flaws and significant downsides. Depending on where they're looking, how they're slicing and dicing the geography, the type of practice, they come up with some very interesting numbers that when you talk to physicians in that area, they all say, well, that's news to me. So I don't put too much credence on these benchmark numbers. And ideally, if you can get a more direct sense from folks about what's going on financially in the area, that's the better way. How do you guys suggest to use benchmarks in any of the faculty? Colleen, does that come up in your interviews with new partners? Do you tell them relative to benchmarks? We use the benchmarks internally for discussion. But when we present a term offer, basically a letter of intent, it has a specific figure in there, along with some other figures that we can use to ice the cake a little bit. What I would add to the discussion is, remember yesterday, we talked generally about the trade-offs that you need to make. We haven't really talked about negotiating contracts. Again, think about really what is most important to you. If you are just a killer worker bee, you might be satisfied with a lower base salary with a productivity bonus, because that'll come back to you. And you might be able to make a trade-off with the moving expenses or something else that's really not a huge deal. You'll be possibly negotiating by email. I'd emphasize what Klaus said, begin and end every discussion with a thank you. And keep the documentation. It may or may not be reflected in the agreement. And you want to make sure that you have a clear understanding of what you agreed on, and that you're agreeing with the right person, the person that makes those decisions. It's a difficult issue, and one that, in my mind, doesn't have a good answer. It's so individual, depending on the geography, what you're looking for, the type of practice. I wish there was one place that we could point you guys to and say, this is really how you would get the answer to that question. I'm sort of the wrong person to ask, because in terms of know your trade-offs and what you want to do, that was never at the top of my list. So I was always more interested in my time there, how much call, what will I be doing work-wise. I would, and Jason has a comment, but ultimately, the good news, of course, is that we're all going to do quite well. And I don't see that change over the next few years. Who knows what's going to happen in the long run? But that is true, by the way, for a non-academic environment. And if you will, relatively speaking, it's even more true in an academic environment. The gap between academia and non-academia incomes was quite a bit larger 10, 15 years ago, and it has narrowed some. Now, there's still a gap, but you have to calculate what it means to be on call. When you're on call in a non-academic environment, sometimes you're on call for every IBS-related call at 2 AM from the ER, whereas that's unlikely to happen to you as an attending in most academic environments. So there's all these different factors that come in there. I think ultimately, hopefully, we'll all do well. And I am sort of hoping that you're not going to make that the main driver, but recognizing it's important. Yeah. I just want to make a brief comment about negotiation. When Klaus was talking about thinking about what's important to the group, if they're talking all about money and whatever, you're judging their values. Well, they're also judging your values in the negotiation. And if you're saying you're focused a lot on money, they may say, well, maybe this person doesn't have the right values for our group. So it works both ways, so be careful when you're doing that negotiation. Yeah, especially the fifth and sixth and seventh time around. If I was to get a fifth email about, oh, and then I forgot to ask, can we increase the CME money allowance from $300 to $500 kind of thing, when you're talking about a $300k, $400k contract. We'll take one more comment from Drew, and then everyone from ASG is going to yell and scream at me for running so late already. I think you're taking my thought time anyway. Yeah, yeah, there you go. It's OK. So yeah, on that same note, you guys are going to be in a little bit of a tough position, especially because of the age differences sometimes between the people interviewing you. And you have the unfortunate distinction of being millennials, which in some groups carries a stigma that, oh, the millennials, they don't want to work, they don't want to do this. And there are a lot of these preconceived notions out there, even though you guys have demonstrated how hard you work, that stigma still carries. So I would say, especially, maybe not so much about the money aspect, but if call is the first question that comes out of your mouth, and you say, so what's the call rotation here? That's a big red flag to the employers. Oh, another millennial doesn't want to pick up the phone. It's all work-life balance, and it's all life and no work. So just a word of caution about how you may be viewed through that lens of different ages. Very good. So let's move on. There's plenty of time during the breaks and afterwards to connect with us. We're running about a half an hour late, and we'll continue with that time frame and make it up this afternoon. So this is definitely a topic here that I asked Drew to present on that I want to spend plenty of time on.

interviews

contracts

fellows

job opportunities

preparation

networking

practice settings

thank-you notes